C2-3 IA facet block and high spinal

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lobelsteve

lobelsteve

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lobelsteve said:



Why are people still going IA?
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I understand the sentiment, but having a complication is not reason to condemn a procedure. Knowing how to do lots of different procedures is a good thing. Some procedures are better than others in most people, but not all people. My two cents.
 
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This whole write up gives me pause. The first sentence strikes me as odd. Using a 21g 7cm spinal needle for a lateral approach cervical z-joint makes me want to run for my life. A 25g 1.5 inch needle is more than adequate for that procedure. The volume is huge. Just weird overall and more of an indicator of what not to do.
 
willabeast said:
I understand the sentiment, but having a complication is not reason to condemn a procedure. Knowing how to do lots of different procedures is a good thing. Some procedures are better than others in most people, but not all people. My two cents.
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Even with Lax's pen it is Level 3 at best.



Postgrad Med. 2016 Jan;128(1):54-68. doi: 10.1080/00325481.2016.1105092. Epub 2015 Dec 10.
Cervical zygapophysial (facet) joint pain: effectiveness of interventional management strategies.
Manchikanti L1,2, Hirsch JA3, Kaye AD4, Boswell MV2.
Author information

Abstract
Diagnostic facet joint nerve blocks have been utilized in the diagnosis of cervical facet joint pain in patients without disk herniation or radicular pain due to a lack of reliable noninvasive diagnostic measures. Therapeutic interventions include intra-articular injections, facet joint nerve blocks and radiofrequency neurotomy. The diagnostic accuracy and effectiveness of facet joint interventions have been assessed in multiple diagnostic accuracy studies, randomized controlled trials (RCTs), and systematic reviews in managing chronic neck pain. This assessment shows there is Level II evidence based on a total of 11 controlled diagnostic accuracy studies for diagnosing cervical facet joint pain in patients without disk herniation or radicular pain utilizing controlled diagnostic blocks. Due to significant variability and internal inconsistency regarding prevalence in a heterogenous population; despite 11 studies, evidence is determined as Level II. Prevalence ranged from 36% to 67% with at least 80% pain relief as the criterion standard with a false-positive rate ranging from 27% to 63%. The evidence is Level II for the long-term effectiveness of radiofrequency neurotomy and facet joint nerve blocks in managing cervical facet joint pain. There is Level III evidence for cervical intra-articular injections.
 
4cc into a cervical joint?

Why not just do an MBB/RFA or a blind greater/lesser ONB?
 
I didn't read the article but they were doing an IA facet from the lateral approach??
 
I will sometimes do C2-3 facet injections in folks, usually elderly with bad arthritis. I usually do them in lateral decubitus too. I just see that joint a lot better in lateral than prone. I do them however with a 1.5” 25g needle, and 1cc total. Haven’t had to do CPR yet.

But yeah, where did they think that 4cc was going to go?
 
These authors are anesthesiologists?
"
Resident Physician
Medical Student
Attending Anesthesiologist
Department of Anesthesiology and Critical Care
Saint Louis University School of Medicine
St. Louis, MO
"

I'm not sure if they managed the post-op care or did the case itself. If the former, it would explain the weird descriptions of the procedure itself as it seems written by non-pain folks working off a procedure note.

"A 21-gauge, 7-cm echogenic spinal needle"
"through the C2-C3 facet joint along the posterior aspect "

The patient's 130 kg , so the 7 cm needle might be necessary, although unlikely. If IR did it, they would have known the cross sectional distance. The description of the procedure makes it sound like it was done with fluoro guidance though, which is weird for IR where CT guidance seems more reasonable.

I'm just all kinds of confused.
 
Orin said:
These authors are anesthesiologists?
"
Resident Physician
Medical Student
Attending Anesthesiologist
Department of Anesthesiology and Critical Care
Saint Louis University School of Medicine
St. Louis, MO
"

I'm not sure if they managed the post-op care or did the case itself. If the former, it would explain the weird descriptions of the procedure itself as it seems written by non-pain folks working off a procedure note.

"A 21-gauge, 7-cm echogenic spinal needle"
"through the C2-C3 facet joint along the posterior aspect "

The patient's 130 kg , so the 7 cm needle might be necessary, although unlikely. If IR did it, they would have known the cross sectional distance. The description of the procedure makes it sound like it was done with fluoro guidance though, which is weird for IR where CT guidance seems more reasonable.

I'm just all kinds of confused.
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Do we know if the block worked? How was the follow up in the IR clinic? Oh that’s right IR doesn’t have a clinic.
 
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I once had an attending in fellowship tell me to inject 6cc into an SIJ.
 
geauxg8rs said:
Do we know if the block worked? How was the follow up in the IR clinic? Oh that’s right IR doesn’t have a clinic.
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I suspect the patient experienced 100% pain relief seconds before losing consciousness.
 
I'm not sure about the grumpiness with IR. I've met some great docs over there. In my area they do have clinics. I've even seen them prescribe things like umm Lidocaine patches.
 
This case gave me chills, because similar thing happened to me. One of my colleague's family member has AA joint arthropathy and occipital neuralgia. I did 2 separate C1-C2 joint injection, first one lasted 2 months, the 2nd one only 1 week. So I did a bilateral c2/3 facet block under local. I used 25g 3.5inch needle using posterior approach. after the right side was done, I even asked the patient if want to proceed with the left side. Patient agrees. Immediately after I injected 0.3cc of 1% lidocaine ( I was on my first of the 3 block targeting immediately above C2/3 joint line and needle was confirmed not too ventral and negative aspiration) patient reports she cannot breath. we turned her over immediately, she began to become less responsive, she had increased work of breathing, but not like the above case needing intubation. She had a high spinal where she was unable to move all 4 limbs. We used non-rebreather mask and provide supplemental oxygen. After about 2 hours she was able to move her distal arm and legs and can follow command, then at 4 hours mark, she was able to walk out of the ASC on her own. I only used 0.3mL of 1%, so I can imagine that high of volume causing more profound effect.

Well, unfortunately, my patient for whatever reason was still having left shoulder weakness the next day, and her entire left side of the body feels cold. We sent her to ER, had imaging, no CVA, but spinal cord does show edema. She received IV steroid, and was ultimately discharged. But to this day, she still have residual pain to her left shoulder, left side of the body feels cold and pain going down to her scapula area. She still report some weakness in the left side, but able to walk on her own. I MRI her brachial plexus, shoulder, brain and cervical spine, and only thing was the trace edema from c3-5. This case happened about 5 months ago, I was almost going to post on here to get people's opinion, but was a little embarrassed, but i ultimately think that 0.3mL of 1% lidocaine some how spread intrathecally on one of the radicular branches that goes to the spinal cord resulting in high spinal. I felt terrible and stress over it as this is a colleague's family member and that patient is still experiencing symptoms.
 
I rarely do cervical facet joint injxns, but when I do I don't use local. I don't think local in a joint has a ton of utility.

Cervical facet joints are so tiny I'd rather get a full cc of steroid in there, and if it spills so what...

WavyGravy your story sounds horrible.
 
Taus said:
Although as an aside from the main post above- I see nothing wrong w lateral on these. I do 99% lateral. Frankly much easier to do imho.
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Just make sure you don’t do them with a 7cm needle I guess 😉
 
wavygravy99 said:
This case gave me chills, because similar thing happened to me. One of my colleague's family member has AA joint arthropathy and occipital neuralgia. I did 2 separate C1-C2 joint injection, first one lasted 2 months, the 2nd one only 1 week. So I did a bilateral c2/3 facet block under local. I used 25g 3.5inch needle using posterior approach. after the right side was done, I even asked the patient if want to proceed with the left side. Patient agrees. Immediately after I injected 0.3cc of 1% lidocaine ( I was on my first of the 3 block targeting immediately above C2/3 joint line and needle was confirmed not too ventral and negative aspiration) patient reports she cannot breath. we turned her over immediately, she began to become less responsive, she had increased work of breathing, but not like the above case needing intubation. She had a high spinal where she was unable to move all 4 limbs. We used non-rebreather mask and provide supplemental oxygen. After about 2 hours she was able to move her distal arm and legs and can follow command, then at 4 hours mark, she was able to walk out of the ASC on her own. I only used 0.3mL of 1%, so I can imagine that high of volume causing more profound effect.

Well, unfortunately, my patient for whatever reason was still having left shoulder weakness the next day, and her entire left side of the body feels cold. We sent her to ER, had imaging, no CVA, but spinal cord does show edema. She received IV steroid, and was ultimately discharged. But to this day, she still have residual pain to her left shoulder, left side of the body feels cold and pain going down to her scapula area. She still report some weakness in the left side, but able to walk on her own. I MRI her brachial plexus, shoulder, brain and cervical spine, and only thing was the trace edema from c3-5. This case happened about 5 months ago, I was almost going to post on here to get people's opinion, but was a little embarrassed, but i ultimately think that 0.3mL of 1% lidocaine some how spread intrathecally on one of the radicular branches that goes to the spinal cord resulting in high spinal. I felt terrible and stress over it as this is a colleague's family member and that patient is still experiencing symptoms.
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So just to clarify, you were doing cervical medial branch blocks right? Not IA facet injections
 
clubdeac said:
IR need to stay out of pain
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I hate these IR ***** in my area. They have no clue what they are doing. One cannot expect someone to be proficient at every single percutaneous intervention, especially with the sheer variety that IR guys do. Ultimately, crappy outcomes like this from poorly trained individuals doing “interventional pain” will destroy this specialty even more than it already has been.
 
wavygravy99 said:
correct, a medial branch block, not intra-articular.
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I get how this can happen using a lateral approach and no multi-planar imaging. You essentially have no idea where that needle tip is. But from a MBB in a posterior approach?? How the heck did you get IT spread? That boggles my mind. Do you have fluoro pics by the way for us to see?
 
wavygravy99 said:
This case gave me chills, because similar thing happened to me.

Well, unfortunately, my patient for whatever reason was still having left shoulder weakness the next day, and her entire left side of the body feels cold.

but spinal cord does show edema.

and only thing was the trace edema from c3-5.

but i ultimately think that 0.3mL of 1% lidocaine some how spread intrathecally on one of the radicular branches that goes to the spinal cord resulting in high spinal.

I felt terrible and stress over it as this is a colleague's family member and that patient is still experiencing symptoms.
Click to expand...

This is not a high spinal. You injected something into a radiculomedulary artery that dissected it, vasospasmed it, or thrombosed it causing cord edema.
If lidocaine plain the needle got somewhere it should not have. Good collateral flow allowed her to have mild symptoms.
 
lobelsteve said:
This is not a high spinal. You injected something into a radiculomedulary artery that dissected it, vasospasmed it, or thrombosed it causing cord edema.
If lidocaine plain the needle got somewhere it should not have. Good collateral flow allowed her to have mild symptoms.
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Couldn’t this be a high spinal, and edema 2/2 intramedullary injection though?
 
I read this last week and thought about commenting on it but I saw another high cervical thread so I didn’t think you guys would appreciate it.

I also thought it was poorly done. Why bupivacaine? Throw that stuff away unless you’re doing ablations. Why the volume?

No disrespect to IR guys because I would do IR if I had a second chance. Especially for all the stroke treatment they do. The entire article was a comedy of errors. I bet their attorney will be contacting them soon.
 
The non-pain IR guys in my area do great work with everything they do.

The pain IR guys do CT guided SI joint injections and bill for both an SI and a diagnostic CT.
 
Ferrismonk said:
The non-pain IR guys in my area do great work with everything they do.

The pain IR guys do CT guided SI joint injections and bill for both an SI and a diagnostic CT.
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I have seen one Ir here do kypho and medial branch blocks at same time.

I also saw one of their patients after kypho made pain worse. No clinic to fu in. Turns out had a nasty osteomyelitis and nearly died
 
Did a C2-3, C3-4 facet injection today. I think I was more nervous doing it today than when I was in training... damn
 
paindoc007 said:
I get how this can happen using a lateral approach and no multi-planar imaging. You essentially have no idea where that needle tip is. But from a MBB in a posterior approach?? How the heck did you get IT spread? That boggles my mind. Do you have fluoro pics by the way for us to see?
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This is the lateral I have, unfortunately didn't have time to take another one in ap before flipping the patient one. I did advance in AP first, until os contact then switch to lateral and adjust to final position.
 

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3 needles? I've never seen that technique.
 
This is the technique described by Bogduk in the SIS practice guidelines on TON block, to take account in the most common course of TON from upper to lower limits of the nerve distribution. It's really one needle, but placement of the needle is repositioned after each block. 3cc above c2/3 joint, 0.3cc at the joint, and 0.3cc below.

I agree, my needle position is slightly above, was just trying to cover the highest possible course of the nerve. Unfortunately she developed the symptoms right after I did the first block. I did do all 3 position on the right side. Who knows, just my luck of the variant anatomy of the blood vessel
 
Orin said:
I'm not sure about the grumpiness with IR. I've met some great docs over there. In my area they do have clinics. I've even seen them prescribe things like umm Lidocaine patches.
Click to expand...

really training dependent. Some IRs gained extensive experience with certain pain mgmt modalities.

while most are (and should) hesitant to work around the spine, many IR are adept at joint injections (axial and appendicular) and celiac axis block/neurolysis.
 
pmrmd said:
Needle looks perfect for TON block. Inexplicable complication you had.
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Thanks for some reassurance, this is the first complication I have in my young career. still stress over this case especially since it's my colleague family member and I still see my colleague at the hospital. They are very understanding of the nature of the risk, and know I was just trying to help and I didn't mean harm. nevertheless still felt terrible. One thing I changed after is started using contrast for my cervical mbb to minimize the chance of any vascular uptake even when there was negative aspirations
 
I haven't had anything nutty happen like this, and I can imagine it sucks to be in your shoes. When I do procedures on employees I worry about this type of thing bc employees get free care in house...with in reason obviously. You're getting billed for a TKR...

I did an RFA L4-S1 on a girl that didn't help her. So whenever I see her she reminds me her back still hurts.

Different ballgame entirely, but still...I hate employee care.
 
lobelsteve said:



Why are people still going IA?
Click to expand...

I am puzzled by that as well. The literature clearly states that intra-articular cervical facet injections are ineffective. However, our new grad was trained to do these; we had to explain to him why they are a 'no-no" and now he no longer does them.
 
SommeRiver said:
I haven't had anything nutty happen like this, and I can imagine it sucks to be in your shoes. When I do procedures on employees I worry about this type of thing bc employees get free care in house...with in reason obviously. You're getting billed for a TKR...

I did an RFA L4-S1 on a girl that didn't help her. So whenever I see her she reminds me her back still hurts.

Different ballgame entirely, but still...I hate employee care.
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RFs have a known failure rate, even if you did everything by the book.
 
pmrmd said:
Yep. Saw pictures of cord after stick during facet block. Edema over multiple levels but linear track notable.
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This was from using a lateral approach correct?
 
pmrmd said:
Yup. AP to initial level at C4-5 IIRC, moved c-arm to lateral, then moved needles to C3-4 and C2-3 using only that lateral view.
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Yep, to my knowledge every report of cord stick for a CMBB is procedure done in lateral view. You’d have to be totally incompetent to have an intramedullary inj under AP view with a cmbb
 
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