Meralgia paresthetica

[PGY2]

I have a young 35 year old male s/p lumbar fusion for radicular pain. After surgery, the pain was still there. He came to my clinic and his pain seemed more like meralgia paresthetica. I did an ultrasound guided LFCN block which gave 100% relief for only 2 days. He wants me to do a neurolysis procedure. I was wondering what you guys think the best techinique would be... heat RF or phenol vs. alcohol. Feel free to chime in. Or do you think PNS is a better option?

Thanks!

---

Members don't see this ad.

 

[Ligament]

Repeat it at least once more with local and steroid. If again short term relief, consider pulsed RF if you can get it paid vs. phenol vs. thermal RF. Stim would be far after these.

 

[Ducttape]

yeah, id try a local with steroid. if no benefit greater than 6-7 weeks, talk to him about doing a pulsed RFA.

 

[lobelsteve]

Local and steroid (to reduce inflammation and prolong block).
Pulsed RF with local and steroid as next step.
Botox as next step.
PNS as next step.
Phenol as next step.
Surgical excision as next step.

 

[Jcm800]

Repeat it at least once more with local and steroid. If again short term relief, consider pulsed RF if you can get it paid vs. phenol vs. thermal RF. Stim would be far after these.

i agree, repeat once or even twice more to confirm dx before anything else to fancy...
glad he got the fusion, god forbid he see you BEFORE the fusion...

 

[PinchandBurn]

I have a young 35 year old male s/p lumbar fusion for radicular pain. After surgery, the pain was still there. He came to my clinic and his pain seemed more like meralgia paresthetica. I did an ultrasound guided LFCN block which gave 100% relief for only 2 days. He wants me to do a neurolysis procedure. I was wondering what you guys think the best techinique would be... heat RF or phenol vs. alcohol. Feel free to chime in. Or do you think PNS is a better option?

Thanks!

Good paper:
http://www.painphysicianjournal.com/2009/september/2009;12;881-885.pdf

 

[jsaul]

i agree, repeat once or even twice more to confirm dx before anything else to fancy...
glad he got the fusion, god forbid he see you BEFORE the fusion...

this is the most troubling thing. this patient has MP but goes to a surgeon who tells him that he has a back problem and a fusion will "fix it" overzealous fusers out there along with insurance companies who will authorize that but give you hell for doing a pulse RF or

 

[Ligament]

I agree with steve, I forgot about botox. Problem is getting it paid for, but would try botox after Pulsed RF and before any neurodestructive or PnFS technique.

 

[Gauss]

How many units of Botox do you use?

 

[PinchandBurn]

I agree with steve, I forgot about botox. Problem is getting it paid for, but would try botox after Pulsed RF and before any neurodestructive or PnFS technique.

yes, how many units. And where are you injecting it. Are you also injecting it with local and steroid in the mix? Finally whats teh CPT code you are using?

Good papers on it?

 

[deleted185747]

where are you injecting the botox and why does this help with pain? The only mechanism that I'm aware of with botox is VAMP/SNARE preventing release of Ach at the NM junction. Please enlighten me, I'm a lowly resident.

 

[NEPain]

I don't get it. You're worried about getting paid for botox, but not for PRF????

How are you getting paid for PRF? Seriously. Last I heard it had to be coded as experimental and I don't see anyone paying for that.

 

[Ducttape]

i personally have not had any problems getting paid for neuroablation via pRF.

Botox has been trickier. i have personally not used it for nerve related conditions, though, only myofascial pain syndromes.

 

[101N]

where are you injecting the botox and why does this help with pain? The only mechanism that I'm aware of with botox is VAMP/SNARE preventing release of Ach at the NM junction. Please enlighten me, I'm a lowly resident.

http://onlinelibrary.wiley.com/advanced/search/results

Single CT-Guided Chemodenervation of the Anterior Scalene Muscle with Botulinum Toxin for Neurogenic Thoracic Outlet Syndrome
PAIN MEDICINE
Volume 11, Issue 4, April 2010, Pages: 504–511, Paul J. Christo, Dana K. Christo, Adam J. Carinci and Julie A. Freischlag
Article first published online : 1 MAR 2010, DOI: 10.1111/j.1526-4637.2010.00814.x
AbstractFull Article (HTML)PDF(272K)ReferencesRequest Permissions
The Emerging Use of Botulinum Toxins for the Treatment of Neuropathic Pain
PAIN MEDICINE
Volume 11, Issue 12, December 2010, Pages: 1750–1752, Charles Argoff
Article first published online : 6 DEC 2010, DOI: 10.1111/j.1526-4637.2010.00997.x
AbstractFull Article (HTML)PDF(110K)ReferencesRequest Permissions
Botox A Injection for Pain after Laparoscopic Ventral Hernia: A Case Report
PAIN MEDICINE
Volume 12, Issue 7, July 2011, Pages: 1121–1123, Dustin Smoot, Martin Zielinski, Donald Jenkins and Henry Schiller
Article first published online : 13 JUN 2011, DOI: 10.1111/j.1526-4637.2011.01147.x
AbstractFull Article (HTML)PDF(162K)ReferencesRequest Permissions
Botulinum Neurotoxin-A for Treatment of Refractory Neck Pain: A Randomized, Double-Blind Study
PAIN MEDICINE
Volume 10, Issue 6, September 2009, Pages: 1012–1017, Diana Miller, Diana Richardson, Mahmood Eisa, Rizma Jalees Bajwa and Bahman Jabbari
Article first published online : 6 JUL 2009, DOI: 10.1111/j.1526-4637.2009.00658.x
AbstractFull Article (HTML)PDF(197K)ReferencesRequest Permissions
Treatment of Refractory, Chronic Low Back Pain with Botulinum Neurotoxin A: An Open-Label, Pilot Study
PAIN MEDICINE
Volume 7, Issue 3, May 2006, Pages: 260–264, Bahman Jabbari, John Ney, Afsoun Sichani, William Monacci, Leslie Foster and Marc Difazio
Article first published online : 19 MAY 2006, DOI: 10.1111/j.1526-4637.2006.00147.x
AbstractFull Article (HTML)PDF(81K)ReferencesRequest Permissions
AMERICAN ACADEMY OF PAIN MEDICINE ANNUAL MEETING ABSTRACTS—2009
PAIN MEDICINE
Volume 10, Issue 1, January/February 2009, Pages: 199–278,
Article first published online : 31 JAN 2009, DOI: 10.1111/j.1526-4637.2008.00537.x
AbstractPDF(1267K)Request Permissions
A Case Series of Pulsed Radiofrequency Treatment of Myofascial Trigger Points and Scar Neuromas
PAIN MEDICINE
Volume 10, Issue 6, September 2009, Pages: 1140–1143, Mazin Al Tamimi, Michael H. McCeney and Jason Krutsch
Article first published online : 6 JUL 2009, DOI: 10.1111/j.1526-4637.2009.00646.x
AbstractFull Article (HTML)PDF(117K)ReferencesRequest Permissions
ABSTRACTS
PAIN MEDICINE
Volume 8, Issue 1, January/February 2007, Pages: 88–117,
Article first published online : 23 JAN 2007, DOI: 10.1111/j.1526-4637.2007.00264.x
Corrected by:
A Multicenter Study Evaluating the Efficacy of Spinal Cord Stimulation (SCS) for Axial Low Back Pain
Vol. 10, Issue 2, 428, Article first published online: 5 MAR 2009
AbstractPDF(260K)Request Permissions
Treatment of Refractory Pain with Botulinum Toxins—An Evidence-Based Review
PAIN MEDICINE
Volume 12, Issue 11, November 2011, Pages: 1594–1606, Bahman Jabbari and Duarte Machado
Article first published online : 29 SEP 2011, DOI: 10.1111/j.1526-4637.2011.01245.x
AbstractFull Article (HTML)PDF(271K)ReferencesRequest Permissions
Botulinum Toxin—A Treatment for Migraine? A Systematic Review
PAIN MEDICINE
Volume 7, Issue 5, September/October 2006, Pages: 386–394, Vinod Kumar Gupta
Article first published online : 27 SEP 2006, DOI: 10.1111/j.1526-4637.2006.00216.x
AbstractFull Article (HTML)PDF(87K)ReferencesRequest Permissions
Use of Botulinum Toxin Type A Injection for Neuropathic Pain after Trigeminal Nerve Injury
PAIN MEDICINE
Volume 11, Issue 4, April 2010, Pages: 630–632, Seung Hyun Yoon, Robert L. Merrill, Jong Hoon Choi and Seong Taek Kim
Article first published online : 4 MAR 2010, DOI: 10.1111/j.1526-4637.2010.00801.x
AbstractFull Article (HTML)PDF(181K)ReferencesRequest Permissions
Botulinum Toxin A Improved Burning Pain and Allodynia in Two Patients With Spinal Cord Pathology
PAIN MEDICINE
Volume 4, Issue 2, June 2003, Pages: 206–210, Bahman Jabbari, Neil Maher and Marc P. Difazio
Article first published online : 5 JUN 2003, DOI: 10.1046/j.1526-4637.2003.03013.x
AbstractFull Article (HTML)PDF(107K)ReferencesRequest Permissions
The Use of Botulinum Toxins for the Management of Chronic Pain and Headache: Making the Most of an Evidence-Based Medicine Approach for These Rapidly Evolving Treatments
PAIN MEDICINE
Volume 12, Issue 11, November 2011, Pages: 1581–1582, E. Charles
Article first published online : 14 NOV 2011, DOI: 10.1111/j.1526-4637.2011.01268.x
AbstractFull Article (HTML)PDF(111K)ReferencesRequest Permissions
A Double-Blind, Randomized, Placebo-Controlled Comparison of Botulinum Toxin Type A Injection Sites and Doses in the Prevention of Episodic Migraine
PAIN MEDICINE
Volume 8, Issue 6, September 2007, Pages: 478–485, Joel R. Saper, Ninan T. Mathew, Elizabeth W. Loder, Ronald DeGryse and Amanda M. VanDenburgh, for the BoNTA-009 Study Group
Article first published online : 1 FEB 2007, DOI: 10.1111/j.1526-4637.2006.00168.x
AbstractFull Article (HTML)PDF(136K)ReferencesRequest Permissions
Trigger Point Injections for Chronic Non-Malignant Musculoskeletal Pain: A Systematic Review
PAIN MEDICINE
Volume 10, Issue 1, January/February 2009, Pages: 54–69, N. Ann Scott, Bing Guo, Pamela M. Barton and Robert D. Gerwin
Article first published online : 5 NOV 2008, DOI: 10.1111/j.1526-4637.2008.00526.x
AbstractFull Article (HTML)PDF(157K)ReferencesRequest Permissions
Subcutaneous Injection of Botulinum Toxin A Is Beneficial in Postherpetic Neuralgia
PAIN MEDICINE
Volume 11, Issue 12, December 2010, Pages: 1827–1833, Lizu Xiao, Sean Mackey, Hui Hui, Donglin Xong, Qian Zhang and Deren Zhang
Article first published online : 6 DEC 2010, DOI: 10.1111/j.1526-4637.2010.01003.x
AbstractFull Article (HTML)PDF(473K)ReferencesRequest Permissions
BOTULINUM TOXIN TYPE A (BOTOX®) IN THE TREATMENT OF REFRACTORY MYOFASCIAL CERVICOTHORACIC PAIN: A PROSPECTIVE TRIAL
PAIN MEDICINE
Volume 3, Issue 2, June 2002, Pages: 173–174,
Article first published online : 4 JUL 2002, DOI: 10.1046/j.1526-4637.2002.20245.x
AbstractPDF(180K)Request Permissions
Botulinum Toxin A (Botox) for Treatment of Proximal Myofascial Pain in Complex Regional Pain Syndrome: Two Cases
PAIN MEDICINE
Volume 11, Issue 9, September 2010, Pages: 1415–1418, Delaram Safarpour and Bahman Jabbari
Article first published online : 23 AUG 2010, DOI: 10.1111/j.1526-4637.2010.00929.x
AbstractFull Article (HTML)PDF(131K)ReferencesRequest Permissions
Botulinum Toxin Decreases Hyperalgesia and Inhibits P2X3 Receptor Over-Expression in Sensory Neurons Induced by Ventral Root Transection in Rats
PAIN MEDICINE
Volume 12, Issue 9, September 2011, Pages: 1385–1394, Lizu Xiao, Jianguo Cheng, Juanli Dai and Deren Zhang
Article first published online : 2 AUG 2011, DOI: 10.1111/j.1526-4637.2011.01182.x
AbstractFull Article (HTML)PDF(761K)ReferencesRequest Permissions
AAPM 2010 ANNUAL MEETINGS ABSTRACTS
PAIN MEDICINE
Volume 11, Issue 2, February 2010, Pages: 284–335,
Article first published online : 26 JAN 2010, DOI: 10.1111/j.1526-4637.2009.00781.x
AbstractPDF(571K)Request Permissions

 

[PGY2]

thanks for the replies...

the first injection I did, I used local and 40mg of kenalog. I agree I should repeat the injection once more however pulsed RF is out of the question as patient cant afford to pay for it. Botox (same reason). I am stuck with either heat RF or phenol I think. Between these two evils, which would you pick?

 

[Mister Mxyzptlk]

Also look for simple things, like a beer belly hanging over a low-slung belt line. You can often see the problem by looking at the skin lines made by the clothing across the lower abdomen.

I think some people have abdominal wall spasm either as a primary etiology or a reciprocating process with the nerve pain so Botox is worth a try. Never done it but I wouldn't criticize anyone who did.

 

[Ducttape]

if his insurance wont cover botox or pRF, you might want to find out if his insurance will cover phenol. I had one patient that could not do phenol because of insurance, and she would have had to pay for it herself, roughly $150 if i remember.

personally, i was taught that phenol and alcohol can lead to worse recurrent pain as opposed to RFA, so i would favor RF and i reserve phenol and alcohol for palliative pain patients.

 

[Ligament]

i personally have not had any problems getting paid for neuroablation via pRF.

Botox has been trickier. i have personally not used it for nerve related conditions, though, only myofascial pain syndromes.

Are you coding 64999, the appropriate code for pRF?

I have one plan that will pay for pRF, all others will deny and I therefore charge cash for the procedure.

 

[Ducttape]

The question that is out there is whether that is the correct code for peripheral nerve pRFA. some sites recommend using that code, and that is definitely the code to use for "spinal" pRFA.

On the other hand, some coders recommend using a different code as we are talking about a peripheral nerve, not a paravertebral facet/MBB.

They recommend coding it as 64640 (destruction by neurolytic agent, other peripheral nerve or branch)...

 

[jsaul]

The question that is out there is whether that is the correct code for peripheral nerve pRFA. some sites recommend using that code, and that is definitely the code to use for "spinal" pRFA.

On the other hand, some coders recommend using a different code as we are talking about a peripheral nerve, not a paravertebral facet/MBB.

They recommend coding it as 64640 (destruction by neurolytic agent, other peripheral nerve or branch)...

64640 is not right if using pulse rf for peripheral nerves. If you get audited then you will be penalized.

 

[PinchandBurn]

just continuously RFA (the real deal, thermal...but for only 50 sec or so, however much the patient can tolerate it). Then I would do a few pRFA as well along the nerve (throw that in for free basically).

Tell the patient there is a potential for neuritis. Use lots of steroids (80mg) and lots of local.

 

[Ducttape]

additionally, technically, since it is a pure sensory nerve, you could just thermal RF the lat fem cutaneous nerve.

 

[clubdeac]

Surprised no one's mentioned pulsing the L2,3 DRG. I've gotten 4-6mos relief of LFCN with it

 

[drf]

Surprised no one's mentioned pulsing the L2,3 DRG. I've gotten 4-6mos relief of LFCN with it

This sounds like my algorithm. US and stim guided diagnostic block at the inguinal ligament. Then pRF in same location or pRF L2 and L3 DRG. However, as I've performed more and more LFC nerve blocks I've started to be able to recognize the nerve and trace it proximal over the iliacus in order to treat it before it gets entrapped. I can only do this on thin patients though. Seeing this tiny nerve when it is 4-5 cm deep is very difficult.

 

[Roguelyn]

Also look for simple things, like a beer belly hanging over a low-slung belt line. You can often see the problem by looking at the skin lines made by the clothing across the lower abdomen.

I think some people have abdominal wall spasm either as a primary etiology or a reciprocating process with the nerve pain so Botox is worth a try. Never done it but I wouldn't criticize anyone who did.

Oh my, you can never suggest that the patient's body habitus may have something to do with their pain. But you definitely bring up a good point.

 

[lobelsteve]

Oh my, you can never suggest that the patient's body habitus may have something to do with their pain. But you definitely bring up a good point.

I tell patients they are fat all the time. THey know it and it ain't going to change. With the relaxing of bariatric coverage, more folks are candidates. If they have seen me, they are candidates for a lap band.

Fatiposity syndrome. It's probably the reason we see half our patients.

 

[101N]

Oh my, you can never suggest that the patient's body habitus may have something to do with their pain. But you definitely bring up a good point.

I recently saw an occupationally injured CNA who 'sprained' her back maneuvering a patient around. The CNA's BMI was >> 40 and, her sprain occurred after 3mo on the job, and she was seeing me a year later. She was shaped like a basket ball. MRI was benign and near the end of the visit I said something to the effect of: Well, your sprain has long since healed. Maybe it's your weight? She literally gave me the stink eye and said: NO, I NEVER HURT BEFORE I GOT HURT!

 

[PMR 4 MSK]

I recently saw an occupationally injured CNA who 'sprained' her back maneuvering a patient around. The CNA's BMI was >> 40 and, her sprain occurred after 3mo on the job, and she was seeing me a year later. She was shaped like a basket ball. MRI was benign and near the end of the visit I said something to the effect of: Well, your sprain has long since healed. Maybe it's your weight? She literally gave me the stink eye and said: NO, I NEVER HURT BEFORE I GOT HURT!

MMI, settle the case, then treat on private insurance.

"But Doctor, why do I still hurt?"
I don't know, but weight loss will likely help.

 

[101N]

mmi, settle the case, then treat on private insurance.

"but doctor, why do i still hurt?"
i don't know, but weight loss will likely help.

1+

 

[Ducttape]

Oh my, you can never suggest that the patient's body habitus may have something to do with their pain. But you definitely bring up a good point.

i use my (excessive) weight to my advantage. i rub my fat belly and belch out "you and i both need to lose weight". people usually dont respond negatively to that...

 

[clubdeac]

Hey is everyone using 64450 (other peripheral nerve) to code for this injection? Now that it pays ~$75 was wondering if it would be possible to bill as a femoral nerve block 64447. That's more in line with what you are doing as it is a branch of the femoral nerve. Any thoughts on problems doing this?

 

[bedrock]

I bill as femoral nerve block for years, no problems.

 

[powermd]

Since you have US, I would recommend trying a more extensive hydrodissection. Start low at the usual location lateral to the sartorious where the LFCN is "looking" at at you, then track back up and over the sartorious to the inguinal ligament. I would use at least 15 mL anesthetic with 80 mg for your second attempt. I would not be enthusiastic about thermal RF for a nerve that covers such a wide area of skin. Sounds like a recipe for a very unhappy patient if they have persistent dysthesias worse than before. I like the botox idea. I'm going to start adding cosmetic procedures to my menu this year which will have the added benefit of simply having small quantities around for blocks like this. I'll charge my patients $10-15/U depending on the procedure.

 

[lobelsteve]

Since you have US, I would recommend trying a more extensive hydrodissection. Start low at the usual location lateral to the sartorious where the LFCN is "looking" at at you, then track back up and over the sartorious to the inguinal ligament. I would use at least 15 mL anesthetic with 80 mg for your second attempt. I would not be enthusiastic about thermal RF for a nerve that covers such a wide area of skin. Sounds like a recipe for a very unhappy patient if they have persistent dysthesias worse than before. I like the botox idea. I'm going to start adding cosmetic procedures to my menu this year which will have the added benefit of simply having small quantities around for blocks like this. I'll charge my patients $10-15/U depending on the procedure.

Please post pics of your US for LCFN, but do not label them. I'd like to see if we can get some interrater reliability.

 

[powermd]

Here is a picture of what I'm looking at when I identify a LFCN.

 

[clubdeac]

Here is a picture of what I'm looking at when I identify a LFCN.

Yes that's a perfect pic! Exactly what I see when doing this.

 

[DOctorJay]

Nice cat's eye. Image I look for as well.

 

[epidural man]

Good paper:
http://www.painphysicianjournal.com/2009/september/2009;12;881-885.pdf

another useful article. sorry couldn't get the PDF today.

http://www.ncbi.nlm.nih.gov/pubmed/22151457

Speaking of getting reimbursed for pRF, how successful would the patient be in small claims court against their insurance company? There are so many articles describing the efficacy of pulsed RF, and very few - if any - that say the opposite.

I have had some recent good success with pRF on the LFCN.

 

[nvrsumr]

Here is a picture of what I'm looking at when I identify a LFCN.

That's a heck of a good pic. Most my meralgia patients are fat and likely pannus is causing problems.

 

[powermd]

I just did a PRF for meralgia parenthetica yesterday. This is in a patient who had excellent, but temporary relief with two blocks. The first used 10mL local and steroid, the second used 20 mL. The injections were performed from the "cat's eye" following a superior and medial track over the sartorious to the inguinal ligament. The first block lasted 2 weeks to the day. The second only lasted 2-3 days.

I used a 5 cm 5mm active tip needle, a lateral to medial approach, and came within a 0.46V sensory threshold with the tip in the lateral aspect of the "cat's eye". I used the 8 min PRF protocol published (somewhere) that had good results for radic. The patient will be away for the season, but I'll keep in touch with her to see what happened. I told her the next step would be botox.

Incidentally, I did a botox injection for ON the same day. I located the occip artery lateral to the protuberance, and put 2 mL containing 50U along the surface of the trap fascia in between, consistent with one of the available studies I reviewed. Thus far the patient had partial relief with TON RF, but he wanted to do better.

 

[UNFADABLE858]

How about the conversation about weight loss or stop use of tight belts or clothes if this was an issue before these fancy procedures are done

 

[powermd]

How about the conversation about weight loss or stop use of tight belts or clothes if this was an issue before these fancy procedures are done

Not an issue for this patient smarty pants.

 

[Taus]

With that high volume of local, how do you know you've only blocked the single nerve you want to later cook?

 

[powermd]

With that high volume of local, how do you know you've only blocked the single nerve you want to later cook?

I don't want to cook it.

The point of the volume is to release the nerve from entrapment within the fascia where it lives.

The symptoms combined with the response is good enough for me.

If I were thinking of thermal RF, sure I'd do the block with 1-2 mL local to make sure.

 

[Taus]

I don't want to cook it.

The point of the volume is to release the nerve from entrapment within the fascia where it lives.

The symptoms combined with the response is good enough for me.

If I were thinking of thermal RF, sure I'd do the block with 1-2 mL local to make sure.

Understood, though I was referring above to where you did pulsed after the large volume block/hydrodissection. I am admittedly not very familiar with prf though.

 

[powermd]

Understood, though I was referring above to where you did pulsed after the large volume block/hydrodissection. I am admittedly not very familiar with prf though.

The large volume injections were done on prior occasions. I didn't inject anything before the PRF. Just stick, stim, and go! She said she felt a not-unpleasant pulsating sensation throughout.