Facet Blocks | Rhizotomies | Nerve Block in the Spine

Facet blocks and rhizotomies are treatment options for back pain. Facets can cause neck or lower back pain. In the neck, facets can cause up to 30% of global neck pain and in the lumbar spine, it is less than 10%. Facet pain occurs typically with extension (bending backwards) but can cause pain with flexion also. Clicking or popping is typically caused by the facet but normally, the noise is not related to pain or dysfunction.

Diagnosis of facet pain is relatively simple and related to the “facet block”. This injection into the facet contains two medications, a numbing agent like novacaine and a corticosteroid. Whether you know it or not, you have had a diagnostic type numbing injection before. When you go to the dentist, you have had an injection into the jaw to numb the area that the dentist is going to work on. He is blocking the sensory nerve to the jaw. This is the exact same experience you should have with an injection into an area of the spine in question.

The facet is populated by pain nerves (nociceptors) and can cause pain. The purpose of the diagnostic pain injection is to temporarily anesthetize (numb) the potential facet pain to prove it is the pain generator. Just like in the jaw, the numbing sensation lasts for 2-3 hours.

After the injection, you must get up and test the blocked facet or facets. If the surgery center keeps you sedated or in bed for the 3 hours after the injection, the diagnostic portion of the block is lost along with the important information that goes along with the block. You must get up and repeat the activity that causes the pain in the next 3 hours as well as keep a record (a pain diary) of the response to the activity. If walking a mile causes onset of pain, then by all means, walk. If prolonged sitting or bending or neck extension causes pain-do those maneuvers and keep a record of the pain! A pain diary is essential to record the responses.

If the block gives good pain relief, then the facet is most likely causing some or most of the pain. There is a caveat. The injection is typically placed into the capsule of the facet and the capsule may have a tear in it. If this tear leaks anesthetic onto the disc and nerve root underneath the facet, these structures will also be “numbed”. If the pain has originated from either lower structure, this results in a false positive test (a test that falsely indicates the facet being tested is the painful one).

There is another way to test the facet. The nerve supply to the facet comes from medial branches of the recurrent nerve of the spine. Instead of blocking the facet itself through the capsule, you can block these medial branches (medial branch blocks). They have a relatively consistent location along the back of the vertebra. The effect will be the same as standard facet blocks- numbness of the facet and hopefully- pain relief.

Some physicians perform the facet block at one appointment and the medial branch block at the next appointment to confirm the findings.

The steroid can give long term relief of the facet pain and may be the only treatment needed for this pain. Injections can be repeated intermittently.

Rhizotomy

There is an outpatient procedure to interrupt the nerves that transmit the facet pain. This procedure is called a dorsal root or medial branch rhizotomy. In this technique, a needle is place into the spine right on top of the medial branch of the nerve that feeds the facet. Using electrical current, the needle tip heats up-destroying the nerve and commonly, stopping the pain transmission. There are normally two nerves that feed a facet so for one facet, two ablations are needed.

This procedure works for both the neck and the lower back if the facet is causing a large percentage of the pain. There is some evidence that this may also work for sacroiliac pain. It must be stated that most sacroiliac pain is NOT from the sacroiliac joint.

For more information on facet blocks and rhizotomies, or for additional resources on treatment options for pain relating to the neck, back or spine, please contact Dr. Donald Corenman, Colorado spine surgeon, at 888-888-5310.

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Facet Blocks and Rhizotomies

Rhizotomy

About the Author: Donald Corenman, MD, DC

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