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Wydase(hyaluronic acid) opinions

Discussion in 'Pain Medicine' started by Doctodd, Dec 16, 2005.

  1. Doctodd

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    What is your opinion and what formulation or brand are you using? Im using it for scar dissolution most often in LFBSS patients, 300units usually.

    Thanks in advance.

    T
     
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  3. C Fiber

    C Fiber Member
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    According to Dr. Raj's atlas "Radiographic imaging for Regional Anesthesia and Pain Management & Dr. Leland Lou's teachings, we have been using 1500 Units of Wydase for lysis of adhesions via caudal epidural catheter. See Page 274 in their book. We have used this technique for many post-laminectomy patients or patients with clear radiculopathy (exam and MRI) but failed traditional ESI (transforminal or translaminar). I have seen dramatic results in patients who other pain physicians were not able to cure.
     
  4. Hank Tong

    Hank Tong New Member

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    Does response to an epidural injection help predict who will respond to this?
     
  5. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Yes, those who have good success with ESI don't require adhesiolysis.

    I am very happy with Target catheter caudal adhesiolysis using Wydase followed by hypertonic saline (3%), in 1cc aliquots along the course of L5 and/or S1. I have seen similar results with short lasting effect doing the same procedure without the Wydase.

    An N of one is an N of none.

    I like to see epidural fibrosis on MRI correlate with the burning pain in the corresponding dermatome and then I happily offer Target cath. Otherwise I have been less encouraged to perform the procedure.
     
  6. ht

    ht Junior Member

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    Since Wydase has not been made since 2001, any thoughts about using Vitrase and dosages.
     
  7. Doctodd

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    I was on the phone with a compounding pharmacy this week. They bottle hyaluronidase, both preservative free(PF) and non PF. From what i was reading, the other hyaluronidase formulations such as Vitrase are NOT PF and have other indications such as for opthalmologic uses. Price being very similar, i opted for the PF form, which is about $40/3cc bottle, adding $20 for shipping in dry ice cuz it has to stay cold. So im thinking id rather do epidural neuroplasty with a catheter and placing 300-450 Units directly over the affected nerve root instead of a RACZ. The other reason being comfort for the patient since i do everything under local in my office, and i think a caudal hurts a dam lot more than an ESI.

    Please correct me if i was misinformed about anything above.

    T

    edit: should i care if it is PF or not?
     
  8. Tenesma

    Tenesma Senior Member
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    while it has been published in textbooks - it has not been supported by the literature... so why do it? especially since it ain't cheap or free
     
  9. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I fellowed at Emory-Geogia Pain Physicians. We used an Atlanta based compounding pharmacy and I was very impressed with their lab and customer service. So as not to sound like an ad, no names, but here is a price list.

    CELESTONE SOLUSPAN $4.99/ML
    CLINDAMYCIN 600MG/4ML $4.65/EA
    DIPHENHYDRAMINE 50MG/ML $2.00/EA
    SODIUM BICARB 8.4% $5.00/EA
    OMNIPAQUE 240MG/ML-10ML $55.00/EA
    SYNVISC 3X2ML $736.23
    FENTANYL 0.05MG/ML-2ML $1.00/EA
    NACL 0.9% 20ML PF $1.75/EA
    HYPERTONIC SALINE-5ML $6.50/EA
    HYALURONIDASE $8 FOR 1ML $64.10 FOR 10ML
    LIDOCAINE 2% PF $1.65/EA
    LIDOCAINE 1% PF $1.00/EA
    MIDAZOLAM 1MG/ML-2ML $1.50/EA
    BUPIVACAINE 0.25% PF $2.00/EA
    BUPIVACAINE 0.5% PF $2.40/EA
    BUPIVACAINE 0.75% PF $2.80/EA
    BOTOX 100U/VIAL $582.00/EA
    CEFAZOLIN 1GM $2.65/EA

    They also compound triple cream for me and take of the billing and insurance- 5% lidocaine, 5% Neurontin, and 20% ketoprofen in a PLO.

    If I hurt I'd be smearing this stuff all over- good response from my patients.

    Back on topic - hyaluronidase is available and not terribly expensive. I'm impressed enough with the results that I'd eat the 24 bucks on the procedure to get the desired results- I'm sure I'm not losing money when adding up the billing for adhesiolysis, J code for steroid, q code for omnipaque, fluoro code.
     
  10. Tenesma

    Tenesma Senior Member
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    this is what Bogduk (ISIS) talks about... why do procedures on patients that have not shown clinical efficacy??? would you perform this procedure on your mother/wife... and if you believe in it so strongly, then either help finance funding for research in it via ISIS or get a manufacturer or clinical research company to do a good randomized study on it. That way you can finally have insurance companies go from INVESTIGATIONAL/NOT medically necessary to approved...
     
  11. Doctodd

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    steve, send me the name of the pharmacy. That is quite a bit cheaper than New England COmpounding Pharm. Any input on PF vs nonPF Wydase?

    Tenesma.....the reason i do it is cuz these patients dont receive any relief from anything else, so the benefit outweighs the risk.

    And let me clear up a small detail....the patients i was describing are NOT the ones with huge Harrington rods and laminectomy defects who dont have much of an epidural space anyway. Those patients i think dont have any other access except caudal/RACZ.

    T
     
  12. Tenesma

    Tenesma Senior Member
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    based on that argument, you could also say we should do
    1) intradiscal steroids
    2) magnesium infusions for CRPS
    3) intradiscal 50% dextrose
    4) IDET..

    have i seen people do better with these? sure... but you know our population - they are all a bit nuts.

    So I believe the responsible thing that we have to do as clinicians is to finally do some good studies to support what we believe anecdotally... OTHERWISE everything else that is printed on this forum is just NOISE without any clinical meaning. This would be like an internist providing garlic tablets to all their HTN patients - just NOISE based on anecdotal and a few poor studies..

    and if you are statistically correct in saying that you have patients that respond to it compared to anything else then it should be your responsibility to publish and get the word out 1) to support our research community 2) to improve our standind in the medical community as an evidence based field 3) and to improve our reimbursements
     
  13. Doctodd

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    True on those counts except i dont think the analogy is fair. Im talking about a procedure most everyone does, an ESI but with a catheter and a different medication added to the mix.

    1. Intradiscal steroids....plenty of risk, need for antibiotics, technically more difficult than an ESI.
    2. I dont know much about Mg infusion. Might as well group it with h202 infusions(just kidding :laugh: ).
    3. See #1.....but add prolotherapy.
    4. See #1.....more risk, technically more difficult.

    T
     
  14. Tenesma

    Tenesma Senior Member
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    points well taken...

    but all of the above listed procedures would be reimbursed by insurance companies if we had better studies...

    by the way, i was talking to a guy at a conference recently who does c1-c2 bilateral joint injections with Synvisc... yikes
     
  15. Doctodd

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    I was thinking something similar. Why shouldnt we be doing more studies for viscosupplementation into other joints such as the SI and other locations in the spine, even intradiscal?

    I meant to bring this up earlier and im sure im not the only guy who knows about it, but Synvisc is the only one of the 3 hyaluronic acid formulations with an allergic/infectious type reaction. Hyalgan and SUpartz dont have it according to the info i browsed a few months ago. For that reason, i would never use Synvisc.

    T
     
  16. Doctodd

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    just felt like resurrecting this thread too since with my increased volume im getting the more difficult patients.

    T
     
  17. stim4u

    stim4u Member
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    DTodd:

    RACZ procedures work well, I use 300 U of wydase just like you (scared of 1500U quoted in the ISIS transforaminal LOA). I use the stuff they use for optho cases, which is believe is PF. I would say I obtain over 60-70% overall pain relief with improved appendicular pain, not much axial/mechanical pain relief. much better than traditional TFESI's especially where you cannot get good L5 spead. whether it is just the steroids deposited in the correct place, or the wydase, they get better. if you do enough of them, and correctly, you will see the results. problem is only, WC, cigna, and a local insurance will pay for it.
     
  18. ampaphb

    ampaphb Interventional Spine
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    Tenesma:

    You mentioned in an earlier post that nucleoplasty and PDD are procedures you specifically tout when meeting with PCPs to distinguish yourself from other pain docs in your community. I wondered what literature you base your enthusiasm on, since you took others to task for performing procedures that lack RCTs to demonstrate efficacy.
     
  19. Tenesma

    Tenesma Senior Member
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    geez - here we go again...

    it is all about informed consent - a lot of these approaches are poorly studied. TLIF vs PLIF is also poorly studied... Casting a distal fibular fracture grade A or B or not casting is poorly studied...

    we have to offer options to the patient, but we also have to inform them that some of these procedures have inherent risk and may not work better than just wearing a lumbar support brace...
     
  20. ampaphb

    ampaphb Interventional Spine
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    Please see above - you are disagreeing with your own prior arguement
     
  21. Tenesma

    Tenesma Senior Member
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    stop trying to read between the lines....

    i stand by my original point that we should not be routinely offering or performing procedures that are not clinically proven to one degree or another...

    i referred to percutaneous discectomy and nucleoplasty in a completely different posting - i do not advocate those procedures for axial pain as there is limited to no evidence to support that - i do think they are reasonable to consider for patients with radicular symptoms who are not candidates for open surgery.
     
  22. ampaphb

    ampaphb Interventional Spine
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    And what is the evidence-based data that you rely on, given that there are no RCTs?
     
  23. nvrsumr

    nvrsumr Member
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    I recently spoke with a group that was injecting wydase intradiscally for discogenic LBP. Any thoughts?
     
  24. Tenesma

    Tenesma Senior Member
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    ampa - what is your point?
     
  25. lobelsteve

    lobelsteve SDN Lifetime Donor
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    It should provide some relief in 30% of patients lasting up to 3 months.

    Pee elle A See E Bee Oh
     
  26. ampaphb

    ampaphb Interventional Spine
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    You crap all over others when they are doing procedures that don't have decent evidence, yet you do procedures like PDD/Nucleoplasty, which has no data that demonstrates efficacy.

    So my point? Seems a bit too "do as I say, not as I do" for my taste.
     
  27. Tenesma

    Tenesma Senior Member
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    i only do things where i have seen improvement - i have stopped performing procedures where i haven't seen improvement (ie: IDET, adhesiolysis)...

    I will continue to crap on procedures that have no demonstrated clinical efficacy - ie: trigger point injections, ESIs for axial pain, and the list goes on... yet, that doesn't mean that I don't "see" or "understand" the role of these procedures ...

    I believe the argument for PDD/nucleoplasty for radicular pain in a patient that isn't a candidate for open surgery is a LOT stronger then the argument for adhesiolysis... of course, as a last resort after all other strategies have failed...
     
  28. ampaphb

    ampaphb Interventional Spine
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    Nice fudge ... there is a world of difference between "no demonstrated clinical efficacy" and "where I have seen improvement"

    Yakovlev, Al Tamimi, Liang, and Eristavi (Pain Physician 2007; 10:319-327) demonstrated efficacy for 12 months in a population that did not distinguish between axial and radicular complaints. It was a retrospective, non-randomized case series.

    Mirzai, Tekin, Yaman, and Bursali from Turkey reported reasonable findings in their prospective non-blinded study looking at radicular pain, published in The Spine Journal (2007 Jan-Feb;7(1):88-92).

    Other studies have been performed by Sharps and Isaac (Pain Physician 2002;5:121–6) (prospective, non-blinded, looking back pain with and without radicular s/s), and Singh, Piryani, Liao, and Nieschulz, (Pain Physician 2002;5:250–9) which was prospective, non-blinded, and looked at axial &/or leg pain

    Clearly none of these studies are adequate, and they are all over the map in terms of the indications the technology was evaluated on.

    Cohen et al at Hopkins (J Spinal Disord Tech. 2005 Feb;18 Suppl:S119-24) did not demonstrate efficacy, even with the use of concurrent IDET, but did not limit his population to protrusions <6mm

    Freeman's review of all PDD technologies (Curr Pain Headache Rep. 2008 Jan;12(1):14-21) makes casual mention of the lack of RCTs for coblation technology, but - applying the old computer GIGO (garbage in, garbage out) logic - it should be remembered that this is the same author who brought us the "nocebo" article regarding IDET (Spine. 2005 Nov 1;30(21):2369-77)

    So I would ask, where exactly is that elusive "demonstrated clinical efficacy"? To me, the above demonstrates only that the literature is all over the map, and that there are no studies that are adequate to conclude whether it nucleoplasty works or not.

    Now if we are using the old "in my experience" logic, that's all well and good, but then you lose the moral high ground, and ought not to disparage others when they use similar disingenuous rationales.
     
  29. Doctodd

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    i feel like i should chime in since this was my original thread.....we are all in this for the greater good and to share information/knowledge. I hope u guys arent taking any of this personally and are just jousting for our benefit. But sometimes we dont have any other options and as long as it is safe with minimal risk, maybe we should consider these things for our more difficult patients.

    i appreciate all the responses

    T
     
  30. Tenesma

    Tenesma Senior Member
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