Cervical Medial Branch Research Articles

Prospective evaluation of the safety of ultrasound-guided cervical medial branch blocks using the in-plane technique

BackgroundWhile fluoroscopic guidance is currently the imaging standard for cervical medial branch blocks (CMBBs), ultrasound guidance (USG) offers several potential safety advantages such as real-time needle visualization and the ability...

Investigation of the anatomical course of articular branches to the thoracic zygapophysial joints

BackgroundRecent studies have questioned the validity of targeting the thoracic medial branch via anesthetic blocks or radiofrequency neurotomy for the diagnosis or treatment of pain from the thoracic zygapophysial joints. PurposeTo define the origin and course of the articular branches to the thoracic zygapophysial joints at all levels. DesignCadaveric dissection. SettingThe Gross Anatomy Laboratory at the University of New England College of Osteopathic Medicine. SubjectsOne cadaveric thoracic spine. MethodsGross and stereoscopic dissection of the bilateral dorsal rami T1–T12 was performed on one embalmed cadaver. The medial and lateral branches were traced from their cutaneous distribution to the origin at the dorsal ramus. The articular branches were identified using stereoscopic dissection by tracing their origin from the dorsal ramus or medial branch to the capsule of the zygapophysial joint. The images were recorded using digital photography. ResultsTwenty-two of the twenty-four articular branches were identified in a single cadaveric specimen. Articular branches at T7 on the right side and T9 on the left side were not identified. 5 of the 22 (18%) articular branches were observed to arise from the proximal segment of the medial branch of the dorsal ramus. Of the remainder, 17 of the 22 (78%) articular branches were observed to arise from the dorsal primary ramus itself. At levels T1-9, the articular branch coursed inferiorly along the lamina to reach the joint capsule. At levels T10-T12, the articular branch traversed the intervertebral foramen to reach the facet joint. The T12 medial branch on the left was seen to travel inferior to innervate the L1/L2 zygapophysial joint. ConclusionThe source of the innervation for the thoracic zygapophysial is variable and can arise from the dorsal ramus itself or from the proximal segment of the medial branch. Unlike the cervical and lumbar medial branches, which innervate two joints each, in this case, the thoracic dorsal rami appear to innervate only the zygapophysial joint at the level of the nerve exit. It should be noted that the findings may be limited in their generalizability due to the reliance on a single cadaver study.

Accuracy and efficacy of ultrasound-guided puncture (vs. computed tomography-guided) in cervical medial branch blocks for cervicogenic pain: A randomized controlled study.

Cervical medial branch block (CMBB) has been recognized as an effective treatment for cervicogenic pain. Previous studies mostly used ultrasound-guided out-of-plane puncture for CMBB, while this prospective study was designed to investigate the efficacy of ultrasound-guided in-plane puncture, specifically focusing on the new target of CMBB for cervical pain. This study includes two parts: the accuracy study (N = 15, CMBB was completed by ultrasound and confirmed by computed tomography [CT], in which a good distribution percentage of the analgesic solution was observed) and the efficacy study (N = 40, CMBB was completed by ultrasound or CT, while the proportion of pain relief (numerical rating scale) decrease by more than 50% postoperatively was analyzed). The results showed that the good distribution percentage of the analgesic solution was 97.8%. Furthermore, in the early period (30 min and 2 h postoperatively), the proportion of patients with pain relief was lower in the ultrasound group than that in the CT group, especially at 2 h postoperatively (52% vs. 94%). However, at 24 h postoperatively and later, the proportion of patients with pain relief gradually stabilized to about 60%-70%, and lasted for about 2 weeks to 1 month. Therefore, the new target for CMBB, guided by ultrasound in-plane, offers high visibility and accuracy. A single CMBB performed under ultrasound guidance resulted in pain relief comparable to that of a CT-guided procedure (1 day to 1 month postoperatively). This study indicated that CMBB guided by ultrasound in-plane could be regarded as a promising approach for treatment of cervicogenic pain.

A Comparison of Precision and Safety using Three Recognized Ultrasound-Guided Approaches to Cervical Medial Branch Blocks: A Cadaver Study

BACKGROUND: Ultrasound (US) guidance is widely used for needle positioning for cervical medial branch blocks (CMBB) and radiofrequency ablation, however, limited research is available comparing different approaches. OBJECTIVE: We aimed to assess the accuracy and safety of 3 different US-guided approaches for CMBB. STUDY DESIGN: A cadaveric study divided into ultrasound-guided needle placement and fluoroscopy evaluation stages. SETTING: Department of Pathology, Forensic, and Insurance Medicine, Semmelweis University. METHODS: Sonographically guided third occipital nerve (TON), C3, C4, C5 and C6 medial branch injections and radiology evaluations were performed. The 3 approaches compared were: 1. ES (published by Eichenberger-Siegenthaler): US probe in the coronal plane to visualize the cervical articular pillars, needle approach out of the plane, from anterior to posterior. 2. Fi (published by Finlayson): US probe in the transverse plane to visualize a cervical articular pillar and its lamina, needle approach in the plane, from posterior to anterior. 3. FiM (Modified Finlayson approach): Needles are placed as in Fi, but then adjusted with a coronal view of the cervical articular pillars. Fluoroscopy images were taken and later evaluated, for “crude”, “high precision” and “dangerous” placement. RESULTS: One hundred and fifty-five needle placements were assessed (10 were excluded, as no anterior-posterior fluoroscopy images were saved). Interobserver agreement on position of needle placement between the 5 observers was very high; the Fleiss’ Kappa was 0.921. For crude placement, no significant differences were identified between various approaches; (77.6%, 79.5%, and 75.6% for the ES, Fi, and FiM respectively). However, for placement in predefined high-precision zones, ES resulted in significantly more success (ES: 42.9%, Fi: 22.7%, and FiM: 24.4%, P = 0.032). Fi and FiM resulted in no dangerous placements, while ES led to the potential compromise of the exiting nerve root and vertebral artery on three occasions. In 10% of the placements, the levels were identified wrongly, with no difference between the various approaches. LIMITATIONS: Feedback from a live patient, may prevent some existing nerve root injections, unlike in a cadaver. Though a higher number of needles were placed in this study than in most available publications, the number is still low at each individual medial branch level. CONCLUSION: Fi proved safer than ES. Fi was equally successful in targeting the articular pillar, however, ES proved the most successful in placing the needle in the center of the articular pillar. Adding another, (coronal) US view to check needle position in FiM did not improve safety or precision. Identifying CMB levels with the US is challenging with all approaches, therefore we still recommend using fluoroscopy for level identification. While there were pros and cons with either procedure, the efficacy findings of previous papers were not replicated on elderly cadavers with arthritic necks. KEY WORDS: Cervical facet, medial branch block, safety, accuracy, ultrasound, fluoroscopy

End-on versus parallel radiofrequency lesioning for neurotomy of the cervical medial branch nerves: a study protocol of a prospective, randomized, double-blind clinical trial: the “EndPaRL” study

BackgroundCervical facet joint disease is a common source of neck pain and its prevalence increases with aging. Conservative multimodal management options (e.g., strengthening of neck muscles, non-steroidal anti-inflammatory medications, massage, and thermal modalities) often fail to relieve pain. Cervical medial branch nerve (CMBN) radiofrequency neurotomy (RFN) is an effective minimally invasive technique for treating chronic neck pain secondary to facet joint disease. An end-on approach for this procedure has been proposed that may be technically easier and require less time while reducing post-procedural discomfort. The protocol presented here is for a study that aims to compare the efficacy of a new end-on approach using multi-tined cannulae, against the conventional parallel technique that employs straight cannulae for RFN of the CMBN in patients with chronic neck pain due to cervical facet joint disease.MethodsA multicentre randomized, non-inferior, active comparator-controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessor. The study will include 72 adults with chronic neck pain secondary to facet joint disease who are candidates for RFA of the CMBN. Participants will be randomized to either the conventional parallel or the end-on approach in a 1:1 ratio. The intensity of pain and pain-related domains (function, quality of life, sleep, adverse effects of the interventions, analgesic intake) will be measured at 1, 3, 6, and 12 months after the procedure.DiscussionNeck pain secondary to cervical facet joint disease is prevalent and RFA of the CMBN is a validated treatment for relieving it. The conventional parallel technique can be technically challenging, and it can be associated with adverse effects while the newer end-on approach has the potential of being a simpler technique with less adverse effects. This trial will be the first non-inferiority study to compare the clinical efficacy of the end-on approach against the conventional parallel approach for RFN of CMBN in patients with chronic neck pain due to cervical facet joint disease.Trial registrationClinicalTrials.gov NCT05818774. Registered on April 20, 2023.

Letter to the Editor Regarding “Comparative Outcome of Lidocaine versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study”

Letter to the Editor Regarding “Comparative Outcome of Lidocaine versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study”

In Reply to the Letter to the Editor Regarding “Comparative Outcome of Lidocaine versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study”

In Reply to the Letter to the Editor Regarding “Comparative Outcome of Lidocaine versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study”

Randomized controlled trial comparing technical features and clinical efficacy of a multi-tined cannula versus a conventional cannula for cervical medial branch radiofrequency neurotomy in chronic neck pain

ObjectivesCompare procedural characteristics and clinical efficacy of cervical medial branch radiofrequency neurotomy (CMBRFN) using a multi-tined cannula (MTC) versus a conventional cannula (CC) to treat chronic neck pain. DesignProspective, double-blinded randomized controlled trial. MethodsPatients who responded to dual medial branch blocks with ≥75% pain relief were randomized to receive RFN with either the MTC or the CC. Primary outcomes: procedural pain, procedure duration, fluoroscopy time and radiation dose. Secondary outcomes: proportion of patients reporting ≥50% numerical rating scale reduction and ≥30% neck disability index reduction at 3, 6 and 12 months. ResultsForty-two patients underwent treatment. There was no difference in procedural pain between the MTC and CC groups (NRS 4.7 ± 2.0 vs. 4.2 ± 1.8, p = 0.465), but three patients, all in the CC group, could not complete the procedure due to pain. CMBRFN in the MTC group was significantly faster than in the CC group (35.5 ± 7.3 min vs. 58.2 ± 14.8 min, p < 0.001), with less fluoroscopy time (167.6 ± 76.4 s vs. 260.8 ± 123.5 s, p = 0.004). Radiation dose was 8.95 ± 7.9 mGy in the MTC group and 11.53 ± 10.3 mGy in the CC group (p = 0.36). Rates of ≥50% NRS reduction were not significantly different between the two groups at 3 months, but at 6 and 12 months, they were significantly higher in the CC group. At 3, 6 and 12 months, rates of ≥30% NDI reduction were significantly higher in the CC group. ConclusionsThe MTC offers technical advantages compared to the CC for both the operator and the patient. However, CMBRFN with the multi-tined cannula seems less effective to treat neck pain than with the conventional cannula.

ID: 206983 Retrospective Review of Real-World Outcomes Following 60-Day PNS of the Cervical Medial Branch Nerves

Axial neck pain is a prevalent and often debilitating pain condition with conventional treatment options that commonly lack efficacy or are neurodestructive (e.g., radiofrequency ablation). Sixty-day percutaneous peripheral nerve stimulation (PNS) has emerged as a potential non-destructive treatment for axial neck pain that targets efferent fibers in the cervical medial branch nerves to secondarily produce comfortable, cycling tension in core cervical musculature (e.g., multifidus). The present work is a retrospective review of outcomes from patients receiving 60-day PNS treatment targeting the cervical medial branch nerves in routine clinical practice.

Comparative Outcome of Lidocaine Versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study

This study evaluated the effect of prolonged concordant response and functional clinical improvement between lidocaine and bupivacaine for cervical medial branch block (CMBB) in chronic cervical facet syndrome. Sixty-two patients diagnosed with chronic cervical facet syndrome were randomized into either lidocaine or bupivacaine groups. The therapeutic CMBB was performed under ultrasound guidance. Either 2% lidocaine or 0.5% bupivacaine with a volume of 0.5-1 ml per level, according to the patient's pain symptoms. The patients, pain assessor, and pain specialist were blinded. The primary outcome was the duration of pain reduction by at least 50%. The numerical rating scale (NRS) of 0-10 and the Neck Disability Index (NDI) questionnaire were recorded. There was no significant difference in the duration of 50% and 75% pain reduction and NDI between the lidocaine and bupivacaine groups. Lidocaine provided significant pain reduction up to 16 weeks (P<0.05) and significant improvement in neck functional outcomes up to 8 weeks (P<0.01) compared to the baseline. Whist bupivacaine yielded significant pain alleviation for up to 8 weeks for pain upon neck mobilization (P<0.05) and demonstrated notable improvement in neck function up to 4 weeks (P<0.01) compared to the baseline. CMBB using lidocaine or bupivacaine provided clinical benefits in prolonged analgesic effect and improving neck functions for chronic cervical facet syndrome. Lidocaine illustrated better performance and could be considered a local anesthetic of choice regarding the prolonged concordance response.

The long-term effectiveness of ultrasound guided cervical medial branch radiofrequency ablation in treatment of chronic neck pain of zygapophysial joints origin

The long-term effectiveness of ultrasound guided cervical medial branch radiofrequency ablation in treatment of chronic neck pain of zygapophysial joints origin

The Negative Screening Rate of Second Cervical Medial Branch Blocks in Patients With Positive First Blocks: A Retrospective Chart Review

The Negative Screening Rate of Second Cervical Medial Branch Blocks in Patients With Positive First Blocks: A Retrospective Chart Review

Are There Optimal Prognostic Block Selection Criteria for Predicting Treatment Success Following Cervical Medial Branch Radiofrequency Neurotomy? A Real-world Cohort Study

Are There Optimal Prognostic Block Selection Criteria for Predicting Treatment Success Following Cervical Medial Branch Radiofrequency Neurotomy? A Real-world Cohort Study

The Effectiveness of Cervical Medial Branch Radiofrequency Neurotomy Using a Perpendicular Approach with a Multi-tined Probe: A Single-Arm, Retrospective Cohort Study

The Effectiveness of Cervical Medial Branch Radiofrequency Neurotomy Using a Perpendicular Approach with a Multi-tined Probe: A Single-Arm, Retrospective Cohort Study

Effectiveness of pulsed radiofrequency on the medial cervical branches for cervical facet joint pain.

BACKGROUNDCervical facet joint pain (CFP) is one of the most common causes of neck pain and headache. Persistent CFP deteriorates the quality of life of patients and reduces their productivity at work.AIMTo investigate the effectiveness of pulsed radiofrequency (PRF) stimulation of cervical medial branches in patients with chronic CFP. METHODSWe retrospectively included 21 consecutive patients (age = 50.9 ± 15.3 years, range 26-79 years; male: female = 8:13; pain duration = 7.7 ± 5.0 mo) with chronic CFP, defined as ≥ 4 on the numeric rating scale (NRS). We performed PRF stimulation on the cervical medial branches. The outcomes of the PRF procedure were evaluated by comparing the NRS scores for CFP before treatment and 1 and 3 mo after treatment. Successful pain relief was defined as a ≥ 50% reduction in the NRS score at 3 mo when compared with the pretreatment NRS score. RESULTSNo patient had immediate or late adverse effects following PRF. The average NRS score for CFP decreased from 5.3 ± 1.1 at pre-treatment to 2.4 ± 0.6 at the 1 mo follow-up, and 3.1 ± 1.1 at the 3 mo follow-up. Compared to the NRS scores before PRF stimulation, those at 1 and 3 mo after PRF stimulation had significantly decreased. Eleven of the 21 patients (52.4%) reported successful pain relief 3 mo after the PRF procedure. PRF stimulation on cervical medial branches may be a useful therapeutic option to control chronic CFP.CONCLUSIONPRF stimulation of the cervical medial branches may be used as an alternative treatment method in patients with CFP. PRF can effectively alleviate CFP, and is safe to perform.

Factfinders for patient safety: Anticoagulant and antiplatelet agents and cervical medial branch procedures

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the safety of anticoagulant and antiplatelet agents for cervical medial branch blocks and cervical medial branch radiofrequency neurotomy.The evidence in support of the following facts is presented: (1) In patients maintained on therapeutic anticoagulant (AC) and/or antiplatelet (AP) therapy, for whom cervical medial branch blocks (CMBBs) are being considered, there is strong evidence to guide decisions on continuing or discontinuing these AC/AP agents in preparation for the procedure. (2) Therapeutic anticoagulation (AC) and antiplatelet (APT) agents should be discontinued prior to cervical medial branch radiofrequency neurotomy (CMBRFN) due to serious hemorrhagic risks.

A comparison of the effectiveness of cervical medial branch radiofrequency ablation for chronic facet joint syndrome in patients selected by two common medial branch block paradigms

BackgroundCervical medial branch radiofrequency ablation (CMBRFA) is effective when patients are selected by dual medial branch blocks (MBBs). SIS guidelines recommend 100% pain improvement after dual comparative MBBs before CMBRFA; however, our prior investigation showed similar outcomes in those selected by a lesser strict paradigm. ObjectiveCompare pain and patient impression of improvement after CMBRFA in individuals stratified by a less stringent (80–99%) dual MBB response than those selected by the 100% criteria. DesignCross-sectional study. MethodsFollow-up was conducted via standardized telephone survey at ≥6 months post-CMBRFA to obtain Numerical Rating Scale (NRS) pain and Patient Global Impression of Change (PGIC) scores. Primary and secondary outcomes were within-group and between-group differences in the proportions of patients reporting ≥50% NRS score reduction and PGIC scores. ResultsMedical records of 195 consecutive patients were reviewed; 100 individuals were analyzed. 48% (95% CI 35–61%) and 52% (95% CI 37–67%) of the 80–99% and 100% MBB groups, reported ≥50% pain reduction at ≥6 months post-CMBRFA. 74% (95% CI 63–85%) and 67% (95% CI 52–81%) of the 80–99% and 100% MBB groups reported a PGIC score consistent with “improved” or “very much improved.” There were no significant between-group differences in any outcome at any time point. ConclusionsWe observed similar rates of pain relief and global improvement after CMBRFA in patients selected by dual MBBs with ≥80% symptom relief versus 100% relief. This provides evidence that a more practical criteria, compared to a more strict selection paradigm, may result in similar clinical outcomes.

Cervical facet joint platelet-rich plasma in people with chronic whiplash-associated disorders: A prospective case series of short-term outcomes

ObjectiveTo explore the safety and feasibility of a single autologous injection of platelet-rich plasma (PRP) in cervical facet joints of people with chronic WAD and facet-mediated pain, and explore the association between pain relief reported with diagnostic medial branch blocks (MBBs) and 3-months post-PRP. DesignA prospective case series of people with chronic whiplash-associated disorders and cervical facet joint mediated pain in a community setting. InterventionsA single autologous PRP injection was provided to cervical facet joints under ultrasound and fluoroscopic guidance. MeasuresAdverse events were recorded one-week, and measures of pain (numerical pain rating scale - NPRS) and disability (Neck Disability Index - NDI) were collected prior to and 3-months following cervical facet joint PRP. People not reached for follow-up were considered failures for worst-case analysis. The correlation between percentage response to diagnostic cervical medial branch blocks (MBBs) and percentage pain relief reported at 3-months was also investigated. ResultsForty-four people (82% female; mean age (SD): 45.2 (10.8) years) underwent cervical facet joint PRP. There was a significant improvement in pain and disability following PRP. Seventy percent of people exceeded MCID for pain. For NDI scores, 80% of people exceeded MCID. Forty-one percent of people reported greater than 50% relief of pain 3-months post-cervical facet joint PRP.There was no significant correlation between percentage relief of pain with cervical MBBs and percentage relief of pain 3-months post-PRP (r ​= ​0.06, p ​= ​0.73).There were no adverse events reported. ConclusionIn people with chronic WAD and facet-mediated pain, preliminary data suggests that PRP is safe and it is feasible to move forwards with randomized studies to further investigate efficacy and effectiveness.

Cervical medial branch radiofrequency ablation and opioid usage: Cross sectional views at six months prior to and six months following procedure

BackgroundZygapophysial joint pain has a prevalence of up to 55% in patients suffering from neck pain. Interventional pain procedures are commonly used to treat facetogenic neck pain including cervical medial branch radiofrequency ablation (CMBRFA), which has been shown to effectively reduce pain. However, there is little research regarding its impact on opioid medication usage. ObjectiveWe aimed to evaluate changes in opioid medication usage after CMBRFA and impact of comorbid conditions on noted changes. DesignRetrospective observational study. MethodsFor patients undergoing CMBRFA between May 01, 2017 and May 31, 2020, the following data were collected: demographics, spinal level of procedure, history of prior neck surgery or pain procedures, presence of comorbid conditions, and opioid medication prescription data at 6 months before and after the procedure. Fisher’s exact tests were used for continuous variables due to inadequate sample for parametric tests. Multivariable analysis was used to assess independent predictive factors. ResultsA total of 140 patients underwent RFA during the 3-year study period. Fifteen percent (N = 21) of the cohort were on opioid medication pre-procedurally – of these, 71 % (N = 15) decreased opioid use post-procedurally which includes the 43 % (N = 9) who ceased opioid use completely. However, no statistically significant difference was noted between pre- and post-procedural MME. Of the 119 opioid-naïve patients, 16 % (N = 19) started opioids by 6 months following CMBRFA; this group was noted to have higher prevalence of anxiety and depression. ConclusionOpioid use, studied in isolation, is not a reliable measure to assess CMBRFA effectiveness. Psychologic considerations such as history of anxiety or depression are significant factors in opioid use and may influence procedure effectiveness. Opioid use patterns are multifaceted. Larger, future studies are needed to analyze post-procedure opioid use in the context of other factors such as pre-procedure opioid use, psychiatric comorbidities, and presence of multiple pain generators.

Comparison of the Effectiveness of Cervical Medial Branch Radiofrequency Ablation for Chronic Facet Joint Syndrome in Patients Selected by a Common Medial Branch Block Paradigm

Comparison of the Effectiveness of Cervical Medial Branch Radiofrequency Ablation for Chronic Facet Joint Syndrome in Patients Selected by a Common Medial Branch Block Paradigm