SPINE VASCULAR/INTERVENTIONAL CME

ABBREVIATIONS KEY
CRF ⫽ continuous radiofrequency
INR ⫽ international normalized ratio
PRF ⫽ pulsed radiofrequency
RF ⫽ radiofrequency
RFA ⫽ radiofrequency ablation
TON ⫽ third occipital nerve

Radio-Frequency Ablation Treatment

Received August 18, 2013; accepted
of Chronic Neck and Low Back Pain after revision January 29, 2014.
From the Department of Radiology

Attributable to Facet Joints (V.A., W.R.), University of

Pittsburgh Medical Center,
Pittsburgh, Pennsylvania; and
Department of Radiology (R.F.),
V. Agarwal, R.T. Fitzgerald, and W.E. Rothfus University of Arkansas for Medical
Sciences, Little Rock, Arkansas.
Please address correspondence to
Vikas Agarwal, MD, Department of
Radiology, University of Pittsburgh
Medical Center, 200 Lothrop St,
CME Credit Pittsburgh, Pennsylvania 15213;
The American Society of Neuroradiology (ASNR) is accredited by the Accreditation Council for Continuing Medical Education e-mail: agarwalv@upmc.edu
(ACCME) to provide continuing medical education for physicians. The ASNR designates this enduring material for a maximum of 1 AMA http://dx.doi.org/10.3174/ng.2140082
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ABSTRACT
Spine pain is a major cause of disability for which conservative treatment strategies are not
universally effective. Radio-frequency ablation of nerves supplying the zygapophysial joints
should be considered in selected patients for whom routine treatments do not provide
acceptable relief. Following a brief discussion of the principles of radio-frequency therapy,
we describe the relevant anatomy, appropriate patient selection, and basic procedural
techniques for ablative therapies of the cervical and lumbar zygapophysial joints.

Learning Objectives: Understand the anatomy, indications, and techniques for radio-fre-
quency ablative treatment of cervical and lumbar zygapophysial joint pain.

INTRODUCTION priate patient selection, work-up, and

Nonsurgical ablative therapy with radio-
frequency (RF) is now regarded as the
next step in treatment of spinal pain re-
fractory to conservative measures. The
rationale for RF is similar to that of other
minimally invasive ablative techniques
that use neurolytic agents such as al-
cohol or phenol—target the nerve supply
to a pain generator to achieve symptom-
atic relief. Although RF has been used
since the 1930s, recent advances in tech-
nology and techniques allow the procedure
to be performed safely on an outpatient basis
by using only standard image-guided
procedural skills and light sedation. In
this article, we review the basics of RF
and its use in the treatment of chronic
pain attributable to cervical and lumbar
facet joints with an emphasis on appro-
outcomes.
Basic Principles of Radio-frequency
Two different types of RF current are used
in chronic pain treatment, continuous RF
(CRF) and pulsed RF (PRF). In continuous
RF, a needle electrode is placed alongside a
target nerve. The needle electrode has an
uninsulated active tip ranging from 2 to 15
mm, which can be selected according to
target nerve size and anatomy. Voltage
from a generator creates a low-energy,
high-frequency (range, 100 –500 kHz) cur-
rent which, when passed through the elec-
trode, generates an electric field. Induction
of oscillatory motion of charged ions
within tissues subjected to this electric field
generates friction and therefore heat. Heat
energy in the tissues, in turn, raises the tem-

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perature of the electrode tip, thus creating a thermal lesion.
Lesion diameter size depends on the size of the electrode. In
general, thermal lesions will be 1–1.5 times the electrode
diameter. Coagulation occurs when the electrode reaches
a sufficient temperature (usually 80°).1 For optimal effect,
the electrode must, therefore, be placed parallel to the target
nerve. Coagulation is followed by an acute inflammatory
reaction, which progresses for 2– 4 weeks to necrosis and
subsequently collagen deposition and scar. The result is
prevention of nociceptive input (A-␦ and C fibers) from
reaching the central nervous system while preserving motor
and/or sensory fibers (A-␤). This concept of differential se-
lection of pain fibers is the accepted theory behind CRF
lesioning.2
As opposed to continuous RF, pulsed RF uses a lower
current frequency, typically 50 kHz, delivered in short
20-ms pulses. Electrode-tip temperature is usually kept at or
⬍42°C because the pause between pulses allows heat dissi-
pation. Therefore, temperatures in the soft tissues are insuf-
ficient to produce a thermal lesion at the target nerve.3
Despite the absence of coagulation at the target, pulsed RF
results in altered signal-intensity transduction of pain path-
ways. Neurons stimulated by PRF show increased expres-
sion of c-Fos, an early activator gene, and activation of Fig 1. Illustration of the posterior view of the lumbar spine and posterior
transcription factor 3, a marker of cellular stress, both of neural structures. Spinous processes of L1 through L5 are labeled. Left: TP3
inidcates transverse process of L3; FJ, facet (zygapophysial) joint L1–2; I,
which are restricted to A-␦ and C fibers.4 Subsequent inferior articular process of L3; S, superior articular process of L4; NR4,
changes in signal-intensity transduction may ultimately fourth lumbar nerve root; MB4, medial branch of the dorsal primary ramus of
lead to pain reduction; however, the mechanisms are still L4. Right: NR2, second lumbar nerve root; MB2, medial branch of the dorsal
not well-understood. As opposed to CRF, electrodes can be primary ramus of L2; NR3, third lumbar nerve root; MB3, medial branch of
placed perpendicular to the nerve. the dorsal primary ramus of L3; DPRL5, dorsal primary ramus of L5.
Because PRF uses a lower temperature application of
facet joints. Although subsequent anatomic studies showed
energy, it has been postulated that it may offer pain relief
the nerves in a different location than where Rees per-
comparable to that in CRF but with less postprocedure
formed his procedure, interest in the lumbar facet joints as
discomfort, neuritis, or the risk of motor nerve damage.
pain generators was renewed and multiple investigators
Many studies have been performed comparing the efficacy
showed that pain could be relieved by anesthetizing the
CRF and PRF individually in the treatment of cervical and
joints.10-12
lumbar zygapophysial pain with conflicting results. Tekin et
Controlled studies implicated lumbosacral facets as the
al5 found that though similar pain relief can be achieved
source of pain in 15%– 45% of patients with chronic low
with both CRF and PRF, the duration of pain relief was back pain.13-17 Although numerous studies have failed to
greater with CRF. Despite a more recent randomized, dou- identify distinct clinical features indicative of lumbar facet
ble-blinded trial, which found similar results, the topic re- joint pain, patients with intermittent or continuous somatic
mains controversial.6 Given that we routinely use CRF or nonradicular low back and/or lower extremity pain of at
rather than PRF for treatment of cervical and lumbar zyg- least 3 months duration causing functional disability that
apophysial joint pain, we will focus on CRF. fails to respond to conservative treatment may benefit from
lumbar facet joint interventions.
Lumbar Facet Joints
Lumbar Zygapophysial Joint Pain. Lumbar facet joints or Anatomy
zygapophysial joints as they are alternatively known were Lumbar facet joints are formed by the superior and inferior
suggested as a possible pain generator in the low back as articular processes of adjacent vertebrae. Each of the facet
early as 1933 when Ghormley7 introduced the oblique pro- joints has dual innervation supplied by 2 medial branch
jection of the lumbar spine to better visualize the joints nerves to the proximal and distal zygapophysial joint (Fig
implicated in osteoarthritic changes. As interest in the role 1). As the L1-L4 dorsal rami exit their respective interver-
of disk herniation in low back pain increased, interest in the tebral foramina, they divide into 2 or 3 branches, which
lumbar facet joints faded. In the early 1970s however, include the medial branch. The medial branches have a
Rees8,9 reported overwhelming success in treating low back constant and reproducible course running across the top of
pain by percutaneously transecting the nerves of the lumbar their respective transverse processes. Each nerve then runs

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Fig 2. Shallow left anterior oblique illustration of the lumbar spine with
pertinent neural structures demonstrated. Medial branch denervation
target zones (green dots) are indicated at multiple lumbar levels. MB2
indicates the medial branch target zone at the L2 level; MB3, medial
branch target zone at the L3 level; MB4, medial branch target zone at the
L4 level; DPRL5, dorsal primary ramus target zone at the L5 level; MAL,
mamilloaccessory ligament labeled at the L2 and L4 levels; NR2, right
second nerve root; S, superior articular process of L3; I, inferior articular
process of L2; TP, transverse process of L1. Spinous processes of L2
through L5 are labeled.
along the bone at the junction of the transverse process and
superior articular process. The nerve then hooks medially
around the base of the superior articular process and is
covered by the mamilloaccessory ligament. Each medial
branch, therefore, supplies the zygapophysial joints above
and below its course. As such, the joint blocked is concor-
dant with the transverse processes targeted for injection (ie,
targeting the medial braches overlying the L4 and L5 trans-
verse processes would ablate innervation to the L4 –5 fact).
Most important, the nerves affected arise from the more
cephalad segment. Therefore, the L4 –5 facet joint is sup-
plied by the medial branches of the dorsal rami of L3 and
L4, which cross the L4 and L5 transverse processes. The L5
medial branch is not the medial branch of L5 but rather the
dorsal primary ramus of L5. It has a slightly different course
and distribution crossing the sacral ala instead of a trans-
verse process (Fig 2) and runs in a groove formed by the
junction of the sacral ala and the superior articular process
of the S1 to hook medially around the base of the lumbo-
108 兩 Neurographics 4:106 –113 June 2014 www.neurographics.com
sacral zygapophysial joint.18 There is no mamilloaccessory
ligament at this level.
Patient Selection
Patients with progressive rather than acute, predominantly
axial lumbar pain in whom serious causes of lumbar pain,
such as tumor and infection, have been excluded and who
have failed at least 3 months of conservative treatment
should be investigated for zygapophysial joint pain. Pa-
tients may present with deep, dull pain in the low back. Pain
may extend into the buttocks and hips or radiate into the
thigh and down the leg in a nondermatomal distribution.
Pain may be exacerbated by moving from a sitting to a
standing position or relieved by standing or walking. Given
the high variability, it is no surprise that clinical signs and
symptoms have not been shown to be sensitive or specific
for the diagnosis, with the exception of paraspinal tender-
ness.19 Pain on extension and ipsilateral rotation (facet
loading), though popularized in older studies, has not been
proved to correlate with lumbar zygapophysial joint pain
consistently.19 Facet degenerative changes are commonly
observed on imaging studies, even in asymptomatic volun-
teers, and are, therefore, not helpful in establishing the
diagnosis.20
Diagnostic blocks are considered the best approach for
identifying a painful zygapophysial joint. Intra-articular
facet blocks can be performed for diagnostic purposes;
however, there is no evidence for the validity of these injec-
tions.21 Furthermore, there is no logical progression to
treatment with intra-articular injections of steroid because
they have not been shown to be more effective than intra-
articular or periarticular saline injections.22-25 Controlled
diagnostic blocks of the medial branches have been vali-
dated and now constitute the best means of diagnosing
lumbar zygapophysial joint pain26,27 False-positive rates of
diagnosis with medial branch blocks have been reported as
high as 41%; therefore, dual comparative blocks with
short- and long acting local anesthetic are recommended to
reduce the false-positive rate in making the diagnosis of
zygapophysial joint pain.14,28 Patients who experience at
least 80% pain relief with dual comparative blocks are con-
sidered good candidates for radio-frequency neurotomy.
Contraindications to radio-frequency neurotomy include
coagulopathy (international normalized ratio [INR] ⬎ 1.5
or platelets ⬍ 50,000/mm3), pregnancy, systemic infection
or skin infection over the puncture site, motor weakness,
absent reflexes, or long tract signs.29 The authors think that
severe allergy to any of the medications used is a relative
contraindication as are any anatomic derangements, surgi-
cal or congenital, that may not allow percutaneous access to
the target medial branch nerve.
Radio-Frequency Ablation
Radio-frequency neurotomy of the medial branches is the
only validated treatment of lumbar zygapophysial joint
pain.30,31 The procedure is performed under fluoroscopy
with the patient prone. Standard recommendations for con-
scious sedation and monitoring should be used. Patients
must be able to verbalize responses to nerve-stimulation
testing during the procedure. In cases in which bilateral
treatment is planned, we advocate starting with the more
symptomatic side and waiting 2 weeks to treat the opposite
side to lessen postprocedural discomfort.
The procedure is performed with disposable probes
ranging in diameter from 18 to 22 ga. Lesion size is directly
proportional to the diameter of the probe. For example, a
20-ga probe with a 10-mm active electrode tip produces an
average lesion width of 4.8 mm. By contrast, an 18-ga
probe with a 10-mm active electrode tip produces a lesion
with an average width of 5.8 mm. When one uses smaller
gauge electrodes, multiple lesions may be required to ade-
quately ablate the nerve. Probe lengths range from 5 to 20
cm; however, in the lumbar region, a 10- or 15-cm length is
adequate to reach the target depth in most patients. Al-
though straight-tip needles are available, a curved tip facil-
itates needle placement by hugging the bony target and
allowing placement parallel to the target nerve for optimal
denervation of the medial branch nerves because the lesion
shape created is elliptic. Varying active tip lengths are also
available (2.5–15 mm). As the electrode tip length increases,
so does the size of the lesion created. In the lumbar region,
an active tip length of 10 or 15 mm should create a sufficient
lesion size to allow a single pass per level. In our practice, we
prefer 20-ga, curved, 10-mm active tip Stryker (Kalamazoo,
MI) needles, 10- or 15 cm in length. An adhesive grounding
pad is placed on the patient’s calf opposite the side of
treatment.
The target zone for the L1-L4 medial branches is the
groove formed by the junction of the transverse process and
superior articular process (Fig 2). Given anatomic variation
of the course of the L5 medial branch, the target zone for L5
is, therefore, the dorsal ramus proper. Placing the needle at
the target zone for the medical branches can be accom-
plished by using a “down the barrel” technique or “pillar
view” with the C-arm rotated 10°-15° laterally and cau-
dally 15°-25° on the basis of the degree of lordosis encoun-
tered. After appropriate local anesthesia, the RF needle is
advanced by using a “down the barrel” technique. Once
bony contact is made, the needle is advanced cranially along
the groove until the tip reaches its final destination at the
superior edge of the groove just above the transverse process
or sacral ala. This location provides access to a long segment of
the nerve along its middle two-fourths as it courses along the
lateral aspect of the neck of the superior articular process. In
the posteroanterior view, the active needle tip should lie
against the superior articular process and above the transverse
process/sacral ala (Fig 3A). Needle tip position should then be
confirmed in the lateral projection where it should lie across
the middle two-fourths of the neck of the superior articular
process for L1-L4 and across the posterior three-fourths of the
superior articular process for the L5 dorsal ramus (Fig 3C).
Fig 3. RFA of the L3 and L4 medial branches and L5 dorsal ramus. A,
Slightly oblique or pillar view shows needle placement in the groove at
the superior aspect of the superior articular process–transverse process
junction. B, Oblique projection demonstrating needle tips at the superior
aspect of the transverse process–superior articular process junction. C,
Lateral projection confirms appropriate needle position with the tip
across the middle two-fourths of the neck of the superior articular pro-
cess for L1–L4 and across the posterior three-fourths of the superior ar-
ticular process for the L5 dorsal ramus.
Bone should be visible between the needle tip and the neural
foramen.
Once the proper needle position is confirmed, the stylets
are removed and replaced with the radio-frequency electrodes.
Sensory and motor stimulation is then performed to optimize
needle placement adjacent to the target medial branch nerve
and, more important, to ensure a safe distance between the
probe and the ventral ramus. Sensory testing is performed by
using a frequency of 50 Hz and a current up to 1 V. At 50 Hz,
paresthesias should be noted by the patient in the back or
paravertebral regions corresponding to the level being stimu-
lated. Motor testing is performed at 2 Hz and up to 2 V. At
these values, the patient may feel a rhythmic thumping sensa-
tion in the back due to contractions of the multifidus muscle
fibers, which are innervated by the medial branch nerves.
These contractions are normal. The patient should not, how-
ever, feel contractions in the gluteus muscles or lower extrem-
ity. After sensory and motor stimulation is completed and
electrode position is verified, 1 mL of local anesthetic is in-
jected to anesthetize the target area. Radio-frequency thermal
lesioning is then performed at each location at 80°C for 90
seconds. After the procedure, patients are monitored for 1–3
hours, mainly for the sedation to wear off and to ensure no
significant motor weakness.
Outcomes
Prospective controlled double-blind randomized studies in
patients with pain attributable to the zygapophysial joints
have shown significant improvement in pain scores at 1 and
6 months in patients treated with radio-frequency neurot-
omy compared with the placebo group.32 In a nonrandom-
ized prospective study by Dreyfuss et al,30 60% of patients
who underwent radio-frequency neurotomy after dual diag-
nostic medial branch blocks obtained at least 80% pain relief
at 12 months with 80% experiencing at least 60% relief. Re-
generation of the medial branch nerves most likely occurs,
accounting for gradual return of symptoms with time, which
can be subsequently treated with repeat procedures.31
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Cervical Facet Joints
Cervical Zygapophysial Joint Pain. Just as Ghormley7 sug-
gested lumbar zygapophysial joints as possible pain gener-
ators in the low back, Hadden in the 1940s33 suggested
cervical zygapophysial joints as a possible source of headache.
Numerous studies have since implicated cervical facet joints as
pain generators in patients with neck pain, in particular related
to whiplash injury. Gibson et al34 found the cervical facet
joints to be the source of pain in 50%– 60% of patients with
neck pain after whiplash injury. Just as in the lumbar region,
multiple investigators have shown that pain can be relieved by
anesthetizing the joints.35-37 Patients who experience neck
pain, limitation of movement, shoulder pain, arm pain, or
headache for at least 3 months’ duration causing functional
disability that fails to respond to conservative treatment (in-
cluding but not limited to rest treatment with nonsteroidal
anti-inflammatory drugs, opioids, muscle relaxants or antide-
pressants, and physical therapy) and have no neurologic defi-
cits may benefit from cervical facet joint interventions.

Anatomy
The cervical facet joints are formed by the articulation of
the superior articular process of 1 vertebra and the inferior
articular facet of the adjacent vertebrae. The C3– 4 to
C7-T1 facet joints are innervated by the medial branches of
the cervical posterior rami at the same level and from the
segmental level above. Therefore the C5– 6 facet joint is
innervated by the C5 and C6 medial branch nerves. These
nerves arise from the posterior primary rami in the cervical
intertransverse spaces and curve dorsally and medially to
wrap around the waist of their respective articular pillars
(Fig 4A). The C7 medial branch crosses the root of the C7
transverse process and therefore lies slightly higher on the
lateral projection of the C7 articular pillar.
The C2–3 facet joint is unique in that it receives inner-
vation not only from the C2 and C3 medial branch nerves
but also from the third occipital nerve (TON) (Fig 4B). The
dorsal ramus of the C3 spinal nerve divides into 2 medial
branches. The larger, more superior branch is the TON. It
curves dorsally and medially around the superior articular
process of the C3 vertebra. Unlike the remainder of the
cervical medial branches, which are obliquely oriented, the
TON has a transverse course crossing the C2–3 facet joint
at or just below the joint. The TON provides the major
innervation for the C2–3 facet joint with a smaller compo-
nent from the C2 medial branch.
Fig 4. Axial (A) and lateral (B) illustrations demonstrate the target
zones (green dots) for medial branch denervation. The medial branch
Patient Selection nerves extend around the lateral margin of the mid-portion of the
Patients with progressive, head, neck, and shoulder pain in articular pillar at each respective level. The only exception is the C7
medial branch, which extends around the pillar slightly higher, just
whom serious causes of pain, such as tumor and infection, below the articular facets. The target zones for the TON denervation
have been excluded and who have failed at least 3 months of are indicated. C2 indicates the spinous process of C2; C7, the spinous
conservative treatment should be investigated for zyg- process of C7; VA, vertebral artery; DPR, dorsal primary ramus; LB,
apophysial joint pain. Unlike in the lumbar spine, cervical lateral branch; MB, medial branch; AP, articular pillar.
zygapophysial joints are more susceptible to injury during
trauma; therefore, patients with a history of whiplash-type
injuries should also be investigated for zygapophysial joint

110 兩 Neurographics 4:106 –113 June 2014 www.neurographics.com

pain.38,39 Patients may present with unilateral or bilateral
paravertebral neck pain and/or headaches. There may be a
decreased range of motion of the neck. Pain may be referred
into the shoulder girdle and can extend down the arm in a
nondermatomal distribution. As in the lumbar spine, given
the high variability, it is no surprise that clinical signs and
symptoms have not been shown to be sensitive or specific
for the diagnosis, with the exception of paraspinal tender-
ness.40 Pain on extension and ipsilateral rotation (facet
loading), though popularized in older studies, has not been
proved to correlate with lumbar zygapophysial joint pain
consistently.40 Facet-degenerative changes are commonly
observed on imaging studies, even in asymptomatic volun-
teers, and are, therefore, not helpful in establishing the
diagnosis.41
As in the lumbar region, diagnostic blocks are considered
the best approach for identifying a painful zygapophysial
joint. Intra-articular facet blocks can be performed for di-
agnostic purposes; however, studies have not shown the
long-term effectiveness of intra-articular injections of ste-
roid.42 Although intra-articular facet blocks can provide
diagnostic information for localizing pain in the cervical
region, medial branch blocks are easier to perform and
theoretically safer. Controlled diagnostic blocks of the me-
dial branches have been validated and now constitute the
best means of diagnosing cervical zygapophysial joint
pain.36 Dual comparative blocks with short- and long-act-
ing local anesthetic are also recommended to reduce the
false-positive rates in making the diagnosis of cervical zyg-
apophysial joint pain.35,37 Patients who experience at least
80% concordant pain relief with dual comparative medial
branch blocks are considered ideal candidates for radio-
frequency neurotomy. Contraindications in the cervical
spine are the same as in the lumbar spine: coagulopathy
(INR ⬎ 1.5 or platelets ⬍ 50,000/mm3), pregnancy, sys-
temic infection or skin infection over the puncture site, mo-
tor weakness, absent reflexes, or long tract signs.29 The
authors think that severe allergy to any of the medications
used is a relative contraindication as is any anatomic de-
rangement, surgical or congenital, that may not allow per-
cutaneous access to the target medial branch nerve.
Radio-Frequency Ablation
Cervical facet denervation by radio-frequency neurotomy
should only be performed after appropriate diagnostic me-
dial branch blocks. The ablation procedure is performed
under fluoroscopy with the patient prone. Standard recom-
mendations for conscious sedation, typically by using midazo-
lam and fentanyl, and monitoring should be used. Patients
must be to verbalize responses to nerve-stimulation testing
during the procedure. In cases in which bilateral treatment is
planned, we advocate initially ablating the most symptomatic
side followed by a 2 week delay before treating the opposite
side to lessen postprocedure discomfort.
As in the lumbar region, there is an assortment of dispos-
able probes available for ablation. Given anatomic differ-
Fig 5. RFA of the C4, C5, and C6 medial branches in a patient with prior
anterior cervical fusion at C5– 6. A, Anteroposterior view shows needle
placement at the midvertebral margin of the C4, C5, and C6 vertebral bodies
along the lateral margin of the articular pillars. B, Lateral projection shows
needle tip at the middle third of the articular pillar. Needles should subse-
quently be advanced to the anterolateral margin of the articular pillar.
ences between the neck and lower back, probe lengths of 5
or 10 cm are usually sufficient to reach target depth in most
patients. A curved tip again facilitates needle placement by
hugging the bony target and allowing placement parallel to
the target nerve for optimal denervation of the medial
branch nerves. As opposed to the lumbar region, an active
tip length of 5 mm should create a sufficient lesion size to
allow a single pass per level and minimize damage to sur-
rounding structures. In our practice, we prefer 22-ga,
curved, 5-mm active tip Stryker needles, 5 or 10 cm in
length. An adhesive grounding pad is placed on the patient’s
scapula opposite the side of treatment.
When targeting the C3 through C6 medial branches, an
anteroposterior projection is first used to identify the facet
joint caudal to the target medial branch. Thus, for the C5
medial branch, a point just lateral to the C5– 6 facet joint is
identified. Without moving the patient, the C-arm is then
rotated 10°-15° oblique to provide a “down the barrel” or
“pillar view.” The previously identified point now overlies
the waist of the articular pillar of C5 allowing the lateral
aspect of the articular pillar to be targeted (Fig 5A). Target
site for the C7 medial branch is more cephalad on the ar-
ticular pillar just below the margin of the superior articular
facet. For the C8 medial branch, the ideal target lies at the
junction of the superior articular facet and transverse pro-
cess of T1. Due to its relatively larger size, the TON often
requires multiple separate lesion sites before adequate de-
nervation is achieved. Typical lesion sites for the TON lie
along a path from the inferior articular facet of C2 to the
superior aspect of the inferior C3 facet.
Once appropriate local anesthesia is achieved, the RF
needle can be advanced by using a “down the barrel” tech-
nique. With a dorsolateral approach, the needle will pass
through muscle and fascial tissues and remain posterior to
important vascular structures, most notably the vertebral
artery. Once bony contact is made, the needle is advanced
by using lateral fluoroscopy to the middle third and even-
tually the anterior third of the articular pillar all the while
maintaining bony contact (Fig 5B). Needle tip should even-
Neurographics 4:106 –113 June 2014 www.neurographics.com 兩 111
tually lie against the anterolateral margin of the articular
pillar. Oblique projection will confirm that the needle tip
remains posterior to the intervertebral foramen. This loca-
tion provides access to a long segment of the medial branch
along the lateral and anterolateral margin of the articular
pillar.
Once the proper needle position is confirmed, the stylets
are removed and replaced with the radio-frequency elec-
trodes. Sensory and motor stimulation is then performed to
optimize needle placement adjacent to the target medial
branch nerve and, more important, to ensure a safe distance
between the probe and the ventral ramus. Sensory testing is
performed by using a frequency of 50 Hz and a current up
to 1 V. At 50 Hz, paresthesias in the cervical area corre-
sponding to the level being stimulated should be noted by
the patient. Motor testing is performed at 2 Hz and up to 2
V. At these values, no stimulation should be felt by the
patient down the upper extremity or in the shoulder. Motor
contraction may be seen in the paraspinous muscles in the
neck. After sensory and motor stimulation is completed and
electrode position is verified, 1 mL of local anesthetic is
injected to anesthetize the target area. Radio-frequency
thermal lesioning is then performed at each location at
80°C for 90 seconds. After the procedure, patients are mon-
itored for 1–3 hours, mainly for the sedation to wear off and
to ensure no significant motor weakness.
Outcomes
Regarding treatment of refractory facet-associated pain in
the cervical spine, relatively few controlled trials have been
performed to assess the efficacy of medial nerve RF ablation
(RFA). A randomized controlled trial by Lord et al39 com-
pared RF facet denervation with sham intervention for pa-
tients with chronic cervical pain after whiplash injury.43
Pain was confirmed by using double-blind, placebo-con-
trolled diagnostic blocks, and the control group consisted of
patients in whom the RF probe was inserted but no current
was applied. Results showed the superiority of the treat-
ment arm. The median elapsed time before pain returned to
at least 50% of the preprocedural level was 263 days in the
active RFA treatment group versus only 8 days in the con-
trol group. Several additional studies have demonstrated
long-term success of cervical facet denervation44,45 Even-
tual return of pain is not unexpected following RFA and can
be retreated with repeat ablation as indicated by the level of
pain and disability.
CONCLUSIONS
Spine pain is a major cause of disability with annual prev-
alence estimates in adults ranging from 12% to 70% for
neck pain and up to 45% for lower back pain.46 RFA ther-
apy should be considered in those patients who fail to
achieve adequate symptom relief with conservation treat-
ment. In the setting of conscientious patient selection by
dual comparative diagnostic blocks, RFA provides a safe
and efficacious therapy that confers long-term symptomatic
112 兩 Neurographics 4:106 –113 June 2014 www.neurographics.com
relief for many patients. With the appropriate anatomic
knowledge and basic image-guided procedural skills, RF
ablation therapy can be readily adopted in most practices
and can serve as an important component to the spine pro-
ceduralist’s armamentarium.
ACKNOWLEDGMENTS
The authors acknowledge and thank Leah Branstetter for
her artistic talent in creating the illustrations in the article.
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