i do the exact same thing. wasnt taught that way, just sort of evolved into it. its funny how different docs end up with the same technique
Same
No reason to start obliqued. Start AP and put your needle in 3 cm lateral to the target. You don't need all that fluoro over a 30 yr career.
I do this as well, oblique 15-20 degrees, no oblique for L5 dorsal ramus. After getting a Scotty dog view I incrementally caudal tilt the image intensifier to as much as possible where I can still see the groove, usually 30 degrees, beyond that it gets really hard to see the TP SAP junction for me. Then I place L3 and L4 MB needles down the barrel. I typically place the L5 needle straight AP and out of plane.
How much caudal tilt do you use? Do you place needles with a coaxial view or just drive them out of plane?
Can someone post the SIS technique lumbar RF study that revealed the superior clinical results to previous ISIS technique.
Would be interested if anyone has tips for maintaining goid view with caudal tilt. I find for very degenerated spines, caudal tilt often makes it nearly impossible to identify the groove with caudal tilt. I will often incrementally tilt in 10 degree increments and find once I get around 30 degrees and then it starts to get hard to view.
no need to waste too much time if you can't see anything. sounds like you have a good technique down.
I’ve been doing 15/15…guess I could try 15/30..L5 always sucks. Results still good with 18 or 20 gauge. In my experience, Rf is a certain % effective, a certain % placebo, a certain % not gonna work despite mbb effectiveness. And no I don’t use steroid for mbb. Maybe just need the extra 15 of caudal tilt..
Maybe it’s cause I never recognized vertebrogenic back pain..
I did this for several years in steep caudal tilt, pretty close to sis. A colleague then suggested I place my rf cannula like I usually would followed by marking my skin entry points with an 18g needle, and then looking in AP….. low and behold I was starting about 1 level down on each, mid to inferior transverse process. Game-changer for me. Next few cases I obliqued 15-20 until junction was crystal clear as I usually would and then placed cannula 1 level down from target, advanced out of plane. Angles to endplates on lateral looked good. Final placement in AP, lateral and 30 oblique were exactly as I’d like. Saves a lot of time and fluoro without sacrificing proper placement or outcomes.
I’ve tried a few different ways, but what I’ve found that works the most reliably for me is I do L5 in true AP. Place my cannula as lateral as the psis will allow, directly medial to it. Advance caudal to cephalad out of plane. Once clearly bypassed psis, then oblique until sap/ala junction is clear and advance to target
I agree, I find driving a large 18G cannula out of plane to be challenging and more Fluoro shots.
Oblique to about 30. I’ll try to dig up some fluoro shots of it. A colleague of mine recommended trying this several years ago. Game changer. You’ll be surprised how frequently you were not dead on accurate after placement in 15-20 oblique and confirming in AP. One or two needle adjustments per procedure will be often needed, particularly in ancient spines with massive hypertrophic SAP. Doing this allows me to confidently say I absolutely covered the medial branch target zone as completely as possible.
Yes I over oblique to 30 degrees to confirm I am in the groove after I place down the barral in a declined and 15-20 oblique view. I find I need to walk off and advance a little deeper and usually adjust medial or lateral a bit, and then just check lateral to confirm safety before testing.
Frankly not sure…
I thought most consider multiplanar view fluoroscopy was a better safety check than motor stim
Well I do check an AP in addition to the oblique view. I check motor up to 2.0 at every level. None of my patients get more than PO Valium either, which helps with safety. I suppose if I ever get a nerve root injury doing that I'd question it.
Most of my attendings didn't, nor did my colleague at my first practice. But then I started thinking for myself more about how to optimize quality while still balancing efficiency. Laterals a must for me. I do an oblique shot on the way to lateral, and it almost always looks good, even when the lateral doesn't.
Funny thing is - when I drive OUT of plane (as people are calling it), I find I have to move the needles much more often after moving to lateral. When I rotate oblique, and caudad- and drive en face, hit Os, turn away, advance a little - then go lateral...almost always the needles are placed perfectly. Adjustments rarely needed.
That is the lazy ass way of doing it. Fine if doing cooled RF, but certainly not with conventional needles and still not that great with venom and nimbus etc.
Thank you! What about TFESI with just AP (hitting TP for depth, walking off and curving medial followed by contrast)? Much appreciated. Again I've learned the conventional approaches at our academic site, but all approaches in this rotation are different. The guys here are able to complete procedures in minutes vs the academic side in 15-20 minutes (perfect coaxial view, perfect contrast spreads, always getting safety views), so it was certainly an attractive difference to learn... But not if it is at the expense of patient outcomes. Thank you again
