Intracept

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Saw my first intracept patient back this week.

80% pain relief in two days. Fun to see.
Will continue to offer this to commercial patients. I made an arrangements with a local RVU based HOPD doc to do intracept for my federal insurance patients. We are both quite happy with the arrangement.
 
bedrock said:
Saw my first intracept patient back this week.

80% pain relief in two days. Fun to see.
Will continue to offer this to commercial patients. I made an arrangements with a local RVU based HOPD doc to do intracept for my federal insurance patients. We are both quite happy with the arrangement.
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My first was pain free at his follow up.
 
For those of you that have done this procedure on your patients already, what are some pitfalls/things to worry about and keep in mind/potential issues and complications that you've across that others can glean from you? I've taken the course and everything seems straight forward so far, but that isn't the important part like all things we do obviously.
 
hopefulgasman said:
For those of you that have done this procedure on your patients already, what are some pitfalls/things to worry about and keep in mind/potential issues and complications that you've across that others can glean from you? I've taken the course and everything seems straight forward so far, but that isn't the important part like all things we do obviously.
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cases are pretty easy.

s1 is tough

payment for your facility is not good. so unless your at a hospital, it will be hard to do on medicare patients.
 
PinchandBurn said:
cases are pretty easy.

s1 is tough

payment for your facility is not good. so unless your at a hospital, it will be hard to do on medicare patients.
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If you have shares in asc, you could negotiate the procedure kit down about 10-15%, that was a difficult negotiation, but makes medicare cases marginally positive in our state.
 
SC Tian said:
If you have shares in asc, you could negotiate the procedure kit down about 10-15%, that was a difficult negotiation, but makes medicare cases marginally positive in our state.
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They won't negotiate. They have a monopoly
 
PinchandBurn said:
They won't negotiate. They have a monopoly
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SC Tian said:
If you have shares in asc, you could negotiate the procedure kit down about 10-15%, that was a difficult negotiation, but makes medicare cases marginally positive in our state.
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Relievant wouldn't even begin to negiotiate with our practice. That is why I refuse to do medicare intracept cases until relievant changes their prices for medicare intracept cases, just like SCS companies offer a different price for medicare SCS implants.

I do look forward to other companies developing their own intracept systems, (as they are currently doing). Competition is the foundation of a free economy.
 
Our experience as well. They would not negotiate at all and we are a high volume account with strong negotiating results with every other vendor we've dealt with. About a month ago their regional manager for my territory started calling and pushing for a meeting, sending me texts about outcomes, etc. My guess is they know competition is going to hit the market soon and they are trying to change their tune. Too little too late for us.
 
PinchandBurn said:
They won't negotiate. They have a monopoly
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It is definitely difficult, my arguments with them were 1st in the state to do this, the market is huge, showing them the numbers of Medicare patients in our asc, asc manager, financial manager and me set up couple meetings with high level director from Relievant. It was before the merging though.
bedrock said:
Relievant wouldn't even begin to negiotiate with our practice. That is why I refuse to do medicare intracept cases until relievant changes their prices for medicare intracept cases, just like SCS companies offer a different price for medicare SCS implants.
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I am not aware the price can be different for Medicare cases.
 
Make sure yall measure pedicles before cases. Had a case Friday with a 2.6 mm pedicle. Big woman too.
 
Has negotiation improved at all with Relievant being bought by Boston?

Mitch, what level?
 
L3, and L4 was like 3.5 or something. I did L5-S1 only.
 
Orin said:
It's a good procedure for the right patient. I'm not the best money person to talk to, but I would suggest looking into off label hardware for the Medicare patients if you don't want to send it to your local hospital based docs. There's similar hardware that uses RF energy to create a lesion around that nerve available from the cancer space.

Stryker's Optablate, Medtronic's Osteocool, and Merit Medical's STAR ablation system are all able to do this.

Merit Medical's STAR Ablation system is what I'm using as it's unipedicular/steerable. This is mainly due to approval/training from Intracept but also I use them for complex cancer pain intermittently. It's priced as an add on to a kyphoplasty with a lower CPT code 20982($6,501 for ASC) compared to 64628 ($9,418 for ASC) so margin should be higher in PP. The procedure is mostly the same between the two but a little more technically challenging due to the lack of a sheath to maintain the pathway, and with the harder bone, you'd need to use something like a sponge stick or cast spreaders to help remove the osteotome.

As they're all off-label for the indication, the reps aren't going to be able to help you out beyond providing hardware, so you would need to know your stuff with getting the RF probe to the right space safely.
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How are you documenting and getting these approved? Does there have to be a cancerous lesion? Having similar frustrations with reimbursement and training of intracept.
 
I had an Intracept case at L5 and S1 about 2 months ago - patient reported about 60% improvement, but we got a follow up MRI to evaluate for any other interval changes. There are clear S1 lesions but nothing at L5, any insight into this? We did a 15 minute lesion at S1 and a 7 minute lesion at L5 but I would imagine that shouldn't change post procedural lesion imaging. I'm asking the reps to see if they can get a lesion history from their generator, but L5 was the second lesion we did so I'm 100% certain we watched that count down.
 
jwheezy said:
I had an Intracept case at L5 and S1 about 2 months ago - patient reported about 60% improvement, but we got a follow up MRI to evaluate for any other interval changes. There are clear S1 lesions but nothing at L5, any insight into this? We did a 15 minute lesion at S1 and a 7 minute lesion at L5 but I would imagine that shouldn't change post procedural lesion imaging. I'm asking the reps to see if they can get a lesion history from their generator, but L5 was the second lesion we did so I'm 100% certain we watched that count down.
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Thoughts?
 
jwheezy said:
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Thoughts?
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There is a lesion at L5 (circled) but the 15 versus 7 definitely look different on mri, not just in size from the cases I’ve seen. 15 looks like a dead zone/void, as in your S1. no idea how the different look impacts the killing of nerve besides trusting Relievant. That said, no drop off in my success rate using primarily seven.

S1 lesion is also low of target. See marked up image. “May” have gotten bvn at the periphery of it. Sometimes the BVN is less than 40% from endplate. Need to review mri pre-op for S1 bvn exact location.
 

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RoloTomassi said:
L5 marrow probably just healed faster. I see what looks to be a small residual lesion. How do the T1 sag and ax look? T1 seems to be the most sensitive when I look at lesions.
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Hey yeah actually found a small dark lesion on the T1 weighted images. thanks for that!
 
The lesions also fade I think. I had a hard time seeing lesions on a patient that was ablated a couple years ago.
 
Ready_User_1 said:
How are you documenting and getting these approved? Does there have to be a cancerous lesion? Having similar frustrations with reimbursement and training of intracept.
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Same as BVNA. Much like Medicare doesn't care if you used a curved or straight needle for a RFA, they aren't arguing about whether you heat it with Merit Medical's hardware or Intracept's toy.

RF electrode across the posterior third of the vertebral body
Heat to goal temperature
Merit's actually measures the temperature at the distal electrode, so you know it gets as hot as you expect, without having to guesstimate about time like with Intracept
 
Anyone has used this machine? Is it good enough to do kypho and intracept? Thanks.
 

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Was it smart of Boston Scientific to purchase Reliviant? Will it survive? IDET hung on for a long time.....
 
epidural man said:
Was it smart of Boston Scientific to purchase Reliviant? Will it survive? IDET hung on for a long time.....
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I have no idea how the business end works out, particularly with pending competition of striker, and maybe others…. But Given the increased coverage adoption by insurers, and it legitimately working in properly selected patients, appears to be here to stay.

IDET was before my time, but my understanding is people started widespread use before the larger studies came out, which then showed it didn’t work better than placebo and was then killed off by insurers.
 
epidural man said:
Was it smart of Boston Scientific to purchase Reliviant? Will it survive? IDET hung on for a long time.....
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After I saw the number of intracept cases for 2022, then 2023, then first 6 months of 2024, I went and bought 50k of Boston stock.

Intracept is the real deal
 
bedrock said:
After I saw the number of intracept cases for 2022, then 2023, then first 6 months of 2024, I went and bought 50k of Boston stock.

Intracept is the real deal
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Marketing success. Like particulate steroids. Overutilization leads to bad outcomes and reduced payments.
 
lobelsteve said:
Marketing success. Like particulate steroids. Overutilization leads to bad outcomes and reduced payments.
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When I was at SIS a little over a year ago they said there was something in the pipeline that indicated particulate works better. But that was the last I’ve heard of it.
 
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?
 
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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lol yep. I’ve done ~3-350 levels…. Still occasionally happens at S1.

Not much to do with combo of rock hard bone and high/medial iliac crests when the J just won’t turn despite every trick. Sometimes I get all the stars to align on one like that, it starts going medial while posterior enough and even the greatly improved gen 3 straight stylet when extending channel still hits something and goes up or down when advancing. Extraordinarily frustrating.

I’m highly tempted to go trans iliac crest next time. Just hoping for no “next time”
 
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 almost always on target if my oblique is 30-35 degrees.

True AP
Cephalad tilt to square S1.
Choose which side (best if you pre-op planned).
Oblique over 30-35 degrees.
If crest is now covering, cephalad tilt past square until you uncover target.
Dock a bit lateral to mid pedicle, walk in medially until you hit SAP, in the deepest part of groove. This ensures you are not on facet and not more lateral than you need to be.
You may want to do all this with a spinal needle, take AP/L, make sure your trajectory is good, then get a hub view, go back in with trocar (diamond or bevel facing medial).
Small taps when you start the J to make sure you don't get on an errant path.
 
@RoloTomassi @Taus OK, I am going to figure out how to post my procedure from today. L4-5 took 10 mins each to start burning (7 min burns). S1 we ended up abandoning. I do not have great experience with S1, nor does my attending (i am in last week of fellowship). I even tried the Rolo method above and no matter what we did we were low on pedicle and did not want to dock/advance there.
 

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Inygma said:
@RoloTomassi @Taus OK, I am going to figure out how to post my procedure from today. L4-5 took 10 mins each to start burning (7 min burns). S1 we ended up abandoning. I do not have great experience with S1, nor does my attending (i am in last week of fellowship). I even tried the Rolo method above and no matter what we did we were low on pedicle and did not want to dock/advance there.
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I mean that seems like a pretty reasonable place to dock, why not try it?
 
Inygma said:
@RoloTomassi @Taus OK, I am going to figure out how to post my procedure from today. L4-5 took 10 mins each to start burning (7 min burns). S1 we ended up abandoning. I do not have great experience with S1, nor does my attending (i am in last week of fellowship). I even tried the Rolo method above and no matter what we did we were low on pedicle and did not want to dock/advance there.
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Right side looks like perfect trajectory. Parallel with endplate, mid pedicle not too low
 
RoloTomassi said:
Right side looks like perfect trajectory. Parallel with endplate, mid pedicle not too low
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ok, this is what I kind of thought... rep said "it looked weird" and doesnt look right, and with my inexperience and my attendings inexperience with S1, we abandoned.

Good to know for future
 
RoloTomassi said:
Right side looks like perfect trajectory. Parallel with endplate, mid pedicle not too low
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Is this the pedicle? We were arguing about it. Ill post unedited and edited.
 

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Inygma said:
Is this the pedicle? We were arguing about it. Ill post unedited and edited.
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Yeah... is that rep new? That's a pretty decent looking image I'm not sure what looks weird to them
 
jwheezy said:
Yeah... is that rep new? That's a pretty decent looking image I'm not sure what looks weird to them
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Agree. Most of their reps are very good, that's surprising. More disappointed in attending. Do they do S1 TF?
 
Inygma said:
Is this the pedicle? We were arguing about it. Ill post unedited and edited.
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For future reference, if you are uncertain of you position on lateral, you can still proceed based on AP and oblique. You can see the medal and inferior pedicle borders.

The left side would've been fine too. Just require adjusting inferior once docked.
 
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