Lumbar RFA efficiency

[BobBarker]

@ragnathor I am always quite a bit deeper than that. I do test motors and sometimes do get a twitch down the leg.

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[MitchLevi]

L3 MB needle looks as much as much as 2 cm too shallow, L4 MB looks maybe 0.5 cm too shallow, and L5 DPR is 3 or 4mm too shallow.

Nice L4-S1 listhesis BTW.

Also, the L3 MB needle looks a bit lateral, but if you deepen that needle it will bring the needle medially another few mm. I think you're bumping into facet rather than sneaking past it.

 

[MitchLevi]

Here's a pic of one of mine I did. I had to look around to find one that wasn't severely arthritic so the needles and anatomy are easier to see.

Bilateral L4-S1. I place all needles and burn one side, remove those needles and burn the other. One image is only the right needles, but that is after I burned the left, removed those needles and I'm now burning the right.

I do 80 Celsius for 2 min, and at the 1 min mark I'll walk the needles medially or laterally 2-3mm and rotate them.

Edit - This is a patient with dementia and he's very aware of it (terrible situation). This procedure helped him walk and bend and twist. Mechanically, it helped him but there was no benefit with regard to pain. Having said that, he is unable to describe where he hurts or how bad. I hope I never get dementia.

 

[BobBarker]

@MitchLevi that is how mine typically look. I place the right side, burn, remove and replace on the left side. Saves $30 in needle costs at the minimum.

 

[clubdeac]

@ragnathor they look shallow to me. @MitchLevi I like those placements

 

[MitchLevi]

@MitchLevi that is how mine typically look. I place the right side, burn, remove and replace on the left side. Saves $30 in needle costs at the minimum.

I place all 6 if I'm in the first hour or two of my procedure schedule. I try to do 3 needles, but sometimes I have to do 6 bc of time.

 

[SC Tian]

L3 MB needle looks as much as much as 2 cm too shallow, L4 MB looks maybe 0.5 cm too shallow, and L5 DPR is 3 or 4mm too shallow.

Nice L4-S1 listhesis BTW.

Also, the L3 MB needle looks a bit lateral, but if you deepen that needle it will bring the needle medially another few mm. I think you're bumping into facet rather than sneaking past it.

View attachment 372166

my friend, imo, L3 mb needle placement is blocked by facet joint hypertrophy with big osteophyte extending laterally on AP view, more lateral needle placement could be helpful. wait for @bedrock and other expert's opinions, thanks.

 

[deleted131481]

@BobBarker @MitchLevi @clubdeac @SC Tian

Thanks for the feedback, agree with the depth. I am generally deeper in less arthritic spines along the lines mitchlevi marked. I have noticed some of my needles look shallow in more arthritic spines as you guys pointed above. Can you be more specific in how you adjust if things look good in oblique and AP but shallow in lateral? Again usually it's the very arthritic spines I will see this - makes sense it's likely the arthritic facet. I suppose I should back up the L3 mb a couple cm and move lateral, is that the adjustment?

Also I don't routinely walk off as Mitchlevi's pics above, but something I could consider. It seems if the other views look good that I'm not sure the extra couple mm will produce a much larger burn. In fellowship I learned RFTC as equivalent to medial branch block, single burn with 20g. It was from this forum/SIS book that I changed to the more inferior to superior trajectory. I'm going to be making another significant change so I may have walking off a couple mm as part of it.

 

[RoloTomassi]

Can you be more specific in how you adjust if things look good in oblique and AP but shallow in lateral? Again usually it's the very arthritic spines I will see this - makes sense it's likely the arthritic facet. I suppose I should back up the L3 mb a couple cm and move lateral, is that the adjustment?

You likely should have started more lateral. Easiest to take needle completely out and enter more laterally. If you just try to retract, depending on how medial you were, you're going to be fighting against the facet the whole time when it can just be completely avoided

 

[Baron Samedi]

Would love some feedback. The bottom one looks a touch superficial to me but was not advanceable. Stryker probes.

I noticed you guys tend to go up and over the junction of the SAP/TP a bit. I typically have not. Curious regarding thoughts on this.

 

[RoloTomassi]

Would love some feedback. The bottom one looks a touch superficial to me but was not advanceable. Stryker probes.

I noticed you guys tend to go up and over the junction of the SAP/TP a bit. I typically have not. Curious regarding thoughts on this.

Bottom one sometimes I'm there sometimes I'm deeper like the others. I actually get more motor twitch there than deeper. And one else experience this?

 

[MitchLevi]

my friend, imo, L3 mb needle placement is blocked by facet joint hypertrophy with big osteophyte extending laterally on AP view, more lateral needle placement could be helpful. wait for @bedrock and other expert's opinions, thanks.

As Rolo said, start more laterally.

He is bumping into facet obviously, but if you start a little more laterally you'll hit the facet anteriorly, not posterolaterally.

Bottom one sometimes I'm there sometimes I'm deeper like the others. I actually get more motor twitch there than deeper. And one else experience this?

My L5 DPR needle often twitches the buttocks substantially. Great place to burn IMO. Obviously, we're talking buttock and not distal leg and heel.

 

[MitchLevi]

Would love some feedback. The bottom one looks a touch superficial to me but was not advanceable. Stryker probes.

I noticed you guys tend to go up and over the junction of the SAP/TP a bit. I typically have not. Curious regarding thoughts on this.

These look quite good IMO, with one issue being you might be 1-2 mm inferior. The mammilo-accessory ligament is my concern.

I try to aim for about 1-2 mm superiorly because I see a lot of older patients, and if the MAL ossifies I worry about RFA failure.

I like your depth, and I love your oblique trajectory.

L5 DPR is probably rubbing hard into os which is why you're not able to advance. I'd retract that 3 cm, flatten the angle with your hub at the skin, drive 1 cm deeper, then flip your hub to the ceiling and that may clear you for another 2-3 mm of depth. At least, that's what I do.

 

[MD87]

Here's a pic of one of mine I did. I had to look around to find one that wasn't severely arthritic so the needles and anatomy are easier to see.

Bilateral L4-S1. I place all needles and burn one side, remove those needles and burn the other. One image is only the right needles, but that is after I burned the left, removed those needles and I'm now burning the right.

I do 80 Celsius for 2 min, and at the 1 min mark I'll walk the needles medially or laterally 2-3mm and rotate them.

Edit - This is a patient with dementia and he's very aware of it (terrible situation). This procedure helped him walk and bend and twist. Mechanically, it helped him but there was no benefit with regard to pain. Having said that, he is unable to describe where he hurts or how bad. I hope I never get dementia.

View attachment 372167View attachment 372168View attachment 372169View attachment 372170View attachment 372171

Do you place these all in the same view? I typically square off each endplate (typically no tilt or minimal tilt for L3 MB, head tilt for L4 MB and L5 DR). Not sure if it makes a true difference but it’s what I was taught.

 

[MitchLevi]

Do you place these all in the same view? I typically square off each endplate (typically no tilt or minimal tilt for L3 MB, head tilt for L4 MB and L5 DR). Not sure if it makes a true difference but it’s what I was taught.

I do.

 

[DrMDAware]

Here's a pic of one of mine I did. I had to look around to find one that wasn't severely arthritic so the needles and anatomy are easier to see.

Bilateral L4-S1. I place all needles and burn one side, remove those needles and burn the other. One image is only the right needles, but that is after I burned the left, removed those needles and I'm now burning the right.

I do 80 Celsius for 2 min, and at the 1 min mark I'll walk the needles medially or laterally 2-3mm and rotate them.

Edit - This is a patient with dementia and he's very aware of it (terrible situation). This procedure helped him walk and bend and twist. Mechanically, it helped him but there was no benefit with regard to pain. Having said that, he is unable to describe where he hurts or how bad. I hope I never get dementia.

View attachment 372167View attachment 372168View attachment 372169View attachment 372170View attachment 372171

Thanks for sharing. The only minor recommendation I could see is to drop the angle and be less perpendicular. Otherwise great depth

 

[Norepi]

Curious here - do most insurances authorize bilateral 3 joint 4 nerves, or do you all just keep it to L3,4, DR5 nerves for bang for buck reasons (treat the most commonly implicated joints).

 

[Ducttape]

you do it based on the joints most likely to be causing your patients pain.

the reason that L3,L4 and L5 nerves are done most frequently is because the L45 and L5S1 facet joints are most likely to be pain generators.

its not because of bang for buck or financial reasons. at least not for me.


medicare allows 2 joints bilateral per session.

 

[DrMDAware]

you do it based on the joints most likely to be causing your patients pain.

the reason that L3,L4 and L5 nerves are done most frequently is because the L45 and L5S1 facet joints are most likely to be pain generators.

its not because of bang for buck or financial reasons. at least not for me.


medicare allows 2 joints bilateral per session.

Please correct me if I’m wrong - Medicare will pay 50% for the other side for both joints, right?

 

[BobBarker]

Yes, correct.

 

[PinchandBurn]

I think op pics are fine. Key is to see multifudus twitch. No need to go to anterior. I also use venom needles. So it's going to be a big lesion.

Remember first rule of medicine do no harm.

 

[bedrock]

you do it based on the joints most likely to be causing your patients pain.

the reason that L3,L4 and L5 nerves are done most frequently is because the L45 and L5S1 facet joints are most likely to be pain generators.

its not because of bang for buck or financial reasons. at least not for me.


medicare allows 2 joints bilateral per session.

Agree that the bilateral L4-L5, L5-S1 are usually, not always, the worse two facet joints in the lumbar spine. This often makes sense for a 60 year old.

However, it doesn't makes as much sense for an 80 year old on medicare. They often need a bilateral L2-L5 RFA, and complain of residual pain superior to their ablation at the L3-L4 facets.

The government/medicare, got it wrong (as government usually does), when they decided to limit RFA to only two joints.

 

[MitchLevi]

I think op pics are fine. Key is to see multifudus twitch. No need to go to anterior. I also use venom needles. So it's going to be a big lesion.

Remember first rule of medicine do no harm.

For those of us buying our own needles and can't spend the money on Venom, it is my opinion there is absolutely a need to advance to anterior 1/3 of the facet. There is a clear difference in outcomes, and that depth is safe.

 

[so55b]

I think op pics are fine. Key is to see multifudus twitch. No need to go to anterior. I also use venom needles. So it's going to be a big lesion.

Remember first rule of medicine do no harm.

Thank you for sharing. Is this evidence based or personal experience? just out of curiosity.

 

[Barleycorn]

Here's a pic of one of mine I did. I had to look around to find one that wasn't severely arthritic so the needles and anatomy are easier to see.

Bilateral L4-S1. I place all needles and burn one side, remove those needles and burn the other. One image is only the right needles, but that is after I burned the left, removed those needles and I'm now burning the right.

I do 80 Celsius for 2 min, and at the 1 min mark I'll walk the needles medially or laterally 2-3mm and rotate them.

Edit - This is a patient with dementia and he's very aware of it (terrible situation). This procedure helped him walk and bend and twist. Mechanically, it helped him but there was no benefit with regard to pain. Having said that, he is unable to describe where he hurts or how bad. I hope I never get dementia.

View attachment 372167View attachment 372168View attachment 372169View attachment 372170View attachment 372171

Please pardon the airheaded question, but do you initially advance in oblique and then walk off the edge of the junction? If you do walk off the edge how do you keep your needle tip on bone? I trained with trident needles and we just went perpendicular and I learned a lot of bad habits.

 

[DrMDAware]

For people who use Trident do you still run parallel to the nerve or do you go perpendicular? I haven’t used those needles. I know the burn size is different. Seems like going perpendicular would really let one fly. Not sure if it would be efficacious though. Just curious.

 

[Tboned]

For people who use Trident do you still run parallel to the nerve or do you go perpendicular? I haven’t used those needles. I know the burn size is different. Seems like going perpendicular would really let one fly. Not sure if it would be efficacious though. Just curious.

You should be perpendicular given the lesion shape.

 

[BobBarker]

Looked up the Trident! How much does that cost?? What a harpoon!

 

[Baron Samedi]

Looked up the Trident! How much does that cost?? What a harpoon!

Just looked it up, too. All I could see was Otto Octavius from Spiderman 2.

 

[MitchLevi]

Simplicity. Yall wanna 'poon Moby Dick? Do Simplicity on a woman approximately 5'3" 90 lbs like I did one time in fellowship.

 

[Agast]

you do it based on the joints most likely to be causing your patients pain.

medicare allows 2 joints bilateral per session.

That’s why I’ve been documenting medial branch blocks and RFA to bilateral L3/4, L5/S1 for some patients. Yes it irks me to get paid less for doing more, but some patients really need it. And I suspect the overlapping innervation is exactly why they changed the reimbursement.


On a side note, I found out a local guy has been using a neuromonitoring company on his RFAs. My patient’s wife showed me a postop pic of her husband with his scalp covered in chloraprep and I was like ??? How that isn’t Medicare fraud is beyond me.

 

[Vie221]

Here's a pic of one of mine I did. I had to look around to find one that wasn't severely arthritic so the needles and anatomy are easier to see.

Bilateral L4-S1. I place all needles and burn one side, remove those needles and burn the other. One image is only the right needles, but that is after I burned the left, removed those needles and I'm now burning the right.

I do 80 Celsius for 2 min, and at the 1 min mark I'll walk the needles medially or laterally 2-3mm and rotate them.

Edit - This is a patient with dementia and he's very aware of it (terrible situation). This procedure helped him walk and bend and twist. Mechanically, it helped him but there was no benefit with regard to pain. Having said that, he is unable to describe where he hurts or how bad. I hope I never get dementia.

View attachment 372167View attachment 372168View attachment 372169View attachment 372170View attachment 372171

Can you clarify what's going on in this oblique view? It looks like the tip is extending off of bone while the shaft of the needle is still contacting the SAP/TP junction. I like to get in the lateral position that you are showing. However, when I see my tip extend past the SAP/TP junction I get nervous that I'm getting too close to the root.

 

[epidural man]

what have you guys modified in private practice (compared with fellowship) to make your lumbar RFA more efficient?

I use SIS technique, 18G, 1cm curved tip cannula, lesion x 2 for 90 seconds (rotate cannula 90-100 degrees between lesions)

I have excellent RFA results but I wonder if I could change a few things to save 5 min per case, and still have similar outcomes

Thoughts on what you found improved your efficiency

I have a suggestion - if you haven't done it already.

Take a chicken breast and take a bunch of RF needles and do some burns in it. I recently did this (I think it is worth while to repeat every once in a while to remind myself).

Notice the size of lesion vs needle size. Notice the distance past the tip. Try different temps and for different times. Try repeating the burn, or rotating the bevel and notice the difference.

I have changed how I do things based on my personal findings after these exercises.

 

[Tboned]

I have a suggestion - if you haven't done it already.

Take a chicken breast and take a bunch of RF needles and do some burns in it. I recently did this (I think it is worth while to repeat every once in a while to remind myself).

Notice the size of lesion vs needle size. Notice the distance past the tip. Try different temps and for different times. Try repeating the burn, or rotating the bevel and notice the difference.

I have changed how I do things based on my personal findings after these exercises.

What are you doing regarding needle gauge, temp/time, bevel rotation, etc?

 

[so55b]

I have a suggestion - if you haven't done it already.

Take a chicken breast and take a bunch of RF needles and do some burns in it. I recently did this (I think it is worth while to repeat every once in a while to remind myself).

Notice the size of lesion vs needle size. Notice the distance past the tip. Try different temps and for different times. Try repeating the burn, or rotating the bevel and notice the difference.

I have changed how I do things based on my personal findings after these exercises.

Was the burn size different from the research paper below?

Factors That Affect Radiofrequency Heat Lesion Size

AbstractObjective. This study aims to compare radiofrequency (RF) heat lesion size across electrodes and generator settings available for interventional pa

academic.oup.com

 

[epidural man]

Was the burn size different from the research paper below?

Factors That Affect Radiofrequency Heat Lesion Size

AbstractObjective. This study aims to compare radiofrequency (RF) heat lesion size across electrodes and generator settings available for interventional pa

academic.oup.com

Not really, but to see it in front of you seems more....I don't know...compelling I guess?

 

[epidural man]

What are you doing regarding needle gauge, temp/time, bevel rotation, etc?

Well, we use 18g. I wish we used 16g.

We also do a small amount of cooled RF. 16g seems to have a very similar burn size - and surprising to me - does come off the tip a bit.

To me, the real advantage of cooled is the distance the burn comes off the tip.

Turning the bevel doesn't seem to make much difference.

Returning or extending the time didn't seem to extend the burn much actually. BUT, I couldn't get it to char - which was reassuring. I didn't try super hard to get char though.

 

[DoYouEvenLiftBro]

On a similar note, does anyone have tips for the posterior fusions with pedicle screws…

 

[Agast]

On a similar note, does anyone have tips for the posterior fusions with pedicle screws…

You’re not supposed to be doing RFA at that level - unless it’s the bottom medial branch of the unfused joint? Adjusting caudal/cephalad tilt usually does the trick. Or line up the pedicle screw in gun barrel view and aim right above it and see what that gets you.

 

[GlowInTheDark]

You’re not supposed to be doing RFA at that level - unless it’s the bottom medial branch of the unfused joint? Adjusting caudal/cephalad tilt usually does the trick. Or line up the pedicle screw in gun barrel view and aim right above it and see what that gets you.

That’s what I understand and how I do it, only if it’s the bottom or top of what I’m trying to target.

There is so much variability in how the surgeons screw up the pedicle, just put it in what looks like base of SAP as best you can. Don’t waste your time trying to get sensory stim. Sometimes you’ll have a hard time getting to temp if close to hardware.

 

[nvrsumr]

Placement by screw is one of the few times I look at the impedance