Medications

Preparation

For rhizotomy, before starting, know what temperature and time the patient was previously ablated at if they have had a prior ablation. Moossy will expect you to know this information. 

No C arm. 

Positioning

For bilateral cases, positioning is prone. Do a full scrub with gown and gloves. 

For unilateral cases, positioning is full lateral with axillary roll and blue towel/tape over the iliac crest only, none over the chest. Head is on a foam head holder. You only need gloves, no need for a gown. 

Draping

Drape with four blue towels, one universal drape going down only. No ioban. Give some local. 

Procedure

Landmarks are the inion and the mastoid tip. Find the midpoint of that line then place your needle down to the bone. For the greater occipital nerve, aim the needle towards the feet and slightly towards midline. For the lesser occipital nerve, use the same entry point but point the needle towards the mastoid and less towards the feet. 

For rhizotomy, move the needle to the location of the greater occipital nerve, go down to bone, and ablate at 90 degrees for 90 seconds. Then move to the lesser occipital nerve location, go down to bone, and ablate at 90 and 90. After completion of rhizotomy, withdraw the electrode but leave the needle in place and give 10 ccs of 10:1 Marcaine:Depo-Medrol. 

If you are doing block only, skip the rhizotomy part in the paragraph above and just go directly to giving 10 ccs of 10:1 Marcaine:Depo-Medrol.

Once done place Band-Aids where they will stick, clean the patient, and take to PACU. 

Follow up

1 month with Moossy, no imaging, no pain meds on discharge.