Experience with Intracept.

[Laryngospasm]

Anyone have any experience with this? If so how have results been and were you able to get it approved. Thanks.

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[inplane]

I’ve done a few during fellowship. Results have been pretty good so far, only a few months since most of them. For most of the patient’s that I have seen this done for they have very degenerated lumbar spines, but have failed MBB/RFA, ESI, often SCS and must have Modic changes at or below L3. The company that does Intracept (Relievant) handles all of the insurance authorization. We had to do them in the OR. Total procedure time was around an hour (15 min ablations at each level, with a minimum 2 levels). So the first ablation doesn’t add any time since you just start on the second level but there is a 15 stand around time on the back end. We did have a home run that was able to come off about 30-40 MMEs after though.

 

[Ligament]

This can only be done in hospital settings due to costs and poor reimbursement in ASC and clinic settings. Keep that in mind.

 

[callmeanesthesia]

This can only be done in hospital settings due to costs and poor reimbursement in ASC and clinic settings. Keep that in mind.

There is supposedly someone in the Bay Area doing it at an ASC, and they are working with the ASC I work with, which is part of the same network (HCA) to get pricing nailed down.

 

[Ducttape]

they are probably losing money then.

the equipment costs are prohibitive to do it in an ASC. then I looked in to this, the ASC would lose about $3000 per case.

 

[nvrsumr]

Any reason the same results can't be obtained by sticking a 16g(or 4) rf cannula in the disc?

 

[SSdoc33]

Any reason the same results can't be obtained by sticking a 16g(or 4) rf cannula in the disc?

you dont RF the disc. you may be thinking of biacuplasty

 

[pmrmd]

they are probably losing money then.

the equipment costs are prohibitive to do it in an ASC. then I looked in to this, the ASC would lose about $3000 per case.

It’s very modestly profitable in an ASC for Medicare right now.

 

[au bon pain]

N of 3 from fellowship. 2 had excellent results. 1 not so much. The 15 min burn time is a bit of a drag.

 

[NJPAIN]

Which insurers are actually paying for INTRACEPT?

 

[stsa84]

Which insurers are actually paying for INTRACEPT?

Medicare approves it fairly easily. And private insurers usually approve it eventually. The company has its own team that works on insurance approvals.

 

[epidural man]

Our hospital just got the machine. Neurosurgery has done a few cases. IR was trained. We have our first cases coming up.

 

[bedrock]

Our hospital just got the machine. Neurosurgery has done a few cases. IR was trained. We have our first cases coming up.

Cool. Let us know how it goes

 

[Agast]

Our hospital just got the machine. Neurosurgery has done a few cases. IR was trained. We have our first cases coming up.

Updates? Intracept rep came by, he's discussing pricing options with the ASC

 

[RoloTomassi]

Updates? Intracept rep came by, he's discussing pricing options with the ASC

I've done about 20. Very impressed. Results consistent with studies.

 

[fathead88]

Did 1 last week, <45 mins from start to finish. The 15 minute wait on the backend is a bit annoying but depends on your setup.

 

[Laryngospasm]

I had a guy today, failed esi, facembb, tons of endplate nodes.. would love to try it.

 

[Agast]

I've done about 20. Very impressed. Results consistent with studies.

What CPT code do you use? I thought it was originally L3 only but he said it was L3-S1

 

[RoloTomassi]

22899 unlisted code. It's approved for L3-S1. I've done it off label for L1 and L2 as well

 

[pmrmd]

It’s getting a CPT code next year.

 

[Agast]

It’s getting a CPT code next year.

The cynical part of me thinks that’s just so they can deny it more efficiently

like genicular and SI joint ablation

 

[bedrock]

The cynical part of me thinks that’s just so they can deny it more efficiently

like genicular and SI joint ablation

Agree. I’m worried the same thing will happen.

 

[Tboned]

The cynical part of me thinks that’s just so they can deny it more efficiently

like genicular and SI joint ablation

That’d be cold as ice and I wouldn’t be surprised

 

[GlowInTheDark]

Done 2, one with great results. 2nd had minimal relief, but they had imaging that completely justified doing L3,4, and 5. However rep advised against doing 3 as it would most likely not get paid by insurance.

So, did 2 levels and now patient is scheduled for a repeat for the 3rd. 🤷‍♂️

 

[RoloTomassi]

The majority do well, and by well I mean 75-100% relief within 1-2 weeks. These are patients with severe pain and disability who really have no options other than fusion, which is not that effective for axial pain. Pain seems more anterior column, MBB/RFA didn't work, disc degeneration too severe for PRP/BMAC, no nerve compression, not SI. That's the impressive part--they are ready for fusion, and you can permanent cure them with a 1 hour procedure with no downtime, nothing implanted in them. Patients are ecstatic and think you're a miracle worker.

The lack of predictability is the kicker. I've had about 3 perfect candidates, perfect placement, minimal relief. Hugely disappointing, but at least no harm done. I chalk it up to the lack of specificity of Modic changes. We've all seen people with terrible Modic changes on MRI but minimal axial pain or pain that was successfully treated with RFA. Maybe I will try PNS for causalgia for the failures.

n=20 for me, 50 total for my group

 

[lobelsteve]

The majority do well, and by well I mean 75-100% relief within 1-2 weeks. These are patients with severe pain and disability who really have no options other than fusion, which is not that effective for axial pain. Pain seems more anterior column, MBB/RFA didn't work, disc degeneration too severe for PRP/BMAC, no nerve compression, not SI. That's the impressive part--they are ready for fusion, and you can permanent cure them with a 1 hour procedure with no downtime, nothing implanted in them. Patients are ecstatic and think you're a miracle worker.

The lack of predictability is the kicker. I've had about 3 perfect candidates, perfect placement, minimal relief. Hugely disappointing, but at least no harm done. I chalk it up to the lack of specificity of Modic changes. We've all seen people with terrible Modic changes on MRI but minimal axial pain or pain that was successfully treated with RFA. Maybe I will try PNS for causalgia for the failures.

n=20 for me, 50 total for my group

3 mo ODI data?
Placebo response?
Sham wow.

 

[RoloTomassi]

3 mo ODI data?
Placebo response?
Sham wow.

Look at the Fischgrund, Macadaeg, and Khalil studies if you want 3+ mo ODI. I'm sure they're not robust enough for you. Placebo response to this but nothing else? Curious what your approach is to these patients? Keep them on opioids? Def level 1 for that.

 

[lobelsteve]

Look at the Fischgrund, Macadaeg, and Khalil studies if you want 3+ mo ODI. I'm sure they're not robust enough for you. Placebo response to this but nothing else? Curious what your approach is to these patients? Keep them on opioids? Def level 1 for that.

Acceptance. DLS. Ultram and occl nsaid.
This is a cultural phenomenon and not something I believe we have reasonable treatment for. For patients who disagree with me, they can seek care elsewhere. They come back after this fails, fusion fails. They then agree to do DLS, CBT. Then I offer SCS. Win win. Except for the patient.

 

[pmrmd]

I believe the data to be clear. It’s all about payment now.

Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results - PubMed

BVN ablation demonstrates significant improvements in pain and function over SC, with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.

pubmed.ncbi.nlm.nih.gov

 

[RoloTomassi]

Acceptance. DLS. Ultram and occl nsaid.
This is a cultural phenomenon and not something I believe we have reasonable treatment for. For patients who disagree with me, they can seek care elsewhere. They come back after this fails, fusion fails. They then agree to do DLS, CBT. Then I offer SCS. Win win. Except for the patient.

What is a cultural phenomenon?

 

[lobelsteve]

I believe the data to be clear. It’s all about payment now.

Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results - PubMed

BVN ablation demonstrates significant improvements in pain and function over SC, with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.

pubmed.ncbi.nlm.nih.gov

Conflict of interest statement​

Competing interests: The following authors declare conflicts of interest related to consulting, teaching/proctoring roles, and/or scientific board roles for Relievant Medsystems: Dr SG, Dr JH, Dr JK and Dr NM. The following authors declare conflicts of interest for research funding paid to their institution from Relievant Medsystem during the conduct of the study: Dr JK, Dr SK, Dr TK, and Dr MS. The following authors declare no conflicts of interest for the submitted work: Dr KB.

Interesting point of the entire study is to rectify the Cham group in the previous study showing the same ODI function at three months as the treatment group.

 

[lobelsteve]

What is a cultural phenomenon?

https://core.ac.uk/download/pdf/131639918.pdf

Start with this article and check out numbers 18 and 19 in the bibliography.

 

[RoloTomassi]

This is a cultural phenomenon and not something I believe we have reasonable treatment for.

I still don't understand what you're getting at. It's cultural so we shouldn't even try? Btw my Intracept patients have been age mid 30s to 70s, all races and ethnicities, different socioeconomic statuses, 2 are immigrants, none on opioids.

fusion fails. They then agree to do DLS, CBT. Then I offer SCS

Why would you make them go through that algorithm? Try the least invasive first. Ok, do DLS and CBT first, but try Intracept before surgery or SCS. SCS isn't a slam dunk for axial pain, especially mechanical, and those studies are no better than the Intracept ones you're ripping.

You respect Doug Beall. Ask him what he thinks.

 

[TIVAndy]

i donated few cases for medicare pts. they refused to pay unlisted code. i refuse to do it now.
result decent >50% improvement in axial pain.

 

[lobelsteve]

I still don't understand what you're getting at. It's cultural so we shouldn't even try? Btw my Intracept patients have been age mid 30s to 70s, all races and ethnicities, different socioeconomic statuses, 2 are immigrants, none on opioids.

Why would you make them go through that algorithm? Try the least invasive first. Ok, do DLS and CBT first, but try Intracept before surgery or SCS. SCS isn't a slam dunk for axial pain, especially mechanical, and those studies are no better than the Intracept ones you're ripping.

You respect Doug Beall. Ask him what he thinks.

When I tell folks we have no good treatment for DDD I tell them the options and the current state of the literature. I trll them they can keep looking and gor 50 years we have not had great treatment. I tell them who does bvna and fusions. They go elsewhere and are welcome back if they try and fail. I do SCS on those that fail other treatment elsewhere.

 

[RoloTomassi]

When I tell folks we have no good treatment for DDD I tell them the options and the current state of the literature. I trll them they can keep looking and gor 50 years we have not had great treatment. I tell them who does bvna and fusions. They go elsewhere and are welcome back if they try and fail. I do SCS on those that fail other treatment elsewhere.

Fair enough. I just think that you should do some because you're good at kypho and being salaried, the questionable reimbursement doesn't limit your ability like it limits others in PP. But if you're not comfortable with the risk-benefit ratio and research, that's your call.

 

[epidural man]

When I tell folks we have no good treatment for DDD I tell them the options and the current state of the literature. I trll them they can keep looking and gor 50 years we have not had great treatment. I tell them who does bvna and fusions. They go elsewhere and are welcome back if they try and fail. I do SCS on those that fail other treatment elsewhere.

Define "good".

I would argue we have pretty good treatment but patients don't want to do it.

It requires expressive writing, acceptance-commitment therapy, core strengthening, good sleep patterns, diet changes, often weight loss, movement therapies such as yoga, dealing with demons in the past, self-love/self-discover, etc.

 

[lobelsteve]

Define "good".

I would argue we have pretty good treatment but patients don't want to do it.

It requires expressive writing, acceptance-commitment therapy, core strengthening, good sleep patterns, diet changes, often weight loss, movement therapies such as yoga, dealing with demons in the past, self-love/self-discover, etc.

That sounds good to me. Like Noom but for pain.

 

[Nodolor]

Define "good".

I would argue we have pretty good treatment but patients don't want to do it.

It requires expressive writing, acceptance-commitment therapy, core strengthening, good sleep patterns, diet changes, often weight loss, movement therapies such as yoga, dealing with demons in the past, self-love/self-discover, etc.

Well that recipe could apply to about 90% of what we do and we would have much better results than the interventions we do

 

[drusso]

Acceptance. DLS. Ultram and occl nsaid.
This is a cultural phenomenon and not something I believe we have reasonable treatment for. For patients who disagree with me, they can seek care elsewhere. They come back after this fails, fusion fails. They then agree to do DLS, CBT. Then I offer SCS. Win win. Except for the patient.

Show me the data for CBT and Modic changes.

 

[lobelsteve]

Show me the data for CBT and Modic changes.

The sky is blue.

 

[drusso]

The sky is blue.

C'mon, man, with an epidemic of vertebrogenic back pain, why aren't scientists studying this?

C

 

[lobelsteve]

C'mon, man, with an epidemic of vertebrogenic back pain, why aren't scientists studying this?

View attachment 341559
C

Despite your posts you are still not in the running to be the next kol.

ffr

 

[clubdeac]

Fair enough. I just think that you should do some because you're good at kypho and being salaried, the questionable reimbursement doesn't limit your ability like it limits others in PP. But if you're not comfortable with the risk-benefit ratio and research, that's your call.

Sounds like you’ve done a fair amount of these. Do you find them to be technically more difficult or easier than kypho? Debating whether I want to go down this road

 

[RoloTomassi]

Sounds like you’ve done a fair amount of these. Do you find them to be technically more difficult or easier than kypho? Debating whether I want to go down this road

I think they're easier, very low risk. Vertebral bodies are squares not wedges. Don't have to worry about pulmonary or other extravertebral cement spread.

Probe placement is key so you have to be more meticulous. I measure out angles on MRI to have a game plan. Drop a spinal needle down first on oblique and get AP and L to make sure I start out on good trajectory--this makes all the difference in how smooth it goes. S1 can be a bit tricky on high iliac crests but if you are good at intradiscal access it's the same technique and more forgiving since you can steer the curved stylet better than a spinal needle. If you mess up you can try on the other side. When you get better at it you should be able to have placed the next cannula when the previous one is still burning since it's a 15 min burn each level. You'll have to trouble shoot things like hard bone every once in a while, but it's not bad.

 

[deleted472101]

Rolotomassi

Can you tell me what the typical patient you are doing these on?

history
Physical
Previous

Tests
Etc

 

[RoloTomassi]

Rolotomassi

Can you tell me what the typical patient you are doing these on?

history
Physical
Previous

Tests
Etc

Axial LBP >6 mo with Modic changes.

Best if history and exam more consistent with anterior column (pain with flexion, twisting, sitting, sustained hip flexion test, axial pain with SLR; less with standing, walking, extension, facet loading). However this is all very nonspecific. Difficult to rule out discogenic contribution based on the above as well but there are no great discogenic options anyway. Presence of severe DDD to where there's not much disc left to be painful also strengthens confidence.

Usually negative MBB/RFA first but in younger patients with no facet arthropathy and negative posterior element history/PE I'll go straight to Intracept.

Presence of radicular pain or stenosis does not deter me if >50% pain is axial and ESI did not help with axial component.

I can find some pics of recent cases.

 

[drusso]

Axial LBP >6 mo with Modic changes.

Best if history and exam more consistent with anterior column (pain with flexion, twisting, sitting, sustained hip flexion test, axial pain with SLR; less with standing, walking, extension, facet loading). However this is all very nonspecific. Difficult to rule out discogenic contribution based on the above as well but there are no great discogenic options anyway. Presence of severe DDD to where there's not much disc left to be painful also strengthens confidence.

Usually negative MBB/RFA first but in younger patients with no facet arthropathy and negative posterior element history/PE I'll go straight to Intracept.

Presence of radicular pain or stenosis does not deter me if >50% pain is axial and ESI did not help with axial component.

I can find some pics of recent cases.

We're seeing spikes in vertebrogenic and Modic-related back pain.

 

[lobelsteve]

Sis has 2 authors in supplement review both paid by company. Boooooo

 

[SSdoc33]

We're seeing spikes in vertebrogenic and Modic-related back pain.

spikes?

its weird how all of a $udden, the type$ of back pain can change. one minute, everyone has facet pain, then the next, its vertebrogenic. very very $trange....