Neck and back pain are escalating health concerns in our modern, aging society, significantly contributing to global socioeconomic and healthcare burdens [1]. Recent decades have witnessed an exponential surge in the prevalence and disability associated with these conditions, with over half a billion individuals globally reporting low back pain (LBP) and a third of a billion experiencing neck pain lasting at least three months [2]. While advancements in medicine have extended lifespans, age-related spinal degeneration and its associated morbidity and functional disability have also increased, affecting a substantial portion of the population over 65 [3]. This rise in spinal pathology has correspondingly driven up healthcare expenditures related to advanced diagnostic imaging and treatments [4,5].
The financial impact of back pain is substantial, encompassing both direct and indirect costs. Direct costs include expenses from primary and specialist care, emergency visits, hospitalizations, and physical therapy. A 2017 survey in Spain estimated direct costs for LBP care at over 2 billion euros [6]. Indirect costs, primarily from lost productivity and years lived with disability (YLD), are equally significant. In 2015, LBP was identified as the leading cause of global disability, accounting for 60.1 million YLD, a 54% increase since 1990 [1]. As healthcare systems allocate more resources to pain diagnosis, ensuring the precision and accuracy of diagnostic techniques becomes paramount. This need for accuracy underscores the importance of refined methods in Diagnosis Injection procedures for spinal pain.
Traditional diagnostic approaches rely heavily on patient history and physical examinations to guide treatment and imaging decisions. Plain radiographs are useful for detecting bony abnormalities, but advanced imaging like MRI and CT are frequently employed for detailed evaluation of neural structures and soft tissues. While advanced imaging offers high sensitivity for structural issues, its diagnostic specificity and clinical correlation in degenerative conditions are debated [7,8,9]. Despite improvements in imaging technology and classification [10], limitations persist in precision and positive predictive value using traditional diagnostic methods alone. Imaging may reveal structural abnormalities that are not the source of pain, or conversely, pain may exist without clear imaging findings. Therefore, physicians seek supplementary methods to enhance diagnostic accuracy, particularly through the use of diagnosis injection techniques.
The spine and surrounding tissues contain numerous potential pain generators. Identifying these sources is crucial to avoid ineffective treatments that expose patients to unnecessary risks and costs. While traditional diagnostic methods remain essential, the correlation of patient responses to diagnosis injection, whether positive or negative, can significantly improve diagnostic specificity and patient outcomes. By preventing unnecessary interventions, diagnosis injection plays a vital role in optimizing healthcare delivery. This review explores current literature on the diagnostic validity of precision spinal injections and their influence on surgical planning and outcomes, focusing on the critical role of diagnosis injection in modern pain management.
2. Methodology of Diagnostic Literature Review
To comprehensively assess the role of diagnosis injection, a thorough literature search was conducted using PubMed. Relevant search terms included “diagnostic,” “predictive value,” “physical exam,” “injection,” “block,” “selective nerve root,” “transforaminal epidural,” “neuroforaminal stenosis,” “lateral recess stenosis,” “radiculopathy,” “facet arthropathy,” “facet joint,” “medial branch block,” “discography,” “discogenic pain,” “sacroiliitis,” and “sacroiliac dysfunction.” Article titles and abstracts were screened for relevance, and reference lists of selected articles were further examined to identify additional pertinent literature. The findings from this rigorous search are synthesized and presented in a narrative format below, emphasizing the utility of diagnosis injection in various spinal conditions.
3. Facet Joint Arthropathy and Diagnostic Injections
Facet joints, or zygapophyseal joints, are crucial bilateral contact points between vertebrae that enable spinal movement and provide stability. Degeneration of these joints over time can become a significant source of pain, known as facet arthropathy. This condition commonly affects the lumbar and cervical spine, presenting with non-radiating back or neck pain exacerbated by axial extension, rotation, or prolonged standing. While patient history and physical examination are necessary, they often lack the diagnostic precision needed for effective management of facet arthropathy. This is where diagnosis injection becomes invaluable.
Historically, studies have shown inconsistent diagnostic validity when relying solely on patient history and physical examination for facet arthropathy [6,7]. Revel’s criteria, a set of physical exam findings, initially showed promise but failed validation in subsequent studies [11,12]. A 2018 meta-analysis by Usunier et al. indicated that intersegmental instability tests and mechanical palpation have moderate diagnostic specificity and sensitivity, but these findings were highly dependent on clinician expertise, limiting generalizability [13]. A larger systematic review by Maas et al. evaluating numerous combinations of history and physical exam findings found no conclusive evidence supporting their diagnostic accuracy, highlighting the necessity for supplementary diagnostic techniques beyond traditional methods and emphasizing the role of diagnosis injection [14].
Initial surgical evaluations for back pain typically include imaging such as plain films, CT, or MRI. The Weishaupt scale is often used to grade facet arthrosis severity based on imaging findings [15]. However, validity studies of this scale for surgical planning have yielded conflicting results [16,17,18]. A retrospective study by Park et al. suggested a correlation between facet angle differences and disc height with medial branch block response, but further research is needed to confirm these findings and to better utilize diagnosis injection in conjunction with imaging [19].
In the absence of a definitive diagnostic gold standard, facet joint injections and medial branch nerve blocks (MBB) with local anesthetic have emerged as crucial tools for both diagnosis injection and treatment of facet arthropathy. Each facet joint receives innervation from two nerve roots, requiring blockade of medial branches from both levels above and below the joint for complete anesthesia. Traditionally performed under fluoroscopic guidance, ultrasound-guided techniques have proven equally safe and effective in both cervical and lumbar regions, improving accessibility and reducing radiation exposure [20,21,22]. The accuracy and safety of diagnosis injection are enhanced by these image-guided approaches.
The response to diagnosis injection in facet joints often predicts outcomes after nerve rhizotomy or radiofrequency ablation (RFA). A 2018 study by Cohen et al. demonstrated that both medial branch blocks and facet joint injections provide significantly better prognostic value before RFA compared to placebo [23]. However, variations in MBB technique, such as local anesthetic volume and interpretation of block success, contribute to a wide range of reported sensitivities and specificities. Cadaveric studies by Wahezi et al. showed that even small differences in injectate volume can significantly affect results, with larger volumes potentially reducing specificity by blocking additional pain generators [24,25]. Standardization of diagnosis injection techniques is crucial for reliable outcomes.
A comprehensive systematic review by Schneider et al. highlighted several technical limitations of diagnostic MBB [26]. Single block techniques have a high false positive rate, which can be mitigated by using dual comparative blocks with local anesthetics of varying durations. Injection into facet joints themselves does not offer more predictive value than sham treatments. The threshold for a positive block response also varies, with higher thresholds increasing diagnostic accuracy but reducing sensitivity. Furthermore, RFA needle gauge and placement orientation affect efficacy. Data suggest that while single and double block techniques have similar success rates, double blocks may provide greater pain relief, underscoring the importance of refined diagnosis injection protocols [27,28].
4. Differentiating Lumbar Radiculopathy with Nerve Root Blocks
Neural foraminal stenosis, leading to nerve root compression, is a prevalent cause of low back pain and disability, affecting a significant percentage of patients with back and leg pain [29]. Compression can result from facet joint hypertrophy, osteophytes, disc herniation, spondylolisthesis, or disc degeneration. Surgical interventions aim to decompress affected nerves, with specific procedures depending on the underlying pathology. Accurate diagnosis injection and identification of affected vertebral levels are crucial for successful surgical outcomes.
Pain distribution patterns, motor testing, and physical tests can indicate laterality and injury levels. Diagnostic imaging further elucidates pathology and assesses disease severity. Studies have shown correlations between MRI findings, such as high-intensity zones (HIZ) indicative of annular tears, and response to transforaminal epidural steroid injections (TFESI) [30]. Ekedahl et al. found that high-grade nerve compression on MRI correlated with improved outcomes after TFESI [31]. However, definitive correlation between these findings and specific vertebral levels remains elusive [32,33,34]. Thus, while history, physical exam, and imaging are foundational, they have limitations, necessitating additional diagnostic tools like diagnosis injection to enhance specificity.
Selective nerve root blocks (SNRB) are widely used, but their diagnostic accuracy varies due to technique, injectate, and needle position. Reported accuracy ranges from 31–100% [35]. Studies have shown that smaller injectate volumes enhance precision by reducing spread to adjacent levels [36,37]. Lateral intervertebral foramen needle tip position also improves specificity by minimizing epidural spread [38]. Despite technical variables, SNRBs, as a form of diagnosis injection, are increasingly supported for surgical planning.
Surgical literature highlights the value of SNRB in improving outcomes. A randomized controlled trial by Li et al. demonstrated significantly better outcomes in patients diagnosed with SNRB before endoscopic microdiscectomy [39]. Yue et al. reported similar findings, with better outcomes in patients with positive SNRBs undergoing surgical decompression [40]. A large retrospective study by Lewandrowski et al. showed high predictive diagnostic value of SNRBs for improved outcomes after lumbar endoscopic transforaminal decompression [41]. However, systematic reviews also reveal mixed data, with Beynon et al. reporting high sensitivity but low specificity for SNRBs in predicting surgical success [42]. Further research is needed to refine diagnosis injection protocols using SNRBs.
While SNRBs offer diagnostic and therapeutic benefits, they carry procedural risks, including drug reactions, bleeding, infection, nerve damage, and post-dural puncture headache. Minor complications occur in 2.4–9.6% of cases [43]. Major complications like spinal cord infarct or epidural hematoma are rare but serious [44]. Caution is needed due to adjacent vascular structures. Ultrasound guidance with real-time visualization is emerging as a safer technique, validated in cervical and lumbar spine SNRBs [45,46,47,48]. Jang et al. describe a detailed ultrasound-guided cervical SNRB technique [45]. While ultrasound may reduce risks, studies show no difference in vascular uptake rates compared to fluoroscopy [49,50]. Ehsanian et al. suggest combining ultrasound and fluoroscopy for optimal safety and efficacy in diagnosis injection [51]. Optimal techniques continue to evolve, requiring more comparative studies.
5. Discography in Diagnosing Discogenic Pain
Discography involves injecting contrast material into spinal discs under image guidance to identify pain sources and guide treatment. Provocative discography specifically pressurizes discs to elicit pain, confirming the disc as the pain source. It is also used to guide treatment of abnormal discs. A non-painful discogram often rules out surgical needs. The diagnostic value of discography has been questioned as non-invasive imaging techniques like MRI have advanced. However, discography remains a valuable form of diagnosis injection in certain cases.
MRI T2 high-intensity zones (HIZ) correlate with disc pathologies and discography outcomes [52]. Guidelines from the International Association for the Study of Pain (IASP)/Spine Intervention Society (SIS) ensure safe and effective provocative discography, focusing on pain response level, contrast volume, and disc pressurization. When these guidelines are followed, provocative discography has a low false positive rate [53]. Proper technique is essential in diagnosis injection via discography.
Imaging alone may be insufficient as anatomical disruptions do not always correlate with pain, and vice versa. Discography helps bridge this gap, aiding in surgical planning. Xi et al. demonstrated that provocative discography combined with CT scanning effectively identifies lumbar fusion candidates, particularly those with concordant discogenic pain and annular tears [54]. Their study showed significant post-surgical improvements in patients selected using discography and CT. This combined approach enhances the precision of diagnosis injection and subsequent surgical decisions.
A 2018 systematic review supports discography as a diagnostic tool for lumbar discogenic pain but found weaker evidence for cervical and thoracic pain due to inconsistencies in studies [55]. While literature comparing ultrasound and fluoroscopy-guided discography is limited, a case study highlights advantages of ultrasound, including better soft tissue visualization, shorter procedure times, and reduced radiation [56]. Ultrasound may enhance the safety and efficiency of diagnosis injection in discography.
Safety concerns exist regarding provocative discography, with some studies suggesting potential adverse events like chronic back pain and accelerated disc degeneration [57,58]. A 10-year cohort study linked discography to disc surgery events, serious back pain, and disability [57], though limitations exist. An in vitro study suggested radiocontrast exposure might contribute to cell damage [58], but this also has limitations. Current evidence indicates that risks are associated with over-pressurization during discography, rather than the procedure itself when performed according to IASP/SIS standards [53]. A review by Migliore et al. noted variability in discography techniques and limited comparable data, calling for more research on efficacy and safety [59]. Despite concerns, when properly conducted, provocative discography remains a valuable diagnosis injection technique, especially for lumbar discogenic pain and surgical planning.
6. Sacroiliac Joint Dysfunction and Diagnostic Blocks
The sacroiliac (SI) joint is a complex structure connecting the spine to the pelvis, crucial for lower extremity movement and force transmission. SI joint pain is often underdiagnosed, estimated to contribute to 10–38% of low back pain cases [60]. Pain typically presents below the belt line, radiating to the lower extremity and groin. Accurate diagnosis is challenging, making diagnosis injection an essential tool.
Current diagnosis involves history, provocation maneuvers, imaging, and diagnostic blockade. Provocative SI joint maneuvers include distraction, compression, Gaenslen, thigh thrust, sacral thrust, and FABER tests. Historically, three positive maneuvers were required for sacroiliitis diagnosis. Telli et al. evaluated provocation tests, finding FABER test with highest sensitivity and Gaenslen with lowest [63]. Imaging modalities like radiography, CT, and MRI have limited sensitivity for SI joint pain diagnosis [64]. MRI is most sensitive for sacroiliitis but limited for other SI joint pathologies [60]. IASP criteria include positive provocation maneuvers and pain relief with local anesthetic diagnosis injection into the SI joint [66].
Fluoroscopy-guided SI joint blocks are the gold standard for diagnostic and therapeutic purposes [65]. A 75% pain reduction post-block is considered positive. 50–75% reduction suggests SI joint as a major pain contributor. Studies indicate good surgical fusion outcomes in patients with significant relief from diagnostic SI joint blocks [67]. A trial comparing pulsed RFA and intra-articular steroid injections found RFA of dorsal rami and lateral branch nerves provided superior and lasting relief [68]. Diagnosis injection via SI joint blocks is critical for accurate diagnosis and treatment planning.
Despite being underdiagnosed, SI joint pain is a significant source of chronic low back pain. A multimodal diagnostic approach, including history, physical exam, imaging, and fluoroscopic-guided diagnosis injection, is essential for effective management of SI joint pain.
7. Conclusions: Enhancing Diagnostic Precision with Spinal Injections
Traditional evaluation of back and leg pain relies on patient history, physical examination, and imaging. However, these methods may not always accurately identify pain etiology. Diagnosis injection with local anesthetic injections or nerve blocks offers valuable diagnostic support. While complications such as bleeding, infection, and ischemia are possible, advanced techniques like ultrasound or CT guidance alongside fluoroscopy may mitigate these risks, though further validation is needed.
A systematic review by Sebaaly et al. reported a significant rate of failed back surgery syndrome, often due to poor patient selection and incorrect intervention levels [69]. This underscores the importance of accurate diagnosis before surgery. Spinal injections provide objective data to guide treatment and improve patient selection for invasive surgeries. Studies suggest positive predictive trends for discography, SNRBs, and SI joint blocks, but more high-quality, randomized controlled trials are needed to solidify these findings. In conclusion, diagnosis injection holds immense potential to enhance diagnostic precision and surgical selection for patients with intractable back pain. Collaborative efforts between pain management and spine surgery specialists, leveraging objective data from diagnosis injection, can lead to improved patient outcomes.
Acknowledgments
The authors thank Walter Orr, MPH, Department of Anesthesiology, University of Kansas Medical Center, for his assistance in technical writing and manuscript preparation.
Author Contributions
B.Y.K., L.C.B., T.A.C., and T.W.K. contributed to various aspects of the article, including conception, design, literature review, analysis, drafting, and revisions. All authors have approved the final submitted version.
Funding
This research received no external funding.
Institutional Review Board Statement
Not applicable.
Informed Consent Statement
Not applicable.
Data Availability Statement
No new data were created or analyzed in this study. Data sharing is not applicable to this article.
Conflicts of Interest
The authors declare no conflict of interest.
Footnotes
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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