Experience with Lumbar RFA in patients with hardware

[Orin]

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SO, probably leaning away from RF, then considering PNS, then saying not to validate their complaint.

Lamictal. Try lamictal. Not the patient.

Hey, I'm a complicated person.

But yeah, I would rather stimulate than ablate this in a person that age, but either way, I hate validating the normal pathology of aging or pathologizing my wishy washiness 😵

 

[MD87]

I would take patients this age down the MBB/RF pathway only if they're engaged already in aggressive PT or dying faster than the average bear. The goal is primarily to get them through more PT to functionalize. I want them to show me how much better they can do the exercises with the MBBs. I will RF them after that if necessary.

I am interested to see how the medial branch targeted peripheral nerve stimulators would do for this.

I fear though that this is someone whose imaging pathology validated their nonspecific pain complaints, and so further interventions will only perpetuate the mentality of doctors/medications/procedures fix everything.

For the record, her symptoms aren’t that non-specific. She has low back pain. Better with sitting and bending and worse with extension I’ll let you guys know how things go with the procedure. If she had pain with ROM in all directions I wouldn’t touch it.


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[maxxor]

For the record, her symptoms aren’t that non-specific. She has low back pain. Better with sitting and bending and worse with extension I’ll let you guys know how things go with the procedure. If she had pain with ROM in all directions I wouldn’t touch it.


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Why not do a block of the screw? Perhaps it’s loose?

 

[lobelsteve]

Why not do a block of the screw? Perhaps it’s loose?

Kidding right?

 

[painfree23]

I see CSI as effective in young adults not that infrequently. I prefer that over RFA in younger pts. I agree with that.

Whats “young”? Less than 40

 

[maxxor]

Kidding right?

I’m MSK IR. We have a couple ortho spine surgeons who will send us patients for lidocaine only injection around a screw after pars fusion with persistent pain. If positive test (and pain relief) they will either remove if fused on CT or revise hardware if not.

Has a CT been done demonstrating fusion across the fixation? I’ve never seen a pars repair like the one there and it would be hard to tell on radiograph.

 

[NJPAIN]

I’m MSK IR. We have a couple ortho spine surgeons who will send us patients for lidocaine only injection around a screw after pars fusion with persistent pain. If positive test (and pain relief) they will either remove if fused on CT or revise hardware if not.

Has a CT been done demonstrating fusion across the fixation? I’ve never seen a pars repair like the one there and it would be hard to tell on radiograph.

Great input. Can you post a radiograph of a “typical” repair type that you see?


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[SSdoc33]

Hooo boy. Here we go. Not too late to slowly back away, maxxor

 

[maxxor]

I mean, I can only speak to what I see in my region, but they tend to do transpedicular lumbar fusion with bone graft. I have cases I've injected which have had relief and proceeded to screw removal. I can throw up Fluoro images of a young (20s-30s) patient who had L3 pars defect with an L3-4 fusion, persistent pain, relief with injection of the L4 screws, incomplete osseous fusion on CT, who went on to screw removal and application of additional bone graft with improvement of pain.

@SSdoc33 I only lurk in here to learn. This just happened to be something I've actually seen in a similar patient.

 

[SSdoc33]

If you don't manage these patients, then its hard to comment on outcomes.

Bone growth across a fused segment does not necessarily = no pain

If you put enough local anywhere, it will make the pain go away. I believe steve was commenting about making a surgical decision making based on a hardware block, which i also think is pretty silly.

If the screw is loose, itll show up on CT.

Conversation goes something like this:

Patient- my back hurts
Surgeon -- ok lets put some hardware in
Patient- my back still hurts
Surgeon- ok, lets take the hardware out

 

[maxxor]

If you don't manage these patients, then its hard to comment on outcomes.

Bone growth across a fused segment does not necessarily = no pain

If you put enough local anywhere, it will make the pain go away. I believe steve was commenting about making a surgical decision making based on a hardware block, which i also think is pretty silly.

If the screw is loose, itll show up on CT.

Conversation goes something like this:

Patient- my back hurts
Surgeon -- ok lets put some hardware in
Patient- my back still hurts
Surgeon- ok, lets take the hardware out

*shrug* it’s what our surgeons do. As for that case, the pars defect hadn’t fused, and the hypothesis was loose screw preventing fusion.

If they didn’t find utility in the block, I’d imagine they wouldn’t send to us. It’s not like they make money doing the block themselves or get a cut of our technical fee.

 

[lobelsteve]

*shrug* it’s what our surgeons do. As for that case, the pars defect hadn’t fused, and the hypothesis was loose screw preventing fusion.

If they didn’t find utility in the block, I’d imagine they wouldn’t send to us. It’s not like they make money doing the block themselves or get a cut of our technical fee.

problem: they ask for a test with no validity, no specificity or sensitivity. Doing the useless test validates their ordering it and then their subsequent surgery. That is not being a physician. That is not science. Your feet should be held to the fire for his complications because you gave him useless information.

 

[SommeRiver]

Whats “young”? Less than 40

I don't have a number TBH.

BTW, I do 50 MBB/RFA for every one facet joint injxn, and I've done 2 cervical facet injxns in my career.

Also...Blocking a screw yields no useful information. I work with two spine surgeons and I've never been asked to do that, and I can't think of a situation where they would ask me to do that.

I understand if you're sent a pt for an easy injxn and you just fulfill the request but this isn't a reasonable request IMO.

 

[SSdoc33]

*shrug* it’s what our surgeons do. As for that case, the pars defect hadn’t fused, and the hypothesis was loose screw preventing fusion.

If they didn’t find utility in the block, I’d imagine they wouldn’t send to us. It’s not like they make money doing the block themselves or get a cut of our technical fee.

shrug? 😡

im not trying to be a dick, but this is why pain docs hate IR. no thought about ongoing patient care. this isnt like an embolization or draining a liver cyst. your actions have long term treatment consequences. in the future, please think twice about hardware blocks. and if there is any question of hesitation -- run it by us. we obviously don't have veto power, but may be able to help optimize patient care