After a Medial Branch Block: Pain Diary, Recovery, and Next Steps

Your pain diary

Stays on this device. What you enter here is saved only in this browser, so you can close the page and come back. Nothing is sent to Modal Pain or to anyone else. Print it or bring your phone to the follow-up visit.

Before the block

Date of the block Time of the block Your usual pain (0–10), doing the activity below Choose 012345678910 The activity that usually brings the pain on (optional)

Pain scores after the block

Check	Pain (0–10)	Relief	Did the activity that usually hurtsDid the activity	Took pain medicinePain pill
15 minutes	– 012345678910	–
30 minutes	– 012345678910	–
1 hour	– 012345678910	–
1½ hours	– 012345678910	–
2 hours	– 012345678910	–
3 hours	– 012345678910	–
4 hours	– 012345678910	–
5 hours	– 012345678910	–
6 hours	– 012345678910	–
8 hours	– 012345678910	–
Next morning	– 012345678910	–

Enter your usual pain score before the block to see your relief.

Print or save my diary Start a new diary

It is 2 p.m. and the lower back pain that has made every chair a negotiation for a year is gone. The block was done at 1. The temptation is to lie on the couch and enjoy it. Do the opposite. Stand up from that chair five times, lean back, walk around the block, and write down the number. A medial branch block is not a treatment. It is a test, and the hours after it are when the test is read.

These are the instructions Dr. Alex Movshis gives after a medial branch block at Modal Pain Management. The same diary applies to genicular nerve blocks before knee ablation and lateral branch blocks before sacroiliac joint ablation. If your block was done elsewhere, the diary still works, but follow your own physician’s discharge instructions where they differ.

How to fill in the diary so it means something

The block numbs the small medial branch nerves that carry pain from the facet joints. If those joints are the source, the familiar pain should fall while the anesthetic works and come back as it wears off. Your job is to give the test a fair chance to show that.

Provoke the pain at every check. Before you score it, do whatever normally brings it on: standing up from a chair, leaning back, twisting, turning your head, walking up stairs. Pain scored while lying still is not the test. The lumbar guideline puts it plainly: a reduction in pain that comes from being less active, even a 50% reduction, should not count as a positive block, and real-time diaries are the most objective way to measure the response (Cohen 2020).

Score the familiar pain, not new soreness. The needle sites may ache. That is a different pain. Rate the one you came in with.

Keep the timing. Lidocaine typically lasts around two hours, and bupivacaine three to eight hours in some studies but not all (Hurley 2022). The diary checks at 15 and 30 minutes, then hourly to eight hours, cover both. Relief that lasts roughly as long as the anesthetic is the pattern that matters.

Don’t add pain medicine unless you need it. A pill and a block both lower the score, and the diary cannot tell them apart. If you take something, tick the box.

Why diagnostic blocks are done without sedation. Sedation can make a block look positive when it is not, and the guideline advises against using it routinely for diagnostic blocks (Cohen 2020).

Why one block is not always enough

A single block can be falsely positive. In a study of 176 patients with low back pain, 47% responded to a first lidocaine block, but only 15% confirmed with a second, longer-acting block, a false-positive rate of 38% (Schwarzer 1994). In a larger series using comparative blocks, false-positive rates were 27% in the lower back and 63% in the neck (Manchikanti 2004). Comparative blocks, where the second anesthetic lasts longer than the first, are specific but miss some true responders: in the neck, they had a specificity of 88% and a sensitivity of 54% (Lord 1995).

The trade-off is real. In a multicenter trial of patients heading toward lumbar ablation, ablation succeeded in 64% of those selected with two blocks, against 39% with one block and 33% with none. But the no-block strategy produced the most successful ablations overall and cost the least, because more people went on to treatment (Cohen 2010). This is why the guideline accepts a single block (Cohen 2020), while the Medicare policy requires two (CMS L35936). For medial branch blocks, we use two for every patient: the second, with longer-acting bupivacaine, comes at least two weeks after the first.

Recovery after the block

There is very little. The needles are fine, the volume of anesthetic is small, and the anesthetic wears off without injuring the nerves. With a long-acting anesthetic, some skin numbness can last 16 to 24 hours. Most people go back to their normal day. A bit of soreness or a small bruise at the needle sites for a day or two is common. In a prospective series of 7,500 procedures and 43,000 facet nerve blocks, there were no major complications, a small hematoma followed 1.2%, and soreness, nerve root irritation and fainting-type reactions were each reported after 1% or fewer of procedures (Manchikanti 2012).

Driving. After a lumbar block without sedation, most people drive themselves home. After blocks of the upper neck, the cervical guideline notes temporary unsteadiness (Hurley 2022), so have someone else drive and avoid ladders and bicycles for the rest of the day.

Blood thinners. Restart on the schedule you were given at discharge. The multisociety guideline groups procedures by bleeding risk and sets restart times by drug (Narouze 2018). If you are not sure, call before you take the next dose.

When pain comes back, or feels worse

The return of the pain as the anesthetic wears off is expected, and by itself it is a good sign: relief that tracks the anesthetic is exactly the pattern the test looks for. Returning pain often feels worse than it is because the contrast with the last few hours is sharp. Score it against your usual number, not against the relief.

Pain that is genuinely worse than your usual level the next day is usually soreness where the needles passed through the back muscles, and it settles within a day or two. If it is still climbing after two days, call us.

Genicular and sacroiliac blocks

The diary works the same way before knee or sacroiliac joint ablation, with one honest caveat for the knee. In a randomized trial, patients who had a genicular nerve block before cooled ablation did no better at six months than patients who went straight to ablation: 59% and 64% had at least half their pain gone (McCormick 2018). For the knee, the block is often skipped. For the sacroiliac joint, the placebo-controlled trial of lateral branch ablation selected patients with a diary recorded every 30 minutes for six hours after a diagnostic injection into the joint (Cohen 2008).

When to go to the emergency room

Serious problems after a diagnostic block are rare: there were none in the 43,000-block series (Manchikanti 2012). That is exactly why the warning signs are worth knowing. Weakness in a leg or arm that is getting worse instead of wearing off, new numbness in the groin, loss of bladder or bowel control, or fever with back or neck pain that is getting worse in the days afterward are emergencies. Call 911 or go to the nearest emergency room, and tell the team you had a spinal nerve block and on what date.

After the result

Dr. Movshis reviews the diary with you at the follow-up visit, usually one to two weeks after the block. A response points toward a confirming block or radiofrequency ablation, and the RFA aftercare instructions cover what follows. No response points toward a different source of the pain, and the routes below are where we usually look next. The medial branch block page explains who the block is for and how it is done.

If the block did not help: what that usually means

A properly placed block that leaves the familiar pain unchanged is useful information. It means the joints those nerves supply are probably not the source. These are the patterns we look at next, including for patients whose block was done elsewhere. Bring the procedure note and your imaging.

Low back and buttock pain below the belt line, worse sitting or getting out of a car, unchanged by a lumbar block

Usually: Sacroiliac joint pain

At Modal Pain: Diagnostic SI joint injection

Pain that runs down a leg or an arm along one nerve, with numbness or tingling in the same strip

Usually: Radicular pain from a pinched nerve root

At Modal Pain: Epidural injection

Groin or front-of-thigh pain, worse walking or putting on socks

Usually: Hip joint pain that mimics back pain

At Modal Pain: Image-guided hip joint injection

Tender, ropy knots in the muscles beside the spine that reproduce the pain when pressed

Usually: Myofascial pain

At Modal Pain: Trigger point injections and physical therapy

Ablation done elsewhere after a single block, and it never helped

Usually: Possibly a false-positive block

At Modal Pain: Repeat diagnostic blocks with a diary before any further ablation

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References

Every figure on this page comes from the sources below. Where no study exists, the page says so and explains the reasoning instead.

1. Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med. 2020. doi:10.1136/rapm-2019-101243 · PubMed
2. Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med. 2022. doi:10.1136/rapm-2021-103031 · PubMed
3. Schwarzer AC, Aprill CN, Derby R, et al. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain. 1994. doi:10.1016/0304-3959(94)90199-6 · PubMed
4. Manchikanti L, Boswell MV, Singh V, et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004. doi:10.1186/1471-2474-5-15 · PubMed
5. Cohen SP, Williams KA, Kurihara C, et al. 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. Anesthesiology. 2010. doi:10.1097/ALN.0b013e3181e33ae5 · PubMed
6. Lord SM, Barnsley L, Bogduk N. The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain. 1995. doi:10.1097/00002508-199509000-00008 · PubMed
7. Kaplan M, Dreyfuss P, Halbrook B, et al. The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint. Spine. 1998. doi:10.1097/00007632-199809010-00008 · PubMed
8. Manchikanti L, Malla Y, Wargo BW, et al. Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7,500 episodes with 43,000 nerve blocks. Pain Physician. 2012. · PubMed
9. McCormick ZL, Reddy R, Korn M, et al. A prospective randomized trial of prognostic genicular nerve blocks to determine the predictive value for the outcome of cooled radiofrequency ablation for chronic knee pain due to osteoarthritis. Pain Med. 2018. doi:10.1093/pm/pnx286 · PubMed
10. Cohen SP, Hurley RW, Buckenmaier CC, et al. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008. doi:10.1097/ALN.0b013e31817f4c7c · PubMed
11. Narouze S, Benzon HT, Provenzano D, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (second edition). Reg Anesth Pain Med. 2018. doi:10.1097/AAP.0000000000000700 · PubMed
12. Wellpoint Federal (Medicare Administrative Contractor). Local Coverage Determination L35936: Facet Joint Interventions for Pain Management. CMS Medicare Coverage Database. 2026. Source

These are general instructions after a medial branch block. If the instructions you were given at discharge differ, follow the ones you were given, because they account for your medications and your procedure. For anything you are unsure about, call (646) 290-6660. See the medial branch block page for how the procedure works and who it helps, or the aftercare instructions for other procedures.