Dorsal Ramus Rhizotomy

Pain that is localized to the back is frequently caused by degenerative disease of the facet joints. Facet injections or dorsal branch blocks can confirm the source of the pain, and radio-frequency ablation of the medial branch of the dorsal ramus can provide a limited period of relief by lesioning the nerve branch that supplies the painful facet. Each facet is supplied by the medial branches from two adjacent dorsal rami, so two ablations are required per facet.

The endoscopic dorsal ramus rhizotomy technique and instrumentation was developed by Dr. Anthony Yeung in conjunction with Richard Wolf to more aggressively address pain mediated by the dorsal rami.  Endoscopic dorsal ramus rhizotomy provides two major advantages over standard radio frequency lesioning techniques. First, the endoscope allows for direct visualization of the medial branch and permits confirmation that the branch has been accurately targeted. Second, a bipolar RF probe is used to definitively ablate a segment of the branch to ensure complete interruption of pain signals. The more definitive transaction of the medial branch provides the patient with more complete and longer relief of pain.1,2 Patients who have received significant relief of pain from medial branch blocks (and/or from RFA) are good candidates for the endoscopic rhizotomy technique.

Technique Summary:

  • Under fluoroscopic guidance, insert the needle and guide wire from a directly posterior approach onto the transverse process  
  • Insert a dilator and working sleeve over the guide wire, onto the transverse process
  • Insert the endoscope to visualize the medial aspect of the transverse process, including the medial branch of the dorsal ramus
  • Use the RF bipolar probe to directly ablate the medial branch under direct endoscopic visualization

1. Yeung, et. al., Endoscopically Guided Foraminal and Dorsal Rhizotomy for Chronic Axial Back Pain Based on Cadaver and Endoscopically Visualized Anatomic Study, International Journal of Spine Surgery, Percutaneous & Endoscopic Special Issue, 2014
2. Siddiqi, Five Year Long-Term Results of Endoscopic Dorsal Ramus Rhizotomy and Anatomic Variations of the Painful Lumbar Facet Joint, SMISS 2013 Annual Conference.