Contrast questions

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avalon10 said:
Read the rest of my comment. Honestly I believe that endoscopic rhizotomies helped me understand MBB/RF much better. It’s not as precise as you think it is if you’ve only ever used flouro. When you’ve done enough rhizotomies, and seen that the the nerve isn’t always exactly at junction of SAP/TP, you’ll understand why it’s not worth all the time and radiation that’s involved in doing the MBB the way you’re describing.
IMO, use AP view, identify the junction as best as possible, insert to bone, save a pic, and inject. Once you’ve done some rhizotomies you’ll also have a better feel for if you’re on the facet capsule or beneath it on the TP. There’s only so precise you can be using flouro. RF isn’t gonna hurt anyone, so if I get a good response from MBB, I do it RF.
Working with spine surgeons for a few years really helped me understand this much better, I think. MBB/RF isn’t that precise, is pretty benign, and IMO many of the people commenting here seem to be way overthinking it.
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You do it all in AP?

Things are starting to make a bit more sense now....
 
NJPAIN said:
My response to this is that if you must do a procedure you need to do it CORRECTLY. That requires enough time, enough imaging views and contrast.

Also no procedure is benign. As a expert witness I have seen both a spinal cord Infarct and a disastrous discitis associated with MBB both in very experienced hands.
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And it would be tough to cause a spinal cord infarct or discitis using the technique I have described.
 
NJPAIN said:
I’m always adjusting needles. First based on a declined view and second based on contrast flow. It’s a pain in the rear and takes time. Look at a spine model and factor in the variability from person to person. The sulcus between SAP and TP is a small target and you have a tiny amount of local to hit it. It’s sooo easy to end up high on the SAP or on the TP on the first pass. Seriously, the “eye” of the Scottie dog? Wow, that’s a precise location. How many of you oblique 20 degrees and don’t adjust the tilt at every level because it takes too long and it’s “ too much radiation”. So with all of that combined you think you can be certain you hit the MB. You simply cannot. That’s ok if you don’t care what the patient reports, plan to “doozle” the results and proceed to RF. In my heart of hearts I think we would be better off skipping MBB and just do RF.
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So if RF is harmless and you would prefer going straight to RF, why not do a larger volume block with no contrast and minimal radiation, hit bone and inject 1 mL of local?
 
NJPAIN said:
My response to this is that if you must do a procedure you need to do it CORRECTLY. That requires enough time, enough imaging views and contrast.

Also no procedure is benign. As a expert witness I have seen both a spinal cord Infarct and a disastrous discitis associated with MBB both in very experienced hands.
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Agree with first paragraph. Regarding the second. Can you give us any more details? Spinal cord infarct from MBB performed by an experienced physician?
Same thing with discitis. Did they actually inject a disc?
 
bedrock said:
Agree with first paragraph. Regarding the second. Can you give us any more details? Spinal cord infarct from MBB performed by an experienced physician?
Same thing with discitis. Did they actually inject a disc?
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I’m not sure how you possibly get a spinal cord infarct doing a MBB if your needle is in the right place. Discitis would be tough too. I definitely did some inadvertent interdiscal injections one upon a time when I used to do transforaminals via “Kambin approach,” but none of them that I’m aware of ended in discitis.
 
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callmeanesthesia said:
No wonder you don’t have any regard for precision of the target. Where are you located? Insurance guidelines in my area mostly follow Medicare, which requires 0.5mL or less, and no steroid to be considered a valid diagnostic block.
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Yeah, I “don’t have any regard for precision of the target.”
LOL. Dude you don’t know what you’re talking about. Let me guess- you’re anesthesia?!? Taught by anesthesiologists?? No surprise.
 
avalon10 said:
Yeah, I “don’t have any regard for precision of the target.”
LOL. Dude you don’t know what you’re talking about. Let me guess- you’re anesthesia?!?
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Yes, anesthesia. You’re dumping a ton of local and steroid on it. There’s no target specificity there. Hey, I agree lumbar RF is low risk that MBBs are a waste of time and radiation. Our patients would be better off if we could just do the RF. But I don’t make the rules. And the rules I have to play by specify 2 MBBs, contrast, <0.5 mL local, and no steroid.

I hope you don’t treat cervical like that though. Much more variability in which joints are the pain generator, more risk to particulate steroid, and can’t just keep burning more levels if you don’t get it right or you might give them a drop-head...
 
callmeanesthesia said:
Yes, anesthesia. You’re dumping a ton of local and steroid on it. There’s no target specificity there. Hey, I agree lumbar RF is low risk that MBBs are a waste of time and radiation. Our patients would be better off if we could just do the RF. But I don’t make the rules. And the rules I have to play by specify 2 MBBs, contrast, <0.5 mL local, and no steroid.

I hope you don’t treat cervical like that though. Much more variability in which joints are the pain generator, more risk to particulate steroid, and can’t just keep burning more levels if you don’t get it right or you might give them a drop-head...
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1. There is “target specificity.”
2. Agree patients would be better off if we could just go straight to RF, but I don’t write the rules, and I’d guess that you don’t either.
3. Cervical- not that much different. Haven’t done cervical endoscopic rhizotomies although I hear that people out there do it. Hit bone at the waist of articular pillar, move laterally off bone and advance slightly, and inject. Same for RF. It’s not rocket science/brain surgery. However before doing that you need to look at MRI and examine patient.
 
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avalon10 said:
Yeah, I “don’t have any regard for precision of the target.”
LOL. Dude you don’t know what you’re talking about. Let me guess- you’re anesthesia?!? Taught by anesthesiologists?? No surprise.
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No need to hate on each other specialities. respectful conversations go a long way
 
avalon10 said:
Yeah, I “don’t have any regard for precision of the target.”
LOL. Dude you don’t know what you’re talking about. Let me guess- you’re anesthesia?!? Taught by anesthesiologists?? No surprise.
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This has nothing to do with specialty. I’m PM&R. I don’t agree with you. I do agree with anatomic/cadaver studies, expert opinion, published research and respected pain society guidelines.
 
bedrock said:
Agree with first paragraph. Regarding the second. Can you give us any more details? Spinal cord infarct from MBB performed by an experienced physician?
Same thing with discitis. Did they actually inject a disc?
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Spinal cord infarct- MBB with particulate steroid. Still a common practice. no contrast.
Discitis - Patient with RA on immunosuppressive agents. Jurassic spine. Injection of LA and steroid. No contrast. Patient called office repeatedly with complaints of unrelenting worsening LBP. He repeatedly said unrelated to procedure. Eventually managed by spine surgeon with IV ABX followed by fusion because the osteo and instability was so bad.

Bad things can happen to anyone. You can have whatever opinions you want to based on your great training , amazing hands and brilliant mind. But when the expert shows you have deviated from established written guidelines who are they going to believe??
 
NJPAIN said:
Spinal cord infarct- MBB with particulate steroid. Still a common practice. no contrast.
Discitis - Patient with RA on immunosuppressive agents. Jurassic spine. Injection of LA and steroid. No contrast. Patient called office repeatedly with complaints of unrelenting worsening LBP. He repeatedly said unrelated to procedure. Eventually managed by spine surgeon with IV ABX followed by fusion because the osteo and instability was so bad.

Bad things can happen to anyone. You can have whatever opinions you want to based on your great training , amazing hands and brilliant mind. But when the expert shows you have deviated from established written guidelines who are they going to believe??
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Fair enough. Complications do happen. To everyone.

My first job out of fellowship was with a pain practice that didn't even do facet blocks before proceeding to RF. They did a blind trigger point injection, called it (and billed for) a facet block, and then proceeded to RF everyone.

One of the doctors there justified it by quoting some article that stated that facet blocks were not good as diagnostic blocks for RF.
 
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I’d be fine to skip a mbb in my geriatric patients if they have axial only pain, painful extension and localized tenderness. Good enough for me. Fortunately Medicare in my area only requires one mbb.

as for the middle aged or younger crowd.... I’d want the prognostic value of at least one mbb as very few truly have facet pain. Though they get two as they’re the ones with commercial ins who usually require 2. I do very little rfa on non-Medicare aged patients. I’d really rather not rf someone who’s unlikely to benefit. I don’t consider it completely benign. Pretty sore for a week or so and sometimes neuritis. Not only is this the crowd who often gets more significant post procedure pain, but I put a lot of time and effort into meticulous rfa technique. Sis placement with 2-3 burns with 18g. The most successful and gratifying procedure I do (along with esi in acute radic from hnp). I prefer not to waste my patients and my time. I’ve gotten a lot more comfortable over time advising patients that there is no indication for any procedures.
 
Agree with @Taus and @bedrock 100%! ILESIs are far superior to TFESIs in those geriatric stenotic patients. And they're much quicker and 100x less painful

And who's this new kid doing all the endoscopic rhizotomies? Apparently that makes you an expert and superior to all others. I need to step up my game
 
clubdeac said:
Agree with @Taus and @bedrock 100%! ILESIs are far superior to TFESIs in those geriatric stenotic patients. And they're much quicker and 100x less painful

And who's this new kid doing all the endoscopic rhizotomies? Apparently that makes you an expert and superior to all others. I need to step up my game
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I did a few endoscopic “rhizotomies” a few years back and I’ve assisted an experienced spine surgeon on dozens as an add on to discectomy. I have never seen the medial branch. You just fry the entire joint capsule. I’m unimpressed with what I have seen.
 
NJPAIN said:
I did a few endoscopic “rhizotomies” a few years back and I’ve assisted an experienced spine surgeon on dozens as an add on to discectomy. I have never seen the medial branch. You just fry the entire joint capsule. I’m unimpressed with what I have seen.
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I disagree, have done a few and have seen the nerve.
 
dipriMAN said:
I disagree, have done a few and have seen the nerve.
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This was my point - that the location of the nerve is variable, and maybe the way that everyone is doing the MBB to try to target such a precise area isn't the right thing to do. I have seen the nerve out on the TP and not where it theoretically "should be"
 
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avalon10 said:
This was my point - that the location of the nerve is variable, and maybe the way that everyone is doing the MBB to try to target such a precise area isn't the right thing to do. I have seen the nerve out on the TP and not where it theoretically "should be"
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this statement suggests that all the prior research done by others is, well, worthless so we should do whatever we want to.

while it may "work" that way in your office, it doesn't work that way for those of us who have to work with CMS. or some private insurance companies.


if you are sure that it doesn't make a difference, please perform a placebo controlled randomized double blinded study comparing essentially blind MBB vs. "targeted" MBB and with end result being which procedure leads to greater utilization of RFA and which procedure leads to greater long term benefit from RFA. include a placebo group in this, most likely a saline group.

while you are at it, please also piggy back a study on whether 1 or 2 MBB (or none) lead to clinically significant benefit in terms of successful RFA.
 
Now you guys got me all worried about gadovist. I use it all the time in my patients with contrast allergies. Granted I’m almost never using more than 1cc. I’ll make sure to use even less now if and when I use it!
 
clubdeac said:
Now you guys got me all worried about gadovist. I use it all the time in my patients with contrast allergies. Granted I’m almost never using more than 1cc. I’ll make sure to use even less now if and when I use it!
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Ask them about the contrast allergy. Almost all of them you can safely give them iodine. Have them take Benadryl before coming in if you’re worried about it.
 
callmeanesthesia said:
Yes, anesthesia. You’re dumping a ton of local and steroid on it. There’s no target specificity there. Hey, I agree lumbar RF is low risk that MBBs are a waste of time and radiation. Our patients would be better off if we could just do the RF. But I don’t make the rules. And the rules I have to play by specify 2 MBBs, contrast, <0.5 mL local, and no steroid.

I hope you don’t treat cervical like that though. Much more variability in which joints are the pain generator, more risk to particulate steroid, and can’t just keep burning more levels if you don’t get it right or you might give them a drop-head...
Click to expand...
I've looked at this plenty. I've dropped 1cc of contrast over a facet joint and it pretty much stayed about the joint, blocking the medial branches but not travelling epidurally or to an adjacent level joint. Specificity drops at 2cc.
 
pmrmd said:
I've looked at this plenty. I've dropped 1cc of contrast over a facet joint and it pretty much stayed about the joint, blocking the medial branches but not travelling epidurally or to an adjacent level joint. Specificity drops at 2cc.
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Contrast is more viscous than local so may not have the same spread pattern.
 
pmrmd said:
I'm with you on this, except I use dex. Diagnostic information is gained before they leave and the steroid gives them a least some short term relief. Even a few days/weeks is better than a few hours.
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Steroids aren't benign either though. I'd rather give a steroid-free injection every time if I have the option.
 
Ferrismonk said:
Steroids aren't benign either though. I'd rather give a steroid-free injection every time if I have the option.
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Most of my patients that have had MBBs with local only complain of worse pain the following day .... sometimes it’s difficult to listen to them complain how the injection made them worse. At least with some steroid they only complain that the pain came back a week after the injection.
 
dipriMAN said:
Most of my patients that have had MBBs with local only complain of worse pain the following day .... sometimes it’s difficult to listen to them complain how the injection made them worse. At least with some steroid they only complain that the pain came back a week after the injection.
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nonsense. MOST of your patients? please
 
how does the steroid make the post procedure pain better if you are putting steroids deep where the MBB is running? isn't most of the post injection pain superficial where you put the local?

from the standpoint that the injection made the pain much better but when it came back it seemed much worse, I use that nugget of info to suggest to the patient that 1. we are on the right track 2. bear with 1 more test injection then we can get to the RFA because that one, when it works, will last months 3. I don't have to field any questions like "why cant we do this again every 2-3 months"
 
"would you put it in your mom?" 🤣

I would not use gadolinium. IMO, if concerned about the use of contrast, don't use it. You likely did countless epidurals blindly on OB.
 
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