Bilateral RFA

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Does anyone do bilateral RFAs?

apparently evictee guidelines are you only get two RFA sessions per year. I asked the peer to peer guy what happens if someone gets 6 months of relief and we’ve already done two RFAs (a left and then a right), he said, that’s why the guidelines are written that way to encourage people to do a bilateral RFA the start, and then repeat the bilateral RFA in 6 months of pain returns.

can some people educate me on what they do. Ever have a bilateral RFA approved, is it safe to do?

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Does anyone do bilateral RFAs?

apparently evictee guidelines are you only get two RFA sessions per year. I asked the peer to peer guy what happens if someone gets 6 months of relief and we’ve already done two RFAs (a left and then a right), he said, that’s why the guidelines are written that way to encourage people to do a bilateral RFA the start, and then repeat the bilateral RFA in 6 months of pain returns.

can some people educate me on what they do. Ever have a bilateral RFA approved, is it safe to do?
~70% of my lumbar RFAs are bilateral. Never issues because of bilateral. It's a rare exception that I will do a bilateral cervical RFA.
 
Same. Most of my lumbar are bilateral on elderly.

none of my cervical rf are bilateral.
 
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~70% of my lumbar RFAs are bilateral. Never issues because of bilateral. It's a rare exception that I will do a bilateral cervical RFA.
So why 70% of lumbars? Do you mean You always do bilateral unless only one sided pain and one sided MBBs?
 
So why 70% of lumbars? Do you mean You always do bilateral unless only one sided pain and one sided MBBs?
If they have pain on both sides, they get a bilateral MBB. If I have positive bilateral MBBs, they get a bilateral RFA.

Cervical is typically unilateral pathology. If it's truly bilateral, I'll do bilateral blocks, then unilateral RFA. I can think of some C5/6 fusions that I've done bilateral C4/5 facet joints, but try to avoid based on longer recovery, higher likelihood of subjective weakness/neuritis/dizziness. I haven't seen compelling studies on this, but it seems to be a general consensus.
 
Yes the guidelines are written to encourage bilateral.. because they don’t pay in full for the second side. And soon won’t pay at all.. just watch. Slowly (Or rapidly) taking away any procedures that pay decently..
 
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Yes the guidelines are written to encourage bilateral.. because they don’t pay in full for the second side. And soon won’t pay at all.. just watch. Slowly (Or rapidly) taking away any procedures that pay decently..
I get payed 50% for the second side. It doesn’t double my procedure time to do the second side because I place both at once. Probably only increases the procedure time by about 50%. Would be nice to get paid commensurate for the work but I have so many patients who travel an hour or more that adding yet another trip on top of the 2 required MBBs and the RF is not good care for them.
 
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Always unilateral. Bilateral RFA pay sucks. No thanks
 
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Sometimes with thinner patients I find that if I do bilateral (L3-5) I approach the lower range of lidocaine toxicity. 6 needles using 1% and then 2% along the nerves themselves can be borderline...
 
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Sometimes with thinner patients I find that if I do bilateral (L3-5) I approach the lower range of lidocaine toxicity. 6 needles using 1% and then 2% along the nerves themselves can be borderline...
This. On cervical, not only is the post procedure pain and neuritis more, but I typically need to use a lot more local then per needle than lumbar and it’s In a more vascular area. Skin to bone and then more on periosteum to walk my 18g off bone to target, hugging bone tightly, then 2% lido before burning. Just not well tolerated bilateral on cervical. Also I find cervical a lot more technically demanding to do well than lumbar. I can’t just bang it out pretty quickly like lumbar.

Or I could say scrap all that and just say it’s the way I was trained and continue to practice by default....
 
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Sometimes with thinner patients I find that if I do bilateral (L3-5) I approach the lower range of lidocaine toxicity. 6 needles using 1% and then 2% along the nerves themselves can be borderline...
Really? How so, how much local do you use? I usually try and limit skin and soft tissue due to testing. Do you do more than 1 cc of local before lesioning?

1 cc 2% x 6 is 120 mg
1 cc 1% x 6 is 60 mg

even a really thin patient 50 kg the max dose is 250 mg
 
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Really? How so, how much local do you use? I usually try and limit skin and soft tissue due to testing. Do you do more than 1 cc of local before lesioning?

1 cc 2% x 6 is 120 mg
1 cc 1% x 6 is 60 mg

even a really thin patient 50 kg the max dose is 250 mg
I think I can count on one hand the # of 50kg pts. I’ve done RF on. I default to 150mm cannula. 1cc going in. 1cc on the spot, occasionally another on the way if they are having trouble. Non-issue.
 
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I use 2cc going in usually. Maybe I can try 1. For what it’s worth I use 18 g needles.

For the average person, I agree it’s a non-issue. But, I’ve had a number of little old ladies. If the patient is uncomfortable and instead of 1 cc per needle you need to get closer to 2 or so, then you are getting very close to that 4.5mg/kg in an elective procedure that may not even work. It’s just something I don’t really like to even have to think about. If I schedule them for a bilateral, I always tell them we may have to switch to unilateral. I’ve never had to, but it has given me extra anxiety.
 
I use 2cc going in usually. Maybe I can try 1. For what it’s worth I use 18 g needles.

For the average person, I agree it’s a non-issue. But, I’ve had a number of little old ladies. If the patient is uncomfortable and instead of 1 cc per needle you need to get closer to 2 or so, then you are getting very close to that 4.5mg/kg in an elective procedure that may not even work. It’s just something I don’t really like to even have to think about. If I schedule them for a bilateral, I always tell them we may have to switch to unilateral. I’ve never had to, but it has given me extra anxiety.
I think that informed consent on the front end covers you. It’s reasonable to come back another day if you run into issues, just like everything else we do.
 
use 1% going in, save the 2% for where you do the RFA.

I cheat and mix 1% lido with 0.25% bupiv, in a 1:1 mixture. in my feeble mind, it gives me more volume to "play with", though the amount of 1% in pure solution or what I am using is the same...
 
For the people I know will have some trouble with the RF (Fibro + arthritis types) I’ve started putting a tiny bit of 1% in the skin (0.25 mL or so) then basically doing a MBB with about 0.5 mL on the target and 0.5 in the tract. Doesn’t add much time, a few extra fluoro shots, but by the time I finish the skin is very numb because it actually had time to kick in. Then, a little 2% lido through the RF needle prior to burning. Most of what you are achieving with a higher concentration of local is faster onset of action.
 
For the people I know will have some trouble with the RF (Fibro + arthritis types) I’ve started putting a tiny bit of 1% in the skin (0.25 mL or so) then basically doing a MBB with about 0.5 mL on the target and 0.5 in the tract. Doesn’t add much time, a few extra fluoro shots, but by the time I finish the skin is very numb because it actually had time to kick in. Then, a little 2% lido through the RF needle prior to burning. Most of what you are achieving with a higher concentration of local is faster onset of action.
So you don’t sensory test?
 
Sensory is so 1990's
Serious question, do people find sensory stimulation useful if it is used, or is it just faster and equal outcomes if you just use fluoro guidance for needle placement.
 
Does anyone do bilateral RFAs?

apparently evictee guidelines are you only get two RFA sessions per year. I asked the peer to peer guy what happens if someone gets 6 months of relief and we’ve already done two RFAs (a left and then a right), he said, that’s why the guidelines are written that way to encourage people to do a bilateral RFA the start, and then repeat the bilateral RFA in 6 months of pain returns.

can some people educate me on what they do. Ever have a bilateral RFA approved, is it safe to do?
You were given wrong information to begin with. Here is the correct one -

If there has been a prior successful radiofrequency (RF) denervation, then a minimum time of six (6) months has elapsed since prior RF denervation treatment (per side, per anatomical level of the spine).

In my practice, I go either way based on patient's preference. Have done very few bilateral Cervical RFA though.
 
Serious question, do people find sensory stimulation useful if it is used, or is it just faster and equal outcomes if you just use fluoro guidance for needle placement.
not needed. SIS, including the two most expert physicians on the subject, Dreyfuss and Bogduk, do not use sensory stim. If you place the needle correctly, sensory stim adds nothing but wasted time.
 
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It would be quite difficult to get LAST from lidocaine on a RFA. You are really going to give 25ml of 1% on a RFA even if the patient is 50kg? If so stop.
 
Why would you do bilateral and get paid 50% for one of the sides? You like being ripped off for your hard work? Who pays the bills where you work?
 
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For the guys using a lot of local for skin...

inject the dorsum of your left hand with a tiny bit of 1% lido. It burns a lot, but is instantly numb and the numbness extends quite far past the skin wheel. You don’t need anywhere close to 1ml.
 
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Why would you do bilateral and get paid 50% for one of the sides? You like being ripped off for your hard work? Who pays the bills where you work?

disagree. if you have a full schedule and they patient is already lying on the table, why not just get the extra 50%? you could bring them back and do the other side on a separate day, but there is no medical reason why this "should" be done in the lumbar spine.

if you are scrounging for procedures, then it makes sense to do it on separate days from a financial standpoint.
 
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not needed. SIS, including the two most expert physicians on the subject, Dreyfuss and Bogduk, do not use sensory stim. If you place the needle correctly, sensory stim adds nothing but wasted time.
There is no need for sensory stim unless you want an answer to a question you already answered via medial branch block. You want the answer a third time?
 
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Does anyone do bilateral RFAs?

apparently evictee guidelines are you only get two RFA sessions per year. I asked the peer to peer guy what happens if someone gets 6 months of relief and we’ve already done two RFAs (a left and then a right), he said, that’s why the guidelines are written that way to encourage people to do a bilateral RFA the start, and then repeat the bilateral RFA in 6 months of pain returns.

can some people educate me on what they do. Ever have a bilateral RFA approved, is it safe to do?

I just got burnt by this. Network has to write off 2 RFA sessions for a patient based on these new guidelines. I repeated lumbar RFA L3-5 at six month mark on separate days (more thav10 days apart) so this counted as 4 sessions in the lumbar spine region and apparently only 2 sessions are allowed per spinal region now.
 
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I just got burnt by this. Network has to write off 2 RFA sessions for a patient based on these new guidelines. I repeated lumbar RFA L3-5 at six month mark on separate days (more thav10 days apart) so this counted as 4 sessions in the lumbar spine region and apparently only 2 sessions are allowed per spinal region now.
That sucks.

What insurance did the patient have?
 
Ya Medicare is one body region (cervical/thoracic/lumbar) every 6 months regardless of laterality.
 
Resurrecting this thread, now with the local coverages of only paying for 2 levels unilaterally or bilaterally per session (medicare and advantage plans) ; instead of the 3 levels unilaterally - is everyone who only does unilateral cervical RF per session, now going to do bilateral?
 
This to me is a case where insurance regulations, more than cutting into our bottom line, are hurting patient care. I have rarely ever done bilateral cervical RF because of neuritis, dizziness, esp on upper levels/TON. Now, I'm mandated to do it that way if pt has bilateral symptoms. Not that they really care about patient outcomes, let alone side effects.
 
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This to me is a case where insurance regulations, more than cutting into our bottom line, are hurting patient care. I have rarely ever done bilateral cervical RF because of neuritis, dizziness, esp on upper levels/TON. Now, I'm mandated to do it that way if pt has bilateral symptoms. Not that they really care about patient outcomes, let alone side effects.
My thoughts exactly. Glad to see I'm not the only one that feels this way.
 
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This to me is a case where insurance regulations, more than cutting into our bottom line, are hurting patient care. I have rarely ever done bilateral cervical RF because of neuritis, dizziness, esp on upper levels/TON. Now, I'm mandated to do it that way if pt has bilateral symptoms. Not that they really care about patient outcomes, let alone side effects.
Nah, you can still do it unilateral x2, you just have to wait a year to repeat.
I always do bilateral cervical RFs in one session unless they had bad symptoms (weakness, dizziness) from the MBBs, which has happened maybe once a year.
 
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