Cervical pulsed RF with RFA for TON

[epidural man]

I almost always do pRF for cervical facet disease. I am looking to move to cooled RF.

My approach is lateral.

However, recently, I have been using pulsed for C3 and below, and placing two needles above and below TON and using a skip lesion (high temp).

Anybody else doing this?

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[ampaphb]

what do you bill for when you do pRF?

 

[DOctorJay]

In fellowship we would pulse the TON and burn below. TON wasn't billed for pRF to my knowledge. Patient's did well with this approach.

 

[lonelobo]

Think the question is what CPT are you using for pRF?

 

[bedrock]

I almost always do pRF for cervical facet disease. I am looking to move to cooled RF.

My approach is lateral.

However, recently, I have been using pulsed for C3 and below, and placing two needles above and below TON and using a skip lesion (high temp).

Anybody else doing this?

skip lesion? Do you mean bipolar?

 

[clubdeac]

skip lesion? Do you mean bipolar?

Not to hijack but speaking of bipolar, does anyone do this and does it work?

 

[dc2md]

Not to hijack but speaking of bipolar, does anyone do this and does it work?

For the original poster, why use pRF for TON and not just thermal that one as well?

For clubdeac, I use bipolar thermal RF for S1, S2, S3 lateral branches for sacroiliac denervation (well, partial denervation). Works well. Take two used cannula from a case and test bipolar lesioning on a piece of thawed chicken breast; pretty cool visualization of the lesioning spread between the needles.

 

[epidural man]

For the original poster, why use pRF for TON and not just thermal that one as well?

For clubdeac, I use bipolar thermal RF for S1, S2, S3 lateral branches for sacroiliac denervation (well, partial denervation). Works well. Take two used cannula from a case and test bipolar lesioning on a piece of thawed chicken breast; pretty cool visualization of the lesioning spread between the needles.

That is what I was talking about - thermal (with a skip or bipolar lesion across the TON), then pRF for the rest.

The advantage is ease of needle placement.

 

[epidural man]

what do you bill for when you do pRF?

Billing? What's that?

I work in a system where I don't have to worry much about that....it's all funny money. If I were billing, I would put 4% lidocaine and bill for neurolysis.

 

[SSdoc33]

Billing? What's that?

I work in a system where I don't have to worry much about that....it's all funny money. If I were billing, I would put 4% lidocaine and bill for neurolysis.

SOMEBODY is paying pay for it.....

 

[ampaphb]

I do heat on the MBBs, and pulse the TON. Concerned about deafferentation.

I asked about billing because the CPT description is destruction by neurolytic agent, and as we all know, pRF is thought not to be destructive

 

[Ligament]

I don't want to sound accusatory, but why pulse the TON when thermal RFA is proven to work so well? I've been melting the hell out of TONs since 2007 at 80-90C with 18ga Cannulae and overlapping isotherms, have done hundreds of them at least, and have consistently impressive results. I've never had a permanent case of neuritis nor balance problems even in bilateral TON RFA. True, the post op neuritis is common, happens in 60-70% of patients, but it goes away in 95% of these folks by 3-5 weeks. It is my favorite procedure to do in terms of effort/benefit ratio.

 

[clubdeac]

Just did a guy 3 weeks ago. He was having terrible cervicogenic HAs and was s/p some sort stupid posterior wire fusion at C3/4. I thought his C2/3 joints were probably getting worked so I did a couple blocks which he responded positively to for 8-12 hrs each. Burned him at he is 80% pain free. Very rewarding procedure

 

[ampaphb]

I don't want to sound accusatory, but why pulse the TON when thermal RFA is proven to work so well?

Because, in my experience, pulsing it works equally well, without the neuritis, nor the risk of deafferentation.

 

[Ligament]

Because, in my experience, pulsing it works equally well, without the neuritis, nor the risk of deafferentation.

Sounds like a good reason. But, how do you get it paid? Pulsed RF is 64999...

 

[DOctorJay]

you don't charge for the pulsed, you just charge for RF for the levels below that you burn - at least I'm pretty sure that's how it was addressed at my fellowship

 

[Ligament]

you don't charge for the pulsed, you just charge for RF for the levels below that you burn - at least I'm pretty sure that's how it was addressed at my fellowship

Hmm, so you are doing it for free.

 

[clubdeac]

I would charge the patient for the needles at least... just sayin

 

[bedrock]

Hmm, so you are doing it for free.

crazy to do it for free. Or just for needles. By the way, can you actually charge patients for needles or supplies that insurance doesn't cover?

I'm sure patients won't like that, however as my payments get cut every year, taking the time to do proper RF makes less financial sense.

I have a good friend, pain-fellowship trained, who does everything but RF, which he send out to colleagues, as he's calculated that he loses money on RF compared to ESI, US guide procedures, etc.

 

[bedrock]

I do heat on the MBBs, and pulse the TON. Concerned about deafferentation.

Agree with lig that permanent deafferentation after TON RF is quite rare.

I would definitely heat lesion TON and get paid for it. I use a technique I learned from Dreyfuss- I cook at 70 degrees for TON only, with a slower ramp-up speed and burn for 60 seconds only. With that technique I get radiofrequency neuritis about 5% of the time after TON RF, not 50% like I used to, and it's milder when it occurs.

Main ideas is not to burn the hell out of TON, like we do with the other MB. I must admit, it works quite well. I still do 3-4 lesions across TON, but kinder ones. Degree of relief hasn't changed, but much less neuritis to deal with.

 

[DOctorJay]

Hmm, so you are doing it for free.

Haven't done any yet as an attending, this is how I believe it was billed in fellowship. I'll probably burn it when I do it though. My partners burn the TON.