Cervical RFA

[DoYouEvenLiftBro]

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Following the lumbar thread, what are y’all’s tricks/tips for the fluffy cervical ablation when can’t use lateral

I try to scrape the pillar, CLO view and start motor stimming early

 

[DrSpine]

Direct AP and CLO view. I'm always on the pillar. I get great results. Of course as usual someone in here will come and bash someone's technique and claim it's the worst thing and wrong.

 

[MustangGtV894]

Direct AP and CLO view. I'm always on the pillar. I get great results. Of course as usual someone in here will come and bash someone's technique and claim it's the worst thing and wrong.

How far oblique are you on the CLO view? 45? Have any picutres to share? I have been doing lateral and that can be challenging sometimes for patient positioning (arms/shoulders getting in way for fluoro)

Thanks!

 

[painfree23]

How far oblique are you on the CLO view? 45? Have any picutres to share? I have been doing lateral and that can be challenging sometimes for patient positioning (arms/shoulders getting in way for fluoro)

Thanks!

I do the full lateral view on c3-5 , usually it’s OK there. Then I Look where the needles are at on 45 CLO, gives me idea on depth for 6-7. It’s not ideal or perfect science, but I think with that and testing, it’s pretty solid.

 

[drrosenrosen]

Usually go over to 50-60 degrees CLO in Cervical. I use 45 for lumbar

 

[RoloTomassi]

There are multiple threads on this with a lot of good info

 

[GlowInTheDark]

Patient supine. lateral view and approach, line up image to get crisp pedicle and facet lines, use bone as back stop. If I’m concerned about position I’ll check in CLO. I was taught this by the docs in my PP group when I joined.

Trained in fellowship done prone with AP for initial placement and then advanced in lateral view, what an awful technique.

 

[Baron S]

Patient supine. lateral view and approach, line up image to get crisp pedicle and facet lines, use bone as back stop. If I’m concerned about position I’ll check in CLO. I was taught this by the docs in my PP group when I joined.

Trained in fellowship done prone with AP for initial placement and then advanced in lateral view, what an awful technique.

So probe completely perpendicular to nerve then?

 

[MitchLevi]

Trained in fellowship done prone with AP for initial placement and then advanced in lateral view, what an awful technique.

This is my technique.

No idea why you'd say it's awful.

 

[GlowInTheDark]

So probe completely perpendicular to nerve then?

Should specific…Oblique entry, usually just posterior to the junction of lateral mass and lamina, add a bit of curve to cannula to help it “wrap” around the waist.

 

[GlowInTheDark]

This is my technique.

No idea why you'd say it's awful.

I think most my angst with it is directed towards patient positioning/movements. I did the first few with the AP/Lateral technique then was shown this approach and have stuck with it.

Do this for C2-6 probably 100% of the tike now. Some C6 and pretty much any C7 (incredibly rare to do a C7 I feel) are easier with posterior approach.

 

[bedrock]

Patient supine. lateral view and approach, line up image to get crisp pedicle and facet lines, use bone as back stop. If I’m concerned about position I’ll check in CLO. I was taught this by the docs in my PP group when I joined.

Trained in fellowship done prone with AP for initial placement and then advanced in lateral view, what an awful technique.

A bit of an aggressive statement to disparage the cervical RFA technique with by far the best literature suppprt per SIS.

 

[pmrmd]

I think most my angst with it is directed towards patient positioning/movements. I did the first few with the AP/Lateral technique then was shown this approach and have stuck with it.

Do this for C2-6 probably 100% of the tike now. Some C6 and pretty much any C7 (incredibly rare to do a C7 I feel) are easier with posterior approach.

Am I understanding patient is supine and neck oppositely rotated and you come in from a posterolateral site to target?

All I can say is post a pic and that C6-7 facet pain is not incredibly rare.

 

[Baron S]

Am I understanding patient is supine and neck oppositely rotated and you come in from a posterolateral site to target?

All I can say is post a pic and that C6-7 facet pain is not incredibly rare.

C6-7 was found to be the symptomatic level in 17% of cases by Cooper et al in a study of 194 pts. PMID 17610457.

Not incredibly rare at all.

 

[MitchLevi]

C6-7 was found to be the symptomatic level in 17% of cases by Cooper et al in a study of 194 pts. PMID 17610457.

Not incredibly rare at all.

Virtually every cervical RFA I do is C3-5.

I do some C4-6 as well, but overwhelmingly C3-5.

 

[ED50]

One thing that has really helped me is getting the patient positioning down prior to starting. I will adjust patients or tilt table if needed. If you can get a really nice AP view straight out of the gate then CLO or lateral views are so much easier to get.

Usually a touch of caudal tilt to get the pillars to start to show and then come inferiolateral and touch os at mid pillar. Switch to CLO or lateral and advance to final position, stim and burn.

I found the pillar view a bit cumbersome and prefer to drive out of plane.

 

[bedrock]

Virtually every cervical RFA I do is C3-5.

I do some C4-6 as well, but overwhelmingly C3-5.

I think you’re definitely missing some levels.

C5-C6 has the most common facet OA.
I believe C2-C3 is #2 but I don’t have my SIS book on me.

C3-C4 is much much less commonly affected level unless it a clear upper cervical issue with headaches etc for it is reasonable to do C2-C4.

I almost never do C3-C5.

I can certainly understand someone doing a lot of C4-C6 RFA but not C3-C5.

 

[Baron S]

I think you’re definitely missing some levels.

C5-C6 has the most common facet OA.
I believe C2-C3 is #2 but I don’t have my SIS book on me.

C3-C4 is much much less commonly affected level unless it a clear upper cervical issue with headaches etc for it is reasonable to do C2-C4.

I almost never do C3-C5.

I can certainly understand someone doing a lot of C4-C6 RFA but not C3-C5.

According to that article:

C2-3 36%
C5-6 35%
C6-7 17%

Remaining joints were each less than 5%

 

[MitchLevi]

I think you’re definitely missing some levels.

C5-C6 has the most common facet OA.
I believe C2-C3 is #2 but I don’t have my SIS book on me.

C3-C4 is much much less commonly affected level unless it a clear upper cervical issue with headaches etc for it is reasonable to do C2-C4.

I almost never do C3-C5.

I can certainly understand someone doing a lot of C4-C6 RFA but not C3-C5.

Cool.

C2-5 facet arthropathy and clinical syndromes, with C7-T1 facet dz next most common in my MRIs.

Majority of my cervical pts have neck and occipital pain.

I see it daily.

You treat radiography or clinical syndromes?

This highlights the majority of my pts.

 

[MD87]

Cool.

C2-5 facet arthropathy and clinical syndromes, with C7-T1 facet dz next most common in my MRIs.

Majority of my cervical pts have neck and occipital pain.

I see it daily.

You treat radiography or clinical syndromes?

This highlights the majority of my pts.

View attachment 370804

FYI, I don’t remember exactly because I haven’t looked at the article recently, but those referral patterns are based on an incredibly small N. I (try) to go off both the imaging and referral patters.

 

[RoloTomassi]

Interesting discussion. I'm more of an even spread:
C2-4 - 30%
C3-5 - 30%
C4-6 - 20%
C5-7 - 20%
The only rare level if no adjacent segment disease is C7-T1.
I also use imaging and referral pattern. Imaging wise, I don't fully agree with that article, as C3-4 is much more likely arthritic than <5%, maybe higher than C5-6.

 

[MitchLevi]

Interesting discussion. I'm more of an even spread:
C2-4 - 30%
C3-5 - 30%
C4-6 - 20%
C5-7 - 20%
The only rare level if no adjacent segment disease is C7-T1.
I also use imaging and referral pattern. Imaging wise, I don't fully agree with that article, as C3-4 is much more likely arthritic than <5%, maybe higher than C5-6.

I haven't done my own "study," but my MRIs are C2-5 + C7-T1 arthropathy.

There are studies that show arthropathy is most common C2-5.

 

[RoloTomassi]

I haven't done my own "study," but my MRIs are C2-5 + C7-T1 arthropathy.

There are studies that show arthropathy is most common C2-5.

Why don't you do 2-3 much? Because you're getting half of it with 3-4 and rather get 5 than TON? Or worried about balance issues?

 

[SC Tian]

 

[SC Tian]

I think you’re definitely missing some levels.

C5-C6 has the most common facet OA.
I believe C2-C3 is #2 but I don’t have my SIS book on me.

C3-C4 is much much less commonly affected level unless it a clear upper cervical issue with headaches etc for it is reasonable to do C2-C4.

I almost never do C3-C5.

I can certainly understand someone doing a lot of C4-C6 RFA but not C3-C5.

I read some of your posts regarding cervical RFA before, i think those are very useful and applicable to the clinical practice, correct me if I am wrong in describing this, clinical pain pattern, palpation technique to identify the levels, imaging confirmation, all together decide the levels to do mbb.

 

[MitchLevi]

Why don't you do 2-3 much? Because you're getting half of it with 3-4 and rather get 5 than TON? Or worried about balance issues?

I do C2-C4. I should probably modify my original post TBH.

I do C3-C5 most commonly, and I do both C2-C4 and C4-C6 as well.

I have one guy I do a C6-T1 once a year and he'll get a solid 10-12 months out of it. Retired football coach. A wild old man that one.

C2-C4 especially with trauma. Neuritis is very common, but not an absolute. I believe C2-3 and trauma go hand in hand. I usually do cervical paraspinal and occipitalis TPI first visit, then MBB after they've done PT.

 

[MitchLevi]

I read some of your posts regarding cervical RFA before, i think those are very useful and applicable to the clinical practice, correct me if I am wrong in describing this, clinical pain pattern, palpation technique to identify the levels, imaging confirmation, all together decide the levels to do mbb.

I base my levels off where they point with their finger. Palpation is irrelevant IMO.

You'll virtually always have myofascial pain which clouds the picture IMO. Palpation will be all over the map.

https://academic.oup.com/painmedicine/article/22/11/2443/6425804

 

[SC Tian]

I base my levels off where they point with their finger. Palpation is irrelevant IMO.

You'll virtually always have myofascial pain which clouds the picture IMO. Palpation will be all over the map.

https://academic.oup.com/painmedicine/article/22/11/2443/6425804

thanks, very useful information, I worked with 2 DOs, and one MD with physical therapy training, and they are so confident that they can palpate the levels of facet joints that are the source, they very often do C7-T1 rfa, consider cervicothoracic junction as one source of pain, i have to say their rfa results are comparable to me, where I only do rfa at C2 to 6 levels, just the different types of practice, do not know which one is better.

 

[bedrock]

View attachment 370820

I haven't done my own "study," but my MRIs are C2-5 + C7-T1 arthropathy.

There are studies that show arthropathy is most common C2-5.

The best studies show what sc tian posted. C5-C6 is almost always involved if mid-lower neck pain and C2-C3 is almost involved if upper neck pain, particularly neck pain with headaches.

MRIs aren’t everything particularly with facet degeneration in patients under 60 years of age. Definitely useful, but only if you combine imaging with physical exam.

Careful palpitation of cervical facet joints really helps localize the lesion, particularly which is second worst cervical facet joint.

I was taught how to distinguish each cervical facet joint on exam by Paul Dreyfuss and I find it very useful in clinical practice.

 

[bedrock]

I read some of your posts regarding cervical RFA before, i think those are very useful and applicable to the clinical practice, correct me if I am wrong in describing this, clinical pain pattern, palpation technique to identify the levels, imaging confirmation, all together decide the levels to do mbb.

Agree. Best way to plan a cervical MBB is to incorporate all three.

 

[MitchLevi]

It probably doesn't matter that much.

My outcomes are most likely identical to yours.

 

[bedrock]

Interesting discussion. I'm more of an even spread:
C2-4 - 30%
C3-5 - 30%
C4-6 - 20%
C5-7 - 20%
The only rare level if no adjacent segment disease is C7-T1.
I also use imaging and referral pattern. Imaging wise, I don't fully agree with that article, as C3-4 is much more likely arthritic than <5%, maybe higher than C5-6.

Not trying to argue, just an academic discussion, but I highly doubt that C3-4 facets are more commonly arthritic than C5-C6. Maybe somewhat higher than this particular study, but not more common than C5-C6.

I'd love to see good articles with high Ns showing otherwise, but all the largest studies so far argue against your point......... (particularly in patients where C2-C3 is not a pain generator)

 

[MitchLevi]

https://academic.oup.com/painmedicine/article/22/11/2443/6425804

Everyone should read this.

 

[bedrock]

https://academic.oup.com/painmedicine/article/22/11/2443/6425804

Everyone should read this.

really nice summary of the literature on the topic.

 

[bedrock]

These were some of the key points mentioned in that article.

The C2–3 and C5–6 joints are the most common clinically implicated in neck pain, [12, 68, 69] while C2–3, C3–4, and C4–5 joints are the most likely to display radiological features of degeneration [15 16]

Cooper et al [49] conducted a study in 194 patients with neck pain who received dual LA diagnostic MBB. They reported the most common cervical facet joints associated with neck pain were C2–3 (36%), followed by C5–6 (35%), and C6–7 (17%). Joints at C1–2, C3–4, C4–5, and were each symptomatic in less than 5% of cases.

In a study involving 125 patients who received dual LA diagnostic cervical MBB, a protocol consisting of manual spinal examination, palpation for segmental tenderness, and extension-rotation testing was found to have a specificity of 84% (95% CI 77% to 90%)

Minimal research has examined the association between radiological findings and RFA outcomes. Cohen et al [20] performed a retrospective study evaluating factors associated with outcomes in 92 patients who underwent cervical medial branch RFA after positive diagnostic blocks. Although facet pathology was found on cervical MRI in almost half the patients, these findings were not predictive of treatment outcomes.

 

[RoloTomassi]

OpNot trying to argue, just an academic discussion, but I highly doubt that C3-4 facets are more commonly arthritic than C5-C6. Maybe somewhat higher than this particular study, but not more common than C5-C6.

I'd love to see good articles with high Ns showing otherwise, but all the largest studies so far argue against your point......... (particularly in patients where C2-C3 is not a pain generator)

All good.

The prevalence cervical facet arthrosis: an osseous study in a cadveric population - PubMed

The prevalence of cervical facet arthrosis increases with age, and occurs more commonly in the upper cervical spine.

pubmed.ncbi.nlm.nih.gov

Results: In the entire population of 465 specimens, the upper cervical specimens appeared to be affected by facet arthrosis more frequently than the lower levels; 12.37% of the specimens had bony evidence of arthrosis at the C2-C3 level; 13.33% of the specimens had arthrosis occur at the C3-C4 level; 14.62% at the C4-C5 level; 7.85% at the C5-C6 level, and 4.84% at the C6-C7 level. The large majority of all cervical facet arthrosis was found to be Grade 1 at all levels. In the older population, the prevalence of facet arthrosis is as high as 29.87% for the C4-C5 level. C4-C5 level appears to be affected the most frequently, followed by the C3-C4 level, then C2-C3, C5-C6, and C6-C7.

Facet joint degeneration of the cervical spine: a computed tomographic analysis of 320 patients - PubMed

It seems that upper cervical levels are more likely to degenerate and to have more advanced degrees of degeneration than the lower cervical levels. As expected, age correlates with worsening degeneration. The proposed computed tomographic grading system for cervical facet arthrosis seemed to be...

pubmed.ncbi.nlm.nih.gov

n=1944
Results: Facet arthrosis is common with older patients and at C2-C3, C3-C4, and C4-C5. Facet arthrosis was more common on the left side and in males. Greater than grade III facet joint arthrosis was common in patients older than 60 and at C2-C3, C3-C4, and C4-C5. The reliability statistics by intraclass correlation for the grading system was 0.878 for the intraobserver reliability and 0.869 for the interobserver reliability.

Cervical facet oedema: prevalence, correlation to symptoms, and follow-up imaging - PubMed

The prevalence of cervical facet oedema is 9%. Cervical facet oedema is associated with ipsilateral radiculopathy. Neuroforaminal narrowing, however, is not associated with facet oedema.

pubmed.ncbi.nlm.nih.gov

One hundred and seventy-three MRI studies with cervical facet oedema were evaluated by each of the two radiologists. In these patients, the grade of bone marrow oedema (BMO) and corresponding neuroforaminal narrowing at the cervical facets was assessed. Correlation with symptoms was performed based on pre-MRI questionnaire.

Results: The prevalence of cervical facet oedema was 9%; the most commonly affected levels were C3-4, C4-5, and C2-3. A total of 202 cervical facets were evaluated:

 

[bedrock]

All good.

The prevalence cervical facet arthrosis: an osseous study in a cadveric population - PubMed

The prevalence of cervical facet arthrosis increases with age, and occurs more commonly in the upper cervical spine.

pubmed.ncbi.nlm.nih.gov

Results: In the entire population of 465 specimens, the upper cervical specimens appeared to be affected by facet arthrosis more frequently than the lower levels; 12.37% of the specimens had bony evidence of arthrosis at the C2-C3 level; 13.33% of the specimens had arthrosis occur at the C3-C4 level; 14.62% at the C4-C5 level; 7.85% at the C5-C6 level, and 4.84% at the C6-C7 level. The large majority of all cervical facet arthrosis was found to be Grade 1 at all levels. In the older population, the prevalence of facet arthrosis is as high as 29.87% for the C4-C5 level. C4-C5 level appears to be affected the most frequently, followed by the C3-C4 level, then C2-C3, C5-C6, and C6-C7.

Facet joint degeneration of the cervical spine: a computed tomographic analysis of 320 patients - PubMed

It seems that upper cervical levels are more likely to degenerate and to have more advanced degrees of degeneration than the lower cervical levels. As expected, age correlates with worsening degeneration. The proposed computed tomographic grading system for cervical facet arthrosis seemed to be...

pubmed.ncbi.nlm.nih.gov

n=1944
Results: Facet arthrosis is common with older patients and at C2-C3, C3-C4, and C4-C5. Facet arthrosis was more common on the left side and in males. Greater than grade III facet joint arthrosis was common in patients older than 60 and at C2-C3, C3-C4, and C4-C5. The reliability statistics by intraclass correlation for the grading system was 0.878 for the intraobserver reliability and 0.869 for the interobserver reliability.

Cervical facet oedema: prevalence, correlation to symptoms, and follow-up imaging - PubMed

The prevalence of cervical facet oedema is 9%. Cervical facet oedema is associated with ipsilateral radiculopathy. Neuroforaminal narrowing, however, is not associated with facet oedema.

pubmed.ncbi.nlm.nih.gov

One hundred and seventy-three MRI studies with cervical facet oedema were evaluated by each of the two radiologists. In these patients, the grade of bone marrow oedema (BMO) and corresponding neuroforaminal narrowing at the cervical facets was assessed. Correlation with symptoms was performed based on pre-MRI questionnaire.

Results: The prevalence of cervical facet oedema was 9%; the most commonly affected levels were C3-4, C4-5, and C2-3. A total of 202 cervical facets were evaluated:

Thanks.

Did you read the 4 quotes I posted from the cervical RFA review article posted by mitchlevi?

Basically it said what I said, which is that the worst radiologic levels are not the most painful facet joint levels.

 

[RoloTomassi]

Thanks.

Did you read the 4 quotes I posted from the cervical RFA review article posted by mitchlevi?

Basically it said what I said which the worst radiologic levels are not the most painful facet joint levels.

Yes. Agree, imaging doesn't correlate well, or else I wouldn't even bother with history and exam. I'm not confident whatsoever with palpation, rather go with distribution + imaging. I do agree C5-6 is commonly symptomatic due to the amount of motion there.

 

[oneforfighting]

Most of my cases come down to deciding which two levels between C3-6 to treat. I’ll usually have the patient choose whether the upper neck or lower neck hurts more to determine the second level (the first being C4-5). Curious how others do it.

 

[Taus]

Basically it said what I said which is that the worst radiologic levels are not the most painful facet joint levels.

this.

Combo of:
- epicenter of pain, referencing the the published referral maps (suboccipital? head? base? trap? scapula?)
- incidence of each joint causing pain, refs above in thread
- imaging
- exam

Cant really hang your hat on any one feature alone, except perhaps unilateral edema in a concordant area of pain…. The rare smoking gun

 

[Taus]

Following the lumbar thread, what are y’all’s tricks/tips for the fluffy cervical ablation when can’t use lateral

I try to scrape the pillar, CLO view and start motor stimming early

Lots of great threads on this going into extensive detail over the last few years.

 

[Ligament]

Patient supine. lateral view and approach, line up image to get crisp pedicle and facet lines, use bone as back stop. If I’m concerned about position I’ll check in CLO. I was taught this by the docs in my PP group when I joined.

Trained in fellowship done prone with AP for initial placement and then advanced in lateral view, what an awful technique.

Do you have any photos of patient with needles in place showing this supine approach, or any publications of a supine RF approach? I'm interested in it but cannot wrap my head around how this is safe.

 

[pmrmd]

Most of my cases come down to deciding which two levels between C3-6 to treat. I’ll usually have the patient choose whether the upper neck or lower neck hurts more to determine the second level (the first being C4-5). Curious how others do it.

History. Exam. Palpate and correlate pain pattern with facet. Add in radiographs to help.