Lumbar RFA Technique

IPSIS: Formerly the Spine Intervention Society
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Agast said:
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 :/
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Would you still use neuromonitoring if you did not own the company?
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I’m assuming the frowny face means that agast doesn’t own the company and is asking about it.

Then again I should not make assumptions or apparently say “woman” in a thread or use pronouns “inappropriately”
 
paindoc503 said:
Would you still use neuromonitoring if you did not own the company?
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I don’t think it’s medically indicated for anyone to use it during RFA, but I’m also kind of a stick in the mud about a lot of things.
 
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Do not ablate like this please:

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drrosenrosen said:
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
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A couple hospitals I've worked at consider posting this kind of information without patient consent a HIPAA violation even if "deidentified". If ever traced back to me, would be all kinds of bad juju through admin. Just not a risk I'm comfortable taking. The image comparisons are phenomenal though.
 
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MitchLevi said:
I have a few other gems I could share but I don't want to take over the thread. We should start a Bad Procedure thread.
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Honestly please do. It serves as an educational opportunity. I’ve learned from “what not to do” as well as “what to do”. I’d personally enjoy reading why something is suboptimal.
 
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I love my Coolief. Allows me to be quicker. I target the MBs perpendicular like that.
 
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agolden1 said:
And the patient probably ended up with 100% relief for two years afterwards. It always seems to be the wacky placements from some of my colleagues who gain extraordinary benefit.
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GoBeers said:
it's the lazy/fast way for sure, but they should still get relief . maybe this patient has gotten 15mo relief with this approach previously
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Haha.

I think ESI outcomes do not have anything to do with procedure technique at times. The RFA seems the opposite.

Rarely see a bad RFA work, and I've done plenty of bad ESIs that completely eradicated pain.

An ugly RFA with steroid is an inaccurate therapeutic MBB if you stop and think about it.

That 1cc of steroid + local spreads quite a bit.
 
@MitchLevi it at least looks like he is trying. He has reasonable depth. I have seen much, much worse from docs with both good and bad reputations.
 
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That being said I have seen some WILD laterals were the needle is not even close to being close to approrpiate location-ultra superficial. Do some docs just not care about laterals...or just how they were trained (or lack there of you could argue).
 
MitchLevi said:
Do not ablate like this please:

View attachment 382429
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This is not at all unusual. I see this all the time coming from practices doing 5-6 procedures/hour. The majority see no “value” in placing needles in an inferior to superior direction parallel to the expected course of the MB. It takes too long. Shoot needles in straight AP and check an oblique…done. Finish off with local and steroid. Then tell the patient what an awesome job you did. Seems to have the same results as doing the procedure correctly.
 
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NJPAIN said:
This is not at all unusual. I see this all the time coming from practices doing 5-6 procedures/hour. The majority see no “value” in placing needles in an inferior to superior direction parallel to the expected course of the MB. It takes too long. Shoot needles in straight AP and check an oblique…done. Finish off with local and steroid. Then tell the patient what an awesome job you did. Seems to have the same results as doing the procedure correctly.
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This is why when patients come in and tell me that they failed RFA, but they have a clinical history, exam, and imaging that supports symptomatic facet OA, I suggest we repeat it. Even if it means another round of MBB.

“I have never repeated RFA on such a patient in my current area where I’ve been the last 3.5 years and the patient has not achieved significantly better pain relief after I perform a proper RFA with SIS technique”

I don’t mean it to sound arrogant but it is true.

The past 18 months I’ve actually even started telling that to second opinion patients now, because it has been easy to fulfill, at least with my local competition.
 
bedrock said:
This is why when patients come in and tell me that they failed RFA, but they have a clinical history, exam, and imaging that supports symptomatic facet OA, I suggest we repeat it. Even if it means another round of MBB.

“I have never repeated RFA on such a patient in my current area where I’ve been the last 3.5 years and the patient has not achieved significantly better pain relief after I perform a proper RFA with SIS technique”

I don’t mean it to sound arrogant but it is true.

The past 18 months I’ve actually even started telling that to second opinion patients now, because it has been easy to fulfill, at least with my local competition.
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those MBBs / RF often get denied tho
 
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stsa84 said:
I like Trident 100x better than cooled. Drives better, stays in place once you reach the target, shorter lesion time. Never going back to cooled.
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What exactly is trident? Not familiar
 
paindoc007 said:
What exactly is trident? Not familiar
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dirostech.com

RF TridentTM Cannulae | Diros Technology | Radiofrequency (RF) Pain Management

RF TridentTM Cannulae – Diros Technology manufactures Radiofrequency (RF) pain management and neurosurgical products.
dirostech.com dirostech.com

Made by Diros Technology, purchased by Avanos a little bit ago. The hub rotates and deploys the tines. Lesion extends past the needle tip, allowing for direct approach for RFA. Similar idea to cooled. Needles are pricy ($160/each), but contain the electrode , and have a pigtail for giving medication. You place the needle, deploy the tines, test, inject local, and burn, without having to remove/adjust anything. My big complaint with cooled, besides price, is that the stupid cannulas don't stay in place when you remove the stylet, usually requiring redirection once you get the probe in. B/l lumbar RFA takes maybe 10 minutes? Cost doesn't make much sense compared to standard needles, but I like it so much more than cooled.
 
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stsa84 said:
My big complaint with cooled, besides price, is that the stupid cannulas don't stay in place when you remove the stylet, usually requiring redirection once you get the probe in.
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Interesting. Not my experience at all. But I’ll look into trident as well, thx for the info.
 
whenever RFAs are discussed, there ends up being a high falutin discussion that a particular technique is the "only one that ever works"...
as always, i wondered "is this the case"?

now mind you, i do position needle tip parallel to the nerve like almost everyone here but know several local practitioners that do not (and are exceedingly efficient at doing so)

i found this study intriguing:
www.ncbi.nlm.nih.gov

Efficacy of needle-placement technique in radiofrequency ablation for treatment of lumbar facet arthropathy

Many studies have assessed the efficacy of radiofrequency ablation to denervate the facet joint as an interventional means of treating axial low-back pain. In these studies, varying procedural techniques were utilized to ablate the nerves that innervate ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

the advanced Australian approach - needle tip parallel - does confer benefits from the early Australian technique, but the study did show that that latter technique did work. just not as long and may not



A total of 373 patients underwent lumbar facet denervation between the years of 2008 and 2012. Ninety-four patients were treated with the advanced Australian technique, while 279 patients were treated with the early Australian technique. However, 12 patients in the advanced Australian group and 38 patients in the early Australian group were excluded from the inclusion cohort due to lack of data or follow-up. Demographic data for the two groups are listed in Table 1. The average age was 57.8 and 60.5 years for the advanced Australian and early Australian groups, respectively. The sex breakdown for these two groups was 41.5% male in the advanced Australian group and 36.1% in the early Australian group. For all demographic data, no statistically significant differences were noted, with the exception of a greater percentage of Asian patients in the advanced Australian group compared to the early Australian group (P=0.001).
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The advanced Australian and early Australian groups showed comparable baseline VNS pain scores, 6.45 and 6.55, respectively, with no statistical difference between the two groups (Table 2). Neither the postablative VNS pain scores nor the VNS pain-score differences from preablation to postablation for the two groups reached a statistically significant level based on t-test analysis.
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To further assess the efficacy of early Australian and advanced Australian techniques on pain relief, a qualitative assessment of patients’ self-reported pain relief was performed. Overall, a significantly larger percentage of patients in the advanced Australian group reported pain relief (85.4% versus 70.5%, P=0.012) (Table 2). The need for nonablative interventional pain procedures (epidural steroid injections, sacroiliac joint injections, piriformis injections) to further treat the patient’s pain syndrome was also assessed. The advanced Australian group had a slightly higher but not statistically significant follow-up procedure rate of 32.9% versus the 27.8% of the early Australian group (P=0.38) (Table 2).
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In addition to analysis of initial pain relief obtained from undergoing a lumbar facet denervation for the treatment of lumbar facet pain, the duration of relief was measured. In the advanced Australian group, 62 of 82 (75.7%) patients had documented recurrence of their pain, while 208 of 241 (82.3%) of patients in the early Australian group had documented recurrence of their pain. A Kaplan–Meier curve was plotted to assess statistical difference between the two groups (Figure 1). Immediate procedural treatment failure was higher in the early Australian group, with 50% of all patients in this group showing initial recurrence of pain by 1.5 months. In contrast, the advanced Australian group showed that 50% of patients continued to remain pain-free until 4 months. This difference in duration of treatment effect was statistically significant (P=0.022). However, by 11 months postprocedure, the difference in pain relief between the advanced Australian and early Australian groups became negligible, with nearly 90% of all patients in both groups reporting recurrence of their pain to preablation levels.
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in addition, the study noted significant differences in males and in younger age groups and in those not on pain meds being more successful. however, the older age group felt better quality of life benefits.

however, the study notes that both groups got benefit from the procedure, but states that the early Australian technique provided 1.5 months of reduced pain vs the advanced for 4 months.

main problem with study was retrospective nonblinded nature.



so yes, we can critique the perpendicular technique as not working as long, maybe not as impactful, but it still works.
 
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Not parallel isn't terrible on it's own, as in good placement deep in the junction, but is when combined with being too superficial, too high on the SAP, too lateral on the TP, all of which I see way too often
 
RoloTomassi said:
Not parallel isn't terrible on it's own, as in good placement deep in the junction, but is when combined with being too superficial, too high on the SAP, too lateral on the TP, all of which I see way too often
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That's the problem with straight AP. Most of these facets have hypertrophied sap which makes it hard to not be too dorsal or lateral. At the very least oblique 20 degrees to angle onto the junction if people want to be lazy or fast
 
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I need someone to explain to me how placing a needle tip perpendicular to the nerve works. How does that treat the nerve? We know 100% that with standard RF needles, there is zero percent chance that the heat around the tip does any damage to the nerve.

I would accept an explanation that involves a discussion of a generated magnetic field that acts in a way similar to pulsed RF

Okay go - those who don’t place parallel - give it a go. Explain it.
 
stsa84 said:
I like Trident 100x better than cooled. Drives better, stays in place once you reach the target, shorter lesion time. Never going back to cooled.
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I do a fair amount of cooled. I hate the needles and design. Although it has improved a lot based on feedback. I do love that they FINALLY bent the probe 90deg. I also love that they gave us a side port to place the local. In my mind, all RF needles should have this.
 
epidural man said:
I need someone to explain to me how placing a needle tip perpendicular to the nerve works. How does that treat the nerve? We know 100% that with standard RF needles, there is zero percent chance that the heat around the tip does any damage to the nerve.

I would accept an explanation that involves a discussion of a generated magnetic field that acts in a way similar to pulsed RF

Okay go - those who don’t place parallel - give it a go. Explain it.
Click to expand...
placebo is one helluva drug
 
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I buy some benefit from perpendicular, especially if you dump steroid in there afterwards bc you just performed a Tx MBB.
 
epidural man said:
I need someone to explain to me how placing a needle tip perpendicular to the nerve works. How does that treat the nerve? We know 100% that with standard RF needles, there is zero percent chance that the heat around the tip does any damage to the nerve.

I would accept an explanation that involves a discussion of a generated magnetic field that acts in a way similar to pulsed RF

Okay go - those who don’t place parallel - give it a go. Explain it.
Click to expand...

There is some lesioning distal to the tip, just not a lot. Would have to be lucky to get a sufficient burn. (I do parallel placement, don’t make fun of me)
 
epidural man said:
I need someone to explain to me how placing a needle tip perpendicular to the nerve works. How does that treat the nerve? We know 100% that with standard RF needles, there is zero percent chance that the heat around the tip does any damage to the nerve.

I would accept an explanation that involves a discussion of a generated magnetic field that acts in a way similar to pulsed RF

Okay go - those who don’t place parallel - give it a go. Explain it.
Click to expand...
I do parallel placement, but I think the simplest answer is that we are oversimplifying the argument by saying it is “perpendicular placement”. The nerves come down at an angle, so no one is likely doing true perpendicular placement. From Bogduk’s own presentations (attached), what we normally describe as perpendicular placement should capture a chunk of the medial branch, it is just that good parallel placement captures even more. That is all assuming good depth and close proximity to nerve, which is a different argument altogether. I otherwise agree placebo can play a role.
IMG_6248.jpeg
IMG_6247.jpeg
 
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epidural man said:
I need someone to explain to me how placing a needle tip perpendicular to the nerve works. How does that treat the nerve? We know 100% that with standard RF needles, there is zero percent chance that the heat around the tip does any damage to the nerve.

I would accept an explanation that involves a discussion of a generated magnetic field that acts in a way similar to pulsed RF

Okay go - those who don’t place parallel - give it a go. Explain it.
Click to expand...
The lesion is an ovoid shape. That includes an area around the tip. The lesioning affects nerves that are within that ovoid shape.

Parallel placement brings a lot more of the lesion area in contact with the nerve and greater area of lesioning and greater likelihood of success.

(Like others have stated, I place it parallel. Being devils advocate.)
 
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JFS said:
I do parallel placement, but I think the simplest answer is that we are oversimplifying the argument by saying it is “perpendicular placement”. The nerves come down at an angle, so no one is likely doing true perpendicular placement. From Bogduk’s own presentations (attached), what we normally describe as perpendicular placement should capture a chunk of the medial branch, it is just that good parallel placement captures even more. That is all assuming good depth and close proximity to nerve, which is a different argument altogether. I otherwise agree placebo can play a role.View attachment 382704View attachment 382705
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The yellow lines are higher up on the SAP than I usually go, which is interesting if that's from the man himself
 
MD87 said:
There is some lesioning distal to the tip, just not a lot. Would have to be lucky to get a sufficient burn. (I do parallel placement, don’t make fun of me)
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Very little - not enough to hurt a nerve. If you doubt me on this, get a chicken breast - burn a lesion and post the pics here - noting that chicken will be even a larger burn than a human.
 
epidural man said:
Very little - not enough to hurt a nerve. If you doubt me on this, get a chicken breast - burn a lesion and post the pics here - noting that chicken will be even a larger burn than a human.
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I doubt you based on these, but I still think you're going to decrease your chances of success if you aren't parallel. I certainly do not doubt you enough to waste a perfectly good chicken breast!
pubmed.ncbi.nlm.nih.gov

The Effect of Local Anesthetics and Contrast Agents on Radiofrequency Ablation Lesion Size - PubMed

Lidocaine 2% and iohexol 240, when used as pre-injections in RFAs, were found to be associated with statistically significant increases in lesion surface area. However, RFAs with lidocaine 1%, iohexol 180, or gadodiamide were not found to produce a statistically significant difference in lesion...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
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