The thoracic dorsal rami arise from each thoracic spinal nerve after it exits the intervertebral foramen and immediately divide into medial and lateral branches. The medial branches supply the facet joints, the multifidus and semispinalis muscles, and the skin of the posterior thorax close to the midline. The lateral branches supply the iliocostalis and longissimus muscles and the skin of the lateral posterior thorax.
The medial branches of thoracic dorsal rami (thoracic medial branch nerves) are the target for thoracic medial branch blocks and radiofrequency ablation in the management of thoracic facet joint pain. The procedure targets the medial branch as it crosses the transverse process at each level, anaesthetising the facet joint capsule innervation. Cluneal neuropathy from the posterior rami of L1-L3 (superior cluneal nerves) is distinct from thoracic dorsal rami pathology. Thoracic dorsal rami are at risk during thoracic fusion surgery with pedicle screw placement.
Thoracic facet joint pain from arthrosis or post-traumatic degeneration is diagnosed by dual medial branch blocks at two consecutive levels under fluoroscopic guidance; greater than 80% relief on both blocks confirms the facet as the pain generator, qualifying the patient for radiofrequency ablation of the thoracic medial branch nerves.
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