Shoulder RF

[bedrock]

We have a thread on hip RF, I'd be interested in hearing from the collective group from those that do pulsed or thermal RF of the suprascapular nerve for shoulder pain.

How often do you do SSN RF?
Just for severe OA in elderly or failed shoulder arthroplasty or do you do it for other indications?
Fluoro guidance or ultrasound?
Pulse or thermal RF?
Any technique suggestions?

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[lobelsteve]

Fluoro, 20g. Touch os below notch. Walk in a cm. Fluoro w contrast to show no iv uptake and not in ss muscle. 80deg 90 sec.

Arm abd to 90 to see notch better

 

[Jcm800]

I do them with u/s. But maybe Fluoro would be better. I have a hard time getting a good view with Fluoro... Do you have them seated or lying prone?
Maybe I should give that a whirl again. I do realistically 5-10 a year? I'm about 50-50 as far as results but I'm sure my technique could be improved upon


Sent from my iPhone using SDN mobile

 

[lobelsteve]

Prone.
https://www.dropbox.com/s/cjh8ehbsxutu60p/Lobel SSNB Presentation.pptx?dl=0

 

[Aether2000]

I am working on a brain denervation technique....requires around 100 lesions intracranial and extra cranial for headaches or for whatever...

 

[pastafan]

Patients with rotator cuff tears who are not surgical candidates are another indicated group. Generally elderly with H/O multiple CVA, MI with stents on anticoagulant or just limited life expectancy who are not willing to lose months of what is remaining doing rehab.

 

[oreosandsake]

post arthroplasty, cont shoulder pain.

US, in plane. medial to lateral so you are deep, away from the lungs.

 

[Ligament]

I inject 1 cc of Phenol as well as do the RF.

Actually, I inject the phenol, fire up the RF generator, ignite the phenol into a fireball, and thats how I roll.

 

[bedrock]

Steve is the only one who posted about thermal vs pulsed lesions.

What about the rest of you, thermal or pulsed?
If pulsed, how do you get paid?

 

[Ligament]

I do thermal. If it does not work, I will repeat with thermal RF + 1 or 2 cc high viscosity Phenol. I have a fear, perhaps irrational, of the phenol tracking up to C5 and C6 roots.

Any pulsed RF I do is paid out of pocket by the patient, as no insurance will pay me for pulsed RF.

 

[pastafan]

Thermal. As JCM800 has experienced, my success is not as high as I would like. Get good twitch at 0.2V but results about 75% success. When it works they get total relief.

 

[Gauss]

Ultrasound-guided block of the suprascapular nerve – a volunteer study of a new proximal approach
C. Rothe1, C. Steen-Hansen1, J. Lund2, M. T. Jenstrup2 and K. H. W. Lange1

 

[epidural man]

Ultrasound-guided block of the suprascapular nerve – a volunteer study of a new proximal approach
C. Rothe1, C. Steen-Hansen1, J. Lund2, M. T. Jenstrup2 and K. H. W. Lange1

This is a good description - although I think they took my report and improved on it....can't blame 'em for that.

Hackworth, Robert J. "A new and simplified approach to target the suprascapular nerve with ultrasound." Journal of clinical anesthesia 25.4 (2013): 347-348.

Bedrock - I used to do these more often with pulsed using the technique I describe above. I used the pulse -dose mode with our Neurotherm - 45C at 45V for 960 pulses.

However, now - I usually just inject the offending area (tendon, bursa, intra-articular) with AmnioFix after a response to local and/or steroid.

Regarding billing - good question.

Could you place the needle, and after treatment use 4% lidocaine and bill it as a chemodenervation? 4% is pretty toxic.

 

[drpainfree]

Ultrasound-guided block of the suprascapular nerve – a volunteer study of a new proximal approach
C. Rothe1, C. Steen-Hansen1, J. Lund2, M. T. Jenstrup2 and K. H. W. Lange1

can anyone share the actual article here?

 

[oneforfighting]

Prone.
https://www.dropbox.com/s/cjh8ehbsxutu60p/Lobel SSNB Presentation.pptx?dl=0

Would you mind reposting this? Link no longer working.

 

[lobelsteve]

Would you mind reposting this? Link no longer working.

PM me, cannot online share from iCloud.

 

[Ferrismonk]

One more reason to hate Apple.

 

[lobelsteve]

As much of a problem with me switching from dropbox to Google Drive to iCloud. My hospital network doesn’t allow me to access any of those when I’m in the office. Ports are locked down.

 

[epidural man]

As much of a problem with me switching from dropbox to Google Drive to iCloud. My hospital network doesn’t allow me to access any of those when I’m in the office. Ports are locked down.

Surprisingly behind the military internet fortress, I can get to iCloud.

 

[lobelsteve]

Lobel SSNB Presentation.pptx

Shared with Dropbox

www.dropbox.com

 

[Painologist]

Do majority of people still prefer thermal RF over pulsed for the suprascapular nerve? Last time it was discussed was 2016.

 

[BobBarker]

Steve,
Think you can find more fluoro shots? Your presentation has only one. Also, “6cc Marcaine, 1cc steroid”??

 

[lobelsteve]

Now just 3cc 0.25%

 

[pmrmd]

Is anyone doing shoulder RF targeting the articular branches? The posterior branch seems to have no landmark and that anterior subclavicular one seems pretty uncomfortable for the patient.

 

[Orin]

Is anyone doing shoulder RF targeting the articular branches? The posterior branch seems to have no landmark and that anterior subclavicular one seems pretty uncomfortable for the patient.

Yes. With cooled RFA, four posterior burns split between axillary and SSN articular branches. Skip the anterior.

 

[cowboydoc]

Cook the posterior/medial aspect of the capsule. I'm doing the dx blocks with u/s, fluoro for RF. I don't do the anterior target (lateral pectoral nerve) if I don't have to. I test them after the 2 other blocks.

The ant approach from lateral to medial is usually reasonably tolerated.

 

[mdo1738]

Is anyone doing shoulder RF targeting the articular branches? The posterior branch seems to have no landmark and that anterior subclavicular one seems pretty uncomfortable for the patient.

Yes, did 2 posterior (SSN and axillary articular) and then the anterior (lateral pectoral) during fellowship. None of them necessarily seemed more uncomfortable than the other from what I noted. The anterior one does seem to have minimal contribution, some folks skipped that one and anecdotally I noticed no difference in results. Saves a lot of time being able to eliminate flipping from prone to supine, re-prepping, etc.

Will try to track down some of the images for landmarks.

 

[Orin]

Putting Our Shoulder to the Wheel: Current Understanding and Gaps in Nerve Ablation for Chronic Shoulder Pain

Abstract. Shoulder pain is prevalent, burdensome, and functionally limiting, with diverse pathology and associated treatments. This narrative review provid

academic.oup.com

This has nice landmarks and discussion if you're into that kinda thing. I'm fine doing A and B, but C and D are rare and never personally. Unlike the genicular where you have to do at least 3 sites, I normally do the 2 and see if they want/need to come back for the anterior targets later.