Does RFA of Lumbar Spine cause multifidus atrophy?

[lobelsteve]

No..

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/23/02.sis.ff.rfa.multifidus.atr.pdf

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[Agast]

And then you implant Reactiv8 to counteract that multifidus muscle atrophy afterwards?

 

[mdo1738]

5 patients for 26 months. I'm not saying it does, but that short, under-powered study also definitely isn't able to say it doesn't.

 

[joshmir]

Steve, link doesn’t work. Can you please summarize in one sentence? Thanks

 

[BobBarker]

I think he summarized in a word.

 

[TIVAndy]

I haven't seen in lumbar but ive seen thoracic multifidus atrophy noticeably in one of my patients.

 

[DrSpine]

But Regenexx guy said RFA is wrong and causes atrophy 😂

 

[Dr. Ice]

Did bilateral intr-articular facet prp on a guy that failed multiple rfas and “intracetpt.” I don’t know why I put it in quotes, maybe for eyebrow raising quasi who cares, as those who do it do the same thing to me about PRP, but I digress. Patient is 6 weeks out and is doing really well. No am pain or stiffness, minimal transitional movement pain, no meds, more active. Oh by the way, he’s a relative of one of the partners so I did it pro bono….must be that pesky places effect. Yeah, except he’s not the guy for that..

 

[lobelsteve]

Did bilateral intr-articular facet prp on a guy that failed multiple rfas and “intracetpt.” I don’t know why I put it in quotes, maybe for eyebrow raising quasi who cares, as those who do it do the same thing to me about PRP, but I digress. Patient is 6 weeks out and is doing really well. No am pain or stiffness, minimal transitional movement pain, no meds, more active. Oh by the way, he’s a relative of one of the partners so I did it pro bono….must be that pesky places effect. Yeah, except he’s not the guy for that..

Funny thing is that you believe the PRP part made him better.

 

[Taus]

Did bilateral intr-articular facet prp on a guy that failed multiple rfas and “intracetpt.” I don’t know why I put it in quotes, maybe for eyebrow raising quasi who cares, as those who do it do the same thing to me about PRP, but I digress. Patient is 6 weeks out and is doing really well. No am pain or stiffness, minimal transitional movement pain, no meds, more active. Oh by the way, he’s a relative of one of the partners so I did it pro bono….must be that pesky places effect. Yeah, except he’s not the guy for that..

That’s great to hear about having that result.

FYI, I have done over 60 intracept now. Results continue to mirror the published literature. Only a couple scattered failures. I have my own ongoing non-industry-sponsored controlled trial, with enrollment halfway completed. Will publish interim data ASAP. This has been the first “game changer” in my 10 year career. The coolest thing has been patients who I have seen for nearly my entire career, previously done everything possible, now overall doing great after intracept. Perhaps I sound like too much of a paid consultant… I most certainly am not.

 

[Dr. Ice]

Funny thing is that you believe the PRP part made him better.

Yeah you’re right, must be all in our heads 🤔

 

[lobelsteve]

Yeah you’re right, must be all in our heads 🤔

It isn't, but maybe you forgot science.
That's not how it works.

 

[bedrock]

That’s great to hear about having that result.

FYI, I have done over 60 intracept now. Results continue to mirror the published literature. Only a couple scattered failures. I have my own ongoing non-industry-sponsored controlled trial, with enrollment halfway completed. Will publish interim data ASAP. This has been the first “game changer” in my 10 year career. The coolest thing has been patients who I have seen for nearly my entire career, previously done everything possible, now overall doing great after intracept. Perhaps I sound like too much of a paid consultant… I most certainly am not.

Great procedure. I refer out anyone who qualifies to the one doc in two states that does them. He is HOPD employed, RVU based….

 

[bedrock]

Did bilateral intr-articular facet prp on a guy that failed multiple rfas and “intracetpt.” I don’t know why I put it in quotes, maybe for eyebrow raising quasi who cares, as those who do it do the same thing to me about PRP, but I digress. Patient is 6 weeks out and is doing really well. No am pain or stiffness, minimal transitional movement pain, no meds, more active. Oh by the way, he’s a relative of one of the partners so I did it pro bono….must be that pesky places effect. Yeah, except he’s not the guy for that..

I think this raises the question of poorly performed RFA. (Or just massive osteophytes?)

However, I also think PRP for facets can make sense.

I’ve done several with good results on young patients s/p trauma, who had short term relief from IA facets and didn’t want to sign up for a lifetime of RFA.

 

[Taus]

Great procedure. I refer out anyone who qualifies to the one doc in two states that does them. He is HOPD employed, RVU based….

Your Asc will net 3.5K per case on medicare. If you get distributions, I think this makes sense. can get a case done routinely in 15 minutes per vertebral body w access and burn once you cross the learning curve. Best when you have two rooms, to bounce while turnover starts. Also, as per other the threads, 460ish pro fee for a single level case for 30 minutes. 215 additional level. While not great versus commercial esi, it’s better than Medicare ESI pro fee.

 

[bedrock]

Your Asc will net 3.5K per case on medicare. If you get distributions, I think this makes sense. can get a case done routinely in 15 minutes per vertebral body w access and burn once you cross the learning curve. Best when you have two rooms, to bounce while turnover starts. Also, as per other the threads, 460ish pro fee for a single level case for 30 minutes. 215 additional level. While not great versus commercial esi, it’s better than Medicare ESI pro fee.

We've discussed before. Again, I'm not dissing the procedure.

On a technical note, if you have someone who makes clinical sense for the procedure but has very modest modic changes, will you still do intracept?

I mean a patient without a spondylolisthesis or significant stenosis, facets were ruled out or s/p RFA. Clearly a disc issue, multiple discs don't look great, but only one has a couple of flecks of modic changes.

1- Will you do an intracept for this?
2- What about the adjacent levels? If say L4-L5 has a couple flecks of endplate changes, and both L4-L5, L5-S1 are black with at least 30% loss of disc height. Will you intracept both L4-L5 and L5-S1?

genuinely curious

 

[Taus]

On a technical note, if you have someone who makes clinical sense for the procedure but has very modest modic changes, will you still do intracept?

100%. Results in the clinical trials, and in my hands are the same. It truly appears to be binary. You’re either pregnant or not.

I mean a patient without a spondylolisthesis or significant stenosis, facets were ruled out or s/p RFA. Clearly a disc issue, multiple discs don't look great, but only one has a couple of flecks of modic changes.

1- Will you do an intracept for this?
2- What about the adjacent levels? If say L4-L5 has a couple flecks of endplate changes, and both L4-L5, L5-S1 are black with at least 30% loss of disc height. Will you intracept both L4-L5 and L5-S1?

genuinely curious

I would temper expectations if I could only truly justify treating one of the levels, but still offer the procedure.

I’d bet that if you really scrutinize T2 and STIR on sagittal, scrolling across the entire segment, you will see some endplate change at S1.

 

[RoloTomassi]

Did bilateral intr-articular facet prp on a guy that failed multiple rfas and “intracetpt.” I don’t know why I put it in quotes, maybe for eyebrow raising quasi who cares, as those who do it do the same thing to me about PRP, but I digress. Patient is 6 weeks out and is doing really well. No am pain or stiffness, minimal transitional movement pain, no meds, more active. Oh by the way, he’s a relative of one of the partners so I did it pro bono….must be that pesky places effect. Yeah, except he’s not the guy for that..

I do all three--RFA, IA PRP, Intracept--routinely. They all have their place. I wouldn't assume the failures you see are treatment failures rather than poor patient selection or technique

 

[MitchLevi]

Here's my problem - I'd guess my clinic volume is roughly similar to what each of you do, bit I can't for the life of me collect enough pts to get trained in the cadaver course. I've yet to find one. ONE!

 

[Taus]

Here's my problem - I'd guess my clinic volume is roughly similar to what each of you do, bit I can't for the life of me collect enough pts to get trained in the cadaver course. I've yet to find one. ONE!

How is that possible? Have you curated the perfect practice, with no chronic axial lbp? This is historically the bane of our existence in ipm.

 

[MitchLevi]

How is that possible? Have you curated the perfect practice, with no chronic axial lbp? This is historically the bane of our existence in ipm.

Like yall, I see a ton of that. RFA and ESI do pretty good.

I don't know. I need to grab some pts and get trained. I spoke with the rep prob 6 months ago...Maybe longer.

Then again...I'm a long-legged mack daddy (only 5'11" though) and I get in the room and convince you chronic pain is normal.

 

[Taus]

Like yall, I see a ton of that. RFA and ESI do pretty good.

I don't know. I need to grab some pts and get trained. I spoke with the rep prob 6 months ago...Maybe longer.

Then again...I'm a long-legged mack daddy and I get in the room and convince you chronic pain is normal.

Lol

Perhaps you’re only looking for classic cases w very prominent modic changes? Take a harder look at the mris of your chronic “discogenic” pain patients. You’ll find some modic.

 

[MitchLevi]

Lol

Perhaps you’re only looking for classic cases w very prominent modic changes? Take a harder look at the mris of your chronic “discogenic” pain patients. You’ll find some modic.

I think you're def right.

 

[bedrock]

Here's my problem - I'd guess my clinic volume is roughly similar to what each of you do, bit I can't for the life of me collect enough pts to get trained in the cadaver course. I've yet to find one. ONE!

That does seem odd. As taus said, even modest modic changes often respond.

Every case I’ve referred for intracept has achieved at least 65% relief. Some noticeably more. All were happy they did it.

 

[MitchLevi]

That does seem odd. As taus said, even modest modic changes often respond.

Every case I’ve referred for intracept has achieved at least 65% relief. Some noticeably more. All were happy they did it.

No offense, but I don't believe 90% of what my colleagues tell me about procedure outcomes.

That's not directed at you dude.

 

[bedrock]

No offense, but I don't believe 90% of what my colleagues tell me about procedure outcomes.

That's not directed at you dude.

No worries. Real science is more than anecdotes.

But it is nice to have an option for these patients that previously had no options, other than pain psych.

 

[MitchLevi]

No worries. Real science is more than anecdotes.

But it is nice to have an option for these patients that previously had no options, other than pain psych.

I'm probably just too stiff in my criteria. Yall would prob walk in and carve one or two out per week.

 

[RoloTomassi]

I don't consider my practice high volume and I order a few a week.

Another way to look at it is axial pain is likely multifactorial. Those RFAs giving 50%--is it possible that endplates are contributing to the other 50%?

 

[MitchLevi]

I don't consider my practice high volume and I order a few a week.

Another way to look at it is axial pain is likely multifactorial. Those RFAs giving 50%--is it possible that endplates are contributing to the other 50%?

Prob.

My ppl that are "better" but still hurting may be the pool I pull from.

 

[bedrock]

I don't consider my practice high volume and I order a few a week.

Another way to look at it is axial pain is likely multifactorial. Those RFAs giving 50%--is it possible that endplates are contributing to the other 50%?

Hm. I might be undercounting.

Though in my experience intracept works best with patients who truly fail RFA. (30% relief or less).

If most of the damage is anterior column I think intracept makes sense, but not enough anterior stress to benefit from intracept if pain is 50/50.

I rarely see much in modic changes in patients with 50% relief or greater after RFA; but I see modic changes regularly in patients that completely fail MBB or RFA.

 

[Taus]

Hm. I might be undercounting.

Though in my experience intracept works best with patients who truly fail RFA. (30% relief or less).

If most of the damage is anterior column I think intracept makes sense, but not enough anterior stress to benefit from intracept if pain is 50/50.

I rarely see much in modic changes in patients with 50% relief or greater after RFA; but I see modic changes regularly in patients that completely fail MBB or RFA.

I think it would be greatly preferable to make this distinction in the office by history and exam, or if mixed clinical picture, by negative MBB, rather than failure of RFA as a criteria.

That said, I have done a handful of cases with similar scenario. Mostly on longtime patients of mine, who would get about 50% relief with facet RFA every one to two years, resolution of their localized tenderness and extension based pain, but with residual midline pain. Previously was nothing else to do about the latter.

 

[bedrock]

I think it would be greatly preferable to make this distinction in the office by history and exam, or if mixed clinical picture, by negative MBB, rather than failure of RFA as a criteria.

That said, I have done a handful of cases with similar scenario. Mostly on longtime patients of mine, who would get about 50% relief with facet RFA every one to two years, resolution of their localized tenderness and extension based pain, but with residual midline pain. Previously was nothing else to do about the latter.

I stand corrected. You have much more experience than me with this.

Did you have to hunt for subtle modic changes in most of these patients who achieved 50% relief from RFA?

 

[Taus]

I stand corrected. You have much more experience than me with this.

Did you have to hunt for subtle modic changes in most of these patients who achieved 50% relief from RFA?

Not in the small n of multifactorial cases I have done. These were pretty prominent on mri, but there was historically just nothing else I could do about it. Our experiences may vary, but I think these truly multifactorial patients with facet and vertebrogenic pain, who get moderate relief from both procedures, are the exception, not common at all.


For the patient’s where I really have had to hunt for subtle mobic changes….. everything else clinically pointed to anterior column pain.

 

[Dr. Ice]

It isn't, but maybe you forgot science.
That's not how it works.

Lol..yes, pro bono so no placebo based on cash payments. The guy has really no reason to lie and tell me it worked. But ok Steve..keep on keepin on my friend

 

[Dr. Ice]

I do all three--RFA, IA PRP, Intracept--routinely. They all have their place. I wouldn't assume the failures you see are treatment failures rather than poor patient selection or technique

Posterior column pain, sis technique for rfa. Took my time. Positive diagnostic blocks with bupivacaine only x 2. Patient had it before, with no relief. Never saw op reports. My own “hubris” made me wanna reinvent the wheel. No relief from rfa. PRP worked very well…he’s not the only one…

 

[RoloTomassi]

Posterior column pain, sis technique for rfa. Took my time. Positive diagnostic blocks with bupivacaine only x 2. Patient had it before, with no relief. Never saw op reports. My own “hubris” made me wanna reinvent the wheel. No relief from rfa. PRP worked very well…he’s not the only one…

How do you explain that? Anomalous MB locations, didn't get burned? Or PRP spreading beyond facets?

 

[Dr. Ice]

How do you explain that? Anomalous MB locations, didn't get burned? Or PRP spreading beyond facets?

Maybe the later.. I have often gotten enough volume from 60cc that I will do intra-articular and then also do almost like a trigger point injection as well. Some of these folk have a myofascial component as well

 

[Tboned]

What did you do on the previous patient? IA only?

 

[DrMDAware]

I do all three--RFA, IA PRP, Intracept--routinely. They all have their place. I wouldn't assume the failures you see are treatment failures rather than poor patient selection or technique

Nice. How do you work IA PRP into the mix? Already failed RF? Younger? Better looking joints? Genuinely curious. Thx.

 

[DrMDAware]

For @Taus and @bedrock (and anyone else who has done a lot of Intracept) what’s your pitch and way to describe it?

I try to explain that it’s like an RFA (because most patients are familiar with that) but the needle goes deeper into the bone. I use a model to show them the location. I tell them it is a one time burn because the nerve is so deep. I tell them there’s no cement. Just heat. No steroid. Nothing left inside body.

I also show them the “puffy cloud” on their MRI.

I feel like I’m not conveying something correctly because some people are convinced it’s a big scary procedure and don’t want to procedure.

Is it because it’s “new”?
Are they conditioned opioids, RFAs or epidurals?

 

[Taus]

For @Taus and @bedrock (and anyone else who has done a lot of Intracept) what’s your pitch and way to describe it?

I try to explain that it’s like an RFA (because most patients are familiar with that) but the needle goes deeper into the bone. I use a model to show them the location. I tell them it is a one time burn because the nerve is so deep. I tell them there’s no cement. Just heat. No steroid. Nothing left inside body.

I also show them the “puffy cloud” on their MRI.

I feel like I’m not conveying something correctly because some people are convinced it’s a big scary procedure and don’t want to procedure.

Is it because it’s “new”?
Are they conditioned opioids, RFAs or epidurals?

In general, I explain it to patients like this:
Similar principle on both procedures, but for different causes of pain. Rfa for the joints in the back of the spine, intracept for the disc in the front. Stopping the nerve that senses pain like a root canal…but don't worry, you're asleep for this. I show them the nerve on MRI. I generally stop there and go into success rates, recovery, risks, etc…. Unless they really want to hear more specific technical details. If they really want to know how I get to the nerve through bone, I am happy to explain it.

 

[Ronin1]

What percentage of your Intracept patients are getting general? At the training one of the guys said he is using mostly heavy MAC which often equated to GA.

 

[Taus]

What percentage of your Intracept patients are getting general? At the training one of the guys said he is using mostly heavy MAC which often equated to GA.

Has been probably 70:30 general vs Mac due to majority of my cases being Medicare, comorbid, multi level thus far (due to lag time getting commercial insurance approvals). Majority of younger, healthy, two or three vertebral body cases have been Mac, unless the anesthesiologist does not feel it is safe enough due to their airway, or other medical factors. I am not an anesthesiologist and will defer to them on that if they don’t think a heavier Mac, prone, for that direction would be safe enough. I frankly wouldn’t really care either way, except turnover time is longer with general, therefore my preference is Mac whenever possible.

 

[RoloTomassi]

What percentage of your Intracept patients are getting general? At the training one of the guys said he is using mostly heavy MAC which often equated to GA.

I think MAC is usually the most appropriate level of sedation but comorbidities, anticipation of long case, or anesthesiologist preference bump a few to GETA. Small percentage IV conscious sedation.

 

[BobBarker]

Guys, what you are calling MAC is general without an airway. They are all getting general.

 

[RoloTomassi]

In general, I explain it to patients like this:
Similar principle on both procedures, but for different causes of pain. Rfa for the joints in the back of the spine, intracept for the disc in the front. Stopping the nerve that senses pain like a root canal…but don't worry, you're asleep for this. I show them the nerve on MRI. I generally stop there and go into success rates, recovery, risks, etc…. Unless they really want to hear more specific technical details. If they really want to know how I get to the nerve through bone, I am happy to explain it.

Yeah going into the technicalities just makes them fearful.

I give same talk as RFA, but say it's for a different target, is permanent, go over high success rates, then say since this nerve is in the VB, we'll put you asleep to make it more comfortable. My population is also non-opioid, come looking for a fix, surgical or nonsurgical, and is happy if there's a nonsurgical option

 

[Ronin1]

Any special position tricks you guys utilize?

 

[RoloTomassi]

Any special position tricks you guys utilize?

Not much. Flatten lordosis with pillows as needed per belly size. Arms up. Airplane table for true AP before each level.

 

[RoloTomassi]

Guys, what you are calling MAC is general without an airway. They are all getting general.

What do you mean? MAC get some combination of Versed, fentanyl, and propofol. No inhalants or neuromuscular blockade. Usually a bit of movement during the painful parts. Fast arousal. I'm not anesthesia so my knowledge is limited here.

 

[Ronin1]

What do you mean? MAC get some combination of Versed, fentanyl, and propofol. No inhalants or neuromuscular blockade. Usually a bit of movement during the painful parts. Fast arousal. I'm not anesthesia so my knowledge is limited here.

MAC refers to level of consciousness not the agents. Essentially if they are getting propofol it’s a general without an airway. In many cases general with a tube is safer than a prone sedation case.