Supraorbital RFA

[SpineandWine]

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Anyone do Supra-orbital RFA - Have a patient who is having pain above his eyeball and I did a 1 cc numbing injection at supraorbital notch which helped improve his pain significantly.
Not sure if anyone has experience doing this procedure/whether it will cause long lasting problems such as neuritis.

 

[deleted131481]

Never done it so I'd likely try pulsed RFA first. If traditional maybe try lower temp like 60c and a smaller needle 22g 5mm tip so don't fry the skin.

 

[Agast]

Since it's sensory only, shouldn't traditional RF be ok? I also read you could use phenol for chemical neurolysis

 

[lobelsteve]

Botox, pulsed.
I wouldn't thermally lesion the face.

 

[Ducttape]

yes, thermal or chemical treatment of such a superficial nerve may lead to disfigurement.

where did you put the pad?

no dont tell me. you shave his head, attach 2 bolts to keep the pad on....

 

[Ferrismonk]

Botox, pulsed.
I wouldn't thermally lesion the face.

I agree with Steve, but pulsed likely won't be covered. It's okay to do repeated blocks as well if they last a while.

 

[painfree23]

Is it for tgn?

 

[ziggyziggy]

I consider Botox and repeat nerve block as reasonable options. If pt has migraine headaches, Botox will be covered benefit.

 

[Baron S]

I did a pulsed RF recently for a lady who had a supraorbital flap after a dog bit half her nose off. I would hesitate to ablate due to how superficial it is and risk of soft tissue injury.

 

[Orin]

I agree with Steve, but pulsed likely won't be covered. It's okay to do repeated blocks as well if they last a while.

Pulsed won't be paid for the RF portion, but if you've got a reusable RF cannula, you can bill for the trigeminal nerve block and eat the costs of the pulse RF-ing.

There's a lot out there in the literature about protecting skin from RF heat with ice packs or injecting air above the needle to protect the skin in thermal ablations. Thermal RF of the TG is an option here, so I wouldn't be bothered by doing it of the peripheral branches, other than the technical aspects of it.

Supraorbital PNS is also an option, but off label.

Agree with trying Botox first if he meets criteria for chronic daily headache

 

[bedrock]

Agree with botox first.

If not sufficient, then offer pulsed for cash. Many patients have $4000 deductibles to pay just when they have an epidural.

Patient needing to pay cash for a non covered procedure isn't a big deal. If it bothers them enough, they will find a way to pay for it.

 

[nvrsumr]

What is the mechanism of pain relief from from perineural Botox injection for supraorbital neuralgia? Old fashioned and I thought debunked for pain

 

[DODOCSS]

W

What is the mechanism of pain relief from from perineural Botox injection for supraorbital neuralgia? Old fashioned and I thought debunked for pain

does It matter if it works? Worth a shot (x31)

 

[crunchymedicine]

Pulsed won't be paid for the RF portion, but if you've got a reusable RF cannula, you can bill for the trigeminal nerve block and eat the costs of the pulse RF-ing.

There's a lot out there in the literature about protecting skin from RF heat with ice packs or injecting air above the needle to protect the skin in thermal ablations. Thermal RF of the TG is an option here, so I wouldn't be bothered by doing it of the peripheral branches, other than the technical aspects of it.

Supraorbital PNS is also an option, but off label.

Agree with trying Botox first if he meets criteria for

Why not just cut the nerve the old fashioned way?

 

[nvrsumr]

Agree. Would try the migraine angle before thermal rf.

think you are supposed to hit the specific 31 spots (as doocs mentioned) and document 15+ days of migraine for it to be kosher. Supraorbital notch is not one of the spots

I had an extremely nice patient who got tremendous relief from a couple Supra orbital blocks. That was when US paid $200 for guidance or I probably would have skipped. Same reason I no longer do Botox for anything.

 

[deleted875186]

To clarify the Botox, are we talking about doing the typical Botox migraine protocol all over the head?

Or are people suggesting injecting a larger number of units of Botox in e supraorbital area?

 

[soccrwz]

I had a patient get burned from someone else RFA her supraorbital now with a facial scar. why not cryo it Iovera?

 

[nvrsumr]

Expensive and probably not covered but the best idea.

 

[Ducttape]

is there any data that shows that cryoablation does not cause local necrosis of skin and subsequent skin damage?

also, my understanding is that cryo needles are 17 gauge - is that correct? what is the smallest needle size and what is the smallest lesion size that one gets?

 

[Baron S]

You can definitely get skin injury after a cooled RFA. The risk is probably higher than convential given the large radius.

 

[soccrwz]

They have a smaller multipronged, and single needle needle with a heating element; look up iovera; this isn't cooled RF; people use it for more superficial nerves.

 

[Ducttape]

the iovera website mentions potential for skin damage.

Proper use of the device as described in the User Guide can help reduce or prevent the following complications:

• At the treatment site(s): injury to the skin related to application of cold or heat, hyper- or hypopigmentation, and skin dimpling
• Outside the treatment site(s): loss of motor function

this is on the forehead... i dont think i would be heads up enough or have the foresight to tell people about the potential for scarring....

 

[jwalker12]

Anyone do Supra-orbital RFA - Have a patient who is having pain above his eyeball and I did a 1 cc numbing injection at supraorbital notch which helped improve his pain significantly.
Not sure if anyone has experience doing this procedure/whether it will cause long lasting problems such as neuritis.

What did you place in your 1cc injectate?

 

[cowboydoc]

is there any data that shows that cryoablation does not cause local necrosis of skin and subsequent skin damage?

also, my understanding is that cryo needles are 17 gauge - is that correct? what is the smallest needle size and what is the smallest lesion size that one gets?

Iovera has a trident configuration with the 3 pins, 27g. Treats 1cm deep, roughly that width, has a mechanism to disperse temp at surface. IMO, this is the most impressive aspect of their proprietary technology. Seems ideal for this scenario, but it’s not a nerve I’ve treated.

Iovera Smart Tips | HCP

As stated, cryo =/ cooledRF

 

[cowboydoc]

I’ve had 2 superficial skin lesions with their 90mm probe, zero with the trident. N=~800

 

[painfree23]

Iovera has a trident configuration with the 3 pins, 27g. Treats 1cm deep, roughly that width, has a mechanism to disperse temp at surface. IMO, this is the most impressive aspect of their proprietary technology. Seems ideal for this scenario, but it’s not a nerve I’ve treated.

Iovera Smart Tips | HCP

As stated, cryo =/ cooledRF

Can u bill RF for iovera? Is it in office? Do u block before?

 

[cowboydoc]

Can u bill RF for iovera? Is it in office? Do u block before?

64640. U/s most nerves, may block immediately before. Don’t do dx block before cryo.

 

[drrosenrosen]

64640. U/s most nerves, may block immediately before. Don’t do dx block before cryo.

Do you do LFCN with this? I have a MP pt I was going to offer pulsed RF. What does the equipment cost?

 

[cowboydoc]

Do you do LFCN with this? I have a MP pt I was going to offer pulsed RF. What does the equipment cost?

For LFCN, I'll hit it with steroid/lido a couple times and do Iovera for recalcitrant cases. Use U/S for all of these.

The handheld is absurd ($6000??) The disposable tips are >$300. You'll use $20-40 of CO2 cartridges, too.

I can't imagine how this would pencil out for PP. My clinic probably breaks even.