Medial Branch Nerve Radiofrequency

Overview

Medial branch nerve radiofrequency(RF) is also called medial branch nerve ablation and rhizotomy. It is used radiowave and heat to ablate medial branch nerve. It is a treatment after medial branch nerve blocks or facet joint injection confirms that the pain indeed comes from facet joint(s). It blocks medial branch nerve permanently. The medial branch nerve branched off from its nerve root and passes through the junction area between superior articular process and transvers process of facet joint, and then innervates to facet joint. The medial branch nerve carries pain signal from facet joint to brain. When the nerve is ablated with RF, the pain signal from facet joint is blocked. It does not travel to brain any more. Then the pain can reduced or relieved. The procedure can be done in doctor’s office or in a hospital. The neck, mid-back and low back pain commonly comes from facet joints. ​​Facet joints are tiny small joints between every two vertebrae. There are two facet joints in each level. Facet joints are lining up from neck to the low back and it is located in the back of spine. This pain is referred to as facet joint syndrome, facet arthropathy, osteoarthritis, facet arthritis.

 

 

Please click here for more information about facet joint pain and treatment.

 

Please click here to learn more about medial branch nerve blocks.

Please click here to learn more about facet joint injection.

The facet joints are tiny small joints between every two vertebrae

Superior Articular Process

Transverse Process

Medial Branch Nerve

The medial branch nerve branches off from its nerve root and passes through the junction area between superior process and transverse process of the facet joint, and then innervates to facet joints.

Indications for Medial Branch Nerve Radiofrequency

The following pain conditions are indicated for the medial branch nerve RF:

  1. Low back pain

  2. Neck pain

  3. Mid-back pain

  4. Post-laminectomy syndrome

  5. Failed back surgery syndrome

  6. History of spine fusion

  7. Post-whiplash injury

 

The medial branch nerve RF is done after medial branch nerve block or facet joint injection confirms that the pain conditions list above indeed comes from the facet joint. 

CONTRAINDICATIONS

 

  • Systemic infection

  • Skin infection over puncture site

  • Bleeding disorders or coagulopathy

  • Allergy to the medications

  • Pregnancy

Preparation for Procedure

The treating physician will review the medications the patient takes again. The patient should provide the treating physician full medication record, including prescription medications and over-the-county medications.  The blood thinner may have to be stopped because it can thin the blood and increase risk of bleeding. Follows are the most common medications which may increase the risk of bleeding:

 

Anticoagulants: 

  • Coumadin has to be stopped 5 days before the injection and check PT/INR in the morning of the injection.  INR has to be around 1 to proceed with the procedure.

  • Lovenox has to be stopped 24 hours before the nerve block.

  • Plavix, Pradaxa, Eliquis and Xarelto should also be stopped before the procedures.

 

Anti-inflammatory medications(NSAID):

  • Ibuprofen, Motrin, Advil, Aleve, Naproxen, aspirin and other anti-inflammatory medications should be stopped for 7 days before the nerve block.

 

The patient should not eat or drink anything after midnight the night before your procedure if you are going to have IV sedation. The patient may also need to consult with his or her physician to find out what other medications he or she can take or can’t take.

The physician may prescribe Valium for the patient  if the patient  is very anxious and if the patient  doesn't need sedation.

 

The patient needs a driver to drive him or her home after the procedure.  The patient may need driver to drive him or her to the facility and home if the patient takes Valium. 

Procedure

  • The procedure can be performed in a doctor's office or in the hospital. The entire procedure may take up to 30 minutes.

  • The treating physician may review the patient's case again with the patient and answer questions before the procedure. The patient should always mention their allergy to the treating physician before the procedure.

  • The patient is going to sign consent form first. 

  • The patient is brought to the procedure room and placed in the prone position (face down) in a surgical table.

  • An X-Ray machine (fluoroscope) is brought into field to locate injection sites.  

  • The treatment area is disinfected with Beta-dine three times.

  • Local anesthetic agent is used to numb the injection sites with a very fine needle. The patients may feel some discomfort with transient burning sensation. 

  • RF needles are then inserted under the guidance of fluoroscope.  

  • The needle is advanced to the junction area of superior process and transverse process of the related facet joint.   

  • X-Ray is used to confirm the needle position.

  • A RF machine will be turned on. A ground pad will be placed on the patient.

  • The RF machine is used to do sensory nerve test to make sure the pain does not travel down to the arm or leg, and motor nerve test to make sure there is not muscle movement in the arm or leg. The patient has to be awaken to have this tests. If the patient is sedated, we have to wait until the patient fully wakes up.

  • The RF treatment can start after the test confirms that there is no leg or arm involvement. The patient should let the treating physician know right way if the pain radiates down the arm and the leg during the RF treatment.

  • If the patient has severe pain during RF treatment, local anesthetic agent can be injected.

  • The needle is withdrawn and puncture area is dressed with Band-Aid or any other type of sterile dressing. 

The procedure can be done with or without sedation. The patient should fully awake for the sensory test and motor test if it is done under sedation. The patient will be observed in recovery area for about 20 minutes if the procedure is done without sedation. The patient can be observed in recovery area much longer if the procedure is done under sedation.

Medial branch nerve ablation: the needle is adjacent to medial branch nerve and the other side of the needle is connected with radiofrequency machine.

A needle is located at the junction area between superior process and transverse process of the facet joint.

Post Procedure Care

  • The patient should not drive the day of the injection unless approved by the treating physician.

  • The patient should not drive for 24 hours after the procedure if sedation was used,.

  • The patient should follow up with treating physician in 2-3 week to assess the effectiveness of the treatment.

  • The patient may resume pain medications or any other medications after the procedure.

  • The patient may remove dressing in 6 hours and may take shower at the night.

  • The pain can be worse for the first several days following the procedure. It may last for 1-3 weeks or 4 weeks occasionally. The patient may take any pain medications for the pain.   

  • The pain relief may take up to three or more weeks to occur. The medial branch nerve can grow back in 6 months. However, the pain relief can last from 6  to12 months or even longer. The procedure can be repeated every six months.

  • If the injection site is uncomfortable after the injection, the patients may apply cold pack to reduce the pain for the first 48 hours.

  • The patient may resume regular activities after the injection. However, the patient should avoid doing any strenuous activities. The patient should get advice from the treating physician when to start regular exercise and what precaution should be followed.

  • If the patient has sign of infection, such as fever, chills, or redness or drainage at the treatment site or have temperature of 101 degrees or greater, call the treating physician’s office or go to emergency room if the treating physician is not available.

  • The patient may be referred back for more physical therapy, acupuncture treatment or other conservative management after the procedure. The combination of medial branch nerve radiofrequency with physical therapy, acupuncture or other conservative management may achieve better result.

Risks and Complications

The potential risks are very low and complications are rare.

  • Bleeding.

  • Infection

  • Nerve or spinal cord damage

  • Allergy to local anesthetic agent

Those are very rare risks and complications.  However, as general rule, patients should always consult with his or her treating physician about the risks and complications about the procedure and mention their allergy to treating physician before any procedures.

Click here if you want to know more about facet joint pain and treatment options.

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