Cervical medial branch blocks

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STIR images have not panned out to be as diagnostic in my experience. Two problems: 1. radiologists don't know what they are looking for and rarely have the expertise to read these microanatomical details from the films. You have to look at the films yourself and become an expert on facet microanatomy and pathology. 2. in many cases, there has been nothing at all notable on STIR MRI yet blocking the joints gave 100% pain relief.

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Phys Med Rehabil Clin N Am 21 (2010) 725–766
"Czervionke and Fenton83 recently reported a series of patients undergoing MRI studies for back pain, and noted that fat-saturated T2-weighted images could detect z-joint synovitis that appeared to corre-late with the clinical pain syndrome. STIR or fat-saturated T2-weighted sequences should be included in the MRI examination in the patient with back pain"

http://www.ajronline.org/content/191/4/973.full
The results of our study suggest that, with high probability, degenerative changes in the posterior paraspinal soft-tissue structures, especially interspinous ligament edema, fac-et joint effusion, neocyst formation, and intrinsic spinal muscle edema, cause LBP in some patients. Because of homogeneous fat suppression and better depiction of soft-tissue edema, the STIR sequence is the best imaging technique for visualizing the afore-mentioned changes, and it adds only 2 min-utes to the imaging examination. Therefore, we suggest that for patients with LBP without other obvious pathologic findings, the STIR sequence be added to the MRI evaluation to visualize degenerative changes in posterior spinal structures as a possible cause of pain.

Am I way off base here?

No you are not. Early in their careers, people tend be order lots of tests to CYA, and they should. As confidence in diagnostic skills grow, and the realization that the last 300 MRIs you ordered didn't change management, you become more comfortable flying on the trapeze without a net. My guess is Facets falls in this category, and you fall into the first, as you should.
 
Algos, that is a helpful response and makes sense. Maus and Murthy read many of our studies which has been hugely educational for me.

And to clarify I'm not in the boat that we should image everyone (Maus teaches us better than that) was just curious if those ordering MRI included STIR. It seems to me I you're going to pull the trigger for the mr you might as well get stir with it to increase your yield.

Thanks for the comments.
 
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Algos, that is a helpful response and makes sense. Maus and Murthy read many of our studies which has been hugely educational for me.

And to clarify I'm not in the boat that we should image everyone (Maus teaches us better than that) was just curious if those ordering MRI included STIR. It seems to me I you're going to pull the trigger for the mr you might as well get stir with it to increase your yield.

Thanks for the comments.

IMHO, Looking at MRI's, STIR is much less clarity than T1 or T2. It is useful for acute vs chronic Fx and nothing else that we do.
 
Phys Med Rehabil Clin N Am 21 (2010) 725–766
"Czervionke and Fenton83 recently reported a series of patients undergoing MRI studies for back pain, and noted that fat-saturated T2-weighted images could detect z-joint synovitis that appeared to corre-late with the clinical pain syndrome. STIR or fat-saturated T2-weighted sequences should be included in the MRI examination in the patient with back pain"

http://www.ajronline.org/content/191/4/973.full
The results of our study suggest that, with high probability, degenerative changes in the posterior paraspinal soft-tissue structures, especially interspinous ligament edema, fac-et joint effusion, neocyst formation, and intrinsic spinal muscle edema, cause LBP in some patients. Because of homogeneous fat suppression and better depiction of soft-tissue edema, the STIR sequence is the best imaging technique for visualizing the afore-mentioned changes, and it adds only 2 min-utes to the imaging examination. Therefore, we suggest that for patients with LBP without other obvious pathologic findings, the STIR sequence be added to the MRI evaluation to visualize degenerative changes in posterior spinal structures as a possible cause of pain.

Am I way off base here?


Since radiologists are notorious for recommending 'more tests'. Do they make more money if we order a STIR sequence of of the facility free/pro fee. That would be interesting to know....
 
IMHO, Looking at MRI's, STIR is much less clarity than T1 or T2. It is useful for acute vs chronic Fx and nothing else that we do.

Yes exactly.... more grainy images in my experience
 
Since radiologists are notorious for recommending 'more tests'. Do they make more money if we order a STIR sequence of of the facility free/pro fee. That would be interesting to know....

nope just more scanner time and images to look at.
 
one reason surgeons are becoming more hesitant to fuse (thank god), is that in 2012 they're going to make just over half what they were paid previously for a spinal fusion.

thank god!!!!!!!!!
 
IMHO, Looking at MRI's, STIR is much less clarity than T1 or T2. It is useful for acute vs chronic Fx and nothing else that we do.

agree. And T2 fat saturated are basically STIRR anyway, from what i have been told, in my non-radiology residency
 
Our local ortho spine group insists on STIR images, and if not done, will repeat with their own MRI to get them.

They use the same radiology group as we do, and the owner of the radiology group has told me that the STIR images they insist on on not necessary, based on literature. I have not reviewed the literature myself.
 
PMR 4 MSK:

Way to just totally carpet bomb every thread in the SDN Pain forum today. That was equivalent to a bilateral cervithoracolumbar MBB. Take no prisoners!
 
PMR 4 MSK:

Way to just totally carpet bomb every thread in the SDN Pain forum today. That was equivalent to a bilateral cervithoracolumbar MBB. Take no prisoners!

I'm just highly-opinionated.

Or so my wife tells me.
 
+1, you never have to worry what we are really thinking
 
Do you all hate when someone replies on an old thread?

Well I was trying to find something and found this one....now I find myself wanting to comment on OP's original question some 4 years ago.

Anyway, prevalence studies of degenerative facets in the neck show that C5/6 is the most common, then C2/3 ( I think..it might be C3/4).

Those levels should be treated the most.

Also, to those who jumped on his nomenclature, he stated that the levels blocked were L4,L5,S1. He DIDN'T say he blocks the S1 medial branch. Sheesh.....

That is how I document. I could give a rats ass what nerve is blocked - I want to know exactly where the needle was placed...so I write, "needle was placed at the TP of L4, L5 and at Sacral ALA". There is no confusion where my needle was and that is the most important communication point.
 
Yes, the terminology can be confusing. If you were going to have bilateral lower 3 facet joint MBB listed on a surgical schedule how would you list it? I list the nerves anatomically(Bil l2, l3, l4, dr5) but the nurses/rad tech/etc don't understand
 
I list joints treated. This also happens to correlate with how you bill so it's less confusing for all involved.
 
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