# Clarification



## Melissa Harris CPC (Dec 19, 2016)

Can someone please clarify this for me?

A Right Lumbar Rami Communicans Nerve Block at L3-S1.   Is this simply a 64493 RT, 64494 RT,and 64495 RT?

Thank you

Melissa Harris, CPC


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## dwaldman (Dec 22, 2016)

Seems like the rami communicates block is not necessarily 64493 64494 64495. What was the diagnosis for the procedure. Seems when look at information for this type of block it is not used for facet joint pain/spondylosis but other conditions. I did see reference from Supercoder to use 64520. but not familiar with any other sources. One the articles I provided describe this procedure for discogenic pain which is not the same as facet block. I also saw a physician forum describing this procedure and techniques of performing and they were referencing it to be like a paravertebral block, since they don't have codes for paravertebral blocks in the lumbar region.


https://www.supercoder.com/my-ask-an-expert/topic/gray-ramus-communications-nerve-block

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Pain Physician. 2005 Jan;8(1):61-5.
Radiofrequency lesioning of the L2 ramus communicans in managing discogenic low back pain.
Simopoulos TT1, Malik AB, Sial KA, Elkersh M, Bajwa ZH.
Author information


Abstract
BACKGROUND: 
Discogenic low back pain is a common cause of chronic low back pain that remains a treatment challenge. The innervation and transmission of nociceptive information from painful lumbar discs has only recently been better described.
OBJECTIVE: 
To report initial experience of effectiveness of radiofrequency lesioning of L2 ramus communicans in managing discogenic pain.
STUDY DESIGN: 
A prospective, case series.
METHODS: 
A case series of 5 patients who had radiofrequency lesioning of the ramus communicans at the L2 level. All patients had discogenic low back pain and had diagnostic blocks with local anesthetic at the level of the L2 ramus communicans demonstrating significant pain relief. Continuous radiofrequency lesioning at 80 degrees C of the L2 ramus communicans for 60 seconds was performed. Standard outcome measures of reduction in the visual analogue scale (VAS), improvement in function, reduction in pain medication, and consistent improvement in low back pain with repeating of the procedure after its initial effect has worn off were recorded.
RESULTS: 
All five patients had consistent pain relief after a minimum of 2 radiofrequency lesioning treatments approximately 4 months apart. Four of the five patients had a reduction in pain medication, and all reported improvement in sitting tolerance and functioning. There were no side effects or complications.
CONCLUSION: 
Radiofrequency lesioning of the L2 ramus communicans seems to offer partial relief for patients suffering from discogenic pain. Further studies are needed to confirm our results.


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The principal branches of the lumbar sympathetic trunks are the rami communicantes to the lumbar ventral rami. White rami communicantes are distributed to the L1 and L2 ventral rami, and grey rami communicantes are distributed to every lumbar ventral ramus. The number of rami communicantes to each lumbar nerve varies from one to three, and exceptionally may be as high as five. In general, the rami communicantes reach the ventral rami by passing through the tunnels deep to the psoas muscle that lie along the concave lateral surfaces of the lumbar vertebral bodies. These tunnels direct them to the lower borders of the transverse processes where the rami communicantes join the ventral rami just outside the intervertebral foramina

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The medial branches of the dorsal rami at segmental levels L1 to L4 assume a constant and similar course. Each nerve emerges from its intervertebral foramen and enters the posterior compartment of the back by coursing around the neck of the superior articular process below the foramen (Figure 1). Still hugging the neck of the superior articular process, the medial branch passes caudally and slightly dorsally to disappear under the mamillo-accessory ligament [22]. Beneath the ligament, the nerve hooks medially around the caudal aspect of the root of the superior articular process to enter the multiﬁdus muscle. Intermediate and lateral branches arise from the dorsal ramus at the same point as the medial branch. These nerves run caudally and laterally, across the transverse process, into the longissimus and iliocostalis muscles, respectively (Figure 1). Two anatomical features govern the constancy of the course of each medial branch. Its point of entry into the posterior compartment is ﬁxed. It enters that compartment through a foramen in the posterior leaf of the intertransverse ligament 

Immediately rostral to the junction of the superior articular process and transverse process. Caudally, the nerve is again ﬁxed by the mamillo-accessory ligament. Fixation of the nerve by the mamilloaccessory ligament allows for virtually no variation in the location or orientation of the nerve as it crosses the neck of the superior articular process. Such variations as do occur are governed by the height of the accessory process and the depth of the mamillo-accessory notch. This can affect the slope of the medial branch as it crosses the neck of the superior articular process by a few degrees, but the nerve always crosses the neck. For the purposes of medial branch neurotomy, the nerve can be considered as always held against the superior articular process by the mamillo-accessory ligament. At the L5 level, the anatomy is different. The L5 dorsal ramus is much longer than at typical lumbar levels. From the L5-S1 intervertebral foramen, it runs along the groove formed between the ala of the sacrum and the root of the S1 superior articular process (Figure 1). Opposite the caudal end of the superior articular process, its medial branch hooks medially around the caudal aspect of that process, running deep to some ﬁbrous tissue that constitutes the analog of the mamillo-accessory ligament at this level (Figure 1). A communicating branch to the S1 dorsal ramus continues the longitudinal course of the dorsal ramus.


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## Melissa Harris CPC (Dec 23, 2016)

The diagnosis is  M51.36 Other intervertebral disc degeneration, lumbar region 

Rationale from the note:  Patient does present today with symptomatic degenerative disc disease.  Treatment options were discussed with the patient and we will plan to offer him a right-sided Rami Comunicans injection at the L3-S1 level with hopes of symptom management which will help to reduce their pain and offer of them a functional improvement.


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