50% relief from cervical RFA

[MitchLevi]

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Dysesthesia is more accurate in this case. It happened immediately after the RFA, started like 3-4 days later.

 

[lobelsteve]

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

Position on table more likely than needle causing this.

 

[MitchLevi]

Position on table more likely than needle causing this.

I would say you’re right in any case but this one. She has sensory changes and it’s real. Bizarre, and TBH…I hate to say this, but she pissed me off yesterday during that visit with evasive answers to my Qs. I think that’s her normal disposition and it wasn’t intentional. I ablated her husband 4 yrs ago, and he’s been great ever since. He was with her yesterday. She feels bitter to me that she didn’t get better with my treatments. Did a TFESI, then ILESI, then MBB/RFA and the latter made her worse. Very bitter that she is surgical.

Win some, lose some.

 

[Dr. Ice]

I would say you’re right in any case but this one. She has sensory changes and it’s real. Bizarre, and TBH…I hate to say this, but she pissed me off yesterday during that visit with evasive answers to my Qs. I think that’s her normal disposition and it wasn’t intentional. I ablated her husband 4 yrs ago, and he’s been great ever since. He was with her yesterday. She feels bitter to me that she didn’t get better with my treatments. Did a TFESI, then ILESI, then MBB/RFA and the latter made her worse. Very bitter that she is surgical.

Win some, lose some.

Is the surgeon really going to be able to do much for these symptoms?

 

[lobelsteve]

I would say you’re right in any case but this one. She has sensory changes and it’s real. Bizarre, and TBH…I hate to say this, but she pissed me off yesterday during that visit with evasive answers to my Qs. I think that’s her normal disposition and it wasn’t intentional. I ablated her husband 4 yrs ago, and he’s been great ever since. He was with her yesterday. She feels bitter to me that she didn’t get better with my treatments. Did a TFESI, then ILESI, then MBB/RFA and the latter made her worse. Very bitter that she is surgical.

Win some, lose some.

If dysesthesia in her leg then no. Unless you were on the wrong side of the TP/SAP junction.

 

[Ducttape]

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.

why cant it be due to the severe spinal stenosis?

 

[MitchLevi]

If dysesthesia in her leg then no. Unless you were on the wrong side of the TP/SAP junction.

Glute, lateral hip and superior hamstring. Certainly plausible and began virtually immediately after the RFA.

 

[MitchLevi]

why cant it be due to the severe spinal stenosis?

It can, which is why I sent her to the surgeon, but this is a new problem, which is a known but rare side effect of lumbar RFA and she’s going to get a decompression and probable fusion not for this issue, but for her chronic back pain not relieved by my treatments.

 

[MitchLevi]

Is the surgeon really going to be able to do much for these symptoms?

Yes, he can help her central problem, which I failed to treat. The neuritis is a temporary issue.

 

[Ducttape]

i suspect that you just unmasked the radicular symptoms with your RFA and that this neuritis is all along due to spinal stenosis ie your injection didnt cause her current symptoms.

 

[MitchLevi]

i suspect that you just unmasked the radicular symptoms with your RFA and that this neuritis is all along due to spinal stenosis ie your injection didnt cause her current symptoms.

Maybe so, but it is a starkly different symptom than her previous complaints, which are ongoing still and why she will be getting surgery.

 

[SSdoc33]

this is a good case that demonstrates why you should try to avoid lumbar RF with concomitant severe stenosis. it just doesnt work that well, even if the patients dont have radicular pain

 

[buddababa]

this is a good case that demonstrates why you should try to avoid lumbar RF with concomitant severe stenosis. it just doesnt work that well, even if the patients dont have radicular pain

agree, i dont even offer it in this condition

 

[clubdeac]

this is a good case that demonstrates why you should try to avoid lumbar RF with concomitant severe stenosis. it just doesnt work that well, even if the patients dont have radicular pain

Here we agree. Yet I have surgeons who still send me patients with severe stenosis and predominantly lbp. Even if they don’t have neurogenic classification, I rarely see great results from RFA in those with severe stenosis

 

[SgtThunderfistMD]

I don't even order MRI's for axial LBP. I go straight to MBB with an XR. Wouldn't even know if they had severe stenosis when I decide. I have fine results.

 

[clubdeac]

I don't even order MRI's for axial LBP. I go straight to MBB with an XR. Wouldn't even know if they had severe stenosis when I decide. I have fine results.

You must be in a very non litigious or capped state

 

[MitchLevi]

I don't even order MRI's for axial LBP. I go straight to MBB with an XR. Wouldn't even know if they had severe stenosis when I decide. I have fine results.

You don’t own an MRI do you?

 

[Taus]

Here we agree. Yet I have surgeons who still send me patients with severe stenosis and predominantly lbp. Even if they don’t have neurogenic classification, I rarely see great results from RFA in those with severe stenosis

Nothing works well on these patients. Axial only. Not even heaviness in legs on ambulation. Severe facet arthritis and central stenosis. Worse stand/walk, better instantly sitting or walking leaning on shopping cart. Limited lumbar extension, but without pain. No tenderness. It’s called interlam w depo and a prayer

 

[MitchLevi]

I don’t think it is always wrong to try and ablate those pts

 

[Taus]

I don’t think it is always wrong to try and ablate those pts

Agreed not wrong if mmbx2+, but really need to temper expectations…. And I expect the rf to fail. If they have even trace facet tenderness and pain on extension I feel much better about it. They usually don’t. Early on I even did some bvna w this clinical picture, multilevel severe ddd modic mainly 2….. 0 for 3 or 4. Won’t offer that anymore even if direct referred to me for it. Tell the patients my success w their clinical picture is 0%.

 

[bedrock]

I don't even order MRI's for axial LBP. I go straight to MBB with an XR. Wouldn't even know if they had severe stenosis when I decide. I have fine results.

I’m sure that most of your Medicare patients do just fine after lumbar RFA.

I’m also sure that a significant amount of your RFA failures and or just mediocre results in this age group are due to unrecognized severe stenosis.

 

[interjectionreflection]

I’m sure that most of your Medicare patients do just fine after lumbar RFA.

I’m also sure that a significant amount of your RFA failures and or just mediocre results in this age group are due to unrecognized severe stenosis.

But is it wrong to try treatment first with RFA. if it works you have a treatment and if it doesn't can always consider MRI after?

 

[clubdeac]

But is it wrong to try treatment first with RFA. if it works you have a treatment and if it doesn't can always consider MRI after?

Not wrong but 1% of the time you’ll miss something significant like cancer, infx, inflammatory arthropathy etc. at such point you will be open to litigation. We can argue the appropriateness of this approach within a vacuum where lawyers do not exist and we can argue within the litigious US healthcare environment. The beauty is you can decide what your threshold is. I’ve found that as one’s net worth increases, tolerance for litigation decreases

 

[SgtThunderfistMD]

All my patients are Medicare/Advantage, maybe that's why it works.
I have ordered thousands of MRI's and have never diagnosed cancer, or inflammatory arthropathy.
Maybe discitis once or twice. 1% would mean I diagnose once per week on average, which is hard to believe.
Maybe this is a patient population issue

 

[callmeanesthesia]

All my patients are Medicare/Advantage, maybe that's why it works.
I have ordered thousands of MRI's and have never diagnosed cancer, or inflammatory arthropathy.
Maybe discitis once or twice. 1% would mean I diagnose once per week on average, which is hard to believe.
Maybe this is a patient population issue

Surprising you’ve never diagnosed a cancer. Do you require MRI for a referral, resulting in them being screened out before being sent to you? I think it’s only a couple times a year that I personally have to break the news to someone, but it definitely happens to me.

 

[BobBarker]

I think physicians are better about getting MRI’s earlier since we have all realized health care is a gigantic scheme and saving the cost of a mri is not doing anything to keep costs down.

I used to dx cancer routinely in my early practice. Hasn’t happened in many years.

 

[SgtThunderfistMD]

Surprising you’ve never diagnosed a cancer. Do you require MRI for a referral, resulting in them being screened out before being sent to you? I think it’s only a couple times a year that I personally have to break the news to someone, but it definitely happens to me.

Thyroid & renal, yes.
But I wouldn't be on the hook for missing those for doing RFA without MRI.

 

[clubdeac]

All my patients are Medicare/Advantage, maybe that's why it works.
I have ordered thousands of MRI's and have never diagnosed cancer, or inflammatory arthropathy.
Maybe discitis once or twice. 1% would mean I diagnose once per week on average, which is hard to believe.
Maybe this is a patient population issue

So you order thousands of MRIs yet don’t order them for the most common diagnosis you treat, axial lbp. You must see a ton of classic radics. Good for you

I’ve diagnosed multiple renal cell’s, various abscesses, disciitis, lymphoma, numerous multiple myelomas, metastatic squamous cell, ovarian, and uterine. It keeps ya on your toes

 

[MitchLevi]

I catch cancer not terribly uncommonly

 

[Gnarvin]

I catch cancer not terribly uncommonly

Same. In the last 6 months I have caught metastatic breast ca, prostate ca, and lymphoma that I can think of. Each one of those patients had plain old axial back pain with no neurologic deficits.

 

[MitchLevi]

I’m prob 5-6 per yr

 

[Taus]

I’m prob 5-6 per yr

Yep. Every year. ~3-4

 

[SSdoc33]

its not malpractice to right to mbb/RF without an MRI, but it IS poor form. and lazy

you may miss severe stenosis. cancers, discitis. most often you may miss significant endplate/modic changes that may preclude you from even doing the facet procedure. if you say that it wouldnt change your decision about whether or not to do the MBBs, then you probably should rethink your algorithm. or better yet, not have an algorithm at all.

 

[MitchLevi]

So after going to 90C for a few months and suddenly getting inundated with phone calls from painful patients, I quit doing it and went back to 85C for 90 sec. Well, I decided this past Tuesday to try 90C one more time. I previously ablated her at 85C with nearly 1Y of 90% relief...She is calling today with pain. Never doing 90C again...EVER...Severe left low back and buttock pain. Describes gait dysfunction. I don't get it. I do not understand what yall are doing that I am not doing.

 

[RoloTomassi]

So after going to 90C for a few months and suddenly getting inundated with phone calls from painful patients, I quit doing it and went back to 85C for 90 sec. Well, I decided this past Tuesday to try 90C one more time. I previously ablated her at 85C with nearly 1Y of 90% relief...She is calling today with pain. Never doing 90C again...EVER...Severe left low back and buttock pain. Describes gait dysfunction. I don't get it. I do not understand what yall are doing that I am not doing.




View attachment 406702

That's interesting. I went from 80 to 90 without any change in postop pain. But recently went down to 85 since the generator overshoots a few degrees. Nice placements.

 

[BobBarker]

anyone ready to try 100c?

“Yep, we are going to heat up that needle to the same temperature of boiling water.”

That should go over well.

 

[hopefulgasman]

for cervical MBB at TON (C2-C3), how many mls of injectate are you placing? Does the 0.3ml rule still apply? I was taught 0.3ml everywhere else, but 1ml at TON

 

[MitchLevi]

for cervical MBB at TON (C2-C3), how many mls of injectate are you placing? Does the 0.3ml rule still apply? I was taught 0.3ml everywhere else, but 1ml at TON

0.5 at the TON will cover the TON and C3 MB.

 

[Taus]

So after going to 90C for a few months and suddenly getting inundated with phone calls from painful patients, I quit doing it and went back to 85C for 90 sec. Well, I decided this past Tuesday to try 90C one more time. I previously ablated her at 85C with nearly 1Y of 90% relief...She is calling today with pain. Never doing 90C again...EVER...Severe left low back and buttock pain. Describes gait dysfunction. I don't get it. I do not understand what yall are doing that I am not doing.




View attachment 406702

Very strange, must be some quirk with your machine. I have noticed no such issues going from 80 to 90° over this past year and a half on Medtronic and Stryker machines. Doing several Rfa every single week.

 

[Taus]

for cervical MBB at TON (C2-C3), how many mls of injectate are you placing? Does the 0.3ml rule still apply? I was taught 0.3ml everywhere else, but 1ml at TON

Generally that’s too much, spreads too far/wide covering other structures. Granted you can judge it based on the contrast spread. If a little drop of contrast over the C23 joint line covers ton and c3 mb, then I would do Max 0.5, often less. If it only partially covers TON zone and or not c3 mbb, I’ll inject about 0.2 or 0.3, move needle, tip slightly, put another drop of contrast and then inject another drop local. 2% lido or 0.5% bup.

 

[lobelsteve]

anyone ready to try 100c?

“Yep, we are going to heat up that needle to the same temperature of boiling water.”

That should go over well.

We have studies that show you will char tissue and this will cause infection and necrosis. There is some insurances that will not pay for lesions under 80° or over 90°.

 

[clubdeac]

We have studies that show you will char tissue and this will cause infection and necrosis. There is some insurances that will not pay for lesions under 80° or over 90°.

A little cavitation never hurt nobody

 

[MD87]

So after going to 90C for a few months and suddenly getting inundated with phone calls from painful patients, I quit doing it and went back to 85C for 90 sec. Well, I decided this past Tuesday to try 90C one more time. I previously ablated her at 85C with nearly 1Y of 90% relief...She is calling today with pain. Never doing 90C again...EVER...Severe left low back and buttock pain. Describes gait dysfunction. I don't get it. I do not understand what yall are doing that I am not doing.




View attachment 406702

Question - before you lesion, what do you inject at the site?

 

[MitchLevi]

Question - before you lesion, what do you inject at the site?

It is 1cc of either lido 2%, bupi 0.5% or ropi 0.5%, or sometimes it’s a mixture of these. I still give Depo before removing the needles.

 

[MD87]

It is 1cc of either lido 2%, bupi 0.5% or ropi 0.5%, or sometimes it’s a mixture of these. I still give Depo before removing the needles.

Got it. There is some literature that says 2% and Omnipaque increase lesion size. I do 0.5 cc of 2% typically. But, if someone has pain when I turn the machine on, I will drop another 0.5-1 cc. I do 90 for 120 seconds both L and C spine and I’ve never had any of the issues you’ve been describing. I use 18 gauge needles and Medtronic machine. My guess is you’ve just had some bad luck and it’s all coincidence but if I were you I’d probably be too spooked to do 90 again also lll.

 

[MD87]

Got it. There is some literature that says 2% and Omnipaque increase lesion size. I do 0.5 cc of 2% typically. But, if someone has pain when I turn the machine on, I will drop another 0.5-1 cc. I do 90 for 120 seconds both L and C spine and I’ve never had any of the issues you’ve been describing. I use 18 gauge needles and Medtronic machine. My guess is you’ve just had some bad luck and it’s all coincidence but if I were you I’d probably be too spooked to do 90 again also lll.

The Effect of Local Anesthetics and Contrast Agents on Radiofrequency Ablation Lesion Size - PubMed

Lidocaine 2% and iohexol 240, when used as pre-injections in RFAs, were found to be associated with statistically significant increases in lesion surface area. However, RFAs with lidocaine 1%, iohexol 180, or gadodiamide were not found to produce a statistically significant difference in lesion...

pubmed.ncbi.nlm.nih.gov

 

[Asclepius186]

So after going to 90C for a few months and suddenly getting inundated with phone calls from painful patients, I quit doing it and went back to 85C for 90 sec. Well, I decided this past Tuesday to try 90C one more time. I previously ablated her at 85C with nearly 1Y of 90% relief...She is calling today with pain. Never doing 90C again...EVER...Severe left low back and buttock pain. Describes gait dysfunction. I don't get it. I do not understand what yall are doing that I am not doing.




View attachment 406702

What they’re doing differently is not answering the phone.

 

[MitchLevi]

The Effect of Local Anesthetics and Contrast Agents on Radiofrequency Ablation Lesion Size - PubMed

Lidocaine 2% and iohexol 240, when used as pre-injections in RFAs, were found to be associated with statistically significant increases in lesion surface area. However, RFAs with lidocaine 1%, iohexol 180, or gadodiamide were not found to produce a statistically significant difference in lesion...

pubmed.ncbi.nlm.nih.gov

I don’t know why they would leave out bupivacaine and ropivacaine in that study.

 

[MitchLevi]

Got it. There is some literature that says 2% and Omnipaque increase lesion size. I do 0.5 cc of 2% typically. But, if someone has pain when I turn the machine on, I will drop another 0.5-1 cc. I do 90 for 120 seconds both L and C spine and I’ve never had any of the issues you’ve been describing. I use 18 gauge needles and Medtronic machine. My guess is you’ve just had some bad luck and it’s all coincidence but if I were you I’d probably be too spooked to do 90 again also lll.

I am wondering if this is Neurotherm.

 

[MD87]

What they’re doing differently is not answering the phone.

False. I don’t have a PA. I see all my procedure follow-ups… would be nice if I didn’t.