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RFA after posterior fusion

Started by paingate21
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paingate21

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In someone who has posterior fusion hardware - do you perform RFA at that level? Does cervical vs lumbar impact decision? I have typically avoided with thought being no motion at joint (can make argument in regards to dual innervation for adjacent segment) and depending on surgery performed MBB may not be present. One small study also showed small risk of thermal burns (below).

Would you consider targeting C2-C3 in this case? Probes would be at waist of pillars so lateral to hardware.

IMG_1542.jpeg


Lamer TJ, Smith J, Hoelzer BC, Mauck WD, Qu W, Gazelka HM. Safety of Lumbar Spine Radiofrequency Procedures in Patients Who Have Posterior Spinal Hardware. Pain Med. 2016 Sep;17(9):1634-7. doi: 10.1093/pm/pnv078. Epub 2016 Jan 13. PMID: 26764338.
 
paingate21 said:
In someone who has posterior fusion hardware - do you perform RFA at that level? Does cervical vs lumbar impact decision? I have typically avoided with thought being no motion at joint (can make argument in regards to dual innervation for adjacent segment) and depending on surgery performed MBB may not be present. One small study also showed small risk of thermal burns (below).

Would you consider targeting C2-C3 in this case? Probes would be at waist of pillars so lateral to hardware.

View attachment 421387

Lamer TJ, Smith J, Hoelzer BC, Mauck WD, Qu W, Gazelka HM. Safety of Lumbar Spine Radiofrequency Procedures in Patients Who Have Posterior Spinal Hardware. Pain Med. 2016 Sep;17(9):1634-7. doi: 10.1093/pm/pnv078. Epub 2016 Jan 13. PMID: 26764338.
Click to expand...
Zero reservation doing c23 here.

In L spine no sense putting it at level of screw on posterior fusion. surgeons strip the sht out that area prior to placing pedicle screw. Some concern re thermal transfer w screw. I’ll just block the other mbb to the adjacent level joint.

In anterior fusion C or L spine, I’ll do at fused level if seems indicated, coding for adjacent joint above and or below (not at, not covered by ins)
 
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At least for C2-3 I think the probe tip is superior enough that there should not be heat transfer through the hardware
 
Above or below fusion? You can try but it probably won’t work

At level of fusion? It won’t work and shouldn’t try
 
Ducttape said:
i dont recall Medicare pays for RFA at posterior fusion level.


otoh, not sure what they are doing at CMS right now...

View attachment 421394
Click to expand...
I looked this up recently and it seems like they won't pay for levels that have fusion spanning them but the cephalad most level that has a screw in it's pedicle seems to be covered. I personally don't do that level.
 
Before knowing better I did an ablation for a lady with a L4-S1 fusion. She got 100% pain relief of her back pain for 11 months. I dont have a great explanation for that. I suppose placebo, but that is a long time for pain relief and pretty consistent with expected outcome. I have since switched to above and below the fusion levels, but it does have me wondering.
 
Even if it is effective (which I don't think it is), most insurances don't authorize or pay for RF at fused levels, even if they're anteriorly fused and you do RF posterior. I would limit RF to above or below hardware.
 
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To OP -many home run patients get 50% multi year improvement with rfa above or below fusion but I wouldn’t do the fused unless failed above and then would probably just do the extra level for free if I liked the patient. I have had successes
 
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