MBB injectate?

[CarabinerSD]

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Just wanted to see what people are using for their MBB injectate? I've noticed that 0.25% Bupivacaine for cervical MBB can induce ataxia or dizziness after procedure so thinking about switching entirely to either 1% or 2% lidocaine for MBB injectate. So wondering what your experiences are with different local anesthetics?

 

[Ducttape]

you should be using 2 different agents.

i use 0.25% bupivavaine 0.3 ml. i have not seen that cause ataxia even with grand total of 1.2 ml for bilateral MBB or 1.8 ml for bilateral 2 level MBB.

for the differential block, i use 1% lidocaine in similar amounts.

 

[callmeanesthesia]

I use 0.5% bupi, 0.3 mL per level. Occasionally do get dizziness mainly upper cervical, but I consider that a warning sign to maybe do the RF one side at a time for that patient.

 

[kstarm]

I thought it was mostly the levels that are the issue (3rd occipital) versus the injectate. we generally use 2% lidocaine and 0.5% ropivacaine

 

[SSdoc33]

0.5% bupi

 

[nvrsumr]

1% lidocaine for everything. Kiss

 

[mille125]

Just wanted to see what people are using for their MBB injectate? I've noticed that 0.25% Bupivacaine for cervical MBB can induce ataxia or dizziness after procedure so thinking about switching entirely to either 1% or 2% lidocaine for MBB injectate. So wondering what your experiences are with different local anesthetics?

havent seen that at all

 

[Taus]

havent seen that at all

Pretty much only when I do TON bilateral

 

[BobBarker]

They get dizzy. I give less than .5 ml 1% lido.

 

[painfree23]

Differential technique is too much work and too much to explain to patients who don’t even understand what a medial branch block is

 

[BoardingDoc]

Differential technique is too much work and too much to explain to patients who don’t even understand what a medial branch block is

Agreed. 0.3cc of 1% lido at all sites for me. A differential technique can definitely help cut down on false positives, but is nearly impossible to get reliable answers about even if the patient doesn't have a room temp IQ.

 

[Taus]

Agreed. 0.3cc of 1% lido at all sites for me. A differential technique can definitely help cut down on false positives, but is nearly impossible to get reliable answers about even if the patient doesn't have a room temp IQ.

This. And when both lido and bup provided 100% relief for first few hours, but relief after lido lasted 4 hours, bup lasted 3….. or whichever initial local you used lasted a few weeks….. hard to make sense of it.

I only focus on what happened in first couple hours and check extension/rotation a few mins after procedure. Anything beyond that… who tf knows what it means. I still use lido then bup, but purely to satisfy insurance criteria.

 

[BoardingDoc]

This. And when both lido and bup provided 100% relief for first few hours, but relief after lido lasted 4 hours, bup lasted 3….. or whichever initial local you used lasted a few weeks….. hard to make sense of it.

I only focus on what happened in first couple hours and check extension/rotation a few mins after procedure. Anything beyond that… who tf knows what it means. I still use lido then bup, but purely to satisfy insurance criteria.

I also have them extend/rotate right afterwards. It's usually a pretty striking before/after difference if successful.

Also, which insurance around you requires two different anesthetics? I've heard that from people but I've never actually seen it written in the coverage guidelines for any of my local plans, including medicare.

 

[Taus]

I also have them extend/rotate right afterwards. It's usually a pretty striking before/after difference if successful.

Also, which insurance around you requires two different anesthetics? I've heard that from people but I've never actually seen it written in the coverage guidelines for any of my local plans, including medicare.

It’s been years since I looked… But I just do it that way to be consistent and avoid getting screwed by one of the insurers that mandates it.

Except bilat ton. Lido only. Limiting that vertiginous duration. And if they have a very long drive home or took a benzo or the rare ones that are sedated… Those are all bup so it’s still active when they can really test it.

 

[Asclepius186]

Never ceases to amaze me how much difficulty some people have with the idea of temporary MBB relief. Can put in handouts, discuss it at appt, discuss it pre procedure, and many of them still say “well it didn’t work. Pain came right back the next day.”

 

[CarabinerSD]

1% lidocaine for everything. Kiss

I might just switch to this and simplify my supply ordering for the clinic as a whole.

 

[Dr. Ice]

Bup 0.5 or 0.25 because they drive..I don’t mix it up. I also don’t use lido cause some of them are like “well I had some soreness from the shot so I can’t tell, and then it wore off and I still had pain.” No interest in dealing with that ****. Like it’s a 25 gauge needle. And then I show them that I can flick the needle with my finger and it bends..

 

[Taus]

Bup 0.5 or 0.25 because they drive..I don’t mix it up. I also don’t use lido cause some of them are like “well I had some soreness from the shot so I can’t tell, and then it wore off and I still had pain.” No interest in dealing with that ****. Like it’s a 25 gauge needle. And then I show them that I can flick the needle with my finger and it bends..

Lol same, though for those who squirm and moan on mbb, I show them the stylet from the 25 gauge afterwards.

And then put note in chart that they need a benzo for the RF

 

[Painologist]

2% lido for me always. ~0.3cc.

 

[Dr. Ice]

Lol same, though for those who squirm and moan on mbb, I show them the stylet from the 25 gauge afterwards.

And then put note in chart that they need a benzo for the RF

Yeah..I started just telling them I’ll send them some low dose benzo to take an hour before and they can decide to take it or not

 

[Dr. Ice]

Never ceases to amaze me how much difficulty some people have with the idea of temporary MBB relief. Can put in handouts, discuss it at appt, discuss it pre procedure, and many of them still say “well it didn’t work. Pain came right back the next day.”

Rfa pathway is the worst conversation, in my world worse than stim trials..at least my nevro rep is there to help with those..

 

[Ducttape]

Never ceases to amaze me how much difficulty some people have with the idea of temporary MBB relief. Can put in handouts, discuss it at appt, discuss it pre procedure, and many of them still say “well it didn’t work. Pain came right back the next day.”

i find it has helped by telling them to send in the pain diary the day after the procedure so "we can order the next step, because this injection only lasts today".

 

[Laryngospasm]

Nothing works lol

 

[DrSpine]

Differential technique is too much work and too much to explain to patients who don’t even understand what a medial branch block is

This. I just do Marcaine both times. Good luck explaining to someone who can barely understand temporary relief. My personal favorite, "it didn't work, the pain came right back."

 

[Dr. Ice]

Agree, these people can’t even tie their shoes let alone understand double block paradigm with different anesthetics

 

[BobBarker]

Agree. You tell them in the office. My speech I give about mbb and RFA is very simple, easy to understand. Reiterate it and answer any questions. Give them a fact sheet. And they still don’t understand why we are doing a 2nd block or they are shocked that the first injection was not supposed to last and we have to do another one. Sometimes they complain to the office manager (my wife) that no one has explained the treatment plan to them. I always, always explain it well unless I can tell they are incapable of understanding. If they are not capable, I just say their treatment plan will have two injections that might last a few hours and then the actual procedure we are intending to do that will help them long term.

 

[Laryngospasm]

Agree. You tell them in the office. My speech I give about mbb and RFA is very simple, easy to understand. Reiterate it and answer any questions. Give them a fact sheet. And they still don’t understand why we are doing a 2nd block or they are shocked that the first injection was not supposed to last and we have to do another one. Sometimes they complain to the office manager (my wife) that no one has explained the treatment plan to them. I always, always explain it well unless I can tell they are incapable of understanding. If they are not capable, I just say their treatment plan will have two injections that might last a few hours and then the actual procedure we are intending to do that will help them long term.

Didn’t work doc

 

[joshmir]

1) In the L/S, anybody add epi to their local for the MBB injectate? Low dose Dex? Why or why not?

2) I don’t run into the same issues with patients getting confused on how much time the MBB is supposed to work for as either I or my staff talks to patients after any injection where the anesthetic phase has a diagnostic value - and tell them it’s going to wear off - and we need to test their pain response to manuevers provocative of their baseline pain *now* (while they are in recovery) because it’s going to wear off in a couple hours. Haven’t needed pain diaries.

But, this is not an efficient workflow and will slow things down. But patients always seem to be appreciative and it’s very rare that I ever see RF non-responders

 

[BobBarker]

I have way too much lido 1% with epi. So I am mixing that with .5% ropi for lumbar mbb’s. Works great.

 

[SSdoc33]

I have way too much lido 1% with epi. So I am mixing that with .5% ropi for lumbar mbb’s. Works great.

always a good standard operating procedure. "just use whatever we have in the cabinet"

i do the same thing when making dinner

 

[BobBarker]

Yes. Agreed. Just don’t recommend switching baking powder for baking soda.

 

[Multimodal]

0.25% marcaine for everything except C2. I use lido there. had 3 seconds of sudden asystole immediately after injecting C2 MBN for an RFA with 1 cc of 0.25%. had to have been vascular uptake but aspiration was negative. weird.

I usually draw up 0.5cc of local per level and add 0.5cc of contrast to the mix now that medicare wants us to use contrast with these. it hardly dilutes the local anesthetic and makes it so much easier to not have to swap between 2 different syringes for each level.

 

[Orin]

0.25% marcaine for everything except C2. I use lido there. had 3 seconds of sudden asystole immediately after injecting C2 MBN for an RFA with 1 cc of 0.25%. had to have been vascular uptake but aspiration was negative. weird.

I usually draw up 0.5cc of local per level and add 0.5cc of contrast to the mix now that medicare wants us to use contrast with these. it hardly dilutes the local anesthetic and makes it so much easier to not have to swap between 2 different syringes for each level.

I don't think 0.25% vascular there would have 3 second kinetics. Maybe a vasovagal reaction?

 

[bedrock]

0.25% marcaine for everything except C2. I use lido there. had 3 seconds of sudden asystole immediately after injecting C2 MBN for an RFA with 1 cc of 0.25%. had to have been vascular uptake but aspiration was negative. weird.

I usually draw up 0.5cc of local per level and add 0.5cc of contrast to the mix now that medicare wants us to use contrast with these. it hardly dilutes the local anesthetic and makes it so much easier to not have to swap between 2 different syringes for each level.

the upper cervical blood vessels are so tiny, that it doesn't surprise you couldn't aspirate anything.

 

[clubdeac]

0.25% marcaine for everything except C2. I use lido there. had 3 seconds of sudden asystole immediately after injecting C2 MBN for an RFA with 1 cc of 0.25%. had to have been vascular uptake but aspiration was negative. weird.

I usually draw up 0.5cc of local per level and add 0.5cc of contrast to the mix now that medicare wants us to use contrast with these. it hardly dilutes the local anesthetic and makes it so much easier to not have to swap between 2 different syringes for each level.

What do you mean by C2? TON or are you for some reason targeting above the C2-3 joint line. If so I’d reconsider your technique