How are people deciding which levels to attempt for a cervical MBB??
C6-7 and C7-T1 as noted above, can’t say I’ve every treated that joint combo before.
as a rule with considering MBB,
you should try to first identify the worst facet joint level, (mostly likely to respond to MBB), and then think decide which is the second worst facet joint level. That decision should be made by 1- imaging findings, 2- biomechanics, and 3- a level by level careful physical exam of the facet joints in the spine area you are treating.
As we recently discussed, if we are talking about bilateral RFA, which is most common, then medicare and BCBS, which compromise over 70% of all patients, only allow 2 joint levels to be treated.
Also important to remember that many insurances will not let you do MBB 3-4 different joints on 3-4 different occasions, so you always want to target two bilateral joints, and never just one bilateral joint.
Consider the practical issues.
1-If you do just the worst joint, and the second worst joint is only responsible for 15% of the pain, you'll still have a fairly happy patient getting 65% relief, but they could be getting 80% if you did them both.
2- most insurances will not let you repeat RFA/MBB very soon afterwards to go after the second worst joint, so you might was well include it right away.
3- over time, the second worst joint will become more painful, and you'll have to convince your patient after 5 years to do another set of MBB, which some patients don't appreciate.
I would definitely recommend you first consider facet joint referral patterns, imaging findings, and exam....but after that, you should consider--
Re cervical MBB.
1-If you're worried about facet driven cervicogenic headache, then of course you target C2-C3, but I'd also do C3-C4.
2-if someone has a C5-C6 ACDF and they have equal pain in mid and lower neck, then target C4-C5, C6-C7,
2a- if the patient with C5-C6 ACDF has dramatically worsened pain inferior to fusion then targeting C6-C7, C7-T1 is reasonable. There is likely only a small component from C7-T1, but even that extra 10% relief is appreciated. And that patient listed above who is a old football coach, likely got his neck hyperextended many times on the field, and so has more C7-T1 facet pathology than most.
3- If Patient has C5-C7 ACDF, and most of their pain appears to be superior to fusion, then do C3-C5 MBB.
Same thing for lumbar. A patients s/p L4-L5 fusion, gets mbb at L3-L4, L5-S1 facets from me, unless over 95% of their pain is inferior to fusion , and the L5-S1 facets look dramatically worse than the L3-L4, in which case I'd just do L5-S1. If fused at L5-S1, then I'd target the L3-L4, L4-L5 facet joints, but be certain to remember the SIJ, if the patient fails the MBB for L3-L4, L4-L5.
Also remember than in the unfused spine, that
1-L4-L5 facet joint is always involved
2- if lower neck pain, then always include C5-C6, which is the most common level affected in the neck
3- If upper neck pain that includes a headache component, then always include the C2-C3 level, which is the second most affected level overall in the neck, though this is bogduk data, which skews towards trauma, as there are more C2-C3 issues after trauma, then just regular chronic facet OA.