Shoulder ablation with pacer in place

[Timeoutofmind]

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Elderly, comorbid, not a candidate for shoulder replacement.

Severe arthritis

Failed flouro guided injection and meds

It’s the left shoulder and pacer is on the left obviously.
Just worried about ruining the pacer battery or electronics given the proximity of the energy… regardless of grounding pad placement…

I typically do a cooled technique with anterior and posterior approach

To boot… Her platelets are chronically around 30. Has done OK with prior preoperative platelet transfusion. So I was going to give her a unit of platelets prior to the procedure given that these are pretty big needles and a sensitive area.

What are your thoughts?

Just too much craziness and bail on the whole thing and tell her to live with it?

Appreciate any input!

 

[DOctorJay]

Bipolar lesions?

 

[MitchLevi]

Bipolar or Butrans

 

[BobBarker]

Bipolar around the joint capsule seems like a good idea. But too much craziness. Platelets have highest risk of iatrogenic bacteremia.

 

[sevo00]

Can’t you just put a magnet on to put the pacemaker in asynchronous mode

 

[lobelsteve]

Not my circus.

 

[PinchandBurn]

Why platelets...use a smaller rfa needle and do it.

 

[callmeanesthesia]

I’d second what others have said. Bipolar RF. No platelet transfusion.
2 20g needles with a bipolar RF produce a much larger lesion than bipolar.
No concern with a pacemaker either.

Cosman et al., 2014

www.bostonscientific.com

 

[au bon pain]

Bipolar around the joint capsule seems like a good idea.

Where specifically would you lesion for this? Any papers/references you go by?

Sincerely,
A bipolar virgin

 

[BobBarker]

Where specifically would you lesion for this? Any papers/references you go by?

Sincerely,
A bipolar virgin

I have never done it but I saw the article posted on LinkedIn and it looked very easy. Let me see if I can find it.

 

[cowboydoc]

Where specifically would you lesion for this? Any papers/references you go by?

Sincerely,
A bipolar virgin

 

[au bon pain]

Thanks much! Aren’t these targets for coolief? Have you done bipolar at these sites?

I’ve done a bit of coolief, but never the shoulder. I hear it’s a pretty painful one and moderate sedation helpful (something I almost never do). How has your experience been?

 

[GatorCHOMPions]

Thanks much! Aren’t these targets for coolief? Have you done bipolar at these sites?

I’ve done a bit of coolief, but never the shoulder. I hear it’s a pretty painful one and moderate sedation helpful (something I almost never do). How has your experience been?

Done two Coolief shoulders, not bipolar, and they actually tolerated it fairly well with local only. Provided decent enough relief that it was worthwhile. I have the Avanos slide decks on all the Coolief procedures. I can try to download/forward to you if needed, PM me.

 

[Ducttape]

um... doesnt sound like the injection was a suprascapular nerve block... try that...

 

[cowboydoc]

Thanks much! Aren’t these targets for coolief? Have you done bipolar at these sites?

I’ve done a bit of coolief, but never the shoulder. I hear it’s a pretty painful one and moderate sedation helpful (something I almost never do). How has your experience been?

I typically do 2 lesions at each spot (1 in the anterior location.) 50/50 whether they get a bit of sedation (50mcg fent/2mg versed most typically) or local only. Parking 2 needles in parallel in the 2 locations 5-8 mm apart and doing a bipolar shouldn't be much of an issue. I'm pretty sure I've done it this way a few times, but it's technically about the same as 2 single lesions, just dropping 2 needles at once.

 

[au bon pain]

I typically do 2 lesions at each spot (1 in the anterior location.) 50/50 whether they get a bit of sedation (50mcg fent/2mg versed most typically) or local only. Parking 2 needles in parallel in the 2 locations 5-8 mm apart and doing a bipolar shouldn't be much of an issue. I'm pretty sure I've done it this way a few times, but it's technically about the same as 2 single lesions, just dropping 2 needles at once.

Thanks, this is very helpful. What settings do you typically use?

 

[cowboydoc]

Thanks, this is very helpful. What settings do you typically use?

80 degrees for 90 sec

 

[Espn123]

Risk/benefit….

 

[Orin]

Cooled or bipolar is fine, but the simplest thing here would be to use that trident needle that Avanos bought from Diros. It's a three tined system that creates a flat but wide lesion which you can use in a conventional, pulsed, or bipolar configuration. If you do a bipolar burn, remember it takes longer to get that lesion to be created so go out 120 - 300 seconds to get a good sized bridge between the two probes. It's cheaper than cooled with two costing ~ 1 cooled system.

I generally skip the anterior targets and just do the posterior ones. I haven't noticed significant benefit with the anterior but I can always repeat it later is my thought process.

I personally would skip the platelets. You can hold pressure on the shoulder sites in my opinion.

If you're in the hospital setting, have someone check the pacemaker and turn off sensing just to make it even less risky. You can put the grounding pad on the forearm or upper arm if they're big enough and hairless to further reduce risk of anything if you must just do cooled.

No risk it, no biscuit as coach always says, but this seems like a reasonable case in an academic HOPD.

 

[Timeoutofmind]

Update

Thanks for all the great advice on here

Did it bipolar
20 gauge 10 mm active tip probes
90°C, 180 seconds

No platelets given

Minimal relief… Around 20%…

Here are the pictures…

 

[lobelsteve]

I don’t see a good view of the suprascapular notch.

 

[Timeoutofmind]

I don’t see a good view of the suprascapular notch.

I’m treating the terminal/articulating branches of the nerves around the shoulder joint.
Not doing a suprascapular ablation in the notch

How I Do It: Shoulder Articular Nerve Blockade and Radiofrequency Ablation

 

[jwheezy]

consider SPRINT PNS vs Nalu? There’s still a suprascapular target that’s not ablated

 

[Timeoutofmind]

consider SPRINT PNS vs Nalu? There’s still a suprascapular target that’s not ablated

Supposedly the terminal branches of the suprascapular nerve that are innervating the shoulder joint are being destroyed with this approach
(second picture top needles)

 

[jwheezy]

Supposedly the terminal branches of the suprascapular nerve that are innervating the shoulder joint are being destroyed with this approach
(second picture top needles)

Yes out peripherally but you can still target proximally potentially. If pain still there then possibly they weren’t ablated well but I would be hesitant to stim something I just ablated

 

[lobelsteve]

I’m treating the terminal/articulating branches of the nerves around the shoulder joint.
Not doing a suprascapular ablation in the notch

How I Do It: Shoulder Articular Nerve Blockade and Radiofrequency Ablation

Why? The best data is for getting the nerve in the notch. You missed.

 

[Tboned]

Burn ‘em then stim ‘em

 

[drmamba]

Majority of shoulder joint is enervated by the articular branches of the suprascapular nerve. Would repeat bipolar lesion closer to the notch x1 as mentioned above and also another one more inferior to your original target at the edge of the scapula x1. Would discuss that some motor weakness is a possibility but at this age and level of disability, it may be a worthwhile risk/benefit. Would also give steroids and long acting local at the end of the case if you did not.

Reasonable alternative is Butrans if you prescribe.

PNS works more often than not but may interfere with pacemaker if higher settings are required and is not sustainable. Would also be hesitant to implant a perm in this patient due to other issues. Would not offer PNS altogether for this patient. There is only so much stim can do for a severely degenerative shoulder.

Won't be able to fix everyone, unfortunately.

 

[Gnarvin]

View attachment 394195
Majority of shoulder joint is enervated by the articular branches of the suprascapular nerve. Would repeat bipolar lesion closer to the notch x1 as mentioned above and also another one more inferior to your original target at the edge of the scapula x1. Would discuss that some motor weakness is a possibility but at this age and level of disability, it may be a worthwhile risk/benefit. Would also give steroids and long acting local at the end of the case if you did not.

Reasonable alternative is Butrans if you prescribe.

PNS works more often than not but may interfere with pacemaker if higher settings are required and is not sustainable. Would also be hesitant to implant a perm in this patient due to other issues. Would not offer PNS altogether for this patient. There is only so much stim can do for a severely degenerative shoulder.

Won't be able to fix everyone, unfortunately.

I have done a fair amount of these using basically the targets you posted. I really don’t like doing them because I often get significant motor stim with the suprascapular and axillary targets. Not just local twitches but actual motor stim of the expected muscles innervated by the nerves. I then spend a lot of time fiddling around trying to eliminate the motor stim. Any advice to reduce or eliminate the motor stim or is some just to be accepted with this procedure? I do caution patients that some weakness is a possibility.

 

[drmamba]

I have done a fair amount of these using basically the targets you posted. I really don’t like doing them because I often get significant motor stim with the suprascapular and axillary targets. Not just local twitches but actual motor stim of the expected muscles innervated by the nerves. I then spend a lot of time fiddling around trying to eliminate the motor stim. Any advice to reduce or eliminate the motor stim or is some just to be accepted with this procedure? I do caution patients that some weakness is a possibility.

Yes, motor stim is frequently achieved for shoulder, but it's important to differentiate between local twitching versus total activation of the muscle group. If it's local twitching only, then I ablate away after some slight adjustments. If I get total activation of the muscle (encounter this seldomly), then I adjust more aggressively. I routinely tell all of my patients that some weakness can occur and generally don't use RFA for younger and/or more functional patients.

 

[lobelsteve]

Simopoulis, Sial et al. Supraspinatus RFA. No functional weakness.

 

[drmamba]

Simopoulis, Sial et al. Supraspinatus RFA. No functional weakness.

Exactly, especially if using the proper targets. Saw a patient last year who got his shoulder roasted in the community and had objective findings of shoulder weakness (4+/5). Reviewed the images and the targets were nowhere near the usual targets for the articular branch nerves. Weakness improved with time and PT.

 

[Sadder]

I am interested in your opinion colleagues

 

[Ducttape]

10 patients.

it is behind a paywall, so i couldnt see the whole article.

case series. not a study per se. so conclusions are limited.



seems like it would take a long time to do this method. 4 lesions, then flip the patient to do an additional 3-4 lesions...

 

[lobelsteve]

10 patients.

it is behind a paywall, so i couldnt see the whole article.

case series. not a study per se. so conclusions are limited.



seems like it would take a long time to do this method. 4 lesions, then flip the patient to do an additional 3-4 lesions...

For $100?

 

[Ducttape]

yea im not a rich pain doc. if you pay for it, ill look at it... or better yet, you can look at it and report your assessment of the article.

 

[lobelsteve]

yea im not a rich pain doc. if you pay for it, ill look at it... or better yet, you can look at it and report your assessment of the article.

I meant reimbursement $100 so it is not worth the time to do exotic academic procedures when simple SSRFA works well enough.

 

[Sadder]

Full

 

[Ducttape]

thanks.

observational "study".

no comparison group. limited analysis because of that. is it better than single nerve pulsed or thermal? cannot draw any conclusions.



will never be done outside of an academic center.

they placed 11 probes (at 5 locations) and did motor and sensory testing and RF for 90 seconds prone and then supine. lobel could do 2 kyphos and replace a tranny in that time period.

 

[lobelsteve]

thanks.

observational "study".

no comparison group. limited analysis because of that. is it better than single nerve pulsed or thermal? cannot draw any conclusions.



will never be done outside of an academic center.

they placed 11 probes (at 5 locations) and did motor and sensory testing and RF for 90 seconds prone and then supine. lobel could do 2 kyphos and replace a tranny in that time period.

Sterility on 2nd kypho would be suspect.