The local orthos refer a fair number of patients with pain after joint replacement, or with end stage joints and too many other end stage issues to operate. Since I started doing these I find that they send me more patients prior to joint replacement, asking me to take care or their back or SIs so that they can tolerate the PT after surgery. When I get a referral for back pain I always ask about other areas of pain and often find that they have had joints replaced that still hurt, so pick up more business there. After a short while you learn which surgeons will leave their patients in pain after surgery and so I screen those a little more diligently.
I haven't gotten to the point that I offer this to patients who don't want surgery, as most of them don't. The orthos would be mad, and if the patient were to develop a charcot joint they would burn me at the stake. That said I have an OR tech who is 2 years from retirement and feels that she can't afford TKA now but plans on it as soon as she retires. She is doing well so far with an Orthocor PEMF unit, but if that doesn't cover her then I would be tempted to RFA. I haven't been doing it long enough to know how long it lasts, but I've done US guided phenol injections at the joint line with over 1 year of relief so far. I occasionally see younger patients after multiple knee surgeries with chronic pain for whom the orthos refuse TKA. I don't see the point of leaving them to suffer and so would be tempted. It would be nice to see long term results of denervation and if there is significant damage to the adjacent bone so that joint replacement becomes impossible.
I asked ISIS to include a dissection of the innervation of the knee, hip and thumb in their next anatomy course. It's not spine, but it is pain. If the nerve lies right on the surface of the bone then a 20 ga should be adequate. I use an 18 ga for the sake of overkill, with fluoro guidance because it's quick and easy. If you believe in Wallerian degeneration then killing a small segment of the nerve should lead to degeneration of the nerve distal to that. The ISIS teaching seems to imply that you have to kill as great a length of the nerve as possible in order to get longer lasting relief.
27035 (for denervating the hip) pays a heck of a lot better than 64640. Anyone know of a code for denervating the knee?