Modic Changes are an independent risk factor for episodes of severe and disabling low back pain.

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Disc's don't get "inflammed" unless they have a vascular supply. Neovasuclarization only occurs after an an anular injury. HIZ's are present in only ~30% of anular injuries. This the presence of modic changes are another objective marker of an acute injury.

Discs have a vascular supply - maybe not a great one, but they certainly do. If they have living cell tissue, they have supply.

Lots of studies have suggested damaged discs are a big source of inflammatory protiens. In addition, LOTS of studies have shown that dessicated discs harbor bacteria which would also cause inflammation.

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he has publically and in the literature said pusled RF doesn't work. That basically means he either never reads, or he can't read very well, or has alzheimer's.
No, what he has written is that it is no better than placebo, and the literature bears him out. The lack of literature support is why Medicare will not pay for pulsed RF. Also, no one has ever been able to document what, exactly, PRF does to elicit it's "therapeutic response"
 
Discs have a vascular supply - maybe not a great one, but they certainly do. If they have living cell tissue, they have supply.

Lots of studies have suggested damaged discs are a big source of inflammatory protiens. In addition, LOTS of studies have shown that dessicated discs harbor bacteria which would also cause inflammation.
Discs are not vascular and therefore depend on the end plates to diffuse needed nutrients.
 
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At an ISIS meeting - he tore a female Pain physician a new hole when she was talking about dermatomal patterns - he basically said dermatomal patterns are crap. Does he not practice pain at all? Stick an RF needle on any peripheral nerve/DRG and you will see - dermatomal patterns absolutely can be very defined and clear - to state otherwise begs a review of that persons psyche and education experience. .
As these are Prof. Bogduk's very own slides (http://www.tourhosts.com.au/archive/physiciansweek/pdf/Presentations/bogduk.pdf) you seem to be mistaken
 
No, what he has written is that it is no better than placebo, and the literature bears him out. The lack of literature support is why Medicare will not pay for pulsed RF. Also, no one has ever been able to document what, exactly, PRF does to elicit it's "therapeutic response"

show me three articles that show that it doesn't work and is equal to placebo.

Also, to be fair, these articles need to show that the electrical field producing the effect (presumably) was either reported or held constant.

The lack of literature is NOT why medicare will not support it. There is clearly not a LACK of literature showing positive results. There is an abundance...but that doesn't seem to matter. Also, not sure why explaining how something works has anything to do with demonstrating wether something works or not (that is called a red hearing in logic speak by the way.)
 
Also, looking at those slides with data from 1991 also clears up a confusion I have had on this board for a long time - that is - I could never figure out why you ISIS supporters were so convinced that TFESI was SOOOOO much better than a caudal....now it makes sense.
 
ISIS was friendly to physiatrists way back before we were allowed into anesthesia run pain fellowships. So
a lot of us joined their ranks and have felt a sense of debt and loyalty to them.
 
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ISIS was friendly to physiatrists way back before we were allowed into anesthesia run pain fellowships. So
a lot of us joined their ranks and have felt a sense of debt and loyalty to them.

Well I totally understand that. I abondoned my "love" with ASRA years ago because of their clear bias and short-sidedness regarding this manner. I haven't been to a meeting for years (although I am going to the regional meeting here in a few weeks). Plus AAPM was WAY more friendly to us military types.
 
show me three articles that show that it doesn't work and is equal to placebo.

Also, to be fair, these articles need to show that the electrical field producing the effect (presumably) was either reported or held constant.

The lack of literature is NOT why medicare will not support it. There is clearly not a LACK of literature showing positive results. There is an abundance...but that doesn't seem to matter. Also, not sure why explaining how something works has anything to do with demonstrating wether something works or not (that is called a red hearing in logic speak by the way.)
All the citations you need are right here: http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2006.00210.x/abstract

Feel free to provide us with that abundance of literature (you'll come up with a reason not to, I know, but I figured I'd at least ask)
 
The interventional section of AAPM is run by ISIS
 
All the citations you need are right here: http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2006.00210.x/abstract

Feel free to provide us with that abundance of literature (you'll come up with a reason not to, I know, but I figured I'd at least ask)
I have critiqued this article before on this site. He doesn't give ANY negative articles..just critiques the technology.

Seriously? You want a list? Every article ever produced on pulsed RF is positive and there are MANY. Most of them suck in quality...but that isn't the point.

Here is the reply to that article by Bogduk (attached) - it is useful to read as it makes some excellent points.


I did a letter to the editor in Pain Medicine with a good table of some of the most recent articles. Look at that. It was done 3 years ago - many more have come out since.
 

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Here is the reply to that article by Bogduk (attached) - it is useful to read as it makes some excellent points.
So exactly which advocated use do you currently apply PRF to? PRF of the DRG? or intra-discal PRF?
 
I have no idea who you are.

Good poinT. I posted my letter but then removed it.

Here are some articles since 2009 - more before that of course. I did list a few case series and reports, but there are WAY more. Also, I get publication bias as well so I am sure there are plenty of people that don't respond to pulsed.

However, the argument at hand - as set by you (and apparently agreed on by insurance companies and Bogduk) is that there is no literature to support the efficacy of pulsed RF. Also, maybe spoken or implied, is that there is literature claiming it doesn't work. The ONLY study Bogduk quotes show inferiority to high temp for lumbar medial branches - that is different than saying it doesn't work. I hope it feels good to agree with insurance companies that apparently don't know how to read. ;)

Shanthanna, Harsha, et al. "Pulsed radiofrequency treatment of the lumbar dorsal root ganglion in patients with chronic lumbar radicular pain: a randomized, placebo-controlled pilot study." Journal of pain research 7 (2014): 47.
Van Boxem, Koen, et al. "Pulsed Radiofrequency for Chronic Intractable Lumbosacral Radicular Pain: A Six‐Month Cohort Study." Pain Medicine (2015).
Vigneri, Simone, et al. "Effectiveness of Pulsed Radiofrequency with Multifunctional Epidural Electrode in Chronic Lumbosacral Radicular Pain with Neuropathic Features." Pain physician 17.6 (2014): 477-486.
Chye, Cien-Leong, et al. "Pulsed radiofrequency treatment of articular branches of femoral and obturator nerves for chronic hip pain." Clinical interventions in aging 10 (2015): 569.
Wu, Yung-Tsan, et al. "Ultrasound-Guided Pulsed Radiofrequency Stimulation of the Suprascapular Nerve for Adhesive Capsulitis: A Prospective, Randomized, Controlled Trial." Anesthesia & Analgesia 119.3 (2014): 686-692.
Fang, Luo, et al. "Computerized tomography-guided sphenopalatine ganglion pulsed radiofrequency treatment in 16 patients with refractory cluster headaches: Twelve-to 30-month follow-up evaluations." Cephalalgia (2015): 0333102415580113.
Yang, Yuecheng, et al. "Efficacy of Pulsed Radiofrequency on Cervical 2-3 Posterior Medial Branches in Treating Chronic Migraine: A Randomized, Controlled, and Double-Blind Trial." Evidence-Based Complementary and Alternative Medicine (2015).
Arai, Young‐Chang P., et al. "Dorsal Root Ganglion Pulsed Radiofrequency for the Management of Intractable Vertebral Metastatic Pain: A Case Series." Pain Medicine (2014).

Choi G, Ahn SH, Cho YW, Lee DG. Long-term effect of pulsed radiofrequency on chronic cervical radicular pain refractory to repeated transforaminal epidural steroid injections. Pain Med 2012;13:368–375
Brennan L, Fitzgerald J, McCrory C. The use of pulsed radiofrequency treatment for chronic benign pancreatitis pain. Pain Pract 2009;9:135–140
Philip CN, Candido KD, Joseph NJ, Crystal GJ. Successful treatment of meralgia paresthetica with pulsed radiofrequency of the lateral femoral cutaneous nerve. Pain Physician 2009;12:881–885.
Liliang PC, Lu K, Liang CL, et al. Pulsed radiofrequency lesioning of the suprascapular nerve for chronic shoulder pain: A preliminary report. Pain Med 2009;10:70–75
Misra S, Ward S, Coker C. Pulsed radiofrequency for chronic testicular pain—A preliminary report. Pain Med 2009;10:673–678.
Halim W, Chua NH, Vissers KC. Long-term pain relief in patients with cervicogenic headaches after pulsed radiofrequency application into the lateral atlantoaxial (C1-2) joint using an anterolateral approach. Pain Pract 2010;10:267–271.
Tsou HK, Chao SC, Wang CJ, et al. Percutaneous pulse radiofrequency applied to the L2 dorsal root ganglion for the treatment of chronic low-back-pain: 3 year experience. J Neurosurg Spine 2010;12:190–196
Kang KN, Park IK, Suh JH, Leem JG, Shin JW. Ultrasound-guided pulsed radiofrequency lesioning of the phrenic nerve in a patient with intractable hiccup. Korean J Pain 2010;23:198–201
Restrepo-Garces CE, Marinov A, McHardy P, Faclier G, Avila A. Pulsed radiofrequency under ultrasound guidance for persistent stump-neuroma pain. Pain Pract 2010;11:98–102.
West M, Wu H. Pulsed radiofrequency ablation for residual and phantom limb pain: A case series. Pain Pract 2010;10:485–491
Eyigor C, Eyigor S, Korkmaz OK, Uyar M. Intra-articular corticosteroid injections versus pulsed radiofrequency in painful shoulder: A prospective, randomized, single-blinded study. Clin J Pain 2010;26:386–392.
Nguyen M, Wilkes D. Pulsed radiofrequency V2 treatment and intranasal sphenopalatine ganglion block: A combination therapy for atypical trigeminal neuralgia. Pain Pract 2010;10:370–374

Zhang J, Shi DS, Wang R. Pulsed radiofrequency of the second cervical ganglion (C2) for the treatment of cervicogenic headache. J Headache Pain 2011;12:569–571.
Van Boxem K, van Bilsen J, de Meij N, et al. Pulsed Radiofrequency treatment adjacent to lumbar dorsal root ganglion for treatment of lumbosacral radicular syndrome: A clinical audit. Pain Med 2011;12:1322–1330.
Fowler IM, Tucker AA, Mendez RJ. Treatment of meralgia paresthetica with ultrasound-guided pulsed radiofrequncy ablation of the lateral femoral cutaneous nerve. Pain Pract 2012;12:394–398.

Rehman SU, Khan MZ, Hussain R, Jamshed A. Pulsed radiofrequency modulation for lingual neuralgia. Br J Oral Maxillofac Surg 2012;50:e4–e5.
Pattnaik, Manorama. "Pulsed Radiofrequency of the Composite Nerve Supply to the Knee Joint as a New Technique for Relieving Osteoarthritic Pain: A Preliminary Report." Pain physician 17 (2014): 493-506.
Chon, Jin Young, et al. "Pulsed radiofrequency under ultrasound guidance for the tarsal tunnel syndrome: two case reports." Journal of anesthesia 28.6 (2014): 924-927.
Ye, Le, et al. "A Comparative Efficacy Evaluation of Ultrasound‐Guided Pulsed Radiofrequency Treatment in the Gastrocnemius in Managing Plantar Heel Pain: A Randomized and Controlled Trial." Pain Medicine 16.4 (2015): 782-790.


I found one case report that was negative.

Bendersky, Damián Claudio, Santiago Matias Hem, and Claudio Gustavo Yampolsky. "Unsuccessful Pulsed Radiofrequency of the Sphenopalatine Ganglion in Patients with Chronic Cluster Headache and Subsequent Successful Thermocoagulation." Pain Practice (2015).
 
Ampaphb,

Let me ask you something (and something of all other pulsed RF haters out there).

What is your beef with pulsed RF? I don't understand it. So you choose not to do it...fine. It isn't that strong of an effect anyway - probably comparable to ESI's. It isn't life saving. But why defend the position that it doesn't work? That seems extremely odd to me.

My guess is this - and I may be WAY wrong - but this what I imagine goes in the minds of you who defend that position....

You know you can't get paid for it - yet it clearly helps in some cases as demonstrated by MANY MANY articles. Yet how can you withold a treatment from a patient that could potentially help based just on money? Well that makes you fell bad... as it should...so a way easier answer is to claim it doesn't work. poof ----off the hook.
 
I think there is something to nerves being subjected to an electrical field - obviously it causes some spinal cord action.

Is it possible that high frequency stimulation - or sub threshold burst - is creating the same type of environment as pulsed RF and the mechanism is the same?
 
oh i forgot this randomized trial on groin pain.

Amr, Yasser M. "Pulsed Radiofrequency for Chronic Inguinal Neuralgia." Pain physician 18 (2015): E147-E155.

Dude, what do you do with your chronic groin pain after inguinal hernia patients anyway? You seriously won't pulse the nerve after you figure out which one is most pain relieving after a diagnostic block?

Sheesh...have a heart.

there are some on occipital neuralgia as well - didn't post those.
 
Ampaphb,

Let me ask you something (and something of all other pulsed RF haters out there).

What is your beef with pulsed RF? I don't understand it. So you choose not to do it...fine. It isn't that strong of an effect anyway - probably comparable to ESI's. It isn't life saving. But why defend the position that it doesn't work? That seems extremely odd to me.

My guess is this - and I may be WAY wrong - but this what I imagine goes in the minds of you who defend that position....

You know you can't get paid for it - yet it clearly helps in some cases as demonstrated by MANY MANY articles. Yet how can you withold a treatment from a patient that could potentially help based just on money? Well that makes you fell bad... as it should...so a way easier answer is to claim it doesn't work. poof ----off the hook.
Nice misquote - I give the citation for the Medicare LCD, yet you chage it to insurance. I give you the Medicare rationale for their unwillingness to pay, yet the best you can do is call me a mercenary. So just so I'm clear you do these procedures for free? Do you bill it as a denervation/ablation (knowing that this is fraud)? Or do u ask your patients to pay cash?
 
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Shanthanna, Harsha, et al. "Pulsed radiofrequency treatment of the lumbar dorsal root ganglion in patients with chronic lumbar radicular pain: a randomized, placebo-controlled pilot study." Journal of pain research 7 (2014): 47.
This certainly looked promising. Unfortunately, as you look further, what you find is

"RESULTS:
Over 15 months, 350 potential patients were identified and 56 were assessed for eligibility. Fifteen of them did not meet the selection criteria. Of the 41 eligible patients, 32 (78%) were recruited. One patient opted out before intervention. Three patients were lost to follow-up at 3 months. Mean VAS differences were not significantly different at 4 weeks (-0.36, 95% confidence interval [CI], -2.29, 1.57) or at 3 months (-0.76, 95% CI, -3.14, 1.61). The difference in mean Oswestry Disability Index score was also not significantly different at 4 weeks (-2%, 95% CI, -14%, 10%) or 3 months (-7%, 95% CI, -21%, 6%). There were no major side effects. Six of 16 patients in the PRF group and three of 15 in the placebo group showed a >50% decrease in VAS score."​

Generally, it's best to actually READ the article, prior to citing it for the proposition you are advocating. Then again

“If you can't dazzle them with brilliance, baffle them with bull$hit.”
W.C. Fields
 
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oh i forgot this randomized trial on groin pain.

Amr, Yasser M. "Pulsed Radiofrequency for Chronic Inguinal Neuralgia." Pain physician 18 (2015): E147-E155.

Dude, what do you do with your chronic groin pain after inguinal hernia patients anyway? You seriously won't pulse the nerve after you figure out which one is most pain relieving after a diagnostic block?

Sheesh...have a heart.

Something fishy:

RESULTS:
Significantly longer duration of pain relief was noticed in Group 1 (P = 0.005) after the first block, while the durations of pain relief of the second block were comparable (P = 0.59). In Group 1 the second PRF produced pain relief from the twenty-fourth week until the tenth month while in Group 2, pain relief was reported from the sixteenth week until the eighth month after the use of PRF. All patients in Group 2 received 3 blocks (the first was a sham PRF) during the one year follow-up period. Meanwhile, 2 PRF blocks were sufficient to achieve pain relief for patients in Group 1 except 4 patients who needed a third PRF block. No adverse events were reported.​

So in both groups, pain relief was 4 months duration. In the first group, it took 6 months to kick in. In the second group, it took 4 months to kick in. I realize we have no idea why PRF works in the first place, but if it excatly the same intervention, why would it take 2 months longer to work?
 
Bring back PASSOR...please.

2nd that.

The AAPMR breaking up PASSOR and creating special interest "councils" was supposed to make everyone feel equal and happy. The old PASSOR members just left and put more of their time and energy into ISIS (and NASS somewhat).
 
Nice misquote - I give the citation for the Medicare LCD, yet you chage it to insurance. I give you the Medicare rationale for their unwillingness to pay, yet the best you can do is call me a mercenary. So just so I'm clear you do these procedures for free? Do you bill it as a denervation/ablation (knowing that this is fraud)? Or do u ask your patients to pay cash?

I do them for free actually.

And I didn't call you anything. Where did that come from?

I sincerely want to know what your huge beef is with pRF? I do not understand it.
 
Amp

Here is your quote...

"Feel free to provide us with that abundance of literature (you'll come up with a reason not to, I know, but I figured I'd at least ask)"

I provided you with an abundance of literature. You didn't say "high quality" literature...and I have never claimed that the majority of the literature was high quality.

What I have claimed is that there are a TON of articles that indicate treatment effect from pulsed RF.

What people - like yourself - have often claimed is that it doesn't work....and I want to know where this comes from - because there isn't even poor quality literature to show that it doesn't.

So again the question....why is there such strong feelings AGAINST this technique? Please please please please please explain this to me.

And I will ask once again - what do you do with those patients in horrible pain after an inguinal hernia repair that you have clearly demonstrated that pain can be completely or nearly removed when you block the offending nerve? What do you do?

What do you do with a guy that responded with 100% relief from your ultrasound guided occipital nerve blocks with local?

What do you do with the guy with severe neuropathic pain in a median nerve distribution and when you block the nerve with exparel he had complete relief for 4 days? What then?

What do you do with the guy that has horrible stump and phantom pain and under ultrasound you see a large neuroma - and his pain was completely taken away with a local anesthetic injection?

What do you do with the skinny girl who has bilateral lateral femoral cutaneous nerve pain and it resolved completely with a local anesthetic injection?

What do you do with the guy that has clear radicular pain that only temporarily responds to steroid injections?

What do you do with the guy that has clear 12th rib syndrome?

I'll tell you what I do. I don't give opioids. They all see our pain psychologist. And if they are relatively high functioning people and they seem like good candidates for interventional therapy, I pulse, pulse, pulse - peripheral nerves and DRGs.


Rather than go through the literature and find problems with each study....because every study has problems...EVERY STUDY has problems....rather than do that...how about address the issue face on. Why do you feel SO STRONGLY against pulsed RF?
 
I'm eager to see the response to this post.

I have to say ampaphb, you are a real special case. How do you make people disprove your "questionable practices" by posting articles about discography when the onus of defense is clearly on YOU, and then turn around and do the exact same thing to epidural man about pRF IN THE SAME THREAD! Here he's doing the "questionable practice" and instead of posting the articles as you had 101N do for you, you show this dude the link to a freaking textbook and tell him the answers are there?!! Man you gotta change your avatar to what the guy from UCSD uses "Here comes a special boy!"
 
Amp

Here is your quote...

"Feel free to provide us with that abundance of literature (you'll come up with a reason not to, I know, but I figured I'd at least ask)"

I provided you with an abundance of literature. You didn't say "high quality" literature...and I have never claimed that the majority of the literature was high quality.

What I have claimed is that there are a TON of articles that indicate treatment effect from pulsed RF.

What people - like yourself - have often claimed is that it doesn't work....and I want to know where this comes from - because there isn't even poor quality literature to show that it doesn't.

So again the question....why is there such strong feelings AGAINST this technique? Please please please please please explain this to me.

And I will ask once again - what do you do with those patients in horrible pain after an inguinal hernia repair that you have clearly demonstrated that pain can be completely or nearly removed when you block the offending nerve? What do you do?

What do you do with a guy that responded with 100% relief from your ultrasound guided occipital nerve blocks with local?

What do you do with the guy with severe neuropathic pain in a median nerve distribution and when you block the nerve with exparel he had complete relief for 4 days? What then?

What do you do with the guy that has horrible stump and phantom pain and under ultrasound you see a large neuroma - and his pain was completely taken away with a local anesthetic injection?

What do you do with the skinny girl who has bilateral lateral femoral cutaneous nerve pain and it resolved completely with a local anesthetic injection?

What do you do with the guy that has clear radicular pain that only temporarily responds to steroid injections?

What do you do with the guy that has clear 12th rib syndrome?

I'll tell you what I do. I don't give opioids. They all see our pain psychologist. And if they are relatively high functioning people and they seem like good candidates for interventional therapy, I pulse, pulse, pulse - peripheral nerves and DRGs.


Rather than go through the literature and find problems with each study....because every study has problems...EVERY STUDY has problems....rather than do that...how about address the issue face on. Why do you feel SO STRONGLY against pulsed RF?
I think pulsed works well in a lot of these cases just from my personal experience when I was at the VA. You're right epidural man, a lot of times you have no other options. And as far as mechanism, I think it increases the expression of c-Fos in the dorsal horn? Right
 
Papa, I will be happy to address your concerns regarding discography in a separate thread.

To be clear, the original part of this discussion was an answer to Steve, who asked:

"How many would send a 30 y/o to a surveon for fusjon if they had axial pain and Modic changes?"

I respoded that I would, if
1) they got no relief from an l/s esi
2) they got no relief from l/s facet joint inj/MBB
3) they had a positive, concordant discogram
4) I knew the spine surgeon took a conservative approach, and fully informed the patient that the likelihood of success was suboptimal.
 
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Epidural man, I didnt think it was necessary to include the modifier "high quality". I dont rely on poor quality studies, and naturaly asumed you didnt either.

I try and do practice evidence-based medicine. When I go outside that realm, I do so only after fully informing the patient that there is poor evidence to suport the proposed procedure, but there are no better alternatives.

If you really perform all of the above procedures at no charge, then you are a better person than I am. I have an office to run, lights to keep on, and staff salaries to pay.
 
Nice try. You are the one making a claim that fusion improves back pain by way of your clinical test. Show me the data.
Actuly, what I said was "I knew the spine surgeon took a conservative approach, and fully informed the patient that the likelihood of success was suboptimal."
 
Epidural man, I didnt think it was necessary to include the modifier "high quality". I dont rely on poor quality studies, and naturaly asumed you didnt either.

I try and do practice evidence-based medicine. When I go outside that realm, I do so only after fully informing the patient that there is poor evidence to suport the proposed procedure, but there are no better alternatives.

If you really perform all of the above procedures at no charge, then you are a better person than I am. I have an office to run, lights to keep on, and staff salaries to pay.

I would argue that the quality of the studies of pulsed RF for relief of pain rivals the quality of evidence for epidural steroid injections - and frankly, pulsed is likely an order of magnitude safer.

You DON'T practice evidence-based medicine because the evidence suggests that pRF works.

But I doubt I am a better person than you...I gamble a lot...make fun of people a lot...am late to work a lot...I try to do everything in my power to go against joint commmision, etc.
 
You DON'T practice evidence-based medicine because the evidence suggests that pRF works.
Poor quality studies are not "evidence", at least for me. I have seen too many technologies (IDET, Distrode, Nucleoplasty, MILD, peripheral stim, etc.) seduce early adopters, only to have the Level III and IV data not be confirmed by RCTs and Cochran analyses.
 
I would argue that the quality of the studies of pulsed RF for relief of pain rivals the quality of evidence for epidural steroid injections
Cochran says otherwise:

CONCLUSION:
The indicated evidence for transforaminal lumbar epidural steroid injections is Level II-1 for short-term relief and Level II-2 for long-term improvement in the management of lumbar nerve root and low back pain.
http://www.ncbi.nlm.nih.gov/pubmed/19165306

as does ISIS:

CONCLUSION:
In a substantial proportion of patients with lumbar radicular pain caused by contained disc herniations, lumbar transforaminal injection of corticosteroids is effective in reducing pain, restoring function, reducing the need for other health care, and avoiding surgery.
http://www.ncbi.nlm.nih.gov/pubmed/23110347
 
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Poor quality studies are not "evidence", at least for me. I have seen too many technologies (IDET, Distrode, Nucleoplasty, MILD, peripheral stim, etc.) seduce early adopters, only to have the Level III and IV data not be confirmed by RCTs and Cochran analyses.

Sir,

First off, that isn't a Cochran review. They used a Cochran grading scale to grade RCT's and Observational trials. They then used Guyatt's table to come up with a final category.

If you were to grade the RCT's done on pulsed RF, then grade the observational trials, they may even get a Guyatt score of 1A or 1B.

Like I said, I think based on quality and efficacy in the literature - it is comparable. if you don't believe me - pull those RCT's and score them. They need >50 to be considered high quality.
 
Amp,
I would like to hear your suggestions for what to do for the list of clinical scenarios epidural guy described.

What do you suggest for these patients? ( assuming they failed several non opiod medications)

pRF is a much better option than opioids, way cheaper and often more effective than a peripheral nerve stimulator.

It's a disservice not to give your patients this option, unless you have some other great treatment you'd like to share with us.
 
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So just so I'm clear you do these procedures for free?

i think he works at the VA. which is why he has the leeway play around with pRF.

so, in actuality, you and I are paying for his shenanigans out of the tax dollars we made by performing regular thermal RF. ironic, isnt it?
 
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Amp,
I would like to hear your suggestions for what to do for the list of clinical scenarios epidural guy described.

What do you suggest for these patients? ( assuming they failed several non opiod medications)

pRF is a much better option than opioids, way cheaper and often more effective than a peripheral nerve stimulator.

It's a disservice not to give your patients this option, unless you have some other great treatment you'd like to share with us.
Let's start with I don't ask my patients to pay out of pocket for procedures.

If I think a procedure might help, and there are no other minimally invasive options, I tell the patient that there is limited evidence, that the likelihood of success is suboptimal, and then leave it to them to decide if they wish to move forward.

If they do, I bill it as a 64450.
 
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande

Walmart wasn’t providing this benefit out of the goodness of its corporate heart, of course. It was hoping that employees would get better surgical results, sure, but also that the company would save money. Spine, heart, and transplant procedures are among the most expensive in medicine, running from tens of thousands to hundreds of thousands of dollars. Nationwide, we spend more money on spinal fusions, for instance, than on any other operation—thirteen billion dollars in 2011. And if there are complications the costs of the procedure go up further. The medical and disability costs can be enormous, especially if an employee is left permanently unable to return to work. These six centers had notably low complication rates and provided Walmart a fixed, package price.
 
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande

Walmart wasn’t providing this benefit out of the goodness of its corporate heart, of course. It was hoping that employees would get better surgical results, sure, but also that the company would save money. Spine, heart, and transplant procedures are among the most expensive in medicine, running from tens of thousands to hundreds of thousands of dollars. Nationwide, we spend more money on spinal fusions, for instance, than on any other operation—thirteen billion dollars in 2011. And if there are complications the costs of the procedure go up further. The medical and disability costs can be enormous, especially if an employee is left permanently unable to return to work. These six centers had notably low complication rates and provided Walmart a fixed, package price.

Even in socialized systems, incentives to do things that "don't work" persist despite central planning and "Data."

"The major barriers that drove referrals for arthroscopy acted in concert. A desire to help patients and meet their expectations, a belief that those expectations did not involve conservative measures (and there was no service available that offered such conservative measures), time pressure in clinic, and a perceived (or real) pressure from patients for an arthroscopy all contributed to a substantial barrier. It is clear from the focus groups that this pressure is not specifically for an arthroscopy; however, patients do want “something” done."

http://www.regenexx.com/2015/05/knee-arthritis-surgery/

http://www.biomedcentral.com/content/pdf/s12891-015-0537-y.pdf
 
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