RFA for transitional segment and/or pars defect pain?

[specepic]

I have two patients right now that I am contemplating RFA for and I'd like to hear if anyone else has had success with these issues with RFA.

One patient has a sacralization of L5 and you can clearly see on her imaging where the oversized TP of L5 (only on one side) connects with the sacrum and SIJ. I blocked that articluation (high up at the transitional artic. not low as with standard SIJ) and she got wonderful but temp relief. Then I did a standard SIJ inject w/o psis and she got less relief. I'm thinking about RFA for longer lasting relief. Thoughts/details with prior success? Heard of surgery for this?

Pt #2 is in her 30s and has has back pain since teens. Clear as day pars defects at L4-5 B/L. Has even formed joint capsules at the defects. Stable on F/E XRs. Saw outside pain doc and surgeon. Pain doc did did facet injs (not pars) which did not help. Surgeon said "come back when you are crawling in pain". She has a lot of pain alreasy and grits it out working full time. I did pars inj's and was even able to aspirate some fluid (no it wasn't csf) from each. Superb relief but I'm guessing it will be short lived. RFA for this or just find a diff. surgeon?

Cheers

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[lobelsteve]

RF L4-5 bilaterally on both patients.
You may not cure their pain, but they'll both hurt less when you are done.

 

[bedrock]

Any thoughts on the most high-yield areas to do extra RF lesions on the transitional segment?

Would likely be some anatomical variations of the medial branch on the transitional segment because of the altered bony anatomy.

 

[specepic]

RF L4-5 bilaterally on both patients.
You may not cure their pain, but they'll both hurt less when you are done.

Yea, my plan with the pars was to RF around it at the typical locations, was also considering RF'ing at the pars itself.

for the transitional segment was thinking about hitting lateral to the upper sacral foramen too.

I appreciate the input

 

[clubdeac]

I've actually read of some good surgical outcomes for bertolotti's syndrome (I think that's where the transitional segment (large tp) hits the iliac crest.) Maybe this is different than a true transitional segment. I've had patient's with pars fx's who didn't respond to pars injections or mbb's who I just sent to the surgeon. I dunno

 

[bedrock]

a bipolar strip lesion all the way around the base may work-

http://www.ncbi.nlm.nih.gov/pubmed/20624239

Relatively conservative surgeries such as resection of the articulation may provide pain relief without resorting to fusion

http://www.ncbi.nlm.nih.gov/pubmed/18596536

 

[olafa]

Thanks for posting those studies. I have a patient right now with that exact problem- Bertolotti's and I didn't know thats what it was called. But it was obvious on fluor an obtrusive boney mass heading over to the illiac crest. Thanks.
We have tried everything in the standard armament and talked about blocking the area base as a trial with goal for RFA if she got relief. How would you bill it? Its not a true facet but procedurally similar. We weren't sure how to deal with that aspect of it and haven't scheduled her yet.

Appreciate your input!

 

[SSdoc33]

I have two patients right now that I am contemplating RFA for and I'd like to hear if anyone else has had success with these issues with RFA.

One patient has a sacralization of L5 and you can clearly see on her imaging where the oversized TP of L5 (only on one side) connects with the sacrum and SIJ. I blocked that articluation (high up at the transitional artic. not low as with standard SIJ) and she got wonderful but temp relief. Then I did a standard SIJ inject w/o psis and she got less relief. I'm thinking about RFA for longer lasting relief. Thoughts/details with prior success? Heard of surgery for this?

walk me thru the logic of this. you inject a pseudojoint, get relief, then RF the medial branch? at 4, 5, and maybe 1? i guess you are assuming the medial branches are innervating the psudojoint? if so, then she should benefit with a standard medial branch block. otherwise, im not sure what you'd burn.

 

[onewithpain]

For a Bertolotti's or batwing I treat it like a small SI. After a positive block I use an RFA needle with a 1 cm active tip and bend it in an arc and then place it so that the active tip lies flat on the surface of the enlarged transverse process and I will paralell the abnormal articulation. I am assuming that there is a medial or lateral branch but since we don't have the benefit of a Bogduk/Dreyfuss style cadaver study I can't say exactly where the nerve is so I kill the hole stretch. I've done a couple dozen with good results.

For transitionals I do the MBs that I can ID, and then I find that there seems to be an LB involved sometimes. When doing the block I ask for the patient to respond and if they say that I have missed one above or below then I look for a likely suspect. I had one that looked normal on one side but on the painful transitional side there was one facet that I couldn't quiet, so I ended up putting the RFA needle tip at the caudal end of the facet joint and got a positive stim, so I ablated. The patient is happy. I've got a bunch of pictures on disc from the OEC 9900 but I haven't figured out how to save and send them.

 

[rubenk1]

onewithpain...that sounds very interesting...I'd love to see those pics if you get a chance to upload them

 

[onewithpain]

Here's one. I'm a little slow figuring how to attach this stuff so let's see if this works and if so I'll try another.

The needle that we're looking at head-on is there as a depth probe so that I can check on lateral. The RFA needle is inched along the surface of the enlarged transverse process until it has all been covered.

 

[onewithpain]

Here's another. I send pics like this out to the docs in my group to show them what I can do and how its better than surgery. This was a great example in that he had the cages placed for a presumed L5 radiculopathy on the left. The batwing side didn't hurt. The surgery did nothing except leave a scar. I did a block and RFA on L3 and 4 MBs, L5 DB, and S1 LB and DB. He said that his leg pain resolved completely and his back pain resolved 50%. He was happy and quit the opioids and went back to work at the mill.

 

[onewithpain]

One more. This one had pain on the right and seemed to have facet syndrome through the lower lumbar, so I blocked and RFAd the angles. She continued to have pain at what would seem like a L5-6 facet joint but I couldn't block that pain until I injected the joint. When I touched the caudal aspect she cried "Eureka", and I ablated at the circle and she is happy.

 

[melancholy]

Specepic - what was the resolution of this? did you do your RFA's?

Have a late twenty old girl with L4 and (incidentally found) L2 pars defects bilaterally. Mild response to facet injections, but significant relief with L4 pars defect injection for a few days. She is planned for spinal fusion in about a month. Does not want to escalate opioids. Considering sending her for L3, L4 bilateral RFA in an attempt to possibly postpone/hold off on surgery. Medial branches from L3 descend to innervate L4 structures, correct? (including the pars interarticularis at L4). I can't find anything really published on this. Does this work?

 

[SSdoc33]

If you fuse L4-5, it's only a matter of time until that L2 defect will cause trouble. I don't love where this is going. I don't think RFs work all that well for pars defects.

 

[melancholy]

If you fuse L4-5, it's only a matter of time until that L2 defect will cause trouble. I don't love where this is going. I don't think RFs work all that well for pars defects.

i believe this spine surgeon plans on surgically fusing both the L2 and L4 pars defects. she doesn't tolerate meds very well.

she is probably going to defer the RFA actually after further thoughts.

just wanted to see if anyone had experience of trying the RFA for pars defects

 

[lobelsteve]

Much better yhan fusion. How bad are her flexion extension films? If not major slippage surgery sounds crazy

 

[hyperalgesia]

Interesting, I was gonna post something like this. Different situation in that this late 20 something girl has 10 mm anterolisthesis. I'm actually not treating her but am a curbside consult. Saw the MRI report only which made no mention of the nerve roots but stated there was exacerbation of slippage on compression (not sure how he could tell). Symptomatically, there is ONLY back pain, no radicular or neurological findings. Initially I told her she doesn't need surgery. Then I start to doubt myself. I lean toward suggesting she see a surgeon for an opinion. But, really that's passing the buck. Would you fuse this patient?

 

[bedrock]

MBB/RF everyone of the patients from the last 3 cases. Why not? Just axial pain, no neurologic compromise and they are in their 20s for pete's sake.

A very low percentage of these case will do well with a fusion, you won't make them worse with RF, and if you even decrease their pain by 40%, it's worth it, as that might be enough relief that they will put the surgery idea, out of their head for a while.

 

[SSdoc33]

A very low percentage of these case will do well with a fusion, you won't make them worse with RF

you sure?

listhesis is slipping forward in a 20-something and you want to denervate the muscles holding it together?

i may get struck down by lightning right now, but in these types of cases, Bogduk is WRONG. there have to be some side effects to the RF. i wouldnt RF a 20 something without a spondy, i sure wouldnt RF one with a spondy.

if there is true translation with flexion/extension, then a fusion is really not the worst path to take. if its just back pain, no instability, and there is no diastasis of the z-joints, then no fusion.

some people believe if can do a diagnostic pars block to diagnose pars-related pain. im a bit skeptical of this.

 

[bedrock]

you sure?

listhesis is slipping forward in a 20-something and you want to denervate the muscles holding it together?

i may get struck down by lightning right now, but in these types of cases, Bogduk is WRONG. there have to be some side effects to the RF. i wouldnt RF a 20 something without a spondy, i sure wouldnt RF one with a spondy.

if there is true translation with flexion/extension, then a fusion is really not the worst path to take. if its just back pain, no instability, and there is no diastasis of the z-joints, then no fusion.

some people believe if can do a diagnostic pars block to diagnose pars-related pain. im a bit skeptical of this.

Are you kidding me?

You're a physiatrist right? Me too, and yes I agree that core strength and biomechanics are important, but it's crazy to suggest that the multifidi are the only thing hold that level together in this patient. There are many other larger paraspinals, with more attachments and more muscle power. And multiple ligaments that are much more critical to the stability of a spinal segment. Core muscle strength won't cure everything.

I can't believe you wouldn't even try RF on a patient with this pathology that is otherwise considering a lumbar fusion. How many times have you seen a patient that did well longterm after a lumbar fusion in their twenties? I can count that number on one hand.


I do agree that pars block is not particularly diagnostic.

 

[willabeast]

i have seen two patients that were RF'ed and seemed to develop increased slippage of their spondylo within 9 months even though they were stable on flex ext.
an interesting study? would be to do flexion extension films before and after MBB or even before and after RF of MB. if there was increased slip after MBB it might prove the point.

 

[SSdoc33]

Are you kidding me?

You're a physiatrist right? Me too, and yes I agree that core strength and biomechanics are important, but it's crazy to suggest that the multifidi are the only thing hold that level together in this patient. There are many other larger paraspinals, with more attachments and more muscle power. And multiple ligaments that are much more critical to the stability of a spinal segment. Core muscle strength won't cure everything.

I can't believe you wouldn't even try RF on a patient with this pathology that is otherwise considering a lumbar fusion. How many times have you seen a patient that did well longterm after a lumbar fusion in their twenties? I can count that number on one hand.


I do agree that pars block is not particularly diagnostic.

i dont think the multifidi are superglue. i also dont think i'd want to burn out the medial branches every year for 60 years (my bank account would, but my ethics wouldnt). it is naive to think that RF has no adverse sequellae. we just dont know exactly what those sequallae are yet.

we dont see the s/p fusion patients that do well. there are some, though. i definitely see the patients with pars defects that have chronic LBP that i cant treat, however. And these are guys who dont respond to MBBs or z-joint injections.

 

[specepic]

Reviving this thread:

1) anyone here add a lesion at the posterior aspect of the pars defect (in addition to MB locations above/below?

 

[SeniorWrangler]

onewithpain, thanks for the images! That is pretty cool!
How did you bill for it, it doesn't really fit the medial branch RFA for painful spondy that one usually uses to bill lumbar RFA

 

[Ligament]

Kill it with fire. Ligament technique.

 

[Ligament]