Q re lumbar MBB/RF post fusion

[Taus]

Q re attempting lumbar MBB/RF post fusion with pedicle screws and or large fusion mass - where one of the medial branches of the targeted facet (either above or below the fusion) is likely either stripped surgically or inaccessible from hardware or bony fusion mass. Generally the ones I've seen have also had absolutely no clear SAP/TP junction visible and my best guess is targeting the superolateral aspect of the pedicle screw.

How many of you attempt to target both medial branches of the targeted facet in the above situation- or just see how they do with blocking the 1 nerve that should be remaining? I can take a guess with 0.5cc of local as it will spread and block something at the surgerized level.... but no idea what I'd RF at that spot generally...

Any other thoughts/strategies for this situation?

---

Members don't see this ad.

 

[clubdeac]

Q re attempting lumbar MBB/RF post fusion with pedicle screws and or large fusion mass - where one of the medial branches of the targeted facet (either above or below the fusion) is likely either stripped surgically or inaccessible from hardware or bony fusion mass. Generally the ones I've seen have also had absolutely no clear SAP/TP junction visible and my best guess is targeting the superolateral aspect of the pedicle screw.

How many of you attempt to target both medial branches of the targeted facet in the above situation- or just see how they do with blocking the 1 nerve that should be remaining? I can take a guess with 0.5cc of local as it will spread and block something at the surgerized level.... but no idea what I'd RF at that spot generally...

Any other thoughts/strategies for this situation?

Don't think you will get good results targeting the facets that have been fused. Now targeting the facets above or below the fusion might work but I have never had great results blocking the fused level. Used to even do alcohol for these due to the spread. That didn't work either

 

[lobelsteve]

Q re attempting lumbar MBB/RF post fusion with pedicle screws and or large fusion mass - where one of the medial branches of the targeted facet (either above or below the fusion) is likely either stripped surgically or inaccessible from hardware or bony fusion mass. Generally the ones I've seen have also had absolutely no clear SAP/TP junction visible and my best guess is targeting the superolateral aspect of the pedicle screw.

How many of you attempt to target both medial branches of the targeted facet in the above situation- or just see how they do with blocking the 1 nerve that should be remaining? I can take a guess with 0.5cc of local as it will spread and block something at the surgerized level.... but no idea what I'd RF at that spot generally...

Any other thoughts/strategies for this situation?

You might want to read the op report. Many of these folks do not have facet joints any longer as they underwent decompression including medial facetectomy. That is why insurance does not cover MBB at prior fused levels.

 

[pmrmd]

Q re attempting lumbar MBB/RF post fusion with pedicle screws and or large fusion mass - where one of the medial branches of the targeted facet (either above or below the fusion) is likely either stripped surgically or inaccessible from hardware or bony fusion mass. Generally the ones I've seen have also had absolutely no clear SAP/TP junction visible and my best guess is targeting the superolateral aspect of the pedicle screw.

How many of you attempt to target both medial branches of the targeted facet in the above situation- or just see how they do with blocking the 1 nerve that should be remaining? I can take a guess with 0.5cc of local as it will spread and block something at the surgerized level.... but no idea what I'd RF at that spot generally...

Any other thoughts/strategies for this situation?

Try positioning far oblique and with much less cephalad tilt (almost AP). I do try to do the RF there even though its almost an end-on approach.

 

[Taus]

Don't think you will get good results targeting the facets that have been fused. Now targeting the facets above or below the fusion might work but I have never had great results blocking the fused level. Used to even do alcohol for these due to the spread. That didn't work either

You might want to read the op report. Many of these folks do not have facet joints any longer as they underwent decompression including medial facetectomy. That is why insurance does not cover MBB at prior fused levels.

Thank you.

Just to be clear- I'm not talking about targeting fused levels, only the level above or below. Ie fusion at L4-L5 and going after L3-4 facet joint with mbb at transverse process/sap of L3 and L4, so L2 and L3 mbb.

 

[lobelsteve]

Thank you.

Just to be clear- I'm not talking about targeting fused levels, only the level above or below. Ie fusion at L4-L5 and going after L3-4 facet joint with mbb at transverse process/sap of L3 and L4, so L2 and L3 mbb.

In that case, get a scout with your level centered. Then collimate the heck out of it until no metal is on screen and you will get good contrast and able to see SAP/TP junction.

 

[ziggyziggy]

What do you guys have best success with in these kinds of patient i.e. facet, axial back pain below 1 level from fusion as Taus said. L5/S1 facet pain after L4/5 fusion with pedicle screw. I tried RF once but only got stimulation on one side which gave relief to that side. Are there any other options besides trying 1 more time on that side (try to burn all three - L5, SA and S1)? Stim trial? any other suggestions.

 

[clubdeac]

Make sure it's not SIJ. I see it all the time in post fusion patients

 

[ziggyziggy]

@clubdeac Great Point. I checked but that's not the case.

 

[Taus]

Had a patient today w/ L4-5 lami/posterior instrumented fusion who likely has adjacent segment facet pain at L5-S1. I suggested MBB at only L5, skipping L4 as that would have been stripped during the surgery. Was brought to my attention that this may create difficulty with insurance coverage, as "they" have it listed as 2 nerves per joint, whereas I am only doing one. Was advised to still attempt L4 mbb, even though it's most likely useless. Granted I'm still in academics.... so curious to hear some opinions on this as I'll be on my own in private practice in a few weeks. Would you expect any insurance coverage issues if I did just L5 dorsal rami block x 2, then RF?

 

[pmrmd]

^ Just say in your note you did B L5-S1 facet blocks with excellent relief of symptoms...

 

[lobelsteve]

Get the op note to know.

Do L5 and S1 if no L4 exists.

 

[Taus]

Good points, thanks.

 

[Ducttape]

Had a patient today w/ L4-5 lami/posterior instrumented fusion who likely has adjacent segment facet pain at L5-S1. I suggested MBB at only L5, skipping L4 as that would have been stripped during the surgery. Was brought to my attention that this may create difficulty with insurance coverage, as "they" have it listed as 2 nerves per joint, whereas I am only doing one. Was advised to still attempt L4 mbb, even though it's most likely useless. Granted I'm still in academics.... so curious to hear some opinions on this as I'll be on my own in private practice in a few weeks. Would you expect any insurance coverage issues if I did just L5 dorsal rami block x 2, then RF?

No insurance issues thus far on the ones ive done with just L5 dorsal rami. i document L45 is fused, and access to the L4 median branch is not accessible...

 

[clubdeac]

I recently did this on a woman s/p L3-5 PLIF. I documented in my note, bilateral L2/3 and L5/s1 facet blocks. Hopefully that'll prevent any confusion amongst the idiot bean counters

 

[bedrock]

No insurance issues thus far on the ones ive done with just L5 dorsal rami. i document L45 is fused, and access to the L4 median branch is not accessible...

Ditto. I do the same all the time, and no problems getting paid.