RFA complication

[10KHertz]

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As the interventionalist, you should be aware of the patients MAC depth. We know when a patient is too sedated( Airway obstruction, nonverbal, insensate, etc) and some just choose not to wait until a safer conscious state ( ie conscious sedation) . Eventually this will bite you . I’m not immune to accepting the risks on more difficult patients.Just default to a extra cautious mode.

also be careful coupling sedative, opioids and propofol for sedation. There is synergy.
And I wouldn’t use lido 2% much, too potent for most of our procedures.

 

[SommeRiver]

For an RFA, using 1mL of 2% lido at each needle is a great way to lesion a pt without having to sedate them. Give it 2-3 min to sit and you're fine. Most I'll do is 3 levels (4 needles) at a time.

When pts come see me and I tell I don't "put them to sleep" or give "twilight" I get looked at like I have a GD hole in my head. Then, I do the injxn and they're shocked it was easy.

Super anxious pt I'll give Valium 5 or 10mg.

This propofol, fentanyl and Versed thing is abhorrent to me. Colossal waste of medical resources and increases the risk of the procedure.

Totally unnecessary.

 

[10KHertz]

For an RFA, using 1mL of 2% lido at each needle is a great way to lesion a pt without having to sedate them. Give it 2-3 min to sit and you're fine. Most I'll do is 3 levels (4 needles) at a time.

When pts come see me and I tell I don't "put them to sleep" or give "twilight" I get looked at like I have a GD hole in my head. Then, I do the injxn and they're shocked it was easy.

Super anxious pt I'll give Valium 5 or 10mg.

This propofol, fentanyl and Versed thing is abhorrent to me. Colossal waste of medical resources and increases the risk of the procedure.

Totally unnecessary.

That’s great you are so accurate that 1ml local is used per lesion. For most of us, 2-3ml of 1%lidocaine is more common. Plus more local (>1ml) has been published to potentially produce a more uniform lesion overall.

Also, a four lesion cervical rfa with 2% lidocaine would cause cervicogenic vertigo in my hands. With the additional Fall risk or driving risk, it’s Not worth it for me . But good to know you have great results.

I use a 20g rf needle and typically get a solid 280 days or so, plus a 20g needle is a lot more tolerable with or without sedation...

 

[SommeRiver]

That’s great you are so accurate that 1ml local is used per lesion. For most of us, 2-3ml of 1%lidocaine is more common. Plus more local (>1ml) has been published to potentially produce a more uniform lesion overall.

Also, a four lesion cervical rfa with 2% lidocaine would cause cervicogenic vertigo in my hands. With the additional Fall risk or driving risk, it’s Not worth it for me . But good to know you have great results.

I use a 20g rf needle and typically get a solid 280 days or so, plus a 20g needle is a lot more tolerable with or without sedation...

I don't do more than 3 needles in the C spine; I will do 4 lumbar needles. Lumbar needle is 18g, cervical is 20g.

I don't think I'm any more accurate than anyone here. I simply burn where I put that 1cc of 2%.

 

[HouseofPain]

SEDATION • Sedation is not intrinsically necessary for ESIs, but if employed in unique circumstances (e.g. movement disorder, cases of extreme anxiety, previous vasovagal response), the patient should remain able to communicate pain or other adverse sensations or events. • The decision to use sedation should be made on a case-by-case basis. • If the physician performing the procedure decides to administer and supervise the sedation, they should be trained and qualified to do so. In these situations, a separate healthcare provider is required to assist with the administration of the medications and monitoring of the patient. • Resuscitation drugs, monitoring equipment, and oxygen must be available if sedation is utilized.

Part of these guidelines?

This is from ESI chapter. Also can reference the fact finder from SIS that I have posted a few times over the years.

Steve

For an RFA, using 1mL of 2% lido at each needle is a great way to lesion a pt without having to sedate them. Give it 2-3 min to sit and you're fine. Most I'll do is 3 levels (4 needles) at a time.

When pts come see me and I tell I don't "put them to sleep" or give "twilight" I get looked at like I have a GD hole in my head. Then, I do the injxn and they're shocked it was easy.

Super anxious pt I'll give Valium 5 or 10mg.

This propofol, fentanyl and Versed thing is abhorrent to me. Colossal waste of medical resources and increases the risk of the procedure.

Totally unnecessary.

Can you show me the data where 1-2 mg of versed and maybe a little fentanyl increase procedure risk? I would be more worried about bad outcomes secondary to bad technique. SIS and ASIPP both say it’s appropriate if needed. Not everyone gets it but if they request it I’m more than happy to provide it. No one is “knocked out” or “put to sleep” that’s the issue. They are awake and able to hold a conversation. Not a waste of resources either.

 

[lobelsteve]

Doctors group on closed claims for cesi is probably best literature to hold up in court and say sedation is a risk factor for complications.

 

[HouseofPain]

Doctors group on closed claims for cesi is probably best literature to hold up in court and say sedation is a risk factor for complications.

Again with what I listed above I don’t think so. Patients being unresponsive (deep sedation, general anesthesia) were the ones that had highest rate catastrophic complications. Mild conscious sedation is fine.
Injury and Liability Associated with Cervical Procedures for Chronic Pain
James P. Rathmell, M.D.; Edward Michna, M.D., J.D.; Dermot R. Fitzgibbon, M.D.; Linda S. Stephens, Ph.D.; Karen L. Posner, Ph.D.; et al
actually group mild sedation and awake patients together. I would never advocate deep sedation for any of the procedures we perform.

 

[lobelsteve]

After the doctors group data, id reference sis guidelines. If you have a complication and sedation was given, it is easy to argue sedation played a part.

 

[SommeRiver]

Give Valium PO instead of placing an IV and running two separate medications for sedation in a procedure that doesn't need it.

Also I'm more talking about propofol, which is crazy for an RFA.

 

[Ducttape]

that article is well quoted, but I'm not sure everyone reads the entire article.

those deemed to be unresponsive were those, by review of the anesthesiologists, to have gotten moderate, deep sedation or general anesthesia. in fact, 25% of patients who got sedation were unresponsive - the other 75% were indeterminable or were responsive.

The use of deep sedation or general anesthesia, during which the patient becomes briefly nonresponsive to verbal commands, has come under much scrutiny.10,24 Advocates state that sedation allays anxiety, allowing treatment in a population that could not otherwise receive treatment; and renders patients temporarily immobile during these procedures and reduces the risk of sudden movement, thereby potentially decreasing the risk of neural injury.10,24–26 Opponents cite ample anecdotes in the form of case reports, in which a responsive patient reported symptoms as a needle contacted a peripheral nerve or the spinal cord itself, allowing the procedure to be discontinued and causing no permanent neural injury.10,24,25,27,28 Indeed, a recent consensus group concluded that warning signs, such as paresthesia or pain on injection of a local anesthetic, inconsistently herald needle contact with the spinal cord; however, some patients do report warning signs of needle-to-neuraxis proximity. The group warned that general anesthesia or heavy sedation removes any ability for the patient to recognize and report warning signs; they recommended that neuraxial regional anesthesia should rarely be performed in adult patients whose sensorium is compromised by general anesthesia or heavy sedation.10 Although imperfect, the current analysis supports the notion that use of sedation or general anesthesia and conduct of cervical procedures in unresponsive patients are associated with a significant increase in the likelihood of permanent spinal cord injury.

in their assessment, what constitutes heavy sedation? one could successfully argue that fentanyl & versed may not be heavy, depending on the dose, but propofol doesn't seem to fall in that category....

 

[deleted993114]

That’s great you are so accurate that 1ml local is used per lesion. For most of us, 2-3ml of 1%lidocaine is more common. Plus more local (>1ml) has been published to potentially produce a more uniform lesion overall.

Also, a four lesion cervical rfa with 2% lidocaine would cause cervicogenic vertigo in my hands. With the additional Fall risk or driving risk, it’s Not worth it for me . But good to know you have great results.

I use a 20g rf needle and typically get a solid 280 days or so, plus a 20g needle is a lot more tolerable with or without sedation...

I ALWAYS do four level cervical rf (unless there is a fused segment). Having done these for 30 years, I have never had a single patient with "cervicogenic vertigo" (that is a very good description of what actually happens in those patients- I have been struggling for years for a proper term for that - thanks! And I do mean that with sincerity).

I have had MANY patients with four level test blocks who have had "cervicogenic vertigo" (Do I have to footnote you for that term, as it is a good one?). In those patients, I re-test block them, eliminating C3 (or TON if I had been so inclined as well) and see if they get dizzy. If not, then go with the rf.

You make an EXCELLENT point about the dizziness that can occur with cervical rf that is an under reported and serious side effect that can occur with higher levels.

Thanks for the point about the extra lidocaine!- I usually use 2cc of local (just because old man Sluyter told me to do so) and had no idea that it increased the lesion size.

That's the cool thing about this site. I've been doing this stuff for many years, yet pick up "pearls" from you guys on a daily basis. Collective knowledge and experiences makes us all better.

 

[10KHertz]

I ALWAYS do four level cervical rf (unless there is a fused segment). Having done these for 30 years, I have never had a single patient with "cervicogenic vertigo" (that is a very good description of what actually happens in those patients- I have been struggling for years for a proper term for that - thanks! And I do mean that with sincerity).

I have had MANY patients with four level test blocks who have had "cervicogenic vertigo" (Do I have to footnote you for that term, as it is a good one?). In those patients, I re-test block them, eliminating C3 (or TON if I had been so inclined as well) and see if they get dizzy. If not, then go with the rf.

You make an EXCELLENT point about the dizziness that can occur with cervical rf that is an under reported and serious side effect that can occur with higher levels.

Thanks for the point about the extra lidocaine!- I usually use 2cc of local (just because old man Sluyter told me to do so) and had no idea that it increased the lesion size.

That's the cool thing about this site. I've been doing this stuff for many years, yet pick up "pearls" from you guys on a daily basis. Collective knowledge and experiences makes us all better.

’cervicogenic vertigo‘ was a recently coined term to describe a well know phenomenon after facet injury or anesthetic blockade. I’m sure you would have come across it sooner or later. glad to help. I learn as well .

I like “catastrophizing” pain syndrome as well. Cool term for our histrionic patients...

 

[clubdeac]

As the interventionalist, you should be aware of the patients MAC depth. We know when a patient is too sedated( Airway obstruction, nonverbal, insensate, etc) and some just choose not to wait until a safer conscious state ( ie conscious sedation) . Eventually this will bite you . I’m not immune to accepting the risks on more difficult patients.Just default to a extra cautious mode.

also be careful coupling sedative, opioids and propofol for sedation. There is synergy.
And I wouldn’t use lido 2% much, too potent for most of our procedures.

What exactly are you concerned about with using 2% lido outside the spinal column? Systemic toxicity?

 

[10KHertz]

What exactly are you concerned about with using 2% lido outside the spinal column? Systemic toxicity?

Unintentionally spinal nerve root block , and partial Axonometisis , with or without sedation.

Typically lidocaine 2-5% is reserved for differential blockage of sympathetic fibers during spinal/epidural anesthesia for general surgery and/or c-sections.

You don’t gain much , but more risk.

Furthermore, if you review the ASA closed claim data(as some refer to) you see that higher doses of Lidocaine causes more peripheral nerve injuries Extraforaminally(and intrathecal, which is a perplexing conundrum-that’s another issue). Peers have been sued for lido spinal anesthesia secondary to motor deficits after spinal anesthesia . Again separate but related issue with lidocaine toxicity on nerves via all routes.

That being said , if people are truly that targeted and using 1ml of lido 2% , that total dose is safe. I just don’t think I can make an rfa comfortable with 1ml personally. The patient complains , you stop the procedure, give more, etc,etc.
Best just titrating lido 1% and repeating motor stim...IMO . Customize based on experience.

 

[Ligament]

Unintentionally spinal nerve root block , and partial Axonometisis , with or without sedation.

Typically lidocaine 2-5% is reserved for differential blockage of sympathetic fibers during spinal/epidural anesthesia for general surgery and/or c-sections.

You don’t gain much , but more risk.

Furthermore, if you review the ASA closed claim data(as some refer to) you see that higher doses of Lidocaine causes more peripheral nerve injuries Extraforaminally(and intrathecal, which is a perplexing conundrum-that’s another issue). Peers have been sued for lido spinal anesthesia secondary to motor deficits after spinal anesthesia . Again separate but related issue with lidocaine toxicity on nerves via all routes.

That being said , if people are truly that targeted and using 1ml of lido 2% , that total dose is safe. I just don’t think I can make an rfa comfortable with 1ml personally. The patient complains , you stop the procedure, give more, etc,etc.
Best just titrating lido 1% and repeating motor stim...IMO . Customize based on experience.

.5-1mL of 4% lidocaine works wonders, if you wish to try it. I used to use 2% but after Ray Baker and Paul Dreyfuss told me they are using 4% I switched, I think it works great. Also is probalby mildly neurotoxic, at least enough to help the lesioned medial branches get killed more dead. Yes that is the medical term. I sometimes wonder if this is why my RFs work so well.

 

[SSdoc33]

.5-1mL of 4% lidocaine works wonders, if you wish to try it. I used to use 2% but after Ray Baker and Paul Dreyfuss told me they are using 4% I switched, I think it works great. Also is probalby mildly neurotoxic, at least enough to help the lesioned medial branches get killed more dead. Yes that is the medical term. I sometimes wonder if this is why my RFs work so well.

your RFs work well b/c you have great technique and use a harpoon. nothing to do with the lido

 

[DrSpine]

A similar situation happened to me today. Literally go on SDN to see if its happened before, but there it was, first page, three threads down. Thank God for OP. Patient just felt some knee buckling 10 minutes afterward with some numbness. Motor and sensory testing was 100% fine. AP and Lateral views were fine, nothing too anterior or into the foramen. I assured them it was probably the anesthetic and would wear off by tonight or tomorrow. Will call back to see how they are feeling tomorrow.

 

[Wkrdoc]

A similar situation happened to me today. Literally go on SDN to see if its happened before, but there it was, first page, three threads down. Thank God for OP. Patient just felt some knee buckling 10 minutes afterward with some numbness. Motor and sensory testing was 100% fine. AP and Lateral views were fine, nothing too anterior or into the foramen. I assured them it was probably the anesthetic and would wear off by tonight or tomorrow. Will call back to see how they are feeling tomorrow.

welcome to the pucker club. Mine resolved in a week. I’m sure yours will too

 

[Ligament]

This leg weakenss after lumbar RF has happened to me a couple dozen times in my career, at least the instances I am told about. It has never once been anything but local anesthetic knocking out the nerve root for awhile.

 

[10KHertz]

This leg weakenss after lumbar RF has happened to me a couple dozen times in my career, at least the instances I am told about. It has never once been anything but local anesthetic knocking out the nerve root for awhile.

“Knocking” out a nerve root for awhile, with sedation, typically is the cause of most RFA catastrophes... it turns out that you did more than a transiently cause a motor block. I’m surprised by the capricious responses . A few insurance carriers have even excluded RFA coverage for physicians due to the neural injuries nation wide. I’m not exaggerating. The settlements are massive.

Many of you are playing a dangerous game with dense local anesthetics to make your patients more comfortable quickly. If you have reviewed malpractice cases( which I’m sure you have) most of the “wonderfully placed” needles were not placed correctly, and slightly off line , with added sedation, and dense local. If you take away the sedation and you still are increasing risk.

Lastly , think about it. On the one hand you are claiming 1-2mls Of lido 2-4% works so well and is so safe, but on the other hand we all have reported significant nerve root sensory and motor blocks. There is a definite spill over close to the formina and if you have a bad day (your 1:20,000 case is when this happens by the way statistically...) you may end up with with a malpractice event.

Hopefully your expert witness can defend your capricious logic in the setting of well established ASA closed claim data .

 

[painfree23]

“Knocking” out a nerve root for awhile, with sedation, typically is the cause of most RFA catastrophes... it turns out that you did more than a transiently cause a motor block. I’m surprised by the capricious responses . A few insurance carriers have even excluded RFA coverage for physicians due to the neural injuries nation wide. I’m not exaggerating. The settlements are massive.

Many of you are playing a dangerous game with dense local anesthetics to make your patients more comfortable quickly. If you have reviewed malpractice cases( which I’m sure you have) most of the “wonderfully placed” needles were not placed correctly, and slightly off line , with added sedation, and dense local. If you take away the sedation and you still are increasing risk.

Lastly , think about it. On the one hand you are claiming 1-2mls Of lido 2-4% works so well and is so safe, but on the other hand we all have reported significant nerve root sensory and motor blocks. There is a definite spill over close to the formina and if you have a bad day (your 1:20,000 case is when this happens by the way statistically...) you may end up with with a malpractice event.

Hopefully your expert witness can defend your capricious logic in the setting of well established ASA closed claim data .

So what’s your suggestion? 1cc of 1% lidocaine with no sedation?

 

[10KHertz]

So what’s your suggestion? 1cc of 1% lidocaine with no sedation?

Read above posts. I provided my opinion fairly clearly.
Do what you like , it’s good to know that maybe other techniques can exist.
I don’t think I’ve ever closed a IPG pocket with more than marcaine 0.25% mixed with lido 1%. Only used lido 4% in a labor epidural/ c section. Or maybe a viscous lido for spheno block.

 

[Ligament]

“Knocking” out a nerve root for awhile, with sedation, typically is the cause of most RFA catastrophes... it turns out that you did more than a transiently cause a motor block. I’m surprised by the capricious responses .

My patients are awake and responsive during the entire procedure, and I have verbal communication with them before and during the lesioning.

You assert I have lesioned many roots on responsive awake patients. Yet, all are walking normally later that day. Can you explain how the root I supposedly lesioned at 90C with a 16ga cannulae fully regenerates in a matter of hours?

 

[callmeanesthesia]

My patients are awake and responsive during the entire procedure, and I have verbal communication with them before and during the lesioning.

You assert I have lesioned many roots on responsive awake patients. Yet, all are walking normally later that day. Can you explain how the root I supposedly lesioned at 90C with a 16ga cannulae fully regenerates in a matter of hours?

Lesion temp and needle size may be playing a role in our varying opinions as well - if you use a 20g at 80 degrees, I’m sure 1% lidocaine is perfectly adequate. For a 16g at 90, I can see how you’d want something a little stronger.

 

[10KHertz]

My patients are awake and responsive during the entire procedure, and I have verbal communication with them before and during the lesioning.

You assert I have lesioned many roots on responsive awake patients. Yet, all are walking normally later that day. Can you explain how the root I supposedly lesioned at 90C with a 16ga cannulae fully regenerates in a matter of hours?

I assert that RFA complications occur, and that risk factors are well known in the literature. I am not specifically critiquing your personal practice. It’s called an opinion.

plus why are you lesioning at 90deg(non standard practice)? The literature shows no additional benefit (ie duration of effect 280days +/-)above 80-82deg, you are increasing neuritis side effects, and obviously rare nerve root injury. I couldn’t defend 90deg as universal accepted practice in the USA(maybe in New Zealand).

But again, your perfect technique avoids the statistics... good luck partner

 

[lobelsteve]

90 deg is preferred and increases lesion size.

Factors that affect radiofrequency heat lesion size - PubMed

Tip gauge, tip length, temperature, and time substantially affect RF lesion size.

www.ncbi.nlm.nih.gov

 

[Ducttape]

Read above posts. I provided my opinion fairly clearly.
Do what you like , it’s good to know that maybe other techniques can exist.
I don’t think I’ve ever closed a IPG pocket with more than marcaine 0.25% mixed with lido 1%. Only used lido 4% in a labor epidural/ c section. Or maybe a viscous lido for spheno block.

you have provided an opinion but I do not believe you have presented any evidence to directly support your opinion.

please post some of this before making global doom and gloom statements.


thanks Steve for posting that study.

 

[Ligament]

I assert that RFA complications occur, and that risk factors are well known in the literature. I am not specifically critiquing your personal practice. It’s called an opinion.

plus why are you lesioning at 90deg(non standard practice)? The literature shows no additional benefit (ie duration of effect 280days +/-)above 80-82deg, you are increasing neuritis side effects, and obviously rare nerve root injury. I couldn’t defend 90deg as universal accepted practice in the USA(maybe in New Zealand).

But again, your perfect technique avoids the statistics... good luck partner

You did specifically critique my personal practice
1. " it turns out that you did more than a transiently cause a motor block. I’m surprised by the capricious responses"
2. "plus why are you lesioning at 90deg(non standard practice)?"

90deg is common practice in my community, including amongst past ISIS leadership that did these same procedures out of the same surgery center I work out of. So is 4% lidocaine, BTW.

 

[lonelobo]

Optimal Temperature for Radiofrequency Ablation of Lumbar Medial Branches for Treatment of Facet-Mediated Back Pain - PubMed

There seems to be significant functional improvement associated with temp of 90°C compared to 80°C, with no added risk of complications. Randomized controlled studies are warranted.

www.ncbi.nlm.nih.gov

 

[10KHertz]

You did specifically critique my personal practice
1. " it turns out that you did more than a transiently cause a motor block. I’m surprised by the capricious responses"
2. "plus why are you lesioning at 90deg(non standard practice)?"

90deg is common practice in my community, including amongst past ISIS leadership that did these same procedures out of the same surgery center I work out of. So is 4% lidocaine, BTW.

This is a rfa thread. Comments are non-specific and general ideas are to be discussed and debated. “Responses” is plural, you are singular, and you are not being targeted. “You” refers to persons with catastrophic rfa complications, which you don’t have. Hence, it doesn’t critique your protocol.

As for 90deg thermal lesioning, do you have any data to support this recommendation? What sources are your gold standard? Do you integrate multiple sources?

fun conversation , no hostility here...

 

[10KHertz]

Optimal Temperature for Radiofrequency Ablation of Lumbar Medial Branches for Treatment of Facet-Mediated Back Pain - PubMed

There seems to be significant functional improvement associated with temp of 90°C compared to 80°C, with no added risk of complications. Randomized controlled studies are warranted.

www.ncbi.nlm.nih.gov

‘Randomized controlled studies are warranted’.. conclusion
International study(ie New Zealand , Korea, etc
N = ?
Non randomized , case control study?
This is akin to abstracts in Pain Medicine monthly journals... means very little in context of the entire body of RFA literature...

Would you base your rfa practice on this international case report??

My personal interpretation of the literature shows 80-85deg is the max (Bogduk, etc). There are a anatomical studies showing that the clinical benefit above this is much less with more side effects .

Looks like there is a 2021 phase three trial trying to prove 90deg is efficacious. But we can’t make that conclusion yet...

 

[soccrwz]

anyone changing the temp or duration in the neck vs back, I usually do two burns per level 180 degree rotation

 

[Baron Samedi]

90 degrees, 105 seconds. No sedation.

Pre-treatment - 1cc of 50/50 1% lidocaine/0.25% bupivacaine, wait 60 seconds before treatment.
Post-treatment - tiny squirt of Kenalog mixed with a little more 1% - something like 2-5mg per level

All but the most anxious patients do well. I'll give them 5mg of valium only if they specifically request it and I can't scare them out of it by quoting increased risks of complications.

 

[10KHertz]

90 degrees, 105 seconds. No sedation.

Pre-treatment - 1cc of 50/50 1% lidocaine/0.25% bupivacaine, wait 60 seconds before treatment.
Post-treatment - tiny squirt of Kenalog mixed with a little more 1% - something like 2-5mg per level

All but the most anxious patients do well. I'll give them 5mg of valium only if they specifically request it and I can't scare them out of it by quoting increased risks of complications.

On average how many months of relief are you getting at 90deg?

 

[Baron Samedi]

On average how many months of relief are you getting at 90deg?

6 to 12. I had a few patients who failed RFA at 80 after slam dunk MBB that I repeated at 90 and had relief, so it's just become my standard now.

 

[clubdeac]

‘Randomized controlled studies are warranted’.. conclusion
International study(ie New Zealand , Korea, etc
N = ?
Non randomized , case control study?
This is akin to abstracts in Pain Medicine monthly journals... means very little in context of the entire body of RFA literature...

Would you base your rfa practice on this international case report??

My personal interpretation of the literature shows 80-85deg is the max (Bogduk, etc). There are a anatomical studies showing that the clinical benefit above this is much less with more side effects .

Looks like there is a 2021 phase three trial trying to prove 90deg is efficacious. But we can’t make that conclusion yet...

There's another study out there showing superiority of 90 degrees over 80. Can't find it at the moment but I started using 90 a year or two ago after it came out. C'mon 10khz, 80 degrees is so 1999

 

[Ducttape]

Would you base your rfa practice on this international case report??

maybe not, but I'm not sure it is more valid basing treatment decisions from a poster such as yourself (pls do not take as a personal attack).

please post studies supporting your position.

 

[lonelobo]

I just do what Steve tells me to do

 

[Baron Samedi]

There's another study out there showing superiority of 90 degrees over 80. Can't find it at the moment but I started using 90 a year or two ago after it came out. C'mon 10khz, 80 degrees is so 1999

Optimal Temperature for Radiofrequency Ablation of Lumbar Medial Branches for Treatment of Facet-Mediated Back Pain - PubMed

There seems to be significant functional improvement associated with temp of 90°C compared to 80°C, with no added risk of complications. Randomized controlled studies are warranted.

www.ncbi.nlm.nih.gov

Unfortunately, I don't have access to the article at my current institution.

 

[lobelsteve]

I just do what Steve tells me to do

 

[SSdoc33]

View attachment 289983

ummmm.... steve would forego allopathic treatment of his pancreatic islet cell cancer for voodoo herbals and psychics. might not be the best person to listen to......

 

[lonelobo]

ummmm.... steve would forego allopathic treatment of his pancreatic islet cell cancer for voodoo herbals and psychics. might not be the best person to listen to......

Let me clarify

I just do what Steve Lobel tells me to do 😉

 

[10KHertz]

maybe not, but I'm not sure it is more valid basing treatment decisions from a poster such as yourself (pls do not take as a personal attack).

please post studies supporting your position.

No insult taken. Now If you called me a “poser” , then I would have been insulted.

Simply pick up a SIS practice guideline for spinal procedures. Take a look at the well summarized references . If you don’t have the $400, I can send you a screen shot of hundreds of references over the last 20years using 80deg as the gold standard... or just look up your insurance company LCD policies and their references as well.

show me a randomized double blind controlled trial showing 90deg is effective. You can’t, it doesn’t exist yet... maybe in 2021.
plus if people aren’t getting result > 280days, why use 90deg as a default? Are you using the extra thermal heat to make up for placement? Maybe increase to 85deg based on some prelim literature first. 90deg in the cervical spine would cause major neuritis pain for my patients . Not worth the call backs if the therapeutic effect doesn’t last 2 years .

I guess I’m much more cautious as I get older and review more catastrophes due to needle placement, excessive heat, sedation, training issues, etc

this would be a good journal club topic for most fellows

 

[10KHertz]

There's another study out there showing superiority of 90 degrees over 80. Can't find it at the moment but I started using 90 a year or two ago after it came out. C'mon 10khz, 80 degrees is so 1999

I’m thinking about braking the 100deg speed limit today ...

 

[Ducttape]

please post some of those pics, with appropriate references.

particularly, please post pics that state that anything above 80 degrees is considered by insurance experimental.

Noridian:

Limitations of Coverage:
A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per rolling 12 month year in the cervical/thoracic spine and five (5) in the lumbar spine.
• For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.
• Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented.
• Non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF are not covered.

Evicore:

CMM 208.4: Non-Indications 
Performance of a radiofrequency joint denervation/ablation for ANY of the following indications is considered not medically necessary: 
When performed without the use of fluoroscopic guidance 
Performing more than two procedures at the same level(s) during a 12 month period of time 
In the absence of two sequential positive diagnostic facet joint injections/medial branch blocks at the same level(s) for an initial radiofrequency treatment, or for a repeat radiofrequency treatment in the absence of at least 50% relief of facet mediated pain for at least 6 months from a previous radiofrequency treatment at the same level(s). 
When performed for neck pain or low back pain in the presence of an untreated radiculopathy 
When performed at a posteriorly fused spinal motion segment (with the exception of patients with clinically suspected pseudarthrosis) 
When performed on more than three (3) contiguous spinal joint levels during the same session/procedure 
When performed to treat pain arising from above C2-3 and below L5-S1 spinal levels 

Performance of radiofrequency joint denervation/ablations for ANY of the following indications is considered experimental, investigational, or unproven: 
Pulsed radiofrequency ablation for chronic pain syndromes 
Endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy 
Cryoablation/cryoneurolysis/cryodenervation 
Chemical ablation (e.g., alcohol, phenol, glycerol) 
Laser ablation 
Ablation by any method for sacroiliac (SI) joint pain 
Cooled radiofrequency ablation

in neither of those 2 guidelines is temperature noted or discussed.


fwiw, the onus is on you to post the articles that are defending your point. just saying that these articles exist in space as evidence as a gold standard does not lend credence to your position.

 

[Laryngospasm]

Has anyone ever been denied by insurance for a 90c burn?

 

[Ligament]

Has anyone ever been denied by insurance for a 90c burn?

no...why would that happen?

 

[Ducttape]

has anyone ever asked for an authorization specifically detailing any of the other specifics of the procedure, like time, secondary lesioning, etc? (other than # levels and bilateral or not, of course)


I think it is ludicrous doing so. its like asking insurance that I plan on closing a wound using subcuticular stitch vs. dermabond.

 

[Laryngospasm]

no...why would that happen?

Seeking edification due to all the insurance talk... not implying any type of rationale.

 

[ateria radicularis magna]

“Knocking” out a nerve root for awhile, with sedation, typically is the cause of most RFA catastrophes... it turns out that you did more than a transiently cause a motor block. I’m surprised by the capricious responses . A few insurance carriers have even excluded RFA coverage for physicians due to the neural injuries nation wide. I’m not exaggerating. The settlements are massive.

Many of you are playing a dangerous game with dense local anesthetics to make your patients more comfortable quickly. If you have reviewed malpractice cases( which I’m sure you have) most of the “wonderfully placed” needles were not placed correctly, and slightly off line , with added sedation, and dense local. If you take away the sedation and you still are increasing risk.

Lastly , think about it. On the one hand you are claiming 1-2mls Of lido 2-4% works so well and is so safe, but on the other hand we all have reported significant nerve root sensory and motor blocks. There is a definite spill over close to the formina and if you have a bad day (your 1:20,000 case is when this happens by the way statistically...) you may end up with with a malpractice event.

Hopefully your expert witness can defend your capricious logic in the setting of well established ASA closed claim data .

What do you mean by “slightly off line”?