Genicular rf- Thanks!

[deleted993114]

Someone on this forum (I forgot who) posted a paper in which the location of the genicular nerves (and thus the placement of needles for rf) was inaccurate and that the femoral component was much deeper and inferior than previously described.

As a result of this, I changed my needle position during rf to reflect this anatomic knowledge. My results have improved from essentially a 20% placebo response to over 75%. Funny how anatomy makes a difference!

That is why this forum is outstanding- lots of very intelligent folks with great information to share.

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[thecentral09]

Can someone re-post the study so we have a copy of it. I had it but lost it

 

[Orin]

Accuracy of fluoroscopic-guided genicular nerve blockade: a need for revisiting anatomical landmarks - PubMed

This study provides physicians with precise anatomical landmarks for the five consistent GN for fluoroscopic-guided GNB. Our revised technique, which targets more nerves with increased accuracy, could potentially lead to improved therapeutic benefits on chronic knee pain.

www.ncbi.nlm.nih.gov

Commentary:
Revisiting the anatomical evidence supporting the classical landmark of genicular nerve ablation | Regional Anesthesia & Pain Medicine
? where to lesion
Anatomical evidence supporting the revision of classical landmarks for genicular nerve ablation | Regional Anesthesia & Pain Medicine
response from authors

 

[pmrmd]

Here it is.

 

[TIVAndy]

I also changed my practice. I was about 50% before.. maybe i boosted that to 60%

 

[deleted993114]

I also changed my practice. I was about 50% before.. maybe i boosted that to 60%

I've had a more dramatic improvement. Again, I was getting about 20%, which is what one would expect from a placebo treatment, which is essentially what we were all doing before the proper localization of the nerves was identified.

I really wonder about all the guys that were describing wonderful results with this procedure at a time when the needle localization being used was essentially "in the next county" compared to where the nerves actually lie.

 

[pmrmd]

I’m still hesitant. My results sucked with genicular RF in the past and I didn’t want to do it anymore. Happy to hear people are having better outcomes now.

 

[deleted131481]

Can some share what mix they use for their diagnostic block? In fellowship and also at my current practice, 3cc at each location is used with steroid to be "diagnostic and therapeutic". It was odd both locations used the same regimen, but seemed poor RF results. This didn't make sense to me so I've changed to 1cc LA only for diagnostic. Thoughts?

 

[painfree23]

Can some share what mix they use for their diagnostic block? In fellowship and also at my current practice, 3cc at each location is used with steroid to be "diagnostic and therapeutic". It was odd both locations used the same regimen, but seemed poor RF results. This didn't make sense to me so I've changed to 1cc LA only for diagnostic. Thoughts?

To piggyback, how many diagnostics are you typically doing?

 

[callmeanesthesia]

Can some share what mix they use for their diagnostic block? In fellowship and also at my current practice, 3cc at each location is used with steroid to be "diagnostic and therapeutic". It was odd both locations used the same regimen, but seemed poor RF results. This didn't make sense to me so I've changed to 1cc LA only for diagnostic. Thoughts?

1 cc each, no steroid. One diagnostic. Used to just skip the diagnostic and offer RF but now that there are specific codes I feel like I need to at least one, so I do. Time permitting I do the diagnostic under ultrasound at the initial consultation.

 

[painfree23]

1 cc each, no steroid. One diagnostic. Used to just skip the diagnostic and offer RF but now that there are specific codes I feel like I need to at least one, so I do. Time permitting I do the diagnostic under ultrasound at the initial consultation.

Ooo nice. Diagnostic under ultrasound? Do u have any images for this or your procedure note? Always used Fluoro.
You just bill 1 unit + u/s for the diagnostic and 1 destructive unit + Fluoro for the burn?

 

[callmeanesthesia]

Ooo nice. Diagnostic under ultrasound? Do u have any images for this or your procedure note? Always used Fluoro.
You just bill 1 unit + u/s for the diagnostic and 1 destructive unit + Fluoro for the burn?

Imaging is included in the new codes (I think).
I just scan parallel and perpendicular to the leg to ensure I’m over the right part of the bone in both axes, and mark a target on the skin, then go in straight down from that with a 27g. If their leg is too large for that I do it under fluoro. I don’t have any recent images handy but the ones I had on my phone were using the old landmarks anyway, at the inflection point.

 

[SommeRiver]

1cc of ropi 0.5%

 

[pastafan]

Marcaine 0.5% 2 ml. Rarely patients get weeks/months of pain relief. Perhaps due to neurotoxicity of high concentration marcaine?

 

[lobelsteve]

Marcaine 0.5% 2 ml. Rarely patients get weeks/months of pain relief. Perhaps due to neurotoxicity of high concentration marcaine?

Nope. That is not enough to be toxic.

 

[deleted993114]

I’m still hesitant. My results sucked with genicular RF in the past and I didn’t want to do it anymore. Happy to hear people are having better outcomes now.

Mine really did suck as well, however they markedly improved with the "new" needle localization.

You may want to try it again now. Obviously, I was nowhere near where I needed to be in the femoral component, thus the poor results. It was sobering (gee......I don't drink anyway) to see how far off the initially suggested placement was from the true location of the nerves.

 

[DOctorJay]

I was hoping this paper would get more traction at AAPM. I asked McCormick about it during his session but he only glanced over the more posterior and distal location of the nerves. For some reason he mentioned the paper but didn't include it in his talk. He has a bunch of additional targets they are looking into.

 

[painfree23]

Do you find the new approach is more or less painful that the old one? (I do most my cases with local only and patients have a lot of pain during it, so I kind of stopped)

 

[deleted131481]

Do you find the new approach is more or less painful that the old one? (I do most my cases with local only and patients have a lot of pain during it, so I kind of stopped)

I have started coming from a lateral approach for the diagnostic block as suggested on this board and it dramatically increases patient comfort.

Sent from my Pixel 3 using Tapatalk

 

[cowboydoc]

Do you find the new approach is more or less painful that the old one? (I do most my cases with local only and patients have a lot of pain during it, so I kind of stopped)

They still hurt!

 

[painfree23]

They still hurt!

Dang

 

[painfree23]

I have started coming from a lateral approach for the diagnostic block as suggested on this board and it dramatically increases patient comfort.

Sent from my Pixel 3 using Tapatalk

What about for the RF

 

[SommeRiver]

2% lido is fine. I use 1-2 cc at each site. Rarely have problems. I still only find this works maybe half the time, and it works for weeks to months at best in my hands.

 

[deleted131481]

What about for the RF

Still doing AP as it makes sense to me to more likely get the nerve. Definitely less comfortable.

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[callmeanesthesia]

I’ve noticed a little more trouble getting them completely numb. I’d gotten it to a pretty decent system with the old landmarks but with the new one, there is often a spot or two that requires supplementary local.

Still doing AP as it makes sense to me to more likely get the nerve. Definitely less comfortable.

Sent from my Pixel 3 using Tapatalk

if you inject local from lateral first just like the block, then numb your skin entry and come in AP with the electrodes, it helps a lot. Not perfect but easier because you give the local time to set up on the periosteum.

 

[Ducttape]

I find doing geniculars on people who have had AKAs is pretty painless.

 

[cowboydoc]

I find doing geniculars on people who have had AKAs is pretty painless.

 

[lobelsteve]

Would be better if you were closer to the targets. Also, WTF are you treating, a boat payment?

 

[cowboydoc]

Would be better if you were closer to the targets. Also, WTF are you treating, a boat payment?

Sheesh! Do you correct grammar errors on memes, too? I had a picture that related to the conversation in my WTF cache. I'm not presenting this at a conference, and I don't have a boat.

 

[SommeRiver]

I did those newer target sites today during an RF. We'll see how it goes. No pain with 2% lido 1.5cc each site with 3 min wait time.

 

[lobelsteve]

Sheesh! Do you correct grammar errors on memes, too? I had a picture that related to the conversation in my WTF cache. I'm not presenting this at a conference, and I don't have a boat.

Sorry, thought you were trying to treat stump pain by missing targets by about a centimeter.

 

[Monterosso]

To potentially further increase accuracy, could also consider use of ultrasound guidance to target the genicular nerves.