genicular nerve RF

jsaul

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    Have any of you done this to the genicular nerves around the knee. and if so have you done it with cooled RF, traditonal RF or some sort of altered needle like the stryker Venom.

    My preference is for cooled RF but getting a lot of interference from the asc to get that machine
     

    onewithpain

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      I do knees and hips. I used to use US to find the nerves close to the joint line, but then was shown the approach at the notch of the tibio and femorocondylar notches and find that it works great. I use an 18 ga RFA needle with a 1 cm active tip and burn 1 cm ventral and 1 cm dorsal to the midline. There is a youtube video on that. I do the hip at the acetabular notch and get great results there too. I do joints that have been replaced and still hurt. I don't do real joints unless the patient is end stage. The orthos refer too much to me to make them mad. They will refer patients to me after they have replaced the joint or if the patient has too many comorbidities for surgery. I have done a couple thumbs after anchovy procedure, one got relief and one didn't. See Steve's thread on Neurotehrm's class in Seattle Saturday.
       

      drf

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        I do knees and hips. I used to use US to find the nerves close to the joint line, but then was shown the approach at the notch of the tibio and femorocondylar notches and find that it works great. I use an 18 ga RFA needle with a 1 cm active tip and burn 1 cm ventral and 1 cm dorsal to the midline. There is a youtube video on that. I do the hip at the acetabular notch and get great results there too. I do joints that have been replaced and still hurt. I don't do real joints unless the patient is end stage. The orthos refer too much to me to make them mad. They will refer patients to me after they have replaced the joint or if the patient has too many comorbidities for surgery. I have done a couple thumbs after anchovy procedure, one got relief and one didn't. See Steve's thread on Neurotehrm's class in Seattle Saturday.


        Any papers you can reference? I have done some for the knee based on a Korean paper but not yet hip.
         
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        clubdeac

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          I do knees and hips. I used to use US to find the nerves close to the joint line, but then was shown the approach at the notch of the tibio and femorocondylar notches and find that it works great. I use an 18 ga RFA needle with a 1 cm active tip and burn 1 cm ventral and 1 cm dorsal to the midline. There is a youtube video on that. I do the hip at the acetabular notch and get great results there too. I do joints that have been replaced and still hurt. I don't do real joints unless the patient is end stage. The orthos refer too much to me to make them mad. They will refer patients to me after they have replaced the joint or if the patient has too many comorbidities for surgery. I have done a couple thumbs after anchovy procedure, one got relief and one didn't. See Steve's thread on Neurotehrm's class in Seattle Saturday.

          Where exactly is the femorocondylar notch? I was taught to perform these at the femoral medial and lateral epicondyle and lateral tibia epicondyle. Is this wrong?
           

          onewithpain

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            I do the medial tibial instead of the lateral tibial, otherwise its at the waist or inside of the curve where the 2 meet. Google it and find the youtube video.
            I read the Korean paper. I've never seen a paper on the hip. I made it up based on the anatomy text and had my local ortho watch, along with an anesthetist who did US to look for vascular structures. All was well so now I do them by myself with fluoro. Here is a picture of one that I did with 5% phenol. That is the way I started and since I was getting good stim I switched to RFA. One time I couldn't get it numb so I bagged the RFA and stuck the needle in the joint and put in 1cc of 10% phenol. Hurt for 3 days and now is golden. Phenol may destroy the cartilage but it was already there on an 89 yo woman who wouldn't have survived the surgery.
             

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            Pacman27

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              Hope these help. I have only done a handful with decent results.

              How are guys billing these cases. They have codes for the denervating the hip joint, but how about the knee


              Have any of you done this to the genicular nerves around the knee. and if so have you done it with cooled RF, traditonal RF or some sort of altered needle like the stryker Venom.

              My preference is for cooled RF but getting a lot of interference from the asc to get that machine
               

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              onewithpain

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                Sorry I meant medial tibial epicondyle, no lateral. I just wasn't sure what you were referring to by femorocondylar notch
                I figured. Look at the articles from pacman for needle location. For the hip I use the location in figure 3 which is the site of the acetabular notch where the genicular branch of the obturator enters. I 've never tried the location of figure 2 but am thinking of a patient who may benefit. An 83 yo man who had his hip replaced and said when he got up to 7 miles a day he started to have groin pain. They took out his testicle and it didn't help. Yikes! I did his SI joint and got 30% relief, then did the obturator with no relief. Have blocked the inguinal canal without relief. May try the location in figure 2 and see.
                 

                Ligament

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                  I do genicular nerve RFA, usually thermal RFA but sometimes pulsed. The korean article (or was it japanese) demonstrates the technique very well. I usually do it under ultrasound in the clinic, pretty easy. You can use 16 ga needles at 90 C to get a very large isotherm just as large as the Baylis water cooled probe, and $720 dollars CHEAPER.
                   

                  nvrsumr

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                    I do genicular nerve RFA, usually thermal RFA but sometimes pulsed. The korean article (or was it japanese) demonstrates the technique very well. I usually do it under ultrasound in the clinic, pretty easy. You can use 16 ga needles at 90 C to get a very large isotherm just as large as the Baylis water cooled probe, and $720 dollars CHEAPER.

                    This is an interesting discussion. I do not perform these currently.
                    Who are the best candidates? Continued pain after TKA or THA? Type of pain? Location? What about just plain OA that only responds for a short time to steroid? Hip labral tears? Any reason not to perform if the other option is TKA or THA?




                    Ligament are you doing bipolar or just two lesions? Tips on doing with US?
                     

                    lobelsteve

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                      This is an interesting discussion. I do not perform these currently.
                      Who are the best candidates? Continued pain after TKA or THA? Type of pain? Location? What about just plain OA that only responds for a short time to steroid? Hip labral tears? Any reason not to perform if the other option is TKA or THA?




                      Ligament are you doing bipolar or just two lesions? Tips on doing with US?

                      Would do with fluoro as this is how it is described. Need AP to see junction and lateral to determine depth along femur and tibia. 20G 10mm tip 80 deg 90 sec.

                      Or I'll see you tomorrow in Seattle.
                       
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                      Pacman27

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                        Personally, I reserve these for patients with pain following TKR or THR, patients who are not candidate for surgical intervention, or patients who do not want surgery. I would never sell this to a surgical candidate as I feel most of these patients after surgery do well.

                        Steve, since you have more experience. Any thoughts on the patient selection? Also, do you do a sensory or motor stim or just base it off anatomical location
                         

                        onewithpain

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                          The local orthos refer a fair number of patients with pain after joint replacement, or with end stage joints and too many other end stage issues to operate. Since I started doing these I find that they send me more patients prior to joint replacement, asking me to take care or their back or SIs so that they can tolerate the PT after surgery. When I get a referral for back pain I always ask about other areas of pain and often find that they have had joints replaced that still hurt, so pick up more business there. After a short while you learn which surgeons will leave their patients in pain after surgery and so I screen those a little more diligently.

                          I haven't gotten to the point that I offer this to patients who don't want surgery, as most of them don't. The orthos would be mad, and if the patient were to develop a charcot joint they would burn me at the stake. That said I have an OR tech who is 2 years from retirement and feels that she can't afford TKA now but plans on it as soon as she retires. She is doing well so far with an Orthocor PEMF unit, but if that doesn't cover her then I would be tempted to RFA. I haven't been doing it long enough to know how long it lasts, but I've done US guided phenol injections at the joint line with over 1 year of relief so far. I occasionally see younger patients after multiple knee surgeries with chronic pain for whom the orthos refuse TKA. I don't see the point of leaving them to suffer and so would be tempted. It would be nice to see long term results of denervation and if there is significant damage to the adjacent bone so that joint replacement becomes impossible.

                          I asked ISIS to include a dissection of the innervation of the knee, hip and thumb in their next anatomy course. It's not spine, but it is pain. If the nerve lies right on the surface of the bone then a 20 ga should be adequate. I use an 18 ga for the sake of overkill, with fluoro guidance because it's quick and easy. If you believe in Wallerian degeneration then killing a small segment of the nerve should lead to degeneration of the nerve distal to that. The ISIS teaching seems to imply that you have to kill as great a length of the nerve as possible in order to get longer lasting relief.

                          27035 (for denervating the hip) pays a heck of a lot better than 64640. Anyone know of a code for denervating the knee?
                           

                          Ligament

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                            Would do with fluoro as this is how it is described. Need AP to see junction and lateral to determine depth along femur and tibia. 20G 10mm tip 80 deg 90 sec.

                            Or I'll see you tomorrow in Seattle.

                            Steve, I have clinic all day on Saturday so won't be at the class, sorry. I was the last to learn about it, even though I sit on the BOARD OF DIRECTORS of the surgery center you will be at. LOL!!! I've got a last minute add on hospice patient with hip mets on Saturday evening, so I'm not sure yet when I'll be done with clinic . Funny enough, this particular patient was referred to me today for RFA of the obturator and femoral nerves for hip mets. I have no idea how her oncologist knew about the procedure or how to find me.
                             

                            Ligament

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                              Just finished didactic at Ligament's office. Going to use his tech and lesion a cadaver on his table. So cool. Ill take selfies and post. My new hobby could be going to all of your offices and drinking your coffee.

                              LOL. If it is my tech Steve, you got a REALLY good tech! He's been doing this for 15+ years most of them with Ray Baker and Paul Dreyfuss at that surgery center.

                              Also, I keep a stash of MILF porn and mescaline in the cabinet under the sink in the procedure room - enjoy.
                               
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                              lobelsteve

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                                LOL. If it is my tech Steve, you got a REALLY good tech! He's been doing this for 15+ years most of them with Ray Baker and Paul Dreyfuss at that surgery center.

                                Also, I keep a stash of MILF porn and mescaline in the cabinet under the sink in the procedure room - enjoy.
                                Marshall beat me to it.
                                 

                                onewithpain

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                                  What kind of reimbursement are you guys getting for this?
                                  (Sorry if this should be posted in the private forum)
                                  Using 64640 I think the pro fee is about 130 for the first nerve, so nothing to brag about but worth doing for the patient's sake and because the orthos will buy the beer at the end of the day. 27035 on the other hand pays about 900. (medicare)
                                   
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                                  onewithpain

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                                    Likewise x 3, with fluoro. I did one for a cancer patient and she did get great relief. Lung CA, not in leg, but knee had severe OA and surgery not an option. I should offer it pre TKR. The orthos hate to see the patient totally deconditioned and this would allow them to do a little PT.
                                     
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                                    bedrock

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                                      Using 64640 I think the pro fee is about 130 for the first nerve, so nothing to brag about but worth doing for the patient's sake and because the orthos will buy the beer at the end of the day. 27035 on the other hand pays about 900. (medicare)

                                      Someone had posted earlier about doing a hip injection with phenol for a LOL that couldn't have surgery. I wonder if you could bill 27035 for the phenol injection, which technically did eliminate the nerve supply to the hip joint?
                                       

                                      onewithpain

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                                        I think that the 27035 is for a surgical denervation, but I plan to try it on the next one I do by RFA since I am targeting the nerves. The phenol is simply an intra-articular injection and so if you bill 27035 and are audited then it would be a more difficult argument. Perhaps if you injected each nerve location with phenol you would have a stronger case for 27035. My results are inconsistent with phenol. Sometimes I see a couple months of relief and sometimes a couple years.
                                         

                                        pmrrulez

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                                          I have a patient in which I did genicular nerve blocks of the knee. He received 90% relief of his pain. I want to proceed with an RFA, but I am unsure if I can get medicare to pay for it. Are you guys having the patient pay for this out of pocket? The patient would have a really hard time paying for it, so I am trying to think of ways to get around him actually paying for it himself.

                                          Thanks!
                                           

                                          Tenesma

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                                            my n=6 for knee denervation based on that paper - using same procedural techniuqe...

                                            1 person had great relief for 1 year
                                            1 person had great relief for 3 months
                                            4 had minimal relief, no relief or worse pain...

                                            all 6 were were non-operative end-stage knee OA

                                            are you guys tracking your data? - because based on my data either I suck at this or the procedure is not reliable due to too much anatomic variability in non-operative knees.
                                             

                                            Pacman27

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                                              my n=6 for knee denervation based on that paper - using same procedural techniuqe...

                                              1 person had great relief for 1 year
                                              1 person had great relief for 3 months
                                              4 had minimal relief, no relief or worse pain...

                                              all 6 were were non-operative end-stage knee OA

                                              are you guys tracking your data? - because based on my data either I suck at this or the procedure is not reliable due to too much anatomic variability in non-operative knees.


                                              By no means am I expert. How are your results with the blocks before or is that for the block? Also, there is an additional branch (per my attending who is brilliant). I will email him and ask him
                                               
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                                              clubdeac

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                                                The additional branch he may talking about could be the infrapatellar branch of the saphenous nerve. This is commonly implicated in chronic knee pain following scopes, especially medial knee scopes. And as far as the anatomic variability, Baylis is pushing this procedure pretty hard for their cooled RF technology stating they can get a larger isotherm.
                                                 

                                                Tenesma

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                                                  my n of 6 was based on patients who had >50% relief with diagnostic block - maybe i should tighten it up to 80%? these patients are so desperate that they are willing to go straight to RF and skip diagnostic blocks.
                                                   

                                                  Pacman27

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                                                    my n of 6 was based on patients who had >50% relief with diagnostic block - maybe i should tighten it up to 80%? these patients are so desperate that they are willing to go straight to RF and skip diagnostic blocks.

                                                    I hate to say this, but you had 2/6 with decent to great results. Unless the other 4 are completely worse off, what other option did they have? Maybe consider phenol? just a thought
                                                     

                                                    Mister Mxyzptlk

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                                                      Try this technique. Equipment is very inexpensive. As far as I can tell from the video you don't even need alcohol wipes. I have done under 1,000 of these. One thing I note is that they make the mistake that you see with rookie porn producers - you can see the cameraman in the mirror. Or so I'm told.

                                                       
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                                                      lobelsteve

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                                                        > To: Lobel, Steven M MD
                                                        > Sent: 5/16/2014 1:58 PM
                                                        >
                                                        PT / CALLER : PT

                                                        PH #

                                                        LMP:

                                                        PHARMACY:

                                                        PRIMARY CARE : LOBEL

                                                        ON--CALL MD :

                                                        PROBLEMS / CONCERNS : PT CALLED TO LET YOU KNOW " HER KNEE FEELS LIKE A BRAND NEW KNEE "
                                                        THANKS SO MUCH "-------****FYI******



                                                        s/p genicular block this AM.
                                                         
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