Would you still use neuromonitoring if you did not own the company?
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Lumbar RFA Technique
Started by jwalker12
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Would you still use neuromonitoring if you did not own the company?
I don’t think it’s medically indicated for anyone to use it during RFA, but I’m also kind of a stick in the mud about a lot of things.
A couple hospitals I've worked at consider posting this kind of information without patient consent a HIPAA violation even if "deidentified". If ever traced back to me, would be all kinds of bad juju through admin. Just not a risk I'm comfortable taking. The image comparisons are phenomenal though.
Is that your partner ? 😂
I have a few other gems I could share but I don't want to take over the thread. We should start a Bad Procedure thread.
this placement could work with cooled or nimbus needles
It's the basic Abbott needle! Ha!
Are there laterals
Honestly please do. It serves as an educational opportunity. I’ve learned from “what not to do” as well as “what to do”. I’d personally enjoy reading why something is suboptimal.
What percent relief do they report?
I love my Coolief. Allows me to be quicker. I target the MBs perpendicular like that.
So you work in a hospital that pays for it I presume?
Yep. I’m aware of the cost the kits. Not something I would pony up myself
I like Trident 100x better than cooled. Drives better, stays in place once you reach the target, shorter lesion time. Never going back to cooled.
And the patient probably ended up with 100% relief for two years afterwards. It always seems to be the wacky placements from some of my colleagues who gain extraordinary benefit.
Avanos reps came by to try to sell me on them. Told me relief is comparable to traditional but just time/fluoro savings.
it's the lazy/fast way for sure, but they should still get relief . maybe this patient has gotten 15mo relief with this approach previously
0 for 3
Haha.
I think ESI outcomes do not have anything to do with procedure technique at times. The RFA seems the opposite.
Rarely see a bad RFA work, and I've done plenty of bad ESIs that completely eradicated pain.
An ugly RFA with steroid is an inaccurate therapeutic MBB if you stop and think about it.
That 1cc of steroid + local spreads quite a bit.
Yes, a rfa with steroid mixed in is very, very close to a 3 level bilateral TFESI.
@MitchLevi it at least looks like he is trying. He has reasonable depth. I have seen much, much worse from docs with both good and bad reputations.
He's a nice guy, does his best.
I've seen a lot worse. That looks like a transitional segment at S1.
Any pics of the worst?
No pics. But way shallow and perpendicular.
This is not at all unusual. I see this all the time coming from practices doing 5-6 procedures/hour. The majority see no “value” in placing needles in an inferior to superior direction parallel to the expected course of the MB. It takes too long. Shoot needles in straight AP and check an oblique…done. Finish off with local and steroid. Then tell the patient what an awesome job you did. Seems to have the same results as doing the procedure correctly.
This is why when patients come in and tell me that they failed RFA, but they have a clinical history, exam, and imaging that supports symptomatic facet OA, I suggest we repeat it. Even if it means another round of MBB.
“I have never repeated RFA on such a patient in my current area where I’ve been the last 3.5 years and the patient has not achieved significantly better pain relief after I perform a proper RFA with SIS technique”
I don’t mean it to sound arrogant but it is true.
The past 18 months I’ve actually even started telling that to second opinion patients now, because it has been easy to fulfill, at least with my local competition.
those MBBs / RF often get denied tho
What exactly is trident? Not familiar
RF TridentTM Cannulae | Diros Technology | Radiofrequency (RF) Pain Management
RF TridentTM Cannulae – Diros Technology manufactures Radiofrequency (RF) pain management and neurosurgical products.
Made by Diros Technology, purchased by Avanos a little bit ago. The hub rotates and deploys the tines. Lesion extends past the needle tip, allowing for direct approach for RFA. Similar idea to cooled. Needles are pricy ($160/each), but contain the electrode , and have a pigtail for giving medication. You place the needle, deploy the tines, test, inject local, and burn, without having to remove/adjust anything. My big complaint with cooled, besides price, is that the stupid cannulas don't stay in place when you remove the stylet, usually requiring redirection once you get the probe in. B/l lumbar RFA takes maybe 10 minutes? Cost doesn't make much sense compared to standard needles, but I like it so much more than cooled.
Interesting. Not my experience at all. But I’ll look into trident as well, thx for the info.
whenever RFAs are discussed, there ends up being a high falutin discussion that a particular technique is the "only one that ever works"...
as always, i wondered "is this the case"?
now mind you, i do position needle tip parallel to the nerve like almost everyone here but know several local practitioners that do not (and are exceedingly efficient at doing so)
i found this study intriguing:
www.ncbi.nlm.nih.gov
the advanced Australian approach - needle tip parallel - does confer benefits from the early Australian technique, but the study did show that that latter technique did work. just not as long and may not
in addition, the study noted significant differences in males and in younger age groups and in those not on pain meds being more successful. however, the older age group felt better quality of life benefits.
however, the study notes that both groups got benefit from the procedure, but states that the early Australian technique provided 1.5 months of reduced pain vs the advanced for 4 months.
main problem with study was retrospective nonblinded nature.
so yes, we can critique the perpendicular technique as not working as long, maybe not as impactful, but it still works.
as always, i wondered "is this the case"?
now mind you, i do position needle tip parallel to the nerve like almost everyone here but know several local practitioners that do not (and are exceedingly efficient at doing so)
i found this study intriguing:
Efficacy of needle-placement technique in radiofrequency ablation for treatment of lumbar facet arthropathy
Many studies have assessed the efficacy of radiofrequency ablation to denervate the facet joint as an interventional means of treating axial low-back pain. In these studies, varying procedural techniques were utilized to ablate the nerves that innervate ...
www.ncbi.nlm.nih.gov
the advanced Australian approach - needle tip parallel - does confer benefits from the early Australian technique, but the study did show that that latter technique did work. just not as long and may not
in addition, the study noted significant differences in males and in younger age groups and in those not on pain meds being more successful. however, the older age group felt better quality of life benefits.
however, the study notes that both groups got benefit from the procedure, but states that the early Australian technique provided 1.5 months of reduced pain vs the advanced for 4 months.
main problem with study was retrospective nonblinded nature.
so yes, we can critique the perpendicular technique as not working as long, maybe not as impactful, but it still works.
Not parallel isn't terrible on it's own, as in good placement deep in the junction, but is when combined with being too superficial, too high on the SAP, too lateral on the TP, all of which I see way too often
That's the problem with straight AP. Most of these facets have hypertrophied sap which makes it hard to not be too dorsal or lateral. At the very least oblique 20 degrees to angle onto the junction if people want to be lazy or fast
I need someone to explain to me how placing a needle tip perpendicular to the nerve works. How does that treat the nerve? We know 100% that with standard RF needles, there is zero percent chance that the heat around the tip does any damage to the nerve.
I would accept an explanation that involves a discussion of a generated magnetic field that acts in a way similar to pulsed RF
Okay go - those who don’t place parallel - give it a go. Explain it.
I would accept an explanation that involves a discussion of a generated magnetic field that acts in a way similar to pulsed RF
Okay go - those who don’t place parallel - give it a go. Explain it.
I do a fair amount of cooled. I hate the needles and design. Although it has improved a lot based on feedback. I do love that they FINALLY bent the probe 90deg. I also love that they gave us a side port to place the local. In my mind, all RF needles should have this.
placebo is one helluva drug
There is some lesioning distal to the tip, just not a lot. Would have to be lucky to get a sufficient burn. (I do parallel placement, don’t make fun of me)
I do parallel placement, but I think the simplest answer is that we are oversimplifying the argument by saying it is “perpendicular placement”. The nerves come down at an angle, so no one is likely doing true perpendicular placement. From Bogduk’s own presentations (attached), what we normally describe as perpendicular placement should capture a chunk of the medial branch, it is just that good parallel placement captures even more. That is all assuming good depth and close proximity to nerve, which is a different argument altogether. I otherwise agree placebo can play a role.
That spine looks too good for the facets to even be causing pain lol..it’s not only bad placement but the patient probably has discogenic pain lol
The lesion is an ovoid shape. That includes an area around the tip. The lesioning affects nerves that are within that ovoid shape.
Parallel placement brings a lot more of the lesion area in contact with the nerve and greater area of lesioning and greater likelihood of success.
(Like others have stated, I place it parallel. Being devils advocate.)
Very little - not enough to hurt a nerve. If you doubt me on this, get a chicken breast - burn a lesion and post the pics here - noting that chicken will be even a larger burn than a human.
I doubt you based on these, but I still think you're going to decrease your chances of success if you aren't parallel. I certainly do not doubt you enough to waste a perfectly good chicken breast!
The Effect of Local Anesthetics and Contrast Agents on Radiofrequency Ablation Lesion Size - PubMed
Lidocaine 2% and iohexol 240, when used as pre-injections in RFAs, were found to be associated with statistically significant increases in lesion surface area. However, RFAs with lidocaine 1%, iohexol 180, or gadodiamide were not found to produce a statistically significant difference in lesion...
pubmed.ncbi.nlm.nih.gov
