New vs old pain management

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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.......................................

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Based on my own clinical observations, SI joint fusions do not help much. Regarding new exciting treatments for chronic pain - "never be the first or last doc to try a new procedure."
 
Many procedures are not paid by insurance any longer including C2 RF, cryoablation, and SPG injections. As for supine foraminal approach for RF- this was abandoned once the anatomy of the cervical medial branches was defined by Lord, and recognition that the neuroforamen exits far anterior. PRP is a money making scheme that many insurers will not cover, therefore it becomes a cash cow. Use of a single lead in my opinion is far less effective than dual or even triple leads- I used to do single lead placements and would use the posterior plica medialis to internally anchor the lead, but I had to add leads later on a number of patients. The SI joint is difficult to denervate but it is possible using enough burns in 3D. The anterior contribution to the joint from the obturator nerve is a minor contributor to innervation. Clinically, the addition of intraarticular denervation of the anterior part of the joint yielded no better results than posterior only denervation. I did the intraarticular denervation with both HoYAG laser and with bipolar RF.
 
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Many procedures are not paid by insurance any longer including C2 RF, cryoablation, and SPG injections. As for supine foraminal approach for RF- this was abandoned once the anatomy of the cervical medial branches was defined by Lord, and recognition that the neuroforamen exits far anterior. PRP is a money making scheme that many insurers will not cover, therefore it becomes a cash cow. Use of a single lead in my opinion is far less effective than dual or even triple leads- I used to do single lead placements and would use the posterior plica medialis to internally anchor the lead, but I had to add leads later on a number of patients. The SI joint is difficult to denervate but it is possible using enough burns in 3D. The anterior contribution to the joint from the obturator nerve is a minor contributor to innervation. Clinically, the addition of intraarticular denervation of the anterior part of the joint yielded no better results than posterior only denervation. I did the intraarticular denervation with both HoYAG laser and with bipolar RF.

We get reimbursed for rf ganglions and sphenopalantine rfs (not injections, due to the charlatans billing over $1K for squirting local anesthetic into a patient's nose). Cryo is indeed more difficult to get reimbursed.

Supine foraminal cervical rf works far better than the prone position. I have seen MANY failed cervical rf procedures that have been successfully treated with the supine approach, not the other way around. This is also reflected by the experience of those who only perform cervical rf in the prone position- they will lament the efficacy of cervical rf and find lumbar rf to be far more successful. Lumbar rf fails in about 30-35% of the cases. I can't remember the last time I had a failed cervical rf.

I think I have to add an additional stim lead about once a year- it doesn't happen very often.

PRP is indeed a money making scheme. It is shocking how many docs, however, will offer this treatment to unsuspecting patients then try to convince themselves they are doing the right thing.
 
We get reimbursed for rf ganglions and sphenopalantine rfs (not injections, due to the charlatans billing over $1K for squirting local anesthetic into a patient's nose). Cryo is indeed more difficult to get reimbursed.

Supine foraminal cervical rf works far better than the prone position. I have seen MANY failed cervical rf procedures that have been successfully treated with the supine approach, not the other way around. This is also reflected by the experience of those who only perform cervical rf in the prone position- they will lament the efficacy of cervical rf and find lumbar rf to be far more successful. Lumbar rf fails in about 30-35% of the cases. I can't remember the last time I had a failed cervical rf.

I think I have to add an additional stim lead about once a year- it doesn't happen very often.

PRP is indeed a money making scheme. It is shocking how many docs, however, will offer this treatment to unsuspecting patients then try to convince themselves they are doing the right thing.
Do you have a diagram or paper describing the supine foraminal approach? I only learned prone.
 
Do you have a diagram or paper describing the supine foraminal approach? I only learned prone.

Well..................... it is in all the textbooks. It was the way the Sluyter described it and the way that everyone used to do it. The old man, as well as the guys currently in Maastrich, used it exclusively, with the exception of hitting very low levels. Given that 95% of cervical facet pain is covered from C3,C4, C5,C6, it deals better with the areas most commonly implicated in cervical axial pain. It is pretty simple-

1. supine
2. head turned to the opposite side
3. Oblique view to optimize foraminal view (it is the same view you would use for a cervical discogram- kind of an ancient test of questionable utility that is rarely done anymore).
4. placement of the needle at the dorsal and inferior to the foramen
5. check in AP view to confirm in the "waist area"
6. It precludes the need for lateral views (sometimes difficult to see) needed in the posterior approach

It's fast, easy, and has theoretically less risk, as one has a nice "boney backstop" for the needles. There will be many, many images of this approach on the net.

To each his own. However, to those who had previously used the posterior approach and changed, they like the results and ease of this approach better.
 
sluijter is primarily known for pRF that only works in the netherlands
 
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Do you have a diagram or paper describing the supine foraminal approach? I only learned prone.
Original paper? Interruption of pain pathways in the treatment of the cervical syndrome. - PubMed - NCBI

Updated techniques:
We call it the posterolateral approach from a supine position.

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Because of the variability in location of medial branches, a lateral or anteolateral approach should be less effective unless sequential linear lesion strips are created. In order to validate claims of superiority of such approaches, one would need a head to head comparison of techniques. As for billing and receiving payment for SPG RF, it would be intetesting to see which codes are being used.
 
Because of the variability in location of medial branches, a lateral or anteolateral approach should be less effective unless sequential linear lesion strips are created. In order to validate claims of superiority of such approaches, one would need a head to head comparison of techniques. As for billing and receiving payment for SPG RF, it would be intetesting to see which codes are being used.


I understand the anatomy. Should be................................. but in practice appears to be better. To each his own, however, having done a number of these by both approaches, the supine/foraminal approach appears to produce superior results. Additionally, I have had a number of patients who have had the posterior approach performed (elsewhere) and failed, only to improve with the supine/foraminal approach. These, of course, are anecdotal experiences, which are not worth much.

As we know, there is more than one way to skin a cat and one must do what they are most comfortable with.

I had just noted that no one seems to do the supine approach anymore, which I find odd, given that it has worked very well for many years. I have found the posterior approach to take longer and yield inferior results; perhaps there are others who have noted this as well, or have completely the opposite experience.

Just something to ponder.
 
Very good to have the perspectve of your experiences on this board.

are you doing continuous RF of the C2/3 ganglion or pulsed?

I just purchased a full sized cryo machine for the suprascapular nerve (as well as other nerves), but the damn thing is a pain in the ass to run. Anyway, it is not totally extinct yet...it is not reimbursed in my state so cash pay.

what was your technique for PRP 20 years ago? U/s machines at that time were super expensive and u/s guidance was rarely performed. What concentration of PRP where you using at that time (back then everybody was on NSAIDS and high dose steroid injections)? Where you doing diagnostic sonography at that time? Where you instructing patients to get off all NSAIDS and steroids peri and post operatively? I fully agree PRP is no panacea. It did cure my biceps tendonopathy and I'm about to inject my own CMC joint tomorrow with it.

SPG ganglion injections are super helpful I agree.

Do you think cervical RF from a posterior approach is more difficult to perform and therefore not as succesful? in other words, if a posterior approach was performed properly do you find similar results?

Having done DRG stim with traditional dorsal column stimulators and the new DRG stim device, I do find it different in many ways, seems to be much more tolerated by patients.
 
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  • A Modified Posterolateral Approach for Radiofrequency Denervation of the Medial Branch of the ...pdf
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The supine approach to cervical RF has not been taught for decades by NASS, SIS, or ostensibly ASIPP (as far as I am aware), PASSOR (in the past) or several other organizations I have been affiliated with. There is at least one paper showing RF failure using an orthogonal approach to the nerve and this paper is being used by insurance companies to attempt to deny coverage for RF. However, perhaps it depends on what tools one has for the performance of the RF procedure:
Reg Anesth Pain Med. 2017 Jan/Feb;42(1):45-51. doi: 10.1097/AAP.0000000000000506.
Ultrasound-Guided Cervical Medial Branch Radiofrequency Neurotomy: Can Multitined Deployment Cannulae Be the Solution?
Finlayson RJ1, Thonnagith A, Elgueta MF, Perez J, Etheridge JB, Tran DQ.
Author information

Abstract

BACKGROUND AND OBJECTIVES:
Novel multitined cannulae constitute an attractive option for ultrasound-guided radiofrequencyneurotomy of cervical medial branches. The deployment tines increase the cannula's active area, thus altering its lesion size. Despite their theoretical benefits, multitined cannulae have not been assessed. In this bench study, we sought to investigate the lesions produced by a standard 18-gauge and 2 commercially available multitined deployment cannulae. We created ex vivo models to evaluate lesion morphology at a periosteal interface using approach angles likely to be encountered during an ultrasound-guided technique.
METHODS:
Two ex vivo models were assembled using chicken breast tissue and bovine tibia. Monopolar lesions were carried out with 3 commercially available cannulae (18-gauge curved , 17-gauge with laterally deploying tines [N], and 18-gauge with distally deploying tines [T]). All cannulae were positioned at 0, 25, 45, and 90 degrees to the periosteal plane. For each angulation and cannula, 2 series of measurements were recorded to document lesion morphology in the axial and sagittal planes. Data collected included the lesion's surface area, shape, and dimensions relative to the needle tip.
RESULTS:
A total of 240 lesions were analyzed. The performances of S and N cannulae were significantly affected by approach angle, with lesion size decreasing as the angle increased. In contrast, T cannulae displayed similar lesion surface areas at 0 and 90 degrees. The multitined N and T cannulae produced the largest lesions at 0/25 and 90 degrees, respectively. Lesion height varied inversely according to approach angle for S and N cannulae, whereas T cannulae displayed stable characteristics.
CONCLUSIONS:
Unlike their S and N counterparts, T cannulae demonstrated stable lesion characteristics at varying approach angles.
 
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