Cryo-ablation

[Dr. Ice]

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Had a joint surgeon approach me about “cryoablation” of genicular nerves for chronic knee pain. He heard about it at a conference. I’m assuming some shmuck renamed cooled rfa into “cryo” to sound like its more important of a treatment. Is that correct or am I missing something? I told him we don’t have 50k or some other ungodly number in the budget in private practice to buy a new rf machine with “cooled” technology...

 

[SommeRiver]

Nope. Doesn't work. I've done a decent amount and started a study on it that was never finished. We had over 100 pts. Very high neuritis. Very high. It probably works for knee pain perioperatively, and occipital neuralgia.

 

[Dr. Ice]

Nope. Doesn't work. I've done a decent amount and started a study on it that was never finished. We had over 100 pts. Very high neuritis. Very high. It probably works for knee pain perioperatively, and occipital neuralgia.

Ok so it is different from cooled rfa? How is it done?

 

[SommeRiver]

Depends. We used Iovera, which gets you down to about -160 degrees. The older studies back in the day that showed efficacy were usually around -190ish. So, temperature matters and in that way, cryo isn't cryo isn't cryo. You basically use US and localize your nerve of interest, then you hold the probe on the nerve for a LONG time. Usually you make 16 or more ice balls on the nerve, and each one is...many seconds in duration. Very time consuming, and physically difficult bc you're positioned over the patient and holding this probe in place. I don't remember exactly but our neuritis was sky high. On the order of something like 1/3 of our pts. The bigger and more robust the nerve the more likely you piss it off and gabapentin isn't always helpful. The old literature boasted a rate of something like 5-10% neuritis. That may be true for specific nerves, and genicular I would guess would be less likely given its size, but we had some FIRE even with occipitals.

 

[willabeast]

Ok so it is different from cooled rfa? How is it done?

I used to do cryo. PITA. the probes I used were large diameter, quite a bit bigger than RF probes. BTW chest surgeons used to cryo I.C. nerves so maybe that is where they got the equipment. I think my old cryo equipment went into the trash.
https://www.annalsthoracicsurgery.org/article/S0003-4975(10)64357-3/pdf

 

[callmeanesthesia]

Iovera makes a comb-like probe with short tips for the knee. You just draw a line medial to the inferior patella, down, and one the thigh, superior to the patella. Numb the lines then march the comb over. At each location the tips cool down. Pretty good efficacy from what I saw in fellowship, but supposedly doesn’t last as long as thermal. It was dead simple to do - usually the attending marked and numbed and a nurse sat there and did the actual ablation. I looked into it when I graduated and the rep told me “as long as you have a good payor mix, you won’t lose money.” I stopped looking into it at that point. The probes and supplies are ungodly expensive.

 

[Dr. Ice]

Thanks all for the input!

 

[cowboydoc]

Thanks all for the input!

There is a description of a few different things here. One is Iovera, which targets the superficial nerves including the AFC N, and inferior saphenous nerve. The latter is cryoablation of the genicular nerves, similar to what some are doing with thermal RF.

I have been surprised with the results of targeting superficial nerves with Iovera. N=~50 had one case of neuritis that resolved with injection of local and steroid.

They have a new probe that is creating a treatment area very similar to thermal RF, allows for direct visualization under ultrasound and seems much more precise. The downside, probes are about $300.

 

[callmeanesthesia]

There is a description of a few different things here. One is Iovera, which targets the superficial nerves including the AFC N, and inferior saphenous nerve. The latter is cryoablation of the genicular nerves, similar to what some are doing with thermal RF.

I have been surprised with the results of targeting superficial nerves with Iovera. N=~50 had one case of neuritis that resolved with injection of local and steroid.

They have a new probe that is creating a treatment area very similar to thermal RF, allows for direct visualization under ultrasound and seems much more precise. The downside, probes are about $300.

Are you in private practice? If so, how do you perform and bill them so it’s actually viable?

 

[cowboydoc]

Are you in private practice? If so, how do you perform and bill them so it’s actually viable?

I am in a multispecialty group associated with a hospital system. I do with US in clinic. I think our system is looking at this as a way to prepare for the move to outpatient total joint arthroplasty. The analysis showed nearly 2 years to recoup actual costs, not looking at the hospital length of stay and other potential downstream benefits. (perhaps I'm giving administrators too much credit)

The hand-held unit is $6 grand. The tips are about $275 and you probably use about $10-20 of nitrous per case. The reimbursement for 1 nerve is $248 for the first, and a 50% reduction for each additional. It looks like we are getting about $100 for ultrasound guidance.

Of course, Medicare reimbursement is $124 for the 1st nerves and no reimbursement for ultrasound, so that does not pencil out at all.

Summary: I have no idea why a private practice would do this.

(RVU is 1.23 for the 64640, 76942 for U/S guidance is 0.67, so for the typical Iovera treatment, I'm getting 2.82 RVU and it takes 20-30 min)

 

[SommeRiver]

Perioperative knee seems like a good pt for Iovera but I can't justify it in PP. It simply doesn't make sense. One of our joint guys in my group asked me if I would go to the hospital and do it before his cases and I nearly laughed out loud.

 

[callmeanesthesia]

I am in a multispecialty group associated with a hospital system. I do with US in clinic. I think our system is looking at this as a way to prepare for the move to outpatient total joint arthroplasty. The analysis showed nearly 2 years to recoup actual costs, not looking at the hospital length of stay and other potential downstream benefits. (perhaps I'm giving administrators too much credit)

The hand-held unit is $6 grand. The tips are about $275 and you probably use about $10-20 of nitrous per case. The reimbursement for 1 nerve is $248 for the first, and a 50% reduction for each additional. It looks like we are getting about $100 for ultrasound guidance.

Of course, Medicare reimbursement is $124 for the 1st nerves and no reimbursement for ultrasound, so that does not pencil out at all.

Summary: I have no idea why a private practice would do this.

(RVU is 1.23 for the 64640, 76942 for U/S guidance is 0.67, so for the typical Iovera treatment, I'm getting 2.82 RVU and it takes 20-30 min)

Thanks for the info. That’s what I figured... I’ve just been doing convention genicular RFA for knees (with fluoro), although even that is a little hard to make it pencil out considering most of them are Medicare.

 

[Ducttape]

Self-pay.