Thoracic procedures

[Piebaldi]

I know this is not super relevant in these trying times … but do you all do thoracic MBBs/RFAs?
If so how successful are you with them in terms of patient satisfaction/pain improvement?

---

Members don't see this ad.

 

[callmeanesthesia]

I always caution people that the course of the medial branch nerves in the thoracic spine are variable but I do see pretty good results considering. I don’t just do it for anybody with thoracic pain though - most of that is muscular. I mainly do it for those with arthritis around prior compression fracture, or above a fusion.

 

[NJPAIN]

Taus has posted some great images in the past.

The scary thing is that those in whom you think about doing thoracic MBB and RFN for are usually so osteoporotic and kyphotic that you can barely see any landmarks.

I’d love to be doing more of this on appropriate patients. Interested to hear any pearls from those that do them more frequently.


Sent from my iPhone using Tapatalk

 

[Piebaldi]

I always caution people that the course of the medial branch nerves in the thoracic spine are variable but I do see pretty good results considering. I don’t just do it for anybody with thoracic pain though - most of that is muscular. I mainly do it for those with arthritis around prior compression fracture, or above a fusion.

Ok cool, yes I was recently talking about this with an attending regarding the variability of medial branch innervations in the thoracic spine and how they don't typically do the procedure as a result. I can't say that I see a lot of ppl doing them so i was curious. Also it is my understanding that insurance companies do not typically cover thoracic mbbs/rfas? thanks for your input!

 

[Piebaldi]

Taus has posted some great images in the past.

The scary thing is that those in whom you think about doing thoracic MBB and RFN for are usually so osteoporotic and kyphotic that you can barely see any landmarks.

I’d love to be doing more of this on appropriate patients. Interested to hear any pearls from those that do them more frequently.


Sent from my iPhone using Tapatalk

Right agreed. I was just curious to see how many of ya'll do it, I am even though in a very early stage, thinking that this is not something that i'd be wanting to do frequently.

 

[paindoc007]

It’s a good procedure for the right patient. I think of it primarily in old/chronic compression deformities, when there is still some tenderness to palpation over that segment

 

[BobBarker]

Pretty good luck with RF of the thoracolumbar junction. Not much need to go higher frequently.

 

[pmrmd]

Thoracic facets respond fairly well to steroid IMO, better than lumbar facets.

People of all ages with scoliosis get joint pains though so you will be doing injections and ablations more than you think.

 

[Piebaldi]

Pretty good luck with RF of the thoracolumbar junction. Not much need to go higher frequently.

When you say thoracolumbar - you mean like T11/T12?

 

[BobBarker]

Yes t11-L1

 

[Piebaldi]

Thoracic facets respond fairly well to steroid IMO, better than lumbar facets.

People of all ages with scoliosis get joint pains though so you will be doing injections and ablations more than you think.

I guess I'm also going to ask this and hijack my own thread - how many procedures did you all roughly do in fellowship? Did you feel confident once you graduated that you were good to go or did you feel any anxiety in terms of being out on your own?

 

[paindoc007]

I guess I'm also going to ask this and hijack my own thread - how many procedures did you all roughly do in fellowship? Did you feel confident once you graduated that you were good to go or did you feel any anxiety in terms of being out on your own?

definitely nerves and anxiety. That’s normal. Keeps you sharp, focused, and on your toes. More worrisome is complete arrogance coming out of a recently graduated fellow. That’s obnoxious

 

[Piebaldi]

definitely nerves and anxiety. That’s normal. Keeps you sharp, focused, and on your toes. More worrisome is complete arrogance coming out of a recently graduated fellow. That’s obnoxious

Yeah definitely. I am just starting, but already feel nervous ha! I feel confident with things like exam, diagnostics, rationale/theory for procedures, etc etc but the actual needling - ya that will take some time.

 

[paindoc007]

Yeah definitely. I am just starting, but already feel nervous ha! I feel confident with things like exam, diagnostics, rationale/theory for procedures, etc etc but the actual needling - ya that will take some time.

Just start simple. Lesi, mbb, RFA, siji, etc. you don’t need to do complicated or difficult procedures right off the bat. Gain confidence before diving into other stuff

 

[PAINISGOOD]

Yeah definitely. I am just starting, but already feel nervous ha! I feel confident with things like exam, diagnostics, rationale/theory for procedures, etc etc but the actual needling - ya that will take some time.

You will learn far more in practice than in fellowship. Fellowship gives you a background in which to build on. Good luck

 

[Piebaldi]

You will learn far more in practice than in fellowship. Fellowship gives you a background in which to build on. Good luck

Yes, I have heard that from multiple sources, but I guess because this is new, and the attendings make it seem so easy and are super fast, and I take forever I feel idiotic.
Also the statement you made above again I've heard it before, but where do you learn from after fellowship? you mean like your colleagues?

 

[Laryngospasm]

Between the difficult anatomy, variable mbb and increased risk of thoracic stuff I try to avoid it unless no other options. Not including ilesi. You learn mostly from yourself. Researching, studying anatomy, doing stuff that raises your bp and evaluating results.

 

[ErrantWhatever]

This is a new topic of interest to me. We recently had a pt admitted to inpatient rehab who basically is a new thoracic spinal cord injury (incomplete) following thoracic rfa. Outside private pain provider’s procedure notes and follow up basically say no complications. Pt presented to ED 6x within 3 weeks of procedure w severe b/l LE paresthesias and weakness. T2 MRI showing new hyperintense cord signal at level of rfa (compared to prior MRI).

I’m assuming this is very rare?

 

[paindoc007]

This is a new topic of interest to me. We recently had a pt admitted to inpatient rehab who basically is a new thoracic spinal cord injury (incomplete) following thoracic rfa. Outside private pain provider’s procedure notes and follow up basically say no complications. Pt presented to ED 6x within 3 weeks of procedure w severe b/l LE paresthesias and weakness. T2 MRI showing new hyperintense cord signal at level of rfa (compared to prior MRI).

I’m assuming this is very rare?

Wtf? Did they document sedation? It was probably done under deep sedation like propofol

 

[gdub25]

Agree, and I think it would be very difficult to damage the spinal cord with an RFA in the thoracic region, how in the world did they get the needles into the spinal cord or even close enough to cause a thermal lesion!

 

[jpb26]

I learned more in my first year out that I could have ever learned during fellowship. It's just different when you are on your own and don't have an attending standing behind you. I would read and look at anatomy books constantly to prepare for the next day's procedures. Id also suggest just plan on doing the 'easy' stuff at first until you are comfortable and then adding from there.

 

[NJPAIN]

Yes, I have heard that from multiple sources, but I guess because this is new, and the attendings make it seem so easy and are super fast, and I take forever I feel idiotic.
Also the statement you made above again I've heard it before, but where do you learn from after fellowship? you mean like your colleagues?

Don’t get over focused on speed despite the fact that some on this forum believe it is absolutely critical. Remember, if you take your time and image as you go it’s far less likely that your needle will stray into undesired territory. Also, if you can’t get a clear enough image to see your target, don’t move forward. I’ve done some expert witness work and a lot of the bad outcomes are not only associated with over sedation they are associated with underutilization of imaging. By that I mean: not taking time to optimize image, not imaging frequently enough and not checking multiple views. One that comes to mind was a brainstem injury associated with an AA injection. Four seconds of fluoro time.


Sent from my iPhone using Tapatalk

 

[gdub25]

I guess I'm also going to ask this and hijack my own thread - how many procedures did you all roughly do in fellowship? Did you feel confident once you graduated that you were good to go or did you feel any anxiety in terms of being out on your own?

I did a couple thousand procedures in fellowship, possibly the highest procedural volume fellowship in the country, and I still had some nerves whenever I came out so having a little anxiety is normal. Learn everything that you can during fellowship and don’t just take what you’re learning from your attending’s but go to courses, ask questions here, watch videos online, there’s always something to be learned somewhere.

 

[Piebaldi]

I did a couple thousand procedures in fellowship, possibly the highest procedural volume fellowship in the country, and I still had some nerves whenever I came out so having a little anxiety is normal. Learn everything that you can during fellowship and don’t just take what you’re learning from your attending’s but go to courses, ask questions here, watch videos online, there’s always something to be learned somewhere.

A couple thousand as in 2000? That's a lot!

Right at this moment, I am not being allowed to do that many procedures but I assume it's normal. Hopefully in the next few weeks I'm going to start doing more.

[/QUOTE]

 

[unchockey21]

Wtf? Did they document sedation? It was probably done under deep sedation like propofol

I don’t care if the patient was under general anesthesia with full muscle relaxation. Those needles shouldn’t be coming anywhere close to the cord with even mediocre technique and never checking a view besides the AP.

 

[gdub25]

Yeah, that’s my feeling as well. How in the world did they get close to the spinal cord!

 

[unchockey21]

Don’t get over focused on speed despite the fact that some on this forum believe it is absolutely critical. Remember, if you take your time and image as you go it’s far less likely that your needle will stray into undesired territory. Also, if you can’t get a clear enough image to see your target, don’t move forward. I’ve done some expert witness work and a lot of the bad outcomes are not only associated with over sedation they are associated with underutilization of imaging. By that I mean: not taking time to optimize image, not imaging frequently enough and not checking multiple views. One that comes to mind was a brainstem injury associated with an AA injection. Four seconds of fluoro time.


Sent from my iPhone using Tapatalk

Agreed. Take the time to make sure the patient is properly positioned and optimize your views and your time will improve just solely based on not having to overcome those obstacles. That becomes even more apparent with things like kyphoplasty and Vertiflex where it can make the difference between walking out after 20 minutes looking like a baller and wanting to stick a trocar in your eye and asking yourself why you ever thought this procedure was a good idea.

 

[Piebaldi]

Agreed. Take the time to make sure the patient is properly positioned and optimize your views and your time will improve just solely based on not having to overcome those obstacles. That becomes even more apparent with things like kyphoplasty and Vertiflex where it can make the difference between walking out after 20 minutes looking like a baller and wanting to stick a trocar in your eye and asking yourself why you ever thought this procedure was a good idea.

What are your thoughts on Vertiflex since you mentioned it? I had a previous attending say it was garbage. I have yet to see it done on anyone.

 

[ErrantWhatever]

Wtf? Did they document sedation? It was probably done under deep sedation like propofol

Agree, and I think it would be very difficult to damage the spinal cord with an RFA in the thoracic region, how in the world did they get the needles into the spinal cord or even close enough to cause a thermal lesion!

Yeah, I'd have to go back to the chart, but I believe sedation was used. The pain doc got a thoracic MRI like 5 days post-procedure that didn't really show anything. The MRI 3 weeks post-procedure and during hospital admission showed the cord signal changes. I obviously assume this is incredibly unusual but was just wondering if anyone had heard of anything like this. The pt is a 36yo M w/ young kids and is just starting to get out of his wheelchair 6 months later. Not a great situation obviously.

 

[pmrmd]

Following this conversation. MRI 5 days out would show damage. MRI right after would show it. Something doesn’t add up.

 

[unchockey21]

What are your thoughts on Vertiflex since you mentioned it? I had a previous attending say it was garbage. I have yet to see it done on anyone.

There’s a thread on the forum elsewhere about it. But in short, I feel like it’s a good option for people looking to avoid traditional spine surgery or who have comorbidities that make surgery not a viable option. The key is patient selection, like with most of what we do. You’ve got a some scumbags who will put it in anyone who fails an epidural just like SCS. And just like when stim is placed for the wrong reasons, those folks aren’t going to do well.

 

[BobBarker]

It is transverse myelitis. Not a cord thermal lesion. Save the poor pain doc, somebody!

 

[BobBarker]

It is transverse myelitis. Not a cord thermal lesion. Save the poor pain doc, somebody!

does it look like this??

 

[DODOCSS]

It is transverse myelitis. Not a cord thermal lesion. Save the poor pain doc, somebody!

agree. hopefully obtained an MR prior to doing the RF.

 

[ErrantWhatever]

Yeah, so to be clear, I'm not trashing on the pain provider here. I honestly posted this to hear if anyone had heard of this. It's a weird case for sure, and that is identified repeatedly in the chart. CSF and serum autoimmune/infectious studies performed and WNL on that admission. The neurology discharge dx was "postablation transverse myelitis." From a cursory glance, however, it looks like you'd expect to find something on CSF labs (pleocytosis, elevated protein concentration, oligoclonal bands?). Not in this case. Is a vascular incident more probable in this context (instead of direct cord ablation?). Just spit balling. I was not involved in this case directly, but the SCI attending had mentioned it in passing to me bc I'm applying to pain. Appreciate the conversation.

 

[Ferrismonk]

I do thoracic RFA periodically and I hate every single one. Usually it's due to scoliosis or significant kyphosis secondary to osteoporosis (where we want to spare steroids). Anatomy is screwy, bones are barely more dense than the lung. You are almost imagining the transverse process, but if you miss you puncture a lung. Lateral view is less reliable since the spine is tortuous in these patients. Works well, but I get more grey hairs on each one.
I usually only do this if the thoracic facet steroid injections (which usually work well) don't last long of if they are super high risk for more steroids.

Wtf? Did they document sedation? It was probably done under deep sedation like propofol

While over sedation does increase risk of bad things happening, the level of sedation has nothing to do with which drug was used.

Agree, and I think it would be very difficult to damage the spinal cord with an RFA in the thoracic region, how in the world did they get the needles into the spinal cord or even close enough to cause a thermal lesion!

It doesn't seem possible to me either, unless they were advancing in the lateral view and the needle went off track.

 

[Laryngospasm]

I do thoracic RFA periodically and I hate every single one. Usually it's due to scoliosis or significant kyphosis secondary to osteoporosis (where we want to spare steroids). Anatomy is screwy, bones are barely more dense than the lung. You are almost imagining the transverse process, but if you miss you puncture a lung. Lateral view is less reliable since the spine is tortuous in these patients. Works well, but I get more grey hairs on each one.
I usually only do this if the thoracic facet steroid injections (which usually work well) don't last long of if they are super high risk for more steroids.


While over sedation does increase risk of bad things happening, the level of sedation has nothing to do with which drug was used.


It doesn't seem possible to me either, unless they were advancing in the lateral view and the needle went off track.

You still getting paid for Facet injections? Much preferred to thoracic rfa for me.

 

[Piebaldi]

You still getting paid for Facet injections? Much preferred to thoracic rfa for me.

 

[Piebaldi]

Well since procedures are slim pickings in fellowship now given the serious restrictions from the corona crisis and the limitations on non essential procedures i'm going to ask a few technique questions - it's so hard to get a good grasp on things if I can't practice!
Anyhow, how do you all hold needles - at the top or bottom? it seems various attendings do thigns so differently - i have been told not to hold the needles a the bottom (near insertion point) before in order to avoid infection? and therefore to hold needles a the top of the needle - a recent attending though told me the opposite - mentioned that they did not like me holding the needle at the top, and that I should hold it at the bottom - and having a finger on the patients' body at all times. while it's reasonable, my hands are small so not sure I can do both?
also what do you all do with the hand not being used for needle maneuvering? I guess I don't know what to do with it, other than to hold it in the air? since some attendings drape and some don't. i guess for the non draping attendings I have occasionally put my non needle holding hand on the patient and contaminated the field. sigh.
needling is hard guys.

 

[dhcofc]

When advancing a large shafted Tuohy needle for example I’d encourage you to always have a tight pinch on the shaft right by the skin to avoid accidentally lurching forwards if resistance to advancing lessens or if patient moves. On fat people you may even want to push the fat down along the shaft to pinch it so it won’t move forwards accidentally (fat won’t stop you from advancing well if not compressed).

You can use one hand to pinch the shaft at the insertion site and the other hand can be on the hub to drive the needle. One safety hand pinching, one pushing hand.

I’m in the camp of hold needle by site of insertion vs just by the hub.

 

[Piebaldi]

When advancing a large shafted Tuohy needle for example I’d encourage you to always have a tight pinch on the shaft right by the skin to avoid accidentally lurching forwards if resistance to advancing lessens or if patient moves. On fat people you may even want to push the fat down along the shaft to pinch it so it won’t move forwards accidentally (fat won’t stop you from advancing well if not compressed).

You can use one hand to pinch the shaft at the insertion site and the other hand can be on the hub to drive the needle. One safety hand pinching, one pushing hand.

I’m in the camp of hold needle by site of insertion vs just by the hub.

Ok thank you. do you always drape?

 

[callmeanesthesia]

Well since procedures are slim pickings in fellowship now given the serious restrictions from the corona crisis and the limitations on non essential procedures i'm going to ask a few technique questions - it's so hard to get a good grasp on things if I can't practice!
Anyhow, how do you all hold needles - at the top or bottom? it seems various attendings do thigns so differently - i have been told not to hold the needles a the bottom (near insertion point) before in order to avoid infection? and therefore to hold needles a the top of the needle - a recent attending though told me the opposite - mentioned that they did not like me holding the needle at the top, and that I should hold it at the bottom - and having a finger on the patients' body at all times. while it's reasonable, my hands are small so not sure I can do both?
also what do you all do with the hand not being used for needle maneuvering? I guess I don't know what to do with it, other than to hold it in the air? since some attendings drape and some don't. i guess for the non draping attendings I have occasionally put my non needle holding hand on the patient and contaminated the field. sigh.
needling is hard guys.

Depends on what you are doing. Interlaminar ESI or other situation where it is critical to avoid unintentional advancement, get it through the skin and in a few centimeters, but then advance it by holding the shaft at the skin. For steering a bent spinal needle, eg MBBs, hold at/near the hub and flex it to steer. To make more exaggerated adjustments you can use your other hand to pull the skin to direct the needle. Many textbooks have a good section on needle steering.

 

[dhcofc]

I always drape for neuraxial procedures. Occasionally I’ll skip the drape for a hip IA for example. I usually use a plastic drape with a cutout in the middle.

 

[dhcofc]

Depends on what you are doing. Interlaminar ESI or other situation where it is critical to avoid unintentional advancement, get it through the skin and in a few centimeters, but then advance it by holding the shaft at the skin. For steering a bent spinal needle, eg MBBs, hold at/near the hub and flex it to steer. To make more exaggerated adjustments you can use your other hand to pull the skin to direct the needle. Many textbooks have a good section on needle steering

Even for MBBs I’d have her start out by gripping the shaft close to the skin just to ensure she doesn’t advance a lot further than she is expecting. I’ve worked with medical students who will sometimes advance a lot further than they’re told to if not holding the needle near the skin to avoid inadvertent huge movements. I usually drive spinal needles for MBB by holding the hub with my right hand fingers and the shaft near the skin with my left hand pointer/thumb.

 

[Piebaldi]

Even for MBBs I’d have her start out by gripping the shaft close to the skin just to ensure she doesn’t advance a lot further than she is expecting. I’ve worked with medical students who will sometimes advance a lot further than they’re told to if not holding the needle near the skin to avoid inadvertent huge movements. I usually drive spinal needles for MBB by holding the hub with my right hand fingers and the shaft near the skin with my left hand pointer/thumb.

Interesting. For MBBS, I have been told to just use the right hand at the hub to drive the needle without holding it at the insertion/skin. I also think my hands are too small to do this one handed - particularly for something like ESIs - I like the two hand approach that I have seen in the past to be honest, where you use both hands for LESI to drive needle itno epidural space, but attending dislikes this approach. Sigh. I also get so anxious - bc attending is super fast and I feel like a screw up. Sigh.

 

[dhcofc]

Using both hands sounds safest for you right now. I’ll always use two hands, it’s safer in my opinion and I have more precise control and great “feel.” Speed is the last thing you should worry about now. You probably realize that this new fellowship, like your last one, probably won’t instill the best and safest approach for procedures in you. I would make sure you continue to question as many people as you can to get a well rounded idea of how to do procedures. There’s some terrible habits you can learn from some doctors, be careful. The more good pain doctors you learn from the more options you have to create your own style eventually.

 

[BobBarker]

I’d have her start out by gripping the shaft close to the skin

Alrightty then!

 

[Piebaldi]

Using both hands sounds safest for you right now. I’ll always use two hands, it’s safer in my opinion and I have more precise control and great “feel.” Speed is the last thing you should worry about now. You probably realize that this new fellowship, like your last one, probably won’t instill the best and safest approach for procedures in you. I would make sure you continue to question as many people as you can to get a well rounded idea of how to do procedures. There’s some terrible habits you can learn from some doctors, be careful. The more good pain doctors you learn from the more options you have to create your own style eventually.

No, this fellowship is not like the last one at all. Previous thing was a joke. And the attendings - there's like 5 plus are all very good, and do a pretty good job at teaching. It's simply that they all do things differently - different techniques. And yes the good thing is that they are all very open to discussing things with me, but I have realized that different people do things differently - so i'm curious what others do. unlike the previous place where i was told - this is how I learned so this is how you will do it. no thanks.

 

[Piebaldi]

Alrightty then!

Sigh, you had to go there didn't ya?

 

[callmeanesthesia]

No, this fellowship is not like the last one at all. Previous thing was a joke. And the attendings - there's like 5 plus are all very good, and do a pretty good job at teaching. It's simply that they all do things differently - different techniques. And yes the good thing is that they are all very open to discussing things with me, but I have realized that different people do things differently - so i'm curious what others do. unlike the previous place where i was told - this is how I learned so this is how you will do it. no thanks.

That’s just part of training at a place that has lots of attendings. For now you learn how each one wants you to do it, and you do it their way when you’re with them. Once you are toward the end of your year, or out on your own, you decide which way you like best and do it that way. One attending bent his needles the opposite of how almost everyone else does it, and it took some getting used to.