Can You Cure Thoracic Facet Pain?

In my experience, the most aggravating facet pain to deal with is thoracic facet pain that doesn’t respond to manipulative, conservative or injection therapy. This pain usually originates from the upper level facets from C7-T1 to T5-6. 

The pain that radiates from the facets can be local over the painful facet or radicular, radiating to the scapula and infraspinatus muscle. This pain can be very confusing when it mimics a C7 nerve radiculopathy and there is nothing on the cervical MRI to correlate with it. Also challenging is when surgery has been performed at the C6-7 level for radicular pain from a compressive issue and the patient receives no relief. 

Since there is no imaging study to confirm the diagnosis of facet syndrome, the diagnosis is made with the injection of marcaine in the painful facet joints. The duration of pain relief from the injection is variable from 6-8 hours to a few days. The patient should report approximately an 80% relief of pain from the injection into the facet joint. Even if the pain relief is short, that is enough for me to make the diagnosis and recommend a definitive treatment.

The typical treatment is thermal ablation of medial branches that supply sensation to the facet joints, but there is a problem with thermal ablation – pain relief is always temporary (about 12 months). The reason for this is that the nerve sheath always remains intact with thermal ablation. The thermal probe denatures the protein inside of the nerves, thus rendering the nerve inoperative, but only temporarily. Since the nerve sheath is intact, the nerve can reestablish itself and start hurting again.  

There is another significant issue with thermal ablation that I’m seeing with increased regularity. Repeated thermal ablation isn’t as effective as the initial procedure and doesn’t last as long. Why does this occur?  

The medial branches can arborize after each ablation, so the ablation treatment can make the problem worse in some patients as the nerves grow back and arborize. I’ve read papers that say this doesn’t happen, but I see this more and more often these days.

What’s the answer to this problem ? 

The initial treatment should divide the medial branches, so there is some measurable distance between severed nerve ends. This distance prevents regrowth of nerve endings and the return of pain.

How can this be done? 

In 2010, I published a paper that described how to use endoscopic spine surgery and a holmium laser to divide the medial branches. The paper had a minimum of a 3 year followup and there was permanent pain relief in 67% of the patients. I believe this process is the best way to definitively treat thoracic facet syndrome.

Onward and upward

Dr. Tony Mork, MD

Endoscopic Spine Specialist