LUMBAR MEDIAL BRANCH BLOCK

LUMBAR MEDIAL BRANCH BLOCK

INDICATION
• Trauma
• Arthritis
• inflammation of the
lumbar facet joints
• acceleration-
deceleration injuries

CT scan showing moderate facet arthrosis

Pain secondary to lumbar facet syndrome may present as pain that
radiates from the low back into the hips, buttocks, and thighs in a
nondermatomal distribution
 The lumbar facet joints are formed by the
articulations of the superior and inferior

Anatomy of the medial

branches
 At each level, the dorsal ramus provides a medial branch that exits the
intertransverse space crossing over the top of the transverse process in a
groove at the point where the transverse process joins the vertebra. The nerve
then travels inferiorly and medially across the posterior surface og the
vertebral lamina, where it gives off branches to innervates the facet joint
Anatomy of L1-L4 medial branch
nerves of the lumbar spine
MBBs VS INTRA - ARTICULAR BLOCKS (IABs)

• MBBs are relatively easier to perform

• MBBs are theoritically safer
• MBBs more easily subject to controls
 IABs lack a valid subsequent treatment
 IABs lack proven therapeutic utility and predictive validity
• MBBs is positive can be followed by RF neurotomy
• MBBs have therapeutic utility and predictive validity

PRINCIPLES

• If pain is not relieved, then pain is not mediated by the medial

branches targeted
• If pain is relieved, the response constitutes prima facie evidence
that the targeted nerves are mediating the patient’s pain
• Tests the hypothesis that the patient’s pain is mediated by the
nerves targeted
CONTRAINDICATIONS

• Absolute
− Patient not able to give consent
− If contrast medium cannot be used (for example history of
anaphylaxis)
− Local infection
− Bleeding diathesis (include anticoagulants)
− Inability to assess patient response to the procedure
− Patient unable to remain still during the procedure

• Relative
− Allergy to injectates
− Pregnancy
− Anatomical dearangements (i.e. congenital or surgical)
− Systemic infection
− Comorbidities producing cardiovascular compromise
− immunosuppression
FACILITIES
• Clean procedure room
• High resolution C-arm fluoroscopy
• Radiolucent procedure table
• Emergency supplies

MATERIALS
• 3cc syringes
• 25 G spinal needle optimal
• Low volume extension tubing
• Pointer and skin marker
• Sterile gloves

MEDICATIONS
• Non – ionic contrast medium
• Local anaesthetic
 Lidocaine 2 or 4%
 Bupivacaine 0.5
PROCEDURE
 FLUOROSCOPICALLY GUIDED TECHNIQUE
1. 18G, 1-inch needle is inserted at
the insertion site to serve as an
introducer
2. The fluoroscope beam is aimed
directly through the introducer
needle, which will appear as a
small point on the fluoroscope
screen
3. The introducer needle is then
repositioned under fluoroscopic
guidance until this small point is
visualized pointing directly toward
the most superomedial point at
which the transverse process joins
the vertebra
4. 25G,2- to -inch needle is then
inserted through the 18-gauge
introducer and directed toward Radiograph of the lumbar spine in
the most superomedial point at anteroposterior view
which the transverse process joins
the vertebra
5. After bony contact is made, the
spinal needle is withdrawn, and
the introducer needle is
redirected to allow the spinal
needle to impinge on the most
superomedial point at which the
transverse process joins the
vertebra
6. This procedure is repeated until
the tip of the 25-gauge spinal
needle rests against the most
superior and medial point at
which the transverse process
joins the vertebra
7. An oblique fluoroscopic image is
then obtained, which should
Posteroanterior image showing needle
show the needle tip in the “eye tips snug against the superior articular
of the Scotty dog”
Oblique image of lumbar vertebrae with the Oblique image showing needle tips
“eye of Scotty dog” shown. TP, transverse at the superior aspect of the junction
process of the transverse proces and superior
articular process
1. After needle placement is
confirmed by biplanar
fluoroscopy, the hub of the 25-
gauge needle is observed for
blood or cerebrospinal fluid
2. Aspration, 1 mL of contrast
medium is slowly injected under
fluoroscopy to reconfirm
needle placement
3. Inject

A, The needle direction and C-arm

projection differ depending on the
degree of lumbar lordosis.
B, different trajectories of needles are
shown
 Top row, Anteroposterior fluoroscopic images showing contrast spread for L3 (left), L4
(middle), and L5 (right) medial branch blocks using the single-needle technique. Bottom
row, oblique fluoroscopic images showing needle placement for the same blocks
POST – PROCEDURE

• Recovery as per standing orders

• Pain evaluation in recovery
• Discharge instructions

Complication

• Neuritis
• Nerve root damage
• Transient increase in pain
• Artery puncture
Note the different – sized
with 20G electrode (left)
versus 18 G electrode
(right). The 20G RF needle
with 10mm active
electrode tip produces an
average lession width of
4.8mm. The 18G RF needle
with 10mm active
electrode tip produces an
average width of lesion of
5.8mm
 Illustration using axial view to demostrate a
lateral (sagittal) pass where the needle lies
over the 9 o’clock sector of the articular
pillar and an anterolateral (oblique) pass
lies over the anterolateral sector

Use of combined oblique and sagittal passes, with overlapping lesion zones
(A) Will produce 33% more coagulation than a single curved pass ,
(B) even though in each case the pass is 60 degrees