INVITED REVIEW ARTICLE

Medial Branch Blocks of the Cervical and Lumbar Spine

Stephan Klessinger, MD

Summary: Medial branch blocks are used to test if the pain stems from a zygapophysial joint because the medial branch innervates the joint. If the pain is not relieved after a medial branch block, the target nerve cannot be regarded as mediating the pain; this means the zygapophysial joint is not the pain source. If the answer is positive, the pain source is identied and a good chance of obtaining pain relief after radiofrequency neurotomy is predicted. The fundamental indication for medial branch blocks is the desire to know if the zygapophysial joints are the pain source. No clinical test exists to identify a zygapophysial joint as pain source. Because the singular reason for performing diagnostic medial branch blocks is to obtain information, the evaluation of the patients response is essential. A strong accuracy of facet joint nerve blocks in the diagnosis of lumbar and cervical facet joint pain can be achieved. Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain. Conicting results of different treatment modalities are discussed: the degree of relief that should occur after medial branch blocks remains contentious. Medial branch blocks are a diagnostic tool. However, there are studies giving a strong recommendation for the use of therapeutic cervical and lumbar facet joint nerve blocks for the treatment of chronic facet joint pain. The evidence for intra-articular injections seems to be poor. Computed tomography (CT) guidance is not supported by guidelines. Key Words: medial branch blockszygapophysial painfacet joint painfacet joint nerve blockspain therapy. (Tech Orthop 2013;28: 1822)

the article Denervation of the zygapophysial joints of the cervical and lumbar spine in this issue.

INDICATION
The fundamental indication for medial branch blocks is the desire to know if the zygapophysial joints are the pain source. Of course the response must affect the management. The only validated treatment for pain mediated by the medial branches is radiofrequency neurotomy.1,2 For patient selection rst serious diseases like tumors, infection, or metabolic diseases must be excluded. Usually patients present with chronic back pain of unknown origin in which a zygapophysial pain seems likely. No clinical test exists to identify a zygapophysial joint as pain source.4,5 X-rays may or may not show sclerosis of the joint, also, often in magnetic resonance imaging degenerative changes can be found without any relevance. Target joints might be identied by the pain pattern, local tenderness over the area and provocation of pain with deep pressure. In the cervical spine pain maps of the zygapophysial joints can be very helpful for identifying the level to treat.69

Contraindications
Absolute contraindications for medial branch blocks exist in patients unwilling or unable to consent to procedure, patients with systemic infection, bleeding, diasthesis, or anticoagulants with high risk of bleeding and pregnancy. Relative contraindications are an allergy to contrast medium or local anesthetics.1,2

PRINCIPLES
Medial branch blocks are a diagnostic tool designed to test if a patients pain is mediated by one or more of the medial branches of the dorsal rami. The target nerve is anesthetized with a small volume of local anesthetic. By convention,13 medial branch blocks are used to test if the pain stems from a zygapophysial joint because the medial branch innervates the joint. For this reason medial branch blocks are also referred to as zygapophysial joint blocks or facet joint blocks. If the pain is not relieved after a medial branch block, the target nerve cannot be regarded as mediating the pain, this means the zygapophysial joint is not the pain source. A new hypothesis about the source of pain is required. If the answer is positive, the pain source is identied and a good chance of obtaining pain relief after radiofrequency neurotomy is predicted.1,2

TECHNIQUE
The detailed description of the implementation of medial branch blocks will follow the guidelines of the International Spine Intervention Society.1,2

Lumbar
Lumbar medial branch blocks are performed as an outpatient procedure. A procedure room suitable for aseptic procedures is needed. It is advisable that the procedure be performed in a room equipped with proper resuscitation facilities to deal with possible allergic reactions. Fluoroscopy is mandatory. The patient is placed prone on a radiolucent uoroscopy table. The width of the operating table should ensure a free rotation of the C-arm. The patients back is prepared and draped in a sterile fashion. All personal must wear appropriate lead aprons and should be supplied with a personalized dosimeter. There should be at least 1 assistant available in the room for documentation, operating the C-arm, and looking after the patient. Generally, no sedation, systemic analgesia, or premedication is required. For the L1-L4 medial branches the target point is the junction of the superior articular process and the transverse process. The medial branch crosses midway between the superior border of the transverse process and the location of the
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ANATOMY
For a medial branch block, exact anatomic knowledge is essential. The anatomy of the medial branches is described in
From the Nova Clinic, Department of Neurosurgery, Biberach, Germany. The author declares that he has nothing to disclose. Address correspondence and reprint requests to Stephan Klessinger, MD, Nova Clinic, Department of Neurosurgery, Eichendorffweg 5, 88400 Biberach, Germany. E-mail: klessinger@nova-clinic.de. Copyright r 2013 by Lippincott Williams & Wilkins ISSN: 0148-703/13/2801-0018

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Medial Branch Blocks

should be at least 1 assistant available in the room for documentation, operating the C-arm, and looking after the patient. Generally, no sedation, systemic analgesia, or premedication is required. A lateral view of the spine must be obtained. For medial branch blocks C3-C6 the target point is the centroid of the articular pillar with the same segmental number as the target nerve. The target point for C7 medial branch block lies high on the apex of the superior articular process. For the third occipital nerve, 3 target points are used lying on a vertical line between the apex of the C3 superior articular process and the bottom of the C2-3 intervertebral foramen. The needle is placed straight along the x-ray beam to the target point. The use of contrast medium has not become a standard component for cervical medial branch blocks. Once the needle is in position, 0.3 mL of local anesthetic is injected (Fig. 2).

Postprocedure Care
Upon removal of the needles, the skin is cleansed and an adhesive dressing is applied. Before rising from the procedure table, patients should be reminded that they may experience unsteadiness. The patients should be observed after the procedure for a sufcient time with monitoring blood pressure and pulse-oximetry. The patient is discharged in the care of a responsible person.

EVALUATION
FIGURE 1. Anteroposterior view of needles in position for an L4 medial branch block and L5 dorsal ramus block after application of contrast medium.

mamillo-accessory notch (see Fig. 2 in Denervation of the zygapophysial joints of the cervical and lumbar spine in this issue). At the L5 level the target nerve is the dorsal ramus. On an oblique view the target point can be found near the eye of the scotty dog or in the middle of a line between the mamillo-accessory ligament and the mamillo-accessory notch. For a given joint both of the 2 nerves that innervate the joint will need to be anesthetized. For example the L5-S1 joint is innervated by the medial branch of the L4 dorsal ramus and the dorsal ramus L5. The needle is placed straight along the x-ray beam in an oblique view to the target point. The correct placement is conrmed by an anteroposterior view. The bevel should be directed caudally and a small amount (0.1 to 0.3 mL) of contrast medium can be injected. If there is no venous uptake, 0.5 mL of local anesthetic is injected (Fig. 1).

Because the singular reason for performing diagnostic medial branch blocks is to obtain information, the evaluation of the patients response is essential. Several potential sources of error exist. Particularly false-positive answers can be produced for example because of the expectations of the patient or the doctor. An ideal approach would be an evaluation of the results immediately after the block, and some time afterwards by an independent observer, for example a registered nurse. A positive response to a block is complete relief of that part of the pain that the blocks are expected to relief for duration commensurate with the expected duration of action of the local anesthetic. If more than one pain source is known, only a proportion of the pain will be relieved. Appropriate instruments for assessing the response are the Visual Analogue Scale and relief of disabilities. Examples of evaluation sheets can be found in the Practice Guidelines of the International Spine Intervention Society.1,2

RESULTS
Single diagnostic blocks are not valid, because they carry an unacceptable high false-positive rate.1013 In order to reduce the likelihood of responses being false positive, controlled blocks are mandatory.1,2 Uncontrolled blocks or intra-articular blocks lack validity.10 Multiple studies and systematic reviews have evaluated the reliability of diagnostic facet joint nerve blocks.1422 Datta et al18 and Falco et al19 recently performed a systematic assessment of the diagnostic accuracy of facet joint nerve blocks and concluded that controlled diagnostic blocks, utilizing at least 80% pain relief from baseline pain and the ability to perform previously painful movements, provide strong evidence in the diagnosis of facet joint pain.23 The review of Datta et al18 included 7 studies2430 utilizing controlled local anesthetic blocks with evaluation of at least 80% pain relief. False-positive rates of 17% to 49% were demonstrated. The
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Cervical
Cervical medial branch blocks are performed as an outpatient procedure. A procedure room suitable for aseptic procedures is needed. Informed consent is obtained. Patients should have a driver with them after the procedure. It is advisable that the procedure be performed in a room equipped with proper resuscitation facilities to deal with possible allergic reactions. Fluoroscopy is mandatory. The patient is placed in lateral position with the target side uppermost on a radiolucent uoroscopy table. The width of the operating table should ensure a free rotation of the C-arm. The patients neck is prepared and draped in a sterile fashion. All personal must wear appropriate lead aprons and should be supplied with a personalized dosimeter. There
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et al23 of the accuracy of diagnosis of lumbar facet joint pain by controlled comparative local anesthetic blocks utilizing either 50% or 80% pain relief as the criteria, have demonstrated the validity of 80% pain relief with controlled diagnostic blocks rather than Z 50% pain relief. The benchmark study on lumbar medial branch neurotomy used at least 80% relief following medial branch blocks as criterion for a positive response.34 A new study from New Zeeland uses 100% pain relief as criterion for cervical radiofrequency neurotomy.35 The distinction between 100% pain relief and being satised with less pain relief after a diagnostic medial branch block is relevant for daily work.36 In patients with >1 pain source, for example after an operation or with spondylolisthesis, only a proportion of the pain will be relieved.37,38

Therapeutic Medial Branch Blocks

Conicting results have been reported for the different treatment modalities for lumbar zygapophysial joint pain in systematic reviews. Radiofrequency neurotomy is discussed in an extra chapter in this issue. For therapeutic medial branch blocks several studies can be found, some reviews are taken into account. Datta et al18 included 2 studies by Manchikanti et al.39,40 Signicant improvement with pain relief and functional improvement was observed in 78% to 85%. The indicated level of evidence is level II-1 or II-2 with a strong recommendation (1B or 1C) for the use of therapeutic joint blocks. In the review of Boswell et al31,32 the evidence for short-term and long-term pain relief after therapeutic medial branch blocks is moderate. The review of Manchikanti et al22 gives a strong recommendation (1B or 1C) for the use of therapeutic cervical and lumbar facet joint nerve blocks to provide both short-term and long-term relief in the treatment of chronic facet joint pain. For the cervical spine the systematic review by Falco et al19 showed moderate evidence for medial branch blocks and radiofrequency neurotomy, that has also been echoed in other reports.22,4144 Thus, medial branch blocks may be utilized as an alternative to radiofrequency neurotomy. Manchikanti et al45 published an observational study and a randomized double-blind trial4648 illustrating approximately 17 to 19 weeks of relief requiring approximately 6 episodes of cervical treatments over a period of 2 years, with between 85% and 93% signicant improvement at 1 and 2 years in 2 groups with and without steroids. In patients after ventral operations of the cervical spine the success rate is 53%.49

FIGURE 2. Lateral view with the needle in position for a C5 medial branch block.

level of evidence was level I or II-1 based on the 7 included studies. For the diagnosis of facet joint pain of the cervical spine, the evidence is level I or II-1 based on the 9 included studies in the review of Falco et al.19 Also Boswell et al31,32 gave a strong accuracy of facet joint nerve blocks in the diagnosis of lumbar and cervical facet joint pain. Similar results can be found in the review of Manchikanti et al22: for the lumbar and cervical spine evidence is level I or II-1. Rubinstein and van Tulder33 in a best-evidence review of diagnostic procedures for low back pain concluded that there is strong evidence for the diagnostic accuracy of lumbar facet joint blocks in evaluating spinal pain. Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain.22

Intra-articular Blocks
Another treatment modality are intra-articular blocks. However, several advantages of medial branch blocks exist1,2: medial branch blocks are easier to perform. Entering a narrow joint space can be difcult. Sometimes osteophytes degenerative changes may block the entry. Medial branches are safer because bone prevents over penetration of the needle and entering the spinal canal. Target nerves can be anesthetized with different agents whose duration of effect is known. If the response to medial blocks is positive radiofrequency neurotomy is a therapeutic utility with predictive validity. No subsequent treatment after intra-articular blocks is known. Several reviews exist about lumbar facet joint interventions including intra-articular injections. The intra-articular injections are always performed in a therapeutic intention, not for diagnostic reasons. Boswell at al31,32 gave a moderate evidence for short-term and long-term improvement in low back pain. The evidence is limited in neck pain. Datta et al.18 found 5 randomized trials and 15 observational studies, none
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DISCUSSION
In the literature and in every day practice differences of the above described proceeding can be found. Four major aspects are worth being discussed.

The Accuracy of Diagnostic Blocks

The degree of relief that should occur after medial branch blocks remains contentious. Ideally, diagnostic blocks should produce complete relief of pain, or near complete relief. This would occur only when the patients sole or principal source of pain lies in the joints innervated by the nerves blocked. Some investigators, however, use a more liberal criterion, such as >50% relief of pain. This criterion allows medial branch neurotomy to be used to provide substantial, but not necessarily complete, relief of pain, which is nevertheless clinically worthwhile.10 The results of a evaluation by Manchicanti

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met the inclusion criteria. The recommendation is very week or not to provide intra-articular injections. A narrative review of Bogduk50 suggested that intra-articular blocks were no better than placebo for chronic lumbar spine pain. There is no recommendation for therapeutic intra-articular facet joint injections in the review of Manchikanti et al22 The evidence for cervical intra-articular injections is lacking.

8. Windsor RE, Nagula D, Storm SA, et al. Electrical stimulation induced cervical medial branch referral patterns. Pain Physician. 2003;6:411418. 9. Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med. 2007;8:344353. 10. Bogduk N, Dreyfuss P, Govind J. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. Pain Med. 2009;10:10351045. 11. Schwarzer AC, Aprill CN, Derby R, et al. The false positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain. 1994;58:195200. 12. Manchikanti L, Pampati V, Fellows B, et al. Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician. 1999;2:5964. 13. Manchikanti L, Pampati V, Fellows B, et al. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain. 2000;4:337344. 14. Bogduk N. International spinal injection society guidelines for the performance of spinal injection procedures. Part 1. Zygapophysial joint blocks. Clin J Pain. 1997;13:285302. 15. Sehgal N, Dunbar EE, Shah RV, et al. Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update. Pain Physician. 2007;10:213228. 16. Sehgal N, Shah RV, McKenzie-Brown A, et al. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician. 2005;8:211224. 17. Boswell MV, Singh V, Staats PS, et al. Accuracy of precision diagnostic blocks in the diagnosis of chronic spinal pain of facet or zygapophysial joint origin: a systematic review. Pain Physician. 2003;6:449456. 18. Datta S, Lee M, Falco FJE, et al. Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician. 2009;12:437460. 19. Falco FJE, Erhart S, Wargo BW, et al. Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. Pain Physician. 2009;12:323344. 20. Atluri S, Datta S, Falco FJE, et al. Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions. Pain Physician. 2008;11:611629. 21. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive review of neurophysiologic basis and diagnostic interventions in managing chronic spinal pain. Pain Physician. 2009;12:E71E120. 22. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidencebased guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699802. 23. Manchikanti L, Pampati S, Cash KA. Making sense of the accuracy of diagnostic lumbar facet joint nerve blocks: an assessment of the implications of 50% relief, 80% relief, single block, or controlled diagnostic blocks. Pain Physician. 2010;13:133143. 24. Schwarzer AC, Wang S, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis. 1995;54:100106. 25. Manchikanti L, Hirsch JA, Pampati V. Chronic low back pain of facet (zygapophysial) joint origin: is there a difference based on involvement of single or multiple spinal regions? Pain Physician. 2003;6:399405. 26. Manchikanti L, Singh V, Pampati V, et al. Is there correlation of facet joint pain in lumbar and cervical spine? An evaluation of prevalence in combined chronic low back and neck pain. Pain Physician. 2002; 5:365371. 27. Manchikanti L, Boswell MV, Singh V, et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musuloskelet Disord. 2004;5:15.

CT Guidance
The International Spine Intervention Society does not mention CT-guided interventions in the guidelines. Fluoroscopy is mandatory.1,2 Using CT means a higher radiation exposition for the patient and the physician, it is much more time consuming. No real time view of the track of the needle is available. Continuous uoroscopy, during and throughout the injection of contrast medium is the only available means of demonstrating, intra-arterial ow away from the site of injection.51,52 CT does not reveal arterial ow.52 A CT demonstrates the anterior-posterior and medio-lateral location of the needle, and might seem to be more convenient because an additional view is not required to check depth of insertion. However, a CT does not provide information on cephalocaudad spread of contrast medium. Consequently, injection into a vertebral artery or radicular artery will not be recognized (most important in transforaminal injections).51

CONCLUSIONS
Medial branch blocks are a diagnostic tool designed to test if a patients pain is mediated by 1 or more of the medial branches of the dorsal rami. An accurate evaluation of the patients response is fundamental. In case of a positive response the zygapophysial joints are identied as pain source and radiofrequency neurotomy is a therapeutic option. At least 80% pain relief should be the criteria. Fluoroscopy is mandatory; CT guidance is not supported by guidelines. Studies with a good recommendation to use therapeutic medial branch blocks with and without steroids exist. The evidence for intraarticular injections seems to be poor.
REFERENCES
1. International Spine Intervention Society. Lumbar medial branch blocks. In: Bogduk N, ed. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. San Francisco, CA: International Spine Intervention Society; 2004:4765. 2. International Spine Intervention Society. Cervical medial branch blocks. In: Bogduk N, ed. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. San Francisco, CA: International Spine Intervention Society; 2004:112137. 3. Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of cervical zygapophyseal joint pain. Reg Anesth. 1993;18:343350. 4. Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007;16:15391550. 5. van Kleef M, Vanelderen P, Cohen SP, et al. 12. Pain originating from the lumbar facet joints. Pain Pract. 2010;10:459469. 6. Dwyer A, Aprill C, Bogduk N. Cervical zygapophysial joint patterns I: a study in normal volunteers. Spine. 1990;15:453457. 7. Fukui S, Ohseto K, Shiotani M, et al. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Pain. 1996;68:7983.
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28. Manchikanti L, Singh V, Pampati V, et al. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician. 2001;4:308316. 29. Manchikanti L, Manchukonda R, Pampati V, et al. Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Arch Phys Med Rehabil. 2007;88:449455. 30. Manchukonda R, Manchikanti KN, Cash KA, et al. Zygapophysial joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech. 2007;20:539545. 31. Boswell MV, Trescot AM, Datta S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007;10:7111. 32. Boswell MV, Colson JD, Sehgal N, et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007;10:229253. Review. 33. Rubinstein SM, van Tulder M. A best-evidence review of diagnostic procedures for neck and low-back pain. Best Pract Res Clin Rheumatol. 2008;22:471482. 34. Dreyfuss P, Halbrook B, Pauza K, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000;25:12701277. 35. Macvicar J, Borowczyk JM, Macvicar AM, et al. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Med. 2012;13:647654. 36. Klessinger S. Cervical medial branch radiofrequency neurotomy. Pain Med. 2012;13:621. 37. Klessinger S. Radiofrequency neurotomy for the treatment of therapyresistant neck pain after ventral cervical operations. Pain Med. 2010;11:15041510. 38. Klessinger S. Radiofrequency neurotomy for treatment of low back pain in patients with minor degenerative spondylolisthesis. Pain Physician. 2012;15:E71E78. 39. Manchikanti L, Singh V, Falco FJ, et al. Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial: clinical trial NCT00355914. Pain Physician. 2008;11:121132. 40. Manchikanti L, Pampati V, Bakhit C, et al. Effectiveness of lumbar facet joint nerve blocks in chronic low back pain: a randomized clinical trial. Pain Physician. 2001;4:101117. 41. Manchikanti L, Datta S, Derby R, et al. A critical review of the American pain society clinical practice guidelines for interventional

techniques: part 1. Diagnostic interventions. Pain Physician. 2010;13: E141E174. 42. Manchikanti L, Datta S, Gupta S, et al. A critical review of the American pain society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician. 2010;13:E215E264. 43. American Society of Anesthesiologists. Task Force on Chronic Pain Management; American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112: 810833. 44. Manchikanti L, Singh V, Derby R, et al. Reassessment of evidence synthesis of occupational medicine practice guidelines for interventional pain management. Pain Physician. 2008;11:393482. 45. Manchikanti L, Manchikanti KN, Damron KS, et al. Effectiveness of cervical medial branch blocks in chronic neck pain: a prospective outcome study. Pain Physician. 2004;7:195202. 46. Manchikanti L, Singh V, Falco FJE. In response to Smuck M, Levin JH. RE: Manchikanti L, Singh V, Falco FJE, et al. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized double-blind, controlled trial with one-year follow-up. Spine (Phila Pa 1976). 2009;34:11161117. 47. Manchikanti L, Singh V, Falco FJ, et al. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain: a randomized, double-blind controlled trial. Pain Physician. 2010;13:437450. 48. Manchikanti L, Damron KS, Cash KA, et al. Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272. Pain Physician. 2006;9:333346. 49. Klessinger S. Zygapophysial joint pain in post lumbar surgery syndrome. The efficacy of medial branch blocks and radiofrequency neurotomy. Pain Med. 2012. doi: 10.1111/pme.12012. [Epub ahead of print]. 50. Bogduk N. A narrative review of intra-articular corticosteroid injections for low back pain. Pain Med. 2005;6:287296. Review. 51. Bogduk N, Dreyfuss P, Baker R, et al. Complications of spinal diagnostic and treatment procedures. Pain Med. 2008;9(S1):1134. 52. Kennedy DJ, Dreyfuss P, Aprill CN, et al. Paraplegia following imageguided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009;10:13891394.

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