Bilateral Sciatica Surgery

Radio Frequency Ablation Demonstration

Our next procedure is something called theright side radiofrequency ablation. We're gonna be doing RF procedure in L 3, 4, 5 onthe right side. We've gone and done conformation diagnostic block approximately two week ago. We perform medial branch block using a localanaesthetic of short duration, and we are back to repeat the procedure with long anestheticwith longer duration such as neuropin. With that conformation of the patients abilityto function, to be able to bend, twist, flex and squat was asked the day following procedurewith conformation that she approved having had the anesthetic done 24 hours prior.

At this point time we're going to pointa camera towards the fluoroscope and go head and start to show you how we position, alignour spine under fluoroscopy and then go head an do the needle positioning along with theconfirmation of the solution with contrast and local anesthetic, to show how the enhancementof the local anesthetic numbs and anesthetizes the medial branch nerve. For this portion of procedure we wanna gohead and mark the inferior sacral alar, and we do that first by using a fluoroscopic guidanceneedle 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 headin using neurotom 15 millimetres exposed, 150 millimeter needle and angle of positiondown to that sacral alar junction. Once we sacral alar junction we'll go head anesthetizewith 2% zylocaine, and little tiny bit of contrast enhancing specifically where needleplacement is. Now we're go head inject this area with2% zylocaine and contrast enhancing the area where the target is. We'll go head placein the neurotherm ablation styled and go head and proceed with one minute at 80 degreesCelsius of targeted tissue ablation. In the meantime we go head and oblique fluoroscopetowards the right and we'll go head and

mark the skin and target at L4 and L3 mediumbranch nerve. Recalling that the L4 medium branch nerveis sitting on the L5 vertebral body and the L3 branch nerve is sitting on the L4 vertebralbody. After anesthetizing skin and subcutaneous tissue of these next two sites we'll gohead and position the needle adjacent to the superior articulated process and we do thatin the very interesting technique in the oblique fashion. We go ahead and started the IAP orintra articulated process and then angle the needles tip and edge up to the lamener borderof the end plate. By the doing so we have confirmation thatthe needle was not going to enter the neuroframen,

and we know that because of the tried theproven method by angulating the SAP curvature to the to the end plate once the target hasbeen 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 needleon the L4 vertebral body, which is consistent with the L3 medium branch nerve. Please recallthat the nomenclature changes one level per segment and you have to remember this in thedictation or you will have a large mistake and misbelief of where your target is. So we'll do a second ablation now, we'llturn the needle slightly down in order to

position it slightly more into the alar grooveand go head ablate it for additional 40 seconds. If we continue to do this in al conditionsat this patient suffers with is very common and typical lumbar spondylosis, physical examhelps to confirm that by doing extension, rotation and palpating the area over facetloading. Recall the facet loading can also give youa 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 orS1 distribution. Remember there is very little neurological weakness or deficits found withfacet pain and usually the reflexes are found

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