vertigo after cervical MBB?

[TIVAndy]

has anyone seen a patient who develop vertigo after cervical MBB?

i had a patient cervical MBB - C3-C6 bilateral - with no sedation. pt stated to me after first MBB that she had dizziness that lasted several hours but good pain relief response to MBB.

I sort of didn't think much of her dizziness but it occurred again on the second MBB. now the legitimate concern is if this will occur more on a permanent basis after RFA. i've seen people treat cervicogenic vertigo with MBB/RFA but haven't heard anyone become dizzy after mbb.

any insights appreciated.

thanks

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[SSdoc33]

Burn one side at a time.

 

[Orin]

What volume of local are you using?

 

[lonelobo]

has anyone seen a patient who develop vertigo after cervical MBB?

i had a patient cervical MBB - C3-C6 bilateral - with no sedation. pt stated to me after first MBB that she had dizziness that lasted several hours but good pain relief response to MBB.

I sort of didn't think much of her dizziness but it occurred again on the second MBB. now the legitimate concern is if this will occur more on a permanent basis after RFA. i've seen people treat cervicogenic vertigo with MBB/RFA but haven't heard anyone become dizzy after mbb.

any insights appreciated.

thanks

I was taught this is a potential side effect and saw it early on in my career, therefore only do one side at a time in cervical region

 

[callmeanesthesia]

See it not infrequently with upper cervical MBBs. I consider the MBBs a trial run - if they get a lot of dizziness I just do the ablation one side at a time. I always warn them before the MBBs, especially bilateral C2-3.

 

[TIVAndy]

What volume of local are you using?

0.5 ml per medial branch

I was taught this is a potential side effect and saw it early on in my career, therefore only do one side at a time in cervical region

Burn one side at a time.

interesting. but what would be the mechanism of vertigo and how would doing RFA one side at a time prevent this?

 

[lobelsteve]

Turning off proprioception to 3 joints on both sides of neck.

 

[pmrmd]

Dizziness is well known effect of blocks especially at C2-3. Agree one sided RF at a time.

 

[Laryngospasm]

You turned them into a bobble head

 

[Orin]

It's a known complication likely due to the lack of proprioceptive feedback like said above, but possible also exacerbated by the robust muscle weakness. The literature rate is as high as 10-15% but I don't think I've seen it or heard it complained about rather by my patients.

I might prehab for this with the vestibular rehab exercises one does for patients with dizziness/vertigo designed to help strengthen the visual pathways.

You could see how they do with unilateral blocks and then RF if needed with the reassurance

You might also try skipping C3 if possible as it's more associated with the superior MBBs I believe. I worry that in tight necks, you may get a lot of spread from that 0.5 mL, but that's also what I use.

 

[Ferrismonk]

All the time. It's transient.

If you're concerned about RF and she had great relief from MBB, agree with doing one side at a time.

 

[MD87]

0.5 cc is a reasonable volume, but it may very well be spreading to the TON, which is known to cause those symptoms more commonly than the other MBs. I agree with what others have said - burn 1 side at a time to be extra cautious. However, if you do burn both at the same time, the patient will likely (short-term) feel the same symptoms after RFA due to local at the site, but hopefully when the local wears off those symptoms would resolve as well. I don't think it's worth chancing it, though.

Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study - PubMed

Results suggest that 0.50 mL injections of local anesthetic during cervical MBBs contacts many nonintended targets, thus decreasing the specificity of a targeted diagnostic cervical MBB. Furthermore, we demonstrated that 0.25 mL of injectate reliably bathed the cervical medial branches without...

www.ncbi.nlm.nih.gov

 

[SommeRiver]

Cervical always unilateral.

 

[TIVAndy]

thanks everyone for the reply. will do unilateral RFA.

 

[Timeoutofmind]

Cervical always unilateral.

What if they are on warfarin/plavix etc for a pretty legit reason (h/o clots for instance)?
You hold it twice?

 

[paindoc007]

What if they are on warfarin/plavix etc for a pretty legit reason (h/o clots for instance)?
You hold it twice?

I don’t hold those for cervical mbb or RFA.

 

[SommeRiver]

What if they are on warfarin/plavix etc for a pretty legit reason (h/o clots for instance)?
You hold it twice?

Here's a better Q - Why would you hold anticoagulants for a medial branch intervention?

 

[callmeanesthesia]

What if they are on warfarin/plavix etc for a pretty legit reason (h/o clots for instance)?
You hold it twice?

Risk vs benefit discussion with patient, probably continue anticoagulant.

 

[Laryngospasm]

Big stroke or MI from holding plavix for those equals big check

 

[Timeoutofmind]

Here's a better Q - Why would you hold anticoagulants for a medial branch intervention?

I don’t hold for MBB
But I do hold for RF

ASRA guidelines are to hold for both

The crappy guidelines put u in a tough spot in a deposition either way it seems...not sure how impressed the judges and lawyers will be with a departure from published guidelines

 

[lonelobo]

I don’t hold for MBB
But I do hold for RF

ASRA guidelines are to hold for both

The crappy guidelines put u in a tough spot in a deposition either way it seems...not sure how impressed the judges and lawyers will be with a departure from published guidelines

Stop Holding For RF...with proper technique worst thing that should happen is localized bleeding in the tissue

 

[SommeRiver]

Single digit risk for holding AC and a decimal point risk for staying on them.

 

[Orin]

I do bilateral RF for some repeats that are high risk for sedation or for those with significant logistical difficulties.

Doing it separately seems more for billing than safety as the risks of problem with either side are independent. This isn't a bilateral RLN/phrenic block where the contralateral side will kill them.

With that said, I do prefer their first set be done at 4-6 week intervals to ensure they're getting some benefits, and most end up being done unilaterally.

 

[bedrock]

Unilateral RFA for cervical every time without exception for many reasons, but vertigo is certainly an important one
Unilateral RFA for lumbar 95% of the time

Never ever hold blood thinners for a MBB or RFA. If you still hold them, you're 5 years behind the times and your colleagues that follow the literature, and so you'll be vulnerable to a lawsuit. I haven't done this, but I would testify against a pain physician who caused a CVA/MI because they required a patient to hold thinners for a MBB, RFA, or a peripheral joint injection.

 

[TIVAndy]

Unilateral RFA for cervical every time without exception for many reasons, but vertigo is certainly an important one
Unilateral RFA for lumbar 95% of the time

Never ever hold blood thinners for a MBB or RFA. If you still hold them, you're 5 years behind the times and your colleagues that follow the literature, and so you'll be vulnerable to a lawsuit. I haven't done this, but I would testify against a pain physician who caused a CVA/MI because they required a patient to hold thinners for a MBB, RFA, or a peripheral joint injection.

problem is.. as someone pointed out on this thread that ASRA guideline does indicate holding for cervical RF/MBB

 

[lonelobo]

problem is.. as someone pointed out on this thread that ASRA guideline does indicate holding for cervical RF/MBB

ARSA= FOS

 

[Ligament]

I echo what everybody else has said
Been doing a lot of cervical RF for over a decade
impaired proprioception is the mechanism; much more common in upper cervical segments and very common if you do b/l same day
I never do b/l RF in c-spine; 1) proprioception impairment which can last weeks 2) I get cheated out of money if I do b/l. screw that.

Remeber balance comes from proprioception, vision, and ears. Many older patients already have all three impaired. Knocking out craniocervical proprioception acutely can decompensate them.

 

[deleted993114]

Turning off proprioception to 3 joints on both sides of neck.

Yep- it's certainly interesting to observe; thankfully we can see that with test blocks such that these symptoms can be avoided.