RA knee pain -- genicular nerves?

[ateria radicularis magna]

Thanks in advance for your thoughts--

Would you try genicular nerve blocks/RF on a patient with RA appropriately treated with DMARD/immune modulation who still has severe knee pain?

There is evidence for knee joint injection of steroids or hyaluronate in RA patients, but I don't find anything on genicular nerves. To speculate, it seems like the pain generator could be the inflamed synovial membrane or interosseous contact (probably both), and I'm not sure how you could tease that out clinically besides asking basic questions like, does it hurt worse in the morning or at night, etc.

In my training the thought was that first and foremost the RA patient needs to be treated by rheumatology, but interventions/medications were considered after appropriate RA treatment. I realize this is a vague outlook, and my intention is to educate myself (if possible).

In fact, throughout fellowship I felt very confused about treatment of pain in rheumatologic disease. I would be very interested to hear about how others try to tackle it.

Gracias.

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[lobelsteve]

Yes.

 

[clubdeac]

Yes to that situation. How bout this one. I got a patient referred by ortho who is s/p TKA, explant with antibiotic spacer placement and 6 weeks IV antibiotics now with MRSA infection on chronic doxy (think that's what it was). Ortho told him the only thing they had to offer was amputation. I'm assuming no one would stick a needle in him even though it's a very superficial block

 

[bedrock]

If this is second explant, then I understand Ortho, however, if just first explant then I don't get why they wouldn't eventually offer another TKA?

if the patient will be ambulating on spacer, and you get ID clearance then I could see a rationale for genicular RF, but if the patient is permanently just bed-ridden or wheelchair bound, I wouldn't bother with genicular RF.

 

[lobelsteve]

Yes to that situation. How bout this one. I got a patient referred by ortho who is s/p TKA, explant with antibiotic spacer placement and 6 weeks IV antibiotics now with MRSA infection on chronic doxy (think that's what it was). Ortho told him the only thing they had to offer was amputation. I'm assuming no one would stick a needle in him even though it's a very superficial block

Already on treatment for infection, nothing to lose.

 

[ziggyziggy]

Yes to that situation. How bout this one. I got a patient referred by ortho who is s/p TKA, explant with antibiotic spacer placement and 6 weeks IV antibiotics now with MRSA infection on chronic doxy (think that's what it was). Ortho told him the only thing they had to offer was amputation. I'm assuming no one would stick a needle in him even though it's a very superficial block

Did similar one with OK results but after IV antibiotics.

 

[clubdeac]

Yeah I just talked to ID and they said go ahead so I'll probably try it. We'll see how it goes

 

[Papa Lou]

Yeah I just talked to ID and they said go ahead so I'll probably try it. We'll see how it goes

Please followup, I'm very interested. I have tried as much as I can to get these RFs to work...it's been very underwhelming.

 

[lobelsteve]

Please followup, I'm very interested. I have tried as much as I can to get these RFs to work...it's been very underwhelming.

Post pics

 

[bedrock]

Post pics

good idea, I think it would be useful for all of us to discuss ways of improving technique and clinical response to genicular RF

 

[clubdeac]

I'll post some when I have my next one. Might not be for awhile though

 

[JARAM1011]

Question: How would I have received second degree burns on my thigh from a genicular ablation? I've tried to look for answers on the internet; this is not listed as a post-procedural complication.

 

[bedrock]

This forum is not for patients to ask medical questions. Please discuss your concerns with your physician.

Mods- we may need to move this thread to private forum.

 

[pmrmd]

Two cases from the other day

 

[bedrock]

nice pics!

It is so much easier to see without hardware in the way

 

[drpainfree]

Two cases from the other day





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do you always use two needles for each genicular branch?

 

[Ligament]

Two cases from the other day





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Nice placement, looks like will get great results! I just saw a patient I did this on a year ago, still 100% pain free in the knee, though she has a large effusion.

 

[Extralong]

Love this procedure.

 

[Papa Lou]

What were the results PMRMD?
I can post pictures if it's necessary but there's not much technicality here from what I can see. My pics look exactly like PMRMD. Only in the second patient they look more distally placed than I would. Mine look exactly like the first patient every time on AP and lateral. The main difference b/c me and his style is I use ONE 18g needle. I burn 80 degrees 90 seconds with the tip slightly deeper on lateral view and then pull back 1cm and burn again. That way I cover a total of roughly 20mm with the active tip. I started doing this to see if I was missing the nerve. I am not happy with results.

To the docs that love this procedure please post some valuable information or pics maybe...? PMRMD were the results good at followup and how do you normally do? Please no hyperbole guys...I know sometimes some of the guys get carried away.

 

[drpainfree]

Two cases from the other day





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again, PMRMD, please clarify why you use two needles on each genicular branch and essentially doubling the procedure time and cost.

 

[pmrmd]

I do two needles because I wasn't happy with the results with one needle. I haven't seen these people back yet but for one of the cases posted above I did her other knee as well and she is 100% improved on that side.