FACET JOINTS

• One of the most r lacement

common sources of LBP e
• True synovial joints s
i
• Formed by SAP of
s
level below, and IAP
t
of level above
• Volume capac ity of 1- f
1.Scc o
• Motion-restric ting joint- r
adds stability w
a
• Upper lumbar joints
r
oriented sagittally-able to d
resist
rotation d
• Progressively i
coronalin orientation as s
you move caudally- p
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FACET JOINT INNERVATION
Primary Dorsal Ramus
·,...;;.....:; ___
• Innervated by medial
bra nch of dorsal ramus
of spinal nerve
• Each has an
ascending and
descending branch
• Each MB s upplies joint at
its own level, and 1
below
(i.e. L3 MB innervates
the L3-L4 and L4-L5
joints )
• Each joint is s upplied
by MB at that level, and
1 level above (i.e. L4-
FACET JOINT INNERVATION
L5 joint is innervate d by
L3 and L4)

Primary Dorsal Ramus
·,...;;.....:; ___
• Innervated by medial
bra nch of dorsal ramus
of spinal nerve
• Each has an
ascending and
descending branch
• Each MB s upplies joint at
its own level, and 1
below
(i.e. L3 MB innervates
the L3-L4 and L4-L5
joints )
• Each joint is s upplied
by MB at that level, and
1 level above (i.e. L4-
L5 joint is innervate d by
L3 and L4)
 FACET JOINT
PAIN
• Arthropathy can lead to low back pain { i.e.
axial pain)
• Hypertrophy or cysts can lead to spinal
nerve impingement and radicular pain
• Ref erral patterns v ary between studies
• Pain pattern can be:
• Low back
• Radiating pain to hip/ buttock/proximal leg
• Radicular
 MEDIAL BRANCH BLOCKS

• May be diagnostic of f acetogenic pain

• MB nerves do innervate surrounding structures as well
• LA can spread to lateral and intermediate branches
• More closely correlated than H and P or
radiology
• Perform l -2 prior to RFA of median branch
• May also perform f acet joint injec tions
• No evidence of benefit over MBB
• Technically more difficult
• Volume l-l.5cc-can rupture capsule leakage of LA
to surrounding structures (including MB)
• AP view (remember to s quare off endplates)
• Can perform in AP or oblique
• Target: junction between SAP and
transvers e process
·R emember:
• MB is located at the junction BELOW the level of the
nerve root (i.e. L 1 MB at SAP/TP of L2 vertebra)
• Facet joint innervated by MB of that level and level
above
• So, to block L4-5 facet, inject at SAP/TP junction of L4
(L3 MB) and L5 (L4 MB)
• L5 (dorsal ramus, NOT MB) located at junction of SAP of
S l and sacral ala
Superior articu l ar process
•
••• B
•
•
•
 MEDIAL BRANCH RFA

• Probes placed along medial branches

• Heated (usually t o 80 degrees) to lesion nerves
• Nerves regrow at aboutlmm/day
• Can giv e long-term (6-1 2 mo) pain relief
• Coming from s omewhat caudad allows needle
tip to lie closer to parallel to nerve (large lesion)
• Lesion is spheroidal and may extend s everal
mm beyond active tip
• Majority of lesion surrounds the axis of the elec trode
• Cross section is 5-6 cm
• Because lesioned end of nerve is coagulated,
must repair its elf before regeneration
• Time f or repair is proportional to length of
nerve coagulated

" ,.
• Fluoro v iew similar to MBB (can use more caudal
tilt)
• When injecting LA, don' t go t oo deep as will
need to do sensorimotor tes t
• Needle placement similar to MBB ( lOcm R F
cannula with Smm active tip)
• S ensory testing: 50Hz should lead to
concordant pain ( lV max)
• Motor tes ting: 2Hz up to 3V should cause
no myotomal stimulation
• Inject .5- lcc LA
• Lesion at 80° C f or 60-90s
 SI JOINT
ANATOMY
• Mainly a support structure, multiple wide ligaments
• Biomechanical studies indicate some motion
• Superior 2/3 f ibroc artilaginous, caudal l/3 true joint
• lnnvervation is f rom
dorsal primary rami of L5-
S3
• Some authors suggest L4
(or even L3) and 54 contribute

·· · ·
l w hool •mo 1.i

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 SI JOINT
tioW

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ANATOMY
-
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 SACROILIITI
S
• SI dysf unction
• Mec hanical dysfunction
• Inflammation
• Infection
• Trauma
• Degeneration
·Symptoms
• Low back pain
• May radiate into buttocks or legs (rarely past knee)
• Often exacerbated by prolonged standing/sitting
• Diagnosis
• Primarily by history and physical
• Can incorporate imaging (X-Ray/CT/M R I) although
there are many false positives and negatives
• Diagnostic/therapeutic blocks
• Physical f indings
• SI tenderness
• Patrick's/FA BER signs
• Gaenslen's test
 SI JOINT INJECTION

• Patient prone
• Caudal C-arm angulation (i.e. 20°)
• Identify posterior (medial) and anterior (lateral)
joint lines
• Oblique angulation away fr om aff ected side
• Angle varies, but can do live fluoro to align anterior
and posterior joint lines
• 22g g, 3.5 in spinal needle
• Insert in inferior l/3 of joint
• If contact os, walk off into joint
• Older patients may be unable to enter joint,
can inject periarticular
SACROILIAC JOINT INJECTIONS
 RFA OF SI JOINT

·Proc eed by
diagnostic injec
tion
• Can be done with a
single, multi
electrode probe
• Must cover L5-S3
dorsal primary
rami