Lumbar Medial branch blocks in patients with Lumbar facet arthropathy

This is a power point presentation explaining lumbar medial branch blocks.
It describes the anatomy of the medial branch nerves that innervate the lumbar facet joints. The techniques used during the blocks are decribed including the relevant fluoroscopy images. The dosages of the local anesthetic are mentioned plus the theraupetic dose of the injection. The patient positioning in theatre is also described.
This is a good power point for back pain management
This power point has been prepared by a minimally invasive spine surgeon.

1. Lumbar Medial branch block Dr. NTAMBI ROGERS ORTHOPAEDIC SURGEON FELLOW OF MINIMALLY INVASIVE AND ENDOSCOPIC SPINE SURGERY

2. Introduction Diagnostic and sometimes therapeutic procedure. Used to determine if the facet (Zygapophyseal) joint is the source of pain. This is a minimally invasive procedure that involves injecting a local anesthetic around the medial branch nerves.

3. Medial Branch Nerve Anatomy For the block, the first choice of target is the medial branch fibro-osseous canal near to the accessory process. The accessory process is at the junction of the superior articular process and the root of the transverse process can be targeted. The lumbar facet joints are innervated by the medial branch of the spinal dorsal ramus.

4. Medial Branch Nerve Anatomy The facet joint in the lumbar spine is innervated by the medial branch of the dorsal ramus of the nerve exiting at the same level and also the medial branch of the nerve one level above. The L4/L5 facet is innervated by medial branches of L4 and L3

5. Medial Branch Nerve Anatomy

6. Medial Branch Nerve Anatomy

7. Procedure Position: Prone position with head turned to one side. Basic monitoring done . Aseptic technique observed.

8. C-Arm views An AP view . A lateral view . An oblique view. Squaring of the end plates done. For the oblique view, C-arm rotated about 10-25 degrees when SAP can be clearly distinguished from the TP. For a block, one needs at least 2 views.

9. Procedure Infiltration with 1-2% of lidocaine for local anesthesia . A 22-23G long spine needle inserted. Bony contact confirmed on AP and lateral or oblique view. 8cc local anesthetic (1% lidocaine or 0.5% bupivacaine) in 10cc syringe as primary injectate.

10. Oblique c-arm Image showing the target area Oblique view showing the target point with the white arrows The black shows the facet joint

11. Ap and Lateral images showing the target area. The k-wires show the target region at the junction of SAP and transverse process.

12. References 1. Clinical Anatomy and Measurement of the Medial Branch of the Spinal Dorsal Ramus, Feng Shuang , et al 2015 Dec 31;94(52) . 2.Takahashi Y, Ohtori S, Takahashi K. Dorsoventral organization of sensory nerves in the lumbar spine as indicated by double labeling of dorsal root ganglion neurons. J Orthop Sci 2010; 15:578–583. 3.Boswell MV, Colson JD, Sehgal N, et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10:229–253. 4.Sehgal N, Shah RV, McKenzie-Brown AM, et al. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician 2005; 8:211–224. [PubMed] [Google Scholar]