A specific target
Facet joints and medial branch nerves are matched to the pain pattern, examination, and imaging.
Spine, pain & sports medicine
Medial branch blocks test the nerves that carry pain from the spinal facet joints. When the response is clear, the result can guide a disciplined next step, including radiofrequency ablation when appropriate.
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Care built around the diagnosis
A medial branch block is most useful when every part of the visit is organized around one clinical question: are these facet joints and their medial branch nerves carrying a meaningful share of your pain?
Facet joints and medial branch nerves are matched to the pain pattern, examination, and imaging.
You track the familiar pain during the anesthetic window so the result can guide the next decision.
A positive sequence can lead to radiofrequency ablation, with rehabilitation kept in the same plan.
From question to plan
I first determine whether the pattern is axial and facet-mediated rather than primarily radicular.
I place local anesthetic beside the relevant medial branch nerves under fluoroscopy and ask you to track the change.
I interpret the response in context and discuss confirmation, rehabilitation, or ablation when supported.
The facet joints are the paired joints that sit at the back of the spine, one on each side of every level. They are true joints, with cartilage and a capsule, and they can develop arthritis the same way a hip or a knee can. When those joints are arthritic or inflamed, they send pain signals through the nerves that innervate them. In the neck that pain can travel into the shoulder girdle or the base of the skull. In the low back it can travel into the buttock or the posterior hip. That pattern usually stays relatively close to the spine, which is one of the ways we separate it from pain that follows a nerve root into the arm or the leg.
The nerves that innervate the facet joints are the medial branches. They run in a predictable course over bone, which is why we can reach them with a needle under live x-ray. A medial branch block places local anesthetic next to those nerves. If the usual pain settles while the anesthetic is working, we have good evidence that the facet joints those nerves supply are generating the pain. If the usual pain does not change, we look elsewhere. The block is a diagnostic test first, and it can also give a short window of relief.
Imaging can show facet arthropathy, hypertrophy, or inflammation, and those findings become more common with age. Degenerative change on an MRI or a CT scan does not, by itself, tell us that a given joint is generating the pain a person feels. The medial branch block exists because the clinical question is more specific than the picture: is this person’s neck or back pain carried by these nerves?
We consider a medial branch block for people whose dominant problem is axial neck or low-back pain that, after a careful visit, looks as if it may be coming from the facet joints. The pattern is often worse with extension or rotation, better with supported flexion, and accompanied by referred discomfort toward the shoulder blade, the buttock, or the posterior hip. Many of these patients have already tried time, activity modification, and physical therapy. Some have imaging that shows facet arthropathy at levels that match the examination. None of those features is a diagnosis on its own; together they can make a diagnostic block a reasonable next step.
This pathway is less useful when the main complaint is radicular pain, meaning pain, numbness, or tingling that follows a nerve-root distribution into the arm or the leg. In that setting we more often discuss epidural steroid injections as part of a plan that still includes rehabilitation. People with progressive weakness, bowel or bladder change, fever, unexplained weight loss, or a recent major trauma need a different kind of evaluation before any elective injection is considered.
Pain and sports medicine visits at the practice do not require membership. The Westport location is planned to open in July 2027; until then, inquiries help us understand what you are looking for and how to plan the first visit.
The procedure is done with fluoroscopy, which is live x-ray used to see bone landmarks and to confirm needle position before any medication is placed. After a pause to review the plan, allergies, medications, and the levels we intend to test, you lie in a position that lets us see the relevant joints. The skin is cleaned. Local anesthetic numbs the skin and the tissue along the needle path. A thin needle is then advanced to the expected location of each medial branch nerve, and a small amount of contrast is typically used to confirm that the injectate will stay where we want it.
What goes through the needle is usually local anesthetic. Some protocols include a small amount of steroid; many diagnostic sequences do not, because the point of the test is the short window of numbness, not a long anti-inflammatory effect. Several nerves are blocked at a sitting because each facet joint is supplied by more than one medial branch. The procedure room time is commonly in the range of twenty to forty minutes, depending on how many levels are treated and whether the neck or the low back is the target.
Most people are awake. Light sedation can be discussed when anxiety or positioning makes it appropriate, and anyone who receives sedation needs a driver. We ask patients to notice, over the next several hours, whether the usual pain is meaningfully better, a little better, or unchanged, and to keep a simple record of that change. That report is the test result. Soreness at the needle sites is common and usually settles over a day or two.
A positive diagnostic block, in the way we use the term, means that the pain you came in with dropped substantially while the local anesthetic was working, and that the relief followed a time course that matches the medication. A negative block means the usual pain did not change in a convincing way. Partial responses are common and need context: the wrong levels, a mixed pain generator, incomplete coverage of the nerves, or a placebo contribution can all produce a muddy answer.
Because a single block can overestimate how much of the pain is truly facet-mediated, many pathways use a second confirmatory block, sometimes with a local anesthetic of a different duration, before radiofrequency ablation is offered. We explain that sequence in advance so the extra visit is understood as diagnostic discipline, not delay for its own sake. A clearly negative block is useful information. It steers us away from ablating those nerves and back toward other sources, which may include the disc, the sacroiliac joint, myofascial pain, or a radicular problem better addressed with an epidural steroid injection and rehabilitation.
We do not treat a good day after the block as a promise of what ablation will do. We treat it as evidence that those nerves are carrying a meaningful share of the pain, which is the prerequisite for discussing radiofrequency ablation of the same targets.
Radiofrequency ablation, also called radiofrequency neurotomy, is the treatment that follows a clearly positive diagnostic sequence. It is not a separate mystery procedure, and it is not a different set of nerves. The medial branch block asks whether these nerves are carrying the pain. Ablation, when the answer is yes, uses heat to interrupt those same nerves so the joint they supply is quieter for a period of time. Dr. Adam Nessim and Dr. Fernando Martinez plan both visits as one pathway, which is why the full ablation explanation lives on this page.
A radiofrequency cannula is a specialized needle with an insulated shaft and an active tip. Under fluoroscopy it is seated along the expected course of a medial branch nerve, lying as parallel to that nerve as the anatomy allows, because a lesion that only nicks the nerve in cross-section is less reliable than one that runs beside it. After position is confirmed, a generator delivers a high-frequency current that heats the tissue around the tip. In conventional thermal ablation the target temperature is typically in the range of eighty degrees Celsius, held for a short, timed lesion. The result is a controlled coagulative lesion of a small sensory nerve. The facet joint stays in place. Nothing is cut with a scalpel. The nerve is not “killed” in the dramatic sense people sometimes imagine; it is interrupted, and over months it can recover.
Some systems use a cooled tip or a different lesion geometry to make a larger burn with a similar intent. We mention that only to say that equipment varies and that the clinical idea does not. The idea is to lesion the medial branch nerves that a diagnostic block has already implicated. Cervical and lumbar anatomy differ in how those nerves run over bone, which changes needle trajectory and the number of lesions at a level. The joint count still follows the same rule as the block: each facet joint is supplied by more than one medial branch, so ablation is planned as a set of nerves, not as a single poke at a single joint.
The medial branch also supplies a portion of the multifidus muscle. That is expected anatomy. Whether a period of local muscle denervation matters clinically is debated in the literature, and it is one reason we keep physical therapy in the plan after ablation, as part of the same pathway, not as an afterthought. A period of local muscle denervation is not, by itself, a reason to skip ablation when the diagnostic blocks have been convincing and the pain is facet-pattern and axial.
We do not ablate first and ask questions later. A positive diagnostic block means that the pain you live with dropped substantially while local anesthetic was working on those nerves, in a time course that matches the medication. Many pathways, including the one we use when the result has to be especially trustworthy, add a second confirmatory block before the ablation visit. The second block exists because a single lucky afternoon can overestimate how much of the pain is truly facet-mediated. If both blocks are convincing, the ablation targets the same levels, the same nerves, and the same side.
If the first block is negative, we stop that pathway. If it is partial, we talk about whether the levels were wrong, whether another generator is sharing the pain, or whether ablation would be a guess. A good block is permission to discuss ablation. It is not a voucher that has to be redeemed. Some people with a clearly positive sequence still choose rehabilitation, time, or another option on the spine, pain, and sports medicine menu, and that is a legitimate end of the conversation.
Ablation is the wrong tool for radicular pain, for stenosis that produces neurogenic claudication, and for an isolated disc herniation whose main job is irritating a nerve root. Those problems are covered on the epidural steroid injections page. A person can have both facet pain and radicular pain; the procedures then have to be sequenced to the question each one can answer.
The day looks familiar if you have already had the diagnostic blocks, and it is a longer, more technical version of the same room. We review the levels that earned the ablation, the medications you take, and whether a driver is needed. You are positioned so that fluoroscopy can see the bony targets. A grounding pad is placed on the skin because the generator needs a return path. The skin is cleaned and numbed. Each cannula is walked to the nerve under live x-ray, with contrast used when it helps confirm that we are on the right bony landmark and not in a vessel.
Before any heat is applied, we stimulate. Sensory testing at a low voltage should reproduce a tingling or pressure in the distribution we expect, which supports that the tip is near the medial branch. Motor testing, when we use it, is a safety check: we do not want a twitch in a limb muscle that would suggest the cannula is too close to a larger ventral ramus. If the stimulation pattern is wrong, the needle is moved. Local anesthetic is then placed through the cannula so the lesion itself is tolerable. The generator is run for a timed burn at each site. Several nerves are treated at a sitting, which is why the appointment is longer than a diagnostic block and why soreness afterward is often more noticeable.
Most people are awake enough to report what they feel during stimulation. Light sedation can be used when anxiety or positioning requires it; anyone who is sedated needs a driver. After the last lesion we observe you in the procedure area, review what the next several days will feel like, and send you home the same day in the usual case. Walking that evening is expected. Heavy lifting, aggressive twisting, and a return to the gym can wait a few days until the treated tissues are less angry.
Relief is not permanent. Medial branch nerves regenerate. When ablation helps, the useful window is often measured in months, and for some people it lasts longer than a year. We do not quote a promised duration, because duration depends on how completely the nerves were lesioned, whether other pain sources were always in the mix, and how the person uses the quieter interval. The honest clinical sentence is that a technically good lesion in a well-selected person can give a substantial period of improvement, and that the same person should plan for the possibility that the pain will eventually return in a familiar pattern.
When that happens, ablation can be repeated. Repeat treatment is appropriate when the returning pain matches the original facet pattern, when the person still has no better explanation, and when enough time has passed that we are not chasing a failed first lesion with an immediate second one. If the pain that returns is a different shape (more leg, more claudication, more sacroiliac, more widespread), we reassess before burning the same nerves again. A repeat diagnostic block is sometimes useful when the story has changed; it is not required every time the original pattern comes back clearly.
We do not enroll people in a standing ablation calendar. The decision is made when the pain returns, with the original diagnostic logic still visible in the chart. Cervical and lumbar ablations are both repeatable under that rule. The limiter is clinical, including how the person responded the first time, not a lifetime cap printed on this page.
After a diagnostic medial branch block, most people go home the same day. The local anesthetic window is hours, not weeks. During that window we want a clear reading of the usual pain. Later the anesthetic wears off and the baseline pain often returns, which can feel disappointing if the purpose of the visit has not been explained. That return is the expected end of a diagnostic test. Soreness from the needles, a bruised feeling, or a day of extra stiffness is common. Ice, usual medications as directed, and ordinary walking are typically enough.
After radiofrequency ablation, the first several days can feel more sore than the diagnostic visit. Some people describe a sunburned or aching band over the treated levels. That post-ablation discomfort usually eases over one to two weeks. The more durable change, when it comes, is often judged over the following weeks, once the procedural soreness is no longer competing with the original pain. We set follow-up so that we are reading the result at the right time, and so that rehabilitation can resume without being asked to do the job of the nerve lesion.
Any injection through the skin can cause bleeding, infection, or a temporary flare of pain. Allergic reaction to local anesthetic, contrast, or skin preparation is uncommon and is reviewed before the procedure. Fluoroscopy uses ionizing radiation; we keep the dose as low as practical and use it because seeing the bony target is part of doing the procedure carefully. Nerve injury is uncommon when the needle is placed under image guidance with the usual safety checks. Vasovagal lightheadedness can occur and is managed in the procedure room.
Radiofrequency ablation adds a few specific possibilities that the diagnostic block does not. Prolonged soreness for one to two weeks is common enough that we describe it as part of the recovery, not as a complication. A patch of skin numbness over a small area supplied by the same nerves is expected anatomy and typically fades. Uncommonly, neuritis appears as an irritated, burning quality along the treated nerve; it usually settles with time and supportive care. Skin burn is rare with contemporary equipment, a properly placed grounding pad, and attention to the active tip. Weakness in a limb would be unexpected for a medial branch procedure and is a reason to call the same day. Because the medial branch also supplies multifidus, a temporary change in local muscle function is theoretically possible; we have not made that a reason to avoid a well-indicated ablation, and we do keep rehabilitation in the weeks that follow. New, severe headache, fever, progressive neurologic change, or a wound that looks infected are same-day calls, as they would be after any spinal injection.
We discuss anticoagulation, infection, pregnancy, and uncontrolled medical issues before scheduling, because those factors change risk even when the procedure itself is straightforward. This page is not a consent form. Consent happens in a visit, with your history in front of us.
For selected people with axial neck or back pain that appears facet-mediated, a diagnostic medial branch block followed by radiofrequency ablation is a standard interventional pathway in pain medicine and physical medicine and rehabilitation. The logic is conservative: do not ablate nerves unless a well-placed anesthetic block has shown that those nerves are carrying the pain. When selection is careful, many patients report a period of meaningful relief that can make rehabilitation more tolerable and daily activity more possible. That sequence (block, then lesion of the same nerves) is the version of this care that has the most coherent evidence, which is why we do not skip the diagnostic step in order to get to the ablation sooner.
The evidence base is real and it is not uniform. Randomized trials and systematic reviews of lumbar and cervical facet radiofrequency exist, and they do not all use the same definition of a positive block, the same number of confirmatory blocks, the same lesion temperature or duration, or the same way of measuring success. Some trials that used more careful diagnostic criteria and more complete lesions look more favorable. Trials that ablated after looser selection look less favorable. Relief is not universal, and it is not permanent. People with mixed pain sources, prior lumbar fusion, widespread pain, or a story that was never clearly axial tend to have less predictable results. We say this in clinic because a procedure that is standard for the right indication can still fail when the indication is wrong, and because quoting a single success percentage from one paper would be theater.
We do not present ablation as a cure for arthritis of the spine. Facet joints can remain degenerate on imaging after a technically successful lesion. Range of motion of the joint is not the target. The target is the pain signal carried by the medial branch nerves, for a period of time, in a person whose diagnostic blocks have earned that next step. If the quieter months are used well, with walking and the work described on our physical therapy page, the procedure has done its job even though the MRI will look largely unchanged.
A medial branch block is a poor fit when the story is primarily radicular, when there is an active infection, when a bleeding risk cannot be managed safely, or when the examination and imaging point to a different generator. It is also a poor fit when the person in front of us is looking for a single injection to settle a problem that still needs a diagnosis. We complete the evaluation, including a conversation about rehabilitation on the physical therapy pathway, before we schedule a block that cannot answer a clear question.
People whose pain is accompanied by progressive neurologic deficit, saddle anesthesia, or systemic warning signs need urgent assessment that is outside the scope of an elective diagnostic injection. Those situations are handled as such. For joint and tendon problems outside the spine, the practice also discusses regenerative options such as PRP injections when they are relevant, and those decisions live on a different page because the anatomy is different.
The anesthetic effect of a diagnostic block is measured in hours. That short window is the point of the test. If steroid is included in a given protocol, a longer anti-inflammatory effect is possible, and it is still not the same thing as the months of relief sometimes seen after radiofrequency ablation. We will tell you which medication we plan to use and what to watch for afterward.
No. A helpful block is information. Many pathways use a second confirmatory block before ablation. We also revisit the whole picture: how much of the pain settled, whether function changed, whether another source is still in play, and whether ablation is the next step you want. A positive diagnostic sequence makes ablation a reasonable discussion. It does not make it mandatory.
They are related and they are not identical. A facet joint injection places medication into the joint itself. A medial branch block anesthetizes the nerves that innervate the joint. For deciding whether radiofrequency ablation is appropriate, the medial branch block is the test that matches the nerves we would later treat. Intra-articular facet injections have their own uses and are listed among the procedures on our spine, pain, and sports medicine page.
Not as a treatment for nerve-root pain. Sciatica and disc-related radicular symptoms are a different problem, and in that setting we more often discuss epidural steroid injections along with rehabilitation. A person can have both axial facet pain and radicular pain; the blocks then have to be chosen for the question we are trying to answer.
Most diagnostic medial branch blocks are done with local anesthetic at the skin and along the needle path, and many people drive themselves home when no sedation is used. If we plan sedation, you will need a driver and a quieter remainder of the day. We decide that together, based on anxiety, positioning, and medical history.
Once we have a convincing diagnostic result, often after a confirmatory block, ablation is scheduled as a separate visit. There is no universal interval. We want the diagnostic information to be recent enough to trust and we want you to have recovered from the block itself. The calendar is set in clinic, not by this page.
No. Nerves can recover. When ablation helps, people often describe months of improvement, and some describe a longer interval. If the same pain pattern returns later, repeating the procedure can be considered. We do not promise a duration, and we do not treat repeat ablation as a subscription.
Dr. Adam Nessim is the interventional spine physician at Westport Longevity, Pain & Performance. Dr. Fernando Martinez is a pain medicine physician on the team. These pages do not diagnose and do not replace a visit. Pain and sports medicine visits do not require membership. The Westport location is planned to open in July 2027; an inquiry helps us plan the first conversation.
The next step
Tell us what you are experiencing and what care you have already tried. We will help you determine the appropriate next step.