How many RF needles per procedure?

[NEPain]

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I was trained to use a fresh RF needle at each lesion. So, for a typical lumbar RF of L3,4,5medial branches, I use 3 needles.

The rationale is since I give local before I lesion, the local may travel far enough to attenuate the motor stim when I subsequently place the other needles. So I need to place them all before I give local and burn

Is this unusual?

I also know that some people do RF at three levels, using the same needle, all through the same skin entry site. I don't do this either because I feel I can't get the proper angle for three nerves through one entry site, and I prefer to get a "tunnel vision" view, which requires me to make three sticks.

I'm always open to change but I'd like to know what people on this forum are doing about the above issues. How many needles, how many skin entry sites? I realize RF needles are expensive and I don't want to be wasting them unnecessarily.

Thanks.

 

[lobelsteve]

I was trained to use a fresh RF needle at each lesion. So, for a typical lumbar RF of L3,4,5medial branches, I use 3 needles.

The rationale is since I give local before I lesion, the local may travel far enough to attenuate the motor stim when I subsequently place the other needles. So I need to place them all before I give local and burn

Is this unusual?

I also know that some people do RF at three levels, using the same needle, all through the same skin entry site. I don't do this either because I feel I can't get the proper angle for three nerves through one entry site, and I prefer to get a "tunnel vision" view, which requires me to make three sticks.

I'm always open to change but I'd like to know what people on this forum are doing about the above issues. How many needles, how many skin entry sites? I realize RF needles are expensive and I don't want to be wasting them unnecessarily.

Thanks.

Most times I use 2 needles and 2 probes and burn 2 at a time.
4 nerves, 3 joints taken care of.

 

[SSdoc33]

3 needles if im doing 3,4,5. sometimes ill go bilateral and use the same 3 needles. why cant you use the same needle for 2 different burns?

 

[NEPain]

I don't mind re-using the same needle in the same patient, but I don't see how one can accurately hit all three levels through one entry site in the skin.

The other issue on which I may not have been clear is this: If you burn one level, does the local you inject prior to burning, affect your ability to get motor stim at adjacent levels, since in order to do three burns with one needle, you would have to lesion one nerve and then go to the next one, which could be affected by tracking of the local. I'm wondering if that's a valid issue or not. I like to place all three needles before I give the local and burn.

 

[specepic]

NEpain:

sounds like you are correct in your technique and are focused on getting the proper angle/stim etc. You will use more needles but assuming the probes are reusable the only downside there is cleaning time/cost.

I use a seperate needle/angle for each site. I only reuse if doing b/l, which I almost never do. I bring them back for the other side.

 

[NEPain]

specepic, I agree on bilateral. Rarely to it but it would be the one time I'd re-use needles.

There's pressure from the boss to use only one needle per patient and to enter at only one skin location for all three burns.

I understand that we need to contain costs but I disagree with him on this issue. However, if I find that I'm an outlier, I will consider changing my technique.

 

[SSdoc33]

specepic, I agree on bilateral. Rarely to it but it would be the one time I'd re-use needles.

There's pressure from the boss to use only one needle per patient and to enter at only one skin location for all three burns.

I understand that we need to contain costs but I disagree with him on this issue. However, if I find that I'm an outlier, I will consider changing my technique.

entering at only one spot for all 3 burns is dumb.

it'll save you money but add time to use only one needle. if you have multi-lesion machine, then i would stick to using 3 needles. if you can only do 1 burn at a time, then the use of only 1 needle is reasonable.

 

[SSdoc33]

specepic, I agree on bilateral. Rarely to it but it would be the one time I'd re-use needles.

There's pressure from the boss to use only one needle per patient and to enter at only one skin location for all three burns.

I understand that we need to contain costs but I disagree with him on this issue. However, if I find that I'm an outlier, I will consider changing my technique.

entering at only one spot for all 3 burns is dumb.

it'll save you money but add time to use only one needle. if you have multi-lesion machine, then i would stick to using 3 needles. if you can only do 1 burn at a time, then the use of only 1 needle is reasonable.

 

[lonelobo]

specepic, I agree on bilateral. Rarely to it but it would be the one time I'd re-use needles.

There's pressure from the boss to use only one needle per patient and to enter at only one skin location for all three burns.

I understand that we need to contain costs but I disagree with him on this issue. However, if I find that I'm an outlier, I will consider changing my technique.

So if you are doing MBB, particularly BIlateral would you use a different needle for each?
Not very cost effective from a private practice standpoint.

 

[NEPain]

Maybe I'm not being clear. I use one needle for multiple diagnostic MBB's.

With RFA I was trained to put local on the nerve prior to burning, but only after all three needles were in place and tested. The reason is that "theoretically", local anesthetic could track in a plane and make stimulation of multifidus difficult or impossible at adjacent levels. SO, if I believe this, I would have to use three needles so that they could all be in place and tested before I administer local anesthetic and lesion them.
The effect of local anesthetic on a motor response is dramatic, if you've ever seen the Raj sign, when stimulating the femoral nerve with a stimulating catheter. The absolute second a drop of local is put through the catheter, the motor response is abolished. Since I rely on a motor response to help me place my needles accurately, I would not want to do anything that might affect it. I also recognize that this may be over conservative and that a very small amount of local administered prior to lesioning may not have a chance of tracking to the adjacent level.

 

[Jcm800]

entering at only one spot for all 3 burns is dumb.

it'll save you money but add time to use only one needle. if you have multi-lesion machine, then i would stick to using 3 needles. if you can only do 1 burn at a time, then the use of only 1 needle is reasonable.

i use the same needle stick/spot for 3 lesions all the time in the neck, it gets crowded with multiple needles. Did one last week where i said, you know i will use a couple of needles and go faster, but it wasnt faster, in my hands. It was clumsy, and i just wasted the needles.

I do a lot of bilateral, i dont have the heart to have patients come back to the have the other side so i can make more money, so when i do bilaterals, i use a few needles, but i reuse needle to do a different lesion on a different nerve on the same patient during that case...

 

[NEPain]

If there is any place where you can use a single entry site, I guess it would be the neck. I assume you approach from posterior. I just find that I can get a better lie along where I believe the nerve is located if I change my entry site for each level. You're clearly not following the ISIS process I guess, so your angle is probably a little different for each nerve.
Do you see much ataxia if you do bilateral upper cervical facets?

 

[Jcm800]

If there is any place where you can use a single entry site, I guess it would be the neck. I assume you approach from posterior. I just find that I can get a better lie along where I believe the nerve is located if I change my entry site for each level. You're clearly not following the ISIS process I guess, so your angle is probably a little different for each nerve.
Do you see much ataxia if you do bilateral upper cervical facets?

You're clearly not following the ISIS process I guess, so your angle is probably a little different for each nerve.



Will i get in trouble for this from the ISIS police? Many ways to skin a cat. No ataxia that i can recall.

 

[101N]

3 needles if im doing 3,4,5. Sometimes ill go bilateral and use the same 3 needles. Why cant you use the same needle for 2 different burns?

1+

 

[NEPain]

This is such a defensive group of people. I didn't say you have to follow ISIS guidelines. How can I put it so that you're not defensive? Dear Sir, although the ISIS guidelines are accepted by many people, and a study following ISIS guidelines did just report some phenomenal outcomes, you certainly are under no obligation to follow them and I would never assume that you do. That would be foolish of me. Heh heh heh. Ahem.
So, assuming you don't follow them, (and there's no good reason why I should assume that you do follow them), may I humbly ask how you feel that you can approach the anatomy of the medial branch nerves of the cervical spine, so elegantly presented to us by ISIS (not that you need to belong) by entering through a single hole in the skin? I humbly assume you enter from a posterior approach or you would most certainly not be able to lesion the nerves in that elegant ISIS fashion. I hope I have in no way implied that you are less than a spectacular god of pain medicine and that I have not offended you or caused you any GI upset of any sort. If so, I assume all blame.
How's that?

 

[specepic]

I get really pissed about people doing RFA in a sloppy way. Doing all 3 lesions from a single skin entry is crap. NEpain-stand your ground and do the right thing for your pts.

 

[jj337]

Have a hard time swallowing that a few drops of local may track to a separate level...

Secondly, there shouldn't (at least theoretically) be much fluid in the needle when the stylet is replaced.

I think years of people like me using the same needle at different locations without problems is at least slightly reassuring...

On the issue of one needle poke and just redirecting, I can't even think how that could be done on a 3 level burn... I adjust the c-arm for every level and can't think of a way to correctly get on the MB.

 

[NEPain]

Thanks. I believe I will consider using a single needle. I'm convinced that the local tracking to an adjacent level is probably just a theoretical concern. Sadly, in bad outcomes, even a theoretical concern can be held against you in court and it becomes more than theoretical. BUT, I won't live in fear.

Finally, I also do not believe it's possible to do a quality RFA through a single skin entry site. I will continue to be very anal about how I approach the nerves.

 

[lobelsteve]

Thanks. I believe I will consider using a single needle. I'm convinced that the local tracking to an adjacent level is probably just a theoretical concern. Sadly, in bad outcomes, even a theoretical concern can be held against you in court and it becomes more than theoretical. BUT, I won't live in fear.

Finally, I also do not believe it's possible to do a quality RFA through a single skin entry site. I will continue to be very anal about how I approach the nerves.

Agree. MBB, easy to get 3 in 1.
RF, using 20G or 22G, too stiff to steer and be parallel.

 

[bedrock]

I believe you can do clinically effective MBB at multiple levels using one needle.
However, I think one can perform multi-level unilateral MBB much quicker and with less radiation when using separate needles than by using single needle for 3-4 targets.
1-If all your MBB take you a few extra minutes, you might as well just use the extra needles, you're actually costing yourself more money than the needles do.
2-Less radiation speaks for itself.

For RF. it's ridiculous to try to do RF with one cannula from a single-entry site. Clinical outcomes would definitely suffer greatly by doing so.

And #1 and #2 would also apply to this situation. 5-10min of a physicians time is worth more than a couple RF cannulae.

 

[clubdeac]

I typically do bilateral L3-5 mbbs with 1 or two needles, injecting and then taking the needle out and moving up the next level. I'm the fastest person I know!

For RFA, I also typically do bilateral L3-5 levels. I have a multigen so I place 4 needles, stim and burn and then restylet the needles and place them in the two remaining spots and stim and burn. Again, fastest person I know...😀

If I were to do a lesion or mbb and inject local and then restylet the needle and move it to the next level, I really can't theoretically imagine how one could track anesthetic. Am I understanding this concern correctly???

 

[pmrmd]

I typically do bilateral L3-5 mbbs with 1 or two needles, injecting and then taking the needle out and moving up the next level. I'm the fastest person I know!

For RFA, I also typically do bilateral L3-5 levels. I have a multigen so I place 4 needles, stim and burn and then restylet the needles and place them in the two remaining spots and stim and burn. Again, fastest person I know...😀

If I were to do a lesion or mbb and inject local and then restylet the needle and move it to the next level, I really can't theoretically imagine how one could track anesthetic. Am I understanding this concern correctly???

I am glad I am not alone using the needles more than once. I was feeling like a cheap-ass.

 

[NEPain]

well you ARE a cheap-ass, but that's what we have to be...

 

[ampaphb]

For RFA, I also typically do bilateral L3-5 levels. I have a multigen so I place 4 needles, stim and burn and then restylet the needles and place them in the two remaining spots and stim and burn.

Why 4 and 2, rather than 3 and 3?

 

[Aether2000]

Real men don't use needles at all for RF...just ram the probes themselves onto the nerve... (JK)

 

[lobelsteve]

Why 4 and 2, rather than 3 and 3?

Left side than right side makes much more sense from a collimation standpoint.

 

[bedrock]

For RFA, I also typically do bilateral L3-5 levels. I have a multigen so I place 4 needles, stim and burn and then restylet the needles and place them in the two remaining spots and stim and burn. Again, fastest person I know...😀

I hope you're kidding about doing doing the 5 levels bilaterally.

How many people really need RF of the entire lumbar spine?

L1-L2 facet joints are almost never pain generators in my book.

L2_L3 facets cause symptomatic pain quite rarely, and most of those are in a patient with a previous nearby fusion.

 

[PinchandBurn]

I hope you're kidding about doing doing the 5 levels bilaterally.

How many people really need RF of the entire lumbar spine?

L1-L2 facet joints are almost never pain generators in my book.

L2_L3 facets cause symptomatic pain quite rarely, and most of those are in a patient with a previous nearby fusion.

agree with this post.

Most common are L3/4 and below.

 

[clubdeac]

Clarification! I typically do bilateral L3-5 mb RFA not 3-5 levels! I do three levels/mb's bilaterally or 2 joints bilaterally. I agree, 5 levels is crazy talk.

And yes I agree with Steve and Pete. 3 and 3 would probably make more sense but I can burn 4 at a time so I do that first. I place my two needles at the L5 DR in AP with caudad tilt. I then oblique ipslaterally ~20 degrees and place two needles at the L3 and L4 mb and then stim and burn all four. I then contralaterally oblique and place 2 needles at the other L3 and L4 mb's and stim and burn. Goes pretty damn fast....

 

[Jcm800]

This is such a defensive group of people. I didn't say you have to follow ISIS guidelines. How can I put it so that you're not defensive? Dear Sir, although the ISIS guidelines are accepted by many people, and a study following ISIS guidelines did just report some phenomenal outcomes, you certainly are under no obligation to follow them and I would never assume that you do. That would be foolish of me. Heh heh heh. Ahem.
So, assuming you don't follow them, (and there's no good reason why I should assume that you do follow them), may I humbly ask how you feel that you can approach the anatomy of the medial branch nerves of the cervical spine, so elegantly presented to us by ISIS (not that you need to belong) by entering through a single hole in the skin? I humbly assume you enter from a posterior approach or you would most certainly not be able to lesion the nerves in that elegant ISIS fashion. I hope I have in no way implied that you are less than a spectacular god of pain medicine and that I have not offended you or caused you any GI upset of any sort. If so, I assume all blame.
How's that?

relax fella, i was joking...

 

[deleted185747]

Why don't you try an experiment and inject some contrast and see if it tracks?