Clinical questions

[jimbomd]

Colleagues,

Just wanted to get some thoughts. I have recently been referred several patients s/p ACDF for BL C-MBBs. For example, pt s/p C4-5 ACDF sent for BL C3, C4, C5 MBBs for "axial neck pain" 6 months after surgery despite solid fusion from a trusted surgeon. Had a few instances as well with referrals for lumbar MBBs at L3,4,5 following L4-sacrum ALIF. Seems to me the fusions would preclude significant motion at facets so MBBs mostly ineffective, at least diagnostically?

Thanks

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[101N]

Here is the problem: " trusted surgeon"

 

[pmrrulez]

If the fusions are solid, then in theory there will be no motion in the facets. I have seen it multiple times that with anterior fusions (ALIF and ACDF) that you can get micromovement (or atleast I think) within the joint space. I have RFA'd a few that have done very well with medial branch blocks, and they have done well. That being said, I have had to do peer-to-peers on all of them to justify the RFA.

Colleagues,

Just wanted to get some thoughts. I have recently been referred several patients s/p ACDF for BL C-MBBs. For example, pt s/p C4-5 ACDF sent for BL C3, C4, C5 MBBs for "axial neck pain" 6 months after surgery despite solid fusion from a trusted surgeon. Had a few instances as well with referrals for lumbar MBBs at L3,4,5 following L4-sacrum ALIF. Seems to me the fusions would preclude significant motion at facets so MBBs mostly ineffective, at least diagnostically?

Thanks

 

[Taus]

If the mbb/rf works and you included an adjacent segment (ie c3,4 mbb with c4-5 fusion and did c3,4,5mbb) then no way to know if the rf at single adjacent segment or fused segment helped. Do you really think the surgeon gives a }#^*+ what you did if the patient got better? I'd consider first doing adjacent segment, then if positive rf. If negative block, then include fused segment. Then if that's positive.... It gets interesting.

 

[emd123]

Colleagues,

Just wanted to get some thoughts. I have recently been referred several patients s/p ACDF for BL C-MBBs. For example, pt s/p C4-5 ACDF sent for BL C3, C4, C5 MBBs for "axial neck pain" 6 months after surgery despite solid fusion from a trusted surgeon. Had a few instances as well with referrals for lumbar MBBs at L3,4,5 following L4-sacrum ALIF. Seems to me the fusions would preclude significant motion at facets so MBBs mostly ineffective, at least diagnostically?

Thanks

Ideally if fused 100%, there should be no motion. But what surgery is 100%? None.

As long as you can get to the medial branches, which post acdf there should be no reason you can't, then do the diagnostic block at whatever level(s) you think are generating pain, acdf or not. If your block is + then move to block 2. If also +, then you have your answer based on the response in that specific patient. That makes more sense than what some book or insurance approval secretary says will happen 100% or the time, or 0% of the time, which we know doesn't bare out in real life.

Get insurance pre-approval obviously, but then if someone comes back to say the patient can't have facet pain, you have a legit diagnostic procedure as evidence to the contrary. If they don't respond to block one then you stop, no harm, no foul.

Just do what you think is right.

 

[willabeast]

i have had quite a few fusions sent to me that had motion on flex extension films. additionally, a bone scan can sometimes light up (although bone scan might be overkill).
lucencies around the screws can mean loose hardware. i would not do bilateral MBB, just do one side (the side that hurts the most) and see if you get rid of the pain on both sides.
at least 50% of the time you will.