Cervical Facet RFA for Neck Pain

Cervical Facet RFA

Cervical Facet RFA: Detailed Posterior Approach for Pain Physicians

Cervical Facet RFA (Radiofrequency Ablation) is an established interventional technique used to treat axial neck pain arising from cervical facet joint arthropathy. Pain physicians rely on precision, anatomical knowledge, and fluoroscopic guidance to achieve effective outcomes. This article provides a comprehensive, step-by-step procedural guide for cervical medial branch block and RFA via the posterior approach.

Understanding Cervical Medial Branch Anatomy for Cervical Facet RFA

The medial branches of the dorsal rami of cervical spinal nerves are responsible for innervating the facet (zygapophyseal) joints of the cervical spine. These joints are a common pain generator in patients with chronic neck pain.

Origin and Course

  • After emerging from the intervertebral foramina, spinal nerves divide into ventral and dorsal rami.
  • The dorsal rami further split into medial and lateral branches, with the medial branch targeting the facet joints.

Segment-Specific Pathways

  • C3 Level: The medial branch at this level innervates C2-C3 facet joint and continues upwards and is known as the third occipital nerve. Another division comes downwards to innervate the C3–C4 facet joint.
  • C4–C7 Levels: Here, the medial branches loop around the waist of the articular pillars, located between the superior and inferior articular processes. They provide innervation to both their level and the joint below.

Dual Innervation

Each facet joint receives sensory input from two adjacent medial branches, a crucial concept when planning effective diagnostic and therapeutic interventions.

Fluoroanatomy for Cervical Facet RFA

Proper imaging is essential for safe and accurate medial branch localization.

AP (Anteroposterior) View

  • Used to confirm vertebral level rather than visualize nerves.
  • Essential for aligning the C-arm and establishing entry points.

Lateral View

  • Offers a profile view of the vertebral bodies and articular pillars.
  • Helps gauge needle depth and trajectory. The medial branch lies at the midpoint of the articular pillar, posterior to the junction of the lamina and transverse process.

Key Landmarks

  • Articular Pillars: Central bony landmarks guiding needle placement.
  • Spinous Processes: Used for midline orientation and level confirmation.

Indications for Cervical Facet RFA

  • Cervical facet joint syndrome with axial neck pain
  • Post-whiplash neck pain with suspected facet involvement
  • Diagnostic medial branch blocks confirming facet-mediated pain
  • Patients seeking long-term relief after positive diagnostic blocks

Contraindications

  • Local or systemic infection
  • Uncontrolled coagulopathy
  • Allergy to local anesthetics or steroids
  • Pregnancy, due to fluoroscopic exposure. USG-guided procedure is recommended.
  • Severe anatomical deformities complicating needle access

Equipment Checklist

Imaging & Needles

  • C-arm fluoroscopy for real-time guidance
  • 20–22G spinal or RF cannula, 3.5–3.9 inches, with 5 mm active tip for RFA

Medication & Supplies

  • Local anesthetics: 1% lidocaine, bupivacaine
  • Steroids: Dexamethasone for post procedure injection.
  • Contrast agents: For vascular spread confirmation
  • Sterile drapes, gloves, prep solution
  • Emergency drugs: Epinephrine, antihistamines
  • Resuscitation kit: Oxygen, BVM, defibrillator

Monitoring

  • ASA Standard: ECG, SpO₂, BP
  • IV access
  • Continuous verbal communication
  • Post-procedure monitoring: 30–60 minutes

Pre-Procedure Protocol

Patient Preparation for Cervical Facet RFA

  • Review history, imaging, and exclude contraindications
  • Informed consent covering risks, benefits, and procedure steps

Positioning

  • Prone position with chest support
  • Neck flexed slightly to widen interlaminar spaces
  • Arms by the side for optimal imaging access

Fluoroscopy Setup

  • Begin with an AP view for vertebral level confirmation
  • Tilt the C-arm caudally (25–35°) to visualize articular pillars

Procedure Steps: Posterior Approach

  1. Obtain AP View:
    • Identify and mark the midpoint of the articular pillar at target levels
  2. Skin Infiltration:
    • Use 1–2 mL of 1% lidocaine at entry points
  3. Needle Insertion:
    • Insert a 22G spinal or RF needle toward the superior lateral edge of the articular pillar
  4. Advance Under Fluoroscopy:
    • Maintain a posterolateral trajectory
    • Stop when bone contact is achieved
  5. Confirm in Lateral View:
    • Needle tip should be at the midpoint of the articular pillar, near the junction of lamina and transverse process
  6. Perform Nerve Stimulation:
    • Sensory test: Paresthesia at <0.5V
    • Motor test: No muscle contraction at 1.5–2.0V
  7. Inject Contrast:
    • 0.3–0.5 mL to confirm correct placement and rule out intravascular spread
  8. Diagnostic Block:
    • Inject 0.3–0.5 mL of local anesthetic (lidocaine or bupivacaine)
  9. Assess Response:
    • Observe for pain relief within 5–10 minutes
  10. Radiofrequency Ablation:
    • Lesion at 75–80°C for 60–120 seconds per level if diagnostic response is positive

Post-Procedure Protocol

  • Needle Withdrawal: Under fluoroscopy, with pressure applied at site
  • Monitor: 30–60 minutes for dizziness, neurologic changes, or allergic response
  • Discharge Instructions:
    • Rest for 24–48 hours
    • Mild soreness is common
    • Report red flags like persistent weakness or fever

Potential Complications

While rare, being aware of possible complications is critical:

ComplicationDescription
Local Pain/BruisingUsually mild, resolves in days
Transient NumbnessDue to local anesthetic, temporary
InfectionRare with sterile technique
HematomaPossible in coagulopathic patients
Nerve InjuryRare, due to improper needle placement
Vascular InjuryVertebral artery puncture risk—avoid with accurate trajectory
Dural PunctureMay lead to headache; avoid deep advancement
Allergic ReactionFrom anesthetics or steroids; pre-check for known allergies

Conclusion

Cervical Facet RFA, when performed with precision and adherence to anatomical landmarks, offers significant and lasting pain relief for patients with facet-mediated neck pain. For pain physicians, mastering this posterior approach is essential to delivering safe, effective care backed by evidence and technique.

References for Cervical Facet RFA

Suer M, Wahezi SE, Abd-Elsayed A, Sehgal N. Cervical facet joint pain and cervicogenic headache treated with radiofrequency ablation: a systematic review. Pain Physician. 2022;25(3):251-263.
Available from: https://pubmed.ncbi.nlm.nih.gov/35652765/

Engel A, Rappard G, King W, Kennedy DJ. The effectiveness and risks of fluoroscopically-guided cervical medial branch thermal radiofrequency neurotomy: a systematic review with comprehensive analysis of the published data. Pain Med. 2016;17(4):658-669.
Available from: https://academic.oup.com/painmedicine/article/17/4/658/2584096