Repeating genicular RF?

[Timeoutofmind]

Have a lady 100% relief with diagnostics.

100% relief with cooled RF x 1 month.

Now pain is back, same distribution as pre-procedure.

I dont think there is ITB/Pes Anserine or other such issue.

I got worried about infection, but her implanting ortho saw her ASAP in office and didnt think so and the ESR/Sed/CBC I sent was neg.

I guess my question is how can I explain this?

Incomplete neurolysis from suboptimal needle positioning?

Should I repeat the RF?

Or is it more "central pain"/neuropathic pain without as much of a nociceptive element and it is more a DRG stim type situation?

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[Taus]

Pain relief x 1 month after RF.... did you use steroid w the RF? Usually I chaulk this up to failed RF and steroids post burn giving temp relief. I don't repeat failed RF unless I reviewed my films and feel I can do it differently next time.


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[bedrock]

Agree this sounds like total RFA failure. I doubt it actually worked at all. This duration of relief is usually a result of injected steroid or placebo effect .

 

[DOctorJay]

If they got 100% relief with the blocks I would not be thinking DRG


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[bedrock]

What was your block technique and in particular how much volume did you inject?

Best way to a false positive block is to inject too much.

 

[Dr. Ice]

False positive response to lumbar/cervical mbb likely relates to corticosteroid use and/or high volume of injectate as this has been studied fairly extensively. While logic would dictate the same applies to genicular nerve rfa..the other factors may include variability of the location of the nerves. The technique described for block and subsequent rfa has not been as extensively studied and so there could be a number of reasons for treatment failure. I have done a fair number of these in recent years mainly on post surgical patients with continued pain and find the results to be pretty varied despite using very standardized block technique in terms of volume of injectate, not utilizing steroid, double block paradigm, etc. I think, as much as I am not necessarily a strong proponent in beating the evidence based medicine horse to death, that some further studies need to be done to better standardize this treatment

 

[Timeoutofmind]

Pain relief x 1 month after RF.... did you use steroid w the RF? Usually I chaulk this up to failed RF and steroids post burn giving temp relief. I don't repeat failed RF unless I reviewed my films and feel I can do it differently next time.


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Local anesthetic + steroid lasting a month! Does not seem consistent with pharmacology...

 

[Taus]

Local anesthetic + steroid lasting a month! Does not seem consistent with pharmacology...

Are you being sarcastic? or you're telling a forum of pain docs that injected steroid on a target lasting a month or more is bs?


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[Agast]

I tell my patients I'm only burning 3 out of the 4 sensory nerve branches to their knee and the 4th one is still capable of sensing pain within the knee.

 

[Papa Lou]

Are you being sarcastic? or you're telling a forum of pain docs that injected steroid on a target lasting a month or more is bs?


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If he's not then I am. A month or more from steroid brah? No that is not something that occurs more than rarely.

 

[Ducttape]

If he's not then I am. A month or more from steroid brah? No that is not something that occurs more than rarely.

I assume then that you do no epidurals, transforaminals, peripheral nerve blocks...


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[Papa Lou]

I assume then that you do no epidurals, transforaminals, peripheral nerve blocks...


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Very bad assumption. different thing altogether

 

[Ducttape]

how so? please explain. especially with regards to peripheral nerve blocks.

 

[bedrock]

Are you being sarcastic? or you're telling a forum of pain docs that injected steroid on a target lasting a month or more is bs?


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Local anesthetic + steroid lasting a month! Does not seem consistent with pharmacology...

Seriously. If you've never seen a patient get a month of relief from steroid injections in various places, you must be a medical student.

 

[ateria radicularis magna]

Pain relief x 1 month after RF.... did you use steroid w the RF? Usually I chaulk this up to failed RF and steroids post burn giving temp relief. I don't repeat failed RF unless I reviewed my films and feel I can do it differently next time.


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What makes you decide on way or the other?

 

[ateria radicularis magna]

I tell my patients I'm only burning 3 out of the 4 sensory nerve branches to their knee and the 4th one is still capable of sensing pain within the knee.

Aren't there 5?

 

[Ligament]

The commonly accepted RF needle placement locations are insufficient to account for the variability in these nerves. It is amazing to me that we ever get them at all with xray guidance. On U/s can usually see them very clearly. I do my genicular blocks under u/s but RF under xray...I'm considering moving to doing all of it under u/s. There is NO WAY we are getting all the nerve with xray needle placement unless you are doing huge swaths of bipolar lesions. This procedure needs some refinement IMHO.

 

[oreosandsake]

The commonly accepted RF needle placement locations are insufficient to account for the variability in these nerves. It is amazing to me that we ever get them at all with xray guidance. On U/s can usually see them very clearly. I do my genicular blocks under u/s but RF under xray...I'm considering moving to doing all of it under u/s. There is NO WAY we are getting all the nerve with xray needle placement unless you are doing huge swaths of bipolar lesions. This procedure needs some refinement IMHO.

+1

 

[painfree23]

just since we are talking about geniculars -- do you do them with the knees flexed, fluoro coming in AP to the knee? Do you do conventional RF, pulsed? Also, are all of them non-surgical candidates or post op knee pains?