Acdf & rf

[bedrock]

I recently posted this twice as part of another thread and no one commented on this at all, so I'm hoping a dedicated thread might work better-----

How many pain physicians have tried/will consider cervical RF for patients at the same levels(not just adjacent levels) in patients with persistent or worsened axial pain s/p ACDF? How good have your results been?

I never did this in fellowship, although I've read about it during the last year. I was discussing the issue with a neurosurgeon friend recently who believes that the posterior cervical facets can be a pain generator from shoddy ACDF technique if that level is over-distracted by the implant and he showed me a few example MRIs from his residency.

I've seen plenty of patients after cervical ACDF with similar or worsened axial neck pain and I'm debating offering them MBB/RF at the surgical levels. Not all insurances will cover this, particularly the blues, but I wonder if I'm missing people who could be helped.

What do you guys think? Anyone have much experience doing this? I'm not trying to troll for more procedures as I'm plenty busy, just wondering if anyone has had much success doing this.

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[Jcm800]

i think its reasonable to do, but i dont know about getting paid...

i believe MC will pay you, but BCBS, united, all those will not. they just say no RF in setting of FUSION.

I recently posted this twice as part of another thread and no one commented on this at all, so I'm hoping a dedicated thread might work better-----

How many pain physicians have tried/will consider cervical RF for patients at the same levels(not just adjacent levels) in patients with persistent or worsened axial pain s/p ACDF? How good have your results been?

I never did this in fellowship, although I've read about it during the last year. I was discussing the issue with a neurosurgeon friend recently who believes that the posterior cervical facets can be a pain generator from shoddy ACDF technique if that level is over-distracted by the implant and he showed me a few example MRIs from his residency.

I've seen plenty of patients after cervical ACDF with similar or worsened axial neck pain and I'm debating offering them MBB/RF at the surgical levels. Not all insurances will cover this, particularly the blues, but I wonder if I'm missing people who could be helped.

What do you guys think? Anyone have much experience doing this? I'm not trying to troll for more procedures as I'm plenty busy, just wondering if anyone has had much success doing this.

 

[101N]

Radiofrequency Neurotomy for the Treatment of Therapy-resistant Neck Pain after Ventral Cervical Operations

PAIN MEDICINE
Volume 11, Issue 10, October 2010, Pages: 1504–1510, Stephan Klessinger
Article first published online : 31 AUG 2010, DOI: 10.1111/j.1526-4637.2010.00942.x

Abstract
Objective.  The objective of this study was to determine if radiofrequency neurotomy is effective for patients with postoperative neck pain after cervical spine operations.

Design.  The study design used was a retrospective practice audit.

Setting.  Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 2.5 years.

Interventions.  Patients with persistent postsurgical neck pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). If pain recurred, diagnostic medial branch blocks were performed. Patients with at least 80% relief following both the therapeutic and the diagnostic block underwent radiofrequency neurotomy. Positive treatment response was defined for at least 50% reduction of pain or sufficiently satisfaction of the patient.

Results.  Two hundred forty-two operations were performed, 125 of which were artificial disc operations, 66 were stand alone cages, and 51 were fusions with cage and plate. Two patients were lost to follow-up. Persistent neck pain occurred in 31% of the patients. The prevalence of zygapophysial pain after surgery was 13.2%. These 32 patients were treated with radiofrequency neurotomy because of recurrent neck pain. The average follow-up time was 15 months. A significant pain reduction was achieved in 59.4%. Significantly, after a double-level operation, more patients suffered persisting neck pain (P = 0.002) compared with all patients being operated.

Conclusions.  Zygapophysial joints are a possible source of postoperative pain after anterior cervical spine surgery. Persistent and therapy-resistant neck pain occurs more often in patients after double-level operation. Radiofrequency neurotomy can provide an effective treatment for persistent neck pain after ventral cervical spine surgery.

 

[PinchandBurn]

Radiofrequency Neurotomy for the Treatment of Therapy-resistant Neck Pain after Ventral Cervical Operations

PAIN MEDICINE
Volume 11, Issue 10, October 2010, Pages: 1504–1510, Stephan Klessinger
Article first published online : 31 AUG 2010, DOI: 10.1111/j.1526-4637.2010.00942.x

Abstract
Objective.  The objective of this study was to determine if radiofrequency neurotomy is effective for patients with postoperative neck pain after cervical spine operations.

Design.  The study design used was a retrospective practice audit.

Setting.  Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 2.5 years.

Interventions.  Patients with persistent postsurgical neck pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). If pain recurred, diagnostic medial branch blocks were performed. Patients with at least 80% relief following both the therapeutic and the diagnostic block underwent radiofrequency neurotomy. Positive treatment response was defined for at least 50% reduction of pain or sufficiently satisfaction of the patient.

Results.  Two hundred forty-two operations were performed, 125 of which were artificial disc operations, 66 were stand alone cages, and 51 were fusions with cage and plate. Two patients were lost to follow-up. Persistent neck pain occurred in 31% of the patients. The prevalence of zygapophysial pain after surgery was 13.2%. These 32 patients were treated with radiofrequency neurotomy because of recurrent neck pain. The average follow-up time was 15 months. A significant pain reduction was achieved in 59.4%. Significantly, after a double-level operation, more patients suffered persisting neck pain (P = 0.002) compared with all patients being operated.

Conclusions.  Zygapophysial joints are a possible source of postoperative pain after anterior cervical spine surgery. Persistent and therapy-resistant neck pain occurs more often in patients after double-level operation. Radiofrequency neurotomy can provide an effective treatment for persistent neck pain after ventral cervical spine surgery.

BINGO.

Just wondering to the OP.

I've never had to do this yet. BUt could you evaluate the patient and dx 'facetogenic crvical pain' and send a Prior Auth to the insurance company. If they give you problems, quote teh study above. Wouldnt that work? I think it's reasonable.....

 

[SSdoc33]

I recently posted this twice as part of another thread and no one commented on this at all, so I'm hoping a dedicated thread might work better-----

How many pain physicians have tried/will consider cervical RF for patients at the same levels(not just adjacent levels) in patients with persistent or worsened axial pain s/p ACDF? How good have your results been?

I never did this in fellowship, although I've read about it during the last year. I was discussing the issue with a neurosurgeon friend recently who believes that the posterior cervical facets can be a pain generator from shoddy ACDF technique if that level is over-distracted by the implant and he showed me a few example MRIs from his residency.

I've seen plenty of patients after cervical ACDF with similar or worsened axial neck pain and I'm debating offering them MBB/RF at the surgical levels. Not all insurances will cover this, particularly the blues, but I wonder if I'm missing people who could be helped.

What do you guys think? Anyone have much experience doing this? I'm not trying to troll for more procedures as I'm plenty busy, just wondering if anyone has had much success doing this.

i do them, but not that often. havent found the results all that compelling, and there are insurance hoops to jump thru to get the RF done. wouldnt hesititate do do a MBB in this setting at all.

i get a lot of these persistent C-spine and L-spine post fusion patients with axial pain. i think that MOST times, the pain is becuase the patients just had a fusion, rather than persistent z-joint pain.

 

[PinchandBurn]

. wouldnt hesititate do do a MBB in this setting at all.

.

why would you even do a MBB on these patients if the goal wasnt to do a RFA?

Unless you place steroids in the MBB for "therapeutic" MBBs...

 

[stim4u]

I think we are in different worlds of pain management....

I see tons of cervical facetogenic pain post ACDF with greater occipital neuralgia associated pain, as well as persistent scapular pain (referred dermatome).

Cervical RFA's work well on these patient's. Furthermore, you can stimulate the multifidus muscle regularly in these patients (during the case), proving that ANTERIOR cervical fusions typically do not destroy the medial branch nerve. Insurances will pay for RFA's in ACDF's not in posterior cervical/lumbar fusion patients. I would put an addendum on the bottom of your procedure note documenting 'meets all medically necessary criteria' for X/y/Z insurance.

Am i missing something here, I would imaging many pain doctors out there are RFAing ACDF patients.

 

[SSdoc33]

why would you even do a MBB on these patients if the goal wasnt to do a RFA?

Unless you place steroids in the MBB for "therapeutic" MBBs...

there i no such thing as a therapeutic MBB, thus steroids are useless (see other threads.

i would consider a MBB for the same reason peole perform discography -- for a more definitive diagnosis with a much easier diagnostic test. if RF is covered by insurance, id go ahead and burn. if not, i give the patient the option of paying themselves (yet to be taken up on this).

 

[facets]

I do RF in these patients with good results. As note in a previous thread I do rf in the fused lumbar spine after all other measures have been exhausted. I do think that the mbs grow back and can cause pain in a fused patient. RF with screws in the way in the lumbar spine, is a major PIA that takes twice as long. The results are not as good as in a virgin back, but it helps enough for the patients to come back and request it again. i actually would love it for myself if it didn't work at all because their backs are such a major PIA. I have no data on this, but I have been in the same location for 22 years so I get to see the long term results of my treatment.

 

[stim4u]

technically most insurances wont pay for an RFA in a posterior fusion pt. But I agree, if you can troll around and find the MBB and multifidus stimulation, and burn, patients notice the pain relief. But this is hard to do regularly, since most lumbar fusions have fusion mass all over the place.

 

[101N]

Where I live a lot of the surgeons have changed from plifs to tlifs with an aspen iss. Facets are by and large preserved.

 

[stim4u]

also, i believe there was a low grade pain study showing some pain benefit after fusion surgery with pre-emptive rhizotomies.

 

[onewithpain]

I do them for lumbar and cervical, and they are always covered except one WC patient for whom they covered the MBB but not the RFA. I get referrals from an ortho spine surgeon who places the pedicle screws slightly medial so that I can see the target for a lumbar MB RFA. Still there are times when it feels like what I am needling is a chunk of scar with a neuroma. I get great results as long as I can get to the target. Otherwise SCS or PFS.

 

[bedrock]

I appreciate the responses. Even if my fellowship attendings didn't do RF for ACDF patients, I figured that some of you guys were doing so, as it makes anatomic sense to me.

I saw a lady yesterday with a C4-C5 arthroplasty (done for a large C4-C5 herniation without radiculopathy), whose axial pain is no better afterwards. She's a straight shooter and MBB are next for her.

 

[bedrock]

I do them for lumbar and cervical, and they are always covered except one WC patient for whom they covered the MBB but not the RFA. I get referrals from an ortho spine surgeon who places the pedicle screws slightly medial so that I can see the target for a lumbar MB RFA. Still there are times when it feels like what I am needling is a chunk of scar with a neuroma. I get great results as long as I can get to the target. Otherwise SCS or PFS.

Are getting results doing peripheral field stim in lumbar fused patients without leg pain? What's your technique/approach to that?

 

[PinchandBurn]

I do RF in these patients with good results. As note in a previous thread I do rf in the fused lumbar spine after all other measures have been exhausted. I do think that the mbs grow back and can cause pain in a fused patient. RF with screws in the way in the lumbar spine, is a major PIA that takes twice as long. The results are not as good as in a virgin back, but it helps enough for the patients to come back and request it again. i actually would love it for myself if it didn't work at all because their backs are such a major PIA. I have no data on this, but I have been in the same location for 22 years so I get to see the long term results of my treatment.

facets-

so you do RFA at the level of the posterior fusion at times? The other reason people told me not to do this is that you can 'heat up' the hardware. Presumably, heating up the hardware can transfer the heat to bad places and potentially cause a 'burn' that you are not desiring......whats your experience with that?

 

[lobelsteve]

facets-

so you do RFA at the level of the posterior fusion at times? The other reason people told me not to do this is that you can 'heat up' the hardware. Presumably, heating up the hardware can transfer the heat to bad places and potentially cause a 'burn' that you are not desiring......whats your experience with that?

I've never seen or heard of that. And I cannot grasp the concept of a 25w heating element having the ability to raise surrounding tissues to any significant temperature. Even if the alloy were a great thermal conductor, it is sitting in a perfect heat sink.

 

[PinchandBurn]

I've never seen or heard of that. And I cannot grasp the concept of a 25w heating element having the ability to raise surrounding tissues to any significant temperature. Even if the alloy were a great thermal conductor, it is sitting in a perfect heat sink.

I'm sure you have also heard that 'bovieing' when placing SCS leads/Coude needle should be avoided. Similar situation.

Again all hearsay, makes some sense....not sure if I want to 'try and find out'.😎

 

[facets]

Yes I do rf occasionally in a posterior fusion. Never got any kind of adverse effect. The screws are usually pretty far from the foramen. I always check ap, latealr, and oblique and do a motor nerve test before every burn, esp on these patients because of their altered anatomy

 

[onewithpain]

Are getting results doing peripheral field stim in lumbar fused patients without leg pain? What's your technique/approach to that?

Surprisingly good results. I place a 4 contact lead laterally across the facets at the levels of pain, so usually at L5-S1 and up, sometimes down one level for SI pain. The literature says to keep the leads shallow but I have had some obese patients for whom shallow placement does not give adequate stim and so I place the needle an inch deeper in the fat and they are good. The 4 contact lead should reach from one facet to the other. Barrolat has some good pictures in his overpriced book.

I asked the neurotherm rep about ablating adjacent to the metal and she said that if the needle is too close to the metal then you will hear a tapping sound, but are unlikely to get a good lesion, and that there is not enough energy to heat the metal. Sometimes it seems like that would be the way to go, just plug that sucker into the 220 outlet and let er rip. But I think that a lot of that pain is from lack of rehab. If you think about what a professional athlete goes through after a surgery, starting with baby steps and working up, it is impressive. But our patients don't seem to be able to afford that effort and certainly don't have the financial incentive.

I realize that a facet joint should not be a pain generator after posterior fusion, but what is truly ridgid? Not metal, not bone, not cement, even concrete is engineered for a little give. So if there is a nerve in a fused joint and that joint has some torque then there may be some pressure on the nerve and then pain. It would be nice if we had some neural Roundup that the surgeons could put in the facet joints and on the MBs to keep them from regrowing, but until then they need to stop being so uppity and realize that the axial pain comes back.

 

[stim4u]

curious, where did you do your fellowship, and was it anesthesia vs. physiatry based?
Sounds like your attendings were a little squeamish.