Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome | Revista Española de Anestesiología y Reanimación (English Edition)

array:24 ["pii" => "S2341192919300484" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.11.013" "estado" => "S300" "fechaPublicacion" => "2019-04-01" "aid" => "991" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2018" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2019;66:213-21" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 16 "formatos" => array:2 [ "HTML" => 3 "PDF" => 13 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935618302354" "issn" => "00349356" "doi" => "10.1016/j.redar.2018.11.008" "estado" => "S300" "fechaPublicacion" => "2019-04-01" "aid" => "991" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2019;66:213-21" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 364 "formatos" => array:2 [ "HTML" => 204 "PDF" => 160 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Formación continuada" "titulo" => "Bloqueos diagnósticos en el manejo del paciente con lumbalgia secundaria a síndrome facetario" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "213" "paginaFinal" => "221" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1064 "Ancho" => 1500 "Tamanyo" => 232589 ] ] "descripcion" => array:1 [ "es" => "Proyección oblicua: esquema en el que se muestra la diana para bloquear el ramo medial del nervio dorsal (RMND). Nótese que la imagen es oblicua, y está marcada la unión del proceso articular superior de L3 con su transversa y correspondería al RMND de L2 (número1), RMND de L3 (número 2) y RMND de L4 (número 3)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. de Andrés Ares, F. Gilsanz" "autores" => array:2 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "de Andrés Ares" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Gilsanz" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192919300484" "doi" => "10.1016/j.redare.2018.11.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300484?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935618302354?idApp=UINPBA00004N" "url" => "/00349356/0000006600000004/v1_201903290609/S0034935618302354/v1_201903290609/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192919300459" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.10.006" "estado" => "S300" "fechaPublicacion" => "2019-04-01" "aid" => "980" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2019;66:222-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Case report" "titulo" => "Endotracheal intubation through laryngeal Ambu® Auragain™ mask airway mask in paediatric patients affected by congenital infiltrating lipomatosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "222" "paginaFinal" => "225" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Intubación orotraqueal a través de mascarilla laríngea Ambu® Auragain™ en paciente pediátrico con lipomatosis infiltrante congénita" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 669 "Ancho" => 905 "Tamanyo" => 93300 ] ] "descripcion" => array:1 [ "en" => "Intubation material, consisting of fibreoptic bronchoscope, number 2 Ambu® Auragain™ laryngeal mask, number 4.5 endotracheal tube, number 4 endotracheal tube without connection, swivel adapter, guedel cannula." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Hernández García, I. Hidalgo, L. Barragán, B. Berenguer, C. Lorca-García, I. Mantilla" "autores" => array:6 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Hernández García" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Hidalgo" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Barragán" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Berenguer" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Lorca-García" ] 5 => array:2 [ "nombre" => "I." "apellidos" => "Mantilla" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S003493561830207X" "doi" => "10.1016/j.redar.2018.10.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493561830207X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300459?idApp=UINPBA00004N" "url" => "/23411929/0000006600000004/v1_201904250611/S2341192919300459/v1_201904250611/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S234119291930054X" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.12.007" "estado" => "S300" "fechaPublicacion" => "2019-04-01" "aid" => "999" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2019;66:206-12" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "European Diploma in Anaesthesiology and Intensive Care in Spain: Results for the part 1 and part 2 exams in the last five years. Are we going in the right direction?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "206" "paginaFinal" => "212" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diploma Europeo en Anestesiología y Cuidados Intensivos en España: resultados de los exámenes de las partes 1 y 2 de los últimos cinco años. ¿Vamos por el buen camino?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 760 "Ancho" => 1472 "Tamanyo" => 55696 ] ] "descripcion" => array:1 [ "en" => "EDAIC Part 1 pass rate." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Brogly, W. Engelhardt, S. Hill, E.-M. Ringvold, A. Varosyan, A. Varvinskiy, M. Zerafa" "autores" => array:7 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Brogly" ] 1 => array:2 [ "nombre" => "W." "apellidos" => "Engelhardt" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Hill" ] 3 => array:2 [ "nombre" => "E.-M." "apellidos" => "Ringvold" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Varosyan" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Varvinskiy" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Zerafa" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935618302469" "doi" => "10.1016/j.redar.2018.12.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935618302469?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234119291930054X?idApp=UINPBA00004N" "url" => "/23411929/0000006600000004/v1_201904250611/S234119291930054X/v1_201904250611/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Continuing education" "titulo" => "Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "213" "paginaFinal" => "221" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. de Andrés Ares, F. Gilsanz" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "de Andrés Ares" "email" => array:1 [ 0 => "javierdeandresares@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Gilsanz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología-Unidad del Dolor, Hospital Universitario La Paz, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueos diagnósticos en el manejo del paciente con lumbalgia secundaria a síndrome facetario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1214 "Ancho" => 1500 "Tamanyo" => 209085 ] ] "descripcion" => array:1 [ "en" => "Anteroposterior view. Anteroposterior view, showing the position of the needles for diagnostic block." ] ] ] "textoCompleto" => "IntroductionLow back pain is an important social, family and health problem worldwide.<a class="elsevierStyleCrossRefs" href="#bib0405">1–4</a> There are many causes of back pain, and the zygapophyseal joints, also called facet joints, are responsible for between 15% and 46% of cases of chronic back pain, depending on the population studied.<a class="elsevierStyleCrossRefs" href="#bib0425">5,6</a> The main problem lies in determining whether chronic low back pain is caused by facet joints or not.Anatomy of zygapophyseal or facet jointsThe spinal vertebrae form a triarticular complex consisting, on the one hand, of the vertebral bodies and the intervertebral disc, and on the other, of the junction between the superior articular processes and the inferior articular processes of each adjacent vertebra. The junction between the superior vertebral process of the vertebra below and the inferior vertebral process of the vertebra above is called the zigoapofisaria or facet joint (FJ).<a class="elsevierStyleCrossRef" href="#bib0435">7</a> Each facet joint derives its name from its associated vertebra; therefore, the FJ between the right L3 and L4 is called the right facet joint L3–L4.<a class="elsevierStyleCrossRef" href="#bib0440">8</a> Each FJ is innervated by 2 medial branches (which are dorsal primary rami). At the lumbar level, they are innervated by the medial branch of the dorsal ramus (MBDR) from the same level and one level above, so that FJ L3–L4 is innervated by the L2 MBDR and the L3 MBDR<a class="elsevierStyleCrossRef" href="#bib0445">9</a> (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Each MBDR innervates 2 FJs, so that the MBDR of L3 will innervate FJ L3–L4 and FJ L4–L5.The medial lumbar ramus arises from the dorsal primary ramus and runs along the pedicle of the superior articular process (SAP) of the vertebra below. After crossing the pedicle of the SAP, it travels towards the lamina, passes inferior to the mamillo-accessory ligament (which protects it), and then divides into 2 branches: one innervates the FJ at that level, and another innervates the FJ one level below, the interspinous ligament and muscle and the multifidus muscle.<a class="elsevierStyleCrossRefs" href="#bib0435">7,8</a> The medial branch of L5, however, originates from the dorsal ramus of L5 nerve in the lower portion of the L5–S1 facet, and then runs along the groove formed between the base of the S1 superior articulating process and the sacral ala.<a class="elsevierStyleCrossRef" href="#bib0445">9</a>The facet joints are the cause of low back painThe FJs have been known for many years to cause low back pain. The first investigator to show this was Ghormley<a class="elsevierStyleCrossRef" href="#bib0450">10</a> in 1933, who introduced the oblique view in radiology to see the intra-articular space and the degree to which it could be affected by osteoarthritis. Later, Mixter and Barr<a class="elsevierStyleCrossRef" href="#bib0455">11</a> showed that nociceptive stimulation of FJs in healthy volunteers caused lumbago. Following this, Shealy<a class="elsevierStyleCrossRefs" href="#bib0460">12,13</a> was the first to argue that the surgical denervation of the nerves that supply the FJs alleviated low back pain. Mooney and Robertson<a class="elsevierStyleCrossRef" href="#bib0470">14</a> showed that the FJs were the source of certain types of low back pain, and that in certain cases FJ pain referral affected certain parts of the legs in a similar way to sciatica. These authors coined the term “facet syndrome”.Facet joint-related low back painFJ pain is usually a lumbar, mechanical, nociceptive pain with a pattern of referral that extends to the gluteal region and the back of the thighs.<a class="elsevierStyleCrossRefs" href="#bib0425">5,15</a> Other structures that can cause low back pain (vertebral bodies, intervertebral disc, dura mater, nerve roots, sacroiliac joint, muscles, ligaments and fascias) may overlap the referred pain pattern of FJ-related pain,<a class="elsevierStyleCrossRef" href="#bib0480">16</a> which is why it is so difficult to establish the cause of low back pain. The main cause of FJ involvement is usually arthritic degeneration, although other pathological processes may also affect these joints, such as rheumatoid arthritis, reactive arthritic processes, ankylosing spondylitis, facet chondromalacia, pseudogout, villonodular synovitis, facet cysts, and of course, low back injury.Physical examination in low back painFor years, many researchers have attempted to develop a series of diagnostic clinical criteria that would establish the FJ as the cause of low back pain. This has led to the inclusion in the patient history and physical examination of the following criteria as indicators of pain that may be FJ-related: unilateral or bilateral lumbar pain in the buttocks, hips or back of the thigh,<a class="elsevierStyleCrossRefs" href="#bib0485">17–21</a> pseudo-radicular pain,<a class="elsevierStyleCrossRef" href="#bib0500">20</a> morning stiffness,<a class="elsevierStyleCrossRef" href="#bib0485">17</a> lumbar flexion pain,<a class="elsevierStyleCrossRefs" href="#bib0510">22,23</a> pain on lumbar extension,<a class="elsevierStyleCrossRefs" href="#bib0485">17,18,23</a> pain on lumbar lateral rotation,<a class="elsevierStyleCrossRefs" href="#bib0490">18–20</a> pain when sitting,<a class="elsevierStyleCrossRef" href="#bib0520">24</a> paravertebral contracture,<a class="elsevierStyleCrossRefs" href="#bib0485">17–19</a> negative neurological examination,<a class="elsevierStyleCrossRefs" href="#bib0485">17,19,25</a> and normal gait.<a class="elsevierStyleCrossRef" href="#bib0530">26</a> However, the sensitivity and specificity of these criteria is very low. This is why patient history and physical examination are fundamental for screening patients with low back pain,<a class="elsevierStyleCrossRef" href="#bib0535">27</a> but cannot establish FJ as the specific cause of the pain.<a class="elsevierStyleCrossRef" href="#bib0540">28</a> After excluding other common ethologies, such as discogenic or radicular pain, unilateral or bilateral symptoms that radiate to one or both buttocks, groin and thighs without passing the knee can be presumed to be facet joint-related pain.Imaging tests in lumbar painArthritis or facet degeneration, which is usually diagnosed with imaging tests, is a potential cause of low back pain. According to Pathria et al., plain oblique radiography has a sensitivity of 55% and a specificity of 69% in distinguishing between the presence and absence of degenerative disease in FJs of L3-4 to L5–S1 in 50 consecutive patients with back pain.<a class="elsevierStyleCrossRef" href="#bib0545">29</a> The specificity of oblique radiography in distinguishing absent or mild disease from moderate or severe disease was higher (94%), but its sensitivity was far lower, at 23%. Interobserver agreement among the radiologists performing the plain radiology study was 57%, but the discrepancy rate was 43%. The interobserver agreement in computerised tomography (CT) scan of patients with facet arthrosis showed a kappa value of 0.46, which represents perfect agreement in 63% of cases, and discrepancy in 27%. This shows that plain radiography is inadequate for early detection of facet degeneration. Both CT and magnetic resonance imaging (MRI) are valid tools for detecting facet degeneration.<a class="elsevierStyleCrossRef" href="#bib0550">30</a> FJ arthritis can be classified into 4 grades, according to the imaging tests<a class="elsevierStyleCrossRefs" href="#bib0550">30,31</a>:Grade 0. NormalGrade 1. Mild degenerative disease: joint space narrowing less than 2mm and/or small osteophytes and/or mild hypertrophy of the articular process.Grade 2. Moderate degenerative disease: joint space narrowing (<1mm) and/or moderate osteophytes and/or moderate hypertrophy of the articular process and/or mild subarticular bone erosions.Grade 3. Severe degenerative disease: narrowing of the facet joint space and/or large osteophytes and/or severe hypertrophy of the articular process and/or severe subarticular bone erosions and/or subchondral cysts and/or vacuum phenomenon.The problem is that patients with grade 2 and 3 degeneration may not have low back pain, and patients with grade 0 and 1 arthritis may present FJ pain; in other words, there is no correlation between specific imaging tests (CT and MRI) and the presence or absence of lumbar pain.<a class="elsevierStyleCrossRef" href="#bib0560">32</a> More complex imaging tests, such as scintigraphy (an imaging technique in which the distribution of a low-dose radioactive tracer is shown in the patient's body), show contradictory results for the diagnosis of low back pain.<a class="elsevierStyleCrossRefs" href="#bib0565">33–35</a>Nerve block diagnosis of lumbar painGiven that the clinical history and physical examination are not diagnostic in this context, and imaging tests lack the sensitivity and specificity needed to show that the low back pain is FJ-related, diagnostic nerve blocks are the only valid method of diagnosing FJ-related low back pain.This diagnostic approach is based on the notion that if the FJ is the cause of low back pain, blocking this joint or the nerve that innervates it with a local anaesthetic will alleviate the patient's back pain.<a class="elsevierStyleCrossRef" href="#bib0580">36</a> There are, therefore, 2 approaches: blockade with local anaesthetic of the FJ itself, or lumbar medial branch block (MBB) to anaesthetise the MBDR. While intra-facet joint block could be a valid approach, it has not been validated as a diagnostic method.<a class="elsevierStyleCrossRef" href="#bib0540">28</a> In addition, intra-facet joint block, like discography in the diagnosis of discogenic pain,<a class="elsevierStyleCrossRef" href="#bib0585">37</a> could accelerate the degenerative process of healthy FJs.Validity of diagnostic nerve blocksFor a test to be valid, it must have both face validity and content validity. In diagnostic MBB, face validity refers to the accuracy of the technique, that is, it anaesthetises exclusively what it sets out to anaesthetises and spares other structures. Content validity refers to the sensitivity, specificity and prevalence of the nerve block. With respect to face validity, the technique must fulfil the following criteria: it anaesthetises exclusively the structure that it aims to anaesthetise; it spares other structures that should not be anaesthetised. Face validity measures the accuracy of the nerve block, and can be tested in anatomical cadaveric studies that evaluate whether the target nerves are exclusively anaesthetised and not others (since this could falsify the result of the test). In the case of diagnostic MBB, these studies evaluate whether this particular nerve is anaesthetised and not adjacent structures that are potential sources pain, which would give a false positive result of the test.<a class="elsevierStyleCrossRef" href="#bib0590">38</a> The anatomical face validity was demonstrated by Dreyfuss, who showed<a class="elsevierStyleCrossRef" href="#bib0595">39</a> that only the MBDR was anaesthetised by placing spinal needles over these nerves and taking radiographs to demonstrate their precise locations, following which an appropriate volume of local anaesthetic was injected in two positions for each nerve. The physiological face validity was demonstrated by Kaplan<a class="elsevierStyleCrossRef" href="#bib0600">40</a> by showing that anaesthetizing the MBDR in healthy volunteers prevented experimentally induced lumbar pain. In order for MBB to give adequate pain relief, the recommendations of the Spine Intervention Society must be followed.<a class="elsevierStyleCrossRef" href="#bib0605">41</a>Content validity refers to the extent to which a test distinguishes patients who have the condition tested (in this case, FJ-related lumbar pain) from those who do not.<a class="elsevierStyleCrossRef" href="#bib0610">42</a> A control nerve block can be used to improve the content validity of a test. For the blockade to be valid, it must be specific and controlled.<a class="elsevierStyleCrossRef" href="#bib0615">43</a> Specific means that it reaches the structures to be anaesthetised, and only anaesthetises those structures. This is demonstrated by injecting small volumes of contrast medium (less than 0.5ml) and observing its spread with the help of an imaging technique, in this case fluoroscopy. The spread of the contrast medium in the target area (in this case, the MBDR)<a class="elsevierStyleCrossRef" href="#bib0620">44</a> should be documented on hard-copy films or on specialised paper. Controlled means that at least 2 blocks should be performed in order to avoid false positives. There are many types of controlled nerve blocks, although the most widely used is the comparative control block,<a class="elsevierStyleCrossRef" href="#bib0625">45</a> which consists of performing one nerve block with a short-acting local anaesthetic such as lidocaine, and a second block with a longer-acting local anaesthetic such as bupivacaine. The patient should report relief coinciding with the duration of the anaesthetic used in each case. Strictly speaking, these nerve blocks should be performed with placebo, although this would raise ethical issues.<a class="elsevierStyleCrossRef" href="#bib0615">43</a> The problem usually arises due to the fact that the analgesic effect of short-acting local anaesthetics can sometimes last beyond their half life.<a class="elsevierStyleCrossRef" href="#bib0630">46</a> This is thought to be due to a neuromodulatory effect, or to the fact that local anaesthetics have been studied in healthy individuals whose nociceptive pathways differ from those of pain patients.<a class="elsevierStyleCrossRef" href="#bib0635">47</a>In diagnostic MBB, studies have shown that single blocks (that is, performing a single block for diagnosis) lack validity, since they have a false positive rate between 25% and 45%.<a class="elsevierStyleCrossRef" href="#bib0640">48</a> If a correctly performed diagnostic block is positive, there is no way of knowing for certain that this is a true positive or a false positive. In order for it to be valid, a control method must be used. A standard control technique has yet to be established.<a class="elsevierStyleCrossRef" href="#bib0645">49</a> One approach is to administer 2 nerve blocks, one with a short-acting local anaesthetic (lidocaine) and another with a long-acting local anaesthetic (bupivacaine); this type of block is called a double, or comparative, block. A comparative block can be positive and concordant, that is, the duration of pain relief corresponds with the duration of action of the local anaesthetic used, or positive and discordant, in which relief in both cases does not correspond to the estimated duration of action of the local anaesthetic.<a class="elsevierStyleCrossRef" href="#bib0625">45</a> The performance of comparative blocks has been validated in neck pain, with a specificity ranging from 65% to 88%, depending on the cutoff pain level<a class="elsevierStyleCrossRef" href="#bib0650">50</a> used to determine positivity. However, they have not been validated in low back pain. This is because a high percentage (over 50%) of cases of chronic cervicalgia are facet joint-related, while the prevalence of facet joint-related low back pain is lower,<a class="elsevierStyleCrossRef" href="#bib0430">6</a> and depends to a great extent on the age of the individual. This has led to the performance of placebo-controlled blocks, in which local anaesthetic and saline are administered during the diagnostic test.Pain relief cutoff pointAnother important issue is the cut-off value used to determine pain relief during diagnostic nerve block, that is, whether 50% relief of baseline pain is considered positive, or 80% of 100% of baseline pain. The sensitivity and specificity data available for diagnostic MBB have been determined with 100% pain relief. This suggest that lowering the pain relief cutoff point (considering the block positive if it alleviates less than 100% of baseline pain) will give worse results.<a class="elsevierStyleCrossRef" href="#bib0655">51</a> It would also suggest that the cause of low back pain could be multifactorial, that is, not exclusively lumbar facet joint-related. However, certain studies have shown that the presence of facet joint-related pain, together with discogenic pain or sacroiliac pain, occurs in only 5% of patients; therefore, chronic low back pain is unlikely to have a multifactorial aetiology.<a class="elsevierStyleCrossRefs" href="#bib0660">52,53</a> The performance of more than one diagnostic block for the diagnosis of facet joint-related low back pain continues to be controversial, and authors such as Cohen report that this approach is not cost-effective.<a class="elsevierStyleCrossRef" href="#bib0670">54</a>Performance of diagnostic nerve blocksFor the best results, diagnostic MBB should always be image-guided. CT-guided techniques,<a class="elsevierStyleCrossRef" href="#bib0675">55</a> undoubtedly the most accurate, have been described, although the radiation received by the patient calls into question their usefulness in routine clinical practice.<a class="elsevierStyleCrossRef" href="#bib0680">56</a> Ultrasound-guided techniques<a class="elsevierStyleCrossRefs" href="#bib0685">57–59</a> have become increasingly popular, and have clear advantages in terms of radiation exposure of patients and doctors. Although some comparative studies have shown their effectiveness when compared to fluoroscopy and CT,<a class="elsevierStyleCrossRef" href="#bib0700">60</a> they are retrospective and methodologically deficient.The most widely accepted technique is fluoroscopically-guided nerve block. We will briefly describe the technique recommended by the Spine Intervention Society, which is accepted by many pain societies, including the Australian and New Zealand Society of Anaesthetists, the American Academy of Pain Medicine and the British Pain Society.<a class="elsevierStyleCrossRef" href="#bib0605">41</a>Fluoroscopically-guided nerve blockThe patient is placed in the prone position, with a small pillow under the hips to correct lumbar lordosis. Check that the patient does not present any transitional anomaly at the vertebral level, as this would complicate the initial management of low back pain.<a class="elsevierStyleCrossRef" href="#bib0705">61</a> The level of the nerve block will depend on the patient's symptoms and possible signs of joint degeneration (if present) on specific imaging tests, such as lumbar CT or MRI.<a class="elsevierStyleCrossRef" href="#bib0605">41</a> It is important to bear in mind that FJs are innervated by 2 MBDRs, so a multisegmentary blockade is required. The block is usually performed at the level of MBDR L2, MBDR L3, MBDR L4 and the posterior ramus of L5. An anteroposterior image is obtained and an attempt is made to “square” the vertebral disc above the level to be treated (so that the X-ray beam is directed parallel to the upper vertebral disc). Once squared, an oblique, 30–40° ipsilateral image is obtained, although this will depend on the patient's anatomy and physiognomy. Try to avoid the “parallax effect”, which involves the apparent displacement or the difference in apparent direction of an object as seen from 2 different points not on a straight line with the object.<a class="elsevierStyleCrossRef" href="#bib0710">62</a> The “parallax” effect distorts the fluoroscopy Image 63 Image,<a class="elsevierStyleCrossRef" href="#bib0715">63</a> and is avoided by placing the target area in the centre of the image. Once the oblique image has been obtained, the junction between the SAP and the transverse process is located. The blocking needle is advanced using the “tunnel vision” technique, so that it is seen as a dot on the fluoroscopy monitor (i.e., the needle is parallel to the X-ray beam). The needle is advanced as far as the periosteum. Anteroposterior, oblique, lateral and “tilted” images are obtained (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3–6</a>). This latter view is very important, since it shows the tip of the needle with respect to the junction between the PAS and the transverse process (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). It is obtained with the c-arm positioned cranial and the collimator caudal with respect to the patient. Once the needle is correctly placed, 0.1–0.3ml of non-ionic iodinated contrast medium suitable for myelography is administered. It is essential to observe the spread of contrast medium, since the local anaesthetic injected later will follow the same pattern. The contrast should spread around the pedicle of the SAP without penetrating the foramen or spreading laterally (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>). If this is not achieved, change the position of the needle. No sign contrast on the fluoroscopy monitor probably indicates intravascular injection, which occurs in up to 3.7% of cases,<a class="elsevierStyleCrossRef" href="#bib0720">64</a> although it could also indicate intraosseous injection, since the prevalence of facet syndrome is higher in elderly patients who are also more likely to present osteoporosis.<a class="elsevierStyleCrossRef" href="#bib0725">65</a> Finally, it should be noted that the diagnostic block should only be performed with local anaesthetic; no steroids should be administered, as they can alter the result.<a class="elsevierStyleCrossRef" href="#bib0730">66</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia>Ultrasound-guided nerve blockSeveral ultrasound-guided techniques for MBB and lumbar facet joint block have been described, and their efficacy has been demonstrated in comparative studies with CT.<a class="elsevierStyleCrossRefs" href="#bib0690">58,67–70</a> The patient is placed in the prone position; a convex transducer is preferably used, placed transversely above the spinous process to be treated. The acoustic shadow of the spinous process should be visualised in the middle part of the ultrasound screen. The transducer is moved slowly in a caudal direction until the lower transverse process is observed. A 22G spinal needle is inserted in plane until it contacts the bone at the junction between superior articular process and the transverse process, which is where the MBDR is located. After negative aspiration, less than 0.5ml of local anaesthetic is injected. The presence of the prominent iliac crests may obstruct the in-plane view at the level of the transverse processes of L5 and the posterior ramus of L5. The main problem with ultrasound-guided block is the absence of contrast. We believe that the use of contrast to predict the posterior spread of the anaesthetic is of paramount importance for successful diagnostic MBB. Combined ultrasound-fluoroscopy techniques, which reduce radiation exposure, both for patients and health personnel, are probably the best approach.After the nerve blockOnce the block has been performed, if it is positive (depending on the criteria used), a longer lasting pain relief technique, such as thermal radiofrequency<a class="elsevierStyleCrossRef" href="#bib0755">71</a> or cryopdenervation can be performed.<a class="elsevierStyleCrossRef" href="#bib0760">72</a> If the diagnostic block is negative, other possible causes of chronic low back pain should be considered.DiscussionAccording to Hildebrandt,<a class="elsevierStyleCrossRef" href="#bib0765">73</a> the diagnostic use of neural blockade rests on three premises. First, pathology causing pain is located in an exact peripheral location, and impulses from this site travel along a unique and consistent neural root. Second, injection of local anaesthetic totally abolishes the sensory function of intended nerves and does not affect other nerves. Third, pain relief after local anaesthetic block is attributable solely to blockade of the target afferent neural pathway. For Hildebrandt, however, the validity of these assumptions is limited by complexities of anatomy, physiology, and the important part that psychology plays in pain perception. Analysing Hildebrandt's premises shows that facet joint pain is transmitted in a consistent manner, that standardised administration of local anaesthetic following the SIS guidelines (anatomically accurate location, low volume, monitored spread of contrast) will anaesthetise the MBDR, and finally, that achieving adequate blockade, that is, without the use of corticosteroids, and establishing a high cutoff value for positivity, will provide pain relief by blocking the afferent pathway. This is why, despite Hildebrandt's remarks, performing the standard nerve block exactly as indicated is undoubtedly a valid diagnostic procedure.<a class="elsevierStyleCrossRef" href="#bib0770">74</a>One of the innovations introduced in pain units in the last decade has been the use of diagnostic nerve blocks to help manage patients with complex pain. These are usually diagnostic, and can predict the main structure that generates pain. Accurate administration of the blockade followed by scientific, ethical analysis of the results will allow clinicians to choose the most appropriate treatment, such as radiofrequency denervation<a class="elsevierStyleCrossRef" href="#bib0775">75</a> or cryopdenervation.<a class="elsevierStyleCrossRef" href="#bib0760">72</a>Three aspects of diagnostic nerve block remain controversial. The first is the number or type of blocks to be administered. Although some studies question not only the benefit of controlled nerve blocks, but also the efficacy and cost-effectiveness of this diagnostic technique,<a class="elsevierStyleCrossRef" href="#bib0670">54</a> we believe that it can effectively reduce the number of false positives, and thus improve the outcomes of denervation procedures.<a class="elsevierStyleCrossRef" href="#bib0780">76</a> However, in the public health system it is difficult to perform double diagnostic blocks due to long waiting lists, and this can have a negative impact on the subsequent denervation technique. The second controversial aspect is the cut-off value used to establish positivity of a block, that is, whether a block with 50%, 80% or 100% of relief from baseline pain should be considered positive. The more optimal the cut-off point to establish positivity of the diagnostic block, the better the outcome of the denervation procedure.<a class="elsevierStyleCrossRef" href="#bib0785">77</a> Finally, the question remains as to whether the diagnostic block should involve the nerves that innervate the joint (lumbar MBB) or the joint itself (intra facetary block). We believe that since radiofrequency denervation or cryodenervation will be the most effective treatment in the long run, it is best to block the same structure that will later be treated. Moreover, diagnostic MBBs have been validated, while intrafacetary blocks have not.<a class="elsevierStyleCrossRef" href="#bib0790">78</a> Finally, we believe that given their size and histological complexity, piercing FJs with the nerve block needle could accelerate the existing degenerative process, as shown by Carragee in diagnostic discography.<a class="elsevierStyleCrossRef" href="#bib0585">37</a>In a recent article, Cohen shows that intra-facial infiltrations of local anaesthetic and corticosteroids do not have long-term analgesic benefit, although they could benefit certain patients in whom denervation of the multifidus muscle (which is unavoidable in radiofrequency denervation of the MBDR) could be harmful, such as young people with inflammatory processes or athletes.<a class="elsevierStyleCrossRef" href="#bib0795">79</a> Some cases of camptocormia, a postural disorder that is characterised by excessive flexion of the spine, after repeated denervation of the multifidus muscle following radiofrequency treatment of the MBDR have been reported.<a class="elsevierStyleCrossRef" href="#bib0800">80</a>ConclusionsFJs can cause of chronic low back pain. Physical examination, patient-reported pain patterns, and imaging tests do not have the sensitivity and specificity required to predict whether low back pain is facet joint-related. Diagnostic nerve blocks, correctly performed in accordance with the guidelines of the Spine Intervention Society,<a class="elsevierStyleCrossRef" href="#bib0605">41</a> are effective in establishing FJ as a possible cause of low back pain, which is an indication for denervation procedures to achieve lasting relief. Ideally, the nerve blocks should be double comparative or controlled, performed under fluoroscopy with <0.5ml radiographic contrast medium using various views, including anteroposterior, oblique and “tilted” to optimise vision of the tip of the needle. It is essential to use contrast medium and observe its spread, as this will predict the spread of the local anaesthetic to the MBDR and will rule out intravascular or intraosseous injection. Further multicentre randomised studies are needed to establish the best method of reliably diagnosing facet joint-related low back pain.Conflicts of interestThe principal author has no conflict of interest to declare. The main author is the Chairman of the International Education Committee of the Spine Intervention Society." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres1183074" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1103662" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1183073" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1103661" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Anatomy of zygapophyseal or facet joints" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "The facet joints are the cause of low back pain" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Facet joint-related low back pain" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Physical examination in low back pain" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Imaging tests in lumbar pain" ] 10 => array:3 [ "identificador" => "sec0035" "titulo" => "Nerve block diagnosis of lumbar pain" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Validity of diagnostic nerve blocks" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Pain relief cutoff point" ] ] ] 11 => array:3 [ "identificador" => "sec0050" "titulo" => "Performance of diagnostic nerve blocks" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Fluoroscopically-guided nerve block" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Ultrasound-guided nerve block" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "After the nerve block" ] ] ] 12 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 13 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusions" ] 14 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflicts of interest" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-01" "fechaAceptado" => "2018-11-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1103662" "palabras" => array:4 [ 0 => "Diagnostic block" 1 => "Low back pain" 2 => "Facet joint syndrome" 3 => "Medial branch radiofrequency neurotomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1103661" "palabras" => array:4 [ 0 => "Bloqueo diagnóstico" 1 => "Lumbalgia" 2 => "Síndrome facetario" 3 => "Radiofrecuencia del ramo medial lumbar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Low back pain is currently one of the main public health problems. Among the multiple causes, pain in the zygapophysial joints, also called facets or posterior vertebral joints, are an important cause, usually secondary to osteoarthritis. The source of low back pain is often difficult to find, making the therapeutic approach to the patient sub-optimal. Diagnostic blocks are a very important tool in establishing an adequate treatment for patients with low back pain, as long as they are performed accurately, with an adequate local anaesthetic volume, with a suitable image and fluoroscopic projection and its result are precisely interpreted. In this article a review is presented on the importance of diagnostic blocks, as well as how they should be performed in order to obtain the maximum information and the greatest therapeutic benefit." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El dolor lumbar o lumbalgia es uno de los principales problemas de salud pública de la sociedad actual. De entre las múltiples causas de la misma las articulaciones zigoapofisarias, también denominadas facetas o articulaciones vertebrales posteriores, son una causa importante, generalmente secundaria a artrosis. El diagnóstico de la causa de la lumbalgia suele ser en muchas ocasiones difícil, haciendo que el enfoque terapéutico del paciente no sea el óptimo. Los bloqueos diagnósticos constituyen una herramienta de suma importancia para establecer un tratamiento adecuado del paciente con lumbalgia, siempre y cuando sean realizados de manera precisa, con un volumen adecuado de anestésico local, con una imagen y proyección fluoroscópica idónea y el resultado sea interpretado de manera exacta. En el siguiente artículo revisaremos la importancia de los bloqueos diagnósticos, así como el modo en que deben ser realizados, para obtener la máxima información de los mismos y el mayor beneficio terapéutico." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: de Andrés Ares J, Gilsanz F. Bloqueos diagnósticos en el manejo del paciente con lumbalgia secundaria a síndrome facetario. Rev Esp Anestesiol Reanim. 2019;66:213–221." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1269 "Ancho" => 1500 "Tamanyo" => 304256 ] ] "descripcion" => array:1 [ "en" => "Diagram showing the position of the medial ramus, which is targeted in diagnostic blocks to determine whether the patient's low back pain in facet joint-related (AZAP). GRD: dorsal root ganglion; 1: ventral ramus; 2: dorsal raums; 3: lateral branch of the dorsal ramus; 4: medial branch of the dorsal ramus; 5: articular branch for the FJ at the same level; 6: articular branch for the FJ one level down." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1009 "Ancho" => 1500 "Tamanyo" => 281771 ] ] "descripcion" => array:1 [ "en" => "Image showing the anteroposterior view of the vertebral bodies of L2–L3–L4 and L5 (in grey). The lines show the course of the medial branch of the dorsal ramus (MBDR). Note that the MBDR of L2 (number 1) passes over the junction of the superior articular process of the L3 vertebra and its transverse process, and gives 2 branches, one for the facet joint (FJ) L2–L3, and another for FJ L3–L4. Note that the MBDR of L3 (number 2) passes over the junction of the superior articular process of the L4 vertebra and its transverse process, and gives 2 branches, one for facet joint (FJ) L3–L4, and another for FJ L4–L5." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1064 "Ancho" => 1500 "Tamanyo" => 233109 ] ] "descripcion" => array:1 [ "en" => "Oblique view: diagram showing the target injection site to block the medial branch of the dorsal nerve. Note that the image is oblique. The numbers mark the site of the juction between the superior articular process of L3 and its transverse process, which corresponds to the MBDR of L2 (number 1), MBDR of L3 (number 2) and MBDR of L4 (number 3)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1115 "Ancho" => 1500 "Tamanyo" => 195046 ] ] "descripcion" => array:1 [ "en" => "Oblique view: insertion of the blocking needles in the junction between the superior articular process and its transverse process." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1214 "Ancho" => 1500 "Tamanyo" => 209085 ] ] "descripcion" => array:1 [ "en" => "Anteroposterior view. Anteroposterior view, showing the position of the needles for diagnostic block." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1148 "Ancho" => 1500 "Tamanyo" => 214923 ] ] "descripcion" => array:1 [ "en" => "“Tilted” view. Image clearly showing the margin of the junction between the superior articular process and the transverse process, together with the posterior branch of 15 at the junction between the superior articular process of S1 and the sacral ala (the furthest caudal). Notice how the blocking needles enter the image in a cranio-caudal direction. The C-arm should be below the patient, in a cranio-caudal direction." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1085 "Ancho" => 1500 "Tamanyo" => 190834 ] ] "descripcion" => array:1 [ "en" => "Contrast-enhanced “tilted” view. Image showing correct spread of contrast medium, except in the needle at the MBDR of L2 (the furthest cranial), in which the contrast spreads laterally. In this case, the needle must be repositioned before administering the local anaesthetic." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:80 [ 0 => array:3 [ "identificador" => "bib0405" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.B. Andersson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Orthop Scand Suppl" "fecha" => "1998" "volumen" => "281" "paginaInicial" => "28" "paginaFinal" => "31" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9771538" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0410" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does back pain prevalence really decrease with increasing age? A systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.E. Clermont" 1 => "K.M. Dunn" 2 => "P.R. Croft" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ageing/afj055" "Revista" => array:7 [ "tituloSerie" => "Age Ageing" "fecha" => "2006" "volumen" => "35" "paginaInicial" => "229" "paginaFinal" => "234" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16547119" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1470204513701438" "estado" => "S300" "issn" => "14702045" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0415" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Aust Fam Physician" "fecha" => "1895" "volumen" => "14" "paginaInicial" => "1168" "paginaFinal" => "1172" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2935131" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0420" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Placing the global burden of low back pain in context" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Buchbinder" 1 => "F.M. Blyth" 2 => "L.M. March" 3 => "P. Brooks" 4 => "A.D. Woolf" 5 => "D.G. Hoy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Best Prac Res Clin Rheumatol" "fecha" => "2013" "volumen" => "27" "paginaInicial" => "575" "paginaFinal" => "589" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0425" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.C. Schwarzer" 1 => "C.N. Aprill" 2 => "R. Derby" 3 => "J. Fortin" 4 => "G. Kine" 5 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1994" "volumen" => "19" "paginaInicial" => "1132" "paginaFinal" => "1137" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8059268" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0430" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence and clinical features of lumbar zygapophysial joint pain. A study in an Australian population with chronic low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.C. Schwarzer" 1 => "S. Wang" 2 => "N. Bogduk" 3 => "P.J. Mc-Naught" 4 => "R. Laurent" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am Rheum Dis" "fecha" => "1995" "volumen" => "54" "paginaInicial" => "100" "paginaFinal" => "106" "itemHostRev" => array:3 [ "pii" => "S0022202X17314823" "estado" => "S300" "issn" => "0022202X" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0435" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical anatomy of the lumbar spine and sacrum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2005" "editorial" => "Elsevier Health Sciences" "editorialLocalizacion" => "Philadelphia" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0440" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The anatomy of the so-called “articular nerves” and their relationship to facet denervation in the treatment of low-back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. Bogduk" 1 => "D.M. Long" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/jns.1979.51.2.0172" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg" "fecha" => "1979" "volumen" => "51" "paginaInicial" => "172" "paginaFinal" => "177" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/156249" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0445" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The human lumbar dorsal rami" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. Bogduk" 1 => "A.S. Wilson" 2 => "W. Tynan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Anat" "fecha" => "1982" "volumen" => "134" "paginaInicial" => "383" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7076562" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0450" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low back pain with special reference to the articular facets, with presentation of an operative procedure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.K. Ghormley" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Med Assoc" "fecha" => "1933" "volumen" => "101" "paginaInicial" => "1773" "paginaFinal" => "1777" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0455" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The anatomical basis for low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Hirsch" 1 => "B. Ingelmark" 2 => "M. Miller" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Orthop Scand" "fecha" => "1963" "volumen" => "33" "paginaInicial" => "1" "paginaFinal" => "17" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13961170" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0460" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of the spinal facets in back and sciatic pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.N. Shealy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Headache" "fecha" => "1974" "volumen" => "14" "paginaInicial" => "101" "paginaFinal" => "104" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4277724" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0465" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous radiofrequency denervation of spinal facets" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.N. Shealy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/jns.1975.43.4.0448" "Revista" => array:7 [ "tituloSerie" => "J Neurosurg" "fecha" => "1975" "volumen" => "43" "paginaInicial" => "448" "paginaFinal" => "451" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/125787" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0022202X15370810" "estado" => "S300" "issn" => "0022202X" ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0470" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The facet syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "V. Mooney" 1 => "J. Robertson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Orthop" "fecha" => "1976" "volumen" => "115" "paginaInicial" => "149" "paginaFinal" => "156" ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0475" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Induced pain referral from posterior lumbar elements in normal subjects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I.W. McCall" 1 => "W.M. Park" 2 => "J.P. O’Brien" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Spine" "fecha" => "1979" "paginaInicial" => "441" "paginaFinal" => "446" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0480" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Fukui" 1 => "K. Ohseto" 2 => "M. Shiotani" 3 => "K. Ohno" 4 => "H. Karasawa" 5 => "Y. Naganuma" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin J Pain" "fecha" => "1997" "volumen" => "13" "paginaInicial" => "303" "paginaFinal" => "307" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9430810" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0485" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The facet joint and its role in spine pain. Management with facet joint injections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.B. Lippitt" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1984" "volumen" => "9" "paginaInicial" => "746" "paginaFinal" => "750" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6239395" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0490" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The lumbar facet syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Helbig" 1 => "C.K. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/2010.3.SPINE09530" "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1988" "volumen" => "13" "paginaInicial" => "61" "paginaFinal" => "64" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20594019" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0495" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Facet joint degeneration as a cause of low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.E. Lewinnek" 1 => "C.A. Warfield" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Orthop" "fecha" => "1986" "volumen" => "213" "paginaInicial" => "216" "paginaFinal" => "222" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0500" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lumbar facet syndrome. Recommendation for staging before and after intra-articular injection treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Schleifer" 1 => "M. Kiefer" 2 => "T. Hagen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Radiologe" "fecha" => "1995" "volumen" => "35" "paginaInicial" => "844" "paginaFinal" => "847" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8657888" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0505" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomy of facet joints and its correlation with low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.K. Selby" 1 => "S.V. Paris" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Contemp Orthop" "fecha" => "1981" "volumen" => "312" "paginaInicial" => "1097" "paginaFinal" => "1103" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0510" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Facet joint block for low back pain. Identifying predictors of a good response" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.E. Revel" 1 => "V.M. Listrat" 2 => "X.J. Chevalier" 3 => "M. Dougados" 4 => "M.P. N’guyen" 5 => "C. Vallee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Phys Med Rehabil" "fecha" => "1992" "volumen" => "73" "paginaInicial" => "824" "paginaFinal" => "828" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1387521" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0515" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Revel" 1 => "S. Poiraudeau" 2 => "G.R. Auleley" 3 => "C. Payan" 4 => "A. Denke" 5 => "M. Nguyen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1998" "volumen" => "23" "paginaInicial" => "1972" "paginaFinal" => "1977" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9779530" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0520" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Apophyseal injection of local anesthetic as a diagnostic aid in primary low-back pain syndromes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.C. Fairbank" 1 => "W.M. Park" 2 => "I.W. McCall" 3 => "J.P. O’brien" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1981" "volumen" => "6" "paginaInicial" => "598" "paginaFinal" => "605" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6461072" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0525" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiofrequency lumbar facet denervation. Analysis of prognostic factors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.B. North" 1 => "M. Han" 2 => "M. Zahurak" 3 => "D.H. Kidd" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pain" "fecha" => "1994" "volumen" => "57" "paginaInicial" => "77" "paginaFinal" => "83" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8065800" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0530" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Facet joint injection in low back pain. A prospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.P. Jackson" 1 => "R.R. Jacobs" 2 => "P.X. Montesano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1988" "volumen" => "13" "paginaInicial" => "966" "paginaFinal" => "971" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2974632" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0535" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Correlation of clinical examination characteristics with three sources of chronic low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Young" 1 => "C. Aprill" 2 => "M. Laslett" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine J" "fecha" => "2003" "volumen" => "3" "paginaInicial" => "460" "paginaFinal" => "465" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14609690" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0540" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidence-informed management of chronic back pain with facet injections and radiofrequency neurotomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.spinee.2007.10.010" "Revista" => array:6 [ "tituloSerie" => "Spine J" "fecha" => "2008" "volumen" => "8" "paginaInicial" => "56" "paginaFinal" => "64" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18164454" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0545" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoarthritis of the facet joints: accuracy of oblique radiographic measurement" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Pathria" 1 => "D.J. Sartoris" 2 => "D. Resnick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiology.164.1.3588910" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "1987" "volumen" => "164" "paginaInicial" => "227" "paginaFinal" => "230" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3588910" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0550" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MR imaging and CT in osteoarthritis of the lumbar facet joints" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Weishaupt" 1 => "M. Zanetti" 2 => "N. Boos" 3 => "J. Hodler" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Skeletal Radiol" "fecha" => "1999" "volumen" => "28" "paginaInicial" => "215" "paginaFinal" => "219" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10384992" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0555" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoarthritis of the facet joints: accuracy of oblique radiographic assessment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Pathria" 1 => "D.J. Sartoris" 2 => "D. Resnick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiology.164.1.3588910" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "1987" "volumen" => "164" "paginaInicial" => "227" "paginaFinal" => "230" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3588910" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0560" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Facet joint osteoarthritis and low back pain in the community-based population" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Kalichman" 1 => "L. Li" 2 => "D. Kim" 3 => "A. Guermazi" 4 => "V. Berkin" 5 => "C.J. O’Donnell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BRS.0b013e318184ef95" "Revista" => array:5 [ "tituloSerie" => "Spine" "fecha" => "2008" "volumen" => "33" "paginaInicial" => "2560" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18923337" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0565" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.G. Pneumaticos" 1 => "S.N. Chatziioannou" 2 => "J.A. Hipp" 3 => "W.H. Moore" 4 => "S.I. Esses" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.2382041930" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2006" "volumen" => "238" "paginaInicial" => "693" "paginaFinal" => "698" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16436824" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0570" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The value of SPECT scans in identifying back pain likely to benefit from the facet joint injection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.L. Dolan" 1 => "P.J. Ryan" 2 => "N.K. Arden" 3 => "R. Stratton" 4 => "J.R. Wedley" 5 => "W. Hamann" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Rheumatol" "fecha" => "1996" "volumen" => "35" "paginaInicial" => "1269" "paginaFinal" => "1273" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9010055" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0575" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Correlation of 99m Tc-DPD SPECT/CT scan findings and diagnostic blockades of lumbar medial branches in patients with unspecific low back pain in a randomized-controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Freiermuth" 1 => "M. Kretzschmar" 2 => "S. Bilecen Schaeren" 3 => "A.L. Jacob" 4 => "A. Aeschbach" 5 => "W. Ruppen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/pme.12841" "Revista" => array:6 [ "tituloSerie" => "Pain Med" "fecha" => "2015" "volumen" => "16" "paginaInicial" => "1916" "paginaFinal" => "1922" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26177035" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0580" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic blocks. A truth serum for malingering" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin J Pain" "fecha" => "2004" "volumen" => "20" "paginaInicial" => "409" "paginaFinal" => "414" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15502684" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0585" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ISSLS Prize Winner: does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E.J. Carragee" 1 => "A.S. Don" 2 => "E.L. Hurwitz" 3 => "J.M. Cuellar" 4 => "J. Carrino" 5 => "R. Herzog" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BRS.0b013e3181ab5432" "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "2009" "volumen" => "34" "paginaInicial" => "2338" "paginaFinal" => "2345" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19755936" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0590" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic and therapeutic nerve blocks" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Curatolo" 1 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "Bonica's management of pain" "paginaInicial" => "1401" "paginaFinal" => "1423" "edicion" => "4th ed." "serieFecha" => "2010" ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0595" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Specificity of lumbar medial branch and L5 dorsal ramus blocks: a computed tomography study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Dreyfuss" 1 => "A.C. Schwarzer" 2 => "P. Lau" 3 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1997" "volumen" => "22" "paginaInicial" => "895" "paginaFinal" => "902" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9127924" "web" => "Medline" ] ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0600" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint: a physiologic challenge" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Kaplan" 1 => "P. Dreyfuss" 2 => "B. Halbrook" 3 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1998" "volumen" => "23" "paginaInicial" => "1847" "paginaFinal" => "1852" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9762741" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0605" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Bogduk N, editor. Practice guidelines for spinal diagnostic and treatment procedures 2013. San Francisco: International Spine Intervention Society; 2013." ] ] ] 41 => array:3 [ "identificador" => "bib0610" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Principles of diagnostic blocks. Interventional spine: an algorithmic approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "fecha" => "2008" "paginaInicial" => "187" "paginaFinal" => "192" "editorial" => "Saunders Elsevier" "editorialLocalizacion" => "Philadelphia" ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0615" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic blocks: a truth serum for malingering" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin J Pain" "fecha" => "2004" "volumen" => "20" "paginaInicial" => "409" "paginaFinal" => "414" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15502684" "web" => "Medline" ] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0620" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: zygapophysial joint blocks" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Bogduk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin J Pain" "fecha" => "1997" "volumen" => "13" "paginaInicial" => "285" "paginaFinal" => "302" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9430809" "web" => "Medline" ] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0625" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparative local anesthetic blocks in the diagnosis of cervical zygapophysial joints pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Barnsley" 1 => "S. Lord" …1 ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pain" "fecha" => "1993" "volumen" => "55" "paginaInicial" => "99" "paginaFinal" => "106" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0630" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prolonged relief of neuralgia after regional anesthetic blocks: a call for further experimental and systematic clinical studies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pain" "fecha" => "1990" "volumen" => "43" "paginaInicial" => "287" "paginaFinal" => "297" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0635" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A double-blind trial of bupivacaine and lignocaine: latency and duration in extradural blockade" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "1968" "volumen" => "23" "paginaInicial" => "331" "paginaFinal" => "337" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 47 => array:3 [ "identificador" => "bib0640" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The value of the provocation response in lumbar zygapophyseal joint injections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin J Pain" "fecha" => "1994" "volumen" => "10" "paginaInicial" => "309" "paginaFinal" => "313" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 48 => array:3 [ "identificador" => "bib0645" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "On the rational use of diagnostic blocks for spinal pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Neurosurg Q" "fecha" => "2009" "volumen" => "19" "paginaInicial" => "88" "paginaFinal" => "100" ] ] ] ] ] ] 49 => array:3 [ "identificador" => "bib0650" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin J Pain" "fecha" => "1995" "volumen" => "11" "paginaInicial" => "208" "paginaFinal" => "213" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 50 => array:3 [ "identificador" => "bib0655" "etiqueta" => "51" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "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" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pain Phys" "fecha" => "2010" "volumen" => "13" "paginaInicial" => "133" "paginaFinal" => "143" ] ] ] ] ] ] 51 => array:3 [ "identificador" => "bib0660" "etiqueta" => "52" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The relative contributions of the disc and zygapophyseal joint in chronic low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1994" "volumen" => "19" "paginaInicial" => "801" "paginaFinal" => "806" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 52 => array:3 [ "identificador" => "bib0665" "etiqueta" => "53" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The sacroiliac joint in chronic low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "1995" "volumen" => "20" "paginaInicial" => "31" "paginaFinal" => "37" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 53 => array:3 [ "identificador" => "bib0670" "etiqueta" => "54" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e3181e33ae5" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2010" "volumen" => "113" "paginaInicial" => "395" "paginaFinal" => "405" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 54 => array:3 [ "identificador" => "bib0675" "etiqueta" => "55" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Technique for CT fluoroscopy-guided lumbar medial branch blocks and radiofrequency ablation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Roentgenol" "fecha" => "2016" "volumen" => "207" "paginaInicial" => "631" "paginaFinal" => "634" ] ] ] ] ] ] 55 => array:3 [ "identificador" => "bib0680" "etiqueta" => "56" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiation exposure in CT-guided interventions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejrad.2013.08.035" "Revista" => array:6 [ "tituloSerie" => "Eur J Radiol" "fecha" => "2013" "volumen" => "82" "paginaInicial" => "2253" "paginaFinal" => "2257" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 56 => array:3 [ "identificador" => "bib0685" "etiqueta" => "57" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound-guided lumbar facet nerve block: a sonoanatomic study of a new methodologic approach" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2004" "volumen" => "100" "paginaInicial" => "1242" "paginaFinal" => "1248" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 57 => array:3 [ "identificador" => "bib0690" "etiqueta" => "58" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound-guided lumbar medialbranch block: a clinical study with fluoroscopy control" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rapm.2006.06.246" "Revista" => array:6 [ "tituloSerie" => "Reg Anesth Pain Med" "fecha" => "2006" "volumen" => "31" "paginaInicial" => "451" "paginaFinal" => "454" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 58 => array:3 [ "identificador" => "bib0695" "etiqueta" => "59" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound for lumbar spinal procedures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Phys Med Rehabil Clin North Am" "fecha" => "2018" "volumen" => "29" "paginaInicial" => "49" "paginaFinal" => "60" ] ] ] ] ] ] 59 => array:3 [ "identificador" => "bib0700" "etiqueta" => "60" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain: a retrospective comparative study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MD.0000000000006655" "Revista" => array:5 [ "tituloSerie" => "Medicine" "fecha" => "2017" "volumen" => "96" "paginaInicial" => "e6655" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 60 => array:3 [ "identificador" => "bib0705" "etiqueta" => "61" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lumbosacral transitional vertebra: relation to disc degeneration and low back pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.BRS.0000107223.02346.A8" "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "2004" "volumen" => "29" "paginaInicial" => "200" "paginaFinal" => "205" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 61 => array:3 [ "identificador" => "bib0710" "etiqueta" => "62" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Parallax. Merriam-Webster Medical Dictionary. <a id="intr0010" class="elsevierStyleInterRef" href="http://www2.merriamwebster.com/cgibin/mwmednlm%26book=Medical%26va=parallax">http://www2.Merriamwebster.com/cgibin/mwmednlm&book=Medical&va=parallax</a>." ] ] ] 62 => array:3 [ "identificador" => "bib0715" "etiqueta" => "63" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The parallax effect in the evaluation of range of motion in lumbar total disc replacement" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Spine Surg" "fecha" => "2008" "volumen" => "2" "paginaInicial" => "184" "paginaFinal" => "188" ] ] ] ] ] ] 63 => array:3 [ "identificador" => "bib0720" "etiqueta" => "64" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The incidence of intravascular penetration in medial branch blocks: cervical, thoracic, and lumbar spines" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BRS.0b013e318166f03d" "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "2008" "volumen" => "33" "paginaInicial" => "E174" "paginaFinal" => "E177" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 64 => array:3 [ "identificador" => "bib0725" "etiqueta" => "65" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00198-007-0370-8" "Revista" => array:6 [ "tituloSerie" => "Osteoporos Int" "fecha" => "2007" "volumen" => "18" "paginaInicial" => "1219" "paginaFinal" => "1224" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 65 => array:3 [ "identificador" => "bib0730" "etiqueta" => "66" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Curr Rev Pain" "fecha" => "2000" "volumen" => "4" "paginaInicial" => "337" "paginaFinal" => "344" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 66 => array:3 [ "identificador" => "bib0735" "etiqueta" => "67" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effectiveness of ultrasonography guided injections in patients with facet syndrome of the low lumbar spine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5535/arm.2012.36.1.66" "Revista" => array:6 [ "tituloSerie" => "Ann Rehabil Med" "fecha" => "2012" "volumen" => "36" "paginaInicial" => "66" "paginaFinal" => "71" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 67 => array:3 [ "identificador" => "bib0740" "etiqueta" => "68" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound-guided lumbar facet nerve block: accuracy of a new technique confirmed by computed tomography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2004" "volumen" => "101" "paginaInicial" => "1195" "paginaFinal" => "1200" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 68 => array:3 [ "identificador" => "bib0745" "etiqueta" => "69" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound guidance for facet joint injections in the lumbar spine: a computed tomography controlled feasibility study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/01.ANE.0000158609.64417.93" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2005" "volumen" => "101" "paginaInicial" => "579" "paginaFinal" => "583" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 69 => array:3 [ "identificador" => "bib0750" "etiqueta" => "70" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound-guided interventional procedures for lumbar pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Tech Reg Anesth Pain Manag" "fecha" => "2013" "volumen" => "17" "paginaInicial" => "96" "paginaFinal" => "106" ] ] ] ] ] ] 70 => array:3 [ "identificador" => "bib0755" "etiqueta" => "71" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Spine" "fecha" => "2000" "volumen" => "25" "paginaInicial" => "1270" "paginaFinal" => "1277" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0190962214011256" "estado" => "S300" "issn" => "01909622" ] ] ] ] ] ] ] 71 => array:3 [ "identificador" => "bib0760" "etiqueta" => "72" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous cryodenervation of lumbar facet joints: a prospective clinical trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00264-006-0208-6" "Revista" => array:6 [ "tituloSerie" => "Int Orthop" "fecha" => "2007" "volumen" => "31" "paginaInicial" => "525" "paginaFinal" => "530" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 72 => array:3 [ "identificador" => "bib0765" "etiqueta" => "73" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relevance of nerve blocks in treating and diagnosing low back pain is the quality decisive?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s004820100035" "Revista" => array:6 [ "tituloSerie" => "Schmerz" "fecha" => "2001" "volumen" => "15" "paginaInicial" => "474" "paginaFinal" => "483" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 73 => array:3 [ "identificador" => "bib0770" "etiqueta" => "74" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Are diagnostic lumbar medial branch blocks valid? Results of 2-year follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pain Phys" "fecha" => "2003" "volumen" => "6" "paginaInicial" => "147" "paginaFinal" => "154" ] ] ] ] ] ] 74 => array:3 [ "identificador" => "bib0775" "etiqueta" => "75" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The surgical anatomy of lumbar medial branch neurotomy (facet denervation)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1526-4637.2004.04042.x" "Revista" => array:6 [ "tituloSerie" => "Pain Med" "fecha" => "2004" "volumen" => "5" "paginaInicial" => "289" "paginaFinal" => "298" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 75 => array:3 [ "identificador" => "bib0780" "etiqueta" => "76" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Controlled zygapophysial joint blocks: the travesty of cost-effectiveness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1526-4637.2000.99104.x" "Revista" => array:6 [ "tituloSerie" => "Pain Med" "fecha" => "2000" "volumen" => "1" "paginaInicial" => "24" "paginaFinal" => "34" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 76 => array:3 [ "identificador" => "bib0785" "etiqueta" => "77" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Correlation of lumbar medial branch neurotomy results with diagnostic medial branch block cutoff values to optimize therapeutic outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1526-4637.2012.01500.x" "Revista" => array:6 [ "tituloSerie" => "Pain Med" "fecha" => "2012" "volumen" => "13" "paginaInicial" => "1533" "paginaFinal" => "1546" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 77 => array:3 [ "identificador" => "bib0790" "etiqueta" => "78" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic value of lumbar facet joint injection: a prospective triple cross-over study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0027991" "Revista" => array:5 [ "tituloSerie" => "PloS One" "fecha" => "2011" "volumen" => "6" "paginaInicial" => "e27991" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 78 => array:3 [ "identificador" => "bib0795" "etiqueta" => "79" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effectiveness of Lumbar Facet Joint Blocks and Predictive Value before Radiofrequency Denervation The Facet Treatment Study (FACTS), a Randomized, Controlled Clinical Trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0000000000002274" "Revista" => array:7 [ "tituloSerie" => "Anesthesiology" "fecha" => "2018" "volumen" => "129" "paginaInicial" => "517" "paginaFinal" => "535" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0022202X15372845" "estado" => "S300" "issn" => "0022202X" ] ] ] ] ] ] ] 79 => array:3 [ "identificador" => "bib0800" "etiqueta" => "80" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Report of an unusual complication of radiofrequency neurotomy of medial branches of dorsal rami" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Pain Phys" "fecha" => "2014" "volumen" => "17" "paginaInicial" => "E654" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006600000004/v1_201904250611/S2341192919300484/v1_201904250611/en/main.assets" "Apartado" => array:4 [ "identificador" => "48761" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Continuing education" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006600000004/v1_201904250611/S2341192919300484/v1_201904250611/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300484?idApp=UINPBA00004N"]

Statistics

Continuing education

Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome

Bloqueos diagnósticos en el manejo del paciente con lumbalgia secundaria a síndrome facetario

J. de Andrés Ares

Corresponding author

javierdeandresares@gmail.com

Corresponding author.

, F. Gilsanz

Servicio de Anestesiología-Unidad del Dolor, Hospital Universitario La Paz, Madrid, Spain

Read

Times
was read the article

Total PDF

Total HTML

Share statistics

 array:24 [
  "pii" => "S2341192919300484"
  "issn" => "23411929"
  "doi" => "10.1016/j.redare.2018.11.013"
  "estado" => "S300"
  "fechaPublicacion" => "2019-04-01"
  "aid" => "991"
  "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
  "copyrightAnyo" => "2018"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "fla"
  "cita" => "Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;English Version&#41;. 2019;66:213-21"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 16
    "formatos" => array:2 [
      "HTML" => 3
      "PDF" => 13
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0034935618302354"
      "issn" => "00349356"
      "doi" => "10.1016/j.redar.2018.11.008"
      "estado" => "S300"
      "fechaPublicacion" => "2019-04-01"
      "aid" => "991"
      "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "fla"
      "cita" => "Rev Esp Anestesiol Reanim. 2019;66:213-21"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 364
        "formatos" => array:2 [
          "HTML" => 204
          "PDF" => 160
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Formaci&#243;n continuada</span>"
        "titulo" => "Bloqueos diagn&#243;sticos en el manejo del paciente con lumbalgia secundaria a s&#237;ndrome facetario"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "213"
            "paginaFinal" => "221"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0020"
            "etiqueta" => "Figura 3"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr3.jpeg"
                "Alto" => 1064
                "Ancho" => 1500
                "Tamanyo" => 232589
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Proyecci&#243;n oblicua&#58; esquema en el que se muestra la diana para bloquear el ramo medial del nervio dorsal &#40;RMND&#41;&#46; N&#243;tese que la imagen es oblicua&#44; y est&#225; marcada la uni&#243;n del proceso articular superior de L3 con su transversa y corresponder&#237;a al RMND de L2 &#40;n&#250;mero1&#41;&#44; RMND de L3 &#40;n&#250;mero 2&#41; y RMND de L4 &#40;n&#250;mero 3&#41;&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "J&#46; de Andr&#233;s Ares, F&#46; Gilsanz"
            "autores" => array:2 [
              0 => array:2 [
                "nombre" => "J&#46;"
                "apellidos" => "de Andr&#233;s Ares"
              ]
              1 => array:2 [
                "nombre" => "F&#46;"
                "apellidos" => "Gilsanz"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2341192919300484"
          "doi" => "10.1016/j.redare.2018.11.013"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300484?idApp=UINPBA00004N"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935618302354?idApp=UINPBA00004N"
      "url" => "/00349356/0000006600000004/v1_201903290609/S0034935618302354/v1_201903290609/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2341192919300459"
    "issn" => "23411929"
    "doi" => "10.1016/j.redare.2018.10.006"
    "estado" => "S300"
    "fechaPublicacion" => "2019-04-01"
    "aid" => "980"
    "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;English Version&#41;. 2019;66:222-5"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
      "titulo" => "Endotracheal intubation through laryngeal Ambu<span class="elsevierStyleSup">&#174;</span> Auragain&#8482; mask airway mask in paediatric patients affected by congenital infiltrating lipomatosis"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "222"
          "paginaFinal" => "225"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Intubaci&#243;n orotraqueal a trav&#233;s de mascarilla lar&#237;ngea Ambu<span class="elsevierStyleSup">&#174;</span> Auragain&#8482; en paciente pedi&#225;trico con lipomatosis infiltrante cong&#233;nita"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 669
              "Ancho" => 905
              "Tamanyo" => 93300
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intubation material&#44; consisting of fibreoptic bronchoscope&#44; number 2 Ambu<span class="elsevierStyleSup">&#174;</span> Auragain&#8482; laryngeal mask&#44; number 4&#46;5 endotracheal tube&#44; number 4 endotracheal tube without connection&#44; swivel adapter&#44; guedel cannula&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "I&#46; Hern&#225;ndez Garc&#237;a, I&#46; Hidalgo, L&#46; Barrag&#225;n, B&#46; Berenguer, C&#46; Lorca-Garc&#237;a, I&#46; Mantilla"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Hern&#225;ndez Garc&#237;a"
            ]
            1 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Hidalgo"
            ]
            2 => array:2 [
              "nombre" => "L&#46;"
              "apellidos" => "Barrag&#225;n"
            ]
            3 => array:2 [
              "nombre" => "B&#46;"
              "apellidos" => "Berenguer"
            ]
            4 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Lorca-Garc&#237;a"
            ]
            5 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Mantilla"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S003493561830207X"
        "doi" => "10.1016/j.redar.2018.10.007"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493561830207X?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300459?idApp=UINPBA00004N"
    "url" => "/23411929/0000006600000004/v1_201904250611/S2341192919300459/v1_201904250611/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S234119291930054X"
    "issn" => "23411929"
    "doi" => "10.1016/j.redare.2018.12.007"
    "estado" => "S300"
    "fechaPublicacion" => "2019-04-01"
    "aid" => "999"
    "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;English Version&#41;. 2019;66:206-12"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "European Diploma in Anaesthesiology and Intensive Care in Spain&#58; Results for the part 1 and part 2 exams in the last five years&#46; Are we going in the right direction&#63;"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "206"
          "paginaFinal" => "212"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Diploma Europeo en Anestesiolog&#237;a y Cuidados Intensivos en Espa&#241;a&#58; resultados de los ex&#225;menes de las partes 1 y 2 de los &#250;ltimos cinco a&#241;os&#46; &#191;Vamos por el buen camino&#63;"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 760
              "Ancho" => 1472
              "Tamanyo" => 55696
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">EDAIC Part 1 pass rate&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "N&#46; Brogly, W&#46; Engelhardt, S&#46; Hill, E&#46;-M&#46; Ringvold, A&#46; Varosyan, A&#46; Varvinskiy, M&#46; Zerafa"
          "autores" => array:7 [
            0 => array:2 [
              "nombre" => "N&#46;"
              "apellidos" => "Brogly"
            ]
            1 => array:2 [
              "nombre" => "W&#46;"
              "apellidos" => "Engelhardt"
            ]
            2 => array:2 [
              "nombre" => "S&#46;"
              "apellidos" => "Hill"
            ]
            3 => array:2 [
              "nombre" => "E&#46;-M&#46;"
              "apellidos" => "Ringvold"
            ]
            4 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Varosyan"
            ]
            5 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Varvinskiy"
            ]
            6 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Zerafa"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0034935618302469"
        "doi" => "10.1016/j.redar.2018.12.009"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935618302469?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234119291930054X?idApp=UINPBA00004N"
    "url" => "/23411929/0000006600000004/v1_201904250611/S234119291930054X/v1_201904250611/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Continuing education</span>"
    "titulo" => "Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "213"
        "paginaFinal" => "221"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "J&#46; de Andr&#233;s Ares, F&#46; Gilsanz"
        "autores" => array:2 [
          0 => array:4 [
            "nombre" => "J&#46;"
            "apellidos" => "de Andr&#233;s Ares"
            "email" => array:1 [
              0 => "javierdeandresares&#64;gmail&#46;com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "F&#46;"
            "apellidos" => "Gilsanz"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Servicio de Anestesiolog&#237;a-Unidad del Dolor&#44; Hospital Universitario La Paz&#44; Madrid&#44; Spain"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Bloqueos diagn&#243;sticos en el manejo del paciente con lumbalgia secundaria a s&#237;ndrome facetario"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1214
            "Ancho" => 1500
            "Tamanyo" => 209085
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Anteroposterior view&#46; Anteroposterior view&#44; showing the position of the needles for diagnostic block&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Low back pain is an important social&#44; family and health problem worldwide&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#8211;4</span></a> There are many causes of back pain&#44; and the zygapophyseal joints&#44; also called facet joints&#44; are responsible for between 15&#37; and 46&#37; of cases of chronic back pain&#44; depending on the population studied&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">5&#44;6</span></a> The main problem lies in determining whether chronic low back pain is caused by facet joints or not&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Anatomy of zygapophyseal or facet joints</span><p id="par0010" class="elsevierStylePara elsevierViewall">The spinal vertebrae form a triarticular complex consisting&#44; on the one hand&#44; of the vertebral bodies and the intervertebral disc&#44; and on the other&#44; of the junction between the superior articular processes and the inferior articular processes of each adjacent vertebra&#46; The junction between the superior vertebral process of the vertebra below and the inferior vertebral process of the vertebra above is called the zigoapofisaria or facet joint &#40;FJ&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">7</span></a> Each facet joint derives its name from its associated vertebra&#59; therefore&#44; the FJ between the right L3 and L4 is called the right facet joint L3&#8211;L4&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">8</span></a> Each FJ is innervated by 2 medial branches &#40;which are dorsal primary rami&#41;&#46; At the lumbar level&#44; they are innervated by the medial branch of the dorsal ramus &#40;MBDR&#41; from the same level and one level above&#44; so that FJ L3&#8211;L4 is innervated by the L2 MBDR and the L3 MBDR<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Each MBDR innervates 2 FJs&#44; so that the MBDR of L3 will innervate FJ L3&#8211;L4 and FJ L4&#8211;L5&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The medial lumbar ramus arises from the dorsal primary ramus and runs along the pedicle of the superior articular process &#40;SAP&#41; of the vertebra below&#46; After crossing the pedicle of the SAP&#44; it travels towards the lamina&#44; passes inferior to the mamillo-accessory ligament &#40;which protects it&#41;&#44; and then divides into 2 branches&#58; one innervates the FJ at that level&#44; and another innervates the FJ one level below&#44; the interspinous ligament and muscle and the multifidus muscle&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">7&#44;8</span></a> The medial branch of L5&#44; however&#44; originates from the dorsal ramus of L5 nerve in the lower portion of the L5&#8211;S1 facet&#44; and then runs along the groove formed between the base of the S1 superior articulating process and the sacral ala&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The facet joints are the cause of low back pain</span><p id="par0025" class="elsevierStylePara elsevierViewall">The FJs have been known for many years to cause low back pain&#46; The first investigator to show this was Ghormley<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">10</span></a> in 1933&#44; who introduced the oblique view in radiology to see the intra-articular space and the degree to which it could be affected by osteoarthritis&#46; Later&#44; Mixter and Barr<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">11</span></a> showed that nociceptive stimulation of FJs in healthy volunteers caused lumbago&#46; Following this&#44; Shealy<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">12&#44;13</span></a> was the first to argue that the surgical denervation of the nerves that supply the FJs alleviated low back pain&#46; Mooney and Robertson<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">14</span></a> showed that the FJs were the source of certain types of low back pain&#44; and that in certain cases FJ pain referral affected certain parts of the legs in a similar way to sciatica&#46; These authors coined the term &#8220;facet syndrome&#8221;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Facet joint-related low back pain</span><p id="par0030" class="elsevierStylePara elsevierViewall">FJ pain is usually a lumbar&#44; mechanical&#44; nociceptive pain with a pattern of referral that extends to the gluteal region and the back of the thighs&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">5&#44;15</span></a> Other structures that can cause low back pain &#40;vertebral bodies&#44; intervertebral disc&#44; dura mater&#44; nerve roots&#44; sacroiliac joint&#44; muscles&#44; ligaments and fascias&#41; may overlap the referred pain pattern of FJ-related pain&#44;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">16</span></a> which is why it is so difficult to establish the cause of low back pain&#46; The main cause of FJ involvement is usually arthritic degeneration&#44; although other pathological processes may also affect these joints&#44; such as rheumatoid arthritis&#44; reactive arthritic processes&#44; ankylosing spondylitis&#44; facet chondromalacia&#44; pseudogout&#44; villonodular synovitis&#44; facet cysts&#44; and of course&#44; low back injury&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Physical examination in low back pain</span><p id="par0035" class="elsevierStylePara elsevierViewall">For years&#44; many researchers have attempted to develop a series of diagnostic clinical criteria that would establish the FJ as the cause of low back pain&#46; This has led to the inclusion in the patient history and physical examination of the following criteria as indicators of pain that may be FJ-related&#58; unilateral or bilateral lumbar pain in the buttocks&#44; hips or back of the thigh&#44;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">17&#8211;21</span></a> pseudo-radicular pain&#44;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">20</span></a> morning stiffness&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">17</span></a> lumbar flexion pain&#44;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">22&#44;23</span></a> pain on lumbar extension&#44;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">17&#44;18&#44;23</span></a> pain on lumbar lateral rotation&#44;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">18&#8211;20</span></a> pain when sitting&#44;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">24</span></a> paravertebral contracture&#44;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">17&#8211;19</span></a> negative neurological examination&#44;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">17&#44;19&#44;25</span></a> and normal gait&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">26</span></a> However&#44; the sensitivity and specificity of these criteria is very low&#46; This is why patient history and physical examination are fundamental for screening patients with low back pain&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">27</span></a> but cannot establish FJ as the specific cause of the pain&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">28</span></a> After excluding other common ethologies&#44; such as discogenic or radicular pain&#44; unilateral or bilateral symptoms that radiate to one or both buttocks&#44; groin and thighs without passing the knee can be presumed to be facet joint-related pain&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Imaging tests in lumbar pain</span><p id="par0040" class="elsevierStylePara elsevierViewall">Arthritis or facet degeneration&#44; which is usually diagnosed with imaging tests&#44; is a potential cause of low back pain&#46; According to Pathria et al&#46;&#44; plain oblique radiography has a sensitivity of 55&#37; and a specificity of 69&#37; in distinguishing between the presence and absence of degenerative disease in FJs of L3-4 to L5&#8211;S1 in 50 consecutive patients with back pain&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">29</span></a> The specificity of oblique radiography in distinguishing absent or mild disease from moderate or severe disease was higher &#40;94&#37;&#41;&#44; but its sensitivity was far lower&#44; at 23&#37;&#46; Interobserver agreement among the radiologists performing the plain radiology study was 57&#37;&#44; but the discrepancy rate was 43&#37;&#46; The interobserver agreement in computerised tomography &#40;CT&#41; scan of patients with facet arthrosis showed a kappa value of 0&#46;46&#44; which represents perfect agreement in 63&#37; of cases&#44; and discrepancy in 27&#37;&#46; This shows that plain radiography is inadequate for early detection of facet degeneration&#46; Both CT and magnetic resonance imaging &#40;MRI&#41; are valid tools for detecting facet degeneration&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">30</span></a> FJ arthritis can be classified into 4 grades&#44; according to the imaging tests<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">30&#44;31</span></a>&#58;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Grade 0</span>&#46; Normal</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Grade 1</span>&#46; Mild degenerative disease&#58; joint space narrowing less than 2<span class="elsevierStyleHsp" style=""></span>mm and&#47;or small osteophytes and&#47;or mild hypertrophy of the articular process&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Grade 2</span>&#46; Moderate degenerative disease&#58; joint space narrowing <span class="elsevierStyleMonospace">&#40;&#60;</span>1<span class="elsevierStyleHsp" style=""></span>mm&#41; and&#47;or moderate osteophytes and&#47;or moderate hypertrophy of the articular process and&#47;or mild subarticular bone erosions&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Grade 3</span>&#46; Severe degenerative disease&#58; narrowing of the facet joint space and&#47;or large osteophytes and&#47;or severe hypertrophy of the articular process and&#47;or severe subarticular bone erosions and&#47;or subchondral cysts and&#47;or vacuum phenomenon&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The problem is that patients with grade 2 and 3 degeneration may not have low back pain&#44; and patients with grade 0 and 1 arthritis may present FJ pain&#59; in other words&#44; there is no correlation between specific imaging tests &#40;CT and MRI&#41; and the presence or absence of lumbar pain&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">32</span></a> More complex imaging tests&#44; such as scintigraphy &#40;an imaging technique in which the distribution of a low-dose radioactive tracer is shown in the patient&#39;s body&#41;&#44; show contradictory results for the diagnosis of low back pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">33&#8211;35</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Nerve block diagnosis of lumbar pain</span><p id="par0070" class="elsevierStylePara elsevierViewall">Given that the clinical history and physical examination are not diagnostic in this context&#44; and imaging tests lack the sensitivity and specificity needed to show that the low back pain is FJ-related&#44; diagnostic nerve blocks are the only valid method of diagnosing FJ-related low back pain&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">This diagnostic approach is based on the notion that if the FJ is the cause of low back pain&#44; blocking this joint or the nerve that innervates it with a local anaesthetic will alleviate the patient&#39;s back pain&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">36</span></a> There are&#44; therefore&#44; 2 approaches&#58; blockade with local anaesthetic of the FJ itself&#44; or lumbar medial branch block &#40;MBB&#41; to anaesthetise the MBDR&#46; While intra-facet joint block could be a valid approach&#44; it has not been validated as a diagnostic method&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">28</span></a> In addition&#44; intra-facet joint block&#44; like discography in the diagnosis of discogenic pain&#44;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">37</span></a> could accelerate the degenerative process of healthy FJs&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Validity of diagnostic nerve blocks</span><p id="par0080" class="elsevierStylePara elsevierViewall">For a test to be valid&#44; it must have both face validity and content validity&#46; In diagnostic MBB&#44; face validity refers to the accuracy of the technique&#44; that is&#44; it anaesthetises exclusively what it sets out to anaesthetises and spares other structures&#46; Content validity refers to the sensitivity&#44; specificity and prevalence of the nerve block&#46; With respect to face validity&#44; the technique must fulfil the following criteria&#58; it anaesthetises exclusively the structure that it aims to anaesthetise&#59; it spares other structures that should not be anaesthetised&#46; Face validity measures the accuracy of the nerve block&#44; and can be tested in anatomical cadaveric studies that evaluate whether the target nerves are exclusively anaesthetised and not others &#40;since this could falsify the result of the test&#41;&#46; In the case of diagnostic MBB&#44; these studies evaluate whether this particular nerve is anaesthetised and not adjacent structures that are potential sources pain&#44; which would give a false positive result of the test&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">38</span></a> The anatomical face validity was demonstrated by Dreyfuss&#44; who showed<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">39</span></a> that only the MBDR was anaesthetised by placing spinal needles over these nerves and taking radiographs to demonstrate their precise locations&#44; following which an appropriate volume of local anaesthetic was injected in two positions for each nerve&#46; The physiological face validity was demonstrated by Kaplan<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">40</span></a> by showing that anaesthetizing the MBDR in healthy volunteers prevented experimentally induced lumbar pain&#46; In order for MBB to give adequate pain relief&#44; the recommendations of the Spine Intervention Society must be followed&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">41</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Content validity refers to the extent to which a test distinguishes patients who have the condition tested &#40;in this case&#44; FJ-related lumbar pain&#41; from those who do not&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">42</span></a> A control nerve block can be used to improve the content validity of a test&#46; For the blockade to be valid&#44; it must be specific and controlled&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">43</span></a> Specific means that it reaches the structures to be anaesthetised&#44; and only anaesthetises those structures&#46; This is demonstrated by injecting small volumes of contrast medium &#40;less than 0&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#41; and observing its spread with the help of an imaging technique&#44; in this case fluoroscopy&#46; The spread of the contrast medium in the target area &#40;in this case&#44; the MBDR&#41;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">44</span></a> should be documented on hard-copy films or on specialised paper&#46; Controlled means that at least 2 blocks should be performed in order to avoid false positives&#46; There are many types of controlled nerve blocks&#44; although the most widely used is the comparative control block&#44;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">45</span></a> which consists of performing one nerve block with a short-acting local anaesthetic such as lidocaine&#44; and a second block with a longer-acting local anaesthetic such as bupivacaine&#46; The patient should report relief coinciding with the duration of the anaesthetic used in each case&#46; Strictly speaking&#44; these nerve blocks should be performed with placebo&#44; although this would raise ethical issues&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">43</span></a> The problem usually arises due to the fact that the analgesic effect of short-acting local anaesthetics can sometimes last beyond their half life&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">46</span></a> This is thought to be due to a neuromodulatory effect&#44; or to the fact that local anaesthetics have been studied in healthy individuals whose nociceptive pathways differ from those of pain patients&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">47</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In diagnostic MBB&#44; studies have shown that single blocks &#40;that is&#44; performing a single block for diagnosis&#41; lack validity&#44; since they have a false positive rate between 25&#37; and 45&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">48</span></a> If a correctly performed diagnostic block is positive&#44; there is no way of knowing for certain that this is a true positive or a false positive&#46; In order for it to be valid&#44; a control method must be used&#46; A standard control technique has yet to be established&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">49</span></a> One approach is to administer 2 nerve blocks&#44; one with a short-acting local anaesthetic &#40;lidocaine&#41; and another with a long-acting local anaesthetic &#40;bupivacaine&#41;&#59; this type of block is called a double&#44; or comparative&#44; block&#46; A comparative block can be positive and concordant&#44; that is&#44; the duration of pain relief corresponds with the duration of action of the local anaesthetic used&#44; or positive and discordant&#44; in which relief in both cases does not correspond to the estimated duration of action of the local anaesthetic&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">45</span></a> The performance of comparative blocks has been validated in neck pain&#44; with a specificity ranging from 65&#37; to 88&#37;&#44; depending on the cutoff pain level<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">50</span></a> used to determine positivity&#46; However&#44; they have not been validated in low back pain&#46; This is because a high percentage &#40;over 50&#37;&#41; of cases of chronic cervicalgia are facet joint-related&#44; while the prevalence of facet joint-related low back pain is lower&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">6</span></a> and depends to a great extent on the age of the individual&#46; This has led to the performance of placebo-controlled blocks&#44; in which local anaesthetic and saline are administered during the diagnostic test&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pain relief cutoff point</span><p id="par0095" class="elsevierStylePara elsevierViewall">Another important issue is the cut-off value used to determine pain relief during diagnostic nerve block&#44; that is&#44; whether 50&#37; relief of baseline pain is considered positive&#44; or 80&#37; of 100&#37; of baseline pain&#46; The sensitivity and specificity data available for diagnostic MBB have been determined with 100&#37; pain relief&#46; This suggest that lowering the pain relief cutoff point &#40;considering the block positive if it alleviates less than 100&#37; of baseline pain&#41; will give worse results&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">51</span></a> It would also suggest that the cause of low back pain could be multifactorial&#44; that is&#44; not exclusively lumbar facet joint-related&#46; However&#44; certain studies have shown that the presence of facet joint-related pain&#44; together with discogenic pain or sacroiliac pain&#44; occurs in only 5&#37; of patients&#59; therefore&#44; chronic low back pain is unlikely to have a multifactorial aetiology&#46;<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">52&#44;53</span></a> The performance of more than one diagnostic block for the diagnosis of facet joint-related low back pain continues to be controversial&#44; and authors such as Cohen report that this approach is not cost-effective&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">54</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Performance of diagnostic nerve blocks</span><p id="par0100" class="elsevierStylePara elsevierViewall">For the best results&#44; diagnostic MBB should always be image-guided&#46; CT-guided techniques&#44;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">55</span></a> undoubtedly the most accurate&#44; have been described&#44; although the radiation received by the patient calls into question their usefulness in routine clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">56</span></a> Ultrasound-guided techniques<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">57&#8211;59</span></a> have become increasingly popular&#44; and have clear advantages in terms of radiation exposure of patients and doctors&#46; Although some comparative studies have shown their effectiveness when compared to fluoroscopy and CT&#44;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">60</span></a> they are retrospective and methodologically deficient&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The most widely accepted technique is fluoroscopically-guided nerve block&#46; We will briefly describe the technique recommended by the Spine Intervention Society&#44; which is accepted by many pain societies&#44; including the Australian and New Zealand Society of Anaesthetists&#44; the American Academy of Pain Medicine and the British Pain Society&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">41</span></a></p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Fluoroscopically-guided nerve block</span><p id="par0110" class="elsevierStylePara elsevierViewall">The patient is placed in the prone position&#44; with a small pillow under the hips to correct lumbar lordosis&#46; Check that the patient does not present any transitional anomaly at the vertebral level&#44; as this would complicate the initial management of low back pain&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">61</span></a> The level of the nerve block will depend on the patient&#39;s symptoms and possible signs of joint degeneration &#40;if present&#41; on specific imaging tests&#44; such as lumbar CT or MRI&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">41</span></a> It is important to bear in mind that FJs are innervated by 2 MBDRs&#44; so a multisegmentary blockade is required&#46; The block is usually performed at the level of MBDR L2&#44; MBDR L3&#44; MBDR L4 and the posterior ramus of L5&#46; An anteroposterior image is obtained and an attempt is made to &#8220;square&#8221; the vertebral disc above the level to be treated &#40;so that the X-ray beam is directed parallel to the upper vertebral disc&#41;&#46; Once squared&#44; an oblique&#44; 30&#8211;40&#176; ipsilateral image is obtained&#44; although this will depend on the patient&#39;s anatomy and physiognomy&#46; Try to avoid the &#8220;parallax effect&#8221;&#44; which involves the apparent displacement or the difference in apparent direction of an object as seen from 2 different points not on a straight line with the object&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">62</span></a> The &#8220;parallax&#8221; effect distorts the fluoroscopy Image 63 Image&#44;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">63</span></a> and is avoided by placing the target area in the centre of the image&#46; Once the oblique image has been obtained&#44; the junction between the SAP and the transverse process is located&#46; The blocking needle is advanced using the &#8220;tunnel vision&#8221; technique&#44; so that it is seen as a dot on the fluoroscopy monitor &#40;i&#46;e&#46;&#44; the needle is parallel to the X-ray beam&#41;&#46; The needle is advanced as far as the periosteum&#46; Anteroposterior&#44; oblique&#44; lateral and &#8220;tilted&#8221; images are obtained &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3&#8211;6</a>&#41;&#46; This latter view is very important&#44; since it shows the tip of the needle with respect to the junction between the PAS and the transverse process &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; It is obtained with the c-arm positioned cranial and the collimator caudal with respect to the patient&#46; Once the needle is correctly placed&#44; 0&#46;1&#8211;0&#46;3<span class="elsevierStyleHsp" style=""></span>ml of non-ionic iodinated contrast medium suitable for myelography is administered&#46; It is essential to observe the spread of contrast medium&#44; since the local anaesthetic injected later will follow the same pattern&#46; The contrast should spread around the pedicle of the SAP without penetrating the foramen or spreading laterally &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; If this is not achieved&#44; change the position of the needle&#46; No sign contrast on the fluoroscopy monitor probably indicates intravascular injection&#44; which occurs in up to 3&#46;7&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">64</span></a> although it could also indicate intraosseous injection&#44; since the prevalence of facet syndrome is higher in elderly patients who are also more likely to present osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">65</span></a> Finally&#44; it should be noted that the diagnostic block should only be performed with local anaesthetic&#59; no steroids should be administered&#44; as they can alter the result&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">66</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ultrasound-guided nerve block</span><p id="par0115" class="elsevierStylePara elsevierViewall">Several ultrasound-guided techniques for MBB and lumbar facet joint block have been described&#44; and their efficacy has been demonstrated in comparative studies with CT&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">58&#44;67&#8211;70</span></a> The patient is placed in the prone position&#59; a convex transducer is preferably used&#44; placed transversely above the spinous process to be treated&#46; The acoustic shadow of the spinous process should be visualised in the middle part of the ultrasound screen&#46; The transducer is moved slowly in a caudal direction until the lower transverse process is observed&#46; A 22<span class="elsevierStyleHsp" style=""></span>G spinal needle is inserted in plane until it contacts the bone at the junction between superior articular process and the transverse process&#44; which is where the MBDR is located&#46; After negative aspiration&#44; less than 0&#46;5<span class="elsevierStyleHsp" style=""></span>ml of local anaesthetic is injected&#46; The presence of the prominent iliac crests may obstruct the in-plane view at the level of the transverse processes of L5 and the posterior ramus of L5&#46; The main problem with ultrasound-guided block is the absence of contrast&#46; We believe that the use of contrast to predict the posterior spread of the anaesthetic is of paramount importance for successful diagnostic MBB&#46; Combined ultrasound-fluoroscopy techniques&#44; which reduce radiation exposure&#44; both for patients and health personnel&#44; are probably the best approach&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">After the nerve block</span><p id="par0120" class="elsevierStylePara elsevierViewall">Once the block has been performed&#44; if it is positive &#40;depending on the criteria used&#41;&#44; a longer lasting pain relief technique&#44; such as thermal radiofrequency<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">71</span></a> or cryopdenervation can be performed&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">72</span></a> If the diagnostic block is negative&#44; other possible causes of chronic low back pain should be considered&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">According to Hildebrandt&#44;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">73</span></a> the diagnostic use of neural blockade rests on three premises&#46; First&#44; pathology causing pain is located in an exact peripheral location&#44; and impulses from this site travel along a unique and consistent neural root&#46; Second&#44; injection of local anaesthetic totally abolishes the sensory function of intended nerves and does not affect other nerves&#46; Third&#44; pain relief after local anaesthetic block is attributable solely to blockade of the target afferent neural pathway&#46; For Hildebrandt&#44; however&#44; the validity of these assumptions is limited by complexities of anatomy&#44; physiology&#44; and the important part that psychology plays in pain perception&#46; Analysing Hildebrandt&#39;s premises shows that facet joint pain is transmitted in a consistent manner&#44; that standardised administration of local anaesthetic following the SIS guidelines &#40;anatomically accurate location&#44; low volume&#44; monitored spread of contrast&#41; will anaesthetise the MBDR&#44; and finally&#44; that achieving adequate blockade&#44; that is&#44; without the use of corticosteroids&#44; and establishing a high cutoff value for positivity&#44; will provide pain relief by blocking the afferent pathway&#46; This is why&#44; despite Hildebrandt&#39;s remarks&#44; performing the standard nerve block exactly as indicated is undoubtedly a valid diagnostic procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">74</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">One of the innovations introduced in pain units in the last decade has been the use of diagnostic nerve blocks to help manage patients with complex pain&#46; These are usually diagnostic&#44; and can predict the main structure that generates pain&#46; Accurate administration of the blockade followed by scientific&#44; ethical analysis of the results will allow clinicians to choose the most appropriate treatment&#44; such as radiofrequency denervation<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">75</span></a> or cryopdenervation&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">72</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Three aspects of diagnostic nerve block remain controversial&#46; The first is the number or type of blocks to be administered&#46; Although some studies question not only the benefit of controlled nerve blocks&#44; but also the efficacy and cost-effectiveness of this diagnostic technique&#44;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">54</span></a> we believe that it can effectively reduce the number of false positives&#44; and thus improve the outcomes of denervation procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">76</span></a> However&#44; in the public health system it is difficult to perform double diagnostic blocks due to long waiting lists&#44; and this can have a negative impact on the subsequent denervation technique&#46; The second controversial aspect is the cut-off value used to establish positivity of a block&#44; that is&#44; whether a block with 50&#37;&#44; 80&#37; or 100&#37; of relief from baseline pain should be considered positive&#46; The more optimal the cut-off point to establish positivity of the diagnostic block&#44; the better the outcome of the denervation procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">77</span></a> Finally&#44; the question remains as to whether the diagnostic block should involve the nerves that innervate the joint &#40;lumbar MBB&#41; or the joint itself &#40;intra facetary block&#41;&#46; We believe that since radiofrequency denervation or cryodenervation will be the most effective treatment in the long run&#44; it is best to block the same structure that will later be treated&#46; Moreover&#44; diagnostic MBBs have been validated&#44; while intrafacetary blocks have not&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">78</span></a> Finally&#44; we believe that given their size and histological complexity&#44; piercing FJs with the nerve block needle could accelerate the existing degenerative process&#44; as shown by Carragee in diagnostic discography&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">37</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In a recent article&#44; Cohen shows that intra-facial infiltrations of local anaesthetic and corticosteroids do not have long-term analgesic benefit&#44; although they could benefit certain patients in whom denervation of the multifidus muscle &#40;which is unavoidable in radiofrequency denervation of the MBDR&#41; could be harmful&#44; such as young people with inflammatory processes or athletes&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">79</span></a> Some cases of camptocormia&#44; a postural disorder that is characterised by excessive flexion of the spine&#44; after repeated denervation of the multifidus muscle following radiofrequency treatment of the MBDR have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">80</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">FJs can cause of chronic low back pain&#46; Physical examination&#44; patient-reported pain patterns&#44; and imaging tests do not have the sensitivity and specificity required to predict whether low back pain is facet joint-related&#46; Diagnostic nerve blocks&#44; correctly performed in accordance with the guidelines of the Spine Intervention Society&#44;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">41</span></a> are effective in establishing FJ as a possible cause of low back pain&#44; which is an indication for denervation procedures to achieve lasting relief&#46; Ideally&#44; the nerve blocks should be double comparative or controlled&#44; performed under fluoroscopy with &#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>ml radiographic contrast medium using various views&#44; including anteroposterior&#44; oblique and &#8220;tilted&#8221; to optimise vision of the tip of the needle&#46; It is essential to use contrast medium and observe its spread&#44; as this will predict the spread of the local anaesthetic to the MBDR and will rule out intravascular or intraosseous injection&#46; Further multicentre randomised studies are needed to establish the best method of reliably diagnosing facet joint-related low back pain&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The principal author has no conflict of interest to declare&#46; The main author is the Chairman of the International Education Committee of the Spine Intervention Society&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:16 [
        0 => array:3 [
          "identificador" => "xres1183074"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1103662"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1183073"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1103661"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Anatomy of zygapophyseal or facet joints"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "The facet joints are the cause of low back pain"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Facet joint-related low back pain"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Physical examination in low back pain"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Imaging tests in lumbar pain"
        ]
        10 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Nerve block diagnosis of lumbar pain"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Validity of diagnostic nerve blocks"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Pain relief cutoff point"
            ]
          ]
        ]
        11 => array:3 [
          "identificador" => "sec0050"
          "titulo" => "Performance of diagnostic nerve blocks"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Fluoroscopically-guided nerve block"
            ]
            1 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Ultrasound-guided nerve block"
            ]
            2 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "After the nerve block"
            ]
          ]
        ]
        12 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Discussion"
        ]
        13 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Conclusions"
        ]
        14 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conflicts of interest"
        ]
        15 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-10-01"
    "fechaAceptado" => "2018-11-13"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1103662"
          "palabras" => array:4 [
            0 => "Diagnostic block"
            1 => "Low back pain"
            2 => "Facet joint syndrome"
            3 => "Medial branch radiofrequency neurotomy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1103661"
          "palabras" => array:4 [
            0 => "Bloqueo diagn&#243;stico"
            1 => "Lumbalgia"
            2 => "S&#237;ndrome facetario"
            3 => "Radiofrecuencia del ramo medial lumbar"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Low back pain is currently one of the main public health problems&#46; Among the multiple causes&#44; pain in the zygapophysial joints&#44; also called facets or posterior vertebral joints&#44; are an important cause&#44; usually secondary to osteoarthritis&#46; The source of low back pain is often difficult to find&#44; making the therapeutic approach to the patient sub-optimal&#46; Diagnostic blocks are a very important tool in establishing an adequate treatment for patients with low back pain&#44; as long as they are performed accurately&#44; with an adequate local anaesthetic volume&#44; with a suitable image and fluoroscopic projection and its result are precisely interpreted&#46; In this article a review is presented on the importance of diagnostic blocks&#44; as well as how they should be performed in order to obtain the maximum information and the greatest therapeutic benefit&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El dolor lumbar o lumbalgia es uno de los principales problemas de salud p&#250;blica de la sociedad actual&#46; De entre las m&#250;ltiples causas de la misma las articulaciones zigoapofisarias&#44; tambi&#233;n denominadas facetas o articulaciones vertebrales posteriores&#44; son una causa importante&#44; generalmente secundaria a artrosis&#46; El diagn&#243;stico de la causa de la lumbalgia suele ser en muchas ocasiones dif&#237;cil&#44; haciendo que el enfoque terap&#233;utico del paciente no sea el &#243;ptimo&#46; Los bloqueos diagn&#243;sticos constituyen una herramienta de suma importancia para establecer un tratamiento adecuado del paciente con lumbalgia&#44; siempre y cuando sean realizados de manera precisa&#44; con un volumen adecuado de anest&#233;sico local&#44; con una imagen y proyecci&#243;n fluorosc&#243;pica id&#243;nea y el resultado sea interpretado de manera exacta&#46; En el siguiente art&#237;culo revisaremos la importancia de los bloqueos diagn&#243;sticos&#44; as&#237; como el modo en que deben ser realizados&#44; para obtener la m&#225;xima informaci&#243;n de los mismos y el mayor beneficio terap&#233;utico&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; de Andr&#233;s Ares J&#44; Gilsanz F&#46; Bloqueos diagn&#243;sticos en el manejo del paciente con lumbalgia secundaria a s&#237;ndrome facetario&#46; Rev Esp Anestesiol Reanim&#46; 2019&#59;66&#58;213&#8211;221&#46;</p>"
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1269
            "Ancho" => 1500
            "Tamanyo" => 304256
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Diagram showing the position of the medial ramus&#44; which is targeted in diagnostic blocks to determine whether the patient&#39;s low back pain in facet joint-related &#40;AZAP&#41;&#46; GRD&#58; dorsal root ganglion&#59; 1&#58; ventral ramus&#59; 2&#58; dorsal raums&#59; 3&#58; lateral branch of the dorsal ramus&#59; 4&#58; medial branch of the dorsal ramus&#59; 5&#58; articular branch for the FJ at the same level&#59; 6&#58; articular branch for the FJ one level down&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1009
            "Ancho" => 1500
            "Tamanyo" => 281771
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Image showing the anteroposterior view of the vertebral bodies of L2&#8211;L3&#8211;L4 and L5 &#40;in grey&#41;&#46; The lines show the course of the medial branch of the dorsal ramus &#40;MBDR&#41;&#46; Note that the MBDR of L2 &#40;number 1&#41; passes over the junction of the superior articular process of the L3 vertebra and its transverse process&#44; and gives 2 branches&#44; one for the facet joint &#40;FJ&#41; L2&#8211;L3&#44; and another for FJ L3&#8211;L4&#46; Note that the MBDR of L3 &#40;number 2&#41; passes over the junction of the superior articular process of the L4 vertebra and its transverse process&#44; and gives 2 branches&#44; one for facet joint &#40;FJ&#41; L3&#8211;L4&#44; and another for FJ L4&#8211;L5&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1064
            "Ancho" => 1500
            "Tamanyo" => 233109
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Oblique view&#58; diagram showing the target injection site to block the medial branch of the dorsal nerve&#46; Note that the image is oblique&#46; The numbers mark the site of the juction between the superior articular process of L3 and its transverse process&#44; which corresponds to the MBDR of L2 &#40;number 1&#41;&#44; MBDR of L3 &#40;number 2&#41; and MBDR of L4 &#40;number 3&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1115
            "Ancho" => 1500
            "Tamanyo" => 195046
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Oblique view&#58; insertion of the blocking needles in the junction between the superior articular process and its transverse process&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1214
            "Ancho" => 1500
            "Tamanyo" => 209085
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Anteroposterior view&#46; Anteroposterior view&#44; showing the position of the needles for diagnostic block&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 1148
            "Ancho" => 1500
            "Tamanyo" => 214923
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">&#8220;Tilted&#8221; view&#46; Image clearly showing the margin of the junction between the superior articular process and the transverse process&#44; together with the posterior branch of 15 at the junction between the superior articular process of S1 and the sacral ala &#40;the furthest caudal&#41;&#46; Notice how the blocking needles enter the image in a cranio-caudal direction&#46; The C-arm should be below the patient&#44; in a cranio-caudal direction&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1085
            "Ancho" => 1500
            "Tamanyo" => 190834
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Contrast-enhanced &#8220;tilted&#8221; view&#46; Image showing correct spread of contrast medium&#44; except in the needle at the MBDR of L2 &#40;the furthest cranial&#41;&#44; in which the contrast spreads laterally&#46; In this case&#44; the needle must be repositioned before administering the local anaesthetic&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:80 [
            0 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "G&#46;B&#46; Andersson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Orthop Scand Suppl"
                        "fecha" => "1998"
                        "volumen" => "281"
                        "paginaInicial" => "28"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9771538"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Does back pain prevalence really decrease with increasing age&#63; A systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46;E&#46; Clermont"
                            1 => "K&#46;M&#46; Dunn"
                            2 => "P&#46;R&#46; Croft"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/ageing/afj055"
                      "Revista" => array:7 [
                        "tituloSerie" => "Age Ageing"
                        "fecha" => "2006"
                        "volumen" => "35"
                        "paginaInicial" => "229"
                        "paginaFinal" => "234"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16547119"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S1470204513701438"
                          "estado" => "S300"
                          "issn" => "14702045"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0415"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Aust Fam Physician"
                        "fecha" => "1895"
                        "volumen" => "14"
                        "paginaInicial" => "1168"
                        "paginaFinal" => "1172"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2935131"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0420"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Placing the global burden of low back pain in context"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Buchbinder"
                            1 => "F&#46;M&#46; Blyth"
                            2 => "L&#46;M&#46; March"
                            3 => "P&#46; Brooks"
                            4 => "A&#46;D&#46; Woolf"
                            5 => "D&#46;G&#46; Hoy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Best Prac Res Clin Rheumatol"
                        "fecha" => "2013"
                        "volumen" => "27"
                        "paginaInicial" => "575"
                        "paginaFinal" => "589"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0425"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical features of patients with pain stemming from the lumbar zygapophysial joints&#46; Is the lumbar facet syndrome a clinical entity&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46;C&#46; Schwarzer"
                            1 => "C&#46;N&#46; Aprill"
                            2 => "R&#46; Derby"
                            3 => "J&#46; Fortin"
                            4 => "G&#46; Kine"
                            5 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1994"
                        "volumen" => "19"
                        "paginaInicial" => "1132"
                        "paginaFinal" => "1137"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8059268"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0430"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and clinical features of lumbar zygapophysial joint pain&#46; A study in an Australian population with chronic low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46;C&#46; Schwarzer"
                            1 => "S&#46; Wang"
                            2 => "N&#46; Bogduk"
                            3 => "P&#46;J&#46; Mc-Naught"
                            4 => "R&#46; Laurent"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Rheum Dis"
                        "fecha" => "1995"
                        "volumen" => "54"
                        "paginaInicial" => "100"
                        "paginaFinal" => "106"
                        "itemHostRev" => array:3 [
                          "pii" => "S0022202X17314823"
                          "estado" => "S300"
                          "issn" => "0022202X"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0435"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical anatomy of the lumbar spine and sacrum"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2005"
                        "editorial" => "Elsevier Health Sciences"
                        "editorialLocalizacion" => "Philadelphia"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0440"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The anatomy of the so-called &#8220;articular nerves&#8221; and their relationship to facet denervation in the treatment of low-back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "N&#46; Bogduk"
                            1 => "D&#46;M&#46; Long"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/jns.1979.51.2.0172"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg"
                        "fecha" => "1979"
                        "volumen" => "51"
                        "paginaInicial" => "172"
                        "paginaFinal" => "177"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/156249"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0445"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The human lumbar dorsal rami"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "N&#46; Bogduk"
                            1 => "A&#46;S&#46; Wilson"
                            2 => "W&#46; Tynan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Anat"
                        "fecha" => "1982"
                        "volumen" => "134"
                        "paginaInicial" => "383"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7076562"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0450"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Low back pain with special reference to the articular facets&#44; with presentation of an operative procedure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46;K&#46; Ghormley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Med Assoc"
                        "fecha" => "1933"
                        "volumen" => "101"
                        "paginaInicial" => "1773"
                        "paginaFinal" => "1777"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0455"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The anatomical basis for low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Hirsch"
                            1 => "B&#46; Ingelmark"
                            2 => "M&#46; Miller"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Orthop Scand"
                        "fecha" => "1963"
                        "volumen" => "33"
                        "paginaInicial" => "1"
                        "paginaFinal" => "17"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13961170"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0460"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of the spinal facets in back and sciatic pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46;N&#46; Shealy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Headache"
                        "fecha" => "1974"
                        "volumen" => "14"
                        "paginaInicial" => "101"
                        "paginaFinal" => "104"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4277724"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0465"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Percutaneous radiofrequency denervation of spinal facets"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46;N&#46; Shealy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/jns.1975.43.4.0448"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Neurosurg"
                        "fecha" => "1975"
                        "volumen" => "43"
                        "paginaInicial" => "448"
                        "paginaFinal" => "451"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/125787"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0022202X15370810"
                          "estado" => "S300"
                          "issn" => "0022202X"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0470"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The facet syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "V&#46; Mooney"
                            1 => "J&#46; Robertson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Orthop"
                        "fecha" => "1976"
                        "volumen" => "115"
                        "paginaInicial" => "149"
                        "paginaFinal" => "156"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0475"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Induced pain referral from posterior lumbar elements in normal subjects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "I&#46;W&#46; McCall"
                            1 => "W&#46;M&#46; Park"
                            2 => "J&#46;P&#46; O&#8217;Brien"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1979"
                        "paginaInicial" => "441"
                        "paginaFinal" => "446"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0480"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Fukui"
                            1 => "K&#46; Ohseto"
                            2 => "M&#46; Shiotani"
                            3 => "K&#46; Ohno"
                            4 => "H&#46; Karasawa"
                            5 => "Y&#46; Naganuma"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin J Pain"
                        "fecha" => "1997"
                        "volumen" => "13"
                        "paginaInicial" => "303"
                        "paginaFinal" => "307"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9430810"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0485"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The facet joint and its role in spine pain&#46; Management with facet joint injections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46;B&#46; Lippitt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1984"
                        "volumen" => "9"
                        "paginaInicial" => "746"
                        "paginaFinal" => "750"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6239395"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The lumbar facet syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "T&#46; Helbig"
                            1 => "C&#46;K&#46; Lee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/2010.3.SPINE09530"
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1988"
                        "volumen" => "13"
                        "paginaInicial" => "61"
                        "paginaFinal" => "64"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20594019"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Facet joint degeneration as a cause of low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "G&#46;E&#46; Lewinnek"
                            1 => "C&#46;A&#46; Warfield"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Orthop"
                        "fecha" => "1986"
                        "volumen" => "213"
                        "paginaInicial" => "216"
                        "paginaFinal" => "222"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lumbar facet syndrome&#46; Recommendation for staging before and after intra-articular injection treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Schleifer"
                            1 => "M&#46; Kiefer"
                            2 => "T&#46; Hagen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiologe"
                        "fecha" => "1995"
                        "volumen" => "35"
                        "paginaInicial" => "844"
                        "paginaFinal" => "847"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8657888"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomy of facet joints and its correlation with low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46;K&#46; Selby"
                            1 => "S&#46;V&#46; Paris"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Contemp Orthop"
                        "fecha" => "1981"
                        "volumen" => "312"
                        "paginaInicial" => "1097"
                        "paginaFinal" => "1103"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Facet joint block for low back pain&#46; Identifying predictors of a good response"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;E&#46; Revel"
                            1 => "V&#46;M&#46; Listrat"
                            2 => "X&#46;J&#46; Chevalier"
                            3 => "M&#46; Dougados"
                            4 => "M&#46;P&#46; N&#8217;guyen"
                            5 => "C&#46; Vallee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Phys Med Rehabil"
                        "fecha" => "1992"
                        "volumen" => "73"
                        "paginaInicial" => "824"
                        "paginaFinal" => "828"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1387521"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0515"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia&#46; Proposed criteria to identify patients with painful facet joints"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Revel"
                            1 => "S&#46; Poiraudeau"
                            2 => "G&#46;R&#46; Auleley"
                            3 => "C&#46; Payan"
                            4 => "A&#46; Denke"
                            5 => "M&#46; Nguyen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1998"
                        "volumen" => "23"
                        "paginaInicial" => "1972"
                        "paginaFinal" => "1977"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9779530"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Apophyseal injection of local anesthetic as a diagnostic aid in primary low-back pain syndromes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;C&#46; Fairbank"
                            1 => "W&#46;M&#46; Park"
                            2 => "I&#46;W&#46; McCall"
                            3 => "J&#46;P&#46; O&#8217;brien"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1981"
                        "volumen" => "6"
                        "paginaInicial" => "598"
                        "paginaFinal" => "605"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6461072"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0525"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Radiofrequency lumbar facet denervation&#46; Analysis of prognostic factors"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46;B&#46; North"
                            1 => "M&#46; Han"
                            2 => "M&#46; Zahurak"
                            3 => "D&#46;H&#46; Kidd"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pain"
                        "fecha" => "1994"
                        "volumen" => "57"
                        "paginaInicial" => "77"
                        "paginaFinal" => "83"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8065800"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0530"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Facet joint injection in low back pain&#46; A prospective study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46;P&#46; Jackson"
                            1 => "R&#46;R&#46; Jacobs"
                            2 => "P&#46;X&#46; Montesano"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1988"
                        "volumen" => "13"
                        "paginaInicial" => "966"
                        "paginaFinal" => "971"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2974632"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0535"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Correlation of clinical examination characteristics with three sources of chronic low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Young"
                            1 => "C&#46; Aprill"
                            2 => "M&#46; Laslett"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine J"
                        "fecha" => "2003"
                        "volumen" => "3"
                        "paginaInicial" => "460"
                        "paginaFinal" => "465"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14609690"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0540"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-informed management of chronic back pain with facet injections and radiofrequency neurotomy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.spinee.2007.10.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine J"
                        "fecha" => "2008"
                        "volumen" => "8"
                        "paginaInicial" => "56"
                        "paginaFinal" => "64"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18164454"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0545"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoarthritis of the facet joints&#58; accuracy of oblique radiographic measurement"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Pathria"
                            1 => "D&#46;J&#46; Sartoris"
                            2 => "D&#46; Resnick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiology.164.1.3588910"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiology"
                        "fecha" => "1987"
                        "volumen" => "164"
                        "paginaInicial" => "227"
                        "paginaFinal" => "230"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3588910"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0550"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "MR imaging and CT in osteoarthritis of the lumbar facet joints"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46; Weishaupt"
                            1 => "M&#46; Zanetti"
                            2 => "N&#46; Boos"
                            3 => "J&#46; Hodler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Skeletal Radiol"
                        "fecha" => "1999"
                        "volumen" => "28"
                        "paginaInicial" => "215"
                        "paginaFinal" => "219"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10384992"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0555"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoarthritis of the facet joints&#58; accuracy of oblique radiographic assessment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Pathria"
                            1 => "D&#46;J&#46; Sartoris"
                            2 => "D&#46; Resnick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiology.164.1.3588910"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiology"
                        "fecha" => "1987"
                        "volumen" => "164"
                        "paginaInicial" => "227"
                        "paginaFinal" => "230"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3588910"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0560"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Facet joint osteoarthritis and low back pain in the community-based population"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Kalichman"
                            1 => "L&#46; Li"
                            2 => "D&#46; Kim"
                            3 => "A&#46; Guermazi"
                            4 => "V&#46; Berkin"
                            5 => "C&#46;J&#46; O&#8217;Donnell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/BRS.0b013e318184ef95"
                      "Revista" => array:5 [
                        "tituloSerie" => "Spine"
                        "fecha" => "2008"
                        "volumen" => "33"
                        "paginaInicial" => "2560"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18923337"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0565"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Low back pain&#58; prediction of short-term outcome of facet joint injection with bone scintigraphy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;G&#46; Pneumaticos"
                            1 => "S&#46;N&#46; Chatziioannou"
                            2 => "J&#46;A&#46; Hipp"
                            3 => "W&#46;H&#46; Moore"
                            4 => "S&#46;I&#46; Esses"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiol.2382041930"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiology"
                        "fecha" => "2006"
                        "volumen" => "238"
                        "paginaInicial" => "693"
                        "paginaFinal" => "698"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16436824"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0570"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The value of SPECT scans in identifying back pain likely to benefit from the facet joint injection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;L&#46; Dolan"
                            1 => "P&#46;J&#46; Ryan"
                            2 => "N&#46;K&#46; Arden"
                            3 => "R&#46; Stratton"
                            4 => "J&#46;R&#46; Wedley"
                            5 => "W&#46; Hamann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Rheumatol"
                        "fecha" => "1996"
                        "volumen" => "35"
                        "paginaInicial" => "1269"
                        "paginaFinal" => "1273"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9010055"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0575"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Correlation of 99m Tc-DPD SPECT&#47;CT scan findings and diagnostic blockades of lumbar medial branches in patients with unspecific low back pain in a randomized-controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Freiermuth"
                            1 => "M&#46; Kretzschmar"
                            2 => "S&#46; Bilecen Schaeren"
                            3 => "A&#46;L&#46; Jacob"
                            4 => "A&#46; Aeschbach"
                            5 => "W&#46; Ruppen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pme.12841"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pain Med"
                        "fecha" => "2015"
                        "volumen" => "16"
                        "paginaInicial" => "1916"
                        "paginaFinal" => "1922"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26177035"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0580"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnostic blocks&#46; A truth serum for malingering"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin J Pain"
                        "fecha" => "2004"
                        "volumen" => "20"
                        "paginaInicial" => "409"
                        "paginaFinal" => "414"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15502684"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0585"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ISSLS Prize Winner&#58; does discography cause accelerated progression of degeneration changes in the lumbar disc&#58; a ten-year matched cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;J&#46; Carragee"
                            1 => "A&#46;S&#46; Don"
                            2 => "E&#46;L&#46; Hurwitz"
                            3 => "J&#46;M&#46; Cuellar"
                            4 => "J&#46; Carrino"
                            5 => "R&#46; Herzog"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/BRS.0b013e3181ab5432"
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "2009"
                        "volumen" => "34"
                        "paginaInicial" => "2338"
                        "paginaFinal" => "2345"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19755936"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0590"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnostic and therapeutic nerve blocks"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Curatolo"
                            1 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "titulo" => "Bonica&#39;s management of pain"
                        "paginaInicial" => "1401"
                        "paginaFinal" => "1423"
                        "edicion" => "4th ed&#46;"
                        "serieFecha" => "2010"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0595"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Specificity of lumbar medial branch and L5 dorsal ramus blocks&#58; a computed tomography study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46; Dreyfuss"
                            1 => "A&#46;C&#46; Schwarzer"
                            2 => "P&#46; Lau"
                            3 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1997"
                        "volumen" => "22"
                        "paginaInicial" => "895"
                        "paginaFinal" => "902"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9127924"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0600"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint&#58; a physiologic challenge"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Kaplan"
                            1 => "P&#46; Dreyfuss"
                            2 => "B&#46; Halbrook"
                            3 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1998"
                        "volumen" => "23"
                        "paginaInicial" => "1847"
                        "paginaFinal" => "1852"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9762741"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0605"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Bogduk N&#44; editor&#46; Practice guidelines for spinal diagnostic and treatment procedures 2013&#46; San Francisco&#58; International Spine Intervention Society&#59; 2013&#46;"
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0610"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Principles of diagnostic blocks&#46; Interventional spine&#58; an algorithmic approach"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:5 [
                        "fecha" => "2008"
                        "paginaInicial" => "187"
                        "paginaFinal" => "192"
                        "editorial" => "Saunders Elsevier"
                        "editorialLocalizacion" => "Philadelphia"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0615"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnostic blocks&#58; a truth serum for malingering"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin J Pain"
                        "fecha" => "2004"
                        "volumen" => "20"
                        "paginaInicial" => "409"
                        "paginaFinal" => "414"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15502684"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0620"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "International Spinal Injection Society guidelines for the performance of spinal injection procedures&#46; Part 1&#58; zygapophysial joint blocks"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46; Bogduk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin J Pain"
                        "fecha" => "1997"
                        "volumen" => "13"
                        "paginaInicial" => "285"
                        "paginaFinal" => "302"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9430809"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0625"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparative local anesthetic blocks in the diagnosis of cervical zygapophysial joints pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Barnsley"
                            1 => "S&#46; Lord"
                             …1
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pain"
                        "fecha" => "1993"
                        "volumen" => "55"
                        "paginaInicial" => "99"
                        "paginaFinal" => "106"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0630"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prolonged relief of neuralgia after regional anesthetic blocks&#58; a call for further experimental and systematic clinical studies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pain"
                        "fecha" => "1990"
                        "volumen" => "43"
                        "paginaInicial" => "287"
                        "paginaFinal" => "297"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0635"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A double-blind trial of bupivacaine and lignocaine&#58; latency and duration in extradural blockade"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesthesia"
                        "fecha" => "1968"
                        "volumen" => "23"
                        "paginaInicial" => "331"
                        "paginaFinal" => "337"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0640"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The value of the provocation response in lumbar zygapophyseal joint injections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin J Pain"
                        "fecha" => "1994"
                        "volumen" => "10"
                        "paginaInicial" => "309"
                        "paginaFinal" => "313"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0645"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "On the rational use of diagnostic blocks for spinal pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Neurosurg Q"
                        "fecha" => "2009"
                        "volumen" => "19"
                        "paginaInicial" => "88"
                        "paginaFinal" => "100"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0650"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin J Pain"
                        "fecha" => "1995"
                        "volumen" => "11"
                        "paginaInicial" => "208"
                        "paginaFinal" => "213"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0655"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Making sense of the accuracy of diagnostic lumbar facet joint nerve blocks&#58; an assessment of the implications of 50&#37; relief&#44; 80&#37; relief&#44; single block&#44; or controlled diagnostic blocks"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Pain Phys"
                        "fecha" => "2010"
                        "volumen" => "13"
                        "paginaInicial" => "133"
                        "paginaFinal" => "143"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0660"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The relative contributions of the disc and zygapophyseal joint in chronic low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1994"
                        "volumen" => "19"
                        "paginaInicial" => "801"
                        "paginaFinal" => "806"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0665"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The sacroiliac joint in chronic low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1995"
                        "volumen" => "20"
                        "paginaInicial" => "31"
                        "paginaFinal" => "37"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0670"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multicenter&#44; randomized&#44; comparative cost-effectiveness study comparing 0&#44; 1&#44; and 2 diagnostic medial branch &#40;facet joint nerve&#41; block treatment paradigms before lumbar facet radiofrequency denervation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ALN.0b013e3181e33ae5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2010"
                        "volumen" => "113"
                        "paginaInicial" => "395"
                        "paginaFinal" => "405"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0675"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Technique for CT fluoroscopy-guided lumbar medial branch blocks and radiofrequency ablation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Roentgenol"
                        "fecha" => "2016"
                        "volumen" => "207"
                        "paginaInicial" => "631"
                        "paginaFinal" => "634"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0680"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Radiation exposure in CT-guided interventions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejrad.2013.08.035"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Radiol"
                        "fecha" => "2013"
                        "volumen" => "82"
                        "paginaInicial" => "2253"
                        "paginaFinal" => "2257"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0685"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound-guided lumbar facet nerve block&#58; a sonoanatomic study of a new methodologic approach"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2004"
                        "volumen" => "100"
                        "paginaInicial" => "1242"
                        "paginaFinal" => "1248"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0690"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound-guided lumbar medialbranch block&#58; a clinical study with fluoroscopy control"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rapm.2006.06.246"
                      "Revista" => array:6 [
                        "tituloSerie" => "Reg Anesth Pain Med"
                        "fecha" => "2006"
                        "volumen" => "31"
                        "paginaInicial" => "451"
                        "paginaFinal" => "454"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0695"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound for lumbar spinal procedures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Phys Med Rehabil Clin North Am"
                        "fecha" => "2018"
                        "volumen" => "29"
                        "paginaInicial" => "49"
                        "paginaFinal" => "60"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0700"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain&#58; a retrospective comparative study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/MD.0000000000006655"
                      "Revista" => array:5 [
                        "tituloSerie" => "Medicine"
                        "fecha" => "2017"
                        "volumen" => "96"
                        "paginaInicial" => "e6655"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0705"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lumbosacral transitional vertebra&#58; relation to disc degeneration and low back pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.BRS.0000107223.02346.A8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "2004"
                        "volumen" => "29"
                        "paginaInicial" => "200"
                        "paginaFinal" => "205"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0710"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Parallax&#46; Merriam-Webster Medical Dictionary&#46; <a id="intr0010" class="elsevierStyleInterRef" href="http://www2.merriamwebster.com/cgibin/mwmednlm%26book=Medical%26va=parallax">http&#58;&#47;&#47;www2&#46;Merriamwebster&#46;com&#47;cgibin&#47;mwmednlm&#38;book&#61;Medical&#38;va&#61;parallax</a>&#46;"
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0715"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The parallax effect in the evaluation of range of motion in lumbar total disc replacement"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Spine Surg"
                        "fecha" => "2008"
                        "volumen" => "2"
                        "paginaInicial" => "184"
                        "paginaFinal" => "188"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0720"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The incidence of intravascular penetration in medial branch blocks&#58; cervical&#44; thoracic&#44; and lumbar spines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/BRS.0b013e318166f03d"
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine"
                        "fecha" => "2008"
                        "volumen" => "33"
                        "paginaInicial" => "E174"
                        "paginaFinal" => "E177"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0725"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of osteoporosis in patients requiring spine surgery&#58; incidence and significance of osteoporosis in spine disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00198-007-0370-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Osteoporos Int"
                        "fecha" => "2007"
                        "volumen" => "18"
                        "paginaInicial" => "1219"
                        "paginaFinal" => "1224"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0730"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Rev Pain"
                        "fecha" => "2000"
                        "volumen" => "4"
                        "paginaInicial" => "337"
                        "paginaFinal" => "344"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0735"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of ultrasonography guided injections in patients with facet syndrome of the low lumbar spine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5535/arm.2012.36.1.66"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rehabil Med"
                        "fecha" => "2012"
                        "volumen" => "36"
                        "paginaInicial" => "66"
                        "paginaFinal" => "71"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0740"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound-guided lumbar facet nerve block&#58; accuracy of a new technique confirmed by computed tomography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2004"
                        "volumen" => "101"
                        "paginaInicial" => "1195"
                        "paginaFinal" => "1200"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0745"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound guidance for facet joint injections in the lumbar spine&#58; a computed tomography controlled feasibility study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1213/01.ANE.0000158609.64417.93"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "2005"
                        "volumen" => "101"
                        "paginaInicial" => "579"
                        "paginaFinal" => "583"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0750"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound-guided interventional procedures for lumbar pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Tech Reg Anesth Pain Manag"
                        "fecha" => "2013"
                        "volumen" => "17"
                        "paginaInicial" => "96"
                        "paginaFinal" => "106"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0755"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Spine"
                        "fecha" => "2000"
                        "volumen" => "25"
                        "paginaInicial" => "1270"
                        "paginaFinal" => "1277"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0190962214011256"
                          "estado" => "S300"
                          "issn" => "01909622"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0760"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Percutaneous cryodenervation of lumbar facet joints&#58; a prospective clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00264-006-0208-6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int Orthop"
                        "fecha" => "2007"
                        "volumen" => "31"
                        "paginaInicial" => "525"
                        "paginaFinal" => "530"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0765"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relevance of nerve blocks in treating and diagnosing low back pain is the quality decisive&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s004820100035"
                      "Revista" => array:6 [
                        "tituloSerie" => "Schmerz"
                        "fecha" => "2001"
                        "volumen" => "15"
                        "paginaInicial" => "474"
                        "paginaFinal" => "483"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0770"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Are diagnostic lumbar medial branch blocks valid&#63; Results of 2-year follow-up"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Pain Phys"
                        "fecha" => "2003"
                        "volumen" => "6"
                        "paginaInicial" => "147"
                        "paginaFinal" => "154"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0775"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The surgical anatomy of lumbar medial branch neurotomy &#40;facet denervation&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1526-4637.2004.04042.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pain Med"
                        "fecha" => "2004"
                        "volumen" => "5"
                        "paginaInicial" => "289"
                        "paginaFinal" => "298"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0780"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Controlled zygapophysial joint blocks&#58; the travesty of cost-effectiveness"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1046/j.1526-4637.2000.99104.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pain Med"
                        "fecha" => "2000"
                        "volumen" => "1"
                        "paginaInicial" => "24"
                        "paginaFinal" => "34"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0785"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Correlation of lumbar medial branch neurotomy results with diagnostic medial branch block cutoff values to optimize therapeutic outcome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1526-4637.2012.01500.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pain Med"
                        "fecha" => "2012"
                        "volumen" => "13"
                        "paginaInicial" => "1533"
                        "paginaFinal" => "1546"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0790"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnostic value of lumbar facet joint injection&#58; a prospective triple cross-over study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0027991"
                      "Revista" => array:5 [
                        "tituloSerie" => "PloS One"
                        "fecha" => "2011"
                        "volumen" => "6"
                        "paginaInicial" => "e27991"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0795"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of Lumbar Facet Joint Blocks and Predictive Value before Radiofrequency Denervation The Facet Treatment Study &#40;FACTS&#41;&#44; a Randomized&#44; Controlled Clinical Trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ALN.0000000000002274"
                      "Revista" => array:7 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2018"
                        "volumen" => "129"
                        "paginaInicial" => "517"
                        "paginaFinal" => "535"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0022202X15372845"
                          "estado" => "S300"
                          "issn" => "0022202X"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0800"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Report of an unusual complication of radiofrequency neurotomy of medial branches of dorsal rami"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Pain Phys"
                        "fecha" => "2014"
                        "volumen" => "17"
                        "paginaInicial" => "E654"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/23411929/0000006600000004/v1_201904250611/S2341192919300484/v1_201904250611/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "48761"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Continuing education"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006600000004/v1_201904250611/S2341192919300484/v1_201904250611/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300484?idApp=UINPBA00004N"
]