Medial Branch Blocks Research Articles

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BackgroundThe past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of...

CT guided cervical medial branch block and radiofrequency ablation

The purpose of this report is to describe the procedure for CT fluoroscopy– guided Cervical medial branch block and facet radiofrequency ablation. CT fluoroscopic guidance allows more-precise needle tip positioning with visualization of bony landmarks and at the same time be aware of the adjoining soft tissue anatomy with good localization of adjacent critical non-targeted areas such as the neural foramina and the dorsal root ganglia. This serves as an alternative method for performing medial branch blocks and facet radiofrequency ablation.

Interventional Pain Medicine Practice in the UK and the USA: A Survey of 242 Pain Physicians

Pain medicine practices vary across different regions within a country and between countries. The objective of the survey was to study the variation in interventional pain medicine practices in the United Kingdom (UK) and the United States (US). A survey was designed in 2019 on Survey Monkey®. Pain physicians from the UK and the US were invited to respond. A total of 120 responses were received from pain physicians in the UK and 122 from the US. Twenty-six percent and 90% of pain physicians in the UK and US, respectively, are in full-time pain medicine practice. There was marked variation in the utilization of diagnostic medial branch blocks before performing radiofrequency denervation (RFD) between the UK and the US. In the UK, 42% of pain physicians, and 50% in the US, use a 20-gauge or a 22-gauge radiofrequency needle for lumbar RFD. Around 30% to 50% of pain physicians, both in the UK and the US, discontinued antithrombotic agents before medial branch blocks at all the spinal levels. Around 50% of pain physicians in the UK and US are stopping anticoagulants before lumbar and cervical RFD. Over 95% of UK and US respondents stopped antithrombotic agents for interlaminar and transforaminal epidural injections along the spine. At the lumbar level, 51% of pain physicians in the UK and 47% in the US use a particulate steroid for the initial lumbar transforaminal epidural injection (TFESI); and 4% and 14% in the UK and US, respectively, use a particulate steroid for initial cervical TFESI. Eight percent of pain physicians in the UK and 20% from the US would switch to a particulate steroid if the initial TFESI with a nonparticulate steroid did not provide satisfactory pain relief. Ten percent of pain physicians from the United Kingdom and 20% from the US believed that this switch provides better pain relief. Interventional pain physicians from the UK and the US were invited to respond. This may not reflect global practice. Our survey has highlighted the wide variation in interventional pain medicine practices both in the UK and the US. The relevant governing bodies in the UK and in the US should encourage clinicians to use at least an 18-gauge radiofrequency needle for RFD at the lumbar level. Discontinuing antithrombotic agents for the lumbar medial branch block is not justifiable. Pain physicians must discuss the advantages and disadvantages of using a nonparticulate over a particulate steroid preparation with the patient before performing TFESI as a standard procedure during the consenting process. Antithrombotic agents, epidural steroid, medial branch blocks, pain practice variations, particulate and nonparticulate steroids, radiofrequency denervation, spinal interventions.

Ultrasound-guided Medial Branch Blocks, Facet Joint, and Multifidus Muscle Injections: How It Is Done under One Needle Insertion Point!

Supplemental Digital Content is available in the text.

Systematic Review of the Effectiveness of Lumbar Medial Branch Thermal Radiofrequency Neurotomy, Stratified for Diagnostic Methods and Procedural Technique.

To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques. Comprehensive systematic review. A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes. Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique-two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement-resulted in 56% of patients experiencing 100% relief of pain at six months. This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement.

The Effectiveness of Cervical Medial Branch Radiofrequency Ablation for Chronic Facet Joint Syndrome in Patients Selected by a Practical Medial Branch Block Paradigm.

Cervical medial branch radiofrequency ablation (CMBRFA) is an effective treatment for facetogenic pain in patients selected by Spine Intervention Society (SIS) guidelines of 100% symptom improvement with dual medial branch blocks (MBBs) ± placebo block. Patient selection for CMBRFA using ≥80% symptom improvement after dual concordant MBBs is common; however, this has not been studied. To evaluate the effectiveness of CMBRFA and compare outcomes in individuals selected by 80-99% vs 100% symptom improvement with dual concordant MBBs. Cross-sectional cohort study. Medical records of 87 consecutive patients were reviewed; 50 met inclusion criteria. A standardized telephone survey was performed at six or more months post-CMBRFA to query numerical rating scale (NRS) pain and patient global impression of change (PGIC) scores. The primary outcomes were the proportion of patients reporting ≥50% reduction of index pain. At a mean follow-up time of 16.9 ± 12.7 months, 54% (95% confidence interval [CI] = 35-73%) and 54% (95% CI = 32-74%) of the 80-99% and 100% MBBs groups, respectively, reported ≥50% pain reduction. Between-group comparison showed a relative risk of 0.99 (95% CI = 0.59-1.66) for meeting the primary outcome. Seventy percent (95% CI = 56-81%) of patients reported a PGIC score consistent with "improved or very much improved" at follow-up. CMBRFA is an effective treatment in patients who report ≥80% symptom relief with dual concordant MBBs. The present study demonstrated an overall ≥50% pain reduction rate of 54% and no significant difference between those selected by 80-99% vs 100% symptom relief with dual concordant MBBs.

Facet joint injections for management of low back pain: a clinically focused review.

Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence.

Epidural steroid and facet joint injection neck in elderly patient: A combined approach

Cervical radicular pain is often due to a combination of factors including intervertebral disc prolapse or herniation, narrowing of the intervertebral foramen, osteoarthritis of facet joints, and spondylolisthesis. Cervical Epidural with local anesthetics along with steroids is used for evaluation and management of radicular pain in patients with pathology that exists at multiple vertebral levels. Medial branch block is given for facet joint arthropathy both for diagnostic and therapeutic purposes. Therefore, the aim of performing this procedure was to provide an interlaminar epidural steroid injection at C7-T1 vertebral level along with a diagnostic right medial branch block under fluoroscopic guidance to 86 years old hypertensive female, with complaints of pain in the neck lower portion, upper part of back and shoulder on the right side, radiating down the arm up to medial two fingers and thumb for 2 years. An interlaminar epidural steroid injection was planned on the right side at the C7-T1 vertebral level under C-arm guidance. A diagnostic right medial branch block was also planned to be given on the same day at 2 levels C5/C6 and C6/C7 facet joint each using 2 mg dexamethasone (0.5 ml) and 1.5 ml of 1% lignocaine. A repeat epidural injection was given using a combination of 1 ml of steroid dexamethasone (4 mg) and 3 ml of 1% lignocaine along with facet medial branch block injection at the same levels using 0.5% bupivacaine 1.5 ml and 2 mg dexamethasone (0.5 ml) on her follow-up visit after 6 weeks. Following the block patient on her first visit, she had considerable pain relief with a visual analog scale (VAS) of 3. She was prescribed gabapentin, methyl-cobalamine and clonazepam. After 6 weeks, the patient had VAS score of 6. She looked comfortable and her paresthesia had grossly improved. At the end of the procedure, patient had good pain relief with no deficit. She was advised to continue gabapentin. On her third follow-up after 3 months, the patient presented with >70% relief in her initial pain with a VAS of <3 and minimal paresthesia along the distribution of the ulnar nerve and hence required no intervention. Cervical epidural steroid injections under fluoroscopy guidance are being used for the conservative management of neck pain or cervical radiculopathy. Facet joint injections and medial branch blocks aim to diagnose and treat the pain arising from facet joints in the spine. It is also important to prescribe drugs to manage the neuropathic component of the pain.

Multiple injections for low back pain: What's the future?

To examine the strength of evidence available for multiple facet joint injections (FJIs) and medial branch blocks (MBBs), and to report on the variations in the NHS England framework using the getting it right first time (GIRFT) data. Systematic review using patient, intervention, comparison, outcome and study strategy. The literature search using Cochrane, MEDLINE and EMBASE databases using MeSH terms: lumbar spine, spinal injection and facet joint ("Appendix A"). Three studies were identified that investigated the efficacy of multiple FJIs or MBBs. None of these studies reported sustained positive outcomes at long-term follow-up. There is a paucity of levels I and II evidence available for the efficacy of multiple FJIs and MBBs in treating low back pain. GIRFT data show a high degree of variation in the use of multiple FJIs, which would not be supported by the literature. These slides can be retrieved under Electronic Supplementary Material.

Comparison of cervical medial branch nerve block versus trigger point injection in patients with chronic neck pain

Background: Annual prevalence of chronic neck pain in general population averages between 30%-50%. Among various causes of chronic neck pain cervical facet joint involvement accounts for about 54% to 67%. Interventional procedures such as medial branch nerve block, trigger point injections and dry needling have been described for management of chronic neck pain. Objectives: To determine the clinical effectiveness of cervical medial branch block and trigger point injections in the management chronic neck pain. Design: Randomized, double blinded, prospective study conducted at two different centers in India, Pain Clinic, Department of Anaesthesiology, J.N. Medical College hospital, Aligarh Muslim University, Aligarh, Delhi Pain management centre, New Delhi, India. Methods: Data analysis was done from a total of 60 patients with 30 patients in each group. Group CMB received cervical medial branch block and group TP received trigger point injection with levobupivacaine (0.25%) and triamcinolone (20mg) at two different levels. There was no sham group. Outcome Measure: Numeric rating scale (NRS), Neck Pain Disability Index (NDI), weekly analgesic requirement and subjective evaluation of patients was done at 1st week, 3rd week, 6th week and 12th week of follow up and compared with the pre-procedure value. Results: Significant pain relief was observed in both the groups of study, at 1st week of study, compared to baseline. Further follow up showed significantly better pain relief in patients receiving medial branch nerve block than patient receiving tender point injections at 3rd, 6th week and 12th week. NDI score in-group CMB was significantly better as compared to group TP at 3rd, 6th and 12th week follow up. Subjective evaluation of pain showed significantly greater proportion of patient with good to excellent pain relief in group receiving medial branch block. Analgesic requirement was significantly less in group CMB compared to group TP during follow up. Conclusion: Cervical medial branch block with local anaesthetic and steroid may provide long-term relief in patients with chronic neck pain than trigger point injection with no major incidence of complications in either group.

Ultrasound-guided L5 dorsal ramus block: validation of a novel technique

BackgroundAlthough the value of ultrasound-guided (USG) lumbar medial branch blocks (MBB) has previously been examined in several clinical trials, blocking the L5 dorsal ramus (DR) remains a technical challenge and...

The Effectiveness of Radiofrequency Ablation of Medial Branch Nerves for Chronic Lumbar Facet Joint Syndrome in Patients Selected by Guideline-Concordant Dual Comparative Medial Branch Blocks.

Although the effectiveness of lumbar medial branch radiofrequency ablation (RFA) for the treatment of zygapophyseal joint (z-joint)-mediated low back pain has been characterized, few studies have described outcomes in patients selected using a guideline-concordant paradigm of ≥80% pain relief with dual comparative medial branch blocks (MBBs). We investigated long-term treatment outcomes of patients selected according to this paradigm. Cross-sectional cohort study. The medical records of 111 consecutive patients were reviewed; 85 met inclusion criteria. A standardized telephone survey was used to capture current numerical rating scale (NRS) and Patient Global Impression of Change (PGIC) scores. The primary outcome was the proportion of patients reporting ≥50% reduction of index pain. Binary logistic regression analysis was performed to explore associations between the primary outcome and covariates, including age, duration of pain, presence of scoliosis, degenerative spondylolisthesis, and >75% disc height loss. At six to 12, 12-24, and >24 months, 63.2% (95% confidence interval [CI] = 41-85%), 65.6% (95% CI = 49-82%), and 44.1% (95% CI = 27-61%) of patients reported a ≥50% pain reduction (P = 0.170), respectively. At a minimum of six months, 70.6% of patients reported a pain reduction of two or more points (minimally clinically important change), and 54.1% reported a PGIC score consistent with "much improved" or better. Older age and a smaller Cobb angle were associated with a ≥50% pain reduction (P < 0.05). Lumbar medial branch RFA is an effective, durable treatment for a significant proportion of patients with recalcitrant lumbar z-joint pain when candidacy is determined by the guideline-concordant paradigm of ≥80% pain relief with dual comparative MBBs.

Using Music During Lumbar Medial Branch Block Procedure

Using Music During Lumbar Medial Branch Block Procedure

199. Identifying the source of neck pain with single photon emission computed tomography/computed tomography (SPECT/CT)

BACKGROUND CONTEXT Diagnosing and treating nonradicular axial neck pain remains difficult. While multiple conventional imaging modalities exist, eg,roentgenograms (X-ray images), computed tomography (CT) scans, magnetic resonance images (MRI), none reliably diagnose the foci for uncomplicated neck pain. Further, facet injections, medial branch blocks and radiofrequency ablations are also variably diagnostic. Hybrid imaging, single photon emission computed tomography/ computed tomography (SPECT/CT) scans may assist in diagnosing etiologies for axial neck pain. PURPOSE To evaluate the diagnostic potential of SPECT/CT in patients with nonradicular axial neck pain. STUDY DESIGN/SETTING A retrospective cohort study performed at a single tertiary care center. PATIENT SAMPLE One hundred and thirteen unique patients were enrolled. All patients received SPECT/CT imaging for no-radicular axial neck pain between 2009-2015 and subsequently underwent procedural intervention at our institution's chronic pain center. Exclusion criteria included prior cervical injection or surgery at a level identified as a potential pain foci on SPECT/CT scan. OUTCOME MEASURES Percentage of pain relief within 24 hours after facet injection, medial branch block or radiofrequency ablation. A positive response was defined as a minimum of fifty percent reduction in pain. METHODS One hundred and seventy-nine patients diagnosed with nonradicular, axial neck pain who received SPECT/CT scans during their workup were identified. One hundred and thirteen of these had no prior intervention at the level of interest and met inclusion criteria. All patients meeting inclusion criteria were referred by our institution's orthopedic and neurosurgical spine providers for diagnostic/ therapeutic intervention by our chronic pain specialists. The cervical joint of intervention was determined based on interpretation of SPECT/CT imaging. Ultimately, the site of intervention was determined based on the clinical examination and image interpretation of the chronic pain providers.Two groups were formed. The first group (Group 1) consisted of 90 patients with an intervention occurring at the level identified on SPECT/CT. The second group (Group 2) consisted of 23 patients with an intervention at a level not indicated by SPECT/CT. A positive response was set at a minimum of 50% reduction in pain within 24 hours of intervention. Data were analyzed using a Chi-square statistic. SPSS (IBM Corp. IBM SPSS Version 24.0) was used for all analyses. RESULTS Sixty-two of 90 patients (68.9%) in Group 1 positively responded to intervention whereas only 6 of 23 patients (26.1%) in Group 2 did (p = 0.0002). CONCLUSIONS In patients receiving SPECT/CT, intervening on a level identified by the imaging study positively correlated with pain reduction. This suggests a role for SPECT/CT in diagnosing therapeutic targets for axial neck pain. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The Accuracy of SPECT/CT for Diagnosing Lumbar Zygapophyseal Joint Pain: a Systematic Review

To determine the accuracy of Tc-99m methylenediphosphonate single photon emission computed tomography (SPECT/CT) for the diagnosis of lumbar zygapophyseal joint-related pain with dual medial branch block (> 70% threshold) as the reference standard. To date, the accuracy of SPECT/CT for the diagnosis of lumbar zygapophyseal joint pain has not been systematically reviewed. One study met inclusion criteria. A prospective cohort study of 35 patients reported a prevalence of 24% (95% CI 9.0–40.0%) using dual medial branch blocks (MBBs) as the means of diagnosis and found that SPECT/CT had a sensitivity of 0.57 (95% CI 0.18–0.90), specificity of 0.77 (95% CI 0.55–0.92), LR+ of 2.51 (95% CI 0.92–6.85), and LR− of 0.55 (95% CI 0.23–1.34). According to OCEBM 2011 guidelines, the evidence is rated as level 3. More research is needed to determine the accuracy of SPECT/CT for the diagnosis of Z-joint pain, as technological improvement and interpretation could potentially improve overall diagnostic accuracy and reduce associated costs.

Medial branch radiofrequency ablation outcomes in patients with centralized pain

Background and objectivesWe hypothesized that patients with characteristics of centralized pain (fibromyalgia (FM)-like phenotype) would be less likely to respond to radiofrequency ablation (RFA), which may explain some of the...

Predictors of Response to a Medial Branch Block: MRI Analysis of the Lumbar Spine.

The aim of this study was to determine the association between radiologic spinal pathology and the response to medial branches block (MBB). This retrospective observational study compared 165 patients. A successful response was defined as ≥30% or a 2-point reduction in the numeric rating scale (NRS) compared with the baseline at the 1-month follow-up. The facet angle, facet angle difference, facet joint degeneration, disc height and spondylolisthesis grade were analyzed from an MRI at the L3 to S1 levels. Univariate and multivariate logistic regression analyses were used to evaluate independent factors associated with a successful response of MBB. In the univariate analysis, the disc height at L5–S1 and facet angle difference at L3–4 were lower in the positive responders (p = 0.022 and p = 0.087, respectively). In the multivariate analysis, the facet angle difference at L3–4 and disc height at L5–S1 were independent factors associated with a successful response (odds ratio = 0.948; p = 0.038 and odds ratio = 0.864; p = 0.038, respectively). In patients with a degenerative disc at L5–S1, MBB can lead to a good response for at least one month. In patients with facet tropism at L3–4 level, the response to MBB after one month is likely to be poor.

Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study.

Neck pain is one of the most common causes of chronic pain and the fourth leading cause of disability worldwide; it is estimated that between 36% and 67% of this pain is due to facet arthropathy. For patients who have pain refractory to conservative treatments literature supports management with diagnostic cervical medial branch blocks (MBBs) to identify the associated facet innervation as the source of pain followed by therapeutic radiofrequency ablation (RFA) of the identified nerves. Cervical RFA has good published outcomes; however, the procedure is dependent upon the specificity of the diagnostic block to achieve maximal success. Currently, this prerequisite test has false positive rates between 27% and 63% and recent studies have shown that this may, in part, be a consequence of currently accepted injection volumes of 0.50 mL or more, which may decrease the sensitivity of MBBs. To evaluate the possible differences in volume dispersion between 0.25 and 0.50 mL of injectate during cervical MBBs. Cadaveric study. An academic medical center in the United States. Not applicable. This was a cadaveric study in which six subjects were chosen with intact cervical spines. Cervical MBB were performed bilaterally at the midcervical spine, using a posterior approach under fluoroscopic guidance. 0.25 or 0.50 mL of a 9:1 solution of Omnipaque 180 mg iodine/mL and 1% medical grade methylene blue were administered on the left and right sides, respectively. Postinjection computed tomography (CT) imaging and gross dissection were performed to assess injectate spread. Outcome measures after using commonly injected volumes for cervical MBB, included visualized and measured spread (by CT and gross dissection) of cervical medial branch blocks, coating adjacent structures not targeted by RFA. Postinjection CT imaging and cadaveric dissection demonstrated that, although both volumes adequately coated the medial branches, the 0.50 mL cohort reliably spread dorsally to superficial muscles (splenius) and nerves distant from the targeted nerves (dorsal motor branches to splenius), whereas the 0.25 mL injectate cohort was contained in the deep and intermediate muscular cervical layers directly juxtaposed to the targeted cMBBs. Results suggest that 0.50 mL injections of local anesthetic during cervical MBBs contacts many nonintended targets, thus decreasing the specificity of a targeted diagnostic cervical MBB. Furthermore, we demonstrated that 0.25 mL of injectate reliably bathed the cervical medial branches without extensive extravasation. This indicates that there would potentially be fewer local anesthetic effects on distant tissues, increasing the specificity of cervical MBBs and likely improving RFA planning.

Postdural Puncture Headache after Cervical Medial Branch Block

Postdural Puncture Headache after Cervical Medial Branch Block

Intra-articular Steroids vs Saline for Lumbar Z-Joint Pain: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial.

To determine if intra-articular (IA) injection of corticosteroids is effective in reducing the need for radiofrequency ablation (RFA) in those with dual comparative medial branch block (MBB)-confirmed lumbar z-joint pain. This was a randomized, double blind, placebo-controlled study. Two academic medical centers. Fifty-six consecutive subjects who had ≥80% pain relief during an initial screening MBB were recruited. Patients received a second confirmatory MBB and concurrent IA injection of either corticosteroid or saline per randomization. Twenty-nine of 56 received intra-articular corticosteroid (triamcinolone 20 mg), of whom 24 also had a positive confirmatory MBB per Spine Interventional Society guidelines, with ≥80% pain relief from both MBBs. Twenty-seven of 56 received IA saline into the z-joint during the confirmatory MBB, of whom 22 also had a positive confirmatory MBB. The primary outcome measure was the categorical need for RFA due to insufficient pain relief with intra-articular injection, and the secondary outcome was time to RFA. There was no statistically significant difference in the need for an RFA between the groups (16/24 steroid, 67%, 95% confidence interval [CI] = 47-82%) vs 15/22 saline (68%, 95% CI = 47-84%, P = 1.00). The average time to RFA was also not different, at 6.00 weeks for steroids vs 6.55 weeks for saline (P = 0.82). Intra-articular corticosteroids were not effective in reducing the need for or the time to a radiofrequency ablation of the medial branches in those with dual MBB-confirmed lumbar z-joint pain.