Scar neuroma injection

[giddyup]

I have a very reliable patient who injured his left arm a number of years ago in a car accident and has about a 10 inch long scar on his forearm that is causing him pretty significant pain. The guy works full time, uses narcs only very sparingly, is a good patient, etc. I have injected the scar twice now with a combo of bupivacaine and kenalog 10mL with about 95% relief for one week. I was thinking about how I could make this last a bit longer for him and was wondering if anyone had experience with alcohol, phenol, or RFA for something like this. If so, how do you get it authorized and bill for it?

Thanks!

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[Ducttape]

RFA for scar neuroma. i believe it is 64640?

 

[pmrrmp]

I inherited a patient, nice lady with a scar neuroma from prior lap chole at one of the trocar sites. Prior doc would just inject the area with local + kenalog in a fan distribution and she'd get one year of relief. I do the same for her now. Lasts long enough (according to her) that she doesn't want anything else.

 

[lobelsteve]

Alcohol contra-indicated close to the skin.

Ref is a 1955 textbook that is out of print.

But you will not be able to defend the complications if infection occurs or if sloughing occurs, no matter the time course.

:cry:

 

[Doctodd]

Prp

 

[joshmir]

I feel like I am the ambassador for botulinum toxin chemodenervation of scar neuromas

I've injected usually 100u into big and small scars (sometimes 200u) 20-30 times; no complications; i draw it up in 4-5 cc local and inject as superficailly within the scar as possible; sometimes I'm so superficial my needle pops through the top of the scar; I may be "breaking up" the scar as well, which some people intentionally due

About half have meaningful relief for at least 3 months; some far longer

I have been working in integrated systems where insurance reimbursement is not an issue

 

[bedrock]

compounded topical pain cream with ketamine, lidocaine, gabapentin, NSAID, etc

 

[drf]

Half my patients have postsurgical scar neuromas. I inject local diagnostically, then Botox. Then pRF. Then either cRF or low concentration alcohol 10-15% several times to minimize chance of necrosis.

Also often diagnostically block the afferent nerve to the area and pulse that. Or if possible depending on nerve have a surgeon transect and bury.

If only one specific area of scar has Tinels and resolves with very specifically applied local ill have my surgeon cut there and dissect out neuroma.

If neuroma is big and I see it on US same thing.

 

[lovebailey2001]

I have done some 15-20 cases of scar injections of Botox with good results, though some patients required repeat injections. All of them did well with anti neuropathic medications (TCA/ Gabapantin) and local application of capsaicin cream, relief up to 75%.

 

[giddyup]

How do you get the Botox covered?? He is a truck driver and isn't exactly rolling in it. Has private insurance though. Even getting the injection covered required two phone calls.

 

[Ligament]

I cannot get botox paid for by anybodies insurance for scar infiltration, I wish I could...

 

[onewithpain]

If you can see the scar on US and especially if you can see the neuroma on US then try using local to bluntly dissect the scar tissue from the nerve. Place a little steroid after to inhibit scar tissue from reforming. I do a lot of belly scars this way with good results. Sometimes I'll place a little phenol on the nerve but I hate to do that if it's superficial as it can cause the skin to slough.
I've got a few patients with bilateral trapeziectomy who still have a lot of pain and have been tempted to use botox there because it is so superficial. The hand surgeons admit that the surgery isn't a good option and have suggested neuro ablation instead. If I thought that I could keep phenol in the joint I'd do it, but the botox would be safer.

 

[lonelobo]

If you can see the scar on US and especially if you can see the neuroma on US then try using local to bluntly dissect the scar tissue from the nerve. Place a little steroid after to inhibit scar tissue from reforming. I do a lot of belly scars this way with good results. Sometimes I'll place a little phenol on the nerve but I hate to do that if it's superficial as it can cause the skin to slough.
I've got a few patients with bilateral trapeziectomy who still have a lot of pain and have been tempted to use botox there because it is so superficial. The hand surgeons admit that the surgery isn't a good option and have suggested neuro ablation instead. If I thought that I could keep phenol in the joint I'd do it, but the botox would be safer.

Really?

 

[olafa]

why not try WYDASE?

 

[onewithpain]

Really! Get the needle into the scar and inject and you can see the layers separate on ultrasound. Advance the needle a hair and separate the next layer. As you get to the nerve the patient will have a revelation. Leave a little steroid there. It's more like hydro-dissection but I call it "fracking". If you can't break up the layers then wydase would be a great choice. Inject and let it stew for a few days and then inject again and see if the layers separate.

 

[lobelsteve]

Really! Get the needle into the scar and inject and you can see the layers separate on ultrasound. Advance the needle a hair and separate the next layer. As you get to the nerve the patient will have a revelation. Leave a little steroid there. It's more like hydro-dissection but I call it "fracking". If you can't break up the layers then wydase would be a great choice. Inject and let it stew for a few days and then inject again and see if the layers separate.

You must be using a 4D US machine.

 

[onewithpain]

It's a mindray so it should have at least 4 dimensions, I just can't find the button that controls them. Try an RFA with US and watch the tissue change as it heats.

 

[Ducttape]

technically, the mindray should follow M theory, and exist in 11 dimensions at one time...

 

[NickZ]

Hi, guys! My mom has been experiencing pelvic pain for over ten years now. She recently had a pelvic floor EMG done, and this is what the neurologist's diagnosis/plan are:

Multifactorial pain with a portion related to a surgical scar neuroma based on reproduction of pain with palpation of the right lateral edge of caesarean section scar and is further supported by a 60% reduction in pain following a diagnostic nerve block with 1 ml of xylocaine. The other portion is related to reactive spasm in the iliopsoas. There is no eloctrodiagnostic evidence of a right ilioinguinal nerve neuropathy based on symmetric findings on nerve conduction studies.

PLAN: Suggest sensory fibre blockage at the level of the neuroma with subcutaneous and intradermal level botulinum toxin injection.

The only problem is that she had the EMG done in upstate New York, but she lives in Florida. She's been having trouble finding somebody to do the injection. Does anybody know where she might be able to get it done in Florida or in the Southeast US?

Thanks so much for the help!

 

[lobelsteve]

Paging doctodd.

 

[drusso]

I feel like I am the ambassador for botulinum toxin chemodenervation of scar neuromas

I've injected usually 100u into big and small scars (sometimes 200u) 20-30 times; no complications; i draw it up in 4-5 cc local and inject as superficailly within the scar as possible; sometimes I'm so superficial my needle pops through the top of the scar; I may be "breaking up" the scar as well, which some people intentionally due

About half have meaningful relief for at least 3 months; some far longer

I have been working in integrated systems where insurance reimbursement is not an issue

Agree with botulinum toxin for scar neuroma.

 

[Timeoutofmind]

I have a very reliable patient who injured his left arm a number of years ago in a car accident and has about a 10 inch long scar on his forearm that is causing him pretty significant pain. The guy works full time, uses narcs only very sparingly, is a good patient, etc. I have injected the scar twice now with a combo of bupivacaine and kenalog 10mL with about 95% relief for one week. I was thinking about how I could make this last a bit longer for him and was wondering if anyone had experience with alcohol, phenol, or RFA for something like this. If so, how do you get it authorized and bill for it?

Thanks!

Bioness stimrouter

 

[Doctodd]

i "cured" a hernia mesh repair guy few weeks ago after 5 failed injections at the Cleveland Clinic. They simply missed(5 times). It was just some lido and kenalog first and lets see how he does in the next few weeks. If a couple injections dont give long lasting relief, then PRP is next...just like i said in 2013.

 

[hyperalgesia]

I suddenly started getting a lot of post-thoracotomy, scar tissue neuroma pain. Might try botox...

 

[Biohazard685]

In fellowship we had a good track record with pulse RFA of painful scar I wish I could remember how we billed it.

 

[Doctodd]

Saw him today...still improving.....turns out I didn’t use kenalog in early February. It was lido and traumeel. He was interested in another injection but I told him if he was still improving it was better to ride it until he plateaued or got worse.

 

[drrosenrosen]

what cpt do you bill for botox scar injection?

 

[pain_doc_]

what type of needle and what details surrounding placement are you using for pulsed ablation? ie what active tip, what depth, how many lesions etc.

 

[willabeast]

what type of needle and what details surrounding placement are you using for pulsed ablation? ie what active tip, what depth, how many lesions etc.

FYI - My technique - YMMV - neurotherm 22 gauge (short) pulsed RF needle set on neurotherm generic pulse RF settings except increase time interval. find the nerve/neuroma with it pulsing. patient will tell you how far or close you are to the nerve or neuroma. once close enough (based on what patient tells me) hold needle in place for 8 - 10 minutes. after done pulsing, remove electrode and inject some lidocaine. remove needle.
now this technique may be at odds with neurotherm instructions, which may not want you to be moving needle around looking for the nerve/neuroma with the electrode in place, but i thought it was faster/more reliable than using the nerve stimulator technique. also - sometimes would inject a little dye into needle and save a fluoro pic so i might find it easier in the future.