Thoracic MBB and RFA technique

[Gnarvin]

During fellowship I did very few thoracic medial branch blocks and RFA. I have looked at the technique in Furman and honestly it is tough for me to see the thoracic transverse processes even in the text and I have a hard time seeing them with real patients. Does anyone have a good technique for thoracic MBB and/or RFA that is easier or where I don’t have to try to visualize the transverse processes as precisely?

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[lobelsteve]

Search forums for this. Well documented in older threads with good images. Mr mxytpk

 

[Taus]

Search forums for this. Well documented in older threads with good images. Mr mxytpk

👍🏻 Search “pedicle shadow”. I

 

[Gnarvin]

Thank you both!

 

[Laryngospasm]

These are especially fun on very thin severely osteoporotic patients..

 

[Taus]

These are especially fun on very thin severely osteoporotic patients..

Yep. Add copd Precisely who I had to use the “pedicle shadow” technique on. On the rare occasions I did T mbb/rf I had always done classic corner TP. One patient in particular forced my hand to use MM’s technique when I couldn’t see jack for reliable landmarks despite every trick I know. I was convinced a pneumothorax was coming. I changed to pedicle shadow….. it worked great. Done a handful that way over last few years…. Easy and worked well. I’ve reviewed the anatomy of original descriptions Tmbb and the newer anatomical studies presented at SIS over last few years re articular branches. Then I just shrug and said well this has worked well…

 

[RoloTomassi]

Thanks, never seen this technique.

Question- the pic I looked up in that old thread showed needles coming in from lateral to medial, seemingly going perpendicular to the yellow line the representing the nerve. Is this the best approach or would going more medial to lateral, or straight caudal to cephalad be better?

 

[DOctorJay]

Thanks, never seen this technique.

Question- the pic I looked up in that old thread showed needles coming in from lateral to medial, seemingly going perpendicular to the yellow line the representing the nerve. Is this the best approach or would going more medial to lateral, or straight caudal to cephalad be better?

I come in perpendicular to the nerve but I use nimbus needles for these. Really appreciate MM’s description of this technique.

 

[nvrsumr]

I am glad I am not the only one using his technique.

I use sis at T 10-12 and pedicle shadow everywhere else

easy (for me at least) to be in the joint so lateral view is important.

 

[callmeanesthesia]

I made up my own - needle insertion inferior and in the midline, oriented out toward the TP. Goal is to get them parallel to the medial branches as shown in the SIS diagrams. This patient is exceptionally thin so you can see the TPs very well but I can usually make out at least a little bit.

 

[painfree23]

I made up my own - needle insertion inferior and in the midline, oriented out toward the TP. Goal is to get them parallel to the medial branches as shown in the SIS diagrams. This patient is exceptionally thin so you can see the TPs very well but I can usually make out at least a little bit.
View attachment 340458

Why can’t you just line the needles so they lay caudal to cranial with the tips in the same spot?

 

[RoloTomassi]

Pedicle shadow technique--doesn't your needle placement in relation to the pedicle shadow change depending on cephalad/caudal tilt? For example, if you have perfect placement, then tilt, does it look off? If so, how do know the best tilt to start with? Square up the pedicle with the TP?

 

[lobelsteve]

Pedicle shadow technique--doesn't your needle placement in relation to the pedicle shadow change depending on cephalad/caudal tilt? For example, if you have perfect placement, then tilt, does it look off? If so, how do know the best tilt to start with? Square up the pedicle with the TP?

Yes, parallax occurs in every procedure.

 

[willabeast]

Thanks, never seen this technique.

Question- the pic I looked up in that old thread showed needles coming in from lateral to medial, seemingly going perpendicular to the yellow line the representing the nerve. Is this the best approach or would going more medial to lateral, or straight caudal to cephalad be better?

Suggest staring at a skeleton for about 15 - 30 minutes then figuring out what would work best for you. I suspect that is what most people do. One thing that has always fascinated me is the difference in procedure times for different practitioners. Some docs want a very fast technique that is fast and usually works. Other docs want a technique that always works and do not care much for speed. Everyone wants safe, but what is a safe procedure technique for a doc that has been doing spine work for 10 years is very different from what is safe for a new doc. So my advice - Suggest staring at a skeleton for about 15 - 30 minutes then figuring out what would work best for you.

 

[RoloTomassi]

Yes, parallax occurs in every procedure.

Right that's what I mean. Standard TP technique parallax less of an issue since distance from needle to target landmark, TP border, is less. Usually start with some caudal tilt to get flatter but was wondering if it was more ideal to square pedicles inside the vertebral body like kypho for this technique

 

[callmeanesthesia]

Why can’t you just line the needles so they lay caudal to cranial with the tips in the same spot?

That works too. This technique lays the needles more parallel to the nerve according to the SIS diagram of the thoracic medial branches. And there’s only one needle entry site even if the procedure is bilateral.

 

[clubdeac]

I made up my own - needle insertion inferior and in the midline, oriented out toward the TP. Goal is to get them parallel to the medial branches as shown in the SIS diagrams. This patient is exceptionally thin so you can see the TPs very well but I can usually make out at least a little bit.
View attachment 340458

That’s how I do it too. Here’s onei did on a post kyphoplasty patient with continued axial mid back pain

 

[painfree23]

Love all these images…anyone got any images of another technique?

 

[pmrmd]

Super thin lady so had to use the 5cm cannulas, slight contralateral but mostly I like to make sure the rib is deep to block my needle.

 

[painfree23]

View attachment 340503
Super thin lady so had to use the 5cm cannulas, slight contralateral but mostly I like to make sure the rib is deep to block my needle.

This is how I do it

 

[Ligament]

That’s how I do it too. Here’s onei did on a post kyphoplasty patient with continued axial mid back pain

This is the approach I take as well.

 

[oneforfighting]

I have a super thin lady (~BMI 22) who I plan on doing T7-9 RFA on and I am concerned about superficial skin burns. For the MBBs, I used 25g 1.5 inch needles and maybe 1 inch was buried underneath the skin. Have you all encountered adverse outcomes on such patients? If so what are your work arounds? I have access to cooled RFA but concerned about aforementioned superficial burns (was thinking about using 50 or 75mm with 2mm active tip). Otherwise, I have conventional 20g 100mm cannulas with 10mm active tips but here I am concerned about the length and getting enough purchase. Thoughts?

 

[lobelsteve]

22g 10cm with 5mm tip. No problem.

 

[Orin]

I have a super thin lady (~BMI 22) who I plan on doing T7-9 RFA on and I am concerned about superficial skin burns. For the MBBs, I used 25g 1.5 inch needles and maybe 1 inch was buried underneath the skin. Have you all encountered adverse outcomes on such patients? If so what are your work arounds? I have access to cooled RFA but concerned about aforementioned superficial burns (was thinking about using 50 or 75mm with 2mm active tip). Otherwise, I have conventional 20g 100mm cannulas with 10mm active tips but here I am concerned about the length and getting enough purchase. Thoughts?

Agree with Dr. Lobel. The risk of superficial burns would be higher with the cooled than conventional due the geometry of the burn. If you have concerns, you can do things to protect the skin. The classic technique is to inject small amounts of air subcutaneously to create an insulating barrier. You could also do ice in a sterile glove to cool the skin, but the injection technique is easier.

Pneumodissection for Skin Protection in Image-Guided Cryoablation of Superficial Musculoskeletal Tumors - PMC

Pneumodissection is described as a simple method for preventing skin injury during cryoablation of superficial tumours. Superficial tumour cryoablations performed from 2009 to 2015 were retrospectively reviewed. Pneumodissection was performed in 13 ...

www.ncbi.nlm.nih.gov

 

[callmeanesthesia]

Insert needles with a steep inferior to superior angulation. That way you also get good coverage laying across the MBN. Can’t put the needles in coaxially but I don’t usually for thoracic anyway, and if you’re running nearly parallel to the skin it would be very hard to stick the needle in between two ribs.

 

[oneforfighting]

22g 10cm with 5mm tip. No problem.

22g 10cm with 5mm tip. No problem.

I only have 20g 10cm with 10mm tip available. Think this would be okay?

 

[oneforfighting]

Agree with Dr. Lobel. The risk of superficial burns would be higher with the cooled than conventional due the geometry of the burn. If you have concerns, you can do things to protect the skin. The classic technique is to inject small amounts of air subcutaneously to create an insulating barrier. You could also do ice in a sterile glove to cool the skin, but the injection technique is easier.

Pneumodissection for Skin Protection in Image-Guided Cryoablation of Superficial Musculoskeletal Tumors - PMC

Pneumodissection is described as a simple method for preventing skin injury during cryoablation of superficial tumours. Superficial tumour cryoablations performed from 2009 to 2015 were retrospectively reviewed. Pneumodissection was performed in 13 ...

www.ncbi.nlm.nih.gov

This is really cool. Thanks!

 

[oneforfighting]

Insert needles with a steep inferior to superior angulation. That way you also get good coverage laying across the MBN. Can’t put the needles in coaxially but I don’t usually for thoracic anyway, and if you’re running nearly parallel to the skin it would be very hard to stick the needle in between two ribs.

Yes, I figured I'd need to place fairly parallel. Both to avoid superficial burns but also to better catch the nerves.

 

[lobelsteve]

I only have 20g 10cm with 10mm tip available. Think this would be okay?

Look at ct or mri axials. You can measure for the answer.
Or just order 1 box of the smaller needles. Same probes for both.

 

[Taus]

I think this question can be answered in a quite straightforward fashion. On initial or confirmatory medial branch block, similar to as you did above, measure the exact depth from skin to bone in perpendicular fashion with the needle. If you have a solid inch, even with a 10 mm active tip in perpendicular fashion which won’t be the case on the RFA, as it will lay even deeper more parallel to nerve, I think this will not be an issue. Ultimately it comes down to knowing exactly how much room dorsal to the most posterior aspect of the active tip do you need between skin to remain safe. I have come across this issue more commonly on the S3 lesion for sacral lateral branches. If I had at least 2x the length of the active tip I proceeded with RFA.

 

[Ducttape]

if you forget to do this during the procedure, measure using a handy dandy ultrasound in the office.