Greater Occipital Nerve: Any way to safely and reliably ablate it?

Discussion in 'Pain Medicine' started by Ligament, Apr 20, 2017 at 2:57 PM.

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  1. Ligament

    Ligament Interventional Pain Management Lifetime Donor SDN Advisor 10+ Year Member

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    RFA too difficult to visualize nerve and place needle parallel to it under US
    Cryo same thing plus probe so thick
    Botox?
    C2 and C3 dorsal root ganglionectomy...
    Pulsed RF treatment
    What do you guys do for tough greater occipital neuralgia?
     
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  3. nvrsumr

    nvrsumr Member 10+ Year Member

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  4. willabeast

    willabeast 5+ Year Member

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    EZ PZ. 3 ways and they all work.
    1. best fix. muscle relaxation exercises. takes about 3 months. i suspect this always works, however difficult to educate patients. lasts forever.
    2. Racz occipital decompression. i used to do these with 5-10 ml of dilute lidocaine with 40 mg of depomedrol. Racz did these with a higher volume. in my hands these last about 3 months. warning - steroid could cause an embolus, and lidocaine (if you go medial) can cause total spinal. risks of which which led me to give these up and do #3 mostly. insist needle against bone when inject.
    Peripheral Nerve Entrapments
    3. Botox suboccipital injection. these work about 3 months. i think they are the less risky than steroid. i would mix 100 units botox with 5 or 10 ml 1/2% PF lidocaine and inject 5 ml both sides (50 units a side) or 5 ml one side (100 units) (hate to waste botox) about 1.5 inches lateral to midline always against bone. a failure usually meant i missed.
    Botulinum Toxin in Painful Diseases
    you have to be quite a salesman to get #1 to work. but it is by far the best solution.
    #2 and #3 do have a learning curve, there will be failures. usually it is because the needle is in the wrong place. i began using #22 gauge 1.5 inch b bevel needles, wound up using #25 gauge 1.5 inch needles. if you go too medial or too inferior to skull could get a total spinal, you need to have airway equipment around and you need to watch patients at least 20 minutes to make sure they do not stop breathing. make sure that needle tip is against bone to insure not in wrong place. also make sure not in an artery. might use fluoro especially when learning. these injections can hurt.
     
  5. Ligament

    Ligament Interventional Pain Management Lifetime Donor SDN Advisor 10+ Year Member

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    That's what I r/o first almost always, but in this case it is not third occipital neuralgia. Wish it was.
     
  6. Ligament

    Ligament Interventional Pain Management Lifetime Donor SDN Advisor 10+ Year Member

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    Thanks
    I'll go for botox next. I do it under u/s.
    Was wondering if any way to truly kill the nerve reliably...
     
  7. bedrock

    bedrock Member 10+ Year Member

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    Not that I know of. If patients fail TON RFA, GON blocks, C1-C2 injection, then I do occipital stim. Works for most true chronic occipital neuralgia that failed the other treatments.
     
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  8. Ligament

    Ligament Interventional Pain Management Lifetime Donor SDN Advisor 10+ Year Member

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    Do you have any tips for getting occipital stim covered by insurance?
     
  9. bedrock

    bedrock Member 10+ Year Member

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    Covered by Medicare at least out east, and by most PPOs out there. Not covered by Medicaid or HMOs.
    Haven't tried to auth one yet in SoCal.

    Mainly I dictate in my clinic note, all the treatments failed, why I'm certain the diagnosis is occipital neuralgia, and that occipital stim is the one and only treatment that will help the patient.
     
  10. bedrock

    bedrock Member 10+ Year Member

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    That got them all authed back east. I did 8-9 occipital stims total during the 6 years I was there.
     
    Last edited: Apr 20, 2017 at 11:02 PM
  11. algosdoc

    algosdoc algosdoc 10+ Year Member

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    You really don't want to "kill" the nerve. Use of thermal, mechanical or chemical neurotomy of a large myelinated nerve may cause anesthesia dolorosa and neuroma formation in a subset of these patients, leading to worsening pain than they had before. Pulsed RF or cryotreatment are probably the kindest gentler approach since they do not disrupt the myelin sheath. Occipital stim can work but is not easy to keep the leads anchored in place. Botox is not a covered treatment if coded correctly. Racz? Well what can I say- Gabor is a wild man at times.
     
  12. NJPAIN

    NJPAIN 5+ Year Member

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    I've had some pretty decent results with Botox around GON. Visualizing occipital artery along ridge. Depositing Botox medial ( a little lateral as well for good measure). Perhaps the C2 approach would be better but visualization using my overpriced Terason is not reliable enough for me to do this in the office


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  13. bedrock

    bedrock Member 10+ Year Member

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    I think this is a good idea, but I no longer have ultrasound in the office, I don't feel comfortable doing this without it, it pays poorly for the time involved, and I can't get insurance to authorize botox for this very often (if coded correctly as algos pointed out), so I no longer include this in my treatment options.

    I admit I didn't do the perms on theses patients. In PA I knew a great functional neurosurgeon with a great interest in SCS, occipital, and peripheral stim. Dr Jay knows who I'm talking about.
    I sent him all my non-standard epidural SCS, occipital, or peripheral stim implants, which he enjoyed as a challenge and he was fantastic at getting occipital and perpheral stim leads to stay in place. I will have to rethink this for my next occipital stim implant case in SoCal, as I do have 1 patient that is headed this direction.
     
    Last edited: Apr 22, 2017 at 6:33 AM
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  14. IN2B8R

    IN2B8R Junior Member 10+ Year Member

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    Neurosurgeon I worked with always did an RF. No anesthesia delarosa issues....


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  15. algosdoc

    algosdoc algosdoc 10+ Year Member

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    Hmmm... There would be credence in such an assertion if you saw all the patients personally in followup weeks and months later and specifically asked them of their occipital pain and any improvement, test them for allodynia or hyperpathia in that area. Or is the stated lack of anesthesia dolorosa or neuralgia formation based on the neurosurgeons undocumented series? Certainly such a result would be reportable if devoid of the complications that beset so many others that attempt to thermally lesion myelinated nerves. There are series detailing post lesion neuralgia of myelinated nerves to be 12% (Incidence of neuropathic pain after radiofrequency denervation of the third occipital nerve. - PubMed - NCBI) and others with 9.4% per patient (Incidence of neuropathic pain after cooled radiofrequency ablation of sacral lateral branch nerves. - PubMed - NCBI).
     
    Last edited: Apr 23, 2017 at 3:29 PM
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  16. hyperalgesia

    hyperalgesia member Lifetime Donor 7+ Year Member

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    We did a fair amount of cyro for these in fellowship. The results from my observation were nothing to write home about.
     
  17. nvrsumr

    nvrsumr Member 10+ Year Member

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    Medial branch(ton) neuritis is not the same as anesthesia delarosa. This is more of an issue with gasserian neurolysis.
     
  18. algosdoc

    algosdoc algosdoc 10+ Year Member

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    Cryo perserves the myelin sheath.....Thermal RF, mechanoneurolysis, and chemoneurolysis do not. The issue is the production of increased neuritis- this may be a neuroma, anesthesia dolorosa, or other pathology, but the idea is that with an average 10% complication rate from neurodestruction of myelinated nerves, you are making a defined subset of the population worse. I would opt for pulsed RF or stimulation instead.
     
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  19. Pacman27

    Pacman27 7+ Year Member

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    My N is low but I do ablations for these.

    I will use the Stryker Venom needles. Take 2 needles and place them a few mm a part and do a parallel region. I will usually do 2 to 3 lesions along the course of where the GON sits. Stay on bone the whole time.

    Results have been decent overall
     
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  20. NJPAIN

    NJPAIN 5+ Year Member

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    So your 2 needles are placed parallel or perpendicular to the course of the nerve?


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  21. IN2B8R

    IN2B8R Junior Member 10+ Year Member

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    Algos: he used to get many of these patients.... he has an N of many that he RF'ed.... I'm not refuting your assertions, merely saying that he did many & he stated that he didn't run into neuralgia issues.... take it for what it is worth.


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  22. algosdoc

    algosdoc algosdoc 10+ Year Member

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    Ok...i understand. Thanks.

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  23. ziggyziggy

    ziggyziggy 5+ Year Member

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    Parallel to GON.
     
  24. hyperalgesia

    hyperalgesia member Lifetime Donor 7+ Year Member

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    When I used cryo in fellowship, it was a large wheeled machine that used liquid nitrogen I believe.

    Lately I've been seeing this iovera device around, which is not unlike a Fisher Price toy. I haven't personally used it.

    Stanford doctors freeze migraine pain
     
  25. algosdoc

    algosdoc algosdoc 10+ Year Member

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    The machine I used to use from the 1990s until about 2005 was a probe that used either CO2 or nitrous oxide to produce -65 deg F temperatures through the mechanism of the expansion of the pressurized gas in the cryoprobe. There was a constricted orifice at the tip of the probe with an expansion chamber beyond that point, resulting in adiabatic cooling. The probes were frequently breaking as was the machine. The probe size was huge- around a 14 ga needle size. Lack of insurance coverage eventually killed the technique for most, but it was very useful for peripheral nerves especially intercostals.
     

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