Intracept

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Honestly, I think the image was better on the computer where I took this from, and it didn't look as good off the crappy xray machine, but that could be me making excuses hah.

Rep is newer and I haven't seen attending do S1 TF over the year so I think overall inexperience with sacral stuff.

Appreciate all the feedback
 
Inygma said:
Ive done about 20 levels as a fellow. I've been in cases that are 2 hours and cases that are 30 minutes. The straight forward ones are great, and Generation 3 > Generation 2 for use imo. S1 seems to be the problem child. I did one case, L3-5 took about 40 mins and S1 took 1.5 hours.

Anyone have any tips for S1?
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I’m not wizard but can routinely do s1 in 15-20 mins

What has helped me
- spend a lot of time getting the absolutely perfect shot before docking. I’ve worked with the rep and the Xray tech frequently . They can do this while I’m scrubbing in
- drop in a 22 gauge spinal needle in this view. Go lateral to get the trajectory. And angle.
- always use bevel to dock
- make your skin nick more lateral and superior than L1-L5.
- if you need to readjust then take the cannula out more than you’d think
- the common error is to go too ventral. Turn the lights off to make sure you’re just past the posterior border to improve Xray quality . When in doubt stay posterior
- when starting to hammer the first few taps are so clutch. I routinely go very very slowly for 1-2 taps and make adjustments. Before I was too aggressive and didn’t leave room to correct
- learn to pull back the cannula while hammering. This will give you more finesse
 
Anyone have links/info on ideal patients? Pain patterns for intercept? I know about looking for MRI modic changes , but what else?
 
painfree23 said:
Anyone have links/info on ideal patients? Pain patterns for intercept? I know about looking for MRI modic changes , but what else?
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Pain with flexion, pain when sitting too long, pain with lifting, axial pain more midline, along with those modic changes.

If any radicular pain then you need to be able to differentiate it or else (unless Medicare) it won’t be approved.
 
I may be doing it wrong.

Here is what I do.

If they have anterior column symptoms as described by the company, I will do it only on the level where MODIC changes are present.

However, the neurosurgeon who does a ton at my place will do any level with a black disc and he is typically doing 3 disc, I’ve seen 4. He reports better outcomes.

But then again, he also doesn’t see the ones that come to the pain clinic after he has done the ablation…so recall bias is a thing.
 
epidural man said:
I may be doing it wrong.

Here is what I do.

If they have anterior column symptoms as described by the company, I will do it only on the level where MODIC changes are present.

However, the neurosurgeon who does a ton at my place will do any level with a black disc and he is typically doing 3 disc, I’ve seen 4. He reports better outcomes.

But then again, he also doesn’t see the ones that come to the pain clinic after he has done the ablation…so recall bias is a thing.
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I highly doubt the neurosurgeon is doing a better job than you. Surgeons don’t have the patience to take the time and make microadjustments needed for optimal placement.

Unfortunately if you’re off by a small amount, you can miss the BVN. See the attached photo of the L5 lesion. Not my case, but one with significantly less pain relief than expected.
 

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bedrock said:
I highly doubt the neurosurgeon is doing a better job than you. Surgeons don’t have the patience to take the time and make microadjustments needed for optimal placement.

Unfortunately if you’re off by a small amount, you can miss the BVN. See the attached photo. Not my case, but one with significantly less pain relief than expected.
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Yep. Especially important if using the 7 minute burn (L5 in this example image). S1 looks like a 15 min burn there.

Results mirror literature… I’ve done between 120-130.
 
Taus said:
Yep. Especially important if using the 7 minute burn (L5 in this example image). S1 looks like a 15 min burn there.

Results mirror literature… I’ve done between 120-130.
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Can you please remind us how big is the 15 min lesion vs the 7 min lesion?

It seems like when they discussed during training that it was less of a difference than I expected considering that than double the time spent on the 15 min lesion.

I think I the diameter of a 7min lesion is 10mm and the 15 min lesion is 12mm.

Does that sound correct to you?
 
bedrock said:
Can you please remind us how big is the 15 min lesion vs the 7 min lesion?

It seems like when they discussed during training that it was less of a difference than I expected considering that than double the time spent on the 15 min lesion.

I think I the diameter of a 7min lesion is 10mm and the 15 min lesion is 12mm.

Does that sound correct to you?
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Correct re size.

That said…. I don’t know how well kill zone corresponds to mri findings. 7 min tends to look like a mostly homogeneous white circle. 15 looks like a heterogenous black dead zone w surrounding rim of presumably edema. Perhaps kill zome is truly no different than 5 vs 6 mm radius but the example you posted is what I’d typically see on mri post bvna.
 
Taus said:
Correct re size.

That said…. I don’t know how well kill zone corresponds to mri findings. 7 min tends to look like a mostly homogeneous white circle. 15 looks like a heterogenous black dead zone w surrounding rim of presumably edema. Perhaps kill zome is truly no different than 5 vs 6 mm radius but the example you posted is what I’d typically see on mri post bvna.
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There might be an additional advantage of the thoroughness of the 15 min lesion. You would know better than me.

One think I was thinking of doing was just pushing the 15 min lesion button on everyone, but if I’m ready to burn the next level between 7 and 15 min, I’ll just turn it off at 10 minutes or whatever it is at that level.

This way, I’m not slowed down waiting, but the patient gets a bit extra lesion.
 
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The doc did a really good job on the L5. The bvn just came off a little low. Tough to account for that unless you pull up the MRI in the OR.
 
BobBarker said:
The doc did a really good job on the L5. The bvn just came off a little low. Tough to account for that unless you pull up the MRI in the OR.
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A good example of why you should always review the BVN location on MRI before the procedure. Uncommon not to be midline L5 and up, but fair amount of variability at S1.
 
It's not hard to be too left or right. If your AP is not perfectly midline, and are using SP as landmark, you could be quite a bit off, especially if not very posterior. Same if you have an angled SP and line it up midline, you have an erroneous target.
 
Probably one level for every fellow present. Nothing to gain for the physician or the system really as they were in the OR for two hours probably.
 
lobelsteve said:
View attachment 391195

Does anyone think this sounds a bit suspicious? 4 levels in an 81 y/o? How to kill a procedure in one easy step.
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I did one case like this during my first six months of doing the procedure, though curve and rotation was a bit more prominent. I’ll try to find the pictures in my records… A longtime patient without other options besides living with it, which wasn’t going too well. It truly sucked, and I vowed never to do another such case. It was a ton of work and radiation. Tortured my xray tech. Lateral view was between 50 to 60° contralateral oblique… I had it measured out per level on my prep sheet. Repeatedly toggling from AP to modified lateral with a lot of wigwag on each level. Patient got like 70% relief…..

Found em….
 

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lobelsteve said:
Im only 19 years out of fellowship. Have not seen a patient yet with 4 level modic changes.
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not saying I see it all the time… But it doesn’t seem rare… Think of those Medicare patients with back pain for multiple decades where L3 to S1 discs are all collapsed and mixed Modic 1/2 changes diffusely. Perhaps I see a more biased sample now as a lot of my partners send me these cases. However, I no longer will just routinely do L3 to S1 on these. If their pain is mainly lumbosacral junction and let’s say just L5 S1 light up on stir…. I would just do that.
 
lobelsteve said:
Im only 19 years out of fellowship. Have not seen a patient yet with 4 level modic changes.
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From cases I’ve done in past couple years, had some saved in my phone.
 

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lobelsteve said:
Im only 19 years out of fellowship. Have not seen a patient yet with 4 level modic changes.
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As common as modic changes are, it'd be rare not to have someone with 3 or 4 level disease I suspect in their 80s, especially in that scoliotic of a spine. I bet you're just thinking of severe modic changes that might mean something clinically though.
 
lobelsteve said:
View attachment 391195

Does anyone think this sounds a bit suspicious? 4 levels in an 81 y/o? How to kill a procedure in one easy step.
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Vafi is a personal friend of mine and a genuinely good guy. Smart, and I’d let him see my mother.

Edit: I see 3-4 level Modic change frequently, usually L2-S1. Unfortunately it seems to all be United pts.
 
I did these two today, L1-S1 and L2-S1. Axial pain, failed everything under the sun.
1000007405.png
1000007404.png
 
lobelsteve said:
In most of those images you all posted, the changes are asymmetrical. Didn’t think that was what the procedure was for.
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Patients with scoliosis, I believe, were excluded from the studies, is this what you’re referring to? It’s not a contraindication to the procedure, though. I have done 11 cases thus far. 2 of my home runs (90-95% relief) were with patients with scoli with unilateral Modic at the apex of their curve and unilateral pain (2 vertebral bodies treated) and “anterior column-type” pain. When I have a third case I’ll write it up, not that 3 is a huge N, but better than 0.
 
MD87 said:
Patients with scoliosis, I believe, were excluded from the studies, is this what you’re referring to? It’s not a contraindication to the procedure, though. I have done 11 cases thus far. 2 of my home runs (90-95% relief) were with patients with scoli with unilateral Modic at the apex of their curve and unilateral pain (2 vertebral bodies treated) and “anterior column-type” pain. When I have a third case I’ll write it up, not that 3 is a huge N, but better than 0.
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I have several similar cases that I have done with unilateral modic and have tried intracept. Probably less than 2/3 responders but definitely some home runs. Time to get some more data
 
Ronin1 said:
I have several similar cases that I have done with unilateral modic and have tried intracept. Probably less than 2/3 responders but definitely some home runs. Time to get some more data
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Cool. Mine were both type 1 modic. Based on my small N of 11, I don’t believe the data that type 1 and 2 respond equally well. My best results have been type 1 modic and severe disc height loss (basically no disc left).
 
I signed up for the intracept lecture at the IPSIS meeting. I’m assuming it’s not the gateway to actually scheduling these procedures since there’s no training certificate at the end, but it seems like a long module.
 
I would be more excited about this procedure if there were a semi-reliable diagnostic block.

I used to do pulsed RF at L1/L2 DRG and got some results.

What about a sinovertebral nerve block as a diagnostic target?
 
epidural man said:
I would be more excited about this procedure if there were a semi-reliable diagnostic block.

I used to do pulsed RF at L1/L2 DRG and got some results.

What about a sinovertebral nerve block as a diagnostic target?
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Great idea, It is even more meaningful to do a diagnostic test for modic 2, in my opinion, maybe a selective nerve block will work to block svn.
 
Done plenty with minimal Modic can't say outcomes are different
 
I don't think they all need it. A lot of people have herniations with nerve contact or severe foraminal stenosis, who are asymptomatic, but if they have clinically correlated radicular symptoms, that's probably the cause. That's how I see Modic. If they have anterior column symptoms and provocation, other generators ruled out, endplates are probably the cause. There's no intradiscal treatment that's more effective, safer, or less painful

pubmed.ncbi.nlm.nih.gov

Modic changes as seen on MRI are associated with nonspecific chronic lower back pain and disability - PubMed

Studies using tightly defined homogenous patient groups may provide the best test for association between MRI-findings and pain and disability. Clinical benefit of basivertebral nerve ablation observed in randomised controlled trials further supports the association between type 1 and type 2...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
MitchLevi said:
Vafi is a personal friend of mine and a genuinely good guy. Smart, and I’d let him see my mother.

Edit: I see 3-4 level Modic change frequently, usually L2-S1. Unfortunately it seems to all be United pts.
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I can second this. He's judicious with his patient selection. Usually exhausts all options before introducing advanced procedures.
 
Patient states another doc offered her an “ablation” for thoracic back pain and a T7 hemangioma. I’m assuming he was referring to intracept(?) is anyone doing it in the thoracic spine?
 
sorry if this was addressed- anyone in noridian jurisdiction? - it seems like they only cover 2 level ablation (1 modic) at a time which seems a bit ridiculous.
btw, from financial standpoint this case is a donation case for me. takes too much time for little reimbursement
 
Agast said:
Patient states another doc offered her an “ablation” for thoracic back pain and a T7 hemangioma. I’m assuming he was referring to intracept(?) is anyone doing it in the thoracic spine?
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i haven't seen anyone do for thoracic but i thought it might be interesting to see how the out come is for those thoracic axial pain cases with modic/degenerative changes where i have very limited option
 
epidural man said:
I would be more excited about this procedure if there were a semi-reliable diagnostic block.

I used to do pulsed RF at L1/L2 DRG and got some results.

What about a sinovertebral nerve block as a diagnostic target?
Click to expand...

RoloTomassi said:
Beall advocates for intradiiscal anesthetic injection
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There is a fairly reliable diagnostic procedure. (MBB and/or RFA) Unless you’re truly worried about SIJ (SIJ is over diagnosed), then a patient without significant radiculopathy, who failed MBB or good technique RFA, and has pain with lifting, prolonged sitting and/or prolonged partial lumbar flexion is your intracept candidate.

Beal is wrong. Not appropriate to violate a disc causing potential harm, when MBB/RFA are so useful diagnostically.
 
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