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

[Ligament]

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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[nvrsumr]

TON

 

[willabeast]

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.

 

[Ligament]

TON

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

 

[Ligament]

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.

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

 

[bedrock]

Was wondering if any way to truly kill the nerve reliably...

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.

 

[Ligament]

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.

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

 

[bedrock]

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

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.

 

[bedrock]

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.

That got them all authed back east. I did 8-9 occipital stims total during the 6 years I was there.

 

[Aether2000]

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.

 

[NJPAIN]

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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[bedrock]

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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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.

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..

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.

 

[IN2B8R]

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


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[Aether2000]

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).

 

[hyperalgesia]

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

 

[nvrsumr]

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

 

[Aether2000]

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.

 

[Pacman27]

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

 

[NJPAIN]

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

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


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[IN2B8R]

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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[Aether2000]

Ok...i understand. Thanks.

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[ziggyziggy]

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


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Parallel to GON.

 

[hyperalgesia]

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

 

[Aether2000]

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.

 

[Pacman27]

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


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The needles would parallel hugging the os and the lesion would be created between the two needle tips. Do about 2 to 3 of these lesions

 

[Pacman27]

The needles would parallel hugging the os and the lesion would be created between the two needle tips. Do about 2 to 3 of these lesions

A instructor at one of the SIS courses showed me this technique a few years ago.

 

[lobelsteve]

A instructor at one of the SIS courses showed me this technique a few years ago.

Bipolar. It's how I do SIJ RF (for free)

 

[Pacman27]

Bipolar. It's how I do SIJ RF (for free)

Yes I cant get any lateral branch or genicular rfas paid for

 

[Orin]

Why ablate when you can stimulate? Just the coverage $ problems?

 

[epidural man]

The needles would parallel hugging the os and the lesion would be created between the two needle tips. Do about 2 to 3 of these lesions

How do you know where the nerve is?

 

[epidural man]

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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The big question (as has been implied above) - is how is he finding the nerve and how is he placing the needle? Because I suspect that if he finds the nerve with stim, and fishes for it going medial to lateral (or lateral to medial), the needle will be perpendicular to the nerve - and in this case - even though he THINKS he is ablating the nerve, he probably isn't, and he may just be creating an electrical field out the TIP of the needle which is given him effect.

The devil is in the details (which we do not know).

 

[epidural man]

I did a pulsed RF yesterday of the GON and LON. The literature describes finding the GON between C1 and C2 as it crosses over the inferior obliques capitis. I find this challenging as it is a steep and sometimes deep block. It is much easier to find the artery near the superior nuchal line (although this isn't always a chip shot either). Once I find the artery, I stim medial to the artery with a little fishing. I usually can get stim right next to the artery.

After pulsing (for 240 seconds at 45C - which had a voltage at around 60V....our constant voltage machine isn't working right now), I then blindly advance towards the mastoid process with the stim on until I captured the stim pattern of LON.

 

[Aether2000]

Of course you can always shave off some of the insulation of the needle to give a 20-30mm active tip if needed for PRF. Chances are somewhere along the needle you would be near the nerve

 

[Pacman27]

How do you know where the nerve is?

I do multiple lesions. I guess I could considering using ultrasound if I had it available to me.

 

[epidural man]

I do multiple lesions. I guess I could considering using ultrasound if I had it available to me.

I don't think you need to if you do multiple lesions and stim.

 

[oreosandsake]

find it at the level of C2 lamina

NYSORA - The New York School of Regional Anesthesia - Greater Occipital Nerve

 

[painfree23]

I do multiple lesions. I guess I could considering using ultrasound if I had it available to me.

Ive tried finding the artery under ultrasound and it's very difficult. So the consensus here is that safest would be pulsed, but insurance doesn't pay so either u do it for free or take the chance and do a traditional RF or bipolar?

 

[epidural man]

Ive tried finding the artery under ultrasound and it's very difficult. So the consensus here is that safest would be pulsed, but insurance doesn't pay so either u do it for free or take the chance and do a traditional RF or bipolar?

Can someone explain how if you do pulsed, then put some lidocaine on it - you can't bill for a GON nerve block?

 

[Pacman27]

I still don't under the big risk just do multiple bipolar lesions. Just make sure your not close to the artery and not burning the skin.

Bill it as a block or destruction of other peripheral nerve

 

[painfree23]

I still don't under the big risk just do multiple bipolar lesions. Just make sure your not close to the artery and not burning the skin.

Bill it as a block or destruction of other peripheral nerve

How do u make sure ur not close to the artery?? Palpating ?? Can't feel it half the time

 

[BobBarker]

How do u make sure ur not close to the artery?? Palpating ?? Can't feel it half the time

Yes, I can't tell whether I am feeling the artery, my own pulse, or the cranial rhythmic impulse??