Thoracic Medial Branch Block

Introduction

A common source of upper back pain, is arthritis of the facet joints. These are small synovial joints (like other joints in the body) that allow for movement of the back. When arthritis becomes significant enough to involve these small joints, simple movements such as bending, twisting, standing, or walking can create significant pain in the upper back. This pain is transmitted to the brain by way of a small nerve from each joint, called the medial branch nerve.

This procedure is a step in the process of identifying your pain, and identifying patients who may be eligible for radiofrequency ablation (neurolysis), which is a procedure that provides longer lasting relief, often 6-12 months duration.

Goal of the injection

In order to determine if pain in the upper back is coming from arthritis of the facet joints, a diagnostic procedure called medial branch blocks is performed. This procedure is done by placing a small amount of local anesthetic on the medial branch nerve, which sits over the joint. While the medial branch nerve is anesthetized, the pain transmitted from the upper back should be significantly improved – helping to localize the source of your upper back pain.

The procedure

You will be accompanied into a sterile procedure suite, and asked to lie face down on the exam table. Using X-ray guidance, the skin is anesthetized and a small needle is inserted over each area of interest. Once the needle is in proper location over the medial branch nerve of each joint, a small amount of anesthetic is injected. Following the injection, the patient is cared for in the recovery area for a brief amount of time, and then discharged home.

After the procedure

Follow the specific instructions given to you by the nurses at the time of discharge from the recovery area:

• Resume activity as tolerated
• You are encouraged to perform activities that typically cause an increase in their normal pain. This is used to “test” whether the diagnostic procedure is helpful in reducing your pain.
• Do NOT soak in a bathtub or lake for 24 hours after the procedure. You may shower.
• Keep a record of your pain and symptoms in the immediate hours after your injection
• You will receive a phone call from a clinic nurse asking about the relief of symptoms you experienced after your injection. If you meet specific criteria designated by the insurance companies, you may be scheduled for a second diagnostic block – or you may be scheduled for radiofrequency ablation as the next step.

If your procedure includes sedation

• You should have no solid foods for 8 hours before the procedure.
• You may have clear liquids up to 2 hours before your procedure. Examples of these clear liquids are:  water, broth, clear juices with NO pulp, tea, coffee WITHOUT cream. Carbonated beverages are NOT allowed.
• No gum chewing for 2 hours before your procedure.
• No candy, throat lozenges, or mints.
• A nurse will call you before your procedure to review your medications and make recommendations as to what medicines you should take before your procedure.

Failure to comply with these instructions may result in cancellation and rescheduling of your procedure.

Potential risks of the procedure

Radiofrequency ablation procedures are considered safe, non-surgical, minimally invasive treatments. As with all medical procedures, there are associated risks and side-effects that may vary between each patient. These rare but potential risks are:

• Pain at the injection site
• Infection. In very rare instances (less than 1%) minor infections can occur
• Increased pain or worsening symptoms.
• Collapsed lung (Pneumothorax). This is a unique risk to thoracic medial branch blocks because of the proximity of the lung in that region of the body.
• Bleeding. You may suffer bleeding from undergoing procedures, especially while on blood thinning medications. Please notify us if you are taking any of the following blood thinning medications: Warfarin (Coumadin), Plavix (Clopidogrel), Aspirin, Xarelto (Rivaroxaban), Heparin, Lovenox (Enoxaparin), Brilinta (Ticagrelor), or any others not listed.
• Nerve or spinal cord damage. In extremely rare instances, a patient may suffer nerve or spinal cord damage from direct trauma from a needle. This could potentially result in permanent nerve damage or paralysis.
• Allergic reactions to medications. The commonly used medications in this procedure include: Lidocaine, Bupivacaine, Ropivacaine, IV contrast dye, and corticosteroid (cortisone).
• Inability to complete the injection due to technical or anatomic difficulty.

Insurance requirements

Insurance companies may require up to two medial branch diagnostic block procedures, demonstrating measurable relief of symptoms for a specific amount of time, prior to approving the radiofrequency ablation procedure.