Overview of Medial Branch Block and RFA
Symptoms/Causes that Suggest a Medial Branch Nerve Block is Necessary
The first signs of neck or back pain are often described as a pain that tends to “come and go”. In time, the individual starts noticing that they are continually having neck pain or back pain. Their daily activities start to become limited. Or perhaps there is an accident or event that afterwards, leaves the victim feeling more pain or the decreased ability to function with each passing day. They may describe an inability to pick things up off the floor or an inability to turn left or right without experiencing pain. Driving a car becomes very dangerous because they can not look over their shoulder to see oncoming traffic.
With time, arthritis continues to set in due to inflammation of the joint. The joints of the spine, called facets, can develop facet arthritis. This is one of the most common causes of neck pain and low back pain. As the facet joints become arthritic, there is a gradual experience of increasing neck stiffness or back stiffness. Inevitably there will be a loss in the range of motion of the neck or lower back. Patients frequently describe their symptoms of stiffness occurring after being in one position for a long period of time. Bending to the left or to the right becomes painful. Arthritis of facet joints can also cause muscles of the back to become tight and spasm causing pain to travel into the shoulders, low back, or buttocks. While a muscle spasm caused by facet syndrome may have temporary relief with a trigger point injection, the resolution of the muscle spasms requires the resolution of the irritated median nerve that lies in the facet joint.
Without the proper diagnosis, patients will be provided treatment for muscle spasms or surgeons will offer surgery that will not resolve the patient’s symptoms or subject them to an unnecessary surgery. The key to diagnosing facet arthritis is by a process because facet syndrome secondary to arthritis is a diagnosis of exclusion that can be achieved without surgery.
Diagnostic Procedure the Suggest a Medial Branch Nerve Block is Necessary
Facet arthritis is diagnosed by first listening to the patient and their symptoms, asking poignant questions, ruling out other possible diagnoses, and performing physical exam. During the physical exam, the patient will be asked, while standing, to bend to the left and bend to the right. This is called the Loading Test. If the patient feels increase pain in the neck or back when bending to the right, for example, this implies there may be a right sided facet syndrome. Similarly, if the pain is on the left side of the neck or back, the cause may be a left sided facet syndrome. A number of other physical examination tests, pinpointing the source of the pain is necessary.
Depending on what is discovered during the physical examination, the pain doctor at CNSO will determine whether any further testing is needed. If so, the appropriate tests will be ordered specific to where the doctor localized the source of pain. These tests could range from an image such as an X-ray or a magnetic resonance imaging (MRI) study, both of which are painless. Based on the results of the test, the most conservative treatment plan from which the patient would further benefit will be provided. If there is no other pathology seen on the imaging study to suggest any other cause of neck pain or back pain other than a pinched medial branch nerve in the facet joint at the level of where the patient is experiencing pain, then the patient will be diagnosed as having facet syndrome at the corresponding pain level.
Treatment for Facet Syndrome Including Medial Branch Nerve Block (MBB)
Most patients diagnosed with pain in the spine’s facet joints are considered to have facet syndrome. Facet joint pain will respond well to conservative care such as a structured physical therapy program and anti-inflammatory medications. This conservative care involves physical therapy sessions two to three days per week during which time the CNSO physical therapy doctors will customize their one on one teaching and train the patient in neck or back stretching and strength building exercises plus perform therapeutic massages that will alleviate the neck pain and the back pain. If after 6 weeks of a structured physical therapy program and anti-inflammatory medications, the neck or back pain persists, the next step for treatment is a medial branch block.
Part of the comprehensive treatment plan for neck and back pain potentially related to facet arthritis yet unresolved by physical therapy, is the medial branch block. It is a quick, non-surgical procedure used to solidify the diagnose of a pinched medial nerve that is too small to be seen on any type of imaging study. They are only done when the patient’s symptoms strongly suggest that such an impingement is the root cause of the patient’s pain and there is no other identifiable cause on an MRI study.
Medial Branch Block Procedure and Recovery
The protocol established by medically-based evidence and followed by insurance plans so it is required prior to the authorization of a medical branch block, is the failure of physical therapy and nonsteroidal anti-inflammatory medications to resolve the patient’s neck pain or back pain. Consequently, only if the attempt to cure a patient from neck pain or low back pain due to facet syndrome via physical therapy has failed, will a medial branch block be offered.
Medial branch blocks are performed in a surgical center and do not require general anesthesia. In other words, patient can remain awake and have a pain free procedure by simply the use of local anesthesia to numb the specific area in need of a medial nerve block. The total time for the procedure is 10 minutes. The patient can leave the surgical center within 20 minutes after the procedure has been completed.
During a medial branch nerve block procedure, a CNSO pain doctor will numb the overlying skin in the area where the nerve block is to be done. Then, under fluoroscopic guidance, the doctor will place a special needle next to each facet joint. Medication to numb the medial nerve branch will be injected into the facet joint. This numbing medication typically lasts from 12-18 hours. If a patient has more than 80% relief during this window of time, then medical-based evidence recommends another injection be repeated within the next few weeks to again confirm the correct median nerve that needs to be blocked. If the second injection gives more than 80% relief, again, during the same window of time, then the diagnosis of facet syndrome secondary to facet arthritis will be considered confirmed. Once confirmed, then the next step towards a cure from medial nerve pain will be offered.
According to medical-based evidence and most insurance plans, after two successful medical branch nerve blocks within a few weeks, they will then advise and authorize a pain doctor to perform radiofrequency ablation of the pain generating medial branch nerves. Radiofrequency ablation will prevent pain from the medial branch nerve for 6 to 12 months or longer!
Radiofrequency ablation can be done in a surgical center environment. The procedure is done within 20 to 30 minutes while the patient is under IV sedation. The patient will be able to leave the facility within 30 minutes after the procedure has been completed. There is little to no pain after the procedure. Patients can return to their regular activities immediately after having the procedure.