No chubsters allowed...

[Stim4me]

http://www.mrctv.org/blog/uk-socialist-health-system-proposes-surgery-ban-obese-and-smokers

NHS bankrupt, so no obese patients allowed for elective surgeries unless they show motivation... Good concept to cover a failed socialist system.

---

Members don't see this ad.

 

[101N]

We need a calorie sin tax that goes to health prevention.

 

[hyperalgesia]

How dare the UK discriminate against sufferers of amotivational disorder...

 

[clubdeac]

That's pretty much what all the surgeons do at the VA....puts a lot more pressure on the pain doc when the patient is really a surgical case but surgery won't operate. I get these "dumps" all the time from neurosurg and ortho...

 

[VA Hopeful Dr]

The vascular surgeons where I did residency wouldn't do elective artery bypass grafts on smokers, you had to quit for at least one month first.

 

[SSdoc33]

i see nothing wrong with this policy

 

[SSdoc33]

That's pretty much what all the surgeons do at the VA....puts a lot more pressure on the pain doc when the patient is really a surgical case but surgery won't operate. I get these "dumps" all the time from neurosurg and ortho...

why is it a surgical case? some slob cant quit smoking or lose 100 lbs, and the doc doesnt want to take the surgical risk? sounds like good medicine to me. it may be a dump, but its the correct medical decision

 

[101N]

If the patient isn't invested in a lifestyle change a referral to behavioral health or a psychologist
would be more appropriate. Club doesn't have a magic wand.

 

[clubdeac]

If the patient isn't invested in a lifestyle change a referral to behavioral health or a psychologist
would be more appropriate. Club doesn't have a magic wand.

Thank you 101N...exactly. Maybe I should refuse to perform an epidural if they smoke or have a certain BMI. When I say they're a good surgical candidate I'm talking about old guys with severe spinal stenosis that have already failed 2-3 epidurals or someone with a nice juicy posterolateral disc protrusion and leg pain who's failed 2-3 epidurals. There's not much else I can do. I refer to neurosurg and sometimes they kick 'em right back due to weight or other comorbidities. Sure, I agree with them in certain situations but the incentive is often not to operate

 

[bedrock]

Thank you 101N...exactly. Maybe I should refuse to perform an epidural if they smoke or have a certain BMI. When I say they're a good surgical candidate I'm talking about old guys with severe spinal stenosis that have already failed 2-3 epidurals or someone with a nice juicy posterolateral disc protrusion and leg pain who's failed 2-3 epidurals. There's not much else I can do. I refer to neurosurg and sometimes they kick 'em right back due to weight or other comorbidities. Sure, I agree with them in certain situations but the incentive is often not to operate

I wouldn't deny someone an ESI due to obesity, but I would deny them an RFA. Unless I'm mistaken, the longest RF cannula is 15cm. I have asked a few device reps if they had anything longer and the answer was always no. I've come across a few fatties for whom proper RFA would be impossible and told them I would be happy to reconsider if they lose weight. Not many lose weight though.

I did have a couple patients right after fellowship on whom I did lumbar RFA, but had to go straight at the nerves instead of proper caudal ISIS technique, due to the thickness of their lumbar adipose layer. Relief lasted 2 months for both. I told them if they lost weight, they might get a year out of it. One went back to her usual self-pitying ways but the other one lost 40 lbs, I repeated his RFA with ideal technique and then his relief lasted over a year.

 

[101N]

I think you are talking apples to oranges. The VA surgeons may be denying surgery - in part - due to anesthetic risk. That never really effects us.

I'd deny or discourage RFA - and I do - if I thought it wouldn't work. Often it doesn't. Although in Cubs setting - old vets - I'd be more liberal with procedures.

 

[Taus]

I wouldn't deny someone an ESI due to obesity, but I would deny them an RFA. Unless I'm mistaken, the longest RF cannula is 15cm. I have asked a few device reps if they had anything longer and the answer was always no. I've come across a few fatties for whom proper RFA would be impossible and told them I would be happy to reconsider if they lose weight. Not many lose weight though.

I did have a couple patients right after fellowship on whom I did lumbar RFA, but had to go straight at the nerves instead of proper caudal ISIS technique. Relief lasted 2 months for both. I told them if they lost weight, they might get a year out of it. One went back to her usual self-pitying ways but the other one lost 40 lbs, I repeated his RFA with ideal technique and then his relief lasted over a year.

I know it's not the main point.... but I've got 20's available in one asc. Stryker.


Sent from my iPhone using SDN mobile app

 

[bedrock]

I think you are talking apples to oranges. The VA surgeons may be denying surgery - in part - due to anesthetic risk. That never really effects us.

I'd deny or discourage RFA - and I do - if I thought it wouldn't work. Often it doesn't. Although in Cubs setting - old vets - I'd be more liberal with procedures.

You can't do proper RFA with the longest 15 cm RF cannulae on pts over 300-350lbs. The needles don't reach the nerves, unless you do a direct perpendicular approach. Relief doesn't last, so the procedure isn't offered, end of story.

On major fatties, even the perpendicular approach doesn't reach the MB.

 

[Ligament]

I wouldn't deny someone an ESI due to obesity, but I would deny them an RFA. Unless I'm mistaken, the longest RF cannula is 15cm. .

There are 20cm cannulae. I have a small supply for my fallen giants. Neurotherm. They also make disposable 20cm RF probes. This pic is using them. Look at the kVp and MA. Oblique imaging as could not penetrate lateral imaging.

 

[bedrock]

I know it's not the main point.... but I've got 20's available in one asc. Stryker.


Sent from my iPhone using SDN mobile app

Thanks Taus. Interesting you say that as when I worked near Philadelphia a year ago, I had my MA call all the academic pain departments (including yours) to see if anyone carried 20cm RF cannulae/probes, and every single one of them said they had nothing longer than 15cm.

 

[bedrock]

There are 20cm cannulae. I have a small supply for my fallen giants. Neurotherm. They also make disposable 20cm RF probes.

Ok, well my Neurotherm rep was a complete idiot then as he was the first person I asked about this 7 years ago.

Disposable RF probes? Because they realize you won't use that length very often? How much are the disposable probes?

Morbid obesity is less common in SoCal than PA, so hopefully this will be less of an issue. As I'm just starting a practice, I can't afford to waste money to buy several 20cm RF probes that I'll use once in a blue moon. I'll just send these morbidly obese RFA patients to the local tertiary medical center. I'd rather avoid extra radiation as well.

 

[Ligament]

Ok, well my Neurotherm rep was a complete idiot then as he was the first person I asked about this 7 years ago.

Disposable RF probes? Because they realize you won't use that length very often? How much are the disposable probes?

Morbid obesity is less common in SoCal than PA, so hopefully this will be less of an issue. As I'm just starting a practice, I can't afford to waste money to buy several 20cm RF probes that I'll use once in a blue moon. I'll just send these morbidly obese RFA patients to the local tertiary medical center. I'd rather avoid extra radiation as well.

Yeah, they make disposable RF probes believe it or not.

They are pretty expensive, I think around $50 each.

We keep a few on stock because we don't use 20cm cannulae often enough to justify reusable RF probes.

Your plan to send the fatties to the tertiary center is a smart business decision.

 

[drpainfree]

Ok, well my Neurotherm rep was a complete idiot then as he was the first person I asked about this 7 years ago.

Disposable RF probes? Because they realize you won't use that length very often? How much are the disposable probes?

Morbid obesity is less common in SoCal than PA, so hopefully this will be less of an issue. As I'm just starting a practice, I can't afford to waste money to buy several 20cm RF probes that I'll use once in a blue moon. I'll just send these morbidly obese RFA patients to the local tertiary medical center. I'd rather avoid extra radiation as well.

what you can do to get around the cost issue is, buy 1 long probe for morbid obese patients, and just do one burn at a time

 

[BobBarker]

Man, I work in a state with a major obesity problem and I rarely need the 150s even.

 

[bedrock]

Man, I work in a state with a major obesity problem and I rarely need the 150s even.

Unfortunately, that statement makes me seriously question your RF technique. The RF cannulae are supposed to be near parallel to the MB when placed correctly as that's how you achieve 12 months or more of pain relief, by burning the longest possible segment of the medial branches.

If you barely need to use the 15cm RF cannulae, even on morbidly obese patients, then you must be directing your RF cannulae perpendicular to the MB, rather than parallel to the MB, which is incorrect technique.

 

[Stim4me]

Do people really think a BMI of 30 warrants cessation of elective surgery??? That would mean most of our parents wouldn't get knee or hip surgeries if truly indicated ... Seems draconian to me

 

[Ducttape]

can you not also increase your burn size by using higher temperature, larger gauge, longer burns?

could you please post the data where there is clinically significant improvement of symptoms with using the SIS technique vs other techniques that precludes us from not exactly following their technique? we are so willing to try all these other different techniques and treatments (see PRP, stem cell, multilevel bilateral TF, etc.) for other injections, but RFA HAS to be the SIS way or no way?

yes there are 20 cm neurotherm probes - ive used them, but none recently (thank goodness). typically if someone is that big, there is a lot more going on to worry about than temporary reduction of back pain.

 

[VA Hopeful Dr]

Do people really think a BMI of 30 warrants cessation of elective surgery??? That would mean most of our parents wouldn't get knee or hip surgeries if truly indicated ... Seems draconian to me

Of course it is, that's socialized medicine for you. This is specifically designed to save money, nothing more.

That said, I wouldn't fault any surgeon for picking a BMI and refusing to operate on patients above that number.

 

[DOctorJay]

Bob is using Venom needles if I recall correctly so he may get nice large volume lesion from this (it's all about the volume of the lesion says SIS recently).

 

[SSdoc33]

all 200 of a patient's 350lbs are anterior in his belly, then you might be able to get away with a 10, let alone a 15. depends on body habitus.

bedrock, if the patient wants the RF, have them buy the disposable 20..... or send them to the teriary center if it wont piss off your referring docs

 

[BobBarker]

I use venoms. My table has a weight limit of 330lbs. Small hospital. 60 percent of my patients are women less than 200lbs and over 60 years old.

 

[bedrock]

I use venoms. My table has a weight limit of 330lbs. Small hospital. 60 percent of my patients are women less than 200lbs and over 60 years old.

can you not also increase your burn size by using higher temperature, larger gauge, longer burns?

could you please post the data where there is clinically significant improvement of symptoms with using the SIS technique vs other techniques that precludes us from not exactly following their technique? we are so willing to try all these other different techniques and treatments (see PRP, stem cell, multilevel bilateral TF, etc.) for other injections, but RFA HAS to be the SIS way or no way?
.

RFA is the only, the only procedure in our field for which there is level one evidence. The evidence for everything else that we do, ESI, sympathetic and peripheral nerve blocks, Kyphoplasty, SCS, PT, psych, PRP, etc, is much weaker.

That level one evidence was accomplished due to the many prospective, randomized clinical trials and papers of Drefyfuss and Bogduk, doing MBB/RFA with SIS technique. No one else to date has generated any data remotely close to level one evidence for doing RF with a different technique, particularly with standard RF cannulae.

ISIS courses teach a lot of techniques including CESI, TESI, LESI, TFESI, sympathetic blocks, SCS, etc. Those are good courses that are intended to summarize good technique options from all the literature in the field. However if you do one of those procedures differently than SIS technique, due to your own clinical background or clinical situation, I'd say that's fine.

MBB/RFA is different as Drefyfuss and Bogduk literally wrote the book on those procedures and they did the level one studies to prove their efficacy, using SIS technique.

So until you personally do several randomized, prospective, clinical trials on RFA with a different technique (using standard RF cannulae), and it works better,........

Then doing RFA (with a single standard RF cannula, even up to 16G), and not using SIS technique, means you are doing the procedure incorrectly.


However, I wouldn't necessarily say that applies for RFA techniques using special needles to create a much larger lesion such as venom or cooled RF probes, or if you use multiple RF cannulae like the case ligament posted a few months ago. For those situations, I would defer to the physician performing them, as it's quite likely the venom probes Bob is using are doing a fine job of ablating the medial branches.

It's just that when using a single standard RF cannula at each level, the SIS technique is the only correct way to do RFA, in order to produce the best clinical results.

 

[101N]

The evidence for CBT for back pain is >>> than the evidence for RFA.

 

[Stim4me]

The evidence for CBT for back pain is >>> than the evidence for RFA.

Selfcare>>>CBT

 

[Ceke2002]

Some more info on this: (it's kind of been blown out of proportion).

- It was a measure that was proposed by the Vale of York Clinical Commissioning Group, which affected North Yorkshire, not the whole of the UK.
- Both the Royal College of Surgeons and the former Health Minister have hit out at the proposed restrictions as being outrageous
- The Vale of York group have since backed down when the NHS asked them to review their plans.

"A spokesman for NHS England said denying operations to a particular group - such as smokers - was 'inconsistent' with the NHS constitution.

He said: 'Major surgery poses much higher risks for severely overweight patients who smoke. So local GP-led Clinical Commissioning Groups are entirely right to ensure these patients first get support to lose weight and try and stop smoking before their hip or knee operation. Reducing obesity and cutting smoking not only benefits patients, but saves the NHS and taxpayers millions of pounds.

'This does not and cannot mean blanket bans on particular patients such as smokers getting operations, which would be inconsistent with the NHS constitution.

'Vale of York CCG is currently under 'special measures' legal direction, and NHS England is today asking it to review its proposed approach before it takes effect to ensure it is proportionate, clinically reasonable, and consistent with applicable national clinical guidelines.'

http://www.dailymail.co.uk/news/art...operations-severe-policy-modern-NHS-seen.html

 

[101N]

Selfcare>>>CBT

If by that you mean 'healthy lifestyle choice' then YES.

 

[Ducttape]

RFA is the only, the only procedure in our field for which there is level one evidence. The evidence for everything else that we do, ESI, sympathetic and peripheral nerve blocks, Kyphoplasty, SCS, PT, psych, PRP, etc, is much weaker.

That level one evidence was accomplished due to the many prospective, randomized clinical trials and papers of Drefyfuss and Bogduk, doing MBB/RFA with SIS technique. No one else to date has generated any data remotely close to level one evidence for doing RF with a different technique, particularly with standard RF cannulae.

ISIS courses teach a lot of techniques including CESI, TESI, LESI, TFESI, sympathetic blocks, SCS, etc. Those are good courses that are intended to summarize good technique options from all the literature in the field. However if you do one of those procedures differently than SIS technique, due to your own clinical background or clinical situation, I'd say that's fine.

MBB/RFA is different as Drefyfuss and Bogduk literally wrote the book on those procedures and they did the level one studies to prove their efficacy, using SIS technique.

So until you personally do several randomized, prospective, clinical trials on RFA with a different technique (using standard RF cannulae), and it works better,........

Then doing RFA (with a single standard RF cannula, even up to 16G), and not using SIS technique, means you are doing the procedure incorrectly.


However, I wouldn't necessarily say that applies for RFA techniques using special needles to create a much larger lesion such as venom or cooled RF probes, or if you use multiple RF cannulae like the case ligament posted a few months ago. For those situations, I would defer to the physician performing them, as it's quite likely the venom probes Bob is using are doing a fine job of ablating the medial branches.

It's just that when using a single standard RF cannula at each level, the SIS technique is the only correct way to do RFA, in order to produce the best clinical results.

really....

but what about these articles?
http://www.ncbi.nlm.nih.gov/pubmed/26495910

Cochrane Database Syst Rev. 2015 Oct 23;(10):CD008572. doi: 10.1002/14651858.CD008572.pub2.
Radiofrequency denervation for chronic low back pain.
Maas ET1, Ostelo RW, Niemisto L, Jousimaa J, Hurri H, Malmivaara A, van Tulder M
AUTHORS' CONCLUSIONS:
The review authors found no high-quality evidence suggesting that RF denervation provides pain relief for patients with CLBP. Similarly, we identified no convincing evidence to show that this treatment improves function. Overall, the current evidence for RF denervation for CLBP is very low to moderate in quality; high-quality evidence is lacking. High-quality RCTs with larger patient samples are needed, as are data on long-term effects.

http://www.ncbi.nlm.nih.gov/pubmed/14589192

Spine J. 2003 Jul-Aug;3(4):3
A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain.
Slipman CW1, Bhat AL, Gilchrist RV, Issac Z, Chou L, Lenrow DA.
Author information
Abstract
BACKGROUND CONTEXT:
Lumbar zygapophysial joints are currently believed to be a cause of axial low back pain. Once this diagnosis is made, decisions about when to institute a particular intervention and which treatment to offer is regionally and specialty dependent.

PURPOSE:
To perform a critical review of prior published studies assessing the use of interventional treatment options for the treatment of lumbar zygapophysial joint syndrome.

STUDY DESIGN:
Evidence-based medicine analysis of current literature.

METHODS:
A database search of Medline (PubMed, Ovid and MDConsult), Embase and the Cochrane database was conducted. The keywords used were low back pain, lumbar zygapophysial joint, lumbar facet joint, radiofrequency denervation, medial branch block, and intraarticular injection. After identifying all relevant literature, each article was reviewed. Data from the following categories were compiled: inclusion criteria, randomization of subjects, total number of subjects involved at enrollment and at final analysis. statistical analysis used, intervention performed, outcome measures, follow-up intervals and results. Guidelines described by the Agency for Health Care Policy and Research were then applied to these data.

RESULTS:
This review determined that the evidence for the treatment of lumbar zygapophysial joint syndrome with intraarticular injections should be rated as level III (moderate) to IV (limited) evidence, whereas that for radiofrequency denervation is at a level III.

CONCLUSIONS:
Current studies fail to give more than sparse evidence to support the use of interventional techniques in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.

http://www.ncbi.nlm.nih.gov/pubmed/27008289

Pain Physician. 2016 Mar;19(3):155-61.
Radiofrequency Neurolysis for Lumbar Pain Using a Variation of the Original Technique.
Leon JF1, Ortiz JG1, Fonseca EO1, Martinez CR1, Cuellar GO1.
Author information
Abstract
BACKGROUND:
Zygapophysial joint arthrosis is a pathology related with axial lumbar pain. The most accepted treatment, after failure of medical management, is the thermal denervation of the medial branch. Nonetheless, the placement of the heat probe remains a challenge to surgeons, even when using the fluoroscope. Using a variation of Shealy's and Bogduk's original techniques, which includes ablation of the medial branch and the nerves present in the joint capsule, we hypothesize that we can obtain similar outcomes to those found in the literature.

OBJECTIVE:
To present the results attained over the last 8 years in the treatment of axial lumbar pain from zygapophysial joints degeneration, by employing a variation of the lumbar medial branch neurotomy technique, called 360-degree facet rhizotomy with radiofrequency.

STUDY DESIGN:
Retrospective evaluation.

SETTING:
Spine Center - Minimally Invasive Surgery in Bogotá, Colombia.

METHODS:
A medical chart review was conducted for patients diagnosed with axial lumbar pain from zygapophysial joint arthrosis and treated with 360-degree facet rhizolysis with a high frequency radiofrequency energy source between 2008 and 2014. Data were evaluated under modified MacNab and pre- and postoperative visual analog scale (VAS) criteria.

RESULTS:
We obtained a total of 73 patients. The average population age was 58.6 years. The preoperative VAS obtained was 7.3, which changed to 1.7 one year after the procedure. The MacNab criteria 12 months after the surgery gave satisfactory outcomes (excellent and good) from 91.7% of the patients.

LIMITATIONS:
This retrospective study includes inherent limitations and only offers one year follow-up data.

CONCLUSIONS:
Thermal therapy for zygapophysial joint arthrosis constitutes a safe and effective technique. The one year follow-up data presented here show that the ablation of the medial branch and nerves present in the joint capsule leads to satisfactory results in a high percentage of patients.

do we know the right temperature?
http://www.ncbi.nlm.nih.gov/pubmed/26369502

Pain Pract. 2015 Sep 15. doi: 10.1111/papr.12346. [Epub ahead of print]
Optimal Temperature for Radiofrequency Ablation of Lumbar Medial Branches for Treatment of Facet-Mediated Back Pain.
Costandi S1,2, Garcia-Jacques M1, Dews T1, Kot M3, Wong K3, Azer G2, Atalla J4, Looka M5, Nasr E6, Mekhail N1,2.
Author information
Abstract
BACKGROUND:
Radiofrequency ablation (RFA) of the medial branch nerves that innervate the facet joints is a well-established treatment modality; however, studies to determine the optimal radiofrequency ablation temperature are lacking. A wide range (70 to 90°C) has been used. This study aimed to compare outcomes with two set temperatures for the lumbar facet medial branch ablation, 90 and 80°C.

METHODS:
This retrospective study compared the degree of patient self-reported functional improvement relief, postoperative opioid dose changes, as well as duration among lumbar facet medial branch (RFA) patients who had the procedures performed at 80 or 90°C.

RESULTS:
Patients who underwent the procedure at 90°C had 3.1 (95% CI 1.7, 6.5) times the odds (P = 0.0004) of reporting functional improvement of at least 50% when compared to those who underwent neurotomy at 80°C. For self-reported functional improvement greater or equal to 75%, the results were sustained with an odds ratio of 2.8 (95% CI 1.2, 5.7) favoring those with 90°C temperature neurotomy (P = 0.002).

CONCLUSION:
There seems to be significant functional improvement associated with temp of 90°C compared to 80°C, with no added risk of complications. Randomized controlled studies are warranted.

 

[bedrock]

really....

but what about these articles?
http://www.ncbi.nlm.nih.gov/pubmed/26495910


http://www.ncbi.nlm.nih.gov/pubmed/14589192

http://www.ncbi.nlm.nih.gov/pubmed/27008289



do we know the right temperature?
http://www.ncbi.nlm.nih.gov/pubmed/26369502

Those articles unfortunately don't mean jack.
1- A cochrane review, really? Have you ever seen a cochrane review that stated a particular treatment was excellent and worked really well? Cochrane reviews are useless because the only medical intervention they MIGHT say worked really well, is that decapitating someone results in death on a consistent basis.
2- Article by Slipman means nothing as he has a beef against ISIS which censured him for the same reasons he was fired from U Penn. Slipman has no credibility
3- Interesting article, doesn't mean much because 1-it's talking about a creating a particularly large lesion,2- it only includes 73 patients, 3- only a retrospective study, and 4- was done in Bogota Columbia.

Duct,
I didn't post my earlier comments on RFA technique as any kind of personal insult. Although in pain we become accustomed to doing procedures our own way, and there are often many ways to skin a cat in medicine, sometimes there is a single best way to do something. Doesn't mean you were bad or inadequate for doing it a different way in the past. Just a matter of putting patients' interests before our own egos, for their future benefit.

RFA with a regular RF cannula is that procedure in pain medicine.
Unless you are using a special RF cannula/probe that creates a particularly large lesion like venom or cooled RF, you aren't doing optimal RFA if you aren't using SIS technique.

 

[Ducttape]

the problem i see with this is that there was an SIS/Bogduk technique. it was the technique that lead to high level recommendation for RFA, which we all agree is effective.

then, research from others - biased, as probably Bogduk was also biased for his technique - shows that the benefits are not as great as espoused.

the response then is - "well, you arent doing it right."

"in fact, we all arent doing it right - theres a better way."

and "you arent getting the right people."

and "you are using the right equipment/right temperature/right duration of lesioning."

if these items are things we learned about over time, fine. but the presentation strikes me more as something fishy - as if someone were trying to find justification for what they put a lot of time into....


and with every other injection, there are multiple different approaches, and the method we are talking about is much more nuanced, than, say, the difference between a transforaminal and a transfacet epidural injection. why is RFA so unique that one and only one way can possibly provide good results, and no other way is acceptable?

 

[101N]

Let's talk after the RCT of MBBs vs sham injections.

 

[SeniorWrangler]

Heck, most of the time you can predict the findings of the article just by reading the names of the author: Bogduk vs Manchikanti vs Chou.

 

[Dr. Ice]

Thanks Taus. Interesting you say that as when I worked near Philadelphia a year ago, I had my MA call all the academic pain departments (including yours) to see if anyone carried 20cm RF cannulae/probes, and every single one of them said they had nothing longer than 15cm.

RI and penn don't believe in sharing

 

[Taus]

Thanks Taus. Interesting you say that as when I worked near Philadelphia a year ago, I had my MA call all the academic pain departments (including yours) to see if anyone carried 20cm RF cannulae/probes, and every single one of them said they had nothing longer than 15cm.

My practice has probably at least 2 dozen sites with in office fluoro or asc/hopd where pain procedures are done. I'm aware of one specific facility that has the 20cm electrodes. Moot point now though for you....


Sent from my iPhone using SDN mobile app

 

[bedrock]

the problem i see with this is that there was an SIS/Bogduk technique. it was the technique that lead to high level recommendation for RFA, which we all agree is effective.

then, research from others - biased, as probably Bogduk was also biased for his technique - shows that the benefits are not as great as espoused.

the response then is - "well, you arent doing it right."

"in fact, we all arent doing it right - theres a better way."

and "you arent getting the right people."

and "you are using the right equipment/right temperature/right duration of lesioning."

if these items are things we learned about over time, fine. but the presentation strikes me more as something fishy - as if someone were trying to find justification for what they put a lot of time into....


and with every other injection, there are multiple different approaches, and the method we are talking about is much more nuanced, than, say, the difference between a transforaminal and a transfacet epidural injection. why is RFA so unique that one and only one way can possibly provide good results, and no other way is acceptable?

Key difference here is that transforaminal epidurals were developed from many physicians, but MBB/RFA techniques were developed by two physicians who published all the key papers and invented the technique that was proven in those papers. No other RFA technique with standard RF cannulae has been validated by thousands of patients in prospective, randomized studies.

Poor RFA outcomes typically arrive from one of three factors. The first isn't related to technique at all.

1- patient selection. Not everyone is candidate for RFA if they fail ESI.
There are many procedure mill type practices that do MBB/RFA on every patient that fails ESI. This is horribly wrong and skews RFA results.
Most patients under 50 years with only generic disc degeneration aren't candidates for MBB/RFA. I offer MBB/RFA much less often for patients under 50 yrs. Typically, I only offer MBB/RFA to a patient under 50 yrs if the patient has more unique circumstances like significant trauma such as s/p MVA, major fall, or have autoimmune disease, spondylolisthesis, transitional anatomy , scoliosis, etc.

2- poor RFA technique. As mentioned, if someone is doing 4 nerve unilateral lumbar RFA in only ten min of procedure time, they aren't doing good RFA and their patients will suffer for it. Same thing if not using SIS technique (unless using special large lesion needles like venom, cooled RF)

3- poor MBB technique. This is the second most common reason for RFA failure. If u don't take the time the ensure your MBB needle tip is right where it's supposed to be, if you fail to use contrast or if you dump too much medication, (SIS recommends 0.3ml only at each MB)...........
Then you'll get false positive blocks, so your RFA is doomed from the beginning.

Also doing dual comparative blocks on most patients, and always on patients under 50 years old, will significantly reduce false positive MBB.

 

[Ducttape]

Key difference here is that transforaminal epidurals were developed from many physicians, but MBB/RFA techniques were developed by two physicians who published all the key papers and invented the technique that was proven in those papers. No other RFA technique with standard RF cannulae has been validated by thousands of patients in prospective, randomized studies.

there are a lot of ways to go with this discussion.... first, the l;iterature suggests that some others have validated RFA. otherwise, besides the respect for which we bestow to the physicians who developed this, one might wonder why we are not as skeptical as we are towards other physicians who tout a technique with poorly reproduced results (see pauza discosteel, methylene blue in discs, 4 weeks antibiotics for disc edema, etc...)

im not doubting the veracity or benefit of RFA. I am doubting the presumption that there can be only one way of doing RFA.

 

[lobelsteve]

there are a lot of ways to go with this discussion.... first, the l;iterature suggests that some others have validated RFA. otherwise, besides the respect for which we bestow to the physicians who developed this, one might wonder why we are not as skeptical as we are towards other physicians who tout a technique with poorly reproduced results (see pauza discosteel, methylene blue in discs, 4 weeks antibiotics for disc edema, etc...)

im not doubting the veracity or benefit of RFA. I am doubting the presumption that there can be only one way of doing RFA.

The only way to do RFA is to burn those little MBBs. How you get there means nothing, as long as you can be parallel to the nerves along the longest segment of your active tip.

 

[bedrock]

why we are not as skeptical as we are towards other physicians who tout a technique with poorly reproduced results
I am doubting the presumption that there can be only one way of doing RFA.

You confuse me. One hand you say, "why do we have to do RFA with SIS technique?, I'd rather do it my way"

And on the other hand, you complain that RFA results don't match the original studies.


I think the answer is looking at you in the face..........Uh, if you want to reproduce the RFA results of the original studies......how about you use the technique of the original studies........SIS technique.

I don't understand your resistance.

 

[Ducttape]

no, what im saying is that, using you as an example, you do not get on a pedestal about there being only one way of doing any other procedure, that you are willing to allow multiple variables (meds used, technique used, equipment used, etc.) to perform multiple other procedures, yet for RFA, there is only one way.

to put it more simply...

as long as you burn the median branch/dorsal ramus on patients with facet mediated arthopathy, you will most likely get benefit.
I would hate to see CMS get involved and say "you aren't following SIS technique for RFA exactly by the book, you aren't going to get paid"...

well, maybe you are right...

 

[DrCommonSense]

http://www.mrctv.org/blog/uk-socialist-health-system-proposes-surgery-ban-obese-and-smokers

NHS bankrupt, so no obese patients allowed for elective surgeries unless they show motivation... Good concept to cover a failed socialist system.

If they implemented this policy in the USA, most Orthopedic surgeons that perform knee replacements and hip replacements as their biggest money makers will go bankrupt.

Can't see this going through in America. Too many obese people.

>95% of medical care could probably be eliminated with exercise, diet, lack of smoking, and good sleep.

Simple but rarely done.

 

[Ducttape]

obesity rate in UK is only slightly less than the obesity rate in the US.

https://www.theguardian.com/news/da...-the-uk-obesity-rates-compare-other-countries

 

[Papa Lou]

The worst is the super westernized people that want to be on 5 different meds from the pain doctor--to go along with the rest of their pharmacy from other specialties. As opposed to just keeping it simple and enduring some proper discomfort.