Intracept failures

[epidural man]

I had patient that reported 2 months of relief and then it came back.

I also have a lot that don't get any benefit. I am very conservative who I do them on (clear anterior column pain, modic a 10 year old could pick out).

So the question is - are you guys getting an MRI on the failures to see if the burn caught the nerve? And if it didn't, what do you do?

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[Taus]

I had patient that reported 2 months of relief and then it came back.

I also have a lot that don't get any benefit. I am very conservative who I do them on (clear anterior column pain, modic a 10 year old could pick out).

So the question is - are you guys getting an MRI on the failures to see if the burn caught the nerve? And if it didn't, what do you do?

Yes, I get new MRI.
If your failure rate is more than about a third of patients, something is off. I’ve done about 150 cases, the published rates are exactly what Ive seen.

 

[TIVAndy]

are you using the traditional 15 minute burn or the truncated version?
we discussed some case at IPSIS where pt was brought back for incomplete pain relief with the short burn and then re did it for a 15 minute burn then had complete relief.
anecdotal yes. I think it was a case at stanford.
european study data indicating bigger burn may have better result (i believe this is true for all RFs.. in general)

 

[RoloTomassi]

I tell them up front there's a 30% chance it doesn't work that great. I chalk it up to anterior column pain being a combination of discogenic and vertebrogenic, and in some people discogenic>>vertebrogenic.

 

[BobBarker]

Lots of reasons for people to hurt.

 

[bedrock]

I had patient that reported 2 months of relief and then it came back.

I also have a lot that don't get any benefit. I am very conservative who I do them on (clear anterior column pain, modic a 10 year old could pick out).

So the question is - are you guys getting an MRI on the failures to see if the burn caught the nerve? And if it didn't, what do you do?

The 2 months is a bit weird.

Though I have several patients (all men) who think they are Superman after intracept and do too much and stress the mid annulus which isn’t supplied by the BVN, and develop more pain. They don’t lose all the relief just part of it.

 

[bedrock]

Yes, I get new MRI.
If your failure rate is more than about a third of patients, something is off. I’ve done about 150 cases, the published rates are exactly what Ive seen.

I don’t have your level of experience. But 1/3 of your patients have less than 50% relief?

Have you noticed some anatomical commonalities of that 1/3?

Main thing I’ve noticed are patients with potential instability have worse results.

 

[Taus]

I don’t have your level of experience. But 1/3 of your patients have less than 50% relief?

Yep. The more cases you do, you’ll likely see outcomes regress to the mean.

Have you noticed some anatomical commonalities of that 1/3?

Main thing I’ve noticed are patients with potential instability have worse results.

Yep, like anything else, happens any time you introduce more variables.

A few I can think of off hand… more will run comment mind later;
-Elderly with decades of pain and multi-level mainly modic 2
-adjacent level to fusion
- symptoms that deviate from the classic anterior column/disc symptoms despite ruling out facets, sij, instability, etc. claudicatory purely axial pain with stenosis comes to mind.

That said…. I’ve still had failures on “classic” cases. Nailed target on postop MRI. I have to assume they are more “discogenic”.

I definitely temper expectations when anything deviates from classic and/or other variables… But still, tell every single patient about 30% chance it doesn’t help much.

 

[drusso]

I had patient that reported 2 months of relief and then it came back.

I also have a lot that don't get any benefit. I am very conservative who I do them on (clear anterior column pain, modic a 10 year old could pick out).

So the question is - are you guys getting an MRI on the failures to see if the burn caught the nerve? And if it didn't, what do you do?

Are they tender to palpation near the distribution of the cluneal nerves?

 

[lobelsteve]

Are they tender to palpation near the distribution of the cluneal nerves?

Only after the SIJ fusion.

 

[Status Sciaticus]

Only after the SIJ fusion.

you can fix that by fusing the other side to even out the biomechanics. /s

 

[bedrock]

Yep. The more cases you do, you’ll likely see outcomes regress to the mean.

Yep, like anything else, happens any time you introduce more variables.

A few I can think of off hand… more will run comment mind later;
-Elderly with decades of pain and multi-level mainly modic 2
-adjacent level to fusion
- symptoms that deviate from the classic anterior column/disc symptoms despite ruling out facets, sij, instability, etc. claudicatory purely axial pain with stenosis comes to mind.

That said…. I’ve still had failures on “classic” cases. Nailed target on postop MRI. I have to assume they are more “discogenic”.

I definitely temper expectations when anything deviates from classic and/or other variables… But still, tell every single patient about 30% chance it doesn’t help much.

If you get a post op mri on a commercial insurance patient, and you think you missed a bit, have you been able to get authed for another intracept?

I expect this easy with regular Medicare, but likely an issue with most commercial insurances?

 

[ErrantWhatever]

I’m sure I was annoyingly selective to my local rep on which patients to do this on initially. Did six or seven with one slam dunk and minimal or no relief with the rest. Stopped doing it.

 

[Taus]

If you get a post op mri on a commercial insurance patient, and you think you missed a bit, have you been able to get authed for another intracept?

I expect this easy with regular Medicare, but likely an issue with most commercial insurances?

I have had two patients with minimal relief where I got MRI and one of the lesions was not optimal. Had an S1 that was a bit too anterior (15 min burn). Other was L3 or L4 that was a bit too cephalad, but looked like only half the lesion formed, bottom of sphere not visible on mri (was a 7 minute burn). The other one or two lesions in these cases were spot on. Given that the patients had almost no relief at all… I was not confident going back in would be beneficial. If 1/2 or 1/3 lesions were off and patient had maybe 30-40% relief…. Perhaps I would have felt differently. If a patient had >50% relief I would not get the new MRI, as that is in line with about published outcomes.

 

[drmamba]

I have had two patients with minimal relief where I got MRI and one of the lesions was not optimal. Had an S1 that was a bit too anterior (15 min burn). Other was L3 or L4 that was a bit too cephalad, but looked like only half the lesion formed, bottom of sphere not visible on mri (was a 7 minute burn). The other one or two lesions in these cases were spot on. Given that the patients had almost no relief at all… I was not confident going back in would be beneficial. If 1/2 or 1/3 lesions were off and patient had maybe 30-40% relief…. Perhaps I would have felt differently. If a patient had >50% relief I would not get the new MRI, as that is in line with about published outcomes.

Outcomes are comparable with those published as well -- this is with strict patient selection and decently high volume as one of the primary people in the area performing/teaching BVNA. I'm routinely performing 15 minute RFAs since there is another mm radius of lesion that is achieved compared to 7min. Patients deserve every chance at an optimal outcome if they're already getting instrumented.

2 months of relief I would consider to either be placebo or unmasking of another pain generator. Like many therapies, it's unclear who is going to be a homerun or not.

 

[bedrock]

Outcomes are comparable with those published as well -- this is with strict patient selection and decently high volume as one of the primary people in the area performing/teaching BVNA. I'm routinely performing 15 minute RFAs since there is another mm radius of lesion that is achieved compared to 7min. Patients deserve every chance at an optimal outcome if they're already getting instrumented.

2 months of relief I would consider to either be placebo or unmasking of another pain generator. Like many therapies, it's unclear who is going to be a homerun or not.

I do wonder about 15 vs 7. Maybe the 7 creates an inconsistent lesion every so often as taus noticed?

I also spoke with a rep that said the difference between 7 and 15 burn was rounded off and is a bit more than 1mm.

15 min burn creates a lesion that is 1.3-1.4mm larger than the 7 min burn.

 

[Taus]

I do wonder about 15 vs 7. Maybe the 7 creates an inconsistent lesion every so often as taus noticed?

I also spoke with a rep that said the difference between 7 and 15 burn was rounded off and is a bit more than 1mm.

15 min burn creates a lesion that is 1.3mm larger than the 7 min burn.

I do a 15 at S1 more often than not, due to the variability in nerve location, even when I can see it on MRI. At other levels if I am dead on…. I’ll go 7. If I am questioning it, or anatomy makes it difficult to confirm true AP, I’ll go 15.

 

[bedrock]

I do a 15 at S1 more often than not, due to the variability in nerve location, even when I can see it on MRI. At other levels if I am dead on…. I’ll go 7. If I am questioning it, or anatomy makes it difficult to confirm true AP, I’ll go 15.

I’ve been doing the same. 15 every time at S1, and 7 at other levels if right on target, but 15min if non ideal but decent placement at levels above S1.

 

[drmamba]

15 min creates a 6mm radius lesion size, max temp 85C, and temp ramp up is 1.0C/sec

7 min creates a 5mm radius lesion size, max temp 75C, and temp ramp up is 0.5C/sec

In faster turnover settings, I'd recommend setting all RFA treatments to 15 min. Whenever the next level is ready for RFA, stop the treatment at the current level and start ablating the next level; this ensures that you reach a higher max temp, ramp up to max temp faster, and increase lesion.

If it is a non-S1 target, the probe placement is impeccable, and it has been at least 7 minutes, then it is reasonable to move on to the next level. Otherwise, 15 min RFA should be the standard.

 

[RoloTomassi]

15 min creates a 6mm radius lesion size, max temp 85C, and temp ramp up is 1.0C/sec

7 min creates a 5mm radius lesion size, max temp 75C, and temp ramp up is 0.5C/sec

In faster turnover settings, I'd recommend setting all RFA treatments to 15 min. Whenever the next level is ready for RFA, stop the treatment at the current level and start ablating the next level; this ensures that you reach a higher max temp, ramp up to max temp faster, and increase lesion.

If it is a non-S1 target, the probe placement is impeccable, and it has been at least 7 minutes, then it is reasonable to move on to the next level. Otherwise, 15 min RFA should be the standard.

That's interesting. If 7 min on the 85 setting is better than 7 min on the 75, do you know what was even the point of creating the 75?

 

[lobelsteve]

I have had exactly zero intracept failures.

 

[Taus]

15 min creates a 6mm radius lesion size, max temp 85C, and temp ramp up is 1.0C/sec

7 min creates a 5mm radius lesion size, max temp 75C, and temp ramp up is 0.5C/sec

In faster turnover settings, I'd recommend setting all RFA treatments to 15 min. Whenever the next level is ready for RFA, stop the treatment at the current level and start ablating the next level; this ensures that you reach a higher max temp, ramp up to max temp faster, and increase lesion.

If it is a non-S1 target, the probe placement is impeccable, and it has been at least 7 minutes, then it is reasonable to move on to the next level. Otherwise, 15 min RFA should be the standard.

I have been thinking about this for a while. Just finished a case, each level got 7 to 10 minutes at 85 degrees Celsius despite optimal placement.

 

[Ronin1]

I have had exactly zero intracept failures.

You should try it. It’s a game changer

 

[Taus]

You should try it. It’s a game changer

Steve, I am a little surprised at your reluctance with this. Has stronger data than pearls.yes, I know, industry sponsored on the RCTs. The smaller independent studies have found similar results. With only rare exceptions, every doc I’ve spoken to is essentially seeing the outcomes mirror the published literature.

 

[lobelsteve]

Steve, I am a little surprised at your reluctance with this. Has stronger data than pearls.yes, I know, industry sponsored on the RCTs. The smaller independent studies have found similar results. With only rare exceptions, every doc I’ve spoken to is essentially seeing the outcomes mirror the published literature.

Rare patient with modic changes and axial back pain in my practice. I would love for my local friends to train to take in those cases.

 

[bedrock]

Rare patient with modic changes and axial back pain in my practice. I would love for my local friends to train to take in those cases.

Crazy. Because we all see those patients at least monthly if not every other week.

At least be sure to send them out for the procedure.

 

[Ducttape]

His patient population is probably different to yours. Hence the dearth of patients with Modic changes.

 

[Dr. Ice]

I just don’t see a lot modic. I look for it now actively and still not. Waiting for something to convince me to take the time out to train on it. Haven’t found it. Maybe in the next venture

 

[Ducttape]

to paraphrase, when some one has a new hammer, all they see are nails...

 

[SSdoc33]

a back is a back. patient populations really dont differ all that much.

if you do the procedure, im sure you magically see more modic changes.

i actually think it is a useful procedure. its one of the few newer things that actually help. i dont do it b/c i dont want to put the work in to train and i cant imagine the $$$ is worth it for the time spent. i could do a probaly 8 injections in the same time span. i will farm it out, though

 

[lobelsteve]

a back is a back. patient populations really dont differ all that much.

if you do the procedure, im sure you magically see more modic changes.

i actually think it is a useful procedure. its one of the few newer things that actually help. i dont do it b/c i dont want to put the work in to train and i cant imagine the $$$ is worth it for the time spent. i could do a probaly 8 injections in the same time span. i will farm it out, though

This week I will see 7 patients younger than me. I am 54.
I see more acute Fxs than Modic changes. Not because I look for them, but because they are sent.

 

[SSdoc33]

This week I will see 7 patients younger than me. I am 54.
I see more acute Fxs than Modic changes. Not because I look for them, but because they are sent.

you can do BVNA in older patients as well

true, referring patterns play a role.

 

[Ronin1]

The vast majority of my intracept patients are medicare. Look at the scans. Most radiologists don’t report end plate edema or modic changes. I agree with the 2/3 benefit ratio

 

[lobelsteve]

Does Modic Change Progresss With Age? - PubMed

4.

pubmed.ncbi.nlm.nih.gov

If only they were 10 years younger.

 

[Taus]

I see a high volume of good candidates….. but also in a large ortho practice and get a lot of direct referrals for consult specifically for the procedure. From just my own consults that weren’t directly referred specifically for it…. Probably one to two candidates per week.

 

[RoloTomassi]

Different populations. I see at least 1 a day. Anterior column, most have failed RFA, ESI. I don't think it's just because I'm trained in it, because I'm trained in everything else but can't seem to find candidates for PNS, mild, SI fusion etc. Even SCS maybe 1/quarter.

 

[epidural man]

Are they tender to palpation near the distribution of the cluneal nerves?

Good thought. Usually no. We look for cluneal nerve neuralgia.