Phenol for facet denerv.

[specepic]

---

Members do not see this ad.

I have a pt with facet OA and + response to MBB and FJI. Relief is 1-2 months. She has a stim so no RFA. Anyone here use phenol on the medial branch, if so what concentration/volume. I would assume you would place the needle a bit below the SAP/TP junction to help avoid anterior spread/spill.

 

[SSdoc33]

She has a stim so no RFA.

come again?

 

[specepic]

She has a stim so no RFA.

come again?

According to St. Jude and BS it is not rec'd to do RFA in a pt with a spinal cord stim (I did not check with medtronic b/c I do not like their stuff). I understand some folks might do it but it is not rec'd. Do you have written evidence otherwise?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3030043/


email #1:
"I called Tech support andthe said that a Radio Frequency Ablation should not be done on a patient withand SCS implant.

Thank you for checkingwith up first.



Jennifer



Jennifer Poveromo

Territory Manager

Neuromodulation

Boston Scientific

(c) 617 797-8299

(fax) 857 233-5091

www.bostonscientific.com

www.controlyourpain.com
www.raceagainstpain.com"

email #2:
"
We do NOTrecommend the use of Radio Frequency Ablation with an implanted SCS patient.



It could cause a jolt to the patientor damage the IPG. We treat RF like using mono electrocautery. Wedo not recommend using either. If for some reason you decide to go aheadwith it, make sure it is set at the lowest possible clinical settings.



Thanks.



Dave"

 

[pmrmd]

I have used 1cc 6% phenol + 1cc dex (4/cc) with injection over the facet joint, not necessarily at the area of the TP/SAP junction. trying to get the smallest nerves coming off the joint. N = maybe 10. Some results were great some so/so. Still better than nothing when RF can't be done b/c of hardware or osteophyte.

 

[powermd]

I have a pt with facet OA and + response to MBB and FJI. Relief is 1-2 months. She has a stim so no RFA. Anyone here use phenol on the medial branch, if so what concentration/volume. I would assume you would place the needle a bit below the SAP/TP junction to help avoid anterior spread/spill.

A different pain doc in my community does this at a facility where he doesn't have access to an RF box. He uses 0.3 mL phenol at the SAP/TP, not sure what concentration. No recognized complications so far.

 

[bedrock]

She has a stim so no RFA.

According to St. Jude and BS it is not rec'd to do RFA in a pt with a spinal cord stim (I did not check with medtronic b/c I do not like their stuff). I understand some folks might do it but it is not rec'd. Do you have written evidence otherwise?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3030043/


email #1:
"I called Tech support andthe said that a Radio Frequency Ablation should not be done on a patient withand SCS implant.

Thank you for checkingwith up first.



Jennifer



Jennifer Poveromo

Territory Manager

Neuromodulation

Boston Scientific

(c) 617 797-8299

(fax) 857 233-5091

www.bostonscientific.com

www.controlyourpain.com
www.raceagainstpain.com"

email #2:
"
We do NOTrecommend the use of Radio Frequency Ablation with an implanted SCS patient.



It could cause a jolt to the patientor damage the IPG. We treat RF like using mono electrocautery. Wedo not recommend using either. If for some reason you decide to go aheadwith it, make sure it is set at the lowest possible clinical settings.



Thanks.



Dave"

Simply them covering their ass and passing any potential blame on to you...

 

[specepic]

Two issues:

- is RFA safe with SCS? if someone here had data beyond anecdote that I could take to a court then great, o/w the only thing I have in writing says don't do it

- The original question: dose and concentration for phenol? any other takers?

 

[emd123]

0.7 ml per level of phenol for MBB, at SAP/TP junction, for one doc I know that does this. I can't recall the concentration.

 

[clubdeac]

Is this post any different than my post about alcohol neurolysis of the medial branches? Everyone seemed adamantly opposed to that... phenol any better??

 

[Ligament]

Where are the stim leads located?

Worst case with Phenol: cord lysis. No control, no warning.

Worst case with RFA: dorsal cord injury. Almost certainly to be very mild if occur at all. You will have warning.

You could do an endoscopic medial branch transection and avoid both of the above...

 

[ghost dog]

I have a pt with facet OA and + response to MBB and FJI. Relief is 1-2 months. She has a stim so no RFA. Anyone here use phenol on the medial branch, if so what concentration/volume. I would assume you would place the needle a bit below the SAP/TP junction to help avoid anterior spread/spill.

What are your thoughts about using phenol with occipital headaches / in place of RFA ( i.e. no access to RFA ) ?

In this typical case, no stim.

 

[LongSnow]

Had a patient with an AICD, and on chronic anti-coagulation. Very prone to clots, had thrown emboli when off anti-coagulation for short periods of time.

She had received diagnostically positive MBB's by a previous provider - I reviewed fluoro images, technique descriptions, drugs used, etc - legit positive response. Very good candidate for RFL.

So - option 1: Hold coumadin, Give lovenox and hold prior to procedure per ASRA guidelings, deal w/ AICD (hassle), lovenox again while coumadin is restarted and INR becomes therapeutic.

option 2 - Phenol 6% 0.3ml at SAP/TP 25 G Quinke.

Did option 2 - no bleeding - easy, effective. Seems less risky in the grand scheme of things. told patient it was an old technique not used very much anymore, and why we were doing it, etc.

Good technique to know.

 

[painstop]

Your option 1 is based on the assumption that anticoagulants must be held prior to RFA. While I agree this is true for epidurals, I have performed hundreds of RFAs while on anticoagulants without any issues and I do not believe there are any published guidelines on this matter (I actually think if you get a veinous bleeder the RF heat will coagulate the vessel but that is me just pondering random thoughts). I know there are some on here that advocate holding anticoagulants. I personally would choose continuing anticoagulants as opposed to the uncontrollable nature of phenol (although I'm sure you are safe as well with 0.3 mL). Choose your risk. Obviously the AICD issue is completely different but I am talking about the anticoagulant issue.

Had a patient with an AICD, and on chronic anti-coagulation. Very prone to clots, had thrown emboli when off anti-coagulation for short periods of time.

She had received diagnostically positive MBB's by a previous provider - I reviewed fluoro images, technique descriptions, drugs used, etc - legit positive response. Very good candidate for RFL.

So - option 1: Hold coumadin, Give lovenox and hold prior to procedure per ASRA guidelings, deal w/ AICD (hassle), lovenox again while coumadin is restarted and INR becomes therapeutic.

option 2 - Phenol 6% 0.3ml at SAP/TP 25 G Quinke.

Did option 2 - no bleeding - easy, effective. Seems less risky in the grand scheme of things. told patient it was an old technique not used very much anymore, and why we were doing it, etc.

Good technique to know.

 

[LongSnow]

interesting - I was not so much worried about the bleeding at the site of the burn at the dorsal elements of the spine but along the needle tract and the resultant hematoma. Set up for infection in a edematous, low flow, ASA 4 patient. Regular patients seldom bleed and bruise from there RF injection sites, but it can occur.

Do you use a smaller RF needle when you perform the procedure on a anticoagulated patient?

 

[Ducttape]

Had a patient with an AICD, and on chronic anti-coagulation. Very prone to clots, had thrown emboli when off anti-coagulation for short periods of time.

She had received diagnostically positive MBB's by a previous provider - I reviewed fluoro images, technique descriptions, drugs used, etc - legit positive response. Very good candidate for RFL.

So - option 1: Hold coumadin, Give lovenox and hold prior to procedure per ASRA guidelings, deal w/ AICD (hassle), lovenox again while coumadin is restarted and INR becomes therapeutic.

option 2 - Phenol 6% 0.3ml at SAP/TP 25 G Quinke.

Did option 2 - no bleeding - easy, effective. Seems less risky in the grand scheme of things. told patient it was an old technique not used very much anymore, and why we were doing it, etc.

Good technique to know.

since you are quoting ASRA...

just be aware what ASA and ASRA have to say...

"Single Modality Interventions Ablative techniques (other treatment modalities should be attempted before consideration of the use of ablative techniques):

• Chemical denervation (e.g., alcohol, phenol, or high concentration local anesthetics) should not be used in the routine care of patients with chronic noncancer pain."

whether you consider that patient to be "routine care" is of course your professional opinion...

 

[Aether2000]

1. Bounce this back to the company and ask what evidence they have that RF in SCS patients is unsafe....clinical evidence???
2. You may safely perform RF two ways in patients with SCS or pacemakers or even AICDs: a) use a bipolar single electrode b) use two needles placed at each end of the medial branch using one as your ground (need an adapter for your RF machine for this). With either system there will be no distant RF, thermal, or magnetic induction fields produced to interfere with these implantable devices. Yes I have done these....

 

[onewithpain]

A few thoughts;
Noridian will not cover chemical denervation, so it will need to be billed as a nerve block if you are under their jurisdiction.

My medtronic rep echoed the official word about no RFAs after SCS, but said unofficially just make sure its turned off while you work and don't needle the leads. Whenever I have checked with a cardiologist about RFA with pacemaker they say no problem. I've never asked about defib.

Phenol is thought to be selective based on concentration, so ~4% will kill the unmyelinated C-fibers. I have seen evidence of this on intercostals for PHN where the patient still has light touch sensation but the pain is gone. Phenol is manufactured at ~89% and was used in the Nazi death camps, but is more commonly used at low concentraion in chloraseptic throat spray. So if you buy 10% and cut it 50/50 with contrast then you cana inject with live fluoro and if it's going where you don't want it then stop. A little 5% diluted with body fluids is unlikely to do harm, but I'm very leary of letting it go vascular. I do a fair number of US guided phenol peripheral nerve blocks for continued pain after joint replacement the patients and orthos are very grateful.

 

[LongSnow]

since you are quoting ASRA...

just be aware what ASA and ASRA have to say...

"Single Modality Interventions Ablative techniques (other treatment modalities should be attempted before consideration of the use of ablative techniques):

• Chemical denervation (e.g., alcohol, phenol, or high concentration local anesthetics) should not be used in the routine care of patients with chronic noncancer pain."

whether you consider that patient to be "routine care" is of course your professional opinion...

So - presumably the gist is that blood that does not coagulate will carry the phenol to places unintended -

add if any other problematic mechanisms come to mind -

i presume a cold lesion generator would be ideal - creating cold via the Joule-Thomson effect - anyone know of any contra-indications of cold lesioning in an anticoagulated patient with and ACID?

 

[drf]

A few thoughts;
Noridian will not cover chemical denervation, so it will need to be billed as a nerve block if you are under their jurisdiction.

My medtronic rep echoed the official word about no RFAs after SCS, but said unofficially just make sure its turned off while you work and don't needle the leads. Whenever I have checked with a cardiologist about RFA with pacemaker they say no problem. I've never asked about defib.

Phenol is thought to be selective based on concentration, so ~4% will kill the unmyelinated C-fibers. I have seen evidence of this on intercostals for PHN where the patient still has light touch sensation but the pain is gone. Phenol is manufactured at ~89% and was used in the Nazi death camps, but is more commonly used at low concentraion in chloraseptic throat spray. So if you buy 10% and cut it 50/50 with contrast then you cana inject with live fluoro and if it's going where you don't want it then stop. A little 5% diluted with body fluids is unlikely to do harm, but I'm very leary of letting it go vascular. I do a fair number of US guided phenol peripheral nerve blocks for continued pain after joint replacement the patients and orthos are very grateful.

Can you be more specific about peripheral phenol techniques, including location of needle tip by fluoro or US, concentration, volume, complications? Ive only been ablating cancer pain and then i just use denydrated etoh. Chicken to burn nonmalignant pain.

 

[101N]

I saw a case of this a few years ago. The physician involved was - appropriately - doing intercostals for metastatic disease. Unbeknownst to him or his circulating nurse the pharmacy provided undiluted phenol and it went vascular. The patient had immediate vision changes on the table and subsequently renal failure. Survived, but it wasn't pretty for anyone involved.

Make sure your pharmacist knows to deliver diluted phenol.

 

[clubdeac]

A few thoughts;
Noridian will not cover chemical denervation, so it will need to be billed as a nerve block if you are under their jurisdiction.

My medtronic rep echoed the official word about no RFAs after SCS, but said unofficially just make sure its turned off while you work and don't needle the leads. Whenever I have checked with a cardiologist about RFA with pacemaker they say no problem. I've never asked about defib.

Phenol is thought to be selective based on concentration, so ~4% will kill the unmyelinated C-fibers. I have seen evidence of this on intercostals for PHN where the patient still has light touch sensation but the pain is gone. Phenol is manufactured at ~89% and was used in the Nazi death camps, but is more commonly used at low concentraion in chloraseptic throat spray. So if you buy 10% and cut it 50/50 with contrast then you cana inject with live fluoro and if it's going where you don't want it then stop. A little 5% diluted with body fluids is unlikely to do harm, but I'm very leary of letting it go vascular. I do a fair number of US guided phenol peripheral nerve blocks for continued pain after joint replacement the patients and orthos are very grateful.

Are you destroying the infrapatellar branch of the saphenous nerve? Can you share your technique. Thanks

 

[PinchandBurn]

Are you destroying the infrapatellar branch of the saphenous nerve? Can you share your technique. Thanks

gotta mix with glyerol to prevent migration as well.

 

[onewithpain]

Definitely gylcerol, I buy it from a compounding pharmacy at 10% phenol in glycerol. Most total knees that still hurt have pain medially and so I target the infrapatellar branch of the saphenous nerve. Based on patient's complaint and palpation we US the affected area and find the nerve. I like to stim and the patient usually lets you know that you have found it, then block with .5 cc 2% lido and give the patient a couple minutes to respond. If they are getting relief then add .5 cc 5% phenol. I used to RFA these nerves which worked well and was fun to watch on US, but I work with an anesthetist who is a whiz with US. She just got back from a 4 week course and was told that neuroma after RFA is common and so her instructor said that he only uses phenol. Its quick and easy. Often these total knees with pain have what seems to be sympathetically maintained pain. I like to start those with a sympathetic block so that it's easier to find the offending peripheral nerve later.

 

[LongSnow]

It is amazing how much of this knee pain I see with TKR's. Instead of the infrapatellar of sural, I usually see it with the branches of the lateral femoral cutaneous or the anterior femoral cutaneous nerves.

I like the idea of getting the phenol from the compounding pharmacy. The compounding pharmacies have been useful during this Voltarin gel shortage.

 

[onewithpain]

The compounding pharmacy is the safe way. If you buy 89% then you need a fume hood to work with it safely.