Rationale for RFA that doesn't work or Delayed ESI Onset

[hopefulgasman]

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Although rare, I have had a few of these cases where MBB #1 and 2 worked flawlessly providing 100% relief for short duration only to be followed up by RFA that had zero benefit. Images reviewed and everything looks good from parallel placement of the needle along the desired junction to adequate depth. This is lesioning performed once at 80C for 90 seconds using Stryker Venom needles and bilaterally in one visit.

I see my own follow ups and need these procedures to work. Should one be pulling back or doing anything to the needles and then lesioning a second time for another 90 seconds? This will prolong my procedures but I'm willing to spend the extra two minutes per side if it'll lead to greater satisfaction. Anyone else seeing this or have tips to troubleshoot?

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Again, although rare, I've had a few cases where lumbar TFESI takes a week or even two weeks to take effect. Pt reports worsening lower extremity radicular pain for a few days after the procedure and when they're about to call it a failure, they report 80-95% resolution of their radicular pain. This last one said resolution of their pain didn't happen until the two week mark. Anyone else also seeing such delayed onset of action of their steroid? This is done using 10mg dex and 1-2cc of preservative free normal saline.

 

[powermd]

Some RF patients take 4-6 weeks to reach the promised land. If not, look lower- SI joints, postural muscles, and who can forget my personal favorite, the cluneal nerves. In cases like this I suspect the MBBs were a false positive due to spread of the local to other pain generators.

 

[MD87]

In my opinion from most likely to least likely:
1) False positive from placebo.
2) Patient lies: "The blocks really didn't help but I really wanted the ablation" - in spite of extensive education before hand. I now tell people "if the blocks don't help, I PROMISE you, the RFA will not help, and my most disappointed patients are the ones who the blocks do not provide life-changing pain relief." - I honestly feel like this has helped reduce my RFA fails, though has hurt my pocket, which I'm OK with.
3) False positive from spread of anesthetic to adjacent structures (unlikely if you don't inject more than 0.5 cc in lumbar or 0.3 cc in cervical).

Consider increasing temperature to 85 or 90 and time to 120 or 150 seconds to increase lesion size. Consider using 18g if you are using 20g needles. I use 18g @ 90 for 120s. Previously used 20g and made the switch a couple years ago and find no increase in procedural pain (lots of local with block needle first) and decreased procedural time due to better control with the 18g.

 

[mygalperin]

Look into si joints, especially if pain became one sided

 

[MitchLevi]

Sometimes, despite our best efforts and meticulous attention to detail, our treatments don’t work. Pain is far more complicated than anatomy. It is by definition a sensory and emotional experience. You do not feel pain, you experience it, and because of this you can’t cure it. Management is all that’s available, and just bc you have a bad July doesn’t mean you’ll have a bad August.

 

[Dr. Ice]

Maybe it’s vertebrogenic back pain…there’s an epidemic these days

 

[Agast]

on physical exam do they still have facetogenic back pain? With my RFA “misses” I can crank them back into their facets and most of the time they don’t hurt.

It does tell me that it means they can go back into PT and perform the exercises more easily so that’s typically one thing I require them to do

 

[SSdoc33]

there is a known RF failure rate

 

[Ducttape]

Yes 10-15% failure rate even with good placement and 2 positive MBB.

It's gonna happen and anyone with 100% success rate has a flawed assessment process.

 

[clubdeac]

Agree with above. Use trident or 18g needles and burn at 90 degrees. Use 0.3-0.5cc for diagnostic blocks

My RF failures usually also have mod to severe central stenosis but the surgeon didn’t want to operate bc they didn’t have classic neurogenic claudication, only axial lbp.

And yes, i see patients that tell me they had no relief from their ESI until 2 weeks after the injection. I tell them all to give it at least 2 weeks before making a judgement call. 6 weeks for RFA

 

[schmee90]

Some RF patients take 4-6 weeks to reach the promised land. If not, look lower- SI joints, postural muscles, and who can forget my personal favorite, the cluneal nerves. In cases like this I suspect the MBBs were a false positive due to spread of the local to other pain generators.

Does anybody know mechism why 4-6 weeks onset of relief after RFA (not a pimp question, curious myself never came across why

 

[stsa84]

Wallerian degeneration takes time

 

[powermd]

Normal cycle for a wound healing response. I find one-sided RF patients are often doing well by two weeks, bilaterals can stretch out to 4+.

 

[bedrock]

In my opinion from most likely to least likely:
1) False positive from placebo.
2) Patient lies: "The blocks really didn't help but I really wanted the ablation" - in spite of extensive education before hand. I now tell people "if the blocks don't help, I PROMISE you, the RFA will not help, and my most disappointed patients are the ones who the blocks do not provide life-changing pain relief." - I honestly feel like this has helped reduce my RFA fails, though has hurt my pocket, which I'm OK with.
3) False positive from spread of anesthetic to adjacent structures (unlikely if you don't inject more than 0.5 cc in lumbar or 0.3 cc in cervical).

Consider increasing temperature to 85 or 90 and time to 120 or 150 seconds to increase lesion size. Consider using 18g if you are using 20g needles. I use 18g @ 90 for 120s. Previously used 20g and made the switch a couple years ago and find no increase in procedural pain (lots of local with block needle first) and decreased procedural time due to better control with the 18g.

Agree with most of this.

1- regarding #1, it is key to decide to do RFA based on the second MBB. Definitely stronger placebo response with 1st block.
2- I think false positive mbbs from sloppy technique cause more RFA failures than does placebo. (Injecting more than 0.4ml of bup, numbing all the way into the paraspinals, not using using contrast).
3- definitely agree on always using 18G or larger cannulae and 90 x90 or longer lesion settings.

 

[lobelsteve]

Agree with most of this.

1- regarding #1, it is key to decide to do RFA based on the second MBB. Definitely stronger placebo response with 1st block.
2- I think false positive mbbs from sloppy technique cause more RFA failures than does placebo. (Injecting more than 0.4ml of bup, numbing all the way into the paraspinals, not using using contrast).
3- definitely agree on always using 18G or larger cannulae and 90 x90 or longer lesion settings.

Not using contrast would cause a false negative.

 

[bedrock]

Not using contrast would cause a false negative.

Unless you have unnoticed epidural spread due to lack of contrast

 

[lobelsteve]

Unless you have unnoticed epidural spread due to lack of contrast

If you have epidural spread from an MBB at Dreyfuss2 site, you are magical.

 

[bedrock]

I’ve definitely seen epidural spread in the c spine. (Not the lumbar)

 

[clubdeac]

I’ve definitely seen epidural spread in the c spine. (Not the lumbar)

From a mbb?! I’ve seen it from my cervical and lumbar facets but not mbb, then again I skip contrast in my mbb’s so who knows

 

[GatorCHOMPions]

From a mbb?! I’ve seen it from my cervical and lumbar facets but not mbb, then again I skip contrast in my mbb’s so who knows

Debating on if I should start skipping contrast. I know it would make my MBB's faster, but occasionally am surprised by non-ideal spread and do change my course more often than I'd otherwise suspect.

 

[bedrock]

From a mbb?! I’ve seen it from my cervical and lumbar facets but not mbb, then again I skip contrast in my mbb’s so who knows

its only happened twice but both times it was

Debating on if I should start skipping contrast. I know it would make my MBB's faster, but occasionally am surprised by non-ideal spread and do change my course more often than I'd otherwise suspect.

You are definitely more accurate with contrast.

After all the time and hoops patient undergo to get auth for MBB, the least we can do as pain physicians is to take an extra 75 seconds confirm proper spread along the MB with contrast.

 

[bubaghanush]

Most of these failures will respond to cluneal nerve stimulation.

 

[ghost800]

its only happened twice but both times it was

You are definitely more accurate with contrast.

After all the time and hoops patient undergo to get auth for MBB, the least we can do as pain physicians is to take an extra 75 seconds confirm proper spread along the MB with contrast.

This 100%. We all know it is important to be efficient with our encounters, especially in private practice, but there is a tipping point where too much efficiency results in an unacceptable quality of service delivered. We’ve all seen this concept illustrated not only in Medicine, but also in pretty much any other economic good or service.

From a procedural standpoint, precision with the “business end” (pun intended) of the needle (the tip) should not be compromised. In this case, a very small amount of contrast can rule out intravascular flow, or flow that does not adequately cover where the mbb would be expected, despite what looks like perfect placement.

Spending 10-30 seconds to make a few micro adjustments might make the difference between a failed block or false positive and a successful mbb.

There are so many other ways to improve efficiency such as processing tasks in parallel rather than sequentially. One can draw up meds while the x-Ray tech lines up the view with the nurse positioning and prepping the patient (with orange chloraprep). It does not involve jamming the needles anywhere and everywhere in 10 seconds under one poorly lined up view, and then proudly declaring “looks great” while taking an unrelated phone call all while not taking one second to purel your hands between cases.

 

[MitchLevi]

Have fun with what will be a substantial amount of added radiation exposure over the course of your career. It is completely unnecessary. How many more ablations is this gonna create?

Who is using hand sanitizer between cases? What?

 

[ghost800]

Have fun with what will be a substantial amount of added radiation exposure over the course of your career. It is completely unnecessary. How many more ablations is this gonna create?

Who is using hand sanitizer between cases? What?

It’s not that much if you collimate. I can’t comment on your hygiene habits. I learned to wash my hands in kindergarten

 

[Taus]

Have fun with what will be a substantial amount of added radiation exposure over the course of your career. It is completely unnecessary. How many more ablations is this gonna create?

Who is using hand sanitizer between cases? What?

I do use contrast, but not live on mbb. I inject like 0.3 ML in each needle and take one still shot at the end. At least every other case has one needle that needs to be adjusted for contrast to cover the MB. I don’t think that adds much radiation at all.

 

[MitchLevi]

I do use contrast, but not live on mbb. I inject like 0.3 ML in each needle and take one still shot at the end. At least every other case has one needle that needs to be adjusted for contrast to cover the MB. I don’t think that adds much radiation at all.

This has impacted your practice how?

Go a month without it and your numbers won’t change. The failures come from the RFA, not the MBB.

 

[MitchLevi]

It’s not that much if you collimate. I can’t comment on your hygiene habits. I learned to wash my hands in kindergarten

…I throw gloves in the trash and grab a new pair.

 

[Ducttape]

So what is the purpose of contrast? To rule out vascular uptake. To reduce risk of false negative results.


If your medical decision making suggests strongly positive for facet mediated pain, but your rate of false negative injections is high, then use of contrast should be introduced.

My false negative rate in the appropriate candidate is pretty low. Contrast would not add additional information and will add the risk of contract allergy and increased radiation exposure. I occasionally use contrast but... for the most part, I skip the contrast.

 

[SSdoc33]

no contrast for MBBs

gave it up 10 years ago

waste of time

you can get on your high horse about needle placement, etc, if you want. but you would be wrong. after about 5000 mbbs, you should know what you are doing

 

[lobelsteve]

no contrast for MBBs

gave it up 10 years ago

waste of time

you can get on your high horse about needle placement, etc, if you want. but you would be wrong. after about 5000 mbbs, you should know what you are doing

I am several times that and surprised how bad I still am at doing these things.

 

[SSdoc33]

I am several times that and surprised how bad I still am at doing these things.

20,000 MBBs? seems like bedrock-level exaggeration

 

[bedrock]

no contrast for MBBs

gave it up 10 years ago

waste of time

you can get on your high horse about needle placement, etc, if you want. but you would be wrong. after about 5000 mbbs, you should know what you are doing

20,000 MBBs? seems like bedrock-level exaggeration

Seems like ssdoc level arrogance.

Everyone here on this board has noticed plenty of times doing MBB when the needle placement looks perfect, but contrast injection demonstrates spread in a very different direction vs what would be expected based on the placement of the needle tip.

Your MBB are significantly less accurate than MBB performed by pain docs using contrast because you’re prioritizing efficiency over patient outcomes.

I guess I should have also mentioned that seems like typical ssdoc selfishness.

 

[SSdoc33]

Seems like ssdoc level arrogance.

Everyone here on this board has noticed plenty of times doing MBB when the needle placement looks perfect, but contrast injection demonstrates spread in a very different direction vs what would be expected based on the placement of the needle tip.

Your MBB are significantly less accurate than MBB performed by pain docs using contrast because you’re prioritizing efficiency over patient outcomes.

I guess I should have also mentioned that seems like typical ssdoc selfishness.

i suppose you might see marginally better results with contrast. but it is a diagnostic injection. needle placement is not as crucial as it is with RF. will adding contrast convert more mbbs to RFs? i really dont think so. will you have fewer RFs failures if you use contrast? again.... i doubt it.

the whole deal with MBBs is that i think we are being too academic in our algorithms. we have bought in to the bogduk and insurance company mantra. RFs are a benign procedure that are not being offered to many who would benefit just b/c they dont meet some arbitrary 80% threshold. or some may just give up b/c it is too hard ot get to three separate appt visits and the f/u in between along with all of the copays, etc. what if they still have pain but can now go for a walk with their partner or go shopping when they previously could not?

catch as many RFs as you can with 1 mL local / mbb in the lumbar spine. you will have some RF failures, but you will end up helping many who otherwise wouldnt have been offered the treatment. with 1 mL local, you can flood the zone and done need the super perfect needle placement nor contrast

 

[Taus]

i suppose you might see marginally better results with contrast. but it is a diagnostic injection. needle placement is not as crucial as it is with RF. will adding contrast convert more mbbs to RFs? i really dont think so. will you have fewer RFs failures if you use contrast? again.... i doubt it.

the whole deal with MBBs is that i think we are being too academic in our algorithms. we have bought in to the bogduk and insurance company mantra. RFs are a benign procedure that are not being offered to many who would benefit just b/c they dont meet some arbitrary 80% threshold. or some may just give up b/c it is too hard ot get to three separate appt visits and the f/u in between along with all of the copays, etc. what if they still have pain but can now go for a walk with their partner or go shopping when they previously could not?

catch as many RFs as you can with 1 mL local / mbb in the lumbar spine. you will have some RF failures, but you will end up helping many who otherwise wouldnt have been offered the treatment. with 1 mL local, you can flood the zone and done need the super perfect needle placement nor contrast

I look at it this way… failed Rfa follow appts suck hard. Remaining options are ****e. 1cc spreads pretty far, definitely not representative of the small target structure I will be doing rfa on. Put a cc of contrast at the MBB target and see. Might as well give them a TPI. Even 0.2-0.3cc spreads further than you’d think. I’m not so worried about the false negatives from the one MBB needle being off target…… more so not giving myself and the patient the prognostic value of the MBB.

 

[Dr. Ice]

I think 1cc is too much per mbb. Def gonna get some spillage. I myself go back and forth about using contrast in the mbb but have been leaning more towards using it lately. Agree the failed Rfa follow up appointments are not fun.

 

[Ducttape]

an anaphylactic reaction to contrast may change opinions on routine use of contrast.

I don't see any issues with failed rfa appt. Just like failed esi or any other failed injection.

Its very helpful prepping patients beforehand about the possibilities of lack of success. It's part of the consent.

For me 0.3 ml cervical and 0.5 ml lumbar....

 

[ghost800]

an anaphylactic reaction to contrast may change opinions on routine use of contrast.

I don't see any issues with failed rfa appt. Just like failed esi or any other failed injection.

Its very helpful prepping patients beforehand about the possibilities of lack of success. It's part of the consent.

For me 0.3 ml cervical and 0.5 ml lumbar....

That’s actually a reasonable consideration especially in the in office or non-facility setting.

 

[clubdeac]

I look at it this way… failed Rfa follow appts suck hard. Remaining options are ****e. 1cc spreads pretty far, definitely not representative of the small target structure I will be doing rfa on. Put a cc of contrast at the MBB target and see. Might as well give them a TPI. Even 0.2-0.3cc spreads further than you’d think. I’m not so worried about the false negatives from the one MBB needle being off target…… more so not giving myself and the patient the prognostic value of the MBB.

Failed RF's just get offered SPRINT. Duh 😉

 

[Ronin1]

It seems like failed RFA happens and then I consider Intracept. Most of these patients have overlapping symptoms and imaging to support either/both procedures