Intercostal Nerve RF

[Disciple]

I've been getting quite a few Post-Thoracotomy/Post-Herpetic Neuralgia patients lately.

What are the opinions on efficacy, pulsed vs. thermal for this specific procedure?

Anybody made the pain worse using thermal?


Thanks in advance.

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[lobelsteve]

Block, pulsed, thermal.

N=15

3 failures. 1 went to scs. Still good at 7 years.

 

[clubdeac]

Cohen did a study showing that PRFA of the thoracic DRGs did better than ICN RFA with less risk for post-thoracotomy pain. I don't think either procedure is that great for PHN. I have had decent results with ICN RFA. Dropped one lung in a severe COPDer with adhesions from scar. When I was young and dumb I did ICN alcohol neurolysis 6 yrs ago. Just saw the lady in clinic last month and her left side is still numb! Would not recommend this though

 

[Disciple]

Thanks for the tips. I looked up the study, pulsed intercostal RF equivalent to med management.

Couldn't find any studies on thermal intercostal RF except for a case series, 6 patients, also in Pain Physician.

 

[cbest]

Did a case with my attending a few weeks ago for intercostal neuralgia. Conventional RF of T9 and 10 thoracic DRG. Patient reports about 50% improvement. Cool case!

 

[gasorrad]

Does anybody do cryo? Clubdeac why r u not a fan of neurolysis with alcohol. That lady who is numb...is the pain still gone?

Have a pt with chronic RUQ pain s/p cholecystectomy 18 yrs ago n chronic severe pain. Did a tap and had complete pain relief first time in 18 yrs but pain is back. TAP neurolysis or intercostal neurolysis?

 

[clubdeac]

Does anybody do cryo? Clubdeac why r u not a fan of neurolysis with alcohol. That lady who is numb...is the pain still gone?

Have a pt with chronic RUQ pain s/p cholecystectomy 18 yrs ago n chronic severe pain. Did a tap and had complete pain relief first time in 18 yrs but pain is back. TAP neurolysis or intercostal neurolysis?

B/c I heard of a case where a woman was paralyzed after the neurolytic traveled from the intercostal space to her spine. I would say the risks outweigh the benefits except in cancer pain. You will get fried in court. Her pain is still gone but now I would do conventional RF instead. And my bad about the pulsed study. I thought it compared it to standard ICN RF. You're right; looks like he compared it to pulsed

 

[Ducttape]

im not sure how you would do a TAP neurolysis. its an area/plane that you are targetting, with large volume local anesthetic. you cant truly RF that entire plane. and dont even think of alcohol neurolytic to that whole area, or you will be looking at fistulas, necrotic muscle, skin, etc......

 

[Disciple]

Did a case with my attending a few weeks ago for intercostal neuralgia. Conventional RF of T9 and 10 thoracic DRG. Patient reports about 50% improvement. Cool case!

Did you have any worries about thermal to the DRG?

 

[cbest]

Did you have any worries about thermal to the DRG?

Part of the testing was heating up the probe to a temperature where the patient noted discomfort then backed off a couple degrees and used conventional RF at that temperature for 60 seconds. What I've read about this is that it may actually cause some lesioning though only to an extent that remains subclinical. Talked to my attending about it that has been doing it for years and he's never had any long term bad complications.

 

[lobelsteve]

Part of the testing was heating up the probe to a temperature where the patient noted discomfort then backed off a couple degrees and used conventional RF at that temperature for 60 seconds. What I've read about this is that it may actually cause some lesioning though only to an extent that remains subclinical. Talked to my attending about it that has been doing it for years and he's never had any long term bad complications.

Sounds like an experiment awaiting a lawsuit. If we used patient comfort as criteria for procedures then I would have bailed on my 2nd level of kypho today. If you do not have the balls to burn, pulse and eat the cost.

 

[cbest]

Sounds like an experiment awaiting a lawsuit. If we used patient comfort as criteria for procedures then I would have bailed on my 2nd level of kypho today. If you do not have the balls to burn, pulse and eat the cost.

I hear you lobelsteve... not sure I'll continue to do it after fellowship yet but you should check out:
Retrospective review of the efficacy and safety of repeated pulsed and continuous radiofrequency lesioning of the dorsal root ganglion/segmental nerve for lumbar radicular pain

in Pain Physician for a little more background.

 

[clubdeac]

Just did a TAP block for a guy with periumbilical pain following an open cholecystectomy that went bad. He was pain free following the block but we'll see how long it lasts. If he comes back I may do direct scar infiltration around the umbilicus or ICNBs. Only problem with ICNBs is that it's bilateral so I'd have to do T9-11 bilaterally which I'm not real keen on doing