Cervical facet joint fluoroscopy

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It’s all about c-arm (or bed rotation) and c-arm wig-wag to line up the joints. Lots of small trial and error movements to line up. Also, start out eyeballing the patient’s alignment to have a good starting position for the neck.
 
Wkrdoc said:
Do you guys have any tricks for lining up cervical facet joints in the lateral view? I do all my RFA/MBB in the lateral position.
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Are the posterior walls of the vb not lined? Oblique the c arm back toward you, or plane the bed toward you.. Are the sup/inf end plates not lined up? Wig wag in one direction. If it gets worse, wig wag in the other.
 
Whey are you doing RFA in lateral?? That's not good
 
clubdeac said:
Whey are you doing RFA in lateral?? That's not good
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ive actually done them both prone and lateral. One of my attendings did them all lateral in fellowship. He was one of the best practitioners I’ve seen.

please expand
 
Wkrdoc said:
ive actually done them both prone and lateral. One of my attendings did them all lateral in fellowship. He was one of the best practitioners I’ve seen.

please expand
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he means ideally with standard RFA probes you want to be as parallel to the nerve as possible, which isn’t a lateral approach. Coolief is different, which is what I use. Kits are pricey though.
 
Wkrdoc said:
ive actually done them both prone and lateral. One of my attendings did them all lateral in fellowship. He was one of the best practitioners I’ve seen.

please expand
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Yeah if you’re using standard RF and not coolief and you’re coming in perpendicular to the nerve you’re an idiot. Sorry if that’s harsh but it’s true. You’re doing your patients a disservice and you’re fraudulently billing for a procedure that was not actually done
 
clubdeac said:
Yeah if you’re using standard RF and not coolief and you’re coming in perpendicular to the nerve you’re an idiot. Sorry if that’s harsh but it’s true. You’re doing your patients a disservice and you’re fraudulently billing for a procedure that was not actually done
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Fraud is a bit excessive. You still get a lesion, just not ideal size.
 
Ligament said:
They are $850 each..how do you get them paid for or afford the kit?
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I work for a hospital, so I just had to convince them when I started that my efficiency would increase, and results would be better/more consistent so in the long run more return customers
 
I know a lot of people are using stryker venom needles, anyone using Nimbus needles consistently for cervical and lumbar RFA?
 
painfree23 said:
how do you know how much wig/wag
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You don't.

Just adjust it and take a pic, adjust, etc...

I recommend you place an MBB needle and adjust it to where you think you're perfect, and then try WigWag and adjust it until your XRAY image is perfect at that level. You'll potentially be a few mm off target.
 
clubdeac said:
Yeah if you’re using standard RF and not coolief and you’re coming in perpendicular to the nerve you’re an idiot. Sorry if that’s harsh but it’s true. You’re doing your patients a disservice and you’re fraudulently billing for a procedure that was not actually done
Click to expand...

I use cooled
 
SommeRiver said:
You don't.

Just adjust it and take a pic, adjust, etc...

I recommend you place an MBB needle and adjust it to where you think you're perfect, and then try WigWag and adjust it until your XRAY image is perfect at that level. You'll potentially be a few mm off target.
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Do you do any caudal tilt?
 
painfree23 said:
Do you do any caudal tilt?
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Sure. All of this varies from patient to patient.

Another issue for me at one of my clinics is that the hole the face goes into is radiopaque and seriously in the way.

I do cephalad tilt on that table and I'm coming in superiorly on that table.
 
Wkrdoc said:
Do you guys have any tricks for lining up cervical facet joints in the lateral view? I do all my RFA/MBB in the lateral position.
Click to expand...

Patient prone, head to contralateral side with 0-10 degrees of caudad tilt to open up the joint.

C-FJI.png
 
Not to steal the thread but quick question about lumbar RFA. Furman has a interesting method but seems time consuming. I’m sure it works great, but I don’t really do it that way. I just line up end plates , start off a pedicle down and go up to the target.

also, He cranially tilts a lot on his L5 DPR, r u doing the same? I know it’s just to line up end plates, but seems like it takes a lot on his model videos. Not taking anything against him at all,just curious how it translates to real world!
 
NJPAIN said:
How about flexion? Any cushion or positioning device for this view?


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I used to ask them to flex but you really need positioning pillows hard to do with blankets and reg pillows. Seems uncomfortable for patient. Now I just turn head contralateral and caudal tilt II 15 deg or so which accomplishes the same thing as flexion.
 
Do you position similarly for MB RFN?? If so, do you find that the head rotation makes getting a true lateral complicated or do you turn the head back to neutral to get a lateral?



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NJPAIN said:
Do you position similarly for MB RFN?? If so, do you find that the head rotation makes getting a true lateral complicated or do you turn the head back to neutral to get a lateral


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I’d like to bump this question. I still find cervical RF to be one of the trickiest procedures I do. All is well and good if you have slender necks, but so many of my patients have short fat necks, and/or really old arthritic necks that make rotation problematic. I still go back and forth between lateral and prone positioning. Lateral (still with oblique needle placement) is great until shadow blocks C5 and below. Prone is easier to keep the patient from moving and you can see lower, but I’ve had to use 15cm needles to get anterior enough (had one such fluffy patient today), and I find it tougher to get the needles looking good in my lateral pics. I think I’m pretty good procedurally, but a couple years out and I’m still trying to fine tune these cervicals.
 
soccrwz said:
Oak works is an absolute game changer, really consider getting one of these
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Yep have used one for last 10 years, can't imagine doing Cervical procedures without
 
It sits on top of table, head piece is adjustable
 
Its like night and day, and patients appreciate the increased comfort from this, the patients also move less so less adjustments
 
how do you position the headpeace for the Oakworks? sometimes i feel like the oakworks actually hinders me, but i don't think I am using it correctly
 
soccrwz said:
Oak works is an absolute game changer, really consider getting one of these
Click to expand...
Thanks, I’m going to have to check this out. Quick online check says these run about $1300, does that sound right?
 
I use that oakworks as well and keep it in a similar position shown in the photo. helps to have a little bit of flexion in the C spine for the procedures and I like how it keeps the patient from moving around too much for CESIs and cervical RFA.
 
manowar rules said:
I’d like to bump this question. I still find cervical RF to be one of the trickiest procedures I do. All is well and good if you have slender necks, but so many of my patients have short fat necks, and/or really old arthritic necks that make rotation problematic. I still go back and forth between lateral and prone positioning. Lateral (still with oblique needle placement) is great until shadow blocks C5 and below. Prone is easier to keep the patient from moving and you can see lower, but I’ve had to use 15cm needles to get anterior enough (had one such fluffy patient today), and I find it tougher to get the needles looking good in my lateral pics. I think I’m pretty good procedurally, but a couple years out and I’m still trying to fine tune these cervicals.
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You will be "fine tuning" your technique your whole career.

You are right- very fat people with short necks are tough to get C6 and lower with a lateral approach. Just do those folks posterior. You can have an assistant (nurse) pull on the arm to get the shadow of the shoulder out of the way.
 
hawkeye2009 said:
You will be "fine tuning" your technique your whole career.

You are right- very fat people with short necks are tough to get C6 and lower with a lateral approach. Just do those folks posterior. You can have an assistant (nurse) pull on the arm to get the shadow of the shoulder out of the way.
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That’s true, although I still may be using the coarse tuning knob for this one, haha. How do you like to do these procedures? Assuming it’s in the prone position, do you put a bolster under the patient’s chest to aid in cervical flexion? I hear people say have the patient turn their head to the contralateral side, but my patients don’t seem to tolerate that well.

I also think I am going to have to start relying more on Mr. Xanax to help patients relax. I rarely find it necessary for lumbar, but these cervical RFs become pretty laborious when my patients are tense and squirmy.
 
manowar rules said:
That’s true, although I still may be using the coarse tuning knob for this one, haha. How do you like to do these procedures? Assuming it’s in the prone position, do you put a bolster under the patient’s chest to aid in cervical flexion? I hear people say have the patient turn their head to the contralateral side, but my patients don’t seem to tolerate that well.

I also think I am going to have to start relying more on Mr. Xanax to help patients relax. I rarely find it necessary for lumbar, but these cervical RFs become pretty laborious when my patients are tense and squirmy.
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I rarely do a posterior approach- only if someone is quite obese or has sclerotomal pain from a C7 level.

Yes- I have always given a little IV versed for cervical rfs, otherwise it is not well tolerated.
 
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