Cervical MBB initial placement tip (posterior approach)?

[CarabinerSD]

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Looking for tips on efficient cervical MBB placement with the posterior approach. What's your initial approach or landmark to getting the nice needle placement almost parallel to the articular pillar / trapezoid without using up a bunch of fluoro time (pictures appreciated)? I know some people do the lateral approach but I like to keep everything posterior for cervical MBB so it directly translates to RFA as well. For posterior I start slightly lateral & inferior but somehow still need a bunch of readjustments to keep everything parallel on the lateral view so looking for ways to improve my technique.

 

[callmeanesthesia]

The guys who trained with the RFA greats will probably take me to town for this but here’s my needle targets and technique (example of C3-5). Touch bone, aspirate, inject. I don’t walk it off lateral/anterior. I use one needle on each side, hit the middle level, redirect to lower level, then redirect to upper level.

 

[sdnuser001]

The guys who trained with the RFA greats will probably take me to town for this but here’s my needle targets and technique (example of C3-5). Touch bone, aspirate, inject. I don’t walk it off lateral/anterior. I use one needle on each side, hit the middle level, redirect to lower level, then redirect to upper level.
View attachment 385255

I do the same

 

[so55b]

The guys who trained with the RFA greats will probably take me to town for this but here’s my needle targets and technique (example of C3-5). Touch bone, aspirate, inject. I don’t walk it off lateral/anterior. I use one needle on each side, hit the middle level, redirect to lower level, then redirect to upper level.
View attachment 385255

I do the same for mbbs. do you use the same target for RFAs?

 

[callmeanesthesia]

I do the same for mbbs. do you use the same target for RFAs?

No, standard placement for RF, as parallel to the nerve as I can.

 

[CleanUp]

Enter at inferolateral border of bone driving cephalad and medial

Go CLO and gauge angle and depth (and double count the correct level!)

Go lateral and make sure angle is fine and not vascular.

 

[PMRorBUST]

Enter at inferolateral border of bone driving cephalad and medial

Go CLO and gauge angle and depth (and double count the correct level!)

Go lateral and make sure angle is fine and not vascular.

Do you hit os before going CLO and lateral?

 

[CleanUp]

Do you hit os before going CLO and lateral?

Usually yes but I don’t stay posterior like others have wittten

 

[paindoc503]

Enter at inferolateral border of bone driving cephalad and medial

Go CLO and gauge angle and depth (and double count the correct level!)

Go lateral and make sure angle is fine and not vascular.

How often do you check the lateral and find that you are too deep? I typically drive in CLO until I am posterior to the lamina, but don't routinely check lateral after. Sometimes I wonder if the CLO is giving me false reassurance.

 

[CarabinerSD]

Enter at inferolateral border of bone driving cephalad and medial

Go CLO and gauge angle and depth (and double count the correct level!)

Go lateral and make sure angle is fine and not vascular.

Much appreciate your advice.

Any chance you have picture of the placement marker prior to needle entry for the first step? That's where I feel my technique isn't optimized because I'm constantly adjusting afterwards to make it parallel afterwards.

As for CLO, I have to say I don't use it enough for MBB (only for ILESI). What's a good placement for MBB on CLO?

 

[CarabinerSD]

The guys who trained with the RFA greats will probably take me to town for this but here’s my needle targets and technique (example of C3-5). Touch bone, aspirate, inject. I don’t walk it off lateral/anterior. I use one needle on each side, hit the middle level, redirect to lower level, then redirect to upper level.
View attachment 385255

Kinda like this approach too so you're literally just AP view, touch os, aspirate, inject away?

Obviously approach for RFA will need to be different for parallel placement but this for MBB might be really efficient.

 

[RoloTomassi]

The guys who trained with the RFA greats will probably take me to town for this but here’s my needle targets and technique (example of C3-5). Touch bone, aspirate, inject. I don’t walk it off lateral/anterior. I use one needle on each side, hit the middle level, redirect to lower level, then redirect to upper level.
View attachment 385255

Are the articular branches only on the posterior joint? If so then this makes sense but if not it seems like you'd be getting some false negatives unless you used a large volume that would spread anteriorly. Curious what contrast spread looks like with this approach.

 

[bedrock]

The guys who trained with the RFA greats will probably take me to town for this but here’s my needle targets and technique (example of C3-5). Touch bone, aspirate, inject. I don’t walk it off lateral/anterior. I use one needle on each side, hit the middle level, redirect to lower level, then redirect to upper level.
View attachment 385255

Are the articular branches only on the posterior joint? If so then this makes sense but if not it seems like you'd be getting some false negatives unless you used a large volume that would spread anteriorly. Curious what contrast spread looks like with this approach.

Sorry but this is $hite technique. Only slightly better than cervical TPI under fluoro. I'm sure this is very fast and I'm also quite sure it isn't very accurate.

This would only anesthetize the nerve supply to the posterior aspect of the joint. Would not do anything for the lateral aspect of the joint.

Likely multiple false negatives, unless someone (cough cough) just numbed the entire track down to the posterior joint, in which case you would get multiple false positives. Either way, it completely defeats the purpose of a diagnostic medial branch block.

SIS standards exist for a reason and anything less than SIS protocol MBB/RFA is providing substandard care to patients.

 

[CleanUp]

How often do you check the lateral and find that you are too deep? I typically drive in CLO until I am posterior to the lamina, but don't routinely check lateral after. Sometimes I wonder if the CLO is giving me false reassurance.

I check lateral every time. I prefer to go more anterior than most.( I know I know this is the danger area. I think I can burn more of the nerve this way. I still do contrast…)

If you picture the waist I go in the most inferolateral part