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    Old 01-19-2005, 07:59 PM   #1
    Join Date: Dec 2004
    Location: Elk Grove, CA
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    aestrella411 HB User
    Medial Branch Block from PM

    Has everyone ever had a medial branch block? How did it work for you? I'm a chronic back sufferer and amd curious if anyone here has gone through this...any info is greatly appreciated. Also, if the medial branch block was successful, what did PM do next???

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    Old 01-20-2005, 06:19 AM   #2
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    Re: Medial Branch Block from PM

    Hi 411, Can I guess your an Aussie from down under, pretty cool we can communicate all the way around the world in just a few seconds.
    Medial branch nerves are the very small nerve branches that communicate pain caused by the facet joints in the spine. These nerves do not control any muscles or sensation in the arms or legs. They are located along a bony groove in the low back and neck and over and down the spine in the mid back.

    The do MBB's when they suspect that the facet joints are the source of a patient's pain. The boney wings on the side of the vertabrea that somewhwat interlock. They can be used to diagnose the source of pain which may lead to surgery r may lead to a more permamanet type of nerve destruction Like RFA "radio frequency ablation, or chemical destruction of the nerves that may produce pain relief for months untill the nerves regenerate. Even when they destroy a nerve they do grow back and can somewtimes take new routes to find something to attach too. But RFA CA still need to be repeated every 6 months to ayear, depending on how long it takes them to regenerate and the new path they may take.

    If your diebetic or have high BP or need heart meds, they want you to take those normal meds but hey don't want you to take your normal pain meds in order to see how much relief you get from the block. Some docs use a little light sedation or something to relax you but your not out because after the block they want you up and moving and trying to reproduce pain. They have you duplicate movement hat would normally cause pain and if the block helps, the next step is a longer acting version Like RFA, or they may do facet injections, If you have allready had unsuccesful facet blcocks , this is still neccesarry to determine where the pain generator is and a longer acting version of blocking the medial nerves can be used but still needs repeating every 6-12 months

    Blocking the medial branch nerves temporarily stops the transmission of pain signals from the joints to the brain. So the results are temporary but the information is valuable in obtaining a proper DX and the next step towards treatment.

    Whether they work or not depends on other factors, If you have instability at that level, The block can help but the instability may need tobe adressed. I don't know if you have had back surgery before so it's hard to say what the next step would be. If the pain is from a disc impinging on a nerve, it will rule out a probelm at the facet oint. and reducing the impingement or stabalizing the spine via fusion may the only way to obtain long term relief or a possible cure. So it's more of a diagnostic tool to leaad them in the proper direction than it is a treatment for your pain as the longes you may get reliewf may be 12 hours depending on the type of numbing agent they use. Lidocaine, Marcaine etc, they all have different durations. Marcaine is one of the longer acting anesthetics so you may get a great day of relief which gyuides them as to the next step, or it may not help and rule out other problems. It's more diagnostic than curative or pallitive "used t make you feel beter".

    More history of your back problems, whether you have had surgery or not, what type , fusion, laminectomy, disc decompresion, foriminotoies, where they drill out the outlests to remove bone spurs and reduce impingement from the outlets, etc..

    They aren't terribly painful and hopefully will give you a day of unpresedented relief if the cause is from the facet joints. Unfortunately the reief is temp and just a tool to guide them to the next procedure or interventional mthod.

    My case is a bit unique in that I had already had 3 back surgeries fail and 2 fusions fail so I have a great amount of spinal instability so I didn't get much relief . My choices now are continue with my present regemin, an IT opioid pump and a few adjuntct meds, bracing or another attempt at fusion with an anteror aproach. So everyone is a little different when they have these done and the information gathered from the block may be useful or may not. But it's not a teribbly invasive procedure as these nerves won't send pain shoting down a leg or arm when the needle is inserted into the nerve.

    General discription of injecions and destruction of nerves:
    Blocks are injections of medication onto or near nerves. The medications that are injected include local anesthetics, steroids, and opioids. In some cases of severe pain it is even necessary to destroy a nerve with injections of phenol, pure ethanol, or by using needles that freeze or heat the nerves. Injections into joints are also referred to as blocks.

    Explanation of RFA
    Facet joint pain syndrome is an example of the type of condition that is associated with severe pain but
    does not have a clear pathological etiology. The facet joints (zygapophyseal joints) are situated in the
    posterior compartment of the spinal column, which contains all structures innervated by the medial branch
    of the spinal nerve dorsal rami and posterior to the plane of the transverse processes. Although the
    primary function of the facet joints is stabilization of movement between vertebrae, they occasionally
    assist in axial weight bearing, particularly in cases of abnormal posture or tissue laxity. It is postulated
    that facet joint pain emanates from the synovial membrane and capsule, which are profusely innervated
    by fine nerve endings from the medial branches of the posterior rami. Facet joint pain may develop as a
    result of repeated stretching, straining, or entrapment of the synovial membrane surrounding the facet
    joint. Other proposed sources of facet joint pain include inflammation, compression of nerve roots by
    hypertrophic osteoarthritic stenosis at the facets, and tension applied to the nerve roots by scar tissue or
    segmental disturbances. However, the precise cause of most facet joint pain remains unknown and there
    is no definitive diagnostic test for this condition (Gallagher, et al., 1994; Mehta, Parry, 1994; Dreyer,
    Dreyfuss, 1996).
    Patients with chronic back pain that is unresponsive to conservative therapy and for which there is no
    clear indication for surgery may be referred for pain-reduction techniques, such as radiofrequency
    ablation (RFA), that are directed at the innervation of pain-producing structures. RFA (also called
    percutaneous radiofrequency facet denervation, percutaneous facet coagulation, percutaneous
    radiofrequency neurotomy, radiofrequency facet rhizotomy, and radiofrequency articular rhizolysis) has
    been introduced as a treatment modality for patients with a variety of chronic spinal pain syndromes,
    • cervicogenic headache
    • occipital neuralgia
    • flexion-extension injury (whiplash)
    • neck and shoulder pain
    • intercostal neuralgia
    • sacroiliac syndrome
    • facet joint pain syndrome
    RFA may target areas adjacent to the dorsal root ganglion (DRG) and the medial branches. The dorsal
    and ventral roots of the 31 pairs of spinal nerves are attached to each segment of the spinal cord. Each
    spinal nerve attaches to the spinal cord by a dorsal (sensory) and a ventral (motor) root. The DRG is
    found on the posterior root of each spinal nerve and is composed of the nerve cell bodies of the sensory
    neurons of the nerve. Both somatic and visceral afferent fibers from potential nociceptors (pain receptors)
    in the spine have cell bodies in the DRG, indicating that the DRG conducts pain impulses inward to the
    spinal cord and brain from the peripheral parts of the body. The medial branch (ramus medialis, or
    internal branch) is a small nerve that arises from the dorsal ramus that in turn branches from the spinal
    cord. This nerve innervates the joint facet and carries nociceptive signals from the spine to the brain. It is,
    in addition to the DRG, a main target for RFA treatment of spinal pain. During RFA, an electrode
    introduced through the skin is used to deliver heat produced by radio waves in order to destroy the
    sympathetic nerve supply of the painful spinal structure.
    Articular (facet) or medial nerve blocks are used for diagnosis of facet joint pain and to determine the
    exact location (spinal level) of the patient’s back pain. Therefore, in most cases, diagnostic nerve blocks
    are undertaken prior to RFA and only chronic back pain patients with a positive temporary response to
    the diagnostic blocks proceed to RFA. To be considered a suitable candidate for RFA, the patient should
    experience significant and physiologic pain reduction; pain relief duration should be consistent with the
    pharmacokinetics and half-life of the local anesthetic administered (Dreyer, Dreyfuss, 1996).
    The data regarding the efficacy and safety of RFA for management of chronic spinal pain are derived from
    both studies of patients with specific diagnoses and heterogenous populations. There are no studies that
    provide a direct comparison between RFA and other types of treatment for chronic back pain. In most
    cases, inclusion in a study required a positive response to diagnostic nerve blocks, defined as a 50-100%
    temporary relief of pain symptoms. Patients were followed prospectively for up to three years. Small sample sizes, lack of controls, insufficient outcome measures and poorly defined patient-selection criteria compromised the quality of most studies.

    If you tell me what level or region of your spine I can give you some stats on success.
    Good luck, Dave

    Old 01-20-2005, 08:44 AM   #3
    Join Date: Dec 2004
    Location: Elk Grove, CA
    Posts: 98
    aestrella411 HB User
    Re: Medial Branch Block from PM

    Thank you so much for that plethora of information! I truly truly appreciate it. Well, to tell you about my back pain, so far as the doctor's told me, I have DDD in L4/L5 with an annular tear and I'm only 20. I've been dealing with the pain for three years now. I have no knowledge of any accident so perhaps I may have lifted something too heavy one day (I'm real small, 4'10" and 93lbs) so perhaps that. The majority of my main is in my back, though about three times a week I get the sciatic pain that goes down my hamstring to the side of my left calf. On bad pain days I get the same symptoms in both legs. Whenever I shower my left foot goes numb down the side of it. I just feel like it gets progressively worse as the hospital takes their time dealing with me and I'm sure it does. I started out just taking tylenol and stuff like that on the instruction of my NP. Then, when the pain started getting worse, I put a request to see and MD who then referred me to a physiatrist. There he ordered an MRI and came up with the DDD. So, since then I've been taking mostly vicodin but did try oxycontin and methadone. My body did not like oxycontin and methadone so I discontinued those and requested to be on anything else. So, the doctor put me back on vicodin twice a day which was all I needed. I worry though for taking viciodin for a full month and a half that it may cause liver damage but I'm more concerned about my back first so on with the vicodin I took. Eventually the physiatrist referred me to PM. There, I received one epidural steroid injection with absolutely no relief. Just this last Tuesday they did the MBB and I had about 5 hours of relief. I haven't felt that great in three years! I never had 5 hours of relief at any point in time. The only downside with feeling no pain in my back was that I also couldn't feel my legs. Maybe it balanced out in some sort of weird way. I was impressed with the MBB as I had about 90% relief for 5 hours and the pain did come back later on that day. I worry about the radiofrequency nerve lesioning (that's what my hospital calls it) because isn't that only masking the pain? If I have DDD in my lumbar spine then what good is it going to do to block the pain receptors? I would think that it would allow me to injure myself more but I am no doctor. One could also say that maybe it will buy me time that I can pursue some other form of treatment. I don't know what their plans are for me. I suspect since my age that they aren't going to do some major surgery. I would have entertained the idea of a Micro-D however I don't know how severe my problem actually is. It must be pretty bad if it's affecting my nerves. I hope I answered your question! Thank you again for responding to me! -Anita

    Last edited by aestrella411; 01-20-2005 at 08:47 AM.

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