Moossy Cervical 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. 

Moossy uses C arm for cervical rhizotomies and a flat plate for thoracolumbar ones. 

Patient is positioned in lateral decubitus with the side of the operation facing upwards. Same as for a stage 1 pump, the patient is positioned such that their back is flush with the edge of the table. An axillary roll is placed. The rhizotomy pad is placed on the superior thigh. A purple foam is placed between the lower knee and bed. A pillow is placed between the knees. A folded pillow is placed between the arms. An arm board is used to support the lower arm if needed. Some patients are small enough that their lower arm is entirely on the bed. The head is on a horseshoe. Mayfield is not positioned midline; it is biased towards one side of the bed or the other, depending on the laterality. If the patient is right side up with their back flush with the right side of the bed, then the Mayfield is biased to the right. The patient lies with the side of their head in the horseshoe with the ear in the horseshoe gap. Tape the patient to the bed at the hips and rib cage, use blue towel under the tape and use two full rolls of tape per general Moossy protocol. 

Prep in the usual Moossy way with iodine, Chloraprep, iodine, then Chloraprep, making sure that each successive field is smaller than the last. 

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

For the occipital nerve block, your landmarks are the inion and the mastoid tip. Find the midpoint of that line then place your needle down to the bone. Remove the stylet and place the radiofrequency ablation probe. Ablate at that point. To get the lesser occipital nerve, follow the inion-mastoid tip line laterally, towards the mastoid, and ablate again. Withdraw the RF probe, before withdrawing the needle, inject 5 ccs of Marcaine. 

For the facet dorsal rhizotomies, bring in the C-arm. He takes lateral shots only, no AP shots. Place the needle tip at the dorsal aspect of the appropriate facet joint. Remove stylet, place RF ablation probe, and ablate. Remove RF probe, inject 5 ccs of Marcaine, remove needle. 

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

Dr. Moossy sees these patients again in 1 month, no imaging, no pain meds on discharge.