Original article
Derivation of a Clinical Decision Guide in the Diagnosis of Cervical Facet Joint Pain

https://doi.org/10.1016/j.apmr.2014.02.026Get rights and content

Abstract

Objective

To derive a clinical decision guide (CDG) to identify patients best suited for cervical diagnostic facet joint blocks.

Setting

Pain management center.

Participants

Consecutive patients with neck pain (N=125) referred to an interventional pain management center were approached to participate.

Interventions

Subjects underwent a standardized testing protocol, performed by a physiotherapist, prior to receiving diagnostic facet joint blocks. All subjects received the reference standard diagnostic facet joint block protocol, namely controlled medial branch blocks (MBBs). The physicians performing the MBBs were blinded to the local anesthetic used and findings of the clinical tests.

Main Outcome Measures

Multivariate regression analyses were performed in the derivation of the CDGs. Sensitivity, specificity, positive and negative likelihood ratios, and 95% confidence intervals (CIs) were calculated for the index tests and CDGs.

Results

A CDG involving the findings of the manual spinal examination (MSE), palpation for segmental tenderness (PST), and extension-rotation (ER) test demonstrated a specificity of 84% (95% CI, 77–90) and a positive likelihood ratio of 4.94 (95% CI, 2.8–8.2). Sensitivity of the PST and MSE were 94% (95% CI, 90–98) and 92% (95% CI, 88–97), respectively. Negative findings on the PST were associated with a negative likelihood ratio of .08 (95% CI, .03–.24).

Conclusions

MSE, PST, and ER may be useful tests in identifying patients suitable for diagnostic facet joint blocks. Further research is needed to validate the CDGs prior to their routine use in clinical practice.

Section snippets

Study design

A prospective cohort study was conducted in a tertiary interventional pain management center in Calgary, Alberta, Canada. Ethical approval was obtained from the Conjoint Health Research Ethics Board at the University of Calgary.

Participants

Data collection occurred between October 2011 and December 2012. Consecutive subjects with persistent neck pain who were referred for diagnostic facet joint blocks were approached to participate. Subjects between the ages of 18 and 65 years with reported neck pain

Results

Of the 177 individuals approached to participate in the study, 38 were excluded based on the inclusion/exclusion criteria, 14 declined participation, and 125 consented to participate (fig 1). There were no clinically relevant differences in age, sex, neck pain intensity, and duration of neck pain between participants (table 1) and nonparticipants. The C5-6, C6-7, and C2-3 facet joints were the most frequent joints to undergo diagnostic facet joint blocks, with a prevalence of 36%, 33%, and 23%,

Discussion

This study is the first, to our knowledge, to derive a CDG that incorporates the findings from a cluster of clinical tests, with utility to predict a diagnosis of cervical facet joint mediated pain. Our findings indicate that a positive stand-alone finding on the ER test lacks the diagnostic accuracy to rule in facet joint mediated pain and suggests a similar conclusion for the MSE and PST when used in isolation. In contrast, our results showed that the MSE and PST exhibit high sensitivity and

Conclusions

This study identified derived CDGs that have clinical sensibility, are easy to implement in clinical practice, and once validated, may augment decision-making when contemplating referral for facet joint blocks. Our initial findings suggest that negative findings on the MSE and/or PST may inform clinicians that facet joint blocks may not be an optimal procedure for their patients with persistent neck pain.

Supplier

  • a.

    StataCorp LP, 4905 Lakeway Dr, College Station, TX 77845.

Acknowledgments

We thank Scott Sherman, PT, Heather Scherer, BSc, and JoAnna Herring, BSc, for their assistance in the organization and evaluation of study subjects.

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  • Cited by (0)

    Supported by the Canadian Institutes of Health Research (grant no. 104587), LifeMark Health, Calgary Orthopaedic Research and Education Fund, and Alberta Spine Foundation.

    Disclosures: None.

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