Timeoutofmind

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Wanted to get your 2 cents people

My only thought is that the inferio-medial needle is a little inferior, but then again the trajectory I took was a little inferior to superior as you can see from the lateral so the final position seems OK

I dont know.

It is just weird when patients have no relief at all after a genicular. I understand there is a central component to chronic pain states, but that is more a sensitization to a peripheral stimulus, not just some purely centralized process.

Maybe its just that this flouro procedure is not that accurate and US is needed at times due to variable anatomy?

Thanks

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lobelsteve

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Placement looks fine.
Superior patellar might not be necessary.

How long since RF?
How much relief for how long after block?
Volume of block?
 
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Timeoutofmind

Timeoutofmind

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Placement looks fine.
Superior patellar might not be necessary.

How long since RF?
How much relief for how long after block?
Volume of block?
Not RF, that's just the diagnostic blocks...from which he got zero relief.

Volume of 1cc

I just don't get it...I mean what is the pain generator that is being missed if the entire joint is blocked???



Thanks for your time and expertise Steve.

Cuz if no one has any other good ideas it's DRG for him...
 
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lobelsteve

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Should have helped.
Can we get some history and HPI, pqrst, etc.

If no infection or loosening, nothing sudomotor, no spinal mojo, tben trial is reasonable.
 

DOctorJay

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Agree with above. Check out the hip and make sure it isn't coming from there. Check spine as well. If nothing on MRI and isn't anything else agree with DRG.


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BobBarker

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Maybe he just likes the norco?
Looks like a nicely done arthroplasty...
 
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epidural man

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I get much more success when I add saphenous/femoral in the adductor canal for diagnostic block and pulsed for treatment. Obturator may contribute to the pain, as well as infrapatellar branch - and of course branches from the femoral. All these pass through the adductor canal.
 
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Timeoutofmind

Timeoutofmind

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Maybe he just likes the norco?
Looks like a nicely done arthroplasty...
Great thoughts all. Thanks much

Not drug seeking, as he is on a non-optional wean which we both agreed to up front and he is doing well with.

I really dont think the pain is referred. Basically his entire replaced knee is just super stiff with poor ROM and generally diffusely painful. No signs of infection, CRPS, radicular pain, etc. How do you assess for loosening by the way, other than plain films? And it brings up an interesting clinical question that you guys raise...what are the remaining pain generators in the knee after a TKA? I usually think about IT band, pes anserine bursa, possibly bakers cyst (anyone ever drained/injected one in a post TKA pt?). Anything else you guys look out for?

He is an unusual case. He had a total shoulder and knee and both joints with the same type of picture. The orthopod was baffled and will not replace his BL hips even though they are also shot! Basically said maybe he has some hyper scarring type syndrome and he has not really seen anything quite like it. He tried hard with a bunch of PT after I blocked his suprascapular for instance and nothing. I did thermal RF of suprascapular and his shoulder is 100% better. He is so happy about it (but I am a little worried and would not have done it in retrospect and am hoping deafferentation pain does not pop up down the road).

Anyway, I was going to DRG at L4 for the knee and while I was in there slip BL leads in at L1 for the hips. I know it is not the most solid indication but I wont be able to RF his fem/obturator articular branches with the DRG in anyway and his knee bothers him a lot more than his hips. And if I denervate his hips up front and it wears off after the knee DRG lead is placed I also am in the same boat. So it seemed like the best bet for durable relief.

Thoughts?
 

bedrock

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If Ortho second opinion has been completed, and recommends no further surgery, you've imagined and examined both the hip and lumbar spine, and neither is a likely source or referred pain, and the patient isn't crazy/addicted, then likely sensitization has taken place and i would proceed to a DRG or Nevro SCS.
 
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Timeoutofmind

Timeoutofmind

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I get much more success when I add saphenous/femoral in the adductor canal for diagnostic block and pulsed for treatment. Obturator may contribute to the pain, as well as infrapatellar branch - and of course branches from the femoral. All these pass through the adductor canal.
You do adductor canal block + geniculars at the same time?
 

lobelsteve

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No procedures during forced wean.

Start cbt.

Wait until 12 weeks after stable new dosing. Then repeat block.
 
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Ducttape

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Great thoughts all. Thanks much

Not drug seeking, as he is on a non-optional wean which we both agreed to up front and he is doing well with.

I really dont think the pain is referred. Basically his entire replaced knee is just super stiff with poor ROM and generally diffusely painful. No signs of infection, CRPS, radicular pain, etc. How do you assess for loosening by the way, other than plain films? And it brings up an interesting clinical question that you guys raise...what are the remaining pain generators in the knee after a TKA? I usually think about IT band, pes anserine bursa, possibly bakers cyst (anyone ever drained/injected one in a post TKA pt?). Anything else you guys look out for?

He is an unusual case. He had a total shoulder and knee and both joints with the same type of picture. The orthopod was baffled and will not replace his BL hips even though they are also shot! Basically said maybe he has some hyper scarring type syndrome and he has not really seen anything quite like it. He tried hard with a bunch of PT after I blocked his suprascapular for instance and nothing. I did thermal RF of suprascapular and his shoulder is 100% better. He is so happy about it (but I am a little worried and would not have done it in retrospect and am hoping deafferentation pain does not pop up down the road).

Anyway, I was going to DRG at L4 for the knee and while I was in there slip BL leads in at L1 for the hips. I know it is not the most solid indication but I wont be able to RF his fem/obturator articular branches with the DRG in anyway and his knee bothers him a lot more than his hips. And if I denervate his hips up front and it wears off after the knee DRG lead is placed I also am in the same boat. So it seemed like the best bet for durable relief.

Thoughts?
you don't like to admit it, but central sensitization (in the CNS, not spinal cord) is the one component you may be missing. im sitting back and reviewing what you wrote:
multiple joints, multiple surgeries, hips next, multiple injections with only the shoulder better after going nuclear on it, on a non-optional wean (meaning he was on a high dose).

you can stick needles everywhere else, I doubt anything will be that effective. he wont like it, but cbt is best option. reconsider injections after he has been stable off opioids for a while.

of course, your bank account will suffer. so never mind.
 
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Timeoutofmind

Timeoutofmind

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you don't like to admit it, but central sensitization (in the CNS, not spinal cord) is the one component you may be missing. im sitting back and reviewing what you wrote:
multiple joints, multiple surgeries, hips next, multiple injections with only the shoulder better after going nuclear on it, on a non-optional wean (meaning he was on a high dose).

you can stick needles everywhere else, I doubt anything will be that effective. he wont like it, but cbt is best option. reconsider injections after he has been stable off opioids for a while.

of course, your bank account will suffer. so never mind.
Good thoughts.

Seems confusing to me why he would have 100% relief with suprascapular nerve block and 0% relief with genicular nerve block if the pain is all central? And also the suprascapular RF helped 100%. So I feel the picture is different here than one of just some centralized patient, with all do respect.

And also, classically, we do multimodal therapy, including injections, during the weaning process to give people options/relief with their pain while we wean them...but I do see the other side of the coin you are pointing out here. Its a tough case.

I have seen one or two other patients with zero relief from genicular NB, but they are usually just the kind of people you could predict are not going to do well with anything
 

Orin

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Basically his entire replaced knee is just super stiff with poor ROM and generally diffusely painful.
He is an unusual case. He had a total shoulder and knee and both joints with the same type of picture.
just the kind of people you could predict are not going to do well with anything
I think you should step back and re-read the chart without thinking of your interactions with that patient.
Sounds like central sensitization with pain avoidance behaviors and likely an element of a pain processing disorder.
Just because it's a guy with arthritis, doesn't mean he can't have something like fibro. Does he have other diagnoses in that cluster like TMJ, migraines, IBS, etc?

I'd agree with CBT. I'd consider Duloxetine as it has an FDA indication for Chronic Musculoskeletal Pain, but I also agree $tim'$ a thing you could try too.

The problem with stim is you're going to have to keep stimming different parts as this pain moves around, and you know I bet his IPG site will start hurting with the size of the DRG battery, and then you're still RFing the shoulder infrequently, etc.
 
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epidural man

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You do adductor canal block + geniculars at the same time?
Depends on where they describe most of the paint so not all the time. Sometimes I do both.
 

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Great thoughts all. Thanks much

Not drug seeking, as he is on a non-optional wean which we both agreed to up front and he is doing well with.

I really dont think the pain is referred. Basically his entire replaced knee is just super stiff with poor ROM and generally diffusely painful. No signs of infection, CRPS, radicular pain, etc. How do you assess for loosening by the way, other than plain films? And it brings up an interesting clinical question that you guys raise...what are the remaining pain generators in the knee after a TKA? I usually think about IT band, pes anserine bursa, possibly bakers cyst (anyone ever drained/injected one in a post TKA pt?). Anything else you guys look out for?

He is an unusual case. He had a total shoulder and knee and both joints with the same type of picture. The orthopod was baffled and will not replace his BL hips even though they are also shot! Basically said maybe he has some hyper scarring type syndrome and he has not really seen anything quite like it. He tried hard with a bunch of PT after I blocked his suprascapular for instance and nothing. I did thermal RF of suprascapular and his shoulder is 100% better. He is so happy about it (but I am a little worried and would not have done it in retrospect and am hoping deafferentation pain does not pop up down the road).

Anyway, I was going to DRG at L4 for the knee and while I was in there slip BL leads in at L1 for the hips. I know it is not the most solid indication but I wont be able to RF his fem/obturator articular branches with the DRG in anyway and his knee bothers him a lot more than his hips. And if I denervate his hips up front and it wears off after the knee DRG lead is placed I also am in the same boat. So it seemed like the best bet for durable relief.

Thoughts?
Bone scan to assess for loosening not seen on plain films, CBC, esr, crp. I'm assuming if ortho saw them they would have ordered it already. Although I will tell you that depending on the ortho, they may not order that stuff if they just plain don't want to be bottered or the patient is crazy or they just want you to take over and manage it.
 

Ligament

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After doing genicular blocks under ultrasound, I'm quite certain that the traditional superolateral and superomedial needle positions when guided under fluoroscopy place the needle in the suprapatellar pouch very frequently. Which means you are getting an intra-articular block frequently, which means you no longer have a diagnostic genicular block...thoughts?
 

Tapspatellas

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After doing genicular blocks under ultrasound, I'm quite certain that the traditional superolateral and superomedial needle positions when guided under fluoroscopy place the needle in the suprapatellar pouch very frequently. Which means you are getting an intra-articular block frequently, which means you no longer have a diagnostic genicular block...thoughts?
Interesting. If you have any pics of this I'd love to see, or try and post one when it comes up.
 

clubdeac

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After doing genicular blocks under ultrasound, I'm quite certain that the traditional superolateral and superomedial needle positions when guided under fluoroscopy place the needle in the suprapatellar pouch very frequently. Which means you are getting an intra-articular block frequently, which means you no longer have a diagnostic genicular block...thoughts?
You think you're hitting the pouch on both your medial and lateral condylar block locations? Is that what you're saying? I really hope the pouch doesn't extend that far lateral!!
 

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I had a lady whose knee was replaced in 2008 and had ongoing pain. Genicular nerve block did nothing. On re-examination I found multiple trigger points and did some needling with local. Pain 98% improved and lasting on her 1 month follow up. A lot of times patients can't tell the difference between pain that's within the knee and around the knee.
 

bedrock

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I had a lady whose knee was replaced in 2008 and had ongoing pain. Genicular nerve block did nothing. On re-examination I found multiple trigger points and did some needling with local. Pain 98% improved and lasting on her 1 month follow up. A lot of times patients can't tell the difference between pain that's within the knee and around the knee.
good point
 

Ligament

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You think you're hitting the pouch on both your medial and lateral condylar block locations? Is that what you're saying? I really hope the pouch doesn't extend that far lateral!!
It often does, especially in a very arthritic, inflammed knee. I once caused a very big hemearthrosis from genicular RFA. How could I get a hemearthrosis if the RF needle did not enter the pouch at some time?
 

DOctorJay

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I got some joint fluid through the cannula on the last one I did
 

Ligament

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I'm not knocking the procedure, I like it and its helped a lot of my patients. Just saying I dont think we understand all aspects of it.
 

melancholy

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Does this guy have a hypermobility syndrome or ligament laxity? Some of these patients seem to have genetic predisposition for local anesthetic resistance. Even sometimes 2% lidocaine won't provide a sufficient local anesthetic response. These patients tend to have difficulties at the dentist. They need more shots, more time, or more intensive approaches such as oral sedatives, nitrous, etc. even just for simple procedures. I've had one or two patients who don't get any sort of local anesthetic response from anything..... so they just do all dental procedures without bothering with the shots. Ouch. I recall also reading about patients with connective tissue disorders that may cause hypermobility may also be predisposed to developing increased scar tissue. Some of them have pain issues growing up that are unexplained, subluxations, sports injuries, etc. Ones that are active in sports growing up may have MSK issues earlier on in life. They may get more surgeries than your average folk, take longer to recovery from surgeries or physical trauma, etc.

Just some food for thought. If the guy gets numb when you inject something more superficial... well, you can ignore the above, lol.
 
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