• Laxmaiah Manchikanti, Mark V Boswell, Vijay Singh, Richard Derby, Bert Fellows, Frank J E Falco, Sukdeb Datta, Howard S Smith, and Joshua A Hirsch.
• Pain Management Center of Paducah, Paducah, KY, USA. drlm@thepainmd.com
• Pain Physician. 2009 Jul 1;12(4):E71-120.

BackgroundUnderstanding the neurophysiological basis of chronic spinal pain and diagnostic interventional techniques is crucial in the proper diagnosis and management of chronic spinal pain. Central to the understanding of the structural basis of chronic spinal pain is the provision of physical diagnosis and validation of patient symptomatology. It has been shown that history, physical examination, imaging, and nerve conduction studies in non-radicular or discogenic pain are unable to diagnose the precise cause in 85% of the patients. In contrast, controlled diagnostic blocks have been shown to determine the cause of pain in as many as 85% of the patients.ObjectiveTo provide evidence-based clinical practice guidelines for diagnostic interventional techniques.DesignBest evidence synthesis.MethodsStrength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II.Diagnostic CriteriaDiagnostic criteria established by systematic reviews were utilized with controlled diagnostic blocks. Diagnostic criteria included at least 80% pain relief with controlled local anesthetic blocks with the ability to perform multiple maneuvers which were painful prior to the diagnostic blocks for facet joint and sacroiliac joint blocks, whereas for provocation discography, the criteria included concordant pain upon stimulation of the target disc with 2 adjacent discs producing no pain at all.ResultsThe indicated level of evidence for diagnostic lumbar, cervical, and thoracic facet joint nerve blocks is Level I or II-1. The indicated evidence is Level II-2 for lumbar and cervical discography, whereas it is Level II-3 for thoracic provocation discography. The evidence for diagnostic sacroiliac joint nerve blocks is Level II-2. Level of evidence for selective nerve root blocks for diagnostic purposes is Level II-3.LimitationsLimitations of this guideline preparation include a continued paucity of literature and conflicts in preparation of systematic reviews and guidelines.ConclusionThese guidelines include the evaluation of evidence for diagnostic interventional procedures in managing chronic spinal pain and recommendations. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a "standard of care."

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