Facet pain at the fused levels after anterior fusions?

[Timeoutofmind]

Wanted to see what people thought about this...

I know after posterior fusions, the thought process is that the hardware destroys the MB and also that there is no mobility of the facets at those levels, so those facets cannot be a source of pain.

But what about after an anterior fusion? It seems to me there could still be some motion of the facets at the fused levels in this circumstance, and thus they could be a pain generator.

What do you think?

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[painfree23]

Yes certainly I think its a possibility and should be addressed with cervical mbnb and/or rfa

 

[Ronin1]

Well I have done countless RFA on fused levels both anterior and posterior with great results. If a positive response to small volume diagnostic block go ahead.

 

[painfree23]

Well I have done countless RFA on fused levels both anterior and posterior with great results. If a positive response to small volume diagnostic block go ahead.

Posterior too??

 

[SSdoc33]

Well I have done countless RFA on fused levels both anterior and posterior with great results. If a positive response to small volume diagnostic block go ahead.

wow. thats amazing. in which journal was your research published?

 

[SSdoc33]

i have found that RF after fusions usually dont work that great -- anterior OR posterior, neck or lumbar. in some cases you might see a little benefit. usually not, IMHO.

you are usually dealing with pain from the fusion itself, not the facets.

 

[Ducttape]

some insurances will not approve RFA for fused elements, irrespective of the location of fusion.

some states WC, for example.

i suspect that getting benefit from those MBBs are not directly affecting the facets, but may be related to other elements which are innovated by the branches.

 

[Ronin1]

wow. thats amazing. in which journal was your research published?

No need to be like that.
I’m a clinical guy like most people here and have a large population of patients that have had various fusion techniques. Many have responded to RFA

 

[Orin]

The difficulty I've been taught with a fused level is the hardware acting as a heatsink limiting your ability to create a lesion. There are some folks who state you could do a neurolytic injection of phenol in this scenario. I don't mind trialing/doing blocks/RF for anterior fusions but I generally stay away from the posterior fusions.

 

[lobelsteve]

The difficulty I've been taught with a fused level is the hardware acting as a heatsink limiting your ability to create a lesion. There are some folks who state you could do a neurolytic injection of phenol in this scenario. I don't mind trialing/doing blocks/RF for anterior fusions but I generally stay away from the posterior fusions.

Bogus concept. If posterior fusion in neck, no motion, no RF. If posterior fusion in back, then the joints should have been decorticated with hemifacetectomy, but depends on technique. Read you op note or review post-op imaging to see if missing half the joint.

 

[Timeoutofmind]

Bogus concept. If posterior fusion in neck, no motion, no RF. If posterior fusion in back, then the joints should have been decorticated with hemifacetectomy, but depends on technique. Read you op note or review post-op imaging to see if missing half the joint.

What do u think about RF at levels of anterior fusion?

 

[nvrsumr]

I have also had a number of patients improve(50%) after rf at fused levels. Usually very few options left for these folks who have many times already had a revision surgery except a stim implant and I think it is very reasonable for a patient not to want a battery implanted in their body.

Little local for a mbb is no big deal and pays less than the stim trial I am avoiding. Patient first.

 

[lobelsteve]

What do u think about RF at levels of anterior fusion?

Burn away....

 

[painfree23]

I have also had a number of patients improve(50%) after rf at fused levels. Usually very few options left for these folks who have many times already had a revision surgery except a stim implant and I think it is very reasonable for a patient not to want a battery implanted in their body.

Little local for a mbb is no big deal and pays less than the stim trial I am avoiding. Patient first.

How do u know where u are placing the end of the needle if u can't see anything because it's blocked by the fusion?

 

[SSdoc33]

No need to be like that.
I’m a clinical guy like most people here and have a large population of patients that have had various fusion techniques. Many have responded to RFA

im a clinical guy as well.

my comment was a bit tongue-in-cheek because i cant imagine that all of these fusion patients would feel so much better if they just had an RF.

in the neck, you usually see ACDFs, so i suppose it is reasonable to try a mbb/RF. however, most ACDFs in legitimate patients do well. those that dont may have pain at the supra or infra-adjacent levels.

in the low back, the most common fusion is a PLIF, usually with big honking pedicle screws. in these patients, Rf is technically difficult and i havent had the greatest luck. if it pretty uncommon to see a primary anterior lumbar fusion, but in those cases, a MBB/RF would make more sense. there arent too many of these.

I am seeing more of these "minimally invasive" TLIFs they call them, where the surgeon comes in a bit more laterally than a regular PLIF. these are also easier to get to with a needle.

the bottom line is that patients who have post-fusion pain have just that -- post fusion pain. their muscle attachments are all ripped out. their biomechanics are completely changed. but there is usually very little motion at the level of the facet at the fused level. 10 years later above of below a fusion makes a lot more sense.

and the end game is not necessarily a SCS. that may just be the last thing that you personally have to offer

 

[nvrsumr]

How do u know where u are placing the end of the needle if u can't see anything because it's blocked by the fusion?

I oblique and tilt cephalad more than usual and can often see the SAP. If alot of bone graft sometimes it will look almost like a cervical spine... then I aim for the "waist" at that level. I do not commonly perform RF on fused patients but have been doing this for awhile so the numbers just add up over time.

 

[SeniorWrangler]

How can you tell this from adjacent segment disease, which is extremely common?

 

[Timeoutofmind]

How can you tell this from adjacent segment disease, which is extremely common?

I would start with the segments above/below, and if MBB neg, do the levels of the fusion ...
But then if you are going to do SIJ (supposedly the most common cause of axial LBP after fusion) too if that fails, you are looking at three negative injections before even offering stim, which I feel is kinda brutal for the patient, and it gets kinda mucky when they get partial relief with SIJ inj, but still have ongoing pain, etc, but what can you do i guess.
What is you guys' practice?