C3 medial branch nerve, TON anatomy

[velodoc]

I have a question: I am an experienced interventionalist and I have performed RFA for many years.

As I understand it, the TON is an extension of the medial branch from the C3 dorsal ramus. Obviously, the TON is targeted for dx block or tx RFA of C23 joint.

I also understand, that the C3 and C4 medial branch nerves innervate the C34 facet joint. So, if I was to perform a block or RF of both C23 and C34 facets, I would target the TON, the C3 medial branch and the C4 medial branch.

My question is: Are there two medial branches from the C3 dorsal ramus: TON and C3 medial branch? Does the C3 medial branch nerve targeted at C3 articular pillar (for C34 facet interventions) branch off from TON? Does it need to be targeted? Does the TON contribute innervation to the C34 facet joint?

This may seem a silly question, but I'm having a hard time finding an anatomical description that provides the answer.

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[Ligament]

There is a C3 superficial medial branch aka third occipital nerve, innervates C2/3 facet joint
there is also a C3 deep medial branch, innervates the C3/4 facet joint

Technically, I've not seen anybody refer to these separately in procedure notes, but they are acknowledged in anatomy books and in the ISIS guidelines books.

 

[velodoc]

Thanks. I assume it is standard to target, and dictate as such, TON and C3 mb separately (joint line C23 and midpillar C3, respectively).

 

[painfree23]

Along these lines -- when do you decide to do GON+LON vs TON vs C3/4, C4/C5 mbnb . Do you ever do TON on its own ?? It kind of seems like a waste and not sure when to do this vs GON+LON. In the past I've done the TON under fluoro (obviously) and the GON/LON at the same time, which is works pretty well

 

[cowboydoc]

Along these lines -- when do you decide to do GON+LON vs TON vs C3/4, C4/C5 mbnb . Do you ever do TON on its own ?? It kind of seems like a waste and not sure when to do this vs GON+LON. In the past I've done the TON under fluoro (obviously) and the GON/LON at the same time, which is works pretty well

If I suspect GON/LON involvement (direct palpation), I'll block that day in clinic. It can be difficult to get this covered. If that's not a home run, I do TON with C2/3 and 3/4 usually. I've never done these two concurrently and I've never just targeted the TON.

 

[cbest]

If patient failed GON, then I used to previously just do TON. Since switching to TON plus C3 and C4, I’ve noticed better outcomes.

 

[painfree23]

If patient failed GON, then I used to previously just do TON. Since switching to TON plus C3 and C4, I’ve noticed better outcomes.

If patient failed GON, then I used to previously just do TON. Since switching to TON plus C3 and C4, I’ve noticed better outcomes.

So you do “two facet joints”?

 

[cbest]

So you do “two facet joints”?

Correct - C2-3 and C3-4 joints

 

[cheetamorf]

This website seems to describe it well based on what ya'll are saying:

USRA - Third Occipital Nerve & Cervical Medial Branch Block