Cervical medial branch blocks

[Pain Applicant1]

When I block lumbar medial branches I almost always block at the L4, L5, and S1 level and it seems that the vast majority of patient respond well. What about cervicals? Are there certain levels that you predominantly block?

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[bedrock]

When I block lumbar medial branches I almost always block at the L4, L5, and S1 level and it seems that the vast majority of patient respond well. What about cervicals? Are there certain levels that you predominantly block?

Are you a resident?

If the you block the lowest two joint levels of the lumbar spine (which take the greatest weight in the lumbar spine), what the two levels of the neck do you suppose might degenerate the fastest?

Seriously though, you need to read a good textbook or you won't understand the why and not just the where.
I'd start with the ISIS guidelines, which every interventional pain doc (or aspiring fellow) should own.

https://netforum.avectra.com/eweb/s...&prd_key=7da4e6aa-c10c-4ad4-89d4-a695207f209c

 

[Pain Applicant1]

Are you a resident?

If the you block the lowest two joint levels of the lumbar spine (which take the greatest weight in the lumbar spine), what the two levels of the neck do you suppose might degenerate the fastest?

Seriously though, you need to read a good textbook or you won't understand the why and not just the where.
I'd start with the ISIS guidelines, which every interventional pain doc (or aspiring fellow) should own.

https://netforum.avectra.com/eweb/s...&prd_key=7da4e6aa-c10c-4ad4-89d4-a695207f209c

Thanks for the advice but I've already completed my ACGME fellowship. I'm both hopkins and harvard trained and have several pain publications. Own and read ISIS guidelines as well as most other interventional textbooks. What guidelines/books/academia says and what happens in clinic private practice do not always correlate. I'm interested in anecdotal information which this forum tends to be good at providing. People's experiences count for a lot.

 

[lobelsteve]

Thanks for the advice but I've already completed my ACGME fellowship. I'm both hopkins and harvard trained and have several pain publications. Own and read ISIS guidelines as well as most other interventional textbooks. What guidelines/books/academia says and what happens in clinic private practice do not always correlate. I'm interested in anecdotal information which this forum tends to be good at providing. People's experiences count for a lot.

So what did the ivory tower teach you?

 

[Pain Applicant1]

that they pay you half in prestige and half in salary. I'm trying that with my employees but it's not working out too well

 

[SSdoc33]

Thanks for the advice but I've already completed my ACGME fellowship. I'm both hopkins and harvard trained and have several pain publications. Own and read ISIS guidelines as well as most other interventional textbooks. What guidelines/books/academia says and what happens in clinic private practice do not always correlate. I'm interested in anecdotal information which this forum tends to be good at providing. People's experiences count for a lot.

if you were SO well trained, you would burn L3 instead of S1, punk.

bedrock's comments were completely justified. thats the sort of thing you learn in day 1, maybe day 2 in a good fellowship.

 

[101N]

if you were SO well trained, you would burn L3 instead of S1, punk.

1+

S1 is like pinning the tail on the donkey

 

[specepic]

Last I checked these forums were for legit exchange of ideas. This guy asks a legit question and everyone jumps on his a**. And last I checked NO ONE out there has all the answers when it comes to curing back pain or chronic pain.

To address the OP: I find the cerv facet to be somewhat of a diff animal than lumbar facets and they also seem to respond better. PE + imaging also is a bit more useful than lumbar it seems (the symptomatic facet can often be directly palpable and ID'd

I end up mostly treating C2-4 for upper neck pain +/- HA and C4-6 for neck + shoulder. I also tx a lot less B/L in the neck

I am also curious as to the approach of others

 

[Pain Applicant1]

Take it easy friends, don't be haters and don't patronize me for trying to get some opinions. See it as a sign of respect and don't regress to junior high school name calling. You should search for some insight as to why you become so defensive. Certainly not the way a professional physician should communicate.

Nonetheless, my point is as follows:
In residency and fellowship we would block levels based on radiating patterns. However, I didn't have great follow up with patients as we would constantly rotate so I never truly saw how my patients would respond. However, when I interviewed prior to starting my own practice, I noticed that private practice guys practice much differently than the way it's done in the university setting. For instance, many folks never did sensory testing on RF. Now that I'm on my own, I've been blocking a lot of lumbar spines. I'm almost always (>95% time) finding myself blocking the facet levels of L3/L4, L4/L5, and L5/S1 and have been getting good results. I've only done one cervical mbb so far so I'm not seeing patterns just yet. However, I'm just curious if the same would hold true for the c-spine. Are there certain levels that you find yourself blocking the majority of the time and getting good results with?

As for tossing around my credentials, I was asked if I was a resident so needed to clarify.

 

[Ligament]

I do a lot of TON blocks and RFA, for headaches, and tons of L3-L5 MBB and RFA, but I have an older and/or more chronic population.

 

[bedrock]

Take it easy friends, don't be haters and don't patronize me for trying to get some opinions. See it as a sign of respect and don't regress to junior high school name calling. You should search for some insight as to why you become so defensive. Certainly not the way a professional physician should communicate.

As for tossing around my credentials, I was asked if I was a resident so needed to clarify.

I wasn't attacking you in my initial post, just clarifying your situation. The reason for that because the way

a professional physician should communicate

involves two things-
1-Proper terminology, L3, L4, L5 MBB(not S1)
2-Phrasing your question in a specific fashion so your audience knows that you understand the core background science, and you're not asking something you should have looked up.

I did my residency at Harvard and my attendings would have ripped me a new one for phrasing a question like that on rounds. Maybe you had nicer attendings during your time in Boston?

Anyway, regarding cervical mbb/rf- I'd say that C5-C6 is the most commonly involved joint for facet pain, but the neck is more complicated that the lumbar spine as cervical facet pain is most common at the most superior and most inferior levels of the neck (in contrast to the lumbar spine where RF is mostly performed at the lower levels)
Because of that variability, it's important to use every tool you have to narrow down cervical MBB/RF to the levels where you can best help your patients.
I find pain patterns to be helpful, but only in conjuction with imaging and palpation. You have to be careful palpating C5-C6 and C6-C7 because it's easy to confuse facet pain with paraspinal pain at the lower cervical levels particularly at C6-C7. I find palpation more reliable at C4-C5 and above. Palpation isn't necessarily useless below that, but I think imaging and pain referral patterns play a larger role diagnosing facet pain at C5-C6 and C6-C7, particularly when you're starting out and your palpation skills are still developing.
If they have headache or upper neck pain, you want to be sure to be in the habit of palpating C2-C3 and C3-C4 as you'll pick up facet pain or TON mediated pain in patients that often have unremarkable upper cervical facets on MR. TON mediated pain is missed all the time by neurologists and spine surgeons.

Finally, all that clinical decision making is for naught unless you perform careful cervical MBB and thorough multi-lesion cervical RF.
It may sound trite, but it's particularly important during your first few years as you build your practice and you'll soon establish a solid mental relationship of MBB/RF results to your initial clinical impression.

 

[Pain Applicant1]

I did not realize I am still in the subservient role of fellow. Nonetheless, I appreciate the input on how to distinguish which levels to inject. However, I was really just curious as to whether or not people find themselves predominantly injecting the same levels of cervical MBBs like I am finding myself injecting in the lumbar spine.

I need to shave off as many minutes as possible and right now I have the fluoro techs setting up the image of the L spine in the same way each time. All they see on the schedule is L spine MBB. I have asked them to set it up in the same way each time since I predominantly inject the same levels on each patient. When I previously asked new techs to set up the image at L3-L5 the image would almost invariably be placed too high so I now tell them L4-S1.

Anyway, does anyone find themselves injecting the same areas of the C-spine most often? Not really a question of how to determine which area to inject, although the input is helpful, but more of a question of whether or not the same levels get injected the majority of the time. I'm trying to make my practice a well-oiled machine and to have my images set up as soon as I walk in the room. Once I'm out of the ASC, this won't really be an issue.

Same levels of c-spine MBB injected the majority of the time:
a. YES? if so, which levels?
b. NO?
c. this simple thread has gotten boring

 

[PMR 4 MSK]

I did not realize I am still in the subservient role of fellow. Nonetheless, I appreciate the input on how to distinguish which levels to inject. However, I was really just curious as to whether or not people find themselves predominantly injecting the same levels of cervical MBBs like I am finding myself injecting in the lumbar spine.

I need to shave off as many minutes as possible and right now I have the fluoro techs setting up the image of the L spine in the same way each time. All they see on the schedule is L spine MBB. I have asked them to set it up in the same way each time since I predominantly inject the same levels on each patient. When I previously asked new techs to set up the image at L3-L5 the image would almost invariably be placed too high so I now tell them L4-S1.

Anyway, does anyone find themselves injecting the same areas of the C-spine most often? Not really a question of how to determine which area to inject, although the input is helpful, but more of a question of whether or not the same levels get injected the majority of the time. I'm trying to make my practice a well-oiled machine and to have my images set up as soon as I walk in the room. Once I'm out of the ASC, this won't really be an issue.

Same levels of c-spine MBB injected the majority of the time:
a. YES? if so, which levels?
b. NO?
c. this simple thread has gotten boring

95% of my lumbars are the bottom 3 levels
90% of my cervicals are "level to be determined." I figure out where the center/focus of pain is and go with the levels most closely related on fluoro. I find myself doing C4-5-6 alot, but much more variably than lumbar.

 

[Pain Applicant1]

95% of my lumbars are the bottom 3 levels
90% of my cervicals are "level to be determined." I figure out where the center/focus of pain is and go with the levels most closely related on fluoro. I find myself doing C4-5-6 alot, but much more variably than lumbar.

Thank you! That's the exact type of answer I was looking for. Much appreciated.

 

[lobelsteve]

L-spine almost always L3-5.
C-spine is either C3/4/TON for neck pain with headache, of C4-7 for neck pain with periscapular referred pain.

 

[Tenesma]

C2/C3-C3/C4 for headaches/neck pain

C4/C5-C5/C6 for neck pain

i typically will order a Cervical CT - and the facet arthrosis will typically guide me to the problematic joint (can't always see these changes by MRI)

 

[Ligament]

L-spine almost always L3-5.
C-spine is either C3/4/TON for neck pain with headache, of C4-7 for neck pain with periscapular referred pain.

Same as steve, minus C4 for headache.

 

[Tenesma]

with cervical disease - if you get the CT you can sometimes see quite well the diseased joint, and just by using 2 needles you can block above/below and get very good results with just a 2 lvl block instead of carpet bombing the whole neck.

 

[Taus]

Anyone outside of a big academic institution routinely getting SPECT/fusion studies to help assess for the levels of active inflammation?

 

[101N]

Anyone outside of a big academic institution routinely getting SPECT/fusion studies to help assess for the levels of active inflammation?

I will on occasion.

 

[bedrock]

Anyone outside of a big academic institution routinely getting SPECT/fusion studies to help assess for the levels of active inflammation?

I get SPECT very rarely but can occasionally be helpful in case of a straight shooter with major axial pain and minimal MRI findings. I've found a couple things that way like early seronegative spondylarthropathy.

 

[bedrock]

C2/C3-C3/C4 for headaches/neck pain
C4/C5-C5/C6 for neck pain

I find myself doing C4-5-6 alot,

How often do you guys RF the C7 MB?
About half of you listed C7 on your frequent burn list.

I don't think C6-C7 is involved as often as C5-C6, but it definitely happens.
C7 is certainly harder to visualize and lesion on many patients.

 

[facets]

I get minimal imaging. My patients are old and have limited funds. I determine clinically what areas need to be treated, I palpate for tenderness and verify levels under fluro. For headaches and neck pain, TON, C3, C4, for lower neck pain radiating into the "shoulders" C5, C6, C7. I usually get good results for about 1 year.
In the low back its usually L4/L5, L5/S1, sometimes I do the SI- L5, S1, S2. Lumbar RF usually lasts 6 months

 

[Tenesma]

i rarely order SPECT - only for weird presentations - and so far have only found 50% of them to actuall be helpful... also some institutions SPECTs are awesome, whereas others the SPECTS look like fuzzy crap

 

[PinchandBurn]

L-spine almost always L3-5.
C-spine is either C3/4/TON for neck pain with headache, of C4-7 for neck pain with periscapular referred pain.

same here.

Occasionally C8 as well. This is a rarity.

 

[bedrock]

How often do you guys RF the C7 MB?
About half of you listed C7 on your frequent burn list.

So how often are you guys burning C7?

 

[lovebailey2001]

I get minimal imaging. My patients are old and have limited funds. I determine clinically what areas need to be treated, I palpate for tenderness and verify levels under fluro. For headaches and neck pain, TON, C3, C4, for lower neck pain radiating into the "shoulders" C5, C6, C7. I usually get good results for about 1 year.
In the low back its usually L4/L5, L5/S1, sometimes I do the SI- L5, S1, S2. Lumbar RF usually lasts 6 months

Not to offend! but in my limited experience, lumber MBB with steroids works almost for the same duration or more. So what is the added advantage of RF over MBB!

 

[facets]

No offense taken, mbb with steroids don't last 6 months. I do a lot, about 10 rf a week and have followed the same patients for years.Also in a lot of my patients I prefer to use a modality that does not involve steroids. There is really no reason, if you live outside Kentucky, to use steroids in a mbb. Even with RF steroids are not neccessary. People with diabetes, lol with osteoporosis, patients with mood disorders could all use minimal if any steroids. Even in younger patients, esp, thin white females, I don't want to contribute to osteoporosis down the road

 

[clubdeac]

I am surprised at the number of you all that are skipping C3/4 for neck pain. A lot of responses said C4-6. I often find it hard to visualize even C6 on lateral due to short neck syndrome. How many of you are RF'ing the articular pillar of C2 when you mention ablating the C2/3 joint? I never do. I always target this joint with the TON.... that's where the vast majority of its innervation comes from, right..

 

[SSdoc33]

[/COLOR]

Not to offend! but in my limited experience, lumber MBB with steroids works almost for the same duration or more. So what is the added advantage of RF over MBB!

great question. why not ask nik? if you truly believe this to be the case, i suggest re-evaluating everything in your life.

 

[ghost dog]

When I block lumbar medial branches I almost always block at the L4, L5, and S1 level and it seems that the vast majority of patient respond well. What about cervicals? Are there certain levels that you predominantly block?

In the spirit of this thread, I have a somewhat related question.

I saw a 61 year old dude with lumbar spinal stenosis. He has pain located inthe lumbar spine, left worse than right , and radiating to both thighs above the knees; the patient has back dominant pain.

An MRI revealed mild disc bulges from the levels of L2-L3 to L5-S1. Ligamentum hypertrophy was noted from L3-L4 to L5-S1,and facet OA was noted at L3-L4 and L4-L5 with resulting moderate canal stenosis. Mild, bilateral foraminal stenosis was also noted at L3-L4 and L4-L5.

(Confusingly) he received a planning right-sided nerve root block at unspecified level which yielded complete pain relief.

He was seen by ortho and deemed not to be a surgical candidate for a foraminotomy.

Have people seen this before, and if so, what has the surgeon's rationale for refusal been ?

 

[Tenesma]

surgeons are refusing to do surgery more and more often for axial back pain unless the patient has exhausted all options - and your MRI report doesn't sound all that bad... and yes, doing a contra-lateral block with great relief is useless... post a sagittal T2 for giggles.

 

[ghost dog]

surgeons are refusing to do surgery more and more often for axial back pain unless the patient has exhausted all options - and your MRI report doesn't sound all that bad... and yes, doing a contra-lateral block with great relief is useless... post a sagittal T2 for giggles.

I found this confusing as well.

Any other feedback people have received from Ortho in regards to surgical Tx of lumbar spinal stenosis would be much appreciated.

In my neck of the woods the wait is roughly 3 - 6 months for a surgical assessment.

 

[PinchandBurn]

surgeons are refusing to do surgery more and more often for axial back pain unless the patient has exhausted all options - and your MRI report doesn't sound all that bad... and yes, doing a contra-lateral block with great relief is useless... post a sagittal T2 for giggles.

This is interseting. I'm seeing more and more surgeons being hesitant to operate. I wonder if medicare/insurance companies are clamping down on them too??

 

[bedrock]

This is interseting. I'm seeing more and more surgeons being hesitant to operate. I wonder if medicare/insurance companies are clamping down on them too??

One reason surgeons are becoming more hesitant to fuse (Thank God), is that in 2012 they're going to make just over half what they were paid previously for a spinal fusion.

 

[facets]

In my neck of the woods the wait is roughly 3 - 6 months for a surgical assessment.[/QUOTE]

Where the heck are you? In my area they are on every corner begging for cases

 

[powermd]

I am surprised at the number of you all that are skipping C3/4 for neck pain. A lot of responses said C4-6. I often find it hard to visualize even C6 on lateral due to short neck syndrome. How many of you are RF'ing the articular pillar of C2 when you mention ablating the C2/3 joint? I never do. I always target this joint with the TON.... that's where the vast majority of its innervation comes from, right..

For upper-mid neck pain I'll usually do C345 or C3456. This is vestigal from fellowship, but it seems to work very well in practice. I'll move up one level for occipital headaches, or down one level if the pain seems lower. For pain closer to the base of the neck I'll do C4567, but this ends up more commonly being myofascial pain in the cervical trap.

For those of you palpating facet joints, how useful is this given the prevalence of concurrent myofascial pain? The age group and strength of the exam findings helps push me in one direction or another.

Regarding MBBs and steroids. I will occasionally do this in young patients who are very unlikely to have true OA of the facets, and in whom I wish to avoid RF. It does occasionally work very well, so worth doing as MBB #1 in some people. I may even try to go intra-articular if I have the time and the anatomy isn't an obstacle.

 

[Pain Applicant1]

If fewer surgeons fuse it will likely evolve into them doing more pain procedures instead of sending them out. It think it's already moving in that direction.

 

[ghost dog]

In my neck of the woods the wait is roughly 3 - 6 months for a surgical assessment.

Where the heck are you? In my area they are on every corner begging for cases[/QUOTE]

I am Canadian ! (like the commercial , eh ?)

 

[facets]

Ah, Canada, where you step on their feet and they apologize for being in your way. Give me a drive by shooting any day

 

[nvrsumr]

I get minimal imaging. My patients are old and have limited funds. I determine clinically what areas need to be treated, I palpate for tenderness and verify levels under fluro. For headaches and neck pain, TON, C3, C4, for lower neck pain radiating into the "shoulders" C5, C6, C7. I usually get good results for about 1 year.
In the low back its usually L4/L5, L5/S1, sometimes I do the SI- L5, S1, S2. Lumbar RF usually lasts 6 months

For axial neck and back pain would you skip an MRI and perform MBBs proceeding to RF based on XR revealing spondylosis and hx and PE?

I order/review MRIs, primarily cya, on all patients before poking them but have been reconsidering this lately.

 

[emd123]

No offense taken, mbb with steroids don't last 6 months. I do a lot, about 10 rf a week and have followed the same patients for years.Also in a lot of my patients I prefer to use a modality that does not involve steroids. There is really no reason, if you live outside Kentucky, to use steroids in a mbb. Even with RF steroids are not neccessary. People with diabetes, lol with osteoporosis, patients with mood disorders could all use minimal if any steroids. Even in younger patients, esp, thin white females, I don't want to contribute to osteoporosis down the road

Is this a rip on ASIPP, being headquartered in Kentucky, or a blast at Kentucky for being the purveyor of all things bass-ackwards? LOL

 

[emd123]

For axial neck and back pain would you skip an MRI and perform MBBs proceeding to RF based on XR revealing spondylosis and hx and PE?

I order/review MRIs, primarily cya, on all patients before poking them but have been reconsidering this lately.

I've wondered this myself. Why do I always need a recent MRI for an MBB? More and more I think insurance companies are going to use this as a backdoor way to block interventions. Not only do you get no MRI, you get none of the interventions which you needed the MRI for. Definitely, if I'm entering the epidural space, I want the MRI. But for MBB, like you said, axial symptoms, facetogenic on exam, facet disease on plain films. MBB seems like the diagnostic test of choice since you get your answer quicker than youd get you MRI report back. You'd like it ideally, depending on the patient, you want to make sure you don't have bone mets, a retroperitoneal mass, aortic disease or some other confounder. That's why we're ordering the MRI, really, isn't it, because MRI findings alone without correlating symptoms don't really prove a pain generator anyway.

I think unfortunately, more and more, we're going to have to proceed without the luxury of a pre-procedure MRI thank you Obama.

On second thought, we might have to do without the post-procedure paycheck too. LOL

 

[facets]

Most MRI are ordered to protect the physician not improve care of the patient. I don't treat MRIs I treat patients. MRIs cannot diagnose facet syndrome, it is a clinical determination, verified by mbb. In the absence of red flags (weakness, reflex changes, fever, cancer history) I don't get an MRI. I think they are a waste of tax dollars and the money is better spent taking care of patients. But then my patients are mostly rural elderly, grateful to have a physician who cares about them, and are not prone to filing lawsuits. I have never, in 22 years, been sued, knock on wood. If I had a lawsuit or treated more litigous patients, say young medicaid patients in an urban area, I would always get an MRI. Its a shame really, estimates are that half of healthcare spending goes to defensive medicine. A person can have severe pain from the facets and a normal MRI, and diseased facets that are asymptomatic. A MRI can actually lead you astray with unneccessary information. If I patient has headaches, neck pain, tenderness to palpation of the articular pillars, exacerbation of pain with facet loading and no reflex, motor or sensory changes or pain in the arms, do you really need to know that there is a bulge at C5/C6? No, get a medical history, examine your patients, and treat them accordingly. Many of my patients not only cannot afford an MRI, they have trouble getting to the imaging center, cannot lie still, etc. When you are 80 years old, that's all a big bother. I'm preaching to the choir, but tort reform is critical to contain health care costs. Just evaluate you patients and treat them, what a concept. We have the government virtually eliminating pain management procedures to the elderly because of costs, yet these stupid tests, which accomplish nothing, keep getting ordered.

 

[DOctorJay]

any of you getting fat sat or STIR images with your MRIs?

 

[facets]

This is hopeless

 

[emd123]

this is hopeless

lol

 

[PinchandBurn]

I'm trying to think of the happy medium between CYA, getting some imaging, etc....

If it's just axial back pain, why not got a non-contrast CT...it's cheaper. Using radiologists can also comment (although not that well) on disc bulges/protrusions if they are present. Plus they are cheaper....

 

[DOctorJay]

Phys Med Rehabil Clin N Am 21 (2010) 725–766
"Czervionke and Fenton83 recently reported a series of patients undergoing MRI studies for back pain, and noted that fat-saturated T2-weighted images could detect z-joint synovitis that appeared to corre-late with the clinical pain syndrome. STIR or fat-saturated T2-weighted sequences should be included in the MRI examination in the patient with back pain"

http://www.ajronline.org/content/191/4/973.full
The results of our study suggest that, with high probability, degenerative changes in the posterior paraspinal soft-tissue structures, especially interspinous ligament edema, fac-et joint effusion, neocyst formation, and intrinsic spinal muscle edema, cause LBP in some patients. Because of homogeneous fat suppression and better depiction of soft-tissue edema, the STIR sequence is the best imaging technique for visualizing the afore-mentioned changes, and it adds only 2 min-utes to the imaging examination. Therefore, we suggest that for patients with LBP without other obvious pathologic findings, the STIR sequence be added to the MRI evaluation to visualize degenerative changes in posterior spinal structures as a possible cause of pain.

Am I way off base here?

 

[bedrock]

any of you getting fat sat or STIR images with your MRIs?

I think the MRI with STIR is useful. There's a doc at Harvard working on a similar study.