L4-5 fusion

[painstop]

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Since insurance companies generally won't pay for MBB/RFA at the level of a fusion, I have a quick question. If a patient has an L4-5 posterior fusion, which nerves do you target:

a) L5 dorsal ramus, L1-L2 medial branches
b) L5 dorsal ramus, L1-L3 medial branches

The L3 medial branch can be difficult to visualize with the pedicle screws in place but theoretically couldn't it contribute to pain at the L3-4 facet joint? Do you guys feel the pedicle screw obliterated that nerve?

 

[SSdoc33]

Do you guys feel the pedicle screw obliterated that nerve?

depends on the surgeon/type of fusion

 

[lobelsteve]

If suspected L5-S1 facet then L4 and L5 MBB (L5 SAP/TP and ALA).
If suspected L3-4 facet then L2 and L3 MBB at L3 and L4 SAP/TP

 

[painstop]

If suspected L5-S1 facet then L4 and L5 MBB (L5 SAP/TP and ALA).
If suspected L3-4 facet then L2 and L3 MBB at L3 and L4 SAP/TP

It's a PLIF with pedicle screws at L4 and L5.
The pt has pain from L5 to approximately the L2 level on palpation and with extension, so I was definitely going to do L1 and L2 medial branches as well as L5 dorsal ramus. The gist of my question is whether the L3 is appropriate. Let's face it, I'm sure he probably has pain at the L4/5 level despite the PLIF but I am hamstrung by the insurance companies at this level until he has his hardware removed.

 

[bedrock]

It's a PLIF with pedicle screws at L4 and L5.
The pt has pain from L5 to approximately the L2 level on palpation and with extension, so I was definitely going to do L1 and L2 medial branches as well as L5 dorsal ramus. The gist of my question is whether the L3 is appropriate. Let's face it, I'm sure he probably has pain at the L4/5 level despite the PLIF but I am hamstrung by the insurance companies at this level until he has his hardware removed.

I'd do L2 medial branch and L5 dorsal ramus. I question whether L1 is appropriate as very few people have L2-L3 facet joint pain.

I think you're also hamstrung by the hardware. I'll burn at the fusion level if they had an interspinous or anterior fusion. After a PLIF the nerve is generally gone or inaccesible to burn except maybe cooled RF.

 

[facets]

How is the screw obliterating the nerve, we all know from RF, nerves grow back. That idea is the biggest fraud by the ortho lobby ever foisted upon the insurance companies, patients and pain docs. I've burned nerves around pedicle screws and it works. It takes at least 3 times as long to get a 3 d view of where you are with all the hardware, but I do it. I usually wonder why the hel& I am bothering and getting nuked, until the patient returns and says they are better, then I remember,

 

[sblau001]

facets, agree with you 100%. I've had numerous patients improve with RF years after fusion.

 

[pharmer]

Is it possible to do a facet joint injection at L3/4 on someone with a L4/5 PLIF? I have patient being referred for that specifically from a spine surgeon and I would suspect the hardware (pedicle screw) would obstruct entry into the L3/4 facet joint itself.

 

[bedrock]

How is the screw obliterating the nerve, we all know from RF, nerves grow back. That idea is the biggest fraud by the ortho lobby ever foisted upon the insurance companies, patients and pain docs. I've burned nerves around pedicle screws and it works. It takes at least 3 times as long to get a 3 d view of where you are with all the hardware, but I do it. I usually wonder why the hel& I am bothering and getting nuked, until the patient returns and says they are better, then I remember,

How often does it help?

The predictability of a MBB goes way down in those patients. I do think it's feasible to ablate around hardware and sometimes with enough lesions, you may burn some medial branches at those levels.

However, you will also have a lot of false positive MBB, with RF less successful than the MBB.
In general a lot of false MBB in patients s/p lumbar fusion, who are desperate for relief. I don't usually do double MBB, but always double MBB in patients who have had a lumbar fusion.

 

[bedrock]

Is it possible to do a facet joint injection at L3/4 on someone with a L4/5 PLIF? I have patient being referred for that specifically from a spine surgeon and I would suspect the hardware (pedicle screw) would obstruct entry into the L3/4 facet joint itself.

Harder, but doable. Aim for top of joint.

 

[facets]

at least 50% with double blocks. Believe me if they didn't work I would not bother

 

[PMR 4 MSK]

Is it possible to do a facet joint injection at L3/4 on someone with a L4/5 PLIF? I have patient being referred for that specifically from a spine surgeon and I would suspect the hardware (pedicle screw) would obstruct entry into the L3/4 facet joint itself.

Just did one today - bilateral. Tilt cephalad if you need to get in there.