Cervical injections

[PAINISGOOD]

Just wanted to see what other practicing pain docs are doing regarding cervical procedures techniques for cervical facets, mnbb, and RF.

At our institution, we perform cervical MNBB and RF in lateral position (aim for quadrangle) and facets in AP.

For Cervical Epidural: enter C7/T1 or C6/C7 and thread catheter to level of pathology.

Based on your experience what is your preferred technique?

thanks,

PAINISGOOD

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[knoxdoc]

Do you do cervical RF from a lateral approach? IOW, are you just dropping the needle end-on onto the pillar? Maybe I'm misunderstanding you, but Bogduk would crap himself if he heard about it done that way. I do MBB from a lateral approach and I do my CILESIs at C7/1 exclusively.

 

[drusso]

I think that he means that the needle tracks posteriorly to anteriorly with the patient lying in the lateral position. I would add that the MBB tend to move superiorly on the pillar toward the SAP as you go cephalad or caudad from C5

 

[knoxdoc]

Whats the advantage of the lateral position drusso?

 

[lobelsteve]

Whats the advantage of the lateral position drusso?

A more wiggly patient?
I cannot see how lateral can be beneficial from a comfort or safety standpoint.

 

[knoxdoc]

A more wiggly patient?
I cannot see how lateral can be beneficial from a comfort or safety standpoint.

The wiggle factor would be my concern. I'll do MBB in the lateral because its a quick path down to the pillar, but it can still be a PIA because patients inadvertently roll forward or back and screw up my alignment under fluoro.

 

[Jcm800]

A more wiggly patient?
I cannot see how lateral can be beneficial from a comfort or safety standpoint.

i cant believe i am agreeing with Steve again...

i cant understand how ANY position other than PRONE could be more optimal, except from the shoulder standpoint, that i understand, but i dont think you gain much in the lateral with respect to visualization of the lower cervical levels...

 

[lobelsteve]

i cant believe i am agreeing with Steve again...

i cant understand how ANY position other than PRONE could be more optimal, except from the shoulder standpoint, that i understand, but i dont think you gain much in the lateral with respect to visualization of the lower cervical levels...

I just don't see how getting parallel to the nerve can be safer and easier than by taking a posterior to anterior, inferior to superior, and medial to lateral approach with a prone patient.

 

[PAINISGOOD]

Interesting discussion. What I meant was that we peform cervical intraarticular facet injections with the patient in the prone position with slight oblique angle.

We do Cervicall MNBB with patient in lateral decubitus position and aim directly for pillar. The Cervical RF's ive done so far are with patient in lateral decub position. Knoxdoc, do you do Cervical RF in prone?

Also, does everyone thread catheter for CESI to level of path? When do you thread catheter in your experience?

Thanks again,

Painisgood

I just don't see how getting parallel to the nerve can be safer and easier than by taking a posterior to anterior, inferior to superior, and medial to lateral approach with a prone patient.

 

[clubdeac]

Yeah, nobody should be doing cervical RF in lateral decub and billing for RF. You ain't burnin nothin.

And, what trick do you guys use when RFing to ensure the probe comes from inferior to superior on the lateral pillar? In AP, I'll often tilt the fluoro a little cephalad to get the chin out of the way. Once I do that though I'm coming in at a more perpendicular angle to the spine and miss the optimal angle to ablate the nerve in its entirety. How do you come in at a steeper angle while still maintaining good visualization of the pillar?

 

[ampaphb]

C-MBB is clearly safer in the lateral view, as you are protected from going too far medical by the lateral pillars.

Taking a PA approach, there is a greater risk of going too far anterior.

It is also far easier to access the joint from a lateral approach

We do conventional RF from a posterior approach, and pulsed RF from the lateral

 

[knoxdoc]

Interesting discussion. What I meant was that we peform cervical intraarticular facet injections with the patient in the prone position with slight oblique angle.

We do Cervicall MNBB with patient in lateral decubitus position and aim directly for pillar. The Cervical RF's ive done so far are with patient in lateral decub position. Knoxdoc, do you do Cervical RF in prone?

Yup, I do C RF prone. I use slight caudal and lateral oblique tilt to try to get parallel to the MB as lobelsteve's pics show.

When you are doing your C RF in the lateral decub position, are you entering the skin along the posterior aspect of the neck (like you do your facets) or lateral aspect (like you do your MBB)?

 

[PAINISGOOD]

Have done both. But, doing C RF in lat decub doesnt make sense as we usually just go straight in and hit pillar like C MNBB. Really not burning much.

I think I will just do C RF prone but C MNBB in lat decub.

Can u further describe your technique for prone C RF?

Yup, I do C RF prone. I use slight caudal and lateral oblique tilt to try to get parallel to the MB as lobelsteve's pics show.

When you are doing your C RF in the lateral decub position, are you entering the skin along the posterior aspect of the neck (like you do your facets) or lateral aspect (like you do your MBB)?

 

[hyperalgesia]

When I'm doing MBBs and RFs on higher cervical, I use a lateral approach with the pt supine. You guys actually have your pt laying in the lateral decub position? I don't see the point, that's why the C-arm can go oblique. For cervicals C4-C7, I have the pt prone and go PA approach. This is how Fenton describes it. I agree the lateral approach is safer but for RF maybe you won't get as much contact with the nerve. I use pulsed RF. I'm the eternal skeptic but I just haven't noticed any difference in success rates from ablation.

 

[Ligament]

When I'm doing MBBs and RFs on higher cervical, I use a lateral approach with the pt supine. You guys actually have your pt laying in the lateral decub position? I don't see the point, that's why the C-arm can go oblique. For cervicals C4-C7, I have the pt prone and go PA approach. This is how Fenton describes it. I agree the lateral approach is safer but for RF maybe you won't get as much contact with the nerve. I use pulsed RF. I'm the eternal skeptic but I just haven't noticed any difference in success rates from ablation.

How are you coding and billing these pulsed RFs?

 

[lobelsteve]

When I'm doing MBBs and RFs on higher cervical, I use a lateral approach with the pt supine. You guys actually have your pt laying in the lateral decub position? I don't see the point, that's why the C-arm can go oblique. For cervicals C4-C7, I have the pt prone and go PA approach. This is how Fenton describes it. I agree the lateral approach is safer but for RF maybe you won't get as much contact with the nerve. I use pulsed RF. I'm the eternal skeptic but I just haven't noticed any difference in success rates from ablation.

I think your success in lateral is due to perpendicular vs parallel placement. How can you get parallel coming en pointe to the nerve? Or are you starting PA and just looking lateral? I don't get it.

 

[Tenesma]

most guys/gals do cervical RF prone--- more recently i have been doing them lateral... but the technique is not much altered.... my patients just prefer that position...

 

[hyperalgesia]

How are you coding and billing these pulsed RFs?

Good question. I work for Uncle Sam on salary so I don't do the coding. 64999 might work. It's listed on the United HC website, scroll down to 'special considerations'.
https://www.oxhp.com/secure/policy/radiofrequency_ablation_610.html
I do need to check on it though, maybe they are miscoding it.

 

[Tenesma]

while i do pulsed RF i just bill as a facet injection - because i do inject local over the joint...

as far as United goes - they have been denying my cervical RFs for a myriad of reasons - none of which make any sense - so i stopped doing cervical RFs on united patients... what i don't get is how they manage to deny over and over again despite the fact they have a clear policy...

 

[hyperalgesia]

I think your success in lateral is due to perpendicular vs parallel placement. How can you get parallel coming en pointe to the nerve? Or are you starting PA and just looking lateral? I don't get it.

My understanding of the anatomy is that the medial branch wraps around the pillar from anterior to posterior. This makes the PA needle approach parallel to the nerve. The lateral approach points the needle perpendicular to the nerve. Right?

 

[Tenesma]

when i do cervical RF in the lateral approach i will take small 27 1.5 inch needles and advance them perpendicular.... they serve as my markers - i then tilt into a far oblique and advance RF towards the junction of the 27g needle tip and articular pillar... this way i can get my needle tip parallel to the artic. pillar.... i retract my 27 g by a few mm, do the sensory/muscle stim testing, then re-advance the 27 g to the bone - inject the lcoal and then pull them out - then RF

 

[specepic]

Just to clarify--is everyone here, regardless of initial approach, ultimately cross checking the needle location with another view 90 degrees or so to the driving view?

 

[Tenesma]

i'd rather double check the positioning of my needles when i am going to be burning tissue at 80 degrees....

 

[hyperalgesia]

when i do cervical RF in the lateral approach i will take small 27 1.5 inch needles and advance them perpendicular.... they serve as my markers - i then tilt into a far oblique and advance RF towards the junction of the 27g needle tip and articular pillar... this way i can get my needle tip parallel to the artic. pillar.... i retract my 27 g by a few mm, do the sensory/muscle stim testing, then re-advance the 27 g to the bone - inject the lcoal and then pull them out - then RF

Nice technique...

 

[Tenesma]

i can't tell you how changing to lateral positioning has made a HUGE difference in terms of patient satisfaction with the procedure itself and with a decrease of post-procedure phone calls (so many prone patients would get all kinds of neck spasms from being in that position)...

 

[Ligament]

i can't tell you how changing to lateral positioning has made a HUGE difference in terms of patient satisfaction with the procedure itself and with a decrease of post-procedure phone calls (so many prone patients would get all kinds of neck spasms from being in that position)...

I do the prone technique and yes, that position flares up other facetogenic pains that often bother the patients afterward. Your approach is interesting Tenesma. Why the need for a marker needle?

 

[Tenesma]

twofold

1) it is a good marker when you are using an oblique view, because the facets start looking kinda funky at that angle

2) with this approach there is less tissue to hold the cannula in place, and so removing the probe, injecting local, replacing the probe, etc causes too much movement - the marker needle negates the need for that degree of cannula manipulation

 

[bedrock]

i can't tell you how changing to lateral positioning has made a HUGE difference in terms of patient satisfaction with the procedure itself and with a decrease of post-procedure phone calls (so many prone patients would get all kinds of neck spasms from being in that position)...

I do my cervical RFs with the patients prone but carefully positioned in cervical flexion(not just through hole in table), which greatly decreased post-procedural calls since I wasn't extending their neck for 30 minutes during the RF.

Do upper cervical MBB (TON, C3,C4) with lateral approach, patient supine, super quick and safe to do that way with easy to identify targets. Cervical MBB below 4, I generally use a prone approach with patient prone as shoulders can block lateral view.

I also use Tenesma's technique when doing RF on someone with unusual or hard to see anatomy and find the lateral marker needle can greatly speed the RF probe placement in these folks.

 

[Tenesma]

as far as upper cervical stuff (ie: C1/C2) i have been seeing a lot of that... and i don't know how best to treat that stuff...

some of the C1/C2 joints i see are sooo nasty i wouldn't know where the joint line is to do an intra-articular joint... one of my attendings used to do C2 ganglion blocks --- but i used to poop in my pants watching those procedures (and i also didn't see great results w/ that) because every once in a while the contrast would make a beautiful outline of the inside of the vertebral artery ...

any suggestions short of fusion?

 

[bedrock]

posterior approach to C2 ganglion block is much less anxiety provoking than lateral approach. Could consider pulsed RF at C2.

 

[lobelsteve]

I marked my starting position. Inferior to superior, posterior to anterior, and medial to lateral.

I cannot see an easier or safer way to get completely parallel to the nerve.
Beam is tilted with caudal intensifier, rotated contralateral oblique to bring out the waist of the pillar. I still don't understand the lateral- I assume this is position and you use cross table lateral to start, then check a true lateral by bringing the beam overhead?

No one is starting the procedure in the side of the neck, right?

 

[PAINISGOOD]

Hey lobelsteve...when you aim for the waist and hit bone (pillar I presume), do u then check a lateral to make sure you are not in neuroforamen?

We do cervical mnbb with patient in lateral decub but image intensifier above neck (so getting lateral view) while doing mnbb.

I marked my starting position. Inferior to superior, posterior to anterior, and medial to lateral.

I cannot see an easier or safer way to get completely parallel to the nerve.
Beam is tilted with caudal intensifier, rotated contralateral oblique to bring out the waist of the pillar. I still don't understand the lateral- I assume this is position and you use cross table lateral to start, then check a true lateral by bringing the beam overhead?

No one is starting the procedure in the side of the neck, right?

 

[lobelsteve]

Hey lobelsteve...when you aim for the waist and hit bone (pillar I presume), do u then check a lateral to make sure you are not in neuroforamen?

We do cervical mnbb with patient in lateral decub but image intensifier above neck (so getting lateral view) while doing mnbb.

It is impossible to get into the foramen with the approach I take. IMPOSSIBLE!

Medial to lateral from behind the lamina makes it so you cannot get there from here (without using a two needle technique and a heck of a lot of effort).

How can you get parallel while following a lateral view to the waist? I can see how it is easy to set depth, but where are you on the skin?

 

[hyperalgesia]

I think your success in lateral is due to perpendicular vs parallel placement. How can you get parallel coming en pointe to the nerve? Or are you starting PA and just looking lateral? I don't get it.

Sorry, now I see what you're asking. For C3, I have been approaching laterally with a lateral view and the probe is NOT parallel to the nerve. To be honest I hardly ever do this level. For RF, I think optimal approach is PA with lateral view for depth confirmation or dual needle 'tenesma technique'.

 

[facets]

Hey Steve why do you go medial to lateral? I go lateral to medial so I snug along the bone and don't end up in the muscle by the time I am far enough anterior. Then I check a foraminal view

It is impossible to get into the foramen with the approach I take. IMPOSSIBLE!

Medial to lateral from behind the lamina makes it so you cannot get there from here (without using a two needle technique and a heck of a lot of effort).

 

[Ligament]

I also go lateral to medial. Steve, I would think your approach is going to make it very difficult to get the needle in the waist of the pillar.

 

[lobelsteve]

 

[PAINISGOOD]

So, anyone do sitting cervical epidural steroid injections? I have done both sitting and prone. Please discuss your experience and which technique you prefer.

 

[lobelsteve]

So, anyone do sitting cervical epidural steroid injections? I have done both sitting and prone. Please discuss your experience and which technique you prefer.

How do stabilize the neck and position the c-arm in sitting?

 

[facets]

Back when dinosaurs roamed the earth and sleep- you were in grade school we did cervical epidurals sitting, without fluro, watching the drop of fluid get sucked in the epidural space (hanging drop) this was much more marked sitting than prone and we depended on marked flexion to find the interspace with our fingers. The nurse just stabilized the patient's head forward. In the 90's we started using C arms and this technique became antiquated, it is too hard to position yourself in the C and the whole room gets nuked so us old farts had to learn how to do these in the prone position.

 

[Jcm800]

Back when dinosaurs roamed the earth and sleep- you were in grade school we did cervical epidurals sitting, without fluro, watching the drop of fluid get sucked in the epidural space (hanging drop) this was much more marked sitting than prone and we depended on marked flexion to find the interspace with our fingers. The nurse just stabilized the patient's head forward. In the 90's we started using C arms and this technique became antiquated, it is too hard to position yourself in the C and the whole room gets nuked so us old farts had to learn how to do these in the prone position.

im not so old, but have done this...
did not like it!!!! yikes. i remember doing this at the VA in residency, asking the patient if he could taste the needle yet...

 

[Tenesma]

just the thought of it makes me want to quit pain medicine...

 

[facets]

What you do is ask the patient to put his fingers on the trachea, and let you know if he feels the needle

 

[mdvol]

Steve, your technique is alot like what I learned with Furman. How much do you counter oblique to get your trajectory view? Trying to see a landmark?

 

[lobelsteve]

Steve, your technique is alot like what I learned with Furman. How much do you counter oblique to get your trajectory view? Trying to see a landmark?

5-15 degrees on the counter oblique, caudal tilt the intensifier.
Pillow under the chest, forehead on a foam block, face area is open.
Furman and I trained in the same place.

 

[painstop]

I'm trying to optimize my approach and have found lateral decub the most convenient for the patient. Tenesma's approach sounds intriguing but I'm wondering if I can do it with just the RF needle. Here is a video online I found that seems like he got the appropriate trajectory. I just don't know how he figured out where to make the initial needle placement since he seems to just ballpark it. Maybe he just places his needle a few centimeters from the spinous process and assumes it will end up okay...since we have people debating medial versus lateral starting positions maybe it doesn't make that much of a difference. Here's the video (he's got the 4-stim which seems like even a nicer way of doing things):

http://www.youtube.com/watch?v=NY-nbJ_aOr0&feature=player_embedded#at=128

 

[ampaphb]

One of the practices I am at has a Stryker Multigen RF machine, and it is clearly faster to burn 4 nerves at a time. I do find, however, that I am less precise in my alignment of multiple probes when I move from one to the next. The video illustrates the problem (his probes are all over the map, and he makes no effort to make them parallel when he heats up the nerves).

Also, I know I am a little nuts doing 2 90 degree lesions for 120 seconds, but 60 degrees for 60 seconds seems patently inadequate. for

Tenesma, I think your idea re perpendicular infiltration of local is brilliant. I have been retracting my probes the length of my exposed tip, injecting local, and then advancing them back to their original position, but will give your approach a try at my next RF.

 

[sweetalkr]

i was trained on cervical esi's - paramedian approach to t1-2 or c7-t1, and take catheter to area of pathology.
if unsure of area of pathology, do a nerve root mapping (hook up positive to needle, negative to catheter) and stimulte til pain is reproduced and block

cervical mbb, uppers we do lateral, c6-t1 we did posterior.
RFTCs, all done in posterior approach

 

[docnyc]

I like Tenesma's approach as well. Tenesma any pics you could post? The 27 gauge idea is slick.

 

[PinchandBurn]

Back when dinosaurs roamed the earth and sleep- you were in grade school we did cervical epidurals sitting, without fluro, watching the drop of fluid get sucked in the epidural space (hanging drop) this was much more marked sitting than prone and we depended on marked flexion to find the interspace with our fingers. The nurse just stabilized the patient's head forward. In the 90's we started using C arms and this technique became antiquated, it is too hard to position yourself in the C and the whole room gets nuked so us old farts had to learn how to do these in the prone position.

Hey facets

I'm not old at all. We use this approach with great success. Except it's a combo of the hanging drop WITH fluro guidance in the sitting position. Using contrast to confirm. As you mentioned, the saline being sucked in is usually very profound in this position, and personally I feel like one has better control over the Touhy.

Doing it w/o fluro is a bit interesting to say the least. I probably will not do it that way.

I've been trained to do it prone with LORTA/saline as well. I didnt like this as MANY patients brady'd down/became hypotensive. For some reason doing it sitting prevents the brady (havent seen any this year). Just an observation which I thought was interesting...