Dec 16, 2018
20
8
Happy New year

I like the CLO view for the interlaminar CESI- life changer
Does anyone use the CLO view for cervical RFA? I read it could be useful especially with shoulder blocking the lateral view. any experience
Thanks
 
Apr 20, 2018
847
521
Status
Attending Physician
I use it in bigger pts when lateral view sucks.

Otherwise I don't see a point for it if the lateral views look good.
 

No Pain All gain

5+ Year Member
Apr 22, 2014
217
92
Philly
Status
Attending Physician
I use it all the time. You can clearly see your probe in the trapezoid.


Sent from my iPhone using Tapatalk
 
About the Ads

Baron Samedi

7+ Year Member
May 30, 2010
668
402
Hell
Status
Attending Physician
So I had a mentor in fellowship that did all her cervical MBBs and RFAs in straight lateral just putting needle/probe down on the middle of the trapezoids. I've started doing this for MBBs with a 27g hypodermic with good results and much faster than starting posterior. She uses 54mm RFA needles for this.

The theoretical downside to doing the RFA straight lateral is you're perpendicular to the nerve and not parallel, but I'm curious how much this really matters. The mentor I had did it this way for years with excellent results. It also cut down on procedure time and fluoro exposure significantly.

I'm assuming most people go posterior onto the edge of the column, slide off, go lateral, and advance to the midpoint of the trapezoid.
 
  • Like
Reactions: Needlejockeys

ragnathor

ASA Member
10+ Year Member
Jan 10, 2007
175
80
Status
Attending Physician
So I had a mentor in fellowship that did all her cervical MBBs and RFAs in straight lateral just putting needle/probe down on the middle of the trapezoids. I've started doing this for MBBs with a 27g hypodermic with good results and much faster than starting posterior. She uses 54mm RFA needles for this.

The theoretical downside to doing the RFA straight lateral is you're perpendicular to the nerve and not parallel, but I'm curious how much this really matters. The mentor I had did it this way for years with excellent results. It also cut down on procedure time and fluoro exposure significantly.

I'm assuming most people go posterior onto the edge of the column, slide off, go lateral, and advance to the midpoint of the trapezoid.
I've changed to doing my cervical mbb with the lateral approach this year and id much simpler/more comfortable. I still do cervical RFA posterior for the reason you started.

I've similarly started doing diagnostic genicular from lateral approach based on a thread in this forum - night and day difference.
 

Ferrismonk

ASA Member
10+ Year Member
Dec 11, 2006
766
508
Status
Attending Physician
I've changed to doing my cervical mbb with the lateral approach this year and id much simpler/more comfortable. I still do cervical RFA posterior for the reason you started.

I've similarly started doing diagnostic genicular from lateral approach based on a thread in this forum - night and day difference.
I may start doing this for CMBB, makes sense. For genicular, I numb from the sides then from top, then big needles come from top to appropriate position. Much better, but now that I think about it, maybe I only need to come in from the side? :thinking:
 

DODOCSS

7+ Year Member
Nov 3, 2011
366
168
Status
Attending Physician
I may start doing this for CMBB, makes sense. For genicular, I numb from the sides then from top, then big needles come from top to appropriate position. Much better, but now that I think about it, maybe I only need to come in from the side? :thinking:
issue is contra knee in the way in fatties, and GNRFA candidate are all fatties
 
OP
M
Dec 16, 2018
20
8
Is the fight for Genicular nerve block approval through insurance still real? I had trouble getting approval for RFA with Blue cross and United health and stopped doing it altogether.
 

ED50

7+ Year Member
Jan 12, 2012
119
28
Status
Fellow [Any Field]
I've changed to doing my cervical mbb with the lateral approach this year and id much simpler/more comfortable. I still do cervical RFA posterior for the reason you started.

I've similarly started doing diagnostic genicular from lateral approach based on a thread in this forum - night and day difference.
Do you do unilateral C MBB or do you flip the patient and reprep the area?
 
About the Ads

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
14,192
4,071
Canton GA
www.stevenlobel.com
Status
Attending Physician

ragnathor

ASA Member
10+ Year Member
Jan 10, 2007
175
80
Status
Attending Physician
I flip them. It’s a pita to re position but procedure then easier and more accurate
Same. I've tried supine before but much easier having them on their side then flipping.
 

BobBarker

Member
10+ Year Member
Dec 13, 2005
3,107
1,105
Status
Attending Physician
@Taus so you do your MBBS in the modified swimmers and then your RFA’s supine with CLO?
 

bedrock

Member
10+ Year Member
Oct 23, 2005
4,171
1,108
Status
Attending Physician
So I had a mentor in fellowship that did all her cervical MBBs and RFAs in straight lateral just putting needle/probe down on the middle of the trapezoids. I've started doing this for MBBs with a 27g hypodermic with good results and much faster than starting posterior. She uses 54mm RFA needles for this.

The theoretical downside to doing the RFA straight lateral is you're perpendicular to the nerve and not parallel, but I'm curious how much this really matters. The mentor I had did it this way for years with excellent results. It also cut down on procedure time and fluoro exposure significantly.

I'm assuming most people go posterior onto the edge of the column, slide off, go lateral, and advance to the midpoint of the trapezoid.
I can certainly understand docs doing lateral MBB but not RFA. It doesn’t make sense to do lateral RFA, and I highly doubt your attending achieved the same results with lateral approach RFA.

I’ve seen a number of patients who had previous lateral RFA by a few other physicians and these same patients with me always achieve more relief and for twice as long when I do posterior approach RFA with multiple lesions.
 
Jun 25, 2019
420
384
Status
Attending Physician
I can certainly understand docs doing lateral MBB but not RFA. It doesn’t make sense to do lateral RFA, and I highly doubt your attending achieved the same results with lateral approach RFA.

I’ve seen a number of patients who had previous lateral RFA by a few other physicians and these same patients with me always achieve more relief and for twice as long when I do posterior approach RFA with multiple lesions.
That is completely backwards. Cervical rf was initially described in a supine/for animal approach.

MOST facet pain is the higher levels and the lateral approach is FAR better. I see A LOT of posterior failures (best for lower segments) and improvement with a supine approach.

Anyone I have ever shown a supine approach gets far better results. RF by this approach has a very high degree of success which far eclipses the posterior approach.
 
  • Like
Reactions: Ronin1

paindoc007

2+ Year Member
Aug 4, 2017
249
150
Mbb lateral swimmers
Rfa prone in clo (technically foraminal oblique)
You oblique to 50 degrees?

Interesting that inc in obliquity is diff than transition cesi in clo in regards to needle depth. Never through about that
 

ragnathor

ASA Member
10+ Year Member
Jan 10, 2007
175
80
Status
Attending Physician
That is completely backwards. Cervical rf was initially described in a supine/for animal approach.

MOST facet pain is the higher levels and the lateral approach is FAR better. I see A LOT of posterior failures (best for lower segments) and improvement with a supine approach.

Anyone I have ever shown a supine approach gets far better results. RF by this approach has a very high degree of success which far eclipses the posterior approach.
Can you explain?

Anatomically RF posterior approach should get a longer portion of the nerve than lateral.
 

NJPAIN

7+ Year Member
Nov 28, 2011
1,791
765
New Jersey
Status
Attending Physician
That is completely backwards. Cervical rf was initially described in a supine/for animal approach.

MOST facet pain is the higher levels and the lateral approach is FAR better. I see A LOT of posterior failures (best for lower segments) and improvement with a supine approach.

Anyone I have ever shown a supine approach gets far better results. RF by this approach has a very high degree of success which far eclipses the posterior approach.
You’re talking about the “old fashioned” way. I haven’t seen that in a long time. Been using a trajectory view for so long it’s difficult to go back to the old anesthesia techniques going “out of plane” and walking off of bone.
You may have to invite us out to see you do this.


Sent from my iPhone using Tapatalk
 
About the Ads

pmrmd

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
Mar 22, 2008
1,361
354
Phoenix, Arizona
Status
Attending Physician
I gave up on CLO for RF a long time ago. The problem with CLO for RF is the angles change. One level CESI C7-T1 oblique to 50 works. The c-spine often has curvature, an altered lordosis and listhesis that alters the need when doing RF. Tilt the c-arm caudally and the picture changes from perfect to terrible. What angle is optimum? I think it changes for everyone. On lateral my needles are close to the anterior border of the pillar, which translates to about 1/3 to 1/2 down on CLO but the angle changed on every patient. Useless.
 

Taus

.
Moderator
10+ Year Member
Feb 1, 2005
3,933
535
Philly
Status
Attending Physician
You oblique to 50 degrees?

Interesting that inc in obliquity is diff than transition cesi in clo in regards to needle depth. Never through about that
45-50. Rough guideline. Optimal angle not fully validated and may vary per patient and level. Therefore just be mindful of depth changing w inc/dec oblique angle as per article (opposite effect on clo w Cesi). And as although see tip behind foramen clearly on clo still motor test for safety, especially when lateral view not visible at that level.

Certainly not perfect but I wouldn’t call it useless. sure beats not seeing your needle tip at all on lateral view at lower levels IMO.
 

smarterchild

Member
10+ Year Member
Jun 28, 2006
118
5
Status
Pre-Medical
When i was in fellowship, I had an attending who did all of his cervical RF from the lateral position. What he would do is start more posteriorly and then guide the needle to the center of the articular pillar. By starting more posteriorly, he claimed that the needle would still sit parallel by the time it was positioned at the articular pillar. I haven't done it like this but wonder if it would be as effective as a prone cervical RF?
 

Ligament

Interventional Pain Management
Lifetime Donor
15+ Year Member
Jan 8, 2002
5,345
1,885
Status
Attending Physician
When i was in fellowship, I had an attending who did all of his cervical RF from the lateral position. What he would do is start more posteriorly and then guide the needle to the center of the articular pillar. By starting more posteriorly, he claimed that the needle would still sit parallel by the time it was positioned at the articular pillar. I haven't done it like this but wonder if it would be as effective as a prone cervical RF?
I dont know how you could do this accurately...was the needle guided under AP view? If so, hard to get an AP view if patient laying on side...
 

BobBarker

Member
10+ Year Member
Dec 13, 2005
3,107
1,105
Status
Attending Physician
There is a video of McJunkin placing 4 RF needles in that fashion in about 1 minute. It was posted on here before.
 

Ligament

Interventional Pain Management
Lifetime Donor
15+ Year Member
Jan 8, 2002
5,345
1,885
Status
Attending Physician
Hard to see that he is doing here, but it looks like only the tips of the needles are touching the medial branches based on the trajectory, no way any more than 20% of the active tip has contact with the medial branch, even though it looks so on xray. There is no AP view shown, so hard to tell.
 
  • Like
Reactions: epidural man

NJPAIN

7+ Year Member
Nov 28, 2011
1,791
765
New Jersey
Status
Attending Physician
Sadly, I believe that the majority of docs do this procedure in a similar fashion. Volume more important than outcomes. I know a doc in my area who went to the SIS RF course and then talked about how ridiculous the SIS technique was and how it was completely inapplicable to private practice. It takes a fair amount of time to do a good job. It’s like that in every profession. A cabinet put together on an assembly line is full of staples and the miters are all off. A cabinet made one at a time by a craftsman looks like a work of art.


Sent from my iPhone using Tapatalk
 
Jun 25, 2019
420
384
Status
Attending Physician
Hard to see that he is doing here, but it looks like only the tips of the needles are touching the medial branches based on the trajectory, no way any more than 20% of the active tip has contact with the medial branch, even though it looks so on xray. There is no AP view shown, so hard to tell.

Agreed- God knows where those needles are actually at. Also, what temp was that guy using? 60 degrees? I guess he forgot to read the literature regarding this.

This is what passes for pain management in many places. This guy had the audacity to put a very poorly performed procedure on the internet, as though he is proud of it. Obviously a young guy just recently out of training and has not reached the point of critically evaluating his outcomes.

It is no wonder that when I do to meetings that people say they have better results with rf in the lumbar vs cervical spine. Cervical rf is FAR MORE effective. However, if you do it as shown in the video, I can see why the results are worse.
 

NJPAIN

7+ Year Member
Nov 28, 2011
1,791
765
New Jersey
Status
Attending Physician
Hasn’t prevented him from making more money than I have ever made.


Sent from my iPhone using Tapatalk
 
About the Ads

Ligament

Interventional Pain Management
Lifetime Donor
15+ Year Member
Jan 8, 2002
5,345
1,885
Status
Attending Physician
This particular doc, McJunkin, is part of a very successful block
Sadly, I believe that the majority of docs do this procedure in a similar fashion. Volume more important than outcomes. I know a doc in my area who went to the SIS RF course and then talked about how ridiculous the SIS technique was and how it was completely inapplicable to private practice. It takes a fair amount of time to do a good job. It’s like that in every profession. A cabinet put together on an assembly line is full of staples and the miters are all off. A cabinet made one at a time by a craftsman looks like a work of art.


Sent from my iPhone using Tapatalk
I can understand his point. The SIS techniques are laborious and take a TON more time to do properly than the easy way.

I am very strict with SIS technique and I"m sure i've absorbed a lot more radiation and made a LOT less money than most as a result. My patients do get great outcomes, but not my bank account.
 
  • Like
Reactions: pastafan

epidural man

ASA Member
10+ Year Member
Jun 3, 2007
3,216
887
49
San Diego
Status
Attending Physician
People who advocate for lateral approach for RF need to stick an RF needle in a chicken breast - burn it - and come back and report. Maybe this will have them change their mind. (or please explain how they think the nerve is getting ablated with a perpendicular needle.)

I do lateral by the way - but used pulsed RF. If I am doing high temp, it's a posterior approach.

I suspect that the effect of high temp RF in the lateral approach is probably getting same results as pulsed RF. It works - sure, but not nearly as well as high temp. I suspect it works because even though you aren't burning the nerve, you are still subjecting it to an intense electrical field.
 

Ligament

Interventional Pain Management
Lifetime Donor
15+ Year Member
Jan 8, 2002
5,345
1,885
Status
Attending Physician
People who advocate for lateral approach for RF need to stick an RF needle in a chicken breast - burn it - and come back and report. Maybe this will have them change their mind. (or please explain how they think the nerve is getting ablated with a perpendicular needle.)

I do lateral by the way - but used pulsed RF. If I am doing high temp, it's a posterior approach.

I suspect that the effect of high temp RF in the lateral approach is probably getting same results as pulsed RF. It works - sure, but not nearly as well as high temp. I suspect it works because even though you aren't burning the nerve, you are still subjecting it to an intense electrical field.
That all makes sense.

I guess the tangent is; high temp PULSED rf from a lateral approach...would this be of any benefit. I've not experimented with this but I'm pretty sure some on here ahve.
 
  • Like
Reactions: epidural man

Baron Samedi

7+ Year Member
May 30, 2010
668
402
Hell
Status
Attending Physician
I've done pulsed lateral and it seems to work well. Zero data to support my experience, though.

Maybe my algorithm will be pulsed lateral RF and if they still have pain repeat it with posterior RFA.
 

epidural man

ASA Member
10+ Year Member
Jun 3, 2007
3,216
887
49
San Diego
Status
Attending Physician
I've done pulsed lateral and it seems to work well. Zero data to support my experience, though.

Maybe my algorithm will be pulsed lateral RF and if they still have pain repeat it with posterior RFA.
What do you mean zero data?
Because if you mean there isn’t data for pulsed rf for cervical medial branches, then that is wrong.
There actually is good data to show it works well - some of the best pulsed rf data exists for cervical medial branches.
 
  • Like
Reactions: clubdeac

smarterchild

Member
10+ Year Member
Jun 28, 2006
118
5
Status
Pre-Medical
What do you mean zero data?
Because if you mean there isn’t data for pulsed rf for cervical medial branches, then that is wrong.
There actually is good data to show it works well - some of the best pulsed rf data exists for cervical medial branches.
What is your protocol for doing lateral pulsed rf? How long do you ablate for? Do you turn the needle or reposition and burn again?
 

Baron Samedi

7+ Year Member
May 30, 2010
668
402
Hell
Status
Attending Physician
What do you mean zero data?
Because if you mean there isn’t data for pulsed rf for cervical medial branches, then that is wrong.
There actually is good data to show it works well - some of the best pulsed rf data exists for cervical medial branches.
I meant zero of my own personal data other than my anecdotal experiences.
 
  • Like
Reactions: epidural man

clubdeac

10+ Year Member
Aug 16, 2007
3,539
723
Status
Attending Physician
What is your protocol for doing lateral pulsed rf? How long do you ablate for? Do you turn the needle or reposition and burn again?
You don't ablate anything, you pulse. And you pulse for anywhere between 4-8 min. Turning of the needle is unnecessary since the electromagnetic energy is coming out of the tip of the needle and not circumferentially around the needle. You need to read up on pRFA a little. WIth all that being said I've only performed traditional RF in the neck. I've pulsed some DRGs in my day though
 

epidural man

ASA Member
10+ Year Member
Jun 3, 2007
3,216
887
49
San Diego
Status
Attending Physician
You don't ablate anything, you pulse. And you pulse for anywhere between 4-8 min. Turning of the needle is unnecessary since the electromagnetic energy is coming out of the tip of the needle and not circumferentially around the needle. You need to read up on pRFA a little. WIth all that being said I've only performed traditional RF in the neck. I've pulsed some DRGs in my day though
High Temp RF works better no doubt.

My reason for doing pulsed all the time? It kinda works - sometimes really well....I don't care about reimbursement...and it's way easier.
 
  • Like
Reactions: clubdeac and NJPAIN
Jun 25, 2019
420
384
Status
Attending Physician
You don't ablate anything, you pulse. And you pulse for anywhere between 4-8 min. Turning of the needle is unnecessary since the electromagnetic energy is coming out of the tip of the needle and not circumferentially around the needle. You need to read up on pRFA a little. WIth all that being said I've only performed traditional RF in the neck. I've pulsed some DRGs in my day though

"read up"? I was the first guy in the US to do pulsed rf. I went and spent time with Sluyter while he was developing it in Masstrich and Amsterdam. We had our radionics machine converted (first in the US) prior to arriving back in the US and tried it for 1-2 years. It didn't work. You get some very short term results, but nothing long term at all. I was dumb enough to believe the old man. Then, of course, regular insurance paid for pulsed rf as they did not know there was a difference between thermal and pulsed.

There is a good reason that insurance companies do not reimburse for pulsed rf (becauase it does not work). Think about it for just a second- if you were an insurance company and pulsed rf worked, not only would you reimburse for it, you would demand that ONLY pulsed rf be used. Why? No side effects at all, no "down time", no post treatment meds, and close to zero chance of neuritis.
 
  • Like
Reactions: lonelobo

epidural man

ASA Member
10+ Year Member
Jun 3, 2007
3,216
887
49
San Diego
Status
Attending Physician
"read up"? I was the first guy in the US to do pulsed rf. I went and spent time with Sluyter while he was developing it in Masstrich and Amsterdam. We had our radionics machine converted (first in the US) prior to arriving back in the US and tried it for 1-2 years. It didn't work. You get some very short term results, but nothing long term at all. I was dumb enough to believe the old man. Then, of course, regular insurance paid for pulsed rf as they did not know there was a difference between thermal and pulsed.

There is a good reason that insurance companies do not reimburse for pulsed rf (becauase it does not work). Think about it for just a second- if you were an insurance company and pulsed rf worked, not only would you reimburse for it, you would demand that ONLY pulsed rf be used. Why? No side effects at all, no "down time", no post treatment meds, and close to zero chance of neuritis.
It doesn’t work?

I disagree. I have lost of (low quality) studies to show it does. Do you have lots of high quality studies to show it doesn’t?
 

clubdeac

10+ Year Member
Aug 16, 2007
3,539
723
Status
Attending Physician
"read up"? I was the first guy in the US to do pulsed rf. I went and spent time with Sluyter while he was developing it in Masstrich and Amsterdam. We had our radionics machine converted (first in the US) prior to arriving back in the US and tried it for 1-2 years. It didn't work. You get some very short term results, but nothing long term at all. I was dumb enough to believe the old man. Then, of course, regular insurance paid for pulsed rf as they did not know there was a difference between thermal and pulsed.

There is a good reason that insurance companies do not reimburse for pulsed rf (becauase it does not work). Think about it for just a second- if you were an insurance company and pulsed rf worked, not only would you reimburse for it, you would demand that ONLY pulsed rf be used. Why? No side effects at all, no "down time", no post treatment meds, and close to zero chance of neuritis.
I don’t disagree with any of this nor does my post. That’s why I said I’ve only done thermal in the neck. I was responding to smarterchild who apparently has very little knowledge about the subject
 

jwalker12

10+ Year Member
Aug 25, 2008
47
0
Status
I've changed to doing my cervical mbb with the lateral approach this year and id much simpler/more comfortable. I still do cervical RFA posterior for the reason you started.

I've similarly started doing diagnostic genicular from lateral approach based on a thread in this forum - night and day difference.

For those of you using the lateral view, how do you see the lower levels (ex: C6, C7). Do you just have someone tug the shoulder down?
 

ragnathor

ASA Member
10+ Year Member
Jan 10, 2007
175
80
Status
Attending Physician
For those of you using the lateral view, how do you see the lower levels (ex: C6, C7). Do you just have someone tug the shoulder down?
Use modified swimmer's view - Taus has posted link previously although not sure if this thread. Or just CLO.
 

smarterchild

Member
10+ Year Member
Jun 28, 2006
118
5
Status
Pre-Medical
The modified swimmers view appears to have the patient in the lateral position with the arm raised slightly to improve the view. How would this improve visualization in a prone cervical rf?
 

smarterchild

Member
10+ Year Member
Jun 28, 2006
118
5
Status
Pre-Medical
I don’t disagree with any of this nor does my post. That’s why I said I’ve only done thermal in the neck. I was responding to smarterchild who apparently has very little knowledge about the subject
yes; I never trained with pulsed rf nor have I ever used it in my practice. Always looking to learn though. If you have any articles you suggest, I would appreciate it. Thank you
 
About the Ads