Expandible probes and lumbar RFA.

[bedrock]

Do any of you do lumbar RFA with a direct (MBB approach), using an expandible probe such as venom, sidekick, cooled RFA?

If so

1- how well does it work and how long does it last compared to standard SIS technique?

2-other than cooled RFA being the largest, is there any major lesion size and efficacy differences between other expandable probes?

3- where do you aim if you do RFA with an MBB approach. Mostly I want to know if you aim directly at the center of the SP/TP junction or if your target is more cranial than the center? How far up is still safe?

BTW, I would never condone doing this MBB technique for lumbar RFA, if I was only using a standard RF cannulae.

---

Members don't see this ad.

 

[stsa84]

I've done a bunch of direct approach with cooled RFA. I do 95% of my RFA's in the clinic, with standard probes, though I recently switched to Venom. I do Venom with traditional approach. The lesion of the Venom needles does not extend much past the tip of the probe. I wouldn't trust that it'd get much nerve with a direct approach.

For the patients that I inherited that have had sedation with prior RFA's and will not contemplate a repeat without sedation, I do them at Day Hospital with fent/versed. The guy before me did all of his RFA's there with sedation. The hospital does not have (will not get) standard needles and the appropriate adapter, so I've been doing all of my RFA's there with cooled.

It works as well as standard, but I don't like it. Burn time is 2:30 instead of 1:30. The stupid cannula always flops around after you take the stylet out, so you have to put in the probe and then reapproach the target. Needles are large (17g). The kit costs a fortune, $1-2k, and I can get the same results with 3 $20 standard needles. From skin local to RFA needle removal, I'm usually 12-14 minutes for cooled, 10-12 minutes for standard (b/l 2 level).

Here's Avanos recommendation on needle placement for direct approach:

 

[RoloTomassi]

The lesion of the Venom needles does not extend much past the tip of the probe.

Agree. Venom and Sidekick only make lesion wider, still need to go parallel. No experience with Trident or Nimbus.

 

[buddababa]

Do any of you do lumbar RFA with a direct (MBB approach), using an expandible probe such as venom, sidekick, cooled RFA?

If so

1- how well does it work and how long does it last compared to standard SIS technique?

2-other than cooled RFA being the largest, is there any major lesion size and efficacy differences between other expandable probes?

3- where do you aim if you do RFA with an MBB approach. Mostly I want to know if you aim directly at the center of the SP/TP junction or if your target is more cranial than the center? How far up is still safe?

BTW, I would never condone doing this MBB technique for lumbar RFA, if I was only using a standard RF cannulae.

I still use traditional approach, sometimes direct approach(10%), but i use sidekick needles. Outcomes have been same as if i was doing a double burn - so it just saves me time. Relief is probably standard 10-18 months, i would say 20% get 6 months of relief and 80% get almost 1 year if not more of relief.

 

[stsa84]

I got a chance to use Trident for 2 lumbar RFA's last week. Very slick. Direct approach. Cannula/probe/infusion port is all one piece. Place the cannula, inject local, motor test, burn, all without making any adjustments, removing stylet, etc. Costs a lot more than standard needles, but a lot less than cooled. May be an option in hospital setting. I like it 1000x better than cooled. Will see how those two patients do over the next few weeks.

 

[bedrock]

I got a chance to use Trident for 2 lumbar RFA's last week. Very slick. Direct approach. Cannula/probe/infusion port is all one piece. Place the cannula, inject local, motor test, burn, all without making any adjustments, removing stylet, etc. Costs a lot more than standard needles, but a lot less than cooled. May be an option in hospital setting. I like it 1000x better than cooled. Will see how those two patients do over the next few weeks.

Hmm. I wasn’t aware of the trident. It looks like it would make more of a spherical lesion, so good for lumbar RFA.

Any idea as to needle cost of trident?

 

[stsa84]

Hmm. I wasn’t aware of the trident. It looks like it would make more of a spherical lesion, so good for lumbar RFA.

Any idea as to needle cost of trident?

$160/needle. Venom is $40 for comparison. And $1-2k for cooled kit.

 

[drrosenrosen]

When I spoke to Nimbus rep at a conference recently, they quoted me $85/needle for theirs

 

[Ferrismonk]

We use Avanos and I've been shown the trident probe. Seems nice that it's all inclusive. In our HOPD, we currently use disposable probes ($97ish each), so the trident isn't that much more expensive when you include the cannula as well. I think we're going to try it out, but it's more valuable as a time saver than any clinical improvement.

 

[stsa84]

We use Avanos and I've been shown the trident probe. Seems nice that it's all inclusive. In our HOPD, we currently use disposable probes ($97ish each), so the trident isn't that much more expensive when you include the cannula as well. I think we're going to try it out, but it's more valuable as a time saver than any clinical improvement.

Along with the direct approach being a good bit more tolerable for patients compared to traditional as well.

 

[sdnuser001]

Along with the direct approach being a good bit more tolerable for patients compared to traditional as well.

Why is this? Is it because the more parallel you are the more you scrape periosteum?

 

[MitchLevi]

Man...I'm paying $14 per needle and 1k per reusable probe. Yall are paying nearly 100 per single use probe and I'm getting way more than 10 uses per reusable.

Are these expensive setups really that great?

I feel like I get great results with cheap stuff.

Edit to say, "I feel like I get good enough results with cheap stuff."

 

[buddababa]

Man...I'm paying $14 per needle and 1k per reusable probe. Yall are paying nearly 100 per single use probe and I'm getting way more than 10 uses per reusable.

Are these expensive setups really that great?

I feel like I get great results with cheap stuff.

Edit to say, "I feel like I get good enough results with cheap stuff."

same as you

 

[Orin]

Avanos bought the Diros portfolio.

RF TridentTM Cannulae | Diros Technology | Radiofrequency (RF) Pain Management

RF TridentTM Cannulae – Diros Technology manufactures Radiofrequency (RF) pain management and neurosurgical products.

dirostech.com

The Trident may obviate the need for cooled RFA for facet targets. It's priced less than cooled and more than conventional. I may still do cooled for some joints as the geometry still seems nicer there for geniculars if anyone still covers them

 

[cowboydoc]

obviate the need for cooled RFA for facet targets

I can't come up with a situation where I thought there was a need, or even a solid use for cooled when targeting facets. I had a heck of a time getting to an L5 DR yesterday because of pelvic angle/listhesis/osteophytes on the L5/S1 facet, but the fix was a second needle and a bipolar lesion. I only do that a handful of times a year and don't think a cooled approach would be any better. Please help me understand the value of cooled for a facet.

 

[Ferrismonk]

Man...I'm paying $14 per needle and 1k per reusable probe. Yall are paying nearly 100 per single use probe and I'm getting way more than 10 uses per reusable.

Are these expensive setups really that great?

I feel like I get great results with cheap stuff.

Edit to say, "I feel like I get good enough results with cheap stuff."

The answer is HOPD. Hospitals do things backwards and seem to find the most expensive way possible.

They used to use reusable probes in our HOPD, but then some genius decided that you had to take each set of probes out of the procedure room, clean them, then package them for transfer to the sterile processing department between patients. Then at end of day, each set of probes had to be brought over to the the main OR sterile processing department (at the other end of the large hospital) and brought back the next day. Sterile processing also was damaging probes because they aren't used to delicate wires. Between tech time to wash/package/transfer probes (almost a full FTE) and the increased damage from sterile processing, it's was found to actually be cheaper to buy and use the disposable probes.

In our private clinic, we use reusable probes and standard needles.

 

[cowboydoc]

The answer is HOPD. Hospitals do things backwards and seem to find the most expensive way possible.

They used to use reusable probes in our HOPD, but then some genius decided that you had to take each set of probes out of the procedure room, clean them, then package them for transfer to the sterile processing department between patients. Then at end of day, each set of probes had to be brought over to the the main OR sterile processing department (at the other end of the large hospital) and brought back the next day. Sterile processing also was damaging probes because they aren't used to delicate wires. Between tech time to wash/package/transfer probes (almost a full FTE) and the increased damage from sterile processing, it's was found to actually be cheaper to buy and use the disposable probes.

In our private clinic, we use reusable probes and standard needles.

One can only imagine how many supervisors and administrators are necessary to oversee this process.

I’m guessing a single boardroom was not enough to hold all the stakeholders involved in deciding between disposable vs. nitinol probes.

 

[SSdoc33]

The answer is HOPD. Hospitals do things backwards and seem to find the most expensive way possible.

They used to use reusable probes in our HOPD, but then some genius decided that you had to take each set of probes out of the procedure room, clean them, then package them for transfer to the sterile processing department between patients. Then at end of day, each set of probes had to be brought over to the the main OR sterile processing department (at the other end of the large hospital) and brought back the next day. Sterile processing also was damaging probes because they aren't used to delicate wires. Between tech time to wash/package/transfer probes (almost a full FTE) and the increased damage from sterile processing, it's was found to actually be cheaper to buy and use the disposable probes.

In our private clinic, we use reusable probes and standard needles.

i have had a near identical experience.

reusables. they break, SPD messes them up -------> ok, lets use disposables. 6 months later the cost of the disposables is realized. holy sh$t, now we go back to re-usables. asinine.

 

[stsa84]

I can't come up with a situation where I thought there was a need, or even a solid use for cooled when targeting facets. I had a heck of a time getting to an L5 DR yesterday because of pelvic angle/listhesis/osteophytes on the L5/S1 facet, but the fix was a second needle and a bipolar lesion. I only do that a handful of times a year and don't think a cooled approach would be any better. Please help me understand the value of cooled for a facet.

Yeah, no real true need for it. Quicker than traditional. For people with really bulky facet arthropathy, may be simper to oblique and target the junction directly instead of trying to navigate around huge facet joints.

 

[lobelsteve]

Avanos bought the Diros portfolio.

RF TridentTM Cannulae | Diros Technology | Radiofrequency (RF) Pain Management

RF TridentTM Cannulae – Diros Technology manufactures Radiofrequency (RF) pain management and neurosurgical products.

dirostech.com

The Trident may obviate the need for cooled RFA for facet targets. It's priced less than cooled and more than conventional. I may still do cooled for some joints as the geometry still seems nicer there for geniculars if anyone still covers them

Huge fan of Avanos. Good people, great product.
Costly.

COI: My FIL worked for Scott Towel (KCC)
My BIL and SIL work for KCC and Avanos.
Beautiful campus on Holcomb Bridge.

 

[stsa84]

What generators are Nimbus needles compatible with? Interested in trialing it. Have access to Stryker and Avanos generators.

 

[Orin]

Please help me understand the value of cooled for a facet.

It's really something I go to after I have not had ideal results with conventional RFA, or in the thoracic space where the anatomy is a so variable. I'll use it first in people that are very challenging to get to a procedure suite for whatever reason and I want a more reliable 12-18 mo burn.

 

[sdnuser001]

Thoughts on using a 16g needle and doing two 90 second burns as an alternative to cooled RF? According to this study the lesion size is similar and this is obviously way cheaper. I know 16g is less comfortable but you could do direct approach which someone already mentioned is better tolerated.

Factors that affect radiofrequency heat lesion size - PubMed

Tip gauge, tip length, temperature, and time substantially affect RF lesion size.

pubmed.ncbi.nlm.nih.gov

 

[epidural man]

Huge fan of Avanos. Good people, great product.
Costly.

COI: My FIL worked for Scott Towel (KCC)
My BIL and SIL work for KCC and Avanos.
Beautiful campus on Holcomb Bridge.

You have my attention....

Do you use this product?

Do we need a new generator or can their probe be used on other technology?

 

[lobelsteve]

You have my attention....

Do you use this product?

Do we need a new generator or can their probe be used on other technology?

I don't use it. I have an Ioniq with disposables.

 

[Orin]

Thoughts on using a 16g needle and doing two 90 second burns as an alternative to cooled RF? According to this study the lesion size is similar and this is obviously way cheaper. I know 16g is less comfortable but you could do direct approach which someone already mentioned is better tolerated.

Factors that affect radiofrequency heat lesion size - PubMed

Tip gauge, tip length, temperature, and time substantially affect RF lesion size.

pubmed.ncbi.nlm.nih.gov

To some extent, yes. It's like painting. You can create the same thing with whatever brush you like if you're careful. If you're trying to burnch as much of the nerve as possible, two 16g needles would need to be positioned well for that purpose.

I would point out though, the magic of internally cooled electrodes for ablation is that they are approach independent. The lesion is spherical so no matter how you get to the target location, the burn is the same. It doesn't matter if you're parallel vs perpendicular vs oblique. So while you can readily reproduce the volume with any variety of needle configurations, the freedom of approach of the burn and projection of the burn off the tip is why you would want to do cooled RF.

 

[hyperalgesia]

I don't use it. I have an Ioniq with disposables.

Same. A lot easier than trying to coil the probes for the autoclave.