Lumbar RFA Technique

[deleted875186]

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

A TFESI should never take 15 mins, multiplanar view is start oblique and place down the barrel, go to a lateral and advance to neuroforamin, go to AP and shoot contrast. I think a straight AP view technique would give questionable contrast spread and difficulty walking off bone enough of the time to make this straight AP approach not ideal, but then again I’ve never tried it.

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[RoloTomassi]

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

I know one guy who does this, and he cuts corners in all aspects of practice.

There's a study that shows that if needle tip is in the anterior half of the foramen, much higher chance of ventral epidural spread than if in posterior half. Got to have lateral to tell.

Another reason is it can sometimes be hard to tell how superior/inferior in the foreman you are using only AP, especially with spondylolisthesis. Going lateral you can stay at the very top and avoid a painful injection.

On obese when lateral is hard to visualize, I'll just do oblique then AP, get to 6 o'clock on the pedicle and inject if dye looks good, but otherwise always a lateral.

 

[PainApp2021]

A TFESI should never take 15 mins, multiplanar view is start oblique and place down the barrel, go to a lateral and advance to neuroforamin, go to AP and shoot contrast. I think a straight AP view technique would give questionable contrast spread and difficulty walking off bone enough of the time to make this straight AP approach not ideal, but then again I’ve never tried it.

Much appreciated! Sorry to clarify I was referring to TFESI for the contrast spread, but b&b procedures in general for the timing (although I do admit it was exaggerated). At my point in training (PGY4) I'm just trying to learn what I can learn. Thanks again!

Also to be fair the spines I'm seeing at the VA are pretty "decent" as opposed to the spine center we also train at. That could contribute to maybe why some of these shortcuts can work or why it seems much quicker.

 

[NJPAIN]

I think many if not the majority of pain docs cut corners to increase production and call it “efficiency”. Lots of one view imaging, no contrast, RF done with MB technique, etc. While I want to believe it significantly negatively affects outcomes I cannot provide data to support that. Hence, my claim that placebo effect must play a significant role in the outcomes of pain procedures.

Quite a few years ago I asked Milt Landers, a senior SIS doc and major contributor to The Guidelines, for tips on how to cut corners and speed up my admittedly slow technique. He responded “ I DON’T CUT CORNERS. You shouldn’t either; your patients deserve better.”

 

[jwalker12]

Can someone post 1-2 fluoro images along with their explaination? I feel like that would help this discussion

This would be very helpful if someone has the time. Currently I line up the SEP, oblique about 20, then drive needle from a bit inferior from the nose of the scotty dog to the SAP/TP junction to mimic the caudal tilt.

When you guys are referring to L5 and having to extremely caudal tilt are you referring to the vertebral body or L5DR? Because in fellowship we tradiationally did L5DR in straight AP --> touch sacral ala --> walk off.

 

[MitchLevi]

This lady just followed up. Multilevel listhesis with gross facets. Long lasting relief from RFA.

Lateral imaging is difficult with her slip. I recommend taking an extra moment with stim on a back like this. I had great stim.

85C x 2 min - 60 sec into burn I move the needle approx 3mm so these pics don't show the entire burn.

 

[GoBeers]

so.... anyone want to talk about cervical techniques? i still hate cervical RFAs.
i somewhat follow the furman technique. 15-20 degree oblique, caudal tilt to see the z-lines. drop needle coaxial, then get lateral view. if i can't see lateral view, then i'll settle for CLO view to make sure i'm at least not anywhere near the foramen (although I believe with this view, i think i'll be more posterior than i'd like)

 

[Baron Samedi]

so.... anyone want to talk about cervical techniques? i still hate cervical RFAs.
i somewhat follow the furman technique. 15-20 degree oblique, caudal tilt to see the z-lines. drop needle coaxial, then get lateral view. if i can't see lateral view, then i'll settle for CLO view to make sure i'm at least not anywhere near the foramen (although I believe with this view, i think i'll be more posterior than i'd like)

I use Furman technique. On lower levels the shoulder often gets in the way. Can have your nurse and xray tech wrap a sheet around their wrists and around the foot of the bed to pull their hands down towards their feet. It looks a bit like medieval torture but my best XR tech showed me this and its been a lifesaver.

 

[jwalker12]

so.... anyone want to talk about cervical techniques? i still hate cervical RFAs.
i somewhat follow the furman technique. 15-20 degree oblique, caudal tilt to see the z-lines. drop needle coaxial, then get lateral view. if i can't see lateral view, then i'll settle for CLO view to make sure i'm at least not anywhere near the foramen (although I believe with this view, i think i'll be more posterior than i'd like)

I am going about 20-30 caudad but only about 5 degrees oblique, patient prone, posterior approach. Currently using 20g needles but am interested in using larger needles just haven't felt comfortable enough to do so.

How many degrees do you go CLO?

 

[Taus]

I am going about 20-30 caudad but only about 5 degrees oblique, patient prone, posterior approach. Currently using 20g needles but am interested in using larger needles just haven't felt comfortable enough to do so.

How many degrees do you go CLO?

A few good threads on here about this topic over the years.
This can help with clo on c rfa:

https://www.painmedicine-casereports.com/current/pdf?article=MjAy&journal=10

 

[GoBeers]

I am going about 20-30 caudad but only about 5 degrees oblique, patient prone, posterior approach. Currently using 20g needles but am interested in using larger needles just haven't felt comfortable enough to do so.

How many degrees do you go CLO?

i typically do 45 degrees CLO . check i'm not in foramen and call it a day

 

[NJPAIN]

Cervical RFN is technically challenging on most cases. After all of these years I’m STILL looking for a technique that is more foolproof. I’m generally positioning the head neutral rather than flexed and turning head to contralateral side. Without flexion the joint spaces are harder to see and turning the head throws off the lateral. But. If I flex the head and/ or don’t turn the head Im trying to see through the dental work and nasal bones. I don’t oblique much more than maybe 5 degrees although many descriptions recommend 30 degrees.

Interested in other’s pearls. SLobel posted an interesting technique a number of years ago- inferior to superior, medial to lateral if memory serves me correctly.

 

[Taus]

Cervical RFN is technically challenging on most cases. After all of these years I’m STILL looking for a technique that is more foolproof. I’m generally positioning the head neutral rather than flexed and turning head to contralateral side. Without flexion the joint spaces are harder to see and turning the head throws off the lateral. But. If I flex the head and/ or don’t turn the head Im trying to see through the dental work and nasal bones. I don’t oblique much more than maybe 5 degrees although many descriptions recommend 30 degrees.

Interested in other’s pearls. SLobel posted an interesting technique a number of years ago- inferior to superior, medial to lateral if memory serves me correctly.

I’ve adapted mine over the years… found what really works reliably for me in terms of proper placement and visualization

-Head a little flexed on positioner, but I don’t get carried away with it.
- from true AP: enter skin 1 level caudal from target on pillar above and about 1-2cm lateral to os (except ton and c7 are directly lateral). This allows walking off os without tip deviating laterally off os
-don’t worry if you can’t perfectly see waist of each pillar and joint lines for initial placement. Just approximate for now.
-place 18g cannula driving out of plane to hit os directly medial to target
-go to lateral, get true lateral with wig-wag and table tilt as needed and redirect each needle to perfect trajectory aiming exactly at target mb location cephalad/caudal on respective pillar. Very easy with an 18g to redirect.
-Add more local and walk off to mb target with tip at ventral margin artic pillar. Ok if can’t see all needles below shoulders. Ideally get at least the most cephalad placed needle in position under lateral as a depth confirmation marker under clo later
- go to clo about 45 degrees from true AP and advance the needles that weren’t visible on lateral. Posterior aspect of lamina seems to approximate depth of needle tip at ventral pillar from lateral view at 45 degrees. At minimum confirm dorsal to foramen
- if can’t see the joint lines under clo to properly place needles cephalad/caudal for each respective mb, then caudal tilt til you can see them just like a lateral view
-confirm under ap then none are deviated laterally off os
-test, local, burn x2-3

With this you don’t have to worry about shoulders blocking lower c spine and don’t worry about marginal initial visualization of precise targets in ap. Cannula will cover full length of nerve on on pillars with appropriate caudal to cephalad trajectory. Takes me 15-20 mins for 2-3 joints with 2 burns per nerve

 

[ED50]

I’ve adapted mine over the years… I keep it pretty simple.

-Head a little flexed on positioner, but I don’t get carried away with it.
- enter skin 1 level caudal from target on pillar above and about 1-2cm lateral to os (except ton and c7 are directly lateral). This allows walking off os without tip deviating laterally off os
-don’t worry if you can’t perfectly see waist of each pillar and joint lines for initial placement. Just approximate for now.
-place 18g cannula driving out of plane to hit os directly medial to target
-go to lateral, get true lateral with wig-wag and table tilt as needed and redirect each needle to perfect trajectory aiming exactly at target mb location cephalad/caudal on respective pillar. Very easy with an 18g to redirect.
-Add more local and walk off to mb target with tip at ventral margin artic pillar. Ok if can’t see all needles below shoulders. Ideally get at least the most cephalad placed needle in position under lateral as a depth confirmation marker under clo later
- go to clo about 45 degrees from true AP and advance the needles that weren’t visible on lateral. Posterior aspect of lamina seems to approximate depth of needle tip at ventral pillar from lateral view at 45 degrees. At minimum confirm dorsal to foramen
- if can’t see the joint lines under clo to properly place needles cephalad/caudal for each respective mb, then caudal tilt til you can see them just like a lateral view
-confirm under ap then none are deviated laterally off os
-test, local, burn x2-3

With this you don’t have to worry about shoulders blocking lower c spine and don’t worry about marginal initial visualization of precise targets in ap. Cannula will cover full length of nerve on on pillars with appropriate caudal to cephalad trajectory. Takes me 15-20 mins for 2-3 joints with 2 burns per nerve

Are you shooting this in ap then?

 

[Taus]

Are you shooting this in ap then?

Yes. Added to my post.

 

[NJPAIN]

Yes. Added to my post.

When you say straight AP do you decline the II at all to try to see the waists of the articular pillars or just center the spinous process and roughly make out the levels with the c-arm perpendicular to the table?

The approach described in Furman atlas works great in younger patients with healthier spines and minimal dental work or edentulous. In older arthritic patients it can take A LOT of time to simply see your target.

 

[Taus]

When you say straight AP do you decline the II at all to try to see the waists of the articular pillars or just center the spinous process and roughly make out the levels with the c-arm perpendicular to the table?

The approach described in Furman atlas works great in younger patients with healthier spines and minimal dental work or edentulous. In older arthritic patients it can take A LOT of time to simply see your target.

I decline a little bit if head isn’t forward flexed much. Just enough to make out the levels and approximate target. Centering spinous process, but as this procedure requires a good lateral view, I would prefer to rotate the patient’s head a little bit until they were true AP to the floor

 

[Ligament]

SIS technique. Beam square to SEP at target level. 15 -20 degrees ipsilateral oblique. Decline II about 30 degrees. Down the beam needle insertion. For L5 DR I decline nearly 50 degrees from square with SEP of sacrum. Ipsilateral oblique 0-5 degrees. I check AP, oblique and lateral. 16 guage conventional cannula. A lot more fluoro than 10 seconds. Any other technique is arguably "unvalidated" if you care. I have to believe that a lot the response to RF is placebo because everyone does whatever technique they dream up, uses cannulae of any size they want and uses a few seconds of fluoro but claims that their results are great.

This is what I do, but 35 degrees caudal tilt from the L5-S1 disc. This places my needle nearly parallel to the dorsum of the sacrum.

This takes a lot of time and fluoro but this may be why my patients get long term benefit.

 

[Drd105]

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

Could you please post a few pics of this TFESI AP method?

 

[po_boy]

Don't want to start a new thread. Can anyone post pics of what a true AP of L5/S1 (squared SEP of S1) looks like (and or tips for obtaining this view) for the purposes of starting optimal trajectory view for L5DR ablation? In fellowship we had an amazing rad tech (not so much out in practice) and were taught to place L5DR in AP. However, this technique does not seem optimal.

 

[DOctorJay]

I find it easiest to place the L5 DR needle by declining the II towards the feet about 30 degrees from straight AP. watch for the sulcus to appear and you can go coaxial down it to touch os. then go to oblique and lateral to tune it up to make sure you're deep enough.

 

[RoloTomassi]

Don't want to start a new thread. Can anyone post pics of what a true AP of L5/S1 (squared SEP of S1) looks like (and or tips for obtaining this view) for the purposes of starting optimal trajectory view for L5DR ablation? In fellowship we had an amazing rad tech (not so much out in practice) and were taught to place L5DR in AP. However, this technique does not seem optimal.

Google Ferguson view

 

[jwalker12]

What are people doing for a Sacralized L5?

 

[RoloTomassi]

What are people doing for a Sacralized L5?

If it looks like it doesn't move, it shouldn't hurt. Go L4-5 and above, just like if there was an L5-S1 fusion.

 

[Drd105]

I searched and could not find this in prior threads- for cervical RF what motor stim level is everyone going up to? Around 2 I sometimes will start getting strong motor twitch that the patient cannot determine if they feel it in the arm or if the shoulder twitching is shaking the arm. When I see this I am very safe on the lateral and the CLO always, not even close to pushing the VILL.

 

[RoloTomassi]

I searched and could not find this in prior threads- for cervical RF what motor stim level is everyone going up to? Around 2 I sometimes will start getting strong motor twitch that the patient cannot determine if they feel it in the arm or if the shoulder twitching is shaking the arm. When I see this I am very safe on the lateral and the CLO always, not even close to pushing the VILL.

2V. Yes in some pts motor can be strong but if your lateral and CLO through the foramen look good, burn away. Sometimes the needles will vibrate the first 10 sec or so of the burn in these people.

 

[Drd105]

2V. Yes in some pts motor can be strong but if your lateral and CLO through the foramen look good, burn away. Sometimes the needles will vibrate the first 10 sec or so of the burn in these people.

Thank you so much!

 

[soccrwz]

2V. Yes in some pts motor can be strong but if your lateral and CLO through the foramen look good, burn away. Sometimes the needles will vibrate the first 10 sec or so of the burn in these people.

why do they vibrate?

 

[RoloTomassi]

why do they vibrate?

I don't know, assuming there's some initial stimulation of the nerves before they die off? Seen it a handful of times, usually younger patients with very strong twitch during motor test.

 

[soccrwz]

I don't know, assuming there's some initial stimulation of the nerves before they die off? Seen it a handful of times, usually younger patients with very strong twitch during motor test.

ive always wonder that, never made sense to me

 

[clubdeac]

I searched and could not find this in prior threads- for cervical RF what motor stim level is everyone going up to? Around 2 I sometimes will start getting strong motor twitch that the patient cannot determine if they feel it in the arm or if the shoulder twitching is shaking the arm. When I see this I am very safe on the lateral and the CLO always, not even close to pushing the VILL.

I’ve had this many times. The cervical twitch can be very dramatic in my opinion sometimes making me second guess myself even when the lateral and CLO look pristine. One I posted pics of recently had very dramatic twitch

 

[bedrock]

I stim cervical at 1.5 for this reason. Never had any false negative motor stim.

 

[plasma.]

So much knowledge in this thread.

I’ve been trying the various techniques for lumbar RFA. Fellowship we did more or less SIS. Then I started doing 15 oblique and 15-20 caudal.

This week I’ve started going 15 oblique but no caudal tilt and putting the needle 1.5 levels below the target TP-SAP. I am so much faster this way.

Will see if outcomes are any different but quite a bit less frustrating than the techniques with significant caudal tilting.

 

[sdnuser001]

So much knowledge in this thread.

I’ve been trying the various techniques for lumbar RFA. Fellowship we did more or less SIS. Then I started doing 15 oblique and 15-20 caudal.

This week I’ve started going 15 oblique but no caudal tilt and putting the needle 1.5 levels below the target TP-SAP. I am so much faster this way.

Will see if outcomes are any different but quite a bit less frustrating than the techniques with significant caudal tilting.

I switched to this style as well and like it so much better

 

[DoYouEvenLiftBro]

Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule

Radiofrequency cervical rhizotomy has been shown to be effective for the relief of chronic neck pain, whether it be due to soft tissue injury, cervical spondylosis, or post-cervical spine surgery. The target and technique have traditionally been taught ...

www.ncbi.nlm.nih.gov

Some talking about cervical here too

Thoughts on this for cervical, would be easier for the tougher to see lower levels

 

[MitchLevi]

Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule

Radiofrequency cervical rhizotomy has been shown to be effective for the relief of chronic neck pain, whether it be due to soft tissue injury, cervical spondylosis, or post-cervical spine surgery. The target and technique have traditionally been taught ...

www.ncbi.nlm.nih.gov

Some talking about cervical here too

Thoughts on this for cervical, would be easier for the tougher to see lower levels

Depth is wrong, and you're not parallel (at all). I'd not be against bipolar for CRFA if you put two probes in the normal position to burn the patient, and maybe place the probes at the upper and lower third aspect of the articular pillars. To burn on the lamina like what's mentioned in that article makes no sense to me.

I don't recommend routinely burning C2-3 using bipolar. It's finnicky vascularity up high. I wouldn't do it routinely.

This is cervical RFA depth IMO:

 

[RoloTomassi]

Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule

Radiofrequency cervical rhizotomy has been shown to be effective for the relief of chronic neck pain, whether it be due to soft tissue injury, cervical spondylosis, or post-cervical spine surgery. The target and technique have traditionally been taught ...

www.ncbi.nlm.nih.gov

Some talking about cervical here too

Thoughts on this for cervical, would be easier for the tougher to see lower levels

Seems like you'd be burning the distal ends of the nerves so any joint innervating branches from the foramen back to the lamina will be missed.

 

[clubdeac]

I’ve had a harder and harder time getting good laterals on my cervical RFs. It’s becoming super frustrating. I have them rotate head away from side I’m doing while in AP then have them look straight ahead for lateral and the laterals have seemed to suck. Been doing this 15 years and cervical RF seems to get harder, specifically on these old arthritic spines

 

[RoloTomassi]

I’ve had a harder and harder time getting good laterals on my cervical RFs. It’s becoming super frustrating. I have them rotate head away from side I’m doing while in AP then have them look straight ahead for lateral and the laterals have seemed to suck. Been doing this 15 years and cervical RF seems to get harder, specifically on these old arthritic spines

Use more CLOs. Especially a very far CLO where you just clear the shoulders and facets are partially superimposed. Depth there is very similar to lateral

 

[callmeanesthesia]

I’ve had a harder and harder time getting good laterals on my cervical RFs. It’s becoming super frustrating. I have them rotate head away from side I’m doing while in AP then have them look straight ahead for lateral and the laterals have seemed to suck. Been doing this 15 years and cervical RF seems to get harder, specifically on these old arthritic spines

I judge depth off of lateral, plus CLO if I don’t get a good lateral. But for positioning the needle in the middle of the articular waist, I rely most of AP with caudal tilt. I’ve found even a perfect-appearing lateral can lead to the needle being several mm too high or low.

 

[drrosenrosen]

I had a guy last week with such a bull neck that I couldn't get a lateral for C2...

 

[PinchandBurn]

In a healthy spine with a decent tech 10-12 seconds using the technique I mentioned above for unilateral L3-L4-L5. I also don't routinely use laterals unless abnormal motor stim which cuts down on exposure.

Don't you need 2 views for lcd??

 

[CleanUp]

1. Has anyone found sensory testing to improve accuracy (longer term relief and/or better relief)?

2. Do you find sensory testing or motor testing to predict better results? I was taught motor is a safety check and some people may not have motor if atrophied.

3. Am I correct in thinking if the patient has a positive sensory test with a lower voltage I am closer to the nerve and thus will have a better long term outcome?

4. Maybe I should just go to epidurals first before mbbs given there always seems to be some stenosis on MRI.

 

[Ducttape]

1., 2., 3. studies suggest that there is no benefit towards sensory or motor testing.

4. it should be done based on predominant complaints, though some insurances seem to "require" epidurals before MBB if there are any radicular symptoms.

 

[kstarm]

1., 2., 3. studies suggest that there is no benefit towards sensory or motor testing.

4. it should be done based on predominant complaints, though some insurances seem to "require" epidurals before MBB if there are any radicular symptoms.

No benefit in improving outcomes, or no benefit in improving safety, or both? What if any sensory/motor testing do you do?

 

[schmee90]

1., 2., 3. studies suggest that there is no benefit towards sensory or motor testing.

4. it should be done based on predominant complaints, though some insurances seem to "require" epidurals before MBB if there are any radicular symptoms.

Are these more of consensus guidelines you are referring to?

 

[agolden1]

Just wanted to thank everyone who has contributed to this thread as well as similar threads. RFA training in fellowship sucked (straight AP placement on point, not parallel to needle). Reviewing these threads, studying Furman, and a bit of an SIS course has been an absolute game changer for technique. Had a really amazing placement victory today (gun shy about posting due to HIPAA violations), and looking forward to many more to come, and the relief it will hopefully bring for my patients. Keep these discussions going for those who really want to improve!

 

[Agast]

What’s the consensus for use of neuromonitoring on RFA patients? Is it fraudulent if the doc happens to own the neuromonitoring company as well :/

 

[drrosenrosen]

Just wanted to thank everyone who has contributed to this thread as well as similar threads. RFA training in fellowship sucked (straight AP placement on point, not parallel to needle). Reviewing these threads, studying Furman, and a bit of an SIS course has been an absolute game changer for technique. Had a really amazing placement victory today (gun shy about posting due to HIPAA violations), and looking forward to many more to come, and the relief it will hopefully bring for my patients. Keep these discussions going for those who really want to improve!

As long as you black out any identifiable information, you can share images here. We have a whole sticky thread that's nothing but sharing images from procedures

 

[cowboydoc]

What’s the consensus for use of neuromonitoring on RFA patients? Is it fraudulent if the doc happens to own the neuromonitoring company as well :/

If a white collar prison camp in Florida is a reasonable retirement plan for you, I see no issues with this.