Post Cervical mbnb HA/dizziness

[googlemister]

I have a patient who I did bilateral c3-5 medial branch blocks approximately 2 weeks ago. Procedure was relatively uncomplicated. He had some dizziness/nausea afterwards which got better by the time I saw him a few days later. 2 days after this visit (6 days ago) he is endorsing intermittent mild to moderate fronto-occipital headaches worse in posterior upper neck with occasional nausea. States it’s somewhat positional, no fevers, neuro deficits. Have any of you seen this before and had any thoughts?
Thanks!

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[Laryngospasm]

Most likely correlation not causation.. I can’t explain it. Maybe someone can.

 

[paindoc007]

Is this his first RFA in the neck?

 

[Agast]

I have a patient with an extremely stiff neck who got vertigo after the MBB. Vertigo eventually improved as pain returned. Did a second MBB and same thing happened.

I suspect the same relief from the blocks allows her to move her neck, and her benign positional vertigo is activated because she’s actually turning her head. When she starts to hurt and stops moving her neck the vertigo resolves.

 

[googlemister]

Is this his first RFA in the neck?

It was just cervical mbnb, first diagnostic

 

[MitchLevi]

Common. No explanation for these Sx longer than a few hrs. Which anesthetic did you use? I’ve never seen this longer than 3-4 hrs, and this is another reason I avoid bilateral CRFA (I realize you said MBB).

 

[googlemister]

Common. No explanation for these Sx longer than a few hrs. Which anesthetic did you use? I’ve never seen this longer than 3-4 hrs, and this is another reason I avoid bilateral CRFA (I realize you said MBB).

bupivacaine 0.5%. Just bizarre that his symptoms have lasted this long. The positional nature is also what is throwing me off

 

[Laryngospasm]

Guy probably has vestibular neuritis.. patients love to blame everything on 2cc of local.

 

[MitchLevi]

I have no idea how you could have caused a PDPH.

 

[sdnuser001]

bupivacaine 0.5%. Just bizarre that his symptoms have lasted this long. The positional nature is also what is throwing me off

I only use bupi 0.25% for cervical MBB after getting several hours of motor weakness once with 0.5%. Consider switching to 0.25% maybe? I haven't noticed any difference in outcomes

 

[interjectionreflection]

I have no idea how you could have caused a PDPH.

Agreed but even if it was PDPH it should have resolved by now. Also possible that it have been an underlying issue patient always had but are now hyperaware of it?

 

[SSdoc33]

I only use bupi 0.25% for cervical MBB after getting several hours of motor weakness once with 0.5%. Consider switching to 0.25% maybe? I haven't noticed any difference in outcomes

Did you use a lateral approach?

 

[MitchLevi]

Agreed but even if it was PDPH it should have resolved by now. Also possible that it have been an underlying issue patient always had but are now hyperaware of it?

Cervical dural puncture is really unlikely to cause Sx though, but it wouldn’t necessarily be resolved. Good Q by SSdoc33.

 

[sdnuser001]

Did you use a lateral approach?

I only do posterior and my needle wasn't even that close to the foramen. As soon as I injected she screamed and her arm went limp

 

[MitchLevi]

I only do posterior and my needle wasn't even that close to the foramen. As soon as I injected she screamed and her arm went limp

Oh…You shoulda lead with that!

 

[painfree23]

I only do posterior and my needle wasn't even that close to the foramen. As soon as I injected she screamed and her arm went limp

Go on…?

 

[sdnuser001]

Go on…?

That was pretty much it. Procedure ended after that as it was the last needle. She had dense weakness of the RUE that slowly improved after about an hour. Kept checking in on her in the PACU. Once I saw that the weakness was improving I discharged her and she was fine at the time of follow up. Haven't used marcaine 0.5% and haven't had any issues since. Now I don't even routinely check laterals for cervical MBB

 

[MitchLevi]

She had dense weakness of the RUE that slowly improved after about an hour.

You spilled into the foramen, which doesn’t explain the HA, and you didn’t inject that bupi into the sac bc she stops breathing. You could have pierced the sac and pulled back, which potentially caused a PDPH without spinal anesthesia.

Now I don't even routinely check laterals for cervical MBB

My friend, change your practice. You’re legitimately putting ppl at harm if you’re skipping lateral on medial branch interventions.

In this scenario you’ve described, you caught a spinal nerve and no one knows where your needle was located bc you didn’t get a lateral. Please do not rely on CLO to give you a true depth. This case should reinforce that fact.

 

[sdnuser001]

You spilled into the foramen, which doesn’t explain the HA, and you didn’t inject that bupi into the sac bc she stops breathing. You could have pierced the sac and pulled back, which potentially caused a PDPH without spinal anesthesia.



My friend, change your practice. You’re legitimately putting ppl at harm if you’re skipping lateral on medial branch interventions.

In this scenario you’ve described, you caught a spinal nerve and no one knows where your needle was located bc you didn’t get a lateral. Please do not rely on CLO to give you a true depth. This case should reinforce that fact.

Sorry to be clear in my case there wasn't any dizziness or headache. I only shared my story because OP mentioned he uses marcaine 0.5%. But also because maybe the fact that 0.5% causes motor block and 0.25% doesn't can contribute to some of these symptoms.

And I don't check laterals anymore because after this experience I realized it's not worth it to be parallel for an MBB so I just go perpendicular in AP and my outcomes haven't changed. You can be medial to the articular waist and still be right over the nerve nowhere near the foramen.

 

[MitchLevi]

Sorry to be clear in my case there wasn't any dizziness or headache. I only shared my story because OP mentioned he uses marcaine 0.5%. But also because maybe the fact that 0.5% causes motor block and 0.25% doesn't can contribute to some of these symptoms.

And I don't check laterals anymore because after this experience I realized it's not worth it to be parallel for an MBB so I just go perpendicular in AP and my outcomes haven't changed. You can be medial to the articular waist and still be right over the nerve nowhere near the foramen.

Sorry to confuse the two of you.

These internet forums are impossible.

I'd still go lateral if I'm you.

 

[CleanUp]

In the spirit of learning and discussion, I find that I may look OK on CLO, but be too far ventral on the lateral view. I like to use the CLO as another way to view the angle of entry, and of course, the depth to some degree.

 

[bedrock]

Both Contrast and Lateral necessary for safety with cervical MBB.
The OP likely had epidural spread. It’s also possible for the needle to hit a radicular artery in the foramen and produce the symptoms described.

 

[sdnuser001]

Both Contrast and Lateral necessary for safety with cervical MBB.
The OP likely had epidural spread. It’s also possible for the needle to hit a radicular artery in the foramen and produce the symptoms described.

If you're going in AP and staying medial to the articular waist (thus perpendicular to MB) I don't see how a lateral is going to help. You're nowhere near the foramen.

For RFA because you're trying to be parallel to the nerve I agree a lateral or CLO is necessary since you're going along the three length of the nerve and have to get closer to the foramen.

 

[Taus]

If you're going in AP and staying medial to the articular waist (thus perpendicular to MB) I don't see how a lateral is going to help. You're nowhere near the foramen.

For RFA because you're trying to be parallel to the nerve I agree a lateral or CLO is necessary since you're going along the three length of the nerve and have to get closer to the foramen.

To confirm you’re needle tip and contrast is accurately covering the targeted mb

 

[sdnuser001]

To confirm you’re needle tip and contrast is accurately covering the targeted mb

https://radiologykey.com/wp-content/uploads/2015/12/B9780323042994000339_f033-010-9780323042994.jpg

It's an MBB. You don't need to be parallel to the nerve because you're not using an RF needle. Look at the course of the MB in the picture above. You can just come down bullseye in AP on the lamina medial to the articular waist and you will be perpendicular to the nerve. Save yourself time and radiation, no need to get a lateral IMO since this way you aren't anywhere near the foramen. I typically do all three levels like this with a single 5" needle.

 

[oneforfighting]

https://radiologykey.com/wp-content/uploads/2015/12/B9780323042994000339_f033-010-9780323042994.jpg

It's an MBB. You don't need to be parallel to the nerve because you're not using an RF needle. Look at the course of the MB in the picture above. You can just come down bullseye in AP on the lamina medial to the articular waist and you will be perpendicular to the nerve. Save yourself time and radiation, no need to get a lateral IMO since this way you aren't anywhere near the foramen. I typically do all three levels like this with a single 5" needle.

Curious if you take the same approach for your lumbars

 

[sdnuser001]

Curious if you take the same approach for your lumbars

Quite often I will do lumbar in straight AP just aiming for 2 o'clock on the pedicle. But I still typically use separate needles for each level. The single needle technique could probably be done but wouldn't really be time efficient

 

[GatorCHOMPions]

Anyone do cooled RF in the side lying position? Too risky, outcomes any different?

 

[paindoc007]

Anyone do cooled RF in the side lying position? Too risky, outcomes any different?

I used to. I realized it doesn’t save time so I went back to AP

 

[Tboned]

Anyone do cooled RF in the side lying position? Too risky, outcomes any different?

That’s all we did in fellowship. As a fellow, we did t followup with all patients so hard to comment on outcomes comparatively to what I see now (use lateral approach trident and conventional approach with Stryker venom).

 

[oneforfighting]

Quite often I will do lumbar in straight AP just aiming for 2 o'clock on the pedicle. But I still typically use separate needles for each level. The single needle technique could probably be done but wouldn't really be time efficient

Good results? Ever have issues with running into bulky facets?

 

[sdnuser001]

Good results? Ever have issues with running into bulky facets?

Results are good enough. I switch between straight AP and oblique depending on mood. Don't notice much of a difference. If one of the needles in AP isn't nearly deep enough then I know it's caught on a facet and readjust.

However, I'm still not sure going in AP really saves that much more time then doing them in oblique. Of all the B&B procedures I still find lumbar MBB the most tedious.

 

[Taus]

Results are good enough. I switch between straight AP and oblique depending on mood. Don't notice much of a difference. If one of the needles in AP isn't nearly deep enough then I know it's caught on a facet and readjust.

However, I'm still not sure going in AP really saves that much more time then doing them in oblique. Of all the B&B procedures I still find lumbar MBB the most tedious.

I don’t think you need to take anyone’s word for the accuracy or lack thereof via this technique… Just prove it to yourself, one way or the other… Place in AP on several cases in a row, once needles on bone, inject a little contrast, oblique to 15 to 20°, and see how often you miss the target.

 

[SSdoc33]

Anyone do cooled RF in the side lying position? Too risky, outcomes any different?

you should always do these standing up. too much medical legal risk if you fall asleep during the procedure

 

[perromaxfilm]

I have had a couple patient get dizzy/vertigo for a few days with cervical mbb. I was reluctant to offer rfa. I wonder if the mechanism is similiar to the sun burn effect some patients get with rfa. Thin accessory nerves to the skin and maybe some are related proprioception of the head.

 

[Multimodal]

Quite often I will do lumbar in straight AP just aiming for 2 o'clock on the pedicle. But I still typically use separate needles for each level. The single needle technique could probably be done but wouldn't really be time efficient

I do the same approach as you do for the lumbar and cervical MBB. for RFA, always get a lateral in both areas. I've noticed that C2 MBB is far more likely to trigger post injection dizziness vs C3 and below. I have a few half baked theories on this. I usually warn patients about this, make sure they have a driver, and never use bupiv at C2 for this reason.