Is anyone still using steroids in MBB's????

[NEPain]

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I've been out of the loop for a while and recently joined a new practice. I thought it was a given that using steroids in a medial branch block is somewhat uncalled for. But that's how they do it here in the little city.

Can I let them know that this is a bad idea or has the world changed?

 

[bedrock]

I've been out of the loop for a while and recently joined a new practice. I thought it was a given that using steroids in a medial branch block is somewhat uncalled for. But that's how they do it here in the little city.

Can I let them know that this is a bad idea or has the world changed?

Very few evidence based, by the book pain doctors, add steroid to MBB because it alters their accuracy............other than our good SteveLobel🙂

 

[PinchandBurn]

I dont use it.

 

[clubdeac]

Most don't use it. Do you practice in NE by chance? If so where? And I don't bother with steroids, I jump straight to 98% alcohol 🙂

 

[NEPain]

Thanks for the reality check.

 

[lobelsteve]

Very few evidence based, by the book pain doctors, add steroid to MBB because it alters their accuracy............other than our good SteveLobel🙂

Explain how accuracy is altered? Needle in same position, same volume.

Discuss.

 

[SSdoc33]

Explain how accuracy is altered? Needle in same position, same volume.

Discuss.

havent we already?

accuracy is fine, but why do it? it is diagnostic block. steroid is unnecessary. dont give me no "therapeutic" lax nonsense

 

[ampaphb]

I don't use it.

But even if one patient gets some therapeutic benefit, what, exactly, is your rationale for opposing their use? One fewer RF you get to do?

 

[joshmir]

I think the steroid, or the preservative, may prolong the effect of the local anesthetic, as demonstrated in anesthesia literature. Before I was aware of the literature, I would have agreed not to use it. This can allow it to be more diagnostic as some patients need to perform some activity they can't do in your office (ie walk for 30 minutes) to evaluate the efficacy

 

[bedrock]

Explain how accuracy is altered? Needle in same position, same volume.

Discuss.

Is is the same volume? Seems that it would include more volume with steroid which would spread around more for false positives.
If you care at all about length of pain relief, then all bets are off when adding steroid, as steroid lengthens the effect of nerve blocks in many locations.
My other main concern is that some patients (more than others) have initial steroid flares and may have false negatives with local + steroid.


It's a diagnostic test and should be utilized and performed as a diagnostic test with local only--------

I appreciate the idea of sparing someone from RF, but if so do a facet injection, knowing that it's for therapeutic not diagnostic purpose. If they do well that's great, and if they don't have sustained relief, they would need a diagnostic MBB before any considered RF.

 

[bedrock]

I think the steroid, or the preservative, may prolong the effect of the local anesthetic, as demonstrated in anesthesia literature. Before I was aware of the literature, I would have agreed not to use it. This can allow it to be more diagnostic as some patients need to perform some activity they can't do in your office (ie walk for 30 minutes) to evaluate the efficacy

30 minutes? So use bupivacaine, that will get you more than 30 minutes.

I started out with 4% lido, but was concerned that too many patients somehow felt indirect pressure to have a positive block by me wanting an answer before they left the building. And many painful motions are best recreated in their home environment.

I've switched to 0.75% bupivacaine.
The patients write down their 2-3 most painful activities while we're discussing their problem during an office visit. They are instructed to do those 2-3 activities the day before their MBB so they remind themselves of how much they hurt, and then they repeat all 2-3 activities in the first couple hours after a MBB with bupivacaine, and again that evening after the MBB has worn off. (all MBB done in AM)

Patient clinical responses to RF has been much more tightly correlated with their MBB results using that protocol.

 

[SSdoc33]

I don't use it.

But even if one patient gets some therapeutic benefit, what, exactly, is your rationale for opposing their use? One fewer RF you get to do?

quite frankly.... yes. therapeutic benefit from an RF is WAY better than maybe a month from a "therapeutic" MBB. im not intersted in diddling around. get the patients the RF they need, rather than all this crap with therapeutic MBBs.

my rationale is that "one" patient may have some therpeutic benefit. but for every one ptient that does, many more will have a steroid flare, complain about some flushing reaction, get a bout of hyperglycemia, etc. makes absolutely no sense.

 

[NEPain]

I too think the steroid confounds the diagnostic results, and it IS a diagnostic procedure. Agree that if you want to get longer benefit, do an intra-artic injection.

I've also noticed that a lot of people do three levels through one needle hole. This precludes having a down the barrel view although it saves the patient 4 sticks. While we're on the topic, any thoughts on this? I go for the 6 sticks and what I perceive as better accuracy.

 

[Ligament]

I too think the steroid confounds the diagnostic results, and it IS a diagnostic procedure. Agree that if you want to get longer benefit, do an intra-artic injection.

I've also noticed that a lot of people do three levels through one needle hole. This precludes having a down the barrel view although it saves the patient 4 sticks. While we're on the topic, any thoughts on this? I go for the 6 sticks and what I perceive as better accuracy.

I usually do multiple MBB through one skin puncture. Can usually do 4 medial branches with one needle this way, sometimes needing a 7", usually a 5". It takes more skill but is faster and I believe more comfortable. There was a study on this from the Brigham I think?

 

[101N]

"Agree that if you want to get longer benefit, do an intra-artic injection."

Agree with this observation. Moreover, I think the innervation of the periosteum is at least partially independent of the innervation of the capsule. I have never been convinced that Bogduk's whiplash model - facet capsular pain - is directly transferable to facet osteo-arthropathy pain. These are different diseases, that is if you even consider WAD to be a 'disease'.

 

[Ducttape]

I do use steroids for MBB, and then have them assess how long the pain relief lasts, because the goal is pain relief and improved functionality.

If the pain relief is shortlived, i schedule for a MBB with 0.5 cc bupiv and RFA a few weeks later depending on the results of this diagnostic injection.

 

[lobelsteve]

I do use steroids for MBB, and then have them assess how long the pain relief lasts, because the goal is pain relief and improved functionality.

If the pain relief is shortlived, i schedule for a MBB with 0.5 cc bupiv and RFA a few weeks later depending on the results of this diagnostic injection.

+1

I don't go IA. I get same relief but better Dx accuracy with mbb + dex

 

[PMR 4 MSK]

What I've found funny is some people will use steroids in their MBB, but then not use it after RF.

 

[bedrock]

I usually do multiple MBB through one skin puncture. Can usually do 4 medial branches with one needle this way, sometimes needing a 7", usually a 5". It takes more skill but is faster and I believe more comfortable. There was a study on this from the Brigham I think?

I'll defer on comfort, but I don't think that a one needle MBB is as accurate. I think the medication has a better chance of staying where you want it, if you approach the groove of the SAP/TP from a perpendicular angle.

That's lumbar, regarding cervical MBB, ISIS tells us that cervical MBB have only been validated when performed in a perpendicular to the articular process (lateral approach). It is the best way to know your medication is truly right on top of the medial branches.

This isn't always possible at C7, but preferable whenever possible.

 

[bedrock]

"Agree that if you want to get longer benefit, do an intra-artic injection."

Agree with this observation. Moreover, I think the innervation of the periosteum is at least partially independent of the innervation of the capsule. I have never been convinced that Bogduk's whiplash model - facet capsular pain - is directly transferable to facet osteo-arthropathy pain. These are different diseases, that is if you even consider WAD to be a 'disease'.

Agree in that when I do intraarticular facet injections, I'll inject half in the joint and half on the capsule. Some people definitely respond better to this. Just like the percentage of SIJ injections that get as much improvement from the SIJ ligament injection as they do from the SI joint injection.

 

[PinchandBurn]

I'll defer on comfort, but I don't think that a one needle MBB is as accurate. I think the medication has a better chance of staying where you want it, if you approach the groove of the SAP/TP from a perpendicular angle.

That's lumbar, regarding cervical MBB, ISIS tells us that cervical MBB have only been validated when performed in a perpendicular to the articular process (lateral approach). It is the best way to know your medication is truly right on top of the medial branches.

This isn't always possible at C7, but preferable whenever possible.

I dont think that's necessarily true. I think you can achieve the ame with doing it from a posterior approach. Plus posterior approach is usually "safer" (less concern of parallax and putting the needle into the cord). The other issue is 'comfort'. I have done posterior approach to MBB but in fellowship and residency. As long as you are using a 25G, I dont think there's that much difference in comfort.

 

[NEPain]

Bedrock,
When you do cervical MBB's from a lateral approach, how do you make sure you're aiming at the correct side's articular process? I know that sometimes we can overlap them so that it doesn't matter, but sometimes not. Do you have any tricks for this, like moving the II and seeing which way the artic process moves, etc.?

 

[lobelsteve]

Bedrock,
When you do cervical MBB's from a lateral approach, how do you make sure you're aiming at the correct side's articular process? I know that sometimes we can overlap them so that it doesn't matter, but sometimes not. Do you have any tricks for this, like moving the II and seeing which way the artic process moves, etc.?

I'm a posterior approach guy. But just going ap will tell you. Then switch back oblique or lateral. More hassle but more accuracy. 3D localization takes 2+ pics

 

[bedrock]

Bedrock,
When you do cervical MBB's from a lateral approach, how do you make sure you're aiming at the correct side's articular process? I know that sometimes we can overlap them so that it doesn't matter, but sometimes not. Do you have any tricks for this, like moving the II and seeing which way the artic process moves, etc.?

Do you mean when you're doing a bilateral cervical MBB?
I've stopped doing bilateral cervical MBB. As the insurers bundle things to undercompensate our work, I fight back by unbundling of my own. All MBB and RF are are now done unilateral. If patient has issue with it, I tell their insurance doesn't pay me to do both sides at once, (which they don't by only paying half for the other side)

If you're asking about this in general--- I ensure that the articular pillars completely overlap.
First you stand at head of patient and ensure the table and their head is 90 degrees. Then shoot lateral. Most patients need a little wigwag to overlap the pillar, which I do live. I usually don't have to do any C-arm oblique adjustments if I got their head at 90 before starting.

 

[bedrock]

I'm a posterior approach guy. But just going ap will tell you. Then switch back oblique or lateral. More hassle but more accuracy. 3D localization takes 2+ pics

3D localization absolutely takes 2 views. Half the reason that insurers are cutting RF payments is because of yahoos doing sloppy false positive MBB, and those patients have poor RF outcomes.


As an "ISIS assassin", I'm surprised you don't do your cervical MBB lateral. Talk to the ISIS bigwigs and ask them if they consider posterior or lateral approach to be more reliable and accurate.

 

[Jcm800]

I usually do multiple MBB through one skin puncture. Can usually do 4 medial branches with one needle this way, sometimes needing a 7", usually a 5". It takes more skill but is faster and I believe more comfortable. There was a study on this from the Brigham I think?

i do multiple mbbs through one stick.
i also almost never use steroid in my Mbs, and i almost always do a set of IA facets first. And i do a lot LESS RF then most of you, because it works for 6-9 months, if not longer sometimes. Just as long as many RFs. Not always of course. but often. so yes, i do IA injections, and often only do one procedure, while the "purists" and academics due three, with the same results. And i am a sucker who makes 1/3 of the money...

 

[bedrock]

i do multiple mbbs through one stick.
i also almost never use steroid in my Mbs, and i almost always do a set of IA facets first. And i do a lot LESS RF then most of you, because it works for 6-9 months, if not longer sometimes. Just as long as many RFs. Not always of course. but often. so yes, i do IA injections, and often only do one procedure, while the "purists" and academics due three, with the same results. And i am a sucker who makes 1/3 of the money...

With the new RF codes, you'll probably make more doing repeat IA facet injections than RF.(at least decently performed RF)

 

[ampaphb]

I don't go IA. I get same relief but better Dx accuracy with mbb + dex

Other than the magical air found in Paducah, I have never understood how anyone could rationalize anything more than a few hours of relief after mbb. IA facets, on the other hand, often are sufficient to not require moving forward with RF at all. I see no reason to not give the patient the chance at avoiding RF if they don't need it.

 

[ampaphb]

What I've found funny is some people will use steroids in their MBB, but then not use it after RF.

If your goal is to napalm the area, why would you want to limit the tissue destruction with an anti-inflammatory?

I flood the area with Marcaine before creating a heat lesion, but the use of steroid is counterproductive, IMHO.

 

[ampaphb]

ISIS tells us that cervical MBB have only been validated when performed in a perpendicular to the articular process (lateral approach). It is the best way to know your medication is truly right on top of the medial branches.

This isn't always possible at C7, but preferable whenever possible.

ISIS courses may say this, but Lord's dissertation, where she mapped out the locations of the cervical medial branches on cadavers, demonstrated location variability from individual to individual, and level to level.

Also, you are kidding yourself if you think the local stays right at the needle tip, even with 0.2ml. I always inject contrast to make sure the flow goes in the direction I had intended, as well as to make certain I am not intravascular, but you are kidding yourself if you think you are "targeting" anything other than a general area where you hope the nerve happens to reside..

 

[ampaphb]

... posterior approach is usually "safer"

False. from a lateral approach, you are protected by the pillar, so long as you touch bone. Now, if you don't have sufficient experience , and end up in the foramen by mistake, it is unsafe, but that is the fault of the doc, not the approach.

The posterior approach runs the risk of advancing too far anterior. Admittedly, if you come in lateral to medial, and touch the pillar as you advance, you can make it safer, but still, there is greater risk coming PA, IMHO.

 

[SSdoc33]

If your goal is to napalm the area, why would you want to limit the tissue destruction with an anti-inflammatory?

I flood the area with Marcaine before creating a heat lesion, but the use of steroid is counterproductive, IMHO.

ah, but if you napalm the area, why would you want to dump water (marcaine) on the fire? a little bit of high conc would be reasonable, but if all that is in the area is water, you will tranfer the thermal energy more to heat the fluid than the nerve.

btw, is there an emoticon for "splitting hairs"?

 

[PinchandBurn]

I'm a posterior approach guy. But just going ap will tell you. Then switch back oblique or lateral. More hassle but more accuracy. 3D localization takes 2+ pics

+1
i think this is safer. less room for error.

 

[NEPain]

I can't see that either lateral or PA is a safer technique. Certainly, either can get you in trouble. I would think it's the skill and care of the person performing the injection. I like lateral for MBB's but sometimes am not clear on whether I am aiming at the correct side. I can't always get the pillars to line up. I realize that going AP will tell me which side I'm on but it won't tell me if I'm where I want to be on the pillar. There was a trick to help with this. I think it was moving the II one way and the pillar closer to you moves the opposite way. If anyone uses this, please correct me...

Doing RF from a lateral approach doesn't seem to make sense in terms of the lesion occurring parallel to the needle tip.

Agree that a well done RF takes time and I see a lot of people rushing through them. I guess it depends if you do 2-3 lesions at each level. And if you do, and you give local before the first lesion, you then lose the ability to stimulate before the second lesion, so I guess people are starting deep and pulling back for subsequent lesions?

I guess the next question is, is anyone using ULTRASOUND?
sorry for the long post,