Cervical Medial Branch RF

RF Treatment of the Ramus Medialis (Medial Branch) of

the Ramus Dorsalis

Percutaneous RF treatment of cervical pain has been intensively studied. The

data from original articles were summarized in seven systematic

reviews.20,27–29–32 There is only one RCT evaluating RF treatment of the

ramus medialis (medial branch) of the ramus dorsalis, but this was in patients

with WADs.21 Consequently, this RCT cannot be rated in the evidence

scoring for degenerative cervical facet joint pain. The effectiveness of RF

treatment for degenerative neck pathology was shown in observational

studies.14,33,34 A retrospective chart analysis on the effect of repeat RF facet

denervations illustrated that the mean duration of effect of the first

intervention was 12.5 months. Patients who responded positively to the first

intervention received from one to six additional interventions. After each

intervention (multiple level treatment of the ramus medialis of the ramus

dorsalis), more than 90% of the patients had satisfactory pain relief, and

duration of effect was between 8 and 12 months.35

Lord et al.21 described a technique for approaching the ramus medialis

(medial branch) of the ramus dorsalis laterally as well as posteriorly. This can

only be carried out in the prone position.

Good results have also been reported using an alternative technique as

described by Sluijter, van Kleef and van Suijlekom.36,37 Theoretically, a

block of the ramus medialis (medial branch), close to the ramus dorsalis,

based on sensory and motor stimulation parameters, could generate a similar

effect as an extensive denervation over the entire length of the nerve. Even

though there are no studies comparing both techniques, we consider the

former to be the least invasive approach. Percutaneous cervical facet

denervation is an acceptable treatment option for a clinical diagnosis of

chronic degenerative cervical facet pain, given the many observational

descriptions of a positive effect.

Complications of Interventional Management

Complications are rare. Nevertheless, one should be aware that the arteria

vertebralis may be punctured if the needle is pushed too far anteriorly into the

foramen intervertebrale. Verification of the needle position should be made

under antero-posterior fluoroscopy to prevent intrathecal injection or

injection of the local anesthetic into the spinal cord. In an observational

study, the incidence of inadvertent intravascular penetration for medial

branch blocks at spinal level was reported to be 3.9%, comparable with the

incidence at lumbar level (3.7%). Some patients experienced short-term

vasovagal reactions. The intravascular uptake of local anesthetic and contrast

solution (due to direct injection into a vessel) was thought to be responsible

for false negative diagnostic blocks. No systemic effects were reported.38 A

report on transient tetraplegia after cervical facet joint injection, done without

imaging, illustrates the vulnerability of the cervical arteries.39Appropriate

monitoring of the vital signs and availability of resuscitation equipment are

essential.

Infections have been described, but the incidence is unknown and probably

very low.40

A recent report on septic arthritis of the facet joints included two cases of

cervical facet joints. In these cases, the port of entry could not be identified,

but in one lumbar case report, percutaneous injection was directly linked to

this severe complication.41 Other potential complications of facet joint

interventions are related to needle placement and drug administration; they

include dural puncture, spinal cord trauma, spinal anesthesia, chemical

meningitis, neural trauma, pneumothorax, radiation exposure, facet capsule

rupture, hematoma formation, and side effects of corticosteroids.42

After RF treatment, postoperative burning pain is regularly reported. This

pain disappears after 1 to 3 weeks.43 Smith et al.44 found contrast

enhancement on MRI typical for paraspinal abscess, even without apparent

infection, which was attributed to a noninfectious postinflammatory process.

There are no incidence data on side effects and complications following

cervical RF facet denervation. At the lumbar level, the incidence of

complications was lower than 1%.