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I have noticed over the last several years some differences in training among new fellows emerging-
1. Very few new docs do cervical rf from a supine/foraminal approach. This is the way that the procedure was described initially and how Sluyter and Bogduk did the procedure. It is faster and has a much better effect on higher segments (which makes up the majority of cervical axial pain). I am not sure why the switch has happened, but it is very consistent.
2. Lack of use of cervical rf C2/C3 ganglion rf procedures. We used to do them all the time for cervicogenic headaches. When occipital stim came around, we abandoned them. When occipital stim was killed off, the utility of that procedure has re-emerged, but not many people do them anymore.
3. Sphenopalantine ganglions are rarely performed anymore- a very effective treatment for cluster/orbital headaches
4. Cryo of suprscapular nerves is extinct. It used to be a good treatment for the scapular pain that is a sclerotome for C6/C7 and posterior shoulder pain from failed shoulders.
5. Use of two stimulator leads instead of one. Leads used to be "snaked" to cover both sides. That was quicker and effective, but one rarely sees one lead.
6. Poor surgical technique. Many of us were taught by neurosurgeons, not pain docs, for implants. I have seen peculiar placements of pulse generators and words from reps that stims take 2 hrs plus by many, many new practitioners. We were trained to get in and get the hell out- hemostasis and minimal trespass was the key. I have seen many, many more explants than we ever used to have. I think that fellows in the current programs are probably not getting enough reps with implants.
7. Resurrection of failed techniques- platelet rich plasma was tried over 20 years ago and it failed. Now it is the "new" wonder treatment.
8. Stimulators for back pain. I've got news for you- the innervation of the lumbar disc is not dorsal, it is ventral. You can stim all day long from a dorsal placement and not stimulate the nerves that provide the innervation for the axial spine.
9. Nerve root stim vs DRG stim. "DRG stim" is just a resurrection of "root stim". From an anatomic standpoint, there is no way in hell that you can stim the DRG and not the root, or vice versa. Root stim had been done for a long period of time for mono-neuropathies and or chest wall pain.
10. Infatuation with the SI joint. While SI joint pathology does exist, most pain over the SI joint is referred from the back. However, I have not seen so many SI joint injections as in the last ten years. The SI joint is also very difficult to dennervate, as its innervation is both ventral and dorsal- one can only access dorsally. I'm not saying that it is useless, but just that the efficacy is not all it is cracked up to be, simply due to the inability to dennervate the entire joint and the fact that most of the time it is just a sclerotome from the back, not a primary source of pathology. SI joint fusions were also abandoned, as those patients all developed severe osteo-arthritis of the hips. Everything old is new again and surgeons are doing these again. Watch for the patients who have the "gangsta rappa" gaits.
Just some observations.......................................
1. Very few new docs do cervical rf from a supine/foraminal approach. This is the way that the procedure was described initially and how Sluyter and Bogduk did the procedure. It is faster and has a much better effect on higher segments (which makes up the majority of cervical axial pain). I am not sure why the switch has happened, but it is very consistent.
2. Lack of use of cervical rf C2/C3 ganglion rf procedures. We used to do them all the time for cervicogenic headaches. When occipital stim came around, we abandoned them. When occipital stim was killed off, the utility of that procedure has re-emerged, but not many people do them anymore.
3. Sphenopalantine ganglions are rarely performed anymore- a very effective treatment for cluster/orbital headaches
4. Cryo of suprscapular nerves is extinct. It used to be a good treatment for the scapular pain that is a sclerotome for C6/C7 and posterior shoulder pain from failed shoulders.
5. Use of two stimulator leads instead of one. Leads used to be "snaked" to cover both sides. That was quicker and effective, but one rarely sees one lead.
6. Poor surgical technique. Many of us were taught by neurosurgeons, not pain docs, for implants. I have seen peculiar placements of pulse generators and words from reps that stims take 2 hrs plus by many, many new practitioners. We were trained to get in and get the hell out- hemostasis and minimal trespass was the key. I have seen many, many more explants than we ever used to have. I think that fellows in the current programs are probably not getting enough reps with implants.
7. Resurrection of failed techniques- platelet rich plasma was tried over 20 years ago and it failed. Now it is the "new" wonder treatment.
8. Stimulators for back pain. I've got news for you- the innervation of the lumbar disc is not dorsal, it is ventral. You can stim all day long from a dorsal placement and not stimulate the nerves that provide the innervation for the axial spine.
9. Nerve root stim vs DRG stim. "DRG stim" is just a resurrection of "root stim". From an anatomic standpoint, there is no way in hell that you can stim the DRG and not the root, or vice versa. Root stim had been done for a long period of time for mono-neuropathies and or chest wall pain.
10. Infatuation with the SI joint. While SI joint pathology does exist, most pain over the SI joint is referred from the back. However, I have not seen so many SI joint injections as in the last ten years. The SI joint is also very difficult to dennervate, as its innervation is both ventral and dorsal- one can only access dorsally. I'm not saying that it is useless, but just that the efficacy is not all it is cracked up to be, simply due to the inability to dennervate the entire joint and the fact that most of the time it is just a sclerotome from the back, not a primary source of pathology. SI joint fusions were also abandoned, as those patients all developed severe osteo-arthritis of the hips. Everything old is new again and surgeons are doing these again. Watch for the patients who have the "gangsta rappa" gaits.
Just some observations.......................................