Best Practice Health TV
By Dan Lieberman, MD In medicine the right treatment depends on understanding exactly what is wrong. The challenging thing about the lower back is that there are so many different problems, and even more treatments. In addition, the stakes are high. It is NOT just about relieving your pain; the wrong treatment is risky, sucks [...]
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Radiofrequency ablation (RFA) is a common procedure for the treatment of low back pain due arthritic facet joints. Prior to RFA a pain management doctor typically performs a medial branch block to make sure your pain originates in a painful joint. Medial branch blocks are done with a needle. Radiofrequency ablation is done through a [...]
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I first realized how much low back pain can feel like hip pain while placing a needle in a guy’s low back. I was using x-ray to guide a needle to inject a facet joint ---his was in the bad old days before we knew facet injection damaged the joint and made the pain we [...]
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If you are reading this article, I am going to assume you have neck pain. That is a pain starting in your neck and radiating into the base of your neck and shoulders. There are a lot of different causes of neck pain, but people with neck pain can be sorted into two buckets. What […]
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To qualify for an RFA in the first place, you should have reported greater than 80% pain relief during the treatment window after Medial Branch Block (MBB). For example, if the MBB brought your pain from a 9 out of 10 to a 2 or below, you qualify for the RFA procedure.
Some doctors even repeat the MBB a second time to minimize the chance of a false positive result. The medial branch block only relieves pain coming from the facet joint. So, the degree of pain relief you get after RFA is the percentage of your pain coming from the blocked facet. Pain left over during the active treatment window of a medial branch block may be coming from a non-facet pain generator, typically a torn disc or inflamed nerve root.
In this image of the cervical spine a needle (silver) has been placed on a facet joint capsule (light blue). The medial branch nerve fibers which go to the facet joints are shown in yellow, blue, and red. During a medial branch block procedure, a numbing agent would be injected through the needle to block the medial branch nerve fibers in the injected area. Note that facet joints receive medial branch fibers from above and below.
For the 40% who had an RFA but did not get the expected relief despite having undergone a MBB that relieves more than 80% of the pain, there many explanations:
No matter what the reason for the failed RFA, if you had a positive medial branch block and did not get relief after RFA then a second opinion from a new pain management doctor is your next step.
You should do 3 weeks of physical therapy before considering an MRI—studies show worse results if you get imaging at this point. If you are not better after 3 weeks of therapy, then (6 weeks since the pan began) you should get an MRI and referral to a board-certified anesthesiologist or physiatrist with subspecialty certification and specialization in pain management. They will do a medial branch block and radiofrequency ablation as appropriate. Don’t let anyone talk you into epidural injection; that is not what you need.
You should do 3 weeks of physical therapy before considering an MRI—studies show worse results if you get imaging at this point. If you are not better after 3 weeks of therapy, then (6 weeks since the pan began) you should get an MRI. We can help you find a board-certified anesthesiologist or physiatrist with subspecialty certification and specialization in pain management who doesn’t over-prescribe dangerous narcotics.
They will offer you medial branch block and epidural injection. Those don’t really work for this problem. Your options are (off label) intradiscal injection of stem cell-derived growth factors, denervation with the relevant procedure, and then referral to a spine surgeon for interbody fusion if those fail.
You need an MRI now and referral to a spine surgeon for possible laminectomy decompression surgery. We can help you find one who is board-certified and specializes in minimally invasive surgery.
You need an MRI now and referral to a board-certified anesthesiologist or physiatrist with subspecialty certification and specialization in pain management. Don’t go to one that prescribes a lot of narcotics, they may get you killed. If you’re not better after 3 epidural injection you will be referred at 12 weeks to a spine surgeon to consider microdiscectomy. Note that you DO NOT need radiofrequency ablation; so, don’t let anyone talk you into a medial branch block.
This stuff can be confusing. Don’t sweat it. We’ve got you. Your MRI came with a report by a radiologist which describes the findings. If you don’t have a copy of your report, you can get one from the imaging center where the x-ray was taken. The doctor who prescribed the MRI has a copy as well. Find the section labeled Impression. First, under the impression, look for the word normal. If you see something like “Normal MRI of the hip then you are done. You do not need to check anything.
Next, search the impression section for the words osteonecrosis or avascular necrosis. If you see either one in the report, then ignore the rest of the report and check the osteonecrosis box. If neither of those is in the report, ignore the rest for now and continue.
This stuff can be confusing. Don’t sweat it. We’ve got you. Your x-ray came with a report by a radiologist which describes the findings. If you don’t have a copy of your report, you can get one from the imaging center where the x-ray was taken. The doctor who prescribed the x-ray has a copy as well. Find the section labeled Impression.
First, under the impression, look for the word normal. If you see something like “Normal x-ray of the hip then you are done. Check the box normal. Next, search the impression section for the word hypoplasia. If you see hypoplasia in the report then ignore the rest, and check the hypoplasia box.
If you are still going, then look for the word arthritis. The radiologist should have given the arthritis a grade from 1 to 4. If you see arthritis in the impression section but there is no grade, then look at the rest of the report for a grade 1,2,3 or 4 and check the appropriate box. If there’s no grade then you have every right to call the imaging center and ask them to have the radiologist to do their job and redo the report with a grade.
Not all orthopedic surgeons are the same. You deserve the best. That means a surgeon who is
In my experience less than 10% of orthopedic surgeons meet all five of these criteria. That means if you go to the surgeon you’ve been seeing, or the one recommended by friends or family, there’s a 90% chance you will not be getting the best.
At Phoenix Spine and Joint we make it our business to know the best. Call us for help finding the best surgeon near you who takes your insurance and is accepting new patients.
If you have any of the following red flags you need to see a doctor NOW!
Radiculopathy. This condition is most often due to herniated disc, but can also be caused by bone spurs, or compression of nerve roots as they leave the spinal canal. The traditional treatment is to confirm the herniation or compression by MRI, followed by a trial of epidural injection, with microdiscectomy or laminectomy surgery if all else fails.
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Facet syndrome. Your low back pain is most consistent with arthritis. Look for confirmation on your x-ray and MRI reports with discussion about “arthritis.” The traditional treatment is radiofrequency ablation done by a pain management physician.
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Discogenic low back pain due to an annular tear. Sorry, this is the least common and the hardest to treat. Traditionally, the recommended procedure is fusion; however, that does not always work and causes adjacent level issues. More recently a denervation procedure was approved called the Intercept procedure from Relievant. Some doctors recommend injection, The two options are stem cell-derived growth factors, and ozone.
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