I need cervical medial branch block and radiofrequency ablation pearls

[Ducttape]

that brings up a separate issue that maybe someone can better explain to me.

i have trouble reconciling that we do an RFA on multiple levels such as L3-S1. this is so nonselective, yet the disease seems like it should be - pretty much the entire lumbar spine. same with doing 3 level cervicals.

can anyone give me a cogent explanation why? besides "well its spondylosis everywhere". these patients, after all, have spinal stenosis everywhere and images may not show severe facet arthropathy at each level that we do.

i suspect that my selectivity (2 levels only) is a contributing factor for treatment failures.

it just seems that we are so selective about all other injections but when it comes to RFA most people carpet bomb...

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[RoloTomassi]

that brings up a separate issue that maybe someone can better explain to me.

i have trouble reconciling that we do an RFA on multiple levels such as L3-S1. this is so nonselective, yet the disease seems like it should be - pretty much the entire lumbar spine. same with doing 3 level cervicals.

can anyone give me a cogent explanation why? besides "well its spondylosis everywhere". these patients, after all, have spinal stenosis everywhere and images may not show severe facet arthropathy at each level that we do.

i suspect that my selectivity (2 levels only) is a contributing factor for treatment failures.

it just seems that we are so selective about all other injections but when it comes to RFA most people carpet bomb...

If they didn't create rules limiting the number of MBB/RFA per area q6mo maybe we could be more selective and progress in a stepwise manner but we are forced to carpet bomb or miss potential targets/80% mark

 

[Ligament]

Anybody do it this way?

 

[RoloTomassi]

Once

Anybody do it this way?

View attachment 352893

Once in a high cervical when I was experimenting approaches. Worked fine but top shoulder gets in the way, hard to prep and drape, hard to use needles as pointers

 

[Ducttape]

If they didn't create rules limiting the number of MBB/RFA per area q6mo maybe we could be more selective and progress in a stepwise manner but we are forced to carpet bomb or miss potential targets/80% mark

maybe.

for me, thats not answering why carpet bombing sometimes works...



to lig - yes.

get rid of the $#^$ drapes. 4 small sterile towels work a lot better to make your sterile field. and people are less claustrophobic.

i dont start true posterior with this approach. its more of a 30 degree angle. needle entry point is just slightly behind and angles anterio-superiorly

 

[10KHertz]

Go prone (if experienced), cheat and anesthetize the Mbb after needle placement (lido 1% only). Motor stim, then burn away. You didn’t hear this from me …

 

[oreosandsake]

Anybody do it this way?

View attachment 352893

then get a lateral image and see that you are 1/2 in superficial to the bone.
perfect lateral spine image more difficult in this position as patient movement in response to the needle pokes imo

 

[clubdeac]

Not to hijack but since we're talking about cervical mbb/RFA pearls, how many of you guys are using contrast for your cervical mbbs? DSA? And if doing them posteriorly do you check a lateral too or just slide off articular pillar 1-2 mm and inject contrast? In other words, how many safety precautions are you using?

 

[RoloTomassi]

Not to hijack but since we're talking about cervical mbb/RFA pearls, how many of you guys are using contrast for your cervical mbbs? DSA? And if doing them posteriorly do you check a lateral too or just slide off articular pillar 1-2 mm and inject contrast? In other words, how many safety precautions are you using?

No contrast or DSA. Can't imagine not doing a lateral for depth and cephalocaudal location. CLO if can't visualize on lateral but def not just AP.

 

[bedrock]

No contrast or DSA. Can't imagine not doing a lateral for depth and cephalocaudal location. CLO if can't visualize on lateral but def not just AP.

I can’t imagine not using contrast. The medication doesn’t go where you think it goes more often than you think.

Agree on lateral/CLO. Also regarding no DSA.

 

[RoloTomassi]

I can’t imagine not using contrast. The medication doesn’t go where you think it goes more often than you think.

Agree on lateral/CLO. Also regarding no DSA.

I used to. I found it didn't change my management much. Almost all the vascular ones had blood backflow in the hub. So now if I see backflow I adjust. I do bilateral often, one side then the other, and didn't like how it muddied up the lateral for the second side.

Do you do contrast for lumbar?

 

[callmeanesthesia]

I used to. I found it didn't change my management much. Almost all the vascular ones had blood backflow in the hub. So now if I see backflow I adjust. I do bilateral often, one side then the other, and didn't like how it muddied up the lateral for the second side.

Do you do contrast for lumbar?

I have been doing contrast since I started my current job, because the previous Noridian LCD included language that seemed to imply contrast was required (ambiguous whether it referred to just facets or also MBBs) and my partner did it.

I just reviewed the new LCD and there is no such language now. I agree with you - very rarely do I change needle position based on contrast spread. Especially for lumbar. Would also save several fluoro shots per procedure.

 

[Ducttape]

i use a blush of contrast. as low as i can go while still making sure not vascular.

for all spine injections, i always get at least 2 views.

 

[nvrsumr]

I just reviewed the new LCD and there is no such language now. I agree with you - very rarely do I change needle position based on contrast spread. Especially for lumbar. Would also save several fluoro shots per procedure.

If this is true I will stop using contrast. Save a lot of time and radiation for negligible benefit

 

[clubdeac]

Do you guys always check laterals on your cervical mbbs when coming from posterior? I never did but am now thinking about it

 

[ateria radicularis magna]

Do you guys always check laterals on your cervical mbbs when coming from posterior? I never did but am now thinking about it

I check laterals

 

[painfree23]

Do you guys always check laterals on your cervical mbbs when coming from posterior? I never did but am now thinking about it

When coming from posterior?? Yes definitely, how would u know ur depth otherwise? When coming in from lateral (patient side laying) sometimes I skip the lateral

 

[callmeanesthesia]

I’m thinking of streamlining my MBBs significantly after this thread. Going to abandon contrast - if I get a false negative due to vascular uptake then the patient can get a “tie breaker.” Frequency of the contrast totally disappearing despite negative aspiration is very low. In the cervical, even 0.3 mL spreads so far an adjacent level will probably cover it, and in the lumber there’s less vascularity and that’s even less common
Also going to modify targets. Currently for cervical I walk the needle off the lateral edge. Instead, looking at anatomy diagrams, it should be adequate to just touch down on the lateral third of the articular waist, right where the “MB” lines touch on the diagram below. This will be lower risk and faster. No need to check a lateral if the needle tip is on bone.

 

[pmrmd]

that brings up a separate issue that maybe someone can better explain to me.

i have trouble reconciling that we do an RFA on multiple levels such as L3-S1. this is so nonselective, yet the disease seems like it should be - pretty much the entire lumbar spine. same with doing 3 level cervicals.

can anyone give me a cogent explanation why? besides "well its spondylosis everywhere". these patients, after all, have spinal stenosis everywhere and images may not show severe facet arthropathy at each level that we do.

L4-5 is the most mobile level, followed by L5-S1 slightly more than L3-4. Lumbar curvatures even below the magical 10 degree definition of scoliosis can cause pain because of the concurrent rotation. Other levels move significantly less than those three.

The vast majority of my patients anyway with significant axial pain have curvature on x-ray.

 

[clubdeac]

When coming from posterior?? Yes definitely, how would u know ur depth otherwise? When coming in from lateral (patient side laying) sometimes I skip the lateral

Sometimes you skip the lateral when coming in from lateral? That makes absolutely no sense

 

[GoBeers]

I’m thinking of streamlining my MBBs significantly after this thread. Going to abandon contrast - if I get a false negative due to vascular uptake then the patient can get a “tie breaker.” Frequency of the contrast totally disappearing despite negative aspiration is very low. In the cervical, even 0.3 mL spreads so far an adjacent level will probably cover it, and in the lumber there’s less vascularity and that’s even less common
Also going to modify targets. Currently for cervical I walk the needle off the lateral edge. Instead, looking at anatomy diagrams, it should be adequate to just touch down on the lateral third of the articular waist, right where the “MB” lines touch on the diagram below. This will be lower risk and faster. No need to check a lateral if the needle tip is on bone.
View attachment 353082

i do exactly this. AP view. sometimes i will ipsilateral oblique just 10 degrees to flesh out the waist. essentially do a coaxial / parasagittal pass and hit os at its most lateral border. then i'll quickly check 40 degree CLO view to make sure i'm not in foramen and i call it a day.

for RFA though I do furman technique with caudal tilt and ipsilateral oblique view, drop needles coaxial and then check lateral if able, otherwise CLO again if fat shoulders.

 

[nopain1234]

why stop at 80..

80 better than 40, better than 20.. more is better?

this is the same logic that got people in trouble with opioids

as an aside, most of the data shows that more CS is not better than less. the therapeutic max is achieved at a low dose

EDIT: SIS CERVICAL RF COURSE? REALLY?

Thoughts on using depo (particulate) in c spine? I know you’d have to be way off to get into vertebral artery. But what if…

 

[clubdeac]

Thoughts on using depo (particulate) in c spine? I know you’d have to be way off to get into vertebral artery. But what if…

For which injection? I’ll still use it in my cervical facets and CESI but that’s it

 

[clubdeac]

Linked it.

so I've read this entire consensus guideline and this freaks me out a bit. If feeder arteries are located over our targets on the articular pillar why are we not seeing more strokes following mbbs and RFAs? Makes me never want to do another TON if there's a 5-8% chance of hitting the vertebral artery?! wth? I assume the other study looking at vascular uptake was predominantly venous?

In a study on the anatomic variations of the vertebral artery evaluated on CT-angiography imaging, a loop of the vertebral artery originating between C1 and C2 coursed over the anterolateral aspect of the caudad quarter of the articular pillar of C2 in 0.2% of subjects, over the cephalad quarter of C3 in 7.9%, and over the C2–3 joint line in up to 5.5% of persons.162 This suggests that vascular injury and catastrophic complications can occur during procedures performed on the TON where it is amenable to treatment on the surface of the C2–3 facet joint. A recent study reported that intravascular spread was detected in 10.7% of DSA images versus 1.7% from static images during cervical MBB. The authors reported a higher incidence of intravascular injections during MBB at the C4, C5, C6 levels but did not perform blocks on the TON.134 Another study reported that 12% of fluoroscopically-guided—but no US-guided—cervical MBBs were associated with intravascular placement of the needle tip. In the US-guided group, vascular structures were found to overlie the C2–3 joint 9% of the time, and the articular pillars of C3, C4, C5, C6, and C7 in 16%, 16%, 12%, 32%, and 46% of cases, respectively.145 However, DSA is the reference standard for detecting intravascular uptake during facet procedures, with real-time fluoroscopy having a sensitivity of approximately 58%, spot radiography having a sensitivity of 35%, and needle aspiration being about 20% sensitive in comparison.133 362

 

[MitchLevi]

I am weaning C2-3 RFA out of my practice. Instead, I'm doing CSI.

C2-3 RFA with 90 sec burn at 80 degrees results in neuritis for me nearly every time I do it, often lasting 3 or more months FFS.

C6 and C7...Wut?

 

[NJPAIN]

I am weaning C2-3 RFA out of my practice. Instead, I'm doing CSI.

C2-3 RFA with 90 sec burn at 80 degrees results in neuritis for me nearly every time I do it, often lasting 3 or more months FFS.

C6 and C7...Wut?

Have you tried Bedrock’s slow ramp up 70 degree technique? I don’t do a ton of TON but it seems to work with minimal neuritis.

 

[MitchLevi]

Technically...If you don't go to 80C and you're audited you owe that reimbursement back to the payer.

I have not seen that, and while temperatures matter wrt RFA, the C2-3 level has cutaneous fibers so it doesn't matter. If you denervate that joint you're prob gonna get PAN.

In my mind, less temp = Higher risk of neuritis. You have to completely lesion the nerve.

 

[pmrmd]

I’m thinking of streamlining my MBBs significantly after this thread. Going to abandon contrast - if I get a false negative due to vascular uptake then the patient can get a “tie breaker.” Frequency of the contrast totally disappearing despite negative aspiration is very low. In the cervical, even 0.3 mL spreads so far an adjacent level will probably cover it, and in the lumber there’s less vascularity and that’s even less common
Also going to modify targets. Currently for cervical I walk the needle off the lateral edge. Instead, looking at anatomy diagrams, it should be adequate to just touch down on the lateral third of the articular waist, right where the “MB” lines touch on the diagram below. This will be lower risk and faster. No need to check a lateral if the needle tip is on bone.
View attachment 353082

Absolutely. Drop a cc at the joint line. Your information is the same.

I am weaning C2-3 RFA out of my practice. Instead, I'm doing CSI.

C2-3 RFA with 90 sec burn at 80 degrees results in neuritis for me nearly every time I do it, often lasting 3 or more months FFS.

Huh? 2-3 is pretty darn common to just stop treating it.

 

[MitchLevi]

Absolutely. Drop a cc at the joint line. Your information is the same.

Huh? 2-3 is pretty darn common to just stop treating it.

I didn't say stop treating C2-3.

I'm trying to stop ablating that level and instead doing CSI instead.

The neuritis occurs virtually every time I do it, and it seems my pts go 2-3 months.

...sick of that conversation.

 

[nopain1234]

For which injection? I’ll still use it in my cervical facets and CESI but that’s it

I use depo with CESI. Dex for facets. I saw an attending cause a massive hemispheric stroke with depo on a cervical TFESI. I’m scarred for life

 

[NJPAIN]

I use depo in CESI. Dex for facets. I saw an attending cause a massive hemispheric stroke with depo on a cervical TFESI. I’m scared for life

Yikes. I’ll bet that resulted in some PTSD.

 

[pmrmd]

I didn't say stop treating C2-3.

I'm trying to stop ablating that level and instead doing CSI instead.

The neuritis occurs virtually every time I do it, and it seems my pts go 2-3 months.

...sick of that conversation.

I inject with dex all the time and sometimes it lasts a little while but stopping RF at C2-3 will just change the conversation to people asking you why they still hurt.

 

[nopain1234]

Yikes. I’ll bet that resulted in some PTSD.

No particulate in c spine ever for me (other than CESI)

 

[RoloTomassi]

I am weaning C2-3 RFA out of my practice. Instead, I'm doing CSI.

C2-3 RFA with 90 sec burn at 80 degrees results in neuritis for me nearly every time I do it, often lasting 3 or more months FFS.

C6 and C7...Wut?

Most payers won't reimburse for that anymore, unless there's a specific CI to RF.

 

[MitchLevi]

I inject with dex all the time and sometimes it lasts a little while but stopping RF at C2-3 will just change the conversation to people asking you why they still hurt.

I use dex with every cervical RFA. Look, the treatment (CRFA) definitely works for neck pain but dang that neuritis is far more common than what everyone I ever trained with told me, and other pain doctors tell me they don't see it.

Rolo. I am very much aware, however "Cash rules everything around me...CREAM...Get the money. Dolla dolla bills yall..."

 

[Dr. Ice]

I use dex with every cervical RFA. Look, the treatment (CRFA) definitely works for neck pain but dang that neuritis is far more common than what everyone I ever trained with told me, and other pain doctors tell me they don't see it.

Rolo. I am very much aware, however "Cash rules everything around me...CREAM...Get the money. Dolla dolla bills yall..."

I see what you see bro..neuritis with upper cervical rfa..usually goes away in 3-4 weeks. Have done low does neurontin which works well (which apparently now the fda has made like Percs and Vics) but I’m sure that’s coming to a thread near you on here.

Cervical esi with particulate works well for me

 

[HyperSonic]

Anybody do it this way?

View attachment 352893

Looks like this guy gets ton of radiation…

 

[SC Tian]

Since I joined a new group about 3 years ago, I did most of cervical rfa in the practice. Initially I had quite common post-rfa neuritis, compared to my previous practice when I was using striker machine. i tried different options to reduce neuritis, from 18 g to 20 g, from 80 c to 70c, from 90 secs to 60 secs, two lesions to one lesion, the final Results from my trial is 60 secs with much infrequent neuritis, followed one to 2 years, the relief is sustained.
I use prone position for rfa, go from 15, 30, 45 and 60 degree clo to guide needle insertion and final needle placement, most procedures are done in 5-10 mins. Just my two cents.

 

[RoloTomassi]

So is neuritis more common with a thorough burn or incomplete lesioning?
I get a decent amount (maybe 1/3, most 2-3 weeks, 6 weeks long side, most not too bothersome) in cervical but not as common or severe as @MitchLevi

18 ga Venom 1-2 burns at 80C, 90s ea

 

[Taus]

So is neuritis more common with a thorough burn or incomplete lesioning?
I get a decent amount (maybe 1/3, most 2-3 weeks, 6 weeks long side, most not too bothersome) in cervical but not as common or severe as @MitchLevi

18 ga Venom 1-2 burns at 80C, 90s ea

This is exactly what I use and see re incidence, severity, duration.

2-3 lesions for TON, even w 18g venom. Above at and below joint line. Fry the ish out of it. Many very grateful patients.

 

[soccrwz]

anyone have any photos and angles for the proper depth for CRFA with CLO?

 

[Taus]

anyone have any photos and angles for the proper depth for CRFA with CLO?

Search “clo rfa” on thus forum. Some very good posts.

 

[bedrock]

hmm... so do i go back to CS or no...

smart re dex... the arteries in this area NOT described in netter are astounding.

As I mentioned on the other thread. Kenalog/depo is much better (not foolproof) to prevent post c RFA neuritis than dex.

Agree regarding unexpected vascular supply around facets, however immediately after cauterizing the MB (and any local blood vessels), I would think it safe to add kenalog post RFA.

 

[bedrock]

I am weaning C2-3 RFA out of my practice. Instead, I'm doing CSI.

C2-3 RFA with 90 sec burn at 80 degrees results in neuritis for me nearly every time I do it, often lasting 3 or more months FFS.

C6 and C7...Wut?

Since I joined a new group about 3 years ago, I did most of cervical rfa in the practice. Initially I had quite common post-rfa neuritis, compared to my previous practice when I was using striker machine. i tried different options to reduce neuritis, from 18 g to 20 g, from 80 c to 70c, from 90 secs to 60 secs, two lesions to one lesion, the final Results from my trial is 60 secs with much infrequent neuritis, followed one to 2 years, the relief is sustained.

I use Dreyfuss technique at TON, and have very little TON neuritis.

1- most importantly only do 60 second lesions at TON.
2- second most important, use 70 degrees for lesion. I still report it as 80 degrees, just like I call all SIJ issues sacroilitis because bean counters are not physicians.
3- I add 10mg of kenalog after the lesion.

Very rare TON neuritis that way.

 

[GoBeers]

Only couple years in practice. I had one case where after removing the cannula on a right c6 rfa needle, I had an arterial bleeder spraying like a water gun. Totally freaked me out but hemostasis achieved with pressure and no complications on multiple phone call follow ups. Netter images suggested maybe I hit a deep cervical artery, but probably some random feeder.

Cervical procedures blow.

 

[MD87]

Particulate/Non-particulate. Bupivacaine/Lidocaine. Pain relief is more complicated than drug metabolism.

Very interesting head scratcher, which is fairly consistent with my experiences:
Patient-perceived duration of effect of lidocaine and bupivacaine following diagnostic medial branch blocks; a multicenter study
Schneider, et al.

 

[deleted875186]

Particulate/Non-particulate. Bupivacaine/Lidocaine. Pain relief is more complicated than drug metabolism.

Very interesting head scratcher, which is fairly consistent with my experiences:
Patient-perceived duration of effect of lidocaine and bupivacaine following diagnostic medial branch blocks; a multicenter study
Schneider, et al.

I have always found duration of pain relief after peripheral nerve blocks fascinating. Just look at a Supraclavicular block with plain bupi, 12-14 hours, but a femoral, usually 24 hours pretty consistently, epidural bolus with bupi only a couple hours, seems to matter where yojr blocking the nerve and maybe how fast the medicine is absorbed from the site.

 

[GoBeers]

I have always found duration of pain relief after peripheral nerve blocks fascinating. Just look at a Supraclavicular block with plain bupi, 12-14 hours, but a femoral, usually 24 hours pretty consistently, epidural bolus with bupi only a couple hours, seems to matter where yojr blocking the nerve and maybe how fast the medicine is absorbed from the site.

But what about those brachial plexopathy patients who swear they get 3 months of relief from supraclavicular brachial plexus block with dex and bupi?

Im like.... right... but I'll take it!

 

[MitchLevi]

I use Dreyfuss technique at TON, and have very little TON neuritis.

1- most importantly only do 60 second lesions at TON.
2- second most important, use 70 degrees for lesion. I still report it as 80 degrees, just like I call all SIJ issues sacroilitis because bean counters are not physicians.
3- I add 10mg of kenalog after the lesion.

Very rare TON neuritis that way.

You do two needle? One immediately inferior and one superior at 60s 70C?

 

[deleted875186]

But what about those brachial plexopathy patients who swear they get 3 months of relief from supraclavicular brachial plexus block with dex and bupi?

Im like.... right... but I'll take it!

I find steroids even more fascinating, they prolong surgical blocks on the order of houra, and somehow in chronic pain patients provide many weeks of pain relief. I don’t think anyone has really described how they have an analgesic effect on peripheral nerves.