My rfa machine is located in my asc so they would want me to charge facility fee too. I’ve already been down this road
the wording suggested that a reminder of neuroplasticity - that you are fully aware of - seemed appropriate.You're so oddly interpretive of information that it makes talking to you very difficult. Thanks for educating me about nerve pain; if not for you I'd never have known any of that.
Of course there is a difference in a facet vs a radic. It was a general statement when I posted that. You're a crazy person if you think a level that's fused can't hurt. I see very nicely done knees and hips that continue to hurt. I work in a large ortho group and see it daily.
Same with spinal surgery. I see nice looking fusions and decompressions that pts tell me have made them worse.
You have no ability to prove to me a "fused" level can't hurt.
well.... facility fees are not a battle i am invested in, but...My rfa machine is located in my asc so they would want me to charge facility fee too. I’ve already been down this road
I won't burn a posterior cervical fusion bc of technical considerations. Just too hard of a procedure IMO.I see lots of knees that still hurt post-op, very rarely hips. Also makes sense for joint replacements to continue to hurt as the motion of the joint is preserved, so tendonitis, bursitis, etc will continue to hurt.
I think spinal fusions are a whole different beast though. Makes sense for people to have persistent neuropathic pain after a fusion or discectomy. The way I explain it to patients is, I think, the same way the surgeons here do - spinal fusion stops the damage from getting worse but it doesn’t undo nerve damage that has already occurred. I RF adjacent segments all the time but not fused levels. My rationale is that the RF is almost exclusively blocking pain from the joint, so if the joint can’t move it seems unlikely to hurt.
Makes me wonder though - those patients with big posterior fusions, like C2-T2, whose entire neck still hurts. Have you done RF for any of them? Since you’re picking off some of the dorsal soft tissue sensory innervation, I can see a rationale. I’ve never tried because it wouldn’t be covered by insurance though.
Cervical anterior fusion I think is covered.The following are considered not reasonable and necessary and therefore will be denied:
- Intraarticular and extraarticular facet joint prolotherapy
- Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation.
- Intra-facet implants
- Facet joint procedure performed after anterior lumbar interbody fusion or ALIF.
- Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome
- Diagnostic injections or MMB at the same level as the previously successful RFA procedure
I’ve done adjacent levels of posterior fusions if the angle of the screws allows.I won't burn a posterior cervical fusion bc of technical considerations. Just too hard of a procedure IMO.
Good post.
Wow. What’s your secret for high success rates? Native or s/p TKA? Obese or normal? I’d like to learn.This is slightly off topic but I have a bunch of patients who have done well with genicular rfa which I can no longer offer. Any good results with peripheral nerve stim for these people?
I personally hate the procedure. I have a handful of people who have gotten a year or so of relief and have been asking for it. The successes have all been post tka. I’ve never done it on a native knee
I know what you say about dumping ground, sadly I’m relieved that it has no insurance coverage now so my ortho partners can’t dump their failed knees on to me every chance they get
I'm cash only. Could have sworn I was told several months ago it's done.What do you mean by it has no insurance coverage now? I thought it was still covered by straight Medicare?
(But not covered by commercial payors or Medicare advantage)
Yeah Medicare still covers it, but there’s so many advantage plans that I see with issues following tkr, that I basically consider it doneWhat do you mean by it has no insurance coverage now? I thought it was still covered by straight Medicare?
(But not covered by commercial payors or Medicare advantage)
Haha he was wondering if worsening stenosis or listhesis was an issue, thought the slip might need surgery with axial pain. Just showing a bad slip, can still be treated with good results, don't forget about endplates.Basically Rolo’s saying don’t worry about it but look at what I did 😆
I know I was just messin 😉Haha he was wondering if worsening stenosis or listhesis was an issue, thought the slip might need surgery with axial pain. Just showing a bad slip, can still be treated with good results, don't forget about endplates.
This is now off-topic but - What is your general experience with Intracept for stable spondylolisthesis? Was this guy presenting as a typical "anterior column" pain? Or was it non-specific and he happened to have Modic? I have a 30 year old with history of scoliosis and surgery from L2 up, who has old pars fractures at L5 with stable spondy at L5-S1 and type 1 Modic. Failed MB RFA and ESI. All axial pain with occasional left leg pain but axial is main complaint. His symptoms are fairly non-specific, but he's a normal guy. Hesitant to offer Intracept, but absolutely do not want to send him for a fusion since he's already fused at L2 and I think it will just be a cascade.Haha he was wondering if worsening stenosis or listhesis was an issue, thought the slip might need surgery with axial pain. Just showing a bad slip, can still be treated with good results, don't forget about endplates.
No hesitation with stable spondy. Even if there's a few mm movement on flex ext but radicular component is mild/intermittent, I still do, just tell them they may have higher chance of radiculitis, though I haven't seen that to be the case. Outcomes still mirror literature.This is now off-topic but - What is your general experience with Intracept for stable spondylolisthesis?
Pain was more "always there", worse with activity, morning stiffness, transitioning from different positionsWas this guy presenting as a typical "anterior column" pain?
I think he's a good candidate. Young people with Modic 1 usually do well, especially since you've ruled out other causesOr was it non-specific and he happened to have Modic? I have a 30 year old with history of scoliosis and surgery from L2 up, who has old pars fractures at L5 with stable spondy at L5-S1 and type 1 Modic. Failed MB RFA and ESI. All axial pain with occasional left leg pain but axial is main complaint. His symptoms are fairly non-specific, but he's a normal guy. Hesitant to offer Intracept, but absolutely do not want to send him for a fusion since he's already fused at L2 and I think it will just be a cascade.
Only thing I do differently is aim for a touch more posterior placement of the needle. I try to make sure the very tip of the needle is at but not beyond the x in the image below. I also take a final lateral right before RFA. I think it helps reduce the frequency of neuritis to be a bit more posterior.
View attachment 395708
I’ve tried 60 sec all the way to 3 minutes of total burn with microadjustments during the lesion. I get neuritis frequently.Based on some discussion on here a few years back, I tried burning 1/2 way along the pillar rather than anterior edge, but felt like I saw an immediate increase in neuritis. I suspect there are at least 2 different causes. Some neuritis comes from burning nerves with a sensory input to the skin, unavoidable, but some comes from being a little off target and only irritating rather than completely burning a medial branch nerve.
Yep. Same. As long as I tell patients ahead of time that they may get a weird sunburn like-sensation for a few weeks and that it is not dangerous and it will go away….. I get very few complaints.Neuritis all of the time with these. Just part of it.
Yep. Same. As long as I tell patients ahead of time that they may get a weird sunburn like-sensation for a few weeks and that it is not dangerous and it will go away….. I get very few complaints.
I get far fewer lumbar. And not as painful when it does occurdo u see same rates of neuritis with lumbar RF?
Post rf neuritis for lumbar is a non issue.
I’ve seen it twice in my career.do u see same rates of neuritis with lumbar RF?
90 for 90 is hot for a long time.Just had a lumbar one today. 3 weeks out after b/l L4-S1, decent amount of pain, very tender to light touch across waist and upper buttocks. I see maybe one lumbar every 1-2 mo. Not nearly as frequent or severe as cervical but surprised at those saying nearly zero. 18 ga Sidekick, 1 burn @ 90 deg 90 sec.
I do the same. There’s a study out there showing superiority90 for 90 is hot for a long time.
I see maybe a couple per year. Rare in L spine, but happens.Just had a lumbar one today. 3 weeks out after b/l L4-S1, decent amount of pain, very tender to light touch across waist and upper buttocks. I see maybe one lumbar every 1-2 mo. Not nearly as frequent or severe as cervical but surprised at those saying nearly zero. 18 ga Sidekick, 1 burn @ 90 deg 90 sec.
75 twice daily for 2 weeksFor those rxing lyrica for neuritis, what dose and how frequently?
I do a mix of uni vs bil. I tell patients I prefer to split it up, esp if TON involved, but a lot just want to do once. No biggie.I normally do bilateral lumbar RFA for patients rather than unilateral and needing to bring the patient back the next week. In fellowship however we generally split up the cervical RFAs. Do people here frequently do bilateral cervical RFAs on the same day or split them up?
Sloppy. Less nerve length burned, likely catching it more distal to articular branches. I'd bet higher rate of failures and shorter duration of benefit.Also- one doc at ASRA this year running a cervical RF lab advocated for just touching down on the lateral aspect of the cervical pillars without getting lateral views/advancing to the traditionally taught mid pillar depth. I couldn’t tell if this was sloppy or actually adequate.
I think this is sloppy too (assuming you're going from posterior approach). I'm sure it works decently but likely higher rate of false negatives. Do an experiment and inject some contrast first then shoot a lateral and see where it ends up.I now do this with my cervical mbbs and it saves time, but I want to get my patients the best and longest relief with RF…
What levels were done? Most societies agree and recommend against bilateral cervical RFAI never do bilateral cervical ablations bc on call one time as a fellow I saw a pt who had a bilateral cervical RFA like 2W prior and had complete inability to hold her head upright. I had to give her a neck brace.
It was legitimately a crazy thing to see.
I’m sure that’s overwhelmingly rare, but that visual was nuts!!!
Yeah, well, Medicare doesn’t. So when they come back at 9 months and want it repeated, I guess I could do a facet injection and tide them over… nope, can’t do that either… well, maybe I can do a facet or periarticular injection and just bill it as a TPI with fluoro… nope, that’s not allowed anymore either.What levels were done? Most societies agree and recommend against bilateral cervical RFA
I can’t remember TBH. It wasn’t done in house, it was a private pain guy IIRC, and she came into the hospital with her head flopping around.What levels were done? Most societies agree and recommend against bilateral cervical RFA