RFA w/ Stryker Venom Needles

[gaschicago]

Going to start using Venom needles for RFA. Office bought 20G 100mm length, 10mm active tip probes for all RFAs.

Those of you using Venom needles, do you use different active tips for cervical vs lumbar/SI/genicular? If so do you mind posting what are you using?

Worried the 10mm active tip in the cervical region will cause too large of a burn and risk of getting closer to vital structures being burned. Thoughts?

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[Agast]

I don’t use venom needles for the cervical spine, too chicken. I was trained to do 5mm active tip for cervical in general.

 

[Taus]

I am really not sure what concern is here. If coming in standard technique posterior approach parallel to the nerve, even with a 10mm active tip 18g venom, what is your concern? Check your lateral and contralateral oblique confirm depth, make sure you’re not in the dorsal foramen and a there’s at least a couple mm bone between tip and foramen. Motor test. Done


If you are talking about coming in with a lateral approach, perpendicular to nerve like cooled rf, then that May be a different story, but still the footprint of a venom is not that big and I see no issue if you were in the mid pillar (besides possible limited efficacy with smaller lesion.

 

[RoloTomassi]

18 ga Venom for everything, no issues. MB position is variable enough that I like have the best chance of catching it

 

[Ferrismonk]

I use 10mm curved standard needles in c-spine with no issues. If you want to use venom there and are afraid, you can always just steer the probe into the needle tip (as opposed to the side port) to get a more standard burn area.

 

[drrosenrosen]

I use 18ga 10mm active tip for all RF. I don't have Venom needles at this job, but I've used them before, and had no problems using them lumbar and cervical. Agree with Ferrismonk - if concerned about the lesion size, you don't have to deploy the Venom probe.

 

[Taus]

I use 18ga 10mm active tip for all RF. I don't have Venom needles at this job, but I've used them before, and had no problems using them lumbar and cervical. Agree with Ferrismonk - if concerned about the lesion size, you don't have to deploy the Venom probe.

I am still unclear what anybody is worried about with venom versus a standard cannula. The lesion does not extend any more distal ventral beyond the tip, versus a standard cannula. The venom part of the tip can extend your lesion width, which is great to capture more medial branch zone on the lateral pillar in the cephalocaudal plane. Doesn’t add any risk of root ventrally

 

[BobBarker]

@Taus I think years ago Stryker used to caution about using Venom in the c spine. It was before our time. When I went to Stryker training in 2015 they were teaching cervical venom.

 

[powermd]

Speaking of RF needles, I tried the Epimed blunt tip 20g for the first time doing a knee RF. Didn't like them. Too difficult to drive- kept getting hung up on soft tissue, and poking around the bone for positioning didn't seem any more comfortable than usual for the patient. I swapped in an 18g 10 mm Quinke tip and the procedure was vastly easier.

 

[Dr. Ice]

for those using 10mm for everyone, do y’all just have thin patients? If I’m using sis technique and trying to get as parallel to mbb as possible, meaning more caudal tilt/oblique, I’m finding in many patients I need more length..speaking of lumbar here, agree 18 or 20g, 10mm for Cspine is ok

Also think you need at least 18g for lumbar, don’t think 20g cuts it unless you are doing a lot of burns…unless it’s venom

 

[callmeanesthesia]

for those using 10mm for everyone, do y’all just have thin patients? If I’m using sis technique and trying to get as parallel to mbb as possible, meaning more caudal tilt/oblique, I’m finding in many patients I need more length..speaking of lumbar here, agree 18 or 20g, 10mm for Cspine is ok

Also think you need at least 18g for lumbar, don’t think 20g cuts it unless you are doing a lot of burns…unless it’s venom

You mean 10 mm active tip, or 10 cm needles? I use 18 g 10mm tip for everything. Length is whatever is needed for the patient. If they have an MRI I pre-measure the route on that to check.

 

[bedrock]

for those using 10mm for everyone, do y’all just have thin patients? If I’m using sis technique and trying to get as parallel to mbb as possible, meaning more caudal tilt/oblique, I’m finding in many patients I need more length..speaking of lumbar here, agree 18 or 20g, 10mm for Cspine is ok

Also think you need at least 18g for lumbar, don’t think 20g cuts it unless you are doing a lot of burns…unless it’s venom

About half of my lumbar RFA are 10cm, but I live in the Rockies which has much less obesity than other areas. Still use a lot of 15cm cannula though. Had a couple former NFL Players who weren’t fat, just big guys so they needed 15cm if doing RFA with SIS Technique.

 

[bedrock]

I am still unclear what anybody is worried about with venom versus a standard cannula. The lesion does not extend any more distal ventral beyond the tip, versus a standard cannula. The venom part of the tip can extend your lesion width, which is great to capture more medial branch zone on the lateral pillar in the cephalocaudal plane. Doesn’t add any risk of root ventrally

I completely understand the utility of venom (and similar) for genicular and SIJ RFA. I can somewhat understand it for cervical.

I don’t understand venom at all for lumbar. If you look at the venom needle with the probe in it, it extends the lesion in the wrong direction or at best only extends it superior/inferior.

Best practice for lumbar RFA is for your RF cannula to bend toward the MB. If that same needle is Venom, then you create a big lateral lesion (not a big lesion medially , which is the location of the MB)

Pain doc whose practice I took over did a lot of venom lumbar RFA.
However, >90% of those repeat customers did better after my SIS RFA, 18G cannulae with the curve bent towards the SAP, two lesions.

I don’t think venom adds much to lumbar RFA results unless your doing some kind of quick perpendicular approach.

 

[Taus]

I completely understand the utility of venom (and similar) for genicular and SIJ RFA. I can somewhat understand it for cervical.

I don’t understand venom at all for lumbar. If you look at the venom needle with the probe in it, it extends the lesion in the wrong direction or at best only extends it superior/inferior.

Best practice for lumbar RFA is for your RF cannula to bend toward the MB. If that same needle is Venom, then you create a big lateral lesion (not a big lesion medially , which is the location of the MB)

Pain doc whose practice I took over did a lot of venom lumbar RFA.
However, >90% of those repeat customers did better after my SIS RFA, 18G cannulae with the curve bent towards the SAP, two lesions.

I don’t think venom adds much to lumbar RFA results unless your doing some kind of quick perpendicular approach.

agreed. My post specifically referenced cervical. I only use it for lumbar bc that’s what they have at my asc.

 

[Ferrismonk]

Venom 20g lesion size is roughly equal to 18g curved.

 

[DrMDAware]

I completely understand the utility of venom (and similar) for genicular and SIJ RFA. I can somewhat understand it for cervical.

I don’t understand venom at all for lumbar. If you look at the venom needle with the probe in it, it extends the lesion in the wrong direction or at best only extends it superior/inferior.

Best practice for lumbar RFA is for your RF cannula to bend toward the MB. If that same needle is Venom, then you create a big lateral lesion (not a big lesion medially , which is the location of the MB)

Pain doc whose practice I took over did a lot of venom lumbar RFA.
However, >90% of those repeat customers did better after my SIS RFA, 18G cannulae with the curve bent towards the SAP, two lesions.

I don’t think venom adds much to lumbar RFA results unless your doing some kind of quick perpendicular approach.

Do you turn the needle for the second burn?

 

[bedrock]

Do you turn the needle for the second burn?

Yes. 75 degrees

 

[Taus]

Do you turn the needle for the second burn?

I move it more than that. I retract a little bit, then advanced tip a few millimeters more cephalad up base of SAP. with the addition of venom, I am making a pretty substantial lesion medial to lateral with first burn, cephalocaudal with second burn. No way I have missed the target. All that being said, I don’t know that my results are any different, in terms of percent success or duration compared to when I use the regular 18 gauge 10 mm active tip. If the cost for venom was coming out of my pocket, I would not use it.

 

[painfree23]

When doing the lumbar RF , how much do you typically tilt the fluoro for the different medial branch levels? Do you change it every time for every level for every patient (square each endplate exactly) or just leave it at a few degrees caudal tilt and just make sure you come into the “groove” between the Sap and TP? I ask because I feel like I’m not getting as long term results as I would like on my lumbar RFs and I’m wondering if my technique is the reason. I test and get a great twitch.

I’m trying to be as efficient as possible: so I just keep it on caudal tilt and get down to the sap while on foot tilt (so I can start off a little lower and have the needle parallel and just advancing them all once it’s in straight AP to the perfect spot.

I used to head tilt for L4 and L5 and then foot tilt for L3 and line up each end plate perfectly . but this was just taking too long. I’m not sure if I need to back to that. I’m also using 20g needles, so this could be another reason my results aren’t as great.

 

[callmeanesthesia]

When doing the lumbar RF , how much do you typically tilt the fluoro for the different medial branch levels? Do you change it every time for every level for every patient (square each endplate exactly) or just leave it at a few degrees caudal tilt and just make sure you come into the “groove” between the Sap and TP? I ask because I feel like I’m not getting as long term results as I would like on my lumbar RFs and I’m wondering if my technique is the reason. I test and get a great twitch.

I’m trying to be as efficient as possible: so I just keep it on caudal tilt and get down to the sap while on foot tilt (so I can start off a little lower and have the needle parallel and just advancing them all once it’s in straight AP to the perfect spot.

I used to head tilt for L4 and L5 and then foot tilt for L3 and line up each end plate perfectly . but this was just taking too long. I’m not sure if I need to back to that. I’m also using 20g needles, so this could be another reason my results aren’t as great.

I use 18g. I’m still frequently changing my technique slightly so I love to hear what others do. I’ve abandoned coaxial needle placement in favor of less fluoro time and placing all 3 needles on a side at once. I oblique 10-15 degrees depending on what the iliac crest allows, and tilt caudal about 10-15 degrees (for some men with particularly in-the-way iliac crests I’ll have to place the sacral ala needle from straight AP). When I mark the skin entry sites I mark on target for the sacral ala, a little inferior and lateral for L5, and 1-2 cm inferior and a little lateral for L4. The degree to which I’m off from coaxial depends on the thickness of the patient and the degree of lumbar lordosis. This also helps to compensate for the parallax effect that will cause the L4 needle, if toward the top of the image, to be more inferiorly angled than desired even when appearing perfectly coaxial.

 

[Dr. Ice]

Along the same lines, I have a Stryker multigen 2 rf machine. Looking to get pricing for 16 and/or 18 gauge cannulas but they keep pushing venom which is out of my price range. Any ideas on compatible cannulas that can work with this machine and how I would find out that info?

 

[cameroncarter]

I completely understand the utility of venom (and similar) for genicular and SIJ RFA. I can somewhat understand it for cervical.

I don’t understand venom at all for lumbar. If you look at the venom needle with the probe in it, it extends the lesion in the wrong direction or at best only extends it superior/inferior.

Best practice for lumbar RFA is for your RF cannula to bend toward the MB. If that same needle is Venom, then you create a big lateral lesion (not a big lesion medially , which is the location of the MB)

Pain doc whose practice I took over did a lot of venom lumbar RFA.
However, >90% of those repeat customers did better after my SIS RFA, 18G cannulae with the curve bent towards the SAP, two lesions.

I don’t think venom adds much to lumbar RFA results unless your doing some kind of quick perpendicular approach.

this makes sense...can you post some fluoro pics please, for the newbies

 

[deleted875186]

When doing the lumbar RF , how much do you typically tilt the fluoro for the different medial branch levels? Do you change it every time for every level for every patient (square each endplate exactly) or just leave it at a few degrees caudal tilt and just make sure you come into the “groove” between the Sap and TP? I ask because I feel like I’m not getting as long term results as I would like on my lumbar RFs and I’m wondering if my technique is the reason. I test and get a great twitch.

I’m trying to be as efficient as possible: so I just keep it on caudal tilt and get down to the sap while on foot tilt (so I can start off a little lower and have the needle parallel and just advancing them all once it’s in straight AP to the perfect spot.

I used to head tilt for L4 and L5 and then foot tilt for L3 and line up each end plate perfectly . but this was just taking too long. I’m not sure if I need to back to that. I’m also using 20g needles, so this could be another reason my results aren’t as great.

this makes sense...can you post some fluoro pics please, for the newbies

I typically do 15 degrees oblique, caudal tilt in 10 degree increments or live watching the SAP/TP junction until I’m at 30 degrees caudal tilt, and then place the L3 and L4 needles in a down the barrel view until I hit bone. Then take out the caudal tilt and oblique more to 25 degrees to see the groove, y typically needle to walk off bone superiority into the groove. Then check AP and lateral and ablate. L5 I place AP, then oblique a bit to make sure in groove, then check lateral.

 

[Taus]

I typically do 15 degrees oblique, caudal tilt in 10 degree increments or live watching the SAP/TP junction until I’m at 30 degrees caudal tilt, and then place the L3 and L4 needles in a down the barrel view until I hit bone. Then take out the caudal tilt and oblique more to 25 degrees to see the groove, y typically needle to walk off bone superiority into the groove. Then check AP and lateral and ablate. L5 I place AP, then oblique a bit to make sure in groove, then check lateral.

I used to do essentially exactly this. First several years in practice. Someone wiser than I suggested to look in AP, where my skin entry points are to reach the target with in plane technique. It is essentially always at the inferior aspect of transverse process one level below. Now, I oblique out approximately 15-20 until I can clearly make out the SAP/TP Junction, no tilt, enter skin level below at inferior aspect TP, advance out of plane. Confirm in AP, confirm in 30 oblique, slightly adjust here prn, check lateral, motor test and and burn. Comparing my pictures from this to my original post fellowship technique which was essentially as above/SIS, the pictures look identical in all views and my outcomes have not changed. The only thing that has changed is my procedure time and fluoro time has been dramatically diminished

 

[deleted875186]

I used to do essentially exactly this. First several years in practice. Someone wiser than I suggested to look in AP, where my skin entry points are to reach the target within plane technique. It is essentially always at the transverse process below. Now, I oblique out approximately 15-20 until I can clearly make out the SAP/TP Junction, enter skin level below at TP, advance out of plane. Confirm in AP, confirm in 30 oblique, slightly adjust here prn, check lateral, motor test and and burn. Comparing my pictures from this to my original post fellowship technique which was essentially as above/SIS, the pictures look identical in all views and my outcomes have not changed. The only thing that has changed is my procedure time and fluoro time has been dramatically diminished

Will have to try this, I’ve done it a few times when it’s really hard to see the junction in a declined view. Have also placed small 25G MBB needles as finders, but this adds more fluoro time which is a killer.

 

[Taus]

Will have to try this, I’ve done it a few times when it’s really hard to see the junction in a declined view. Have also placed small 25G MBB needles as finders, but this adds more fluoro time which is a killer.

👍🏻 Do it in your standard fashion. Then, take a bent 18 gauge needle as a marker, lay it on skin against your rf cannula where it enters skin, take a look in straight AP where they intersect.

 

[Taus]

Along the same lines, I have a Stryker multigen 2 rf machine. Looking to get pricing for 16 and/or 18 gauge cannulas but they keep pushing venom which is out of my price range. Any ideas on compatible cannulas that can work with this machine and how I would find out that info?

I cannot see how venom is the only cannula that fits. Rep is effing with you to make a buck.

 

[BobBarker]

Any rf needle will work. I have a multigen 1 with venom probes I use Medtronic needles with. I have also used ABT, Epimed, and some other generic needle with it.

 

[pastafan]

These used to be the best priced, good quality. Distribution Unlimited - RadioFrequency Ablation Cannulae

 

[BobBarker]

Yes, I have used those with multigen 1/venom probes and they worked well

 

[geauxg8rs]

These used to be the best priced, good quality. Distribution Unlimited - RadioFrequency Ablation Cannulae

Do you remember off hand the price per needle? You have to register to get a price. Thanks

 

[pastafan]

They used to be $9 while the closest price wise was $13. If you call and speak to representative you get much better pricing than listed online.

 

[RoloTomassi]

They used to be $9 while the closest price wise was $13. If you call and speak to representative you get much better pricing than listed online.

Are their spinal needles cheap?

 

[BobBarker]

I think you can get mdt needles for $8-10 now. I have a multigen 1 and a MDT RFA machine sitting side by side. Don’t have enough electrodes to use one machine exclusively. So use both machines through the course of the day with the MDT needles.

 

[pastafan]

Are their spinal needles cheap?

Yes, but I like BD needles. If I remember correctly their stylettes were difficult to withdraw.

 

[bedrock]

I think you can get mdt needles for $8-10 now. I have a multigen 1 and a MDT RFA machine sitting side by side. Don’t have enough electrodes to use one machine exclusively. So use both machines through the course of the day with the MDT needles.

I know the stryker reps will be annoyed and say the machine will explode if you don't use their needles.

Have any of you had any issues using generic needles with a Stryker RF generator?

I have a Stryker multigen 2 at one ASC and a new Cosman (boston) RF generator at my other ASC. I'd like to find cheaper standard RF cannulae for both machines.

Any thoughts on generic RF cannulae compatible with both?

 

[pastafan]

Used these with Stryker single lesion machine and Halyard multiple lesion unit w/o problem.

 

[BobBarker]

I think nearly any needle will work with any machine. The Stryker is out of warranty and has been for years. I have been ghosting those reps for years also.

 

[painfree23]

I typically do 15 degrees oblique, caudal tilt in 10 degree increments or live watching the SAP/TP junction until I’m at 30 degrees caudal tilt, and then place the L3 and L4 needles in a down the barrel view until I hit bone. Then take out the caudal tilt and oblique more to 25 degrees to see the groove, y typically needle to walk off bone superiority into the groove. Then check AP and lateral and ablate. L5 I place AP, then oblique a bit to make sure in groove, then check lateral.

When you say you place L5 in AP, do you mean you cranially tilt so that the end plate is lined up or the machine is just straight above the L5. Do you come in a caudal angle for the L5 at all or just barrel down?

 

[deleted875186]

When you say you place L5 in AP, do you mean you cranially tilt so that the end plate is lined up or the machine is just straight above the L5. Do you come in a caudal angle for the L5 at all or just barrel down?

Take an AP shot, skin entry below around S1 foramin, drive out of plane so it lands on ala, walk off a bit and oblique to see if in the groove.

Would be interested to hear how others place their L5 needles. There’s occasionally not a good motor response at L5, makes me less confident.

 

[cowboydoc]

Take an AP shot, skin entry below around S1 foramin, drive out of plane so it lands on ala, walk off a bit and oblique to see if in the groove.

Would be interested to hear how others place their L5 needles. There’s occasionally not a good motor response at L5, makes me less confident.

There isn’t usually much contractile tissue there to stimulate.

 

[callmeanesthesia]

There isn’t usually much contractile tissue there to stimulate.

That’s what she said.

 

[Taus]

Take an AP shot, skin entry below around S1 foramin, drive out of plane so it lands on ala, walk off a bit and oblique to see if in the groove.

Would be interested to hear how others place their L5 needles. There’s occasionally not a good motor response at L5, makes me less confident.

Straight AP. Place needle directly medial to psis, ie play it where it lies, as lateral as anatomy allows. Drive cephalad towards target out of plane. When clearly get past psis and iliac crest, oblique about 15 and adjust angle to hit junction sap/ala.

 

[callmeanesthesia]

Straight AP. Place needle directly medial to psis, ie play it where it lies, as lateral as anatomy allows. Drive cephalad towards target out of plane. When clearly get past psis and iliac crest, oblique about 15 and adjust angle to hit junction sap/ala.

I tend to start AP in men and 10-15 oblique in women.

 

[geauxg8rs]

I know the stryker reps will be annoyed and say the machine will explode if you don't use their needles.

Have any of you had any issues using generic needles with a Stryker RF generator?

I have a Stryker multigen 2 at one ASC and a new Cosman (boston) RF generator at my other ASC. I'd like to find cheaper standard RF cannulae for both machines.

Any thoughts on generic RF cannulae compatible with both?

I have been using spectra for my Cosman machine. I pay $10 a needle and the needles look and
Feel exactly the same as Cosman.
The rep says that Spectra used to make the needles for Cosman.
Supposedly spectra is going to make electrodes for Cosman machines. We shall see

 

[MD87]

I used to do essentially exactly this. First several years in practice. Someone wiser than I suggested to look in AP, where my skin entry points are to reach the target with in plane technique. It is essentially always at the inferior aspect of transverse process one level below. Now, I oblique out approximately 15-20 until I can clearly make out the SAP/TP Junction, no tilt, enter skin level below at inferior aspect TP, advance out of plane. Confirm in AP, confirm in 30 oblique, slightly adjust here prn, check lateral, motor test and and burn. Comparing my pictures from this to my original post fellowship technique which was essentially as above/SIS, the pictures look identical in all views and my outcomes have not changed. The only thing that has changed is my procedure time and fluoro time has been dramatically diminished

To clarify - if you are doing L3-5 MB/dorsal ramus RF, do you place all 3 needles using the same view and not square off the end plates? Thanks.

 

[MitchLevi]

To clarify - if you are doing L3-5 MB/dorsal ramus RF, do you place all 3 needles using the same view and not square off the end plates? Thanks.

I don't square off all end plates. You don't need to...I place them all simultaneously.

 

[Taus]

To clarify - if you are doing L3-5 MB/dorsal ramus RF, do you place all 3 needles using the same view and not square off the end plates? Thanks.

Correct. Often I need to advance a little bit to perfect target, I do this in 30° oblique as the final step before lateral view.

 

[deleted875186]

I don't square off all end plates. You don't need to...I place them all simultaneously.

Agree, I adjust needles in 30 degrees oblique to ensure I’m in the groove, then check AP and lateral.

 

[MitchLevi]

I only check oblique after I've tested and dropped lido. I start AP, when I'm deep I go lateral and advance the last cm or so. Test. Numb. Back to AP and stop at the oblique on the way...Save that oblique. Burn in the AP.

All these XRAY adjustments are just hitting you and your staff with more and more radiation.