What is your RF protocol?

[ampaphb]

When you do a lumbar RF, do you

1) inject saline to lower tissue impedance?
2) record tissue impedance
3) perform motor or sensory stimulation?

10 yrs ago, when I trained, I was taught to do all of the above. Today, the teaching appears to be place the needles anatomically, anesthetize, and light 'em up.

Curious what y'all do.

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[BobBarker]

Place needles, motor testing, anesthetize, burn

I have gotten L5 motor stim twice in the past year. Including yesterday.

 

[NJPAIN]

Place needles using oblique and declined view. Check AP, oblique and lateral views. Motor stim to 2.5 v. Inject local. Burn x 2, rarely 3. If I did sensory testing I would be there all day.


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[Ligament]

When I do a lumbar RF, I
1) do not inject saline to lower tissue impedance
2) do not record tissue impedance
3) do perform motor stimulation to 2V

Motor stim is primarily for medlegal documentation, and though I do like to see multifidi twitch, it does not always happen, and it does not seem to affect outcome too often. 16ga, 90degC (lumbar thoracic) 80degC (cervical), 60 seconds x 2

 

[powermd]

How do you all approach using the declined view?

I've started performing the procedure this way and find it takes a lot longer to get the needles in position. I start in AP or oblique (for a given level), and decline until the SAP pops up from the TP. I then return to 5 degrees oblique and aim for the SAP/TP groove. Next I return to a squared oblique view to see where the needle tip ended up. Frequently I find the tip is too low on the SAP based on the likely MB position (based on the 2013 PP article). So I wiggle it up to hug the SAP, but with no easy bony end point. It's just hanging there next to the SAP. I sure hope the outcomes are worth all this extra effort.

 

[Timeoutofmind]

Place needles, motor testing, anesthetize, burn

I have gotten L5 motor stim twice in the past year. Including yesterday.

Isn't it safer to hold off on anesthetic until after burning if possible? Don't want to numb up a nerve root and then cook it...and there is never a guarantee that the needle didn't move after testing...

 

[Taus]

Isn't it safer to hold off on anesthetic until after burning if possible? Don't want to numb up a nerve root and then cook it...and there is never a guarantee that the needle didn't move after testing...

One cc of local on the mb before burning won't block the nerve root even if some spills on to it. Have you ever attempted to do an rf without local before burning? I can't see that being tolerated.

As for needle moving after testing... Agreed. Just re check a lateral before burning and keep your patient awake.



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[Taus]

When you do a lumbar RF, do you

1) inject saline to lower tissue impedance?
2) record tissue impedance
3) perform motor or sensory stimulation?

10 yrs ago, when I trained, I was taught to do all of the above. Today, the teaching appears to be place the needles anatomically, anesthetize, and light 'em up.

Curious what y'all do.

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1) no
2) I peek at it just to make sure not way too high
3) motor for the lawyers. No sensory.


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[clubdeac]

Isn't it safer to hold off on anesthetic until after burning if possible? Don't want to numb up a nerve root and then cook it...and there is never a guarantee that the needle didn't move after testing...

You obviously have never done an RF

 

[powermd]

You obviously have never done an RF

It's amazing how many horror stories I hear about RF being performed without anesthetic. The moment you mention repeat RF to these people it's "I'm never having THAT again". Usually these are non-anesthesia trained docs, but my former employer back in 2009-10 would do propofol sedation and RF without anesthetic. The room got a lot quieter when I started doing the RFs.

 

[lobelsteve]

RF without local is torture.

 

[ampaphb]

It's amazing how many horror stories I hear about RF being performed without anesthetic. The moment you mention repeat RF to these people it's "I'm never having THAT again". Usually these are non-anesthesia trained docs, but my former employer back in 2009-10 would do propofol sedation and RF without anesthetic. The room got a lot quieter when I started doing the RFs.

Burning the nerves under Propofol is foolish.

I understand why you might place the needles under Propofol, but patient response is one of my primary indicators that my needle tip is too anterior, putting the spinal nerve at risk. Using deep sedation during the actual ablation is a bad idea


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[Aether2000]

Either deep sedation/general anesthesia and use of motor stim (advantage of General anesthesia is the chance of patients moving less with subsequent less needle movement) or no sedation using motor stim and possibly sensory stim (although the needles used with the 10mm active tip do not allow fine discrimination of needle location relative to the nerve). Toronto General Hospital published one of the larger studies of RF and did these cases under general anesthesia without any adverse outcomes. Medico-legally in the US it is probably more prudent to do these without sedation or at most with very minimal sedation.

 

[NOSfan]

Either deep sedation/general anesthesia......

Yes.....same technique with trigger point injections.

 

[bedrock]

1- place needles per SIS protocol
2- motor stim
3-numb
4-burn
5-rotate 90 degrees
6-burn again


Agree with above in that it's cruel to burn without local and that 1ml of local won't block the nerve root.

 

[Ligament]

1- place needles per SIS protocol
2- motor stim
3-numb
4-burn
5-rotate 90 degrees
6-burn again


Agree with above in that it's cruel to burn without local and that 1ml of local won't block the nerve root.

1ml of 4% lidocaine will work very well, if that is something you have on stock.

 

[oreosandsake]

thoughts on this?

 

[oreosandsake]

and this...

 

[smarterchild]

when you guys are doing the RF, how much deeper than the skin wheal do you guys numb the patient? I find a lot of patients not tolerating needle placement despite having sedation.

 

[BobBarker]

First guy needs to do a Henry ford style analysis of what he is doing.
Second has a bad haircut.
Both use too much fluoro and stand to close to the c arm.

 

[lonelobo]

Does the 1st guy thinks his radiation gloves protect his hands from all that direct Fluoro?

 

[pastafan]

First procedure. One view=No view.

 

[lonelobo]

http://www.internationalhouseofpain.com/

 

[lobelsteve]

http://www.internationalhouseofpain.com/

Chip off the Windsor block.

 

[Ligament]

and this...

This has to be the fastest 4 medial branch cervical RF I've ever seen. Do any of you do RF with the patient in a lateral position?

 

[Ligament]

Chip off the Windsor block.

"I do not like braggarts, but I am blessed to know pain and pain medicine as well as the best in America, and perhaps the world."

 

[Taus]

when you guys are doing the RF, how much deeper than the skin wheal do you guys numb the patient? I find a lot of patients not tolerating needle placement despite having sedation.

As deep as possible. Then sometimes when you pass that depth if painful stop and local more through RF canula. When hit os then even more local.


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[bedrock]

As deep as possible. Then sometimes when you pass that depth if painful stop and local more through RF canula. When hit os then even more local.


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exactly. numb the hell out of everything, patients really appreciate it. I have patients come to me all the time who didn't tolerate the RFA of my partner who only does skin wheel and they tolerate it so much better when I numb everything sensitive on the way in.

The only time you need to be judicious with local is if you think the tip of the needle is too far anterior.

 

[nvrsumr]

This has to be the fastest 4 medial branch cervical RF I've ever seen. Do any of you do RF with the patient in a lateral position?

Interesting. I thought it looked a bit cramped for the doc but maybe aomething to consider.

 

[smarterchild]

exactly. numb the hell out of everything, patients really appreciate it. I have patients come to me all the time who didn't tolerate the RFA of my partner who only does skin wheel and they tolerate it so much better when I numb everything sensitive on the way in.

The only time you need to be judicious with local is if you think the tip of the needle is too far anterior.

Thanks for the input! Do you find that numbing up deeper structures makes sensory testing more difficult?

 

[bedrock]

Thanks for the input! Do you find that numbing up deeper structures makes sensory testing more difficult?

I think sensory testing is a complete waste of time, and not recommended by SIS so I never do sensory testing.

 

[smarterchild]

I think sensory testing is a complete waste of time, and not recommended by SIS so I never do sensory testing.

Thanks! How do you proceed if you don't get the motor twitch even after a few attempts at repositioning?

 

[lobelsteve]

Sensory testing. No.

Motor testing only makes sure you are not on root. Nothing else gained. Twitch ir no twitch means nothing. I drop local from skin to MAL. Then 1.5cc marcaine .25% on each MBB. Then cook.

 

[Aether2000]

It does make me wonder why occasionally I will get an actual motor activation with lower extremity movement when stimulating the medial branch of L3 with the needle positioned only half way across the SAP....

 

[NJPAIN]

This has to be the fastest 4 medial branch cervical RF I've ever seen. Do any of you do RF with the patient in a lateral position?

I'm "impressed" that that he marked his entry for 4 needles on one view. He has 4 needles in his hand like your would if you were throwing darts.

 

[NJPAIN]

http://www.internationalhouseofpain.com/

Love the pancake house name and the list of great docs.

 

[SSdoc33]

It does make me wonder why occasionally I will get an actual motor activation with lower extremity movement when stimulating the medial branch of L3 with the needle positioned only half way across the SAP....

L3 always has a bigger twitch. i think the multifidi are generally stronger and more fully innervated at that level. a lot of times, what you are seeing is the whole back twitch and the leg jumps with it. if you (or your tech) actually feels a quad contraction, then thats a different story.

 

[Aether2000]

These are not multifidus movements....lowe ext...

 

[SSdoc33]

These are not multifidus movements....lowe ext...

do you use a big gauge? stim up to 2V? 3V?

 

[lobelsteve]

These are not multifidus movements....lowe ext...

Incomplete lateral making tip appear further posterior than actual.

 

[NJPAIN]

http://www.internationalhouseofpain.com/

Was McPain taken? Perhaps McJunkin got it before McRoberts.

 

[Aether2000]

It is a true lateral with stim with lowe extremity movement at around 0.9v. It is uncommon but when i see it is perplexing....back the tip to the posterior 1/3 of the gutter just anterior to the MAL in order to stop the motor recruitment.

 

[lobelsteve]

It is a true lateral with stim with lowe extremity movement at around 0.9v. It is uncommon but when i see it is perplexing....back the tip to the posterior 1/3 of the gutter just anterior to the MAL in order to stop the motor recruitment.

Disc at this level pushing root back towards your needle?

 

[Aether2000]

I had noted such a correlation, but I will look for it. I am using a Baylis generator, so who knows how much juice it is really putting out on stim. I wonder if 1 Canadian volt = 2 US volts....

 

[ateria radicularis magna]

1- place needles per SIS protocol
2- motor stim
3-numb
4-burn
5-rotate 90 degrees
6-burn again


Agree with above in that it's cruel to burn without local and that 1ml of local won't block the nerve root.

After step 5, do you motor stim again? If it's a curved needle aren't you in a totally different location when you turn 90? [Devil's advocate]

 

[bedrock]

After step 5, do you motor stim again? If it's a curved needle aren't you in a totally different location when you turn 90? [Devil's advocate]

If turning the needle 180 degrees, yes, but not with 90 degrees. And it's really 45 superior to horizontal axis of the SAP, and then 45 inferior to that axis for the second burn.

 

[Papa Lou]

It's better to do a 180 degree turn or no turn at all....the tiny curve won't benefit much from a 90 degree turn. It's all theoretical I'm not sure turning has been compared to not turning within a chicken breast for example.

I do same as bedrock. I would argue that getting medial branch stim IS important. I like to see it, and as I've gotten more particular about placement I've seen it more. The MB rides up along the SAP more than it lays over the bottom connection b/w TP and SAP. I put needle with curve facing up and to SAP along the upper part of that curve, then I flip 180 degrees. Anesthesiologist reduces sedation as we start first burn then no more sedation so they are not sedated as much during the second burn...I still image that second burn a lot of times but needle tip never advances ventrally near the nerve root, it just catches more potential laterally running MB. This is all in my head. But I feel since I've made adjustments my pictures and "results" have improved.

 

[lobelsteve]

I'm really astounded at the degree of difficulty people reported having the needle please try to get good results. I guess I just kind of wing it and get lucky. 10 years running. No flip turns no back kicks No Nonsense. Get a good X-ray pick out your target Put the Needle on the target burn the sucker

 

[Aether2000]

Anyone burning at 90 or 95 deg C?

 

[Papa Lou]

It's a 15-25 minute procedure boss, nobody said it's difficult. You just shouldn't go doing things you don't think about and try to perfect. I'm sure SIS spent a respectable amount of time coming up with best practice guidelines.

On another note, how do you guys explain or rationalize staging the RFA into unilateral procedures? If it's one paravertebral facet level I have always done bilateral but for 2 facets which is what I regularly do, I stage to right side then left side a couple of weeks later. I don't have a good rationalization for patients other than: it takes a long while to do bilateral multilevel RFA. Saying it's "too much local otherwise" as they did in my fellowship seems like an obvious fib. So does saying "it may be too painful" or "that's how I trained."

What do you guys say?