Genicular nerve RFA

[Extralong]

So I started doing these, and I was wondering, aside for the term "knee pain" what are the medical indications? I don't care about what insurance says, this question is more academic in nature. Also, I wouldn't mind hearing what kind of experience you had with sucessful patients. Thanks!

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[bedrock]

Might want to do a search. At least two threads on this already.

 

[Extralong]

Okay thanks

 

[freddydpt]

I've done an N of 1. Severe OA in right knee, medial and lateral compartments. 78yo Asian F, did not want knee replacement. Antalgic gait, tender along joint line, lots of bone marrow edema on MRI... really an impressive arthritic knee. She reports 75% relief of her knee pain. She even tested it out by jogging on it a little... yes... 78F.

 

[oreosandsake]

had a lady in fellowship with bilateral TKA
obese, diabetic, about 50 y/o

had RFA bialteral, at separate times. 1 side responded greater than 80% relief. the other side no effect. when looking at the imaging, you could see how the anatomical placement of the needles was much more aligned with the described landmarks in the positive response knee.

 

[Extralong]

Wow

 

[Agast]

I've also been getting good results in patients with knee replacements that are still painful. 70-80% pain reduction.

 

[Papa Lou]

Can you post pics please? I'm not satisfied with my results I'm getting around 25% relief per patients on average. I do believe some of this is centralized pain.
Better than nothing But I hate those results. The patella is in the way typically on the lateral humeral epicondyle but I go around and get it to where it's supposed to be pretty routinely. I'm looking for better results can you guys post pics please?

 

[lobelsteve]

From a prior course.

 

[Extralong]

From a prior course.

Sweet. Thank you

 

[Sig123]

80 yo F s/p left knee replacement 7 years ago. "Adequate anatomical alignment of hardware"
left knee hurt so bad she used a walker and couldn't get out of the house. RFd her 2 weeks ago.
Saw her back 2 days ago. Walker was at home as was her cane. She walked in unassisted.
Reports 95% pain reduction. Even I was blown away. She said I have given a 80 year old woman her life back.
Makes me love what I do (sometimes).

 

[pastafan]

70 y.o. F S/P TKA with post-op MRSA infection/removal hardware. She had been miserable for years.

I did RFA a year ago with 100% pain relief and just repeated it last week. Yes, this can be a great field.

 

[Papa Lou]

Wow this sounds like "great" results are being achieved all the time. Are these the norm or the outliers? I know sometimes it works very well too.
Pictures would be helpful. The pdf Steve posted with those pictures and lesion settings are how I already do it. If it's unanimous that this is giving >75% of patients >50% pain relief then that's what I was asking I guess.

 

[Extralong]

I think the biggest problem is poor to no reimbursement. I realize doing them is more like a charity case.

 

[bedrock]

Wow this sounds like "great" results are being achieved all the time. Are these the norm or the outliers? I know sometimes it works very well too.
Pictures would be helpful. The pdf Steve posted with those pictures and lesion settings are how I already do it. If it's unanimous that this is giving >75% of patients >50% pain relief then that's what I was asking I guess.

I'd say that that two thirds of patients achieve two thirds relief.

 

[bedrock]

I think the biggest problem is poor to no reimbursement. I realize doing them is more like a charity case.

True. I kinda want Medicare to stop paying for it completely so I can charge an appropriate cash rate for these.

 

[pastafan]

Wow this sounds like "great" results are being achieved all the time. Are these the norm or the outliers? I know sometimes it works very well too.
Pictures would be helpful. The pdf Steve posted with those pictures and lesion settings are how I already do it. If it's unanimous that this is giving >75% of patients >50% pain relief then that's what I was asking I guess.

Definitely >75% of patients >50% pain relief. Probably closer to 75% and 75%. I'm still trying to figure out max duration. I have some folks at 15+ months still feeling great.

Reimbursement isn't great but E&M for initial visit plus follow-ups help. It is rare that they only have painful knees.

 

[leecheater]

We have been doing them for over 2 years with the same rates of success, around 75% get very good relief, some as long as a year. Some real homeruns. Even if the reimbursement isn't great when they have a different pain issue they remember who reduced their pain and come back.

 

[Ligament]

they work surprisingly well, and honestly I'm not sure we are optimally targeting the genicular nerves on X-ray. I do the diagnostic blocks on U/s and it seems the nerves are more cranial from the flanges than conventionally thought.

 

[deleted185747]

they work surprisingly well, and honestly I'm not sure we are optimally targeting the genicular nerves on X-ray. I do the diagnostic blocks on U/s and it seems the nerves are more cranial from the flanges than conventionally thought.

I would love to see someone do ultrasound, find the nerves, place radiopaque wires and do some X-rays to get a small sample data of the location of the nerve. Similar to Lord et al on the MBs

 

[freddydpt]

I would love to see someone do ultrasound, find the nerves, place radiopaque wires and do some X-rays to get a small sample data of the location of the nerve. Similar to Lord et al on the MBs

I review the knee MRI to give me a visual estimate of where the nerve is. I use the coronal T1 and STIR images... sagittal hasn't been very helpful yet. I'm afraid I'd be burning a vessel alongside the nerve. With my N of 1, it hasn't been a problem.

Does anyone have Genicular nerve pics on US? I'd love to see it. Thanks.

 

[PinchandBurn]

I review the knee MRI to give me a visual estimate of where the nerve is. I use the coronal T1 and STIR images... sagittal hasn't been very helpful yet. I'm afraid I'd be burning a vessel alongside the nerve. With my N of 1, it hasn't been a problem.

Does anyone have Genicular nerve pics on US? I'd love to see it. Thanks.

Your concern is also mine. HOw do we know we aren't RFing a vessel . And this is a MAJOR joint, not a minor facet joint. It seems like there are larger blood vessels . Anyone have problems with this procedure?

 

[lobelsteve]

Your concern is also mine. HOw do we know we aren't RFing a vessel . And this is a MAJOR joint, not a minor facet joint. It seems like there are larger blood vessels . Anyone have problems with this procedure?

Collateral circulation. Big red is in the fossa. Not gonna booger a joint due to this.

 

[pastafan]

Collateral circulation. Big red is in the fossa. Not gonna booger a joint due to this.

Keep in mind the future of this joint. It is eventually going to meet a power saw and end up in the red bag. That is what I remind patients when they ask if their knee will continue to get worse.

 

[Papa Lou]

This would be very valuable if you braggarts (j/k congrats) who get 75% relief on 75% of patients posted fluoro images of your home runs so we can all see placement. There may be variability. This would make the forum truly valuable

 

[oreosandsake]

US image

pulsatile artery directly adjacent to the nerve.

I have video clip as well. it is nice "nerve looking" honey comb ish. I did not save all the images, but the same structure was found at all 3 described locations

 

[oreosandsake]

genicular, cryoablation

 

[Gauss]

US image

pulsatile artery directly adjacent to the nerve.

I have video clip as well. it is nice "nerve looking" honey comb ish. I did not save all the images, but the same structure was found at all 3 described locations

Image obtained with a Konica Minolta HS1 US machine. The best image quality I have ever seen

genicular, cryoablation

this approach looks out of plane?
With the artery in such close proximity do you alter your trajectory at all?

 

[oreosandsake]

this approach looks out of plane?
With the artery in such close proximity do you alter your trajectory at all?

short axis to the nerve.

long axis (parallel) the the long axis of the femur. the nerve is just slightly distal to the artery. with US, can come in out of plane. put the center of the probe over target, and then put the needle just distal to the center mark of your probe. field block, end up right next to the nerve. if you want to come in in plane you can as well, but will need much more needle and it will be more painful.

fwiw, I have been having patients report significant benefit from these blocks. an obese 50+ guy came in this week dancing about 11 days after the diagnostic blocks. said his knees felt better after this than any other injection he's ever had (has OA, and has had 2 corticosteroid injections into the joint).

another guy i spoke with at 3 days and said his knees still felt great. I use 0.5% bupivicaine. not sure if I'm "breaking the pain cycle" or other placebo at play. I'm honest with people during the consent that the medication doesn't last more than a day

I do have some folks that get zero benefit from it as well.

 

[Gauss]

short axis to the nerve.

long axis (parallel) the the long axis of the femur. the nerve is just slightly distal to the artery. with US, can come in out of plane. put the center of the probe over target, and then put the needle just distal to the center mark of your probe. field block, end up right next to the nerve. if you want to come in in plane you can as well, but will need much more needle and it will be more painful.

fwiw, I have been having patients report significant benefit from these blocks. an obese 50+ guy came in this week dancing about 11 days after the diagnostic blocks. said his knees felt better after this than any other injection he's ever had (has OA, and has had 2 corticosteroid injections into the joint).

another guy i spoke with at 3 days and said his knees still felt great. I use 0.5% bupivicaine. not sure if I'm "breaking the pain cycle" or other placebo at play. I'm honest with people during the consent that the medication doesn't last more than a day

I do have some folks that get zero benefit from it as well.

good info
any corticosteroids with marcaine block?
do you block all of them under US: inf & sup medial geniculars along with lateral ?

 

[clubdeac]

Went to a refresher course last month and the instructor said after hundreds of these he started doing them farther down on the condyle, so the needle are no higher than the superior patella on AP and deeper on lateral. Instead of 50% depth on lateral he goes 2/3rds of the way across the femure and tibia

 

[Ligament]

Went to a refresher course last month and the instructor said after hundreds of these he started doing them farther down on the condyle, so the needle are no higher than the superior patella on AP and deeper on lateral. Instead of 50% depth on lateral he goes 2/3rds of the way across the femure and tibia

Ok, but the nerves do not live there....

 

[oreosandsake]

good info
any corticosteroids with marcaine block?
do you block all of them under US: inf & sup medial geniculars along with lateral ?

no steroids. sometimes I used Dex in peripheral nerve blocks. some evidence for many of these adjuvants in acute pain for prolongation of the block but really this only lasts maybe an extra 12-24 hours above and beyond the LA only per those research protocols. it's unclear MOA in the first place. I hear the word "neuro-inflammation" thrown around but am unclear how corticosteroids play a role in PNBs for more than a relatively short period of time and thus ? utility chronic pain states. (think steroids in your mbbs)

 

[oreosandsake]

i recently saved images for all 3 nerves for genicular. in this small sample so far, it seems the inferior medial is most consistent and distinct. will post when i get back to town

 

[Papa Lou]

Just do sensory stim before you burn. See how far that gets you. Guy was crying at 1mV 50hz. I burned. 3 weeks later 10% relief. Fml

 

[Extralong]

Just do sensory stim before you burn. See how far that gets you. Guy was crying at 1mV 50hz. I burned. 3 weeks later 10% relief. Fml

Lol

 

[promethius]

So I will be doing my first genicular nerve radiofrequency ablations pretty soon. What type of radiofrequency ablation do you use for these procedures? Do you use sedation or just local? What do you look for with sensory and motor testing? How long do you burn for? Thanks!

 

[Ferrismonk]

I'm not an expert, but we use standard RF, definitely sedation, test sensory & motor for completeness, then 80 deg for 180 seconds.

 

[lobelsteve]

I'm not an expert, but we use standard RF, definitely sedation, test sensory & motor for completeness, then 80 deg for 180 seconds.

Sedation not necessary, increases risk, drives up cost. And SIS says not for routine use.

 

[bedrock]

Agree with Steve that sedation is not necessary for genicular RF, 99% of the time.
Plus you're not making much much on the genicular procedure and sedation takes more time.

Sensory stim not necessary. Motor stim isn't essential, but I do it.

16-18G RF cannulae. Burn for 90, flip cannulae, burn again for 90.

 

[Ligament]

Agree with Steve that sedation is not necessary for genicular RF, 99% of the time.
Plus you're not making much much on the genicular procedure and sedation takes more time.

Sensory stim not necessary. Motor stim isn't essential, but I do it.

16-18G RF cannulae. Burn for 90, flip cannulae, burn again for 90.

I don't think my patients could tolerate genicular RF without IV sedation. How are you doing it?

 

[bedrock]

I don't think my patients could tolerate genicular RF without IV sedation. How are you doing it?

After marking the entry point, I drive a 25G 3.5 in Quincke down to numb the tract with 2% lidocaine before inserting the RF cannulae.

The diagnostic genicular blocks are the key, if they really can't tolerate the block with just a 25G quincke, then I would consider IV sedation for the RF, but I find that the people who really struggle with the blocks, usually fail the blocks and or will fail the RF much more often.

I do offer 0.5-1mg of Xanax to be taken PO before genicular RF.

 

[pastafan]

I don't think my patients could tolerate genicular RF without IV sedation. How are you doing it?

I prescribe 1 tablet of hydrocodone or oxycodone to be taken 1 hour pre-procedure. Those on COT are instructed to take 1 additional dose. Bury 1.5" 25 gauge injecting Lidocaine 1% and then inject Lidocaine as I advance RF needle.

 

[lobelsteve]

Ive got 1% lidocaine. Ive got .25% marcaine. And i use them.

 

[Orin]

I use these as bridge/destination therapies for folks who have knee pain pre or post op and are married to working with PT/weight loss etc. Been doing a few of these with fluoro and transitioning to U/S.

The nerve location is so variable and the data are so mixed that I've been trying to do sensory capture and using U/S to help find things.

Cooled and Cryo probes would be nice, but they are just too cumbersome to use.

IV Sedation works great for select few patients, but only if you can't tolerate the diagnostic nerve block or have shown you can't do it in other blocks before.

For the diagnostics, what volume are you using?

Any phenol lovers over RF?

Anyone tried peripheral stim of these?

 

[Ducttape]

I make sure my genicular patients all have had an AKA before...


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[promethius]

What do you look for with sensory and motor testing during radiofrequency ablations of the genicular nerves? I am assuming just local stimulation with sensory testing and no jerking of the leg with motor testing?

 

[Lunatik]

Have any of you guys run into any rare complications during or post RFA?

 

[Ligament]

I had a hemearthrosis on an anticoagulated patient, pretty bad one. It resolved after a few weeks. Other than that, nothing.

 

[chibadriver]

Anyone have issues with not having enough 'meat' on the medial tibial area to accommodate ablation? On some I worry I will burn a path from epidermis to os.


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