How do you position your cervical radiofrequency ablation patients?

[Ligament]

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I have traditionally placed my patients in the Oakworks patient positioning device, prone, head not rotated at all.

Take and AP shot, then decline caudally to see a pillar view. This does not expose the upper cervical facets too well, so often I'll contralateral oblique some to elongate and expose the targeted pillars better. This is cumbersome.

I've recently been placing a foam wedge under the patients sternum/clavicles, which flexes the neck, and I turn the patients head contralateral to the side to be treated. This exposes the upper cervical pillars nicely as it gets the jaw out of the field of view.

Kinda like this, but in this image the head is turned IPSILateral to the target side (why do this?)

What do you guys do?

I want a faster easier method.

 

[SommeRiver]

Plain Jane prone.

 

[willabeast]

//I want a faster easier method.// me too.

 

[lobelsteve]

Regular pillow under chest, car wash sponge under forehead.
CLO, declined.

 

[pmrmd]

5-10 degrees ipsi for TON, C3, usually prone for the rest. I don’t think it could be sped up if you want to great placement and avoid adverse outcome.

 

[drusso]

Depends on anatomy of the patient. Sometimes do what Lig does. Sometimes do what Steve does.

 

[epidural man]

I did my CLO approach for the first time today. I need help with that. Are you marking with a prone AP view, then advancing in the CLO?

Or starting CLO and doing ON FACE (dot shot)?

IN fellowship, we would place a small 27g needle on the pillar in the lateral view (like doing an MBB in the lateral position), then in the prone, just head to the tip of the needle. That was super fast and easy. I wonder why I stopped doing that.

 

[epidural man]

Can anyone post pictures of cervical treatment of medial branch blocks in the CLO view?

 

[Ligament]

Ok, here is what I've been experimenting with. These are my own images.

Treating the left side.
Prone, foam wedge under clavicles, neck flexed due to this, head rotated to the right about 30-40 degrees, forehead resting on table.

AP images are easy to get given this position, the c-arm is basically in neutral position as all the angles are set up by patient positioning, not c-arm movement.

Lateral images are a little harder in this position, but not too bad.

Needle positions are not perfect but this gives you an idea.

I like this quite a bit. Look how nicely I can visualize the ipsilateral upper facets...

 

[drusso]

Ok, here is what I've been experimenting with. These are my own images.

Treating the left side.
Prone, foam wedge under clavicles, neck flexed due to this, head rotated to the right about 30-40 degrees, forehead resting on table.

AP images are easy to get given this position, the c-arm is basically in neutral position as all the angles are set up by patient positioning, not c-arm movement.

Lateral images are a little harder in this position, but not too bad.

Needle positions are not perfect but this gives you an idea.

I like this quite a bit. Look how nicely I can visualize the ipsilateral upper facets...

View attachment 261013
View attachment 261014

Looks good, Man.

 

[painfree23]

Ok, here is what I've been experimenting with. These are my own images.

Treating the left side.
Prone, foam wedge under clavicles, neck flexed due to this, head rotated to the right about 30-40 degrees, forehead resting on table.

AP images are easy to get given this position, the c-arm is basically in neutral position as all the angles are set up by patient positioning, not c-arm movement.

Lateral images are a little harder in this position, but not too bad.

Needle positions are not perfect but this gives you an idea.

I like this quite a bit. Look how nicely I can visualize the ipsilateral upper facets...

View attachment 261013
View attachment 261014

Why are we rotating the head here?

 

[Ligament]

Looks good, Man.

thx!

 

[Ligament]

Why are we rotating the head here?

To get the jaw and face out of the way of the upper cervical pillars, to better visualize them and spend less time in the procedure, bascially.

 

[epidural man]

Love the images. Caudal tilt with the camera? Also, are you using 5mm active tip? Your needle is placed deeper than I usually go. I can see going that anterior with a 10mm active tip.

 

[Ligament]

I did my CLO approach for the first time today. I need help with that. Are you marking with a prone AP view, then advancing in the CLO?

Or starting CLO and doing ON FACE (dot shot)?

IN fellowship, we would place a small 27g needle on the pillar in the lateral view (like doing an MBB in the lateral position), then in the prone, just head to the tip of the needle. That was super fast and easy. I wonder why I stopped doing that.

This is good idea too. I'll experiment with it and see if it is faster/easier. I suppose you need to spend time placing the "marker" needle as I call it..., but can make up time with placing the RF cannulae this way.

 

[Ligament]

Love the images. Caudal tilt with the camera? Also, are you using 5mm active tip? Your needle is placed deeper than I usually go. I can see going that anterior with a 10mm active tip.

Thank you.

Here is the great thing about this positioning...you do not really need to move the II around at all (so no or minimal caudal tilt) This is basically how it looks with the c-arm in neutral position, since the patietns neck is flexed, we get a nice pillar view right out of the gate...

As far as the anterior needle position, thats pretty typical how far anterior I go, and after doing 1000++ of these over 10+ years in the c-spine no complications at all and typically 1-3 years of relief. Not saying this is what everybody should do.

 

[Bsb2015]

Ok, here is what I've been experimenting with. These are my own images.

Treating the left side.
Prone, foam wedge under clavicles, neck flexed due to this, head rotated to the right about 30-40 degrees, forehead resting on table.

AP images are easy to get given this position, the c-arm is basically in neutral position as all the angles are set up by patient positioning, not c-arm movement.

Lateral images are a little harder in this position, but not too bad.

Needle positions are not perfect but this gives you an idea.

I like this quite a bit. Look how nicely I can visualize the ipsilateral upper facets...

View attachment 261013
View attachment 261014

I do roll under chest, neck flexed, small cushion for forehead rest, neck slightly turned to opposite side. I was taught to go from level below, hit os and walk off laterally. Thoughts?

 

[Taus]

I do same- but found this fairly cheap head positioner to work great. Pillow under chest/overlying bottom of this positioner. Less cumbersome than an Oakworks imo.


Enter a level below. Hit os on posterior pillar waist. Walk off under clo. Never tried head rotation.

 

[painfree23]

I do same- but found this fairly cheap head positioner to work great. Pillow under chest/overlying bottom of this positioner. Less cumbersome than an Oakworks imo.


Enter a level below. Hit os on posterior pillar waist. Walk off under clo. Never tried head rotation.

Nice, may get this. Also do you have a pic of clo with ur rfa needle? 45 degrees ?

 

[Ligament]

I do roll under chest, neck flexed, small cushion for forehead rest, neck slightly turned to opposite side. I was taught to go from level below, hit os and walk off laterally. Thoughts?

Makes sense to me.

 

[Taus]

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

 

[painfree23]

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

Part of the article states:
“ Foraminal oblique (FO) views from 35 to 50 degrees. The needle tip appears to move ventral and deeper with increasing angle of obliquity with respect to the lamina.“

How do u know how deep to go? With a true lateral I feel like it’s more definite with your depth

 

[Taus]

Part of the article states:
“ Foraminal oblique (FO) views from 35 to 50 degrees. The needle tip appears to move ventral and deeper with increasing angle of obliquity with respect to the lamina.“

How do u know how deep to go? With a true lateral I feel like it’s more definite with your depth

45 clo seems to correlate pretty well with max safe depth on lateral. Can’t say it’s fully validated but as long as the your tip is not in foramen on clo it should be fine, regardless of what it looks like in comparison to lamina as the paper describes. Agreed true lateral is more definite. The problem lies when you cannot see the targets and needle tips on lateral, which is not infrequent at lower levels.

 

[drpainfree]

Ok, here is what I've been experimenting with. These are my own images.

Treating the left side.
Prone, foam wedge under clavicles, neck flexed due to this, head rotated to the right about 30-40 degrees, forehead resting on table.

AP images are easy to get given this position, the c-arm is basically in neutral position as all the angles are set up by patient positioning, not c-arm movement.

Lateral images are a little harder in this position, but not too bad.

Needle positions are not perfect but this gives you an idea.

I like this quite a bit. Look how nicely I can visualize the ipsilateral upper facets...

View attachment 261013
View attachment 261014

I do it this way, except I would do a little ipisolateral oblique about 10 degree, and insert/advance needles gun&barrel to touch os, then walk off to advance slightly. the issue I come across is sometimes I touch os too early and make the advance more difficult

 

[epidural man]

Ligament,

If not a patient privacy violation, can you lost a pic of how you are positioning them with the foam and everything?

 

[Ligament]

Ligament,

If not a patient privacy violation, can you lost a pic of how you are positioning them with the foam and everything?

Sure, I'll try to take some pictures soon.

 

[Taus]

I do it this way, except I would do a little ipisolateral oblique about 10 degree, and insert/advance needles gun&barrel to touch os, then walk off to advance slightly. the issue I come across is sometimes I touch os too early and make the advance more difficult

I’d rather touch os too early than late. Just inject some more local, retract and redirect/walk off laterally.

 

[NJPAIN]

I often wish that the headrest on the OakWorks swiveled so you could turn the head. I find if I turn the head enough to get the massive dental work out of my view it ultimately ends up back midline when the face slips back in the hole.
Wedge sounds like a good idea. Anyone turn the head for needle placement and turn it back to neutral to shoot a lateral?