Medial branch transection

[Drd105]

Surgeon nearby offering this from Arthrex…
Reimbursing $1k and taking a few minutes
Anyone else have this happening nearby? Or anyone here performing it?

Hoping the link works- sending from my phone..

Medial Branch Transection

An endoscopic approach to medial branch nerve transection can lead to relief from pain caused by facet joint arthropathy. Combining 4K visualization with minimally invasive techniques allows surgeons to view and treat the spinal pathology while maintaining surgical precision and reducing...

www.arthrex.com

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[runfastnow]

We got a new spine surgeon that offers it. He likes doing all the new endoscopic stuff.

Been happy to pawn off failed or losing effectiveness RFs (both outside and my own failures) and let him give it a go. The 2-3 he's done so far seem to be happy but too early to tell duration of benefit. Certainly not giving up all my MBB/RF to him though.

 

[soccrwz]

i do this works well on the right pt

 

[Agast]

Anecdotally I’ve heard it works

There is some upcoding involved to make it profitable that will likely bite someone in the boot later

 

[PinchandBurn]

i do this works well on the right pt

64772?

How, much?

 

[jsaul]

Why don't you do it yourself rather then refer to surgeon. It does take more than "a few minutes" though

Elliquence also has an endoscopic neurecromy

 

[bedrock]

Anecdotally I’ve heard it works

There is some upcoding involved to make it profitable that will likely bite someone in the boot later

I thought you said you’d seen after endoscopic medial branch ligation, that the medial branches would still usually regrow, but in 2 years instead of 1?

 

[Agast]

I thought you said you’d seen after endoscopic medial branch ligation, that the medial branches would still usually regrow, but in 2 years instead of 1?

Hm I think you’re thinking of someone else

I’m curious about the potential for scar tissue formation in that area though and what that would mean for the remaining portion of the nerve. There’s a debridement portion that leaves the area looking pretty chewed up.

 

[DOctorJay]

Surgeon nearby offering this from Arthrex…
Reimbursing $1k and taking a few minutes
Anyone else have this happening nearby? Or anyone here performing it?

Hoping the link works- sending from my phone..

Medial Branch Transection

An endoscopic approach to medial branch nerve transection can lead to relief from pain caused by facet joint arthropathy. Combining 4K visualization with minimally invasive techniques allows surgeons to view and treat the spinal pathology while maintaining surgical precision and reducing...

www.arthrex.com

videos were pretty interesting. always wondered what it would look like through the scope. thanks for posting.

 

[SSdoc33]

Hm I think you’re thinking of someone else

I’m curious about the potential for scar tissue formation in that area though and what that would mean for the remaining portion of the nerve. There’s a debridement portion that leaves the area looking pretty chewed up.

yeah, thats the issue. we all have patients that we repeat the RFs on every year or 2. what happens when the pain inevitably comes back? you have the soft tissue scarring that you dont get with a simple needle. i imagine that subsequent transections would be much more difficult

 

[Scottie_Dog]

I thought you said you’d seen after endoscopic medial branch ligation, that the medial branches would still usually regrow, but in 2 years instead of 1?

Haven't read the literature about medial branch ligation lasting longer but it makes sense. Lets say they do grow back after 2 years. If that is the case, why cant we do medial branch RFA on patients that have had fusions? Everyone says the joints don't move anymore so they cant have facetogenic pain. Medial branches are likely destroyed with surgery. But if what you say is true and they grow back after a few years, I would imagine these patients might benefit from RFA. Insurance wont approve it though which has always confused me.

I see a lot of patients that had fusions 10-15 years ago that present with axial/mechanical low back pain and I've been tempted to do MBB->RFA but due to insurance, wouldn't ever get approved. Just curious what you all think

 

[RoloTomassi]

I've heard that most of the time you can't see the MB. If that's the case I don't see the benefit

 

[Ducttape]

there'$ $ignificant odd$ that thi$ procedure ha$ benefit$ that u$ non$pecialized pain doc$ cant appreciate....

 

[soccrwz]

it does not reimburse well considering case cost and set up requirements; the patients do well afterwards though

 

[PinchandBurn]

it does not reimburse well considering case cost and set up requirements; the patients do well afterwards though

Is thr cpt 64772


I have heard tht reiumbursement isn't great for.mcr

 

[soccrwz]

Patients do really well, for axial LBP, but reimbursement isn't blockbuster considering: disposable probe each time. Stryker tower and endoscopic tray are expensive initial capital investments

 

[Snowmen96]

Does anyone have an estimate of what the costs are per procedure in terms of single use supplies, and the cost of the equipment necessary to have the required set-up.

 

[jwheezy]

Patients do really well, for axial LBP, but reimbursement isn't blockbuster considering: disposable probe each time. Stryker tower and endoscopic tray are expensive initial capital investments

is the coding 64772 x however many number you treat? so doing bilateral L4/5 and L5/S1 joint levels would be 64772 x 6?

 

[soccrwz]

tray: 10 blade nondisposable, scope, bullet, obturator, grasper and single use bovie( $600 for trigger flex); I don't use guide needle
Generator (can rent)
Stryker tower/ screen
Gravity bag usually 2Ls of NS, no need for pump and its tubing
OR time maybe 30 minutes for two levels two incision two joints
Sterile draping/gown, etc
simple suture x2 or staples
64772x2

I don't remember the exact breakdown of profit but it isn't stellar, but like I said patients do well after, several studies support this

 

[bedrock]

tray: 10 blade nondisposable, scope, bullet, obturator, grasper and single use bovie( $600 for trigger flex); I don't use guide needle
Generator (can rent)
Stryker tower/ screen
Gravity bag usually 2Ls of NS, no need for pump and its tubing
OR time maybe 30 minutes for two levels two incision two joints
Sterile draping/gown, etc
simple suture x2 or staples
64772x2

I don't remember the exact breakdown of profit but it isn't stellar, but like I said patients do well after, several studies support this

what insurance actually pays for this?

How does the pay per time spent, compared between standard RFA and this procedure?

 

[clubdeac]

tray: 10 blade nondisposable, scope, bullet, obturator, grasper and single use bovie( $600 for trigger flex); I don't use guide needle
Generator (can rent)
Stryker tower/ screen
Gravity bag usually 2Ls of NS, no need for pump and its tubing
OR time maybe 30 minutes for two levels two incision two joints
Sterile draping/gown, etc
simple suture x2 or staples
64772x2

I don't remember the exact breakdown of profit but it isn't stellar, but like I said patients do well after, several studies support this

Wow sounds like a lot of work and expense to just destroy the medial branch. Might as well just do an RFA with a 16g

 

[PinchandBurn]

I also think u can probably do this on a commercial patient as it's not a rfa core ur using. It's transection....totally different cpt. So u don't have to wait 6months I would assume...

 

[soccrwz]

Its permanent, takes 25-30 minutes for years of relief

 

[bedrock]

Its permanent, takes 25-30 minutes for years of relief

Which is cool.


However, no one has answered my questions as to which insurances cover this?
What is the pay per time spent on procedure?
How high are the upfront equipment costs?

Those 3 questions need answers

For example Intracept is cool and permanent except federal insurance pays terrible so I send those to HOPD employed doc, while I do intracept on patients with commercial insurance. The pay per time spent isn't worth it to me to do intracept on patients with federal insurance.

 

[Taus]

Its permanent, takes 25-30 minutes for years of relief

Years as in 3-5+ or 1-2?

 

[SSdoc33]

Its permanent, takes 25-30 minutes for years of relief

permanent?

is there something about this technique which makes the medial branch behave differently than every other peripheral nerve it the body.

FWIW, i dont believe that basiverterbal nerve ablation is "permanent" either

 

[jsaul]

Most of these cases are done on personal injury cases....

Also if you do a good job on that nerve it should be permanent

 

[RoloTomassi]

FWIW, i dont believe that basiverterbal nerve ablation is "permanent" either

Why is that? Physiologically, if a nerve doesn't grow back in 5 years, do you still think it has as chance?

 

[SSdoc33]

Why is that? Physiologically, if a nerve doesn't grow back in 5 years, do you still think it has as chance?

no.

the pathologists from intracept think that the specific physiology inside the vertebral body prevents nerve regrowth. im not sure i buy that. it is a peripheral nerve. why wont it regenerate? they always do. whether they become functional, however, is a different story.

after 18 months, i wouldnt expect any chance at "regrowth". really after 1 year, there is no chance. that being said, "pain" is different than nerve regeneration. we have all had RFs that last 2-3 years. there is not a great explanation for this.

 

[RoloTomassi]

it is a peripheral nerve. why wont it regenerate? they always do.

Fair points but peripheral nerves don't always regrow. We see lots of permanent partial limb numbness/weakness from trauma, surgery, herniations

 

[SSdoc33]

Fair points but peripheral nerves don't always regrow. We see lots of permanent partial limb numbness/weakness from trauma, surgery, herniations

they always regrow. they may not re-innervate or regain function, but they always regrow

 

[hyperalgesia]

they always regrow. they may not re-innervate or regain function, but they always regrow

The only thing I know that stops them is a physical barrier like scar tissue.

Peripheral nerves should regrow pretty fast, whether they are transected or ablated, on the order of 1mm/day. I suspect the main difference with full transection is the broad area of destruction of nerve fibers. I guess the brain has a harder time reestablishing the signal and pain pattern after this compared to the sometimes localized and less reliable RFAs.

 

[SSdoc33]

The only thing I know that stops them is a physical barrier like scar tissue.

Peripheral nerves should regrow pretty fast, whether they are transected or ablated, on the order of 1mm/day. I suspect the main difference with full transection is the broad area of destruction of nerve fibers. I guess the brain has a harder time reestablishing the signal and pain pattern after this compared to the sometimes localized and less reliable RFAs.

that makes sense. although i would assume it is operator-dependent. not all transections, nor ablations are the same. id bet that transections probably do last longer

 

[Ducttape]

how would resection of a medial branch be different than chemical neurolysis of that branch?


that initial post from Arthrex is just advertising.

there are 2 papers in that initial post. the second was a case series and review of lit to discuss whether to discuss endoscopic surgery can be helpful.

the first is a retrospective study that was about endoscopic transforaminal disc resection.

 

[soccrwz]

I took the ASIPP course, and had someone proctor me. I've started doing these over the last 3 years. I've probably done 50-100 of these cases. Performed overwhelmingly on nonPI patients after diminishing benefit from RFA. To my understanding most insurances cover this procedure. We had the tower and the endoscopic trays, you'd have to call the reps joimax, or elliquience, but whatever a strkyer tower cost 50k? A tray to only get the above mentioned items maybe 30K. Upfront cost are high. Patients do extremely well. I've posted the below study note years of relief. Effectively you are avulsing the nerve and its tributaries in a wide area with direct visualization under the scope with higher temperatures with the bipolar. Jason Kapra does these in 15 minutes I believe under single incision. Some use the burring tool, I do not routinely. I get these referrals from some of the spine surgeons in the area.
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Percutaneous radiofrequency ablation of spinal nerves is effective; however, the long-term efficacy is unsatisfactory due to the variation of dorsal medial branch and the recurrence caused by nerve regeneration [10].

Indications for EFRA include (1) chronic lumbar zygapophysial joint pain with a definite diagnosis of controlled MBB and patient has a pronounced surgical aspiration and (2) failure or short-time recurrence after 6-week standard conservative treatment and percutaneous radiofrequency ablation. In the current study, the therapeutic effect of ERFA is superior to percutaneous radiofrequency ablation. The reasons may include direct vision of the variability of the nerve under endoscopy [11], with direct vision under endoscopy, ablation can be more accurate and reduce nerve root injury rate, reducing the incidence of sensory loss or analgesia of skin; nerve regeneration is fairly rare after a long segment ablation and additional radiofrequency denervation on the severed nerve end, the long-term efficacy is better [12]. The sensation and motor tests with radiofrequency needle contribute to determine the accurate position that endoscopic channel placement was immediate and prompt.



In summary, radiofrequency needle guiding ERFA has advantages of more accurate positioning, more thorough denervation, fewer complications, lower risk, and better long-term efficacy up to 5 years post-procedure. The surgery may be used in selected patients. However, this study involves a small sample size and short follow-up time. The long-term efficacy needs further follow-up studies.

Go to:

Endoscopic rhizotomy for chronic lumbar zygapophysial joint pain - PMC

Chronic lumbar zygapophysial joint pain is a common cause of chronic low back pain. Percutaneous radiofrequency ablation (RFA) is one of the effective management options; however, the results from the traditional RFA need to be improved in certain ...

www.ncbi.nlm.nih.gov

 

[lobelsteve]

I took the ASIPP course, and had someone proctor me. I've started doing these over the last 3 years. I've probably done 50-100 of these cases. Performed overwhelmingly on nonPI patients after diminishing benefit from RFA. To my understanding most insurances cover this procedure. We had the tower and the endoscopic trays, you'd have to call the reps joimax, or elliquience, but whatever a strkyer tower cost 50k? A tray to only get the above mentioned items maybe 30K. Upfront cost are high. Patients do extremely well. I've posted the below study note years of relief. Effectively you are avulsing the nerve and its tributaries in a wide area with direct visualization under the scope with higher temperatures with the bipolar. Jason Kapra does these in 15 minutes I believe under single incision. Some use the burring tool, I do not routinely. I get these referrals from some of the spine surgeons in the area.
---
Percutaneous radiofrequency ablation of spinal nerves is effective; however, the long-term efficacy is unsatisfactory due to the variation of dorsal medial branch and the recurrence caused by nerve regeneration [10].

Indications for EFRA include (1) chronic lumbar zygapophysial joint pain with a definite diagnosis of controlled MBB and patient has a pronounced surgical aspiration and (2) failure or short-time recurrence after 6-week standard conservative treatment and percutaneous radiofrequency ablation. In the current study, the therapeutic effect of ERFA is superior to percutaneous radiofrequency ablation. The reasons may include direct vision of the variability of the nerve under endoscopy [11], with direct vision under endoscopy, ablation can be more accurate and reduce nerve root injury rate, reducing the incidence of sensory loss or analgesia of skin; nerve regeneration is fairly rare after a long segment ablation and additional radiofrequency denervation on the severed nerve end, the long-term efficacy is better [12]. The sensation and motor tests with radiofrequency needle contribute to determine the accurate position that endoscopic channel placement was immediate and prompt.



In summary, radiofrequency needle guiding ERFA has advantages of more accurate positioning, more thorough denervation, fewer complications, lower risk, and better long-term efficacy up to 5 years post-procedure. The surgery may be used in selected patients. However, this study involves a small sample size and short follow-up time. The long-term efficacy needs further follow-up studies.

Go to:

Endoscopic rhizotomy for chronic lumbar zygapophysial joint pain - PMC

Chronic lumbar zygapophysial joint pain is a common cause of chronic low back pain. Percutaneous radiofrequency ablation (RFA) is one of the effective management options; however, the results from the traditional RFA need to be improved in certain ...

www.ncbi.nlm.nih.gov

342 to get 60 to meet criteria?
5 years? They studied to 12 months.
Complications less than a needle? No way.

 

[Ducttape]

this is pretty much exactly like ESI vs discectomy.

the study was prospective but obviously not blinded. people including researchers knew what they were getting. that does not so subtly affect results, but given the differences between the studies, it would be extraordinarily difficult to do blinded.

the results should not be surprising. at 3 months, essentially no difference. at 12 months, endoscopic is better. we expect RFA to "wear out" or regenerate or whatever by 6 months.

there was no significant difference in VAS scores between the ERFA group and the control group at 1 day, 1 month, and 3 months (P > 0.05). In the ERFA group, the low back pain showed a lower score at postoperative 6 and 12 months (P < 0.05)

some of the more surprising stats include the fact that the McNab score was high in the endoscopic group (96%) at 12 months, but was also 70% for the RFA group. at 12 months.

complication "rate" was wierd. no discussion on post op infection or bleeding or rash, just analgesia and lack of skin sensation.

so a procedure that takes roughly twice as long lasts longer. it has a role, but not sure it should be the primary treatment. and frankly, having watched some of the educational talks (ie infomercials) given by some of the endoscopic surgeons, it would be prudent to have interventional spine docs do these procedures, primarily on people who fail or have decreasing benefit from RFA.

 

[soccrwz]

I do both, endoscopic is a skill set, beyond RFA. For me with diminishing benefit after RFA or progressively relief. They last longer which is the purpose, they achieve good relief, I have not had to repeat the 100 or so I've done. Clearly more research needs to be done and studied longer. Not alot of people are doing it in the states, more commonly being done in Korea and germany. Bleeding is very small since the incision is pretty tiny. I don't think its being used as a primary treatment for most people, some may but this is probably in the rarity in the states. This is a procedure significantly less complicated than fusions and pedicle screws that could be tackled by well trained doctors that has a place.

 

[hyperalgesia]

I do both, endoscopic is a skill set, beyond RFA. For me with diminishing benefit after RFA or progressively relief. They last longer which is the purpose, they achieve good relief, I have not had to repeat the 100 or so I've done. Clearly more research needs to be done and studied longer. Not alot of people are doing it in the states, more commonly being done in Korea and germany. Bleeding is very small since the incision is pretty tiny. I don't think its being used as a primary treatment for most people, some may but this is probably in the rarity in the states. This is a procedure significantly less complicated than fusions and pedicle screws that could be tackled by well trained doctors that has a place.

Just for clarification, you're not doing transections but RFAs with endoscopic guidance?

 

[soccrwz]

you are resecting the tissue and transecting the nerve under direct visualization via endoscope
Process: incision, dissect tissue manually with obturator get to TP, place channel, place graspers dissect tissue down to bone, uses combo of bi tip bovie and graspers. You often see the medial branch on the screen, cauterize bleeders as needed

 

[hyperalgesia]

you are resecting the tissue and transecting the nerve under direct visualization via endoscope
Process: incision, dissect tissue manually with obturator get to TP, place channel, place graspers dissect tissue down to bone, uses combo of bi tip bovie and graspers. You often see the medial branch on the screen, cauterize bleeders as needed

Ah I see. That's pretty invasive business but would be interesting to see if it deters some fusions...