Lumbar RFA general Qs

Panacea Financial Contract Review
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
M

MD87

Full Member
10+ Year Member
Joined
Jan 23, 2012
Messages
391
Reaction score
369
Current fellow here - I have 2 unrelated questions regarding lumbar RFA. #1 is a technique question and #2 is conceptual.

#1 I’ve been told by some attendings to “scrape along the periosteum” once the needle is close to being in the correct place until the needle is snug up against the SAP. Others have told me not to scrape the periosteum – not because it’s painful, but because you can get “excessive bleeding” which can then “increase the conduction of the RF probes” and potentially result in getting yourself into trouble by having a larger lesion and frying a nerve root. What are your thoughts on this?

#2 This one has been driving me crazy for a while, and I haven’t been able to find any answers. Depending on the attending I work with, I either do RF similar to the SIS technique or more closely related to a typical MBB approach. For the record, we use venom probes, and I know these probes create a wider but not more distal lesion. I appreciate that the SIS approach places more of the active tip along the length of the nerve, and thus, more of the nerve is ideally burned.

My question is: if you’re actually causing axonal degeneration, why does it matter whether a single point of the MBB vs. a large amount of it is burned? If axonal loss occurs, everything distal to the lesion will degenerate. And if peripheral nerves regenerate at roughly 1mm per day and the probe is 10mm in length, wouldn’t it make sense that burning using SIS technique compared to the typical MBB approach would only buy you at most about 1-2 extra weeks of pain relief? And for that matter, do we really understand why people get such long relief w/ RFA if the nerve doesn’t have very far to regrow regardless of the technique?

Thanks for any insight.
Members don't see this ad.
 
With the venoms you can pretty much do them like MBBs and get good results.

or5bwk.jpg


Takes like 10 minutes from start to finish tops.
 
Members don't see this ad :)
MD87 said:
Current fellow here - I have 2 unrelated questions regarding lumbar RFA. #1 is a technique question and #2 is conceptual.

#1 I’ve been told by some attendings to “scrape along the periosteum” once the needle is close to being in the correct place until the needle is snug up against the SAP. Others have told me not to scrape the periosteum – not because it’s painful, but because you can get “excessive bleeding” which can then “increase the conduction of the RF probes” and potentially result in getting yourself into trouble by having a larger lesion and frying a nerve root. What are your thoughts on this?

#2 This one has been driving me crazy for a while, and I haven’t been able to find any answers. Depending on the attending I work with, I either do RF similar to the SIS technique or more closely related to a typical MBB approach. For the record, we use venom probes, and I know these probes create a wider but not more distal lesion. I appreciate that the SIS approach places more of the active tip along the length of the nerve, and thus, more of the nerve is ideally burned.

My question is: if you’re actually causing axonal degeneration, why does it matter whether a single point of the MBB vs. a large amount of it is burned? If axonal loss occurs, everything distal to the lesion will degenerate. And if peripheral nerves regenerate at roughly 1mm per day and the probe is 10mm in length, wouldn’t it make sense that burning using SIS technique compared to the typical MBB approach would only buy you at most about 1-2 extra weeks of pain relief? And for that matter, do we really understand why people get such long relief w/ RFA if the nerve doesn’t have very far to regrow regardless of the technique?

Thanks for any insight.
Click to expand...


Learning proper technique is key but so if efficiency. IMO using Venom needle or 18 gauge needles and hugging the periosteum as much as you can is the way to go. The junction between the SAP and TP. Just make sure you do a good motor test
 
SIS techniques are those with a significant body of literature proving their worth within the context of historical use. SIS therefore does not readily embody newer technologies, and does not teach new techniques or employ these techniques in their "standards". Subsequently, SIS tends to lag years behind the actual practices in interventional pain medicine. Such an approach protects patients from fraudulent practices using techniques or technologies of unproven worth but may also drive new techniques into the ground such as the SIS stance against pulsed RF, resulting in a non-coverage decision nationwide. Venom sounds like an interesting technique, definitely inconsistent with SIS "standards", that probably drives up the cost of a relatively simple procedure, but with potential for multiple small 1mm circular lesions instead of a 10mm x 4 mm single lesion. It will be interesting over time to see how the results pan out.
 
If the average patient I do rf for had a spine that looks like that I could do 10-15 mins. Not used to seeing that thing called a disc space in my rf patients....
BobBarker said:
Venom needles are around $40 and not crosscompatible.
Click to expand...
plus need the venom electrodes. Can’t use your existing ones. That’s over a grand each x at least 8 (4x 100mm, 4x150mm)
 
With the venom needle are you going perpendicular to the nerve instead of lying it parallel to the nerve? We do have venom needles but I try and practice the SIS technique. However, this takes me a longer time than I would like...
 
Best to learn SIS technique. You can do it anywhere regardless of available equipment. Time consuming to do correctly.
Must be nice to do a 3 level MB RFN in 10-15 minutes. I’m generally working on a 70+ yo. Each vertebral level oriented differently. Hence, even with MBB I’m in the habit of lining up every level individually. 16ga needles, at least 2 lesions per level and limited to lesioning two levels simultaneously. Usually takes honestly 45 minutes with those limitations. Had a Jurassic spine a few weeks ago that took 75 minutes because of all the deformity and poor visualization of landmarks. To boot, looks like the outcome not great but I tried my best. Would have been great to have the technology that didn’t require the cannula to be parallel to the MB. Save time and perhaps better results. Had a 40 year old 135 lb a few months back, 25-30minutes (using same technique) but the landmarks were great. 100% relief.


Sent from my iPhone using Tapatalk
 
Last edited:
Taus said:
If the average patient I do rf for had a spine that looks like that I could do 10-15 mins. Not used to seeing that thing called a disc space in my rf patients....

plus need the venom electrodes. Can’t use your existing ones. That’s over a grand each x at least 8 (4x 100mm, 4x150mm)
Click to expand...

Good to know. But do the electrodes work/socket compatible with all RF generators? Can you have a halyard RF generator and use/fit venom (Stryker) electrodes?
 
Members don't see this ad :)
bedrock said:
Good to know. But do the electrodes work/socket compatible with all RF generators? Can you have a halyard RF generator and use/fit venom (Stryker) electrodes?
Click to expand...

I am pretty sure you can only use Venom with a Multigen (Stryker) generator. But I’m not 100% sure. I would love to buy some venom probes for my nuerotherm.
 
We upgraded to the Stryker and venom technology last year. Seems superior to the old Bayliss model that we keep for backup if I have too many RF in one day. Results to me seem better. It is definitely fast in my population of RF candidates.
 
Ronin1 said:
We upgraded to the Stryker and venom technology last year. Seems superior to the old Bayliss model that we keep for backup if I have too many RF in one day. Results to me seem better. It is definitely fast in my population of RF candidates.
Click to expand...

BobBarker said:
Venom needles are around $40 and not crosscompatible.
Click to expand...

Taus said:
If the average patient I do rf for had a spine that looks like that I could do 10-15 mins. Not used to seeing that thing called a disc space in my rf patients....

plus need the venom electrodes. Can’t use your existing ones. That’s over a grand each x at least 8 (4x 100mm, 4x150mm)
Click to expand...

I can definitely see the value of Venom for lumber RF, so you can bang them out quickly.

I expect it works better than standard RF for SIJ and genicular? What do you see?

Do you also use for cervical RFA? How safe do you feel with it compared to standard RFA for C spine?
How much time does it save you and does it seem to work as well and last as long?
 
I use them for everything. They work as well as any traditional choice for geniculars and SIJ’s. I think cooled is still probably better, though. I use them for cervicals but I do very few cervical RFs. My patients have wrenched backs from picking up feed sacks not whiplash injuries.
 
I don’t think venom is “approved” for cervical usage. I use them for all other RFA. Cooled RF takes way too long and is more painful for the patients in my opinion. Definitely faster than cooled for SI and genicular as well
 
would you mbnb --> RF a patient who has a compression fracture (L1) who does not want kypho?
 
I use Venom as well. They work only with Stryker machines, I'm 90% sure. I use standard SIS technique, still getting the needle parallel to the nerve, and deploy the Venom tip so that both the needle tip and the electrode are touching bone. I know that the cooled RF produces a more spherical lesion, so a perpendicular needle placement will still produce a significant lesion along the length of the nerve. However, an 18ga Venom produces a lesion nearly identical in shape and size to a 16ga traditional probe, which is what I was using at my last site. Because I was still using SIS placement for the 16ga, I don't know why I would be able to get away with a perpendicular, MBB style placement with these. I'm interested that people have had success using that approach. I typically get 6-9 months relief with lumbar RF, and it takes me about 35 minutes to do bilateral L3-5 using SIS technique
 
bedrock said:
Yes
Click to expand...
So far I have not offered medial branch blocks for pain after compression fracture. What levels would you block for a compression fracture of T12 for example? Would you do T12 and L1 anatomical levels MBB to denervate the T12-L1 joint or would you do other levels? In other words with a T12 compression which joints are getting undue stress and increase in pain?
 
lobelsteve said:
At and above.
Click to expand...

So for a T12 compression fracture you would block the medial branch nerve at T11 and T12 effectively denervating the T11-12 joint? I want to make sure I understand what you're saying...
 
dhcofc said:
So far I have not offered medial branch blocks for pain after compression fracture. What levels would you block for a compression fracture of T12 for example? Would you do T12 and L1 anatomical levels MBB to denervate the T12-L1 joint or would you do other levels? In other words with a T12 compression which joints are getting undue stress and increase in pain?
Click to expand...

I’d recommend treating both joints that connect to your T12 vertebral fracture, so the T11-T12 and T12-L1 joints.
 
hi ,
what about the cannulas?are the neurotherm cannulas compatible with stryker rf machine?
 
#1 I’ve been told by some attendings to “scrape along the periosteum” once the needle is close to being in the correct place until the needle is snug up against the SAP. Others have told me not to scrape the periosteum – not because it’s painful, but because you can get “excessive bleeding” which can then “increase the conduction of the RF probes” and potentially result in getting yourself into trouble by having a larger lesion and frying a nerve root. What are your thoughts on this?

I thought that active blood flow would decrease the size of the lesion?
 
What sort of adapter? Was that something Halyard supplied?
At first the Stryker rep told me that I couldn’t use the Neurotherm needles because the probe would not extend to the end of the needle. When I tried it I could see what she was talking about. However, I wasn’t convinced that was an issue. However, I contacted a generic cannula supplier and they told me that Stryker probes were only compatible with Stryker cannula. I’m willing to be convinced otherwise.




Sent from my iPhone using Tapatalk
 
NJPAIN said:
What sort of adapter? Was that something Halyard supplied?
At first the Stryker rep told me that I couldn’t use the Neurotherm needles because the probe would not extend to the end of the needle. When I tried it I could see what she was talking about. However, I wasn’t convinced that was an issue. However, I contacted a generic cannula supplier and they told me that Stryker probes were only compatible with Stryker cannula. I’m willing to be convinced otherwise.
Sent from my iPhone using Tapatalk
Click to expand...

Just like the Halyard rep telling me I needed $600 of cables and adopters to do bipolar with my unit. Bought adapter online for $47 and good to go.
 
NJPAIN said:
What sort of adapter? Was that something Halyard supplied?
At first the Stryker rep told me that I couldn’t use the Neurotherm needles because the probe would not extend to the end of the needle. When I tried it I could see what she was talking about. However, I wasn’t convinced that was an issue. However, I contacted a generic cannula supplier and they told me that Stryker probes were only compatible with Stryker cannula. I’m willing to be convinced otherwise.




Sent from my iPhone using Tapatalk
Click to expand...
Can't speak to compatibility, but don't use a shorter probe because the temp monitor is on the end of the probe and the temp up in the cannula is measuring a cooler temp than the tissue you are heating.
 
pastafan said:
Cannula=needle. I used Halyard needles with my Stryker machine. The nitinol probes were usable with an adapter. Why wouldn’t neurotherm needles work?
Click to expand...

where can I find the adaptor?
 
studentdocg said:
#1 I’ve been told by some attendings to “scrape along the periosteum” once the needle is close to being in the correct place until the needle is snug up against the SAP. Others have told me not to scrape the periosteum – not because it’s painful, but because you can get “excessive bleeding” which can then “increase the conduction of the RF probes” and potentially result in getting yourself into trouble by having a larger lesion and frying a nerve root. What are your thoughts on this?

I thought that active blood flow would decrease the size of the lesion?
Click to expand...

If your needle tip is in a pool of blood then when your machine begins sending energy to heat it up it will shut off with an error message that it’s not heating up as expected. I usually restart the machine and if it faults again then reposition the needle and restart the machine.

Your concern about creating a larger lesion is valid and some of the older machines will not recognize that the temperature is not climbing as anticipated and just keep on going and the lesion will be large. There was an article about RFing near hardware and if needle tip contacted hardware then massive lesion was result.

I don’t know which machines fault if the temperature doesn’t climb as expected. I know my neurotherm says “temp out of range”
 
Last edited by a moderator:
Came in a little late , did they say it matters if u do it in parallel or oblique/perpendicular ?
 
You must log in or register to reply here.

Similar threads

P
Chronic abx for chronic uti- lumbar rfa?
Replies
20
Views
1K
MitchLevi
MitchLevi
bedrock
Repeat lumbar RFA time restrictions
Replies
36
Views
4K
Ronin1
Ronin1
bedrock
Expandible probes and lumbar RFA.
Replies
26
Views
2K
hyperalgesia
hyperalgesia
O
Lumbar RFA after fusion
Replies
36
Views
3K
MitchLevi
MitchLevi
D
Testing for RFA
2
Replies
66
Views
3K
Ferrismonk
Ferrismonk
Top