RFA/pacemaker poll

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Drd105

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I have been getting cardiology clearance for “okay for magnet over pacemaker during RFA” and if they sign off, going for it. A patient today told me a local competitor whom he saw told him IA facet inj only. I was just wondering if I’m in the minority or majority here or are we split?
 
I don't even consider the fact you've got a pacer when I'm ablating you.

N = All the n's.
 
Aware of a case in last 2 months of an RF gone wrong with defib popping 2x on a guy during RF. Doc freaked out a little but patient got seen by cardiology and was fine. Place your grounding pad as close to the worksite as possible, and opposite the pacer.
 
lobelsteve said:
Aware of a case in last 2 months of an RF gone wrong with defib popping 2x on a guy during RF. Doc freaked out a little but patient got seen by cardiology and was fine. Place your grounding pad as close to the worksite as possible, and opposite the pacer.
Click to expand...
Oh shoot I always do calf…so if I’m left lumbar, I should place it right lumbar? And since pacer is on the left- for right lumbar where would you place?
 
ive seen a lot of differing opinions, including from EP cardiologists. also, different pacemaker/defibs have different recs. i dont even think about it for lumbar, but for cervicals ill do a little digging. happens maybe once a year. one patient was adamant about using a magnet. one cardiologist was as well. i get nervous turning them off with the magnet. i dont feel like its my role to mess with it
 
Screen Shot 2022-11-30 at 10.35.06 AM.png
 
lobelsteve said:
Aware of a case in last 2 months of an RF gone wrong with defib popping 2x on a guy during RF. Doc freaked out a little but patient got seen by cardiology and was fine. Place your grounding pad as close to the worksite as possible, and opposite the pacer.
Click to expand...
Happened to me on a cervical a couple years ago. No issues, lit search with no issues reported with pacer or AICD complications related to RF.
 
I do RFAs at Day Hospital if patient wants IVCS. Basically, this just includes some patients I inherited, who are used to prior RF's with sedation. If a patient has a PM or ICD, I'll do them in Day Hospital as well. There's always device reps in the building. If it's an ICD, I'll have them interrogate before and after. If it's just PM, I'll monitor. Right or wrong, I have a better comfort level doing them in this manner.
 
If for whatever reason you WANT to do intraarticular facet injections (those handful of patients who have had them in the past and have done well with them when they were still popular), you can document that RF is contraindicated to pacer or blood thinners. We all do RF on patients with pacers and blood thinners, but insurance is stupid. I did a peer to peer on a patient who previously had 6 months relief from a steroid injection and the doc on the other end said “is there a reason you can’t do RF? Pacemaker, on blood thinners?” Not saying this is the case for all insurances, but it may work for you.
 
Side question: i've had quite a few patients with significant scoliosis who have facet disease. have tried to do my best to get optimal needle placement for RFA but often times imaging is a nightmare and its tough to get great views. any advice on how to get better results with RFA on these types of patients?
 
gaschicago said:
Side question: i've had quite a few patients with significant scoliosis who have facet disease. have tried to do my best to get optimal needle placement for RFA but often times imaging is a nightmare and its tough to get great views. any advice on how to get better results with RFA on these types of patients?
Click to expand...

Nimbus needles or cooled RF
 
gaschicago said:
Side question: i've had quite a few patients with significant scoliosis who have facet disease. have tried to do my best to get optimal needle placement for RFA but often times imaging is a nightmare and its tough to get great views. any advice on how to get better results with RFA on these types of patients?
Click to expand...
Book a little more time for those cases, as you'll probably need to airplane the table, oblique, wig/wag differently for each level.

This is actually one situation where being good at using AP only is helpful. It might be hard to get good laterals and obliques, but you can usually get a good true, squared up AP at each level. Skin entry inferior to inferolateral corner of TP, advance to groove until you start to walk off superomedially. Check motors and call it a day. Paraspinal contraction is reassuring in a tough case.
 
RoloTomassi said:
Book a little more time for those cases, as you'll probably need to airplane the table, oblique, wig/wag differently for each level.

This is actually one situation where being good at using AP only is helpful. It might be hard to get good laterals and obliques, but you can usually get a good true, squared up AP at each level. Skin entry inferior to inferolateral corner of TP, advance to groove until you start to walk off superomedially. Check motors and call it a day. Paraspinal contraction is reassuring in a tough case.
Click to expand...
you may have to adjust angle of obliquity based on each individual level.

for this lady's RF, i ended up changing obliquity at each level for her L34/L45 RFA. the left side was pretty easy. not so much the right. i think the obliquity was close to 60 degrees.....
spine scoliosis.GIF
 
RoloTomassi said:
Book a little more time for those cases, as you'll probably need to airplane the table, oblique, wig/wag differently for each level.

This is actually one situation where being good at using AP only is helpful. It might be hard to get good laterals and obliques, but you can usually get a good true, squared up AP at each level. Skin entry inferior to inferolateral corner of TP, advance to groove until you start to walk off superomedially. Check motors and call it a day. Paraspinal contraction is reassuring in a tough case.
Click to expand...
agree with most of this. even so, results in bad scoliosis patients arent the best
 
i would not apply a magnet to an ICD without at least talking to the rep.


they are readily accessible, if the cardiologist is not.
 
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