Any experience with hip and shoulder rfa?

[JelloIsJigglin]

Did a coolief course on hip and shoulder RFA. Seems easy and safe enough.

Anyone have any experience using these techniques?

Safe as it seems?
Good outcomes in your practice?

Anyone try with non-coolief system like venom?

I have several patients interested but I have cold feet.

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[Ligament]

Pro tip; a 16ga 10mm active tip cannulae will make a lesion as large as the coolief probe which costs $850. The 16ga cannulae is $9-$22. If you do a bipolar 16ga lesion then you make a larger lesion than coolief. This is why coolief probes are only sold to hospitals, academic centers and VAs, where they have a huge SOS markup that can absorb the ridiculous cost.

The only advantage in using cooled RF probes is if you must (or can and you are lazy and don't care about cost) ablate the nerve from a perpendicular instead of parallel approach. In those situations, it appears to be better.

 

[Gnarvin]

In fellowship we did the hip femoral and obturator sensory branch RFA with conventional RF under combined fluoro and ultrasound guidance. Was kind of a pain in the butt. Since it was fellowship, I didn’t always get to see the patients that I did the procedure on so can’t speak too much on how well it worked for patients.

I don’t have any experience with Coolief.

 

[manowar rules]

I did a few hip RFA until the ortho guys just started sending me all the people who were too fat for surgery. Placing that obturator probe is not very fun in the morbidly obese. Relief was mixed. Haven’t done any in a long time, would probably only consider in an elderly patient with obvious hip OA whose morbidities prevent arthroplasty. Have seen it work well a few times with them.

 

[JelloIsJigglin]

I did a few hip RFA until the ortho guys just started sending me all the people who were too fat for surgery. Placing that obturator probe is not very fun in the morbidly obese. Relief was mixed. Haven’t done any in a long time, would probably only consider in an elderly patient with obvious hip OA whose morbidities prevent arthroplasty. Have seen it work well a few times with them.

The approach described by the coolief folks I assume is generally safe?

Ever had positive motor responses on testing? If so how did you reorient the needle placements?

 

[manowar rules]

The approach described by the coolief folks I assume is generally safe?

Ever had positive motor responses on testing? If so how did you reorient the needle placements?

Yes it's safe. I used ultrasound to avoid neurovascular structures during placement, but again, visualization is tougher in the obese. I don't recall getting motor twitches but I'm sure I just readjusted if I did. You should be lateral to the obturator nerve and deep to the femoral nerve
http://www.pfiedler.com/cooledrf/Presentations/Hip July 2015.pdf

 

[lobelsteve]

Taught these for Neurotherm after Ligament bailed to work for a review committee. Easy. Effective. That was 6 years ago. Now do hip, knee, and/or shoulders every day.

 

[Gnarvin]

I am not sure of the technique taught by Coolief, but the obvious concern is going through the femoral Nerve/artery/vein with a relatively large sized needle while you are the way to the target sites. Ultrasound helps avoid hitting those structures.

Worst case scenario would probably be accidentally carrying through with the RFA with the active tip in the femoral nerve or artery.

 

[Ronin1]

Taught these for Neurotherm after Ligament bailed to work for a review committee. Easy. Effective. That was 6 years ago. Now do hip, knee, and/or shoulders every day.

Thermal or cooled?

 

[lobelsteve]

Thermal. Cooled is unaffordable.

 

[painfree23]

Thermal. Cooled is unaffordable.

80 degrees?

 

[pmrmd]

For hip bipolar 18g from lateral approach for femoral and obturator with usual settings. Results are pretty darn good.

 

[lobelsteve]

80 degrees?

80 deg. 90 sec.

 

[buddababa]

Suprascapular nerve for shoulder? Any concern about nearby artery/vasculature?

 

[cowboydoc]

The approach described by the coolief folks I assume is generally safe?

Ever had positive motor responses on testing? If so how did you reorient the needle placements?

Their initial AP technique to get to the obrurator Branch puts you in line with the femoral artery in many patients. I think updated their materials? I mark the course of the artery with u/s before going in with fluoro and take a lateral to medial approach.

I do as few of these as possible, mixed results despite great results with the dx blocks.

I do 2 lesions with 18g venoms.

 

[lobelsteve]

Suprascapular nerve for shoulder? Any concern about nearby artery/vasculature?

Nope

 

[med7343]

Piggy backing:
suprascapular RFA
1- do you do fluoro or US guided RFA?
2- Warfarin and suprascapular RFA- reverse A/C?
Thanks

 

[lobelsteve]

Fluoro. Never hold ac or platelet drugs unless il esi or bigger.

 

[swamprat]

Fluoro. Never hold ac or platelet drugs unless il esi or bigger.

You do TFESI on thinners ? I feel like I remember you saying so in your prior posts.. if so

I understand that if you bleed you are likely to bleed out of the spine but ASRA guidlines still say to hold. Something bad happens you and the patient are F’d. You have any lit to support it ?

 

[lobelsteve]

You do TFESI on thinners ? I feel like I remember you saying so in your prior posts.. if so

I understand that if you bleed you are likely to bleed out of the spine but ASRA guidlines still say to hold. Something bad happens you and the patient are F’d. You have any lit to support it ?

Go read the threads. SIS. Endres data.

Short story: You hold thinners and they die from MI or CVA? Do you know which is worse? Do you know which is more likely? Do you know how many cases I have been paid to review on this topic?

Go to court likely in either case. You can argue they consented for tfesi and knew risks. Better bring in that form outlining what you said about rebound hypercoaguable MI/CVA risks.

 

[JelloIsJigglin]

Pro tip; a 16ga 10mm active tip cannulae will make a lesion as large as the coolief probe which costs $850. The 16ga cannulae is $9-$22. If you do a bipolar 16ga lesion then you make a larger lesion than coolief. This is why coolief probes are only sold to hospitals, academic centers and VAs, where they have a huge SOS markup that can absorb the ridiculous cost.

The only advantage in using cooled RF probes is if you must (or can and you are lazy and don't care about cost) ablate the nerve from a perpendicular instead of parallel approach. In those situations, it appears to be better.

Ever any attempts doing lateral branch RFA with these 16g 10mm tip needles?

 

[TIVAndy]

Go read the threads. SIS. Endres data.

Short story: You hold thinners and they die from MI or CVA? Do you know which is worse? Do you know which is more likely? Do you know how many cases I have been paid to review on this topic?

Go to court likely in either case. You can argue they consented for tfesi and knew risks. Better bring in that form outlining what you said about rebound hypercoaguable MI/CVA risks.

hey this is the fear i always have for following ASRA guidelines - can you expand on the your side of the argument? ultimately we want to have the best outcome for the pt but at the same time to defend ourselves in case rare **** happens

 

[pmrmd]

Ah, the TFESI on anticoagulants topic. Again.

If you’re still holding, welcome to 2014.

 

[lobelsteve]

hey this is the fear i always have for following ASRA guidelines - can you expand on the your side of the argument? ultimately we want to have the best outcome for the pt but at the same time to defend ourselves in case rare **** happens

On the topic of anticoagulation...

But when you hold it and he dies from MI you are in court and add extra zeroes. which is worse? Which is more likely? There wouldn’t be a judgment. The societal SOC is to hold anti-coagulation. Patient signs consent aware of risks, physicians say the standard was met and any case goes away...

forums.studentdoctor.net

5-10 threads on this.

Search asra in pain forums and my username.

 

[Ferrismonk]

For hip bipolar 18g from lateral approach for femoral and obturator with usual settings. Results are pretty darn good.

I just was trained on these procedures. Avanos is recommending a lateral approach for both the femoral branch (lateral to medial) and the obturator (inferior to superior) to go deep to the neurovascular bundle. I'm told the obturator path is very painful though since it's really the medial thigh. Do you take a different approach?

 

[pmrmd]

I just was trained on these procedures. Avanos is recommending a lateral approach for both the femoral branch (lateral to medial) and the obturator (inferior to superior) to go deep to the neurovascular bundle. I'm told the obturator path is very painful though since it's really the medial thigh. Do you take a different approach?

I anesthetize the track first, or as much as I can with a spinal needle. When I get more medial with the cannula I’ll shoot more lido before I advance. Lateral approach is easy. Can’t get both targets with the same starting point though as much as I’ve tried.

 

[ateria radicularis magna]

I anesthetize the track first, or as much as I can with a spinal needle. When I get more medial with the cannula I’ll shoot more lido before I advance. Lateral approach is easy. Can’t get both targets with the same starting point though as much as I’ve tried.

It would be awesome if you posted pictures of your rfa needles. I do hip but not often because I feel unsure of it. I don’t really know why. It’s easy enough.

 

[cowboydoc]

It would be awesome if you posted pictures of your rfa needles. I do hip but not often because I feel unsure of it. I don’t really know why. It’s easy enough.

 

[NJPAIN]

I just was trained on these procedures. Avanos is recommending a lateral approach for both the femoral branch (lateral to medial) and the obturator (inferior to superior) to go deep to the neurovascular bundle. I'm told the obturator path is very painful though since it's really the medial thigh. Do you take a different approach?

Can you share the updated Avanos technique slides?

 

[lobelsteve]

https://www.painphysicianjournal.com/current/pdf?article=NTIwOQ==&journal=111 Coolief.

 

[lobelsteve]

I would have gone close to Cowboys targets. Tip of the arrow is where my probe starts, then goes 10mm away from lateral starting position.

 

[drrosenrosen]

Is anybody else having an impossible time getting these paid for hips and shoulders? UHC, Aetna, BCBS are all calling it experimental in Texas

 

[cowboydoc]

I would have gone close to Cowboys targets. Tip of the arrow is where my probe starts, then goes 10mm away from lateral starting position.View attachment 343565

A hopefully better example with both lesion sites. Steve would probably argue for a more medial placement of the superior (femoral) target. I don’t necessarily disagree, but l’ve seen “12 o’ clock” on the acetabulum as the target. Probably not a lot of work being done to optimize these nerve locations.

Regular RF probes are going to look a lot different than the Avanos “Coolief” direct approach.

 

[cowboydoc]

Is anybody else having an impossible time getting these paid for hips and shoulders? UHC, Aetna, BCBS are all calling it experimental in Texas

I’m doing more iovera for shoulders. Issues with hips sometimes, but I rarely offer this. BCBS here paid without issue, Medicaid was a hard no.

 

[SpineandWine]

Go read the threads. SIS. Endres data.

Short story: You hold thinners and they die from MI or CVA? Do you know which is worse? Do you know which is more likely? Do you know how many cases I have been paid to review on this topic?

Go to court likely in either case. You can argue they consented for tfesi and knew risks. Better bring in that form outlining what you said about rebound hypercoaguable MI/CVA risks.

Hi, may you please share the thread. I know medico-legally, if someone does develop hematoma, you could be liable unless following societal guidelines. If you could please share me portion of SIS/Endres Data that advocates for not holding blood thinners for certain procedures, that would be helpful.

 

[lobelsteve]

Hi, may you please share the thread. I know medico-legally, if someone does develop hematoma, you could be liable unless following societal guidelines. If you could please share me portion of SIS/Endres Data that advocates for not holding blood thinners for certain procedures, that would be helpful.

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/2020/sis_factfinder_20_02_anticoa.pdf

Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines - PubMed

Continuing antiplatelet and anticoagulant medications for intermediate- to low-risk interventional spine procedures may be advisable. The MSAAA table may be a reasonable guideline reference for managing antiplatelet and anticoagulant drugs.

pubmed.ncbi.nlm.nih.gov

Update of a Study of Not Ceasing Anticoagulants for Patients Undergoing Injection Procedures for Spinal Pain - PubMed

Lumbar transforaminal injections and lumbar facet injections have a very low rate of hemorrhagic complications when patients continue to take anticoagulants.

pubmed.ncbi.nlm.nih.gov

Update from Endres.

 

[Crybaby]

I’m doing more iovera for shoulders. Issues with hips sometimes, but I rarely offer this. BCBS here paid without issue, Medicaid was a hard no.

Is there a reason you are choosing iovera over conventional rf?

 

[cowboydoc]

Is there a reason you are choosing iovera over conventional rf?

Conceptually, the freeze is not causing neurotmesis, so it's relatively safer. The theoretical downside is shorter duration of relief than thermal RF. The data for what is happening to the nerve is contradictory in the Iovera literature. (I lost my chance to be a KOL for them because I pressed them on their bad information.) In my setup, I can do an Iovera in clinic with U/S in a fraction of the time at a fraction of the price than sending pts. to the HOPD ASC for thermal RF. As of late, Iovera gets a lot better coverage than genicular RF, too. In my hand, the Iovera typically lasts 3-6 months, which is on par with my thermal RF results. I find that the relatively cheaper, faster, safer option has about the same duration, so I offer Iovera preferentially, consider thermal RF if/when it fails. My thermal RF numbers for genicular have decreased substantially.

 

[Ferrismonk]

Conceptually, the freeze is not causing neurotmesis, so it's relatively safer. The theoretical downside is shorter duration of relief than thermal RF. The data for what is happening to the nerve is contradictory in the Iovera literature. (I lost my chance to be a KOL for them because I pressed them on their bad information.) In my setup, I can do an Iovera in clinic with U/S in a fraction of the time at a fraction of the price than sending pts. to the HOPD ASC for thermal RF. As of late, Iovera gets a lot better coverage than genicular RF, too. In my hand, the Iovera typically lasts 3-6 months, which is on par with my thermal RF results. I find that the relatively cheaper, faster, safer option has about the same duration, so I offer Iovera preferentially, consider thermal RF if/when it fails. My thermal RF numbers for genicular have decreased substantially.

On a side note, I can't seem to get genicular thermal or Coolief covered at all except for straight Medicare. Is Iovera covered and is there some secret to get the auth?

 

[cowboydoc]

On a side note, I can't seem to get genicular thermal or Coolief covered at all except for straight Medicare. Is Iovera covered and is there some secret to get the auth?

Since the target isn't the genicular nerves, it's a 3 nerve generic 64640 code that hasn't been flagged like the bundled genicular code.

 

[lobelsteve]

Since the target isn't the genicular nerves, it's a 3 nerve generic 64640 code that hasn't been flagged like the bundled genicular code.

Name your target

 

[cowboydoc]

Name your target

Ant. Femoral cutaneous nerve. 2 branches of the inferior saphenous nerve almost every time. Occasionally the LFCN or superior medial genicular branch. Very rarely the articular branch of the peroneal nerve.

The company guidance is 3 nerves, can count 2 for the branches of the ISN. Doesn’t make sense to me, but the way it’s been billed for the 3+ years I’ve been doing it without issue??

 

[deleted875186]

I would like to start doing these, currently only do genicular.

1. For the hip, can I do these without ultrasound to avoid the vessels? Don’t have an ultrasound at my clinic. Do you start lateral and drive the needle out of plane or use a down the barrel view

2. What are people doing for shoulder? Ablating the suprascapular nerve? What is the technique?

 

[Ronin1]

There are some videos on the coolief site for the ssn and axillary articulor branch. Pretty straightforward

 

[cowboydoc]

I would like to start doing these, currently only do genicular.

1. For the hip, can I do these without ultrasound to avoid the vessels? Don’t have an ultrasound at my clinic. Do you start lateral and drive the needle out of plane or use a down the barrel view

2. What are people doing for shoulder? Ablating the suprascapular nerve? What is the technique?

Hip is ok to do without u/s, just palpate femoral, use a lateral to medial approach, touch down early and walk it medially.

See attached for shoulder.

 

[cxx2777]

There are some videos on the coolief site for the ssn and axillary articulor branch. Pretty straightforward

Curious about these. Any concern about motor block with ssn ablation? Doesn’t it supply some of the shoulder muscles?

 

[lobelsteve]

We have a dozen of these threads with articles attached.

Shoulder- Simopoulis article- no functional weakness.
Lots of technique articles attached to older threads as well.