Post RFA Neuritis

[Dr. Ice]

My rfa machine is located in my asc so they would want me to charge facility fee too. I’ve already been down this road

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[Ducttape]

You're so oddly interpretive of information that it makes talking to you very difficult. Thanks for educating me about nerve pain; if not for you I'd never have known any of that.

Of course there is a difference in a facet vs a radic. It was a general statement when I posted that. You're a crazy person if you think a level that's fused can't hurt. I see very nicely done knees and hips that continue to hurt. I work in a large ortho group and see it daily.

Same with spinal surgery. I see nice looking fusions and decompressions that pts tell me have made them worse.

You have no ability to prove to me a "fused" level can't hurt.

the wording suggested that a reminder of neuroplasticity - that you are fully aware of - seemed appropriate.

i never said a fused level cant hurt. you made that assumption out of thin air. the statement implied that radiculitis was due to facet arthropathy in a level that was fused, which does not appear logical for multiple reasons.

My rfa machine is located in my asc so they would want me to charge facility fee too. I’ve already been down this road

well.... facility fees are not a battle i am invested in, but...

i would suggest that the care for the patient with a proven and effective treatment with facility is probably preferable to a little performed treatment with unclear outcomes, particularly since the overall cost of peripheral stim to the patient is probably higher than an RFA at an ASC.

 

[SSdoc33]

RFA at fused levels dont work as well. im not saying it can never be done, but expectation bar should be set really low.

likely have better RF outcomes if level fused was fused anteriorly

 

[Ducttape]

The following are considered not reasonable and necessary and therefore will be denied:

1. Intraarticular and extraarticular facet joint prolotherapy
2. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation.
3. Intra-facet implants
4. Facet joint procedure performed after anterior lumbar interbody fusion or ALIF.
5. Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome
6. Diagnostic injections or MMB at the same level as the previously successful RFA procedure

 

[MitchLevi]

I see lots of knees that still hurt post-op, very rarely hips. Also makes sense for joint replacements to continue to hurt as the motion of the joint is preserved, so tendonitis, bursitis, etc will continue to hurt.

I think spinal fusions are a whole different beast though. Makes sense for people to have persistent neuropathic pain after a fusion or discectomy. The way I explain it to patients is, I think, the same way the surgeons here do - spinal fusion stops the damage from getting worse but it doesn’t undo nerve damage that has already occurred. I RF adjacent segments all the time but not fused levels. My rationale is that the RF is almost exclusively blocking pain from the joint, so if the joint can’t move it seems unlikely to hurt.

Makes me wonder though - those patients with big posterior fusions, like C2-T2, whose entire neck still hurts. Have you done RF for any of them? Since you’re picking off some of the dorsal soft tissue sensory innervation, I can see a rationale. I’ve never tried because it wouldn’t be covered by insurance though.

I won't burn a posterior cervical fusion bc of technical considerations. Just too hard of a procedure IMO.

Good post.

 

[MitchLevi]

The following are considered not reasonable and necessary and therefore will be denied:

1. Intraarticular and extraarticular facet joint prolotherapy
2. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation.
3. Intra-facet implants
4. Facet joint procedure performed after anterior lumbar interbody fusion or ALIF.
5. Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome
6. Diagnostic injections or MMB at the same level as the previously successful RFA procedure

Cervical anterior fusion I think is covered.

 

[callmeanesthesia]

I won't burn a posterior cervical fusion bc of technical considerations. Just too hard of a procedure IMO.

Good post.

I’ve done adjacent levels of posterior fusions if the angle of the screws allows.

 

[CleanUp]

This is slightly off topic but I have a bunch of patients who have done well with genicular rfa which I can no longer offer. Any good results with peripheral nerve stim for these people?

Wow. What’s your secret for high success rates? Native or s/p TKA? Obese or normal? I’d like to learn.

 

[MitchLevi]

I'm offering GRFA for cash only, and those pts are exclusively referrals from my partners under specific circumstances.

Be careful though, you'll be a dumping ground if you're not explicitly clear with whose knees you'll burn.

 

[Dr. Ice]

I personally hate the procedure. I have a handful of people who have gotten a year or so of relief and have been asking for it. The successes have all been post tka. I’ve never done it on a native knee

I know what you say about dumping ground, sadly I’m relieved that it has no insurance coverage now so my ortho partners can’t dump their failed knees on to me every chance they get

 

[bedrock]

I personally hate the procedure. I have a handful of people who have gotten a year or so of relief and have been asking for it. The successes have all been post tka. I’ve never done it on a native knee

I know what you say about dumping ground, sadly I’m relieved that it has no insurance coverage now so my ortho partners can’t dump their failed knees on to me every chance they get

What do you mean by it has no insurance coverage now? I thought it was still covered by straight Medicare?
(But not covered by commercial payors or Medicare advantage)

 

[MitchLevi]

What do you mean by it has no insurance coverage now? I thought it was still covered by straight Medicare?
(But not covered by commercial payors or Medicare advantage)

I'm cash only. Could have sworn I was told several months ago it's done.

 

[Dr. Ice]

What do you mean by it has no insurance coverage now? I thought it was still covered by straight Medicare?
(But not covered by commercial payors or Medicare advantage)

Yeah Medicare still covers it, but there’s so many advantage plans that I see with issues following tkr, that I basically consider it done