Genicular RFA. Any input helpful!

[runfastnow]

That’s for sharing.

What’s the rationale for not being overly aggressive about offering it? I imagine it’s because it’s not as slam dunk as other things we do.

Clinical judgement. I get a fair number of referrals for people who are still in the fringes of post-op pain or have been non-compliant with PT, etc. so I just don't start doing it for people because they are likely poor candidates. If they finish PT, compliant with conservative therapy, and continue to have pain then we will change plan to GNB RF. If the referral is for painful hardware or CRPS then wait at least 3 months post-op, failed Lyrica, etc.

Do one GNB then RF. Bill 64624.

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[cowboydoc]

Have full PDF that I can DM to whoever if willing to share e-mail. Saved locally on computer and SDN won't share it. Pic is the crux of the paper and the targets I use.

I only go for: C, D1, D2, H, and I. Tried B2 and F but ultimately very painful for patient and seemed to not change outcomes. Not messing with anything near the peroneal. Do motor stim prior to lesion (don't really have a good reason other than wanting something documented to CYA) then burn 90 sec 80*C at each location (with location H getting burn x 2) with 20 gauge 10 mm.

Happy with results since finding this technique. Judge success based on whether patient is satisfied. If need to repeat typically 10-12 month window. Have ortho colleague with high volume TKA and revision referrals that we've had good results for chronic knee pain, painful hardware, etc.. Only offer if failed legit PT, can't get off post-op opiates + Lyrica, and do not/want surgery. Try not to be overly aggressive about offering.

That's a nice model to simplify the procedure. The problem with it becomes clear when you do these nerve blocks with U/S and see the location of these nerves is quite variable.

I'm not being critical of you, as you are clearly being diligent. I appreciate the work being done to improve localization and presumably outcomes with Genicular RF, but essentially suggesting 9 shoot from the hip locations is grossly impractical. McCormick rolled his eyes at me when I said these nerves are typically visible with U/S. (I'm an average at best ultrasonographer). The ISN/inferior medial genicular can be hard to see but the region of interest is easy to ID. The superior nerves aren't that hard to ID most of the time, and their # and location is quite variable.

 

[TIVAndy]

That's a nice model to simplify the procedure. The problem with it becomes clear when you do these nerve blocks with U/S and see the location of these nerves is quite variable.

I'm not being critical of you, as you are clearly being diligent. I appreciate the work being done to improve localization and presumably outcomes with Genicular RF, but essentially suggesting 9 shoot from the hip locations is grossly impractical. McCormick rolled his eyes at me when I said these nerves are typically visible with U/S. (I'm an average at best ultrasonographer). The ISN/inferior medial genicular can be hard to see but the region of interest is easy to ID. The superior nerves aren't that hard to ID most of the time, and their # and location is quite variable.

View attachment 360744

were you the one commenting to him at SIS maui

 

[cowboydoc]

were you the one commenting to him at SIS maui

Yes, that’s when we were talking about it.

 

[Ronin1]

I’ve switched over to iovera in my practice for these patients. Good results. I usually do the geniculates with fluro guidance. And switch to us for the anterior femoral and supratellar branch of saphenous. Takes 15 -20 minutes though

 

[cowboydoc]

I’ve switched over to iovera in my practice for these patients. Good results. I usually do the geniculates with fluro guidance. And switch to us for the anterior femoral and supratellar branch of saphenous. Takes 15 -20 minutes though

So you are using fluoro with iovera? How do you get that brick to stay put without your hand in the beam??

I do Iovera on everyone now before considering genicular RF. In clinic u/s is way cheaper and faster. Results about the same.

 

[Ronin1]

I have a good tech and use spot images plus bend the probe a little. It works. I have in office procedure room with my own tech so it’s pretty fast

 

[TIVAndy]

Yes, that’s when we were talking about it.

i actually do all genicular blocks under ultrasound - sometimes i see the nerve, but sometimes not. still target similar area and much easier with US. RFA i still do fluoro.

 

[TIVAndy]

I have a good tech and use spot images plus bend the probe a little. It works. I have in office procedure room with my own tech so it’s pretty fast

is iovera reimbursed? i have so many surgeons that want to send to us but i told them financially it's not feasible

 

[Ronin1]

The facility fee is pretty good in HOPD. Professional fee is weak. If you are in an office setting it would be tough to make it pencil out without a hefty discount on the disposables. That said we have an ortho in town that does do it in the office but his pa does it and they use the anatomical technique. I think they make about 100/ case after the disposable cost

 

[TIVAndy]

The facility fee is pretty good in HOPD. Professional fee is weak. If you are in an office setting it would be tough to make it pencil out without a hefty discount on the disposables. That said we have an ortho in town that does do it in the office but his pa does it and they use the anatomical technique. I think they make about 100/ case after the disposable cost

Exactly. Lvl 3 visit takes shorter time.

 

[bedrock]

Exactly. Lvl 3 visit takes shorter time.

Yep. genicular RFA only pays decently if HOPD employee. Otherwise in any other payment setup you make more with clinic visits than with genicular RFA

 

[Ronin1]

It’s about 5.5 wrvus if I remember. Plus a preop consult. So about 7 units in all. Small potatoes individually but adds up to 700plus units annually.

I think the hospital gets about 1800 on the facility side minus about 600 in disposables. So that’s another 100k I make for them lol

 

[DrMDAware]

I’ve been using those newest anatomical landmarks. Two burns. Pulling back the most for inferomedial one.

In addition, I’ve been doing moderate sedation for these cases. I’ll give 1mg versed and maybe 25 of fentanyl if they are not too frail. Then I do sensory testing.

My hopes are with the new anatomical landmarks, two burns, and sensory testing that I will hopefully increase my chances of success.

 

[MitchLevi]

I’ve been using those newest anatomical landmarks. Two burns. Pulling back the most for inferomedial one.

In addition, I’ve been doing moderate sedation for these cases. I’ll give 1mg versed and maybe 25 of fentanyl if they are not too frail. Then I do sensory testing.

My hopes are with the new anatomical landmarks, two burns, and sensory testing that I will hopefully increase my chances of success.

Zero need for IV sedation when performing a genicular.

 

[TIVAndy]

Zero need for IV sedation when performing a genicular.

Periosteum can be pretty painful

 

[RoloTomassi]

1mg versed and maybe 25 of fentanyl

At such a low dose, why not just do PO? If I'm going through the hassle of putting in an IV, it's because I need heavier doses, ability to titrate

 

[MitchLevi]

Periosteum can be pretty painful

You understand that statement is at a minimum sort of ridiculous right?

Is there something special about the periosteum at the genicular nerve sites that are somehow different than the periosteum during a cervical or lumbar RFA? What about my suprascapular nerve target considering I touch bone all the time during that.

ILESI and I touch the lamina with no issues...

Greater trochanter and subacromials...

Geniculars are easily tolerated with Valium 2 x 2mg 30 min prior and use lido buffered with sodium bicarb for the skin.

Your pts will enjoy getting to know you during the procedure when they do it this way.

 

[painfree23]

You understand that statement is at a minimum sort of ridiculous right?

Is there something special about the periosteum at the genicular nerve sites that are somehow different than the periosteum during a cervical or lumbar RFA? What about my suprascapular nerve target considering I touch bone all the time during that.

ILESI and I touch the lamina with no issues...

Greater trochanter and subacromials...

Geniculars are easily tolerated with Valium 2 x 2mg 30 min prior and use lido buffered with sodium bicarb for the skin.

Your pts will enjoy getting to know you during the procedure when they do it this way.

What gauge needle r u using for ur genicular rfs?

 

[bedrock]

I definitely have some patients who need IV sedation for genicular RFA. Generally the younger ones.

 

[MitchLevi]

What gauge needle r u using for ur genicular rfs?

18-20

 

[Espn123]

Used to do motor, now I just lesion.

Same

 

[painfree23]

18-20

Wow. Do u go parallel to nerve or perpendicular?

 

[PinchandBurn]

I agree with people tht say mod sedation is needed. I never sedate for the blocks. Never sedate for esi etc. I can get away many times with no sedation for lumbar rfa. I anesthetize the skin and subcutaneous tissues fairly well. Nonetheless thr genicular rfa is painful in my expeience...plus if you're in private practice you can't be hurting patients like someone at a hospital or academic center. I have worked in both and the expectation is different in private

 

[lobelsteve]

I agree with people tht say mod sedation is needed. I never sedate for the blocks. Never sedate for esi etc. I can get away many times with no sedation for lumbar rfa. I anesthetize the skin and subcutaneous tissues fairly well. Nonetheless thr genicular rfa is painful in my expeience...plus if you're in private practice you can't be hurting patients like someone at a hospital or academic center. I have worked in both and the expectation is different in private

I think you’re using excuses for your lack of skills.

 

[MitchLevi]

Wow. Do u go parallel to nerve or perpendicular?

Parallel, bc perpendicular makes no sense when the lesion is created along the length of the active tip. I use 18-20g with 10mm active tip (99% of all my RFA).

I don't do cold, but if I did I may go perpendicular.

Also..."Wow?" Why? This isn't impressive or special in any way.

I can get away many times with no sedation for lumbar rfa. I anesthetize the skin and subcutaneous tissues fairly well. Nonetheless thr genicular rfa is painful in my expeience...plus if you're in private practice you can't be hurting patients like someone at a hospital or academic center. I have worked in both and the expectation is different in private

Lucky for me, I always get away with no sedation. I did 251 fluoro shots last month (my most ever) and IV sedation wasn't used once. I'm in private practice, and when I ablate your bilateral L4-S1 facets and your door-to-door time is 35 min, you'll go tell your neighbor about me.

No fasting past midnight. No IV stick. Just getting on the table and listening to me and my staff discuss Netflix shows, UGA football, concerts we liked, my fave Dungeons and Dragons character, why Sugar Ray Robinson is the greatest boxer of all time...You'll get to know me while I do your procedure, bc unfortunately in the clinic we can't waste too much time on small talk. There's psych importance in this.

Valium 2mg x 2 tabs 30 min prior to the procedure, Amazon music playing in the background and WE ARE MERE WEEKS FROM MY CHRISTMAS PLAYLIST!!!

 

[DrMDAware]

It’s about 5.5 wrvus if I remember. Plus a preop consult. So about 7 units in all. Small potatoes individually but adds up to 700plus units annually.

I think the hospital gets about 1800 on the facility side minus about 600 in disposables. So that’s another 100k I make for them lol

What’s the regular genicular RFA wRVU?

At such a low dose, why not just do PO? If I'm going through the hassle of putting in an IV, it's because I need heavier doses, ability to titrate

Fair point. As an anesthesiologist I still prefer to titrate. I’ve been surprised how far 1mg goes in some people. Others I’ll go up to 3 and 50 sometimes.

 

[DrMDAware]

I view PO Valium in the same way as IV versed so where is the difference?

 

[MitchLevi]

I view PO Valium in the same way as IV versed so where is the difference?

IV stick with fasting (turning a mimimally-invasive procedure into something much bigger), cost, bulky process with a need for monitoring, added risk especially in medically-fragile pts, future expectations, amnesia, greater recovery time, entirely unnecessary...

I've done procedures both ways - There is clearly superiority doing it my way, at least in my pt population and in my experience. Maybe your pt population is somehow different than mine.

The majority of my pts who had procedures with IV sedation before coming to me prefer my way...

I wonder how many failed RFA have been done after successful MBB in pts who were given Versed and fentanyl during their MBB? IV benzos + fentanyl for an ablation...

Why is the genicular special to some of you? It is no more painful than anything else.

 

[Orin]

Why is the genicular special to some of you? It is no more painful than anything else.

Maybe it's my patient population, but it appears to be one of the most painful things I do. It's worse for them with the conventional approach that runs parallel to the periosteum for a long period of the trajectory and especially bad if I'm trying to avoid local deep for robust sensorimotor testing. If I come in laterally with a cooled probe, much less pain.

 

[PinchandBurn]

Parallel, bc perpendicular makes no sense when the lesion is created along the length of the active tip. I use 18-20g with 10mm active tip (99% of all my RFA).

I don't do cold, but if I did I may go perpendicular.

Also..."Wow?" Why? This isn't impressive or special in any way.


Lucky for me, I always get away with no sedation. I did 251 fluoro shots last month (my most ever) and IV sedation wasn't used once. I'm in private practice, and when I ablate your bilateral L4-S1 facets and your door-to-door time is 35 min, you'll go tell your neighbor about me.

No fasting past midnight. No IV stick. Just getting on the table and listening to me and my staff discuss Netflix shows, UGA football, concerts we liked, my fave Dungeons and Dragons character, why Sugar Ray Robinson is the greatest boxer of all time...You'll get to know me while I do your procedure, bc unfortunately in the clinic we can't waste too much time on small talk. There's psych importance in this.

Valium 2mg x 2 tabs 30 min prior to the procedure, Amazon music playing in the background and WE ARE MERE WEEKS FROM MY CHRISTMAS PLAYLIST!!!

I hear ya..

I do the exact same thing... can't explain why genicular hurts still
.

 

[TIVAndy]

IV stick with fasting (turning a mimimally-invasive procedure into something much bigger), cost, bulky process with a need for monitoring, added risk especially in medically-fragile pts, future expectations, amnesia, greater recovery time, entirely unnecessary...

I've done procedures both ways - There is clearly superiority doing it my way, at least in my pt population and in my experience. Maybe your pt population is somehow different than mine.

The majority of my pts who had procedures with IV sedation before coming to me prefer my way...

I wonder how many failed RFA have been done after successful MBB in pts who were given Versed and fentanyl during their MBB? IV benzos + fentanyl for an ablation...

Why is the genicular special to some of you? It is no more painful than anything else.

as you have mentioned, patient population maybe different, technique maybe different etc. I think you should be respectful why other clinicians have chosen (For a good medical reason) why an IV sedation is given. In my neck of woods a lot of post TKA patients have borderline CRPS type of presentation, swollen knee, allodynia, and hyperalgesia. perhaps you do it for virgin knees - advanced OA. a lot of my patients scream when I examine the knee in clinic - esp when I press on the IPS area.
I use 16 gauge and I do bipolar - and also burn twice on each target after pulling. that's total of 6 - 16 gauge needle and 3 separate RFA burns (total 4minutes 30seconds)
can I do it under local with no sedation ?- yes i can but i prefer not to based on my circumstance.

 

[MitchLevi]

as you have mentioned, patient population maybe different, technique maybe different etc. I think you should be respectful why other clinicians have chosen (For a good medical reason) why an IV sedation is given. In my neck of woods a lot of post TKA patients have borderline CRPS type of presentation, swollen knee, allodynia, and hyperalgesia. perhaps you do it for virgin knees - advanced OA. a lot of my patients scream when I examine the knee in clinic - esp when I press on the IPS area.
I use 16 gauge and I do bipolar - and also burn twice on each target after pulling. that's total of 6 - 16 gauge needle and 3 separate RFA burns (total 4minutes 30seconds)
can I do it under local with no sedation ?- yes i can but i prefer not to based on my circumstance.

I work in a large ortho group and routinely see post TKA knees. Been here since 2017 and I've yet to see one of these "causalgia" knees I've heard so much about. There are 6 guys in my group doing total knees, and I'm the only guy in the group who does geniculars.

I went to the DRG course. I heard a lot of talk about these swollen, neuropathic knees. I haven't seen that even one time.

Who's being disrespectful? I'm just stating my opinion man...

Edit - No wonder your pts hurt - 16g needles x 6!?!? You're spending a lot of money on that procedure without making much in return.

 

[DrMDAware]

IV stick with fasting (turning a mimimally-invasive procedure into something much bigger), cost, bulky process with a need for monitoring, added risk especially in medically-fragile pts, future expectations, amnesia, greater recovery time, entirely unnecessary...

I've done procedures both ways - There is clearly superiority doing it my way, at least in my pt population and in my experience. Maybe your pt population is somehow different than mine.

The majority of my pts who had procedures with IV sedation before coming to me prefer my way...

I wonder how many failed RFA have been done after successful MBB in pts who were given Versed and fentanyl during their MBB? IV benzos + fentanyl for an ablation...

Why is the genicular special to some of you? It is no more painful than anything else.

1. Even with local patients in my ASC get monitored. If one tiny IV causes the healthcare system to collapse that’s a shame.
2. My patients are extremely affluent. Will not tolerate any procedural pain.
3. I don’t do moderate sedation for diagnostic mbbs
4. It is a very painful area for my posts who are sp TKA TKR etc.
5. Fair point about fent clouding the diagnostic abilities

 

[Ducttape]

I work in a large ortho group and routinely see post TKA knees. Been here since 2017 and I've yet to see one of these "causalgia" knees I've heard so much about. There are 6 guys in my group doing total knees, and I'm the only guy in the group who does geniculars.

I went to the DRG course. I heard a lot of talk about these swollen, neuropathic knees. I haven't seen that even one time.

Who's being disrespectful? I'm just stating my opinion man...

Edit - No wonder your pts hurt - 16g needles x 6!?!? You're spending a lot of money on that procedure without making much in return.

ive seen a "causalgia" knee, on an urgent referral by the surgical team.

red, swollen, hot. decreased range of motion. allodynia.

i suggested she go back to the surgeon to get the sutures taken out and get some antibiotics for the cellulitis.

 

[pastafan]

No sensory testing, plenty of local as you advance. Don’t jam needle into periosteum, just slide next to bone. No need for sedation. Patients comfortable.

 

[Agast]

So you are using fluoro with iovera? How do you get that brick to stay put without your hand in the beam??

I do Iovera on everyone now before considering genicular RF. In clinic u/s is way cheaper and faster. Results about the same.

How are you making iovera viable in a clinic setting? I was quoted $5000 for the unit and it’s $370 per patient for disposable equipment. I’m tempted to tell my ortho partners if they really want this done they need to purchase everything themselves.

Do patients need to do diagnostic genicular blocks first?

Private insurance and Medicare advantage plans seem pretty anti-genicular nerves.

 

[cowboydoc]

How are you making iovera viable in a clinic setting? I was quoted $5000 for the unit and it’s $370 per patient for disposable equipment. I’m tempted to tell my ortho partners if they really want this done they need to purchase everything themselves.

Do patients need to do diagnostic genicular blocks first?

Private insurance and Medicare advantage plans seem pretty anti-genicular nerves.

No dx blocks. Coverage is dropping precipitously. It doesn’t pencil, which is too bad because it’s a good tool to have.

 

[Agast]

No dx blocks. Coverage is dropping precipitously. It doesn’t pencil, which is too bad because it’s a good tool to have.

Yeah, I was a little suspicious when I asked the rep who in town was using it and she could only think of two orthopedic groups. But how do they get around the requirement for diagnostic blocks? Does that mean I can do genicular nerve RFA on my patients without blocking them first?

 

[RoloTomassi]

Bringing back this thread re: modified vs traditional targets. No clear consensus so I did both, would burn both x1 lesion 18g Venom.

Question--pt super thin, BMI 16. Any risk of superficial burn? Needles were barely in there, just past 1 cm on some.

Also, I asked this on a separate thread. Just want to make sure there's no significant risk in young 40 yo pt who wants to be active.

What happens to genicular blood vessels when you ablate? Collateral damage or are they a heat sink, spared?

 

[deleted131481]

Bringing back this thread re: modified vs traditional targets. No clear consensus so I did both, would burn both x1 lesion 18g Venom.

Question--pt super thin, BMI 16. Any risk of superficial burn? Needles were barely in there, just past 1 cm on some.

Also, I asked this on a separate thread. Just want to make sure there's no significant risk in young 40 yo pt who wants to be active.

I have heard of superficial skin burn resulting in necrosis. 1cm awfully shallow, you mean from AP or lateral direction?

I was told by an Ortho knee surgeon that ablation resulting in destruction of genic arteries can lead to accelerated arthritis of the joint. He was also a paid speaker for Overall, not aware of any literature that shows such.

 

[lobelsteve]

Bringing back this thread re: modified vs traditional targets. No clear consensus so I did both, would burn both x1 lesion 18g Venom.

Question--pt super thin, BMI 16. Any risk of superficial burn? Needles were barely in there, just past 1 cm on some.

Also, I asked this on a separate thread. Just want to make sure there's no significant risk in young 40 yo pt who wants to be active.

Yes, skin can be burned if not deep enough or unable to get deep enough. Can change to 5mm tips.
In pics above, there is no arthritis, what are you treating?

 

[RoloTomassi]

I have heard of superficial skin burn resulting in necrosis. 1cm awfully shallow, you mean from AP or lateral direction?

I was told by an Ortho knee surgeon that ablation resulting in destruction of genic arteries can lead to accelerated arthritis of the joint. He was also a paid speaker for Overall, not aware of any literature that shows such.

Thanks. AP approach, very little purchase, needles were flopping around. Worried a heavier RFA needle might dislodge even, with the weight of the cord. I think I'll enter further away to get more needle in tissue.

Can change to 5mm tips.

Yes might do this. Also think I'll go 20 ga. Is ice pack on the skin possible? I feel like I've heard that here

In pics above, there is no arthritis, what are you treating?

Severe pain after tibial tubercle osteotomy, can see screw in AP. No CRPS criteria.

 

[nvrsumr]

On thin lols I inject more local. Needle is on os and a couple centimeters of fluid between bone and skin. Seems helpful

My needle tips are a bit deeper on lateral

 

[MitchLevi]

You're spending the money on 5 RF needles on a procedure that reimburses modestly? I use 3 and do 90 sec burn. Move the needles and burn again for 90 sec.

 

[RoloTomassi]

On thin lols I inject more local. Needle is on os and a couple centimeters of fluid between bone and skin. Seems helpful

My needle tips are a bit deeper on lateral

Thanks I'll do that

 

[RoloTomassi]

You're spending the money on 5 RF needles on a procedure that reimburses modestly? I use 3 and do 90 sec burn. Move the needles and burn again for 90 sec.

I plan on using 3, just did the blocks that way for speed and rad exposure

 

[painfree23]

How many diagnostic blocks y’all doing?

 

[bedrock]

How many diagnostic blocks y’all doing?

1

 

[drrosenrosen]

You're spending the money on 5 RF needles on a procedure that reimburses modestly? I use 3 and do 90 sec burn. Move the needles and burn again for 90 sec.

I just use 2 needles these days, 3 bipolar lesions. Takes a little longer, but I like the idea of burning a larger area since the nerve location is less predictable