CLO for cervcal RFA?

[med7343]

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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

 

[SommeRiver]

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]

I use it all the time. You can clearly see your probe in the trapezoid.


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[drusso]

I use it all the time. You can clearly see your probe in the trapezoid.


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Got a good picture?

 

[med7343]

Right cervical RFA- CLO image, is the C4 not deep enough?
On lateral- the shoulder was blocking C6

 

[Baron Samedi]

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.

 

[deleted131481]

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]

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?

 

[DODOCSS]

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?

issue is contra knee in the way in fatties, and GNRFA candidate are all fatties

 

[med7343]

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]

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?

 

[Taus]

I use it every case. This should help.

https://ipmreportsjournal.com/current/pdf?article=MjAy&journal=10

for improving mbb w lateral view.

https://www.painphysicianjournal.com/current/pdf?article=NTIxMg%3D%3D&journal=111

 

[Taus]

Do you do unilateral C MBB or do you flip the patient and reprep the area?

I flip them. It’s a pita to re position but procedure then easier and more accurate

 

[lobelsteve]

I use it every case. This should help.

https://ipmreportsjournal.com/current/pdf?article=MjAy&journal=10

for improving mbb w lateral view.

https://www.painphysicianjournal.com/current/pdf?article=NTIxMg%3D%3D&journal=111

fig 3b is showing early male pattern baldness

 

[Baron Samedi]

Do you do unilateral C MBB or do you flip the patient and reprep the area?

Unilateral

 

[deleted131481]

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]

@Taus so you do your MBBS in the modified swimmers and then your RFA’s supine with CLO?

 

[Taus]

@Taus so you do your MBBS in the modified swimmers and then your RFA’s supine with CLO?

Mbb lateral swimmers
Rfa prone in clo (technically foraminal oblique)

 

[bedrock]

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.

 

[deleted993114]

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.

 

[paindoc007]

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

 

[deleted131481]

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]

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.


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[pmrmd]

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]

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]

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]

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]

There is a video of McJunkin placing 4 RF needles in that fashion in about 1 minute. It was posted on here before.

 

[BobBarker]

 

[Ligament]

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.

 

[NJPAIN]

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.


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[deleted993114]

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]

Hasn’t prevented him from making more money than I have ever made.


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[Ligament]

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.


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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.

 

[epidural man]

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]

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.

 

[Baron Samedi]

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]

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.

 

[smarterchild]

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]

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.

 

[clubdeac]

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]

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.

 

[deleted993114]

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.

 

[epidural man]

"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]

"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]

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?

 

[deleted131481]

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]

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]

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

 

[deleted131481]

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?

I only use it for cervical mbb not RF.