An updated (2026) best-evidence synthesis appraisal of the diagnostic accuracy and utility of facet (Zygapophysial) joint injections in chronic spinal pain

Authors

• Laxmaiah Manchikanti, Pain Management Centers of America, Paducah, KY.
• Mark V. Boswell, University of Toledo College of Medicine and Life Sciences, Toledo, OH.
• Mahendra R. Sanapati, Pain Management Centers of America, Evansville, IN.
• Alan D. Kaye, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, Tulane School of Medicine and LSU School of Medicine, New Orleans, LA.
• Miles Day, Department of Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX.
• Nebojsa Nick Knezevic, Advocate Health - MidwestFollow
• Mittal S. Prajapati, Harvard Medical School, Beth Israel Deaconess Medical, Boston, MA.
• Amol Soin, Ohio Pain Clinic, Dayton, OH.
• Annu Navani, Le Reve Regenerative Wellness, San Jose, CA, and Boomerang Health Care, Walnut Creek, CA.
• Vidyasagar Pampati, Pain Management Centers of America, Paducah, KY.
• Christopher G. Gharibo, Department of Orthopedic Surgery at NYU Grossman School of Medicine and Medical Director of Pain Medicine, NYU Langone Health, New York, NY, USA.
• Devi Nampiaparampil, Metropolis Pain Medicine PLLC and NYU Grossman School of Medicine, New York, NY.
• Vivek Manocha, Department of Surgery, Wright State University School of Medicine, Dayton, OH; Interventional Pain Physician, Beacon Orthopedics & Sports Medicine, Cincinnati, OH.
• Navneet Boddu, Advanced Pain and Regenerative Specialists, Oceanside, CA.
• Sairam Atluri, Tri-State Spine Care Institute, Cincinnati, OH.
• Shalini Shah, Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, USA.
• Alexander Bautista, Duke University, Durham, NC.
• Vinita Singh, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA.
• Joshua A. Hirsch, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Recommended Citation

Manchikanti L, Boswell MV, Sanapati MR, et al. An Updated (2026) Best-Evidence Synthesis Appraisal of the Diagnostic Accuracy and Utility of Facet (Zygapophysial) Joint Injections in Chronic Spinal Pain. Pain Physician. 2026;29(4S):S229-S271.

Affiliations

Advocate Illinois Masonic Medical Center

Abstract

Background: Chronic axial spinal pain is one of the leading causes of disability. The literature demonstrates that expenditures for low back and neck pain continue to rise, not only in parallel with increasing disability, but also with escalating healthcare costs, accounting for the highest spending among multiple disease categories. Based on current evidence utilizing controlled diagnostic blocks, facet joints, nerve root dura, and sacroiliac joints have been identified as potential sources of spinal pain.

Study design: A systematic review of the diagnostic accuracy of spinal facet joint nerve blocks.

Objective: To determine the diagnostic accuracy of spinal facet joint nerve blocks in chronic spinal pain.

Methods: Methodological quality of the included studies was assessed using the Quality Appraisal of Reliability Studies (QAREL) instrument. Only diagnostic accuracy studies meeting at least 50% of the predefined inclusion criteria were included in the analysis.The strength of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Levels of evidence were classified using a modified best evidence synthesis, ranging from Level I to Level V.Data sources included relevant literature identified through PubMed and other electronic searches published from 1966 through September 2025, Cochrane reviews, and manual searches of the bibliographies of primary and review articles.

Outcome measures: Eligible studies were required to use placebo-controlled or comparative local anesthetic blocks. A positive diagnostic standard was defined as at least 50% pain relief from baseline scores along with the ability to perform previously painful movements.

Results: The available evidence demonstrated Level I for lumbar facet joint nerve blocks, based on 18 studies employing dual diagnostic blocks, demonstrating 75% to 80% pain relief, with an average prevalence of 16% to 45% and estimated or presumed false-positive rates of 25% to 50%.Evidence for the diagnosis of cervical facet joint pain using cervical facet joint nerve blocks is Level II, derived from 12 controlled diagnostic accuracy studies, showing substantial heterogeneity and internal inconsistency. Reported prevalence ranged from 36% to 67% with ≥ 80% pain relief and estimated or presumed false-positive rates of 26% to 63%.The level of evidence for the diagnostic accuracy of thoracic facet joint nerve blocks is Level II, based on 3 studies using dual diagnostic blocks, demonstrating 80% or greater pain relief, with prevalence ranging from 34% to 48% and estimated or presumed false-positive rates ranging from 42% to 58%.

Limitations: Limitations of this systematic review include the limited number of studies involving the thoracic spine, ongoing debate regarding the appropriate reference standard, challenges in determining false-positive rates, concerns regarding the appropriateness of diagnostic blocks, the scarcity of recent publications, and issues related to clinical utility.

Conclusion: There is Level I evidence for the diagnostic accuracy of lumbar facet joint nerve blocks and Level II evidence for cervical and thoracic facet joint nerve blocks in the evaluation of chronic spinal pain.

Type

Article

PubMed ID

42370931