lumbar RFA technique tips

[epidural man]

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Looking at the anatomical pictures here:
http://www.asipp.org/reference3/Lau2004PainMed.pdf

I doubt it matters whether your angle is steep caudal or more perpendicular as long as the tip of the needle is in the groove. I'm burning at 90°C x 2 with a 90° rotation medial in between.

I'll try a few your way to see if there is a difference in sensory stimulation.

That article specifically says you may miss it if you are perpendicular.

 

[epidural man]

This has been a great discussion.

But it also highlights something - it begs that we need a national pain registry.

We perseverate on technics - but the real truth is - we don't know what works better. Anecdote is great for while, but it would be wonderful to actually know if and what makes the biggest difference. Dreyfuss may have the best outcomes, but it may have nothing to do with needle placement.

I have met and worked with many pain physicians, all with different techniques - all say their outcomes are the best. Some come right down perpendicular to it - swear it works awesome...but without tracking...without data...it's all just a fun story to talk about between us.

 

[bedrock]

This has been a great discussion.

But it also highlights something - it begs that we need a national pain registry.

We perseverate on technics - but the real truth is - we don't know what works better. Anecdote is great for while, but it would be wonderful to actually know if and what makes the biggest difference. Dreyfuss may have the best outcomes, but it may have nothing to do with needle placement.

I have met and worked with many pain physicians, all with different techniques - all say their outcomes are the best. Some come right down perpendicular to it - swear it works awesome...but without tracking...without data...it's all just a fun story to talk about between us.

agree on the pain registry.

Dreyfuss and Bogduk have far more high level prospective publications on RFA technique and patient selection than anyone else. I'd be happy to consider other RFA techniques, but they have a mountain of evidence on their side so until someone else publishes several prospective randomized trials with thousands of patients on other RFA techniques, I'm inclined to believe that other techniques with standard RF needles are inferior and these docs likely do perpendicular RFA only so they can do more cases in a day, and not for a superior or longer lasting outcome.

Perpendicular with cooled RF, venom, etc is another story.

 

[powermd]

That article specifically says you may miss it if you are perpendicular.

I started doing steep caudal angulation in August, I think. No immediate failures so far- except one, who had very high pretest probability. When he returned for the opposite side, I reverted to my old technique and repeated his RF on the side that didn't work in addition to the new side. Waiting to see what happened.

 

[clubdeac]

I've been having a slew of failures lately... really pisses me off. However, at the VA my patients have a high degree of comorbid psychiatric diagnoses, use tobacco and we only do one set of mbb's due to long wait times. I'm chalking it up to that but seriously it's really pissing me off!

 

[pastafan]

I've been having a slew of failures lately... really pisses me off. However, at the VA my patients have a high degree of comorbid psychiatric diagnoses, use tobacco and we only do one set of mbb's due to long wait times. I'm chalking it up to that but seriously it's really pissing me off!

How many are on COT and don't want to admit improvement in fear of med reduction?

 

[Taus]

I've been having a slew of failures lately... really pisses me off. However, at the VA my patients have a high degree of comorbid psychiatric diagnoses, use tobacco and we only do one set of mbb's due to long wait times. I'm chalking it up to that but seriously it's really pissing me off!

I effing hate failed RFA. Over the past year I'm bw 85-90% success, but the conversations after a failed one are difficult. Options are not great at that point. I think that's likely a lot of us on here given the many threads on optimizing technique. At least with esi failure and limb pain a surgical referral is next, but not rf.


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[Ducttape]

Anyone just repeat the RFA? I don't bother but, Local pain guy will just repeat RFA if it fails, apparently, given failure rate of 20% or so (or so he says)...

The hard work for me with these patients is before I do the RFA - prepping patients for chronicity of pain and the focus on functionality. I keep the expectations low, so the discussion after is typically not painful.


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[SSdoc33]

I've been having a slew of failures lately... really pisses me off. However, at the VA my patients have a high degree of comorbid psychiatric diagnoses, use tobacco and we only do one set of mbb's due to long wait times. I'm chalking it up to that but seriously it's really pissing me off!

make sure you address the SIJ as well. if you ablate the medial branches, but they still have concomitant SIJ pain, they may not realize the full extent of the relief from the RF.

i dont "feel bad" if the patients still have LBP after an RF. the fact is that these patients likely dont have many other options and are not surgical candidates. we do the best we can with the tools we have, but the patients need to accept some responsibility and some pain, frankly.

 

[bedrock]

I effing hate failed RFA. Over the past year I'm bw 85-90% success, but the conversations after a failed one are difficult. Options are not great at that point. I think that's likely a lot of us on here given the many threads on optimizing technique. At least with esi failure and limb pain a surgical referral is next, but not rf.


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Do you do two comparative MBB? I find that cuts down on RF failures.

Agree with ssdoc in that RF reduces pain but doesn't eliminate it. Patients need to take responsibility for their own lives and their age. I had a few otherwise sweet grandmothers back in PA, who complained more than I expected after my RFA only provided 85% relief of her lumbar pain. She was annoyed that at in her 80s, she might have to cut back on her activity a bit.....

Realistic expectations are key as well. When someone comes in after two blocks with 90% relief, I always say there is no guarantee the RFA will reproduce the exact relief of the blocks. In fact I usually say that RFA relief is usually less than block relief. So when that person comes in with 65% relief after RFA, its not a surprise.

 

[Ligament]

There is a technical failure rate of even perfectly performed RF, don't forget that.

 

[Taus]

There is a technical failure rate of even perfectly performed RF, don't forget that.

I haven't looked at the literature on this in a couple years. It's around 15% failure after comparative mbb or more than that?

Re feeling bad... thanks for the perspective. It's usually after grandma gets 90% on 2 mbb then nothing w RFA despite technique I'm very confident about. . I am upfront re lack of 100% success rate.. . but still, a difficult conversation with a non surgical candidate.

Perhaps I need to temper expectations even more like I do with SI RF. I clearly and repeatedly emphasize the approx 30% failure rate despite 2 blocks w 100% relief. Definitely softens the blow with failures. I haven't gone to that extent w RF in c/l spine given the higher success rate.


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[NJPAIN]

How many of you do NOT do two comparative blocks and accept a higher RF failure rate? I find two "diagnostic/prognostic" blocks a nearly impossible sell in my patient population. They look at me like I'm crazy if I suggest doing two injections that will provide no long lasting relief.


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[Ligament]

How many of you do NOT do two comparative blocks and accept a higher RF failure rate? I find two "diagnostic/prognostic" blocks a nearly impossible sell in my patient population. They look at me like I'm crazy if I suggest doing two injections that will provide no long lasting relief.


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I do two of them. Put it in the context of medical assurance. I say "I do NOT want to melt any nerves unless I'm confident they are the bad guys. That's why we do two test injections. Does that make sense?"

98% of the time they are then fine with two diagnostic blocks.

 

[Gospe1]

What do people think of cooled RFA or pulsed RFA? My question is does pulsed RFA really avoid any "burning tissue"?

 

[cbest]

How many of you do NOT do two comparative blocks and accept a higher RF failure rate? I find two "diagnostic/prognostic" blocks a nearly impossible sell in my patient population. They look at me like I'm crazy if I suggest doing two injections that will provide no long lasting relief.


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Pretty much every insurance company is making me do two rounds of MBB before RF


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[clubdeac]

What do people think of cooled RFA or pulsed RFA? My question is does pulsed RFA really avoid any "burning tissue"?

Are you a pain doc????? Do you do these procedures? Are you a NP!?!

 

[Ligament]

Are you a pain doc????? Do you do these procedures? Are you a NP!?!

ie. are you an unqualified imposter?

 

[epidural man]

What do people think of cooled RFA or pulsed RFA? My question is does pulsed RFA really avoid any "burning tissue"?

I'm a huge fan of pulsed - except for lumbar medial branches. Data is pretty clear that high temp is superior.

I like cooked for failed RF that you really expected to work. Anatomical studies in cadavers seem to show a pretty high variability in location of those pesky small nerves.

 

[epidural man]

I haven't looked at the literature on this in a couple years. It's around 15% failure after comparative mbb or more than that?

Re feeling bad... thanks for the perspective. It's usually after grandma gets 90% on 2 mbb then nothing w RFA despite technique I'm very confident about. . I am upfront re lack of 100% success rate.. . but still, a difficult conversation with a non surgical candidate.

Perhaps I need to temper expectations even more like I do with SI RF. I clearly and repeatedly emphasize the approx 30% failure rate despite 2 blocks w 100% relief. Definitely softens the blow with failures. I haven't gone to that extent w RF in c/l spine given the higher success rate.


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I tell patients that even with a perfect dx test, failures are 30%. I seem to think that is literature based.

 

[SSdoc33]

How many of you do NOT do two comparative blocks and accept a higher RF failure rate? I find two "diagnostic/prognostic" blocks a nearly impossible sell in my patient population. They look at me like I'm crazy if I suggest doing two injections that will provide no long lasting relief.


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i only do 2 when it is mandated by insurance. if it were up to me, id go right to RF. i tell the patient that it is an insurance requirement when i need to do 2. id say 75% of the time, i am doing 2 blocks.

 

[NJPAIN]

I know that time is money and all of us are looking to do as much as we can in as short a period of time as can be done safely and effectively. Hence, I suspect most of us are lesioning multiple levels simultaneously. However, as I am paying more attention to squaring every endplate individually and then declining 30-35 degrees I am finding that my needles are at times entering the skin really close to one another making placing the needles coaxially a real challenge on some. Today I used the Milt Landers technique and placed the needle and lesioned prior to moving on to the next level. Not fast but sure made needle placement easier with no other needles sitting in the way. Anyone else experiencing these challenges or are most squaring one endplate and using that angle for all subsequent levels?

 

[DOctorJay]

I definitely experience those issues and have slightly changed the obliquity if necessary for proper placement.

 

[bedrock]

I definitely experience those issues and have slightly changed the obliquity if necessary for proper placement.

agree with Dr. Jay, sometimes you have to change it a little so the needles fit.

I know that time is money and all of us are looking to do as much as we can in as short a period of time as can be done safely and effectively. Hence, I suspect most of us are lesioning multiple levels simultaneously. However, as I am paying more attention to squaring every endplate individually and then declining 30-35 degrees I am finding that my needles are at times entering the skin really close to one another making placing the needles coaxially a real challenge on some. Today I used the Milt Landers technique and placed the needle and lesioned prior to moving on to the next level. Not fast but sure made needle placement easier with no other needles sitting in the way. Anyone else experiencing these challenges or are most squaring one endplate and using that angle for all subsequent levels?

what is the milt landers technique?

 

[NJPAIN]

agree with Dr. Jay, sometimes you have to change it a little so the needles fit.



what is the milt landers technique?

Place a needle, burn, remove needle. Repeat. One at a time.


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[Taus]

I run into this more often w cervical. Solve same as J. If it looks like my skin entry points are very close together, I will alter the obliquity to spread apart more. Also made much easier if I start at the most cephalad level. I find that pulling the hubs caudal to get the tip cephalad is when I run into the needle/hub hitting each other. Starting with most cephalad needle gets around this often


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[bedrock]

I run into this more often w cervical. Solve same as J. If it looks like my skin entry points are very close together, I will alter the obliquity to spread apart more. Also made much easier if I start at the most cephalad level. I find that pulling the hubs caudal to get the tip cephalad is when I run into the needle/hub hitting each other. Starting with most cephalad needle gets around this often


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agree completely. Start with most caudal needle and make it as caudal as possible, and work cranially. if the you need to be an extra 5 degrees cranial at a particularly level, its no problem and easy to adjust on the fly.

 

[Ligament]

I definitely experience those issues and have slightly changed the obliquity if necessary for proper placement.

Agree, or you could use a longer needle so the hubs do not touch each other and get in the way.

I find this to occur in about 25% of my patients, but it is only a problem in about .5% of them. In other words, common issue but you will find ways to easily adapt.

Just changing the obliquity a few degrees is sufficient.

 

[drusso]

I know that time is money and all of us are looking to do as much as we can in as short a period of time as can be done safely and effectively. Hence, I suspect most of us are lesioning multiple levels simultaneously. However, as I am paying more attention to squaring every endplate individually and then declining 30-35 degrees I am finding that my needles are at times entering the skin really close to one another making placing the needles coaxially a real challenge on some. Today I used the Milt Landers technique and placed the needle and lesioned prior to moving on to the next level. Not fast but sure made needle placement easier with no other needles sitting in the way. Anyone else experiencing these challenges or are most squaring one endplate and using that angle for all subsequent levels?

I didn't know it was called the "Milt Landers" technique but I've done this for years...

 

[NJPAIN]

I gave it that name. It makes a lot of sense to me especially if patient is receiving no sedation. Why deal with other needles in the way and loosing optimal position on needles as patient wiggles around? Obviously it is not the way most are doing this otherwise no one would be making those multichannel Rf generators.


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[Ducttape]

but doesn't this greatly increase your time? or do you place the subsequent needles while you are "burning"?

I don't do more than 2 levels a session, but it still takes me a good 30 minutes to position and do primary and secondary burns... (I know, I could spend less time worrying about getting it in "just the right location", but isn't that what this procedure is about?)

 

[drusso]

but doesn't this greatly increase your time? or do you place the subsequent needles while you are "burning"?

I don't do more than 2 levels a session, but it still takes me a good 30 minutes to position and do primary and secondary burns... (I know, I could spend less time worrying about getting it in "just the right location", but isn't that what this procedure is about?)

Yes. slows it down...

 

[NJPAIN]

but doesn't this greatly increase your time? or do you place the subsequent needles while you are "burning"?

I don't do more than 2 levels a session, but it still takes me a good 30 minutes to position and do primary and secondary burns... (I know, I could spend less time worrying about getting it in "just the right location", but isn't that what this procedure is about?)

I agree, getting it in the correct location is what it is all about. It takes me 30-45 minutes to do 2-3 levels respectively. The other day a case took me even longer because after I lesioned at L3 and the sacral ala I didn't like my placement at L4 and L5. I had struggled with overlapping needles at those levels. Pulled needles out and positioned again. I could easily have just lesioned and not bothered to seek perfection.

Results could still be sh-t but I gave it my best shot.


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