Superior cluneal nerve pulsed radiofrequency treatment

[Ligament]

Pulsed RF of left superior cluneal nerves
Do you guys think the contrast outlines branches of the nerves, or just muscle fibers of the glutes? I am not sure either way.
Patient did have strongly concordant stimulation at the lateral most 3 branches with 50hz stimulation.

This guy weighs around 400lbs so U/s was not a good option.

---

Members don't see this ad.

 

[NJPAIN]

Pulsed RF of left superior cluneal nerves
Do you guys think the contrast outlines branches of the nerves, or just muscle fibers of the glutes?
He did have strongly concordant stimulation at the lateral most 3 branches....

View attachment 279871

Lig. Can you give us some description of the problem being treated?

 

[Ligament]

Lig. Can you give us some description of the problem being treated?

Patient has intractable pain in the left buttock/iliac crest. Excellent local doc did left superior cluneal blocks, got excellent anesthetic phase pain relief, no lasting benefit. Sent to me for pulsed RF or cryo.

 

[TheLoneWolf]

Prior surgery or injury at the site?

 

[NJPAIN]

Patient has intractable pain in the left buttock/iliac crest. Excellent local doc did left superior cluneal blocks, got excellent anesthetic phase pain relief, no lasting benefit. Sent to me for pulsed RF or cryo.

You doing much Cryo? Did you get the Epimed cryo unit?

 

[Ligament]

Prior surgery or injury at the site?

He has had a ton of surgeries there, lots of reasons for cluneal neuralgia.

 

[Ligament]

You doing much Cryo? Did you get the Epimed cryo unit?

I did buy the EpiMed cryo unit finally after bothering you guys about cryo for 10 years or so.

I do not do a lot of it, it serves a very specialized niche. It is slow too, logistically cumbersome. Just did genitofemoral cryo today however.

 

[Orin]

Stimulate it! You can lay a Stimwave or Bioness lead along it, using a nerve stimulator to map out the individual nerve locations.

 

[Ronin1]

Are you getting paid for peripheral RF, pulsed no less?

 

[drusso]

Curious how you billed this and if you did it in ASC vs Office SOS. I would think it is viable as cash service in the office.

 

[TIVAndy]

why pulsed not regular rf?

 

[Ligament]

Are you getting paid for peripheral RF, pulsed no less?

Cash pay.

 

[Ligament]

why pulsed not regular rf?

Referring doc requested pulsed, patient wanted to try neuromodulation before neurodestruction. Patient has had a lot of surgery as you can see wants to try more conservative options.

 

[Ligament]

Curious how you billed this and if you did it in ASC vs Office SOS. I would think it is viable as cash service in the office.

Just cash. Did in ASC cause he wanted sedation and I wanted a four output RF generator. My in office generator just has one output.

 

[BobBarker]

Just cash. Did in ASC cause he wanted sedation and I wanted a four output RF generator. My in office generator just has one output.

I’m sure your local ABT/BSX/MDT rep would be very happy to help you remedy this problem. Perhaps you may be interested in a bulk trial lead purchase as well?

 

[Timeoutofmind]

He has had a ton of surgeries there, lots of reasons for cluneal neuralgia.

What surgeries?

 

[Ligament]

What surgeries?

Hahaha did you look at the image?

 

[Timeoutofmind]

Hahaha did you look at the image?

So no prior surgery or injury at the iliac crest...

 

[painfree23]

How do diagnose cluneal neuralgia vs factogenic?

 

[Ferrismonk]

How do diagnose cluneal neuralgia vs factogenic?

Where the pain is (iliac crest and buttocks) and diagnostic blocks.

 

[Ligament]

Where the pain is (iliac crest and buttocks) and diagnostic blocks.

I agree with this. Need to palpate the patient. Upper quadrant buttock pain? Rule out Facets, SIJs. This patient has both fused. Is it the glute tendon origins (VERY common, in fact I think more commonly a pain generator than facets or SIJs)? Steroid or PRP to the glute origins. Not the glute origins, but still tender over the superior iliac crest? Consider superior cluneal neuralgia. Do a diagnostic block or two. If good anesthetic relief, try steroid, pulsed, platelet lysate, cryo, RF, or stim. Can also cut the nerves surgically if you send to one of the few peripheral nerve surgeons, they like to work on these nerves, very easy and safe location.

 

[Ligament]

Andrea Trescot has published a lot on cluneal neuralgia. There is a fairly new u/s guided cluneal nerve block technique recently published as well (more of a fascial plane block that captures the superior cluneal nerves).

 

[Orin]

How do diagnose cluneal neuralgia vs factogenic?

I normally palpate overlying iliac crest to see if there is cluneal entrapment and something approximating a Tinel's sign. As the others said, the cluneal pain also tends to be far more lateral/buttock region than the facet line.

Ultrasound/stim or fluoro guided field block over the crest is great.

 

[oreosandsake]

Ultrasonographic Technique for Imaging and Injecting the Superior Cluneal Nerve

The video demonstrates the anatomy of the superior cluneal nerve and the ultrasonographic technique for imaging and injecting the superior cluneal nerve.

journals.lww.com

 

[painfree23]

does insurance pay for his injection?

 

[Ferrismonk]

It's a nerve block, 64450. RFA 64640. Pulsed not usually covered, hence the cash-pay.

 

[Ligament]

does insurance pay for his injection?

Insurance does not cover pulsed RF, so no. This is cash pay.

 

[TheLoneWolf]

How much do you charge?

 

[Orin]

Insurance does not cover pulsed RF, so no. This is cash pay.

But they do pay for PNS?