Medial branch blocks/RFA after fusion

[No_Pain_No_Gain]

Patient has had prior L4-5 posterior decompression and fusion. Patient now has axial low back pain reproduced by facet loading bilaterally, has failed conservative measures including physical therapy, and MRI shows significant facet degeneration at L2-3, L3-4, and L5-S1 joints bilaterally. Which medial branch nerves do you choose to target and why? L1-5 bilaterally? L1, L2, L3, & L5 bilaterally? L1, L2, L4, & L5 bilaterally? Thanks in advance for any input.

---

Members don't see this ad.

 

[DOctorJay]

I go above and below the fusion if clinically that seems appropriate. Insurance typically doesn’t cover blocks at the fused levels.

Also make sure to rule out the SIJs.

 

[No_Pain_No_Gain]

I go above and below the fusion if clinically that seems appropriate. Insurance typically doesn’t cover blocks at the fused levels.

Also make sure to rule out the SIJs.

I agree with going above and below the fusion, that is my plan and why I asked the question to get more clarification. Technically, the L2-3 facet joint is innervated by the L1 and L2 medial branch nerves, the L3-4 joint is innervated by the L2 and L3 medial branch nerves and the L5-S1 joint is innervated by the L4 and L5 medial branch nerves. So which medial branch nerves do you target for going above and below?

 

[SSdoc33]

I agree with going above and below the fusion, that is my plan and why I asked the question to get more clarification. Technically, the L2-3 facet joint is innervated by the L1 and L2 medial branch nerves, the L3-4 joint is innervated by the L2 and L3 medial branch nerves and the L5-S1 joint is innervated by the L4 and L5 medial branch nerves. So which medial branch nerves do you target for going above and below?

this is a rare occasion where i may do intra-articular at both 5-1 z-joints.

in these patients, you will end up sticking a lot of needles in there with relatively poor outcomes

 

[callmeanesthesia]

L2, L3, L4 medial branches and L5 dorsal ramus - functionally for this patient just the joints above and below the joint. If the pain extends signficantly into the mid to upper lumbar would also add L1 MB.

 

[DOctorJay]

I'd go for L1, L2, L5 medial branch/dorsal ramus in this case. I'm presuming there are pedicle screws at the L3 and L4 medial branches.

I'm interested in hearing others' take on this as well.

 

[callmeanesthesia]

I'd go for L1, L2, L5 medial branch/dorsal ramus in this case. I'm presuming there are pedicle screws at the L3 and L4 medial branches.

I'm interested in hearing others' take on this as well.

I will usually put a needle at a level with pedicle screws as well (not to try to denervate the fused level but for its contribution to the adjacent segment) The medial branch may or may not be intact but I figure it’s worth including. I’ve sometimes gotten multifidus activation when motor testing at those levels.

 

[BobLoblaw78]

L2, 3, 4, 5 branches to cover both branches to adjacent levels. RFA becomes more difficult to verify separation from hardware at L3 and L4 and worry about conduction and risks. I am not a huge fan of the amount of actual obtainable benefit in the long term. How long ago was the fusion? Was back pain fixed by surgery for years? If it is more recent, I would have even less optimism.

 

[Ducttape]

L2, L3 and L5, and L4 if accessible depending on images.

 

[DOctorJay]

do any of you guys have trouble getting these levels covered after a fusion? I've had denials in the past which is why I've changed the levels I address.

 

[Ducttape]

ask for specific levels and document that you are doing the non-fused levels to reduce risk of denial.

in your case, ask specifically for L34 and L5S1, "above and below the L45 fusion".

 

[10KHertz]

For me it depends on the pedicle screw placement at the fusion level. If the screw is medial to the later pedicular margin, and I can stimulate the mbn, and insurance allows it, I burn it.... most fusions have lateral screw placement with bone growth factors that causes a nightmare in the peri-pedicular region . So, no mbn to locate, and thus the rfa is ineffective at the surgical level. Plus most insurances don’t pay .