Abstract
Radiofrequency facet ablation (RFA) has been performed using the same technique for over 50 years. Except for variations in electrode size, tip shape, and change in radiofrequency (RF) stimulation parameters, using standard, pulsed, and cooled RF wavelengths, the target points have remained absolutely unchanged from the original work describing RFA for lumbar pain control. Degenerative changes in the facet joint and capsule are the primary location for the majority of lumbar segmental pathology and pain. Multiple studies show that the degenerated facet joint is richly innervated as a result of the inflammatory overgrowth of the synovium. The primary provocative clinical test to justify an RFA is to perform an injection with local anesthetic into the facet joint and the posterior capsule and confirm pain relief. However, after a positive response, the radiofrequency lesion is made not to the facet joint but to the more proximal fine nerve branches that innervate the joint. The accepted target points for the recurrent sensory branch ignore the characteristic rich innervation of the pathologic lumbar facet capsule and assume that lesioning of these recurrent branches is sufficient to denervate the painful pathologic facet joint. This report describes the additional targets and technical steps for further coagulation points along the posterior capsule of the lumbar facet joint and the physiologic studies of the advantage of the bipolar radiofrequency current in this location. Bipolar RF to the facet capsule is a simple, extra step that easily creates a large thermo-coagulated lesion in this capsule region of the pathologic facet joint. Early studies demonstrate bipolar RF to the facet capsule can provide long-term pain relief when used alone for specific localized facet joint pain, to coagulate lumbar facet cysts to prevent recurrence, and to get more extensive pain control by combining it with traditional lumbar RFA, especially when RFA is repeated.
Highlights
The facet joint has been identified as a cause of lumbar pain as long as the spine has been studied both anatomically and clinically
After radiofrequency ablation (RFA), the RF electrode is partially retracted along the lateral wall of the superior facet and angled slightly medially toward the radiologic line of the facet joint space identified under fluoroscopy
Since the original development of radiofrequency facet ablation for the thermocoagulation of the lumbar dorsal medial recurrent sensory branch for back and facet pain, there has been no change in the original lesioning targets at the base of the transverse process and superior facet
Summary
The facet joint has been identified as a cause of lumbar pain as long as the spine has been studied both anatomically and clinically. Clinical observations using hypertonic saline and findings of pain relief after making small incisions around the facet joint were later adapted to use radiofrequency ablation (RFA) with heat as a simple percutaneous procedure targeting the dorsal recurrent sensory branch for relief from back pain [5,6]. These targets for RFA were based on von Luschka's anatomic work [1,7]. After RFA, the RF electrode is partially retracted along the lateral wall of the superior facet and angled slightly medially toward the radiologic line of the facet joint space identified under fluoroscopy This repositions the electrode to the mid-dorsal surface of the posterior facet capsule. The white arrow is an RF electrode with a curved tip positioned within the joint space
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