Here is what I am see among pain doctors in treating facet pain.
Facet Joint Pain – Conservative treatment
- Physical therapy including heat and massage
- NSAIDs and muscle relaxants
- Underlying sleep disturbance and depression can be treated with tricyclic antidepressants.
- Treat co-existing disease
- Positive response to controlled local anesthetic blocks (<1 ml per nerve). Patient needs to be reminded that this is purely a diagnostic block and that its effects will wear off in a few hours.
- 80% pain relief. Patients may need some direction as they will often report other pain sources.
- Ability to perform prior painful movements without any significant pain.
Here is what I am see among pain doctors in performing RF ablation.
Standard RFA Procedural Steps made easy.
Prior to Procedure:
- Must have sterile probes of adequate length and quantity.
- Must have RF needles and grounding patches in sufficient quantity. For a typical RF procedure, one must have four sterile RF needles and a dedicated grounding patch. For the majority of patients, 100 mm RF needles and probes will be adequate. Very large patients will require 145 mm RF Needles and Probes.
- Consent obtained for the procedure.
- Mild sedation is optional (e.g. valium) but not necessary provided the patient is sufficiently relaxed and compliant.
- Physician and/or staff should have familiarity with managing code (ACLS) and adequately supplied crash cart should be available.
- Skin prepped in the standard manner. At all times during procedure, proper sterile technique is observed.
- Injection site is draped using 22×28 inch fenestrated drape or four utility drapes.
- Skin anesthetized using lidocaine in a skin wheel technique.
- Spinal Column is visualized under fluoroscopy in AP View. Depending on the curvature of the spine and the resulting shadowing of vertebral endplates, it may be necessary to square up the endplates.
- On right sided RFA, identify the oval which delineates the pedicle. Use a sterile pointer, to mark the 5:00 o’clock position. This position marks the entry point for the RF needle. For a more oblique approach, one may begin about a quarter inch “southeast” of the 5:00 o’clock position.
- The RF needle should initially be advanced almost vertically with perhaps 5 degrees of caudal tilt. An axial “gun-barrel” view of the needle can be helpful in visualizing the trajectory of the RF needle.
- The initial target is the transverse process as it meets the pedicle.
- Once the RF needle is on bone, rotate the c-arm to a 45 degree ipsalateral oblique view. The RF needle is then skived upward toward the eye of the scotty dog.
- The dot which identifies the curvature of the needle should face the shoulder opposite the side on which the RFA is performed. Save the fluoroscopic image for patient records.
- With the tip of the RF needle positioned at the eye of the scotty dog, rotate the C-arm to a lateral position to confirm depth. The tip to the RF needle should never cross an imaginary line which marks the posterior edge of the foramen.
- Once the needle is positioned, motor and sensory testing are performed. (See Below)
- After testing confirms final position, inject 1 ml of lidocaine at each RF site and wait 30 seconds before lesioning.
Testing and Lesioning
- Sensory Testing is performed by selecting a stimulation rate of 50 hertz. Slowly, output is increased up to 1.0 volt. If a patient experiences pressure, tingling or pain, the test is positive.
- Motor Testing is performed by selecting a stimulation rate of 2 hertz. Quickly, the output is increased to 2.5 volts. If the patient experiences twitching at or below the knee, the RF needle should be repositioned. Twitching at or near the needle site is usually a good indication of needle position.
- Lesioning is performed at 80 degrees celcius for 90 seconds. An additional ramp time of 15 to 30 seconds should be added to the total time of thermal lesioning.
- Post lesioning, it may be prudent to test the patient for any numbness in the leg closest to the RFA. The patient should further be assisted off the table to prevent a possible fall.
- The patient should be advised of the likelihood of soreness for up to one week after the procedure. The patient should be advised to apply ice to the treatment site at home.