MBB volume

[pmrmd]

Literature says over 0.3cc is non-selective. But I've done this little experiment with my medical students multiple times. 1cc of contrast/local stays put. Each picture is 30 seconds apart.

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[pmrmd]

Each picture was 30 seconds apart.

 

[BobBarker]

Yep, 1ml is fine. I just do 1ml of 1% lido before RFA as well.

 

[painfree23]

Yep, 1ml is fine. I just do 1ml of 1% lido before RFA as well.

Wat does the rfa have to do with this?

 

[lobelsteve]

1ml is not fine. Contrast spread on your table is not the same as spread of the anesthetic when patients get up and move around. How do you think SIS developed the guidelines?

 

[SommeRiver]

You know, this is an interesting question I've thought about in the past.

I usually do 0.5 - 0.75 cc per MBB needle. If I did higher volume, what is the structure I've anesthetized that confers a false positive block?

 

[lobelsteve]

0.3 to 0.5 mL.

Recommendations Lumbar MBBs should be performed with <0.5mL (total volume) to reduce spread to adjacent structures.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group | Regional Anesthesia & Pain Medicine

 

[SommeRiver]

Wow...Big PDF. I'll read later today after I fight with my 1140 pt about why I'm not going to start opiates on her...Thanks Steve.

 

[pmrmd]

1ml is not fine. Contrast spread on your table is not the same as spread of the anesthetic when patients get up and move around. How do you think SIS developed the guidelines?

When I inject someone I have them get up and move right then. If I leave an adjacent level out, they know it even 5-10 minutes later. Block the adjacent level and the result changes. This technique appears to provide the same result than when I use SIS technique.

What different methods for blocks have you investigated yourself over the years?

 

[lobelsteve]

When I inject someone I have them get up and move right then. If I leave an adjacent level out, they know it even 5-10 minutes later. Block the adjacent level and the result changes. This technique appears to provide the same result than when I use SIS technique.

What different methods for blocks have you investigated yourself over the years?

I follow the guidelines. I am not an investigator. I read and believe the literature. All hail Nik. (And Charlie, Paul, Rick, Susan, et al.)

 

[SSdoc33]

You know, this is an interesting question I've thought about in the past.

I usually do 0.5 - 0.75 cc per MBB needle. If I did higher volume, what is the structure I've anesthetized that confers a false positive block?

i have always erred on the side off too many false positives vs. too many false negatives b/c there is so little downside to RF. that means more volume with the block. IMHO, SIS guidelines are too rigid. double block with .3 cc will give better results with RF for literature studies. in the real world, you want to capture as many RFs as possible.

 

[SSdoc33]

also, are you going straight AP for your L4?

 

[deleted131481]

I use 0.5cc with guidelines as above. Well placed needles should give you as good or better results as you would in RF. 1cc will cover significantly greater volume than our RF.

I wouldn't oppose with straight to RF in some, but if insurance is requiring 2 blocks may as well make them count.

 

[callmeanesthesia]

How many trials of this did you do? That’s a nice little blob you’ve got there but the contrast spread is often no so neat and tidy. More pertinent to actual practice and not academic papers is that Medicare considers a valid MBB to be 0.5 mL or less so if you get audited and all your op reports show 1mL at each site for your MBBs, they could potentially rake back all your RF payments.

 

[pmrmd]

I’ve done this maybe 10-15 times to show my med students. It’s always the same with 1cc. 2cc travels to an adjacent level.

 

[painfree23]

I’ve done this maybe 10-15 times to show my med students. It’s always the same with 1cc. 2cc travels to an adjacent level.

Do your med students understand wat ur doing and why

 

[pmrmd]

Do your med students understand wat ur doing and why

I have the SIS Guideline book there for them. These are kids going into fields other than this usually. It’s more to make the point to think critically and be reasonable investigators.

 

[SSdoc33]

I’ve done this maybe 10-15 times to show my med students. It’s always the same with 1cc. 2cc travels to an adjacent level.

you'd have to flouro them an hour out, then 2, then 3 then 4 then 5. i dont think you'd even see the contrast after that long, but im not sure.

 

[SSdoc33]

How many trials of this did you do? That’s a nice little blob you’ve got there but the contrast spread is often no so neat and tidy. More pertinent to actual practice and not academic papers is that Medicare considers a valid MBB to be 0.5 mL or less so if you get audited and all your op reports show 1mL at each site for your MBBs, they could potentially rake back all your RF payments.

LCDs vary.

with the collective experience on this board, has anyone had to pay back RFs for not following injectate guidelines? id seriously doubt it

 

[pmrmd]

you'd have to flouro them an hour out, then 2, then 3 then 4 then 5. i dont think you'd even see the contrast after that long, but im not sure.

I'll do 5, 10, 15 minutes next time. That's more than enough for me personally. If you hurt with motion before the shot and can move fully after, I'm moving to RF.

 

[Baron Samedi]

I'll do 5, 10, 15 minutes next time. That's more than enough for me personally. If you hurt with motion before the shot and can move fully after, I'm moving to RF.

Do you do anesthetize the skin and/or soft tissue? Think you'll get a ton of false positives with that criteria.

 

[thiswonthurtabit]

Do you do anesthetize the skin and/or soft tissue? Think you'll get a ton of false positives with that criteria.

Yeah I think the surrounding soft tissues are as big of an issue as worrying about spread to adjacent levels. So many patients I've run across have axial lower back pain exacerbated by standing/walking/extension with positive facet loading that have a strong myofascial component (as strong or stronger than the facet arthropathy). When I do my MBBs I only do skin with no numbing of the tract and use <.5cc/level to reduce false positive rate from numbing myofascial pain. I don't want to burn for myofascial pain and have a 'failed' RFA when it doesn't work.

 

[SommeRiver]

I'll do 5, 10, 15 minutes next time. That's more than enough for me personally. If you hurt with motion before the shot and can move fully after, I'm moving to RF.

That isn't enough for Aetna...I had a woman go from 8 - 3 after her MBB, and she was doing yardwork all day after the blocks. Aetna denied MBB #2, so I did an appeal and spoke to an anesthesiologist and pain doctor who told me it doesn't qualify.

Forget whether or not the patient was doing yardwork all day and generally can't stand for longer than 15 to 20 minutes. He told me his patients are instructed to "go home and take it easy." He did not care when I told him I treat functional status and not pain...I explained to him my patients are instructed to go home and live their life as they would like to live their life...If you want to do yardwork, go F'ing do it.

When the patient called Aetna to dispute my failed P2P, they actually told her I can request a P2P...This is after I had already done one, and the insurance company knows I don't have time to argue over an MBB and potential RFA. The time investment isn't there unfortunately.

I fail to see why MBB are required on a patient with axial back pain, especially if they've failed other conservative treatments and are lit up with facet arthropathy. A 75 yo with large facets should be able to skip the MBB because a failed RFA isn't the same as a failed thrombectomy in a stroke patient.

Your RFA didn't work...Big deal...

Think about this - If I am doing around 200 fluoro procedures per month right now (Sept is trending to 204), and let's say 50% are MBB/RFA (don't know true breakdown but that's an easy number), that is potentially 100 facetogenic interventions, and what...35-40 are RFA maybe?

That is NOT a nontrivial amount of radiation over the course of a year, and definitely NOT nontrivial over a career.

That is thousands and thousands of pictures.

I shouldn't have to do ALL of those MBBs.

 

[NJPAIN]

I see two schools of thought. You can place your needle in the vicinity of the medial branch as seen on a 15-20 degree oblique view without your superior endplate parallel to the x-ray beam, inject 1 ml of contrast followed by 1ml LA. You will have more false positives and more failed RFN. In exchange you will have a lot less radiation exposure, move quicker and have more RFN billed out. On the opposite end you can make certain endplate is square, check a declined view and make certain your needle tip is in the SAP/TP sulcus and then get away with 0.3 ml of contrast and LA. In exchange you get a lot more radiation exposure, and less RFN billed out. If you use only 0.3 ml I believe your needle placement needs to be more precise or you will get a lot of false negative using low volume. I find that nearly 1/3 of the time, especially at L5, when I check a declined view my needle tip is actually half way up the SAP and not close enough to the MB for a low volume injection. I use the "more precise" technique to satisfy my OCD. However, the additional radiation exposure and time involved probably make that a foolish choice.

 

[lobelsteve]

I see two schools of thought. You can place your needle in the vicinity of the medial branch as seen on a 15-20 degree oblique view without your superior endplate parallel to the x-ray beam, inject 1 ml of contrast followed by 1ml LA. You will have more false positives and more failed RFN. In exchange you will have a lot less radiation exposure, move quicker and have more RFN billed out. On the opposite end you can make certain endplate is square, check a declined view and make certain your needle tip is in the SAP/TP sulcus and then get away with 0.3 ml of contrast and LA. In exchange you get a lot more radiation exposure, and less RFN billed out. If you use only 0.3 ml I believe your needle placement needs to be more precise or you will get a lot of false negative using low volume. I find that nearly 1/3 of the time, especially at L5, when I check a declined view my needle tip is actually half way up the SAP and not close enough to the MB for a low volume injection. I use the "more precise" technique to satisfy my OCD. However, the additional radiation exposure and time involved probably make that a foolish choice.

Nope. Put tip in Dreyfuss position 2.

 

[painfree23]

I see two schools of thought. You can place your needle in the vicinity of the medial branch as seen on a 15-20 degree oblique view without your superior endplate parallel to the x-ray beam, inject 1 ml of contrast followed by 1ml LA. You will have more false positives and more failed RFN. In exchange you will have a lot less radiation exposure, move quicker and have more RFN billed out. On the opposite end you can make certain endplate is square, check a declined view and make certain your needle tip is in the SAP/TP sulcus and then get away with 0.3 ml of contrast and LA. In exchange you get a lot more radiation exposure, and less RFN billed out. If you use only 0.3 ml I believe your needle placement needs to be more precise or you will get a lot of false negative using low volume. I find that nearly 1/3 of the time, especially at L5, when I check a declined view my needle tip is actually half way up the SAP and not close enough to the MB for a low volume injection. I use the "more precise" technique to satisfy my OCD. However, the additional radiation exposure and time involved probably make that a foolish choice.

Wats s “decline” view?

 

[SommeRiver]

I don't understand the role of contrast in an MBB.

If you touch os at the jxn of the TP/SAP I would assume you're there and the procedure is done.

What more is there to confirm or do?

Why run live fluoro and soak up talent extra radiation?

 

[Ferrismonk]

One thing not mentioned, extra pain of moving the needle around trying to get a "perfect" placement. That isn't always trivial.

 

[DOctorJay]

I don't understand the role of contrast in an MBB.

If you touch os at the jxn of the TP/SAP I would assume you're there and the procedure is done.

What more is there to confirm or do?

Why run live fluoro and soak up talent extra radiation?

when I used to do these with contrast I'd occasionally pick up some vascular spread meaning potentially I wouldn't get a good block at that level, reposition and reinject. no one else in my group was doing this so I stopped. haven't noticed any less effectiveness without the contrast.

 

[SommeRiver]

#str8ablate
#neverMBB

 

[painfree23]

#str8ablate
#neverMBB

Lol Gluck getting that approved

 

[NJPAIN]

Wats s “decline” view?

It's shown in the SIS technique. Tilt the II toward the feet. If you are on target, in the TP/SAP sulcus, the needle will point obliquely into the sulcus and you will see the tip right in the groove. If you are not in the sulcus you will see the needle tip climb up on the SAP. Yes, extra time and radiation. I use contrast too. I find that there is often vascular uptake and sometimes the contrast flow in a direction away from the groove. Again, extra time and radiation.

 

[Baron Samedi]

You get even less radiation and time loss if by the time you walk in the room the patient is face down, ass up, and ready to inject with your trajectory view already on the screen.

 

[Laryngospasm]

Face down ass up that’s the way I like to stuck

 

[Ducttape]

that might qualify as TMI......

 

[deleted875186]

It's shown in the SIS technique. Tilt the II toward the feet. If you are on target, in the TP/SAP sulcus, the needle will point obliquely into the sulcus and you will see the tip right in the groove. If you are not in the sulcus you will see the needle tip climb up on the SAP. Yes, extra time and radiation. I use contrast too. I find that there is often vascular uptake and sometimes the contrast flow in a direction away from the groove. Again, extra time and radiation.

Can you post a link or something to this?

 

[GoBeers]

Can you post a link or something to this?

I think it's that SIS technique where you line up endplate for given facet level, then oblique ipsilateral 25 degrees and caudal tilt ~45 degrees. then you go co-axial with needle into the junction of the SAP/TP. when you turn AP, the needle is perfectly oblique by Barton's point. On lateral it is perfectly angulated , overlaying the TP but remains posterior to foramen. It's a sweet method but technically you should be adjusting the endplate at every level so then it becomes kind of time intensive in the private practice setting to be quite honest.

Also similarly for cervical medial branch, you caudal tilt until you see the Z joint lines. then you ipsilateral oblique 30 degrees. then you move needle co-axial to the beam and you'll get perfect placement onto the articular pillars in oblique and parasagittal fashion... but again you're supposed to technically adjust for each level with the caudal tilt.

Someone please correct me if i'm wrong. These were techniques i would have liked to really master in fellowship but never got around to it...

 

[TIVAndy]

I think it's that SIS technique where you line up endplate for given facet level, then oblique ipsilateral 25 degrees and caudal tilt ~45 degrees. then you go co-axial with needle into the junction of the SAP/TP. when you turn AP, the needle is perfectly oblique by Barton's point. On lateral it is perfectly angulated , overlaying the TP but remains posterior to foramen. It's a sweet method but technically you should be adjusting the endplate at every level so then it becomes kind of time intensive in the private practice setting to be quite honest.

Also similarly for cervical medial branch, you caudal tilt until you see the Z joint lines. then you ipsilateral oblique 30 degrees. then you move needle co-axial to the beam and you'll get perfect placement onto the articular pillars in oblique and parasagittal fashion... but again you're supposed to technically adjust for each level with the caudal tilt.

Someone please correct me if i'm wrong. These were techniques i would have liked to really master in fellowship but never got around to it...

ha.. this is the first time i'm seeing someone mention barton's point. i couldn't find this terminology ever since my fellowship

 

[NJPAIN]

Can you post a link or something to this?

Here you go. I find the declined view very helpful. I often find that I reposition the needle based on what I see in this view especially at L5 and sometimes at S1/sacral ala. If you are in the camp that does not believe that the needle tip needs to be right in the sulcus and that you can compensate by using a larger volume of LA then this is a waste of time.

 

[NJPAIN]

I think it's that SIS technique where you line up endplate for given facet level, then oblique ipsilateral 25 degrees and caudal tilt ~45 degrees. then you go co-axial with needle into the junction of the SAP/TP. when you turn AP, the needle is perfectly oblique by Barton's point. On lateral it is perfectly angulated , overlaying the TP but remains posterior to foramen. It's a sweet method but technically you should be adjusting the endplate at every level so then it becomes kind of time intensive in the private practice setting to be quite honest.

Also similarly for cervical medial branch, you caudal tilt until you see the Z joint lines. then you ipsilateral oblique 30 degrees. then you move needle co-axial to the beam and you'll get perfect placement onto the articular pillars in oblique and parasagittal fashion... but again you're supposed to technically adjust for each level with the caudal tilt.

Someone please correct me if i'm wrong. These were techniques i would have liked to really master in fellowship but never got around to it...

Since you bring up the SIS cervical MB RFN technique which recommends a 30 degree ipsilateral oblique approach, I'm curious how many on this forum actually oblique that much?

 

[lobelsteve]