Our next procedure is something called the right side radiofrequency ablation. We’re gonna be doing RF procedure in L 3, 4, 5 on the right side. We’ve gone and done conformation diagnostic block approximately two week ago.
We perform medial branch block using a local anaesthetic of short duration, and we are back to repeat the procedure with long anesthetic with longer duration such as neuropin.
With that conformation of the patients ability to function, to be able to bend, twist, flex and squat was asked the day following procedure with conformation that she approved having had the anesthetic done 24 hours prior.
At this point time we’re going to point a camera towards the fluoroscope and go head and start to show you how we position, align our spine under fluoroscopy and then go head an do the needle positioning along with the confirmation of the solution with contrast and local anesthetic, to show how the enhancement of the local anesthetic numbs and anesthetizes the medial branch nerve.
For this portion of procedure we wanna go head and mark the inferior sacral alar, and we do that first by using a fluoroscopic guidance needle position, anesthetizing the skin, and deeper tissue with quarter percent lidocaine. Once we achieved that and the patient is relatively anesthetized in that zone. We’re going head in using neurotom 15 millimetres exposed, 150 millimeter needle and angle of position down to that sacral alar junction. Once we sacral alar junction we’ll go head anesthetize with 2% zylocaine, and little tiny bit of contrast enhancing specifically where needle placement is.
Now we’re go head inject this area with 2% zylocaine and contrast enhancing the area where the target is. We’ll go head place in the neurotherm ablation styled and go head and proceed with one minute at 80 degrees Celsius of targeted tissue ablation. In the meantime we go head and oblique fluoroscope towards the right and we’ll go head and mark the skin and target at L4 and L3 medium branch nerve.
Recalling that the L4 medium branch nerve is sitting on the L5 vertebral body and the L3 branch nerve is sitting on the L4 vertebral body. After anesthetizing skin and subcutaneous tissue of these next two sites we’ll go head and position the needle adjacent to the superior articulated process and we do that in the very interesting technique in the oblique fashion. We go ahead and started the IAP or intra articulated process and then angle the needles tip and edge up to the lamener border of the end plate.
By the doing so we have confirmation that the needle was not going to enter the neuroframen, and we know that because of the tried the proven method by angulating the SAP curvature to the to the end plate once the target has been meet there is no possible way the nerve or the actual needle enters into the neuroframen. We’ll go head and continue to do our ablation on the L5 S1; we will position our next needle on the L4 vertebral body, which is consistent with the L3 medium branch nerve. Please recall that the nomenclature changes one level per segment and you have to remember this in the dictation or you will have a large mistake and misbelief of where your target is.
So we’ll do a second ablation now, we’ll turn the needle slightly down in order to position it slightly more into the alar groove and go head ablate it for additional 40 seconds.
If we continue to do this in clinical conditions at this patient suffers with is very common and typical lumbar spondylosis, physical exam helps to confirm that by doing extension, rotation and palpating the area over facet loading.
Recall the facet loading can also give you a referred pattern of pain to the bottom, gluteal area and outer aspect of the leg, but does not typically create a sciatica like the pain that descends down the L4 or L5 or S1 distribution. Remember there is very little neurological weakness or deficits found with facet pain and usually the reflexes are found to be intact.
You can do a positive Hoffman sign and a positive Patrick sign, to help to rule in and rule out whether you have adjacent sacroiliac pain and now we almost completed 40 seconds ablation so we go ahead position next needle at site of where that juncture of the L4 vertebral body is located. So under again fluoroscopic guidance we can see a needle is set down towards SAP and starts to wrap around hug the SAP and not move beyond the border. We’ll go head and inject contrast and 2% lidocaine.
I like to use a curve needle because it allows for easier steer ability, so as we know this solution has infiltrated the area, we’ll go head and start the heat ablation and complete procedure in the next two levels. So once again use the SAP as a target, make sure you don’t go beyond the end plate that assures you that you are not inside that neuroframent. We’ll catch up next time for the other procedure we’ll see you all later.