Facet Syndrome – Should you get a Medial Branch Block?
Pain management centers are popping up left and right and one of the most common treatments for neck and low back pain is a treatment called radio-frequency ablation therapy. Before ablation therapy is performed, usually the doctors perform a procedure known as a medial branch block. The question is, is this treatment right for you?
The medial branch nerves are the nerves that supply your facet joints in the spine. (see image) The facet joints are the primary joints that restrict you if you try and bend backwards. This makes people like gymnasts and dancers particular susceptible to injury.
Even if you aren’t a gymnast or dancer, facet syndrome (or inflammation of the facet joint) is one of the most common causes of low back pain.
When a medial branch block is performed, the doctor usually injects a combination of anesthesia and steroids into the area of the facet joints to decrease inflammation and local pain, effectively calming the nerve down or blocking any sensation of pain from the nerves. The injections usually wear off within hours as this is only a test to see if the facet joint is the problem. If the medial branch block injections are successful, meaning decreased pain, this is considered diagnostic that the facet joints and their corresponding nerves are the source of your pain. Given that the diagnosis is now confirmed, this clears the patient to receive radio-frequency ablation.
RADIOFREQUENCY ABLATION (AKA Radiofrequency Neurotomy)
So what is radio-frequency neurotomy anyway? If you break up the word into to parts, “Neuro” and “otomy,” it literally means cutting of the nerve. It is an irreversible process that severs your nerves through the process of burning them.
A metal probe is used to heat up the tissue between 60 and 90 degrees Celsius, which cuts/kills the nerve by burning it. Often, when I tell patients that the procedure involves burning or cutting nerves, many are surprised and say, “my doctor never told me that.” Now I don’t think the doctors aren’t sharing the information, after all the name alone describes the procedure, it’s just that it is so easy to get excited about a “new” and “minimally invasive” procedure that some of the information gets overlooked. Also, while many hear loud and clear the potential benefits of 1-2 years or more of pain relief, this also means if the procedure doesn’t go as planned then it may be 1-2 years of suffering or more if the nerves don’t grow back properly.
Risks of Radio-frequency Ablation
Risks of radio-frequency ablation are definitely less than surgical spine interventions but there are some documented case reports that are definitely concerning. This case report for example discusses the loss of head control after neck ablation. Surgical spinal fusion was required to get the neck back to where the patient could keep their head upright again. Often times people like to refer to traditional medicine as “evidence based”, but with regards to radiofrequency neurotomy, the evidence is still “limited”.
The Facet Joints
Just like anything other organ or part of the body that is severed, removed or surgically altered, the nerves to the facet joints serve a purpose. Their purpose is to allow your neck or back to know exactly where your joint is in time and space. The facet joint nerves provide mechanoreception and proprioception.
Mechanoreception is the process by which tiny receptors are stimulated by mechanical input such as loading, stretching and joint motion. These receptors then carry this information to the central nervous system (brain). Segmental or local effects of mechanoreceptors can act to excite pathways or inhibit pathways. One of the most important inhibitory effects of these receptors is to stop pain pathways.
Proprioception refers to kinesthetic awareness. Kinesthetic awareness is your body’s awareness of where you are in space. The body primarily uses the combination of all of the incoming messages from your mechanoreceptors, eyes and ears to put together your kinesthetic awareness.
By losing these two receptors, your body loses a lot of input to the brain that it needs to help your joints move and function properly. Essentially your brain loses a sense of where and what those joints are doing. These joints will still retain some function as some muscle reactions don’t require input to the brain, but much of it will be lost. As I mentioned in the section above on risks, without these nerve inputs, the muscles surrounding it can become so “uninformed” as what to do that they literally become flaccid. They are still there, but they just won’t work without the proper input.
As you can imagine, flaccid muscles, even if only minimally altered will not lead to a long-term pain-free solution. It actually can make things much worse and lead to more invasive procedures, more long-term costs and even more pain.
So is Ablation worth the Risk?
This is a decision you will have to make with your doctor, but until you have tried all natural means, cutting nerves should be closer to a last resort than a primary treatment option.
Are we Missing the Ball?
I think often times in chronic low back scenarios we are missing the ball many times because we compartmentalize the body too much.
Example #1 – If you have pre-diabetes, your body is in a chronic state of inflammation. This means that if you use your back frequently (most of us do) then the frequent use can cause aggravation. Usually a body that is healthy would send some chemicals your way to calm down the area and your back pain would resolve. But if your whole body is inflamed, the body doesn’t know what to do first and if it sends too many anti-inflammatory chemicals then it will alter (mess up) other important processes, so instead it just lets your back hurt.
Example #2 – Let’s say you have dysbiosis. Dysbiosis is an imbalance of healthy vs. unhealthy organisms in your digestive tract. This can cause both body wide inflammation and local inflammation since your digestive tract lies right next to your spine.
Now you may be thinking, “Dr. Anderson, dysbiosis may cause some inflammation but is it really going to give me this excruciating back pain?” The answer is an astounding YES!!
If you follow this link here, (click me) you can read about a study of low back pain where the researchers found that 80% of the patients that had chronic back pain for over 6 months and also had bone swelling, had significantly less low back pain after taking antibiotics. This clearly demonstrates the connection between back pain and dysbiosis.
The purpose of these two examples is to demonstrate that if you saw a traditional physical therapist, chiropractor or massage therapist, it is unlikely you would get results as your primary problem lies in things they don’t usually deal with. Also if you were to see a traditional medical doctor he may catch your pre-diabetes, but I have never heard of one prescribing antibiotics or even probiotics for low back pain.
The key to avoiding invasive procedures in difficult low back pain and/or facet syndrome is to take a multi-faceted approach that considers as many contributing factors as possible in order to relieve your pain.
Part 2 Facet Syndrome the Natural Way.