Lumbar Zygapophysial Joint Nerve (Medial Branch) Radiofrequency Neurotomy, Posterior Approach

Chapter 15 Lumbar Zygapophysial Joint Nerve (Medial Branch) Radiofrequency Neurotomy, Posterior Approach



Ruby E. Kim, James J. Gilhool, Michael B. Furman


Note: Please see page ii for a list of anatomical terms/abbreviations used in this book.


The zygapophysial joints (Z-joints) in the spine are diarthrodial joints with synovial linings that are covered with hyaline cartilage. All Z-joints are innervated by two medial nerve branches: one from the posterior ramus above and one at the same segmental level (e.g., the L3 and L4 medial branches innervate the L4-L5 Z-joint). The only caveat is that the L5-S1 Z-joint is innervated by the L4 medial branch and the L5 dorsal ramus. Please see Figure 14–7 for more details regarding the anatomy of these joints.


Lumbar radiofrequency neurotomy is typically performed after significant pain relief is documented with either an intraarticular Z-joint joint injection and/or a medial branch block injection. However, the approach to lumbar radiofrequency neurotomy is different from the approach used in those injections. In addition, no contrast dye is necessary. The probe is positioned to lay parallel and over the medial branch nerve. Because there is anatomic variation of the course of the medial branch nerve, many practitioners perform, at a mininum, two lesions at each site.1


With the approach described here, the needle is placed with the use of a trajectory view and advanced with the use of multiplanar imaging, with an emphasis on safely using the lateral and ipsilateral oblique views to confirm depth. Before neurotomy, sensory and motor stimulation confirms non-radicular stimulation and 0.5 to 1 cc of anesthetic is typically placed. The time and duration of the denervation varies with different practitioners (e.g., up to three 90-second cycles at 80–85° C).1


Often used synonyms for “neurotomy” include “ablation,” “denervation,” and “lesion.” We do not recommend the term “rhizotomy” becuase it implies lesioning of nerve roots.



image Trajectory View




image Confirm the level (with the anteroposterior view).


image Tilt the C-arm image intensifier to square off the superior end plate (SEP) of the vertebral body (VB) and then tilt the C-arm image intensifier 15 to 20 degrees caudally from the squared SEP.


image Oblique the C-arm image intensifier 15 degrees toward the symptomatic side (the right side, in this case).


image This angle is used for entry and to approximate the trajectory of the target nerve.


image The probe tip destination is the lateral border of the superior articular process (SAP) and the very small concavity that is formed by the junction of the SAP and the transverse process.


image Note that this is one of the few procedures where we recommend specific angles.

image At the L5 level, the iliac crest may interfere with needle positioning. If the recommended angle does not allow for proper needle trajectory, the tilt angle may need to be adjusted to optimize the visualization of the target.

image Because this is the trajectory view, the needle entry position should be parallel to the C-arm beam (Figure 15–1


image image image

Figure 15–1 A, Fluoroscopic image of a trajectory view with the radiofrequency probe tip in position over the right L3 medial branch nerve. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view. Please see above for set up details. The probe is placed so it approximates the trajectory of the target nerve.



After approaching the target, advance the needle safely using the other views and respecting their safety considerations.


).



image Optimal Needle Position in Multiplanar Imaging

Related posts:

Atlantoaxial Joint Intraarticular Injection Thoracic Zygapophysial Joint Intraarticular Injection, Posterior Approach Thoracic Transforaminal Epidural Steroid Injection, Infraneural Approach Cervical Zygapophysial Joint Nerve (Medial Branch) Radiofrequency Neurotomy and Nerve Injection, Posterior Approach Thoracic Interlaminar Epidural Steroid Injection, Paramedian Approach Cervical Discography/Disc Access

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Dec 23, 2015 | Posted by in INTERVENTIONAL RADIOLOGY | Comments Off on Lumbar Zygapophysial Joint Nerve (Medial Branch) Radiofrequency Neurotomy, Posterior Approach

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