Lumbar RFA efficiency

[bedrock]

what have you guys modified in private practice (compared with fellowship) to make your lumbar RFA more efficient?

I use SIS technique, 18G, 1cm curved tip cannula, lesion x 2 for 90 seconds (rotate cannula 90-100 degrees between lesions)

I have excellent RFA results but I wonder if I could change a few things to save 5 min per case, and still have similar outcomes

Thoughts on what you found improved your efficiency?

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[BobBarker]

Single lesion for sure. You are creating a big enough lesion with the 18g.

 

[Ferrismonk]

I do 20G 10mm curved, 1 burn, 80 seconds. I come in a bit more lateral and lay down across SAP/TP junction. I don't walk off the edge. I find this allows me to more reliably get the medial branch (esp if it's grown back all squirrely) and causes less neuritis. I almost never get motor with testing. Works well, but might not last as long as yours. I reliably get the 8-12 months goal, some more some less. Partners who burn twice don't get longer relief than mine. A B/L RF takes me about 20 min.

 

[Taus]

Single lesion for sure. You are creating a big enough lesion with the 18g.

I’ve considered this, particularly as I use 18g venom…. But hesitant as I worry about effecting my results even a little bit. I make my 2nd lesion several mm up the sap from tp junction, not just rotating cannula


Biggest efficiency change Ive made was advancing out of plane. No decline view. I still oblique to 15-20 degrees to get junction clearly visualized. Enter skin at level of tp below.

 

[oneforfighting]

I do 20G 10mm curved, 1 burn, 80 seconds. I come in a bit more lateral and lay down across SAP/TP junction. I don't walk off the edge. I find this allows me to more reliably get the medial branch (esp if it's grown back all squirrely) and causes less neuritis. I almost never get motor with testing. Works well, but might not last as long as yours. I reliably get the 8-12 months goal, some more some less. Partners who burn twice don't get longer relief than mine. A B/L RF takes me about 20 min.

Can you elaborate on “a bit more lateral”. Pics?

 

[oneforfighting]

what have you guys modified in private practice (compared with fellowship) to make your lumbar RFA more efficient?

I use SIS technique, 18G, 1cm curved tip cannula, lesion x 2 for 90 seconds (rotate cannula 90-100 degrees between lesions)

I have excellent RFA results but I wonder if I could change a few things to save 5 min per case, and still have similar outcomes

Thoughts on what you found improved your efficiency?

I do the same as you

 

[RoloTomassi]

I cut down to single burn a while ago, no change that I can tell. 18 ga Sidekick.

Not sure how you're doing other steps but advancing 3 needles at a time helps, and for motor testing I just hold one probe and touch into each needle briefly

 

[Ferrismonk]

Can you elaborate on “a bit more lateral”. Pics?

At the risk of being torn apart by my needle placement....

 

[jwalker12]

what have you guys modified in private practice (compared with fellowship) to make your lumbar RFA more efficient?

I use SIS technique, 18G, 1cm curved tip cannula, lesion x 2 for 90 seconds (rotate cannula 90-100 degrees between lesions)

I have excellent RFA results but I wonder if I could change a few things to save 5 min per case, and still have similar outcomes

Thoughts on what you found improved your efficiency?

Same technique as you. I found that while the peri-op is connecting the other probes, I keep one probe "active for testing" and just move that same probe from cannula to cannula for testing, saves some time.

 

[SSdoc33]

anesthetize the contralateral side while you are burning.

 

[MitchLevi]

Numb all skin simultaneously.

AP, then lateral to finish up needles.

Test.

Local.

Oblique, AP.

Time it takes to go from lateral to oblique and AP is sufficient for local to work.

Burn after saving that AP image.

Time from local in the lateral view after testing until saving oblique and AP and starting burn is no more than 20-30 seconds.

 

[oneforfighting]

At the risk of being torn apart by my needle placement....

Do you have a lateral view of these?

 

[drusso]

what have you guys modified in private practice (compared with fellowship) to make your lumbar RFA more efficient?

I use SIS technique, 18G, 1cm curved tip cannula, lesion x 2 for 90 seconds (rotate cannula 90-100 degrees between lesions)

I have excellent RFA results but I wonder if I could change a few things to save 5 min per case, and still have similar outcomes

Thoughts on what you found improved your efficiency?

Are you testing for sensory stim?

 

[Greenbayslacker]

20g cannulas. I did advance the L4 and sacral ala needles a few mm after the images here, prior to testing.

Patient did get excellent results but I would still love to hear critiques.

 

[bedrock]

Are you testing for sensory stim?

heck no. Never have.

 

[BobBarker]

20g cannulas. I did advance the L4 and sacral ala needles a few mm after the images here, prior to testing.

Patient did get excellent results but I would still love to hear critiques.

Got to down shift those needles. Stick the patient more inferiorly. Nice depth and views though.

 

[Ferrismonk]

Do you have a lateral view of these?

Not in the habit of getting laterals. Sorry. I oblique, come in more lateral, touch bone on the TP, walk medial lying the active tip on the bone. Bone is my depth gauge.

 

[runfastnow]

Where can I get some spines this healthy?!

 

[bedrock]

20g cannulas. I did advance the L4 and sacral ala needles a few mm after the images here, prior to testing.

Patient did get excellent results but I would still love to hear critiques.

How long do the patients get these excellent results? 4-6 months?
Your needles need to be much more parallel to the nerves. Depth is good though

 

[sdnuser001]

I’ve considered this, particularly as I use 18g venom…. But hesitant as I worry about effecting my results even a little bit. I make my 2nd lesion several mm up the sap from tp junction, not just rotating cannula


Biggest efficiency change Ive made was advancing out of plane. No decline view. I still oblique to 15-20 degrees to get junction clearly visualized. Enter skin at level of tp below.

Can you tell us more about the out of plane approach and how exactly it saves time?

 

[clubdeac]

Not in the habit of getting laterals. Sorry. I oblique, come in more lateral, touch bone on the TP, walk medial lying the active tip on the bone. Bone is my depth gauge.

From these pics your most inferior needle on both pics looks like it’s sitting on the MAL instead of superior to it where the nerve is most exposed

 

[RoloTomassi]

20g cannulas. I did advance the L4 and sacral ala needles a few mm after the images here, prior to testing.

Patient did get excellent results but I would still love to hear critiques.

In the groove with good depth but top two too perpendicular. Your entry for the middle one should be used for the top one.

 

[Greenbayslacker]

How long do the patients get these excellent results? 4-6 months?
Your needles need to be much more parallel to the nerves. Depth is good though

6 months so far for this Pt. Thanks for the feedback

 

[Taus]

Can you tell us more about the out of plane approach and how exactly it saves time?

Starting with a big decline view necessitates coming out of that view to a relatively square endplate and walking the tip up to target for each level. Otherwise, you will be much inferior to junction from what you see in declined you. At this point, I pretty much just go from straight Ap, oblique15 to 20 till I see the junction, enter skin inferior aspect of transverse process 1 level below my target. This gets proper lateral to medial and inferior to superior trajectory to lie nicely along the nerve. Then oblique to about 30° to confirm I am perfectly on target, make minor adjustments prn, lateral view to make short tip not in foramen local, test, burn. Motor test and lateral are almost purely for medicolegal documentation.

For years, I did this in true SIS decline view. A colleague challenged me to do it my way, but then put a marker next to the needle insertion site on skin at the end, and take a look where I am entering under ap view. It essentially closely approximates the above. Saves me a significant amount of time and radiation without compromising placement or results.

 

[deleted131481]

Starting with a big decline view necessitates coming out of that view to a relatively square endplate and walking the tip up to target for each level. Otherwise, you will be much inferior to junction from what you see in declined you. At this point, I pretty much just go from straight Ap, oblique15 to 20 till I see the junction, enter skin inferior aspect of transverse process 1 level below my target. This gets proper lateral to medial and inferior to superior trajectory to lie nicely along the nerve. Then oblique to about 30° to confirm I am perfectly on target, make minor adjustments prn, lateral view to make short tip not in foramen local, test, burn. Motor test and lateral are almost purely for medicolegal documentation.

For years, I did this in true SIS decline view. A colleague challenged me to do it my way, but then put a marker next to the needle insertion site on skin at the end, and take a look where I am entering under ap view. It essentially closely approximates the above. Saves me a significant amount of time and radiation without compromising placement or results.

With this AP view, where do you decide to enter skin for L5dr?

 

[Taus]

With this AP view, where do you decide to enter skin for L5dr?

Just inferomedial to PSIS. From ap. Once I get past iliac crest, ill oblique to clarify target

 

[SSdoc33]

Just inferomedial to PSIS. From ap. Once I get past iliac crest, ill oblique to clarify target

same

 

[SC Tian]

Numb all skin simultaneously.

AP, then lateral to finish up needles.

Test.

Local.

Oblique, AP.

Time it takes to go from lateral to oblique and AP is sufficient for local to work.

Burn after saving that AP image.

Time from local in the lateral view after testing until saving oblique and AP and starting burn is no more than 20-30 seconds.

similar approach, except below:
oblique w caudal tilt for skin wheals at all levels;
Drop the needles down to touch TP;
AP, square off upper endplate each level, fine tune the needles, lower than upper endplate (I constantly compare this view with needle position in lateral view, imo this is very reliable safe level, passing MAL);
Lateral view only for checking purpose only, I rarely changes the needles, motor test,
lesions times 2;
bilateral procedure: started the needle placement on the opposite site right after burning began.
I recorded time for the procedure last year, average 8 minutes for unilateral procedures.
Patients do have months to years relief, there are some failures.

 

[bedrock]

bilateral procedure: started the needle placement on the opposite site right after burning began.
I recorded time for the procedure last year, average 8 minutes.
Patients do have months to years relief, there are some failures.

I don’t want to criticize as my thread is about optimizing RFA efficiency. But 8 minutes for a bilateral L3-5 RFA?

8 minutes is too fast, which impacts results. Sorry, but I think that extreme speed does affect your % of failures and duration of relief.

98% of my lumbar RFA patients achieve at least 50% relief >12 months. I almost never have a complete RFA failure.
90% of my lumbar RFA patients achieve 75% (or more) relief>12 months.

My patients commonly achieve 15+ months of relief.

I think you go too fast. I likely go too slow.

I’m trying to find the happy medium.

 

[MitchLevi]

Why do you need to square off each endplate?

Once you've done a few yrs of these you shouldn't need to do that. You know exactly where the adjustment is going to be.

 

[SC Tian]

I don’t want to criticize as my thread is about optimizing RFA efficiency. But 8 minutes for a bilateral L3-5 RFA?

8 minutes is too fast, which impacts results. Sorry, but I think that extreme speed does affect your % of failures and duration of relief.

98% of my lumbar RFA patients achieve at least 50% relief >12 months. I almost never have a complete RFA failure.
90% of my lumbar RFA patients achieve 75% (or more) relief>12 months.

My patients commonly achieve 15+ months of relief.

I think you go too fast. I likely go too slow.

I’m trying to find the happy medium.

sorry, this is a pure technical discussion, the time is unilateral 3-levels lumbar rfa, not bilateral, bilateral will add 3-5 minutes to burn the other side, I do a lot of rfas, when I first started I used standard sis approach, booked 20 minutes for unilateral, 40 minutes for bilateral, when I do more, I save times gradually.
as far as effects are concerned, imo, strict criteria for dual diagnostic blocks increase the rate of success. but the duration of effects is a separate aspect of this treatment, I have been in this place for about three years, I still see maybe 10-20% people their pain has not returned yet, majority of them lasted for 6- 12 months though.
when I was trained in a large private pain group, quite a few of physicians teaching in SIS, there bilateral rfa in and out time is 15 minutes.

 

[SC Tian]

Why do you need to square off each endplate?

Once you've done a few yrs of these you shouldn't need to do that. You know exactly where the adjustment is going to be.

maybe @bedrock can educate this more, correct me if I am wrong, the traditional sis approach is using block needle to target the nerve, I use square off view to fine tune the tip of needle with no block needle. please see the picture from the sis book.

 

[SC Tian]

 

[interjectionreflection]

heck no. Never have.

I have noticed this practice recently a couple of cities over. They see the patient for the first consultation and during that meeting they will do RFA without doing medial branch blocks they'll just do sensory stim and do RF right off the bat. I never heard about this, I talked to one of the people that worked at the clinics. He was very vague about it but did report this was a accepted practice and apparently this also reviewed and the facility assessor was okay with it. My spidey sense goes off when I hear this. Has anyone ever heard of this or is this done anywhere else?

 

[Taus]

I have noticed this practice recently a couple of cities over. They see the patient for the first consultation and during that meeting they will do RFA without doing medial branch blocks they'll just do sensory stim and do RF right off the bat. I never heard about this, I talked to one of the people that worked at the clinics. He was very vague about it but did report this was a accepted practice and apparently this also reviewed and the facility assessor was okay with it. My spidey sense goes off when I hear this. Has anyone ever heard of this or is this done anywhere else?

In a far away land, where insurance does not require two sets of medial branch blocks. Or just takes cash.

 

[interjectionreflection]

In a far away land, where insurance does not require two sets of medial branch blocks. Or just takes cash.

Canada so they don't run into the insurance issue though some do private pay as well but these are mostly people trained in big programs in the US and they explained it as something they were taught in fellowship which doesn't make sense to me either

 

[sdnuser001]

Starting with a big decline view necessitates coming out of that view to a relatively square endplate and walking the tip up to target for each level. Otherwise, you will be much inferior to junction from what you see in declined you. At this point, I pretty much just go from straight Ap, oblique15 to 20 till I see the junction, enter skin inferior aspect of transverse process 1 level below my target. This gets proper lateral to medial and inferior to superior trajectory to lie nicely along the nerve. Then oblique to about 30° to confirm I am perfectly on target, make minor adjustments prn, lateral view to make short tip not in foramen local, test, burn. Motor test and lateral are almost purely for medicolegal documentation.

For years, I did this in true SIS decline view. A colleague challenged me to do it my way, but then put a marker next to the needle insertion site on skin at the end, and take a look where I am entering under ap view. It essentially closely approximates the above. Saves me a significant amount of time and radiation without compromising placement or results.

Very helpful! So you will out of plane insert needle to just L5 dorsal ramus in AP and then out of plane insert needle to L3 and L4 MB in oblique?

And any issue with injecting local to MB prior to testing? Are you using bupivicaine 0.25% with the thought this shouldn't be dense enough to block motor fibers?

 

[bedrock]

View attachment 370543

Those look great.

And I agree with you that squaring off each superior end plate is important for optimal RF lesioning position.

Though I only square L4 endplate separate from L5 and top of the sacrum (L5/top of sacrum are same view).

So just two separate final AP views.

 

[lobelsteve]

Canada so they don't run into the insurance issue though some do private pay as well but these are mostly people trained in big programs in the US and they explained it as something they were taught in fellowship which doesn't make sense to me either

Off top of my head: Cohen et al got 70% of patients sustained relief with RF and no MBB. If it looks like a facet, smells like a facet, 7/10 are facets.

 

[Taus]

Those look great.

And I agree with you that squaring off each superior end plate is important for optimal RF lesioning position.

Though I only square L4 endplate separate from L5 and top of the sacrum (L5/top of sacrum are same view).

So just two separate final AP views.

Pretty sure that it’s just a screenshot from the SIS text.

 

[lobelsteve]

Pretty sure that it’s just a screenshot from the SIS text.

Look at the perfectly straight facet joint in the pic. Definitely not a patient

 

[SC Tian]

Pretty sure that it’s just a screenshot from the SIS text.

Look at the perfectly straight facet joint in the pic. Definitely not a patient

Yes, i stated they are sis pictures in my message

 

[Multimodal]

Very helpful! So you will out of plane insert needle to just L5 dorsal ramus in AP and then out of plane insert needle to L3 and L4 MB in oblique?

And any issue with injecting local to MB prior to testing? Are you using bupivicaine 0.25% with the thought this shouldn't be dense enough to block motor fibers?

When lateral, I inject local at each needle. swing back to AP and then hook up the probes. by the time I get this done, the local has kicked in but I still get motor stim alot of the time. I have not noticed a difference between visible motor stim with or without local. its a huge time saver to test while the local is still setting in.

 

[stsa84]

When lateral, I inject local at each needle. swing back to AP and then hook up the probes. by the time I get this done, the local has kicked in but I still get motor stim alot of the time. I have not noticed a difference between visible motor stim with or without local. its a huge time saver to test while the local is still setting in.

Thanks! Just used this technique, saved about 1.5 minutes per side. Less overall procedure time, and less time standing around waiting. Great tip.

 

[Taus]

When lateral, I inject local at each needle. swing back to AP and then hook up the probes. by the time I get this done, the local has kicked in but I still get motor stim alot of the time. I have not noticed a difference between visible motor stim with or without local. its a huge time saver to test while the local is still setting in.

Thanks! Just used this technique, saved about 1.5 minutes per side. Less overall procedure time, and less time standing around waiting. Great tip.

I do this all under lateral after initial placement in AP and oblique. If I place the probes under AP, I would need another lateral to confirm they haven’t moved anterior before burning.

 

[drg123]

What about using one of the probes that burns perpendicular like Nimbus or Trident? That would save time, no? No decline view or estimating parallel trajectory. Just go to the junction as you would for an MBB.

 

[RoloTomassi]

What about using one of the probes that burns perpendicular like Nimbus or Trident? That would save time, no? No decline view or estimating parallel trajectory. Just go to the junction as you would for an MBB.

Cost prohibitive for most

 

[deleted131481]

Starting with a big decline view necessitates coming out of that view to a relatively square endplate and walking the tip up to target for each level. Otherwise, you will be much inferior to junction from what you see in declined you. At this point, I pretty much just go from straight Ap, oblique15 to 20 till I see the junction, enter skin inferior aspect of transverse process 1 level below my target. This gets proper lateral to medial and inferior to superior trajectory to lie nicely along the nerve. Then oblique to about 30° to confirm I am perfectly on target, make minor adjustments prn, lateral view to make short tip not in foramen local, test, burn. Motor test and lateral are almost purely for medicolegal documentation.

For years, I did this in true SIS decline view. A colleague challenged me to do it my way, but then put a marker next to the needle insertion site on skin at the end, and take a look where I am entering under ap view. It essentially closely approximates the above. Saves me a significant amount of time and radiation without compromising placement or results.

same

I tried this today for the first time and it was substantially faster compared to using caudad tilt. Also I am coming from a bit more lateral to medial trajectory with this.

Can some of you critique my images? Tech didn't save the ipsilateral oblique to 30. Looking at it I think they could all be a bit deeper.

 

[SSdoc33]

I tried this today for the first time and it was substantially faster compared to using caudad tilt. Also I am coming from a bit more lateral to medial trajectory with this.

Can some of you critique my images? Tech didn't save the ipsilateral oblique to 30. Looking at it I think they could all be a bit deeper.

L5 may have started a tad bit too medial, but otherwise the pics look like mine do.

 

[Taus]

I tried this today for the first time and it was substantially faster compared to using caudad tilt. Also I am coming from a bit more lateral to medial trajectory with this.

Can some of you critique my images? Tech didn't save the ipsilateral oblique to 30. Looking at it I think they could all be a bit deeper.

glad to hear it was helpful. The 30° oblique view always confirms in my mind that I am covering my target well, Im often making some adjustments here to optimize what I otherwise would not have known about. If ap, trajectory view in 15 oblique, 30 oblique look good and im firmly on bone, I do not worry about optimizing depth on lateral unless way too superficial or deep.

Given that I use venoms, I went to single lesion yesterday for the first time. Nice timesaver, but I would only do it if I am very confident in my placement in all views.