Cervical Medial Branch Block Pain Diary Template

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CERVICAL MEDIAL BRANCH BLOCK PAIN DIARY
What are the cervical facet joints, and why are medial branch blocks helpful?
Cervical facet joints are small joints about the size of your thumb nails located in pairs on the back of your
spine. They provide stability and guide motion in your neck. When the joints become painful, they may cause
pain in your neck, shoulders and arms.
The medial branches are little nerves which carry the pain signal from the inflamed and damaged facet
joints. A medial branch block can be both diagnostic and therapeutic and it serves several purposes. First, by
placing numbing medicine around the nerve, the amount of immediate pain relief you experience will help
confirm or deny the joint as a source of your pain. Also, time-release steroid will serve to reduce any presumed
inflammation around the nerve and may also alleviate pain from the joint.
What should I do before the procedure?
Write down 3 ACTIVITIES that trigger your neck pain and include a PAIN SCORE (0 to 10)
0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10
No pain
Mild Pain
Moderate Pain 
Severe Pain 
Very Severe
Worst Pain
PRE-PROCEDURE
ACTIVITY
PAIN LEVEL
1.
2.
3.
What should I do after the procedure?
It is very important for you to fill out a pain diary after the medial branch block so that I can determine
how much relief you have had from the medial branch block. Based on the results from the medial branch block,
we will then determine whether or not the facet joints are the source of your pain.
Please record the SAME ACTIVITIES you listed above and record the PAIN SCORE while doing these
activities at the times listed POST-PROCEDURE.
ACTIVITY
15 MIN
1 HOUR
3 HOURS
1 DAY
3 DAYS
1.
2.
3.
**Please bring this with you to your follow up visit after the procedure!

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