Cervical MBB-Supine positioning of the patient?

[EruditeDoc]

---

Members don't see this ad.

Hi guys,

I have been previously performing my cervical medial branch blocks with the patient in lateral decubitus position and the image intensifier right about the patient ( Straight AP view). I've been inserting the needle , adjusting until its coxial with the target (midpoint of the targeted articular pillar.) Once I have reached the target I will then check a lateral view to confirm positioning. Seems like I could potentially get in trouble with this technique ( Vertebral artery)? Does anyone do this procedure with the patient Supine and the head turned away from the affected side?

 

[willabeast]

i have tried every position possible for CMBB. seems to me that it is possible to hit the wrong thing in any position.
a good way to avoid the VA would be to not go deep enough to hit it. depth can be checked with an AP or PA view.
i think ? you meant "right above the patient" not "right about the patient". if patient is in lat decubitus position and the C arm is right above the patient then i think that is a lateral view. a lateral view will not help with depth of needle insertion on a CMBB. to check depth do an AP or PA view. sorry if i did not make this clear, but what do you expect for free 🙂
//I have been previously performing my cervical medial branch blocks with the patient in lateral decubitus position and the image intensifier right about the patient ( Straight AP view). I've been inserting the needle , adjusting until its coxial with the target (midpoint of the targeted articular pillar.) Once I have reached the target I will then check a lateral view to confirm positioning. Seems like I could potentially get in trouble with this technique ( Vertebral artery)? Does anyone do this procedure with the patient Supine and the head turned away from the affected side?//

 

[ampaphb]

Not sure how you envision the vert comes into play. I also do these in the lateral position, bullseyeing the needle to the midbody of each pillar.

To me, it is much safer than those who do it with the patient prone, as they then have to triangulate the AP depth, potentially puting the anterior structures at risk

Sent from my SAMSUNG-SM-G930A using SDN mobile

 

[EruditeDoc]

Ok, I wanted to make sure that I wasn't completely off here with my approach. My partners swear by this supine approach which has made me start to consider if my technique was an appropriate variation. I am fairly new to practice and I was taught to do it this way and in the prone position in fellowship. However, I am finding that outside of the academic setting things are done a little different.

 

[ampaphb]

You are only as smart as the doc who trained you, unless you apply your own critical reasoning skills to the matter.

In this case, you are thinking about why you do what you do. Your partners will tell you they are more efficient in their approach, and can do bilateral mbbs. I think the way we do it is inherently safer. But the one thing I am certain of is that others here will be happy to tell you I am an arrogant *****

 

[oreosandsake]

Not sure how you envision the vert comes into play. I also do these in the lateral position, bullseyeing the needle to the midbody of each pillar.

To me, it is much safer than those who do it with the patient prone, as they then have to triangulate the AP depth, potentially puting the anterior structures at risk

Sent from my SAMSUNG-SM-G930A using SDN mobile

but you still need to go prone, needle Posterior to Anterior to get the cannula placed for RFA...

 

[bedrock]

but you still need to go prone, needle Posterior to Anterior to get the cannula placed for RFA...

there are those who do it with a lateral approach. I still do posterior 90% of the time, but the lateral approach can be helpful for short necks/big shoulders.

 

[AKMD_1984]

i always use prone positiong. start with AP and caudal tilt, and anesthetize the lateral aspect of the pillars where I am going to enter. i always use a curved needle. then i go lateral, land the needle middle of the trapezoid. i advance the other needles in lateral also as I have the A/P plane already established with the first needle, and i dont check an AP view. I ensure that the needles are all on the same plane and not medial (and hitting bone will tell you this - so turn the bevel). the rest are minor tweeks that can be accomplished by manipulating the needle and tip, i..e turning the hub. I do take a final AP to see where the final positioning is.

learned this at the stryker course by one of the instructors. tried other approaches, but this is the fastest and easiest and best results.

 

[oreosandsake]

there are those who do it with a lateral approach. I still do posterior 90% of the time, but the lateral approach can be helpful for short necks/big shoulders.

lateral approach for RF?

is the RF probe perpendicular to the trapezoid, or parallel?

I've heard about a CA pain fellowship that teaches perpendicular, with traditional RF probes.... even though little to zero RF energy is projected from the tip. Who needs Science when Placebo works so well!

 

[Tapspatellas]

I've met some who do lateral. You go perpendicular to the MB, just like a lateral block. It's faster, that's why they do it. From what I've seen they get such a small lesion the pain is back within 3 months.

 

[bedrock]

I've met some who do lateral. You go perpendicular to the MB, just like a lateral block. It's faster, that's why they do it. From what I've seen they get such a small lesion the pain is back within 3 months.

I don't think it works as well either. Thats why I do posterior 90% of time, unless forced to lateral with their anatomy.

And if you do the lateral, you can still come in a more oblique angel so you get at least 6 months out of it, but yes posterior is best.

 

[drpainfree]

cervical MNBB can be done safely and much easier on lateral view. but you have to make sure both lateral mass structures align perfectly on lateral view, otherwise you might hit the cord.

for RFA, I don't see how one can do it with lateral approach and claim it's done properly.

 

[epidural man]

Hi guys,

I have been previously performing my cervical medial branch blocks with the patient in lateral decubitus position and the image intensifier right about the patient ( Straight AP view). I've been inserting the needle , adjusting until its coxial with the target (midpoint of the targeted articular pillar.) Once I have reached the target I will then check a lateral view to confirm positioning. Seems like I could potentially get in trouble with this technique ( Vertebral artery)? Does anyone do this procedure with the patient Supine and the head turned away from the affected side?

Please do not do a procedure in the neck aiming for a bony structure with the neck turned. That is extremely dangerous.

I saw a great lecture one time where the needle - thought to be over the articular pillar - went right through the foramen because the neck was turned.

Straight AP - or Straight Lateral.

 

[Ligament]

Please do not do a procedure in the neck aiming for a bony structure with the neck turned. That is extremely dangerous.

I saw a great lecture one time where the needle - thought to be over the articular pillar - went right through the foramen because the neck was turned.

Straight AP - or Straight Lateral.

wouldn't the neck have to be rotated extremely toward the side of injection to make this a possibility? Usually the head is turned away from the side of injection...

 

[epidural man]

wouldn't the neck have to be rotated extremely toward the side of injection to make this a possibility? Usually the head is turned away from the side of injection...

I don't think it has to be turned much. Even with them trying to lay very still - often the articular pillars become very misaligned when it seems like they haven't even moved.

The pictures that where shown (I think at ASRA) where very compelling.

 

[EruditeDoc]

I did the procedure in the lateral position as described in my initial post. I think someone above noted that they also utilize the contralateral oblique approach which I utilized to confirm safe location of my needle tips. The only problem I had with the procedure was movement of the patient causing me to have to constantly readjust the fluoro to get accurate alignment

 

[lonelobo]

http://www.oakworksmed.com/spine-positioning-system-ii.asp

get this will make your cervical procedures much easier