Endoscopic Medial Branch Transection

What it is and why we do it

The facet joints are the small joints at the back of each level of the spine. Like any joint, they can wear out and ache, and in some people they are the main source of low back pain, worse with standing, arching back, or twisting. Each facet joint sends its pain signal through a tiny nerve called the medial branch, which runs across a bony landmark on the side of the vertebra. Interrupting that nerve stops the pain signal without affecting the strength or feeling of the legs, because the medial branch only carries sensation from the joint and supplies a small muscle beside the spine.

The common way to interrupt it is radiofrequency ablation (RFA): a needle heats the nerve using X-ray guidance. It works for many people, but the nerve grows back and the pain often returns after six to twelve months, and the procedure is repeated. An endoscopic medial branch transection does the same thing under direct vision: a small endoscope finds the nerve where it crosses the bone, and I cut it and remove a segment, so it cannot reconnect as easily.

Who it suits

This is for people whose back pain has been shown to come from the facet joints. The test for that is a medial branch block: a numbing injection on the nerve. If your pain drops by at least half, and ideally more, while the numbing medicine is working, the joints are the source. The best candidates have had one or more successful RFA treatments that wore off, or have pain from several joints, or cannot easily keep repeating RFA. It is not for pain from a disc, a pinched nerve, stenosis, or an unstable spine, and it is not a treatment for general back pain.

What happens during surgery

Under sedation or general anesthesia, lying face down, X-ray guides a thin tube, about the width of a drinking straw, to the junction of the transverse process and the facet joint at each level. The endoscope shows the nerve as it crosses the bone. I free it, confirm it with a stimulating probe, and cut it with a radiofrequency tip, removing a short segment. Each level takes about 10 to 15 minutes, and both sides of several levels can be treated through one or two small incisions per side. The incisions are closed with a strip of tape.

Your recovery

You go home the same day. The incisions are sore for a few days, and the back can feel bruised for a week or two. Pain relief is usually noticed within days to weeks. No restrictions beyond common sense: walk from the first day, no heavy lifting for two weeks, and return to work in a few days for most people. Physical therapy afterward helps you build the strength that keeps the pain from returning.

The science: for the curious

Radiofrequency ablation lesions the nerve by heat, through a needle placed by X-ray without seeing the nerve, and the nerve regrows along its sheath. Cutting and removing a segment under direct vision makes regrowth harder. In a randomized trial comparing the two, patients treated endoscopically had lower pain scores at six and twelve months and more good or excellent results. Real-world studies report relief lasting around twice as long as RFA, with most follow-up reported to two years. The evidence is still young, and not every study agrees, so I describe it honestly as "likely to last longer than RFA" rather than as a cure. The facet joints are still worn afterward, which is why strength and activity remain part of the plan.

Learn more

Arthrex, Medial branch transection for patients: arthrexspinepatient.com (opens in a new tab)

OrthoInfo, Low Back Pain: orthoinfo.aaos.org (opens in a new tab)

My overview of endoscopic spine surgery compares every endoscopic procedure I offer.

Watch

Endoscopic medial branch nerve transection2:56

This handout is general education about this procedure and does not replace the specific plan, risks, and consent discussion we have together. Your own situation may differ: if anything here does not match what we talked about, what we talked about wins, so please ask me.