Cervical facet injection technique

[ED50]

How are you all doing your cervical facets. I line up the pillar view in a/p touch os and then move lateral and try to enter the joint space from there. Just wondering if there are any tips or alternative ways you all are doing these. Anyone using obliques or approaching from the lateral?

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[SommeRiver]

No utility in a cervical facet CSI.

MBB and then burn.

 

[bronchospasm]

MBB / RFA unless patient is on blood thinner and can not come off it. Also avoid bilateral MBB’s due to balance / equilibrium issues.

 

[callmeanesthesia]

MBB / RFA unless patient is on blood thinner and can not come off it. Also avoid bilateral MBB’s due to balance / equilibrium issues.

If they can’t come off blood thinners, discuss small risk of major bleeding and proceed. If they do fine with the bilateral MBB they will do fine with the bilateral RF. I do it all the time including C2-3. If they get really dizzy with the MBB, do one side, wait a couple months, then do the other side.
I rarely do facet steroid injections but technique is as you describe. Hit the joint on the lateral edge. Usually if patient dead set against RF but has had lots of benefit from steroids before, or for insurance reasons can’t do an RF for a while. Saw one to follow up today and she was doing great.

 

[pmrmd]

How are you all doing your cervical facets. I line up the pillar view in a/p touch os and then move lateral and try to enter the joint space from there. Just wondering if there are any tips or alternative ways you all are doing these. Anyone using obliques or approaching from the lateral?

Caudal tilt and get in where you can but have done lateral as well.

You will probably get the same result with putting steroid on the joint instead of in it.

Blood thinners don’t matter with injections, blocks, or RF.

 

[Taus]

Lateral approach. Modified swimmers view to get shoulders out of way. My rate of intra-articular/arthrogram much higher with lateral than posterior approach. If posterior If I can’t see joint space clearly despite caudal tilt I’ll hit at approximately joint line, go lateral or clo and try to slip in joint. Still usually ends up mostly peri-articular.... though I’m not convinced outcome would be any different

I’ll inject steroid for younger s/p whiplash if not responding to pt etc. or older if they’re not interested or ready for rfa despite the explanation that the steroids most likely won’t last too long.

blood thinners a non-issue. No reason to stop for injection or the rf

 

[stsa84]

MBB / RFA unless patient is on blood thinner and can not come off it. Also avoid bilateral MBB’s due to balance / equilibrium issues.

Do you always avoid bilateral cervical MBB's, or just in certain patients? I haven't seen many people do that.

 

[SommeRiver]

I have a rule in my clinic for cervical and I'm unilateral always. Lumbar I'll do bilateral.

 

[pmrmd]

Do you always avoid bilateral cervical MBB's, or just in certain patients? I haven't seen many people do that.

It’s more like never avoid bilateral cervical blocks even at C2-3. RFs though ought to be done unilaterally IMO.

 

[ED50]

Thanks for the replies. I agree with everyone that CMBB -> RFA is my first choice, but for various reasons: insurance, very strong patient preference, I'll occasionally consider facet injections. Just wondering what technique everyone is using for that. Can you all clarify your position on blood thinners? ASRA guidelines recommend holding blood thinners for these procedures. Do you think they are too conservative?

 

[Laryngospasm]

I think most of us don’t hold them for mbb rfa. And honestly I have turned down patients with lots of heart problems for interlaminars because I didn’t feel the risk of them coming ofF was worth it.

 

[SommeRiver]

Never stop AC for a facet intervention, especially if atrial fib is the Dx.

 

[lobelsteve]

Thanks for the replies. I agree with everyone that CMBB -> RFA is my first choice, but for various reasons: insurance, very strong patient preference, I'll occasionally consider facet injections. Just wondering what technique everyone is using for that. Can you all clarify your position on blood thinners? ASRA guidelines recommend holding blood thinners for these procedures. Do you think they are too conservative?

ASRA is not conservative. They are flat out wrong and do great harm compared to doing the opposite. Never hold for MBB/RF/TFESI/joint.

Hold for kypho, SCS, ILESI, LSB, Stellate, Celiac, Gasserian.

 

[Disciple]

So then, when doing certain injections without holding anticoagulation, which guidelines/studies should be cited for med-legal?

 

[lobelsteve]

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/Anticoagulant_FactFinder_3-1.pdf

FactFinders - Spine Intervention Society

 

[clubdeac]

I still hold for my cervical facets. I actually like doing cervical facets as I usually get beautiful arthrograms (unless I get a neurogram like the last one I posted). Do a steep caudal tilt and have the patient turn their head to the opposite side to get their facet/jaw out of the way. The facets should be pretty clear. I approach from one level below and slide the needle right into the joint. Usually you get good tactile feedback once you're in the joint and the arthrogram is pretty

 

[manowar rules]

ASRA is not conservative. They are flat out wrong and do great harm compared to doing the opposite. Never hold for MBB/RF/TFESI/joint.

Hold for kypho, SCS, ILESI, LSB, Stellate, Celiac, Gasserian.

I am aware of case reports of epidural hematoma after TFESI. That one seems like a gray area

 

[SommeRiver]

I am aware of case reports of epidural hematoma after TFESI. That one seems like a gray area

Exceptionally rare, and you know what is not rare?

Embolic events after stopping Coumadin.

Edit - Speaking of Coumadin. Y'all know how finicky it is to get a pt to Tx INR and keep them there right? I read a study years ago claiming 60% of the time a pt on Coumadin is Tx, and 40% they're either over/under.

So maybe 6 weeks ago (maybe longer...wtf knows these days), I sent a frail woman to the ED with dexamethasone 10mg via lumbar TFESI.

She was on Xarelto or Eliquis maybe...One of the newer agents and not Coumadin.

We've all had plenty of pts get dexamethasone and have that 48 hr hypomanic, can't sleep, anxious stuff. She had CP and SOB - That dexamethasone sped her up and her A fib went nuts.

Now had she stopped that thinner, what happens?

If you stop it, you restart it that night after the shot...But had she been on Coumadin, she wouldn't have Tx yet and who knows what would have happened there...CVA?

So don't stop the thinner for TFESI, especially not a lower lumbar TFESI.

 

[manowar rules]

Exceptionally rare, and you know what is not rare?

Embolic events after stopping Coumadin.

I’m sure you’re right, and I’m also sure that lawyer would not have a hard time finding a doctor to testify against me and sink me if that exceptionally rare event happened.

I allow blood thinners for TFESIs on case-by-case basis, but I don’t think it’s quite the “obviously don’t stop their Coumadin” situation that some make it out to be. At least with current guidelines.

 

[SommeRiver]

I’m sure you’re right, and I’m also sure that lawyer would not have a hard time finding a doctor to testify against me and sink me if that exceptionally rare event happened.

I allow blood thinners for TFESIs on case-by-case basis, but I don’t think it’s quite the “obviously don’t stop their Coumadin” situation that some make it out to be. At least with current guidelines.

I will take the SIS data and tell ASRA to do their job.

 

[SommeRiver]

Plus...I bet I can find a lawyer to sue you for stopping that thinner too.

 

[Laryngospasm]

Most cases of epidural hematoma are treated without resultant permanent defects. Not so for CVAs.. especially lumbar epidural hematoma. So the odds of you being sued for this are slim.. now how about the odds of being sued for a debilitating or deadly CVA or PE that resulted from doing a procedure with limited evidence of efficacy especially long term?

 

[au bon pain]

Most cases of epidural hematoma are treated without resultant permanent defects. Not so for CVAs.. especially lumbar epidural hematoma. So the odds of you being sued for this are slim.. now how about the odds of being sued for a debilitating or deadly CVA or PE that resulted from doing a procedure with limited evidence of efficacy especially long term?

Is this cited in the literature or from anecdotal experience? I do agree with your overall premise.

 

[Laryngospasm]

I found a literature review before that reviewed all the cases.. notably lumbar hematomas faired much better than thoracic especially the post spinal puncture ones.. but of course the numbers werent very high

 

[Ducttape]

I would say I agree with everything....

except one should strongly consider holding anticoagulation before doing cervical TFESI.


otoh, I don't do cervical TFESI at all, so I guess in a way its a nonissue for me.

 

[ED50]

Thanks for the input, my fellowship program was actually more conservative then ASRA which I thought was ridiculous. @lobelsteve as you seem to have much more medicolegal experience then me when two guidelines are in contradiction how does that play out in a legal case?

 

[lobelsteve]

Thanks for the input, my fellowship program was actually more conservative then ASRA which I thought was ridiculous. @lobelsteve as you seem to have much more medicolegal experience then me when two guidelines are in contradiction how does that play out in a legal case?

The plaintiff and the defendant will select their literature based on what is most favorable to them. Your best hopes are minimizing the risk for that patient in front of you. If you hold it and they have a stroke or heart attack is that better or worse than if you do not hold it and they have a hematoma? The likelihood of death is much higher in one of these than the other.

 

[au bon pain]

The plaintiff and the defendant will select their literature based on what is most favorable to them. Your best hopes are minimizing the risk for that patient in front of you. If you hold it and they have a stroke or heart attack is that better or worse than if you do not hold it and they have a hematoma? The likelihood of death is much higher in one of these than the other.

While you’re right and I would do the same, the twisted irony is that if things go for the plaintiff the payout from somebody becoming a para or a quad will probably be much more than for a death.

 

[lobelsteve]

While you’re right and I would do the same, the twisted irony is that if things go for the plaintiff the payout from somebody becoming a para or a quad will probably be much more than for a death.

If a hematoma develops, it rarely goes to para or quad. Decompression and urgency are your friends. But tell me, how many cases involving this have you worked on? Ive done 2. One for each side.

 

[au bon pain]

If a hematoma develops, it rarely goes to para or quad. Decompression and urgency are your friends. But tell me, how many cases involving this have you worked on? Ive done 2. One for each side.

My comment was not about incidence and I'm sure you have more experience than me.

I've worked on both sides as well though not for this condition. But for other things that resulted in disability. My point was that permanent disability typically pays out more than a death. At least according to the lawyers I know and the cases I've seen.

Do you have a good citation for incidence of hematomas that result in permanent disability?

 

[oreosandsake]

here's another approach. very accurate. check out that flow