MBB poll

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Do you numb the skin first when doing MBB's?

  • Yes, I numb the skin/subq first, then advance my spinal needle for MBB

    Votes: 41 57.7%

  • No, I do not use any local anesthic other than at the MBB target

    Votes: 29 40.8%

  • Well, I do something else and I have specified in a comment below

    Votes: 1 1.4%
  • Total voters
    71
Previously I only used LA at the MBB site. Use a 25g 3.5.
Recently, I have had several patients complain of post-procedural needle pain that was making it difficult to differentiate how much relief they received. So I started to numb the tract on my way out which has helped. These are usually the more anxious patients.
 
no local for anything (edit, for BB)
 
MD87 said:
25g 3.5 or 5. No local. Haven’t used a 22g in a few years for MBBs. If they can’t tolerate it (95%+ can), the facets are not the problem.
Click to expand...
I would agree with that. After a decade in practice don’t think I have had someone have a robust response to lumbar RFA after lots of trouble tolerating MBB with a 25 gauge.
 
Thin, reasonable patients - no superficial numbing. Bigger, anxious patients - yes.
 
Interesting comments for sure! Not as simple of a concept as the OP hoped for (or maybe so). Very patient dependent. Agree with others in that patients jumping a off the table from a LA pinprick is a pseudo-red flag.

Im assuming those not using any local do multiple needles at time?
 
I go back and forth. Numbing with a 22g is much faster sometimes.

When the patient squirms and muscle is doing what muscles do, that 25g is not easy to dock - it takes some finesse and time.

I think if speed is your most important goal, local with 22g is better.
 
Bounce back and forth - older person who is somewhat frail = 25 gauge, 50-70 year old guy who refuses/can't give up farming or anyone with psych Lido + 22 gauge for speed.

Sometimes the 25 gauge led to more squirming and patient complaints.
I do like 25 gauge without lido on skinny/average young people when doing TFESI and have used for ILESI with success.
 
I mix lido with sodium bicarb for numbing and use 22g.

Not the most cost-efficient, but I found it to be the best balance for my practice that often includes fellows and patients and staff used to doing IV sedation.
 
If body habitus allows, 25g 3.5” without skin local. If patients have a hard time with it for round one, I’ll use skin and subq local for round 2. I see this most helpful for the neck, but that may relate to my technique. I put one needle in each side to the center target level (e.g C6 for a C5-7), inject, then reorient down to C7, then up to C5.
For bigger patients especiallly with lumbar, 22g 5” with skin local. Used to use 25g but it took much more time to steer them.
 
Anyone using the madajet out there?
 
Many practices in my area sedate for everything, including MBBs, so it's tough to convince most pts to do anything without at least a touch of lido. So usually lido w/25g 3.5" unless 5" needed in which case lido+22g.

On thinner older folks with less robust musculature I'll use a 27g 3.5g w/o lido. Harder to steer but good challenge and patients do great.
 
25g for everyone unless a 5" isn't long enough, at which point I do a 22g 7". I am looking into 23g longer needles.

The smaller the diameter of the needle, the easier the pt's experience, and word of mouth does what it does...Clean, easy procedures result in a 3m wait list.
 
MitchLevi said:
25g for everyone unless a 5" isn't long enough, at which point I do a 22g 7". I am looking into 23g longer needles.

The smaller the diameter of the needle, the easier the pt's experience, and word of mouth does what it does...Clean, easy procedures result in a 3m wait list.
Click to expand...
Let me know if you find a 23G longer than 3.5. I’d definitely use them.

For 3.5 in (normal thickness)patients I use a 23G for everything except MBB and ILESI.
 
bedrock said:
Let me know if you find a 23G longer than 3.5. I’d definitely use them.

For 3.5 in (normal thickness)patients I use a 23G for everything except MBB and ILESI.
Click to expand...
I use thin needles as often as possible. I don't like thin needles in the SIJ bc of the resistance and I am trying to protect my hands from OA. 22g in the SIJ.
 
So so far it seems like things are about 50-50

Looking back at my last few years of practice I feel like I was getting some false positives on medial branch blocks so I’m trying to move away from numbing the skin. I used to only do one set of medial branch blocks for everyone just cause I was trying to save appointments slots and safe patience time and money but with Medicare requiring two sets I’m thinking of doing one set with skin numbing and the other without and comparing the results
 
specepic said:
So so far it seems like things are about 50-50

Looking back at my last few years of practice I feel like I was getting some false positives on medial branch blocks so I’m trying to move away from numbing the skin. I used to only do one set of medial branch blocks for everyone just cause I was trying to save appointments slots and safe patience time and money but with Medicare requiring two sets I’m thinking of doing one set with skin numbing and the other without and comparing the results
Click to expand...
Do one side with, one without, and ask the patients which was worse. That’s how I’ve trialed changes to MBB technique.
 
callmeanesthesia said:
Do one side with, one without, and ask the patients which was worse. That’s how I’ve trialed changes to MBB technique.
Click to expand...
This doesn’t work, I’ve tried several times and patients always think the first side is more painful than the second no matter what.
 
lobelsteve said:
Ill argue if it takes a 7” needle to perform an MBB, don’t.
Click to expand...
my patient population may be a little more gravitationally challenged than yours...

i do have roughly 5 regulars who need 7 inch needles for diagnostic blocks and have had favorable outcomes with RFA (with the 15s). facet arthropathy can happen to anyone.
 
Ducttape said:
my patient population may be a little more gravitationally challenged than yours...

i do have roughly 5 regulars who need 7 inch needles for diagnostic blocks and have had favorable outcomes with RFA (with the 15s). facet arthropathy can happen to anyone.
Click to expand...
www.cdc.gov

New Adult Obesity Maps

Obesity remains high, varies, by state, and affects some groups more than others.
www.cdc.gov www.cdc.gov

I thought we in Georgia were heavier than that.
 
I do an occasional 7" needle. RFA and ESI. Not sure I'd say obese do any worse with procedures than other pts TBH. We want to say they do, but come on...That's not entirely true.

I've got pts weighing under 100 pounds that fail procedures too.
 
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