50% relief from cervical RFA

[MitchLevi]

---

Members don't see this ad.

Does anyone find cervical RFA to be far more effective than lumbar RFA? I’ve never had a single patient tell me cervical RFA didn’t help quite a bit. I’ve absolutely had complete non-responders to lumbar RFA despite having no pain following MBB

Very effective procedure, rife with side effects unfortunately

 

[MD87]

Does anyone find cervical RFA to be far more effective than lumbar RFA? I’ve never had a single patient tell me cervical RFA didn’t help quite a bit. I’ve absolutely had complete non-responders to lumbar RFA despite having no pain following MBB

Yes. 100%. My unilateral cervical facet patients are some of my happiest patients after RF, especially, if they have 1 or maybe 2 joints on the affected side that light up on STIR. Lumbar RF I feel is often a crapshoot, though some patients obviously do quite well

 

[clubdeac]

Very effective procedure, rife with side effects unfortunately

Your patients have lots of side effects from cervical RF? What you doing wrong man?

 

[MitchLevi]

Your patients have lots of side effects from cervical RF? What you doing wrong man?

Neuritis in more than half

 

[Taus]

Neuritis in more than half

I find it to be rarely problematic as long as you give patients a heads up that it is likely to happen, is harmless, and will go away except for the occasional residual numb spot.

 

[MitchLevi]

I find it to be rarely problematic as long as you give patients a heads up that it is likely to happen, is harmless, and will go away except for the occasional residual numb spot.

I do, and most of the time it isn’t a huge problem but I’ve had a handful who flip their lid bc of it. It forever prevents you from touching them again, and a few have been pretty resentful about it. I tell everyone it is a good possibility that it is gonna happen.

 

[Taus]

I do, and most of the time it isn’t a huge problem but I’ve had a handful who flip their lid bc of it. It forever prevents you from touching them again, and a few have been pretty resentful about it. I tell everyone it is a good possibility that it is gonna happen.

Interesting. I can only recall two patients (both incl c23/ton) over my 11 year career where it was truly bad enough to prevent them from wanting to repeat it.

 

[hopefulgasman]

I do, and most of the time it isn’t a huge problem but I’ve had a handful who flip their lid bc of it. It forever prevents you from touching them again, and a few have been pretty resentful about it. I tell everyone it is a good possibility that it is gonna happen.

Those patients were likely crazy to begin with. I’ve had several tell me that the neuritis they can deal with and is nothing and are grateful because their neck pain, stiffness, and headaches are completely gone.

 

[hopefulgasman]

I find it to be rarely problematic as long as you give patients a heads up that it is likely to happen, is harmless, and will go away except for the occasional residual numb spot.

Yes you have to warn them about it. If you give them the heads up, they are not as concerned at the follow up.

 

[MitchLevi]

I've been on this forum for a long time, and we've had this conversation repeatedly. I've posted pictures many times, and I've referenced the large study published like a year or two ago which boasts rates that mirror my own in the real world.

If you're not getting hypersensitivity, sun burn sensation or dullness at the skin, you didn't burn the nerve.

I still do quite a lot of cervical ablations.

 

[MitchLevi]

Those patients were likely crazy to begin with. I’ve had several tell me that the neuritis they can deal with and is nothing and are grateful because their neck pain, stiffness, and headaches are completely gone.

No, no I disagree.

I have a few nutcase people of course, but my top 3 worst neuritis pt is a British guy who is stone cold normal. I set him at PRN last visit, and at that point he was over 12M out from the procedure. Numbness in the scalp, trap and occipital, auricular area. Not crazy. Mid 50's guy, rows for exercise 4-5x per week. I can tell you everything about him because of how well I know his case.

I realize the timeline makes no sense, but he is not FoS.

 

[Taus]

I've been on this forum for a long time, and we've had this conversation repeatedly. I've posted pictures many times, and I've referenced the large study published like a year or two ago which boasts rates that mirror my own in the real world.

If you're not getting hypersensitivity, sun burn sensation or dullness at the skin, you didn't burn the nerve.

I still do quite a lot of cervical ablations.

Agree re frequency…. My point was re how often it’s truly awful for a significant enough duration that it sours the outcome

 

[BobBarker]

I agree with @MitchLevi

Great procedure, but there is quite a bit of post procedure pain if done properly. I am very clear at the mbb f/unto expect post procedure pain.

 

[hopefulgasman]

No, no I disagree.

I have a few nutcase people of course, but my top 3 worst neuritis pt is a British guy who is stone cold normal. I set him at PRN last visit, and at that point he was over 12M out from the procedure. Numbness in the scalp, trap and occipital, auricular area. Not crazy. Mid 50's guy, rows for exercise 4-5x per week. I can tell you everything about him because of how well I know his case.

I realize the timeline makes no sense, but he is not FoS.

That’s Unfortunate because it sounds like you did everything right. One year out and a permanent neuritis is what you’re saying?

 

[MitchLevi]

That’s Unfortunate because it sounds like you did everything right. One year out and a permanent neuritis is what you’re saying?

That’s just one guy, but I have around 3-4 who claim PAN over 12M. He is not crazy, but two of the others definitely are crazy. In fact, one of them is a dude who told one of my MAs that he takes his girlfriend to “Pound Town” frequently.

But yeah, I get rates well above half, and all C2-3.

 

[Dr. Ice]

That’s just one guy, but I have around 3-4 who claim PAN over 12M. He is not crazy, but two of the others definitely are crazy. In fact, one of them is a dude who told one of my MAs that he takes his girlfriend to “Pound Town” frequently.

But yeah, I get rates well above half, and all C2-3.

Can you really call the guy crazy if he is just using colloquial “man speak” and just might be out of touch with modern day appropriateness. Crazy is more like I have had pain all over my body and your trigger point injection exacerbated all of it

🤔

 

[BoardingDoc]

That’s just one guy, but I have around 3-4 who claim PAN over 12M. He is not crazy, but two of the others definitely are crazy. In fact, one of them is a dude who told one of my MAs that he takes his girlfriend to “Pound Town” frequently.

But yeah, I get rates well above half, and all C2-3.

When you guys are doing c2-3, are you simply doing a burn at the 2/3 joint to catch the TON since that's what innervates that joint and technically you only need 1 needle? Or are you routinely doing 3-4 as well and burning on 3 and 4 plus TON?

 

[Taus]

I

When you guys are doing c2-3, are you simply doing a burn at the 2/3 joint to catch the TON since that's what innervates that joint and technically you only need 1 needle? Or are you routinely doing 3-4 as well and burning on 3 and 4 plus TON?

rarely TON in isolation unless fused C3 down.

Also, unless using a venom or similar, you need more than one burn to capture the full TON.

 

[MitchLevi]

When you guys are doing c2-3, are you simply doing a burn at the 2/3 joint to catch the TON since that's what innervates that joint and technically you only need 1 needle? Or are you routinely doing 3-4 as well and burning on 3 and 4 plus TON?

C2-3 requires at least 2 needles and substantial burn time. It is 1.4mm on avg, and IMO that means a different treatment protocol than the others.

I wouldn’t fault anyone from treating it the same as C4 for example (0.9mm on avg), but in my hands the TON gets crucified and that’s the only way to lesion it.

I do C2-4 or C2-5.

 

[soccrwz]

C2-3 requires at least 2 needles and substantial burn time. It is 1.4mm on avg, and IMO that means a different treatment protocol than the others.

I wouldn’t fault anyone from treating it the same as C4 for example (0.9mm on avg), but in my hands the TON gets crucified and that’s the only way to lesion it.

I do C2-4 or C2-5.

what do you mean by substantial burn time? Any increase in post neuritis with longer times?

 

[bedrock]

I’ve found that acdf frequently still has movement of the facet joints leading to pain. I have never had it be an issue with prior auths but other people here certainly have far greater numbers than I do. You could also consider PNS at those levels.

You could do C45 and C7T1. Likely get similar results and get paid without having to be shady

A tough situation if patient has a 3 level ACDF. Agree with rollo. If if 1-2 level ACDF, such as a C5-C6 ACDF, you can do a C4-C5 and C6-C7
RFA. helps the patient and will get paid

 

[bedrock]

Does anyone find cervical RFA to be far more effective than lumbar RFA? I’ve never had a single patient tell me cervical RFA didn’t help quite a bit. I’ve absolutely had complete non-responders to lumbar RFA despite having no pain following MBB

Agree that cervical RFA on average is more effective than lumbar RFA.

I’m not trying to go after you personally, but even lumbar RFA should provide >50% relief >95% of the time.

If you are seeing complete non responders to lumbar RFA more than 3 times a year, then you are either doing the MBB or the RFA incorrectly.
Most common reason for failed RFA is a non specific lumbar MBB. Use contrast and only 0.3 ml of anesthetic per IPSIS guidelines.
If you skip contrast for speed And/or inject more than 0.4ml of medication per nerve, then you can easily get a false positive lumbar MBB.

Regarding lumbar RFA, assuming an accurate MBB, then the key things that greatly impact lumbar RFA outcomes are 1- strict IPSIS technique, 2- 18G RFA cannulae, 3-burning 90 degrees for 90 seconds.

If you’re not doing all three for every lumbar RFA; then you’re not giving the patient the best chance for a good treatment outcome.

 

[MitchLevi]

Since I started burning at 90 in the low back, I’ve gotten more phone calls. I went back down to 85.

 

[Taus]

Since I started burning at 90 in the low back, I’ve gotten more phone calls.

Interesting. I switched from 80 degrees x 90secs to 90 degrees x 120 secs about a year ago. Have not noticed anything unusual.

I also went from 2 burns to 1 when I made this switch. 18g, 10mm tip, perfect parallel placement. No appreciable decline in outcome either.

 

[MitchLevi]

Interesting. I switched from 80 degrees x 90secs to 90 degrees x 120 secs about a year ago. Have not noticed anything unusual.

I’ve wondered about my machine TBH. Am I sneaking up to 93 at times bc the Neurotherm I believe gives you a 3 degree +/-. Not sure if I am getting microcavitation or something. I never get phone calls after lumbar RFA, go to 90 for 90 and I’ve gotten them recently.

 

[lobelsteve]

C2-3 requires at least 2 needles and substantial burn time. It is 1.4mm on avg, and IMO that means a different treatment protocol than the others.

I wouldn’t fault anyone from treating it the same as C4 for example (0.9mm on avg), but in my hands the TON gets crucified and that’s the only way to lesion it.

I do C2-4 or C2-5.

Maybe you are over-burning this nerve and causing more neuritis than necessary to get reliable pain relief.

50% relief is a win. 80% relief is a huge win. 100% relief is not a thing to care about.

The enemy of good is great.

Give them all Lyrica 75 bid for a month post procedure. I do this for anyone saying boo post RF.

 

[MitchLevi]

Maybe you are over-burning this nerve and causing more neuritis than necessary to get reliable pain relief.

50% relief is a win. 80% relief is a huge win. 100% relief is not a thing to care about.

The enemy of good is great.

Give them all Lyrica 75 bid for a month post procedure. I do this for anyone saying boo post RF.

I started doing 120 second burns prob 12M ago (started at 60 seconds in 2017, then 90 seconds at like 2018 or 2019, then 120 seconds maybe late 2023 to early 2024 perhaps), and honestly I have not seen any change. I think neuritis is potentially a misnomer, and it may be there are a lot of cutaneous fibers coming off the TON, C3 and C4 MB nerves, and less of them at C5 and lower, so if you do an appropriate TON, C3 or C4 RFA you're denervating those cutaneous tissues and you're going to have changes...What I don't understand is why it gets better with such a variable timeline.

Probably had maybe 1-2 patients with neuritis in the lumbar MB nerves, but after recently going to 90 for 90 started getting phone calls from patients with post RFA complaints, so I am going back to 85 for 90 seconds. Can't imagine there being that big of a difference between 85 and 90 other than the fact Neurotherm can shoot you up over 90 at times, and 90C is where cavitation occurs.

Either way, I am a big supporter of the RFA, and I honestly believe it is the only really durable treatment we offer people. I hope it doesn't start getting curtailed by insurance companies for overutilization.

 

[Taus]

I started doing 120 second burns prob 12M ago (started at 60 seconds in 2017, then 90 seconds at like 2018 or 2019, then 120 seconds maybe late 2023 to early 2024 perhaps), and honestly I have not seen any change. I think neuritis is potentially a misnomer, and it may be there are a lot of cutaneous fibers coming off the TON, C3 and C4 MB nerves, and less of them at C5 and lower, so if you do an appropriate TON, C3 or C4 RFA you're denervating those cutaneous tissues and you're going to have changes...What I don't understand is why it gets better with such a variable timeline.

Probably had maybe 1-2 patients with neuritis in the lumbar MB nerves, but after recently going to 90 for 90 started getting phone calls from patients with post RFA complaints, so I am going back to 85 for 90 seconds. Can't imagine there being that big of a difference between 85 and 90 other than the fact Neurotherm can shoot you up over 90 at times, and 90C is where cavitation occurs.

Either way, I am a big supporter of the RFA, and I honestly believe it is the only really durable treatment we offer people. I hope it doesn't start getting curtailed by insurance companies for overutilization.

Prob just random re the calls w 90 degrees.

Yep. Kypho, Intracept, RFA, ESI for acute/subacute hnp/radic.

For rfa: some of that’s already been done re limiting levels, “sessions” per year and documentation requirements on mbb and for repeat rfa.

 

[bedrock]

Since I started burning at 90 in the low back, I’ve gotten more phone calls. I went back down to 85.

Interesting. I switched from 80 degrees x 90secs to 90 degrees x 120 secs about a year ago. Have not noticed anything unusual.

I also went from 2 burns to 1 when I made this switch. 18g, 10mm tip, perfect parallel placement. No appreciable decline in outcome either.

I’ve wondered about my machine TBH. Am I sneaking up to 93 at times bc the Neurotherm I believe gives you a 3 degree +/-. Not sure if I am getting microcavitation or something. I never get phone calls after lumbar RFA, go to 90 for 90 and I’ve gotten them recently.

mitch, I think there is some issue with your RF machine. Not you, but the machine, because you report far more neuritis than anyone else on this board.

I have used 18G cannulae, 90 deg x 90 sec for a long time. I have never had a single case of neuritis after lumbar spine RFA, and their degree of pain relief is excellent. I have some neuritis cases after cervical RFA, but if I'm not lesioning C2, C3, then even my post RFA neuritis is very rare. (However, for years, I do add .5ml of 0.5% bup and 10mg of depo at each cervical lesion site just before I withdraw the cannulae)

You should contact companies who make RF generators and tell them you are thinking of making a switch and can you use their RF generator for 2 weeks to test it out (not just one case). Do this with a couple companies and then compare your # of patient with neuritis.

 

[Ducttape]

Agree that cervical RFA on average is more effective than lumbar RFA.

I’m not trying to go after you personally, but even lumbar RFA should provide >50% relief >95% of the time.

If you are seeing complete non responders to lumbar RFA more than 3 times a year, then you are either doing the MBB or the RFA incorrectly.
Most common reason for failed RFA is a non specific lumbar MBB. Use contrast and only 0.3 ml of anesthetic per IPSIS guidelines.
If you skip contrast for speed And/or inject more than 0.4ml of medication per nerve, then you can easily get a false positive lumbar MBB.

Regarding lumbar RFA, assuming an accurate MBB, then the key things that greatly impact lumbar RFA outcomes are 1- strict IPSIS technique, 2- 18G RFA cannulae, 3-burning 90 degrees for 90 seconds.

If you’re not doing all three for every lumbar RFA; then you’re not giving the patient the best chance for a good treatment outcome.

would just like to point out that contrast would really not lead to a false positive result. placement of local intravascularly would be a false negative.

Prob just random re the calls w 90 degrees.

Yep. Kypho, Intracept, RFA, ESI for acute/subacute hnp/radic.

For rfa: some of that’s already been done re limiting levels, “sessions” per year and documentation requirements on mbb and for repeat rfa.

too early to fully assess Intracept.

data on Kypho is mixed. good short term relief but studies suggest no difference longer term.

ESI moderate data for acute radic, but otherwise pretty poor.


i have done either 80 or 90 for 2 minutes for lumbar. it depends on the patient's response to the local anesthetic. no difference in neuritis and it is not often at all.

 

[MitchLevi]

Since going to 90…That location the procedure pics are scanned in by paper so posting the procedure pics will be difficult to see my needles. I can barely see them on PACS after they’re scanned in…I don’t get it. Why would 90 be any worse than 85 other it creeping up to 92 or 93, which I don’t think Neurotherm will actually allow.

 

[lobelsteve]

Since going to 90…That location the procedure pics are scanned in by paper so posting the procedure pics will be difficult to see my needles. I can barely see them on PACS after they’re scanned in…I don’t get it. Why would 90 be any worse than 85 other it creeping up to 92 or 93, which I don’t think Neurotherm will actually allow.

View attachment 405843

I burn 90 for 90 in the back and 80 for 90 in the neck- all 20G. Less neuritis.
Get them in for T15R100 IM and Lyrica for a few weeks. Holding hands.

 

[MitchLevi]

I burn 90 for 90 in the back and 80 for 90 in the neck- all 20G. Less neuritis.
Get them in for T15R100 IM and Lyrica for a few weeks. Holding hands.

Bringing her in and I’ll talk to her. Never had lumbar PAN until doing 90.

 

[Ducttape]

it was nice you blocked out the patients phone number in the message but you forgot to block out the phone number twice in the second line....

i agree with you seeing her. skin infection unlikely but it happens.

if she is still concerned, a sed rate and a cbc go a long way towards reassuring patients that there is no active infection.

 

[lobelsteve]

it was nice you blocked out the patients phone number in the message but you forgot to block out the phone number twice in the second line....

i agree with you seeing her. skin infection unlikely but it happens.

if she is still concerned, a sed rate and a cbc go a long way towards reassuring patients that there is no active infection.

Fixed numbers/DOB/etc.

 

[MitchLevi]

it was nice you blocked out the patients phone number in the message but you forgot to block out the phone number twice in the second line....

i agree with you seeing her. skin infection unlikely but it happens.

if she is still concerned, a sed rate and a cbc go a long way towards reassuring patients that there is no active infection.

Dang it!!!!

 

[sloh]

Any theories on why cervical RFA is more successful than lumbar RFA?

 

[lobelsteve]

Any theories on why cervical RFA is more successful than lumbar RFA?

More consistent needle placements around the waist allows for scraping the bone as you dock in the parallelogram.
Smaller and less robust MBs

 

[clubdeac]

I burn 90 for 90 in the back and 80 for 90 in the neck- all 20G. Less neuritis.
Get them in for T15R100 IM and Lyrica for a few weeks. Holding hands.

Steve you give 1000mg robaxin IM? How do you like it?

 

[lobelsteve]

Steve you give 1000mg robaxin IM? How do you like it?

T15
R100

 

[Snowmen96]

More consistent needle placements around the waist allows for scraping the bone as you dock in the parallelogram.
Smaller and less robust MBs

What makes it all the more interesting is that a paper from an anatomy/cadaver dissection study showed the existence of a direct articular branch coming from the dorsal root itself. Since it can't be targeted during RFA, cervical RFA should theoretically be less effective, and yet it isn't!

The innervation of the cervical facet joints—an anatomical and histological approach - PMC

Cervical facet joint pain syndrome accounts for a great amount of cervical pain worldwide. This study aims to provide updated knowledge of cervical facet joint innervation with new anatomical findings. Twenty‐seven cervical facet joints and their ...

pmc.ncbi.nlm.nih.gov

 

[lobelsteve]

What makes it all the more interesting is that a paper from an anatomy/cadaver dissection study showed the existence of a direct articular branch coming from the dorsal root itself. Since it can't be targeted during RFA, cervical RFA should theoretically be less effective, and yet it isn't!

The innervation of the cervical facet joints—an anatomical and histological approach - PMC

Cervical facet joint pain syndrome accounts for a great amount of cervical pain worldwide. This study aims to provide updated knowledge of cervical facet joint innervation with new anatomical findings. Twenty‐seven cervical facet joints and their ...

pmc.ncbi.nlm.nih.gov

22 of the 36 samples of nerve were actually nerve.
Not a lot of faith in that.

 

[Taus]

What makes it all the more interesting is that a paper from an anatomy/cadaver dissection study showed the existence of a direct articular branch coming from the dorsal root itself. Since it can't be targeted during RFA, cervical RFA should theoretically be less effective, and yet it isn't!

The innervation of the cervical facet joints—an anatomical and histological approach - PMC

Cervical facet joint pain syndrome accounts for a great amount of cervical pain worldwide. This study aims to provide updated knowledge of cervical facet joint innervation with new anatomical findings. Twenty‐seven cervical facet joints and their ...

pmc.ncbi.nlm.nih.gov

Along similar lines… Regarding the pedicle shadow rfa technique on thoracic. Well described on this forum, lots of docs with reliable success for many years. The newer anatomical studies still don’t describe anything in that zone, more so that articular branch that is basically under the lamina. Yet it still works.

 

[Taus]

too early to fully assess Intracept.

data on Kypho is mixed. good short term relief but studies suggest no difference longer term.

ESI moderate data for acute radic, but otherwise pretty poor.

still, they are the best, most reliable procedures I do with the most consistently happy patients, with a lot less pain and improved quality of life in the majority of cases.

 

[Snowmen96]

22 of the 36 samples of nerve were actually nerve.
Not a lot of faith in that.

100% agree that it is a very inconsistent nerve but it might account for some RFA/MBB failures in the cervical spine.

 

[MD87]

Any theories on why cervical RFA is more successful than lumbar RFA?

I think there are more patients with "pure" facet pain in neck, while more patients have "mixed" pain in the low back (disc, modic, facet... fat). No evidence to support this, just a guess based on my anecdotal experience with better results in the cervical spine.

 

[MitchLevi]

Since going to 90…That location the procedure pics are scanned in by paper so posting the procedure pics will be difficult to see my needles. I can barely see them on PACS after they’re scanned in…I don’t get it. Why would 90 be any worse than 85 other it creeping up to 92 or 93, which I don’t think Neurotherm will actually allow.

View attachment 405844

Just saw her...Referring to surgery. Nothing is better, failed two recent ESI and now with severe neuritis in the right glute, lateral hip and proximal hamstring. Did bilateral L3-S1 RFA, left side is great. Moderate-severe facet arthropathy L2-S1, severe spinal stenosis L4-5. Sensation is abnormal to light touch. Definitely neuritis, don't understand why she got it.

 

[clubdeac]

Just saw her...Referring to surgery. Nothing is better, failed two recent ESI and now with severe neuritis in the right glute, lateral hip and proximal hamstring. Did bilateral L3-S1 RFA, left side is great. Moderate-severe facet arthropathy L2-S1, severe spinal stenosis L4-5. Sensation is abnormal to light touch. Definitely neuritis, don't understand why she got it.

Listened to a lecture recently where the speaker, based on some paper, was advocating for more superficial lesions to avoid zapping the lateral and intermediate branches. He postulated this was the primary cause of post RF neuritis. Personally I go pretty deep and do encounter neuritis from time to time as well

 

[callmeanesthesia]

Listened to a lecture recently where the speaker, based on some paper, was advocating for more superficial lesions to avoid zapping the lateral and intermediate branches. He postulated this was the primary cause of post RF neuritis. Personally I go pretty deep and do encounter neuritis from time to time as well

Tried going more superficial in the neck. Needle tips about mid articulate pillar in lateral view. Immediate significant increase in neuritis.

 

[MD87]

Just saw her...Referring to surgery. Nothing is better, failed two recent ESI and now with severe neuritis in the right glute, lateral hip and proximal hamstring. Did bilateral L3-S1 RFA, left side is great. Moderate-severe facet arthropathy L2-S1, severe spinal stenosis L4-5. Sensation is abnormal to light touch. Definitely neuritis, don't understand why she got it.

Allodynia or loss of sensation? I’ve never seen this in the lumbar either. Any chance it’s coincidence and just her stenosis?