3rd lumbar RFA session within rolling 12 months?

[Drd105]

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has anyone had any luck with more than two sessions per rolling 12 mos? example- i did right lumbar RFA May 2021 and left lumbar RFA Nov 2021- pt now would like to repeat the right side possibly Jan 2022 which would be a third session within 12 mos. this question is probably too soon to ask but may come up in the spring 2022 for others....would I have to just repeat the RFA and then request payment- then if it is denied try to appeal it with a letter? any thoughts on this would be greatly appreciated- he cannot afford the cash price.

 

[Dr. Ice]

Tell him he might have to wait till may 2022, and then just do it bilaterally

 

[geauxg8rs]

Tell him he might have to wait till may 2022, and then just do it bilaterally

Make sure he knows it is the government fault

 

[jsaul]

Just do bilateral

 

[Drd105]

Tell him he might have to wait till may 2022, and then just do it bilaterally

That’s what I was assuming I would have to do- thanks!

 

[Dr. Ice]

FWIW, in 11 years of being an attending, I have never done lumbar rfas one side at a time, even when the procedure actually made more money and was reimbursed more for 1 side at a time. Just felt it was unnecessary for the patient to have to go through multiple visits for the treatment. Probably left money on the table, but it was/is the right thing to do IMO

 

[Drd105]

Make sure he knows it is the government fault

That is already crossed off my list 😉

FWIW, in 11 years of being an attending, I have never done lumbar rfas one side at a time, even when the procedure actually made more money and was reimbursed more for 1 side at a time. Just felt it was unnecessary for the patient to have to go through multiple visits for the treatment. Probably left money on the table, but it was/is the right thing to do IMO

I agree- this particular patient said the left side had never hurt before when I initially did the right, then when he complained of the left side hurting we burned the left only because the right side still felt great, so I have been in this alternating pattern with him

 

[drusso]

has anyone had any luck with more than two sessions per rolling 12 mos? example- i did right lumbar RFA May 2021 and left lumbar RFA Nov 2021- pt now would like to repeat the right side possibly Jan 2022 which would be a third session within 12 mos. this question is probably too soon to ask but may come up in the spring 2022 for others....would I have to just repeat the RFA and then request payment- then if it is denied try to appeal it with a letter? any thoughts on this would be greatly appreciated- he cannot afford the cash price.

We offer to do it for cash, take payments/installments at 0 interest, layaway, care credit, etc. One of the local pawn shops will also expedite medically-related financing and assist patients with a Go-FundMe page.

 

[Agast]

Unless it’s Medicare primary you can get prior authorization/pre-determination and it will tell you if they will pay.

 

[NJPAIN]

Food for thought:
Perhaps if you take your time, optimally position cannulae, perform at least two lesions per level and do one side at a time rather than rush to perform bilaterally in the time it should take to do unilaterally, it would last 12 months?

Ask John MacVicar in NZ (former SIS President), how long it takes him to do a lumbar MB RFN. You will be shocked to find out that this experienced physician with amazing RFN outcomes takes 3-4 times as long as what most docs claims it takes them to do the same procedure.

Just something to think about. Obviously incompatible with the US orthopedic block shop model.

 

[Dr. Ice]

Food for thought:
Perhaps if you take your time, optimally position cannulae, perform at least two lesions per level and do one side at a time rather than rush to perform bilaterally in the time it should take to do unilaterally, it would last 12 months?

Ask John MacVicar in NZ (former SIS President), how long it takes him to do a lumbar MB RFN. You will be shocked to find out that this experienced physician with amazing RFN outcomes takes 3-4 times as long as what most docs claims it takes them to do the same procedure.

Just something to think about. Obviously incompatible with the US orthopedic block shop model.

Umm..I book 45 minutes to do bilateral. Not rushing, no sedation. People generally get 1 years worth of relief even in my horrible “block shop” ortho practice. If you are getting longer relief, give me your contact and I’ll send my patients your way. How long does John take?

 

[NJPAIN]

Umm..I book 45 minutes to do bilateral. Not rushing, no sedation. People generally get 1 years worth of relief even in my horrible “block shop” ortho practice. If you are getting longer relief, give me your contact and I’ll send my patients your way. How long does John take?

My comment is aimed at the 9 minutes per side crowd. Unless you are an absolute superstar THAT is a block shop.

 

[jsaul]

I do as NJ pain says. 2 lesions with nimbus 18 Guage needles in lumbar. For bilateral lumbar it takes me about 35 min with sedation. I get minimum 1 year relief. Usually much longer, closer to 2

 

[NJPAIN]

I do as NJ pain says. 2 lesions with nimbus 18 Guage needles in lumbar. For bilateral lumbar it takes me about 35 min with sedation. I get minimum 1 year relief. Usually much longer, closer to 2

Given the cost of Nimbus do you use only one needle at a time?
Do you find that Nimbus saves you time because your radiographic setup is like doing a MBB as the needle doesn’t need to be parallel to the MB?

 

[bedrock]

Food for thought:
Perhaps if you take your time, optimally position cannulae, perform at least two lesions per level and do one side at a time rather than rush to perform bilaterally in the time it should take to do unilaterally, it would last 12 months?

Ask John MacVicar in NZ (former SIS President), how long it takes him to do a lumbar MB RFN. You will be shocked to find out that this experienced physician with amazing RFN outcomes takes 3-4 times as long as what most docs claims it takes them to do the same procedure.

Just something to think about. Obviously incompatible with the US orthopedic block shop model.

Agree with this. I trained with Dreyfuss and I take longer than most to do RFA, but my results are far better than my local competition, who are in the 10 min per side bragging crowd. Because of the time, I do insist to patients that the RFA be performed unilateral, and I don't have any issues with these 12 month rolling RFA rules, because my RFA never last less than a year.

Literally, just Friday I saw a patient who had undergone 3 RFA by two other local pain docs in the past, with about 50% relief for 4-6 months, and this past friday he came in estastic with his 90% relief after my RFA. His gratitude is why I take time to do things right.

You can't do quality RFA in just 10 min per side, unless maybe you are doing cooled in HOPD

 

[clubdeac]

Agree with this. I trained with Dreyfuss and I take longer than most to do RFA, but my results are far better than my local competition, who are in the 10 min per side bragging crowd. Because of the time, I do insist to patients that the RFA be performed unilateral, and I don't have any issues with these 12 month rolling RFA rules, because my RFA never last less than a year.

Literally, just Friday I saw a patient who had undergone 3 RFA by two other local pain docs in the past, with about 50% relief for 4-6 months, and this past friday he came in estastic with his 90% relief after my RFA. His gratitude is why I take time to do things right.

You can't do quality RFA in just 10 min per side, unless maybe you are doing cooled in HOPD

I know we’ve reviewed this ad nauseam but post some pics, AP, lat, oblique and down the barrel. just curious if your technique looks like mine. Also do you care about sensory motor stim other than just making sure the leg doesn’t move?

 

[painfree23]

Agree with this. I trained with Dreyfuss and I take longer than most to do RFA, but my results are far better than my local competition, who are in the 10 min per side bragging crowd. Because of the time, I do insist to patients that the RFA be performed unilateral, and I don't have any issues with these 12 month rolling RFA rules, because my RFA never last less than a year.

Literally, just Friday I saw a patient who had undergone 3 RFA by two other local pain docs in the past, with about 50% relief for 4-6 months, and this past friday he came in estastic with his 90% relief after my RFA. His gratitude is why I take time to do things right.

You can't do quality RFA in just 10 min per side, unless maybe you are doing cooled in HOPD

What do you think you are doing differently that’s taking much longer? What’s “quality” mean? Motor testing? Sensory testing? Burn time? Number of burns?

 

[DrSpine]

It takes me 20 minutes to do a b/l RFA, and 10 minutes for one side. I'm not rushing, nor am I trying to go slow, just identify the landmarks, do your local, and go at it. But everyone is different and to each his/her own.

I think if you're finding yourself needing to do more than 2 RFAs a year, or even more than one I would wager, maybe look into other causes of pain? Could be a good candidate for Intracept if there's modic changes, perhaps try MILD or Vertiflex if stenosis. If it's a disc issue, can approach that as well. MinuteMan also possibility. What are their symptoms?

 

[SeniorWrangler]

We offer to do it for cash, take payments/installments at 0 interest, layaway, care credit, etc. One of the local pawn shops will also expedite medically-related financing and assist patients with a Go-FundMe page.

I’d like to take payment directly in handguns and electric guitars.

 

[NJPAIN]

It takes me 20 minutes to do a b/l RFA, and 10 minutes for one side. I'm not rushing, nor am I trying to go slow, just identify the landmarks, do your local, and go at it. But everyone is different and to each his/her own.

I think if you're finding yourself needing to do more than 2 RFAs a year, or even more than one I would wager, maybe look into other causes of pain? Could be a good candidate for Intracept if there's modic changes, perhaps try MILD or Vertiflex if stenosis. If it's a disc issue, can approach that as well. MinuteMan also possibility. What are their symptoms?

That's REALLY impressive skills and efficiency. Assuming two levels (three needles), that's 3 minutes per needle to setup a trajectory view for each level, administer local, place the needles, check true PA/LA/OBLIQUE for each level, make any adjustments, administer local for lesion and create two lesions per level (assuming simultaneous). I have a lot of elderly patients and I often have to spend few minutes setting up the most "perfect" lateral view in the C-spine or even the lumbar spine. I envy anyone who has a rad tech good enough to need no direction. Our rad techs have no idea what a "perfect" lateral looks like. To them a lateral is simply when the C-arm is in the lateral position.

 

[painfree23]

That's REALLY impressive skills and efficiency. Assuming two levels (three needles), that's 3 minutes per needle to setup a trajectory view for each level, administer local, place the needles, check true PA/LA/OBLIQUE for each level, make any adjustments, administer local for lesion and create two lesions per level (assuming simultaneous). I have a lot of elderly patients and I often have to spend few minutes setting up the most "perfect" lateral view in the C-spine or even the lumbar spine. I envy anyone who has a rad tech good enough to need no direction. Our rad techs have no idea what a "perfect" lateral looks like. To them a lateral is simply when the C-arm is in the lateral position.

do you differ the trajectory view for each level so much?

 

[Dr. Ice]

That's REALLY impressive skills and efficiency. Assuming two levels (three needles), that's 3 minutes per needle to setup a trajectory view for each level, administer local, place the needles, check true PA/LA/OBLIQUE for each level, make any adjustments, administer local for lesion and create two lesions per level (assuming simultaneous). I have a lot of elderly patients and I often have to spend few minutes setting up the most "perfect" lateral view in the C-spine or even the lumbar spine. I envy anyone who has a rad tech good enough to need no direction. Our rad techs have no idea what a "perfect" lateral looks like. To them a lateral is simply when the C-arm is in the lateral position.

That’s cause we work in jersey bro..we are living in a “New York State of mind” Gotta try to be perfect. I have patients that request me to print out their fluoro pics so they can show it to their so and so who works at hss/Mayo/penn/Rothman (although this last one is laughable since I know what at least half of them can do with a needle). Twenty minutes for an rfa doesn’t cut it

 

[NJPAIN]

do you differ the trajectory view for each level so much?

If you are using SIS or similar technique with optimal trajectory, most often I find I need to change the tilt of the II when moving from L4 to L5. At the sacral ala for L5DR I always start from scratch with a view through the L5-S1 disc and work from there to setup a trajectory view.

Regarding checking needle position, if you are not working with optimal (orthogonal) views you can’t really know exactly where the needle is. Just look at your oblique once all your needles in. Then, align the beam with the SEP for each level and see how much the needle moves.

Now, with large lesions, etc maybe this is overkill and a waste of time. I agree it’s not terribly efficient or cost effective. I just want to know if the treatment fails it’s not because I failed.

 

[MitchLevi]

I can do a bilateral lumbar RFA in 18-20 min, and I've done plenty of them. That's L4-S1 or L3-S1 facet joints. Unfortunately, the results aren't as reliable as the 25 min version.

IMO, if you want the procedure to work you need to place each needle individually, each with its own series of XRAYs.

Start AP, square off endplate, go oblique and place needles, back to AP, true lateral, test motor (I still do not understand why anyone tests sensory), 1cc local...Next needle...Burn one side for at least 2 min at 80C or higher. Now do same contralateral.

This also helps with the saving of images bc needles at one level may appear off target relative to other levels.

If volume is more important do the 18-20 min version. This method works, just not as effective in my hands.

In my experience, I sometimes do not have a choice but to fly through any number of procedures. In PP, that's an unfortunate reality much of the time.

Sometimes there are other reasons to go fast, and i think having the ability to go quickly is important:

Two days ago I did a unilateral L4-S1 RFA in under 10 min. Morbidly obese pt on 02 with fluctuating sats. Those needles were place simultaneously and fast. One oblique view, fast AP, then lateral was hard to see bc of body habitus and her grade 2 isthmic spondy at L5-S1.

Quick burns in the past have helped her, and I alternate RFA and ILESI at L5-S1 through her slip. Generally does well.

 

[Taus]

That’s cause we work in jersey bro..we are living in a “New York State of mind” Gotta try to be perfect. I have patients that request me to print out their fluoro pics so they can show it to their so and so who works at hss/Mayo/penn/Rothman (although this last one is laughable since I know what at least half of them can do with a needle). Twenty minutes for an rfa doesn’t cut it

I get this request sometimes too. Glad to print it out for them. Most commonly it’s just SI arthrograms when a surgeon requests a diagnostic block, or a medicolegal case…. But 1-2x/year I have a “main line” patient request my fluoro pics to their doctor in the family…. Gladly…. I’ll autograph it too so they can hang it on their ceiling over their bed

 

[NJPAIN]

I’m doing a ton of peer review for INTRACEPT. Many originate from the same physician(s). Not infrequently it’s in patient who has had a few MB RFN with relatively good response lasting 5-7 months. I’d love to know how the RF was done. I would not be surprised if 20 ga cannula, single lesion and cannula placed perpendicular to nerve. You can easily do that in 10 min.


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[bedrock]

I’m doing a ton of peer review for INTRACEPT. Many originate from the same physician(s). Not infrequently it’s in patient who has had a few MB RFN with relatively good response lasting 5-7 months. I’d love to know how the RF was done. I would not be surprised if 20 ga cannula, single lesion and cannula placed perpendicular to nerve. You can easily do that in 10 min.


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Sad,
And indicative of physicians just looking to do yet another procedure on a patient whether it makes sense or not. If patient gets a decent but short lived response to MB RFA, then they answer is to take the time to do proper RFA, the disc didn't suddenly become the primary pain generator, so the pivot to Intracept is inappropriate.

 

[RoloTomassi]

I’m doing a ton of peer review for INTRACEPT. Many originate from the same physician(s). Not infrequently it’s in patient who has had a few MB RFN with relatively good response lasting 5-7 months. I’d love to know how the RF was done. I would not be surprised if 20 ga cannula, single lesion and cannula placed perpendicular to nerve. You can easily do that in 10 min.


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I wouldn't put much stock into accuracy of those numbers. They've had to document good response to RFA for 6 months or else another RFA will never get approved.

Say the RFA helped some but probably not the only or even main pain generator. If you deny Intracept and notes said RFA didn't work--now they're stuck with nothing moving forward. If notes said RFA was too effective, Intracept gets denied.

Just like MBBs helping >80%. How does that make sense if pain is 50/50 facetogenic/vertebrogenic? But it has to be documented to get covered. It's just the silly game we have to play.

 

[bedrock]

What do you think you are doing differently that’s taking much longer? What’s “quality” mean? Motor testing? Sensory testing? Burn time? Number of burns?

I know we’ve reviewed this ad nauseam but post some pics, AP, lat, oblique and down the barrel. just curious if your technique looks like mine. Also do you care about sensory motor stim other than just making sure the leg doesn’t move?

Nothing more than SIS technique. Yes I trained with Dreyfuss, but it is really just proper SIS technique.

(Other considerations are 18G cannulae, lesioning X 2. I use 85 degree X 90 seconds, Dreyfuss does 120 seconds) Motor stim for safety only.

Do your patients a favor and go to an SIS RFA course. It's surprising that SIS techniques are not taught in more ACGME pain fellowships. SIS course comes with CME.

 

[NJPAIN]

Nothing more than SIS technique. Yes I trained with Dreyfuss, but it is really just proper SIS technique.

(Other considerations are 18G cannulae, lesioning X 2. I use 85 degree X 90 seconds, Dreyfuss does 120 seconds) Motor stim for safety only.

Do your patients a favor and go to an SIS RFA course. It's suprising that SIS techniques are not taught in more ACGME pain fellowships. SIS course comes with CME.

Unfortunately, many fellowships now teach how to do production work rather proper technique. It’s all about volume. I’m all for teaching efficiency but i think it’s poor practice to teach shortcuts that compromise the quality of work.

 

[drrosenrosen]

People who do multiple lesions, how do you reposition before second burn? I do 18ga 90deg 150s, single burn.

 

[MitchLevi]

People who do multiple lesions, how do you reposition before second burn? I do 18ga 90deg 150s, single burn.

2 min total at 85C

60s into burn I reposition 2-3mm to whatever direction I think I need to go, usually flipping the needle 180 degrees.

Not sure spinning needle 180 deg does anything TBH - I use standard Abbott needles 18 gauge.

 

[paindoc007]

Unfortunately, many fellowships now teach how to do production work rather proper technique. It’s all about volume. I’m all for teaching efficiency but i think it’s poor practice to teach shortcuts that compromise the quality of work.

It’s worse at non-accredited “fellowships”. Those practices turn fellows into factory workers.

 

[NJPAIN]

It’s worse at non-accredited “fellowships”. Those practices turn fellows into factory workers.

That’s what practices want. I vividly recall a senior participant on this forum stating “the problem with fellowships is that they don’t teach fellows to be fast”. I may be biased as I consider myself pretty caught up on technique and therefore pretty slow.


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[Taus]

People who do multiple lesions, how do you reposition before second burn? I do 18ga 90deg 150s, single burn.

18g. 10mm active bent tip. Tip tight to junction pointed medial. Then for burn 2 retract a few mm and drive few mm up wall at base of sap, tip pointed cephalad.