GENERAL
As described more analytically in the chapter of intradiscal degenerative disease, the intervertebral disc is innervated by the recurrent meningeal nerve (at each side of the spine) conveying pain signals of nociceptors from the posterior annulus fibrosus (envelope of the disc) to the ramus communicans of the sympathetic chain, then to the posterior spinal root ganglion and finally to the spinal cord. (7,9,25)
Nakamura et al conducted studies to observe the afferent nerve pathways responsible for discogenic pain of lower lumbar levels, by blocking the 2nd lumbar root bilaterally in 33 patients. Based on their findings, the writers concluded that the 2nd lumbar root may probably be the most important afferent pathway of discogenic pain in lower lumbar levels, mainly through the afferent sympathetic fibres of the recurrent meningeal nerve. Infiltration of the 2nd lumbar root may be useful for the diagnosis and therapy of discogenic pain.
Chandler et al investigated the application of the ramus communicans nerve block as treatment for pain due to vertebral fractures. Oh και Shim studied the efficacy of conventional radiofrequency and ablation applied on the ramus communicans of the sympathetic chain in 49 patietns with discogenic pain at one lumbar level. (1,2,8)
All investigators concluded that ablation of the sympathetic ramus communicans is effective in treating discogenic pain from intradiscal degeneration and pain from vertebral fracture. The duration of the result still remains unpredictable.
INDICATIONS
• Discogenic pain due to intradiscal degeneration
• Vertebral body fracture
TECHNIQUE
The patient is placed in the prone position under conscious light sedation. Using an oblique fluoroscopic view of approximately 200, the needle entry point is marked with a radiopaque metallic forceps on the skin to the site corresponding to the lateral margin of the vertebra below the transverse process. Following local anaesthesia at the entry point and with the needle advancing more deeply, another needle with a bent end is inserted dorsally moving slowly under fluoroscopic guidance, until it comes in contact with the vertebral body. At this point, a lateral fluoroscopic view is used. The end of the needle is advanced slightly in advance to the posterior margin of the vertebral body and in contact with it. Contrast medium is injected (0,5ml) and anteroposterior and another lateral fluoroscopic view are taken again to ensure the proper site of the needle. Then, 1 ml local long-acting anaesthetic is administered for selective block of the ramus communicans. For every painful disc, the block is performed to the adjacent superior and inferior vertebra.
RADIOFREQUENCY APPLIED TO RAMUS COMMUNICANS
Radiofrequency application to ramus communicans is the same technique as in the diagnostic block, with the only difference that a special needle with an active metallic end 2mm is used for inserting an electrode connected with a radiofrequency generator. After the proper needle site has been confirmed, sensory testing is conducted during which the patient should feel mild paraesthesia or pressure or tingling or pain in the low back. The needle tip point is corrected with fine movements until the desirable result of the sensory test is achieved. Then, motor testing is applied to check whether the needle tip is near a motor nerve, something that would cause contraction of lower limb muscles. Should this occur, the needle is moved to localize the point where there is a positive sensory test result (paraesthesia etc) with low-tension current and a negative motor test result with high-tension current (no lower limb movement). (1,2,8)
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