Iovera

[Crybaby]

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Has anyone had any experience with Iovera?

I was contacted by an ortho that does joint replacements (great guy) about doing this procedure on his patients prior to totals as an attempt to reduce opioid use after surgery. I wanted to test these waters on this forum to see if anyone had previous experience.

 

[Orin]

Looked into it and have seen/played with it in cadaver labs.

It's a large device that requires keeping the probe mostly upright.
Insurance coverage is spotty.
Small risk of frostbitten skin in skinnier people and shallower nerves depending on the probe utilized.
Cost quoted was similar to a Cooled RF kit.

Would use it if insurance coverage was less problematic as the data regarding ability to freeze mixed sensorimotor nerves is nice.

 

[lobelsteve]

Why not conventional genic rf?

 

[Crybaby]

I have yet to do my own research on it. So perhaps I should have waited on this post. But, I’m lazy so....
This guy is under the impression that if used for preop pain management this technique does not require the 2 blocks prior to as in conventional RF. I have been getting decent results with RF, however I don’t have the time to block x 2 and burn each of his patients and likely one of his partners.
I’ll get more details soon, I talked to him in between patients- a bit rushed.

 

[Orin]

So honestly, I have not seen any requirement for a block prior to a peripheral RF. That's a hold over from facet targeted interventions that people are applying to peripheral nerves.

 

[callmeanesthesia]

Why not conventional genic rf?

Mostly this:

Radiofrequency ablation of genicular nerves prior to total knee replacement has no effect on postoperative pain outcomes: a prospective randomized sham-controlled trial with 6-month follow-up - PubMed

NCT02746874.

pubmed.ncbi.nlm.nih.gov

Whether you believe it or not is another issue but Iovera does have some studies showing postop pain reduction on their website.

 

[lobelsteve]

Mostly this:

Radiofrequency ablation of genicular nerves prior to total knee replacement has no effect on postoperative pain outcomes: a prospective randomized sham-controlled trial with 6-month follow-up - PubMed

NCT02746874.

pubmed.ncbi.nlm.nih.gov

Whether you believe it or not is another issue but Iovera does have some studies showing postop pain reduction on their website.

But that is cooled RF and not conventional RF.

It means it should have done better with larger lesion size. I have not been asked to do pre-op lesioning. Now I can say no.

 

[callmeanesthesia]

I have yet to do my own research on it. So perhaps I should have waited on this post. But, I’m lazy so....
This guy is under the impression that if used for preop pain management this technique does not require the 2 blocks prior to as in conventional RF. I have been getting decent results with RF, however I don’t have the time to block x 2 and burn each of his patients and likely one of his partners.
I’ll get more details soon, I talked to him in between patients- a bit rushed.

Did some iovera in fellowship, with the short probe landmark-guided technique. It’s time-intensive but seems to work well. It doesn’t pencil out in private practice because of the equipment cost, at least when I looked at it. Break even or a loss even. Not sure whether it would be affected by the coding changes. According to the guy I did them with in fellowship, you can personally mark and inject the local, then have a nurse sit there and do the actual ablation (which basically just involves marching the little comb of probes along the line for about 20 minutes while it does it’s cooling cycles). I think that’s the only way to really have this pencil out with the setup you’re taking about with Ortho. Line up a couple patients in a row, you mark and anesthetize, then go see some other patients, and your nurse follows behind and does the ablations, then rinse and repeat.

 

[lobelsteve]

Until a complication occurs.
Would recommend against anyone other than a physician performing the work of a physician. This abandonment of the patient during lesioning sounds like a bad idea. Kinda how anesthesiologists gave away their specialty to nurses.

 

[SommeRiver]

Line up a couple patients in a row, you mark and anesthetize, then go see some other patients, and your nurse follows behind and does the ablations, then rinse and repeat.

What? Are you for real?

I have good experience with this POS device. I will admit it is not too bad with knee lesioning.

It frequently, and I mean frequently causes neuritis. The genicular nerves not so much, but you try and use Iovera (only gets you to -160 deg) on other nerves and you're getting a pissed off pt at follow up. We were going to publish our data but something happened and it fell off into oblivion somehow...We had just under 200 pts (I think), and the neuritis was between 1/3 to 1/2 of pts who were lesioned for anything other than occipital (common neuritis, but not as common as bigger nerves) and genicular. I don't think the LFCN was an issue...

If you lesion virtually everything else you're getting neuritis.

Obviously size matters.

Reimbursement sucks too, especially for something so time intensive.

 

[callmeanesthesia]

What? Are you for real?

I have good experience with this POS device. I will admit it is not too bad with knee lesioning.

It frequently, and I mean frequently causes neuritis. The genicular nerves not so much, but you try and use Iovera (only gets you to -160 deg) on other nerves and you're getting a pissed off pt at follow up. We were going to publish our data but something happened and it fell off into oblivion somehow...We had just under 200 pts (I think), and the neuritis was between 1/3 to 1/2 of pts who were lesioned for anything other than occipital (common neuritis, but not as common as bigger nerves) and genicular. I don't think the LFCN was an issue...

If you lesion virtually everything else you're getting neuritis.

Obviously size matters.

Reimbursement sucks too, especially for something so time intensive.

Yeah, he had his nurse do the lesioning. Not saying I think it’s a great idea. All I saw him do was genicular so not sure about the neuritis issue. I thought that was supposed to be less common with cryoablation...

 

[SommeRiver]

Yeah, he had his nurse do the lesioning. Not saying I think it’s a great idea. All I saw him do was genicular so not sure about the neuritis issue. I thought that was supposed to be less common with cryoablation...

It has been awhile since I looked at this stuff but the older studies looking at cryo were done at like -190 to -200 deg (something like that), and Iovera is simply not as cold. It is -160 (pretty sure at least).

 

[Orin]

Iovera's system only gets down to -88 C at the coldest. In reality, the cold lesions and heat lesions are similar in that there are zones/lines of different temperatures, with the coldest/warmest being at the center generally. The -88 C is nice in that it should be reversible to an extent without the damage to the endo-/peri-/and epineurium per their marketing and some old data.

The size of the lesion is dependent on a few factors, but mostly the probe geometry. The old probe Iovera provided was this tiny fork like thing that was great for shallow nerves like the occipital or superficial nerves to the skin overlying the knee, but really sucked for anything big. They have a proper nerve ablation probe now that can create an 7 by 16 mm almond shaped lesion which should be great for a genic using the conventional RF approach, as the lesion doesn't project off the tip that well.

It does take a while per location to freeze, and you may want more freeze/thaw cycles due to the anatomy/size of the nerve if you were doing something crazy big/thick. The nice thing is you can visualize it all under ultrasound, including the ice ball forming. It's kinda cool, but it is no where close in size or temperature to the stuff they do with the huge big cryoprobes that are used for cyrosurgery to kill tumors/etc.

 

[deleted993114]

Has anyone had any experience with Iovera?

I was contacted by an ortho that does joint replacements (great guy) about doing this procedure on his patients prior to totals as an attempt to reduce opioid use after surgery. I wanted to test these waters on this forum to see if anyone had previous experience.

All the knees at out hospital have this done first.

If you are hospital based, it is economical. If it is office based, train an NP or PA to do it. It is VERY easy, yet takes 30 minutes, so it is not practical for a physician to do unless in a hospital setting.

It will be the standard of care for total knees, much like epidurals for labor. It works that well.

 

[deleted993114]

What? Are you for real?

I have good experience with this POS device. I will admit it is not too bad with knee lesioning.

It frequently, and I mean frequently causes neuritis. The genicular nerves not so much, but you try and use Iovera (only gets you to -160 deg) on other nerves and you're getting a pissed off pt at follow up. We were going to publish our data but something happened and it fell off into oblivion somehow...We had just under 200 pts (I think), and the neuritis was between 1/3 to 1/2 of pts who were lesioned for anything other than occipital (common neuritis, but not as common as bigger nerves) and genicular. I don't think the LFCN was an issue...

If you lesion virtually everything else you're getting neuritis.

Obviously size matters.

Reimbursement sucks too, especially for something so time intensive.

Cryo doesn't cause a neuritis. That is why we use it on myelinated nerves, rather than rf.

Our experience has been fantastic. Most patients after total knees are using nothing more than Tylenol- it is really remarkable. We do see these patients later and ask them about their experience, so it is not a "hit and hope" approach.

 

[SommeRiver]

Cryo doesn't cause a neuritis.

Okay dude. Saw dozens and dozens of times and it was all documented and was supposed to be published. Never was for some reason (I left fellowship and never heard anything about it).

We had a few hundred pts, and neuritis occurred not uncommonly.

Let me add (like I stated in my earlier posts which you didn't read - par for the course when exchanging posts with you)...Neuritis wasn't common in the knee or occipitals.

 

[cowboydoc]

Okay dude. Saw dozens and dozens of times and it was all documented and was supposed to be published. Never was for some reason (I left fellowship and never heard anything about it).

We had a few hundred pts, and neuritis occurred not uncommonly.

Let me add (like I stated in my earlier posts which you didn't read - par for the course when exchanging posts with you)...Neuritis wasn't common in the knee or occipitals.

I’ve had 1% incidence of neuritis, n=400+
In the Knee. All resolved with injection of local and steroid.

 

[SommeRiver]

I’ve had 1% incidence of neuritis, n=400+
In the Knee. All resolved with injection of local and steroid.

...in the knee.

When Iovera first came in the market they pushed it in every nerve their probes would reach.

Edit - when Iovera first came TO the market, not IN the market...

 

[cowboydoc]

...in the knee.

When Iovera first came in the market they pushed it in every nerve their probes would reach.

Edit - when Iovera first came TO the market, not IN the market...

The trident was junk IMO. The direct visualization of placement is far better (in capable hands.)

I’ve been underwhelmed with treatment of ilioinguinal, lat. fem. cutaneous, saphenous, stump neuromas, etc.

Results in shoulder have been ok. Early cases had been accepted for poster Pre-Covid, more to come...

When first presented with the product, incidence of neuritis was my very first question. They acted like they had never heard the word. Their Initial data/info demonstrated a lack of understanding basic neurophysiology. I’ve been unimpressed with myoscience and pacira in general, but I guess that is my distaste for dealing with “industry.”

 

[SommeRiver]

The trident was junk IMO. The direct visualization of placement is far better (in capable hands.)

I’ve been underwhelmed with treatment of ilioinguinal, lat. fem. cutaneous, saphenous, stump neuromas, etc.

Results in shoulder have been ok. Early cases had been accepted for poster Pre-Covid, more to come...

When first presented with the product, incidence of neuritis was my very first question. They acted like they had never heard the word. Their Initial data/info demonstrated a lack of understanding basic neurophysiology. I’ve been unimpressed with myoscience and pacira in general, but I guess that is my distaste for dealing with “industry.”

I think Iovera for knees is a great treatment, with very low risk. We were freezing EVERYTHING, bc that is what the company wanted. Earlier I posted something like just under 200 pts, and that may be too low. It was a big number. The trident on the occipitals wasn't terrible. They watched their outcomes run down like zhit through a tin horn, and then you watched them slowly begin focusing their efforts on knees.

Learning experience for my young behind...Industry is FoS.

 

[deleted993114]

The trident was junk IMO. The direct visualization of placement is far better (in capable hands.)

I’ve been underwhelmed with treatment of ilioinguinal, lat. fem. cutaneous, saphenous, stump neuromas, etc.

Results in shoulder have been ok. Early cases had been accepted for poster Pre-Covid, more to come...

When first presented with the product, incidence of neuritis was my very first question. They acted like they had never heard the word. Their Initial data/info demonstrated a lack of understanding basic neurophysiology. I’ve been unimpressed with myoscience and pacira in general, but I guess that is my distaste for dealing with “industry.”

You usually need a bony "backstop" for cryo to be effective. The Iovera for the knee is the exception.

 

[deleted993114]

Okay dude. Saw dozens and dozens of times and it was all documented and was supposed to be published. Never was for some reason (I left fellowship and never heard anything about it).

We had a few hundred pts, and neuritis occurred not uncommonly.

Let me add (like I stated in my earlier posts which you didn't read - par for the course when exchanging posts with you)...Neuritis wasn't common in the knee or occipitals.

I detect some latent hostility. It is not good to be so young and to harbor such sentiments- it can be corrosive.

I read your post regarding IOVERA (which infers the knee- that is what it was made for) and you stated you had a high incidence of neuritis.

 

[SommeRiver]

I detect some latent hostility. It is not good to be so young and to harbor such sentiments- it can be corrosive.

I read your post regarding IOVERA (which infers the knee- that is what it was made for) and you stated you had a high incidence of neuritis.

No hostility in a general sense, rather an extreme amount of suspicion of industry.

Neuritis was not common in the knee or occipitals, nor the LFCN, but we still saw it occasionally.

All other nerves we had a zhit-ton of neuritis bc the company was pushing it for every nerve you can imagine.

 

[deleted993114]

Okay dude. Saw dozens and dozens of times and it was all documented and was supposed to be published. Never was for some reason (I left fellowship and never heard anything about it).

We had a few hundred pts, and neuritis occurred not uncommonly.

Let me add (like I stated in my earlier posts which you didn't read - par for the course when exchanging posts with you)...Neuritis wasn't common in the knee or occipitals.

Well...…………………….. in 30 years I have never seen a single case of neuritis with cryo. That has always been the reason for using cryo, rather than rf, for mylenated nerves. Lots of neuritis with rf.

What nerves have I used cryo on? Occipitals, knees, and suprascapular. Does not work for illio-inguinals and iffy for intercostals. Have done supra-orbitals for V1 TICs that has worked pretty well. Never a single case of neuritis.

I too am suspicious when someone says they have seen a lot of neuritis with cryo, which rarely, if ever, occurs. Particularly when we know that cryo results in Wallerian degeneration with an intact epineurium and perineurium. This is the mechanism of cryo which results in essentially no cases of neuritis, as there is regeneration of the nerve fibers. Just physiology- not my opinion.

 

[Crybaby]

What is the duration of relief you guys were seeing?

 

[SommeRiver]

Well...…………………….. in 30 years I have never seen a single case of neuritis with cryo. That has always been the reason for using cryo, rather than rf, for mylenated nerves. Lots of neuritis with rf.

What nerves have I used cryo on? Occipitals, knees, and suprascapular. Does not work for illio-inguinals and iffy for intercostals. Have done supra-orbitals for V1 TICs that has worked pretty well. Never a single case of neuritis.

I too am suspicious when someone says they have seen a lot of neuritis with cryo, which rarely, if ever, occurs. Particularly when we know that cryo results in Wallerian degeneration with an intact epineurium and perineurium. This is the mechanism of cryo which results in essentially no cases of neuritis, as there is regeneration of the nerve fibers. Just physiology- not my opinion.

I can only tell you what our data showed, and cryo isn't cryo isn’t cryo.

I'm talking specific to Iovera, which you've not done for 30 yrs.

The temperature matters, and Iovera won't get you down to the temperatures that were being published in the 80s.

So, it matters which device you're using, and in that regard Iovera simply isn’t that cold.

 

[lonelobo]

No hostility in a general sense, rather an extreme amount of suspicion of industry.

Neuritis was not common in the knee or occipitals, nor the LFCN, but we still saw it occasionally.

All other nerves we had a zhit-ton of neuritis bc the company was pushing it for every nerve you can imagine.

Haven't you only been in practice for a year?

 

[SommeRiver]

Haven't you only been in practice for a year?

No, two weeks.

 

[lonelobo]

No, two weeks.

Legitimate question..... thought I recalled stating you started practice in 2019

 

[SommeRiver]

Legitimate question..... thought I recalled stating you started practice in 2019

3 years out

 

[cowboydoc]

What is the duration of relief you guys were seeing?

3-6 months in non-op knees.

 

[lobelsteve]

3-6 months in non-op knees.

Not as good as genic rf then.

 

[cowboydoc]

Not as good as genic rf then.

If you're consistently getting >6 months doing genicular RF using a technique that is attainable for us mere mortals, you should be publishing and teaching more courses.

 

[lobelsteve]

Have had one doc visit this month for training. Another doc next month.

 

[deleted993114]

Have had one doc visit this month for training. Another doc next month.

Nice of you to allow that. By teaching folks, you are doing God's work and making a difference to ensure that things are done properly. Most would not take the time or effort to do so.

We used to have guys visit my practice in the 90s, but that faded over time.