IPSIS meeting highlights

[bedrock]

Those of you who attended, can you please share with us the most important things you learned?

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[cowboydoc]

SI (lateral branch) RFA works if you do a robust palisade technique, too bad it doesn’t get paid for.

ESIs for stenosis have poor evidence, but we’ll keep doing them.

MILD makes sense if there is a thick ligament. It may even help NFN at treated levels.

Intracept is a game changer.

We need to do a lot more sacroplasty. Beall will teach you how.

SIBone has serious issues, but there are several other SI fusion options.

Genicular RF may work better if we do more sites.

Si joints can look funny. You can use steroids in diagnostic injections to treat them.

Transitional vertebrae are common. They may hurt if type II or IV. They feel better if a Mayo radiologist injects them. If that doesn’t work, the evidence isn’t clear on what to do. Some have RFed them, they are sometimes resected.

SCS is the answer. What was the question?

 

[Agast]

#gamechanged

 

[bedrock]

SI (lateral branch) RFA works if you do a robust palisade technique, too bad it doesn’t get paid for.

ESIs for stenosis have poor evidence, but we’ll keep doing them.

MILD makes sense if there is a thick ligament. It may even help NFN at treated levels.

Intracept is a game changer.

We need to do a lot more sacroplasty. Beall will teach you how.

SIBone has serious issues, but there are several other SI fusion options.

Genicular RF may work better if we do more sites.

Si joints can look funny. You can use steroids in diagnostic injections to treat them.

Transitional vertebrae are common. They may hurt if type II or IV. They feel better if a Mayo radiologist injects them. If that doesn’t work, the evidence isn’t clear on what to do. Some have RFed them, they are sometimes resected.

SCS is the answer. What was the question?

Lol. Thank you. I really do appreciate it.

I’m glad that intracept is a game changer, I just wished it paid better for non HOPD employed pain physician.

Same thing with genicular RFA. I’m not particularly excited about spending even more time on a procedure that already pays very poorly for the time spent.

I’m kinda surprised that SIS is promoting SIJ fusions. I’ve never seen a great outcome from those. (I’ve never personally done them) A few ok outcomes , and many terrible outcomes are what I have seen.

Glad that there is good data proving the efficacy of SIJ RFA….now that nobody still pays for it.

Good on MILD

regarding ESI and stenosis they are correct….if we keep doing mostly TFESI with dex for those not understanding the different pathophysiology of stenosis vs acute disc herniation.

 

[DOctorJay]

That’s a really good summary @cowboydoc

I’ll add:

Start making someone in your practice create templates based off the LCDs and keep them updated to make sure you get paid

Don’t submit bills for 26 epidurals on the same patient in a year or 51 RFA sites on a patient in one day

Vertiflex might work better than X stop but surgeons don’t like when local kyphosis affects sagittal balance

Inject enough contrast to get to your target - video of delayed vascular uptake in a CTFESI was shown and was really interesting

Probably best to avoid gad altogether in the epidural space regardless of approach

TFESIs have the best (although not great) evidence for LSS

Don’t miss spinal dural AVFs

 

[Ducttape]

Inject enough contrast to get to your target - video of delayed vascular uptake in a CTFESI was shown and was really interesting

was any comment made why people are still doing CTFESI?

I’m glad that intracept is a game changer, I just wished it paid better for non HOPD employed pain physician.

intracept apparently wont pay will for HOPD physician either.

 

[DOctorJay]

was any comment made why people are still doing CTFESI?



intracept apparently wont pay will for HOPD physician either.

you know the sense that I got was that they were making a case that this procedure shouldn't be abandoned and we just need to review the MRI for potential vascular anomalies, enter the posterior foramen at a more shallow angle of approach, only use dex (and don't mix dex with local), and use digital subtraction imaging to make it as safe as possible.

I thought that was pretty interesting and I don't do any CTFESI.

 

[SC Tian]

Shoulder rfa

 

[SC Tian]

Chemical neurolysis of genicular nerves

 

[SC Tian]

Ssn, an and lateral pectoris n

 

[Ducttape]

that chemical neurolysis for knee article is behind a firewall, but the summary is kind of a waste of time.

retrospective observational study. contacted by phone for follow up.




at least they used phenol, which one can still conceivably get (absolute alcohol too expensive for neurolysis)

 

[Taus]

That’s a really good summary @cowboydoc

I’ll add:

Start making someone in your practice create templates based off the LCDs and keep them updated to make sure you get paid

Don’t submit bills for 26 epidurals on the same patient in a year or 51 RFA sites on a patient in one day

Vertiflex might work better than X stop but surgeons don’t like when local kyphosis affects sagittal balance

Inject enough contrast to get to your target - video of delayed vascular uptake in a CTFESI was shown and was really interesting

Probably best to avoid gad altogether in the epidural space regardless of approach

TFESIs have the best (although not great) evidence for LSS

Don’t miss spinal dural AVFs

Thanks. Bummed I couldn’t make it this year. Pretty sure I’ll be there next year.

 

[SC Tian]

that chemical neurolysis for knee article is behind a firewall, but the summary is kind of a waste of time.

retrospective observational study. contacted by phone for follow up.




at least they used phenol, which one can still conceivably get (absolute alcohol too expensive for neurolysis)

Nice comments, they claimed the rct will be published soon, assuming it is positive.

 

[drusso]

Never put ketchup on a Chicago dog.

Italian hot beefs sweet and juicy are better than hot and dry.

The Aviary and London House are where the cool kids are for fun.

A Chicago Handshake tastes like cunilingus with a Koala bear.

If you can buy shares in a physician-owned hospital, you should.

If you can't control incentives people receive, you can't control their behavior.

Most of the dancers at Rick's are saving their money for college.

"They will never love you back."

 

[Ducttape]

"Most of the dancers at Rick's are saving their money for college."

i heard this line before, in establishments in Myrtle Beach.

 

[kstarm]

That’s a really good summary @cowboydoc

I’ll add:

Start making someone in your practice create templates based off the LCDs and keep them updated to make sure you get paid

Don’t submit bills for 26 epidurals on the same patient in a year or 51 RFA sites on a patient in one day

Vertiflex might work better than X stop but surgeons don’t like when local kyphosis affects sagittal balance

Inject enough contrast to get to your target - video of delayed vascular uptake in a CTFESI was shown and was really interesting

Probably best to avoid gad altogether in the epidural space regardless of approach

TFESIs have the best (although not great) evidence for LSS

Don’t miss spinal dural AVFs

Thanks for the updates. Can you say more about the Gad? I still will use for TFESI but have stopped for interlaminar. Thanks

 

[cowboydoc]

Thanks for the updates. Can you say more about the Gad? I still will use for TFESI but have stopped for interlaminar. Thanks

As little as 0.1ml has been implicated in encephalitis with IT administration

 

[Agast]

A Chicago Handshake tastes like cunilingus with a Koala bear.

Is that where you told your wife the chlamydia came from

 

[DOctorJay]

Thanks for the updates. Can you say more about the Gad? I still will use for TFESI but have stopped for interlaminar. Thanks

they showed some cases were you can get a root sleeve in the foramen and could potentially inject into it and be intrathecal

 

[lobelsteve]

Never put ketchup on a Chicago dog.

Italian hot beefs sweet and juicy are better than hot and dry.

The Aviary and London House are where the cool kids are for fun.

A Chicago Handshake tastes like cunilingus with a Koala bear.

If you can buy shares in a physician-owned hospital, you should.

If you can't control incentives people receive, you can't control their behavior.

Most of the dancers at Rick's are saving their money for college.

"They will never love you back."

Why is it called a Chicago Handshake?


In the Chicago drinking world, the Chicago Handshake is slang for a drink special involving a shot of Jeppson's Malört paired with an 'old-school' Midwestern beer, most typically Old Style Beer. Although Old Style originated in Wisconsin, it became Chicago's beer after crossing state lines in 1935.


Had to look it up.

 

[cowboydoc]

Why is it called a Chicago Handshake?


In the Chicago drinking world, the Chicago Handshake is slang for a drink special involving a shot of Jeppson's Malört paired with an 'old-school' Midwestern beer, most typically Old Style Beer. Although Old Style originated in Wisconsin, it became Chicago's beer after crossing state lines in 1935.


Had to look it up.

I did too. Based on Dr. Usso's description, I thought it was political/sexual innuendo.

 

[lobelsteve]

I did too. Based on Dr. Usso's description, I thought it was political/sexual innuendo.

Based on his reputation, so did I.

 

[drusso]

Based on his reputation, so did I.

 

[SC Tian]

Scs vs pns

 

[SC Tian]

Is it the time to do Peripheral nerve stim? where to start?

 

[LineEmTubeEm]

does anyone have a PDF of the IPSIS textbook they could share?

 

[drusso]

Are they tender to palpation over the cluneal nerves?

 

[SC Tian]

haha cluneal nerve , I am more interested in the knee, and shoulder, if failed genicular rfa, should stim be the reasonable next step?

 

[drrosenrosen]

PNS is still only for HOPD?

 

[SpineandWine]

PNS is still only for HOPD?

Office trials are lucrative re Nalu

 

[nvrsumr]

Office trials are lucrative re Nalu

Whats the reimbursement and lead cost? Thanks

 

[SpineandWine]

Whats the reimbursement and lead cost? Thanks

I’d reach out to rep for office based trials.
Lead cost- should be able to get it to 100/lead with good bargaining. They make most of money on implants

 

[SC Tian]

Peripheral nerve stimulation for chronic knee pain:

Peripheral nerve stimulation for the treatment of chronic knee pain - Scientific Reports

The average age of our population is increasing, resulting in a high incidence of chronic degenerative knee pathologies. Several treatment options, including surgical procedures are available to help mitigate these pathologies. However, the percentage of subjects with chronic post-surgical knee...

www.nature.com

Any comments on this are welcome and appreciated, thanks.

 

[lobelsteve]

Peripheral nerve stimulation for chronic knee pain:

Peripheral nerve stimulation for the treatment of chronic knee pain - Scientific Reports

The average age of our population is increasing, resulting in a high incidence of chronic degenerative knee pathologies. Several treatment options, including surgical procedures are available to help mitigate these pathologies. However, the percentage of subjects with chronic post-surgical knee...

www.nature.com

Any comments on this are welcome and appreciated, thanks.

2/33 got infected. Study done by Neurosurgery departments. For OA knee.
6/33 did not benefit.

COI reports none, yet it reads like an advertisement in the conclusion/discussion.
Shady at best. Lying is much more likely.

 

[SC Tian]

2/33 got infected. Study done by Neurosurgery departments. For OA knee.
6/33 did not benefit.

COI reports none, yet it reads like an advertisement in the conclusion/discussion.
Shady at best. Lying is much more likely.

Thanks for the quick response, comments are appreciated, Authors from Germany, are they lying very often
Maybe there are some pain physicians in the NSG department just like in US, The trial-to-implant ratio is 27/33 which is very reasonable compared to DC stim, a 12-month follow-up is a relatively long time window and the retrospective observation study makes it less convincing.
My big concern is migration, there is no mention of stim-wave lead migration that is concerning. I saw some forward migrations, fractures, and other complications from the referred patients.

 

[Laryngospasm]

SI (lateral branch) RFA works if you do a robust palisade technique, too bad it doesn’t get paid for.

ESIs for stenosis have poor evidence, but we’ll keep doing them.

MILD makes sense if there is a thick ligament. It may even help NFN at treated levels.

Intracept is a game changer.

We need to do a lot more sacroplasty. Beall will teach you how.

SIBone has serious issues, but there are several other SI fusion options.

Genicular RF may work better if we do more sites.

Si joints can look funny. You can use steroids in diagnostic injections to treat them.

Transitional vertebrae are common. They may hurt if type II or IV. They feel better if a Mayo radiologist injects them. If that doesn’t work, the evidence isn’t clear on what to do. Some have RFed them, they are sometimes resected.

SCS is the answer. What was the question?

I’m all in for doing 15 or so sites with two burns each for genicular.. with any luck I’ll soon be able to afford a new little tykes tricycle to commute with..

 

[Ducttape]

2/33 got infected. Study done by Neurosurgery departments. For OA knee.
6/33 did not benefit.

COI reports none, yet it reads like an advertisement in the conclusion/discussion.
Shady at best. Lying is much more likely.

so they really only "studied" the patients that had benefit.

what kind of study is that? there is no comparison. of course the people who said "it works" would agree on a survey that "it works"...

im also wondering why stimulating the saphenous nerve below the knee is going to lead to significant benefit. i guess Melzack & Wahl's gate theory?

A further notable limitation of our study is the absence of a control group, specifically patients who underwent TKA with standard post-operative care. This absence may introduce potential biases, as comparisons with standard care or other treatment options cannot be made. Future studies should consider including control groups to better elucidate the relative effectiveness of the treatment under investigation.

 

[SC Tian]

2/33 got infected. Study done by Neurosurgery departments. For OA knee.
6/33 did not benefit.

COI reports none, yet it reads like an advertisement in the conclusion/discussion.
Shady at best. Lying is much more likely.

This week i talked to a guy in boston Edgar Ross, he was very positive about genicular nerve stim for post-surgical knee pain, he followed up patients for decades. Any comments on this? Thanks

 

[lobelsteve]

This week i talked to a guy in boston Edgar Ross, he was very positive about genicular nerve stim for post-surgical knee pain, he followed up patients for decades. Any comments on this? Thanks

Go see who pays him to spout this nonsense. Bet you sprintpns and Medtronic are on the list of many.

 

[nvrsumr]

Edgar was head of the pain dept for my fellowship. He is a gem of a guy and a hell of a doc. I’m sure he has innumerable industry sponsors.

 

[MitchLevi]

Medtronic has paid him over 100k.

 

[nvrsumr]

We had a dedicated Medtronic rep just for our fellowship. I’m sure she made more $ than I do currently. Not surprised by those numbers.

Pennies for him as he left his hugely successful PP in the aughts to go back to academics when the real $ left pain. Was a great mentor.

I’m skeptical of stim for knee pain but that type of academic practice is gonna see a way different patient population than most on this forum.

 

[MitchLevi]

I’m skeptical of stim for knee pain but that type of academic practice is gonna see a way different patient population than most on this forum.

Also makes him far more delusional about outcomes bc he's buffered with layers of personnel between him and the pt.

 

[nvrsumr]

Not here to pick a fight. Delusional and spouting nonsense is not Ed.

 

[MitchLevi]

Not here to pick a fight. Delusional and spouting nonsense is not Ed.

No one here is fighting dude.

The more ppl involved in a pt's care the more filtered the message is when it gets to the top.

He could be the best guy on Earth, but it doesn't change the fact academic physicians overseeing residents and fellows get a different picture from pts than your avg PP doc.

I've seen it countless times.

 

[nvrsumr]

Agreed.

 

[lobelsteve]

I dont know Ed. Ed is a ***** for industry. Numbers are the facts.

 

[nvrsumr]

Thanks steve. I mean he graduated med school in 1980 but nothing you could learn from him.

 

[SC Tian]

Thanks for everyone's input. Just my first impression: he has put a lot of thought into treating post-op knee pain, including sequences and steps of stimulation such as genicular, saphenous, femoral, back to DRG stimulation, and how to appropriately anchor the lead where the IPG is placed. I believe what he said suggests that some people are doing extremely well, but he can't tell me which subgroup benefits the most. IMO, it will not work well for advanced knee osteoarthritis that is bone on bone with alignment issues, especially with instability. maybe a sympathetic nerve block should be an indicator for stim.

 

[lobelsteve]

Nociceptive pain. Stimulation.

Nope.