Sedation protocols for RFA/rhizotomy

[DocMcCoy]

In med school/residency, 5-10 years ago we did these with a wiff of versed and copious local in the office.

New pain guys want essentially a motionless field, GA without an airway/ deep heavy propofol sedation in the OR.

Sometimes they are just too fat or sick and there is no way to make this happen.

Couple weeks back had a BMI 50 anxious chronic pain patient for bilateral c3-5 RFA. Usually I’d just tell pain guy I’m going to give a wiff of versed and deal with it. they expect more because that’s the group culture right now. I decided to play ball with propofol and it turned into a **** show with thankfully a good outcome.

What’s your practice and how do you handle the tough to “sedate” patients?

These days suck.

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[teacher2md]

Some people are just too fat for sedation. GA with a tube.

Oh the Cardiologist/GI/pain guy promised the patient it would just be light sedation and that they wouldn’t feel anything? They’re welcome to push their own propofol.

 

[coffeebythelake]

In med school/residency, 5-10 years ago we did these with a wiff of versed and copious local in the office.

New pain guys want essentially a motionless field, GA without an airway/ deep heavy propofol sedation in the OR.

Sometimes they are just too fat or sick and there is no way to make this happen.

Couple weeks back had a BMI 50 anxious chronic pain patient for bilateral c3-5 RFA. Usually I’d just tell pain guy I’m going to give a wiff of versed and deal with it. they expect more because that’s the group culture right now. I decided to play ball with propofol and it turned into a **** show with thankfully a good outcome.

What’s your practice and how do you handle the tough to “sedate” patients?

These days suck.

Are these pain guys anesthesia-pain? They should know better.

 

[coffeebythelake]

Oh the Cardiologist/GI/pain guy promised the patient it would just be light sedation and that they wouldn’t feel anything? They’re welcome to push their own propofol.

Speaking about proceduralists who overpromise and underdeliver.. Had a 20 some year old thin healthy woman get what amounted to ptsd after being told "she wouldn't feel a thing" in the emergency department for a large perianal abscess drainage. Thry gave her 25 mcg fentanyl. She said she was screaming the whole time. Don't lie to patients or do better sedation. We had to GA her because she was so traumatized by what happened previously

 

[LivetoTell]

Anybody doing prone LMAs? A "well seated" prone LMA versus trying your luck with the infamous prone MAC ( AKA room air general)?

 

[DocMcCoy]

Are these pain guys anesthesia-pain? They should know better.

Yes. I agree I joke about it all the time. Nevertheless, it’s a culture thing and expected of the group do it “their” way. I’m already fighting a lot of battles

 

[DocMcCoy]

Speaking about proceduralists who overpromise and underdeliver.. Had a 20 some year old thin healthy woman get what amounted to ptsd after being told "she wouldn't feel a thing" in the emergency department for a large perianal abscess drainage. Thry gave her 25 mcg fentanyl. She said she was screaming the whole time. Don't lie to patients or do better sedation. We had to GA her because she was so traumatized by what happened previously

I ALWAYS tell these patients they will be sedated but awake and as comfortable as I can make them safely. As soon as we get to the room “when are you going to put me to sleep doc?”. EVERY TIME. I tell preop nurses don’t use phrases like general anesthesia or you will be asleep. “I want to be asleep doc, I don’t want to remember a thing”. Still amazed at the unrealistic expectations some times.

 

[Hoya11]

Anybody doing prone LMAs? A "well seated" prone LMA versus trying your luck with the infamous prone MAC ( AKA room air general)?

i sometimes do this for achilles on easy airway thin patients fast surgeon combo, works great

 

[Hoya11]

Some people are just too fat for sedation. GA with a tube.

Oh the Cardiologist/GI/pain guy promised the patient it would just be light sedation and that they wouldn’t feel anything? They’re welcome to push their own propofol.

i think the idea is to avoid GA/ heavy sedation in case the pain docs needles are near a nerve and the patient "cant respond" .. i wouldnt want anything to go wrong for one of these crazy patients and them blame the sedation

 

[Iso4ane]

Some people are just too fat for sedation.

In the back of my mind, patients with Obesity Hypoventilation Syndrome are literally too fat to breathe, and that alone should be a relative contraindication to deeper levels of sedation.

 

[deleted875186]

i think the idea is to avoid GA/ heavy sedation in case the pain docs needles are near a nerve and the patient "cant respond" .. i wouldnt want anything to go wrong for one of these crazy patients and them blame the sedation

This is correct, patient needs to be awake to report any movement during motor stimulation before ablating.

I do all my ablations with local and oral benzodiazepine. If IV sedation is needed then versed and fentanyl with local.

Note that if these pain docs are prescribing opioids then may need to be more generous with the versed and fentanyl. Would ask all these patients what they are taking every day.

 

[TeslaCoil]

I use IM versed 2-5 mg and heavy local. Would never use deep sedation and definitely never general anesthesia for RFA.

 

[coffeebythelake]

I use IM versed 2-5 mg and heavy local. Would never use deep sedation and definitely never general anesthesia for RFA.

Why IM. No IV?

 

[caligas]

Not an answer to your question but I have personally had 3 multi level RFAs at thoracic level wide awake.

Yes it’s painful but I don’t see it requiring GA.

 

[lobelsteve]

Sedation not recommended. I'd give the doc crap about his skills or patient choice. Lido goes a long way towards comfort.

 

[jwk]

Sedation not recommended. I'd give the doc crap about his skills or patient choice. Lido goes a long way towards comfort.

I don't know about RFAs but I was pleasantly surprised with a recent facet/SI joint block without any sedation, after having several done in the past with sedation. 10 minutes in and out vs 3 hrs for IV, procedure, recovery, etc.

 

[MirrorTodd]

Anybody doing prone LMAs? A "well seated" prone LMA versus trying your luck with the infamous prone MAC ( AKA room air general)?

I have been very tempted these last couple years, but I can't figure out how the head is supposed to be positioned. Like a prone pillow might work, but then you have to pad all the underbody/chest area, then the lma's are much stiffer and longer out of the mouth than an ETT so it's sticking straight down into the table and you can't bend it out of the way.

 

[Hoya11]

I have been very tempted these last couple years, but I can't figure out how the head is supposed to be positioned. Like a prone pillow might work, but then you have to pad all the underbody/chest area, then the lma's are much stiffer and longer out of the mouth than an ETT so it's sticking straight down into the table and you can't bend it out of the way.

patient enters OR and lays themselves on the table prone with a regular pillow, head facing to the side.
you leave the stretcher in the room.
you preoxygenate with their head facing to the side and induce prone.
open mouth and insert LMA, then I usually double up (fold in half) the pillow to make it more narrow and not touching face/airway.
if any issues you flip over back onto the stretcher supine.
if success (never had any issues) the stretcher leaves the room

 

[GassYous]

patient enters OR and lays themselves on the table prone with a regular pillow, head facing to the side.
you leave the stretcher in the room.
you preoxygenate with their head facing to the side and induce prone.
open mouth and insert LMA, then I usually double up (fold in half) the pillow to make it more narrow and not touching face/airway.
if any issues you flip over back onto the stretcher supine.
if success (never had any issues) the stretcher leaves the room

I've heard of people intubating prone and don't see an issue with your strategy in the right patient population but I prefer to do a minimal mac or tube.

 

[nimbus]

patient enters OR and lays themselves on the table prone with a regular pillow, head facing to the side.
you leave the stretcher in the room.
you preoxygenate with their head facing to the side and induce prone.
open mouth and insert LMA, then I usually double up (fold in half) the pillow to make it more narrow and not touching face/airway.
if any issues you flip over back onto the stretcher supine.
if success (never had any issues) the stretcher leaves the room

Same. I’ve been doing that in appropriate patients for 20+ yrs. Typically younger patients for hemorrhoids and anal fistulas. No issues, definitely smoother than the “big MACs” we used to do for the same cases.

 

[2Fast2Des]

Same. I’ve been doing that in appropriate patients for 20+ yrs. Typically younger patients for hemorrhoids and anal fistulas. No issues, definitely smoother than the “big MACs” we used to do for the same cases.

I don't know, I feel like prone LMA regardless is just putting unnecessary risk for minimal reward. Sure it can be done, but prone and ETT is the best bang for the buck and doesn't take that much more time honestly

 

[nimbus]

I don't know, I feel like prone LMA regardless is just putting unnecessary risk for minimal reward. Sure it can be done, but prone and ETT is the best bang for the buck and doesn't take that much more time honestly

Understand your point but you have to consider that before prone LMAs, our standard practice was “MAC” with no airway at all. That was significantly worse.

Maybe I’m lazy but I prefer the patients prone themselves. At the end, we airplane them onto the gurney.

 

[caligas]

I don't know about RFAs but I was pleasantly surprised with a recent facet/SI joint block without any sedation, after having several done in the past with sedation. 10 minutes in and out vs 3 hrs for IV, procedure, recovery, etc.

Yeah. I’ve had 3 RFAs and 5-6 injections. The injection is a bit of a sting but the RFA is truly 60 seconds of “I can do this! I can do this!”

I figure it’s nothing compared to natural labor, so it’s the least we can do.

 

[2Fast2Des]

Yeah. I’ve had 3 RFAs and 5-6 injections. The injection is a bit of a sting but the RFA is truly 60 seconds of “I can do this! I can do this!”

I figure it’s nothing compared to natural labor, so it’s the least we can do.

Many of the pts I deal with for pain cases, well actually many in general, get upset that they remember being wheeled in and seeing the OR. Many people don't have your mentality of hey I'm getting something done to help with my pain and grit it for 5 minutes. Very much spoiled population. Don't know how the pain guys deal with these special characters in the office, it's a pathology in both parties I think 🤣

 

[GassYous]

Many of the pts I deal with for pain cases, well actually many in general, get upset that they remember being wheeled in and seeing the OR. Many people don't have your mentality of hey I'm getting something done to help with my pain and grit it for 5 minutes. Very much spoiled population. Don't know how the pain guys deal with these special characters in the office, it's a pathology in both parties I think 🤣

Children in other countries have entire surgeries with local only. Here people demand an induction just to get rolled into the operating room.

 

[coffeebythelake]

Children in other countries have entire surgeries with local only. Here people demand an induction just to get rolled into the operating room.

Yeah the American public is spoiled and demanding.

 

[lobelsteve]

Many of the pts I deal with for pain cases, well actually many in general, get upset that they remember being wheeled in and seeing the OR. Many people don't have your mentality of hey I'm getting something done to help with my pain and grit it for 5 minutes. Very much spoiled population. Don't know how the pain guys deal with these special characters in the office, it's a pathology in both parties I think 🤣

I tell them to grow a pair or get walking. See my reviews on healthgrades. "Angry little troll"

 

[coffeebythelake]

Here people demand an induction just to get rolled into the operating room.

These are the same patients btw that blame doctors for the opioid crisis and everything else

 

[narcusprince]

I have been very tempted these last couple years, but I can't figure out how the head is supposed to be positioned. Like a prone pillow might work, but then you have to pad all the underbody/chest area, then the lma's are much stiffer and longer out of the mouth than an ETT so it's sticking straight down into the table and you can't bend it out of the way.

For this case a fast pain doc plenty of local and
Midaz/ketamine works well and ask the surgeons to localize all the sites. Also prior to ablation a little local through the needles prior to burning helps.

Prone LMA works with either a probe pillow or a pain table with the hole in it for rhizotomies. Also I position the head above the stomach. The most challenging part of prone lma insertion is opening the mouth. I typically place a bite block once i start pushing propofol that way i can slip the lma in. Prone lmas can be challenging rarely will I have a problem with them.

 

[TheLoneWolf]

In med school/residency, 5-10 years ago we did these with a wiff of versed and copious local in the office.

New pain guys want essentially a motionless field, GA without an airway/ deep heavy propofol sedation in the OR.

Sometimes they are just too fat or sick and there is no way to make this happen.

Couple weeks back had a BMI 50 anxious chronic pain patient for bilateral c3-5 RFA. Usually I’d just tell pain guy I’m going to give a wiff of versed and deal with it. they expect more because that’s the group culture right now. I decided to play ball with propofol and it turned into a **** show with thankfully a good outcome.

What’s your practice and how do you handle the tough to “sedate” patients?

These days suck.

Late to party.

Practice pain management and anesthesiology full-time. Previously academic, mostly PP now.

I have seen this previously, mostly the non-anesthesia guys, lassiez fare with use of sedatives and no idea have to handle a prone compromised airway if needed. Most careless, including my co-fellows, were the PMR guys. This is my n=1 but interactions with a large number of fellowship and non-fellowship-trained guys.

off top of my head, I know of a local pmr high volume guy in a cosmopolitan localtion- apparent high spinal during a cervical procedure - apnea unrecognied and brain dead by ambulance arrival, slap on wrist and back at it.

Another case, a non-anesthesia pain doc caused a case of LAST during a nerve block, had utilized sedation; patient started seizing then apenic, they immediately called for an anesthesia pain doc in the clinic to get involved; couldnt intubate or ventilate, again brain dead- that anesthesia pain doc lost his license over it.

Quite common in PP where the practice employs a CRNA or an anesthesia background pain doc to give mac anesthesia for pretty much every case to pad billings. So called 'double dipping' by billing for both the sedation and procedure. Epidurals, joint injections, minor peripheral nerve blocks.

We had an issue with this in inner-city academia where we were not sure if select patients were coming in for the procedure, the IV high, or a combination of both. ie asking for sedatives and doses by name was concerning. When offered reassurance instead, they suddenly don't want the procedure or reschedule.

Recently, around 2021, medicare and private insurance is fighting back by outright denying or bundling sedation for pain procedures. I don't disagree with this given the data and my experiences.

In 2 years of private practice pain with no ability to prescreen patients, I have not once given sedation. Cervical procedures, RFA, facial blocks, the gamut, all you need is good local, time, and reassurance. If someone has uncontrolled anxiety or is catastrophizing, I readily offer visits to psych prior to offering a procedure. I have not had one instance of patients giving me any issues or freaking out in the procedure suite.

Don't take my word for it. The Practice Guidelines for Spinal Diagnostic & Treatment Procedures - 2nd Edition by the Spine Intervention Society by Bogduk et al essentially states this.

Here is the 2018 factfinder sheet regarding sedation for pain procedures:

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjT8dHWoKf9AhWcEFkFHRF5AO8QFnoECB4QAQ&url=https%3A%2F%2Fcdn.ymaws.com%2Fwww.spineintervention.org%2Fresource%2Fresmgr%2Ffactfinder%2FFactFinder_2018_02_Conscious.pdf&usg=AOvVaw3gzOgssCBvum_d_SfU9gK2

 

[sevoflurane]

I drove myself to all my medial branch blocks/rfa’s (3 sets).
Local only.

 

[ambiturner]

Somewhat off topic but lots of people in this thread have had RFAs and injections! Is there something about our day to day job that makes us more likely to have issues? I’m closing in on 40 and starting to worry about all the bending and pushing involved in our jobs…

 

[nimbus]

Somewhat off topic but lots of people in this thread have had RFAs and injections! Is there something about our day to day job that makes us more likely to have issues? I’m closing in on 40 and starting to worry about all the bending and pushing involved in our jobs…

I think the bending and pushing is actually good for most of us. Habitually holding our phone and staring at it is bad, at least for me.

 

[anaesthetic]

Somewhat off topic but lots of people in this thread have had RFAs and injections! Is there something about our day to day job that makes us more likely to have issues? I’m closing in on 40 and starting to worry about all the bending and pushing involved in our jobs…

Too much time on the golf course.

 

[Greenbayslacker]

2cc of 2% lido instilled for 2 minutes pre-burn does the trick. At the most I will give a half milligram of Xanax

 

[neutro]

I don't know about RFAs but I was pleasantly surprised with a recent facet/SI joint block without any sedation, after having several done in the past with sedation. 10 minutes in and out vs 3 hrs for IV, procedure, recovery, etc.

yes these are routinely done in clinic.

walk in walk out

anesthesia for pain procedures (esp. propofol) is a scam imo

 

[neutro]

Late to party.

Practice pain management and anesthesiology full-time. Previously academic, mostly PP now.

I have seen this previously, mostly the non-anesthesia guys, lassiez fare with use of sedatives and no idea have to handle a prone compromised airway if needed. Most careless, including my co-fellows, were the PMR guys. This is my n=1 but interactions with a large number of fellowship and non-fellowship-trained guys.

off top of my head, I know of a local pmr high volume guy in a cosmopolitan localtion- apparent high spinal during a cervical procedure - apnea unrecognied and brain dead by ambulance arrival, slap on wrist and back at it.

Another case, a non-anesthesia pain doc caused a case of LAST during a nerve block, had utilized sedation; patient started seizing then apenic, they immediately called for an anesthesia pain doc in the clinic to get involved; couldnt intubate or ventilate, again brain dead- that anesthesia pain doc lost his license over it.

Quite common in PP where the practice employs a CRNA or an anesthesia background pain doc to give mac anesthesia for pretty much every case to pad billings. So called 'double dipping' by billing for both the sedation and procedure. Epidurals, joint injections, minor peripheral nerve blocks.

We had an issue with this in inner-city academia where we were not sure if select patients were coming in for the procedure, the IV high, or a combination of both. ie asking for sedatives and doses by name was concerning. When offered reassurance instead, they suddenly don't want the procedure or reschedule.

Recently, around 2021, medicare and private insurance is fighting back by outright denying or bundling sedation for pain procedures. I don't disagree with this given the data and my experiences.

In 2 years of private practice pain with no ability to prescreen patients, I have not once given sedation. Cervical procedures, RFA, facial blocks, the gamut, all you need is good local, time, and reassurance. If someone has uncontrolled anxiety or is catastrophizing, I readily offer visits to psych prior to offering a procedure. I have not had one instance of patients giving me any issues or freaking out in the procedure suite.

Don't take my word for it. The Practice Guidelines for Spinal Diagnostic & Treatment Procedures - 2nd Edition by the Spine Intervention Society by Bogduk et al essentially states this.

Here is the 2018 factfinder sheet regarding sedation for pain procedures:

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjT8dHWoKf9AhWcEFkFHRF5AO8QFnoECB4QAQ&url=https%3A%2F%2Fcdn.ymaws.com%2Fwww.spineintervention.org%2Fresource%2Fresmgr%2Ffactfinder%2FFactFinder_2018_02_Conscious.pdf&usg=AOvVaw3gzOgssCBvum_d_SfU9gK2

frame worthy.

 

[narcusprince]

I agree anesthesia in pain doc in boxes is a scam and wrought with fraudulent billing. I remember having to provide 3-4 sedations an hour in older sick patients. Cancel a case find a new gig. Im happy to have stopped doing that kind of work. Give me a call room and a hospital. Much rather work with folks who have standards.

 

[GassYous]

Somewhat off topic but lots of people in this thread have had RFAs and injections! Is there something about our day to day job that makes us more likely to have issues? I’m closing in on 40 and starting to worry about all the bending and pushing involved in our jobs…

Sitting in an uncomfortable chair for hours
I have some back pain that goes away completely when I'm on vacation

 

[sevoflurane]

Somewhat off topic but lots of people in this thread have had RFAs and injections! Is there something about our day to day job that makes us more likely to have issues? I’m closing in on 40 and starting to worry about all the bending and pushing involved in our jobs…

What did it for me was competitive tennis.
2x a week w a pro and practiced with a college team for 2-3 hrs until my early 40’s. Now just bike and snowboard.
Do miss those long rally’s. 😭

But like others have mentioned, sitting in a chair for 8 hrs a day isn’t good. Silver lining is that as you age a lot of people autofuse and back issues get better or go away. Keeping your core strong is also extremely important.

 

[neutro]

MBBs leading upto RFA's probably have the best evidence among all pain procedures. Have heard Dr Bogduk say this many times.

 

[Aether2000]

Late to this party in responding but here are some of the considerations in Lumbar RFA:
1. No sedation is absolutely necessary in the majority of these procedures, but lying in the prone position for 15-30 minutes may be more than many with facet arthropathy can tolerate without something. Heating the nerve to 180-200 degrees F is painful initially in many patients.
2. Sedation, TIVA, even general inhalational anesthesia without neuromuscular blockers does not interfere with motor stimulation of the anterior ramus that can be assessed by the physician via manual exam or observation of the foot, knee, and hip activation. However, many physicians will instead concentrate only on muscle stimulation of the intermediate and lateral branches of the posterior primary rami, of which denervation is of secondary importance.
3. Sensory stimulation using a needle with a 1cm unshielded tip is woefully inaccurate, and was not part of the SIS protocols for good reason. Therefore NOT sedating for this reason is using fallacious logic.
4. Whereas keeping the patient responsive may help assure no lesioning of the anterior ramus, if appropriate anatomic placement is used, then a responsive patient is not necessary provided an excess of local anesthetic is not used through the needle prior to lesioning- this is usually anything more than 0.5ml of local since 1ml will partially anesthetize the anterior ramus.
5. Anatomical placement using fluoroscopic evaluation is the primary method of needle placement for RFA but not infrequently corners are cut by physicians (including pain physicians) placing the needles (e.g. never obtaining a lateral view), improper entry angles to best approach the medial branch (some physicians use no lateral tilt on fluoroscopy), or inaccurate tip placement too far posterior on the transverse process with the tip being in the MAL rather than on the nerve.
6. Surgeons are abysmal at needle placement for these, and may have needle placement far out on the transverse process or on the lamina or posterior facet joints.
7. As anesthesiologist, unless you are watching the fluoroscopy closely, you have no idea whether the doc doing the procedure has a clue about what they are doing. Surgeons frequently request heavy sedation but their patients are most endangered by sedation given their lack of skill in needle placement. Some do not use stimulation at all- just slam the needle in somewhere in the spine on a straight AP view, then lesion.