Medical branch blocks

[NeuroGuyIP]

I have seen a couple of pain docs in private practice use 22 gauge 3.5 inch spinal needles for medial branch blocks saying it is more efficient. They anesthetize skin and some in subq tissue. I am still in fellowship and we always use the 25 gauge needles, but they can be challenging to maneuver and many patients seem really uncomfortable. Curious to hear what gauge needle others use in practice and if using 25 gauge needles, any tips on maneuvering and minimizing patient discomfort?


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[bedrock]

Patients tolerate 25G better. It's easier for the doctor to use 22g, easier for the patient if we use 25g.

The only time I use 22G is if the patient is fat and I need 5 inch needles. The 5 inche 25G needles are harder to navigate than the 22G ones.

There are many patients who will be uncomfortable no matter what needle you're using, generally patients already on opioids, s/p fusion surgery, or with overlapping mental problems.

As you're in fellowship I bet a high percentage of your patients fit one of those categories. Should be less in private practice.

For those you have to decide if you want to give them a light dose of a benzo to help relax them without compromising your results.
Also in private practice, docs who practice at their ASC, often give propfol only for MBB, which most of us here think is overkill, but quite common out in the real world, and does wear off quickly.

 

[painfree23]

I have seen a couple of pain docs in private practice use 22 gauge 3.5 inch spinal needles for medial branch blocks saying it is more efficient. They anesthetize skin and some in subq tissue. I am still in fellowship and we always use the 25 gauge needles, but they can be challenging to maneuver and many patients seem really uncomfortable. Curious to hear what gauge needle others use in practice and if using 25 gauge needles, any tips on maneuvering and minimizing patient discomfort?


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Use 22G on 95% of cases, works great as long as u use good local. The other benefit of the 22g is that it's more versatile, can use for joints etc so it's fine to have wayyy more of those in ur clinic set up instead of different needles for different procedures, just something else to consider

 

[BobBarker]

22g. Drive it down to 12:00 on the pedicle. Too fast and easy.

 

[Tapspatellas]

If I can get there with a 3.5", I've switched to 27G. Hard to drive initially, but get used to it. If you use a coaxial view not hard. I'll do 25G for 4.69"., for the few that I've needed something hint longer than 5", I'll use 22G for the 7".
For my lumbar TFESI I won't typically go with a 25G for longer than 3.5", too much tip deflection with the 4.69" and I want good tip control so I don't stray towards the root.

 

[willabeast]

some of the injection atlas books have some good advice on guiding needles. usually in one of the first chapters.

 

[Taus]

Patients tolerate 25G better. It's easier for the doctor to use 22g, easier for the patient if we use 25g.

The only time I use 22G is if the patient is fat and I need 5 inch needles. The 5 inche 25G needles are harder to navigate than the 22G ones.

There are many patients who will be uncomfortable no matter what needle you're using, generally patients already on opioids, s/p fusion surgery, or with overlapping mental problems.

As you're in fellowship I bet a high percentage of your patients fit one of those categories. Should be less in private practice.

For those you have to decide if you want to give them a light dose of a benzo to help relax them without compromising your results.
Also in private practice, docs who practice at their ASC, often give propfol only for MBB, which most of us here think is overkill, but quite common out in the real world, and does wear off quickly.

Spot on

Try to avoid skin local as they may feel better from your trigger point and get false positive mbb

25g def takes time to master steering as a fellow. Well worth your time to work at it. Key is getting coaxial close to skin as can't easily redirect deeper as much as stiffer needle. 25/27 local needle w a skin wheel is as painful or more (wheel) than just quickly going through skin w 25g 3.5".


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[pastafan]

Agree that bedrock nailed it. IMO if you need propofol for patient to tolerate MBB in private practice then patient probably would not get good results from RFA no matter what you do.

I anesthetize the skin but I have never used a skin wheel for any invasive procedure. Skin wheals hurt. Quickly bury a 27 gauge and inject on the way out. With my patients I am not getting close to the depth for a trigger point injection.

 

[painfree23]

Spot on

Try to avoid skin local as they may feel better from your trigger point and get false positive mbb

25g def takes time to master steering as a fellow. Well worth your time to work at it. Key is getting coaxial close to skin as can't easily redirect deeper as much as stiffer needle. 25/27 local needle w a skin wheel is as painful or more (wheel) than just quickly going through skin w 25g 3.5".


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Amount of fluoro time to get coaxial every few mm with a 25g is not worth it in my opinion. I can do bilateral lumbar mbnbs in under 9 seconds of fluoro with 22g bc they are so easily to direct

 

[Pain_doc]

I use 25g. I stopped numbing up the skin a few years ago when there was a bicarb shortage and patients complained more about the stinging from the local anesthetic in the skin than from the needle being driven. Patients actually tolerate it well.

 

[PapaDosh]

Just curious if anybody out there is using the 16 or 18 g needles that Neurotherm offers when doing a RFA- I couldn't imagine trying to drive one of those without a skin wheal.

 

[bedrock]

Just curious if anybody out there is using the 16 or 18 g needles that Neurotherm offers when doing a RFA- I couldn't imagine trying to drive one of those without a skin wheal.

You have to numb for RFA. Most of us here use 18g RFA cannulae.

I use 25g. I stopped numbing up the skin a few years ago when there was a bicarb shortage and patients complained more about the stinging from the local anesthetic in the skin than from the needle being driven. Patients actually tolerate it well.

No need for skin wheel with 25G needles for MBB. Quicker procedure and less chance of false positive too.

 

[Ligament]

Just curious if anybody out there is using the 16 or 18 g needles that Neurotherm offers when doing a RFA- I couldn't imagine trying to drive one of those without a skin wheal.

I use the 16 ga RF cannulae. Absolutely need skin wheal at least!

 

[NJPAIN]

I use 16 ga for lumbar RF. You need a skin wheal. However, in general, they are better tolerated than I expected. I don't see more complaints from 18 ga up to 16 ga.
Other observations (subject to change without notice):
- The more sedation, the more they move. Local and communication with patient goes a long way.
- I'm currently liking doing one level at a time. In theory, putting all of you needles in and then injecting or lesioning simultaneously sounds really efficient (and that is what I have been doing for years) but doesn't exactly turn out that way for me. It makes getting the needles in at optimal angles a challenge. Furthermore, with every subsequent needle placement comes a patient wiggle that moves your previously placed needle.

 

[epidural man]

OP -

I have the fellows use 22g - at least until they are doing very well, then they can use whatever they want.

2gG+ takes a lot more skill - especially in a squirly, muscle-ly, Marine who "hates needles".

I use 25G so I don't have to use skin local when I am by myself.

Off - topic - but regarding RF. One thing I see all the time (that bugs me) is when physicians - to localize the burn area - use the same volume of local that they used for the Dx MBB. WFT? What kind of specificity are you going for with your local during RFA treatment?

 

[Tapspatellas]

I use 18G for all RF. Wheal and I infiltrate all the way along to os.

 

[painfree23]

OP -

I have the fellows use 22g - at least until they are doing very well, then they can use whatever they want.

2gG+ takes a lot more skill - especially in a squirly, muscle-ly, Marine who "hates needles".

I use 25G so I don't have to use skin local when I am by myself.

Off - topic - but regarding RF. One thing I see all the time (that bugs me) is when physicians - to localize the burn area - use the same volume of local that they used for the Dx MBB. WFT? What kind of specificity are you going for with your local during RFA treatment?

Hopefully they are just using lidocaine for the local before the burn to block the nerve so the burn doesn't hurt...should wear off in a few hours, not sure what specificity you are talking about? Uve already done a diagnostic block hopefully before the burn to prove u got ur target?

 

[cowboydoc]

OP -

I have the fellows use 22g - at least until they are doing very well, then they can use whatever they want.

2gG+ takes a lot more skill - especially in a squirly, muscle-ly, Marine who "hates needles".

I use 25G so I don't have to use skin local when I am by myself.

Off - topic - but regarding RF. One thing I see all the time (that bugs me) is when physicians - to localize the burn area - use the same volume of local that they used for the Dx MBB. WFT? What kind of specificity are you going for with your local during RFA treatment?

I made switch to 25s with slight bend after getting solid with 22s.

Interestingly, I did my first RF with coolief today. The rep told me I "used too much local" when I dropped a healthy ml of local before lesioning. The machine was cutting out because it was requiring too much energy to heat... She said from low impedance because of local.

Sooo, they want you to anesthetize an area smaller than they claim to lesion???

 

[clubdeac]

I made switch to 25s with slight bend after getting solid with 22s.

Interestingly, I did my first RF with coolief today. The rep told me I "used too much local" when I dropped a healthy ml of local before lesioning. The machine was cutting out because it was requiring too much energy to heat... She said from low impedance because of local.

Sooo, they want you to anesthetize an area smaller than they claim to lesion???

She doesn't know what she's talking about... I do cooled all the time. Use 2% lido

 

[epidural man]

Hopefully they are just using lidocaine for the local before the burn to block the nerve so the burn doesn't hurt...should wear off in a few hours, not sure what specificity you are talking about? Uve already done a diagnostic block hopefully before the burn to prove u got ur target?

You use 0.3-0.4ml of local on a Dx MBB because you want to be incredibly specific to just the medial branch. However, when you do RF, no specificity required - so why only use a small amount? Numb the crap out of the area - that high-temp RF sh$t hurts.

 

[Ligament]

I made switch to 25s with slight bend after getting solid with 22s.

Interestingly, I did my first RF with coolief today. The rep told me I "used too much local" when I dropped a healthy ml of local before lesioning. The machine was cutting out because it was requiring too much energy to heat... She said from low impedance because of local.

Sooo, they want you to anesthetize an area smaller than they claim to lesion???

She has no clue. I've localized with 2-3 cc of local per lesion site before (maybe more), no issues. Usually use 1cc but I've used more.

 

[epidural man]

She doesn't know what she's talking about... I do cooled all the time. Use 2% lido

I don't like it. I still do it - but man...I feel uncomfortable with it for some reason. For one, their equipment is horribly designed. It could be 1000x better.

The other day I was using cooled for the knee - and the one placed midline above the patella - was popping. I have heard that before - but it always freaks me out.

 

[clubdeac]

I don't like it. I still do it - but man...I feel uncomfortable with it for some reason. For one, their equipment is horribly designed. It could be 1000x better.

The other day I was using cooled for the knee - and the one placed midline above the patella - was popping. I have heard that before - but it always freaks me out.

Whoa I haven't encountered that yet. Although I haven't done the midline suprapatellar burn yet. Will start doing that. I'd be concerned too though. Think it's the quad tendon popping from the heat?

 

[bedrock]

No sure why cooled RF is necessary. The only time I want a big ass lesion is SIJ RFA.

I worry about burning things I don't intend with cooled RF. Heard about a case of total femoral neuropathy after cooled RF of the hip.

Plus in my mind it's unneccssary health care dollars being spent, other than SIJ RFA.

 

[PapaDosh]

I had a patient last Thursday who seemed to be having more discomfort with the local for skin wheal, and I ended up driving the rest of his 25 g needles sans skin wheal which went much smoother. Thanks for the tips.

 

[Taus]

I had a patient last Thursday who seemed to be having more discomfort with the local for skin wheal, and I ended up driving the rest of his 25 g needles sans skin wheal which went much smoother. Thanks for the tips.

Not uncommon. Instead of a wheel, try burying the 25/27g local needle quickly, then injecting local on the way out. Much better tolerated than a wheal for any injection where you need local.



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[clubdeac]

Not uncommon. Instead of a wheel, try burying the 25/27g local needle quickly, then injecting local on the way out. Much better tolerated than a wheal for any injection where you need local.



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But then you can't see where you injected the local... unless they bleed

 

[pastafan]

But then you can't see where you injected the local... unless they bleed

I mark the site prior to injecting local.

 

[Taus]

But then you can't see where you injected the local... unless they bleed

I leave the needle in. There is then zero question.


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[Ducttape]

I leave the needle in. There is then zero question.


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how many complaints do you get at their follow up about feeling like a needle is still there?

 

[cowboydoc]

I leave the needle in. There is then zero question.


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I tried that, but darn near every patient complained of pain with facet loading immediately post procedure.

 

[painfree23]

how many complaints do you get at their follow up about feeling like a needle is still there?

Yes i hear that too , any thoughts?

 

[Timeoutofmind]

Whoa I haven't encountered that yet. Although I haven't done the midline suprapatellar burn yet. Will start doing that. I'd be concerned too though. Think it's the quad tendon popping from the heat?

I was gonna start entering lateral to medial with this needle as opposed to anterior to posterior in order to avoid poking the tendon...

 

[RM38]

I went on an interview this winter where the guy was using alcohol instead of RF for medial branch neurolysis. Said it was faster, much cheaper and that he felt that he got the same results clinically. Has anyone ever done this before and had success? I did phenol blocks in residency for spasticity, and have done a few for other peripheral neurolytics in fellowship, but the thought of putting alcohol anywhere near the spine would make me nervous.

 

[lobelsteve]

I went on an interview this winter where the guy was using alcohol instead of RF for medial branch neurolysis. Said it was faster, much cheaper and that he felt that he got the same results clinically. Has anyone ever done this before and had success? I did phenol blocks in residency for spasticity, and have done a few for other peripheral neurolytics in fellowship, but the thought of putting alcohol anywhere near the spine would make me nervous.

Your thought process is correct. His is not.

 

[Ligament]

I went on an interview this winter where the guy was using alcohol instead of RF for medial branch neurolysis. Said it was faster, much cheaper and that he felt that he got the same results clinically. Has anyone ever done this before and had success? I did phenol blocks in residency for spasticity, and have done a few for other peripheral neurolytics in fellowship, but the thought of putting alcohol anywhere near the spine would make me nervous.

This guy was either pulling your chain to see if you knew anything about your subspecialty or is a total idiot.

 

[clubdeac]

I know a pain doc down in Jacksonville Florida who does this frequently.... and he's making over 1 mil

 

[SeniorWrangler]

I went on an interview this winter where the guy was using alcohol instead of RF for medial branch neurolysis. Said it was faster, much cheaper and that he felt that he got the same results clinically. Has anyone ever done this before and had success? I did phenol blocks in residency for spasticity, and have done a few for other peripheral neurolytics in fellowship, but the thought of putting alcohol anywhere near the spine would make me nervous.

Wow, that seems risky to me, and I bet it hurts like hell too.

 

[NJPAIN]

Makes no sense. The only reason to use chemical neurolysis for medial branches is to save money and time at the expense of additional risk. The other pain docs in our ASC were using phenol after RF neurotomy. Fortunately, after the NECC disaster, the ASC could not find a source for phenol unless it was custom compounded for each individual patient so they had to stop using it.

 

[RM38]

After watching that guy do some of his other procedures I realized he was not somebody I wanted to work with and took another job the next week. I just wanted to make sure I wasn't totally crazy for thinking everything he did was incorrect. He sedated all of his patients to limit any pain they would feel when he injected.