MBB tip

[med7343]

I do Bilateral 3 level MBB with only local and 25G 3.5 inch needle
Almost all Patient complaint about it being intolerable
I do 8 local and then 8 needle pokes
I am thinking about using no local on the skin at all maybe same discomfort but more efficient?
any one of you got any tips to make it comfortable without using sedation

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[SommeRiver]

Do not consider sedation for MBB

For every 4cc lido 1% add 1cc bicarb

Straight needles - Steering hurts

Play music

My procedures are basically a "hang out" where me, the pt, XRAY tech and nurse are shooting BS and talking about movies, music, food, our families, etc...

No such thing as a free lunch - Pt may feel the shot and it may even be uncomfortable to a degree but come on...It is a medical procedure for God's sake...Not everything is 100% easy in life.

 

[MD87]

I almost never do 3 level. I do L3-5 most of the time, so only 6 needles. No local. 25g. If they are very large, I will use a little bit of local and 22g. Most people tolerate it relatively well. It’s not a fun procedure for them, but it shouldn’t be terrible. If it is, that is usually a red flag that the RFA is not going to work...

 

[paindoc007]

Local prior to 25G needle is fairly useless in my opinion. Increases pain not comfort. But if you insist, a splash of bicarb takes the burn out of your lido

 

[Espn123]

2 needles sticks and redirect the needle for 3 levels/2 joints

 

[SommeRiver]

2 needles sticks and redirect the needle for 3 levels/2 joints

Cervical I do one needle per joint, so a C3-6 MBB is one needle at C3-4 and one at C5-6.

 

[xvaderx]

2 needles sticks and redirect the needle for 3 levels/2 joints

yes

 

[Baron Samedi]

2 needles sticks and redirect the needle for 3 levels/2 joints

Ends up being more fluoro time and slower

 

[Laryngospasm]

Why are you doing separate pokes for every level? Pt. Must feel like a pin cushion. Two pokes.. one for each side and redirect. And do the same for facets and tfesi. Not sure I agree on more flouro time. And for those of you in PP the cost of 8 needles vs 2 adds up.

 

[DOctorJay]

I do these with a 25 gauge needle, no skin wheal. Any procedure I can do with a 25 gauge doesn’t get a skin wheal.

 

[pmrmd]

One stick each side with 25g spinal, redirect to get three joints--4sec fluoro time per target is the norm.

 

[SSdoc33]

No skin wheal for mbb. 1 needle on each side makes sense for saving money, not patient comfort

There is no way to make it painless. You shouldn't routinely be blocking 3 facets (4 medial branches) on each sides. That's a lot.

I suspect if you can get in and out faster with fewer redirections, your patients will tolerate it better.

 

[painfree23]

2 needles sticks and redirect the needle for 3 levels/2 joints

Can u explain this please?

 

[Espn123]

Can u explain this please?

Insert the needle at the middle level, then pull back to the skin and redirect superiorly and inferiorly. You are doing it without a co-axial view for two of the 3 levels

 

[Taus]

I think that works better on a cervical lateral approach mbb given how superficial it is. For a lumbar depth, going out of plane with a 25 g, redirecting needle to get precision target of mbb.... more painful and time consuming imo then quickly going skin to bone in coaxial x3. Would be much easier with a 22g. Perhaps you’re just better than me.
I find a 25g no skin local very fast and well tolerated. One needle per site. Will reuse if bilateral.

 

[callmeanesthesia]

I think that works better on a cervical lateral approach mbb given how superficial it is. For a lumbar depth, going out of plane with a 25 g, redirecting needle to get precision target of mbb.... more painful and time consuming imo then quickly going skin to bone in coaxial x3. Would be much easier with a 22g. Perhaps you’re just better than me.
I find a 25g no skin local very fast and well tolerated. One needle per site. Will reuse if bilateral.

I agree. I use that technique for cervical but for lumber I do one needle per level. For lumbar, 25g and no local unless the patient asks.

 

[deleted131481]

I think that works better on a cervical lateral approach mbb given how superficial it is. For a lumbar depth, going out of plane with a 25 g, redirecting needle to get precision target of mbb.... more painful and time consuming imo then quickly going skin to bone in coaxial x3. Would be much easier with a 22g. Perhaps you’re just better than me.
I find a 25g no skin local very fast and well tolerated. One needle per site. Will reuse if bilateral.

I picked up the cervical mbb technique from here, likely from one of your posts. It has made these much faster and more comfortable for the patient.

 

[Ferrismonk]

Don't use local on the skin, hurts more in my experience.
Use 25G if you can, they hurt a lot less than 22G. This will require some practice.
The biggest factor for patient pain is moving the needle. The less you do the better.

One stick each side with 25g spinal, redirect to get three joints--4sec fluoro time per target is the norm.

I use the 3-4 needles and am usually 4-6sec fluoro time altogether.

 

[perromaxfilm]

Try an injection with lidocaine and bicarb and one without bicarb on Yourself! Bicarb can help though it adds costs. Tight skin wheels hurt - anesthetize superficial tissue and maybe a bit deeper without leaving that "quarter" imprint on their back.

 

[pmrmd]

Don't use local on the skin, hurts more in my experience.
Use 25G if you can, they hurt a lot less than 22G. This will require some practice.
The biggest factor for patient pain is moving the needle. The less you do the better.


I use the 3-4 needles and am usually 4-6sec fluoro time altogether.

I think my techs use 3-5 sec just getting the spine imaged appropriately, with tilt and obliquity, before I even start.

 

[Nodolor]

Why are you doing separate pokes for every level? Pt. Must feel like a pin cushion. Two pokes.. one for each side and redirect. And do the same for facets and tfesi. Not sure I agree on more flouro time. And for those of you in PP the cost of 8 needles vs 2 adds up.

I have used one needle for multiple sites, why wouldn't you?

 

[Ligament]

Lumbar I use a single 22ga 5" and redireect for L2-L5 medial branches. Works 95% of the time. Seems more comfortable for the patients. Cheaper. Neurograms generally not as pretty as using a single spinal needle per level. I always mix contrast with my local for MBBs.

 

[painfree23]

Lumbar I use a single 22ga 5" and redireect for L2-L5 medial branches. Works 95% of the time. Seems more comfortable for the patients. Cheaper. Neurograms generally not as pretty as using a single spinal needle per level. I always mix contrast with my local for MBBs.

What does everyone mean by redirect? You start at the L5 and then tunnel it all the way under the skin to get eventually to L2? That seems so much more painful than a single site straight down at l2

 

[Ligament]

What does everyone mean by redirect? You start at the L5 and then tunnel it all the way under the skin to get eventually to L2? That seems so much more painful than a single site straight down at l2

Yup that is correct.

Sounds more painful but folks are most sensitive at the skin, and then at the thoracodorsal fascia. So, one skin poke vs. 4.

 

[hyperalgesia]

I make a skin wheal with a 30g 1/2 inch needle. If they make a big deal about it, I show them the needle and it usually elicits a laugh and disarms them.

 

[pmrmd]

What does everyone mean by redirect? You start at the L5 and then tunnel it all the way under the skin to get eventually to L2? That seems so much more painful than a single site straight down at l2

Start at the middle level and redirect cephalad and caudal to hit your targets. It is far less painful than multiple pokes and patients are happy when I tell them I used one poke to get everything I’m trying to block.

No skin wheal for mbb. 1 needle on each side makes sense for saving money, not patient comfort

There is no way to make it painless. You shouldn't routinely be blocking 3 facets (4 medial branches) on each sides. That's a lot.

I suspect if you can get in and out faster with fewer redirections, your patients will tolerate it better.

It depends on the patients about the number of levels treated. Oldster with scoliosis may have well more than three painful levels because the symptoms are not necessarily bilateral but on different sides of the curve. Every old lady I see is like this, I swear, so it is almost routine, at least for me. These administrative procedural limitations make me want to get all I can for people.

 

[SSdoc33]

Start at the middle level and redirect cephalad and caudal to hit your targets. It is far less painful than multiple pokes and patients are happy when I tell them I used one poke to get everything I’m trying to block.

It depends on the patients about the number of levels treated. Oldster with scoliosis may have well more than three painful levels because the symptoms are not necessarily bilateral but on different sides of the curve. Every old lady I see is like this, I swear, so it is almost routine, at least for me. These administrative procedural limitations make me want to get all I can for people.

well, now we are getting into the nitty gritty.

i actually like your single entry approach for the concave side of a lumbar curve. you start pretty close together anyway. but of the convex, side, you are way far apart.

in an ugly looking spine, you can easily denervate 3 joints. 3 joints on each side routinely feels like a lot

 

[SommeRiver]

Commonly doing bilateral L3-S1.

 

[painfree23]

Commonly doing bilateral L3-S1.

I sorta agree. What’s the downside of doing one too many? The upside is potential extra pain relief?

 

[Laryngospasm]

If they have demonstrated arthritis at L1-5 like so many do it seems reasonable.

 

[callmeanesthesia]

I sorta agree. What’s the downside of doing one too many? The upside is potential extra pain relief?

More weakness of the multifidus muscle (you get the strongest activation motor testing the L2 MBN so it stands to reason you would preserve some function by sparing it). Medicare restrictions on 2 RF procedures per 12 months - if you are routinely doing each side separately. I only do L3-S1 routinely for those with more extensive degenerative changes, which is mostly the 75+ set with degenerative scoliosis. I figure they have a better chance of taking a year or more to regenerate anyway

 

[Gnarvin]

Commonly doing bilateral L3-S1.

Just out of curiosity, do you mean L3 to S1 facet joints, or L3 to S1 medial branches? In my fellowship we commonly did L3 and L4 medial branch and L5 dorsal ramus blocks/rfa, but did not block any S1 contribution. Is there thought to be contribution from S1 to the L5/S1 facet joint?

 

[lobelsteve]

Just out of curiosity, do you mean L3 to S1 facet joints, or L3 to S1 medial branches? In my fellowship we commonly did L3 and L4 medial branch and L5 dorsal ramus blocks/rfa, but did not block any S1 contribution. Is there thought to be contribution from S1 to the L5/S1 facet joint?

Old literature was 15% contribution.

 

[painfree23]

More weakness of the multifidus muscle (you get the strongest activation motor testing the L2 MBN so it stands to reason you would preserve some function by sparing it). Medicare restrictions on 2 RF procedures per 12 months - if you are routinely doing each side separately. I only do L3-S1 routinely for those with more extensive degenerative changes, which is mostly the 75+ set with degenerative scoliosis. I figure they have a better chance of taking a year or more to regenerate anyway

I don’t get this Medicare rule, can you explain using facet joints to make it more clear?

 

[Gnarvin]

Sorry for more questions, but does that mean more current literature doesn't show a contribution from S1 to L5/S1 facet joint? Does 15% mean that there was contribution of S1 in 15% of the population or that S1 contributed to 15% of the innervation of the L5/S1 facet joint in the population in general?

 

[callmeanesthesia]

I don’t get this Medicare rule, can you explain using facet joints to make it more clear?

In my area (Noridian Medicare LCD, California) max 4 joints per session, 2 sessions per rolling 12 month period, per spine region (cervical/thoracic count as one region, lumbar as another). So if you do L3-4, L4-5, L5-S1 unilateral, then bring them back 2 weeks later for the other side, that’s 2 sessions, and it’s 12 months before they can have it repeated.

 

[DrSpine]

For Lumbar MBBs, I typically just do b/l L4-L5 and L5-S1 if its bilateral pain. If unilateral, I do L3-4, L4-5, and L5-S1. Just the way they did it in training, and what I still do. If relief, I'll then do L3-4, L4-5, and L5-S1 RFA.

 

[painfree23]

Yup that is correct.

Sounds more painful but folks are most sensitive at the skin, and then at the thoracodorsal fascia. So, one skin poke vs. 4.

Are you changing the fluoro at all? Cephalad/ Caudad?

 

[bedrock]

It's more accurate for your MBB to be perpendicular to the target. less overflow onto other structures.

This is per Paul Dreyfuss. Came up in fellowship.

 

[mja75]

Buffered lidocaine will increase patient comfort significantly. Low cost and very effective.

 

[clubdeac]

Buffered lidocaine will increase patient comfort significantly. Low cost and very effective.

Where can one buy this or do you have to add bicarb yourself?

 

[SommeRiver]

I mix 1cc bicarb into every 4cc lido.

It makes a difference, truly.

Be careful though, an 18g needle for drawing meds will tear up the rubber stopper on top of a bicarb bottle. I get little chunks of rubber in my lido syringe towards the end of a bicarb bottle.

 

[painfree23]

I mix 1cc bicarb into every 4cc lido.

It makes a difference, truly.

Be careful though, an 18g needle for drawing meds will tear up the rubber stopper on top of a bicarb bottle. I get little chunks of rubber in my lido syringe towards the end of a bicarb bottle.

Nice. I wanna do this but bicarb is $$

 

[NJPAIN]

It's more accurate for your MBB to be perpendicular to the target. less overflow onto other structures.

This is per Paul Dreyfuss. Came up in fellowship.

I’ve had a respected (by me) senior SIS guy tell me that a posterior approach to MBB is not a validated technique and therefore a sham procedure.

 

[deleted875186]

I’ve had a respected (by me) senior SIS guy tell me that a posterior approach to MBB is not a validated technique and therefore a sham procedure.

I don’t understand

 

[SommeRiver]

All my MBB are straight down to the jxn of TP and SAP. I may occasionally oblique ipsilaterally a little bit, but an MBB isn't an RFA and there's no need to treat it as such.

Where am I going wrong?

 

[NJPAIN]

I don’t understand

I was talking about cervical.

 

[pmrmd]

I’ve had a respected (by me) senior SIS guy tell me that a posterior approach to MBB is not a validated technique and therefore a sham procedure.

Disagree. Makes no sense. Blocks can can performed like an RF.

 

[NJPAIN]

Disagree. Makes no sense. Blocks can can performed like an RF.

I would not go as far as to call it a sham procedure but I would say that you are more likely to reliably hit your target with a good lateral view and touching down perpendicular to bone using 0.3-0.5 Ml. Lots of variables with posterior approach not the least of which is that the stream of LA is exiting in an anterior orientation. Needle in too anterior or not close enough to lateral mass and the LA is missing the mb.
That said, if for safety, speed, comfort, etc you are OK with some false negatives I can’t fault you.

 

[BobBarker]

I tried lateral. Very hard to visualize c6 and c7. It was quite nice for the more superior levels.