I need cervical medial branch block and radiofrequency ablation pearls

[SC Tian]

I use Dreyfuss technique at TON, and have very little TON neuritis.

1- most importantly only do 60 second lesions at TON.
2- second most important, use 70 degrees for lesion. I still report it as 80 degrees, just like I call all SIJ issues sacroilitis because bean counters are not physicians.
3- I add 10mg of kenalog after the lesion.

Very rare TON neuritis that way.

Other factor causing neuritis maybe rfa machine, i used to use stryker venom, rare and mild neuritis, now cheaper Abbott machine more neuritis; my partner did cervical rfa for years, he rarely has any, we shared one NP, that is her observation as well, we reviewed imaging side by side, location of needle tip placement may be related to the incidence of neuritis, imo.

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[bedrock]

You do two needle? One immediately inferior and one superior at 60s 70C?

I use two needles, but do this via one sagittal and one oblique pass at TON.

This the only level I do it this way.

Lower temp and shorter burn time does impact successful RFA, so I move my C3 cannula to TON, and burn once for 60 seconds. As that burns I remove the C4 cannula, and come directly perpendicular to C2-C3 for second burn with that cannula (that was previously at C4).

 

[bedrock]

I used to. I found it didn't change my management much. Almost all the vascular ones had blood backflow in the hub. So now if I see backflow I adjust. I do bilateral often, one side then the other, and didn't like how it muddied up the lateral for the second side.

Do you do contrast for lumbar?

Not just an issue of vascular uptake. Sometimes your needle placement looks 95% perfect but the contrast spreads somewhere else besides the MBB. Both cervical and lumbar.

Dreyfus and I repeated MBB on many failed RFA patients, and a very large amount of them failed our MBB, so they shouldn’t have even undergone RFA. The other common scenario was patients who did pass our repeat MBB, then achieved at least 50% relief after a proper (not sloppy) RFA.

Bottom line is—-The vast majority of patients who fail RFA, had either sloppy MBB, or sloppy RFA.

 

[MitchLevi]

Other factor causing neuritis maybe rfa machine, i used to use stryker venom, rare and mild neuritis, now cheaper Abbott machine more neuritis; my partner did cervical rfa for years, he rarely has any, we shared one NP, that is her observation as well, we reviewed imaging side by side, location of needle tip placement may be related to the incidence of neuritis, imo.

Neurotherm here...I've thought about this.

 

[HyperSonic]

Since I joined a new group about 3 years ago, I did most of cervical rfa in the practice. Initially I had quite common post-rfa neuritis, compared to my previous practice when I was using striker machine. i tried different options to reduce neuritis, from 18 g to 20 g, from 80 c to 70c, from 90 secs to 60 secs, two lesions to one lesion, the final Results from my trial is 60 secs with much infrequent neuritis, followed one to 2 years, the relief is sustained.
I use prone position for rfa, go from 15, 30, 45 and 60 degree clo to guide needle insertion and final needle placement, most procedures are done in 5-10 mins. Just my two cents.

What is “final needle placement” for you in AP, CLO 15, 30, 45, 60 and lateral?

 

[HyperSonic]

Other factor causing neuritis maybe rfa machine, i used to use stryker venom, rare and mild neuritis, now cheaper Abbott machine more neuritis; my partner did cervical rfa for years, he rarely has any, we shared one NP, that is her observation as well, we reviewed imaging side by side, location of needle tip placement may be related to the incidence of neuritis, imo.

So what’s the difference in the needle tip location with your and her placement?

 

[SC Tian]

So what’s the difference in the needle tip location with your and her placement?

My partner puts needle more superficial than my placement, now i changed to 60 clo to laminar line from 45 clo🤔

 

[HyperSonic]

My partner puts needle more superficial than my placement, now i changed to 60 clo to laminar line from 45 clo

How close to lamina do you come in 60 clo? Do you have pictures by any chance?

 

[MitchLevi]

Recent one of mine. I rotate the needle 180 degrees at the halfway point of the burn. This angle may not be the best, but here's the lateral view to go with it for perspective. BTW, lateral view good here to show one lateral view isn't lateral for all cervical levels.

 

[soccrwz]

Recent one of mine. I rotate the needle 180 degrees at the halfway point of the burn. This angle may not be the best, but here's the lateral view to go with it for perspective. BTW, lateral view good here to show one lateral view isn't lateral for all cervical levels.
View attachment 353268

View attachment 353269

Whats your angle?

 

[MitchLevi]

Whats your angle?

?

No idea. I don't adhere to a specific angle bc it doesn't always work out the same for every neck.

 

[SC Tian]

?

No idea. I don't adhere to a specific angle bc it doesn't always work out the same for every neck.

Imo, the foramens are so large, likely 40-50 degree, for different levels of spine, facet orientation is different, therefore the shapes at the same angle can be different. The reason i choose a set of angles is it is more operable for xray tech to do, they like concise orders.

 

[epidural man]

I'm interested in using CLO view for cervical RF placement. But I don't quit get it. Can someone who uses CLO post some pics?

 

[epidural man]

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.

This speeds things up a little.

While prone, get a lateral, and place 27G needles as if you are doing a medial branch block (en face placement with tip in the center of the pillar or C2/3 joint line). Then when placing the RF needles from prone, just head for the tip of your 27g needles.

I don't really understand why it helps so much, but placement seems much faster and accurate (less needle manipulation after initial placement).

 

[Taus]

I'm interested in using CLO view for cervical RF placement. But I don't quit get it. Can someone who uses CLO post some pics?

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

 

[SC Tian]

 

[SC Tian]

Here is one case I did lately, big guy 30, 45 and 60 degree clo, just fyi.

 

[Ferrismonk]

I’m thinking of streamlining my MBBs significantly after this thread. Going to abandon contrast - if I get a false negative due to vascular uptake then the patient can get a “tie breaker.” Frequency of the contrast totally disappearing despite negative aspiration is very low. In the cervical, even 0.3 mL spreads so far an adjacent level will probably cover it, and in the lumber there’s less vascularity and that’s even less common
Also going to modify targets. Currently for cervical I walk the needle off the lateral edge. Instead, looking at anatomy diagrams, it should be adequate to just touch down on the lateral third of the articular waist, right where the “MB” lines touch on the diagram below. This will be lower risk and faster. No need to check a lateral if the needle tip is on bone.
View attachment 353082

At the risk of getting scorn here, this is very similar to what I do.

My patients lie prone, I use 25G quinkes and advance in AP view until needle tips touch bone along the lateral edge of the posterior articular pillar. I walk lateral until needle tip either just falls off bone or is right at the edge, then inject there. Local only. I get good results on my MBB with this technique.

RF is similar (using 20G, 10mm curved tip), but I'll start a little more medial do more effort to make sure needle tip is parallel to nerve. If I'm walking off edge, I'll rotate my needle to hug the pillar better. Motor test, inject local only, then burn. 60s at 80C. Neuritis is rare and relief is good.

 

[RoloTomassi]

A modified approach I've been thinking about is, instead of doing the traditional way like Mitch (posterior approach, tip along the lateral waist, cephalad angle/parallel with nerve), if a posterior but more PERPENDICULAR approach would account for anatomic variability better.

In the pic below, the red lesion would hit all three yellow anatomic variations, but a parallel approach may miss. Probably won't last as long, as the nerve segment burned would be shorter, but seems like it could have higher efficacy.

 

[clubdeac]

A modified approach I've been thinking about is, instead of doing the traditional way like Mitch (posterior approach, tip along the lateral waist, cephalad angle/parallel with nerve), if a posterior but more PERPENDICULAR approach would account for anatomic variability better.

In the pic below, the red lesion would hit all three yellow anatomic variations, but a parallel approach may miss. Probably won't last as long, as the nerve segment burned would be shorter, but seems like it could have higher efficacy.

View attachment 353319

you could get a great burn doing it that way if you used coolief and had big balls

 

[nvrsumr]

Big necks and C 7, 8 I do prone. inject contrast after walking 25g needle tip off lateral edge in AP. If contrast isn’t along lateral border but obscures dorsal articulate pillar I advance and reinject contest til I get the pattern.

For skinny necks lateral decubitus and use 27g 1 1/2 to center of trapezoid, touch os and injected contrast

Gonna stop contrast for the latter group. Never used contrast until a few years ago reading on this board that cms required.

For rf use 22g. start bit less than a level below and 1 cm lateral to border in AP. Advance to os and then go lateral. For big necks cone and adjust contrast til I see the cannula tip. Infrequently will check a 45 clo if really suboptimal. Don’t trust my clo view for placement but as a safety check. 90 for 60 seconds

 

[MitchLevi]

A modified approach I've been thinking about is, instead of doing the traditional way like Mitch (posterior approach, tip along the lateral waist, cephalad angle/parallel with nerve), if a posterior but more PERPENDICULAR approach would account for anatomic variability better.

In the pic below, the red lesion would hit all three yellow anatomic variations, but a parallel approach may miss. Probably won't last as long, as the nerve segment burned would be shorter, but seems like it could have higher efficacy.

View attachment 353319

I've done a similar modified approach several yrs ago. Don't recall how it went though.

Basically it was in the lateral position with a big oblique approach. Touch posterior aspect of target and walk anterior.

 

[SC Tian]

A modified approach I've been thinking about is, instead of doing the traditional way like Mitch (posterior approach, tip along the lateral waist, cephalad angle/parallel with nerve), if a posterior but more PERPENDICULAR approach would account for anatomic variability better.

In the pic below, the red lesion would hit all three yellow anatomic variations, but a parallel approach may miss. Probably won't last as long, as the nerve segment burned would be shorter, but seems like it could have higher efficacy.

View attachment 353319

Any evidence to support the longer the nerve burnt, the longer the relief lasts? One lesion will make the distal nerve dead, time of regeneration is determined by length of lesion? I saw people over one year relief from lateral approach.

 

[RoloTomassi]

Any evidence to support the longer the nerve burnt, the longer the relief lasts? One lesion will make the distal nerve dead, time of regeneration is determined by length of lesion? I saw people over one year relief from lateral approach.

Good point, I don't know if there is science behind that

 

[callmeanesthesia]

Wow, eliminating contrast from MBBs saves a lot of time and fluoro shots. Might even be able to add in another procedure per half day.

 

[lobelsteve]

Good point, I don't know if there is science behind that

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group | Regional Anesthesia & Pain Medicine

Science reviewed here.

 

[SC Tian]

Good point, I don't know if there is science behind that

 

[SC Tian]

View attachment 353383

Lateral approach for this one, over one year 🥲

 

[deleted875186]

Lateral approach for this one, over one year 🥲

Can you explain how yoj do a lateral approach? Also, the X-ray looks like it’s some sort of oblique view? But hard to tell with all the hardware in the way.

 

[SC Tian]

Can you explain how yoj do a lateral approach? Also, the X-ray looks like it’s some sort of oblique view? But hard to tell with all the hardware in the way.

Just like lateral approach mbb described from this thread, starting from the back, walking to the front. For this case prone is very difficult due to hardware, this is oblique view trying to separate hardwares from both sides. Imo.

 

[MitchLevi]

View attachment 353383

What's happening here? Is that 3 needles? Nasty neck.

 

[SC Tian]

What's happening here? Is that 3 needles? Nasty neck.

 

[SC Tian]

From sis book

 

[MitchLevi]

You're doing a 3 needle C2-3.

Ever done a bipolar C2-3 with two needles?

 

[SC Tian]

You're doing a 3 needle C2-3.

Ever done a bipolar C2-3 with two needles?

From lateral approach, only tips are on the Os, bipolar more from posterior approach is what I understand, as we normally do not bipolar lesion of soft tissue🤔

 

[oneforfighting]

So is consensus to burn for 60 seconds to reduce incidence of neuritis? 120 seconds if you do two lesions? Haven't done too many cervical RF's as an attending yet.

 

[lobelsteve]

So is consensus to burn for 60 seconds to reduce incidence of neuritis? 120 seconds if you do two lesions? Haven't done too many cervical RF's as an attending yet.

I do not buy that line of thinking.
Anyone got evidence for this and not anecdotes?

Lesion size: temp, time, probe size.
Neuritis: unsure if we have any good data, and we all think upper C-spine is more likely to get this.

 

[MitchLevi]

So is consensus to burn for 60 seconds to reduce incidence of neuritis? 120 seconds if you do two lesions? Haven't done too many cervical RF's as an attending yet.

Debatable topic.

It is clear (to me at least) a 20g needle with meticulous placement will completely lesion the C3-7 medial branch nerves (TON and C8 are different IMO) in 60sec at 80C. This procedure is reliably effective at C3-7.

What isn't clear (to me at least) is whether or not neuritis risk increases bc of (a) a complete burn, an (b) under treated nerve, or (c) something else.

You could theoretically cause neuritis by a huge lesion covering lots of real estate, or you could merely piss that off bc your needles are placed poorly and as your lesion grows with time you only manage to catch the nerve for the final 20 sec or so. No legit lesion, just angry nerve.

The reality is probably in the middle...There is a likely a sweet spot where adequate thermal destruction occurs and neuritis is less likely, but it also depends on which nerve you're talking about.

If I do a TON burn, that pt will get neuritis bc that nerve has cutaneous branches FFS. So, when ppl come in here saying they don't get it, I have to Q their input bc there are known cutaneous branches off the TON so if you lesion it there will be...in most cases...Some form of superficial sensory change.

C8 placement is variable IMO. Less reliable RFA, probably bc of technique on avg. I've had some C7-T1 joint RFA go very well. I have an old football coach I ablate every 1.5 yrs of so. C6-T1.

 

[deleted875186]

How are people deciding which levels to attempt for a cervical MBB??

C6-7 and C7-T1 as noted above, can’t say I’ve every treated that joint combo before.

 

[MitchLevi]

How are people deciding which levels to attempt for a cervical MBB??

C6-7 and C7-T1 as noted above, can’t say I’ve every treated that joint combo before.

Severe facet dz with concordant referral in that pt, but in general I go off referral pattern. Sometimes I just use MRI or XRAY imaging to choose levels, and yes I know to treat the pt not the picture.

Most of mine are either C3-5 or C4-6 unless I'm doing C2-3, in which case I'm doing either C2-4 or C2-5.

 

[bedrock]

How are people deciding which levels to attempt for a cervical MBB??

C6-7 and C7-T1 as noted above, can’t say I’ve every treated that joint combo before.

as a rule with considering MBB, you should try to first identify the worst facet joint level, (mostly likely to respond to MBB), and then think decide which is the second worst facet joint level. That decision should be made by 1- imaging findings, 2- biomechanics, and 3- a level by level careful physical exam of the facet joints in the spine area you are treating.

As we recently discussed, if we are talking about bilateral RFA, which is most common, then medicare and BCBS, which compromise over 70% of all patients, only allow 2 joint levels to be treated.
Also important to remember that many insurances will not let you do MBB 3-4 different joints on 3-4 different occasions, so you always want to target two bilateral joints, and never just one bilateral joint.

Consider the practical issues.
1-If you do just the worst joint, and the second worst joint is only responsible for 15% of the pain, you'll still have a fairly happy patient getting 65% relief, but they could be getting 80% if you did them both.
2- most insurances will not let you repeat RFA/MBB very soon afterwards to go after the second worst joint, so you might was well include it right away.
3- over time, the second worst joint will become more painful, and you'll have to convince your patient after 5 years to do another set of MBB, which some patients don't appreciate.

I would definitely recommend you first consider facet joint referral patterns, imaging findings, and exam....but after that, you should consider--

Re cervical MBB.
1-If you're worried about facet driven cervicogenic headache, then of course you target C2-C3, but I'd also do C3-C4.
2-if someone has a C5-C6 ACDF and they have equal pain in mid and lower neck, then target C4-C5, C6-C7,
2a- if the patient with C5-C6 ACDF has dramatically worsened pain inferior to fusion then targeting C6-C7, C7-T1 is reasonable. There is likely only a small component from C7-T1, but even that extra 10% relief is appreciated. And that patient listed above who is a old football coach, likely got his neck hyperextended many times on the field, and so has more C7-T1 facet pathology than most.
3- If Patient has C5-C7 ACDF, and most of their pain appears to be superior to fusion, then do C3-C5 MBB.

Same thing for lumbar. A patients s/p L4-L5 fusion, gets mbb at L3-L4, L5-S1 facets from me, unless over 95% of their pain is inferior to fusion , and the L5-S1 facets look dramatically worse than the L3-L4, in which case I'd just do L5-S1. If fused at L5-S1, then I'd target the L3-L4, L4-L5 facet joints, but be certain to remember the SIJ, if the patient fails the MBB for L3-L4, L4-L5.

Also remember than in the unfused spine, that
1-L4-L5 facet joint is always involved
2- if lower neck pain, then always include C5-C6, which is the most common level affected in the neck
3- If upper neck pain that includes a headache component, then always include the C2-C3 level, which is the second most affected level overall in the neck, though this is bogduk data, which skews towards trauma, as there are more C2-C3 issues after trauma, then just regular chronic facet OA.

 

[deleted875186]

as a rule with considering MBB, you should try to first identify the worst facet joint level, (mostly likely to respond to MBB), and then think decide which is the second worst facet joint level. That decision should be made by 1- imaging findings, 2- biomechanics, and 3- a level by level careful physical exam of the facet joints in the spine area you are treating.

As we recently discussed, if we are talking about bilateral RFA, which is most common, then medicare and BCBS, which compromise over 70% of all patients, only allow 2 joint levels to be treated.
Also important to remember that many insurances will not let you do MBB 3-4 different joints on 3-4 different occasions, so you always want to target two bilateral joints, and never just one joint.

Consider the practical issues.
1-If you do just the worst joint, and the second worst joint is only responsible for 15% of the pain, you'll still have a fairly happy patient getting 65% relief, but they could be getting 80% if you did them both.
2- most insurances will not let you repeat RFA/MBB very soon afterwards to go after the second worst joint, so you might was well include it right away.
3- over time, the second worst joint will become more painful, and you'll have to convince your patient after 5 years to do another set of MBB, which some patients don't appreciate.

I would definitely recommend you first consider facet joint referral patterns, imaging findings, and exam....but after that, you should consider--

Re cervical MBB.
1-If you're worried about facet driven cervicogenic headache, then of course you target C2-C3, but I'd also do C3-C4.
2-if someone has a C5-C6 ACDF and they have equal pain in mid and lower neck, then target C4-C5, C6-C7,
2a- if the patient with C5-C6 ACDF has dramatically worsened pain inferior to fusion then targeting C6-C7, C7-T1 is reasonable. There is likely only a small component from C7-T1, but even that extra 10% relief is appreciated. And someone who was a old football coach, likely got his neck hyperextended many times on the field, and so has more C7-T1 facet pathology than most.
3- If Patient has C5-C7 ACDF, and most of their pain appears to be superior to fusion, then do C3-C5 MBB.

Same thing for lumbar. A patients s/p L4-L5 fusion, gets mbb at L3-L4, L5-S1 facets from me, unless over 95% of their pain is inferior to fusion , and the L5-S1 facets look dramatically worse than the L3-L4, in which case I'd just do L5-S1.

Also remember than in the unfused spine, that
1-L4-L5 facet joint is always involved
2- if lower neck pain, then always include C5-C6, which is the most common level affected in the neck
3- If upper neck pain that includes a headache component, then always include the C2-C3 level, which is the second most affected level overall in the neck, though this is bogduk data, which skews towards trauma, as there C2-C3 issues after trauma, then just regular chronic facet OA.

I’m typically going by referral pattern of pain and correlating with imaging, will typically try to do most common joints like C5-6, and will do above or below a fusion.

What do you mean by level by level physical exam? Not sure I really get much from examining the neck rather than asking patients where they are felling symptoms.

 

[bedrock]

I’m typically going by referral pattern of pain and correlating with imaging, will typically try to do most common joints like C5-6, and will do above or below a fusion.

What do you mean by level by level physical exam? Not sure I really get much from examining the neck rather than asking patients where they are felling symptoms.

Something I learned from Paul Dreyfuss.

I learned to palpate each specific facet joint level, both posteriorly and laterally. I can distinguish C4-C5 from C5-C6 and C3-C4 from C4-C5, C2-C3 from C3-C4, etc.

Very useful skill to further clarify pain generators when imaging and/or or pain referral patterns don't give you the answer.

The lateral joint line palpation is also more accurate in many patients who have overlapping myofascial pain, and they can give more concrete answers during your exam.

 

[RoloTomassi]

as a rule with considering MBB, you should try to first identify the worst facet joint level, (mostly likely to respond to MBB), and then think decide which is the second worst facet joint level. That decision should be made by 1- imaging findings, 2- biomechanics, and 3- a level by level careful physical exam of the facet joints in the spine area you are treating.

As we recently discussed, if we are talking about bilateral RFA, which is most common, then medicare and BCBS, which compromise over 70% of all patients, only allow 2 joint levels to be treated.
Also important to remember that many insurances will not let you do MBB 3-4 different joints on 3-4 different occasions, so you always want to target two bilateral joints, and never just one joint.

Consider the practical issues.
1-If you do just the worst joint, and the second worst joint is only responsible for 15% of the pain, you'll still have a fairly happy patient getting 65% relief, but they could be getting 80% if you did them both.
2- most insurances will not let you repeat RFA/MBB very soon afterwards to go after the second worst joint, so you might was well include it right away.
3- over time, the second worst joint will become more painful, and you'll have to convince your patient after 5 years to do another set of MBB, which some patients don't appreciate.

I would definitely recommend you first consider facet joint referral patterns, imaging findings, and exam....but after that, you should consider--

Re cervical MBB.
1-If you're worried about facet driven cervicogenic headache, then of course you target C2-C3, but I'd also do C3-C4.
2-if someone has a C5-C6 ACDF and they have equal pain in mid and lower neck, then target C4-C5, C6-C7,
2a- if the patient with C5-C6 ACDF has dramatically worsened pain inferior to fusion then targeting C6-C7, C7-T1 is reasonable. There is likely only a small component from C7-T1, but even that extra 10% relief is appreciated. And that patient listed above who is a old football coach, likely got his neck hyperextended many times on the field, and so has more C7-T1 facet pathology than most.
3- If Patient has C5-C7 ACDF, and most of their pain appears to be superior to fusion, then do C3-C5 MBB.

Same thing for lumbar. A patients s/p L4-L5 fusion, gets mbb at L3-L4, L5-S1 facets from me, unless over 95% of their pain is inferior to fusion , and the L5-S1 facets look dramatically worse than the L3-L4, in which case I'd just do L5-S1. If fused at L5-S1, then I'd target the L3-L4, L4-L5 facet joints, but be certain to remember the SIJ, if the patient fails the MBB for L3-L4, L4-L5.

Also remember than in the unfused spine, that
1-L4-L5 facet joint is always involved
2- if lower neck pain, then always include C5-C6, which is the most common level affected in the neck
3- If upper neck pain that includes a headache component, then always include the C2-C3 level, which is the second most affected level overall in the neck, though this is bogduk data, which skews towards trauma, as there are more C2-C3 issues after trauma, then just regular chronic facet OA.

Spot on, this is how I do the vast majority.

Occasionally, I'll get something like C5-6 severe DDD and facet arthropathy, but they also have upper cervical pain/cervicogenic headaches/C2-3 arthropathy, and I'll do bilateral C2-3, C5-6.

Or if they have severe b/l C2-6 facet arthropathy but 70/30 or greater unilateral predominance I'll do 3-level uni rather than 2-level b/l.

In lumbar, if L3-4 disc is darker than L5-S1, facets are equally arthritic, and pain is not in buttocks, I'll do L3-5, but otherwise usually L4-S1.

Other imaging indicator other than arthropathy or DDD, is segment of peak reversal of lordosis or scoliosis.

If I can't tell based on imaging and history, I'll usually palpate under fluoro and adjust my levels accordingly, especially with thoracic with normal MRI.

 

[lobelsteve]

Something I learned from Paul Dreyfuss.

I learned to palpate each specific facet joint level, both posteriorly and laterally. I can distinguish C4-C5 from C5-C6 and C3-C4 from C4-C5, C2-C3 from C3-C4, etc.

Very useful skill to further clarify pain generators when imaging and/or or pain referral patterns don't give you the answer.

The lateral joint line palpation is also more accurate in many patients who have overlapping myofascial pain, and they can give more concrete answers during your exam.

That's funny. You (and Paul) think your exam is that accurate.
Nik: "Only the needle knows."

 

[epidural man]

I do not buy that line of thinking.
Anyone got evidence for this and not anecdotes?

Lesion size: temp, time, probe size.
Neuritis: unsure if we have any good data, and we all think upper C-spine is more likely to get this.

Totally agree.

Tissue damage at 45C. Dead nerve at 60C. Dead nerve at 80C.

Neuritis is highly likely from a dead nerve (makes sense since everything we know about cutting nerves and neuritis concludes this way).

So the reason to do 80C is to increase lesion size which increases probability of a good treatment.

Medial branches innervate a patch of the skin in lumbar region. I don't know about in the cervical region. TON clearly innervates part of the skin. I'm disappointed when I DON'T get a neuritis. That sunburn feeling always resolves, and proves a great burn of the nerve you were seeking.

Although, unlike you all, I rarely do RFA in the neck. Most treatment is pulsed RF.

 

[epidural man]

I have always found duration of pain relief after peripheral nerve blocks fascinating. Just look at a Supraclavicular block with plain bupi, 12-14 hours, but a femoral, usually 24 hours pretty consistently, epidural bolus with bupi only a couple hours, seems to matter where yojr blocking the nerve and maybe how fast the medicine is absorbed from the site.

Once on call, I had the worst canker of all cankers - at the base of the tongue at the corner of the floor of my mouth, so every motion hurt. It was MISARABLE. It was so bad, that I injected myself (lido with epi) and the relief was the most beautiful experience I've ever had in my life. I would have taken that over an orgasm with Catherine Zeta-Jones right after she filmed the scene with her sliding under the lasers in the movie Entrapement (holy crap..if you haven't seen it...I suggest watch). Anyway, it lasted 5 MINUTES!!! I was pissed.

So I tried bupivicaine with epi. That lasted a whopping 40 minutes.

It was extremely difficult to inject myself by the way.

 

[SC Tian]

I do not buy that line of thinking.
Anyone got evidence for this and not anecdotes?

Lesion size: temp, time, probe size.
Neuritis: unsure if we have any good data, and we all think upper C-spine is more likely to get this.

Here is my opinion, just for discussion, clinical anecdotes always come first, if anything clinically Important, it may worth more clinical research of some sorts. Our pain practice is so diversified, it is even so for cervical rfa. For cervical facet palpation, I can not palpate accurately from the back especially for some muscular guy with big neck. From lateral approach, i mark the patient with my palpation impression, check fluoro, found 4-5-6 more reliable, 6-7, 2-3 are less, just sharing my finding, imo.

 

[bedrock]

That's funny. You (and Paul) think your exam is that accurate.
Nik: "Only the needle knows."

of course the needle is more accurate than my exam. Paul would say the same. Remember he did the study proving that SIJ blocks are much more accurate than physical exam of the SIJ.

My point is that good physical exam skills helps narrow down your targets, particularly in patients that "hurt across the entire neck". But ultimately the needle is what proves whether or not you were correct.

 

[bedrock]

Spot on, this is how I do the vast majority.

Occasionally, I'll get something like C5-6 severe DDD and facet arthropathy, but they also have upper cervical pain/cervicogenic headaches/C2-3 arthropathy, and I'll do bilateral C2-3, C5-6.

Or if they have severe b/l C2-6 facet arthropathy but 70/30 or greater unilateral predominance I'll do 3-level uni rather than 2-level b/l.

In lumbar, if L3-4 disc is darker than L5-S1, facets are equally arthritic, and pain is not in buttocks, I'll do L3-5, but otherwise usually L4-S1.

Other imaging indicator other than arthropathy or DDD, is segment of peak reversal of lordosis or scoliosis.

If I can't tell based on imaging and history, I'll usually palpate under fluoro and adjust my levels accordingly, especially with thoracic with normal MRI.

good points.

severely degenerated necks are hard because they often need 3 level l RFA, which medicare won't pay for.

Agree on lumbar plan.

I would add that in patients with a highly sacralized L5, and pain in the mid lumbar area, I will target L3-L4, L4-L5, instead of L5-S1. (However if the low-medium sacralized L5 patients have fairly inferior pain, and I'll do L4-L5, L5-S1 for those)

Agree with thoracic and palpating those under fluoro