Post CRFA Neuritis

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giddyup

giddyup

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Just curious how everyone treating post-cervical RFA neuritis? I’ve had two patients call this week with neuritis-type symptoms—sunburn feeling, etc. I feel like I’m extremely meticulous with my needle placement, but I know this happens in a certain percentage of patients regardless of what you do.

I inject 40 mg of Kenalog divided among all the levels after the ablation and lesion at 80 degrees for 120 seconds. Typically, I’ll just give them a Medrol Dosepak or some gabapentin afterward. Does anyone else have any hot tips?
 
Medrol Dosepak and Lyrica/gabapentin. Most likely will improve over time. Would recommend against particulate steroid (especially Kenalog) and go with dexamethasone during the procedure. This is a prominent feature of the procedure if done correctly. In the interest of efficiency, would recommend 85 degrees at 60 sec unless you are doing TON, in which case do 90 sec at that level.
 
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In addition to the above, topical lido ointment or patch. But mostly set expectation that it will probably happen and need to suck it up.
 
Education ahead of time has drastically cut down on the calls about it. Most just tell me “the sunburn feeling” went away a few weeks after rfa when I see them at 6 weeks post
 
I don’t know if I’m doing something wrong compared to you guys but I get about 10% of patients with severe pain afterward. The sunburn feeling is higher than that. I prep them and they usually just mention it later. But patients with 10/10 stabbing pain, neck stiffness, trouble sleeping. I usually do a steroid injection and give them some gabapentin/Lyrica if they’re not already on it, and some Norco. It can take a few weeks to resolve but I’ve had a couple that took months. I burn for 120 seconds, 85 degrees. 18g needles. I’m pretty careful about placement, including CLO almost every time. I tried for a little while positioning the needles further dorsal, so the tips were more mid facet in the lateral, but that seemed to make it much worse.
 
callmeanesthesia said:
I don’t know if I’m doing something wrong compared to you guys but I get about 10% of patients with severe pain afterward. The sunburn feeling is higher than that. I prep them and they usually just mention it later. But patients with 10/10 stabbing pain, neck stiffness, trouble sleeping. I usually do a steroid injection and give them some gabapentin/Lyrica if they’re not already on it, and some Norco. It can take a few weeks to resolve but I’ve had a couple that took months. I burn for 120 seconds, 85 degrees. 18g needles. I’m pretty careful about placement, including CLO almost every time. I tried for a little while positioning the needles further dorsal, so the tips were more mid facet in the lateral, but that seemed to make it much worse.
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feels like you are sacrificing increase post-RF neuritis for greater procedural efficacy.

you are burning the sh$t out of those nerves, which is why you are getting the neuritis. but months 3-12 im sure are great.

im at 20g, 90 sec, 80 degrees C
 
callmeanesthesia said:
I don’t know if I’m doing something wrong compared to you guys but I get about 10% of patients with severe pain afterward. The sunburn feeling is higher than that. I prep them and they usually just mention it later. But patients with 10/10 stabbing pain, neck stiffness, trouble sleeping. I usually do a steroid injection and give them some gabapentin/Lyrica if they’re not already on it, and some Norco. It can take a few weeks to resolve but I’ve had a couple that took months. I burn for 120 seconds, 85 degrees. 18g needles. I’m pretty careful about placement, including CLO almost every time. I tried for a little while positioning the needles further dorsal, so the tips were more mid facet in the lateral, but that seemed to make it much worse.
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It is typically a self limiting issue. I tell patients that. Like Mitch Levi I use Dex. I dont care what the studies say but I can tell you that before I used Dex my neuritis rates were double at least. Like SS Doc I use 20G 80 degrees/90sec. I see some neuritis but not nearly as high as what has been quoted here. I dont know why but it is what it is.

If you are getting the expected response rate from your RFAs, I would not worry about anyone telling you anything about your technique. Two years ago I studied about 500 of my own patients retrospectively. 478 had greater than 50% relief for at least 6 months which was my benchmark for success. I suggest you do the same study for your own patients. If you are greater than 90% at your endpoint (whatever it is) then you are not doing anything wrong and should continue as you are. Placebo effects are not nearly that high so it is your technique.

Just my 2 cents.
 
callmeanesthesia said:
I don’t know if I’m doing something wrong compared to you guys but I get about 10% of patients with severe pain afterward. The sunburn feeling is higher than that. I prep them and they usually just mention it later. But patients with 10/10 stabbing pain, neck stiffness, trouble sleeping. I usually do a steroid injection and give them some gabapentin/Lyrica if they’re not already on it, and some Norco. It can take a few weeks to resolve but I’ve had a couple that took months. I burn for 120 seconds, 85 degrees. 18g needles. I’m pretty careful about placement, including CLO almost every time. I tried for a little while positioning the needles further dorsal, so the tips were more mid facet in the lateral, but that seemed to make it much worse.
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That is an hellacious amount of burn with a large diameter needle at a high temp and too long. The neck is not the back. Sure, plenty of people will tell you otherwise, but 85C for 60 is all you need to do, and you'll be faster if you cut out that extra 60 seconds. I used to burn the life out of TON, I cut it back to 90 seconds and it really did not improve my TON neuritis, but it made my procedure much quicker.
 
MitchLevi said:
That is an hellacious amount of burn with a large diameter needle at a high temp and too long. The neck is not the back. Sure, plenty of people will tell you otherwise, but 85C for 60 is all you need to do, and you'll be faster if you cut out that extra 60 seconds. I used to burn the life out of TON, I cut it back to 90 seconds and it really did not improve my TON neuritis, but it made my procedure much quicker.
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Agree it is a lot of burn
 
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No steroid. For cervical: 20g 80c/90 sec and for lumbar: 18g 90c/120sec. I get occasional neuritis and a handful of times mild weakness/slight head droop, resolved with PT. I warn about both.
 
20G for neck, 18G for lumbar. No steroid. 80 degrees for 90 seconds. Rarely get neuritis, I also educate, which I think goes a long way regarding expectations
 
MitchLevi said:
That is an hellacious amount of burn with a large diameter needle at a high temp and too long. The neck is not the back. Sure, plenty of people will tell you otherwise, but 85C for 60 is all you need to do, and you'll be faster if you cut out that extra 60 seconds. I used to burn the life out of TON, I cut it back to 90 seconds and it really did not improve my TON neuritis, but it made my procedure much quicker.
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I have been doing 90°, 120 seconds, 18g on all Rfa levels for the last few years. I have not noticed excessive neuritis or postoperative pain
 
Taus said:
I have been doing 90°, 120 seconds, 18g on all Rfa levels for the last few years. I have not noticed excessive neuritis or postoperative pain
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I don’t get post procedure pain, but I get a lot of sunburn sensation and hypersensitivity
 
jsaul said:
You.must like.your steaks cooked well done
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I dry brined these for 24 hrs and then grilled them tonight. Filet.
IMG_1424.jpeg
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Lumbar: 18g 90 degrees 120 seconds. +/- depo.
Cervical: 20g 85 degrees 120 seconds +/- dex.

I increased the temperature of my cervical RFA from 80 to 90 degrees and anecdotally had more neuritis. I settled at a happy medium of 85 degrees in the neck. I’ve been going away from injecting steroid after the ablation, particularly in diabetics. I know the literature showed no difference in neuritis but I do think it helps with post op pain. Just be aware that if you do inject steroid, make sure you do it AFTER your burn. I’ve seen people inject it through the cannula prior to the burn and at least one of the papers showed that steroids decreased the lesion size.
 
Scottie_Dog said:
Lumbar: 18g 90 degrees 120 seconds. +/- depo.
Cervical: 20g 85 degrees 120 seconds +/- dex.

I increased the temperature of my cervical RFA from 80 to 90 degrees and anecdotally had more neuritis. I settled at a happy medium of 85 degrees in the neck. I’ve been going away from injecting steroid after the ablation, particularly in diabetics. I know the literature showed no difference in neuritis but I do think it helps with post op pain. Just be aware that if you do inject steroid, make sure you do it AFTER your burn. I’ve seen people inject it through the cannula prior to the burn and at least one of the papers showed that steroids decreased the lesion size.
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Also do any of us know for certain what happens to steroid if you heat it to 80 or 85 or 90 degrees C?

That is an unknown that we have no reason to play around with.

I will tell you that there is data that my MLS laser can precipitate out steroids from previous injections and laser is contraindicated in an area of previous steroid injection for at least 10 days.

Just don't do it.
 
i dont and while i get some neuritis it is not severe enough to prescribe lyrica or do additional injection.

80 degrees, 20 gauge needle, 2 minutes.

for those much older, i will go lateral approach (with AP safety views). i notice less neuritis than going posterior.


MitchLevi said:
I dry brined these for 24 hrs and then grilled them tonight. Filet.
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next time, try koji. i dont have time or fridge space to dry age meat anymore, and you can get very good results with 4-24 hours of koji "aging".
 
Ducttape said:
i dont and while i get some neuritis it is not severe enough to prescribe lyrica or do additional injection.

80 degrees, 20 gauge needle, 2 minutes.

for those much older, i will go lateral approach (with AP safety views). i notice less neuritis than going posterior.



next time, try koji. i dont have time or fridge space to dry age meat anymore, and you can get very good results with 4-24 hours of koji "aging".
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Less neuritis laterally bc you’re burning less nerve perpendicularly
 
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For cervical, I do lateral approach: Trident, 85 deg, 120 sec.

Around 1/4th get the sunburn sensation. Most have significant post op discomfort for about a week or so. Rarely have someone who hurts like the dickens for 2-3 weeks. It's the cost of doing business. These last for 6-24 months, average is around 12-14 months.
 
To sum it up from what I am hearing on here, those using single burns at less time are having similar efficacy and less patient discomfort than those burning longer times especially cervical.

Those using dex appear to have less neuritis but that isn't conclusive.
 
mille125 said:
To sum it up from what I am hearing on here, those using single burns at less time are having similar efficacy and less patient discomfort than those burning longer times especially cervical.

Those using dex appear to have less neuritis but that isn't conclusive.
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- Yes, I changed my burn time based on Cosman paper as well, single burn
- I use dex for TON, no other place
- Sunburn feeling after neck burn is common
- TON has cutaneous branch so “neuritis” is common in its distribution
- I don’t get much neuritis in lower cervical levels
- I hope people are differentiating neuritis from too anterior of placement and getting lateral branch which is not neuritis and in classic sense
 
SpineandWine said:
- Yes, I changed my burn time based on Cosman paper as well, single burn
- I use dex for TON, no other place
- Sunburn feeling after neck burn is common
- TON has cutaneous branch so “neuritis” is common in its distribution
- I don’t get much neuritis in lower cervical levels
- I hope people are differentiating neuritis from too anterior of placement and getting lateral branch which is not neuritis and in classic sense
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Say more about that last one.
 
SpineandWine said:
- Yes, I changed my burn time based on Cosman paper as well, single burn
- I use dex for TON, no other place
- Sunburn feeling after neck burn is common
- TON has cutaneous branch so “neuritis” is common in its distribution
- I don’t get much neuritis in lower cervical levels
- I hope people are differentiating neuritis from too anterior of placement and getting lateral branch which is not neuritis and in classic sense
Click to expand...
agree with your last statement
 
I didn’t notice a difference when I stopped adding steroid to my burns on neuritis incidence.

20g 90 degree 60s in neck.

Like limiting my total number of steroid injections per patient. They all need a hip shoulder or knee as well at some point
 
i would call that medium rare. wouldnt want it any darker or it will become shoe leather quickly

still mostly ribeyes, tho i have been experimenting with picanha, but you have to undercook it compared to ribeye.
 
I use 20-10-10 at 80°C for 120 seconds with two lesions; severe post-neuritis has been uncommon over recent years. I place the needle tips slightly more posteriorly, which I believe helps reduce neuritis; imo, neuritis arises from incomplete dorsal ramus ablation.
 
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