Lumbar RFA Technique

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Hey everyone as always thanks in advance for all the guidance.

Are many of you guys lining up the level you are targeting and then going significantly caudad as suggested by SIS to target the MBB better? Any tips on how to do this faster?
 
Nah. Stryker venom 18G creates a 6 cm^3 lesion size. It's huge. Start just a touch caudad to the target(bottom half of the TP) groove in scotty dog view and barely walk off. Take an AP view and make sure not too lateral. Average about 10-12 seconds of fluoro for unilateral usual suspects(3 level).
 
I just start with straight AP for most patients (sometimes a little cephalad or caudal depending on lordosis, iliac crest), advance out of plane. Start all a little lateral. More and more inferior from target the higher up you go i.e. L5 DR straight down, L4 MB start below TP, L3 start at inf endplate, etc. When you go lateral you can see if your angles were good
 
i generally do 20 degree ipsilateral oblique, 15 degrees caudal tilt. aim down the barrel to the TP/SAP junction. confirm on AP that i'm not too lateral of target. then lateral view to advance appropriately.

i think SIS mentions like a 45 degree tilt or something outrageous like that. i feel like the distance of tissue to traverse through is too much.
 
RoloTomassi said:
I just start with straight AP for most patients (sometimes a little cephalad or caudal depending on lordosis, iliac crest), advance out of plane. Start all a little lateral. More and more inferior from target the higher up you go i.e. L5 DR straight down, L4 MB start below TP, L3 start at inf endplate, etc. When you go lateral you can see if your angles were good
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i do the exact same thing. wasnt taught that way, just sort of evolved into it. its funny how different docs end up with the same technique
 
I used 20G 10mm curved tip needles. I oblique ipsilateral somewhere around 15-20 degrees, as long as the iliac crest doesn't block the L5DR. If there is no way, I'll just do the L5DR in AP. I use a little caudal/cranial tilt until I can see all my targets well. I insert all needles at the same time and start somewhere around 4 o'clock to the pedicle (depending on patient habitus) and advance until needle is lying flat on bone at the superior junction of the SAP and transverse process. Test, numb, then burn all at the same time.
 
RoloTomassi said:
I just start with straight AP for most patients (sometimes a little cephalad or caudal depending on lordosis, iliac crest), advance out of plane. Start all a little lateral. More and more inferior from target the higher up you go i.e. L5 DR straight down, L4 MB start below TP, L3 start at inf endplate, etc. When you go lateral you can see if your angles were good
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Same
 
I do 1 needle at a time. Square off endplate. Oblique 15-20 degrees. Insert needle about a level below and slightly lateral to target. 18g venom.

Maybe I should start doing all 3 needles at once. Doesn’t take that much longer to do 1 at a time, except when I have a terrible XR tech.
 
GoBeers said:
i generally do 20 degree ipsilateral oblique, 15 degrees caudal tilt. aim down the barrel to the TP/SAP junction. confirm on AP that i'm not too lateral of target. then lateral view to advance appropriately.

i think SIS mentions like a 45 degree tilt or something outrageous like that. i feel like the distance of tissue to traverse through is too much.
Click to expand...

I echo this technique. Typically with 20 G straight. Two burns 90 sec 80C. Readjust a few millimeters for second burn.

Tried the SIS technique after fellowship - all it gave me was frustration and crazy high fluoro times. Even the instructors admit to not going 45 degrees all the time if you press some of them.

In fellowship we had 18G Cooled RF that you could just do same as MBB with good results. Alas none of that in private practice.
 
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runfastnow said:
I echo this technique. Typically with 20 G straight. Two burns 90 sec 80C. Readjust a few millimeters for second burn.

Tried the SIS technique after fellowship - all it gave me was frustration and crazy high fluoro times. Even the instructors admit to not going 45 degrees all the time if you press some of them.

In fellowship we had 18G Cooled RF that you could just do same as MBB with good results. Alas none of that in private practice.
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No reason to start obliqued. Start AP and put your needle in 3 cm lateral to the target. You don't need all that fluoro over a 30 yr career.

Put all your needles in at the same time. It cuts down fluoro time.
 
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Having done 1 needle at a time before, I think adjusting 3-4 needles at a time between XR shots is quite a bit faster, and a lot less radiation.
 
SIS technique. Beam square to SEP at target level. 15 -20 degrees ipsilateral oblique. Decline II about 30 degrees. Down the beam needle insertion. For L5 DR I decline nearly 50 degrees from square with SEP of sacrum. Ipsilateral oblique 0-5 degrees. I check AP, oblique and lateral. 16 guage conventional cannula. A lot more fluoro than 10 seconds. Any other technique is arguably "unvalidated" if you care. I have to believe that a lot the response to RF is placebo because everyone does whatever technique they dream up, uses cannulae of any size they want and uses a few seconds of fluoro but claims that their results are great.
 
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NJPAIN said:
SIS technique. Beam square to SEP at target level. 15 -20 degrees ipsilateral oblique. Decline II about 30 degrees. Down the beam needle insertion. For L5 DR I decline nearly 50 degrees from square with SEP of sacrum. Ipsilateral oblique 0-5 degrees. I check AP, oblique and lateral. 16 guage conventional cannula. A lot more fluoro than 10 seconds. Any other technique is arguably "unvalidated" if you care. I have to believe that a lot the response to RF is placebo because everyone does whatever technique they dream up, uses cannulae of any size they want and uses a few seconds of fluoro but claims that their results are great.
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I do this as well, oblique 15-20 degrees, no oblique for L5 dorsal ramus. After getting a Scotty dog view I incrementally caudal tilt the image intensifier to as much as possible where I can still see the groove, usually 30 degrees, beyond that it gets really hard to see the TP SAP junction for me. Then I place L3 and L4 MB needles down the barrel. I typically place the L5 needle straight AP and out of plane.
 
Centurion38 said:
I do the SIS technique because my patients aren't on opioids, I see my follow ups and I need the procedure to work
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How much caudal tilt do you use? Do you place needles with a coaxial view or just drive them out of plane?
 
Centurion38 said:
I do the SIS technique because my patients aren't on opioids, I see my follow ups and I need the procedure to work
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Can someone post the SIS technique lumbar RF study that revealed the superior clinical results to previous ISIS technique.

If youve got the study showing larger gauge cannulas provide superior clincial results to smaller guage that would be great too.
 
dipriMAN said:
How much caudal tilt do you use? Do you place needles with a coaxial view or just drive them out of plane?
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30-35 deg except for L5DR which is sometimes more. Needles coaxial.
 
Centurion38 said:
30-35 deg except for L5DR which is sometimes more. Needles coaxial.
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Would be interested if anyone has tips for maintaining goid view with caudal tilt. I find for very degenerated spines, caudal tilt often makes it nearly impossible to identify the groove with caudal tilt. I will often incrementally tilt in 10 degree increments and find once I get around 30 degrees and then it starts to get hard to view.
 
dipriMAN said:
Would be interested if anyone has tips for maintaining goid view with caudal tilt. I find for very degenerated spines, caudal tilt often makes it nearly impossible to identify the groove with caudal tilt. I will often incrementally tilt in 10 degree increments and find once I get around 30 degrees and then it starts to get hard to view.
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no need to waste too much time if you can't see anything. sounds like you have a good technique down.
 
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If it doesn’t work, just contact your local KOL and refer to them for stim for arthritic low back pain. They most definitely have an implantable option. Double leads, burst whatever, hf something or other, lots of letters, not much else..
 
dipriMAN said:
Would be interested if anyone has tips for maintaining goid view with caudal tilt. I find for very degenerated spines, caudal tilt often makes it nearly impossible to identify the groove with caudal tilt. I will often incrementally tilt in 10 degree increments and find once I get around 30 degrees and then it starts to get hard to view.
Click to expand...

I always place a spinal needle at the uppermost target level at a position for MBB. Helps me find the correct level and the groove when I caudal tilt.
 
I’ve been doing 15/15…guess I could try 15/30..L5 always sucks. Results still good with 18 or 20 gauge. In my experience, Rf is a certain % effective, a certain % placebo, a certain % not gonna work despite mbb effectiveness. And no I don’t use steroid for mbb. Maybe just need the extra 15 of caudal tilt..🤷🏽‍♂️

Maybe it’s cause I never recognized vertebrogenic back pain..
 
Dr. Ice said:
I’ve been doing 15/15…guess I could try 15/30..L5 always sucks. Results still good with 18 or 20 gauge. In my experience, Rf is a certain % effective, a certain % placebo, a certain % not gonna work despite mbb effectiveness. And no I don’t use steroid for mbb. Maybe just need the extra 15 of caudal tilt..[emoji2375]

Maybe it’s cause I never recognized vertebrogenic back pain..
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L5 is tougher for anything, especially MBB and MB RFN, given the architecture of the vertebral body is so different from other lumbar levels.
 
NJPAIN said:
I always place a spinal needle at the uppermost target level at a position for MBB. Helps me find the correct level and the groove when I caudal tilt.
Click to expand...
I did this for several years in steep caudal tilt, pretty close to sis. A colleague then suggested I place my rf cannula like I usually would followed by marking my skin entry points with an 18g needle, and then looking in AP….. low and behold I was starting about 1 level down on each, mid to inferior transverse process. Game-changer for me. Next few cases I obliqued 15-20 until junction was crystal clear as I usually would and then placed cannula 1 level down from target, advanced out of plane. Angles to endplates on lateral looked good. Final placement in AP, lateral and 30 oblique were exactly as I’d like. Saves a lot of time and fluoro without sacrificing proper placement or outcomes.
Haven’t looked back.

I think if you place in straight AP, even starting lateral to target and advance out of plane, without checking an oblique (even better is “over oblique” ~30) you can’t guarantee you’re at precise target particularly with hypertrophic sap in ancient spines. Also, even if using venom, without a caudal to cephalad trajectory you will not be lesion if maximal length of nerve.


It really sucks when rf fails as no good procedure options remain. Do it right…
 
Taus said:
I did this for several years in steep caudal tilt, pretty close to sis. A colleague then suggested I place my rf cannula like I usually would followed by marking my skin entry points with an 18g needle, and then looking in AP….. low and behold I was starting about 1 level down on each, mid to inferior transverse process. Game-changer for me. Next few cases I obliqued 15-20 until junction was crystal clear as I usually would and then placed cannula 1 level down from target, advanced out of plane. Angles to endplates on lateral looked good. Final placement in AP, lateral and 30 oblique were exactly as I’d like. Saves a lot of time and fluoro without sacrificing proper placement or outcomes.
Haven’t looked back.

I think if you place in straight AP, even starting lateral to target and advance out of plane, without checking an oblique (even better is “over oblique” ~30) you can’t guarantee you’re at precise target particularly with hypertrophic sap in ancient spines. Also, even if using venom, without a caudal to cephalad trajectory you will not be lesion if maximal length of nerve.


It really sucks when rf fails as no good procedure options remain. Do it right…
Click to expand...

Please explain the “over oblique” as opposed to the oblique concept.
 
NJPAIN said:
L5 is tougher for anything, especially MBB and MB RFN, given the architecture of the vertebral body is so different from other lumbar levels.
Click to expand...
I’ve tried a few different ways, but what I’ve found that works the most reliably for me is I do L5 in true AP. Place my cannula as lateral as the psis will allow, directly medial to it. Advance caudal to cephalad out of plane. Once clearly bypassed psis, then oblique until sap/ala junction is clear and advance to target
 
Can someone explain to me how driving in AP saves fluoro time as compared to an oblique view driving En Face?

I have done it both ways.

I feel like I can get the needle tip where I want it much faster using the dot shot.
 
epidural man said:
Can someone explain to me how driving in AP saves fluoro time as compared to an oblique view driving En Face?

I have done it both ways.

I feel like I can get the needle tip where I want it much faster using the dot shot.
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I agree, I find driving a large 18G cannula out of plane to be challenging and more Fluoro shots.
 
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NJPAIN said:
Please explain the “over oblique” as opposed to the oblique concept.
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Oblique to about 30. I’ll try to dig up some fluoro shots of it. A colleague of mine recommended trying this several years ago. Game changer. You’ll be surprised how frequently you were not dead on accurate after placement in 15-20 oblique and confirming in AP. One or two needle adjustments per procedure will be often needed, particularly in ancient spines with massive hypertrophic SAP. Doing this allows me to confidently say I absolutely covered the medial branch target zone as completely as possible.
 
Taus said:
Oblique to about 30. I’ll try to dig up some fluoro shots of it. A colleague of mine recommended trying this several years ago. Game changer. You’ll be surprised how frequently you were not dead on accurate after placement in 15-20 oblique and confirming in AP. One or two needle adjustments per procedure will be often needed, particularly in ancient spines with massive hypertrophic SAP. Doing this allows me to confidently say I absolutely covered the medial branch target zone as completely as possible.
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Yes I over oblique to 30 degrees to confirm I am in the groove after I place down the barral in a declined and 15-20 oblique view. I find I need to walk off and advance a little deeper and usually adjust medial or lateral a bit, and then just check lateral to confirm safety before testing.
 
Taus said:
Oblique to about 30. I’ll try to dig up some fluoro shots of it. A colleague of mine recommended trying this several years ago. Game changer. You’ll be surprised how frequently you were not dead on accurate after placement in 15-20 oblique and confirming in AP. One or two needle adjustments per procedure will be often needed, particularly in ancient spines with massive hypertrophic SAP. Doing this allows me to confidently say I absolutely covered the medial branch target zone as completely as possible.
Click to expand...

I always oblique to 45 degrees with the beam square to the SEP. Will 30 provide more benefit or just less travel from 15 degrees?
 
I used to not do laterals early on, but when I started doing them routinely I was surprised at how often I was too posterior, rather than near posteroinferior foramen (esp L5 DR), and how often I thought my cephalad angle was good on AP but was really quite perpendicular.
 
Baron Samedi said:
In a healthy spine with a decent tech 10-12 seconds using the technique I mentioned above for unilateral L3-L4-L5. I also don't routinely use laterals unless abnormal motor stim which cuts down on exposure.
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I thought most consider multiplanar view fluoroscopy was a better safety check than motor stim
 
RoloTomassi said:
I used to not do laterals early on, but when I started doing them routinely I was surprised at how often I was too posterior, rather than near posteroinferior foramen (esp L5 DR), and how often I thought my cephalad angle was good on AP but was really quite perpendicular.
Click to expand...

What prompted you to start doing them? Failed response to tx? Weird testing patterns?
 
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dipriMAN said:
I thought most consider multiplanar view fluoroscopy was a better safety check than motor stim
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Well I do check an AP in addition to the oblique view. I check motor up to 2.0 at every level. None of my patients get more than PO Valium either, which helps with safety. I suppose if I ever get a nerve root injury doing that I'd question it.

If they have unusual anatomy or poor bone density then I'll check a lateral, but usually not the case.

I'll give it a try for a bit though and see how much it affects my placement.
 
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Baron Samedi said:
What prompted you to start doing them? Failed response to tx? Weird testing patterns?
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Most of my attendings didn't, nor did my colleague at my first practice. But then I started thinking for myself more about how to optimize quality while still balancing efficiency. Laterals a must for me. I do an oblique shot on the way to lateral, and it almost always looks good, even when the lateral doesn't.
 
bedrock said:
Really bad idea not to do laterals for RFA. Your depth is wrong a high percentage of the time without them. Particularly on ancient spines.

Not just too far but also not far enough. Makes a big difference with longevity of relief after RFA.
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Funny thing is - when I drive OUT of plane (as people are calling it), I find I have to move the needles much more often after moving to lateral. When I rotate oblique, and caudad- and drive en face, hit Os, turn away, advance a little - then go lateral...almost always the needles are placed perfectly. Adjustments rarely needed.
 
Baron Samedi said:
In a healthy spine with a decent tech 10-12 seconds using the technique I mentioned above for unilateral L3-L4-L5. I also don't routinely use laterals unless abnormal motor stim which cuts down on exposure.
Click to expand...

First - I seem to never work on a healthy spine. Most of my patients are > 70. Second - sadly we don’t have techs who know the radiographic landmarks. So I’m starting AP and setting up my own views. My fluoro time is from start to finish. Doing all that and using SIS technique (with three views per level and some adjustments) my fluoro times are probably triple that. GASP.

I know some well respected people who don’t motor or sensory test but I don’t know anyone who skips the lateral. I would definitely rethink that. That’s the lawyer view.
 
Asking out of complete ignorance- Do any of you do straight AP approach, land at the convergence of the SAP and TP, and burn there? At our academic location we are taught the SIS technique, however on my current rotation at the VA they do the straight AP approach to the SAP/TP basically perpendicular to the site. I haven't seen any of these patients in follow-up so I have no way of gauging which have better outcomes.
 
PainApp2021 said:
Asking out of complete ignorance- Do any of you do straight AP approach, land at the convergence of the SAP and TP, and burn there? At our academic location we are taught the SIS technique, however on my current rotation at the VA they do the straight AP approach to the SAP/TP basically perpendicular to the site. I haven't seen any of these patients in follow-up so I have no way of gauging which have better outcomes.
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:smack:
 
Medial branch ablations were performed prior to Bogduk definitively determining the anatomy.

It’s been a long time since I read these studies but I think it was as far back as the 70s. Patients reported relief but the docs weren’t anywhere near the medial branches
 
PainApp2021 said:
Asking out of complete ignorance- Do any of you do straight AP approach, land at the convergence of the SAP and TP, and burn there? At our academic location we are taught the SIS technique, however on my current rotation at the VA they do the straight AP approach to the SAP/TP basically perpendicular to the site. I haven't seen any of these patients in follow-up so I have no way of gauging which have better outcomes.
Click to expand...
That is the lazy ass way of doing it. Fine if doing cooled RF, but certainly not with conventional needles and still not that great with venom and nimbus etc.

Plenty of local docs do that around here. I see their patients as a second opinion, I redo the RFA with SIS/Dreyfuss technique and they always have dramatically more relief and for well over a year.

I’m not bragging, I’m just telling you to use your VA experience as an example of what not to do.
 
bedrock said:
That is the lazy ass way of doing it. Fine if doing cooled RF, but certainly not with conventional needles and still not that great with venom and nimbus etc.

Plenty of local docs do that around here. I see their patients as a second opinion, I redo the RFA with SIS/Dreyfuss technique and they always have dramatically more relief and for well over a year.

I’m not bragging, I’m just telling you to use your VA experience as an example of what not to do.
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Thank you! What about TFESI with just AP (hitting TP for depth, walking off and curving medial followed by contrast)? Much appreciated. Again I've learned the conventional approaches at our academic site, but all approaches in this rotation are different. The guys here are able to complete procedures in minutes vs the academic side in 15-20 minutes (perfect coaxial view, perfect contrast spreads, always getting safety views), so it was certainly an attractive difference to learn... But not if it is at the expense of patient outcomes. Thank you again
 
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