Cervical mbb and RFA best approach?

[itzamemario]

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What does everyone do to quickly and safely do cervical mbbs and RFA? Posterior or lateral?
Obliqued posterior?
I am always trying to do better and haven't found a smooth way where the patients don't seem miserable. Lumbar and thoracic are usually so smooth but cervical is just never enjoyable.
Please post a video or where to find the technique if you can.

 

[callmeanesthesia]

Posterior approach, one 25g needle on each side. Target the lateral edge of periosteum at the waist. Angle down to lowest level, inject, then redirect to middle level, inject, then redirect to upper level. Skin local if they seem like the sensitive sort. Fast and safe, but not as accurate as obtaining lateral views.

 

[SSdoc33]

all posterior. Asking for trouble if you use a lateral approach

 

[PinchandBurn]

Posterior approach, one 25g needle on each side. Target the lateral edge of periosteum at the waist. Angle down to lowest level, inject, then redirect to middle level, inject, then redirect to upper level. Skin local if they seem like the sensitive sort. Fast and safe, but not as accurate as obtaining lateral views.

I like tht

Thus you only pay for 1 needle


Because we have tonsave ap and lateral images...arent you having to flip back and forth ap and lat?

 

[callmeanesthesia]

I like tht

Thus you only pay for 1 needle


Because we have tonsave ap and lateral images...arent you having to flip back and forth ap and lat?

Where does it say you have to save AP and lateral?

 

[PinchandBurn]

Where does it say you have to save AP and lateral?

2 views must be saved

 

[callmeanesthesia]

2 views must be saved

Source? I just went and looked through the Medicare LCD (Noridian for me) and I couldn’t find anything specifying number of fluoro views.

From a safety standpoint, the bone is a backstop between the needle tip and high value real estate.

 

[BobBarker]

I don’t get laterals on blocks.

 

[MD87]

Source? I just went and looked through the Medicare LCD (Noridian for me) and I couldn’t find anything specifying number of fluoro views.

From a safety standpoint, the bone is a backstop between the needle tip and high value real estate.

2 views with contrast (unless allergy) must be saved for SIJ injections and ESI. MBBs for whatever reason don't require contrast and don't require 2 views per medicare guidelines (for now...)

 

[Painologist]

Posterior approach, one 25g needle on each side. Target the lateral edge of periosteum at the waist. Angle down to lowest level, inject, then redirect to middle level, inject, then redirect to upper level. Skin local if they seem like the sensitive sort. Fast and safe, but not as accurate as obtaining lateral views.

I do this but with 3 needles, may try with 1 needle tomorrow. I do all lumbar MBBs from one injection site on each side.

 

[callmeanesthesia]

I do this but with 3 needles, may try with 1 needle tomorrow. I do all lumbar MBBs from one injection site on each side.

Oh, I still use 3 needles for lumbar. Too many of my patients the 3.5” needles wouldn’t reach with that much angle anyway :/

 

[Status Sciaticus]

posterior approach. slight lateral to medial approach. Bent needle lands at the waist and walks off. Move to lateral and walk off to the midpoint of the trapezoid. 3 needles at a time. Do the right, then the left.

I hate taking multiple fluoro shots rather than multiple needles. We are switching to a kit that has 6 needles at a $1/needle more. saving 3 dollars isnt worth my time. RFA though, 3 needles at a time.

 

[paindoc503]

anyone here using contralateral oblique instead of lateral for cervical mbbs?

 

[clubdeac]

anyone here using contralateral oblique instead of lateral for cervical mbbs?

Me

 

[ghost800]

2 views with contrast (unless allergy) must be saved for SIJ injections and ESI. MBBs for whatever reason don't require contrast and don't require 2 views per medicare guidelines (for now...)

What is your source for this? I don’t see this specifically stated in my LCD (NGS)

 

[Painologist]

Oh, I still use 3 needles for lumbar. Too many of my patients the 3.5” needles wouldn’t reach with that much angle anyway :/

5 inch, 22g for all lumbar MBBs. Can reach all 3 targets from middle level

 

[MD87]

What is your source for this? I don’t see this specifically stated in my LCD (NGS)

Google medicare LCD ESI, facet, and SIJs. Put up a link if you see something different... Last I checked was about a month ago

 

[Ferrismonk]

Posterior approach, one 25g needle on each side. Target the lateral edge of periosteum at the waist. Angle down to lowest level, inject, then redirect to middle level, inject, then redirect to upper level. Skin local if they seem like the sensitive sort. Fast and safe, but not as accurate as obtaining lateral views.

I do the same, but use one needle per location. Do you think it's less painful to move the needle around? I try to use as little fluoro as possible.

 

[Ferrismonk]

2 views with contrast (unless allergy) must be saved for SIJ injections and ESI. MBBs for whatever reason don't require contrast and don't require 2 views per medicare guidelines (for now...)

Also worth noting, it doesn't actually say you need an AP and lateral. You can do your oblique and an AP to satisfy this requirement.

 

[callmeanesthesia]

I do the same, but use one needle per location. Do you think it's less painful to move the needle around? I try to use as little fluoro as possible.

When I first started doing it that way I did one needle on one side and three on the other for a bunch of patients, and they all said the one needle side hurt less or the same.

 

[BoardingDoc]

Google medicare LCD ESI, facet, and SIJs. Put up a link if you see something different... Last I checked was about a month ago

LCD - Facet Joint Interventions for Pain Management (L38841)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.

www.cms.gov

Nothing in here about needing to save any particular number of images. It just says you must use CT or flouro. US and MRI are not allowed.

 

[MD87]

LCD - Facet Joint Interventions for Pain Management (L38841)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.

www.cms.gov

Nothing in here about needing to save any particular number of images. It just says you must use CT or flouro. US and MRI are not allowed.

Correct. Like I said, MBBs there’s no contrast requirement or 2 images. For SIJ and ESI, though, there is.

Having said that, IMO if you want to make sure the needles are actually in the right spot, it’s best practice to get 2 images.

 

[itzamemario]

anyone here using contralateral oblique instead of lateral for cervical mbbs?

Do you have a video of this? I can't seem to find one.

 

[BoardingDoc]

Correct. Like I said, MBBs there’s no contrast requirement or 2 images. For SIJ and ESI, though, there is.

Having said that, IMO if you want to make sure the needles are actually in the right spot, it’s best practice to get 2 images.

Epidural does not specify that you require two saved images. It does require contrast. Only SIJ requires both contrast and two saved images.

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID

www.cms.gov

 

[drg123]

Does no one here do lateral approach? I find it to be very fast and easy and more comfortable for patients. Yes, it requires flipping and re-prepping for bilateral. For RFA, I do cooled.

 

[Ducttape]

For bilateral its posterior approach.

For unilateral it's lateral approach.

In all cases, AP and lateral views are taken.

 

[MD87]

Epidural does not specify that you require two saved images. It does require contrast. Only SIJ requires both contrast and two saved images.

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID

www.cms.gov

Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56681)

Use this page to view details for the Local Coverage Article for Billing and Coding: Epidural Steroid Injections for Pain Management.

www.cms.gov

This indicates you are required to have 2 views. Seems there is conflicting information. Given that it is probably safer to do two views for the patient, your wallet, and your ass in court if you are ever sued, I see no reason to not check and save 2 views.

 

[ghost800]

Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56681)

Use this page to view details for the Local Coverage Article for Billing and Coding: Epidural Steroid Injections for Pain Management.

www.cms.gov

This indicates you are required to have 2 views. Seems there is conflicting information. Given that it is probably safer to do two views for the patient, your wallet, and your ass in court if you are ever sued, I see no reason to not check and save 2 views.

Right, I did previously “google” this and went through the lcd for epidurals and did not see “two views saved” which is why I was wondering the source for this because we hear it all the time. Interestingly, for si joint it does require the two views saved.

It obviously makes sense to check more than one view on the actual machine depending on the procedure and the adequacy of flow from the first shot.

We have an antiquated paper system and it is slightly extra work for the tech to print out two views on each case. So it does save a bit of time if we don’t have to print out unnecessary views for selected cases. We always print out two views for interlaminar cesi and tesi. Not always for lesi but we probably should for liability reasons.

 

[hopefulgasman]

one or two needles if necessary. 25g. Pull back and redirect. Cervical MBB and RFA are some of the easiest and fastest of its kind if you have an appropriately positioned patient...

 

[Taus]

Does no one here do lateral approach? I find it to be very fast and easy and more comfortable for patients. Yes, it requires flipping and re-prepping for bilateral. For RFA, I do cooled.

Mbb:
Lateral for unilateral. Modified swimmers position. Prone if bilateral… I used to flip and re-prep. Too much pita. Gave up on that.

 

[Fox800]

For cervical MBBs with a posterior approach: walk off or no?

 

[BobBarker]

I don’t. I just tag the waist and move along.

 

[Fox800]

How about lumbar RF: walk off or no? I've seen both. The "no walk" patients seem to still test just fine.

 

[RoloTomassi]

How about lumbar RF: walk off or no? I've seen both. The "no walk" patients seem to still test just fine.

I walk off cervical. Not sure what you mean by walking off in lumbar. Where is needle if "no walk", just on the posterior facet?

 

[Fox800]

I walk off cervical. Not sure what you mean by walking off in lumbar. Where is needle if "no walk", just on the posterior facet?

Hit the junction of the SAP and TP. Spin the curved needle 180 degrees so it goes forward a hair then stop.

 

[RoloTomassi]

Hit the junction of the SAP and TP. Spin the curved needle 180 degrees so it goes forward a hair then stop.

Ah, have not heard of that. No I inject on os at junction.

 

[Gnarvin]

I walk off cervical. Not sure what you mean by walking off in lumbar. Where is needle if "no walk", just on the posterior facet?

I also will walk off just a bit for CMBB. I do them in AP, hit lateral aspect of the lateral mass and then walk off just a couple millimeters.