Post RFA Neuritis

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MitchLevi said:
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.
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the wording suggested that a reminder of neuroplasticity - that you are fully aware of - seemed appropriate.

i never said a fused level cant hurt. you made that assumption out of thin air. the statement implied that radiculitis was due to facet arthropathy in a level that was fused, which does not appear logical for multiple reasons.

Dr. Ice said:
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
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well.... facility fees are not a battle i am invested in, but...

i would suggest that the care for the patient with a proven and effective treatment with facility is probably preferable to a little performed treatment with unclear outcomes, particularly since the overall cost of peripheral stim to the patient is probably higher than an RFA at an ASC.
 
RFA at fused levels dont work as well. im not saying it can never be done, but expectation bar should be set really low.

likely have better RF outcomes if level fused was fused anteriorly
 
The following are considered not reasonable and necessary and therefore will be denied:

  1. Intraarticular and extraarticular facet joint prolotherapy
  2. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation.
  3. Intra-facet implants
  4. Facet joint procedure performed after anterior lumbar interbody fusion or ALIF.
  5. Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome
  6. Diagnostic injections or MMB at the same level as the previously successful RFA procedure
 
callmeanesthesia said:
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.
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I won't burn a posterior cervical fusion bc of technical considerations. Just too hard of a procedure IMO.

Good post.
 
Ducttape said:
The following are considered not reasonable and necessary and therefore will be denied:

  1. Intraarticular and extraarticular facet joint prolotherapy
  2. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation.
  3. Intra-facet implants
  4. Facet joint procedure performed after anterior lumbar interbody fusion or ALIF.
  5. Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome
  6. Diagnostic injections or MMB at the same level as the previously successful RFA procedure
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Cervical anterior fusion I think is covered.
 
Dr. Ice said:
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?
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Wow. What’s your secret for high success rates? Native or s/p TKA? Obese or normal? I’d like to learn.
 
I'm offering GRFA for cash only, and those pts are exclusively referrals from my partners under specific circumstances.

Be careful though, you'll be a dumping ground if you're not explicitly clear with whose knees you'll burn.
 
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
 
Dr. Ice said:
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
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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)
 
bedrock said:
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)
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I'm cash only. Could have sworn I was told several months ago it's done.
 
bedrock said:
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)
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Yeah Medicare still covers it, but there’s so many advantage plans that I see with issues following tkr, that I basically consider it done
 
I have a case of what seems like post RFA neuritis now 2 months out but wondering if it's something else. This was cooled RF at L34, L45. In addition to facet hypertrophy, they also have listhesis at L34, reduced 5 mm with passive extension on imaging a year ago. Saw a surgeon who deferred anything given 100% axial symptoms at the time.

At the time of RF they had pretty strong multifidus twitch, no other motor activation but may have had some mild sensations to the upper buttock. Of note, pain during RF lesioning at the site of the needles was a little more than typical but again nothing distal noted. No sedation had been given. On the first follow up 3 weeks later they endorsed a burning/itching type sensation and sensitivity into the upper buttock and thighs. On next follow up 2 months out, just upper buttock. There also seems to be baseline lumbar axial pain at 2 months but wasn't present at 3 weeks. I prescribed steroids and lyrica but they weren't filled. I'm going to order repeat imaging to see if listhesis/stenosis worsened. Does this sound like RF neuritis? Anything else to do?
 
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Likely neuritis if your placement was good. Could be a radiculitis component depending on your placement. I've had neuritis last several months. The fact that it's getting better is very positive. Hard to make any decisions on next steps until it's completely resolved and you have a clear picture of efficacy or lack thereof. Modic? Just saw this guy back, 4 mo out from Intracept, 80% relief since week 2.
1000007653.png
 
clubdeac said:
Basically Rolo’s saying don’t worry about it but look at what I did 😆
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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.
 
RoloTomassi said:
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.
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I know I was just messin 😉
 
RoloTomassi said:
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.
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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.
 
MD87 said:
This is now off-topic but - What is your general experience with Intracept for stable spondylolisthesis?
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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.
MD87 said:
Was this guy presenting as a typical "anterior column" pain?
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Pain was more "always there", worse with activity, morning stiffness, transitioning from different positions
MD87 said:
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.
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I think he's a good candidate. Young people with Modic 1 usually do well, especially since you've ruled out other causes
 
MitchLevi said:
Nasty neuritis. This is 80 degrees 90 seconds.

View attachment 379514View attachment 379515View attachment 379520View attachment 379525View attachment 379526View attachment 379528View attachment 379527View attachment 379529
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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.

RFA needle placement.png
 
NMOI said:
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
Click to expand...

I appreciate the input, but I'm using a 10mm active tip and I'm burning quite a bit of MBN in that pic right there. Going more posterior theoretically means I'm getting less of it.


I think there is a very substantial cutaneous aspect to these nerves.
 
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.
 
callmeanesthesia said:
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.
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I’ve tried 60 sec all the way to 3 minutes of total burn with microadjustments during the lesion. I get neuritis frequently.
 
BobBarker said:
Neuritis all of the time with these. Just part of it.
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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.
 
Taus said:
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.
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Yep. This
 
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.
 
RoloTomassi said:
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.
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90 for 90 is hot for a long time.
 
RoloTomassi said:
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.
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I see maybe a couple per year. Rare in L spine, but happens.

most of the prior literature of neuritis rates are reviewed in this article.
academic.oup.com

Incidence of Neuropathic Pain after Cooled Radiofrequency Ablation of Sacral Lateral Branch Nerves

AbstractObjective. To determine the incidence of neuropathic pain after cooled radiofrequency ablation (RFA) of the sacral lateral branches for the treatme
academic.oup.com academic.oup.com

0.5% per lesion, 2.6-% per procedure in lumbar.

Kornick C et al. Complications of lumbar facet radiofrequency denervation. Spine 2004; 29:1352–1354.

The rates of postprocedure neuropathic pain from cervical spine radiofrequency neurotomy, as demonstrated by Govind et al. [8], are much higher than both the sacroiliac and lumbar regions. When evaluating the results from the third occipital nerve (TON), they found a 55% incidence of dysesthesias per procedure and 9.2% per lesion in the cutaneous distribution of the TON. These side effects were self-limiting, lasting typically 7–10 days, and none was distressing enough to require intervention. The authors felt that this phenomenon reflected central disinhibition of adjacent cutaneous nerves that overlap into the third occipital territory. Another study in the cervical spine on typical medial branch nerves found the incidence of neuritis to be 2% and dysesthesias to be 19% per procedure. Again, all resolved without intervention, and no patients felt that it was an equivalent or worse problem than the pain treated [9].
 
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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?

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 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…

My hesitation has nothing to do with billing but more related to the relative discomfort for the patient I was taught to believe.

Thank you
 
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PMROralBoards said:
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?
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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.
PMROralBoards said:
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.
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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.
PMROralBoards said:
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…
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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 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!!!
 
MitchLevi said:
I 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!!!
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What levels were done? Most societies agree and recommend against bilateral cervical RFA
 
hopefulgasman said:
What levels were done? Most societies agree and recommend against bilateral cervical RFA
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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.

Fwiw, I do bilateral all the time. If a patient has neck weakness or severe dizziness after the MBB, I’ll split it up into unilateral several months apart. That happens maybe 1-2x/year
 
hopefulgasman said:
What levels were done? Most societies agree and recommend against bilateral cervical RFA
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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.
 
Timely discussion. I have a long term patient strongly insisting on a bilateral cervical RFA to get it done by end of year.

He’s not crazy but I feel more comfortable doing unilateral cervical RFA
 
Pretty much always do bilateral RF if the mbb was bilateral
 
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