RFA complication

[Wkrdoc]

I’ve been doing RFAs in private practice for 5 years, never any complications. Today, I slipped off the left L4 pedicle a few times, it was challenging. Adjusted the fluoro and was satisfied. No motor, lateral image did not indicate foraminal encroachment. Injected lidocaine prior to ablation. I was firmly in os and I held the probe the entire 2:30.

In PACU patient complained of weakness and numbness in the L4 dermatome (FML). I was hoping it could be chalked up to the lidocaine. Persisted for 2 hours. The symptoms improved slightly prior to discharge.

I gave Decadron, plan on scanning him tomorrow. Will send to neurology and Physiatrist if issue persist.

Here to ask the board for advice, I’m a bit perplexed bc I’ve had the needle slip off a million times without issues. I had no motor response and nothing appeared concerning on lateral.

TIA

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[DOctorJay]

I bet it's just from the local and will be back to normal tomorrow. If the patient wasn't complaining of severe pain radiating down the leg in an L4 distribution during your burn it's very unlikely you fried her root.

why 2:30? how much lidocaine prior to ablation? any anesthetic after the ablation?

 

[Wkrdoc]

Manufacturer recommends 230-245. What we did in fellowship with same device.

2cc 1% lido with epi prior to ablation. Nothing afterwards.

wouldn’t you anticipate the local to wear off in an hour or so? Man I would be over the moon if this deal resolves tonight

and he’s had zero pain and still doesn’t. I was thinking the same thing.

 

[mazinger]

It’s the lido, there is no way you can fry a nerve root regardless of hoe much lido you give in the awake patient. Limit your lido to 1 cc and always do it awake and you will never have this problem again.

 

[Wkrdoc]

It’s the lido, there is no way you can fry a nerve root regardless of hoe much lido you give in the awake patient. Limit your lido to 1 cc and always do it awake and you will never have this problem again.

we use light sedation for our RFAs. Patients seem to enjoy the experience much much more. This is what worries me about sedation, but never had an issue until today.

 

[callmeanesthesia]

we use light sedation for our RFAs. Patients seem to enjoy the experience much much more. This is what worries me about sedation, but never had an issue until today.

Light sedation as defined by the ASA (minimal sedation/anxiolysis- patient is normally responsive to verbal stimuli)? Or light sedation as in the CRNA pushes propofol until the patient stops responding but they don’t have an endotracheal tube? If the former the patient would definitely respond if you were ablating a nerve root. If the latter then definitely stop doing that.

 

[Wkrdoc]

Light sedation as defined by the ASA (minimal sedation/anxiolysis- patient is normally responsive to verbal stimuli)? Or light sedation as in the CRNA pushes propofol until the patient stops responding but they don’t have an endotracheal tube? If the former the patient would definitely respond if you were ablating a nerve root. If the latter then definitely stop doing that.

as in 2 versed 100 fent and 2-3 cc prop

 

[willabeast]

Some people are outliers when it comes to how long the local lasts. // Lignocaine’s onset of action is rapid, and blockade, whilst dependent of dose given, concentration used, nerves blocked and status of the patient, may last for up to 5 h when administered as a peripheral nerve block[7].//

7.	Xylocaine and xylocaine with adrenaline: Product information. : AstraZeneca Pty Ltd A 2010;

 

[Orin]

I assume with that burn time you are using a cooled RF system. I still agree the probability of a thermal RF of the motor roots being covered by lidocaine is pretty low, even with sedation. You may have dinged a nerve root with the larger needle, but still, it should resolve. Give it time and see. I agree with the steroids.

 

[Wkrdoc]

Thanks gents. I’ve been lucky on the complication side of things thus far. Not a fun thing to deal with.

I’ll keep you posted on the outcome

 

[callmeanesthesia]

as in 2 versed 100 fent and 2-3 cc prop

That’s probably not enough to cover up ablating a spinal nerve unless they were really old. I’d agree that’s probably the lidocaine - with epi in a more sensitive patient that could certainly happen.

 

[Ligament]

Thanks for posting your question. It takes guts to do so.

It is the lidocaine. There is no way you fried a root unless the patient was nonresponsive. Frying a root hurts like hell.

I use 1cc of 4% lidocaine prior to RF and even with that, patients can report radicular pain if they are awake.

Curious why you use epi?

Also curious what you mean by slipping off the pedicle? The only way I could see you'd be targeting pedicle is if you are doing cooled rf with a perpendicular approach the the medial branch?

 

[paindoc007]

Thank you for posting this. This is an excellent discussion.

I agree with the above. It’s most likely lidocaine effect. I’d have given IV steroids in post op, and PO steroids plus gaba/lyrica until followup in a few days.

A good example as to why deep sedation such as propofol is not indicated in routine spine injections. As long as they’re awake, you really can’t burn something important without knowing

Are you using avanos coolief? That’s what I use, also do 2:30 burn. Aim square on Pedicle from a slight oblique. No caudal tilting. I think maybe you’re doing that and causing the “slip off” which isn’t necessary if you’re using coolief

 

[Ferrismonk]

Doesn't sound like you fried the nerve root. If you stabbed it, they'd jump off the table. If you burned it, they'd also jump off the table.

FWIW, I use 2cc 2% Lido and don't really ever have this problem (except in fellowship haha).

Also, I would not have done the steroids/gaba/lyrica/etc that you did. I would have just kept them in recovery until the local wore off (1-4 hours).

 

[SSdoc33]

couple of things:

#1 i agree with the above
#2 move away from sedation. you are bound to have problems like these if you continue to use it
#3 why epi in the lido?
#4 i have had patients complain of "radicular pain" after an RF. i think a lot of it is just facet radiation. occasionally it can last, and a TFESI at the brunt level (in this case an L4) usually takes care of it. there are cases when the anatomy is pretty weird and you could theoretically bag a nerev. in this case, you need to look for WEAKNESS, not pain. who the hell knows what pain means, anyway. if there is legit weakness, then an EMGNCS after 3 weeks would confirm the issue.... but this probably just goes away

 

[Timeoutofmind]

Thank you for posting this. This is an excellent discussion.

I agree with the above. It’s most likely lidocaine effect. I’d have given IV steroids in post op, and PO steroids plus gaba/lyrica until followup in a few days.

A good example as to why deep sedation such as propofol is not indicated in routine spine injections. As long as they’re awake, you really can’t burn something important without knowing

Are you using avanos coolief? That’s what I use, also do 2:30 burn. Aim square on Pedicle from a slight oblique. No caudal tilting. I think maybe you’re doing that and causing the “slip off” which isn’t necessary if you’re using coolief

Square on the pedicle?

Will lumbar cooled RF dont you still aim for the same target point as standard RF...junction of SAP/TP (e.g. superolateral aspect of pedicle)?

 

[10KHertz]

as in 2 versed 100 fent and 2-3 cc prop

2mg verses, 100mcg fentanyl, and 30ml of propofol is DEEP MAC if given through my IV...

The patient may be too deep during 1-2 of your lesion sites.

Try to minimize this sedation protocol.

I use 2-3 5mg Valium 30 min prior to procedure. I used to use 10mg 2-3 po, but patients took it incorrect and couldnt get out of the car and became fall risks . So I stopped that oral regimen.

I’ll tell you about a cervical rfa case and ‘flame lesion’ later, after this case sorts itself out, which it will...

 

[clubdeac]

Since you were doing cooled you could’ve fried a nerve. That lesion as you know expands anteriorly beyond the tip of the needle. I wouldn’t come close to sliding over the pedicle with cooled. If you were doing standard RF then no problem

 

[SommeRiver]

I wouldn't worry about this patient.

I still can't believe people use propofol, Versed, and fentanyl for procedures that are so routine you can do them on both aspirin and Plavix.

 

[painfree23]

OP, any update?

 

[paindoc007]

Square on the pedicle?

Will lumbar cooled RF dont you still aim for the same target point as standard RF...junction of SAP/TP (e.g. superolateral aspect of pedicle)?

I don’t no. Needle tip is too anterior in that case, since coolief’s burn grows out from the distal tip

 

[deleted993114]

Thanks gents. I’ve been lucky on the complication side of things thus far. Not a fun thing to deal with.

I’ll keep you posted on the outcome

As above, if you “cooked” a root, you would have to pull them off the ceiling, as it would hurt like hell even with the lidocaine.

BTW- what did the needle position look like in the lateral view? I have seen guys who only take an AP view (I don’t know why). Always a good idea to make sure nothing has slipped into the foremen.

DON’T WORRY- the guy will be okay. We are swimming in a shark tank in pain mgmt. complications can take an emotional toll. However, this is a “nothing” and the guy will be okay.

YOU WILL, however, have complications in the future. Just try to learn from them and don’t internalize- it will make you old prematurely.EVERYBODY gets complications- it’s just that some folks don’t share theirs.

 

[painfree23]

“ As above, if you “cooked” a root, you would have to pull them off the ceiling, as it would hurt like hell even with the lidocaine.”

Everyone keeps saying this , is this anecdotal or just in theory?

 

[Ducttape]

no, its real.

during a lumbar RFA, needles in good position, the L4 on AP lateral looked good but at the top edge. did motor testing, negative. injected lido. patient squirmed.
I should have reshot an image after the lido but I was in a hurry.
started the RFA, and when it hit 70, she screamed and her leg was contracting.

of course, stopped, pain stopped immediately, re-xrayed and it had slipped off... no consequences after tho.

 

[SommeRiver]

Come on y'all...We've all done an RFA on a scoliotic patient and zapped them. I have an older gentleman with a 50-ish degree Cobb who got severe L3 pain within 1 sec of my Neurotherm getting to about 55 degrees. We've all been there...

Definitely real, and a spinal nerve is way too thick/robust to injure it in the 2 sec the needle would be there before the pt yells and you back it out.

 

[SSdoc33]

Come on y'all...We've all done an RFA on a scoliotic patient and zapped them. I have an older gentleman with a 50-ish degree Cobb who got severe L3 pain within 1 sec of my Neurotherm getting to about 55 degrees. We've all been there...

Definitely real, and a spinal nerve is way too thick/robust to injure it in the 2 sec the needle would be there before the pt yells and you back it out.

i dont know. if you put in a sh$tload of lido AND there is sedation you definitely could fry a nerve

 

[SommeRiver]

i dont know. if you put in a sh$tload of lido AND there is sedation you definitely could fry a nerve

I guess anything is possible in this field.

 

[Ligament]

There is no way you RFd the nerve root unless that patient was unresponsive from the sedation. 1% lidocaine is not going to kill that type of pain. Even using 4% lidocaine as I do, I have had some patient breifly complain of radicular pain and I reposition the needle, even when it looks great on imaging.

I think you shoudl be more concerned about using propofol, MAC is when injuries happen in our field.

 

[lobelsteve]

Anyone know what the SIS guidelines say about this exact thing?

 

[SommeRiver]

Completely and foolishly unnecessary.

 

[BobBarker]

Usually, my RFs get 1-2mg versed, 50-100mcg fentanyl. Just part of being at the hospital. Propofol not necessary. The patients that elect to not use sedation do great. 1ml 1% lido injected BEFORE motor testing. Gives it a bit more time to set up.

 

[No Pain All gain]

I use 16 ga RF cannulae. Patients who choose sedation get 2 versed +\- 50 fent and 30 ketorolac.

Local patients get IM ketorolac in ASC. Nothing in office.


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[Wkrdoc]

As above, if you “cooked” a root, you would have to pull them off the ceiling, as it would hurt like hell even with the lidocaine.

BTW- what did the needle position look like in the lateral view? I have seen guys who only take an AP view (I don’t know why). Always a good idea to make sure nothing has slipped into the foremen.

DON’T WORRY- the guy will be okay. We are swimming in a shark tank in pain mgmt. complications can take an emotional toll. However, this is a “nothing” and the guy will be okay.

YOU WILL, however, have complications in the future. Just try to learn from them and don’t internalize- it will make you old prematurely.EVERYBODY gets complications- it’s just that some folks don’t share theirs.

thank you guys for the overwhelming support!

For the update, the patients symptoms dissipated over the following three days. The numbness is resolved and the weakness is over 80% improved and I anticipate he will make a full recovery.

My best guess is the local contributed to the complete loss of motor and sensory in the L4 dermatome. But due to the fact that he had lasting symptoms, I must’ve dinged the nerve with the needle.

The patient has been AMAZING and completely understanding. All in all, I’ll just say we play a high stakes game and do not get in a rush even though most of us do 30-40 procedures in a day.

I wanna again thank you guys for being non-judgmental and for the advice

 

[Wkrdoc]

thank you guys for the overwhelming support!

For the update, the patients symptoms dissipated over the following three days. The numbness is resolved and the weakness is over 80% improved and I anticipate he will make a full recovery.

My best guess is the local contributed to the complete loss of motor and sensory in the L4 dermatome. But due to the fact that he had lasting symptoms, I must’ve dinged the nerve with the needle.

The patient has been AMAZING and completely understanding. All in all, I’ll just say we play a high stakes game and do not get in a rush even though most of us do 30-40 procedures in a day.

I wanna again thank you guys for being non-judgmental and for the advice

Additionally, I repeated an MRI the next day with emphasis on the L4 nerve root, and it came back exactly the same as the previous scan. No evidence of edema formation or nerve root disruption. Just goes to show a little irritation goes a long way

 

[clubdeac]

Additionally, I repeated an MRI the next day with emphasis on the L4 nerve root, and it came back exactly the same as the previous scan. No evident of edema formation or nerve root disruption. Just goes to show a little irritation goes a long way

a little irritation or a lot of psych overlay

 

[Wkrdoc]

a little irritation or a lot of psych overlay

Trust me, that thought has crossed my mind...

 

[Ronin1]

“All in all, I’ll just say we play a high stakes game and do not get in a rush even though most of us do 30-40 procedures a day”

I would say that most of us do not do 30-40 procedures a day .....

 

[10KHertz]

“All in all, I’ll just say we play a high stakes game and do not get in a rush even though most of us do 30-40 procedures a day”

I would say that most of us do not do 30-40 procedures a day .....

Maybe he’s including tpis

 

[SommeRiver]

I don't do 30 to 40 procedures in a day, and while I definitely have the referrals for that type of volume I simply won't do it.

Also find it weird that 5 yrs of practice at that volume and we get this thread.

 

[SommeRiver]

douche statement. I know a lot of guys with that volume.

first complication in 5 years, I’d say that’s pretty solid

I think you missed my point.

People get zinged during procedures all the time, and with an RFA it's virtually impossible to completely lesion a spinal nerve bc the patient simply won't allow it, even with Versed and fentanyl running.

Propofol is out of my league and I don't know when you're giving it or how you're using it but you're doing motor testing right? So at some point that patient is talking to you.

If you're doing that many procedures over 5 yrs you've surely had an adverse event and seen this exact scenario right?

You've caused neuritis several times or tickled someone nerve root but you're simply not able to ablate a spinal nerve for multiple reasons.

What I meant by my post isn't that you're a bad proceduralist, it's just I'd expect someone with that much volume to see this kind of thing occasionally.

Edit - Regarding volume...I know people who see 3 to 4 dozen patients per day, and I know a guy who sees that many in an afternoon. I personally won't go over 30 in a whole day bc I don't want to...

 

[lobelsteve]

douche statement. I know a lot of guys with that volume.

first complication in 5 years, I’d say that’s pretty solid

Number one problem with pain medicine. Pain docs.

 

[NJPAIN]

When I first started doing RFN everyone received sedation simply because EVERYONE in practice in my area routinely sedated patients and rumor circulated that it was “barbaric” to do them any other way. Then I started hearing about docs doing them with local anesthesia only and decided to give it a try. The nurses in the hospital thought I was nuts and the patients thought I was as well. Now, years later, I am still in the minority. Nurses who work elsewhere are amazed. Lidocaine 2%, 1 Ml through each cannula, wait 3 minutes and they often feel nothing at all. Best part is if there is any post procedure weakness I know it’s the local and not a fried root.


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[Ligament]

Are you guys not offering IV sedation following ISIS needle placement guidelines? Are you using large gauge RF cannulae? Following ISIS needle placment requires traversing quite a bit of tissue. I can see doing it the "easy way" ie oblique then straight down to SAP/TP junction can be much less painful and time consuming.

 

[NJPAIN]

Are you guys not offering IV sedation following ISIS needle placement guidelines? Are you using large gauge RF cannulae? Following ISIS needle placment requires traversing quite a bit of tissue. I can see doing it the "easy way" ie oblique then straight down to SAP/TP junction can be much less painful and time consuming.

For lumbar I do it the “hard” ISIS way with 16 ga cannulae. I do it slowly and carefully. It takes a long time; longer than I would like it to. I use a lot of local and wait for it to take effect. Occasional versed if patient is off the wall but I try to discourage that. No additional sedation at all after cannulae in position. For cervical however, I find I often need some versed and fentanyl before the 18 ga cannulae go in. Just enough for anxiolysis. Otherwise, I have had a few vasovagal and start vomiting. One time I had to abort just after the fourth cannula went in. Perhaps if I was really slick and really fast I could get away without it but getting good views takes me a long time in the neck and I’m reluctant to rush through.



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[Wkrdoc]

Guess I’m in the minority, but I tried doing these with minimal sedation and patients absolutely hated it. Heck, they jump off the table when I’m numbing up the skin. I even started mixing bicarbonate in with the LA

 

[paindoc007]

PO sedation works great. I offer versed 10mg prior. Most take me up on that

 

[BobBarker]

The local does burn quite a bit. I injected the top of my hand in fellowship and it does hurt. Not as bad as injecting Ancef IM though.

 

[callmeanesthesia]

Depends on your patients. I generally find if they tolerate the MBBs well they tolerate the RF well. I do RF in office and at ASC - I just tell patients the choice is up to them. About 3/4 choose in office. Xanax for in office sedation, 2% lido and wait 2 minutes for it to work prior to lesion. 18g for both cervical and lumbar. Inferior-lateral approach to nerve like SIS for lumbar, and they seem to tolerate it well.

 

[HouseofPain]

Are you guys not offering IV sedation following ISIS needle placement guidelines? Are you using large gauge RF cannulae? Following ISIS needle placment requires traversing quite a bit of tissue. I can see doing it the "easy way" ie oblique then straight down to SAP/TP junction can be much less painful and time consuming.

I go strictly with SIS technique and also use sedation. Usually it’s just 1-2mg of versed occasionally 50-100 mcg of fentanyl mostly with cervical RFA as that seems to be much less tolerable than lumbar. That being said the patient is always able to communicate. Most of the time we’re carrying on a conversation about whatever while I’m doing the procedure. I also use 18ga venom and make at least 3 lesions for lumbar usually 2 for cervical. Use 1cc 2% polocaine before lesion and majority do well. The thing is nothing is wrong with sedation as long as you’re able to communicate with the patient.

 

[lobelsteve]

SEDATION • Sedation is not intrinsically necessary for ESIs, but if employed in unique circumstances (e.g. movement disorder, cases of extreme anxiety, previous vasovagal response), the patient should remain able to communicate pain or other adverse sensations or events. • The decision to use sedation should be made on a case-by-case basis. • If the physician performing the procedure decides to administer and supervise the sedation, they should be trained and qualified to do so. In these situations, a separate healthcare provider is required to assist with the administration of the medications and monitoring of the patient. • Resuscitation drugs, monitoring equipment, and oxygen must be available if sedation is utilized.

Part of these guidelines?

This is from ESI chapter. Also can reference the fact finder from SIS that I have posted a few times over the years.