Bilateral CRFA

[giddyup]

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How does everyone feel about these? I used to do B CMBB then the RFA one side then the other 2 weeks later. There were a handful of patients I would do bilateral on because they wanted them done more than once a year. Changed practices, it is the culture here to do bilateral CRFA on everyone - 3 other pain docs here. I hate it. I do the majority in my office with local only or local plus valium, select few at surgery center with few mg IV versed. I had one patient I did B C4-6 on who actually needed a neck brace due to the neck weakness. She was a CRNA of course. Resolved after PT and time. I had only every read about this at the higher levels. I kind of want to go back to one side then the other. What do most people do?

 

[mdo1738]

I prefer unilateral staged but do about 1/3 as bilateral for various reasons (patient poorly tolerates procedures, comes from far away, and/or is probably going to need another one within 12 months).

 

[BoardingDoc]

How does everyone feel about these? I used to do B CMBB then the RFA one side then the other 2 weeks later. There were a handful of patients I would do bilateral on because they wanted them done more than once a year. Changed practices, it is the culture here to do bilateral CRFA on everyone - 3 other pain docs here. I hate it. I do the majority in my office with local only or local plus valium, select few at surgery center with few mg IV versed. I had one patient I did B C4-6 on who actually needed a neck brace due to the neck weakness. She was a CRNA of course. Resolved after PT and time. I had only every read about this at the higher levels. I kind of want to go back to one side then the other. What do most people do?

I do BL. Otherwise, the patient has no option for a repeat RF in 6 months if needed. Also, dropped head syndrome is a rare complication and there are case reports of it both with BL and with staged RFAs a week apart, so I'm not sure that it really helps anything (except the wallet) by doing it unilaterally.

Also, I've never understood the need for any significant sedation for RFAs. 95% of my patients get local only. 5% get 5mg of diazepam before the procedure. If you need an IV to get an RFA, you don't get an RFA.

 

[Taus]

I do BL. Otherwise, the patient has no option for a repeat RF in 6 months if needed. Also, dropped head syndrome is a rare complication and there are case reports of it both with BL and with staged RFAs a week apart, so I'm not sure that it really helps anything (except the wallet) by doing it unilaterally.

Also, I've never understood the need for any significant sedation for RFAs. 95% of my patients get local only. 5% get 5mg of diazepam before the procedure. If you need an IV to get an RFA, you don't get an RFA.

I do 1 side a time for cervical rfa, min 2 weeks apart (I’ll do bilat lumbar). Too much local (18g) and too much work for me to do bilat. Plus the risk of head drop. Also,if incl c23, risk of persistent vertigo (perhaps theoretical, but it’s what I was taught and def see it frequently on bilat c23 mbb)

 

[BoardingDoc]

I do 1 side a time for cervical rfa, min 2 weeks apart (I’ll do bilat lumbar). Too much local (18g) and too much work for me to do bilat. Plus the risk of head drop. Also,if incl c23, risk of persistent vertigo (perhaps theoretical, but it’s what I was taught and def see it frequently on bilat c23 mbb)

Yeah, that's fair about the vertigo. I make all my CMBB patients have a ride home for that exact reason. I feel like a lot of them get vertigo for an hour or so afterwards.

 

[bedrock]

All cervical RFA are done unilateral, 2 weeks or more apart.

No exceptions other than doing a single bilateral inferior level (such as C6-C7 in patient s/p C5-C6 ACDF)

 

[SSdoc33]

I do bilateral. Pretty much all the time. If you have to repeat it in< a year then it’s not facet mediated anyway

 

[callmeanesthesia]

Bilateral RFA unless it only hurts on one side. I use 0.5% bupi for the MBBs, which is plenty strong enough to produce motor block. If they don’t get head drop with the MBBs, I don’t see how they could from the RF. In the rare cases where there is significant dizziness or neck weakness during the MBBs, I do one side at a time separated by 2-3 months.

 

[Dr. Ice]

I do it most of the time because I don’t want to hear people whine about having to come back another time for the other side.

If the patient is a reasonable human, I’ll tell them I prefer to do it one side at a time..it’s few and far between

 

[BobBarker]

Always both sides. Doesn’t really work otherwise office based. Better for scheduling, saves $40 in supplies.

 

[BobBarker]

I did do unilateral at first in the office as that is what I did at the hospital. Then I gave away about 10 thoracic RFAs.

 

[bedrock]

I do it most of the time because I don’t want to hear people whine about having to come back another time for the other side.

If the patient is a reasonable human, I’ll tell them I prefer to do it one side at a time..it’s few and far between

Bilateral RFA unless it only hurts on one side. I use 0.5% bupi for the MBBs, which is plenty strong enough to produce motor block. If they don’t get head drop with the MBBs, I don’t see how they could from the RF. In the rare cases where there is significant dizziness or neck weakness during the MBBs, I do one side at a time separated by 2-3 months.

Unfortunately, I have seen patients get head weakness after RFA who did not report it initially after MBB. All but one those cases were cervical RFA done bilateral.

Anything cervical I'm immune to patient "whining" as I'm happy not to do the cervical CESI/RFA as we are not appropriately paid for our time for those procedures. If a patient whines about anything cervical, they can go somewhere else. Meanwhile I'll crank out another quick lumbar ESI/RFA for a non prima dona patient.

 

[po_boy]

I do BL. Otherwise, the patient has no option for a repeat RF in 6 months if needed. Also, dropped head syndrome is a rare complication and there are case reports of it both with BL and with staged RFAs a week apart, so I'm not sure that it really helps anything (except the wallet) by doing it unilaterally.

Also, I've never understood the need for any significant sedation for RFAs. 95% of my patients get local only. 5% get 5mg of diazepam before the procedure. If you need an IV to get an RFA, you don't get an RFA.

Because it is the most painful procedure we do. Or maybe it's just me

 

[BobBarker]

Yes. It is the most painful procedure we routinely do in offices.

 

[BobBarker]

I give maybe 80% diazepam 10mg. Helps relax them which makes life easier on me. If they flinch, it moves the needle too a lot.

 

[MitchLevi]

Unilateral only, Valium 5-10mg. Office based usually. Patient's whining about coming back for the contralateral side...So?

 

[buddababa]

Unilateral only, Valium 5-10mg. Office based usually. Patient's whining about coming back for the contralateral side...So?

its the whole session thing per year, so your way, they have to wait a full year for a repeat, what do you do if it in 6-7months "wears off"?

 

[SSdoc33]

its the whole session thing per year, so your way, they have to wait a full year for a repeat, what do you do if it in 6-7months "wears off"?

it doesnt wear off in 6-7 months. if it does, its either not the facets, or you are doing it wrong.

just give them a TPI until you are a year out if in a pinch

 

[MitchLevi]

its the whole session thing per year, so your way, they have to wait a full year for a repeat, what do you do if it in 6-7months "wears off"?

Interestingly, this has yet to be a problem.

 

[geauxg8rs]

its the whole session thing per year, so your way, they have to wait a full year for a repeat, what do you do if it in 6-7months "wears off"?

Cash pay at 6 months?

 

[geauxg8rs]

Cash pay at 6 months?

there is no medical justification to not pay for two unilateral rfas every 6 months, but only pay bilateral every 6 months?
It’s only for cost on their part. When someone from CMS came to asipp like 10 years ago when we were arguing for the in office epidural cuts they said that they don’t look at cost. I mean you can’t keep a straight face with this nonsense

 

[Snowmen96]

I do BL. Otherwise, the patient has no option for a repeat RF in 6 months if needed. Also, dropped head syndrome is a rare complication and there are case reports of it both with BL and with staged RFAs a week apart, so I'm not sure that it really helps anything (except the wallet) by doing it unilaterally.

Also, I've never understood the need for any significant sedation for RFAs. 95% of my patients get local only. 5% get 5mg of diazepam before the procedure. If you need an IV to get an RFA, you don't get an RFA.

I feel like RFAs with deep sedation are also much more dangerous, and especially so in the cervical spine. A few weeks ago, I had a patient who insisted on getting IV sedation who got very confused during the procedure and tried to get off the table with the cannulas in his neck DURING the burn. Also, threw her wig at me while fighting to get off the table, which was a first (and hopefully last).

Patients get confused because of the sedation and act unpredictably. PO benzo is the most I would personally do.

 

[jsaul]

I did a bilateral cervical rfa one time in nearly 20 years and the patient got significant head drop.

 

[clubdeac]

I did a bilateral cervical rfa one time in nearly 20 years and the patient got significant head drop.

I got a head drop once back in the day when we were allowed to do 3 levels bilaterally. I only do staged unilateral now and also switched from 18g to 20g needles. Probably not as good of a burn but I feel like it’s safer

 

[po_boy]

I give maybe 80% diazepam 10mg. Helps relax them which makes life easier on me. If they flinch, it moves the needle too a lot.

How much do you localize before placing the cannulas?

 

[BobBarker]

Around 1ml of 2% lido per location.

 

[lobelsteve]

I use 10-15cc lido from skin to target for C4-6 RF.
I add 1.5cc 0.25% bupi per level before the burn.

Still no head drop case in 20 years. But I still have 12 years left.
YMMV

 

[po_boy]

I use 10-15cc lido from skin to target for C4-6 RF.
I add 1.5cc 0.25% bupi per level before the burn.

Still no head drop case in 20 years. But I still have 12 years left.
YMMV

Why do you think you have never gotten head drop?

 

[lobelsteve]

Why do you think you have never gotten head drop?

I am so bad at this I never got close to the MBs

 

[Sparkymd]

Funny that over the years, I had a few dizzy after diagnostic blocks. But it always seemed passing. I read this thread yesterday, did diagnostic CMBB today at bilateral C2C3 & C3/C4 and she couldn't walk for over an hour. Thanks Pain Forum. 😂😝

 

[BobBarker]

Yep. Me too.

 

[buddababa]

Funny that over the years, I had a few dizzy after diagnostic blocks. But it always seemed passing. I read this thread yesterday, did diagnostic CMBB today at bilateral C2C3 & C3/C4 and she couldn't walk for over an hour. Thanks Pain Forum. 😂😝

too much local then, i do it these all the time and no significant issues

 

[clubdeac]

too much local then, i do it these all the time and no significant issues

If too much local, how does Steve use that boat load of local without ever having an issue

 

[Taus]

too much local then, i do it these all the time and no significant issues

It’s not necessarily the volume. I use 0.2-0.3 cc of 2% lidocaine per mb nerve. Still intermittently get vertigo when including C2-3 level, especially bilateral.

 

[Sparkymd]

too much local then, i do it these all the time and no significant issues

So do I.. thats what I was saying. Over the years, I have done this many times, it is a coincidence. I didn't use too much local. I used 3 ml for two level (0.5 per nerve) like always. But this is still a good amount more than Taus uses, but not excessive.

 

[clubdeac]

I use 0.3125cc and have never had a problem. Just saying

 

[MitchLevi]

0.5cc before each burn is all you need. Give it 20-30 sec.

 

[Taus]

0.5cc before each burn is all you need. Give it 20-30 sec.

Before the burn, yes. Granted, I do one cc of 2%. To get the 18 gauges there under straight local… I do a track needle 25 gauge skin to bone with 2 to 3 cc 1% lidocaine per level. Then some more on periosteum before I walk off laterally.

 

[nvrsumr]

I use 1% lido for everything. Kiss

 

[MitchLevi]

Lido 1% for the skin and soft tissue and in the in the neck, I’d argue 1cc at each level prior to the burn spreads to adjacent levels, and yes, I sometimes do 1cc too. For sure 1cc at the C2-3 facet line covers both TON and C3 MB.