Oral sedation for RFA

[callmeanesthesia]

I did my first 4 in office RFAs this morning. We don’t have the capability to do IVs in the office, so I gave them all Xanax for sedation. The cervical and lumbar did great but the 2 geniculars had a tough time. Do any of you do them with oral sedation? I’m thinking a few oxycodones might be a better option than xanax but it’s more logistically difficult and more risk of side effects. Can you describe your technique to me (both what you give for sedation and how you do local and insert the needles to keep them comfortable but preserve sensory stim testing)? I have a Stryker RF system and do the ablation under fluoro.

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[No Pain All gain]

Genicular RF hurts. I tell my patients it’s the most uncomfortable procedure I do.


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[pastafan]

Genicular RF hurts. I tell my patients it’s the most uncomfortable procedure I do.


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??? No, genicular RFA is not painful if you use adequate lidocaine 1% as you advance needles. I prescribe 1 Vicodin/Percocet to be taken one hour pre-procedure. No sensory testing, motor only. Keep needle trajectory target immediately adjacent to bone and don't ram needle into femur. I use about 15 ml lidocaine per procedure. N=hundreds

 

[painfree23]

??? No, genicular RFA is not painful if you use adequate lidocaine 1% as you advance needles. I prescribe 1 Vicodin/Percocet to be taken one hour pre-procedure. No sensory testing, motor only. Keep needle trajectory target immediately adjacent to bone and don't ram needle into femur. I use about 15 ml lidocaine per procedure. N=hundreds

Do u keep the knee flat/needles perpendicular and take ap views while advancing? What size rfa needle? I try this but patients always uncomfortable . Even with blocks using 25g spinals

 

[pastafan]

Do u keep the knee flat/needles perpendicular and take ap views while advancing? What size rfa needle? I try this but patients always uncomfortable . Even with blocks using 25g spinals

Leg is on pillow, knee straight but beam is parallel. I stay AP until needle is near target depth then fine tune in lateral view. Switch back to AP and record second image. 20 gauge needle. I anesthetize skin and subQ with 27 gauge 1.5 inch. Then microbore tubing attached to RFA needle and keep injecting local as I advance.

Stopped using 25g spinal for this procedure. Almost all diagnostic blocks performed with 25g 1.5" needle coming in perpendicular to lateral/medial aspect of extremity. Severely obese may need 3.5 spinal. Much less painful than advancing AP with 25g spinal.

 

[callmeanesthesia]

Leg is on pillow, knee straight but beam is parallel. I stay AP until needle is near target depth then fine tune in lateral view. Switch back to AP and record second image. 20 gauge needle. I anesthetize skin and subQ with 27 gauge 1.5 inch. Then microbore tubing attached to RFA needle and keep injecting local as I advance.

Stopped using 25g spinal for this procedure. Almost all diagnostic blocks performed with 25g 1.5" needle coming in perpendicular to lateral/medial aspect of extremity. Severely obese may need 3.5 spinal. Much less painful than advancing AP with 25g spinal.

Do you use fluoro guidance for the diagnostic block? I’ve been wondering about trying it with a 27g from the side. Of course, they’re almost all obese but coming in from lateral with a 25g 3.5” would still be more comfortable.

Still good results without doing sensory testing? My second one did better I think because I dumped a lot more local in deep initially, but didn’t get very good sensory stim I think because it was already numb. The ablation still hurt him quite a bit though even though I let the local through the ablation cannula sit at least a full minute. I’m also using 18g though, to maximize the lesion.

Would you mind sharing a couple AP/lateral fluoro images of your final needle positions so we can see how close it is to bone?

 

[emd123]

I don't routinely give xanax for RFAs although on occasion I do, patient dependent. Most people get through them fine with lots of local. The most important thing for pain control with any type of RFA, I've learned, is waiting a solid two minutes after the lidocaine, before the burn. If you burn right away, they freak, it's torture. If you wait that two minutes for the lidocaine to work, although it feels like 100 minutes, they do infinitely better. Sometimes I'll turn on pulse/dose for 240 (120 sec, mainly as a time keeper, not for therapy) then do my usual burn. I just tell them, "Now we're going to wait 2 minutes for the numbing medication to take effect. The hard part's over. All you have to do it lay hear and stay still," then listen to two minutes of the machine beeping while we talk about how their kids are doing, etc. After that two minutes procedure pain is way, way down.

 

[DOctorJay]

I do the same emd123, I notice if I wait 60 seconds most people do fine but some require more time. If I give another 30-60 seconds and maybe put a little more local in no more complaints.

 

[pastafan]

Do you use fluoro guidance for the diagnostic block? I’ve been wondering about trying it with a 27g from the side. Of course, they’re almost all obese but coming in from lateral with a 25g 3.5” would still be more comfortable.

Still good results without doing sensory testing? My second one did better I think because I dumped a lot more local in deep initially, but didn’t get very good sensory stim I think because it was already numb. The ablation still hurt him quite a bit though even though I let the local through the ablation cannula sit at least a full minute. I’m also using 18g though, to maximize the lesion.

Would you mind sharing a couple AP/lateral fluoro images of your final needle positions so we can see how close it is to bone?

Yes, I use fluoro for diagnostic. I mark skin AP targets then tape a paper clip on side of leg and mark entry point.

I have been very pleased with results. Only a few failures, one got relief with redoing RFA. Worst results 50% relief for 6 months, average 9-12 months 90% plus, and I have some folks out 4 years still pain free.

These are from RFA I just did, inferomedial not perfect but it should do the trick.

 

[callmeanesthesia]

Yes, I use fluoro for diagnostic. I mark skin AP targets then tape a paper clip on side of leg and mark entry point.

I have been very pleased with results. Only a few failures, one got relief with redoing RFA. Worst results 50% relief for 6 months, average 9-12 months 90% plus, and I have some folks out 4 years still pain free.

These are from RFA I just did, inferomedial not perfect but it should do the trick.

Thank you, that’s very helpful!! Those needle positions are so nice and coaxial. I’ll try going a little deeper with the local and not worrying about sensory testing. What do you mean by taping a paper clip to identify entry point? Do you go lateral or just feel the femur and stay AP?

 

[pastafan]

Thank you, that’s very helpful!! Those needle positions are so nice and coaxial. I’ll try going a little deeper with the local and not worrying about sensory testing. What do you mean by taping a paper clip to identify entry point? Do you go lateral or just feel the femur and stay AP?

I use a bent wire with a wood handle a patient made me to mark entry points for my procedures. This is a bit thicker than a paper clip but thinner than a clothes hangar wire. This tool allows me to mark in AP view the level that I am aiming my needle. I then go lateral with paper clip taped to leg to identify midshaft and mark this entry point. The mark is made directly below the AP mark made earlier. Go back to AP, introduce 27 gauge needle while injecting lidocaine. Stop needle immediately prior to hitting os. When in final position inject Marcaine 0.5%.

 

[drusso]

I use a bent wire with a wood handle a patient made me to mark entry points for my procedures. This is a bit thicker than a paper clip but thinner than a clothes hangar wire. This tool allows me to mark in AP view the level that I am aiming my needle. I then go lateral with paper clip taped to leg to identify midshaft and mark this entry point. The mark is made directly below the AP mark made earlier. Go back to AP, introduce 27 gauge needle while injecting lidocaine. Stop needle immediately prior to hitting os. When in final position inject Marcaine 0.5%.

This seems clever. Can you post a picture on a model showing how you mark it out?

 

[pastafan]

This seems clever. Can you post a picture on a model showing how you mark it out?

I have one scheduled later, I'll ask patient about photos. If not, I can post next week.

 

[drusso]

I have one scheduled later, I'll ask patient about photos. If not, I can post next week.

No HIPPA issues if its just an unidentified body part...

 

[pastafan]

O.K., 340 pound patient, needed 5" 25 gauge needles as 3.5" came up short. Thinner knee would demonstrate AP and lateral marks better. Femur dot a bit off, I went in a little caudad. Got off table and did a deep knee bend first time in years.

 

[painfree23]

O.K., 340 pound patient, needed 5" 25 gauge needles as 3.5" came up short. Thinner knee would demonstrate AP and lateral marks better. Femur dot a bit off, I went in a little caudad. Got off table and did a deep knee bend first time in years.

so are you entering with the needles horizontal (to the ground)?

 

[pastafan]

so are you entering with the needles horizontal (to the ground)?

Yes. Usually a 27 g 1.5" needle will reach the target.

 

[painfree23]

Yes. Usually a 27 g 1.5" needle will reach the target.

Oh wow. So the fluorobeam is AP to the flat knee? And you advance in that view?

 

[pastafan]

Oh wow. So the fluorobeam is AP to the flat knee? And you advance in that view?

That's it. I had a patient years ago that I did one knee traditional way and then this approach on the other. Night and day difference in patient comfort.

 

[callmeanesthesia]

That's it. I had a patient years ago that I did one knee traditional way and then this approach on the other. Night and day difference in patient comfort.

Ok, so how do you bill for these? (Sorry to bug you so much but you are so full of good info). Our coders are telling me that 77002 is considered bundled with 64450. Do you just bill 64450 x1?

 

[pastafan]

Ok, so how do you bill for these? (Sorry to bug you so much but you are so full of good info). Our coders are telling me that 77002 is considered bundled with 64450. Do you just bill 64450 x1?

There is a thread in private forum regarding billing.

 

[DODOCSS]

I don't routinely give xanax for RFAs although on occasion I do, patient dependent. Most people get through them fine with lots of local. The most important thing for pain control with any type of RFA, I've learned, is waiting a solid two minutes after the lidocaine, before the burn. If you burn right away, they freak, it's torture. If you wait that two minutes for the lidocaine to work, although it feels like 100 minutes, they do infinitely better. Sometimes I'll turn on pulse/dose for 240 (120 sec, mainly as a time keeper, not for therapy) then do my usual burn. I just tell them, "Now we're going to wait 2 minutes for the numbing medication to take effect. The hard part's over. All you have to do it lay hear and stay still," then listen to two minutes of the machine beeping while we talk about how their kids are doing, etc. After that two minutes procedure pain is way, way down.

agree 100%, i wait 2:30 and 95% of patients feel nothing during burn.

 

[callmeanesthesia]

I use a bent wire with a wood handle a patient made me to mark entry points for my procedures. This is a bit thicker than a paper clip but thinner than a clothes hangar wire. This tool allows me to mark in AP view the level that I am aiming my needle. I then go lateral with paper clip taped to leg to identify midshaft and mark this entry point. The mark is made directly below the AP mark made earlier. Go back to AP, introduce 27 gauge needle while injecting lidocaine. Stop needle immediately prior to hitting os. When in final position inject Marcaine 0.5%.

Tried a modified version of your technique today. Marked the skin AP then went in lateral with a 27g. Definitely less painful - now I’ll just have to see how their results are. Thanks for all the tips!

 

[pastafan]

Tried a modified version of your technique today. Marked the skin AP then went in lateral with a 27g. Definitely less painful - now I’ll just have to see how their results are. Thanks for all the tips!

Glad to hear it went well. Let us know how it turns out.

 

[soccrwz]

Maybe I'm slow but I don't understand why you are marking both AP and lateral. So you put the paperclips on in lateral to mark entry point and have the XR in AP and advance needles to the bone. Why do you mark AP as well? I'm not understanding how you are adjusting your XR and using your AP and lateral points with this different technique? Could you clarify this process as this seems like a useful way to do it

O.K., 340 pound patient, needed 5" 25 gauge needles as 3.5" came up short. Thinner knee would demonstrate AP and lateral marks better. Femur dot a bit off, I went in a little caudad. Got off table and did a deep knee bend first time in years.

 

[pastafan]

Maybe I'm slow but I don't understand why you are marking both AP and lateral. So you put the paperclips on in lateral to mark entry point and have the XR in AP and advance needles to the bone. Why do you mark AP as well? I'm not understanding how you are adjusting your XR and using your AP and lateral points with this different technique? Could you clarify this process as this seems like a useful way to do it

The majority of these patients are quite large. To reach the target with 1.5" needle it needs to be a pretty straight shot from entry point to target. By knowing desired AP lineup for entry point the distance can be minimized. It also seems to be the fastest way to do the procedure.

 

[painfree23]

Maybe I'm slow but I don't understand why you are marking both AP and lateral. So you put the paperclips on in lateral to mark entry point and have the XR in AP and advance needles to the bone. Why do you mark AP as well? I'm not understanding how you are adjusting your XR and using your AP and lateral points with this different technique? Could you clarify this process as this seems like a useful way to do it

I also do not get it.

 

[callmeanesthesia]

Maybe I'm slow but I don't understand why you are marking both AP and lateral. So you put the paperclips on in lateral to mark entry point and have the XR in AP and advance needles to the bone. Why do you mark AP as well? I'm not understanding how you are adjusting your XR and using your AP and lateral points with this different technique? Could you clarify this process as this seems like a useful way to do it

I also do not get it.

I tried it today. It’s like marking the greater trochanter in AP then coming in from the side.
I used a marking pen to mark the inflection points in AP. Then you track that point lateral the the mid shaft (so that when you stick the needle in from the side, it will hit that “point” by going perpendicular to skin/parallel to the table. The knee has to be propped up to see it well in lateral without the other knee in the way.

 

[soccrwz]

So you mark in AP at the phalanges then trace down to lateral switch your XR to lateral mark the entry point and introduce the needles in lateral under AP fluro till you get close to the bones?

 

[painfree23]

So you mark in AP at the phalanges then trace down to lateral switch your XR to lateral mark the entry point and introduce the needles in lateral under AP fluro till you get close to the bones?

But how do u know how far down to “tracedown to lateral” ? ESP in 340 lb ppl ?

 

[callmeanesthesia]

So you mark in AP at the phalanges then trace down to lateral switch your XR to lateral mark the entry point and introduce the needles in lateral under AP fluro till you get close to the bones?

I just marked in AP, went s

But how do u know how far down to “tracedown to lateral” ? ESP in 340 lb ppl ?

Prop up the leg with a few pillows so you can get a good lateral fluoro shot without the shadow of the other knee. Skinny person you can probably just feel the femur and stay AP.

 

[lobelsteve]

Triangulation - Wikipedia

Two known points can reliably deduce a third point known as the target using the process of triangulation.

 

[clubdeac]

Yeah I don't get it either? If I understand correctly you're just anesthetizing the target from lateral. Your RF needles are still entering from above using AP fluoro (vertical trajectory as seen in your initial fluoro pics)

 

[painfree23]

Yeah I don't get it either? If I understand correctly you're just anesthetizing the target from lateral. Your RF needles are still entering from above using AP fluoro (vertical trajectory as seen in your initial fluoro pics)

Same here

 

[pastafan]

I’m sure there is something against this under the Fair Labor Standards act


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Yeah I don't get it either? If I understand correctly you're just anesthetizing the target from lateral. Your RF needles are still entering from above using AP fluoro (vertical trajectory as seen in your initial fluoro pics)

No, let me restate my other post more clearly. I am only using this approach for the diagnostic blocks. For RFA I use a 27 g 1.5" needle and copious local from AP approach. I then continue to inject local through the RFA needle as I advance. No sensory testing, motor only at 2V. The patients get 1 Vicodin/Percocet to take 1 hour pre-RFA and they are not having pain with this combo and not sticking their femur with RFA needle.

 

[Timeoutofmind]

Do you use fluoro guidance for the diagnostic block? I’ve been wondering about trying it with a 27g from the side. Of course, they’re almost all obese but coming in from lateral with a 25g 3.5” would still be more comfortable.

Still good results without doing sensory testing? My second one did better I think because I dumped a lot more local in deep initially, but didn’t get very good sensory stim I think because it was already numb. The ablation still hurt him quite a bit though even though I let the local through the ablation cannula sit at least a full minute. I’m also using 18g though, to maximize the lesion.

Would you mind sharing a couple AP/lateral fluoro images of your final needle positions so we can see how close it is to bone?

My friend told me the other day he quit doing the diagnostic blocks. He just does the RF. Unlike the medial branches, insurance does not require the diagnostic blocks.

At first I thought it was strange but then I thought about it…

I have probably done hundreds of genicular diagnostic blocks, using 1cc local at each site, no sedation. I have maybe have three or four patients that were non responders. Everyone else >70% relief

I use only cooled RF and put my needles in the exact same spot but success is much less pronounced than the diagnostic blocks many times.

Scientifically speaking, the only explanation must be a combination of the placebo factor with the test block, and also that RF just does not work as well as it theoretically should at permanently destroying the nerve for some technical or anatomical reasons.

Anyway, why am I even doing the diagnostic blocks? Just another bill for patients...and doesn’t pay crap for us anymore either...

 

[callmeanesthesia]

My friend told me the other day he quit doing the diagnostic blocks. He just does the RF. Unlike the medial branches, insurance does not require the diagnostic blocks.

At first I thought it was strange but then I thought about it…

I have probably done hundreds of genicular diagnostic blocks, using 1cc local at each site, no sedation. I have maybe have three or four patients that were non responders. Everyone else >70% relief

I use only cooled RF and put my needles in the exact same spot but success is much less pronounced than the diagnostic blocks many times.

Scientifically speaking, the only explanation must be a combination of the placebo factor with the test block, and also that RF just does not work as well as it theoretically should at permanently destroying the nerve for some technical or anatomical reasons.

Anyway, why am I even doing the diagnostic blocks? Just another bill for patients...and doesn’t pay crap for us anymore either...

I was wondering this because I haven’t found insurance policies saying diagnostic block is required... can anyone else verify this? Would be great to be able to skip the diagnostic blocks!

 

[painfree23]

I was wondering this because I haven’t found insurance policies saying diagnostic block is required... can anyone else verify this? Would be great to be able to skip the diagnostic blocks!

I haven’t even found insurance policies saying the RF is covered. What is this billed as?

 

[callmeanesthesia]

I haven’t even found insurance policies saying the RF is covered. What is this billed as?

64640

 

[painfree23]

64640

X 3?

 

[callmeanesthesia]

X 3?

Yes, x3 for knee, x2 for hip (64450 for nerve block is only x1 no matter how many nerves - makes no sense but that’s how it is)