Techniques and Pearls for Thoracic MBB/RFA

[bedrock]

---

Members don't see this ad.

18 years in on T-spine RF. 100's to over a thousand done.
Medial to lateral, inferior to superior. Needle tip sitting on upper outer quadrant of pedicle shadow. Active tip as flat on lamina as possible.



View attachment 366265

But are you distal or proximal to where the medial branch innervates the joint using that technique? I would say distal which does nothing. Much like the lady who does her cervical mbb’s on the posterior articular pillar.

And if one argues otherwise, this technique still has problems as the probe is placed perpendicular and not parallel to the nerve as you show above. If someone did this in the cervical or lumbar spine, you’d eviscerate em. I’d say you’re living in a glass house

I also use this technique for thoracic RFA. Quick, safe and it works.

 

[Dr. Ice]

Whoever wants my thoracic anything procedures, send me your contact info, happy to send. For the n, it’s just not worth the time, insurance ridiculousness, effort, risk etc.

I say this as I have multiple legacy thoracic epidural, thoracic rfa pateints that I begrudgingly do mainly because they have Medicare and I have no interest in taking on any new patients in this category

 

[clubdeac]

Yet somehow I manage....
20 years doing it this way with success rates = to cervical literature.
Must be lucky.
If following the diagram I posted above, my target appears to be a few mm distal to the lateral branch takeoff. So I am getting almost the entire medial branch from there. Articular branches are not shown... a caveat for us all.

Let me see if you can guess who I am “Your anecdotes and n of 10 mean nothing to me. Show me the DBRCTs” 😜

 

[BobBarker]

Ok guys. The pedicle shadow and the S1 tfesi’s both work quite well.

 

[bedrock]

Ok guys. The pedicle shadow and the S1 tfesi’s both work quite well.

Not sure about deac, but I “liked” the post as a good natured jab at Steve.
Deac is right that Steve always “insists” on level 1-2 evidence, but Steve’s post (#100) does seem to conveniently forgot about that principle…..

 

[bedrock]

Whoever wants my thoracic anything procedures, send me your contact info, happy to send. For the n, it’s just not worth the time, insurance ridiculousness, effort, risk etc.

I say this as I have multiple legacy thoracic epidural, thoracic rfa pateints that I begrudgingly do mainly because they have Medicare and I have no interest in taking on any new patients in this category

I don’t live near you and I don’t need anymore patients.

However, I’d rather do thoracic ESI and thoracic RFA over CESI and cervical RFA.
Pays the same and is safer and quicker. (At least with the thoracic RFA technique that Steve and I both use).

I’ve had issues with many BCBS plans not covering thoracic RFA, but no issues with straight Medicare, Cigna, Aetna, UHC, or our state WC.

 

[RoloTomassi]

But are you distal or proximal to where the medial branch innervates the joint using that technique? I would say distal which does nothing. Much like the lady who does her cervical mbb’s on the posterior articular pillar.

And if one argues otherwise, this technique still has problems as the probe is placed perpendicular and not parallel to the nerve as you show above. If someone did this in the cervical or lumbar spine, you’d eviscerate em. I’d say you’re living in a glass house

I insert midline and basically follow SP with Sidekick tip like so. I feel like it's actual quite parallel. Whether it's distal to articular branches that's up for debate, but seems to work well anecdotally.

 

[clubdeac]

I insert midline and basically follow SP with Sidekick tip like so. I feel like it's actual quite parallel. Whether it's distal to articular branches that's up for debate, but seems to work well anecdotally.
View attachment 388381

The needles I’m seeing people post look more like this. What your showing is similar to how I place my needles

 

[oreosandsake]

View attachment 388357

Ok even safer than trying to find the TP

 

[oreosandsake]

This is how I do them…
Trying to lay down flatish on the TP

 

[schmee90]

So I have been revieing this thread...just confirming you only do pedicle shadow for T10 MBB and above. T11 and below is traditional target Junction of the SAP and TP based on the anatomy and the course of the Medial branches.

For Pedicle shadow technique you start one level below, go in medial to lateral and land on the upper outer quadrant of the pedicle shadow.

I guess my question is for the Pedicle shadow technique do you do this pretty much from an AP approach?

 

[drmamba]

So I have been revieing this thread...just confirming you only do pedicle shadow for T10 MBB and above. T11 and below is traditional target Junction of the SAP and TP based on the anatomy and the course of the Medial branches.

For Pedicle shadow technique you start one level below, go in medial to lateral and land on the upper outer quadrant of the pedicle shadow.

I guess my question is for the Pedicle shadow technique do you do this pretty much from an AP approach?

Yes, I do AP using the pedicular shadow technique.

 

[hopefulgasman]

on your AP when you are placing the needles using the pedicular shadow technique, are you putting on any caudal tilt or just 0 degrees AP and then climbing up starting one level below? Have an upcoming T8, T9, T10 RFA. Okay to use 18g venom needles? @lobelsteve @drmamba

 

[lobelsteve]

on your AP when you are placing the needles using the pedicular shadow technique, are you putting on any caudal tilt or just 0 degrees AP and then climbing up starting one level below? Have an upcoming T8, T9, T10 RFA. Okay to use 18g venom needles? @lobelsteve @drmamba

I caudal tilt to square endplates. Start at inferior VB plate and head superiolateral. Nothing but skin/fat/muscle- if skinny patient risk of skin burn based on depth.

 

[schmee90]

Probably dumb questions but honestly curious. do people actualy document this pedicle shadow technique on procedure note officially..is it an accepted way to do the procedure. it seems well accepted on this forum but is there any pubnlished literature on it. Curious as I have dont only a few thoracic RFAs, 99% of my RFA are cervical and lumbar.

 

[DoYouEvenLiftBro]

Probably dumb questions but honestly curious. do people actualy document this pedicle shadow technique on procedure note officially..is it an accepted way to do the procedure. it seems well accepted on this forum but is there any pubnlished literature on it. Curious as I have dont only a few thoracic RFAs, 99% of my RFA are cervical and lumbar.

I average 1/week, did two today.

This is the snippet of our note, no issues billing or legality

Procedure in Detail : … A curved radio frequency cannula 20 gauge, 10 cm was placed at the appropriate level, at each site. Multiplanar views were used to confirm placement of the needle and motor was tested at each individual level…

 

[DoYouEvenLiftBro]

I’ve been contemplating scraping thoracic rfa and just doing sprint SPR… it takes like 5 minutes and a nice filler at the asc

Thoughts?

 

[Gnarvin]

I’ve been contemplating scraping thoracic rfa and just doing sprint SPR… it takes like 5 minutes and a nice filler at the asc

Thoughts?

I’ve never done Sprint in the T spine. I am assuming you would just place the lead at the pedicle shadow for this technique?

One issue I see is which ICD10 code would you use? In the L spine I have been using the lumbar multifidus dysfunction code.

 

[PMROralBoards]

I’ve never done Sprint in the T spine. I am assuming you would just place the lead at the pedicle shadow for this technique?

One issue I see is which ICD10 code would you use? In the L spine I have been using the lumbar multifidus dysfunction code.

G58.8 other specified mononeuropathy

 

[Gnarvin]

G58.8 other specified mononeuropathy

Just to play devils advocate, do you really feel that there is a neuropathy of the medial branch nerve in this case? I would assume most of us would be doing the procedure to help with pain presumably from spondylosis. I think using that diagnosis code is a bit of a gray area. I am not criticizing you or anything, just putting my thoughts out there.

 

[clubdeac]

Just to play devils advocate, do you really feel that there is a neuropathy of the medial branch nerve in this case? I would assume most of us would be doing the procedure to help with pain presumably from spondylosis. I think using that diagnosis code is a bit of a gray area. I am not criticizing you or anything, just putting my thoughts out there.

Is there a closer/more appropriate code that’s an acceptable Medicare PNS code?

 

[Gnarvin]

Is there a closer/more appropriate code that’s an acceptable Medicare PNS code?

Not that I can find. That is the problem that I am running in to. I think the therapy could potentially help but I am not really comfortable using a diagnosis code that I don’t think is accurate or appropriate.

 

[DOctorJay]

Not that I can find. That is the problem that I am running in to. I think the therapy could potentially help but I am not really comfortable using a diagnosis code that I don’t think is accurate or appropriate.

reminds me of docs using CRPS codes for knee pain after TKA to get DRG approved

 

[Gnarvin]

reminds me of docs using CRPS codes for knee pain after TKA to get DRG approved

I agree 100%.

 

[PMROralBoards]

Just to play devils advocate, do you really feel that there is a neuropathy of the medial branch nerve in this case? I would assume most of us would be doing the procedure to help with pain presumably from spondylosis. I think using that diagnosis code is a bit of a gray area. I am not criticizing you or anything, just putting my thoughts out there.

It’s the closest one. Lumbar spondy is not an approved icd10 for Medicare

 

[DoYouEvenLiftBro]

[td]M62.85[/td][td]Dysfunction of the multifidus muscles, lumbar region[/td]

Can’t you use this for lumbar region?

 

[PMROralBoards]

[td]M62.85[/td][td]Dysfunction of the multifidus muscles, lumbar region[/td]

Can’t you use this for lumbar region?

Not covered for my lcd

 

[Gnarvin]

[td]M62.85[/td][td]Dysfunction of the multifidus muscles, lumbar region[/td]

Can’t you use this for lumbar region?

This what I use for the lumbar region, yes. There is no analogous covered code for the thoracic region, however.