Local anesthetic of choice for MBB

[GottaHaveIt]

I was wondering what you all use for local anesthetic out there. Is there any data or are there any guidelines indicating what we should be using?

I looked in the SIS textbook and it didn't say anything about which med to use. Didn't see anything in ASIPP guidelines either.

I used 2% lido and then 0.5% bupivacaine in fellowship. Currently only using 0.5% bupi but my partner is using 1% lidocaine...

Another question, is one more myotoxic than another?

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[GlowInTheDark]

I’d refer to the ASRA Lumbar Facet guidelines. They’re introducing the Cervical facet guidelines this week at the conference.

https://rapm.bmj.com/content/rapm/early/2020/04/03/rapm-2019-101243.full.pdf

We use 0.5 mL 2% Lidocaine for lumbar and 0.3 mL 2% Lido for cervical—all for diagnostic purposes to proceed to ablation

 

[DOctorJay]

2% lido and then 0.5% bupivacaine here

 

[PinchandBurn]

0.5% bupicicaine x 2

 

[bedrock]

Dreyfuss fellow here so 0.75% bup and 4% lidocaine, small volumes.

I generally do bup X2 , except in cases where I’m not optimistic that it will work and chance for placebo is high in which times I do lido first and bup second as the placebo response is highest with the first MBB, so they always overreport the duration of the relief after the first MBB , and underreport the second.

 

[Ducttape]

in the ASRA guidelines, there is no specific comment made on the type of local anesthetic, only the volume

Recommendations​

Lumbar MBBs should be performed with <0.5 mL (total volume) to reduce spread to adjacent structures; grade C recommendation, low level of certainty. Lumbar IA facet joint injections should be performed with a volume of <1.5 mL to prevent capsular rupture and reduce spread to adjacent structures; grade C recommendation, low level of certainty.

 

[Laryngospasm]

10cc bup. Always a good result.

 

[painfree23]

Why does it matter?

 

[DODOCSS]

Why does it matter?

LCD

 

[ED50]

Curious, how do you all interpret the results of your blocks. Success with concordant responses only? Max pain relief over the course of the block?

 

[pastafan]

Curious, how do you all interpret the results of your blocks. Success with concordant responses only? Max pain relief over the course of the block?

Success is getting the patient to answer how long did the pain relief last?

 

[10KHertz]

Lumbar = anything that’s not expired…
Cervical = 1% lido to avoid cervicogenic vertigo. More common With more potent agents, like 10ml bupiv 😂

 

[deleted131481]

I like bupiv because it gives the patient the rest of the day to test it out. I used to assess them directly after the block, but I got the impression too much placebo right after or they feel pressured to want it to work if I ask right away.

 

[lobelsteve]

My understanding of the double diagnostic paradigm meant that there were two different local anesthetics used on different days and they would provide a different length of action.

 

[painfree23]

My understanding of the double diagnostic paradigm meant that there were two different local anesthetics used on different days and they would provide a different length of action.

Good luck getting patients trying to tell u whether they got 4 hours or 8 hours of relief. I have patients who come back 2 weeks later - “that didn’t help at all”. I ask, how were u that day? They say - “oh I was great til the next morning.” …then I have to explain it again, the process of these injections before RF.

 

[pastafan]

Good luck getting patients trying to tell u whether they got 4 hours or 8 hours of relief. I have patients who come back 2 weeks later - “that didn’t help at all”. I ask, how were u that day? They say - “oh I was great til the next morning.” …then I have to explain it again, the process of these injections before RF.

Pain diary and contact patient day after block for results.

 

[nvrsumr]

Your patients can do a pain diary??

Mine has two options to circle >80 oh wait just one haha

 

[painfree23]

Lol

 

[deleted875186]

Your patients can do a pain diary??

Mine has two options to circle >80 oh wait just one haha

Let’s reflect on how ridiculous this 80% pain relief is. What will the insurrance company do after they up the requirement to 100% pain relief. Require increase in the number of abdominal crunches the patient can do during the local anesthetic phase.

 

[Ducttape]

i hate asking loaded questions.

instead, im thinking of taking an online hypnosis course to be able to hypnotize people in saying "yes.... the shot helped 80% for a couple of hours..."

The basis of 80% is not from insurance. They took that number from long ago studies and ran with it. Unfortunately it seems codified. Obviously I'd prefer some simple number like 50% or 2 point decrease in pain....

 

[epidural man]

I’ve been using mepivicaine pre-rf. It’s amazing how much better it works than lidocaine and bupivicaine.

 

[geauxg8rs]

i hate asking loaded questions.

instead, im thinking of taking an online hypnosis course to be able to hypnotize people in saying "yes.... the shot helped 80% for a couple of hours..."

The basis of 80% is not from insurance. They took that number from long ago studies and ran with it. Unfortunately it seems codified. Obviously I'd prefer some simple number like 50% or 2 point decrease in pain....

Why not just tell patients from the start. If you don’t have 80 percent relief you aren’t getting the RFA.

 

[10KHertz]

Are you numb in the back? Yes?
80%

 

[painfree23]

Why not just tell patients from the start. If you don’t have 80 percent relief you aren’t getting the RFA.

Placebo effect ?

 

[geauxg8rs]

Placebo effect ?

Problem?

 

[geauxg8rs]

Problem?

I guess the point is what do you do with 70 percent relief? Offer nsaids and PT and tell them they didn’t get relief?
Or do you then tell them it has all been a game?
It’s like playing Joe millionaire, which I hear is making a comeback none too soon.

 

[MD87]

I have been telling patients what insurance requires in order to approve a repeat block and then ablation. I don’t tell them to lie. I tell them that these are the rules set by insurance and these rules are public knowledge. I tell them that if the procedure makes a “significant improvement” in their lives, it is reasonable to repeat it and that we can only repeat it or move forward with the next step if insurance criteria is met. I tell them that the procedure making a significant difference in their lives is the most important thing to me, but insurance has stringent criteria that is more important than what I or the patient care about. I think this results in appropriate patients moving forward with block #2 and RFA.

Overall, I find all of this extremely exhausting. I wish we could just do RFA and hope for the best without the blocks

 

[Multimodal]

Let’s reflect on how ridiculous this 80% pain relief is. What will the insurrance company do after they up the requirement to 100% pain relief. Require increase in the number of abdominal crunches the patient can do during the local anesthetic phase.

You laugh but Regence(BCBS) UMP plans in WA state require 100% relief for cervical MBB.....have a patient now going through this. they were nice enough to offer to lie on the form, lol. had to send her to our sister clinic 45 minutes away where they have an RFA machine and she can pay cash. I encouraged her to write/call her insurance and let them know her frustration. im sure it all goes direct into a shred bin over there but at least we feel like we did something

 

[paindoctor2014]

Good luck getting patients trying to tell u whether they got 4 hours or 8 hours of relief. I have patients who come back 2 weeks later - “that didn’t help at all”. I ask, how were u that day? They say - “oh I was great til the next morning.” …then I have to explain it again, the process of these injections before RF.

Glad it’s not just me