Cervical RFA - approach

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SpineandWine

SpineandWine

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I recently started out of fellowship in hospital group. The rad tech is not best at optimizing lateral view for my cervical RFA (she just started as well).
My approach in fellowship was as follows assuming L C4, C5, C6 MBNRF: 1) Get an AP shot of C-spine, do local anesthetic skin infiltration at lateral waist and drive one RF cannulae down (@C4) 2) Get lateral view, drive in lateral the other two cannulae to C5 and C6 (approximate medio-lateral position based on first cannulae at skin - be more lateral than medial to be more conservative when driving) 3) drive my three cannulae to anterior 1/3rd of articular waist in mid-line 4) check motor, LA, burn.

However, the view for lateral cervical is difficult to obtain by rad tech (have to align the waist perfectly in patient that may move).
Does anyone have another approach/better way to do it? Or tips in optimizing view so it's safe.
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I experimented with that approach for a while but gave it up because I have a lot of old patients with very degenerated spines, where it’s impossible to obtain a nice lateral of multiple levels at once. I’d go back to AP to double check and realize 1 or 2 of them were way off despite looking perfect in the lateral. So now I rely on an AP view with caudal tilt (unless they’ve got significant thoracic kyphosis, then straight AP is usually adequate) to visualize the articular waist, and lateral just to gauge depth. For cervical I put a little local at the skin, then stick a spinal needle down and basically do a sloppy high volume (1 mL 1% lido per site) MBB around the targets and in the needle tract before placing the RF needles - helps with tolerability immensely (most of my patients have had .25 to .5 mg Xanax for the procedure, rarely need IV sedation).
Then I mark all 3 entry sites, put them down to touch the lateral edge of the bone and walk it off anterior. Then I check a lateral.
For larger patients, where even telling them to reach down doesn’t get the shoulders out of the way enough for a good lateral, I’ll use a CLO as a double check to judge depth - it’s not perfect but at least can make sure it’s deep enough but back from the neural foramen. There’s a thread somewhere a while back discussing that view for RF in more detail.
 
callmeanesthesia said:
I experimented with that approach for a while but gave it up because I have a lot of old patients with very degenerated spines, where it’s impossible to obtain a nice lateral of multiple levels at once. I’d go back to AP to double check and realize 1 or 2 of them were way off despite looking perfect in the lateral. So now I rely on an AP view with caudal tilt (unless they’ve got significant thoracic kyphosis, then straight AP is usually adequate) to visualize the articular waist, and lateral just to gauge depth. For cervical I put a little local at the skin, then stick a spinal needle down and basically do a sloppy high volume (1 mL 1% lido per site) MBB around the targets and in the needle tract before placing the RF needles - helps with tolerability immensely (most of my patients have had .25 to .5 mg Xanax for the procedure, rarely need IV sedation).
Then I mark all 3 entry sites, put them down to touch the lateral edge of the bone and walk it off anterior. Then I check a lateral.
For larger patients, where even telling them to reach down doesn’t get the shoulders out of the way enough for a good lateral, I’ll use a CLO as a double check to judge depth - it’s not perfect but at least can make sure it’s deep enough but back from the neural foramen. There’s a thread somewhere a while back discussing that view for RF in more detail.
Click to expand...

How do you test for motor if you’ve already anesthetized the target with 1% lido?
 
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There is indeed a recent thread about this. I like starting with caudal tilt to visualize the joint lines and an ipsilateral oblique to accentuate the waist, usually don’t have lateral issues but anymore I use CLO as a confirmatory view before going to lateral, especially helpful in the lower cervical spine, of course. I now use 10 mm active tip on all, one burn with the venom close to the foramen (in CLO) and another more posterior to wrap the lesion around the pillar.
 
How are you all managing cervicogenic headache? I will typically go straight TON ablation without including adjacent segments. Most of my colleagues do C2-3 through C4-5. I think this approach is fine if they have significant neck pain as well, but it seems like the whiplash HA patients do well with just C2-3… I also have a colleague who does GON (C2 MB) with his upper cervical patients and this seems to be a trend in my locale, though this might be his misunderstanding of the innervation…
 
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chibadriver said:
How are you all managing cervicogenic headache? I will typically go straight TON ablation without including adjacent segments. Most of my colleagues do C2-3 through C4-5. I think this approach is if they have significant neck pain as well, but it seems like the whiplash HA patients do well with just C2-3… I also have a colleague who does GON (C2 MB) with his upper cervical patients and this seems to be a trend in my locale, though this might be his misunderstanding of the innervation…
Click to expand...
For cervicogenic HA usually b/l C2-4 as there's usually some upper cervical pain. If only occipital headaches C2-3. Never just TON. Never RF'd GON.
 
SSdoc33 said:
? you mean a solid couple of SECONDS, right?

do yourself a favor and try a burn immediately. you (and the patient) won't notice a difference and it will save you several minutes/RF
Click to expand...
Gotta disagree on that anecdotally. The more I wait the less they scream..
 
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SSdoc33 said:
no stagger. 1 mL 2% lido and those 2 minutes/side add up. seriously, try it. it doesn't take minutes. onset is within seconds
Click to expand...

I always wait two minutes after giving 2% lido. Interesting though, I doubt a single person here waits two minutes before inserting your needle after localizing the skin… I have two on Monday, I’m gonna send it. I’ll report back.
 
1% lido usually won’t fully abolish the multifidus twitch, and certainly isn’t enough to anesthetize a spinal nerve and ablate it. I’ve gradually brought my time down. Used to wait 1.5 minutes, then got impatient and did a minute or so, now for lumbar I put in a little 1% while moving for the lateral view, and cervical I’ve already pre-anesthetized as I outlined above. After testing I add about 1 mL 2% per site, wait 10 seconds or so, and start. If they react I pause and add a little more, and wait 30 seconds.
 
You all doing bilateral cervicals given the new Medicare guidelines of only 2 visits of rfa per year?
 
My process:
Prep/Drape/Mark sites on one side
1% Lido to skin
Get the probes from RN and prepare them
Insert cannulas to MB, test, 1% lido in
Wait 2 min then burn
While waiting 2 min and burning 90s, C-arm to other side, mark, local to skin
Once cannulas done with side one, insert on side 2 (skin numb at this point), test, 1% lido in
Wait 2 min and burn.

Bilateral RF takes maybe 20 min this way.
 
painfree23 said:
You all doing bilateral cervicals given the new Medicare guidelines of only 2 visits of rfa per year?
Click to expand...

if RFA's properly done, most pts will get at least 10months - 1 year relief. lumbar i will do bilateral, but cervical i've had rare vertigo issues and i like to do unilateral at a time.
 
anujacket said:
I'm not too familiar with CLO view for this- what degree obliquity do you ask from AP?
I've utilized CLO for CESI but never cervical RF
Click to expand...

Same degree of oblique, about 60, ensuring your tip is posterior to the ipsalateral foramen
 
chibadriver said:
How are you all managing cervicogenic headache? I will typically go straight TON ablation without including adjacent segments. Most of my colleagues do C2-3 through C4-5. I think this approach is if they have significant neck pain as well, but it seems like the whiplash HA patients do well with just C2-3… I also have a colleague who does GON (C2 MB) with his upper cervical patients and this seems to be a trend in my locale, though this might be his misunderstanding of the innervation…
Click to expand...
Always C2-3-4, commonly C4-5, and occasionally O-A joints.
 
I've taken to doing a quick pulsed RFA in that wait time for the local. It gives me a timer for waiting and may help. Generally though I can only last 90s before my patience runs out.

For imaging, I have found that positioning prone is easier for cervicals, even when doing unilateral procedures. Patients have less gross movement of the head when they are face down. I can still shoot lateral across or under if I want to take a lateral approach
 
paindoc007 said:
Try waiting 5 s then burn instead of 2 m. Results will be the same. In that 1 min 55s you could do a stem cell injection in the other room and be richer.
Click to expand...

I’m a believer. Cervical, thoracic and SI RFA today, only waited as long as it took for the nurse to ask me if I was sure I wanted to ablate right away… no problems whatsoever.
 
chibadriver said:
Same degree of oblique, about 60, ensuring your tip is posterior to the ipsalateral foramen
Click to expand...
I've seen two levels of oblique. I've seen the traditional 50-60 until you get that foraminal oblique and I've also seen a lesser degree ~30 where it actually looks like articular pillars. Is one better than the other?
 
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jwalker12 said:
I've seen two levels of oblique. I've seen the traditional 50-60 until you get that foraminal oblique and I've also seen a lesser degree ~30 where it actually looks like articular pillars. Is one better than the other?
Click to expand...

I believe that second edition Furman Atlas advocates 30 degree CLO? If I’m correct, it’s one of the few instances in which the atlas advocates a specific angle.

Taus is our resident expert on this.
 
GetAttachmentThumbnail
 
So, ipsilateral oblique for depth, and clo for what exactly? Does anyone do it like this? what angles do you use?
 
drrosenrosen said:
So, ipsilateral oblique for depth, and clo for what exactly? Does anyone do it like this? what angles do you use?
Click to expand...
I tried CLO 50 degrees for a giant patient I was doing prone CMBBs today and couldn’t get a good lateral, couldn’t see anything. I thought it worked, but going back to AP my needles wandered a little lateral, I had the nurse pull the shoulders down to get at least some sort of lateral and the needles were way to deep.
 
NJPAIN said:
I believe that second edition Furman Atlas advocates 30 degree CLO? If I’m correct, it’s one of the few instances in which the atlas advocates a specific angle.

Taus is our resident expert on this.
Click to expand...

Unfortunately I can’t open that article on mobile. But I think you’re thinking of a 30° ipsilateral oblique view for your initial (trajectory) pass to get better contact with the medial branch as it hugs the articular pillar. Confirmatory view is a contralateral foraminal view, approximately 60° CLO, to evaluate the position of your needle tip relative to the foramen…
View attachment 344118
View attachment 344119
View attachment 344120
View attachment 344121
(Furman, 2nd Ed)
 
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Actually I think the recommended 30 degree CLO is to confirm intraarticular placement for cervical facet injection.
 
Taus said:
Same. As per the linked article above. Just ALWAYS motor test, as the SIS technique is validated with lateral for depth marker, not clo. I get an occasional surprise.
Click to expand...
Well … I should add that I always check one lateral before going clo to 100% confirm levels counting down from c2 to my most cephalad cannula. I also will do c23, c34 in just ap/lateral as generally no issues seeing my needle tips
 
Unless you're doing only low cervical or super large shoulders, you can usually see at least one needle well on lateral. Then when you CLO, use that needle as your depth gauge as to where to get the others
 
I've always done the same technique as OP (since I taught it to him 😉), but now working with an MA driving the C-arm instead of a rad tech, I find it's a bigger pain to get a really good lateral view, so I'm interested in trying this CLO approach, which I've only ever used as a salvage when I couldn't get a lateral on lower cervical levels. Next cervical rf I'm going to try this technique as described in the article. I always do motor testing, anyway, so that will be unchanged.
 
drrosenrosen said:
I've always done the same technique as OP (since I taught it to him 😉), but now working with an MA driving the C-arm instead of a rad tech, I find it's a bigger pain to get a really good lateral view, so I'm interested in trying this CLO approach, which I've only ever used as a salvage when I couldn't get a lateral on lower cervical levels. Next cervical rf I'm going to try this technique as described in the article. I always do motor testing, anyway, so that will be unchanged.
Click to expand...
Lol- yeah, i'm gonna switch over to CLO as well.
Apparently our rad tech was great.
 

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