I need cervical medial branch block and radiofrequency ablation pearls

[Ligament]

I've done thousands of cervical medial branch blocks and radiofrequency ablations. My needles go to the right place, and the final images look great. Excellent outcomes. No serious complications.

HOWEVER, I'm tired of agonizing over the patient positioning, excessive radiation exposure, and time.

I do my cervical medial branch blocks in the side lying position. That takes a good bit of time to set up properly. Should I convert to patient supine (from lateral approach) or prone (from posterior to anterior approach) to speed things up?

TON and C4 mb radiofrequency ablation frequently takes me a decent amount of time to image with patient prone and looking straight ahead. C5-7 go quickly in this position.

I've done patient prone with head rotated to contralateral side, which works nice for C4-7 but the rotation makes lateral views at TON and C4 difficult. For TON and C4, I've been toying with the idea of starting with head rotated to contralateral, placing needles down to pedicle, then manually rotating the patients head back to looking straight ahead to obtain a lateral view and advance further.

Any tips to make things more efficient appreciated.

I'm also open to ultrasound guided cervical medial branch blocks, if indeed insurance is reimbursing for them.

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[RoloTomassi]

I've done side-lying and prone, much prefer prone. Position is straightforward and more consistent.

-2 pillows under chest, chin tuck, oblique table to center SPs for true AP.

-5 deg ipsi oblique to mark your spots, go straight down toward os. Optional intermittent CLO and/or lateral shots to help confirm trajectory.

-When moderately deep, switch to lateral view, fix the wag and/or table oblique.

-Adjust cephalocaudal trajectory, advance to os and walk anteriorly.

Why do the upper ones give you a hard time prone? Those are the easiest to see on lateral. Jaw sometimes obscures on AP but not that much that you can't at least get started on AP then easily adjust on lateral. The lower ones can be tough but CLO helps with those. Not sure where your sticking point is.

 

[painfree23]

I've done side-lying and prone, much prefer prone. Position is straightforward and more consistent.

-2 pillows under chest, chin tuck, oblique table to center SPs for true AP.

-5 deg ipsi oblique to mark your spots, go straight down toward os. Optional intermittent CLO and/or lateral shots to help confirm trajectory.

-When moderately deep, switch to lateral view, fix the wag and/or table oblique.

-Adjust cephalocaudal trajectory, advance to os and walk anteriorly.

Why do the upper ones give you a hard time prone? Those are the easiest to see on lateral. Jaw sometimes obscures on AP but not that much that you can't at least get started on AP then easily adjust on lateral. The lower ones can be tough but CLO helps with those. Not sure where your sticking point is.

When do you do CLO , how much degrees to go to for the rf?

Also, what do you mean adjust the table oblique ? Do u need to do this for clo too or just straight lateral? Thanks!!

 

[paindoc007]

I second prone all day. I used to do side lying. The positioning was obnoxious and I’ll never go back.

 

[NJPAIN]

I've done thousands of cervical medial branch blocks and radiofrequency ablations. My needles go to the right place, and the final images look great. Excellent outcomes. No serious complications.

HOWEVER, I'm tired of agonizing over the patient positioning, excessive radiation exposure, and time.

I do my cervical medial branch blocks in the side lying position. That takes a good bit of time to set up properly. Should I convert to patient supine (from lateral approach) or prone (from posterior to anterior approach) to speed things up?

TON and C4 mb radiofrequency ablation frequently takes me a decent amount of time to image with patient prone and looking straight ahead. C5-7 go quickly in this position.

I've done patient prone with head rotated to contralateral side, which works nice for C4-7 but the rotation makes lateral views at TON and C4 difficult. For TON and C4, I've been toying with the idea of starting with head rotated to contralateral, placing needles down to pedicle, then manually rotating the patients head back to looking straight ahead to obtain a lateral view and advance further.

Any tips to make things more efficient appreciated.

I'm also open to ultrasound guided cervical medial branch blocks, if indeed insurance is reimbursing for them.

I’m glad I’m not the only one. In fact, I’m signed up for the SIS RF course. I did the course 20 + years ago and have done many RF since. I’m just not happy with how challenging it is and how long it takes me. Hoping to pick up some peals. Unfortunately. In these cadaveric courses you will be taught on a 80 lb edentulous specimen not the typical 200lb grandma with a mouthful of dental hardware. I agree that C2-3 is a particular challenge as the appearance of the joint seems so variable and getting a good lateral of C1 does not reliably set you up for success at C2-3.

 

[Ducttape]

i do them decubitus for upper levels 90% of the time, and for C67 and C7T1 i do them prone. the other reason to go prone for the upper levels is if i am doing bilateral. i havent tried having someone rotate their body on the table. i hear some people rotate from one lateral to another lateral position.

i use more radiation for patients prone than decubitus (on their side). for some reason, the jaw usually seems to get in the way so i use more radiation to see "through" the jaw itself or take a bunch more angulated pics. i tried turning the head CLO but started to doubt my target (that is "its not obvious so screw it, go prone"). i really have to try this method again.


lateral positioning seems that it would be uncomfortable but the patients seem to tell me they prefer that position as opposed to prone.

especially if they have a pendulous abdomen...

 

[Baron Samedi]

Agree with Duct -- side lying and lateral approach for upper levels and prone for lower for MBB.

For upper levels can often get away with just using local needle for entire procedure in thin/normal necks. I mark out the spots with a skin marker, poke down with 27G connected to tubing, take a pic or two, touch os, and inject. Withdraw and go to next level. Very quick and easy, only challenging part is getting your tech to get a "true" lateral in the side lying position.

 

[RoloTomassi]

When do you do CLO , how much degrees to go to for the rf?

40-50

Also, what do you mean adjust the table oblique ? Do u need to do this for clo too or just straight lateral? Thanks!!

Airplane the table to account for anatomic or positional rotation, so that your lateral is a true lateral and facets are lined up

 

[GoBeers]

I hate cervical RFA. Good to know that even the seasoned vets here hate them too

 

[MitchLevi]

Prone. Slight ipsi oblique. 20g 10mm tip. 80C for 90 sec.

Side lying is obnoxious and awkward bc the pt's face is exposed.

Done an untold number of them and I hate them. Least fav procedure.

Post ablation neuritis extremely common for me, to the extent that if a colleague says they rarely get it I automatically assume they're blind, lying or incompetent.

The recent article in Anesthesia journal about CRFA is fantastic. I suggest everyone read it. Feb edition.

 

[NJPAIN]

Prone. Slight ipsi oblique. 20g 10mm tip. 80C for 90 sec.

Side lying is obnoxious and awkward bc the pt's face is exposed.

Done an untold number of them and I hate them. Least fav procedure.

Post ablation neuritis extremely common for me, to the extent that if a colleague says they rarely get it I automatically assume they're blind, lying or incompetent.

The recent article in Anesthesia journal about CRFA is fantastic. I suggest everyone read it. Feb edition.

Which journal? I've searched both February Anesthesia and A&A but cant't find it. If you would be kind enough to post a PDF, you can save me $35 to download the article.

 

[bedrock]

Which journal? I've searched both February Anesthesia and A&A but cant't find it. If you would be kind enough to post a PDF, you can save me $35 to download the article.

I second the request

 

[Ligament]

Which journal? I've searched both February Anesthesia and A&A but cant't find it. If you would be kind enough to post a PDF, you can save me $35 to download the article.

I third it

 

[MitchLevi]

Wrong journal. My bad.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group | Regional Anesthesia & Pain Medicine

 

[NJPAIN]

Wrong journal. My bad.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group | Regional Anesthesia & Pain Medicine

A likely story. Saboteurs everywhere. LOL.

 

[lobelsteve]

Wrong journal. My bad.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group | Regional Anesthesia & Pain Medicine

Linked it.

 

[oreosandsake]

Prone. Slight ipsi oblique. 20g 10mm tip. 80C for 90 sec.

Side lying is obnoxious and awkward bc the pt's face is exposed.

Done an untold number of them and I hate them. Least fav procedure.

Post ablation neuritis extremely common for me, to the extent that if a colleague says they rarely get it I automatically assume they're blind, lying or incompetent.

The recent article in Anesthesia journal about CRFA is fantastic. I suggest everyone read it. Feb edition.

cooled RF in the neck seems like a poor choice

there are numerous cases of injured skin due to the large lesion size. coming in perpendicular, or PA you could get really close to the NF with the lollipop lesion

agree re the neuritis. I think the better you are at this (not tooting my own horn) the more it happens when you do the burn. I use a 20G venom needle and i think the venom and my approach has resulted into a lot of neuritis.. i stopped putting steroids after the burn 3 years ago based on some papers but might re-start due to a lot of post burn neuritis

 

[oreosandsake]

are people trying to place the active tip at the waist, or a little higher C3 and C7

I think the injectate prior and venom as well as going at the waist allow me to hug the bone and still have a large lesion. who's actually doing 4 burns per level???

 

[RoloTomassi]

are people trying to place the active tip at the waist, or a little higher C3 and C7

I think the injectate prior and venom as well as going at the waist allow me to hug the bone and still have a large lesion. who's actually doing 4 burns per level???

A little higher than waist, with both Venom prongs on os

 

[MitchLevi]

cooled RF in the neck seems like a poor choice

there are numerous cases of injured skin due to the large lesion size. coming in perpendicular, or PA you could get really close to the NF with the lollipop lesion

agree re the neuritis. I think the better you are at this (not tooting my own horn) the more it happens when you do the burn. I use a 20G venom needle and i think the venom and my approach has resulted into a lot of neuritis.. i stopped putting steroids after the burn 3 years ago based on some papers but might re-start due to a lot of post burn neuritis

I always put dex but I get neuritis very, very commonly.

This is why cervical facet edema in a young adult should be CSI x 2 and RFA on the 3rd injxn, especially if that's a young pt.

Edit - Plain Abbott needles. Above waist C3 + C4 MB, at waist C5, based off stim C6 + C7. The C8 is variable at the T1 TP in my experience, so I sweep the probe laterally along the bone.

 

[oreosandsake]

I always put dex but I get neuritis very, very commonly.

This is why cervical facet edema in a young adult should be CSI x 2 and RFA on the 3rd injxn, especially if that's a young pt.

Edit - Plain Abbott needles. Above waist C3 + C4 MB, at waist C5, based off stim C6 + C7. The C8 is variable at the T1 TP in my experience, so I sweep the probe laterally along the bone.

hmm... so do i go back to CS or no...

smart re dex... the arteries in this area NOT described in netter are astounding.

 

[MitchLevi]

hmm... so do i go back to CS or no...

smart re dex... the arteries in this area NOT described in netter are astounding.

I was going to attend a SIS cervical RF course and one of the instructors is a local guy. I got a pt of his recently and he does 80mg Depo with his MBB.

 

[RoloTomassi]

I always put dex but I get neuritis very, very commonly.

This is why cervical facet edema in a young adult should be CSI x 2 and RFA on the 3rd injxn, especially if that's a young pt.

Edit - Plain Abbott needles. Above waist C3 + C4 MB, at waist C5, based off stim C6 + C7. The C8 is variable at the T1 TP in my experience, so I sweep the probe laterally along the bone.

C8 do you search until you find twitch? If so how frequently do you find? I just place and burn even if I don't see but it's nice to see, like L5 PDR

 

[oreosandsake]

I was going to attend a SIS cervical RF course and one of the instructors is a local guy. I got a pt of his recently and he does 80mg Depo with his MBB.

why stop at 80..

80 better than 40, better than 20.. more is better?

this is the same logic that got people in trouble with opioids

as an aside, most of the data shows that more CS is not better than less. the therapeutic max is achieved at a low dose

EDIT: SIS CERVICAL RF COURSE? REALLY?

 

[Ligament]

why stop at 80..

80 better than 40, better than 20.. more is better?

this is the same logic that got people in trouble with opioids

as an aside, most of the data shows that more CS is not better than less. the therapeutic max is achieved at a low dose

EDIT: SIS CERVICAL RF COURSE? REALLY?

I think the ISIS instructors as a whole are fantastic, and I mean no criticism, but you will see ISIS guidelines admonishing IV sedation, steroid, this, that, etc and many of the instructors employ those same things in real practice. I have no issues with this but there is good reason not to take ISIS guidelines as dogma.

 

[lobelsteve]

I think the ISIS instructors as a whole are fantastic, and I mean no criticism, but you will see ISIS guidelines admonishing IV sedation, steroid, this, that, etc and many of the instructors employ those same things in real practice. I have no issues with this but there is good reason not to take ISIS guidelines as dogma.

Learn from the authors, not the instructors.

 

[DODOCSS]

Learn from the authors, not the instructors.

Huh?

 

[lobelsteve]

Huh?

Guideline authors are not usually the course instructors.

 

[MitchLevi]

C8 do you search until you find twitch? If so how frequently do you find? I just place and burn even if I don't see but it's nice to see, like L5 PDR

No. No. Never.

If I'm at T1 TP left side my needle direction is basically between 10 and 11 o'clock. Touch os inferiorly and in the medial 1-3rd of the TP. Retract and sweep towards the 10-11 direction and wind up lateral 1/3rd of TP and tip of probe 1mm superior to os.

I'd post a pic but can't recall last time I did a C8 TBH.

 

[Taus]

I cut and pasted my technique and pearls from another recent thread:

I’ve adapted mine over the years… found what really works reliably for me in terms of proper placement and visualization

-Head a little flexed on positioner, but I don’t get carried away with it.
- from true AP: enter skin 1 level caudal from target on pillar above and about 1-2cm lateral to os (except ton and c7 are directly lateral). This allows walking off os without tip deviating laterally off os
-don’t worry if you can’t perfectly see waist of each pillar and joint lines for initial placement. Just approximate for now.
-place 18g cannula driving out of plane to hit os directly medial to approx target
-go to lateral, get true lateral with wig-wag and table tilt as needed and redirect each needle to perfect trajectory aiming exactly at target mb location cephalad/caudal on respective pillar. Very easy with an 18g to redirect. Adjust all needles before taking another picture to spare radiation.
-Add more local and walk off to mb target with tip at ventral margin artic pillar. Ok if can’t see all needles below shoulders. Ideally get at least the most cephalad placed needle in position under lateral as a depth confirmation marker under clo later. As above, save rads by adjusting all visible needle tips before taking another picture
- go to clo about 45 degrees from true AP and advance the needles that weren’t visible on lateral. Posterior aspect of lamina seems to approximate depth of needle tip at ventral pillar from lateral view at 45 degrees. At minimum confirm dorsal to foramen
- if can’t see the joint lines under clo to properly place needles cephalad/caudal for each respective mb, then caudal tilt til you can see them just like a lateral view
-confirm under ap then none are deviated laterally off os
-test, local, burn x2-3

With this you don’t have to worry about shoulders blocking lower c spine and don’t worry about marginal initial visualization of precise targets in ap. Cannula will cover full length of nerve on on pillars with appropriate caudal to cephalad trajectory. Takes me 15-20 mins for 2-3 joints with 2 burns per nerve. I use venom bc I have it available in asc. Would otherwise use 18g 10mm active tip.

I also get neuritis more often then not. I find most patients aren’t too bothered by it as long as you forewarn them and provide re-assurance about transient nature. I use a little dex by convention. empirically (and by literature) no difference in rates of neuritis, but I think it helps with post-procedure pain. Old/frail/dm/extensive recent steroid use…. Skip it. They’re not the ones I see have trouble with post-op pain anyway . It’s the younger post-traumatic Cervical facet patients…. and they can more often safely tolerate the steroid IMO

 

[RoloTomassi]

No. No. Never.

If I'm at T1 TP left side my needle direction is basically between 10 and 11 o'clock. Touch os inferiorly and in the medial 1-3rd of the TP. Retract and sweep towards the 10-11 direction and wind up lateral 1/3rd of TP and tip of probe 1mm superior to os.

I'd post a pic but can't recall last time I did a C8 TBH.

Ok sounds like what I do. When you said sweep I thought you meant you were moving around looking for it

 

[NJPAIN]

I cut and pasted my technique and pearls from another recent thread:

I’ve adapted mine over the years… found what really works reliably for me in terms of proper placement and visualization

-Head a little flexed on positioner, but I don’t get carried away with it.
- from true AP: enter skin 1 level caudal from target on pillar above and about 1-2cm lateral to os (except ton and c7 are directly lateral). This allows walking off os without tip deviating laterally off os
-don’t worry if you can’t perfectly see waist of each pillar and joint lines for initial placement. Just approximate for now.
-place 18g cannula driving out of plane to hit os directly medial to approx target
-go to lateral, get true lateral with wig-wag and table tilt as needed and redirect each needle to perfect trajectory aiming exactly at target mb location cephalad/caudal on respective pillar. Very easy with an 18g to redirect. Adjust all needles before taking another picture to spare radiation.
-Add more local and walk off to mb target with tip at ventral margin artic pillar. Ok if can’t see all needles below shoulders. Ideally get at least the most cephalad placed needle in position under lateral as a depth confirmation marker under clo later. As above, save rads by adjusting all visible needle tips before taking another picture
- go to clo about 45 degrees from true AP and advance the needles that weren’t visible on lateral. Posterior aspect of lamina seems to approximate depth of needle tip at ventral pillar from lateral view at 45 degrees. At minimum confirm dorsal to foramen
- if can’t see the joint lines under clo to properly place needles cephalad/caudal for each respective mb, then caudal tilt til you can see them just like a lateral view
-confirm under ap then none are deviated laterally off os
-test, local, burn x2-3

With this you don’t have to worry about shoulders blocking lower c spine and don’t worry about marginal initial visualization of precise targets in ap. Cannula will cover full length of nerve on on pillars with appropriate caudal to cephalad trajectory. Takes me 15-20 mins for 2-3 joints with 2 burns per nerve. I use venom bc I have it available in asc. Would otherwise use 18g 10mm active tip.

I also get neuritis more often then not. I find most patients aren’t too bothered by it as long as you forewarn them and provide re-assurance about transient nature. I use a little dex by convention. empirically (and by literature) no difference in rates of neuritis, but I think it helps with post-procedure pain. Old/frail/dm/extensive recent steroid use…. Skip it. They’re not the ones I see have trouble with post-op pain anyway . It’s the younger post-traumatic Cervical facet patients…. and they can more often safely tolerate the steroid IMO

You need to make another video on this technique. My compliments; the other two videos were very well done.

 

[bedrock]

You need to make another video on this technique. My compliments; the other two videos were very well done.

I second that idea.

And I want to see the other two videos too. Taus, can you please post them again?

 

[Orin]

Prone with a lateral approach, get the best of both worlds and can do a true prone approach for the deeper ones if visualization sucks. Mark out the lateral border of the pillar line with the C-arm in an AP orientation, rotate to lateral and align/shift the neck to optimize view.

What're y'all calling "neuritis"

 

[deleted875186]

I cut and pasted my technique and pearls from another recent thread:

I’ve adapted mine over the years… found what really works reliably for me in terms of proper placement and visualization

-Head a little flexed on positioner, but I don’t get carried away with it.
- from true AP: enter skin 1 level caudal from target on pillar above and about 1-2cm lateral to os (except ton and c7 are directly lateral). This allows walking off os without tip deviating laterally off os
-don’t worry if you can’t perfectly see waist of each pillar and joint lines for initial placement. Just approximate for now.
-place 18g cannula driving out of plane to hit os directly medial to approx target
-go to lateral, get true lateral with wig-wag and table tilt as needed and redirect each needle to perfect trajectory aiming exactly at target mb location cephalad/caudal on respective pillar. Very easy with an 18g to redirect. Adjust all needles before taking another picture to spare radiation.
-Add more local and walk off to mb target with tip at ventral margin artic pillar. Ok if can’t see all needles below shoulders. Ideally get at least the most cephalad placed needle in position under lateral as a depth confirmation marker under clo later. As above, save rads by adjusting all visible needle tips before taking another picture
- go to clo about 45 degrees from true AP and advance the needles that weren’t visible on lateral. Posterior aspect of lamina seems to approximate depth of needle tip at ventral pillar from lateral view at 45 degrees. At minimum confirm dorsal to foramen
- if can’t see the joint lines under clo to properly place needles cephalad/caudal for each respective mb, then caudal tilt til you can see them just like a lateral view
-confirm under ap then none are deviated laterally off os
-test, local, burn x2-3

With this you don’t have to worry about shoulders blocking lower c spine and don’t worry about marginal initial visualization of precise targets in ap. Cannula will cover full length of nerve on on pillars with appropriate caudal to cephalad trajectory. Takes me 15-20 mins for 2-3 joints with 2 burns per nerve. I use venom bc I have it available in asc. Would otherwise use 18g 10mm active tip.

I also get neuritis more often then not. I find most patients aren’t too bothered by it as long as you forewarn them and provide re-assurance about transient nature. I use a little dex by convention. empirically (and by literature) no difference in rates of neuritis, but I think it helps with post-procedure pain. Old/frail/dm/extensive recent steroid use…. Skip it. They’re not the ones I see have trouble with post-op pain anyway . It’s the younger post-traumatic Cervical facet patients…. and they can more often safely tolerate the steroid IMO

I started doing this technique after reading, seems very reliable, starting inferior and lateral and driving to hit posterior articulated pillar and then walk off in lateral tends to usually give a good trajectory.

I also see neuritis cervical much more than lumbar, I use steroid in all RFAs. Usually call neuritis increased sharp pain in the neck, sunburn like sensation, etc, usually patient describing aching different than their typical joint pain, but maybe it’s just post procedure discomfort. I doubt it though, I use a 20G in the neck compared to 18G in the back, and nobody ever complains after lumbar RFA.

 

[MitchLevi]

Prone with a lateral approach, get the best of both worlds and can do a true prone approach for the deeper ones if visualization sucks. Mark out the lateral border of the pillar line with the C-arm in an AP orientation, rotate to lateral and align/shift the neck to optimize view.

What're y'all calling "neuritis"

Last sentence is exactly what I'm talking about earlier...Not sure how you miss it.

Neuritis is a very obvious condition when you ablate someone and for 3-6 weeks they have hypersensitivity in the shower and don't like anything touching their neck.

It usually lasts 3-6 weeks but I've had a handful of pts get it for months. MONTHS!

 

[RoloTomassi]

A little off topic but I used to do b/l C2-3 RFA, never had balance issues, but then switched to uni 2 weeks apart to be on the safe side.

If it takes 6-12 months for nerve regeneration, shouldn't you theoretically have to wait that long before doing the other side?

 

[drrosenrosen]

Looking at the article, a couple of things that stand out from the way I practice:
1. Recommending <0.3ml volume for MBB - I usually use 0.5ml
2. Recommending placing the needle in the posterior 2/3 of the C2-3 joint for TON RF. I have traditionally placed it anteriorly, which the article reports puts the VA in play.
3. Recommending sensory stim

I will probably change these aspects of my practice (especially needle placement on TON)

 

[MitchLevi]

Looking at the article, a couple of things that stand out from the way I practice:
1. Recommending <0.3ml volume for MBB - I usually use 0.5ml
2. Recommending placing the needle in the posterior 2/3 of the C2-3 joint for TON RF. I have traditionally placed it anteriorly, which the article reports puts the VA in play.
3. Recommending sensory stim

I will probably change these aspects of my practice (especially needle placement on TON)

I've been doing posterior half of the C2-3 for years. No appreciable difference in outcomes.

 

[oreosandsake]

I think the ISIS instructors as a whole are fantastic, and I mean no criticism, but you will see ISIS guidelines admonishing IV sedation, steroid, this, that, etc and many of the instructors employ those same things in real practice. I have no issues with this but there is good reason not to take ISIS guidelines as dogma.

Yes, on the whole they are great. and I expect the SIS instructors as physicians to adhere to the highest standards.

but a lot of things become very dogmatic... "the medial br is in the middle 2/5 up the wall of the SAP"

I did not know that I was doing cervical rfa wrong the whole time. i guess i was supposed to be doing 4 lesions per level?

"Do as I say, not as I do." - the pharisees

 

[oreosandsake]

A little off topic but I used to do b/l C2-3 RFA, never had balance issues, but then switched to uni 2 weeks apart to be on the safe side.

If it takes 6-12 months for nerve regeneration, shouldn't you theoretically have to wait that long before doing the other side?

I think the point is to wait some time to see if it even happens. if you develop issues, like head drop etc would you consider doing the other side

 

[RoloTomassi]

I think the point is to wait some time to see if it even happens. if you develop issues, like head drop etc would you consider doing the other side

But I don't think there's any risk of head drop or balance issues if doing uni since the other side compensates, so it wouldn't be a predictor

 

[Ligament]

I had a patietn who I thought was deveoping head drop about 5 years ago. I did a thourough review of the literature at that time. I think the total number of head drop cases reported was around 13 or something...maybe less. So extremely rare.

 

[clubdeac]

I had a patietn who I thought was deveoping head drop about 5 years ago. I did a thourough review of the literature at that time. I think the total number of head drop cases reported was around 13 or something...maybe less. So extremely rare.

Got a mild case of it 5 years ago after a bilateral 4 level burn with 18g. Fortunately it resolved with time

 

[MitchLevi]

Got a mild case of it 5 years ago after a bilateral 4 level burn with 18g. Fortunately it resolved with time

Nearly impossible to burn anything other than 2 levels in today's world, so this shouldn't ever be a problem.

 

[clubdeac]

Nearly impossible to burn anything other than 2 levels in today's world, so this shouldn't ever be a problem.

Well technically it was 3 levels but 4 burns. But yeah I agree with how things have changed

 

[soxman]

I've been using this technique for cervical MBB RFAs lately and has had good results with no neuritis yet. Suggested to me by one of my previous attendings.

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

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...

www.cureus.com

 

[bedrock]

Nearly impossible to burn anything other than 2 levels in today's world, so this shouldn't ever be a problem.

In my neck of the woods I can still do 3 joint RFA on WC and all commercial patients except BCBS. Limited to just two joints on Medicare and BCBS patients.

However, clinically I most often need to do 3 joint RFA on Medicare patients, not commercial patients.

System is backwards.

 

[callmeanesthesia]

I've been using this technique for cervical MBB RFAs lately and has had good results with no neuritis yet. Suggested to me by one of my previous attendings.

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

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...

www.cureus.com

If that works, it would be great for the people who like to do their facet procedures from the lateral - you could put one needle per level, parallel to the back edge of the facet joint, from medial to lateral.
Can only do one level bilateral at a time if you’re doing it bipolar though, right? Good technique for patients with AICDs though.

 

[MitchLevi]

In my neck of the woods I can still do 3 joint RFA on WC and all commercial patients except BCBS. Limited to just two joints on Medicare and BCBS patients.

However, clinically I most often need to do 3 joint RFA on Medicare patients, not commercial patients.

System is backwards.

Most Medicare pts referred to me need L3-S1 facet denervation for axial back pain. I am usually just billing L4-S1 and giving them a free needle.

I once did a P2P for an SIJ and was told by a guy in NYC to bill an L5-S1 MBB, get paid for the MBB and do a free SIJ CSI.

I laughed at him...Still did what he recommended too.