Cervical MBB/RFA: Why "center of trapezoid"?

[sdnuser001]

In fellowship we were traditionally taught to aim for waist of lateral mass on AP and then advance on lateral until needle is at "center of the trapezoid" but based on figures like below is this really necessary?

https://rapm.bmj.com/content/rapm/47/1/3/F3.large.jpg

Why not aim medial of waist on AP and just catch medal branch farther away from the foramen? Wouldn't this be faster (no lateral/CLO needed) and safer?

On a loosely related note I've heard in Korea they also do a direct AP approach like described in this article although this appears different as it specifically targets the sensory fibers innervating the facet capsule:

Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule - PubMed

Radiofrequency cervical rhizotomy has been shown to be effective for the relief of chronic neck pain, whether it be due to soft tissue injury, cervical spondylosis, or post-cervical spine surgery. The target and technique have traditionally been taught using an oblique approach to the anterior...

pubmed.ncbi.nlm.nih.gov

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[DOctorJay]

To come in posterior instead of along the trapezoid, like I think you’re suggesting, you’d need a cooled RF setup. Otherwise only the very tip of the RF needle will be touching the nerve which isn’t where most of the lesion is happening with a traditional RF needle.

 

[Asclepius186]

Yes, If you come in posterior with a slight medial to lateral trajectory you can still lay the needle along the waist but you’ll be a bit more posterior, and the needle tip will be hanging off the bone just a bit lateral instead of pointing directly at the foramen.

 

[sdnuser001]

Yes, If you come in posterior with a slight medial to lateral trajectory you can still lay the needle along the waist but you’ll be a bit more posterior, and the needle tip will be hanging off the bone just a bit lateral instead of pointing directly at the foramen.

Right so RFA no but MBB it should be fine to come perpendicular no?

 

[RoloTomassi]

Theoretically you'd get a better block laterally, as you're hitting it at it's origin off the nerve root thus getting all the distal branches

 

[Baron Samedi]

Right so RFA no but MBB it should be fine to come perpendicular no?

Lateral MBB is so unbelievably quick and easy. In thin patients you can get away with using a 27G local needle for the entire procedure.

 

[callmeanesthesia]

Lateral MBB is so unbelievably quick and easy. In thin patients you can get away with using a 27G local needle for the entire procedure.

For logistical reasons (and because it’s what I trained with) I prefer posterior. I do a lot of bilateral and a lot of lower cervical. Also have a lot of badly degenerated necks where it’s hard or impossible to get a clean lateral.

I use one needle on each side, and reorient it for each level.

 

[RoloTomassi]

Lateral MBB is so unbelievably quick and easy. In thin patients you can get away with using a 27G local needle for the entire procedure.

Maybe I need to revisit. I liked the short needle travel distance, less painful but
1. Longer positioning/fluoro setup time
2. Hard to put skin marker on lower levels
3. Hard to see lower levels
4. Cord is deep to needle.
Any suggestions to improve the above?

 

[Baron Samedi]

Maybe I need to revisit. I liked the short needle travel distance, less painful but
1. Longer positioning/fluoro setup time
2. Hard to put skin marker on lower levels
3. Hard to see lower levels
4. Cord is deep to needle.
Any suggestions to improve the above?

For #1 the best solution is to have the staff position the patient and get the images before you enter the room.

C7 can be a bit more challenging in the lateral view. Collimation can sometimes help. Can also have your tech pull the patients arm down.

Vast majority of my MBBs are TON/C3/C4 or C4/C5/C6 so it tends to be less of an issue.

For bilateral procedures or badly degenerated necks, I will still use a posterior approach.

 

[RoloTomassi]

For #1 the best solution is to have the staff position the patient and get the images before you enter the room.

C7 can be a bit more challenging in the lateral view. Collimation can sometimes help. Can also have your tech pull the patients arm down.

Vast majority of my MBBs are TON/C3/C4 or C4/C5/C6 so it tends to be less of an issue.

For bilateral procedures or badly degenerated necks, I will still use a posterior approach.

Oh also, how do you deal with external jugular? I'd go around when visible but when not I'd enter more posterior, advance out of plane. I know some just poke through it but don't like the idea of that

 

[Baron Samedi]

Oh also, how do you deal with external jugular? I'd go around when visible but when not I'd enter more posterior, advance out of plane. I know some just poke through it but don't like the idea of that

In all seriousness a 27G or 25G won't matter. I don't even think about it.

 

[drrosenrosen]

Also, since we brought it up, why do we say "center of the trapezoid" when it is very clearly a parallelogram?

 

[MitchLevi]

Also, since we brought it up, why do we say "center of the trapezoid" when it is very clearly a parallelogram?

Hold up...I was told math wouldn't be part of this.

 

[GoBeers]

Oh also, how do you deal with external jugular? I'd go around when visible but when not I'd enter more posterior, advance out of plane. I know some just poke through it but don't like the idea of that

external jugular vein should be no where near where our needles start or end up

 

[Ducttape]

and even if you hit the external jugular, facetiously speaking, so what?

this is from someone that used to cannulate the external jugular in ER all the time. great vein to get access in.

 

[RoloTomassi]

external jugular vein should be no where near where our needles start or end up

Talking about lateral approach here.

 

[RoloTomassi]

and even if you hit the external jugular, facetiously speaking, so what?

this is from someone that used to cannulate the external jugular in ER all the time. great vein to get access in.

Just don't like bleeding or clot forming. Obviously no problem but to the patient it's "he nicked a blood vessel". Lose some style points.

 

[GoBeers]

Talking about lateral approach here.
View attachment 372183

ya that picture doesn't exude safety and confidence for sure.
but typically extrenal jugular vein is visible when patient prone or supine. and it typically crosses anterosuperiorly over the SCM so it'd be very strange to have it located on the posterior half of the neck. either way 23g or 25g needle no big deal, just hold pressure if necessary. otherwise avoid as you've said altogether.

my scariest moment was doing cervical RFA where one of my C6 needles had pulsating blood shooting out of it. looking at netters, I may have hit a branch of the ascending deep cervical artery. freaked me out but held pressure, and kept her in pacu for 6 hours. i must've called her twice an hour until midnight.

 

[RoloTomassi]

ya that picture doesn't exude safety and confidence for sure.
but typically extrenal jugular vein is visible when patient prone or supine. and it typically crosses anterosuperiorly over the SCM so it'd be very strange to have it located on the posterior half of the neck. either way 23g or 25g needle no big deal, just hold pressure if necessary. otherwise avoid as you've said altogether.

my scariest moment was doing cervical RFA where one of my C6 needles had pulsating blood shooting out of it. looking at netters, I may have hit a branch of the ascending deep cervical artery. freaked me out but held pressure, and kept her in pacu for 6 hours. i must've called her twice an hour until midnight.

Still don't think we're talking about the same thing. Not talking about OPs question of being lateral v posterior on facet but true lateral approach Baron Samedi was talking about, with pt side lying, going through the SCM usually, not coming in posteriorly. But yeah no biggie regardless.

 

[Ducttape]

personally, in all my years, i think i have maybe hit it with RFA like twice? not that i can recall with 25 gauge MBB.

a bit of bruising, held pressure for an extra minute, and told him there will be a bruise.

i usually start posterior and aim anteriorly typically aim for needle to end in the posterior half, then confirm with AP view. should avoid any consdieration for potential cord injury. needle path should be posterior where external jugular is running...

 

[Ferrismonk]

In my experience, from my patients who have had CMBB/RFA via lateral approach with others in my office, lateral approach hurts more, bruises more, and causes neuritis much more. It's also more difficult to get good xray views and more dangerous to perform. Additionally, RFA from posterior approach allows a parallel burn vs a perpendicular burn in lateral approach. Hence, I do all my cervical facet stuff from posterior.

Actually, I do exactly was OP questioned in the first post. I do AP view, come down and touch the articular pillar, and walk laterally until at the waist. Inject there. Much safer imo and still get good results.

 

[Baron Samedi]

In my experience, from my patients who have had CMBB/RFA via lateral approach with others in my office, lateral approach hurts more, bruises more, and causes neuritis much more. It's also more difficult to get good xray views and more dangerous to perform. Additionally, RFA from posterior approach allows a parallel burn vs a perpendicular burn in lateral approach. Hence, I do all my cervical facet stuff from posterior.

Actually, I do exactly was OP questioned in the first post. I do AP view, come down and touch the articular pillar, and walk laterally until at the waist. Inject there. Much safer imo and still get good results.

I still do all my RFA procedures using a posterior approach. I've never had any of those issues with lateral approach MBB but I'll keep that in mind.

 

[oreosandsake]

also, how anterior do you guys push the RF cannula and rf probes? there should be a posterior tubercle to block you from going any more anterior but i stay in the middle of the trape lellogram...

 

[Taus]

also, how anterior do you guys push the RF cannula and rf probes? there should be a posterior tubercle to block you from going any more anterior but i stay in the middle of the trape lellogram...

to the max possible

just dorsal to anterior border of pillar on lateral view and posterior aspect of lamina on clo.

 

[GlowInTheDark]

In my experience, from my patients who have had CMBB/RFA via lateral approach with others in my office, lateral approach hurts more, bruises more, and causes neuritis much more. It's also more difficult to get good xray views and more dangerous to perform. Additionally, RFA from posterior approach allows a parallel burn vs a perpendicular burn in lateral approach. Hence, I do all my cervical facet stuff from posterior.

Actually, I do exactly was OP questioned in the first post. I do AP view, come down and touch the articular pillar, and walk laterally until at the waist. Inject there. Much safer imo and still get good results.

When you did lateral was patient supine or lateral decubitus? Lateral imaging is quite easy to line up with patient supine…not such much decubitus. Def more fluoro time than posterior approach though in my experience.

 

[po_boy]

Can anyone post pics of their needles using CLO for MBB/RFA? Thanks

 

[RoloTomassi]

Can anyone post pics of their needles using CLO for MBB/RFA? Thanks

If you do a search there's a paper with various depths depending on CLO angle

 

[cowboydoc]

If you do a search there's a paper with various depths depending on CLO angle

IIRC, posted by @Taus

 

[Orin]

This one?

https://www.painmedicine-casereports.com/current/pdf?article=MjAy&journal=10

 

[clubdeac]

Can anyone post pics of their needles using CLO for MBB/RFA? Thanks

Here’s one I did recently

 

[GoBeers]

Here’s one I did recently

pt with long neck and skinny... must be nice

 

[clubdeac]

pt with long neck and skinny... must be nice

Yeah he was only 15 y/o….jk jk

 

[OM1027]

Here’s one I did recently

my lateral images never look that clean. how do you position these patients prone? pillow under chest?

 

[SC Tian]

54 yo F, bmi 35 with good relief

 

[MitchLevi]

So are yall getting paid for 3 levels, or are you eating that 4th needle?

 

[SC Tian]

Most of our community insurance covers the third joint, but Medicare does not.