Experience with Intracept.

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Lol. It is part of the LA tradition to have a major placebo response to any procedure about which someone does a post/brag on social media.
 
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He seemed too well on day 4/5/6 postop. He should have been very sore from being smacked with the hammer hard enough to access 40 something year old male bone.

I remember seeing his MRI posted somewhere. He looked like a good intracept candidate but an ALIF was always in the cards. He must have developed more radic or complained about it more after the intracept.
 
Sucks for him and relievant, hope the surgery helps and he’s not in the 40-50% camp without relief of axial lbp after fusion. 75% chance success with intracept… I’d still take those odds any day before coin-flip odds of fusion.
 
bedrock said:
Bummer. But we all need to develop rational expectations about this procedure. Won’t cure everyone, though it is great some patients do so well.
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Yup.

Getting new mri to rule out targeting failure?

I have been very blunt with the outcome odds with patients based on the data. In general 3/4 get at least 50% better. 1/2 get at least 75% and 1/3 get 100%. 1/4 get no benefit.
 
Baron Samedi said:
Saw lady back for 3mo follow up. Pain back to baseline womp womp
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Interesting, I've never seen return of pain.

I have had perfect candidates with perfect placement and no relief, but lack of response is from the get go.

Some do recovery very fast, as in exercising in 1-3 days.
 
Taus said:
Yup.

Getting new mri to rule out targeting failure?

I have been very blunt with the outcome odds with patients based on the data. In general 3/4 get at least 50% better. 1/2 get at least 75% and 1/3 get 100%. 1/4 get no benefit.

I have some patients contemplating paying cash for this. They all know fusion is an option and they all know the odds of success with fusion. It is very expensive for the device, facility fee, anesthesia, pro fee, even staying at Medicare rates. >10k all in. Those odds are spelled out verbally and in writing for the patients.
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I have a hard time with the idea of offering this for cash. 10-15k is a lot of money to pony up for a 25% failure rate. Then again people spend that sort of money on much more absurd things in medicine with much worse evidence (stem cells etc.).

I'd hate to look someone in the eye after they've had a treatment failure at 12k out of pocket. But maybe I'm just not capitalist enough.
 
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Asclepius186 said:
I have a hard time with the idea of offering this for cash. 10-15k is a lot of money to pony up for a 25% failure rate. Then again people spend that sort of money on much more absurd things in medicine with much worse evidence (stem cells etc.).

I'd hate to look someone in the eye after they've had a treatment failure at 12k out of pocket. But maybe I'm just not capitalist enough.
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Agreed. I do not advocate for that. And it’s really not that profitable to me on pro fee. I however have had two patients whose insurance denied it despite all possible levels of appeals. They asked me what the price would be. I inquired to asc & practice… that’s the number.

What would you do? Years of moderate to severe axial pain and functional limitations. 1 crappy disc. No listhesis or instability. Fusion odds as they are. Years of PT/HEP, meds, DC, injections, etc. You gonna rec BMAC? COT? Scs? Reactiv8?
 
Taus said:
Agreed. I do not advocate for that. And it’s really not that profitable to me on pro fee. I however have had two patients whose insurance denied it despite all possible levels of appeals. They asked me what the price would be. I inquired to asc & practice… that’s the number.

What would you do? Years of moderate to severe axial pain and functional limitations. 1 crappy disc. No listhesis or instability. Fusion odds as they are. Years of PT/HEP, meds, DC, injections, etc. You gonna rec BMAC? COT? Scs? Reactiv8?
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That sounds reasonable if it comes about that way. Didn’t mean to sound to harsh. I know that’s just the cost of the procedure.

In that situation I would probably agree to do it for cash, but I would also be kind of hoping they wouldn’t want to.
 
Taus said:
Agreed. I do not advocate for that. And it’s really not that profitable to me on pro fee. I however have had two patients whose insurance denied it despite all possible levels of appeals. They asked me what the price would be. I inquired to asc & practice… that’s the number.

What would you do? Years of moderate to severe axial pain and functional limitations. 1 crappy disc. No listhesis or instability. Fusion odds as they are. Years of PT/HEP, meds, DC, injections, etc. You gonna rec BMAC? COT? Scs? Reactiv8?
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tell them the truth.


injections wont cure what has been there for years and failed multiple treatments. if they want to take the risk, and you are willing to do the procedure, then good luck. but its reasonable to consider that the pain is just not ever going to go away...
Taus said:
I have been very blunt with the outcome odds with patients based on the data. In general 3/4 get at least 50% better. 1/2 get at least 75% and 1/3 get 100%. 1/4 get no benefit.
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remember this data is probably industry sponsored, so might want to take with grain of salt. or a pound.
 
Ducttape said:
tell them the truth.


injections wont cure what has been there for years and failed multiple treatments. if they want to take the risk, and you are willing to do the procedure, then good luck. but its reasonable to consider that the pain is just not ever going to go away...

remember this data is probably industry sponsored, so might want to take with grain of salt. or a pound.
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I do not disagree with you at all.

I am actually initiating a prospective, non industry sponsored study.

Hearing some longtime members of this forum also seeing the results in the real world that I am, mirroring literature, is somewhat reassuring.
 
I’ve been giving mine 125 mg Solu-Medrol IV intra op to mitigate postoperative pain and any transient radiculitis. So far so good. No major issues with post op pain or radiculitis, granted mine have been 90% Medicare so far as my commercial cases wait in the portal for approval. Everyone feels “great“ postop day one. All come down to earth within a week or two. The “laser spine“ treatment.

Mostly 80-100% relief at 6-8 weeks out, one at 50% relief, but constant pain is now only intermittent/positional in that case. As I do more, I know I will see regression to the mean and more failures. I have two per week scheduled this entire month. All Medicare except one younger patient. My volume will probably double as soon as the commercial approval‘s start trickling in.
 
In my head, the ideal candidate for this procedure a younger (30-60) patient with discogenic-type pain with Modic changes at 1, maybe 2 levels. Are you seeing good results in older patients?
 
MD87 said:
In my head, the ideal candidate for this procedure a younger (30-60) patient with discogenic-type pain with Modic changes at 1, maybe 2 levels. Are you seeing good results in older patients?
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I am, granted these patients have had the same problem since they were in that age range. All except two of my cases have been Medicare age, specifically because my younger patients are waiting for insurance approval
 
I would say my <65 cohort does better than my >65 cohort. Not sure if it would be statistically significant, but anecdotally I see that trend. I think that's logical, as there's likely less facet, SI contribution to their overall pain if they're young.
 
RoloTomassi said:
I would say my <65 cohort does better than my >65 cohort. Not sure if it would be statistically significant, but anecdotally I see that trend. I think that's logical, as there's likely less facet, SI contribution to their overall pain if they're young.
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Anterior column pain is pretty uncommon in the older population so by even offering this treatment to them you're working against the grain from a pure epidemiologic standpoint.
 
Taus said:
These patients of mine have had the issue for decades…
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Vertebrogenic pain should only persist while they have active inflammation/fatty infiltration in their vertebral endplates(correlating to Type I/II Modic), right? Eventually those endplates burn out and transition to Type III(sclerosis) and are thought to no longer be symptomatic levels?
 
Baron Samedi said:
Vertebrogenic pain should only persist while they have active inflammation/fatty infiltration in their vertebral endplates(correlating to Type I/II Modic), right? Eventually those endplates burn out and transition to Type III(sclerosis) and are thought to no longer be symptomatic levels?
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I think anterior column pain is quite common in older patients still. Type 1, 2, and mixed 1/2 are much more common than 3, in any population.
 
Baron Samedi said:
Vertebrogenic pain should only persist while they have active inflammation/fatty infiltration in their vertebral endplates(correlating to Type I/II Modic), right? Eventually those endplates burn out and transition to Type III(sclerosis) and are thought to no longer be symptomatic levels?
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Maybe, but if it’s type one and/or two on current MRI, No localized facet or sacroiliac tenderness and the history otherwise fits, so be it
 
Taus said:
Popped my cherry on this- did my first case earlier this week. Definitely a learning curve, particularly for the feel of it, as I haven’t done vertebral augmentation, transpedicular access since fellowship in 14. After some initial troubleshooting, where the rep was very helpful, All went smoothly, took a little over an hour. Should get down to 30 to 40 minutes with the new seven minute burn time. So far this case appears to be a home run, chronic constant midline axial is gone pod 1. Very different from medial branch RF, more analogous to root canal. I know they won’t all be home runs like this, but will take it. Second case is next week.

Probably what I have enjoyed the most is the shift in conversation seeing these patients in the office, where previously we had no more decent options to offer once the usual conservative care fails…. Beyond conversation of acceptance, coping, learning to live with chronic pain etc., which sucks
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2.5 months out. My first 2 cases both 100% relief at rest and with sitting, standing, walking, bending. Only mild brief pain on transitions, out of chair/car/bed, lasts a few seconds. That’s it. Both beyond thrilled. One has been my patient for years. Results for everything else I have done prior to this have been modest. Had been med management, tramadol, hep and putting out a fire every once in a while with a Medrol pack. Had exhausted all else.

Done about 6 or 7 now. Results continue to mirror the literature. Not all slam dunks, but overly positive. I have two per week scheduled for the next six weeks.
 
RoloTomassi said:
Haha he just went from being the best spokesperson to the worst
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not really. if a patient has vertebrogenic pain and radiculopathy due to severe foraminal stenosis refractory to conservative care including ESI, the approach I would take would be intracept followed by laminectomy vs. lumbar fusion (dependent on severity and pathology).

he might enjoy the benefit of intracept so much that he decided to take the next step.
 
drpainfree said:
not really. if a patient has vertebrogenic pain and radiculopathy due to severe foraminal stenosis refractory to conservative care including ESI, the approach I would take would be intracept followed by laminectomy vs. lumbar fusion (dependent on severity and pathology).

he might enjoy the benefit of intracept so much that he decided to take the next step.
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That can make sense to us, but to the average layperson who watches Today Show or follows him on social media, the impression will be that it didn't work.
 
no, it wasn't a joke.

we know patients with failed back pain syndrome often have axial LBP. Some of these patients have vertebrogenic LBP. With therapy option like intracept we can treat vertebrogenic LBP PRIOR to spinal fusion to reduce failed back.

this is why some spine surgeons are sending failed back patients to get intracept procedures nowaday because they recognize vertebrogenic LBP could be potential source of failed back pain.

if a patient is a candidate for spinal fusion because of refractory foraminal stenosis/radic, for example, pre-existing vertebrogenic LBP should be treated to optimize outcome of spinal fusion.

in a bigger picture, anterior column pain should be addressed and treated prior to surgeries aimed at alleviating posterior column pain. it's possible this was what happened to Carson Daly.
 
drpainfree said:
no, it wasn't a joke.

we know patients with failed back pain syndrome often have axial LBP. Some of these patients have vertebrogenic LBP. With therapy option like intracept we can treat vertebrogenic LBP PRIOR to spinal fusion to reduce failed back.

this is why some spine surgeons are sending failed back patients to get intracept procedures nowaday because they recognize vertebrogenic LBP could be potential source of failed back pain.
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Perhaps a few, however I suspect it is just a new way to get that patient out of their office forever without saying generic “go to pain management“
drpainfree said:
if a patient is a candidate for spinal fusion because of refractory foraminal stenosis/radic, for example, pre-existing vertebrogenic LBP should be treated to optimize outcome of spinal fusion.
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I would rephrase that as pre-existing axial back pain, if the primary issue, should be treated to optimize the pain and functional outcome of the patient, not a surgical outcome

it’s it’s a truly unstable spondy with some radic, fudion is the indicated treatment and should be successful. It’s the gray zones in between that are the challenge… Where if axial was a significant component and not unstable ie fusion unlikely to help back pain, I do think I would offer intracept.
drpainfree said:
in a bigger picture, anterior column pain should be addressed and treated prior to surgeries aimed at alleviating posterior column pain. it's possible this was what happened to Carson Daly.
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Possible. But also possible he was one of the lucky 25-30% failure rate. I would have been interested to see his flexion extension films, as I did read some articles where he talked about his leg pain. He undoubtably had some foraminal narrowing at the level from up-down stenosis.
 
nvrsumr said:
I wonder if the KOL who did the intracept on Carson whose self congratulatory post popped up on my Linkedin feed will update.....
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maybe someone should post the link to her feed to assist
 
Um no.

We should not be doing prophylactic Intracept. First, do you have any evidence that prophylactic treatment prevents axial back pain in patients who subsequently undergo fusion?

You don't even establish what proportion of fusion patients develop axial back pain.

Treatment after fusion makes sense. Intracept for axial back pain sans fusion makes sense. To prevent something? No way.

FYI this was done before with striking failure - a local surgeon used to put in stim leads during fusion surgery with none being used.
 
I know about Carson Daly’s compression fracture! That bugger started it all!
 
Does anyone have tips on how to move more efficiently for this procedure?

A few of my thoughts
- use 7 minute burn
- start at S1 (always the most challenging for me) then go to other levels

- put two trochars in at once + use straight AP view.

What am I missing?
 
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DrMDAware said:
Does anyone have tips on how to move more efficiently for this procedure?

A few of my thoughts
- use 7 minute burn
- start at S1 (always the most challenging for me) then go to other levels

- put two trochars in at once + use straight AP view.

What am I missing?
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- use 7 minute burn
Definitely, as long as targeting is dead on.
- start at S1 (always the most challenging for me) then go to other levels
Agreed. Plus start on left so moving c arm to lateral is easier. If doing L4 L5 and S1, after the S1 left, do L4 right, as often entry point for S1 left is same as entry point for L5 left.

Also consider, Only going oblique just enough to see borders of S1 pedicle, entering skin just medial to iliac crest and accessing out of plane. Pull tip hard medial and consider using bevel tip. My last few cases have actually ended up to posterior at S1, would’ve been ideal at L3 through L5, even straight stylet wasn’t getting ventral enough. had to advance Trocar further into vertebral body then re start J stylet. Still ended up a bit off, at border 60% anteriorly. 15 minute burn time needed… also, don’t forget retraction method if need to get it more posterior.

- have 2 c-arms
Yes, but can be somewhat cumbersome around the table. That said, a lot of time is spent maneuvering to lateral, getting around a right sided trochar, re-obtaining proper wigwag, etc. I may revisit this myself next case.

- put two trochars in at once + use straight AP view.
- unless docked in bone, trocar tends to flop without holding it with a clamp.
Also Don’t know how much this would help, as could only burn one at a time. If/when I get the next access point ready to burn before the first lesion is done, I do move on to the next level access if there is one. Granted, I then have to reposition the C-arm back to second lesion location confirming in AP and lateral electrode is in correct position. not a big deal if no asymmetrical collapse, scoliosis, or vert body rotation etc. but if those are present and each level has to be set up really individually on AP and lateral, it has been more trouble than it’s worth. The time I seem to have gained setting up the next level is then lost repositioning the C-arm for the prior level


All that being said, I am not the most experienced in the world on this, trying to learn more every case I do. Interested in hearing others opinions
 
DrMDAware said:
Does anyone have tips on how to move more efficiently for this procedure?

A few of my thoughts
- use 7 minute burn
- start at S1 (always the most challenging for me) then go to other levels

- put two trochars in at once + use straight AP view.

What am I missing?
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On MRI axial, I map out the trajectory (how much to oblique) and choose the best side for each level, prioritizing S1. So on procedure day I know exactly how much to oblique.

I always place a spinal needle first, check lat to make sure my cephalocaudal angle is good, numb periosteum to skin, then back to oblique, adjust tilt if necessary, and dock trocar hub view. When docking, I walk into the deepest part of the groove first to minimize travel through bone.

Taking these steps on the front end to ensure a good trajectory really makes the rest easy. Rarely need bevel, just straight in with diamond.

Don't think 2 c-arms is that helpful, but I use oblique a lot. Nor is 2 trocars at once because you'll take more time placing both, then have downtime when the first burn is going.
 
RoloTomassi said:
On MRI axial, I map out the trajectory (how much to oblique) and choose the best side for each level, prioritizing S1. So on procedure day I know exactly how much to oblique.

I always place a spinal needle first, check lat to make sure my cephalocaudal angle is good, numb periosteum to skin, then back to oblique, adjust tilt if necessary, and dock trocar hub view. When docking, I walk into the deepest part of the groove first to minimize travel through bone.

Taking these steps on the front end to ensure a good trajectory really makes the rest easy. Rarely need bevel, just straight in with diamond.

Don't think 2 c-arms is that helpful, but I use oblique a lot. Nor is 2 trocars at once because you'll take more time placing both, then have downtime when the first burn is going.
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These are some real pro tips. Greatly appreciate it. Some granular qs below.

For mapping out the trajectory on mri, how do you find that compares to what they teach, oblique until the facet joint is 50% across the end plate?

For proper cephalad/caudal tilt and trajectory, do you think still best to square superior endplate or you tilt til pedicle at a specific location or other?

I have been placing a needle first to numb skin to bone, but not checking the angle on lateral with that, as I have been just adjusting angle by pulling trochar at skin before malleting under lateral.

To find that deepest part before you docking bone, if you walk the Tip around under lateral, do you then go back to AP or oblique to check entry point before you mallet? If I look superficial on lateral, I have presumed I am on the facet joint And when I walk it to a deeper location, it’s not always worked out as proper when checking again in aP or oblique. Sometimes I’m then docking mid or medial on pedicle as opposed to the taught point superolateral.


Regarding S1 entry, to determine which side I will do, I usually look at the AP on x-ray and see which side has the most room between iliac crest.
 
Taus said:
For mapping out the trajectory on mri, how do you find that compares to what they teach, oblique until the facet joint is 50% across the end plate?
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I don't even look at the facet in relation to endplate. If you think about it, some people have long/short pedicles, small/huge facets, etc, it's just not a very precise way. And there's a pretty big range of oblique that can look "halfway".
Taus said:
For proper cephalad/caudal tilt and trajectory, do you think still best to square superior endplate or you tilt til pedicle at a specific location or other?
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Yes I square the endplate, but there's also a range of what looks "square", so I am surprised sometimes when the angle isn't great on lateral, and I need to re-enter directly superiorly/inferiorly. I try not to take much of a celphalad to caudad angle though. With every tap, you're moving in 3 planes, so I try to take the cephalocaudal movement out of the picture by going pretty parallel to the BVN on lateral.
Taus said:
I have been placing a needle first to numb skin to bone, but not checking the angle on lateral with that, as I have been just adjusting angle by pulling trochar at skin before malleting under lateral.
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You can do that too but I hate constantly cranking on it and fighting against fascia resistance, having it change angle when you let go, etc. If needle doesn't look great on lateral, I'll just estimate and make my stab more superior or inferior.
Taus said:
To find that deepest part before you docking bone, if you walk the Tip around under lateral, do you then go back to AP or oblique to check entry point before you mallet?
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I walk it in deep on oblique, then check AP/L. Usually start a bit lateral and walk it down the TP medially till it feels like you're starting to ride up the SAP. If anything when I switch to AP it looks more lateral than I expect, not medial. Having mapped out the oblique angle beforehand I think helps with this part too.
Taus said:
Regarding S1 entry, to determine which side I will do, I usually look at the AP on x-ray and see which side has the most room between iliac crest.
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I use a combination of XR and MRI to predict, but even then, sometimes it's easier to tell live. Narrowness is key, but also look at crest height, S1 endplate angulation, asymmetrically hypertrophied S1 SAP. I do S1 on oblique too, so it's not hard to swing c-arm each side and see which I can oblique more on.

I err on the side of more posterior. The more anterior the more parallax when lining the probe up with the SP, meaning your probe can be more lateral or medial than you think. It seems like this is the easy part but looking at post-op MRI axials, if there's angled SP or pedicles, it's not hard to be off midline. Also, like you said, easy to correct being too posterior by driving trocar deeper, but if you're too anterior, you basically have to redo on the other side.
 
How are you justifying this procedure financially, you are not making much at all on the professional fee, and probably taking a loss on $/unit time.
 
Ligament said:
How are you justifying this procedure financially, you are not making much at all on the professional fee, and probably taking a loss on $/unit time.
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Facility fee isn't bad if you're fast. Plus, I do cash, PI, WC, too, not just Medicare, so the pro fees average out to be ok.
 
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