Frequently
Asked Questions

we provide a wide range of specialized orthopedic services to address various musculoskeletal conditions and injuries.

Frequently
Asked Questions

we provide a wide range of specialized orthopedic services to address various musculoskeletal conditions and injuries.

Category

  • Ankle

  • Arthritis

  • Arthroscopy

  • Chest

  • Elbow

  • EMGs/NCVs

  • Foot

  • Fractures

  • General Medical Conditions

  • General Orthopedic Conditions

  • Hand

  • Hip

  • Knee

  • Laboratory Test Results

  • Miscellaneous

  • MRI

  • Orthopedic Surgical Procedures

  • Pelvis

  • Shoulder

  • Spine

    • Cervical

    • Thoracic

    • Lumbar

  • Wrist

  • X-rays

How and why do rib fractures lead to chronic pain?

Rib fractures can lead to chronic pain through several mechanisms and reasons.

The first is through inadequate healing during which either a nonunion, where the rib fracture fails to heal, or malunion where the bone ends reunite, but in a misaligned way leading to ongoing pain.

Immobilization of a fracture is a priority for orthopedists treating broken bones. The purpose of a splint, cast or surgery with rods, plates or screws is to provide fracture stability and immobilization during the healing process. But, with rib fractures there is no splint/cast available because the chest is constantly required to move during respiration. Fortunately, the vast majority of fractures heal and slight degrees of malalignment do not cause significant problems.

The intercostal nerve is a small nerve that travels from the back along the underneath side of each rib. Fractured ribs can damage or irritate the intercostal nerves, leading to persistent nerve pain or neuropathy.

Rib fractures near the costochondral junction (where the rib meets the cartilage) can be particularly painful and can lead to chronic pain due to the movement of the chest wall.

The intercostal muscles (the barbecue rib meat) may be strained or injured at the time of the fracture and can remain painful.

Scar tissue forming as part of the healing process may compress nerves or limit mobility, leading to ongoing discomfort.

Though not a true source of pain, the shallow breathing to the avoid pain from a rib fracture can lead to decreased lung function or pneumonia, compounding pain issues.

There are several reasons why the aforementioned issues may develop. The rib cage is in constant motion due to breathing, coughing, and physical activity, which can impede the healing process and exacerbate pain.  Ribs also have a relatively limited blood supply, and the slow healing process can contribute to prolonged pain.

Chronic pain after rib fractures can severely impact one’s quality of life.  In rare cases, if conservative care and injections do not provide adequate relief of the pain, surgery may become an option.

How does diabetes mellitus affect musculoskeletal healing?

Diabetes mellitus can significantly impact musculoskeletal healing through several mechanisms.

Diabetes can cause vascular complications, reducing blood flow to affected areas and slowing the delivery of essential nutrients and oxygen needed for healing.

High blood glucose levels, the hallmark of diabetes, can impair the body's ability to repair tissues efficiently, leading to delayed wound healing.

Collagen is crucial for tissue repair, and diabetes can decrease collagen synthesis, leading to weaker scar tissue and slower healing processes.

Diabetic individuals are more susceptible to infections, which can complicate and prolong the healing of musculoskeletal injuries and surgical procedures.

Nerve damage associated with diabetes (diabetic neuropathy) can lead to decreased sensation, which might result in further injuries and complications during the healing process due to lack of protective pain sensations.  This is especially important for patients that require casting or splinting of an injured extremity.  Pressure sores may develop in diabetic patients beneath the cast/splint because of the lack of pressure recognition caused by their neuropathy.  In a worst case scenario, a tight cast may lead to vascular insufficiency causing gangrene and the need for an amputation.

Diabetes can alter the normal inflammatory response, either prolonging inflammation or impairing the transition to the healing phase, both of which can delay recovery.

Diabetes can impair bone metabolism, leading to delayed fracture healing and increased risk of complications such as nonunion or malunion.

These factors collectively compromise the body's ability to efficiently repair musculoskeletal injuries, leading to longer recovery times and an increased risk of complications in individuals with diabetes mellitus.

Why are obese people more likely to be traumatically injured?

Obese people are more likely to be injured traumatically due to several reasons.

Most obviously, the extra body weight increases the force exerted on the body during falls or collisions, leading to more severe injuries.  The extra weight places stress on joints, making them more prone to injuries such as sprains and fractures.

Obesity leads to limited mobility and balance and can slow down reflexes which increases the likelihood of a fall on a slippery floor, uneven sidewalk, or cluttered walkway.

Obese individuals may have comorbid conditions like diabetes, hypertension, and cardiovascular diseases that can complicate injury recovery.

Finally, the general lower levels of fitness in the obese may make it harder for them to withstand and recover from injuries, and treating their injuries can be more challenging, leading to a possibly prolonged and complicated recovery process.

Why are elderly people more likely to be injured after a traumatic event?

Elderly people are more likely to be injured after a traumatic event due to several factors.

Osteoporosis, low bone density, is one of the more common causes of brittle bones in the elderly or in postmenopausal women which leads to a higher risk of fractures.

Slower reflexes, which are a result of aging makes one less likely to prevent a stumble or fall, and then the reduced muscle mass of aging leaves less cushion for protection upon impact.

In general, frailty makes recovery from injuries slower and more complicated and these factors collectively contribute to a higher likelihood and severity of injuries among the elderly after a traumatic event.

What is considered conservative care for musculoskeletal injuries?

Conservative care for musculoskeletal injuries involves non-surgical and non-invasive treatments aimed at managing pain, promoting healing, and restoring function.

Initially, conservative care begins with rest and activity modification using splints, braces, casts or slings to stabilize and protect the injured area or joint.  Canes and crutch walking allows for reduced weight across an injured joint.  A cane should be used in the hand opposite from the injury with the bodyweight shifted toward the cane and away from the injured leg.  A walker provides for more stability than a cane or crutches.

Physical Therapy provides strengthening, stretching, and range-of-motion exercises tailored to the specific injury. Occupational Therapy is similar to physical therapy, but it focuses on the upper extremity and hand.

Manual Therapy techniques such as massage, joint mobilization, and manipulation are used to improve movement and decrease pain.

Medications include over-the-counter medications like acetaminophen, Aleve or Ibuprofen.  Prescription nonsteroidal anti-inflammatory medications (NSAIDs) may be recommended.  Topical creams and gels that can be applied to the skin over the affected area are also beneficial.

Ice and Heat Therapy are front line treatments.  Ice packs are applied to reduce acute inflammation and numb the area to alleviate pain.  Whereas heat therapy is used to relax and loosen tissues and stimulate blood flow to the area.

TENS (Transcutaneous Electrical Nerve Stimulation) units are devices that deliver small electrical impulses to a painful or injured area to help reduce pain.

Teaching proper posture and body mechanics to prevent further injury and strain, and modifying workspaces and activities to reduce stress on the injured area are encouraged.

Maintaining a healthy weight to reduce stress on joints and muscles, and engaging in low-impact activities to maintain overall fitness and strength is also part of conservative care and preventive therapy.

Teaching individuals about their injury and how to manage it effectively can be extremely valuable. Common sense is not always as common as you may think when dealing with a painful injury.  Being taught routines for managing symptoms at home, including exercises and application of ice or heat are financially helpful and time saving.

Alternative therapies such as acupuncture and chiropractic treatment may help reduce pain and improve function. However, spinal adjustments may not always be appropriate in a recently injured or elderly patient.

Injections are the most aggressive form of conservative care.  For significant inflammation and pain, doctors may inject corticosteroids directly into the affected area.  A more recent type of injection, Platelet Rich Plasma (PRP) Injection, involves spinning down a patient’s blood in a centrifuge in order to collect the platelets and plasma which are then reinjected into the injured area to promote healing.

Finally, Mother Nature is always on the job enabling most injuries to heal overtime.

But, the aforementioned measures help reduce discomfort and speed up healing, allowing the patient to perform some of their daily activities at home and work effectively while their recovery is taking place.

What is serologic arthritis and are these joints more easily injured by trauma?

Serologic arthritis is a type of arthritis that is characterized by the presence of specific antibodies in the blood, which can be detected through serologic (blood serum) tests. These antibodies are typically markers of autoimmune disorders. Some of the more common types of serologic arthritis includes rheumatoid arthritis, lupus, sarcoidosis, Reiter’s syndrome, psoriatic arthritis and Lyme disease.

And yes, these joints are more easily injured by trauma for several reasons. The chronic inflammation associated with these diseases, can weaken the joint structures making it easier for them to be injured from even minor trauma.  Serologic arthritis is often associated with stiffness and reduced flexibility which makes a joint less capable of handling stress and the sudden movements that can occur during a traumatic event.

Many of these conditions lead to bone erosion, and joint deformities with malalignment. These structural changes may compromise the stability and integrity of the joint, making it more vulnerable to an injury.

Finally, chronic pain and inflammation can lead to decreased physical activity, resulting in muscle atrophy (weakening). Weaker muscles provide less support and protection to the joints, leading to an increased risk of injury.

Can fractures lead to the onset of osteoarthritis in a joint?

Yes, fractures can lead to the onset of osteoarthritis in a joint. This type of osteoarthritis is often referred to as "post-traumatic osteoarthritis."

An intra-articular fracture that extends into the joint can damage the articular cartilage, which is the smooth, gliding surface of the joint. This damage can lead to increased wear and tear of the cartilage over time.  The result is a loss of cartilage and the development of osteoarthritis.

Fractures can sometimes heal with slight misalignment or malunion, which can alter the normal mechanics of the joint. This altered alignment can increase stress on certain parts of the joint, accelerating cartilage breakdown.

The healing process after a fracture may involve chronic inflammation, which can contribute to the degradation of cartilage and the development of osteoarthritis.

Finally, prolonged immobilization or altered movement patterns during the healing process can weaken joint structures and change the load distribution across the joint, making it more susceptible to osteoarthritis.

Can a strain cause an asymptomatic osteoarthritic joint to become symptomatic?

Yes, a strain or injury can indeed cause an asymptomatic osteoarthritic joint to become symptomatic.

A strain can lead to inflammation in the joint, which can exacerbate underlying osteoarthritis and turn a previously asymptomatic condition into a symptomatic one.

An injury to surrounding tissues (like muscles, tendons, or ligaments) can shift the mechanical stress onto the joint, making the osteoarthritic changes more apparent and painful.   A strain that affects ligaments and tendons might reduce the stability of the joint, leading to increased pain and discomfort in areas already compromised by osteoarthritis.

Or finally, to avoid pain caused by the strain, an individual may unconsciously alter his movement patterns, placing abnormal stress on the osteoarthritic joint and causing symptoms to emerge.

What percentage of asymptomatic people have clinical features or radiographic findings consistent with osteoarthritis in their shoulders, hips or knees?

The exact percentage of asymptomatic individuals with osteoarthritis can vary, but studies suggest that a significant portion of people with osteoarthritis may not experience noticeable symptoms.

Shoulder research indicates that up to 30% of people over the age of 60 may have shoulder osteoarthritis, but a substantial number of them might not exhibit symptoms.

Approximately 20% of people over the age of 65 may have radiographic evidence of hip osteoarthritis, yet many of them are asymptomatic.

Estimates suggest that around 40% of individuals over the age of 70 have knee osteoarthritis based on radiographic or MRI imaging, but about half of these individuals may not report symptoms.

These estimates highlight the prevalence of osteoarthritis that can remain asymptomatic and undetected without noticeable symptoms.

Is osteoarthritis always symptomatic?

No, the abnormal joint findings associated with osteoarthritis are not always symptomatic, especially in its early stages. Many people with this condition may not experience significant symptoms for a long time, if ever.

The asymptomatic nature of osteoarthritis means that the radiographic abnormalities developed without noticeable signs.

Additionally, the radiographic abnormalities may even progress without the development of symptoms.

But when symptoms do manifest, they typically include either pain, stiffness, swelling, reduced range of motion, painful grinding sensations, or bones spurs leading to joint enlargement.

The pain is often associated with or after activity and can vary in intensity. Stiffness is often after a prolonged period of inactivity or when awakening in the morning. Perceived swelling may be due to soft tissue swelling or actual fluid in the joint. The reduced range of motion may be as result of changes in the bony architecture of the joint, soft tissue damage or fluid accumulation. Tenderness is associated with inflammation.

The grinding sensations and popping may be due to soft tissues passing over bone spurs or the loss of the cushioning cartilage in the joint.

Bone spurs associated with arthritis develop due to the abnormal stresses that develop from the changes in joint alignment as the years pass.

What is osteoarthritis?

Symptomatic osteoarthritis is a painful, common joint disorder that occurs when the protective cartilage that cushions the ends of the bones (the “gristle” on the end of a chicken drumstick) wears down over time. It often affects joints in the hands, knees, hips, and spine.

Symptoms include pain, stiffness, swelling, and a reduced range of motion of the involved joint. The pain may wax and wane, depending upon an individual’s level of activity.

Risk factors include age, joint injury, repetitive stress, obesity, and genetics.

While there is no cure, treatments like physical therapy, nonsteroidal medications (NSAIDs), and lifestyle changes can help manage the symptoms.

Can Carpal Tunnel Syndrome (CTS) be caused by trauma?

Yes, Carpal Tunnel Syndrome (CTS) can be caused by trauma, although it is more commonly associated with repetitive movements and prolonged wrist flexion or dorsiflexion.

Carpal Tunnel Syndrome is caused by the compression of the median nerve as it travels through the carpal tunnel, a narrow passageway in the wrist. The median nerve runs from the forearm into the palm of the hand and controls sensation to the thumb, index finger, middle finger, and part of the ring finger. Compression of the median nerve leads to a variety of symptoms mainly affecting the hand and fingers.  Numbness, tingling on the thumb side of the hand, weakness of grip, and pain especially at night are some of the more common symptoms associated with CTS.

On physical exam, a Tinel’s sign is usually positive over the median nerve at the level of the wrist, and Phalen’s testing is typically positive. Nerve studies may be obtained to confirm the diagnosis although the need is not absolutely necessary and/or not always positive in spite of clinical CTS.

The inflammation, swelling or alterations in anatomy associated with severe sprains or wrist fractures can lead to the onset of carpal tunnel syndrome. A direct blow over the carpal tunnel can cause swelling, and inflammation of the median nerve leading to CTS.

The treatment for trauma induced CTS involves ice, rest, splinting and elevation while the initial traumatic injury heals. Anti-inflammatory medications and corticosteroid injections may help lessen the swelling and inflammation. Ultimately, in cases that don’t improve with conservative care, carpal tunnel release surgery, during which the ligament overlying the median nerve is divided to relieve pressure, is recommended.

Can tennis elbow (lateral epicondylitis) be caused by trauma?

Yes, tennis elbow (lateral epicondylitis) can be caused by trauma, although it is more commonly associated with repetitive stress and overuse.

The extensor carpi radialis brevis (ECRB) muscle is located in the dorsal forearm and aids in wrist extension. Pain emanating from the ECRB’s tendinous origin near the outside of the elbow is what is most frequently associated with lateral epicondylitis.

A direct blow to the outside of the elbow can cause immediate pain and lead to inflammation of the ECRB tendon.  A sudden forceful motion of the wrist or elbow, such as catching oneself during a fall, can strain the extensor tendons, causing microscopic tears leading to the onset of pain.

The treatment for trauma related tennis elbow is basically the same as for overuse, tennis elbow. Ice and rest of the injured elbow initially allows the inflammation from the trauma to subside. Avoidance of forceful gripping and squeezing, and heavy lifting for the first week to 10 days is beneficial. Anti-inflammatory medication should help with the pain. Should the symptoms persist then physical therapy and/or corticosteroid injections may be needed. Only as the last resort is surgery necessary.

Can trauma cause an asymptomatic rotator cuff tear to become symptomatic?

Yes, trauma can indeed cause an asymptomatic rotator cuff tear to become symptomatic. Trauma, such as a fall or sudden heavy lifting, can worsen an existing tear, increasing its size or severity.

Inflammation and swelling due to a recent injury can lead to the onset of pain in the previously asymptomatic shoulder.

Recent trauma could cause injury to surrounding previously healthy structures, which were supporting and aiding the damaged rotator cuff.

Or finally, after a recent trauma, the biomechanics of the shoulder may be compromised, placing extra strain on the already weakened and torn asymptomatic rotator cuff, causing it to become symptomatic.

What percentage of degenerative rotator cuff tears are symptomatic?

Degenerative rotator cuff tears, which occur due to the gradual wear and tear of the tendons rather than a sudden injury, are quite common, especially in older adults. However, not all degenerative tears result in symptoms.   Studies suggest that roughly 35% to 50% of degenerative rotator cuff tears are symptomatic, meaning they cause noticeable symptoms such as pain, weakness, and limited range of motion. The remaining 50% to 65% tend to be asymptomatic and may be discovered incidentally during imaging for other issues or routine check-ups.

Larger tears or ones that have recently progressed, especially in more active individuals are more likely to cause symptoms.  Overtime, large asymptomatic tears can lead to rotator cuff arthropathy (osteoarthritis of the shoulder joint secondary to a rotator cuff tear), which may then cause shoulder pain.

What percentage of rotator cuff repairs fail?

The failure rate of rotator cuff repairs can vary based on several factors, including the size and severity of the tear, the patient's age, the quality of the tendons, and the patient’s adherence to post-operative rehabilitation protocols.

Studies suggest that small to medium tear (less than 3 centimeters) repairs generally have a higher success rate, with failure rates ranging from 10% to 20%.

Larger tears, and those involving more than two of the tendons are more challenging to repair and have higher failure rates, which are estimated to be between 20% and 50%.

Older patients may have poor tendon quality which can affect tendon healing.  The skill and experience of the shoulder surgeon also plays a role in the retear rate.  Finally, failure to adhere to the deliberative and slowly progressive rehabilitation process, and pushing to return to activity too soon may lead to failure of the repair.

What is a rotator cuff tear?

A rotator cuff tear is a common shoulder injury involving a tear in one or more of the four muscles or their tendons that comprise the rotator cuff. These muscles and tendons arise from the shoulder blade and help stabilize the shoulder joint.  By passing in front of, on top of, and behind the ball of the shoulder joint, the rotator cuff muscles and tendons keep the humeral head (ball of the shoulder) pressed firmly into the flat, dish-like shoulder socket (the glenoid). The shallowness of the glenoid allows for a wide range of shoulder movements which are initiated by the rotator cuff muscles.

The four muscles that make up the rotator cuff are the supraspinatus, infraspinatus, subscapularis, and teres minor. They motor the shoulder joint through the widest range of motion of any joint in the body.

Rotator cuff tears may be partial (incomplete) where the tendon is damaged but not completely severed. A complete tear is a full thickness tear which goes all the way through the tendon or muscle potentially causing the tendon to detach from the ball of the shoulder, leading to significant loss of motion, pain and weakness.

The causes of a rotator cuff tear include acute injury, such as a fall, heavy lifting or a sudden jerking motion. Chronic overuse and repetitive strain from overhead activities may lead to tearing. In older adults, age related wear and tear is often asymptomatic. However, the older, painless degenerative tears may become symptomatic as the result of comparatively minor shoulder trauma.

Pain, especially when lowering the arm, limitation of motion and shoulder weakness are classic findings identified on physical exam. Pain that worsens at night, especially when sleeping, is also commonly described.

Like with impingement syndrome, the physical exam is used to identify pain, range of motion and weakness.  MRI and ultrasound can be used to visualize and objectively confirm the tear.

Conservative care can be provided for incomplete or minor tears in older individuals whose symptoms are not severe. This would include activity modification and avoidance of activities that aggravate the pain.  Anti-inflammatory medication can be used for pain control, and physical therapy will help strengthen the intact rotator cuff muscles and maintain shoulder range of motion.

However, surgical repair of the torn tendons with enlargement of the subacromial space is the preferred treatment, especially in younger, active and working individuals.

Surgery can either be performed arthroscopically or via a traditional surgical incision in order to reattach the torn tendon to the bone.

Recovery after a rotator cuff repair surgery is a slow and deliberative process. There is a balancing act between regaining strength and range of motion while avoiding retearing the repaired tendon from the bone.

Complete recovery and return to work may require a period of 8 to 12 months.

What is impingement syndrome and can it be caused by trauma?

Impingement syndrome of the shoulder occurs when the tendons of the rotator cuff become irritated or inflamed as they pass through the subacromial space, the narrow passage between the acromion (a part of the shoulder blade) and the humeral head (the top of the upper arm bone). This can cause pain, weakness, and reduced range of motion.

Yes, trauma such as falls or direct blows to the shoulder can trigger inflammation or damage to the rotator cuff leading to impingement syndrome. The risk of impingement developing can be increased with certain bone shapes or structures that lead to a smaller subacromial space.

Overhead activities, like swimming, tennis, painting, or ceiling work when excessive can wear down the rotator cuff tendons, causing the symptoms of impingement syndrome. Age related wear and weakness about the shoulder may also be a factor in the development of impingement.

Symptoms of impingement syndrome include pain when lifting the arm and night pain, especially when lying on the affected shoulder. There may be weakness and limitation of shoulder motion.

The history and physical exam often lead to the diagnosis which is confirmed by x-rays, MRI or ultrasound studies.

The initial treatment includes rest and activity modification with avoidance of activities that caused or aggravate the pain. Anti-inflammatory medications and physical therapy may also aid in lessening the inflammation and maintaining strength and flexibility. Corticosteroid injections may reduce severe inflammation and lessen the pain, and in severe cases arthroscopic surgical procedures that increase the subacromial space and lessen the impingement on the rotator cuff tendons is beneficial.

Do all torn anterior cruciate ligaments require surgery?

Not all torn anterior cruciate ligaments (ACL) require surgery. The decision depends on several factors including the individual's activity level, the severity of the injury, and personal goals.

Minor tears and partial tears are often treated with physical therapy to strengthen the muscles that support the knee.

Older or less active individuals that have a low demand lifestyle may be able to avoid the need for surgery by focusing on muscle strengthening and possibly using a knee brace.

On the other hand, athletes, those engaged in physical work or individuals with active lifestyles that have complete ACL ruptures with a desire to return to high demand activities typically require ligament reconstruction to regain functionality and stability. Patients that have failed non-operative treatment due to significant knee instability or pain should undergo and ligament reconstruction.

In general, younger, active individuals are more likely to benefit from ACL reconstruction surgery than non-operative treatment. If the knee remains unstable and causes issues like giving away, surgery should be considered. Finally, if the individual has plans to return to sports or high impact activities, the decision-making should lean toward surgical reconstruction.

What is the typical rehab and recovery after an ACL injury and reconstruction?

Rehabilitation after ACL reconstruction is crucial for recovery.  It is understood that all patients heal at different rates, and different ACL reconstructive procedures may have subtle differences in their rehabilitation protocol.

Likewise, there is physician variation regarding the duration and type of postop bracing immediately after surgery and long-term bracing after a successful  recovery.  Different physicians may vary in their timelines regarding the degrees of range of motion and the type and intensity of strengthening exercises during rehab. How much weight and when weight can be born on the operated extremity is also physician dependent and may vary based on the surgical findings.

The general timeline for recovery and rehab begins in the immediate post surgical period during the first two weeks.   Rest, ice, and elevation help minimize the swelling and pain. Pain medication can be taken as prescribed by the doctor. Crutches to allow non weight-bearing and a knee brace are utilized.

During weeks 2-6 range of motion exercises are gently performed along with isometric strengthening exercises of the quadriceps and hamstrings. Gradual toe touchdown weight bearing is allowed with physician approval.

Between weeks 6-12 the focus shifts to lower body strengthening exercises to improve balance, coordination and stability and low impact activities like cycling or swimming to build cardiovascular strength.

From 3 to 6 months sports specific functional training and agility exercises are begun. Lower body workouts intensify and drills to improve strength, agility, and stability are begun in order to prepare for eventual testing.

From 6-12 months the patient may slowly resume sports and activities with training continuing to focus on sports specific skills and conditioning.

What is the typical rehab and recovery after a partial meniscectomy?

Typical recovery after a partial meniscectomy occurs in phases.  It is understood that all patients heal at different rates and these are just general guidelines.

The first phase is the immediate postoperative period when the knee should be rested and ice applied to reduce swelling. Pain medicine is prescribed and taken as necessary and elevation of the leg will prevent swelling.

The second phase occurs during the first two weeks after surgery and encompasses early rehabilitation. Gentle range of motion exercises may be begun with gradual return to weight-bearing as tolerated. Crutches may be discarded. Physical therapy is started to restore strength, and movement will begin as symptoms allow.

Phase three spans weeks 2-6 during which time strengthening exercises, focusing on the quadriceps and hamstring muscles are instituted. Activities that mimic daily activities are instituted. Stretching and range of motion exercises to improve flexibility are encouraged.

The last phase includes weeks 6-12 and beyond. During this phase gradual re-introduction to sports and work specific activities and high demand activities occurs depending on the patient’s progress and physician approval.

When can a laminectomy or discectomy treat a lumbar disc herniation without the need for a fusion?

A laminectomy or discectomy can treat a lumbar disc herniation effectively without requiring fusion in cases where the herniation is isolated, and there is no severe instability or deformity in the spine. When a lumbar disc herniation is causing nerve compression leading to leg pain, possibly with associated numbness or weakness, removal of a small amount of lamina and the herniated disc material may eliminate the problem without creating instability and the need for a fusion.  In a younger, healthy patient when there is only mild degeneration at the neighboring levels a simple discectomy may be all that is required.

What are the potential complications associated with an ACF procedure?

Nonunion

- **Description:** Occurs if the bone graft does not successfully fuse with the vertebrae.

- **Implications:** This can lead to continued instability and pain in the neck.

Hardware Failure:

- **Description:** If hardware such as screws, plates, or cages are used, they might fail or break.

- **Implications:** This could require additional surgeries to correct or replace the hardware.

Infection:

- **Description:** As with any surgery, there is a risk of infection at the surgical site.

- **Implications:** Infections may require antibiotic treatment or further surgical intervention.

Adjacent Segment Disease:

- **Description:** Stress is transferred from the operated/fused level to adjacent spinal segments.

- **Implications:** Over time, this can cause degeneration and issues in the segments above or below the fused level.

Nerve Damage:

- **Description:** Accidental injury to the spinal cord or nerve roots during surgery.

- **Implications:** This can lead to numbness, weakness, or paralysis in certain areas.

Esophageal Injury:

- **Description:** Because the surgery is performed through the front of the neck, there is a risk of injury to the esophagus.

- **Implications:** This can result in difficulty swallowing and may require additional treatment.

Vascular Injury:

- **Description:** There is a risk of damaging the nearby blood vessels.

- **Implications:** This can lead to serious complications such as excessive bleeding or stroke.

Hoarseness or Voice Changes:

- **Description:** Manipulation and pressure on the recurrent laryngeal nerve.

- **Implications:** This can cause temporary or sometimes permanent changes in voice quality.

Cerebrospinal Fluid (CSF) Leak:

- **Description:** There is a risk of a dural tear, which can result in CSF leak.

- **Implications:** This often requires additional treatment or surgery to repair the leak.

Respiratory Issues:

- **Description:** Post-operative swelling or hematoma can compress the airway.

- **Implications:** It may require emergency intervention to secure the airway.

What are some of the factors that may affect the success rate of an ACF?

Though the ACF procedure is normally associated with a very high success rate, there are some factors that could negatively influence the outcome. The overall patient health, age, smoking status and bone quality can influence the success rate. The degree of disc herniation, and the presence of any additional spinal issues/pathology is important.  The skill and experience of the surgeon also plays a critical role in the success of the procedure.

How successful is anterior cervical fusion for a cervical disc herniation?

Anterior Cervical Fusion (ACF) is generally considered a highly successful treatment for cervical disc herniation.  Most clinical studies report that approximately 80-90% of patients experience significant relief from symptoms such as neck pain, radiculopathy (arm pain), numbness, and weakness after an ACF.

The success rate of the actual fusion process—where the bone graft successfully fuses with the adjacent vertebrae—ranges from 90-95%. This high rate is crucial for long-term stability and symptom relief.

ACF effectively reduces or even eliminates nerve pain caused by a cervical disc herniation. Many patients report a dramatic improvement in their quality of life and in their ability to perform daily activities without pain or neurological deficits.

How is the anterior cervical fusion performed?

A small incision is made in the front of the neck. Care is taken to avoid injury to the trachea (windpipe) and esophagus (the tube carrying food from the mouth to the stomach).  The symptomatic disc is identified and often confirmed with an x-ray.  The disc is carefully removed, after which a bone graft or synthetic cage is inserted in place of the removed disk in order to maintain the spacing between the vertebra and to facilitate fusion. Often, a plate and screws are used to hold and stabilize the vertebrae thus allowing the fusion material to successfully incorporate into them.

Why is an anterior cervical fusion (ACF) the surgical treatment of choice for a cervical disc herniation?

An anterior cervical fusion (ACF) is often the surgical treatment of choice for a cervical disc herniation due to several key reasons.

The anterior approach used during the ACF procedure allows the surgeon direct access to the herniated disc without the need to manipulate the spinal cord and nerve roots, which lie posterior. By approaching anteriorly, the surgeon can effectively remove the herniated disc and decompress the spinal cord and nerve roots thus alleviating the pain and symptoms with less risk of damage to the spinal cord.

After the anterior removal of the disc, fusion of the vertebrae adds stability to the cervical spine, reducing movement and the risk of a future disc herniation at the same level.

The fusion helps to maintain or even restore the normal curvature and alignment of the cervical spine, which can be disrupted by disc herniation.

Finally, the anterior approach often results in less postoperative pain compared to posterior approaches, as there is less muscle dissection and tissue disturbance.

Why might a patient still experience spinal pain after a RFA procedure?

A patient might still experience spinal pain after a radiofrequency ablation (RFA) procedure for several reasons.

A RFA procedure is performed using x-ray (fluoroscopy). However, the medial branch nerves do not show up on x-ray, only the bones of the spine are visible. The treating physician knows where the nerve is supposed to be in relation to the bones. But sometimes the nerve is not exactly where it should be. Particularly after a previous RFA procedure, scar tissue may have altered the course of the regrown nerve.

The residual pain might stem from other structures or conditions not addressed by the RFA, such as discs, muscles, or other joints.

Differences in technique and the skill of the practitioner can influence the effectiveness of the procedure.  Some physicians choose to only burn the nerve once for 1 1/2 minutes as opposed to 3 minutes.  The second burn increases the likelihood that the nerve will be captured in the burn radius. However, it also increases the possibility complications such as nerve root injury.

Post-procedural inflammation or irritation can temporarily exacerbate pain which usually resolves within 3 to 6 weeks. A corticosteroid dose pack may benefit these patients.

Finally, despite proper diagnosis and testing, excellent needle placement and physician technique, some patients still don’t respond as the medial branch blocks suggested they would. Chronic pain over a prolonged period of time can lead to central sensitization or other complex chronic pain mechanisms that can persist despite perfectly diagnosed and performed peripheral nerve ablation.

Central sensitization occurs when the central nervous system becomes hypersensitive and amplifies pain signals.  The pain threshold can also be lowered making non-painful stimulation like light touch be perceived as painful.

Other complex chronic pain mechanisms include sensitization of peripheral nerves at the injury site that can enhance pain signals sent to the CNS. The central nervous system can also undergo changes that perpetuate pain, even after the original cause has healed because of its neuroplasticity.

The patient may be cursed by a dysfunctional pain modulation system. Normally, the body modulates pain through inhibitory signals and chronic pain modulation can be impaired leading to persistent pain.

And finally, emotional and psychological factors such as anxiety, depression and stress which are associated with chronic pain may exacerbate pain perception.

If facet pain recurs after a RFA procedure is a repeat medial branch block necessary?

Whether or not a repeat medial branch block (MBB) is needed after a radiofrequency ablation (RFA) procedure depends on the treating  physician and the insurer. Some insurers require a repeat set of MBBs.  However, I am of the opinion that the patient does not necessarily require a repeat set of diagnostic medial branch blocks if the pain occurs during the six month to two year time frame, and is of the same quality and character, and in the same location as the pain prior to initial procedure.

If the patient receives less than complete relief after the initial RFA procedure, and there is evidence of facet pathology at additional levels, then a repeat medial branch block incorporating those additional levels may be a value prior to a repeat RFA.

What percentage of patients will need more than one RFA procedure and how often do RFA's need to be repeated?

The need for multiple RFA procedures and the frequency of repeats can vary based on the condition being treated and the individual's response. The medial branch nerves, which are destroyed (burned) usually at 80°C for 1 1/2 to 3 minutes during the RFA procedure, grow back within a six months to two years. When this occurs, they may reinnervate the painful facet joints leading to a recurrence of pain.

Generally, for chronic pain management 30-50% of patients may need more than one procedure.  Patient should benefit from repeated RFAs if the pain occurs during the six month to two year time frame, and is of the same quality and character, and in the same location as the pain prior to initial procedure.

What is the success rate of a RFA procedure?

The success rate of an Radiofrequency Ablation (RFA) procedure for chronic pain, especially back and neck pain due to facet joint issues, ranges from 70% to 80%.

What are medial branch blocks (MBB) and radiofrequency ablation (RFA) procedures?

Medial Branch Blocks are injections performed in the spine, which anesthetize (numb) the nerves sending pain signals from the facet joints to the brain. They only have diagnostic value.  The amount of pain relief a patient receives after a medial branch block will determine whether or not the patient is a candidate for a RFA procedure.

Some insurers require a certain percentage of relief from the medial branch block-MBB prior to proceeding with the RFA.  The percentage most often quoted is in the neighborhood of 70 to 80%.  Other providers feel more strongly that if after the MBB the patient is improved and they become more functional and able to perform their daily activities with less discomfort, and they understand the risk associated with the RFA procedure, then a designated percentage improvement is not necessarily needed prior to proceeding with the RFA.

Some insurers also require that two sets of medial branch blocks be performed because there is a small percentage of people that have a false positive result after the first set.  Again, unless the payor requires a second set of confirmatory blocks, the physician may bypass them if he feels that he obtained a valid response from the first set.

The Radiofrequency Ablation procedure (RFA) utilizes heat to disrupt the nerve function of the medial branch nerves, which were anesthetized during the medial branch block.  During the RFA procedure, the patient is sedated and the medial branch nerves are destroyed (burned) usually at 80°C for 1 1/2 to 3 minutes by a fluoroscopically placed heated probe.

When does a person need an epidural steroid injection (ESI) after a cervical or lumbar injury?

A person might benefit from an epidural steroid injection after a cervical or lumbar injury if they are experiencing severe pain, nerve symptoms, inflammation or difficulty functioning. The intense pain associated with a disc herniation or nerve root irritation that doesn’t improve with other conservative measures warrants an epidural steroid injection. Numbness, tingling or weakness in the legs suggests nerve root irritation, which likewise would benefit from an epidural injection containing corticosteroid.

Typically, 3-6 weeks of physical therapy, rest, and medication are employed prior to considering an ESI. However, if the pain is severe and limiting a persons ability to function, then a sooner rather than later approach is acceptable.

What are the different types of interventional injections of the spine?

The different types of interventional injections for the spine include:

Epidural Steroid Injections which are injections typically given in the epidural space of the spinal canal either in the neck, mid or lower back to reduce inflammation and pain.  They are mainly therapeutic and provide little diagnostic value.

Facet Joint Injections target specific facet joints that are most likely to be the pain generators. They are of therapeutic and diagnostic value.

Medial Branch Blocks are injections performed in the spine, which anesthetize (numb) the nerves sending pain signals from the facet joints to the brain. They only have diagnostic value.  The amount of pain relief a patient receives after a medial branch block will determine whether or not the patient is a candidate for a RFA procedure.  Some insurers require a certain percentage of relief from the medial branch block-MBB  prior to proceeding with the RFA.  The percentage most often quoted is in the neighborhood of 70-80%.  Does that mean that a patient that receives 69% percent relief is not able to receive additional?   However, other providers feel more strongly that if within the first several hours after the MBB the patient improves and becomes more functional and is able to perform daily activities with less discomfort, and they understand the risk associated with the RFA procedure, then a designated percentage improvement is not necessarily required prior to proceeding with the RFA.

The Radiofrequency Ablation procedure (RFA) utilizes heat to disrupt the function of the medial branch nerves, which were anesthetized during the medial branch block.

The sacroiliac joint is located in the pelvis/buttocks between the sacrum and the iliac bone on either side of the midline. These joints have very little motion, but can be injured during a traumatic event. When conservative measures fail Sacroiliac Joint Injections with corticosteroid or PRP  may relieve pain in the sacroiliac joints.  A sacroiliac RFA may also be performed for chronic unrelenting pain. Sacroiliac joint injections, provide some diagnostic and therapeutic value.

Nerve Blocks temporarily anesthetize (disable, numb) the nerves causing pain and provide diagnostic and occasionally therapeutic value.

Trigger Point Injections address localized pain due to myofascial or muscular injury or spasm.

Discography is a controversial procedure that provides an objective means of diagnosing a symptomatic disc. Dye is injected into the intervertebral disc and the pressures and volumes associated with the injection are monitored, the spread of the dye within the disc is noted and whether or not concordant pain is produced is recorded.  Most discographers consider injecting a normal, control disc during the procedure to assess the patient’s response at a known normal level; however, there is some concern that by doing so there may be some long-term consequences to the normal control disc.

A Vertebroplasty/Kyphoplasty procedure is used to strengthen a vertebrae that has undergone a compression fracture. It is not uncommon that such fractures occur in the elderly after a traumatic event due to osteoporosis.

During Prolotherapy hypertonic solution is injected into tissue stimulating repair.

Intrathecal Pump Implants and Spinal Cord Stimulators are actually surgical procedures more so than injections.

With the intrathecal pump medication is delivered into the spinal canal to control chronic nerve pain, whereas the spinal cord stimulator sends an electrical impulse via an implanted electrode in the spinal canal in order to achieve chronic pain control.  These procedures are typically necessary after failed back procedures, in patients that are not a candidate for back surgery, or in patients that choose not to have surgery.

Why do patients sometimes lose control of their bowels or bladder after a traumatic event?

You’ve provided a comprehensive overview of the impact of trauma on bowel and bladder control. Here’s a concise summary of the key points:

  • **Immediate Medical Attention:**

    • - Loss of bowel or bladder control following trauma is a medical emergency. Immediate evaluation can prevent long-term damage and improve recovery.

  • **Causes:**

    • - **Spinal or Brain Trauma:** Damage to nerves controlling bladder and bowel functions, especially from spinal cord injuries (lower back), can disrupt communication to these organs.

    - **Cauda Equina Syndrome:** A serious condition typically caused by herniated discs compressing nerves at the spinal cord’s end. Symptoms include severe lower back pain, saddle area numbness, and loss of bladder or bowel control. Immediate medical and possibly surgical intervention is necessary.

    - **Extreme Stress:** Psychological shock or extreme stress from a traumatic event can temporarily disrupt control over bodily functions due to the "fight or flight" response.

    - **Pelvic Trauma:** Direct injuries can damage muscles and nerves responsible for bladder and bowel control.

    - **Altered States of Consciousness:** Severe trauma can lead to impaired consciousness, causing loss of voluntary control over bladder and bowel functions.

    Prompt diagnosis and treatment are crucial. Recognizing these symptoms early can significantly influence recovery outcomes.

    What is sciatica and is the straight leg raising test always positive in a person with sciatica?

    Sciatica is a condition in which one or more of the nerve roots making up the sciatic nerve are injured, compressed or irritated.  It is characterized by pain that radiates along the path of the sciatic nerve, which branches from the lower back through the buttock and hip and then down the leg.  It may occur in one or both legs. Common causes include a herniated disc, spinal stenosis, or a bone spur pressing on a nerve root . Symptoms may include sharp pain, tingling, numbness, and muscle weakness in the affected leg.  Muscle weakness or an absent reflex may be noticed on physical exam.

    The Straight Leg Raising test, also known as the Lasegue test, is a physical examination technique used to diagnose sciatica. During the test, a patient lies flat, and the examiner lifts one leg while keeping the knee straight. The test is considered positive if the patient experiences pain along the sciatic nerve, typically between 30 to 70 degrees of leg elevation.

    However, the Straight Leg Raising Test is not always positive in every person with sciatica. Its sensitivity (70-90%) and specificity (30-60%) may vary. Some individuals with sciatica might not exhibit positive results due to variations in individual pain perception, mild compression or some patients may adapt postures or movements that minimize the discomfort during the testing maneuver.

    Can chiropractic manipulation aggravate the discomfort described by patients with symptomatic cervical or lumbar spondylosis?

    Yes, chiropractic manipulation can potentially aggravate discomfort in patients with symptomatic cervical or lumbar spondylosis.

    Often times osteophytes (bone spurs) are present in patients with spondylosis.  During manipulation the osteophytes may irritate or compress adjacent tissues, thus exacerbating the discomfort.

    Manipulating a spine with disc degeneration may further stress the vertebral segment and possibly cause or worsen the symptoms. Additionally, in spines where nerve root irritation, inflammation, or pre-existing weakness and instability exists, chiropractic manipulation may increase pain or discomfort.

    However, not all chiropractic interventions are harmful in these cases. Chiropractors often tailor treatments to individual conditions, and conservative, low-force techniques may provide relief without significant risk.

    Am I more likely to develop neck or lower back pain after a motor vehicle accident if I have a pre-existing asymptomatic herniated disc, DDD or spondylosis?

    Absolutely true! Pre-existing spine conditions like herniated discs, degenerative disc disease (DDD), or spondylosis can indeed increase the risk of neck or lower back pain following a car accident. Here's a quick breakdown:

  • **Weakened Structure:** These conditions weaken the spine's structure, making it more prone to injury.
  • **Accident Severity:** The nature and severity of the accident play critical roles in determining the impact on your spine.
  • **Individual Factors:** Personal health factors, including your overall physical condition and age, also influence susceptibility to injury.

    • Facet joint pain: diagnosis, conservative care, medial branch blocks, and radiofrequency ablation

    An educational overview from OrthOpinions. Not case-specific and not medical advice for any particular patient.

    What are facet joints, and why do they cause pain?

    The facet joints (also called zygapophyseal or “z-joints”) are small paired joints at the back of every level of the spine. Each pair guides motion between two adjacent vertebrae and, together with the disc in front, forms a three-joint complex. Like any synovial joint, facets can develop osteoarthritic changes, capsular inflammation, and pain after injury or with age. Facet-mediated pain is a common and under-recognized source of neck pain and low back pain, especially in older adults, after motor-vehicle collisions with rotational or extension mechanisms, and in patients with degenerative spondylosis on imaging.

    Clinical evaluation and diagnostic uncertainty

    Facet pain has no single pathognomonic finding on exam or imaging. The clinical pattern typically includes axial (midline or paraspinal) pain worse with extension, rotation, and prolonged standing, with referral into the buttock or thigh from the lumbar facets, and into the shoulder or occiput from the cervical facets. It is usually NOT true radicular pain: it does not follow a dermatome and is not reproduced by nerve-root tension tests. Imaging findings such as facet hypertrophy, effusion, or synovial cysts are supportive but not diagnostic; asymptomatic degenerative facet changes are extremely common on MRI. The most rigorous confirmatory test for facet-mediated pain remains a diagnostic medial branch block (MBB) with a small volume of local anesthetic on the medial branches of the dorsal ramus that innervate the target joint.

    Conservative care

    Conservative management is first-line for most patients. Reasonable initial measures include:

    • Activity modification to reduce extension and rotational loading of the painful segment.
    • Structured physical therapy focused on core stabilization, hip and thoracic mobility, and posture retraining.
    • Short courses of NSAIDs when appropriate for the patient, with attention to cardiovascular, renal, and gastrointestinal risk.
    • Weight management, sleep, and general reconditioning, all of which meaningfully affect axial spine pain outcomes.
    • Adjuncts such as heat, topical agents, and short-term manual therapy, chosen on a per-patient basis.

    Most facet-mediated pain responds to a fair trial of conservative care over three weeks to three months. Escalation is considered when function does not improve and the clinical pattern still points to the facet joint.

    Interventional injections

    When conservative care has been given a fair trial and the exam suggests facet-mediated pain, image-guided interventional options are considered. The two most common are:

    • Intra-articular facet injection — a small dose of local anesthetic (with or without steroid) placed inside the facet joint under fluoroscopic guidance. Useful in selected cases; the diagnostic value is limited by the small joint volume and by spread outside the capsule.
    • Diagnostic medial branch blocks (MBBs) — targeted anesthesia of the medial branches that innervate the joint. Modern practice typically requires two positive blocks (a “dual block” protocol) to select patients likely to benefit from radiofrequency ablation. Concordant, time-limited relief after each block is the key finding.

    Injections are diagnostic and therapeutic tools, not cures. The evidence for durable pain relief from steroid injections alone at the facet joint is modest and inconsistent; their most reliable role is helping identify the pain generator.

    Radiofrequency ablation (RFA)

    When two properly performed diagnostic MBBs give concordant, time-limited relief and function improves during the anesthetic window, radiofrequency ablation of the medial branches is a reasonable next step. RFA uses heat to interrupt the small medial branch nerves that carry pain from the target facet joints. Well-selected patients often experience meaningful pain relief for approximately six to eighteen months; because the nerve regenerates, RFA can be repeated. Reported benefits, durability, and complication rates depend heavily on patient selection, image guidance, needle technique, and the number of levels treated. RFA is not appropriate for radicular pain, discogenic pain, or non-facet mechanical pain, and its evidence base is stronger in the lumbar and cervical spine than in the thoracic spine.

    Evidence-based indications and honest limits

    The stronger indications for interventional facet care are: axial pain of at least several weeks’ duration; a clinical pattern consistent with facet mediation; failure of a reasonable conservative program; and concordant relief on properly performed diagnostic blocks. The weaker indications are: pain with prominent radicular features; unexplained neurological deficits; suspicion of infection, tumor, or fracture; or an unclear anatomic target on imaging. In those settings further evaluation is warranted before any procedure is scheduled.

    When further evaluation is warranted

    Red flags that prompt urgent or specialty referral include new weakness, bowel or bladder dysfunction, saddle anesthesia, unexplained weight loss, fevers, night pain, a history of cancer or immunosuppression, trauma with suspected fracture, and progressive neurological signs. These findings do not describe facet pain and should not be attributed to it without imaging and, when indicated, laboratory or specialty workup.

    Related educational articles

    This is the hub article for our facet joint cluster. Related material published on OrthOpinions:

    Educational only. Not a substitute for individual medical evaluation and treatment. Questions or comments, or a topic you would like us to address in a future edition? Contact us through our website: OrthOpinions.

    Cervical versus lumbar spine numbering — why the labels on a facet workup can mislead

    Sent to attorneys August 20, 2026.

    A short note on the nomenclature attorneys see in cervical and lumbar spine records. It matters because the numbering conventions differ, and a report that reads clean at first glance can name a different anatomy than the reader assumes.

    Every facet joint[1] is named for the two vertebrae that form it — the C5-6 facet is the joint between C5 and C6, the L4-5 facet the joint between L4 and L5. Every facet joint has a DUAL nerve supply from two medial branches[2]: the one from its own level, and the one from the level above. That is why a diagnostic block always targets two nerves for each joint.

    Cervical numbering aligns cleanly with the labeling. To block the C5-6 facet, the C5 and C6 medial branches are the targets, and the injection report will name them by those numbers. The one well-known cervical exception is the C2-3 facet, which is supplied by the third occipital nerve[3], a specialized superficial branch of the C3 dorsal ramus. A C2-3 facet workup for headache of cervical origin therefore targets the third occipital nerve rather than a generic “C2 medial branch,” and reports may name either the TON or the C2-3 facet by name.

    Lumbar numbering does not align as cleanly, particularly at the last level. From L1 through L4, each dorsal ramus divides into a medial branch and a lateral branch in a predictable pattern, and each facet joint follows the same “own level plus one above” rule — an L3-4 facet block anesthetizes the L2 and L3 medial branches. The L5-S1 facet is anatomically different, and that difference is the reason a separate note follows this one; the short version is that a report reading “L5-S1 medial branch block” does not describe two ordinary medial branches, and the label alone should not be read literally without looking at the actual needle positions and the fluoroscopic images.

    Medical terms
    [1] Facet joint — the paired small joints at the back of each spinal level, one on each side. They allow adjacent vertebrae to glide against each other during motion and are a common source of neck and low-back pain.
    [2] Medial branch — a small nerve twig that comes off the dorsal ramus (the back-turning branch) of a spinal nerve, immediately after the nerve exits the spine. Medial branches carry the pain signals from the facet joints they supply; blocking or ablating them is how facet-generated pain is diagnosed and treated.
    [3] Third occipital nerve (TON) — a specialized superficial branch of the C3 dorsal ramus that supplies the C2-3 facet joint and the skin over the back of the head. Its involvement is what makes C2-3 the anatomic target for post-injury headache of cervical origin.

    I hope you found this interesting.

    Questions or comments about today’s educational update, or a topic you would like us to address in a future edition? Contact us through our website: OrthOpinions

    F. Allen Johnston, MD
    Louisiana Orthopedic Institute
    Baton Rouge
    (225) 751-6666 Office
    (225) 270-0000 Cell

    Treating facet-joint pain: intra-articular injections and radiofrequency ablation

    Sent to attorneys Wednesday, August 19, 2026 at 1:07 PM CT.

    Counsel,

    Part three. Once diagnostic medial branch blocks have shown that a specific facet joint is generating a patient’s pain, treatment follows a two-step ladder. The first therapeutic step is often an intra-articular facet injection: under fluoroscopy, a small mixture of local anesthetic and corticosteroid is placed directly into the joint capsule of the identified facet. The idea is to quiet the inflamed synovial lining, break the pain-and-guarding cycle, and give physical therapy a window to work. Relief from a well-placed injection is variable, usually weeks to a few months, and in some patients it is enough on its own. In others it is temporary confirmation that the joint is the problem, but not a durable answer.

    Radiofrequency ablation (RFA) is the follow-on when intra-articular relief is short-lived, incomplete, or repeatedly required. A small insulated probe is placed on the same medial branch nerves that were tested by the diagnostic blocks, guided by fluoroscopy, and the tip is heated to roughly 80 degrees Celsius for about 90 seconds. That controlled heat lesion interrupts the medial branch’s ability to carry pain signals from the facet it supplies. Nothing is cut. The joint itself, the bone, and the surrounding structures are not damaged. Patients typically go home the same day and return to normal activity within a day or two.

    Two practical points. Because the medial branch nerves regenerate slowly, RFA is not permanent: meaningful relief usually lasts about six to twelve months, sometimes longer, and the widely accepted repeat criteria (CMS local coverage and ASIPP guidelines) look for at least about 50 percent relief lasting six months or more from the prior ablation and the same clinical pain pattern returning. Under those conditions a repeat is medically reasonable, and the chart should document the prior relief duration and the current pain pattern to support it. If a patient with a previously well-controlled RFA level is then involved in a new event and the pain quality, distribution, or examination changes, the correct next step is not simply to re-ablate. It is to re-image and, if warranted, repeat the diagnostic MBBs before any new ablation. New trauma can introduce new pain generators (a disc, a nerve root, an adjacent-level facet) that the prior workup never addressed, and treating the old target while missing the new one is a common source of poor outcomes and disputed causation.

    I hope you found this interesting.

    Questions or comments about today’s educational update, or a topic you would like us to address in a future edition? Contact us through our website: OrthOpinions

    F. Allen Johnston, MD
    Louisiana Orthopedic Institute
    Baton Rouge
    (225) 751-6666 Office
    (225) 270-0000 Cell

    See also the hub article: Facet joint pain: diagnosis, conservative care, medial branch blocks, and radiofrequency ablation.

    Medial branch blocks — what they are, which levels matter, and when they explain a headache

    Sent to attorneys August 18, 2026.

    A short note on medial branch blocks (MBBs), the diagnostic injection used to prove that a facet joint at the back of the spine is generating a patient’s pain. The facet joints are the paired joints on either side of each vertebral level. Each one is supplied by tiny nerve twigs called medial branches, which come off the dorsal ramus of the spinal nerve — the branch that turns backward as soon as the nerve exits the spine. Because every facet joint has a dual nerve supply from the medial branch of its own level and the medial branch of the level above, at least two branches must be blocked to test a single joint. A well-performed MBB that gives strong short-term relief is what qualifies a patient for radiofrequency ablation as the follow-on treatment.

    The levels that carry the load. In the neck, C5-6 and C6-7 are the most common axial pain generators after whiplash-type injuries; C2-3 is the classic source of headache of cervical origin. In the low back, L4-5 and L5-S1 do most of the work, particularly after hyperextension or axial-loading injuries. Thoracic facet pain exists but is uncommon in litigation. When a records reviewer sees medial branch blocks documented at these levels, that is not shotgun treatment — that is the anatomically sensible workup.

    The headache piece. The C2-3 facet is innervated by the third occipital nerve, a specialized branch of the C3 dorsal ramus, and it is a well-recognized source of occipital and upper-neck headaches after a neck injury. C3-4 can also contribute; C1-2 headaches come from a different mechanism and are worked up differently. When a patient reports post-collision headaches that start at the base of the skull and spread over the crown, a third occipital nerve/C2-3 diagnostic block is the correct anatomic path — not a generic migraine workup.

    I hope you found this interesting.

    Questions or comments about today’s educational update, or a topic you would like us to address in a future edition? Contact us through our website: OrthOpinions

    F. Allen Johnston, MD
    Louisiana Orthopedic Institute
    Baton Rouge
    (225) 751-6666 Office
    (225) 270-0000 Cell

    See also the hub article: Facet joint pain: diagnosis, conservative care, medial branch blocks, and radiofrequency ablation.

    The facet joints: what they are and why they matter in neck and back injury cases

    Sent to attorneys Monday, August 17, 2026 at 1:10 PM CT.

    Counsel,

    A brief note on the facet joints, since much of what follows in this series turns on them. Every level of the spine stacks on the level below at three points: the intervertebral disc in front, and a pair of small facet joints in back. The facet joints are true synovial joints, meaning they have a smooth cartilage surface, a lubricated joint capsule, and a small amount of joint fluid, just like a knee or a hip on a much smaller scale. They sit at the back of each vertebra where two bony processes overlap and articulate.

    Their job is mechanical. The discs handle compression from above; the facets handle guidance and constraint. They tell each spinal level how far it can bend, twist, and extend before the motion stops, and they carry a meaningful share of the load whenever the spine is extended backward or loaded off-center. That load-sharing role is why facet pain often flares with prolonged standing, walking downhill, lying prone, or reaching overhead. All of those postures load the facets, not the discs.

    The joint capsule itself is richly innervated by small pain nerves called medial branches, one from the level of the joint and one from the level above. That dual innervation is what makes each facet joint capable of generating pain on its own, and it is also what determines the diagnostic and treatment approach that will come up in the notes to follow. When a facet is inflamed, torn, arthritic, or capsularly stretched by a hyperextension or whiplash-type injury, the pain is typically axial (neck or low back rather than radiating down a limb), one-sided or asymmetric, worse with extension, and often referred into predictable patterns: into the shoulder blade or upper arm from the cervical facets, into the buttock or upper thigh from the lumbar facets. These referral patterns are not radiculopathy; they follow the sclerotome (the deep somatic pattern of a joint), not a dermatome, which is why they stop short of the hand or foot.

    Two practical points for records review. First, a normal MRI does not rule out a facet-mediated injury. Facet capsular tears and inflammation are frequently invisible on standard MRI sequences, and the diagnosis is usually made physiologically with a medial branch block rather than radiographically. Second, when a patient has axial neck or low-back pain that worsens with extension after a rear-end collision, a fall, or a lifting injury, the facets belong on the working differential from the start, not after everything else has been ruled out.

    I hope you found this interesting.

    Questions or comments about today’s educational update, or a topic you would like us to address in a future edition? Contact us through our website: OrthOpinions

    F. Allen Johnston, MD
    Louisiana Orthopedic Institute
    Baton Rouge
    (225) 751-6666 Office
    (225) 270-0000 Cell

    See also the hub article: Facet joint pain: diagnosis, conservative care, medial branch blocks, and radiofrequency ablation.

    Radicular pain and referred pain are not the same thing

    Sent to attorneys August 14, 2026.

    Two spine-pain patterns get collapsed in medical records into “the pain is going down the leg, so it must be a pinched nerve.” They are not the same thing, and the distinction changes what the record is actually saying.

    Radicular pain arises from irritation or inflammation of a spinal nerve root, the point where a nerve exits the spinal canal. Patients typically describe it as sharp, electric, or lancinating, projected along a narrow band into the arm or leg (roughly a stripe tracing that nerve’s territory). Somatic referred pain arises from deep spinal structures such as the disc annulus, the facet joint, or the supporting ligaments. It is typically deep, dull, and poorly localized, felt in the buttock, groin, or thigh without following a specific nerve distribution. The working definitions most spine physicians use are the ones set out in Bogduk’s 2009 paper in Pain, which the International Association for the Study of Pain has adopted as its terminology. Radiculopathy is a third and separate term: it refers to objective nerve-root dysfunction (weakness, loss of a reflex, sensory loss in a defined dermatome) and can exist with or without pain.

    Why this matters for causation analysis. A patient whose only complaint after a rear-end collision is deep, aching buttock or posterior-thigh pain may well have a real injury to a disc or facet joint, but the pain pattern alone does not support a diagnosis of a compressed nerve root, and an MRI showing an incidental disc bulge does not close the loop. Conversely, a patient with true radicular pain in a defined nerve distribution, positive tension signs on examination, and imaging that correlates at the same level presents a much stronger anatomic story. When a treating physician, an IME reviewer, or a records summary uses “radiculopathy,” “radicular pain,” and “referred pain” interchangeably, the causation opinion tends to blur along with the vocabulary. Asking a witness to define the term they used, and to point to the specific examination finding that supports it, usually clarifies more than any additional imaging would.

    Medical terms

    1. Somatic referred pain — pain that comes from a deep body structure (a disc, a joint, a ligament) but is felt in a nearby region such as the buttock, groin, hip, or thigh. “Somatic” simply means “of the body.” The pain generator is at the spine; the brain projects the sensation elsewhere. This is different from pain caused by a compressed or irritated nerve.
    2. Disc annulus — the tough outer ring of a spinal disc (annulus fibrosus). It surrounds the softer nucleus in the center. Tears or inflammation in the annulus can generate pain on their own, without any nerve being compressed.
    3. Facet joint — the paired small joints at the back of each spinal level, one on each side. They allow adjacent vertebrae to glide against each other during motion and are a common source of neck and low-back pain after injury.
    4. Radiculopathy — objective (measurable) dysfunction of a spinal nerve root: weakness in the specific muscles that nerve supplies, loss of a reflex, or numbness in that nerve’s defined skin territory. It is a physical-examination finding, not a description of what the pain feels like.
    5. Dermatome — the strip of skin whose sensation is served by a single spinal nerve. Numbness that follows a dermatome (rather than the whole leg or a random patch) is a signal that the nerve itself is involved.

    Educational only, not case-specific, and not legal or medical advice for any particular matter.

    F. Allen Johnston, MD
    Louisiana Orthopedic Institute
    Baton Rouge
    (225) 751-6666 Office
    (225) 270-0000 Cell

    When a routine MRI is a snapshot: why a static supine study does not always tell the whole story

    Sent to attorneys August 13, 2026.

    A short note on a pattern that comes up regularly in orthopaedic records review: the patient’s history and examination are consistent with a real spine problem, symptoms are provoked by movement or by everyday load, and the MRI report reads as normal, minor, or degenerative-only. That combination invites the oversimplification that a “normal” or minimally abnormal MRI means there is no injury and the complaints are exaggerated. It does not.

    A standard MRI is a static, unloaded snapshot. It is acquired with the patient lying flat (supine) and at rest, the spine not carrying the person’s body weight, not extended, not rotated, and not being asked to do anything mechanical during the scan. Under those specific conditions, some real anatomic problems are less visible than they behave in daily life. Peer-reviewed work on axial-loaded MRI and upright / positional MRI has documented, in symptomatic patients, measurable reductions in the dural sac cross-sectional area and, at some levels, additional narrowing of the neural foramen that were not present on the same patient’s relaxed supine images. Willén and Danielson’s 2001 Spine paper and the earlier Danielson 1998 Acta Radiologica series established this in the workup of lumbar stenosis; a 2020 weight-bearing MRI series (Nordberg and colleagues) additionally reported that lumbar disc herniations were on average larger in standing than in supine position and more often in contact with the exiting nerve root; Michelini’s 2018 Acta Biomedica review summarizes the broader literature; Kanno’s 2011 Spine paper reported that the change in dural sac area between unloaded and loaded imaging correlated with clinical symptom severity. These are not fringe findings. They are also not a claim that every twisting or lifting movement causes unseen nerve compression, and they are not an argument that routine MRI is invalid. Routine supine MRI remains the first-line study and is diagnostically sufficient in most cases.

    Separately, some symptom-provoking maneuvers rest on established physiology rather than on new imaging techniques. Coughing, sneezing, straining, and other Valsalva maneuvers briefly raise pressure inside the spinal canal, which is why they can worsen radicular pain when a nerve root is already being contacted or irritated (Dejerine’s sign is the century-old clinical description). Extension and rotation of the spine physiologically narrow the neural foramen at the moment of the movement. These are recognized clinical patterns captured on physical examination (straight-leg raise, Spurling’s maneuver, extension provocation); they do not, by themselves, prove nerve compression at rest, and they are not something a routine MRI records during the maneuver. What they do provide is real information about how the patient’s spine behaves under load, which is not information the resting supine MRI is designed to give.

    The practical point for records review is a narrow one. When the clinical picture is credible, when the examination documents movement- or load-provoked symptoms, and when the routine MRI reads as minor or discordant, dynamic or intermittent pathology is one possibility that deserves consideration. Not a conclusion to be drawn, but an alternative to a reflexive “the MRI was normal, so nothing is really wrong.” In selected cases the appropriate next step in the medical record is a documented provocative physical examination and, where clinically indicated and locally available, an axial-loaded, flexion-extension, or upright MRI. In many cases the routine study will remain sufficient. The point is that a static supine MRI is a snapshot of one position at rest, a good one and usually the right one, but a snapshot, and its limitations, not the patient’s honesty, are what a thoughtful records review should weigh when the imaging and the clinical picture seem to disagree.

    Educational only, not case-specific, and not legal or medical advice for any particular matter.

    F. Allen Johnston, MD
    Louisiana Orthopedic Institute
    Baton Rouge
    (225) 751-6666 Office
    (225) 270-0000 Cell

    Why an early MRI and a late MRI can tell different stories

    Sent to attorneys August 12, 2026.

    A short note from my practice on something that comes up often in orthopaedic records review.

    An MRI obtained within a few weeks of a soft tissue spine injury and an MRI obtained six months later are not interchangeable studies, and the difference matters whenever imaging is being used to support or contest causation. In the acute window, fluid-sensitive sequences (T2 and STIR) can show edema in paraspinal muscle, interspinous ligaments, facet capsules, or vertebral marrow, sometimes with small effusions or signal changes that indicate a recent injury. These acute findings tend to fade over weeks to a few months as the tissues heal, and by six months the same segment may read as “unremarkable” on a routine study while the patient still has real symptoms. A disc herniation itself also changes on imaging over time. Systematic reviews of the natural history of lumbar disc herniation report that spontaneous resorption most often occurs within roughly three to six months, with extrusions and sequestrations regressing more reliably than protrusions or bulges.

    The practical consequence is that timing has to be part of the argument, not a footnote to it. An MRI performed four to six weeks after an event is the study most likely to capture acute markers that a late study may no longer show, and a normal late MRI does not by itself prove there was never an acute injury. On the other side, a chronic imaging appearance with disc desiccation, endplate osteophytes, and multilevel degenerative change does not, by itself, tell you whether a specific event aggravated a preexisting condition. Correlation with prior imaging, the documented symptom timeline, and the physical examination is what supports or weakens the inference. When only one MRI exists in a file, its date relative to the incident is one of the most important pieces of information in the record.

    Educational only, not case-specific, and not legal or medical advice for any particular matter.

    F. Allen Johnston, MD
    Louisiana Orthopedic Institute
    Baton Rouge
    (225) 751-6666 Office

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