Medical Necessity of Bilateral C2, C3, C4, and C5 Medial Branch Blocks

Patient Clinical Presentation and Indication

The patient has chronic neck pain with symptoms suggestive of facet joint syndrome, including pain aggravated by extension and rotation of the spine without radiculopathy, and has failed multiple conservative treatments, including home exercise regimen, NSAIDs, and pain medications, with reported pain levels of 7-8/10 requiring opioid medication for pain control 1
Physical examination confirms facet-mediated pain with axial/facet loading maneuvers causing ipsilateral neck and peri-scapular pain, and tenderness at the approximate location of facet joints 2
MRI findings show multi-level cervical spondylosis, which supports the clinical diagnosis, and the patient has failed conservative treatments including physical therapy, chiropractic care, and trigger point injections 3
Symptoms have persisted for more than 3 months, and pain has significantly limited daily activities 4

The American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) strongly agree that medial branch blocks should be used for facet-mediated spine pain, with ASA practice guidelines stating that "medial branch blocks may be used for the treatment of facet-mediated spine pain" 1, 2
Medial branch blocks are considered medically necessary for diagnosis of facet pain when symptoms are suggestive of facet joint syndrome, and pain limits daily activities 1, 3
Radiofrequency facet neurolysis is being considered, and medial branch blocks are necessary for diagnosis, with the American Society of Anesthesiologists (ASA) recommending blocking no more than three facet joint levels bilaterally in a single session 1, 5, 6

If the patient obtains appropriate relief (80+%) from diagnostic and confirmatory cervical medial branch blocks, she would then be an appropriate candidate for radiofrequency ablation to provide longer-duration pain relief, with goals of treatment including significant pain relief, reduced or eliminated opioid requirements, and improved range of motion and tolerance for exercise 3, 5

Cervical medial branch blocks are not indicated for radicular symptoms, which this patient does not exhibit, according to the American Academy of Physical Medicine and Rehabilitation (AAPMR) and the American Society of Anesthesiologists (ASA) 7, 8