pulsed radiofrequency question

[epidural man]

After reading some posts, I just realized that some (many) of you don’t like pulsed RF, and I have a sincere question.

Could you all that don’t use it or like it in your practice please – in a way that is kind, respectful, gracious, professional, and non-condescending – explain why that is?

My thought is as such – there are many patients that seem to derive some benefit from it, and if I can take a person with some severe functionally disability (maybe an ODI of 60%) with shoulder pain and do a pretty quick and easy and pretty safe pulsed RF suprascapular treatment – and bring his ODI maybe to 30% for 3 months, that seems worth it to me. It certainly seems (although I have no idea if this is true or not) to have numbers needed to harm A LOT less than any med I give.

What about a guy who has severe phantom limb pain, and you have him on opioids, nueropathic pain meds, marinol, alpha-2 agonists, you’ve tried calcitonin and ketamine infusion, and probably a bunch of other stuff. Why WOULDN’T you try pulsing the offending nerve (ie…sciatic)? I suppose you can rotate through the 20 different AED’s and 1 year later consider it – but again, the procedure route to me seems to have a pretty low numbers needed to harm, and the medicines have pretty high NNH.

I can think of LOTS of scenarios where it just (to me) makes a lot of sense if you truly want to help someone who you don’t have a lot of other options – or you don’t like the other options (ie…fusion).

And how about the TON? I have had one to many allodynic patients on the top of their head after using continuous on the TON. Are you non-pulsers not seeing this with continuous on the TON?

I get that billing is an issue – but I don’t think it should matter. Doing what is right by the patient seems to be what should matter – not how much money one gets, but I may be VERY naïve in this since I don’t have to deal with that. However, it seems that you could simply bill for a nerve block – just like you do for the diagnostic. You get paid for that – and for the imaging modality (ultrasound or fluoro). It seems you could make it work financially.

Well, just curious. I’m anxious to hear what some of you have to say.

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[Ligament]

After reading some posts, I just realized that some (many) of you don’t like pulsed RF, and I have a sincere question.

Could you all that don’t use it or like it in your practice please – in a way that is kind, respectful, gracious, professional, and non-condescending – explain why that is?

My thought is as such – there are many patients that seem to derive some benefit from it, and if I can take a person with some severe functionally disability (maybe an ODI of 60%) with shoulder pain and do a pretty quick and easy and pretty safe pulsed RF suprascapular treatment – and bring his ODI maybe to 30% for 3 months, that seems worth it to me. It certainly seems (although I have no idea if this is true or not) to have numbers needed to harm A LOT less than any med I give.

What about a guy who has severe phantom limb pain, and you have him on opioids, nueropathic pain meds, marinol, alpha-2 agonists, you’ve tried calcitonin and ketamine infusion, and probably a bunch of other stuff. Why WOULDN’T you try pulsing the offending nerve (ie…sciatic)? I suppose you can rotate through the 20 different AED’s and 1 year later consider it – but again, the procedure route to me seems to have a pretty low numbers needed to harm, and the medicines have pretty high NNH.

I can think of LOTS of scenarios where it just (to me) makes a lot of sense if you truly want to help someone who you don’t have a lot of other options – or you don’t like the other options (ie…fusion).

And how about the TON? I have had one to many allodynic patients on the top of their head after using continuous on the TON. Are you non-pulsers not seeing this with continuous on the TON?

I get that billing is an issue – but I don’t think it should matter. Doing what is right by the patient seems to be what should matter – not how much money one gets, but I may be VERY naïve in this since I don’t have to deal with that. However, it seems that you could simply bill for a nerve block – just like you do for the diagnostic. You get paid for that – and for the imaging modality (ultrasound or fluoro). It seems you could make it work financially.

Well, just curious. I’m anxious to hear what some of you have to say.

Others may not agree, but I concur with your thinking. I used to be in a situation where I was legally paid to do pulsed RF, and did a good amount of it (still did mostly continous RF however). It worked well in many oddball cases.

It is not legal to bill for a nerve block or steroid injection when your real intention is to do pulsed RF. While many people will bill this way, they would not survive an audit. It is therefore 64999 unlisted procedure. Now, I only do it for cash.

I have never pulsed the TON. I see no need. I have done hundreds of thermal RF at 80degrees C. Frequently get post op neuritis, which has ALWAYS resolved in no more than 8 weeks, usually no more than 4 weeks post op. Thermal RF of the TON works GREAT, and I do very extensive burns with 18ga 10mm active tip needles using ISIS technique.

 

[lobelsteve]

I only use pulsed when I am too chicken to burn a nerve.

1. Gasserian
2. DRG
3. Peripheral nerves

I burn the snot out of the TON and give 2 weeks of Lyrica with free card and the postRF dysesthesia abates.

I believe there is an effect to PRF, but that it doesn't last as long as thermal.

Dawn the literature, don't care about the money, 1st do no harm.

 

[Aether2000]

I use pulse as a last resort and only if the procedure can be done quickly, with one needle, and is associated with a legitimate injection or RF concurrently. The economics of running a pain practice coupled with the parsimony of our population unwilling to pay out of pocket for a procedure has forced me into a this pragmatic compromise. I simply do not bill for it because given the insurers stance in my area using 999 codes, it is a waste of time.

 

[epidural man]

It is not legal to bill for a nerve block or steroid injection when your real intention is to do pulsed RF. While many people will bill this way, they would not survive an audit. It is therefore 64999 unlisted procedure. Now, I only do it for cash.

Why is it illegal? My real INTENT is to block the nerve for a prolonged period. The insurance companies can't tell me that pulsed RF isn't blocking the nerve. I'm not claiming it does anything other than prolonged nerve blocking.

That seems strange to me. But again, that is way out of my realm.

 

[epidural man]

I only use pulsed when I am too chicken to burn a nerve.

1. Gasserian
2. DRG
3. Peripheral nerves

I burn the snot out of the TON and give 2 weeks of Lyrica with free card and the postRF dysesthesia abates.

I believe there is an effect to PRF, but that it doesn't last as long as thermal.

Dawn the literature, don't care about the money, 1st do no harm.

Thanks for the input. I agree with you - although I think I am more chicken than you on some nerves - I probably pulse a few more things.

We (I didn't - a partner) tried pulsing the splanchnics for a guy with chronic pancreatitis. He got great relief from the diagnostic. Pulsed didn't do jack. I'm a little nervous to do bipolar continuous lesioning, or even just straight high temp RF.

The TON thing - a problem in medicine is we tend to make judgements on 1 or 2 cases, and the last continuous I did had severe allodynia - the guy was so pissed at me - made me not ever want to do that again, so now I pulse it with some success. Maybe I'll restart the continuous on it again.

 

[Ligament]

Why is it illegal? My real INTENT is to block the nerve for a prolonged period. The insurance companies can't tell me that pulsed RF isn't blocking the nerve. I'm not claiming it does anything other than prolonged nerve blocking.

That seems strange to me. But again, that is way out of my realm.

I should qualify that comment. If you bill anything other than 64999 for pulsed RF with medicare or medicaid, that can land you in jail due to civil liabilities with these programs with billing errors.

For private insurers, it is not illegal, but you still wont get paid.

 

[Ligament]

Thanks for the input. I agree with you - although I think I am more chicken than you on some nerves - I probably pulse a few more things.

We (I didn't - a partner) tried pulsing the splanchnics for a guy with chronic pancreatitis. He got great relief from the diagnostic. Pulsed didn't do jack. I'm a little nervous to do bipolar continuous lesioning, or even just straight high temp RF.

The TON thing - a problem in medicine is we tend to make judgements on 1 or 2 cases, and the last continuous I did had severe allodynia - the guy was so pissed at me - made me not ever want to do that again, so now I pulse it with some success. Maybe I'll restart the continuous on it again.

Encourage you to burn the **** out of the TON. It really works GREAT. Allodynia post op is expected, I tell the patients that, and they don't complain since I warned them. Honestly, try it, the patients will thank you long term.

For what its worth, I'm seen such great results, I just did an RFA of the TON on a 15 year old a couple weeks ago (had failed 2 years of treatment at Stanford inpatient and UCSF, would not do this otherwise on a youngster like this). He is doing great right now.

 

[drf]

What settings do you guys use when you do pulse? As a fellow all patients got 2 mins using 20 ms pulses with a goal of 45 volts and limiting temp of 42'C. Our Neurotherm has two pulsing modes, one constant time (ie when the tissue heats up the voltage drops to 5-10 volts per pulse) and constant voltage (ie heat leads to extended inter-pulse time but each pulse is always 45 volts). I was not impressed with the results using constant time and 2 minutes.

My current practice has evolved to always using the 45 volt dose mode and hitting the nerve for 8 minutes. I also visualize the needle tip touching the nerve with US. I now have quite a few patients that return every 6-12 months for repeat pulsing and I have regained faith in the modality.

 

[epidural man]

What settings do you guys use when you do pulse? As a fellow all patients got 2 mins using 20 ms pulses with a goal of 45 volts and limiting temp of 42'C. Our Neurotherm has two pulsing modes, one constant time (ie when the tissue heats up the voltage drops to 5-10 volts per pulse) and constant voltage (ie heat leads to extended inter-pulse time but each pulse is always 45 volts). I was not impressed with the results using constant time and 2 minutes.

My current practice has evolved to always using the 45 volt dose mode and hitting the nerve for 8 minutes. I also visualize the needle tip touching the nerve with US. I now have quite a few patients that return every 6-12 months for repeat pulsing and I have regained faith in the modality.

You bring up an excellent point. One of the reasons that the data on pulsed is soooo piss pour is that MOST studies don't hold voltage constant - which is the actually 'dose'...the actual treatment. Temp has NOTHING to do with it. In fact in my clinic, we have 3 different machines from different companies, and not a single one ALLOWS me to hold voltage constant.

Publishing a pulsed RF study without saying what the voltage was - or even holding it constant is like publishing a study on gabapentin but not reporting the doses, AND saying that patients took a variable amount of dosing throughtout the study period. It is ridiculous.

So I think you are very smart to hold the voltage at 45V. Some of the newer and better quality - and consequently - better result studies are doing that.

 

[Ligament]

I have only pulsed with the radionics and mostly the Baylis machines. Do at least 720seconds temp at or less than 42 C 20ms pulses, 2 pulses/second keep voltage around 45V but Baylis does not have a constant voltage pulsed mode.

 

[Ligament]

You bring up an excellent point. One of the reasons that the data on pulsed is soooo piss pour is that MOST studies don't hold voltage constant - which is the actually 'dose'...the actual treatment. Temp has NOTHING to do with it. In fact in my clinic, we have 3 different machines from different companies, and not a single one ALLOWS me to hold voltage constant.

Publishing a pulsed RF study without saying what the voltage was - or even holding it constant is like publishing a study on gabapentin but not reporting the doses, AND saying that patients took a variable amount of dosing throughtout the study period. It is ridiculous.

So I think you are very smart to hold the voltage at 45V. Some of the newer and better quality - and consequently - better result studies are doing that.

Can you point me to some literature discussing constant voltage pRF? Thanks!

 

[Ligament]

http://www.neurotherm.com/documents/Principles_of_Radiofrequency.pdf

 

[Ligament]

2010 Congress of Neurological Surgeons Annual Meeting
October 16 - 21, 2010
San Francisco, California
Pain Abstracts
1510
New Concept of Pulsed Radiofrequency Treatment for Refractory Radicular Pain: The
Pulsed Dose Radiofrequency Technique
Jung Yul Park MD, PhD; Sang-kook Lee CI, MD; Dong-Jun Lim MD, PhD; Sang-Dae Kim
INTRODUCTION: Based on results from 640 cases of PRF rhizotomy for the refractory radicular
pain, its disadvantages are longer operation time, shorter duration of effect(, early recurrence, less degrees
of maximum & prolonged efficacy, longer period for initial action to take place, and minimal immediate
response. These may be due to insufficient electrical energy delivery to the affending neural structures as
well as other factors. Thus, recently a newer concept of pulsed radiofrequency technique, so called
pulsed dose radiofreuqency (PDRF), has been introduced.
METHODS: In this report, different mechanisms of pulsed and pulsed dose rafiofrequency
techniques are described with some of early clinical results based on recent clinical experience from 150
consecutive patients with chronic, refractory radicular pain. Average VAS was 7.6 with average duration
of 8.2 months. All patients underwent PDRF rhizotomy on corresponding dorsal root ganglions under Carm fluoroscopy after confirmation of precise targets with rootsleevogram, impedance, sensory and motor
stimulation tests. Local anesthtics and anagesics were not used. Minimal follow up period was 12 months.
RESULTS: The average VAS at 12 month decreased from 7.2 to 2.4 and overall satisfaction was
85%. Reduction(>75%) or withdrawl of medication was possible in 70% and 20%, respectively. Only 5%
of patients showed no change and there were no cases of worsening after the procedures. Also, there
were no neurologic complications except 12 cases with transient leg pain or worsening of parestheisia.
CONCLUSION: The main difference of PDRF from PRF is delivering the maximum (both width
and amplitude) electrical energy with possible interruption of intervals. Although it is early to address the
overall efficacy of pulsed dose RF treatment in various painful disorders, it provides substantially better
pain relief with longer duration compared to previous PRF treatment in similar clinical settings. Also,
there has not been any worrisome complications from the procedures. But, longer term evaluation is
mandatory before justifying its general use.

 

[101N]

2010 Congress of Neurological Surgeons Annual Meeting
October 16 - 21, 2010
San Francisco, California
Pain Abstracts
1510
New Concept of Pulsed Radiofrequency Treatment for Refractory Radicular Pain: The
Pulsed Dose Radiofrequency Technique
Jung Yul Park MD, PhD; Sang-kook Lee CI, MD; Dong-Jun Lim MD, PhD; Sang-Dae Kim
INTRODUCTION: Based on results from 640 cases of PRF rhizotomy for the refractory radicular
pain, its disadvantages are longer operation time, shorter duration of effect(, early recurrence, less degrees
of maximum & prolonged efficacy, longer period for initial action to take place, and minimal immediate
response. These may be due to insufficient electrical energy delivery to the affending neural structures as
well as other factors. Thus, recently a newer concept of pulsed radiofrequency technique, so called
pulsed dose radiofreuqency (PDRF), has been introduced.
METHODS: In this report, different mechanisms of pulsed and pulsed dose rafiofrequency
techniques are described with some of early clinical results based on recent clinical experience from 150
consecutive patients with chronic, refractory radicular pain. Average VAS was 7.6 with average duration
of 8.2 months. All patients underwent PDRF rhizotomy on corresponding dorsal root ganglions under Carm fluoroscopy after confirmation of precise targets with rootsleevogram, impedance, sensory and motor
stimulation tests. Local anesthtics and anagesics were not used. Minimal follow up period was 12 months.
RESULTS: The average VAS at 12 month decreased from 7.2 to 2.4 and overall satisfaction was
85%. Reduction(>75%) or withdrawl of medication was possible in 70% and 20%, respectively. Only 5%
of patients showed no change and there were no cases of worsening after the procedures. Also, there
were no neurologic complications except 12 cases with transient leg pain or worsening of parestheisia.
CONCLUSION: The main difference of PDRF from PRF is delivering the maximum (both width
and amplitude) electrical energy with possible interruption of intervals. Although it is early to address the
overall efficacy of pulsed dose RF treatment in various painful disorders, it provides substantially better
pain relief with longer duration compared to previous PRF treatment in similar clinical settings. Also,
there has not been any worrisome complications from the procedures. But, longer term evaluation is
mandatory before justifying its general use.

That seems fair enough.

 

[drf]

I set a world record today on a patient who is a retired MD with knee pain s/p TKAs who lives across the country.

In february of 2011 I did bilateral saphenous nerve pRF at constant 45 volts for 8 mins on each nerve. Excellent pain relief and increase in function (ie walking and golfing again) until October, so 8 months.

Today i had two probes so i decided to use the same total time, ie 16 minutes of pulsing, on both nerves simultaneously. I set the machine for a 1920 count. With constant time this would have been 16 minutes. The actual time ended up being 25 minutes of treatment as after the first couple minutes the intervals increased to maintain a temp lower than 42.

So, 1920 45 v pulses over more than twenty minutes. I'm excited to follow up and see if the pain relief is more significant and if the duration increases.

For fun I turned the machine on regular pulse mode to see what would happen. Over 20-30 seconds the highest pulse voltage I saw was 11, with a single digit average and several 2-3 second periods where it remained 0.

 

[epidural man]

Can you point me to some literature discussing constant voltage pRF? Thanks!

It isn't easy - but just something that a few people talk about here and there but most people don't discuss it or even think about it.

Sluitjer has been saying it for a few years now - in fact, he says that it is not even temp (at high temp treatment) that is treating the nerve, but an electrical field effect. That is a fascinating concept really.

If you can get a hold of his book on Radiofrequency, I would grab it. It is something to cherish. Attached is his most recent review on the subject (written this year) and he goes through some of the physics behind pulsed, but other reviews and letters to the editor he has written are worthwhile to seek out as well.

 

[101N]

It isn't easy - but just something that a few people talk about here and there but most people don't discuss it or even think about it.

Sluitjer has been saying it for a few years now - in fact, he says that it is not even temp (at high temp treatment) that is treating the nerve, but an electrical field effect. That is a fascinating concept really.

If you can get a hold of his book on Radiofrequency, I would grab it. It is something to cherish. Attached is his most recent review on the subject (written this year) and he goes through some of the physics behind pulsed, but other reviews and letters to the editor he has written are worthwhile to seek out as well.

Slultjer is making Martin Flieschmann's mistake.

 

[epidural man]

Slultjer is making Martin Flieschmann's mistake.

Interesting....

First of all Flieschmann didn't make a mistake. It was the dean of the school who released the statement BEFORE the scientists wanted them too - and against their council. All flieschmann wanted to do was publish the findings in a small science journal. Had he been allowed to do that, things would have been different. It was the school admin's fault. Flieschmann never claimed to have solved cold fusion.

But that isn't the point.

Your point is - you don't believe Sluitjer.

That's cool. Lot's of people don't believe terrorists brought down the towers either. We believe what we believe. Life is fun that way!

 

[101N]

Interesting....

First of all Flieschmann didn't make a mistake. It was the dean of the school who released the statement BEFORE the scientists wanted them too - and against their council. All flieschmann wanted to do was publish the findings in a small science journal. Had he been allowed to do that, things would have been different. It was the school admin's fault. Flieschmann never claimed to have solved cold fusion.

But that isn't the point.

Your point is - you don't believe Sluitjer.

That's cool. Lot's of people don't believe terrorists brought down the towers either. We believe what we believe. Life is fun that way!

You are correct; I don't believe Sluitjer. I acknowledge that I am biased in that regard. I've read his book and heard him speak and I do not find him to be credible. He is an unabashed, and unscientific, cheerleader for PRF for virtually any indication.

It may turn out the PRF has some utility, but it will require the kind of scrutiny, and intellectual honesty, that Sluitjer does not possess.

 

[clubdeac]

I have only pulsed with the radionics and mostly the Baylis machines. Do at least 720seconds temp at or less than 42 C 20ms pulses, 2 pulses/second keep voltage around 45V but Baylis does not have a constant voltage pulsed mode.

Baylis' system does not have a constant voltage pulsed mode? Dammit I thought it did. I've been doing pulsed of the DRGs with good success for variable problems (LFCN, ilioinguinal neuralgia, ICN etc). Suprascapular is another one of my favorites.

 

[clubdeac]

I set a world record today on a patient who is a retired MD with knee pain s/p TKAs who lives across the country.

In february of 2011 I did bilateral saphenous nerve pRF at constant 45 volts for 8 mins on each nerve. Excellent pain relief and increase in function (ie walking and golfing again) until October, so 8 months.

Today i had two probes so i decided to use the same total time, ie 16 minutes of pulsing, on both nerves simultaneously. I set the machine for a 1920 count. With constant time this would have been 16 minutes. The actual time ended up being 25 minutes of treatment as after the first couple minutes the intervals increased to maintain a temp lower than 42.

So, 1920 45 v pulses over more than twenty minutes. I'm excited to follow up and see if the pain relief is more significant and if the duration increases.

For fun I turned the machine on regular pulse mode to see what would happen. Over 20-30 seconds the highest pulse voltage I saw was 11, with a single digit average and several 2-3 second periods where it remained 0.

Hey I think we've touched on this elsewhere but what is your technique for pRF of the saphenous nerve? Do you use US and what are your landmarks if one was to not use US?

 

[epidural man]

Hey I think we've touched on this elsewhere but what is your technique for pRF of the saphenous nerve? Do you use US and what are your landmarks if one was to not use US?

Why wouldn't you use ultrasound? It makes it easy and safe...oh, and reliable.

 

[clubdeac]

Why wouldn't you use ultrasound? It makes it easy and safe...oh, and reliable.

Because I don't have an US machine, duhhhh 😀

 

[drf]

Hey I think we've touched on this elsewhere but what is your technique for pRF of the saphenous nerve? Do you use US and what are your landmarks if one was to not use US?

Usra.ca

Can't really do it without US. I go mid thigh. Scan on Anterior thigh, find femur. Move probe medially, seeing rectus and vastus intermedius turn into vastus medialis and sartorius. It is more medial than you think. Find fem artery deep to sartorius. Trace the artery prox and distal to find the adductor hiatus, where it dives deep into the pop fossa. Block proximal to here. Poke a ten cm curved needle to the superficial ventral part of the artery. With the probe short axis over thigh, needle enters anterior to probe. You will see two nerves, saphenous and motor branch to vastus. Stim to figure out which is which. Saphenous is usually the more superficial one. Be careful to get stim past the knee as vastus activation is also perceived as radiating to the knee.

To do it without US best bet would be trying to find superficial infra patellar branches proximal and medial to patella. Hard to find saphenous nerve proper in adductor canal for a block. Much more so for a pRF.

 

[epidural man]

Because I don't have an US machine, duhhhh 😀

C'Mon guys. It's so simple maybe you need a refresher course. It's all ball bearings nowadays. Uh....I mean ultrasound.

http://wavs.unclebubby.com/wav/MOVIES/Fletch/ballbearings.wav

 

[epidural man]

Encourage you to burn the **** out of the TON.

Just did it.

If it doesn't go well, I'm comin' after ya 'all jason borne style.

 

[Ligament]

Just did it.

If it doesn't go well, I'm comin' after ya 'all jason borne style.

It'll be all good! Remember the neuritis is expected. Treat with Lyrica and or Lidoderm gel. Will resolve within a few weeks, and patient will be happy.

 

[clubdeac]

C'Mon guys. It's so simple maybe you need a refresher course. It's all ball bearings nowadays. Uh....I mean ultrasound.

http://wavs.unclebubby.com/wav/MOVIES/Fletch/ballbearings.wav

haha classic Fletch

 

[onewithpain]

Others may not agree, but I concur with your thinking. I used to be in a situation where I was legally paid to do pulsed RF, and did a good amount of it (still did mostly continous RF however). It worked well in many oddball cases.

It is not legal to bill for a nerve block or steroid injection when your real intention is to do pulsed RF. While many people will bill this way, they would not survive an audit. It is therefore 64999 unlisted procedure. Now, I only do it for cash.

I have never pulsed the TON. I see no need. I have done hundreds of thermal RF at 80degrees C. Frequently get post op neuritis, which has ALWAYS resolved in no more than 8 weeks, usually no more than 4 weeks post op. Thermal RF of the TON works GREAT, and I do very extensive burns with 18ga 10mm active tip needles using ISIS technique.

It is my understanding that you need to pull the RF needle and then place another needle for a block or steroid injection in order to bill for the other injection when doing the pRF.