Anterior column pain treatments

[paingate21]

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How do you approach this patient population? Especially after exhausting the common options below.

Ie these patients are typically younger with midline low back pain that increases with sitting, bending forward, etc. Lumbar MRI without any significant central or foraminal stenosis - decreased disc signal at 1 or 2 levels +/- modic endplate changes.

- exhaust PT/exercise/lifestyle measures
- medications - NSAIDs, cymbalta
- injections: try TFESI level below ie for L4-L5 changes perform L5; consider MBBs to rule out facet
- if modic changes try for intracept approval

 

[bedrock]

Basically. Intracept is a game changer.

 

[Taus]

Restore or regenerate!

 

[pmrmd]

Intrdiscal PRP

 

[cowboydoc]

Restore or regenerate!

Reactiv8!

 

[paingate21]

cowboydoc - what is your N with reactiv8? How have your outcomes been?

Pmrmd - are you offering PRP as cash option as no insurance coverage?

 

[drusso]

Intradiscal PRP FTW

 

[cowboydoc]

cowboydoc - what is your N with reactiv8? How have your outcomes been?

Pmrmd - are you offering PRP as cash option as no insurance coverage?

N=2
1 really happy thus far 9 months out. (80% better subjectively)
1 zero improvement over a year out

 

[CB1Antagonist]

Hi All, has anyone tried Basivertebral nerve ablation using medtronic osteocool probe? Also, any pointers on how to access the S1 level with kypho type 10 gauge cannula for BVNA? Thanks!

 

[RoloTomassi]

Hi All, has anyone tried Basivertebral nerve ablation using medtronic osteocool probe? Also, any pointers on how to access the S1 level with kypho type 10 gauge cannula for BVNA? Thanks!

Why make it harder on yourself instead of using the tools made to access reliably?Especially with Osteocool, going in bilaterally is doing your patient a disservice. S1, not going to hit without a curved kypho system. Then are you going to burn with an RF needle where lesioning in bone hasn't been established? There's also the potentially fraudulent aspect of using the tools off label.

 

[Snowmen96]

Hi All, has anyone tried Basivertebral nerve ablation using medtronic osteocool probe? Also, any pointers on how to access the S1 level with kypho type 10 gauge cannula for BVNA? Thanks!

At IPSIS in Boston, they mentioned two European studies using CT guidance and systems similar to Osteocool where they actually got betterresults than Intracept. Probably because it results in a bigger lesion, but there is the question of vertebral stability to take into account because of that.

 

[Tboned]

At IPSIS in Boston, they mentioned two European studies using CT guidance and systems similar to Osteocool where they actually got betterresults than Intracept. Probably because it results in a bigger lesion, but there is the question of vertebral stability to take into account because of that.

They used merit. Available in US

 

[drusso]

At IPSIS in Boston, they mentioned two European studies using CT guidance and systems similar to Osteocool where they actually got betterresults than Intracept. Probably because it results in a bigger lesion, but there is the question of vertebral stability to take into account because of that.

BVN-Ablation – NEW4MED

new4med.com

 

[CB1Antagonist]

Why make it harder on yourself instead of using the tools made to access reliably?Especially with Osteocool, going in bilaterally is doing your patient a disservice. S1, not going to hit without a curved kypho system. Then are you going to burn with an RF needle where lesioning in bone hasn't been established? There's also the potentially fraudulent aspect of using the tools off label.

I've been doing kypho since 2008 using kyphon/MDT. When I asked the relevant rep, the guy was a jerk and asked that I line up 5 cases before he gave me time of day. Hence I asked my MDT rep who said some folks were using Osteocool off label for BVNA

 

[jwheezy]

I've been doing kypho since 2008 using kyphon/MDT. When I asked the relevant rep, the guy was a jerk and asked that I line up 5 cases before he gave me time of day. Hence I asked my MDT rep who said some folks were using Osteocool off label for BVNA

Any rep that pulls that **** is automatic blacklist for me

 

[DOctorJay]

I've been doing kypho since 2008 using kyphon/MDT. When I asked the relevant rep, the guy was a jerk and asked that I line up 5 cases before he gave me time of day. Hence I asked my MDT rep who said some folks were using Osteocool off label for BVNA

they really should stratify their training and allow physicians like yourself to get trained quickly.

 

[IHawkDO]

Wanted to piggy back off of this. I have a 39 F with a >20 year history of disc issues (multiple discectomies at L4/5) with persistent anterior column pain, Modic changes, and an MRI more consistent with a 60 year old at that level. Has anyone done Intracept on a patient this young? How have your outcomes been? My only cases have been in the 60+ folks.

 

[Taus]

Wanted to piggy back off of this. I have a 39 F with a >20 year history of disc issues (multiple discectomies at L4/5) with persistent anterior column pain, Modic changes, and an MRI more consistent with a 60 year old at that level. Has anyone done Intracept on a patient this young? How have your outcomes been? My only cases have been in the 60+ folks.

Definitely, many cases 40-60yo. Many post discectomy. As long as the clinical picture and mri fits, no other major confounding variables, results mirror literature.

 

[RoloTomassi]

Wanted to piggy back off of this. I have a 39 F with a >20 year history of disc issues (multiple discectomies at L4/5) with persistent anterior column pain, Modic changes, and an MRI more consistent with a 60 year old at that level. Has anyone done Intracept on a patient this young? How have your outcomes been? My only cases have been in the 60+ folks.

Plenty as well. Lots of home runs with the 30-50 crowd

 

[Centurion38]

Definitely, many cases 40-60yo. Many post discectomy. As long as the clinical picture and mri fits, no other major confounding variables, results mirror literature.

I'm getting denied every time for BVN ablation at diskectomy levels. This is with the commercials.

 

[bedrock]

I'm getting denied every time for BVN ablation at diskectomy levels. This is with the commercials.

Depends on the exact commercial payor.

Every Cigna patient gets authed if they go through the steps. But that often takes a 2-3 months.

Each of our state BCBS get authed in two weeks.

However, our state WC will never cover. Aetna will never cover. Medicaid/tricare don’t cover or don’t cover my costs.
Medicare covers but not worth my time so I send those intracept to HOPD docs.

I’m trying two UHC auths, been a couple months. We’ll see.

I don’t get a lot of Anthem or Regence in my area. Taus could comment on his experience with them.

 

[MD87]

Wanted to piggy back off of this. I have a 39 F with a >20 year history of disc issues (multiple discectomies at L4/5) with persistent anterior column pain, Modic changes, and an MRI more consistent with a 60 year old at that level. Has anyone done Intracept on a patient this young? How have your outcomes been? My only cases have been in the 60+ folks.

My youngest was somewhere between 32-34. Normal guy, thin/average build. No hx surgery. Pain for 10+ years, worsening. Failed everything under the sun. Pain with tying shoes, had to stop playing sports. 100% improved on his left side and 90% on the right side after L4-L5 Intracept. Back to playing soccer. One of my happiest patients. He told all of his friends about me, for better or worse.

 

[Taus]

I'm getting denied every time for BVN ablation at diskectomy levels. This is with the commercials.

Which insurance? If it’s one that covers bvna in their written policy, should have specific language re prior surgery (ie resolved leg pain, at least 6 months from decompressive surgery, not fused).

I have not seen denials for this specific reason…. Or any clinical reason other than certain carriers still consider it experimental.

 

[Taus]

Depends on the exact commercial payor.

Every Cigna patient gets authed if they go through the steps. But that can take a couple months.

Each of our state BCBS get authed in two weeks.

However, our state WC will never cover. Aetna will never cover. Medicaid/tricare don’t cover or don’t cover my costs.
Medicare covers but not worth my time so I send those intracept to HOPD docs.

I’m trying two UHC auths, been a couple months. We’ll see.

I don’t get a lot of Anthem or Regence in my area. Taus could comment on his experience with them.

That’s great your state BCBS covers. Mine (IBC) does not and retroactively denied the ones I did despite written approvals on external appeals. I won’t do any more IBC until it’s approved on their written policy.

I see some Anthem and Highmark sporadically… both cover easily. Same with Cigna. Wish I saw more of these insurances.

Agreed re Medicare fee- I’ll still do the cases, but greatly limit the volume. I also will no longer do Medicare advantage cases. Going through 3 to 6 months of appeals, medical law judge… Getting an approval, and then frequently retroactively denied, followed by a lengthy and spotty appeals process after the fact. Most definitely not worth it in my experience. Not even really about my piddly professional fee on these… The facility already laid out be 6500 or so on the equipment upfront. I send these to the academic university hospital based pain program

Aetna has been 0%.

United, small sample size, I believe 1 for 4

 

[Tboned]

Depends on the exact commercial payor.

Every Cigna patient gets authed if they go through the steps. But that can take a couple months.

Each of our state BCBS get authed in two weeks.

However, our state WC will never cover. Aetna will never cover. Medicaid/tricare don’t cover or don’t cover my costs.
Medicare covers but not worth my time so I send those intracept to HOPD docs.

I’m trying two UHC auths, been a couple months. We’ll see.

I don’t get a lot of Anthem or Regence in my area. Taus could comment on his experience with them.

UHC sucks

 

[Tboned]

Wanted to piggy back off of this. I have a 39 F with a >20 year history of disc issues (multiple discectomies at L4/5) with persistent anterior column pain, Modic changes, and an MRI more consistent with a 60 year old at that level. Has anyone done Intracept on a patient this young? How have your outcomes been? My only cases have been in the 60+ folks.

Sounds like a great candidate. A number of grand slams for patients in their 30s. Why do you think 39 is too young?

 

[IHawkDO]

Appreciate all of the input. It’s not that I specifically think the patient is too young, I just haven’t had a similar case in training or practice. Thanks for letting me lean on all of your expertise.

 

[Taus]

Intradiscal PRP FTW

I get the itch to do this periodically. Then I read the published data again re outcomes and discitis and scrap it again. If failed all else reasonable, no deformity, pars defect or instability to increase odds of successful surgery and no modic to indicate intracept, I send out to another local practice for consideration of intradiscal PRP. Maybe 2-3/year.

 

[bedrock]

I get the itch to do this periodically. Then I read the published data again re outcomes and discitis and scrap it again. If failed all else reasonable, no deformity, pars defect or instability to increase odds of successful surgery and no modic to indicate intracept, I send out to another local practice for consideration of intradiscal PRP. Maybe 2-3/year.

I tell many of these patients about intracept, and essentially let them know in a few years, there is a good option waiting for them, so they shouldn't do anything rash like get a fusion right now, as they can likely benefit from Intracept in a few years once modic changes are visible.

 

[drmamba]

Yes - it works on younger patients. We perform them on local semi pro and pro athletes and they do well. Would make sure to really rule out psych, engage in PT first, wait for disc to fully heal, and re-engage in PT 2-3 months out.

Have tried a low n for Viasdisc. Zero responders in the short term and long term. Was skeptical to begin with.

Low volume Reactiv8 thus far -- waiting to see if there are any benefits in the short term and long term.

SPR multifidi helps but doesn't typically last long after system removal.