TON ablation: More pain than its worth?

[manowar rules]

I have done several TON/C2-3 RFA for what I considered classic upper cervical and occipital pain, usually in the setting of bad C2-3 arthropathy. Patients had good MBB response. My problem is that most of the patients are getting the undesirable, and pretty severe, post-RFA occipital neuralgia. Uncomfortable to even touch the back of their head, brush their hair, etc. I get that this is a risk, but I was quoted in residency 20-25% of patients and the incidence of neuralgia I see from myself and my partner who does it is probably over 50%. Can take a month to go away with very mild improvement with gabapentin/Lyrica, steroid injection around C2-3. And that month sucks, patients who have done well with other procedures are miserable. I think that most of them would not repeat the ablation, even after the relief eventually comes. So I am considering abandoning the TON ablation even for patients with classic pain in that distribution, and sticking with C3-6, where I have not had these issues.

Does anyone share this experience where the neuralgia outweighs the benefit? For what its worth, I use 20g cannulas (2 burns at each site, withdrawing a few mm after first burn) and my partner uses 18g.

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[Taus]

I see frequent mild neuritis that patients agree feels like a mild sunburn. I tell all up front that may get this and that it always goes away. Telling them that seems to decrease rate of those bothered or complaining about it. Very rare- ie maybe 1x/year get one considered painful enough that I have to do something about. I use 18g 10mm active tip x 3-4 burns for TON. 2 burns other levels.

of course now that I’m writing this will see way more bad neuritis shortly....

 

[willabeast]

I found in my hands doing a suboccipital injection of botox worked better than anything else. The injection took me 5 minutes, no xrays, and lasted about 4 months. Since i was working in an HMO it only cost the patient a co-pay. So for 15 minutes of my time i could keep a patient happy for 12 months. used a #25 gauge needle. never had a complication over course of 20 years. Since no one else seems to do them i assume there are issues, but i never ran into them. I think neurology does a similar procedure. Botulinum toxin occipital nerve block for the treatment of severe occipital neuralgia: a case series. - PubMed - NCBI

 

[Ferrismonk]

I see terrible neuritis from this procedure as well. I let patients know and they decide risk/benefit. I give them gaba/lyrica, topical lidocaine, and maybe Tramadol if it gets really bad.

Regarding the botox, I do Botox for Migraine prophylaxis which also seems to work really well. The suboccipitals are also targeted during this procedure. Most insurances will cover this, as long as you've tried and failed enough of the meds.

 

[NJPAIN]

I found in my hands doing a suboccipital injection of botox worked better than anything else. The injection took me 5 minutes, no xrays, and lasted about 4 months. Since i was working in an HMO it only cost the patient a co-pay. So for 15 minutes of my time i could keep a patient happy for 12 months. used a #25 gauge needle. never had a complication over course of 20 years. Since no one else seems to do them i assume there are issues, but i never ran into them. I think neurology does a similar procedure. Botulinum toxin occipital nerve block for the treatment of severe occipital neuralgia: a case series. - PubMed - NCBI

I have had success with this as well. Mostly in the region of the GON. Difficult to get insurance coverage.

Regarding neuritis associated with TON RFN, I recall Bedrock posting a technique using temp around 70 deg and slow temp ramp up speed. Anyone try this?


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[SommeRiver]

I don't do the procedure bc of this. I had one pt with severe neuritis that she still complains about over a yr later.

 

[paindoc007]

I don't do the procedure bc of this. I had one pt with severe neuritis that she still complains about over a yr later.

Chronic neuritis from a ton rfa? Err, no. She prob wants you to cont her opioids is why is still a chief complaint.

 

[Ligament]

I have done several TON/C2-3 RFA for what I considered classic upper cervical and occipital pain, usually in the setting of bad C2-3 arthropathy. Patients had good MBB response. My problem is that most of the patients are getting the undesirable, and pretty severe, post-RFA occipital neuralgia. Uncomfortable to even touch the back of their head, brush their hair, etc. I get that this is a risk, but I was quoted in residency 20-25% of patients and the incidence of neuralgia I see from myself and my partner who does it is probably over 50%. Can take a month to go away with very mild improvement with gabapentin/Lyrica, steroid injection around C2-3. And that month sucks, patients who have done well with other procedures are miserable. I think that most of them would not repeat the ablation, even after the relief eventually comes. So I am considering abandoning the TON ablation even for patients with classic pain in that distribution, and sticking with C3-6, where I have not had these issues.

Does anyone share this experience where the neuralgia outweighs the benefit? For what its worth, I use 20g cannulas (2 burns at each site, withdrawing a few mm after first burn) and my partner uses 18g.

Don't give this procedure up! It may be the very best and most helpful procedure I offer. The incidence of neuralgia should be soemewhere around 50% ish, and should last 1-3 weeks in most folks.

Very important you educate them on the neurtiis, and if they expect it, they will not be as miserable. Spend a LOT of time on this. Also educate them it will take around 8 weeks to see the full benefits, no sooner.

You can also tell them to use solarcaine, it is now 4% liodcaine, if I am not mistaken.

Don't listen to what you were told in residency; most likely they were doing a shoddy job, not ablating enough of the nerve for sake of expediency. You can watch the yahoos on youtube doing this procedure and the crap technique they use is astounding. It is very easy to do this procedure incorrectly and quickly, difficult to do it properly.

I have patients that come back every 1-3 years on the regular for a repeat of this procedure for over 10 years now. They love the outcomes. Has been life changing in a lot of "Migraine" and MVA whiplash patients. Sure, I wish it was permanent, but 1-3 years of relief is nothing to sneeze at.

I have done many hundreds of TON RFAs... Can only recall about 10-15 cases of very bothersome neuritis that lasted more than a couple weeks.

I've used everything from 20ga to 16ga using ISIS technique. I've posted my images previously.

 

[SommeRiver]

Chronic neuritis from a ton rfa? Err, no. She prob wants you to cont her opioids is why is still a chief complaint.

I know it's not my procedure, and she's not on opiates.

 

[NJPAIN]

Don't give this procedure up! It may be the very best and most helpful procedure I offer. The incidence of neuralgia should be soemewhere around 50% ish, and should last 1-3 weeks in most folks.

Very important you educate them on the neurtiis, and if they expect it, they will not be as miserable. Spend a LOT of time on this. Also educate them it will take around 8 weeks to see the full benefits, no sooner.

You can also tell them to use solarcaine, it is now 4% liodcaine, if I am not mistaken.

Don't listen to what you were told in residency; most likely they were doing a shoddy job, not ablating enough of the nerve for sake of expediency. You can watch the yahoos on youtube doing this procedure and the crap technique they use is astounding. It is very easy to do this procedure incorrectly and quickly, difficult to do it properly.

I have patients that come back every 1-3 years on the regular for a repeat of this procedure for over 10 years now. They love the outcomes. Has been life changing in a lot of "Migraine" and MVA whiplash patients. Sure, I wish it was permanent, but 1-3 years of relief is nothing to sneeze at.

I have done many hundreds of TON RFAs... Can only recall about 10-15 cases of very bothersome neuritis that lasted more than a couple weeks.

I've used everything from 20ga to 16ga using ISIS technique. I've posted my images previously.

Lig. Since you are so experienced with, passionate about and have such great results with this procedure please run through your current technique including positioning, needle size, lesion temp,etc. Do you use a sagittal and oblique path with their associated different target zones? Do you always include the subadjacent level? Also, what characteristics are cluing you in to incorporating in 'migraine" treatment?

I find the procedure is often technically very challenging from the get go. Many of my patients are elderly so there is a ton of dental work that gets in the way on AP and then the joint is a big hypertrophic mess.

 

[pmrmd]

C2-3 is a prime headache generator. You have to RF the level. Come down AP on it with two cannulas, burn then rotate then burn again. Personally I stopped the three position SIS since I felt I got it with the rotations.

IMO unless there is a tumor or aneurysm in there, headaches are cervical with variable amounts of psychosomatic overlay.


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[callmeanesthesia]

I warn patients several times before the ablation that numbness of the back of the head and a bad sunburn feeling are common and the discomfort usually goes away by 4 weeks but the numbness can last months. Rarely do I get calls - most just tell me about it at follow up.

 

[NJPAIN]

C2-3 is a prime headache generator. You have to RF the level. Come down AP on it with two cannulas, burn then rotate then burn again. Personally I stopped the three position SIS since I felt I got it with the rotations.

IMO unless there is a tumor or aneurysm in there, headaches are cervical with variable amounts of psychosomatic overlay.


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Do you feel that holds true for HA that meet criteria for episodic and/or chronic migraine if there is accompanying neck pain?

 

[Orin]

We don't often see true neuritis here. What're y'all injecting pre/post RF?

 

[deleted993114]

I have done several TON/C2-3 RFA for what I considered classic upper cervical and occipital pain, usually in the setting of bad C2-3 arthropathy. Patients had good MBB response. My problem is that most of the patients are getting the undesirable, and pretty severe, post-RFA occipital neuralgia. Uncomfortable to even touch the back of their head, brush their hair, etc. I get that this is a risk, but I was quoted in residency 20-25% of patients and the incidence of neuralgia I see from myself and my partner who does it is probably over 50%. Can take a month to go away with very mild improvement with gabapentin/Lyrica, steroid injection around C2-3. And that month sucks, patients who have done well with other procedures are miserable. I think that most of them would not repeat the ablation, even after the relief eventually comes. So I am considering abandoning the TON ablation even for patients with classic pain in that distribution, and sticking with C3-6, where I have not had these issues.

Does anyone share this experience where the neuralgia outweighs the benefit? For what its worth, I use 20g cannulas (2 burns at each site, withdrawing a few mm after first burn) and my partner uses 18g.

The higher you go in the neck, the higher incidence of neuritis. Just count on it and treat it as you have described above. If you prepare patients for that possibility and offer treatment for it, patients are not that bunched over it. The problem with fellowships is that fellows don't see how things work (or don't) longer term. The recent grad in our practice has been surprised by his change in perception of things in seeing patients longer term. Everyone has to go through that and what you are seeing is just one of the many things they don't tell you about in training.

Read the literature from the Dutch guys- I believe that VanKleef has the best articles. They were very enthusiastic about c2/C3 rf and rf ganglion treatments in the 90s. However, their articles in the mid 2000s tended to demonstrate that such treatments were not particularly effective for cervicogenic headaches.

I would definitely suggest a "field trip" to Maastrich for those who are very enthusiastic about radiofrequency and see how they approach things. They have done it all and then some. They are pretty approachable to visiting docs and are very friendly and informative. For those guys of you who are young and single, the Dutch women are some of the best looking in the world. Be warned- they speak better English than we do (as well as about five other languages). The closer you get to Germany, however, the worse the food becomes. The Germans can take any combination of good ingredients and make them taste horrible.

 

[SSdoc33]

The higher you go in the neck, the higher incidence of neuritis. Just count on it and treat it as you have described above. If you prepare patients for that possibility and offer treatment for it, patients are not that bunched over it. The problem with fellowships is that fellows don't see how things work (or don't) longer term. The recent grad in our practice has been surprised by his change in perception of things in seeing patients longer term. Everyone has to go through that and what you are seeing is just one of the many things they don't tell you about in training.

Read the literature from the Dutch guys- I believe that VanKleef has the best articles. They were very enthusiastic about c2/C3 rf and rf ganglion treatments in the 90s. However, their articles in the mid 2000s tended to demonstrate that such treatments were not particularly effective for cervicogenic headaches.

I would definitely suggest a "field trip" to Maastrich for those who are very enthusiastic about radiofrequency and see how they approach things. They have done it all and then some. They are pretty approachable to visiting docs and are very friendly and informative. For those guys of you who are young and single, the Dutch women are some of the best looking in the world. Be warned- they speak better English than we do (as well as about five other languages). The closer you get to Germany, however, the worse the food becomes. The Germans can take any combination of good ingredients and make them taste horrible.

too tall. not good for my napoleon complex

 

[bedrock]

I have had success with this as well. Mostly in the region of the GON. Difficult to get insurance coverage.

Regarding neuritis associated with TON RFN, I recall Bedrock posting a technique using temp around 70 deg and slow temp ramp up speed. Anyone try this?


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I learned the 70 degree trick from Dreyfuss with a slower ramp up speed to the temp. Still works fine and you still get long term relief if you do multiple burns. I also always inject a small amount of dex on the TON before removing the needle.

Very rare TON neuritis with this approach.

 

[Ligament]

Dr. Dreyfuss had been using 85C for a while until retirement, but nothing wrong with 70C.

 

[clubdeac]

Dr. Dreyfuss had been using 85C for a while until retirement, but nothing wrong with 70C.

Dreyfuss uses 85C for his RFs?! What?! Blasphemy! Does @10KHertz know about this 😉

 

[10KHertz]

Dreyfuss uses 85C for his RFs?! What?! Blasphemy! Does @10KHertz know about this 😉

Yo, you pulled me into this thread via my bell alert...
I’m liking the 70deg TON advice.
I’m gong to be honest , I perform my cervical rhizotomies at 78deg due to neuritis.... I am a fraud, I like low temp .