MBB/RFA approval after fusion?

[CarabinerSD]

I have a patient that is fused extensively from mid thoracic to pelvis due to severe scoliosis and DDD. Imaging does not show any significant disc herniation or stenosis, and doesn't have radicular symptoms. His pain is mostly mechanical & axial, and TPI helps for a short amount of time. I'm thinking back about my training days where some patients did get some relief with MBB/RFA despite having had lumbar fusion. However I've read that some insurances will not allow MBB post-fusion (patient has Medicare). Is this typical experience for you guys or are you able to do MBB/RFA after fusion?

---

Members don't see this ad.

 

[knoxdoc]

Medicare does not allow RF at the level of an ALIF per their LCD. Not sure about PLIF.

 

[Taus]

Cash pay and a prayer.

 

[Laryngospasm]

nothing will help

 

[Taus]

nothing will help

Agreed. This is med management.

 

[donaldduck]

Maybe try cluneal nerve block/pns? I’ve encountered a lot of patients with plifs who have benefited.

 

[Ducttape]

Steroid effect.

Or placebo. Take your choice.

 

[CarabinerSD]

Maybe try cluneal nerve block/pns? I’ve encountered a lot of patients with plifs who have benefited.

Interesting idea...although would you expect more pain the lower buttock region as opposed to just midline axial pain?

 

[donaldduck]

Interesting idea...although would you expect more pain the lower buttock region as opposed to just midline axial pain?

From my experience Cluneal mediated pain can present as axial pain at the level of fusion but typically but typically the gluteal area is the most common presentation. The way I see it if you want to try something closer to the level of the fusion this the only option.

 

[CleanUp]

From my experience Cluneal mediated pain can present as axial pain at the level of fusion but typically but typically the gluteal area is the most common presentation. The way I see it if you want to try something closer to the level of the fusion this the only option.

Sorry I’m not following. Long day. So you’re saying place a PNS by the pedicle or cluneal nerve?

 

[donaldduck]

Sorry I’m not following. Long day. So you’re saying place a PNS by the pedicle or cluneal nerve?

By the cluneal nerve

 

[Ferrismonk]

I don't do MBB/Rf at fused levels. The medial branch has been obliterated, drilled through, or covered in scar tissue. Any effect you would get would only be from the steroid (if added) imo.

If it's mechanical, TPI and other muscle treatments are what I would suggest. Cluneal is a possibility if the pain pattern matches, but you said it's mostly axial.

One thing you can try, if you really want to, is a normal SCS. Scoliosis surgery doesn't involved laminectomies and often the epidural space is preserved. Obviously not as good for mechanical pain vs neuropathic, and there is higher risk, but it's on-label and might help.

 

[gaspasser127]

SIJ pain is exceptionally common in post-thoracolumbar fusion patients especially if it’s been several years.

If positive provocative maneuvers, I would do a couple diagnostic injections into
The SIJs to rule that out

Agree with above that MBB/RF in post fusion patients doesn’t make sense

 

[drrosenrosen]

SIJ pain is exceptionally common in post-thoracolumbar fusion patients especially if it’s been several years.

If positive provocative maneuvers, I would do a couple diagnostic injections into
The SIJs to rule that out

And then fuse that sucker!

 

[CarabinerSD]

SIJ pain is exceptionally common in post-thoracolumbar fusion patients especially if it’s been several years.

If positive provocative maneuvers, I would do a couple diagnostic injections into
The SIJs to rule that out

Agree with above that MBB/RF in post fusion patients doesn’t make sense

Problem is area of pain is way too high for SIJ, and TPIs (including paraspinals, PSIS) only provide short-term relief of a few days.

 

[SpineandWine]

turmeric may help

 

[drrosenrosen]

turmeric may help