Cervical RFA approaches - Pros/Cons

[huskydoc]

Currently in Fellowship where until recently all of Cervical RF is performed in the Lateral Recumbent position with 5cm RF needles

While this approach works well for targeting the upper Cervical Medial Branches, such as TON, C3 and C4...
Occasionally C5 is not easily visible (big guys with big shoulders) and when indicated it is very difficult to target C6, C7 and C8 in the lateral recumbent position.

Having attended ISIS Cervical RF Course a year ago, the teaching was that Cervical RF should be done in prone position for optimal lesion orientation with respect to the course of the Cervical Medial Branch.

So my question to those on this forum:
1. What is your approach when performing Cervical MBB/RF? Prone vs Lateral
2. Are you having to sedate significantly to minimize discomfort with prone approach? That is the reasoning why we do lateral - more comfort, less sedation required
3. If doing prone - is there a lot of post-procedural neck cramping? If so how do you address it?
4. Other thoughts on optimal approach to Cervical RF?

Appreciate input from the group in advance

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[powermd]

Currently in Fellowship where until recently all of Cervical RF is performed in the Lateral Recumbent position with 5cm RF needles

While this approach works well for targeting the upper Cervical Medial Branches, such as TON, C3 and C4...
Occasionally C5 is not easily visible (big guys with big shoulders) and when indicated it is very difficult to target C6, C7 and C8 in the lateral recumbent position.

Having attended ISIS Cervical RF Course a year ago, the teaching was that Cervical RF should be done in prone position for optimal lesion orientation with respect to the course of the Cervical Medial Branch.

So my question to those on this forum:
1. What is your approach when performing Cervical MBB/RF? Prone vs Lateral
2. Are you having to sedate significantly to minimize discomfort with prone approach? That is the reasoning why we do lateral - more comfort, less sedation required
3. If doing prone - is there a lot of post-procedural neck cramping? If so how do you address it?
4. Other thoughts on optimal approach to Cervical RF?

Appreciate input from the group in advance

Prone.
No sedation.
Lots of skin local.
Two burns per level, 80 for 60s.
No frequent post procedure issues.
Like many around here, I try to wrap the curved tips around the lateral mass to get as flat an orientation to the bone as possible. Sometimes a slight contralateral oblique tilt helps achieve an optimal view for this.I can often do two levels with the same needle with simple repositioning. I shoot a lateral view for confirmation and final tweaking.
Surprisingly good results.

 

[DOctorJay]

In fellowship myself

We do prone with minimal sedation, 2 and 2 usually. No major complaints regarding neck cramping. Can still run into trouble with high riding shoulders though.

 

[clubdeac]

prone, two burns,18g needle, 80 degrees for 90s each. Get good results with a lot of anesthesia over the posterior neck and shoulders but also see a fair amount of post RF neuritis. Treatment with lidoderm and neurontin usually takes care of it.

 

[Ligament]

You are doing a good job if you are seeing a lot of post RF neurotomy neuritis.

 

[huskydoc]

You are doing a good job if you are seeing a lot of post RF neurotomy neuritis.

Ligament - are you serious in that "Post-RF Neuritis" is a good indicator?
I was always under the impression that the neuritis was a complication.

Also - for the many people who post on the forum, are the sentiments of the first 3 posters, the status quo

1. Prone
2. Multiple lesions at each level

Add to my original questions -

Are people testing sensory and/or motor before RF?
if so, how do you test after initial lesion at a given level? or do you?

thanks

 

[SSdoc33]

Ligament - are you serious in that "Post-RF Neuritis" is a good indicator?
I was always under the impression that the neuritis was a complication.

Also - for the many people who post on the forum, are the sentiments of the first 3 posters, the status quo

1. Prone
2. Multiple lesions at each level

Add to my original questions -

Are people testing sensory and/or motor before RF?
if so, how do you test after initial lesion at a given level? or do you?

thanks

you SHOULD do (IMHO):
-prone
-18g
-multiple lesions
-sensory and motor testing

that being said, doing all of that can take a lot more time and i am willing to bet that many practitioners dont do all of those steps.


post-RF neuritis is a complication, i guess, but it does mean that you've really fried the nerve well. its not necessarily a "bad" thing, but not getting post-RF neuritis does not necessarily mean that you did a "bad" job, either

 

[NEPain]

Prone, 18 or 20 ga needle. I use 5mm active tip in the neck. Two burns per level. I see no value in sensory testing.
Definitely do motor testing.
Lateral approach doesn't make sense for thermal RF considering that the lesion is proximal to the needle tip.

 

[nvrsumr]

Does everyone do motor testing on TON? I do but had a buddy ask why and couldnt really come up with a great reason.

 

[epidural man]

Currently in Fellowship where until recently all of Cervical RF is performed in the Lateral Recumbent position with 5cm RF needles

While this approach works well for targeting the upper Cervical Medial Branches, such as TON, C3 and C4...
Occasionally C5 is not easily visible (big guys with big shoulders) and when indicated it is very difficult to target C6, C7 and C8 in the lateral recumbent position.

Having attended ISIS Cervical RF Course a year ago, the teaching was that Cervical RF should be done in prone position for optimal lesion orientation with respect to the course of the Cervical Medial Branch.

So my question to those on this forum:
1. What is your approach when performing Cervical MBB/RF? Prone vs Lateral
2. Are you having to sedate significantly to minimize discomfort with prone approach? That is the reasoning why we do lateral - more comfort, less sedation required
3. If doing prone - is there a lot of post-procedural neck cramping? If so how do you address it?
4. Other thoughts on optimal approach to Cervical RF?

Appreciate input from the group in advance

Continuous RF won't work with a lateral approach. That should be obvious why. Does Baylis make a Cervical-cool (like the LumbarCool?). That would be great and fast and easy. The lateral approach is so much faster.

I do the lateral approach but used pulsed RF for cervical. If it doesn't work very long, I will do continuous.

 

[specepic]

Continuous RF won't work with a lateral approach. That should be obvious why. Does Baylis make a Cervical-cool (like the LumbarCool?). That would be great and fast and easy. The lateral approach is so much faster.

I do the lateral approach but used pulsed RF for cervical. If it doesn't work very long, I will do continuous.

according to my Kimberly-Clark representative cervical cooled radiofrequency is just around the corner. I am hospital-based and plan to switch quite a bit of my lumbar radiofrequency over to cooled lesioning, the technology really makes much more sense. the optimal needle driving view is also the optimal needle placement view of opposed standard RF

 

[huskydoc]

Continuous RF won't work with a lateral approach. That should be obvious why. Does Baylis make a Cervical-cool (like the LumbarCool?). That would be great and fast and easy. The lateral approach is so much faster.

I do the lateral approach but used pulsed RF for cervical. If it doesn't work very long, I will do continuous.

So all the Cerivcal RF is Continuous RF in the lateral approach and we see benefit in patients, so it does work. That said, the length of benefit IMO is short (a few months) in comparison to what I expected. Additionally I plan to switch to prone approach approx 1 day following fellowship.

What length of improved neck pain are you all seeing with - Prone, Multiple lesions per level, etc? Obviously its variable but a rough estimate would be interesting to compare to what we are seeing.

 

[epidural man]

So all the Cerivcal RF is Continuous RF in the lateral approach and we see benefit in patients, so it does work. That said, the length of benefit IMO is short (a few months) in comparison to what I expected. Additionally I plan to switch to prone approach approx 1 day following fellowship.

What length of improved neck pain are you all seeing with - Prone, Multiple lesions per level, etc? Obviously its variable but a rough estimate would be interesting to compare to what we are seeing.

It's quite possible that the benefit you are seeing is from an electrical field effect, and not from neural destruction.

 

[bedrock]

it's quite possible that the benefit you are seeing is from an electrical field effect, and not from neural destruction.

+1

 

[bedrock]

according to my Kimberly-Clark representative cervical cooled radiofrequency is just around the corner. I am hospital-based and plan to switch quite a bit of my lumbar radiofrequency over to cooled lesioning, the technology really makes much more sense. the optimal needle driving view is also the optimal needle placement view of opposed standard RF

Any good studies on the safety of lumbar cooled RF?

Seems it would be easier to accidentally cook a nerve root with the larger cooled RF lesion, particularly in a severely degenerated spine or spine with severe scoliosis

 

[huskydoc]

It's quite possible that the benefit you are seeing is from an electrical field effect, and not from neural destruction.

I assume that "electrical field effect" is a way of describing Pulsed RF?

Is there anything that would help to distinguish that the benefit patients report with lateral approach is an electrical field effect rather than neural destruction?

Would the fact that we see virtually no neuritis be more indicative of an "electrical field effect" rather than neurolysis/neurotomy. From the earlier responses to this thread, it appears that neuritis indicates effective nerve destruction.

thanks

 

[epidural man]

Any good studies on the safety of lumbar cooled RF?

Seems it would be easier to accidentally cook a nerve root with the larger cooled RF lesion, particularly in a severely degenerated spine or spine with severe scoliosis

The placement makes this unlikely (it isn't placed parallel to the nerve per ISIS guidelines - it is placed like a medial branch block).

However, don't know about evidence.

Here is something at least.

http://omicsgroup.org/journals/JPAR/JPAR-1-e107.php?aid=4299

 

[Ducttape]

Can anyone post images of Cervical RFA or MBB from the prone approach?

i get decent (and expected, for the most part) results when i go lateral, but i never was taught how to do it prone. every time i decide on doing an MBB... i end up doing it lateral.

I have Furmans book, but for some reason, i just am too tentative...

can anyone post some good pics of MBB or RFA from the prone position that they are proud of?

many thanks.

 

[SeniorWrangler]

I find it sometimes helps to have someone gently pull the patients' arms downwards to expose the lower cervical spine, especially for people with meaty shoulders. They took away the cute little printer on our fluoroscope, so no pictures.

 

[clubdeac]

Can anyone post images of Cervical RFA or MBB from the prone approach?

i get decent (and expected, for the most part) results when i go lateral, but i never was taught how to do it prone. every time i decide on doing an MBB... i end up doing it lateral.

I have Furmans book, but for some reason, i just am too tentative...

can anyone post some good pics of MBB or RFA from the prone position that they are proud of?

many thanks.

How do you do RFA from lateral?? The burn can't be good from that angle!?! I would post pics if I knew how. I'm computer illiterate

 

[bedrock]

How do you do RFA from lateral?? The burn can't be good from that angle!?! I would post pics if I knew how. I'm computer illiterate

+1

lateral RF would not work unless u did cooled RF or pulsed

 

[dc2md]

+1

lateral RF would not work unless u did cooled RF or pulsed

Since the lesioning area of the cannula is around all sides of the exposed tip (including the tip; check it out with room temp chicken breast) is certainly WOULD work in the lateral approach too. The problem would be that the area of lesioning would be so small that numerous lesions would have to be done to cover the same area that a well-positioned prone/dorsal approach does.

 

[deleted185747]

I also use posterior/prone approach and have the patient rotate the head and look away from the side I'm working on. (Left side RFA, look to the right) This makes it less likely to hit the vertebral artery.

 

[Ligament]

+1

lateral RF would not work unless u did cooled RF or pulsed

Lots of physicians here in Seattle take the lateral approach (non ISIS) to RFA of the c-spine, and many of them are such ******* and/or lazy they will only pulse it! Oh sure, they'll temporarily turn the temp up to 45 C to say they are doing a thermal RFA, but we know the difference.

Ultimately, I end up seeing a lot of these folks who are wondering why they got such great relief from the MBBs but maybe a month from the pulsed RFA. Using 18ga cannulae and standard ISIS technique in the neck for a few years now with multiple isotherms at 80C I am consistently getting results matching the Bogduk and Dreyfuss data. Seeing people come back for repeats at 1.5-3 years post op. I'm now using 16ga cannulae in the lumbar spine and considering using them in the c-spine as well.

I'm not boasting here, rather saying if you do the procedure properly (ISIS techniques) the results are consistently impressive.

 

[bedrock]

Since the lesioning area of the cannula is around all sides of the exposed tip (including the tip; check it out with room temp chicken breast) is certainly WOULD work in the lateral approach too. The problem would be that the area of lesioning would be so small that numerous lesions would have to be done to cover the same area that a well-positioned prone/dorsal approach does.

We might have different definitions of work. Needing to do 15 lesions instead of 2, technical works I suppose, but is crazy. Plus you'd need to make lots of holes in their neck.

 

[bedrock]

Lots of physicians here in Seattle take the lateral approach (non ISIS) to RFA of the c-spine, and many of them are such ******* and/or lazy they will only pulse it! Oh sure, they'll temporarily turn the temp up to 45 C to say they are doing a thermal RFA, but we know the difference.

Ultimately, I end up seeing a lot of these folks who are wondering why they got such great relief from the MBBs but maybe a month from the pulsed RFA. Using 18ga cannulae and standard ISIS technique in the neck for a few years now with multiple isotherms at 80C I am consistently getting results matching the Bogduk and Dreyfuss data. Seeing people come back for repeats at 1.5-3 years post op. I'm now using 16ga cannulae in the lumbar spine and considering using them in the c-spine as well.

I'm not boasting here, rather saying if you do the procedure properly (ISIS techniques) the results are consistently impressive.

d

Agree on all points.

Sorry but laziness is the reason people do cervical RF with lateral approach, not the quality of the results.

Same with ISIS RF technique in general. I've repeated RF dozens of times on patients who slipshod lazy RF technique by their first doctor, and so only achived minimal relief afterward. I repeat the procedure with ISIS technique and, then they do great for a full year.

 

[onewithpain]

Lots of physicians here in Seattle take the lateral approach (non ISIS) to RFA of the c-spine, and many of them are such ******* and/or lazy they will only pulse it! Oh sure, they'll temporarily turn the temp up to 45 C to say they are doing a thermal RFA, but we know the difference.

Ultimately, I end up seeing a lot of these folks who are wondering why they got such great relief from the MBBs but maybe a month from the pulsed RFA. Using 18ga cannulae and standard ISIS technique in the neck for a few years now with multiple isotherms at 80C I am consistently getting results matching the Bogduk and Dreyfuss data. Seeing people come back for repeats at 1.5-3 years post op. I'm now using 16ga cannulae in the lumbar spine and considering using them in the c-spine as well.

I'm not boasting here, rather saying if you do the procedure properly (ISIS techniques) the results are consistently impressive.

Where do you get the 16 ga needles? I use 18 ga and when I asked the neurotherm rep for 16 ga he said that I would have to order 500.
Neurotherm says that the 18 ga gives a 1.2 cm lesion and their 17 ga SI joint harpoon gives a 1.5 cm lesion. The 16 ga lesion should be about big enough to cover the entire articular pillar with one shot. If the lesions are truly that wide then when you use a lateral approach you would have to estimate the distance of the needle tip from the foramen and make sure that you lesion is not extending into the foramen.

 

[Ligament]

Where do you get the 16 ga needles? I use 18 ga and when I asked the neurotherm rep for 16 ga he said that I would have to order 500.
Neurotherm says that the 18 ga gives a 1.2 cm lesion and their 17 ga SI joint harpoon gives a 1.5 cm lesion. The 16 ga lesion should be about big enough to cover the entire articular pillar with one shot. If the lesions are truly that wide then when you use a lateral approach you would have to estimate the distance of the needle tip from the foramen and make sure that you lesion is not extending into the foramen.

You are correct about Neurotherm until about 2 months ago. They used to require a 500 quantity minimum order. Now they will allow you to order any quantity in 16 ga !!!!!!!!

I've been using the 16 ga in the thoracic and lumbar spine. The bleeding is definately more significant than with 18 ga. Seems like the average puncture site looses about 0-3 cc of blood. Other than that, no downsides yet.

 

[Ducttape]

So no one has the cajones to post images of their prone rfas?

The reason I have done them lateral is, well, because I did zero of them prone in fellowship, ostensibly because there is greater risk, I was told, for doing them prone.

I've tried hard to do them prone, reading fur mans chapter like 6000 times, Waldmans the same amount. I just don't feel I'm getting the results I should be getting - at least compared to my successes with lumbar mbb and RFA.

If you guys are thinking they are so much better, put your money where your mouths (proverbially speaking) are, and post done images.

 

[Taus]

On a semi-related topic.... has anyone been utilizing a foraminal oblique view to better visualize the anatomy for lower cervical medial branch blocks (ie C7 in particular), as described in Furmans book? Having patients lower their shoulders and/or having someone pull their arms down has been a PITA w/ variable success...

 

[Taus]

So no one has the cajones to post images of their prone rfas?

The reason I have done them lateral is, well, because I did zero of them prone in fellowship, ostensibly because there is greater risk, I was told, for doing them prone.

I've tried hard to do them prone, reading fur mans chapter like 6000 times, Waldmans the same amount. I just don't feel I'm getting the results I should be getting - at least compared to my successes with lumbar mbb and RFA.

If you guys are thinking they are so much better, put your money where your mouths (proverbially speaking) are, and post done images.

I'm only a fellow so my input on this may be rather meaningless... but I've been trained to do them from the beginning w/ the prone approach using 1 of 2 variations by my attendings....
-1 is to start straight AP, enter 1 level caudal and slightly lateral of targeted waist of desired articular pillar (ie not using true coaxial technique). When land on os, then go to lateral view and fine-tune the position
-2nd way is pretty much ISIS/furman, with starting AP, then caudal tilt and slight oblique, driving coaxial towards waist, then again fine tune under lateral view. Typically only doing one burn with an 18g.

I haven't read the 1st edition of ISIS, but the new edition did a pretty good job of describing the details of the prone approach.

Granted I had never learned to RF from the lateral view, so I have no basis for comparison, but the results I've been seeing have been pretty solid

 

[RickKane]

Prone
20 g Venom Stryker needle.
ISIS technique (except I very rarely check sensory)
1 burn 80 deg for 90's...with the Venom no need for a second burn
Pretty impressed with the results so far vs my previous technique of 20 g burn then turn

 

[onewithpain]

I ordered some of the 16 ga needles and neurotherm said that they are not being distributed in the states yet but that they would make an exception and sell me a few boxes if I would give them feedback. I plan to use them for SI joint RFAs. I'm not sure of the advantage for facet joint RFAs. Unfortunately I didn't do any cervical RFAs this week and I don't have any pictures saved, but they are pretty much the same as those in the ISIS guidelines. I will get some on the next case and show the gun barrel view so that you can see the needle hub overlying the active tip. The relevance is that with 18 ga needle the hub is .9 cm and the lesion is 1.2 cm. So if you think conservatively that the size of the hub is the size of the lesion then you can see that if the needle is in a good spot then one burn is all you need. For the SI joint on the other hand the needle is perpendicular to the nerve and the surface of the sacrum is irregular, so I can see the benefit of a larger lesion. On cervicals I do a foraminal view, with the fluoro beam travelling from ipsilateral to contralateral and then about 10-20 degrees from ventral to dorsal. Using that view and checking the gun barrel position I don't do stim. The patients are awake and talking to me. When I didn't do foraminal view I would occasionally get a stim onto the nerve root, but never with the foraminal so I stopped. That way I can put local on the ablation site before the RFA needle hits it. I get very good results and people start coming back at about 1 year and 9 months, with some out several years and reporting that they still have relief. I watched a guy do cervical RFA with about a 45 degree oblique view to check depth, and I check that occasionally but am not as comfortable with the landmarks.

My technique is about the same for prone. I start by placing a landmark needle from a lateral approach, then switch to AP and tilt back until I can see the waist of the articular pillar and the facet joints open up. I approach from about 5 degree oblique and use a 25 ga to place local along the track, touch bone and can check my angle and depth on the lateral. Then the RFA needle goes in along the same track. I use the map in the ISIS guidelines and place my needle in the middle of where the nerve could be. The only time I do multiple burns is on the TON. If I were doing lateral (and I am tempted to try) I would want to use a 5 cm active tip so that my lesion wouldn't extend too far lateral from the articular pillar, but I think that 5 cm active tips are available on 20 ga or smaller so I would need to do more than 1 lesion.

 

[rbsc]

Stupid question, but where do you guys find all these ISIS guidelines (that feels weird to say now that ISIS usually means something else)? I suppose you have to either go to a course or pay for them, right?

On a related note, any thoughts on ASIPP vs ISIS courses? About to finish fellowship and starting to doubt my skills after reading all these debates on approaches.

Thanks!

 

[Aether2000]

Call the SIS: They will be happy to sell you a copy

 

[bedrock]

However, the SIS/ISIS book can be a bit confusing about some of the RF techniques. I would just go to an SIS RFA course. Best way to learn the most reliable RFA techniques. Money and time well spent.

 

[willabeast]

i have done cervical RF many ways. my feeling at this point is that because of dental work obscuring image, you probably need to know a few different approaches. i think the ISIS courses were really good with the power point presentations - the lab with the cadavers were average at best. a few things i learned on my own - a 25 gauge marker needle going in lateral can really speed things up, because it gives the x ray tech something to focus on. you have to have a good x ray tech - if you do not, it will double your procedure time and double the x ray exposure to the patient. 20 gauge needles no need for sedation.
18 gauge some do need sedation.