post RFA deafferentiation pain?

[neutro]

Hi,

Heard about this deafferentiation pain concept two weeks ago at NYSIPP...now that I look back at one of my patients and I am wondering if this is the case...Briefly, I have a patient that has had lumbar RFA X 3 from community pain docs and each time the pain relief diminished (not saying that those docs are not good and those werent done properly). First RFA lasted 9 months and then after 4 months and the third one did not help and infact made it worse.
The patient feels helpless that he has exhausted these procedures and doesnt want any more. He is not drug seeker - actually a nice guy and pastor at local church, and has known his PCP for > 30 years who vetted his case to me. So although the likelihood of "injections dont work, give me my pain meds" conundrum may be present, it is not very likely. He has also consented to other interventional modalities (caudal cath for post lami pain - and has had moderate pain relief thus far).

Anyways, now I am not sure if this is how "deafferentiation pain" will manifest? but
a) how do you diagnose this - am I supposed to elicit something on exam? allodynia?? that is an impossible task given the guy has chronic LBP for decades.
b) what can be done if this is infact deafferentiation pain.

Thank you,

Sincerely,

-AK

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[BobBarker]

Nevro trial

I wouldn't over think this.

 

[bedrock]

Not sure how RFA working less and less suddenly become deafferentation pain. That's a big leap.

Agree with Nevro trial.

 

[Timeoutofmind]

Not sure how RFA working less and less suddenly become deafferentation pain. That's a big leap.

Agree with Nevro trial.

Agree with nevro trial
But I do wonder about deafferentiation pain generally...
I know it is a real clinical phenomenon and has been well described many times.
However, it seems like people are getting more and more aggressive with burning stuff, how that no one is paying for pulsed anymore. Geniculars, hips, GON, even some of the head/face blocks and even DRG.
And it seems like we very rarely hear anything at all about deafferentiation pain in these cases.
Does it have to do with the size of the nerve, whether it is a mixed motor and sensory nerve?
I am just wondering if we could provide very superior pain care if we were not so chicken about this? It would seriously increase the options for people! I am very conservative in this regard, but wonder whether I am missing the boat

 

[willabeast]

if it really was deafferentation pain it would go away once the nerves hooked up again.
it is something else.
i would rule out the usual suspects after obtaining history, physical exam, labs (including ESR), imaging.
i would not assume anything regarding previous treatment - it may have been done inadequately.

 

[neutro]

Not sure how RFA working less and less suddenly become deafferentation pain. That's a big leap.

Agree with Nevro trial.

He has persistent pain after the last rfa - not just rfa working less and less.

 

[neutro]

Nevro trial

I wouldn't over think this.

thanks.
For post Lami patients with predominant LBP, and no leg pain - whats the long term benefit that it works?

 

[BobBarker]

I think the two year study showed good durability of relief compared to conventional stim. My oldest one is a year old and it is doing fine. Got the patient down from 60mg of hydrocodone a day to 22.5.

 

[neutro]

if it really was deafferentation pain it would go away once the nerves hooked up again.
it is something else.
i would rule out the usual suspects after obtaining history, physical exam, labs (including ESR), imaging.
i would not assume anything regarding previous treatment - it may have been done inadequately.

Thanks

 

[Timeoutofmind]

if it really was deafferentation pain it would go away once the nerves hooked up again.
it is something else.
i would rule out the usual suspects after obtaining history, physical exam, labs (including ESR), imaging.
i would not assume anything regarding previous treatment - it may have been done inadequately.

Why ESR? Are you worried about infection here? Are you thinking about referring them to rheumatology? Do you order this on everyone who presents with back pain? Or only people who have ongoing pain after procedures or what ?