which facet joints to block?

[med7343]

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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

 

[pmrmd]

The history tells you the pain pattern and the exam suggests the more painful levels.

 

[Ferrismonk]

And it's usually the lower ones in the L- spine

 

[lobelsteve]

L3-5 for 90% of my patients.

 

[callmeanesthesia]

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.

 

[pastafan]

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.

 

[SSdoc33]

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

 

[geauxg8rs]

The problem with unilateral is that Medicare won’t pay for you doing the other side if needed. They are forcing more bilateral procedures

 

[callmeanesthesia]

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.

 

[thiswonthurtabit]

Almost always L3-5 unless fusion present

 

[geauxg8rs]

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

 

[ED50]

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

 

[RoloTomassi]

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.

 

[Ducttape]

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..."

 

[lobelsteve]

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?

 

[drrosenrosen]

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

 

[Ducttape]

ok.

I'm probably antiquated, but I always talk in terms of the actual joints...

 

[painfree23]

Wait so for Medicare you are doing bilateral RF everytime?

 

[Orin]

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.

The provocative lumbar facet joint - PMC

Low back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the ...

www.ncbi.nlm.nih.gov

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.