which facet joints to block?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

med7343

Full Member
5+ Year Member
Joined
Dec 16, 2018
Messages
49
Reaction score
17
if there are multiple facet joints with arthropathy eg L3-4, 4-5, 5-S1
how do you guys decide which 2 joints to block? does anyone map the pain on the skin and block the respective joints?
thanks

Members don't see this ad.
 
Members don't see this ad :)
Almost always L4-5 and L5-S1 joints but if there is uncertainty I’ll palpate the joints under fluoro and adjust the targets when they come for procedure. I do this more commonly for cervical and thoracic than lumbar. Somewhat guide but the X-ray/MRI too - if the facets look particularly bad at one level or they have an old compression fracture.
 
Agree almost always L4-5 and L5-S1 joints but I palpated and marked using fluoro. Do the most painful side first and if all pain relieved skip other side. Surprising number have pain relief both sides with unilateral blocks/RFA.
 
if unilateral, ill sometimes do a L2, L3, L4, and L5 dorsal ramus.

there is no magic to it. usually the lower 2 joints, unless there is active arthropathy at L3-4 on MRI or exam points to a higher lumbar lumbar level
 
The problem with unilateral is that Medicare won’t pay for you doing the other side if needed. They are forcing more bilateral procedures
 
The problem with unilateral is that Medicare won’t pay for you doing the other side if needed. They are forcing more bilateral procedures
They will, you just can’t repeat it for a year. And with the new changes they allow up to 4 diagnostic blocks per region, so you can do blocks on one side, then the other if necessary.
 
They will, you just can’t repeat it for a year. And with the new changes they allow up to 4 diagnostic blocks per region, so you can do blocks on one side, then the other if necessary.
But you are limited on number of rf per 12 months
 
Agree with above, for cervical spine I base more on their pain referral pattern. For lumbar spine they need a compelling reason for me not to do L3-5
 
You could do L3-4, L5-S1 if you wanted to be really nice and essentially do a 3 level but only bill 2.

I'm 50/50 between L3-5 and L4-S1. More buttock usually gets L5-S1, band-like/beltline L3-4. Otherwise, I look at which facets look worse, and if there's corresponding DDD, ie if L3-4 and L5-S1 facets look equally bad but L3-4 disc is much more degenerated then L3-4. CT SPECT can help if you really need to know for some reason.
 
just to be clear for those who are saying L3-5, I assume you are discussing L34 and L45 facet joints, and not the L3, L4 and L5 median branches.

I look at the patient, location of pain, and then if possible cross correlate with imaging, though it is rare I will change assessed levels based on imaging alone. If there is a discrepancy under live fluoro, then yes.

if the MBB doesn't work,... "He chose poorly..."
 
just to be clear for those who are saying L3-5, I assume you are discussing L34 and L45 facet joints, and not the L3, L4 and L5 median branches.

I look at the patient, location of pain, and then if possible cross correlate with imaging, though it is rare I will change assessed levels based on imaging alone. If there is a discrepancy under live fluoro, then yes.

if the MBB doesn't work,... "He chose poorly..."

Last Crusade?
 
just to be clear for those who are saying L3-5, I assume you are discussing L34 and L45 facet joints, and not the L3, L4 and L5 median branches.

I look at the patient, location of pain, and then if possible cross correlate with imaging, though it is rare I will change assessed levels based on imaging alone. If there is a discrepancy under live fluoro, then yes.

if the MBB doesn't work,... "He chose poorly..."
When I say L3-5, I mean L3 and L4 medial branches and primary dorsal ramus of L5, aka L4-5, L5-S1, aka L4, L5, sacral ala. And those are the levels I do almost always
 
Wait so for Medicare you are doing bilateral RF everytime?
 
if there are multiple facet joints with arthropathy eg L3-4, 4-5, 5-S1
how do you guys decide which 2 joints to block? does anyone map the pain on the skin and block the respective joints?
thanks
Reg skin mapping/referral patterns, I think about that more for the C-spine than L-spine, but the issue is that there is great variability and significant expansion of the regular spread in chronic pain patients.


12178_2008_9039_Fig3_HTML.jpg



With telehealth visits, I often am pulling up images like this one, but it's a lot of correlating to spinal imaging and ideally exam.
8c86e8674d2532d8b4452737c2dbdb3f.jpg
 
Top