From the Guidelines
I strongly advise against proceeding with another cervical facet medial branch nerve block (MBB) and left occipital nerve block at this time, and instead recommend following up with Dr. Adams in clinic to assess the need for radiofrequency ablation (RFA) as a more permanent solution to the patient's discomfort. The patient's previous response to the MBB and occipital block performed on March 3rd raises concerns about the utility of repeating this intervention, as it caused significant post-procedure pain and provided only short-lived relief of approximately 8 days 1. This outcome is consistent with the American College of Radiology's appropriateness criteria for cervical neck pain or cervical radiculopathy, which suggests that joint, medial branch blocks, or discography may not be the most effective first-line test in this clinical presentation 1.
Key points to consider in this case include:
- The patient's history of significant post-procedure pain after the previous MBB and occipital block, which required medical attention
- The short duration of pain relief provided by the previous intervention, which lasted only approximately 8 days
- The original treatment plan documented by Dr. Adams, which included evaluating the patient for RFA as a potential long-term solution to their discomfort
- The need for a thorough clinical evaluation to determine the most appropriate pain management strategy for this patient, taking into account their medical history and previous responses to treatment.
Given these considerations, proceeding with RFA evaluation as originally planned is the most appropriate next step in managing this patient's pain, rather than repeating a procedure that has already demonstrated limited efficacy and significant potential for adverse effects 1.
From the Research
Medical Appropriateness of Another MBB/Occipital Block
- The medical appropriateness of another cervical facet medial branch (MBB) nerve block and a left occipital nerve block is unclear based on chart review 2.
- The patient's last MBB and occipital block on 3/3 provided initial pain relief, but significant pain developed at the site after the anesthetic wore off, and the improvement was short-lived, lasting only a week 2.
Effectiveness of MBB and Radiofrequency Neurotomy
- Studies have shown that cervical therapeutic medial branch blocks and radiofrequency neurotomy have equivalent clinical outcomes and cost utility in managing chronic neck pain of facet joint origin 2.
- Cervical medial branch radiofrequency ablation (CMBRFA) is an effective treatment for facetogenic pain in patients selected by a practical medial branch block paradigm, with a ≥50% pain reduction rate of 54% at a mean follow-up time of 16.9 months 3.
Selection Criteria for MBB and Radiofrequency Neurotomy
- The selection criteria for MBB and radiofrequency neurotomy are crucial, with more stringent criteria likely to improve denervation outcomes but at the expense of false-negatives (i.e., lower overall success rate) 4.
- Medial branch blocks are more predictive than intra-articular injections in selecting patients for radiofrequency ablation, and a positive block is typically defined as ≥75% to 80% pain relief 4.
Alternative Methods for MBB and Radiofrequency Ablation
- CT fluoroscopy-guided cervical medial branch block and facet radiofrequency ablation is an alternative method that allows for more precise needle tip positioning and visualization of bony landmarks and soft tissue anatomy 5.