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.
