Hip Denervation

Discussion in 'Pain Medicine' started by giddyup, Jul 29, 2015.

  1. giddyup

    giddyup ASA Member
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    I remember a thread a while back about a hip denervation procedure that could be done for patient's hip pain similar to a genicular block for knees. I did a search but couldn't find the thread or the article. I remember people had some billing pearls as well. Does anyone have that info handy by chance?
     
  2. DOctorJay

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  3. bedrock

    bedrock Member
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    I have two young patients in their thirties who may benefit from this. One has failed all conservative care including stem cells, and another came to me late s/p bilateral hip replacements in late thirties. Both are great patients without psych issues, but in unfortunate clinical situations.

    Can anyone recommend a physician experienced with hip RF ablation in the Philadelphia to D.C corridor?

    Or NYC?
     
  4. DOctorJay

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  5. bedrock

    bedrock Member
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    Hey Jay,

    I was spending too much time on SDN and a few other websites, and I decided to take a break and spend more time outside. Some of that was tracking my GT3, which has been a blast., and yes, racing Nurburgring and Spa are on my bucket list.

    This forum is full of useful info so I couldn't stay away forever, thus my hip question today.

    Thank you for the link, however, that link just indicates physicians doing cooled RF(its not specific to the hip), and I expect most of those docs just perform it for the spine and SIJ.


    Does anybody know a physician from NYC to DC that has experience with RF ablation of the hip joint?
     
    #5 bedrock, Aug 3, 2015
    Last edited: Aug 3, 2015
  6. DOctorJay

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    Yup that's true regarding the site. I did cooled rf on a knee the other day but haven't done any hips yet. Thought it would at least provide a possibility for you though.

    Taus, you know anyone doing hip RF?
     
  7. Taus

    Taus .
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    I might- waiting to hear back from a few ppl
     
  8. Taus

    Taus .
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    No luck. Sorry.
     
  9. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Hip rf is simple. Follow the articles. Know your anatomy. Know your fluoro. Done.
     
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  10. bedrock

    bedrock Member
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    sorry steve, but I'm not quite as arrogant as you.

    Hip RF is not as simple as knee RF, and I don't want to just do it on these very nice patients after only reading the articles.
    Would greatly prefer to go to a course or observe a case before just cowboying up and doing a new ablative procedure.
     
  11. lobelsteve

    lobelsteve SDN Lifetime Donor
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    So go to a course.
     
  12. clubdeac

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    So I've done a couple of these. My question for you more experienced is how do you approach the obturator branch. The slide show says to come from directly inferior at the anterior thigh. I'd be worried about femoral artery puncture from that approach. Do you guys come from a more lateral approach for this branch just like you do for the more lateral femoral branch?
     
  13. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Lateral approach similar to IA hip. 2 skin wheals 2-3c, apart vertically. Go under the bundle and over the capsule to acetabular targets as per the article pics.
     
  14. BobBarker

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    Steve are you using ultrasound to help stay away from the neurovascular bundle or just staying low and lateral? I did the blocks with a 22g spinal needle using fluoro only but was thinking about using ultrasound when I do it with the 18g RF needle.
     
  15. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Fluoro only. Start over lateral part of neck.
     
  16. bedrock

    bedrock Member
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    A few questions

    1-Doesn't anybody know anyone in the most populated part of our country (NYC- DC corridor ) that currently does hip RF?

    2- I would like to offer this procedure in the future. Can anyone recommend a course? Who and what companies teach this technique?

    3-Would like to hear thoughts on the relative necessity for cooled RF. The link that Jay posted stated that hip RF was best done with cooled RF because of "variable anatomy" but that lecture was corporate and we all know that the companies just want to sell cooled RF machines and expensive cooled RF probes.
    Personally I have had good success performing knee RF with 16G regular RF cannulae, and suspect that those same 16G regular RF cannulae are likely adequate for hip RF, but would appreciate thoughts from those of you who have done hip RF cases or attended courses.
     
  17. lobelsteve

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    Come visit in Georgia and I can get 2 cases back to back. Cooled RF is marketing nonsense and associated with increased pain for a month afterward. 20G works fine for my n=20 to 30.
     
  18. bedrock

    bedrock Member
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    I appreciate the invite, particularly since we've sometimes had a acrimonious relationship on this forum.

    You've been using 20G RF cannulae for both knee and hip RF? Do you rotate and do two burns or anything else to expand your lesion?
     
  19. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I do single burns with 20g for everything i rfa except i use a 22g for gasserians.
     
  20. epidural man

    epidural man ASA Member
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    Bedrock,

    Do you have Cooled RF in your clinic? Because the reps will come and step you through the procedure.

    I totally agree with Steve and disagree with you. You COULD easily and safely do this procedure with a little study on your part. You DON'T need a course.

    Consider this:
    1. You know how to drive a needle safely and you are able to get the tip where you need it.
    2. You know (or will know) the anatomy of the hip and what you absolutely need to miss in order to keep the procedure safe.
    3. You know about the physiology and expected results and pitfalls of RF energy in the body.

    Seriously - hip RF is was easier than probably 80% of what you do already. Don't refer - do it yourself.

    Before you RF, you will be doing a diagnostic injection under fluoro. That will be your first time through it. Very little can go wrong. The backstops are hard, bony edges.

    Probably the worst thing (assuming you miss the neurovascular bundle) is that you put some local inside the hip joint. Well oops if that happens.
     
  21. clubdeac

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    The only thing I'm always concerned about is hitting the femoral artery/nerve. You are presumably going under it but you have no way of knowing on fluoro
     
  22. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Netter
     
  23. Ligament

    Ligament Interventional Pain Management
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    bedrock;

    It is indeed rather easy. However, I respect your concern for the neurovascular bundle.

    What I'd suggest it doing a combined U/s and fluoro procedure.

    from a far lateral to medial approach, Use U/s to visualize the neurovascular bundle, guide your RF needle well dorsal to it. Once dorsal, switch to AP fluoro. You know are certain you will not hit the bundle, and there is little of concern or danger from that point on.
     
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  24. Ducttape

    Ducttape SDN Lifetime Donor
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    but only bill for the fluoro...
     
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  25. Ligament

    Ligament Interventional Pain Management
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    Absolutely, good point!
     
  26. Crybaby

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    Stryker offers a course, but really focuses much more on genicular.
     
  27. Mister Mxyzptlk

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    Bumping this thread because I did my first prognostic block today (not for lack of interest, just didn't have a candidate). I watched the video and read up on it. I don't understand why people are going far lateral to get the obturator branch. I went medial and had plenty of room away from the arterial pulse. It was the femoral articular where I had to go more lateral. 100% relief after the block though, which was nice to see.
     
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  28. Ligament

    Ligament Interventional Pain Management
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    There is a reason to consider using cooled RF for hip RFA. Cooled RF produces a spherical lesion. Traditional cannulae a elliptical lesion (except 2mm active tips I suppose). One cannot place the active tip of a traditional cannulae parallel to the obturator and femoral sensory branches for maximum isothermal coverage. This is where the spherical lesion of cooled RF has an advantage. Whether it is worth $850 for the damned cooled RF probe is another matter.
     
  29. Mister Mxyzptlk

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    I started doing cooled RF last June so it's too early for me to say if it works better or not.
     
  30. Agast

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    Cost to my ASC is $600 for cooled RF probes, my two hip patients have reported 60-70% relief. I am considering using the Stryker venom probes (where an active tip comes out a side port for a larger lesion) to see if they're comparable for my next hip.
     
  31. olafa

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    For needle placement techniques for obturator do the lateral approach make more sense to over NV bundle very caudad to cephalad placement??
     
  32. Uncovert

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    I do them. I troll these boards but never post. Worked under clubdeac back in the day!
    I'm in the Baltimore-DC Corridor.
     
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  33. cowboydoc

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    I agree with above reference to do u/s to get under bundle and fluoro to place it. For the first few and now with more difficult cases, I mark skin with course of NV bundle before procedure with u/s, note depth, use inferior to Superior/lateral to medial approach to avoid trouble.

    They changed their slides, as when I went through their course, they showed a "gun barrel" coaxial approach in the AP to the obturator branch, and I thought it was crazy.
     

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