Pain relief that is complete within the expected region of the block for the span of the local anesthetic constitutes a positive response. If 100% of the pain in the target segment is relieved, but there is persistence of other segmental pain, this block is still classified as a positive response for that segment. If all the pain is not relieved then additional levels or other pain generators should be sought. Patients with pain apparently mediated by upper and lower segments such as C2, C3 and C5, C6 should be blocked at only two consecutive levels at a time to separate the response to the blocks. Patients with headache as the predominant symptom should have a C2-C3 TON

FIGURE 8 Lateral projection. Extra-articular third occipital nerve block. Lateral approach. The needle target is the lateral cortex superior to the joint, adjacent to the superior articular cortex, and then below the joint near the midline on lateral view. The course of this nerve is slightly variable and requires these additional sites to fully anesthetize it. The tip of the needle is withdrawn 1 to 2 mm before the injection of contrast and local anesthesia to avoid an intra-articular puncture.

block because this is the most likely source in 54% of such patients (3). This block should produce cutaneous anesthesia in the posterior occiput to be judged effective. In the case of an unsuccessful block at C2-C3, a C3 and C4 medial branch block would be the next most likely to yield a diagnosis, followed by a C1-C2 intra-articular block, if necessary. Lower neck pain is most likely to be referred from the segments C5 and C6 and less frequently from C6, C7 or C4, C5 (7).

The pain intensity response and the change in the daily activities are recorded immediately following the block, and the patient is then followed by a clinical or a telephone follow-up until pain has returned to the original level. A repeat confirmational block with another type of local anesthetic or block of additional levels is scheduled for a separate session.

Evidence of positive short term (relief lasting less than six weeks) and long term pain relief (six weeks or longer) of chronic cervical pain with intra-articular facet joint injections is limited, while in cervical medial branch blocks the evidence for short- and long-term pain relief blocks is moderate in multiple observational studies (21).

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