Lumbosacral RFA Benefit

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hopefulgasman

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I know this has been beaten like a dead horse (or not), but being that the lumbosacral RFA is our annuity and true bread winner, I wanted to query you smart folks again.

It has been my experience that the cervical RFA absolutely works like a charm. I have never had a patient say that it didn't provide some benefit and never had a patient that made it through MBB x2 to RFA not get at the very least 50% relief (the majority report 70-100% relief) regarding their axial neck pain with no regrets having gone through the trouble of 3-4 procedures (I warn about head drop with bilateral, and some have opted for unilateral at a time).

The lumbosacral RFA has been far more variable for me. I have had some patients get through MBB x2 80-100% relief, only to obtain zero benefit from the RFA, unfortunately. I don't believe I missed ablating the medial branches as I perform the procedure as consistently as possible technique-wise and do get 100% relief regarding their axial low back pain from time to time.

I might be being too hard on myself expecting 80-100% relief with the lumbar RFA similar to the cervical RFA. I've even considered attending a course to try to beef up my lumbar RFA benefit up to my cervical RFA.

Regarding your lumbosacral RFA that "works", what kind of benefit are you obtaining and what would you call a win? At least 50% relief as reported by the patient?

What about those that say "I got 30-40% relief." Is this "some relief" better than no relief or considered a failure in your eyes (and the insurance company)?

Appreciate your anecdotal responses.
 
LOL. I had opposite experience. Lumbar RF much higher success rate than cervical. But...I had lumbar RF down to a science. I had the angles figured out from the MRI. Cervical was more problematic for me. Conclusion...it was my technique. That does not mean your lumbar technique is poor, but my cervical tech I think was not nearly as good as my lumbar. Got a question though...do you use different electrodes for cervical vs low back? Different machine? Different x-ray tech? Different facility? Times/diameters? Stimulation numbers?
 
hopefulgasman said:
I know this has been beaten like a dead horse (or not), but being that the lumbosacral RFA is our annuity and true bread winner, I wanted to query you smart folks again.

It has been my experience that the cervical RFA absolutely works like a charm. I have never had a patient say that it didn't provide some benefit and never had a patient that made it through MBB x2 to RFA not get at the very least 50% relief (the majority report 70-100% relief) regarding their axial neck pain with no regrets having gone through the trouble of 3-4 procedures (I warn about head drop with bilateral, and some have opted for unilateral at a time).

The lumbosacral RFA has been far more variable for me. I have had some patients get through MBB x2 80-100% relief, only to obtain zero benefit from the RFA, unfortunately. I don't believe I missed ablating the medial branches as I perform the procedure as consistently as possible technique-wise and do get 100% relief regarding their axial low back pain from time to time.

I might be being too hard on myself expecting 80-100% relief with the lumbar RFA similar to the cervical RFA. I've even considered attending a course to try to beef up my lumbar RFA benefit up to my cervical RFA.

Regarding your lumbosacral RFA that "works", what kind of benefit are you obtaining and what would you call a win? At least 50% relief as reported by the patient?

What about those that say "I got 30-40% relief." Is this "some relief" better than no relief or considered a failure in your eyes (and the insurance company)?

Appreciate your anecdotal responses.
Click to expand...

Can you post some procedure images? Gauge, temperature, duration, number of burns?

Also, still need to consider placebo responses on the MBB. What volume of anesthetic?

If they don’t have pain with extension/rotation and localized tenderness… highly sensitive, but poorly specific findings, it just the ain’t the facets.

Also, if it is a younger or middle-aged patient without severe disc height collapse or some other unusual anatomical finding… It’s highly unlikely to be the lumbar facets. Destined to fail


I’ve been doing this over a dozen years now… If I need the Mbb to convince me that it’s the facets in L spine….. it’s highly unlikely the facets. I used to go out on a limb more… and still “try it”…. That leads to very mixed to poor responses.
 
hopefulgasman said:
I know this has been beaten like a dead horse (or not), but being that the lumbosacral RFA is our annuity and true bread winner, I wanted to query you smart folks again.

It has been my experience that the cervical RFA absolutely works like a charm. I have never had a patient say that it didn't provide some benefit and never had a patient that made it through MBB x2 to RFA not get at the very least 50% relief (the majority report 70-100% relief) regarding their axial neck pain with no regrets having gone through the trouble of 3-4 procedures (I warn about head drop with bilateral, and some have opted for unilateral at a time).

The lumbosacral RFA has been far more variable for me. I have had some patients get through MBB x2 80-100% relief, only to obtain zero benefit from the RFA, unfortunately. I don't believe I missed ablating the medial branches as I perform the procedure as consistently as possible technique-wise and do get 100% relief regarding their axial low back pain from time to time.

I might be being too hard on myself expecting 80-100% relief with the lumbar RFA similar to the cervical RFA. I've even considered attending a course to try to beef up my lumbar RFA benefit up to my cervical RFA.

Regarding your lumbosacral RFA that "works", what kind of benefit are you obtaining and what would you call a win? At least 50% relief as reported by the patient?

What about those that say "I got 30-40% relief." Is this "some relief" better than no relief or considered a failure in your eyes (and the insurance company)?

Appreciate your anecdotal responses.
Click to expand...
I have a similar experience. My cervical RFA has an excellent success rate. Many home runs on terrible arthritis. Much more variable with lumbar. I use SIS technique. Definitely over 50% in lumbar with very good results, maybe 70%. Cervical is 90+%. I figure low back pain is just so multifactorial. I tend to have disappointing RFA results with bad lumbar scoliosis patients who got relief from MBB. Not sure why. I usually will go back and do facet steroid injections with those.
 
hopefulgasman said:
I know this has been beaten like a dead horse (or not), but being that the lumbosacral RFA is our annuity and true bread winner, I wanted to query you smart folks again.

It has been my experience that the cervical RFA absolutely works like a charm. I have never had a patient say that it didn't provide some benefit and never had a patient that made it through MBB x2 to RFA not get at the very least 50% relief (the majority report 70-100% relief) regarding their axial neck pain with no regrets having gone through the trouble of 3-4 procedures (I warn about head drop with bilateral, and some have opted for unilateral at a time).

The lumbosacral RFA has been far more variable for me. I have had some patients get through MBB x2 80-100% relief, only to obtain zero benefit from the RFA, unfortunately. I don't believe I missed ablating the medial branches as I perform the procedure as consistently as possible technique-wise and do get 100% relief regarding their axial low back pain from time to time.

I might be being too hard on myself expecting 80-100% relief with the lumbar RFA similar to the cervical RFA. I've even considered attending a course to try to beef up my lumbar RFA benefit up to my cervical RFA.

Regarding your lumbosacral RFA that "works", what kind of benefit are you obtaining and what would you call a win? At least 50% relief as reported by the patient?

What about those that say "I got 30-40% relief." Is this "some relief" better than no relief or considered a failure in your eyes (and the insurance company)?

Appreciate your anecdotal responses.
Click to expand...

Its 1, 2, or all 3 of these things-----

1- patient selection. Unless patient has history of trauma (MVA, major fall, violence), or autoimmune disease, RFA generally not super effective in patients under 40yrs old
1b- keep in mind the things that mimic lumbar facet OA in that they are often painful with extension (annular tears, stenosis) If one of those is a likely pain generator, then ESI make sense as first step. Patients should not completely fail both ESI and RFA unless you're doing something wrong.
2- sloppy MBB technique- Using more than 0.4ml of bup at any level is asking for a false positive. Contrast also increases MBB accuracy.
3- sloppy RFA technique- Firstly, only use 18G (or larger) cannulae and always lesion at 90 degrees for 90 seconds (longer if you wish).
3b-If you aren't using IPSIS technique for lumbar RFA, then do your patients a favor and go to a IPSIS course that includes lumbar RFA. (CME)

Regarding patient outcomes to be considered a win. Most patients and all US insurance carries consider 50% relief to be sufficient to repeat it again in a year when MB regrow.

If you pay attention to patient selection and MBB/RFA technique then those 3 things your outcomes will improve .

Proper RFA technique is important. I'm definitely not slow, but also I'm not setting records with my RFA times. That said, 95% of my patients for whom I perform cervical or lumbar RFA will achieve 65% relief (or more) for 12 months (or more). Of these patients, the vast majority achieve 75%+ relief. I have very few complete RFA failures.
 
Last edited:
bedrock said:
Its 1, 2, or all 3 of these things-----

1- patient selection. Unless patient has history of trauma (MVA, major fall, violence), or autoimmune disease, RFA generally not super effective in patients under 40yrs old
1b- keep in mind the things that mimic lumbar facet OA in that they are often painful with extension (annular tears, stenosis) If one of those is a likely pain generator, then ESI make sense as first step. Patients should not completely fail both ESI and RFA unless you're doing something wrong.
2- sloppy MBB technique- Using more than 0.4ml of bup at any level is asking for a false positive. Contrast also increases MBB accuracy.
3- sloppy RFA technique- Firstly, only use 18G (or larger) cannulae and always lesion at 90 degrees for 90 seconds (longer if you wish).
3b-If you aren't using IPSIS technique for lumbar RFA, then do your patients a favor and go to a IPSIS course that includes lumbar RFA. (CME)

Regarding patient outcomes to be considered a win. Most patients and all US insurance carries consider 50% relief to be sufficient to repeat it again in a year when MB regrow.

If you pay attention to patient selection and MBB/RFA technique then those 3 things your outcomes will improve .

Proper RFA technique is important. I'm definitely not slow, but also I'm not setting records with my RFA times. That said, 95% of my patients for whom I perform cervical or lumbar RFA will achieve 65% relief (or more) for 12 months (or more). I have very few complete RFA failures.
Click to expand...
There are variations on IPSIS technique that is not the standard but can still get proper positioning..paging taus…

I have yet to try it, but apparently less fluoro, less time, good outcomes
 
I’m just gonna throw this out there..

There’s an attending working with me. She makes probably 15-16k rvu/year and she’s started out with a generous base…

She does maybe 8 seconds of fluoro max for bilateral cervical rfa..she does 10 rfa per procedure session weekly

High patient volume, repeat customers…

Very well liked..been in the community for some time

I’ve been working for a long time, and know very well docs like her…

Over the years in my honest opinion, personality>>skill set in what we do

Makes you wonder about placebo effect
 
With cervical is she just driving it to the lamina near the waist? I saw a pretty talented doc post that on LinkedIn recently. Not the way I would do it but the mb nerve is supposed to be there.
 
BobBarker said:
With cervical is she just driving it to the lamina near the waist? I saw a pretty talented doc post that on LinkedIn recently. Not the way I would do it but the mb nerve is supposed to be there.
Click to expand...
Likely, only the AP views are saved..
 
My theory is once the lumbar facets feel better, patients shift their posture and the change in activity allows them to feel pain from other components (“The relief only lasted a month”)

We stress our lower back more heavily than we use our necks
 
perhaps, but if it only lasted a month, I think it’s more likely the steroid used at the end of it (if it was used)
 
If your lumbar rfa failed and you are confident in your patient selection, clinical picture supporting primarily facet, strict mbbx2 w low volume, high % relief…

Post your rf with 30 degree oblique view after placing however you normally do. I think you will be surprised how often you are still missing the target. Just about every case needs an adjustment in this view on my end after an initial placement in AP/15 to 20 oblique
 
Taus said:
If your lumbar rfa failed and you are confident in your patient selection, clinical picture supporting primarily facet, strict mbbx2 w low volume, high % relief…

Post your rf with 30 degree oblique view after placing however you normally do. I think you will be surprised how often you are still missing the target. Just about every case needs an adjustment in this view on my end after an initial placement in AP/15 to 20 oblique
Click to expand...
You’re talking about the oblique view showing the cannula across the face of the Scottie dog?
 
Dr. Ice said:
Likely, only the AP views are saved..
Click to expand...
terrifying.

cerv RF can be done going straight won in AP and hitting OS...... but you can easily just go right to the spinal nerve that way -- esp if there is no lateral. hard to hit the waist EVERY time
 
SSdoc33 said:
terrifying.

cerv RF can be done going straight won in AP and hitting OS...... but you can easily just go right to the spinal nerve that way -- esp if there is no lateral. hard to hit the waist EVERY time
Click to expand...
It's easy if you go prone. And hit the pillar posteriorly. Then scrape your way out to the waist. Earplugs needed so you can focus over the screams.
 
SSdoc33 said:
terrifying.

cerv RF can be done going straight won in AP and hitting OS...... but you can easily just go right to the spinal nerve that way -- esp if there is no lateral. hard to hit the waist EVERY time
Click to expand...
I don’t think the people with <10s fluoro are getting to the lateral pillar at the waist. I think it’s all on posterior pillar/lamina. Safe, but likely a complete sham procedure.
 
hopefulgasman said:
I know this has been beaten like a dead horse (or not), but being that the lumbosacral RFA is our annuity and true bread winner, I wanted to query you smart folks again.

It has been my experience that the cervical RFA absolutely works like a charm. I have never had a patient say that it didn't provide some benefit and never had a patient that made it through MBB x2 to RFA not get at the very least 50% relief (the majority report 70-100% relief) regarding their axial neck pain with no regrets having gone through the trouble of 3-4 procedures (I warn about head drop with bilateral, and some have opted for unilateral at a time).

The lumbosacral RFA has been far more variable for me. I have had some patients get through MBB x2 80-100% relief, only to obtain zero benefit from the RFA, unfortunately. I don't believe I missed ablating the medial branches as I perform the procedure as consistently as possible technique-wise and do get 100% relief regarding their axial low back pain from time to time.

I might be being too hard on myself expecting 80-100% relief with the lumbar RFA similar to the cervical RFA. I've even considered attending a course to try to beef up my lumbar RFA benefit up to my cervical RFA.

Regarding your lumbosacral RFA that "works", what kind of benefit are you obtaining and what would you call a win? At least 50% relief as reported by the patient?

What about those that say "I got 30-40% relief." Is this "some relief" better than no relief or considered a failure in your eyes (and the insurance company)?

Appreciate your anecdotal responses.
Click to expand...
What do you mean by your percentages?

80% response rate from RFA, or 80% pain relief from those that respond?

I think in the best conditions with the best technique in quality study conditions, only 70% of those that responded to DxMBB will respond to RFA.

I am unaware of any study to show better results than that.
 
epidural man said:
What do you mean by your percentages?

80% response rate from RFA, or 80% pain relief from those that respond?

I think in the best conditions with the best technique in quality study conditions, only 70% of those that responded to DxMBB will respond to RFA.

I am unaware of any study to show better results than that.
Click to expand...
No. What percentage of pain relief does the pt obtain when they are a responder to the therapy.
 
bedrock said:
Its 1, 2, or all 3 of these things-----

1- patient selection. Unless patient has history of trauma (MVA, major fall, violence), or autoimmune disease, RFA generally not super effective in patients under 40yrs old
1b- keep in mind the things that mimic lumbar facet OA in that they are often painful with extension (annular tears, stenosis) If one of those is a likely pain generator, then ESI make sense as first step. Patients should not completely fail both ESI and RFA unless you're doing something wrong.
2- sloppy MBB technique- Using more than 0.4ml of bup at any level is asking for a false positive. Contrast also increases MBB accuracy.
3- sloppy RFA technique- Firstly, only use 18G (or larger) cannulae and always lesion at 90 degrees for 90 seconds (longer if you wish).
3b-If you aren't using IPSIS technique for lumbar RFA, then do your patients a favor and go to a IPSIS course that includes lumbar RFA. (CME)

Regarding patient outcomes to be considered a win. Most patients and all US insurance carries consider 50% relief to be sufficient to repeat it again in a year when MB regrow.

If you pay attention to patient selection and MBB/RFA technique then those 3 things your outcomes will improve .

Proper RFA technique is important. I'm definitely not slow, but also I'm not setting records with my RFA times. That said, 95% of my patients for whom I perform cervical or lumbar RFA will achieve 65% relief (or more) for 12 months (or more). Of these patients, the vast majority achieve 75%+ relief. I have very few complete RFA failures.
Click to expand...
Forgive the question, but if more than 0.4ml of Bup is used and you get a false positive, what else got numb (aside from the mbb)? Is it myofascial? Also, I believe most insurers are now up to 80% relief to require it? Or is that only that they need 80% relief from the MBB to progress to RFA, but 50% relief from RFA to get another RFA
 
TrailRun said:
Forgive the question, but if more than 0.4ml of Bup is used and you get a false positive, what else got numb (aside from the mbb)? Is it myofascial? Also, I believe most insurers are now up to 80% relief to require it? Or is that only that they need 80% relief from the MBB to progress to RFA, but 50% relief from RFA to get another RFA
Click to expand...
Try it yourself. Put 0.5ml contrast on your next mbb.

Then try 0.1-0.2 contrast. You’ll cover mbb just fine
 
Taus said:
I don’t think the people with <10s fluoro are getting to the lateral pillar at the waist. I think it’s all on posterior pillar/lamina. Safe, but likely a complete sham procedure.
Click to expand...

Agree. One of the biggest issues in our field who patients who “failed “ an ESI or RFA because the procedure was performed poorly, and then they either get unnecessary surgery or unnecessary chronic medications because they “failed” interventional treatment
 
bedrock said:
Agree. One of the biggest issues in our field who patients who “failed “ an ESI or RFA because the procedure was performed poorly, and then they either get unnecessary surgery or unnecessary chronic medications because they “failed” interventional treatment
Click to expand...
Too many questions quacks and yahoos doing our procedures. I know a few
 
TrailRun said:
Forgive the question, but if more than 0.4ml of Bup is used and you get a false positive, what else got numb (aside from the mbb)? Is it myofascial? Also, I believe most insurers are now up to 80% relief to require it? Or is that only that they need 80% relief from the MBB to progress to RFA, but 50% relief from RFA to get another RFA
Click to expand...
i use 0.3 ml for cervical, 0.5 for lumbar.

almost all insurers require 80% or greater relief and improved functioning for appropriate duration of local anesthetic for MBB proceed to next step (MBB #2 or RFA), and 50% improvement of pain and improved functioning of >6 months for repeat radiofrequency ablation.
 
Taus said:
I don’t think the people with <10s fluoro are getting to the lateral pillar at the waist. I think it’s all on posterior pillar/lamina. Safe, but likely a complete sham procedure.
Click to expand...
It's interesting, I don't know how people get such low fluoro times even if they are doing procedures correctly. I know I play a role in longer fluoro times, more than likely a result of having reviewed medical board cases for a while and having people in the communities in which I have worked have terrible outcomes.

Do most of you work with the same x-ray techs or RN's? I don't ever work with the same person from week to week and I think it does make an impact. The person running the C-arm normally takes multiple pics just to get to the initial view and still by the time I face the table it's not usually optimal and needs to be adjusted.
 
collimate.

spot image.

pulsed and low dose makes huge difference.

limit continuous fluoro on tfesi to a few seconds.

essentially take the foot pedal away from the doctor.


a standard lumbar epidural in a non obese patient with healthy spine should take no more than 8 seconds fluoro.
 
DrSwede said:
It's interesting, I don't know how people get such low fluoro times even if they are doing procedures correctly. I know I play a role in longer fluoro times, more than likely a result of having reviewed medical board cases for a while and having people in the communities in which I have worked have terrible outcomes.

Do most of you work with the same x-ray techs or RN's? I don't ever work with the same person from week to week and I think it does make an impact. The person running the C-arm normally takes multiple pics just to get to the initial view and still by the time I face the table it's not usually optimal and needs to be adjusted.
Click to expand...
you arent facing the table when your abdominal organs and the back of your skull is getting blasted by radiation?
 
Ducttape said:
collimate.

spot image.

pulsed and low dose makes huge difference.

limit continuous fluoro on tfesi to a few seconds.

essentially take the foot pedal away from the doctor.


a standard lumbar epidural in a non obese patient with healthy spine should take no more than 8 seconds fluoro.
Click to expand...

I agree with this for ESIs. What about fluoro time for bilateral 3-needle RFAs?
 
I did a ESI in a minimal amount of shots on 8 pulses per second and it still showed 9 seconds. I think some c arms probably calculate this differently.
 
i still average 8 seconds. of course, L45 & L5S1 is a little bit more than say L34 & L45, maybe 9 seconds.
 
Ducttape said:
collimate.

spot image.

pulsed and low dose makes huge difference.
Click to expand...
All of this.

Pay attention to total dose rather than fluoro time. Minimize lateral. Accept adequate rather than perfect images. Take a step back before each shot.
 
I'm going to work on making some changes tomorrow. Hoping to see the times come down.
 
DrSwede said:
I'm going to work on making some changes tomorrow. Hoping to see the times come down.
Click to expand...
just dont try to make every picture look perfect. no laterals for TFESIs if the AP looks fine. lots of ways to not have such a heavy lead foot. think about when you actually need to step on the pedal, adn when you are doing it just b/c you dont know what else to do
 
SSdoc33 said:
just dont try to make every picture look perfect. no laterals for TFESIs if the AP looks fine. lots of ways to not have such a heavy lead foot. think about when you actually need to step on the pedal, adn when you are doing it just b/c you dont know what else to do
Click to expand...
Our techs “don’t allow” the docs to use the foot pedal for this reason
 
that is insane. tell your "techs" they can pound sand. you are probably doubling the amount of radiation that you (and they) receive.

so do you have to say "take a pic" every time you want a flouro shot? what about live contrast?
 
I just say “picture” it’s not that bad actually. My numbers are lower and I have been using the shield now where I never did it before
 
it is very easy to say "image" and have the rad tech take the pic. since they press the button, typically only 1 image is taken and not several that can happen when the physician is a little slow on letting up on the pedal.

in addition, it helps to be able to step back from the patient and the c arm, say "image", and thus reduce radiation exposure.



i have been told unequivocally by each and every single rad tech that my exposure numbers are markedly lower than those of colleagues who use the pedal.
 
i dont even say anything, i just use my fingers to communicate and they know what im doing
 
buddababa said:
i dont even say anything, i just use my fingers to communicate and they know what im doing
Click to expand...
I'm known for a lot of hand signals too. drive some of the rad techs nuts which I find funny.
 
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