"PERMANENT ANESTHETIC BLOCK OF SPINAL FACET JOINTS"
(RADIO FREQUENCY LESIONING, RADIOFREQUENCY NEUROTOMY, JOINT DENERVATION, THERMOCOAGULATION OF FACET NERVES)
What is this procedure?
This is a minimally invasive technique for relieving neck and back pain. It uses a specialized machine called a “radiofrequency lesion generator” to block pain signals coming from painful joints or fractures in the spine.
Who is a candidate for this procedure?
Currently, Radio Frequency Lesioning is offered to patients with:
1. Neck or back pain due to facet joint disease, such as arthritis (The source of pain has to be proven to be these joints with test blocks--either facet injections or facet nerve block. Please see the patient education pamphlet on facet blocks for details on that testing procedure). The facet joints are true joints just like the knee and hip - they have cartilage lining, a joint capsule, and contain synovial joint fluid. They are vulnerable to the same types of arthritis as any other joint in the body. There are facet joints all up and down the spine, from the neck to the lower back.
This diagram above shows where the facet joints are in the low back, and also shows arthritis of the facet
This diagram above shows a normal cervical facet joint, seen from the side of the spine. The long bones to the left of the picture are the spinous processes which can be felt as the boney bumps in the midle of the back of the neck
What is facet pain usually like?
• Back pain from facet joints is usually worse with standing. Sometimes, patients with spinal stenosis have back pain in addition to their leg pain, and the back pain may be from painful joints. If so, this procedure may help. Facet pain does not cause pain to radiate down the leg past the knee, this is caused by a different spine problem.
• Neck pain from facet joints is often worse on one side and bad with turning the head to look over the shoulder. Facet pain is a common cause of persistent pain after a whiplash injury. Patients with neck pain from painful facet joints (or from any cause) may have pain radiating all the way down the arm to the forearm or hand from painful muscle spasm around the injured neck - and this can be difficult to differentiate from a true nerve problem - see the education materials on referred muscle pain for more details.
2. Patients with painful “stress fractures” of the lumbar spine, also called spondylolysis. The procedure described in this monograph anesthetizes the fracture and the adjacent facet joint, because the sensory nerve supply to the fracture site is the same as the nerve supply to the facet joints.
This diagram shows the location of a stress fracture of a vertebra, called "spondylolysis".
How is the procedure performed?
The goal for the procedure is to heat the tiny nerve branches that supply the painful facet joints or stress fracture enough so that they do not work. This amounts to “cutting” the nerves to the joints, although only heat is used. Lesioning needles (shown below) are positioned close to the target nerves and a small electrical current from the radiofrequency lesion generator is passed through the needle to heat the target nerves. The doctor controls the heat very precisely, using the radiofrequency lesion generator machine. The needles are then withdrawn and the procedure is over.
This diagram shows the lumbar spine viewed from the back. The tiny nerve branches that supply the painful facet joints or stress fracture are shown in black on the left side. The diagram shows how lesioning needles are placed right next to the nerves, on the back of the spine where the nerves are easy to find.
This is a closeup picture of the tip of the lesioning needle used for this procedure. The needle is insulated except for the very tip. When current is passed through the needle, it comes out only at the tip of the needle, which is positioned close to the target nerve. The current heats the target nerve to the desired temperature.
During the procedure you will be lying on your stomach. Depending on which area the procedure is taking place, the skin is cleansed with antiseptic solution and then the procedure. X-ray (fluoroscopy) is used to guide the needles close to the small nerve branches that supply the painful joints.
This is what the room looks like during the lumbar lesioning procedure.
Since nerves cannot be seen on x-ray, the needles are positioned using bone landmarks that indicate where the nerves usually are. Fluoroscopy (x-ray) is used to identify those bony landmarks, and you will receive a small amount of x-ray during the procedure as the doctors positions the needles (much less than a chest x-ray dose). A small test current is passed through the needle tip to assess the location of the needle. You will feel a twitch of the back muscles when this is done, this is not painful. A local anesthetic is injected before lesioning.
What are my chances of having pain relief; and does this procedure ever not work?
A lasting 50% decrease in pain occurs about 75% of the time. On occasion, the procedure is not helpful; this is probably because the nerves can be hard to locate. There are several systematic reviews of this procedure in the literature. One of the most recent found that the scientific evidence that the radifrequency procedure is effective for long term relief of neck and back pain is "moderate" (Boswell et al 2007, on radiofrequency neurotomy, which is the procedure we are describing here). This means that the researchers studying the effectiveness of the procedure have demonstrated that it probably is effective - but they have not proven that conclusively (that is very hard to do); we interpret this to mean that there is good support in the medical literature for continuing to offer the procedure to well educated and carefully selected patients. Our own experience after over 1000 procedures is that it helps 75% of patients long term.
What are the risks and side effects?
Generally speaking this procedure is safe - meaning that serious complications are very, very uncommon. However, with any procedure there are risks, side effects and the possibility of complications. The risks and complications are dependent upon the sites that are lesioned. Anytime there is an injection through the skin, there is a risk of infection. This is why sterile conditions are used for these blocks. The needles must penetrate skin and soft tissues, which causes soreness for up to one week. The nerves to be lesioned may be near blood vessels or other nerves which can be potentially damaged. Great care is taken when placing the radio frequency needles but complications could occur, although they are extremely rare. These include damage to major nerves that would cause pain, numbness or weakness. This is very, very uncommon, so uncommon that there are no statistics on this risk. Please discuss any specific concerns with your physician.
How long does pain relief usually last after the procedure?
Pain relief is often permanent. Sometimes pain returns in 6-12 months, and when this happens the procedure is repeated, usually with good results.
Will the procedure hurt?
Layers of muscle and soft tissues protect nerves. The procedure involves inserting a needle through skin and those layers of muscle and soft tissues so there is some discomfort involved. However we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle.
Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia. Occasionally patients receive intravenous sedation and analgesia. It is necessary for you to be awake enough to communicate easily during the procedure.
Who should not have this procedure?
If you are on a blood thinning medication (e.g. Coumadin®, Heparin, Plavix®) you should not have the procedure unless you can stop the medication (5 days before the procedure for Coumadin, 10 days for Plavix, 1 day for heparin/Lovenox); if you are or could be pregnant, have an active infection, you should not have the procedure. If your pain has not responded to local anesthetic blocks you may not be a candidate for this procedure - with the exception of patients who are too ill to have the diagnostic blocks. We sometimes (rarely) skip the diagnostic blocks when we feel the patient cannot tolerate them or will not be able to accurately report the results to us.
Can the procedure make me worse?
There is no reason for the procedure to make back pain worse, it does not change the spine. Patients occasionally have new numbness and sometimes burning pain near the treatment site that last up to a few months, but this is temporary. In our experience, an occasional patient reports worsening of their pain after the procedure but this is very uncommon and it is not possible to say whether it is the procedure or simply the natural progression of their back pain causing the pain increase.
How long does the procedure take?
Depending upon the areas to be treated the procedure can take from about 20 minutes to 45 minutes.
Where is the procedure performed?
The procedure is sometimes performed in an operating room but usually in a fluoroscopy (x-ray) room at a clinic or surgery center. We usually do the procedure in an office-based fluoroscopy suite specially designed for this type of procedure, with a nurse and a fluoroscopy technician dedicated to assisting the doctor. This dramatically reduces the overall cost of the procedure and reduces or eliminates co-pays, yet maintains the quality of service needed to do this procedure well and safely.
What to expect after the procedure?
Initially there will be muscle soreness for up to a week. Ice packs and nonsteroidal anti-inflammatory medications or acetaminophen will usually control this discomfort, but you will leave the procedure with a prescription for a small number of pain relievers to fill if the needed for pain, and directions for an over the counter cream to apply to the skin if you have painful skin sensitivity. After the first week, your pain may be gone or considerably less.
What should I do after the procedure, are there any restrictions?
You should have a ride home. We advise you to take it easy for a day or so after the procedure. It is a good idea to take the day after the procedure off from work. You may want to apply ice to the affected area. Perform normal activities as you can tolerate them, use pain as your guide as you would always, there are no special restrictions, and the procedure does not increase the chances that you will hurt yourself with your usual activity.
Can I go to work the next day?
It is a good idea to take the day after the procedure. Plan on returning 2 days after the procedure.