Where would you place needles?

[SpineandWine]

May be basic question but let’s say you were going to do treat adjacent level facets and you saw this fusion.

Where would you place your needle for diagnostic medial branch nerve block (please clarify if you’re referring to the nerve or the vertebral body on which medial branch courses)

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[Agast]

I would need to know where their pain is. Sometimes if I’m not sure what level to attack I draw on them in Preop and then verify levels under fluoro

 

[oneforfighting]

If pain is above fusion then I treat levels above. If below, then treat levels below or SIJ. If at fusion, then for the above example I would do L1, L2 MB and L5 DR since L3 and L4 were presumably lesioned during surgery.

 

[pmrmd]

Levels with hardware I align my c-arm so that the needle is in the same trajectory as the pedicle screw. No its not optimal but I get it there.

 

[Ferrismonk]

If the physical exam matches facets and the pain is above the fusion, I would do T12, L1, and L2 medial branches. If below, I would not do the L5DR and just do an SIJ.

 

[callmeanesthesia]

Maybe it’s a waste of time but I’ll do ablation at levels with pedicle screws if the geometry allows reaching the targets. Just depends on how aggressive the surgeons were with tearing up the area, but often there’s still a SAP/TP junction. CT is very helpful for seeing that (I won’t order it just for that but often they’ve had one, or had a CT abdomen/pelvis). For the example above, assuming they seem to have pain both above and below the fusion, I would do L3-4 and L5-S1 facet joints, with needles on L3, L4, L5, and S1.

 

[RoloTomassi]

Depends on pain location and how facets (and discs to some extent) look on MRI.

I almost always do 2+ facet levels so for this case, either:

1. L3-4 and L5-S1 facet levels if pain seems lower and L5-S1 facets are arthritic and disc is as or more degenerated than L3-4.

2. L2-4 facet levels if pain is waist level/above scar/no buttock.

I just do my best at levels where screws are present, usually extra oblique, more perpendicular placement. Those screws are more on the inferior side, not too bad.

 

[Tboned]

Considerations for Lumbar Medial Branch Nerve Radiofrequency at Spinal Motion Segments Adjacent to a Fusion Construct

Abstract. Instrumented lumbar spinal fusion is common and results in biomechanical changes at adjacent spinal segments that increase facet load bearing. This ca

academic.oup.com

 

[NJPAIN]

Considerations for Lumbar Medial Branch Nerve Radiofrequency at Spinal Motion Segments Adjacent to a Fusion Construct

Abstract. Instrumented lumbar spinal fusion is common and results in biomechanical changes at adjacent spinal segments that increase facet load bearing. This ca

academic.oup.com

Exactly.

 

[lobelsteve]

May be basic question but let’s say you were going to do treat adjacent level facets and you saw this fusion.

Where would you place your needle for diagnostic medial branch nerve block (please clarify if you’re referring to the nerve or the vertebral body on which medial branch courses)

View attachment 366967

Only a single view, but L3-4 looks normal.
Drop a needle in the sacral ala as well as the L4 MB on the TP/SAP junction of L5. Lots of oblique to see it.

 

[SpineandWine]

If pain is above fusion then I treat levels above. If below, then treat levels below or SIJ. If at fusion, then for the above example I would do L1, L2 MB and L5 DR since L3 and L4 were presumably lesioned during surgery.

MBB are outside their hardware, you’re right potentially damaged. But don’t think necessarily

 

[lobelsteve]

View attachment 366978

MBB are outside their hardware, you’re right potentially damaged. But don’t think necessarily

Hit the red dot on top pic.

 

[Ducttape]

just be careful as CMS does not approve of RFA of fused levels...



personally, i would target the area of pain - if above level of fusion, then L34 facets. if below, then L5 DR nerve for the L5S1 facets, or both if it is more global pain consistent with disease at both levels...

i dont target L4 median branch.

 

[callmeanesthesia]

just be careful as CMS does not approve of RFA of fused levels...



personally, i would target the area of pain - if above level of fusion, then L34 facets. if below, then L5 DR nerve for the L5S1 facets, or both if it is more global pain consistent with disease at both levels...

i dont target L4 median branch.

It’s also iffy under CMS requirements to do only one medial branch nerve and bill for a full joint level. In the above described circumstances you would not be billing for RFA of the fused level, just the adjacent levels.

 

[SSdoc33]

some claim that RF at a fused level helps. i find it rarely does.

you can go above or below. or SIJ. no wrong answer, but you are nibbling around the edges here

 

[lobelsteve]

The L5-S1 segment is not fused and doing the L4 and L5 MB/DR is completely appropriate for all guidelines.

 

[SpineandWine]

Yes, if L4-5 is fused (has no movement, so can’t do MBNB), I can still target L3-4 joint, meaning I have to place my needle where there is hardware.

Anyone have tips on doing RF at level of that L4 vertebral body with hardware?

 

[Multimodal]

just be careful as CMS does not approve of RFA of fused levels...



personally, i would target the area of pain - if above level of fusion, then L34 facets. if below, then L5 DR nerve for the L5S1 facets, or both if it is more global pain consistent with disease at both levels...

i dont target L4 median branch.

our LCD specifies no RFA if anterior fusion but still allows RFA if posterior fusion. ass backwards in my opinion but that's what it says.

The following are considered not reasonable and necessary and therefore will be denied:

1. Intraarticular and extraarticular facet joint prolotherapy
2. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation.
3. Intra-facet implants
4. Facet joint procedure performed after anterior lumbar interbody fusion or ALIF.

 

[RoloTomassi]

Means you can't do an L4-5 facet level RFA. Just specify you're doing L3-4 and/or L5-S1 level and you won't have any issues.

 

[oneforfighting]

View attachment 366978

MBB are outside their hardware, you’re right potentially damaged. But don’t think necessarily

Not guaranteed sure but a good surgeon will try to lesion, at least from what I understand. Also, if the level is fused, you have less reason to expect pain from those facets as there is no movement.

 

[MitchLevi]

If this is my pt, I'm abating L3-4 and L5-S1, both above and below the L4-5 fusion. This is something I see and do commonly.

If there is ZERO pain above, I'd do L5-S1 and S1 LB, and I'd just eat the S1 needle.

 

[DrMDAware]

Just for learning opportunities, let’s say that you did the RFA at L3-L4 and for L5-S1 with suboptimal relief.

What’s your next step?

It’s technically Failed Back so I could see some say SCS but others say the data for SCS for axial back pain is not outstanding.

ReActiv8?
Push core strengthening?
Other?

 

[Ducttape]

wouldnt suggest SCS, and even so, most of my patients fail the psych component for SCS....

core strengthening.

active exercise

non opioid med management

pain psychology - CBT, EAAT

 

[oneforfighting]

If this is my pt, I'm abating L3-4 and L5-S1, both above and below the L4-5 fusion. This is something I see and do commonly.

If there is ZERO pain above, I'd do L5-S1 and S1 LB, and I'd just eat the S1 needle.

What’s your rationale for including S1 LB?

 

[MitchLevi]

What’s your rationale for including S1 LB?

I get tired of being nickel and dimed in the post RFA follow up!

 

[DrMDAware]

wouldnt suggest SCS, and even so, most of my patients fail the psych component for SCS....

core strengthening.

active exercise

non opioid med management

pain psychology - CBT, EAAT

They formally fail psych clearance or that’s your intuition and clinical sense?

Sounds like a very tough population you treat.

 

[RoloTomassi]

Just for learning opportunities, let’s say that you did the RFA at L3-L4 and for L5-S1 with suboptimal relief.

What’s your next step?

It’s technically Failed Back so I could see some say SCS but others say the data for SCS for axial back pain is not outstanding.

ReActiv8?
Push core strengthening?
Other?

SIJ
Intracept
SCS Nevro

 

[BobBarker]

T12/L1
14g

 

[oneforfighting]

I get tired of being nickel and dimed in the post RFA follow up!

No I meant what are you treating by adding S1? SIJ?

 

[MitchLevi]

No I meant what are you treating by adding S1? SIJ?

Mmmhmmm.

 

[DrMDAware]

SIJ
Intracept
SCS Nevro

I can see why SIJ.

Care to explain your rationale for Intracept at L3 and L5-S1?

Any reason why Nevro?

Looking to learn. Cheers.

 

[cowboydoc]

Just for learning opportunities, let’s say that you did the RFA at L3-L4 and for L5-S1 with suboptimal relief.

What’s your next step?

It’s technically Failed Back so I could see some say SCS but others say the data for SCS for axial back pain is not outstanding.

ReActiv8?
Push core strengthening?
Other?

Look for Modic changes, consider Intracept?

Reactiv8 is out because of the fusion.

 

[RoloTomassi]

I can see why SIJ.

Care to explain your rationale for Intracept at L3 and L5-S1?

Any reason why Nevro?

Looking to learn. Cheers.

If Modic that is. Supposedly high frequency is better for axial but who knows

 

[bedrock]

SIJ
Intracept
SCS Nevro

Agree.

Though only nevro if a lot of pain below belt line. The more stim I do , the less faith I have in it for axial pain superior to belt line.

 

[DrMDAware]

Look for Modic changes, consider Intracept?

Reactiv8 is out because of the fusion.

I’ve never done ReActiv8. Is the idea rhe multif can’t be stimulated because it’s been disrupted by the fusion dissection?

 

[Taus]

Agree.

Though only nevro if a lot of pain below belt line. The more stim I do , the less faith I have in it for axial pain superior to belt line.

I dont do much stim, and only a handful ever for pure axial…. But was taught that the constant component of axial pain, regardless of position/activity, is what responds best. Ive never rec’d scs for “mechanical” axial pain. Thoughts from those more experienced?

My results from adjacent level facet rfa have been “okay”. Generally less robust and durable of a benefit than native spines

So far pretty good results with intracept at adjacent levels when modic present, but limited sample size… time will tell.

 

[RoloTomassi]

I’ve never done ReActiv8. Is the idea rhe multif can’t be stimulated because it’s been disrupted by the fusion dissection?

It's also not MRI compatible which I hate to do in that pt

 

[SpineandWine]

Levels with hardware I align my c-arm so that the needle is in the same trajectory as the pedicle screw. No its not optimal but I get it there.

Just to clarify, you tilt your c-arm so that it's co-axial with pedicle screw and then hit where that junction of TP and SAP? I've been having hard time with hardware with RF.

 

[cowboydoc]

Look for Modic changes, consider Intracept?

Reactiv8 is out because of the fusion.

AFAIK, it is not approved for pts with a hx of fusion or lami. I don’t believe it’s been studied in that population.

 

[cowboydoc]

I’ve never done ReActiv8. Is the idea rhe multif can’t be stimulated because it’s been disrupted by the fusion dissection?

AFAIK, it is not approved for pts with a hx of fusion or lami. I don’t believe it’s been studied in that population.

 

[DrMDAware]

To further the educational bend what is everyone’s thoughts about Via Disc instead of Intracept?

 

[Ducttape]

They formally fail psych clearance or that’s your intuition and clinical sense?

Sounds like a very tough population you treat.

formally. and thats after i weed out the questionables.

sometimes, no psych around that will see based on their insurance.

 

[MitchLevi]

formally. and thats after i weed out the questionables.

sometimes, no psych around that will see based on their insurance.

Dude...Are you the pain doctor in a psych ward?

 

[bedrock]

Dude...Are you the pain doctor in a psych ward?

He sees a high volume of Medicaid…..which the majority of the time is psych just by a different name.

 

[Ducttape]

thread on patient comments on private forum may shed some light

 

[MitchLevi]

thread on patient comments on private forum may shed some light

Well, whatever light it sheds I can't help but wonder if that's why you're so conservative. I am too BTW, and maybe I'm wrong about you but you seem a little more conservative than most...

If I get a crazy person I go out of my way to avoid them with a needle.

 

[SC Tian]

Imo, flexion and extension views of fluoro, Ct scan would be preferred for persistent micro instability and pseudoarthrosis At fusion level, for these conditions, mb rfa won‘t work well; also subclinical infection of hardware happens as well, if choose to do l4 and l5 dr rfa, I normally use bipolar to prevent incidental heating of hardware.

 

[MitchLevi]

Imo, flexion and extension views of fluoro, Ct scan would be preferred for persistent micro instability and pseudoarthrosis At fusion level, for these conditions, mb rfa won‘t work well; also subclinical infection of hardware happens as well, if choose to do l4 and l5 dr rfa, I normally use bipolar to prevent incidental heating of hardware.

You're not gonna heat the hardware.

What is subclinical infection?

 

[SC Tian]

You're not gonna heat the hardware.

What is subclinical infection?

You're not gonna heat the hardware.

What is subclinical infection?

Maybe subclinical is not accurate description,
I encountered one case of hardware infection with Propionibacterium acnes, we did all sorts of injection and stim that did not work, until hardware removed and culture back positive. Low virulent infection causing back pain can be under estimated, another lady had initial spine infection, long term abx, both ID and spine colleagues cleared her, again developed significant back pain, no fevers, no significant elevated blood marker, found to be reinfection. Just some of my observations in practice.