RFA needle sizing for local anesthesia (without sedation)?

[CarabinerSD]

At my current setup, we only offer local anesthesia (no sedation) for procedures. RFA cannula sizing is 20g (lumbar) and 22g (cervical), MDT Accurian (no cooled RF setup). Needles are placed parallel to medial branch nerve with 90 seconds initial burn followed by a 180 degrees rotation for a 2nd burn. Patients do well with local and don't need sedation. Results are pretty good but I'm always wondering if I could optimize the outcome more by upsizing the needle gauge.

• For those who don't do sedations, can patients reasonably tolerate 18g lumbar & 20g cervical RFA with just local?
• My Cervical RFAs are done with 5mm active tip, would 10mm active tip be more optimal here?
• Genicular is pretty painful, so thinking of sticking with just 20g cannula?
• I'm adding steroid flush for upper cervical RFAs after burning due to possible neuritis. I know some people don't...thoughts on steroid flush after RFA?

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[BobBarker]

I use 10mm 20g for cervicals. One burn. Why not give an oral benzo? It helps a great deal.

 

[RoloTomassi]

I don't think tolerability is a function of size. I do 18 ga 10 mm Sidekick cervical and lumbar, 90s, 1 burn, do not routinely sedate. The ones who need sedation need it for even the MBBs, cry and squirm during the numbing. Just cannot tolerate any procedure. I numb each track with 3 mL lido 1%, each burn with 1.5 mL lido 2%. That 2% makes a big difference.

 

[DODOCSS]

17 cooled, local only usually, sometimes 5 of valium

 

[CarabinerSD]

I use 10mm 20g for cervicals. One burn. Why not give an oral benzo? It helps a great deal.

I do give benzo for the really skittish folks...but most of the time don't since they'll need a driver which complicates scheduling for patients. But yea I can give benzo.

But yes I'm hoping to go up a size for needles to do one burn instead of 2 as I'm doing now.

 

[CarabinerSD]

I don't think tolerability is a function of size. I do 18 ga 10 mm Sidekick cervical and lumbar, 90s, 1 burn, do not routinely sedate. The ones who need sedation need it for even the MBBs, cry and squirm during the numbing. Just cannot tolerate any procedure. I numb each track with 3 mL lido 1%, each burn with 1.5 mL lido 2%. That 2% makes a big difference.

OK that's pretty encouraging so I'm going to go ahead and try 18g lumbar & 20g cervical (all 10 mm active tips) since we need to re-order supplies anyways.

 

[Taus]

25g 3.5-5” track needle skin to bone plus wheel. By the time I place the last one, first is numb. Stick w 18g all c/l spine. 2% lido. Motor test. Burn. Nearly always well tolerated. Po benzo depending on how was during mbb.

 

[oneforfighting]

10mm 20g for cervical, 18 for lumbar. LA only. Occasional PO benzo.

 

[GoBeers]

I do 16g for lumbar always with or without sedation. 18g for cervical but patients usually get sedation

 

[BobBarker]

2% lido very helpful as mentioned by others for the RF site.

I think cervical mbb/rfa always need a driver. My patients are always very dizzy after.

 

[deadhead2]

I use only local for all RFA, with or without Norco/Ativan preprocedure. No sedation.

18 gauge for cervical, 16 or 18 for lumbar depending on the patient. For patients who didn’t flinch at all with MBB, 16 is usually well tolerated. Everyone else does fine with 18, unless they are the type of patient who had trouble MBB as @RoloTomassi mentioned.

Agree with generous local and 2% before lesioning. I always tell the patient to let me know if they start to experience more discomfort as the needle approaches the target so I can give additional local if needed.

I do inject steroids after cervical RFA, but I still see neuritis not uncommonly, so not sure if it helps.

I also use 16 or 18 for genicular. Generous local down to periosteum, from both AP and lateral approach, is key.

 

[DOctorJay]

10mm 20g for cervical, 18 for lumbar. LA only. Occasional PO benzo.

Same here

 

[oneforfighting]

I think cervical mbb/rfa always need a driver. My patients are always very dizzy after.

Do you do unilateral or bilateral cervical rfa?

 

[BobBarker]

Bilateral 90% of the time.

 

[MitchLevi]

Me:

20g 10mm cervical, 18g 10mm lumbar

Lido 1% skin

Lido 2%, bupi 0.5% or mixture for lesion

Valium 4, 5 or 10mg 45 min prior

Depo in lumbar, dex in the neck. I have a significant amount of post RFA neuritis in the neck. I don't think dex helps it TBH, but I still do it. I've mentioned my neuritis rates in the neck on this forum, and I've posted pics.

Bilateral cervical MBB for me, really don't like bilateral cervical RFA. I've seen drop head from a cervical RFA. On call as a fellow and saw a disturbing scene where a woman had no ability to keep her upright. Collar dependent. Like something out of a movie. I can't explain it, but she'd just had an RFA. Cervical RFAs take longer, and it's a lot of local in the neck. I do them 2w apart.

 

[oneforfighting]

Bilateral 90% of the time.

No complaints of neck weakness/drop head? I’ve always done them unilateral ever since fellowship. Thankfully they tend to last longer than lumbars for me so I can repeat yearly or so.

 

[BobBarker]

Had a younger lady today with a neuritis that wasn’t too troublesome but did have some mild drop head type sensation. Nothing that an observer could perceive but she could sense it occasionally. I just told her it was because I did a great job and she will get better before the pain comes back.

 

[RoloTomassi]

Can anyone explain why head drop doesn't occur if you do 2 weeks apart?

Or why b/l TON doesn't cause balance issues if 2 weeks apart?

Seems like the idea is the non-denervated side compensates for the ablated one, but why then after the second side is done are there no issues?

I split TON but can't explain it.

 

[BobBarker]

It just avoids dousing TON in 2% lidocaine bilaterally simultaneously. The RF is a less complete lesion than the 2 hours or so when the lidocaine is active.

 

[MitchLevi]

I split cervical RFA 2w apart because weakness would be present by then, and I'd just not do the contralateral side.

 

[Taus]

I split cervical RFA 2w apart because weakness would be present by then, and I'd just not do the contralateral side.

I split cervical because it’s too much pita/work for me plus volume of local. I still find this more technically demanding to do well than most other procedures.

 

[RoloTomassi]

It just avoids dousing TON in 2% lidocaine bilaterally simultaneously. The RF is a less complete lesion than the 2 hours or so when the lidocaine is active.

Thanks that makes sense for short term balance but I thought that the concern was a long term balance issue

 

[callmeanesthesia]

I only split cervical sides if they had trouble with the block. And if so I’ll split it by at least a month.

 

[Timeoutofmind]

I give everyone tons of local. Up to and at times exceeding toxic doses according to the anesthesia literature (5mg/kg lido)

And I give it plenty of time to set up

And I use 4% at the lesion site

Still

About half of my patients still complain of a lot of pain throughout the procedure and are at times crying, etc.

I don’t know. Maybe I’m just in an area with sub optimal patients.

 

[BobBarker]

They really can’t feel the burning much at all with 1 minute wait and 2%. So more of a patient issue

 

[oneforfighting]

I mix bupi and lido which seems to help more although some literature says otherwise. Older patients usually do better probably because of less sensitive nerve endings overall. It’s the young ones that feel everything.

 

[Taus]

I give everyone tons of local. Up to and at times exceeding toxic doses according to the anesthesia literature (5mg/kg lido)

And I give it plenty of time to set up

And I use 4% at the lesion site

Still

About half of my patients still complain of a lot of pain throughout the procedure and are at times crying, etc.

I don’t know. Maybe I’m just in an area with sub optimal patients.

Benzo on board? Perhaps give more?

 

[Timeoutofmind]

Benzo on board? Perhaps give more?

Yeah.
I usually give around 2 mg of versed.

I used to give more, like four to eight depending…

But I found a lot of these difficult patients just get disinhibited at the higher doses and move all around and the procedure takes forever and sucks.

 

[Taus]

Yeah.
I usually give around 2 mg of versed.

I used to give more, like four to eight depending…

But I found a lot of these difficult patients just get disinhibited at the higher doses and move all around and the procedure takes forever and sucks.

Got it.

I’d wager the that bs behavior during rfa inversely correlates to success of rfa….

 

[NJPAIN]

They really can’t feel the burning much at all with 1 minute wait and 2%. So more of a patient issue

I agree. Some patients will flinch and scream no matter what. All the lidocaine in the world won’t fix that. If you use IV sedation and are over zealous in snowing patients into La La land, be prepared to have one eye on the procedure field and another on the pulse ox and airway; you will be flipping patients to ventilate them. As an anesthesiologist, I consciously fight the urge to supervise deep sedation while performing a procedure. If you can’t tolerate the procedure with local and a touch of anxiolytic, find someplace else to go. This isn’t kindergarten.

 

[MitchLevi]

I give everyone tons of local. Up to and at times exceeding toxic doses according to the anesthesia literature (5mg/kg lido)

And I give it plenty of time to set up

And I use 4% at the lesion site

Still

About half of my patients still complain of a lot of pain throughout the procedure and are at times crying, etc.

I don’t know. Maybe I’m just in an area with sub optimal patients.

4% lido probably increases the size of your lesion and denatures the nerve. It also prob hurts a lot more to inject.

Not sure what 4% costs but it's prob expensive.

 

[bedrock]

I refuse to do cervical RFA bilateral. I’ve also seen a flail neck. And a patient with long term balance issues. Each of them could have been greatly minimized if the doctor just stopped after the first unilateral RFA.

I will do bilateral thoracic and lumbar RFA.

 

[bedrock]

At my current setup, we only offer local anesthesia (no sedation) for procedures. RFA cannula sizing is 20g (lumbar) and 22g (cervical), MDT Accurian (no cooled RF setup). Needles are placed parallel to medial branch nerve with 90 seconds initial burn followed by a 180 degrees rotation for a 2nd burn. Patients do well with local and don't need sedation. Results are pretty good but I'm always wondering if I could optimize the outcome more by upsizing the needle gauge.

• For those who don't do sedations, can patients reasonably tolerate 18g lumbar & 20g cervical RFA with just local?
• My Cervical RFAs are done with 5mm active tip, would 10mm active tip be more optimal here?
• Genicular is pretty painful, so thinking of sticking with just 20g cannula?
• I'm adding steroid flush for upper cervical RFAs after burning due to possible neuritis. I know some people don't...thoughts on steroid flush after RFA?

Yeah.
I usually give around 2 mg of versed.

I used to give more, like four to eight depending…

But I found a lot of these difficult patients just get disinhibited at the higher doses and move all around and the procedure takes forever and sucks.

4% lido probably increases the size of your lesion and denatures the nerve. It also prob hurts a lot more to inject.

Not sure what 4% costs but it's prob expensive.

I did 99% of RFA in office for 5 years at my first job. I gave Xanax to 100% of the cervical RFA, and 80% of the thoracic/lumbar RVA.

The OP should offer Xanax to 100% of his RFA patients under 60 years old. Xanax definitely helps with in office RFA.

OP, I’d suggest you use 10mm active tip for all spine RFA including cervical.

Agree with 2% lidocaine. Helps a lot and is much less expensive than 4%.

Time out if mind, why do you give IV versed only? If you’re already going to offer an IV med, the usual combo of versed and fentanyl works much better than just versed. And if they struggle with the procedure, then you give them more fentanyl not more versed. Versed is more disinhibiting than fentanyl.

Your average middle aged (not elderly) patient will tolerate RFA much better with 2 versed and 50 mcg fentanyl, than they will with 4 of versed only. And they’ll be more disinhibited with double the versed.

Personally I use 18G needles for all three areas of spine RFA.
16G needles for SIJ and genicular.

 

[Timeoutofmind]

I did 99% of RFA in office for 5 years at my first job. I gave Xanax to 100% of the cervical RFA, and 80% of the thoracic/lumbar RVA.

The OP should offer Xanax to 100% of his RFA patients under 60 years old. Xanax definitely helps with in office RFA.

OP, I’d suggest you use 10mm active tip for all spine RFA including cervical.

Agree with 2% lidocaine. Helps a lot and is much less expensive than 4%.

Time out if mind, why do you give IV versed only? If you’re already goong to offer an IV med, the usual combo of versed and fentanyl works much better than just versed. And if they struggle with the procedure, then you give them more fentanyl not more versed. Versed is more disinhibiting than fentanyl.

Your average middle aged (not elderly) patient will tolerate RFA much better with 2 versed and 50 mcg fentanyl, than they will with 4 of versed only. And they’ll be more disinhibited with double the versed.

Personally I use 18G needles for all three areas of spine RFA.
16G needles for SIJ and genicular.

Thanks man

I still do operating room anesthesia one day a week… and the longer I do it the more paranoid I get!

Which is why I was avoiding the fentanyl and just doing versed. No one gets apneic with just versed.

But your points are well taken and insightful.

 

[MD87]

Thoughts on Valium vs Xanax for in office procedures? I’ve always used valium. Any anecdotes?

 

[Ducttape]

valium probably deeper effects, but half life is 24+ hours.

xanax might not be as sedating, but its half life is 11 hours.

ativan in my experience is least effective and half life is 12 hours or so.

 

[BobBarker]

Valium seems to get them quite a bit deeper.

 

[CarabinerSD]

2% lido very helpful as mentioned by others for the RF site.

I think cervical mbb/rfa always need a driver. My patients are always very dizzy after.

More dizzy the higher up the cervical segment right?

 

[BobBarker]

Correct but most of mine get dizzy anyways. Might just be the orthostasis.