Chronic pain

[Bsb2015]

90 year old patient with chronic low back (prior lami/fusion) and continued knee pain after TKA. I’m the 3rd PM doc she’s seen. She failed to follow up with the other PM bc she says nothing was helping. per chart review she’s been tried on multiple meds(meds all with side effects or no relief: gaba, Lyrica, cymbalta, savella, Tylenol #3, Vicodin, oxycodone) I’m hesitant to try TCA at her age and she has afibb. I tried her on Butrans but didn’t help. Compound cream slightly helpful. Starting a trial of Gralise. she doesn’t want any more interventions at this time-talked with her about SI bc on PE LBP seemed more SI mediated, although postlami syndrome likely also playing a role. She’s not had genicular dx/RFA but again doesn’t want any more interventions. She’s being going to PT, trying to do exercises at home, but this pain is causing her to be really depressed. Anything else? I want to try and help her have some quality of life at this stage.

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[tmvguy03]

If knee pain is the primary complaint, and knee provocation illicit the pain, I would encourage her to try the gen blocks. She’s probably just tired of being prodded but if you leave it on the table as a safe minimally invasive way to possibly decrease the pain, I bet she’ll request it in the next few months.
Also important to r/o hip pain as the generator. I’ve seen a number of patients who had a knee replacement for “knee” pain, get no better, come to me and turns out to be all coming from the hip. Good luck, I hope she does well

 

[Shufflin]

CBD:THC in a 25:1 ratio. helps with pain and appetite in that age group. watch for fall risk issues, dizziness, that sort of thing.

 

[painfree23]

CBD:THC in a 25:1 ratio. helps with pain and appetite in that age group. watch for fall risk issues, dizziness, that sort of thing.

Seriously?

 

[Shufflin]

Yes. Try it and see what she says.

 

[painfree23]

Maybe I’ll prescribe half a brownie and gummie with it too

 

[SommeRiver]

CBD:THC in a 25:1 ratio. helps with pain and appetite in that age group. watch for fall risk issues, dizziness, that sort of thing.

STFU

 

[swamprat]

Oxycodone ?

But no seriously if she doesn’t want interventions and she’s 90 I personally think a low dose may be beneficial to her and improve her QOL. I am sure ppl will disagree but mehh

 

[lobelsteve]

90 and nothing helps. So give her nothing.

No blocks unless she requests. Meds are risk>benefit. But she is going to die soon. Try lexapro and dilaudid.

 

[willabeast]

Whatever you do remember
your patient is at great risk of a fracture, which may kill eventually kill her. Don't get blamed.

 

[SommeRiver]

This pt is set up for an adverse event no matter what you do. The better part of valor is minimal medical risk. I would seriously give her 5-10mg of oxy and that's about it. Very unfortunate situation.

Edit - Not everyone gets to see 90. Also she should get a TENS unit and don't forget the almighty knee sleeve. I have some 90+ yo pts that have done well with just a compression sleeve under their pants.

 

[callmeanesthesia]

Sounds like a great RF candidate. If you can talk her in to genicular blocks that’s where I’d start. I do them in office with ultrasound from a lateral/medial approach - quick, easy, and minimally painful with a high success rate. A diagnostic block that totally takes away her knee pain may buy you some trust. Just make sure she understands it only lasts a few hours. Get her through that then set her up for ablation and do SI injection, maybe RF that too of steroids don’t last.

 

[soccrwz]

venlafaxine, SNRI good for anxiety depression, some data for neuropathic pain

 

[painfree23]

Sounds like a great RF candidate. If you can talk her in to genicular blocks that’s where I’d start. I do them in office with ultrasound from a lateral/medial approach - quick, easy, and minimally painful with a high success rate. A diagnostic block that totally takes away her knee pain may buy you some trust. Just make sure she understands it only lasts a few hours. Get her through that then set her up for ablation and do SI injection, maybe RF that too of steroids don’t last.

Lateral to medial approach ??

 

[Tapspatellas]

Scrap the gralise if not helping and give a low dose of horizant a try. I’ve been much more impressed with both efficacy and tolerability compared to IR gabapentin and gralise. Maybe a bit better knee penetration with pennsaid pump vs voltaren gel or pennsaid drops.

 

[callmeanesthesia]

Lateral to medial approach ??

 

[painfree23]

View attachment 259771

Niceeee.
What r the marks on the knee? And how do u know how anterior / posterior to go?

 

[callmeanesthesia]

Niceeee.
What r the marks on the knee? And how do u know how anterior / posterior to go?

The marks are the target point marked on fluoro. For skinny knees I do the nerve blocks with ultrasound. For fat knees with fluoro. (For really skinny knees if I’m in a hurry I just feel the landmarks). I put the probe longitudinally and mark the inflection point, then transverse and mark the most superficial point of the femur/tibia. I just put little lines on the skin a few cm away from the probe. Then at the intersection of those lines, I prep and stick in a 27g perpendicular to the skin down to bone, and inject 1 mL 0.5% bupi.

That picture is from an ablation but I do the same thing with big patients for the test nerve block. I mark the inflection points under fluoro in AP - that’s the x marks, then aim at that point from lateral. I just redirect a little anterior/posterior and inject in 2-3 different spots. For the ablation, I start by injecting 1.5 mL 2% lidocaine per nerve with the same technique as the genicular under fluoro, then glove and prep while it gets numb. I now have no issue doing these ablations with just a Xanax, and the patients practically sleep through it.

 

[painfree23]

The marks are the target point marked on fluoro. For skinny knees I do the nerve blocks with ultrasound. For fat knees with fluoro. (For really skinny knees if I’m in a hurry I just feel the landmarks). I put the probe longitudinally and mark the inflection point, then transverse and mark the most superficial point of the femur/tibia. I just put little lines on the skin a few cm away from the probe. Then at the intersection of those lines, I prep and stick in a 27g perpendicular to the skin down to bone, and inject 1 mL 0.5% bupi.

That picture is from an ablation but I do the same thing with big patients for the test nerve block. I mark the inflection points under fluoro in AP - that’s the x marks, then aim at that point from lateral. I just redirect a little anterior/posterior and inject in 2-3 different spots. For the ablation, I start by injecting 1.5 mL 2% lidocaine per nerve with the same technique as the genicular under fluoro, then glove and prep while it gets numb. I now have no issue doing these ablations with just a Xanax, and the patients practically sleep through it.

“then aim at that point from lateral. I just redirect a little anterior/posterior and inject in 2-3 different spots”
Is your fluoro in AP while ur doing this?

 

[callmeanesthesia]

“then aim at that point from lateral. I just redirect a little anterior/posterior and inject in 2-3 different spots”
Is your fluoro in AP while ur doing this?

Yeah, but I don’t take a lot of pictures. Usually 1 per nerve to make sure I landed the needle near the right spot. It’s 2% lido and it has at least 5 minutes to spread before I’m sticking the RF probe through that area. Time for the local to set up is key. I also wait at least a minute, preferably 2 after injecting in the skin and subq (at the spots on the skin I already marked in AP), so I use that time to set up the electrodes.
Before I adjusted my technique (taking a queue from someone on this board), I almost abandoned genicular RF because even the diagnostic blocks were causing patients to scream and jump all over.

 

[SommeRiver]

For the ablation, I start by injecting 1.5 mL 2% lidocaine per nerve with the same technique as the genicular under fluoro, then glove and prep while it gets numb.

You just put on regular gloves and do your marking and numbing, then prep and put on sterile gloves and set up while the anesthetic works? Not a bad use of time...

 

[painfree23]

Yeah, but I don’t take a lot of pictures. Usually 1 per nerve to make sure I landed the needle near the right spot. It’s 2% lido and it has at least 5 minutes to spread before I’m sticking the RF probe through that area. Time for the local to set up is key. I also wait at least a minute, preferably 2 after injecting in the skin and subq (at the spots on the skin I already marked in AP), so I use that time to set up the electrodes.
Before I adjusted my technique (taking a queue from someone on this board), I almost abandoned genicular RF because even the diagnostic blocks were causing patients to scream and jump all over.

Call me stupid, I guess I still don’t understand how u predict the depth of the needle, like how anterior to the leg enter to make sure u hit the femur in the right spot

 

[callmeanesthesia]

Call me stupid, I guess I still don’t understand how u predict the depth of the needle, like how anterior to the leg enter to make sure u hit the femur in the right spot

If I’m doing the diagnostic block under ultrasound I can directly visualize. If I’m using fluoro, I feel for the bone from the side, then I just redirect the needle a little anterior/posterior if I need to. The local spreads a long way. If their leg is huge though I go lateral with the c arm.

 

[painfree23]

If I’m doing the diagnostic block under ultrasound I can directly visualize. If I’m using fluoro, I feel for the bone from the side, then I just redirect the needle a little anterior/posterior if I need to. The local spreads a long way. If their leg is huge though I go lateral with the c arm.

Same technique for Rfa? Being perpendicular to the nerve gives u good results?

 

[Ferrismonk]

She doesn't want the treatments that may help. Why is that your problem? Move on to someone else you can help.

 

[callmeanesthesia]

Same technique for Rfa? Being perpendicular to the nerve gives u good results?

For ablations I inject local onto the bone from the same approach as the diagnostic blocks (then more at the skin insertion site) but the RF needles come in AP. I burn 3 x (burn, turn 180 and burn, pull back 1 cm and burn). The one closest to the camera is a little caudally angulated the get around the patella

 

[painfree23]

For ablations I inject local onto the bone from the same approach as the diagnostic blocks (then more at the skin insertion site) but the RF needles come in AP. I burn 3 x (burn, turn 180 and burn, pull back 1 cm and burn). The one closest to the camera is a little caudally angulated the get around the patella
View attachment 259832

So they tolerate these awake well by numbing it up laterally to medically first?

 

[siliso]

Offer it up for the souls in Purgatory? Sounds like a thorn in the flesh that there’s not a reliable medical solution for. But treat the depression and the pain may be more manageable. With attention to social engagement and sense of meaning and purpose in life and how those might be strengthened.

 

[Orin]

These geriatric cases require a lot of trust rebuilding, but it does sound like a set of genicular nerve blocks might be good start, if she understands and buys in. It's up to you how much you feel this one is worth fighting with though.

If you're left with medications, I sometimes will use low doses of methadone with good effect in this group. She might be someone who is fine though with a low doses of PRN Oxycodone for activity. I might also consider mirtazapine QHS which is relatively safe for sleep/mood in this age group

 

[callmeanesthesia]

So they tolerate these awake well by numbing it up laterally to medically first?

Extremely well. 1.5 mL 2% lido per nerve delivered from medial/lateral for the periosteum and nerve, then about 2 mL 1% from anterior for skin/subq. Another 2 mL 1% through the needle and I wait a full 2 minutes before starting ablation.

 

[Sadder]

I burn 3 x (burn, turn 180 and burn, pull back 1 cm and burn).

Do u us curved canula?

 

[callmeanesthesia]

Do u us curved canula?

Yes, 18g curves tip, 10mm active tip, 85 deg 90 sec

 

[Sadder]

Yes, 18g curves tip, 10mm active tip, 85 deg 90 sec

How directed by the beak of the cannula primary?

 

[callmeanesthesia]

How directed by the beak of the cannula primary?

Sorry, I don’t understand what you mean. Which direction does the curve face? Pointing toward the feet for the first burn, then turn 180 degrees for the second (or vice versa), then pull it back 1 cm and burn again.

 

[Sadder]

What you think about 80 yo pain 9/10

 

[lobelsteve]

What you think about 80 yo pain 9/10

Missing superior lateral needle. Inferior medial is in muscle >1cm from target.

 

[Tapspatellas]

What you think about 80 yo pain 9/10

Have to get a true lateral to gauge depth during the procedure. Get the femoral condyles superimposed. Have X-ray tech rotate leg and hold while snapping the pic if you can’t compensate with the fluoroscope, ie, would have to go lateral past 90 degree machine limit.

 

[Sadder]

Missing superior lateral needle. Inferior medial is in muscle >1cm from target.

can you point to a point in the picture?

 

[SommeRiver]

That injxn is doomed to fail. I'd recommend getting a great pic before you stick the pt bc set up is key and that doesn't look set up adequately. Agree on the inferomedial needle.

 

[lobelsteve]

can you point to a point in the picture?

I cannot point as the pic does not show the third needle placement.

 

[Sadder]

2 days after genicular block. 24 hours pain 2-3/10. The second day 70% of the original. Friday 16.30 RF Genicular. evaluation of outcome 2.5.19 please comment

 

[callmeanesthesia]

2 days after genicular unit. 24 hours pain 2-3/10. The second day 70% of the original. Friday 16.30 RF Genicular. evaluation of outcome 2.5.19 please commentView attachment 260601View attachment 260602View attachment 260603View attachment 260604

I don’t quite understand what you are saying - is this another diagnostic block or are those your electrodes for RF?
Much better images this time at least of the femur. Your superior medial and lateral needles look well placed for nerve block. The inferior medial needle is much too high. If these are your electrodes you may need to repeat the inferior medial ablation and possibly the superior lateral since it’s coming in at quite a lateral to medial angle. (and also, get some bigger RF needles - 18g at least). I assume you took that angle to avoid the patella. Try moving your skin entry point superior rather than lateral to keep the needle from going perpendicular to the nerve - see the image I uploaded above with the RF needles in place for an example. The needle closest to the camera is angled to avoid the patella.

I would recommend you look at fluoro images and anatomy in published papers, or even just type genicular nerve block in Google image search to get a better idea of the targets.

 

[lobelsteve]

2 days after genicular block. 24 hours pain 2-3/10. The second day 70% of the original. Friday 16.30 RF Genicular. evaluation of outcome 2.5.19 please commentView attachment 260601View attachment 260602View attachment 260603View attachment 260604

Maybe go to a course. SM is off, IM is way off. Go to apex of the curve, start with a better AP.

 

[Sadder]

I don’t quite understand what you are saying - is this another diagnostic block or are those your electrodes for RF?
Much better images this time at least of the femur. Your superior medial and lateral needles look well placed for nerve block. The inferior medial needle is much too high. If these are your electrodes you may need to repeat the inferior medial ablation and possibly the superior lateral since it’s coming in at quite a lateral to medial angle. (and also, get some bigger RF needles - 18g at least). I assume you took that angle to avoid the patella. Try moving your skin entry point superior rather than lateral to keep the needle from going perpendicular to the nerve - see the image I uploaded above with the RF needles in place for an example. The needle closest to the camera is angled to avoid the patella.

I would recommend you look at fluoro images and anatomy in published papers, or even just type genicular nerve block in Google image search to get a better idea of the targets.

It's RFA canullas.

I would recommend you look at fluoro images and anatomy in published papers, or even just type genicular nerve block in Google image search to get a better idea of the targets.

 

[Sadder]

3 weeks after the procedure. Pain reduction 50%+. Good technique, Thank you. I'm planning on hip Denervation now. Same patient.

 

[SommeRiver]

No idea how yall are getting genicular procedures reimbursed to any degree that would it worthwhile for you to do.