RF of the GON

[SIIMS]

I work with a doc who does RF of the greater occipital nerve (not pulsed). He has a fairly steady referral pattern from a local neurology group for this.

I have never seen or heard of anyone doing this during residency or fellowship. Treatment options besides meds or therapies at least as I thought available were, anesthetic/steroid injection, neuromodulation or C2 ganglionectomy.

I would think that the possibility of deafferentation pain would be high, however, he states in his practice that is not so. Also, I wonder about coagulation the GO artery, and he said he has never had this complication.

Thoughts on this??

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[drf]

I'd love to hear of anyone cRFing any peripheral nerve in a non cancer patient. I think I've asked on this forum before.

I still haven't done it.

 

[emd123]

I work with a doc who does RF of the greater occipital nerve (not pulsed). He has a fairly steady referral pattern from a local neurology group for this.

I have never seen or heard of anyone doing this during residency or fellowship. Treatment options besides meds or therapies at least as I thought available were, anesthetic/steroid injection, neuromodulation or C2 ganglionectomy.

I would think that the possibility of deafferentation pain would be high, however, he states in his practice that is not so. Also, I wonder about coagulation the GO artery, and he said he has never had this complication.

Thoughts on this??

As far as efficacy, I'm not sure. As far as the GO artery: the scalp is extremely vascular. Ischemic necrosis would be extremely unlikely. People get deep scalp lacks down to the skull that can be through an artery, all the time. Such lacs bleed ferociously, but can be closed easily without vascular repair of any artery. Collateral circulation is more than adequate.

Anatomically, nerves run with their arterial supply as a rule anyways. This gets RF'd anytime you do a (thermal) RF.

 

[bedrock]

I work with a doc who does RF of the greater occipital nerve (not pulsed). He has a fairly steady referral pattern from a local neurology group for this.

I have never seen or heard of anyone doing this during residency or fellowship. Treatment options besides meds or therapies at least as I thought available were, anesthetic/steroid injection, neuromodulation or C2 ganglionectomy.

I would think that the possibility of deafferentation pain would be high, however, he states in his practice that is not so. Also, I wonder about coagulation the GO artery, and he said he has never had this complication.

Thoughts on this??

I've never seen it in residency or fellowship either.
Some of my referring MDs have requested this, but I'm too concerned about the risk of deafferentation pain as well, which is why I was taught not to do it.

Does your friend do these under ultrasound? Seems like that would be the only reasonable way to ensure you were selectively burning the nerve. And to ensure you missed the artery.

I guess you could just RF a bigger area to ensure you lesion it, but that would increase your vascular complication rate, and post-procedural pain.

 

[clubdeac]

I did a few of these when I started on my own at the VA. At the time I didn't know any better. I'd do a block and they'd get relief for a week or two. I thought why not try CRF. I never got great results but never had any deafferentation pain or uncontrollable bleeding either. I always thought it was kinda stupid w/o US as the nerve could be anywhere and I was creating such a relatively small lesion in comparison to my block. I only did a handful of cases before I gave up

 

[Jcm800]

I've never seen it in residency or fellowship either.
Some of my referring MDs have requested this, but I'm too concerned about the risk of deafferentation pain as well, which is why I was taught not to do it.

Does your friend do these under ultrasound? Seems like that would be the only reasonable way to ensure you were selectively burning the nerve. And to ensure you missed the artery.

I guess you could just RF a bigger area to ensure you lesion it, but that would increase your vascular complication rate, and post-procedural pain.

Had aguy do these in fellowship. I was always worried about the usuals, but never a problem...

 

[PinchandBurn]

I've done cRF of the ilioinguinal nerve and the GF nerve with ultrasound. Got great results for the GF nerve, not so great for the ilioinguinal nerve. No defferantion pain.

In fellowship we did occasionally do cRF of the GON. I cant recall any deaff pain....

 

[Ligament]

I've thermal RF'd intercostal nerves for 12th rib syndrome, and have a thermal RF GON pending in a couple weeks. These nerves hurt like hell while burning, but so far no negative long term sequelae in my low n.

 

[Ducttape]

in fellowship, we did cRF without deafferentation pain.

 

[Jcm800]

in fellowship, we did cRF without deafferentation pain.

Yet we all talk about...wierd. Is it some old pain folklore that doesnt really apply? I used to crank the temp to 50 degrees to satisfy the code, but now I just do c2-3

 

[epidural man]

I work with a doc who does RF of the greater occipital nerve (not pulsed). He has a fairly steady referral pattern from a local neurology group for this.

I have never seen or heard of anyone doing this during residency or fellowship. Treatment options besides meds or therapies at least as I thought available were, anesthetic/steroid injection, neuromodulation or C2 ganglionectomy.

I would think that the possibility of deafferentation pain would be high, however, he states in his practice that is not so. Also, I wonder about coagulation the GO artery, and he said he has never had this complication.

Thoughts on this??

I would think it is similar to RFing the TON. I was scared of that, but y'all convinced me otherwise.

 

[PinchandBurn]

I would think it is similar to RFing the TON. I was scared of that, but y'all convinced me otherwise.

man...but these guys (RF of TON), almost always get post RFA neuritis.


If you RF the greater occ nerve, i dont see the reason not to place depo steroid (depomedrol) in the location that you RF'd. This would hpeflly prevent defferntiaion/post neuritis time pain I would presume..........atleast attenuate it. I doubt anyone is placing depot steroids right next to the TON after RFing it these days....

 

[NEPain]

If you're going to burn the GON, why not just stick the needle medial to the palpable artery and fish around a little while stimulating until you get paresthesias in the GON distribution?

Then you're on the nerve and can burn if you want.

 

[bedrock]

man...but these guys (RF of TON), almost always get post RFA neuritis.


If you RF the greater occ nerve, i dont see the reason not to place depo steroid (depomedrol) in the location that you RF'd. This would hpeflly prevent defferntiaion/post neuritis time pain I would presume..........atleast attenuate it. I doubt anyone is placing depot steroids right next to the TON after RFing it these days....

not depot, but I always inject dexamethasone after TON RF

 

[bedrock]

If you're going to burn the GON, why not just stick the needle medial to the palpable artery and fish around a little while stimulating until you get paresthesias in the GON distribution?

Then you're on the nerve and can burn if you want.

The artery isn't always palpable.

 

[sweetalkr]

my two cents, i just RF'd the occipital nerve today and i do it once a month. i do suboccipital compartment decompressions or occipital nerve blocks. if after repeating them i don't get greater than 1 month relief, I usually Cryo the nerve. however we are still buying a cryo machine and waiting on it so I have RF'd it (along with saphenous nerve which i usually cryo). so far no issues. I put it across the nuchal ridge as we did with cryo in fellowship, stim to make sure i can reproduce pain, negative aspirate, and burn the sucker at 65 degrees (for pt comfort) for 90 and drag across nuchal ridge. have gotten good results comparable to cryo so far however my N = about 6 right now

 

[SIIMS]

Thanks for the responses, haven't done it yet

But the more I think about it, not much different than TON as far as anatomy goes (both medial branches of spinal nerves)

 

[Ducttape]

If you are worried about it, why not use ultrasound?

 

[drf]

my two cents, i just RF'd the occipital nerve today and i do it once a month. i do suboccipital compartment decompressions or occipital nerve blocks. if after repeating them i don't get greater than 1 month relief, I usually Cryo the nerve. however we are still buying a cryo machine and waiting on it so I have RF'd it (along with saphenous nerve which i usually cryo). so far no issues. I put it across the nuchal ridge as we did with cryo in fellowship, stim to make sure i can reproduce pain, negative aspirate, and burn the sucker at 65 degrees (for pt comfort) for 90 and drag across nuchal ridge. have gotten good results comparable to cryo so far however my N = about 6 right now

How do you do the decompression? US?

So you are cryoing the GON at the skull, not as it wraps around the obliquus capitis inferior?

Where are you RFing the saphenous? Subsartorial with US or at the knee simply fishing for infrapatellar branches.

 

[sweetalkr]

saphenous - i personally use nerve stim at the median patellar branch and get pretty decent results with OA patients in young people not getting a knee replacement for a while. it gives them a bit of relief (30-80%) and rarely complete relief albeit a short time. i use nerve stim to get a "buzzing" sensation over the medial aspect and sometimes more of the knee.

the decompression is described in Raj's interventional pain book, the yellow one i own. i have it on kindle and hard copy. basically go with a 25 g spinal needle just lateral and inferior to the A-A joint, go down to approximately 1-2 cm posterior to the C2 spinous process. check the book for what muscle you want to see and the shape/outline on contrast. inject about 5-7 mLs of local/steroid/saline/any concoction you want to decompress. amazingly i get great relief. on average it is 1-2 months, however some pts get prolonged relief (maybe 40%?) the others i repeat and some get longer, the ones that don't i burn. i cryo over nuchal ridge, use the stim to isolate the nerves and palpate for artery.

 

[PinchandBurn]

my two cents, i just RF'd the occipital nerve today and i do it once a month. i do suboccipital compartment decompressions or occipital nerve blocks. if after repeating them i don't get greater than 1 month relief, I usually Cryo the nerve. however we are still buying a cryo machine and waiting on it so I have RF'd it (along with saphenous nerve which i usually cryo). so far no issues. I put it across the nuchal ridge as we did with cryo in fellowship, stim to make sure i can reproduce pain, negative aspirate, and burn the sucker at 65 degrees (for pt comfort) for 90 and drag across nuchal ridge. have gotten good results comparable to cryo so far however my N = about 6 right now

You are RFing the occ nerve every month? How do you get paid for that? With RFing the MBBs, I thought you can only do it every six months. THere's no issues in doing it for peripheral nerves?

THen the question is begged, why RFing monthly instead of just doing steroid injection every month?

I have a guy htat I RFed the Ilioinguinal nerve, marginal results. i want to repeat it, but it hasnt been 6months, so I was going to wait....

Also, you do it only for 65seconds? can you get paid for that? i thought it had to be at 80deg celsius...

 

[drrosenrosen]

Reviving this thread from the dead. I'm in a new area, where I have a neurologist sending me a lot of headache patients for C2/GON RF. I haven't been able to talk to her yet about it. I've never done the procedure, but of course have done a lot of TON for headaches with good results. For now, I've been offering pts TON, and told them I'd be willing to consider trying the GON/C2 RF if it fails. Is anyone doing these now? Technique? Coding? Things to watch out for?

 

[PainDrain]

I would use caution with RF of the GON as I have seen a case of severe deafferentation pain. It's rare but it can happen. Why not try pulsed if you can bill for it or if it's severe GO neuralgia then maybe stim it.

 

[BobBarker]

Don't RF the saphenous. I have allodynia and hyperalgesia from my saphenous nerve getting burned durning saph vein ablation over one year ago.

 

[bedrock]

I would just pulse both nerves, and stim GON if it failed the pulsed.

None of this is covered so cash pay for all the procedures.

 

[bronchospasm]

RFed the Occipital nerve with good relief for 11 months. Just 1 patient so far. Just repeated it again. Let's see how long it lasts this time. I should offer it more.