Thoracic RF

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caedmon

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Just wanted to get some opinion on thoracic RF technique.

Anybody using phenol post burn, dual burn technique or multiple burns to account for the variability in certain segments?

18g or 20g cannula?
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18 ga all the way....I would use 12 ga if I could get it. Thoracool or whatever the Baylis product is called, is far too expensive for routine use, but the idea is a good one. The T1-4, and T9-12 levels are not a problem since the medial branch anatomy is fairly constant, and located at the superior lateral edge of the transverse process. The T5-8 levels are the problems since they can be anywhere between transverse processes.
I would suggest never using phenol that close to the spine since even a small amount tracking into the epidural space or intrathecal could have catastrophic consequences.
 
Agree with Algos. Burn the hell out of the area. Six burns at least. 18 ga or larger needle. Thoracool great idea but very expensive. If you put 4 needles in at once you can burn the crap out of the area quickly.
 
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Ligament said:
Agree with Algos. Burn the hell out of the area. Six burns at least. 18 ga or larger needle. Thoracool great idea but very expensive. If you put 4 needles in at once you can burn the crap out of the area quickly.
Click to expand...

If this is the case, why not just open with an 11 blade and fillet the muscle off the TP then just decorticate the upper back third of the TP from distal to pars?

I do very few thoracic RF's because of the variability of the nerves. I also go proximal and try and catch the nerve on its way into the joint. I do single lesions for 90 seconds. 50% success rate = what Dreyfuss said in 1997 ISIS handout/newsletter. I could get my success higher at the expense of 1 hour procedures and 1 week of post-procedure soreness that would get tomatoes thrown at me.
 
Also, this is the one procedure I do without any stimulation, and use 90 sec 90 deg C burns... Burn baby burn
 
I believe low success rates for T rf are due to the time it takes to strip lesion the area and the frustration of the physician. I do 5-10 T rf per year and try and talk patients out of it. Doing it properly with technique as above takes 4 min cooking plus 2-8 min per level of needling. Scs, vplasty, disco are shorter.
 
I get great results with thoracic RF using a completely different technique. I think I mentioned it here a long time ago. The MB runs over the pedicle shadow so just come in at a steep inferior angle and place the tip of the cannula on the lamina across the pedicle shadow.

I do a single burn with a 10 mm active tip and it works like a charm. No fussing around on the transverse process. I've recently done a few w/o even trying for a sensory paresthesia.

I have attached a lateral view of the procedure. The AP view is a no-brainer.
 

Attachments

I used to do it with the approach described in Sluijter's "Radiofrequency Part 2", but I did a fair amount of fishing. Then bipolar was suggested and its quick and easy and I get a good result. I like the Mxyzptlk approach. How long does it last?
 
Thanks for the input everyone.

I try not to do a ton of these either. Have a younger patient with chronic thoracic spine pain with bad looking discs and facets. The only thing that helped him even temporarily were facet procedures and a double blocks reduced his pain by greater than 50% each time, so I offered it to him.

Mister Mxyzptlk: Do you do your MBBs in the same place as you burn or the more superolateral approach?

My primary mentor used phenol. Don't remember the exact concentration, but put in about 0.5cc on the superolateral aspect of the transverse process after the burn. Don't think I want to mess with that.
 
I was taught to do it with phenol also. Mix with contrast to dilute it to 3% on the assumption that at that concentration you kill only the C fibers. Inject with live fluoro and watch the spread. I think that you can get a good result without phenol and the phenol effect is temporary just as the RFA effect is. I would expect that it could give you a wider kill zone than just the RFA so if the relief from the RFA alone is not long enough then it might be worth it. I occasionally use phenol for SIs and for arthritic joints that are inoperable, with good results.
 
For the MBB I just plant some local on the pedicle shadow in an AP view.

When you do the RF just check a lateral to make sure you didn't accidentally slide into the facet joint.

I guess what will really piss me off is if they name the procedure the "Mxyzptlk technique" and I get 15 mins of pseudonymous fame.
 
Mister Mxyzptlk said:
I get great results with thoracic RF using a completely different technique. I think I mentioned it here a long time ago. The MB runs over the pedicle shadow so just come in at a steep inferior angle and place the tip of the cannula on the lamina across the pedicle shadow.

I do a single burn with a 10 mm active tip and it works like a charm. No fussing around on the transverse process. I've recently done a few w/o even trying for a sensory paresthesia.

I have attached a lateral view of the procedure. The AP view is a no-brainer.
Click to expand...

This is the real deal. I tried this a few years ago on MM's advice, and have been doing it ever since with great results. As I recall, there was an AP photo with lines drawn in to illustrate the course of medial branches from TP and across the pedicle shadow.
 
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yankeeh8r said:
I've got a thoracic MBB I'm doing later today. I'm gonna try your approach Mr Mxyzptlk for the MBB and keep you posted.

If we end up going to RF, I'm thinking using your approach, but maybe doing a two needle technique to widen the burn and get longer lasting results. Have you tried that as well?
Click to expand...

I do single burns for cervical, thoracic, and lumbar. I have no idea if two burns would last longer. Typically it's about 10-11 months before they ask for a repeat.
 
FLK 1 said:
This is the real deal. I tried this a few years ago on MM's advice, and have been doing it ever since with great results. As I recall, there was an AP photo with lines drawn in to illustrate the course of medial branches from TP and across the pedicle shadow.
Click to expand...

I can't find that picture. I wanted to post it along with the other shot. Actually, I can't even find the web site where I posted my collection of pictures any more.
 
Are most people doing unilateral RF? During my training we would do bilateral. Now I'm getting this modality up and running in my new practice and finding out you don't necessarily get paid to do bilateral RF.

I will be doing this in a surgery center (that I have no vested interest in) and I hate to have to have patients pay two facility fees, but I also want to get paid to do my work.
 
If you can't get paid for bilateral you should do unilateral. If asked, tell the patient that their insurer doesn't want you to do bilateral procedures. How do you know? Because they won't pay for it.

You didn't buy them the insurance policy. You are just the one who has to live with its rules - along with the patient. Until the policy owners start getting pissed the carriers won't do anything. It's obvious that they don't listen to us.
 
onewithpain said:
I was taught to do it with phenol also. Mix with contrast to dilute it to 3% on the assumption that at that concentration you kill only the C fibers. Inject with live fluoro and watch the spread. I think that you can get a good result without phenol and the phenol effect is temporary just as the RFA effect is. I would expect that it could give you a wider kill zone than just the RFA so if the relief from the RFA alone is not long enough then it might be worth it. I occasionally use phenol for SIs and for arthritic joints that are inoperable, with good results.
Click to expand...

Please explain a bit more specific. You inject what % and what volume directly into the joints?
 
yes please explain more of how you do your

-intra-articular joint injections with phenol

-volume of injectate you use for your thoracic phenol injections

-did you train to use phenol for any other purposes that are not often done by pain docs?

Thanks, also very curious
 
Mister Mxyzptlk said:
For the MBB I just plant some local on the pedicle shadow in an AP view.

When you do the RF just check a lateral to make sure you didn't accidentally slide into the facet joint.

I guess what will really piss me off is if they name the procedure the "Mxyzptlk technique" and I get 15 mins of pseudonymous fame.
Click to expand...

i have done MBB this way for years but i never thought of doing a thoracic RF this way. i think i will try it. thank you.
 
I don't do the thoracic RFAs with phenol but I was trained that way. Mix your phenol with contrast so that you end up with 3% phenol. Then after performing a bipolar RFA over the thoracic transverse process withdraw the needle about 5 mm and inject the phenol/contrast mix using live fluoro. When it looks like you have covered the area in which you did your RFA then stop (often .1-.2 ml). When I have an SI that won't quiet with PT and steroid I will do a live injection of the phenol/contrast mix. First you need to get a primo intra-articular spread pattern with about .2 ml of contrast, then add about .5 ml of 2 percent lido and wait for a minute, then live phenol/contrast mix of about 3 ml. Stop if you get a significant extra-articular leak. Burns a bit going in even after lido but feels good the next day. Similar process for hips or knees. The phenol may irritate the tissues in the joint and thereby speed the degenerative process, so I only do this if the knee or hip is already considered end-stage but the patient is not a candidate for surgery.
 
onewithpain said:
I don't do the thoracic RFAs with phenol but I was trained that way. Mix your phenol with contrast so that you end up with 3% phenol. Then after performing a bipolar RFA over the thoracic transverse process withdraw the needle about 5 mm and inject the phenol/contrast mix using live fluoro. When it looks like you have covered the area in which you did your RFA then stop (often .1-.2 ml). When I have an SI that won't quiet with PT and steroid I will do a live injection of the phenol/contrast mix. First you need to get a primo intra-articular spread pattern with about .2 ml of contrast, then add about .5 ml of 2 percent lido and wait for a minute, then live phenol/contrast mix of about 3 ml. Stop if you get a significant extra-articular leak. Burns a bit going in even after lido but feels good the next day. Similar process for hips or knees. The phenol may irritate the tissues in the joint and thereby speed the degenerative process, so I only do this if the knee or hip is already considered end-stage but the patient is not a candidate for surgery.
Click to expand...

REALLY?!! That sounds logical in theory due to the ability of the phenol to spread along the joint and kill any nerves in its path but I would be hella scared about anterior spread despite the contrast...how do you bill for this: destruction peripheral nerve?
 
I just bill for an intra-articular injection. There is probably some way to bill for more. The theory is that the 3 percent phenol will have minimal effect on the large myelinated fibers. I have seen injections described using higher concentrations but I've never done those. I do worry about anterior spread but haven't had a problem. I inject slowly and keep the patient talking so that I get plenty of feedback.
 
onewithpain said:
I just bill for an intra-articular injection. There is probably some way to bill for more. The theory is that the 3 percent phenol will have minimal effect on the large myelinated fibers. I have seen injections described using higher concentrations but I've never done those. I do worry about anterior spread but haven't had a problem. I inject slowly and keep the patient talking so that I get plenty of feedback.
Click to expand...

So with a pt who is bone on bone and next step is tha or tka. What is your exact mixture, volume, and technique for each joint?
 
If I were going to try phenol I'd inject along the posterior joint line and denervate it. Not all SI pain is intra-articular.
 
Mister Mxyzptlk said:
If I were going to try phenol I'd inject along the posterior joint line and denervate it. Not all SI pain is intra-articular.
Click to expand...
for patients whose insurance wont pay for SI alteral br RF, we use phenol, intraarticular as well as the three loactions lateral to the foramen when the nerve traverses on its path to the SIJ. Using dye you can control the spread.
 
olafa said:
for patients whose insurance wont pay for SI alteral br RF, we use phenol, intraarticular as well as the three loactions lateral to the foramen when the nerve traverses on its path to the SIJ. Using dye you can control the spread.
Click to expand...

The contrast controls nothing more than your ability to see where the injectate is going. And if it starts going somewhere you do not like, then what? This is not kypho/ vplasty where the injectate does not flow like a liquid.
 
lobelsteve said:
The contrast controls nothing more than your ability to see where the injectate is going. And if it starts going somewhere you do not like, then what? This is not kypho/ vplasty where the injectate does not flow like a liquid.
Click to expand...

By reaptedly inecting a very small vol until you get the spread desired to cover the area. It works nicely. You may may to repeat 2X + since phenol doesn't quite do the job like an RF machine. Needless to say its something to offer patients who otherwise have been denied by the insurance for a good treatment. Never do we blast the area and then say now what! Thats just how I was taught, for what its worth.
 
M&M could you post your APs for this technique? I am so tired of seperating ribs from the tp. I was taught like most to go for the upper outer tp.
 
I just got back from a class in which an ISIS instructor said that he had been to a recent cadaver dissection course in which they demonstrated that the MBs in the thoracic area were often found several mm above the transverse process at the location where it crosses over the cephalad border/lateral aspect, leading to a recommendation for a phenol injection after the RFA when performed at that location in order to make sure that you get the surface of the bone with the RFA as well as a possible high-riding nerve with the phenol.
 
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