The Surgical Anatomy of Lumbar Medial Branch Neurotomy (Facet Denervation)

University of Otago, Taieri, Otago, New Zealand
Pain Medicine (Impact Factor: 2.3). 10/2004; 5(3):289-98. DOI: 10.1111/j.1526-4637.2004.04042.x
Source: PubMed


To demonstrate the validity of placing electrodes parallel to the target nerve in lumbar radiofrequency neurotomy.
Previous data on the anatomy of the lumbar dorsal rami were reviewed and a demonstration cadaver was prepared. Under direct vision, electrodes were placed on, and parallel to, the L4 medial branch and the L5 dorsal ramus. Photographs were taken to record the placement, and radiographs were taken to illustrate the orientation and location of the electrode in relation to bony landmarks.
In order to lie in contact with, and parallel to, the target nerve, electrodes need to be inserted obliquely from below, so that their active tip crosses the neck of the superior articular process. At typical lumbar levels, the tip should lie opposite the middle two quarters of the superior articular process. At the L5 level, it should lie opposite the middle and posterior thirds of the S1 superior articular process.
If electrodes are placed parallel to the target nerve, the lesions made can be expected to encompass the target nerves. If electrodes are placed perpendicular to the nerve, the nerve may escape coagulation, or be only partially coagulated. Placing the electrode parallel to the nerve has a demonstrated anatomical basis, and has been vindicated clinically. Other techniques lack such a basis, and have not been vindicated clinically. Suboptimal techniques may underlie suboptimal outcomes from lumbar medial branch neurotomy.

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    • "Therefore, the multifidus inserting the same spinous process received innervation from the same medial branch of dorsal ramus, with a same segmental number of the spinous process, even if the origins of multifidus were different [21]. And then, each of the L1-L5 medial branches sent innervating nerves to multifidus via its dorsal surface at each midlamina, or mid-spinous process level of the vertebra with one level below the segmental number of dorsal ramus [6,15,20-22]. For instance, the fascicles of multifidus arise from the spinous process of L4 vertebra are innervated by L4 medial branch around the dorsal surface of L5 midlamina level, and the fascicles of multifidus arise from the spinous process of L5 vertebra are innervated by L5 medial branch around the dorsal surface of S1 midlamina level. "
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    ABSTRACT: To identify the correlations between the location of multifidus atrophy and the level of lumbar radiculopathy. Thirty-seven patients who had unilateral L4 or L5 radiculopathy were divided into 2 groups; the L4 radiculopathy (L4 RAD) group and the L5 radiculopathy (L5 RAD) group. Bilateral lumbar multifidus muscles at the mid-spinous process level of L4 vertebra (L4 MSP), the mid-spinous process level of L5 vertebra (L5 MSP), and the mid-sacral crest level of S1 vertebra (S1 MSC) were detected in T1 axial magnetic resonance imaging. The total muscle cross-sectional area of multifidus muscles (TMCSA) and the pure muscle cross-sectional area of multifidus muscles (PMCSA) were measured by a computerized analysis program, and the ratio of PMCSA to TMCSA (PMCSA/TMCSA) was calculated. There were no significant differences in TMCSA between the involved and the uninvolved sides in both groups. PMCSA was only significantly smaller at the S1 MSC on the involved side as compared with the uninvolved side in the L5 RAD group. The ratio of PMCSA to TMCSA was the lowest at the L5 MSP on the involved side in the L4 RAD group and at the S1 MSC on the involved side in the L5 RAD group. Our findings suggest that the most severe atrophy of multifidus muscle may occur at the mid-spinous process or mid-sacral crest level of the vertebra which is one level below the segmental number of the involved nerve root in patients with a single-level, unilateral lumbar radiculopathy.
    Annals of Rehabilitation Medicine 08/2013; 37(4):498-504. DOI:10.5535/arm.2013.37.4.498
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    • "One of the structures of the spinal motion segment that has been implicated in mechanical low back pain is the lumbar facet joint; however, the contribution of facet joints to low back pain is still controversial [9] [10] [11]. Facet joints participate in load bearing in the lumbar spine during spinal motions and compressions [12] [13] [14] [15] [16]; they are wellinnervated with nociceptors [17] [18] [19] [20] [21] [22] [23] [24] [25] [26]; low back pain can be provoked in experimental conditions by irritation of the lumbar facet joints [27] [28] [29]. Anesthetic blockade can identify a contribution from facet joints in 15–67% of back pain cases [9, 11, 30–35]; neurotomy procedures can relieve chronic facet joint pain [36] [37] [38] [39]. "
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    ABSTRACT: Objective. To develop a novel animal model of persisting lumbar facet joint pain. Methods. Sprague Dawley rats were anaesthetized and the right lumbar (L5/L6) facet joint was exposed and compressed to ~1 mm with modified clamps applied for three minutes; sham-operated and naïve animals were used as control groups. After five days, animals were tested for hind-paw sensitivity using von Frey filaments and axial deep tissue sensitivity by algometer on assigned days up to 28 days. Animals were sacrificed at selected times for histological and biochemical analysis. Results. Histological sections revealed site-specific loss of cartilage in model animals only. Tactile hypersensitivity was observed for the ipsi- and contralateral paws lasting 28 days. The threshold at which deep tissue pressure just elicited vocalization was obtained at three lumbar levels; sensitivity at L1 > L3/4 > L6. Biochemical analyses revealed increases in proinflammatory cytokines, especially TNF-α, IL-1α, and IL-1β. Conclusions. These data suggest that compression of a facet joint induces a novel model of local cartilage loss accompanied by increased sensitivity to mechanical stimuli and by increases in inflammatory mediators. This new model may be useful for studies on mechanisms and treatment of lumbar facet joint pain and osteoarthritis.
    Pain Research and Treatment 06/2012; 2012(4):127636. DOI:10.1155/2012/127636
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    • "It is innervated by the medial branch of L4 and the dorsal ramus of L5. The L5 dorsal ramus courses along a groove formed between the base of the S1 superior articulating process and the sacral ala [23, 26] (Fig. 1). "
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    ABSTRACT: Abstract Low back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the etiology of low back pain is multifactorial. However, the facet joint has been increasingly recognized as an important cause of low back pain. Facet joint pain can be diagnosed with local anesthetic blocks of the medial branches or of the facet joints themselves. Subsequent radiofrequency lesioning of the medial branches can provide more long-term pain relief. Despite some of the pitfalls associated with facet joint blocks, they have been shown to be valid, safe, and reliable as a diagnostic tool. Medial branch denervation has shown some promise for the sustained control of lumbar facet joint-mediated pain, but at this time, there is insufficient evidence that it is a wholly efficacious treatment option. Developing a universal algorithm for evaluating facet joint-mediated pain and standard procedural techniques may facilitate the performance of larger outcome studies. This review article provides an overview of the anatomy, pathophysiology, diagnosis, and treatment of facet joint-mediated pain.
    Current Reviews in Musculoskeletal Medicine 04/2009; 2(1):15-24. DOI:10.1007/s12178-008-9039-y
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