pulsed RF to lesser occ. nerve???

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jsaul

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a patient has had short term relief with 3 occ nerve blocks to the lesser occ nerve. anyone out there done pulsed rf to that area?

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Have not RF'd it but have had a decent case series of patients (8-10) with a single quatrode or octrode from the mastoid running inferomedially go to implantation with very happy patients at 6 mo follow up.
 
on that note...anyone with experience with median nerve RF?
 
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lobelsteve said:
Have not RF'd it but have had a decent case series of patients (8-10) with a single quatrode or octrode from the mastoid running inferomedially go to implantation with very happy patients at 6 mo follow up.
the patient shys away from implantables
 
jsaul said:
the patient shys away from implantables

It depends how much it hurts! I've seen lots of patients forced into SCS trials who really did not want or need (based on pain pattern or Dx).

See if you can get Advanced Bionics to send you one of their Bion keychains and show the patient what an entire device can look like. The Bion sounds promising and I think clinicals are under way for occipital neuralgia and migraine.

Another line of though- how about Phenol?
 
C Fiber said:
Try Cryo?
2 things--- #1 cryo usually lasts only 3 weeks--- I have heard some success with pulsed rf lasting much longer

#2 don't have cryo readily avail to us
 
algosdoc said:
And how does one bill for a pulsed RF of the occipital nerve?


Im guessing this is a redundant question by algos......but ill say 64640 which is destruction of other peripheral nerve.

Algos?

T
 
I've had some success with pulsed RF of lesser occipital, but the patients who respond are so hard to predict and the yield is low, so I tend not to use this treatment anymore. Billing obviously can't be neurolysis. Could put local and bill for occipital nerve block I guess.
Bion looks very interesting. Haven't looked into it for awhile. Is there an end of life of the device at which point it would need to be explanted? That might be tricky.

The times I tried PRF, I did not use local on skin. Didn't want any interference with my sensory stimulation.
 
algosdoc said:
And how does one bill for a pulsed RF of the occipital nerve?
algos, have you done pulsed rf to the greater or lesser occ nerve? Just wondering what your thoughts were on that. Understand your point on the billing issue. but please expand on the actual procedure
 
Since pulsed RF by definition does not reach the thermal threshholds to induce neural destruction, none of the destructive codes apply. The only applicable code is 64999....unlisted procedure.

Our approach to the C2 DRG PRF and occipital nerve PRF are through stimulation to acquire the paresthesia (with the caveat that using a RF needle to stimulate with their very long active tips is inherently a very inaccurate way to locate nerves), then are followed by 180sec x 1 or 2. Generally no local anesthesia is used other than with the skin entry since pulsed RF only uncommonly causes pain during the cannula activation.
 
Has anyone been involved in neuromodulation of nucleus caudalis for facial/head pain?
 
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Had great success with pulsed Rf for occipitals. Use the Baylis Medical generator. If you bump up the temp to 43 degrees, you can legally bill for standard RF.
 
The real question becomes whether 43 degrees results in protein degradation, cellular destruction, or neurodestruction.
Pulsed RF as defined by the CPT committee of the AMA is coded 64999. There are no exceptions for bumping the temperature to 43 degrees, which is still 40 deg C away from the common temperatures used in neuroablative procedures during RFTC.
 
algosdoc said:
The real question becomes whether 43 degrees results in protein degradation, cellular destruction, or neurodestruction.
Pulsed RF as defined by the CPT committee of the AMA is coded 64999. There are no exceptions for bumping the temperature to 43 degrees, which is still 40 deg C away from the common temperatures used in neuroablative procedures during RFTC.

So when you do a pulsed RF procedure, what do you bill it as? It is my understanding that the 64999 code you mentioned in a previous post is rarelyt covered by most carries - are you doing these procedures without the expectation of being paid? Or asking your patients to pay cash when their insurance deines? Neither of those seem like terribly good options.
 
I'm resurrecting an old thread but do you guys recommend pulsing the occipital if good but temporary relief from GON block or doing a thermal lesion? I've got a guy scheduled for this and I'm not sure if I should pulse or burn it? Any thoughts? The only downside of burning would be the risk of anesthesia dolorosa I guess. So is there any evidence that it's that much more superior to PRFA for occipital neuralgia to warrant the increased risk??
 
ETOH 50-100%, 4cc. 1cc lido ahead of the ETOH.

n of 5-6 for GON. I use 98% ETOH.

Are you US or stimming to find an exact spot, or do you infiltrate?

As above, deafferentation complications with etoh on peripheral nerves?

I regularly etoh scar neuroma type pain, but havejn't pulled the trigger on a peripheral nerve outside terminal cancer.
 
Also, in terms of billing, I've been doing pRF and billing as injections based on the non-destructive lesioning. My colleagues are billing destructive. My biller has looked at this for a couple of months and came back to me this week, stating I should bill destructive.

We always pre-auth these procedures, and as far as I know (and biller) there have been no problems with this.
 
Ok, I already did 50% etoh. I did a cc or two of lido and bupiv before it and he had no pain for about 12 hrs then it returned. Maybe I had a bad batch of etoh? Anyway, was going to try and stim it to find the closest spot and then either pulse or burn. I dunno... if that doesn't work I was going to hit the nerve down at C2/3 diagnostically and then burn there. If that didn't work, occipital stim even tho I've never done one. Can't be that hard right? Tunnel with a touhy right under the skin and go from mastoid up to occipital protuberance?
 
Ok, I already did 50% etoh. I did a cc or two of lido and bupiv before it and he had no pain for about 12 hrs then it returned. Maybe I had a bad batch of etoh? Anyway, was going to try and stim it to find the closest spot and then either pulse or burn. I dunno... if that doesn't work I was going to hit the nerve down at C2/3 diagnostically and then burn there. If that didn't work, occipital stim even tho I've never done one. Can't be that hard right? Tunnel with a touhy right under the skin and go from mastoid up to occipital protuberance?

Call your stim rep and ask for peer assistance before this case is posted.
 
What about RF the TON?

On the occasions that I consider a PRF of C2 I usually do it as part of a C2 TFESI and just bill for the injection.

This is called the "Dutch Technique" and if it works you can claim that PRF is an effective modality and ignore the fact that you injected a steroid as well (not that I'm cynical or anything). :bullcrap:
 
Are you US or stimming to find an exact spot, or do you infiltrate?

As above, deafferentation complications with etoh on peripheral nerves?

I regularly etoh scar neuroma type pain, but havejn't pulled the trigger on a peripheral nerve outside terminal cancer.

Pmt. 1/2 way between eop and mp. I have a gon neoroma from a skull fx as a kid. I get it.
 
What about RF the TON?

On the occasions that I consider a PRF of C2 I usually do it as part of a C2 TFESI and just bill for the injection.

This is called the "Dutch Technique" and if it works you can claim that PRF is an effective modality and ignore the fact that you injected a steroid as well (not that I'm cynical or anything). :bullcrap:
Did one of these about 3 mo ago. Pain returned, so my colleague advised a heat lesion, which he did earlier this week. I will report back when we see her in follow-up.
 
Did one of these about 3 mo ago. Pain returned, so my colleague advised a heat lesion, which he did earlier this week. I will report back when we see her in follow-up.

i have a colleague that burns all of these, and he swears no problem. He says hes done at least 30...

its possible that he is missing the nerve...
 
Burning the C2 or C3 DRG? Wow, that's balsy. I'd pulse it. I think I'd burn the TON or mb of C2/C3 for occipital neuralgia before pulsing or burning the DRG....
 
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