lower cervical RFA

[painstop]

I was wondering if any of you guys had experience using the contralateral or ipsilateral oblique view when performing lower cervical MBBs or RFA because it can be pretty tough to visualize the C6 and C7 articular pillars with those darn shoulders. Any pics? Otherwise, any tips on the lower cervical levels? I must say that after using contralateral oblique for CESI's there is no other way I would perform it any other way.

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[BobBarker]

Furman Atlas or Stryker RFA course

 

[Taus]

I use it extensively at these levels for rf and the occasional mbb I do prone (most mbb in lateral). I couldn't imagine doing it any other way for prone. Place needles in ap towards concavity on artic pillar at c6/7. Hit os. Go contralateral oblique about 40-50. The key is then caudal tilting until you really see the joint lines appear so can walk off os and place your tip at proper location ceph/caudal on pillar and also verify depth.

I really prefer lateral for mbb. Certainly harder at c6/7. What has helped me tremendously is doing a swimmers position, i.e. the arm that's down on table gets abducted overhead and patient lays head on that outstretched shoulder. The up arm on treatment side can then easily get pulled down to hip nicely. This gets one shoulder below c7 and other shoulder above. I can generally see c7 with this even w short necks. Even if one shoulder and clavicle in way, can still see through well enough. If patients have signif shoulder issues, especially the down side, it can be a problem and I'll do these prone.

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[clubdeac]

I use it extensively at these levels for rf and the occasional mbb I do prone (most mbb in lateral). I couldn't imagine doing it any other way for prone. Place needles in ap towards concavity on artic pillar at c6/7. Hit os. Go contralateral oblique about 40-50. The key is then caudal tilting until you really see the joint lines appear so can walk off os and place your tip at proper location ceph/caudal on pillar and also verify depth.

I really prefer lateral for mbb. Certainly harder at c6/7. What has helped me tremendously is doing a swimmers position, i.e. the arm that's down on table gets abducted overhead and patient lays head on that outstretched shoulder. The up arm on treatment side can then easily get pulled down to hip nicely. This gets one shoulder below c7 and other shoulder above. I can generally see c7 with this even w short necks. Even if one shoulder and clavicle in way, can still see through well enough. If patients have signif shoulder issues, especially the down side, it can be a problem and I'll do these prone.

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Nice Taus! Can you share any pics of your contralateral oblique for RF. I imagine the tip of the probes lying b/w the each football or teardrop (whatever you want to call the contralateral lamina)

 

[Taus]

Nice Taus! Can you share any pics of your contralateral oblique for RF. I imagine the tip of the probes lying b/w the each football or teardrop (whatever you want to call the contralateral lamina)

Thanks, will grab some shots of this when able. Actually you DO NOT want to go bw lamina/footballs. Must stay behind them for safe depth. Unless cordotomy desired.


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[clubdeac]

This is what I was picturing on the contralateral oblique? Is this what yours look like?

 

[Taus]

Not my best shots, but a good example of being unable to see c5 clearly in lateral, no chance at 6/7, then after placing in AP, a crystal clear view of c6/7 in clo.

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[Taus]

Another example, though this doesn't have the caudal tilt in clo to separate facet joints.

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[Taus]

Had a great example of this today... Huge shoulders, short neck. See nothing below c4 on lateral. See perfectly on clo with caudal tilt. Makes cervical rf a breeze.


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[cbest]

Great job as always! Just curious, what angles are you using on the CLO and caudal? Thanks!


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[Aether2000]

Sweet!!!

 

[Taus]

Great job as always! Just curious, what angles are you using on the CLO and caudal? Thanks!


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Thx.

Approx 40 degrees oblique +/-5. Until it looks like a foraminal oblique.

Caudal tilt varies, usually 10-20. I tilt until I can clearly see the joint spaces and it almost looks like articular pillars on a lateral.


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[Ligament]

I use it extensively at these levels for rf and the occasional mbb I do prone (most mbb in lateral). I couldn't imagine doing it any other way for prone. Place needles in ap towards concavity on artic pillar at c6/7. Hit os. Go contralateral oblique about 40-50. The key is then caudal tilting until you really see the joint lines appear so can walk off os and place your tip at proper location ceph/caudal on pillar and also verify depth.

I really prefer lateral for mbb. Certainly harder at c6/7. What has helped me tremendously is doing a swimmers position, i.e. the arm that's down on table gets abducted overhead and patient lays head on that outstretched shoulder. The up arm on treatment side can then easily get pulled down to hip nicely. This gets one shoulder below c7 and other shoulder above. I can generally see c7 with this even w short necks. Even if one shoulder and clavicle in way, can still see through well enough. If patients have signif shoulder issues, especially the down side, it can be a problem and I'll do these prone.

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What are the proper depth landmarks in the CLO view? ie what is the "safety view"? thanks for posting!

 

[Papa Lou]

If you're not past the spinolaminar line on CLO you're not past foraminal territory so you're clear from the nerve roots. On a *true lateral* the needle should be at the anterior border of the lateral masses, but no further. On CLO you'll see the needle clearly behind the foramen. Some will use this CLO view only, instead of the lateral (b/c the lateral in the lower c/s is hard to visualize) to make adjustments for the second/third burns.
But I don't think c/s RFA is that much of a breeze. Particularly with 18g or 16g needles and a short neck. Using swimmer's view changes everything too much for RF and SIS does not recommend it.

Taus, your last image is beautiful.

 

[Taus]

If you're not past the spinolaminar line on CLO you're not past foraminal territory so you're clear from the nerve roots. On a *true lateral* the needle should be at the anterior border of the lateral masses, but no further. On CLO you'll see the needle clearly behind the foramen. Some will use this CLO view only, instead of the lateral (b/c the lateral in the lower c/s is hard to visualize) to make adjustments for the second/third burns.
But I don't think c/s RFA is that much of a breeze. Particularly with 18g or 16g needles and a short neck. Using swimmer's view changes everything too much for RF and SIS does not recommend it.

Taus, your last image is beautiful.

Ha thx. It was the best shot of it I've had in a bit so thought worthwhile to share as can help others.

I agree re depth for safety, With caveats. It has not been studied and still some uncertainties. For the levels where I can see on lateral view clearly, have a "true" lateral, and then go clo, the depth seems fairly accurate/equivalent between posterior lamina/football on clo and anterior pillar on lateral. At times I have noticed it looks very safe, behind lamina or touching it on clo, then looks a bit beep for comfort on lateral. Hard to say for sure as my lateral view is not always "true" on these and my clo angle not standardized. So can look deeper/shallower on clo w varying angle oblique just like on cesi w clo.


Accordingly, I pay very close attention to stim on these for safety, not accuracy. About 10-20% of time I do get root stim and retract til disappears. Moreso at c7 though w it's skinny pillar. I generally can't see that on lateral to correlate where I am ventrally vs clo at c7.


Sounds like a good idea for a study... I plan on doing it. Doing one right now on swimmers for mbb. Those views have been absolute game changers for me.


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[NJPAIN]

Nice work Taus. Thanks for sharing the images. I guess this is the one that I almost saw live?


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[bedrock]

Ha thx. It was the best shot of it I've had in a bit so thought worthwhile to share as can help others.

I agree re depth for safety, With caveats. It has not been studied and still some uncertainties. For the levels where I can see on lateral view clearly, have a "true" lateral, and then go clo, the depth seems fairly accurate/equivalent between posterior lamina/football on clo and anterior pillar on lateral. At times I have noticed it looks very safe, behind lamina or touching it on clo, then looks a bit beep for comfort on lateral. Hard to say for sure as my lateral view is not always "true" on these and my clo angle not standardized. So can look deeper/shallower on clo w varying angle oblique just like on cesi w clo.


Accordingly, I pay very close attention to stim on these for safety, not accuracy. About 10-20% of time I do get root stim and retract til disappears. Moreso at c7 though w it's skinny pillar. I generally can't see that on lateral to correlate where I am ventrally vs clo at c7.


Sounds like a good idea for a study... I plan on doing it. Doing one right now on swimmers for mbb.
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Agree re depth. CLO very helpful for thick necks but the depth doesn't seem quite as consistent as a true lateral so I don't trust it quite as much. I general place needle tip 2-3mm posterior to lamina because of this, basically the depth of your final picture. I motor test even there, just to be sure.

Talk to me about swimmers view for MBB. Never done that.

 

[clubdeac]

This is what I was picturing on the contralateral oblique? Is this what yours look like?

So on your contralateral view, should your needle be in line with the contralateral lamina like in your pics or between the lamina like in the pic I posted above?

 

[heathermed]

Does anyone have a technique for medial branch blocks or facets using the contralateral oblique view?

 

[Taus]

Does anyone have a technique for medial branch blocks or facets using the contralateral oblique view?

It can be used to confirm depth exactly as above with Rf from prone approach. It can also be used in lateral approach, except on lateral approach you will need to tilt to head, not feet) with image intensifier in front of patient to see joint spaces in clo.


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[Taus]

Agree re depth. CLO very helpful for thick necks but the depth doesn't seem quite as consistent as a true lateral so I don't trust it quite as much. I general place needle tip 2-3mm posterior to lamina because of this, basically the depth of your final picture. I motor test even there, just to be sure.

Talk to me about swimmers view for MBB. Never done that.

Re swimmers for mbb w lateral approach at c5-7, it's been a game changer like clo for me on rf and cesi. paper coming out soon on that comparing clarity to lateral view . Until then, I think I've posted about it before in some detail. Will search for the post.


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[Taus]

If you're not past the spinolaminar line on CLO you're not past foraminal territory so you're clear from the nerve roots. On a *true lateral* the needle should be at the anterior border of the lateral masses, but no further. On CLO you'll see the needle clearly behind the foramen. Some will use this CLO view only, instead of the lateral (b/c the lateral in the lower c/s is hard to visualize) to make adjustments for the second/third burns.
But I don't think c/s RFA is that much of a breeze. Particularly with 18g or 16g needles and a short neck.

I use a pretty simple approach that does make it rather easy,... but I agree not a true breeze and took me a few years to get to this level of comfort on them. Still a technically demanding procedure to do correctly.

I image true AP, enter skin 1 level down from targeted pillar and about 1cm lateral to os. No precise trajectory angles like lumbar. I drive electrode out of plane/coaxial, hitting os at lateral border in middle/centroid of desired pillar. Add more local. Go lateral and/or clo and walk off os to final target. That's it. Test, burn x 2 per nerve w 18g.


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[Ducttape]

Pics please?



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[NJPAIN]

Do you find that you need a 15cm cannula most of the time? I have stopped even trying anything less.


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[Taus]

Do you find that you need a 15cm cannula most of the time? I have stopped even trying anything less.


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Yes in most medium or large builds.


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[thecentral09]

I use a pretty simple approach that does make it rather easy,... but I agree not a true breeze and took me a few years to get to this level of comfort on them. Still a technically demanding procedure to do correctly.

I image true AP, enter skin 1 level down from targeted pillar and about 1cm lateral to os. No precise trajectory angles like lumbar. I drive electrode out of plane/coaxial, hitting os at lateral border in middle/centroid of desired pillar. Add more local. Go lateral and/or clo and walk off os to final target. That's it. Test, burn x 2 per nerve w 18g.


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I love it.

The only question I would have regarding your experience with this is do you think your motor test is compromised by the additional local once you hit off at the waist of the desired posterior pillar. It sounds like your motor test is not compromised with the additional local so close to the medial/lateral branch.

 

[Disciple]

Ha thx. It was the best shot of it I've had in a bit so thought worthwhile to share as can help others.

I agree re depth for safety, With caveats. It has not been studied and still some uncertainties. For the levels where I can see on lateral view clearly, have a "true" lateral, and then go clo, the depth seems fairly accurate/equivalent between posterior lamina/football on clo and anterior pillar on lateral. At times I have noticed it looks very safe, behind lamina or touching it on clo, then looks a bit beep for comfort on lateral. Hard to say for sure as my lateral view is not always "true" on these and my clo angle not standardized. So can look deeper/shallower on clo w varying angle oblique just like on cesi w clo.


Accordingly, I pay very close attention to stim on these for safety, not accuracy. About 10-20% of time I do get root stim and retract til disappears. Moreso at c7 though w it's skinny pillar. I generally can't see that on lateral to correlate where I am ventrally vs clo at c7.


Sounds like a good idea for a study... I plan on doing it. Doing one right now on swimmers for mbb. Those views have been absolute game changers for me.


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Kudos to Taus!

Used the Taus technique today. Worked great!

Also had C7 nerve root stim, even though the depth appeared to be correct on CLO. After retracting, final position on CLO was well posterior to the lamina.

 

[neutro]

Beautiful images Dr. Taus.
I tried the CLO technique last week on one of my patients and she did quite well. More importantly, it was an easier experience for me and really cut down the fluoro time.

 

[Tapspatellas]

Kudos to Taus!

Used the Taus technique today. Worked great!

Also had C7 nerve root stim, even though the depth appeared to be correct on CLO. After retracting, final position on CLO was well posterior to the lamina.

Like Taus I see the root stim most frequently at C7, even when able to obtain a clear lateral and appears properly located. CLO has been phenomenal!

 

[drpainfree]

I use a pretty simple approach that does make it rather easy,... but I agree not a true breeze and took me a few years to get to this level of comfort on them. Still a technically demanding procedure to do correctly.

I image true AP, enter skin 1 level down from targeted pillar and about 1cm lateral to os. No precise trajectory angles like lumbar. I drive electrode out of plane/coaxial, hitting os at lateral border in middle/centroid of desired pillar. Add more local. Go lateral and/or clo and walk off os to final target. That's it. Test, burn x 2 per nerve w 18g.


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Thanks for sharing your beautiful images.

I'm a little confused with what you described. Do you start out with a true AP as you described above, or do you use caudal tilt 10-20 deg as you described earlier?

 

[Taus]

Brief paper on using Clo (technically foraminal oblique) on cervical rf is out. Hope some people find it helpful.

http://www.ipmreportsjournal.com/current/pdf?article=MjAy&journal=10