knee pain

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clubdeac

clubdeac

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  1. Attending Physician
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So I've got several patients with chronic knee pain following various arthroscopic procedures. Both over the anterior/inferior knee. I injected the infrapatellar branch of the saphenous nerve in one of them with chronic bilateral knee pain who was not felt to be a surgical candidate. He had immediate relief. Said it was the first time in yrs he's had any relief whatsoever. I haven't seen him in f/u so not sure how long it's gonna last. I have another guy sent to me after arthroscopic surgery with anterior/inferior neuropathic knee pain diagnosed as CRPS of the knee. I'm guessing he's got an injury of the infrapatellar branch and am planning on injecting him too. My question is, do you guys have any good techniques for injecting this nerve? and if it works, what do you do for long term relief? PRFA, RFA, cryo, alcohol....
 
I had a 73 y/o s/p total knee referred to me for chronic knee pain. He had multiple other issues, heavy narcotic use, many many surgeries all over his body. I did one of these blocks because I though it might help. He had an excellent response and reported this back to the referring orthopod who then forwarded me a journal article on surgical transection of this nerve. The pt followed up with me and was giddy with excitement about another surgery. Great... So I told him we should do another block to confirm and told him to keep a diary. This time he had equivocal relief. Nevermind, the ortho was all over it and transected the nerve. No relief... I've done a few others, all blind, but did not have adequate F/U. I would like to see this done with a nerve stimulator to record concordant pain.
 
we cryo the saphenous nerve here. mixed results

at the NANS conference, someone put 4 peripheral nerve stims around the knee hahaha i don't think that's a great idea, but if you want to spend a lot of government money and try something crazy...
 
sweetalkr said:
we cryo the saphenous nerve here. mixed results

at the NANS conference, someone put 4 peripheral nerve stims around the knee hahaha i don't think that's a great idea, but if you want to spend a lot of government money and try something crazy...
Click to expand...

It wasn't done to pend Govt money, it was done to pocket some of said money.
NANS is a joke. Last time I was there I saw a poster on treatment of GT bursitis using a PNS array.
 
we cryo the saphenous nerve here. mixed results


Sweet, how are you localizing the nerve? Electrical stimulation? Ultrasound? Percutaneous cryo or incision and exposing the nerve? I've started doing all cryo's "open", as the results are so much better. Of course, I have the benefit of ENTs doing the dissection with the face & occiput stuff. Cryo is so labor intensive and poorly reimbursed (I use the cryo machine at the hospital or asc) that I perform it quite rarely. However, I do have a young girl (17yo) that may be a candidate.
 
Pain,
are we talking about knee pain? You mentioned ENT, and i want to make sure we are on the same page here...
after examining the patient, if the patient has saphenous neuralgia consistent with their pain, we schedule them for a block. If the block is successful, we proceed to a cryo.
for the cryo, it is performed percutaneously. We essentially use landmarks, a 16g angiocath (i think that's the size; im a fellow, excuse my lack of knowledge 🙂) and place the cryo probe. we then stimulate with the cryo probe and ensure we have the same pain. then we freeze, depending on the attending, 90 seconds x 2 or one attending will freeze until the pain is not able to be stimulated. he will move the probe around the area until the sucker is good and freezed.
as for reimbursement, we are a teaching hospital so i don't have to worry about it for now...
does that answer your question?
You mentioned ENT so i thought maybe you were referring to trigeminals.. we do that percutaneous also and we will pulse more often than anything. sometimes they will rftc. and next week we are placing a PNS lead near the foramen ovale. i have never done it so i can't give you details until i do.
we have also done a few PNS leads in the tract of v1/2/3 and had great results with some patients, so we are starting to do more. we are also doing a permanent placement next week so i could let u know on that also.


Pain_doc said:
we cryo the saphenous nerve here. mixed results


Sweet, how are you localizing the nerve? Electrical stimulation? Ultrasound? Percutaneous cryo or incision and exposing the nerve? I've started doing all cryo's "open", as the results are so much better. Of course, I have the benefit of ENTs doing the dissection with the face & occiput stuff. Cryo is so labor intensive and poorly reimbursed (I use the cryo machine at the hospital or asc) that I perform it quite rarely. However, I do have a young girl (17yo) that may be a candidate.
Click to expand...
 
Thanks. I mentioned ENT as they assist with open cryo of facial/occipital nerves. I recently received a referral for cryo of the infrapatellar nerve. I prefer to perform "open" cryo. Under direct vision I'll typically make lesions at 2 or 3 areas on the nerve (depending on the probe size and nerve size). The stimulation part of the cryo probes are quite sh**ty. I'm also concerned about perc placement as it may also produce cryo along the entire saphenous. Just curious as to what others are doing.
 
Cryotherapy in the pain area is for specific nerves. There is ample evidence for trigeminal nerves, intercostal nerves, etc. The code is the generic nerve destruction code (sorry I don't recall the codes) for peripheral nerve. The treatment does work. In my practice, I offer it rarely. These are patients who have failed all other treatments and do not wish to pursue neuromodulation/aren't candidates and I'm out of other good ideas. I'm not a big fan of peripheral alcohol/phenol due to increased risk of complications (vs. cryo). The bad things about cryo: it takes a long time, it reimburses quite poorly (i.e., losing money) & it may only last for a few months. I've had some excellent successes. Each of the "open" cryo's I've done have received at least 6 months relief.
 
How do I learn to do this cryo you speak of? What I mean is do you just find the nerve with a nerve stimulator, cut a 1cm incision and stick the probe in and freeze for how many minutes?
 
botox has been used here. no downside so i highly recomend trialing it

can also try alcohol/phenol

there are peripheral neurosurgoens (many specialize in hand) who will go in and wrap a vein around the nerve after they transect it which significantly reduces risk of new neuroma
 
Botox is expensive and I've had no luck with insurance paying for it. My patient population can't pay out of pocket. I've offered it to a couple of patients but they declined due to cost.

I don't use the stimulator if its done "open". Dissect down to the nerve and cryo away. I've known some docs who will use the rf needle/machine to stim. These are superficial nerves, but as stated above, I usually have a surgeon do the dissecting. Typically 2 freeze-thaw cycles for 120 sec at 2 or 3 locations on the nerve.
 
Have two patients of Knee Pain- one with sev., systemic RA and another with OA, I hv planned for I A Botox 100 IU. Any one having sm first line experience with Botox for knee pain!
 
Check the hip. I bet external rotation is diminished on the symptomatic side compared to the other. The knee will work wherever the hip puts it.
 
Anyone tried pulsed RF of the IPN after succesful local block? Any tips? Any luck with pulsed RF of the GFN or intercostal nerves?
 
For chronic post op knee pain I usually do a saphenous block using ultrasound proximal to the adductor canal. Maybe only 10-20% of these diagnostics have NOT helped with the pain, so it is usually a saphenous neuralgia vs. the infrapatellar branches.

In any case I follow up with pRF. I have a group of maybe half-dozen pts that get these every 4-6 months or so. Most have responded. Sometimes I've had the patients get pain relief after only the diagnostic block with Kenalog that lasts for weeks.

If it is a scar neuroma I also try a scar injection followed by botox or alcohol.

For OA pain, consider RF of the geniculate nerves. I read an article where I think a Korean group did diagnostic blocks on both sides of the femus and on the side of the tibia. If good response they cRFed the same 3 locations with some good results. I haven't done this yet but would consider for the pt in whom IA or saphenous techniques don't help and they want to hold off TKA for a bit longer.
 
I went to a class a couple weeks ago that was strong on pulsed RF. The recommendation was that you needed to have the needle close enough to get a sensory response at .1 - .2 volts. The instructors felt that those who have not gotten good results with pRF were probably not close enough to the nerve. Also that pRF may be superior to ablation as you can avoid anesthesia dolorosa.
 
I think this is the study you mentioned.

I'd like to learn more about innervation of knee joint before attempting the technique described.


drf said:
For chronic post op knee pain I usually do a saphenous block using ultrasound proximal to the adductor canal. Maybe only 10-20% of these diagnostics have NOT helped with the pain, so it is usually a saphenous neuralgia vs. the infrapatellar branches.

In any case I follow up with pRF. I have a group of maybe half-dozen pts that get these every 4-6 months or so. Most have responded. Sometimes I've had the patients get pain relief after only the diagnostic block with Kenalog that lasts for weeks.

If it is a scar neuroma I also try a scar injection followed by botox or alcohol.

For OA pain, consider RF of the geniculate nerves. I read an article where I think a Korean group did diagnostic blocks on both sides of the femus and on the side of the tibia. If good response they cRFed the same 3 locations with some good results. I haven't done this yet but would consider for the pt in whom IA or saphenous techniques don't help and they want to hold off TKA for a bit longer.
Click to expand...
 

Attachments

onewithpain said:
I went to a class a couple weeks ago that was strong on pulsed RF. The recommendation was that you needed to have the needle close enough to get a sensory response at .1 - .2 volts. The instructors felt that those who have not gotten good results with pRF were probably not close enough to the nerve. Also that pRF may be superior to ablation as you can avoid anesthesia dolorosa.
Click to expand...

Wow, what class was this?
 
drpainfree said:
I think this is the study you mentioned.

I'd like to learn more about innervation of knee joint before attempting the technique described.
Click to expand...
nice..

i was thnking of this study too! Unfortunately, didnt have the link.

Question is how do you bill for this?

Also, as someone pointed out...wht about anesthesia dolorosa or painful dysesthesias from doing a peripheral nerve.....

I agree though, it seems to be a safe and benign procedure.
 
I have tried the medial joint nerves for ongoing capsular pain post surgery, but did not want to go for the saphenous proximally. Block was successful, pulsed was not better than the block (not US guided). Has had suceesful LSB atother pain clinic prior to seeing me. Might consider US guided (using a tech to tell me where to go (until I get trained)) saphenous block as it could help avoid costlier interventions.
 
lobelsteve said:
I have tried the medial joint nerves for ongoing capsular pain post surgery, but did not want to go for the saphenous proximally. Block was successful, pulsed was not better than the block (not US guided). Has had suceesful LSB atother pain clinic prior to seeing me. Might consider US guided (using a tech to tell me where to go (until I get trained)) saphenous block as it could help avoid costlier interventions.
Click to expand...

U/S saphenous block pretty easy. Steve, you will pick up U/S very easily. You can teach yourself. Get those books that were recommended to you and you are good to go.
 
The genicular nerve block seems straightforward. If any of you guys are doing it, how are you billing for it? Destruction peripheral nerve? If so, are you doing continous RF instead of pRF?
 
Ligament said:
Infrapatellar nerve blocks under U/S guidance work surprisingly well in my experience.
Click to expand...

How are you specifically picking up the infrapatellar nerves? Do you find the saphenous, which is easy, and trace it distal until you see little branches?
 
onewithpain said:
I went to a class a couple weeks ago that was strong on pulsed RF. The recommendation was that you needed to have the needle close enough to get a sensory response at .1 - .2 volts. The instructors felt that those who have not gotten good results with pRF were probably not close enough to the nerve. Also that pRF may be superior to ablation as you can avoid anesthesia dolorosa.
Click to expand...

I generally don't care about the sensory stim. I turn it to 0.5 or so just to confirm that:
1. It is concordant with area of pain for dx info
2. I didn't screw up and it actually is the nerve

Then I visualize the needle tip touching and pushing the nerve away a bit and pulse for 6-8 minutes.

I found that touching the same nerve in separate locations can create a huge range in required stim. By that I mean I touch the top half of whatever nerve, see this on the US, and get weak stim at 0.8. Then touch the bottom half and get strong stim at 0.2. Both times I'm touching the nerve.

As such I mainly use the stim, as mentioned, to confirm it is the nerve, then the endpoint is a clear picture of the tip touching the nerve.
 
PinchandBurn said:
nice..

i was thnking of this study too! Unfortunately, didnt have the link.

Question is how do you bill for this?

Also, as someone pointed out...wht about anesthesia dolorosa or painful dysesthesias from doing a peripheral nerve.....

I agree though, it seems to be a safe and benign procedure.
Click to expand...

I would only do it selected pts who are truly end-stage OA, not tolerating meds, other blocks don't work, and don't want TKA. I see enough chronic s/p TKA pain to believe that this can't possibly worse than that.
 
lobelsteve said:
I have tried the medial joint nerves for ongoing capsular pain post surgery, but did not want to go for the saphenous proximally. Block was successful, pulsed was not better than the block (not US guided). Has had suceesful LSB atother pain clinic prior to seeing me. Might consider US guided (using a tech to tell me where to go (until I get trained)) saphenous block as it could help avoid costlier interventions.
Click to expand...

usra.ca
neuraxiom.com

these sites taught me how to do it. Find the artery under the sartorius proximal to mid thigh. Probe is on medial thigh. Skin local lateral to the probe. Needle straight toward the artery with stim. The nerve is generally superficial to the artery on the side that you are approaching with the needle.
 
drf said:
usra.ca
neuraxiom.com

these sites taught me how to do it. Find the artery under the sartorius proximal to mid thigh. Probe is on medial thigh. Skin local lateral to the probe. Needle straight toward the artery with stim. The nerve is generally superficial to the artery on the side that you are approaching with the needle.
Click to expand...

Will review. I'll try it on myself and staff first (without the needle part).
 
no one yet has answered if they're getting paid for pulsed RF.

I can see the risk/benefit of regular RF for an end-stage knee with no other options, but do you offer them pulsed RF first as self-pay and or just go straight to regular RF?
 
Nobody gets paid from insurance companies for pulsed RF. If they do, you can bet they are coding it incorrectly as RF ablation, which it is not. Pulsed RF is properly coded as 64999. There are of course some very rare exceptions such as the VA system and closed HMO plans.

When I do pulsed RF I am paid cash by the patient.

I don't see why one would do pulsed RF of these nerves in the knee. Why not go straight to RFA?
 
Ligament said:
Nobody gets paid from insurance companies for pulsed RF. If they do, you can bet they are coding it incorrectly as RF ablation, which it is not. Pulsed RF is properly coded as 64999. There are of course some very rare exceptions such as the VA system and closed HMO plans.

When I do pulsed RF I am paid cash by the patient.

I don't see why one would do pulsed RF of these nerves in the knee. Why not go straight to RFA?
Click to expand...

For what its worth- Theres an article in the months pain medicine of heat RF lesion involving intrapatellar branch of sural nerve for refractory inferomedial kee pain and OA
 
olafa said:
For what its worth- Theres an article in the months pain medicine of heat RF lesion involving intrapatellar branch of sural nerve for refractory inferomedial kee pain and OA
Click to expand...

You mean infrapatellar branch of the saphenous nerve right? can you post the article olafa
 
We cryo the saphenous just proximal to knee with great results .one of our bread/butter procedures.. great results
 
sweetalkr said:
We cryo the saphenous just proximal to knee with great results .one of our bread/butter procedures.. great results
Click to expand...

sweets - you're gonna show me how to exactly do this at ASIPP in DC this summer. And I got to tell you about my new lady. Blows BS out of the water... 😉
 
clubdeac said:
sweets - you're gonna show me how to exactly do this at ASIPP in DC this summer. And I got to tell you about my new lady. Blows BS out of the water... 😉
Click to expand...

is she on your fb? i never met BS . ill see you there. did you see my newsletter?
 
Would you guys consider doing the genicular nerve RFA on post-op TKA patients? Obviously you have to be extra cautious about sterility (which you should be anyway) to avoid infecting the hardware but does it make anatomical sense that those same nerves are the pain generators?
 
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