Discogenic pain case

[drusso]

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Any endplate changes? This sounds like a textbook case of "vertebrogenic" back pain with sclerotomal referral. I've heard that Intracept has been good.

Chronic Low Back Vertebrogenic Pain Involves the Spinal Vertebral Endplates

Chronic low back pain research shows the lumbar vertebral endplates can cause vertebrogenic pain and involve the basivertebral nerve (BVN). How BVN pain is diagnosed and treated using BVN nerve ablation.

www.spineuniverse.com

 

[SSdoc33]

Any endplate changes? This sounds like a textbook case of "vertebrogenic" back pain with sclerotomal referral. I've heard that Intracept has been good.

Chronic Low Back Vertebrogenic Pain Involves the Spinal Vertebral Endplates

Chronic low back pain research shows the lumbar vertebral endplates can cause vertebrogenic pain and involve the basivertebral nerve (BVN). How BVN pain is diagnosed and treated using BVN nerve ablation.

www.spineuniverse.com

View attachment 338870

you are going to drill a hole and fry a nerve in a 26 year old?

 

[Orin]

you are going to drill a hole and fry a nerve in a 26 year old?

What? Is there longterm data suggesting that's bad?

Honestly worries me if they'll fracture or get a charcot bone in there, but the company data says no issues. I don't think the hole is the issue as much as the burn is though.

 

[deleted875186]

What? Is there longterm data suggesting that's bad?

Honestly worries me if they'll fracture or get a charcot bone in there, but the company data says no issues. I don't think the hole is the issue as much as the burn is though.

We do kyphos on osteoporotic old people with pedicle fractures.

 

[Orin]

We do kyphos on osteoporotic old people with pedicle fractures.

Yes, that cement is wonderful. BVN just burns the bone/nerve/etc and doesn't leave anything behind in that cooked tissue.

 

[deleted875186]

Yes, that cement is wonderful. BVN just burns the bone/nerve/etc and doesn't leave anything behind in that cooked tissue.

I didn’t think the cement actually got into the pedicles, just the vertebral body.

 

[Orin]

I didn’t think the cement actually got into the pedicles, just the vertebral body.

Depends if you do it wrong or not.

What I'm saying is I'm not really bothered by a hole in the pedicle to get to the nerve though. It's the burn and risk of body fracture.

 

[ctts]

Great discussion here.

In response to OP, in general, I think a long detailed discussion is necessary here. It validates their pain complaint, and it shows them you are being thoughtful to consider the treatment options, even if there is no definitive solution (I don't think there is one). Difficult discussion to have, depending on how much they are willing to accept this or not, but I think these patients generally appreciate it. I think ESI does help sometimes for discogenic pain, especially if there is an annular fissure/tear, but agree that it is hit or miss, and would tell the patient it will not fix his problem in the long-run. I would offer it as an option in that case, but the patient needs to be the one asking for it. I think ESI in his case should be reserved for acute flare-ups that do not resolve in a reasonable time frame for him (I think most of these patients have this experience at some point or another), but ESI probably would not be that helpful if he is at baseline chronic level of pain. If it has been that way for years, then I think PT, core strengthening as able, and activity modification is the key to try to avoid making it worse, and learn to live with it.

I have done some stem cell procedures (intradiscal autologous stem cell from concentrated bone marrow aspirate), only when patients ask me for it, and if the indications are reasonable, so I have not done many. I generally don't make it a point to offer it, as I am somewhat a skeptic myself, despite some of the positive outcomes I have seen (certainly not all positive), but not unreasonable to consider in these cases.

 

[drusso]

I have done some stem cell procedures (intradiscal autologous stem cell from concentrated bone marrow aspirate), only when patients ask me for it, and if the indications are reasonable, so I have not done many. I generally don't make it a point to offer it, as I am somewhat a skeptic myself, despite some of the positive outcomes I have seen (certainly not all positive), but not unreasonable to consider in these cases.

Why not do it when patients "need it" instead of just "ask you for it?"

 

[RoloTomassi]

I would offer ESI all day, with discussion that it's not great but it's so low risk that it's reasonable. Some do really well for a decent amount of time. Some respond better to IL, some to TF.

I also offer intradiscal BMAC. I go over the literature, my success rates and those of my partners. I go over risks, including discitis thoroughly. It's a last resort for me. These people are getting fusions if I can't help, and most are young. Not as low risk as ESI obviously, and very painful initially, but can be life changing when successful.

I also do Intracept when there are Modic changes, and pain seems more vertebrogenic than actual discogenic. This is one of the most game changing procedures. Success rates consistent with the studies. If there are Modic changes I always do Intracept before offering intradiscal, and have never had to do intradiscal as a plan B. Very low risk, well tolerated, post-op course very short. Doesn't burn holes like someone else said, structure is intact. No hesitation to do younger patients, and so much better than fusion.

I think not discussing or offering/ referring out for these things is a disservice. I don't push anything, I just lay out the options, risks, success rates. Patient chooses. This is how I would like to be treated.

 

[drusso]

I would offer ESI all day, with discussion that it's not great but it's so low risk that it's reasonable. Some do really well for a decent amount of time. Some respond better to IL, some to TF.

I also offer intradiscal BMAC. I go over the literature, my success rates and those of my partners. I go over risks, including discitis thoroughly. It's a last resort for me. These people are getting fusions if I can't help, and most are young. Not as low risk as ESI obviously, and very painful initially, but can be life changing when successful.

I also do Intracept when there are Modic changes, and pain seems more vertebrogenic than actual discogenic. This is one of the most game changing procedures. Success rates consistent with the studies. If there are Modic changes I always do Intracept before offering intradiscal, and have never had to do intradiscal as a plan B. Very low risk, well tolerated, post-op course very short. Doesn't burn holes like someone else said, structure is intact. No hesitation to do younger patients, and so much better than fusion.

I think not discussing or offering/ referring out for these things is a disservice. I don't push anything, I just lay out the options, risks, success rates. Patient chooses. This is how I would like to be treated.

Any problems with the pre-auth on the Intracept?

 

[RoloTomassi]

Any problems with the pre-auth on the Intracept?

Takes forever for commercial, low approval rate. Medicare is good to go. Reimbursement highly variable for all payers. WC/PI/self pay is helping compensate. Next year should be better because right now it's an unlisted code, but will have a new CPT next year. Still going to do it because it's so effective, for people who have very few other options.

 

[drusso]

Takes forever for commercial, low approval rate. Medicare is good to go. Reimbursement highly variable for all payers. WC/PI/self pay is helping compensate. Next year should be better because right now it's an unlisted code, but will have a new CPT next year. Still going to do it because it's so effective, for people who have very few other options.

You're saying straight Medicare pays for it?

 

[RoloTomassi]

You're saying straight Medicare pays for it?

Yes but payment has been variable. The company has a whole reimbursement team that works closely with your billing people. They are very helpful in getting approvals and payment.

 

[sdnuser001]

Grc had better literature than mbb for disc as well as esi for axial lbp

My understanding from the literature was that GRC blocks seem to work better than GRC radiofrequency ablation. Has anyone tried GRC peripheral stimulation (ie in the manner some folks use sprint PNS on medial branches for multifi activation)?

 

[Ferrismonk]

Takes forever for commercial, low approval rate. Medicare is good to go. Reimbursement highly variable for all payers. WC/PI/self pay is helping compensate. Next year should be better because right now it's an unlisted code, but will have a new CPT next year. Still going to do it because it's so effective, for people who have very few other options.

My crystal ball says if it gets it's own cpt code, it's dead because it's now "experimental".

 

[clubdeac]

No one’s mentioned swimming or aquatic therapy for these patients. I have found this to be one of the most effective treatments for my discogenic lbp patients. It truly can be a game changer. I think a new study came out in support of this as well. Can’t remember where I saw it but will try and find it

 

[lobelsteve]

No one’s mentioned swimming or aquatic therapy for these patients. I have found this to be one of the most effective treatments for my discogenic lbp patients. It truly can be a game changer. I think a new study came out in super if this as well. Can’t remember where I saw it but will try and find it

It is great. But not convenient or cheap. TAT for swimming adds an hour to the routine.