Experience with Intracept.

[BobBarker]

You got it! It is the only way to fly. Next time you “fall off” the pedicle just take it and you will be happy with the result. I only go transpedicular inadvertently or if there is a big osteophyte that pushes the trochar too lateral on trying to touch down “parapedicular”. @gdub25 anything to add? B/w me and gdub we probably have 2000 kypho levels done.

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[bedrock]

A lot less than 2/3. Last year, off the top of my head 20%. Only 1 this year. Many months usually, 2-3 level appeals. A few weeks on the fast end, always has been with patients who get very involved with pressuring their insurance. Never Cigna. Last year pro fee all over the map. This year, the one, about same as Medicare

Thank you for the information. That is certainly disappointing.

I am pretty excited about this procedure… Two for two so far. My second case is about two weeks out, over 85% relief, best has felt in years. First case three weeks out over 95% relief.

Several more pending, but all Medicare. Hopefully the situation will improve with commercial coverage, or maybe I will get lucky and payers in my area will be a little easier to approve. I will definitely get patients on the horn with their insurance companies.

I have definite libertarian leanings, but this is a good example of where the government needs to step in and force all insurances to cover intracept and offer payment similar to other pain procedures. Similarly the government should force all insurance companies to cover butrans, belbuca etc.

The government spends billions on drug wars and over a hundred thousand people die each year from drug overdoses. Not every addict suffers from severe DDD, and not every patient will do well on bup medications. However those two measures would still be more effective that what the government has been doing so far to battle the opioid epidemic in the US.

Intracept procedure should be covered, and at a reasonable rate to the physician by every insurance company in the country for eligible patients.

Same thing with butrans/beluca.

 

[Kissmyabjj]

Carson Daly getting intracept

 

[clubdeac]

Carson Daly getting intracept

That’s awesome on so many levels

 

[Taus]

You got it! It is the only way to fly. Next time you “fall off” the pedicle just take it and you will be happy with the result. I only go transpedicular inadvertently or if there is a big osteophyte that pushes the trochar too lateral on trying to touch down “parapedicular”. @gdub25 anything to add? B/w me and gdub we probably have 2000 kypho levels done.

I have an otherwise ideal candidate for this at L45, failed all else reasonable, who has L2-4 fusion with pedicle screws. I don’t think I have the balls to do my first ever extrapedicular access for anything ever. He is fully fused on CT scan and no motion on x-ray… his surgeon is willing to remove an L4 screw so I can do this

 

[lobelsteve]

I have an otherwise ideal candidate for this at L45, failed all else reasonable, who has L2-4 fusion with pedicle screws. I don’t think I have the balls to do my first ever extrapedicular access for anything ever. He is fully fused on CT scan and no motion on x-ray… his surgeon is willing to remove an L4 screw so I can do this

If you must try this just go extra pedicular. Think of where your target is and where the bad stuff lies and ignored the screw. It’s not hard to get there. So long as you have a small patient or a long needle

 

[BobBarker]

Don’t remove the screw. That makes a little case, big. It is safer and easier going extrapedicular.

 

[BobBarker]

If you can intentionally narrowly miss) the medial wall of the pedicle (which is what you are doing with the traditional approach you can guide a trochar in high and outside. I know you can do it. Do you have any seasoned kyphon reps you can talk to? We could have Doug Beall on FaceTime for you too during the case even. He is a consultant for them.

 

[Taus]

If you can intentionally narrowly miss) the medial wall of the pedicle (which is what you are doing with the traditional approach you can guide a trochar in high and outside. I know you can do it. Do you have any seasoned kyphon reps you can talk to? We could have Doug Beall on FaceTime for you too during the case even. He is a consultant for them.

Concerns re heating up the screws and heat transfer to canal/root?

 

[BobBarker]

Since it is bipolar there shouldn’t be any inadvertent transfer. If the edge of a pedicle screw is at the Edge of the burn zone I don’t think it should transfer to the canal or root. The hardware should be insulated by bone from these structures.

 

[clubdeac]

This sounds like a baller case. Let us know if you do it with the screw in place!

 

[RoloTomassi]

I would leave the screw but also have never gone around them myself. Seems like on DocMatter several have reported no issues with heating. Do you have any images? Would be interesting to see the approach.

 

[Taus]

I would leave the screw but also have never gone around them myself. Seems like on DocMatter several have reported no issues with heating. Do you have any images? Would be interesting to see the approach.

thanks. I read through the threads on DocMatter. Seems mixed some advocating screw removal some advocating Doug Bealls extra pedicular approach. Watched his video on approaches for kypho. I will further scrutinize the CT and MRI and then decide.

 

[Taus]

That’s awesome on so many levels

Yeah, pretty crazy how many patients were asking about it right after it aired. Amazing free advertising for the company.

 

[Centurion38]

Carson Daly looks like he has gained 100 lbs. Could that be the proximate cause of his worsening axial low back pain?

Will they film the 6 month office follow up (with the mid-level) when the BVN ablation "wore off?"

Next up, intradiscal PRP...

 

[BobBarker]

Yes, I thought the same thing. Next up is a 12 month gastric sleeve “journey” for him.

 

[RoloTomassi]

Not sure when you are doing the case, but next month the 7 minute smaller 5mm radius burn will officially be released, so that would likely keep heat further from screws.

 

[Taus]

I would leave the screw but also have never gone around them myself. Seems like on DocMatter several have reported no issues with heating. Do you have any images? Would be interesting to see the approach.

Private forum

 

[RoloTomassi]

Doug Beall going over the top of screw

 

[Taus]

Doug Beall going over the top of screwView attachment 357209View attachment 357210View attachment 357211
View attachment 357213

That’s pretty awesome

 

[lobelsteve]

Look at all that degeneration.

 

[Orin]

Concerns re heating up the screws and heat transfer to canal/root?

The pedicle screw is within the bony pedicle normally, so even if it acts as a heat sink, you wouldn't necessarily be burning the canal/nerve root.

There are cadaveric data out on this for conventional medial branch RFA that suggested it heats up (Safety of Lumbar Spine Radiofrequency Procedures in the Presence of Posterior Pedicle Screws: Technical Report of a Cadaver Study) but there are real world data showing no clinical significance (A Retrospective Review of Spinal Radiofrequency Neurotomy Procedures in Patients with Metallic Posterior Spinal Instrumentation - Is it Safe? - PubMed)

There are cadaveric data coming on this for intraosseous RF as this is an important question for tumor ablative work. The posters I have seen suggested no significant clinical effect, but I haven't seen the manuscript published yet.

I would agree that removing the screws should not be counselled unless there is a problem with the screw position itself, for example if it is invading into the endplate. That's not as trivial as an RFA, especially if it is in the middle of a fusion construct. As aggressive as it seems, I suspect Beall's approach is optimal.

You can always roll in another generator system and place an RF needle/cannula on the pedicle screw or near the nerve root yourself if you want to see if it is heating up during your case.

 

[BobBarker]

Surprised he didn’t go low and outside.

 

[Ducttape]

 

[Tboned]

Not sure when you are doing the case, but next month the 7 minute smaller 5mm radius burn will officially be released, so that would likely keep heat further from screws.

Per my rep, the 7 minute burn would only be advised if you have perfect placement. They have this transparent ruler they can hold up to the fluoro shots as a guide. 7 minute burn will definitely be nice, especially on the last burn. I need better jokes for that 15 minutes

 

[Taus]

Per my rep, the 7 minute burn would only be advised if you have perfect placement. They have this transparent ruler they can hold up to the fluoro shots as a guide. 7 minute burn will definitely be nice, especially on the last burn. I need better jokes for that 15 minutes

I leave the room during last burn…. Do office messages, mri reviews, consents in pre-op. Return to remove it and close.

 

[lobelsteve]

7 min lesion created because at 15 min no one wants to do these cases.

 

[DOctorJay]

Carson Daly looks like he has gained 100 lbs. Could that be the proximate cause of his worsening axial low back pain?

Will they film the 6 month office follow up (with the mid-level) when the BVN ablation "wore off?"

Next up, intradiscal PRP...

it certainly wasn't the T12 compression fracture he mentioned at the start of the video

 

[deleted131481]

You got it! It is the only way to fly. Next time you “fall off” the pedicle just take it and you will be happy with the result. I only go transpedicular inadvertently or if there is a big osteophyte that pushes the trochar too lateral on trying to touch down “parapedicular”. @gdub25 anything to add? B/w me and gdub we probably have 2000 kypho levels done.

Just did my first today with this approach. Went well, thanks for the tips!

Edit: for a kypho, wasn't Intracept

 

[Taus]

Outcomes have been the real deal for my cases so far…. N=5. On par with the published data. Many more cases pending. Very excited about this procedure.

 

[Dr. Ice]

What is the reimbursement/cost ratio for this procedure in asc?

Medicare covers it? Do any of the privates?

 

[drrosenrosen]

Finally did my first one this week. Pretty good anatomy, case went smoothly. 50 minutes, skin to skin. They've gone live with the 7 minute burn protocol, so I'm hoping that the next one I do in a couple of weeks I'll be able to get down to around 35.

Final probe position on these was a little more anterior than I would have liked, but still about 45%, so within range. Next time I'm going to start more laterally to try to aim it closer to the posterior cortex of the body.

 

[RoloTomassi]

Finally did my first one this week. Pretty good anatomy, case went smoothly. 50 minutes, skin to skin. They've gone live with the 7 minute burn protocol, so I'm hoping that the next one I do in a couple of weeks I'll be able to get down to around 35.

Final probe position on these was a little more anterior than I would have liked, but still about 45%, so within range. Next time I'm going to start more laterally to try to aim it closer to the posterior cortex of the body.

View attachment 358027

View attachment 358028

Not sure if that AP is your final but looks like it could be obliqued left a few degrees. Can make a huge difference on if you're perfectly midline. Try it next time --get perfect midline placement then oblique a few degrees each way and see how far off midline it can make you, especially if you're more anterior. That skinny part should straddle the SP as well, but I'm assuming you stopped a little short to stay more posterior. Lesion size is pretty big so it's forgiving, just a tip though.

 

[drrosenrosen]

Not sure if that AP is your final but looks like it could be obliqued left a few degrees. Can make a huge difference on if you're perfectly midline. Try it next time --get perfect midline placement then oblique a few degrees each way and see how far off midline it can make you, especially if you're more anterior. That skinny part should straddle the SP as well, but I'm assuming you stopped a little short to stay more posterior. Lesion size is pretty big so it's forgiving, just a tip though.

The picture she saved was not the best one. True AP showed ideal placement straddling the spinous process

 

[Agast]

I have yet to come across a patient I thought this would help. What are you looking for on history and physical exam?

 

[Dr. Ice]

I have yet to come across a patient I thought this would help. What are you looking for on history and physical exam?

Doug Beal does a nice speal on YouTube. Patient 50s, midline axial pain, similar in presentation to discogenic pain. Mri shows modic changes. Failed other conservative measures. As usually physical exam not much of benefit

 

[TIVAndy]

isn't medicare rate ridiculously low to do this procedure, and privates are not covering it?

 

[RoloTomassi]

I have yet to come across a patient I thought this would help. What are you looking for on history and physical exam?

Basically anyone with discogenic-type axial pain and MRI shows any amount of Modic changes. I see candidates everyday.

 

[Taus]

isn't medicare rate ridiculously low to do this procedure, and privates are not covering it?

Pays about equal to 4-5 Medicare epidural pro fees in the surgery center.…single level (2 lesions) case about 45 mins so far for me. Will be faster w 7 min burn and more experience. First couple cases took an hour. So at worst net neutral, probably come out ahead of esi. Not a financial boon, but also not a loss.

ASC makes over 3k on Medicare cases. Commercial insurance they quote 2/3 will get approved, can take a few months for the company to go through multilevel appeal process…. But they handle it all. I’ve done one commercial case and have over 10 more in the auth portal.

 

[drrosenrosen]

Has anyone done a commercial case and seen it paid yet? Better than medicare rates?

 

[Agast]

OMG the X-ray tech was just telling me about a 3-level case she did where the guy took over two hours and did everything under live fluoro (foot on pedal) with 12 minutes fluoro time. I didn’t know that was a lot until she told me my SCS implant was under a minute of fluoro time…

 

[Taus]

OMG the X-ray tech was just telling me about a 3-level case she did where the guy took over two hours and did everything under live fluoro (foot on pedal) with 12 minutes fluoro time. I didn’t know that was a lot until she told me my SCS implant was under a minute of fluoro time…

Had to be a surgeon or IR?! I have seen reports of three minutes fluoro time for SI injections…

No role for live fluoro on this

 

[Agast]

Had to be a surgeon or IR?! I have seen reports of three minutes fluoro time for SI injections…

No role for live fluoro on this

Nope. Pain doc who has been around a long time. Wears a lead scrub hat and has a lead foot apparently. Difficult case due to fusion hardware.

 

[Taus]

Nope. Pain doc who has been around a long time. Wears a lead scrub hat and has a lead foot apparently. Difficult case due to fusion hardware.

Wow. I can see it taking a while to make multiple adjustments or restarting with different approach coming around a fusion….. but still zero reason for live fluoro.

 

[Taus]

Finally did my first one this week. Pretty good anatomy, case went smoothly. 50 minutes, skin to skin. They've gone live with the 7 minute burn protocol, so I'm hoping that the next one I do in a couple of weeks I'll be able to get down to around 35.

Final probe position on these was a little more anterior than I would have liked, but still about 45%, so within range. Next time I'm going to start more laterally to try to aim it closer to the posterior cortex of the body.

View attachment 358027

View attachment 358028

Can ask your rep to review the “retraction” method with you. Very helpful to get medial without going to anterior when the angle of cannula is not as lateral to medial as ideal, particularly at S1 due to iliac crest. Basically create the usual channel into the cortex of vertebral body with the cannula, Place J stylet, Then slowly rotate to retract the cannula half to 1 cm, coming out of cortex. Then tap in the stylet slowly and the medial curve will start sooner/more dorsal.

 

[Ducttape]

Had to be a surgeon or IR?! I have seen reports of three minutes fluoro time for SI injections…

No role for live fluoro on this

i can confirm this.

 

[Dr. Ice]

Ok I’ll bite, guess I’ll get trained

 

[Baron Samedi]

Had 6 week follow up from my first patient, the one who got admitted for pain control immediately post proc.

Reports 50% pain reduction, improved activity tolerance. Gotten back into surfing and weightlifting. She still has some pain with sitting that she wants to further address but overall satisfied with the procedure.

 

[Taus]

Had 6 week follow up from my first patient, the one who got admitted for pain control immediately post proc.

Reports 50% pain reduction, improved activity tolerance. Gotten back into surfing and weightlifting. She still has some pain with sitting that she wants to further address but overall satisfied with the procedure.

75% at a month out

 

[Taus]

100% a month out