RFA complication

[Wkrdoc]

“Knocking” out a nerve root for awhile, with sedation, typically is the cause of most RFA catastrophes... it turns out that you did more than a transiently cause a motor block. I’m surprised by the capricious responses . A few insurance carriers have even excluded RFA coverage for physicians due to the neural injuries nation wide. I’m not exaggerating. The settlements are massive.

Many of you are playing a dangerous game with dense local anesthetics to make your patients more comfortable quickly. If you have reviewed malpractice cases( which I’m sure you have) most of the “wonderfully placed” needles were not placed correctly, and slightly off line , with added sedation, and dense local. If you take away the sedation and you still are increasing risk.

Lastly , think about it. On the one hand you are claiming 1-2mls Of lido 2-4% works so well and is so safe, but on the other hand we all have reported significant nerve root sensory and motor blocks. There is a definite spill over close to the formina and if you have a bad day (your 1:20,000 case is when this happens by the way statistically...) you may end up with with a malpractice event.

Hopefully your expert witness can defend your capricious logic in the setting of well established ASA closed claim data .

I do a lot of cooled RF with 16G needles. I use 1% lido and versed/fent/prop (1-3 cc). The patients are EXTREMELY uncomfortable. I’ve tried using minimal sedation/no sedation and it’s simply too stimulating for the patients to handle.

I’m curious as to how you guys pull this off without sedation? I can pull off standard RF with minimal sedation/no sedation (local only) using 18/20G needles. But never with 16G

---

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[NJPAIN]

In the lumbar spine: At least 5ml local at each level. Wait at least 90 seconds before placing cannula. Talk to patient. Tell them In advance what they will feel. Tell them how you prefer local because it is safer for them.


Sent from my iPhone using Tapatalk

 

[Wkrdoc]

In the lumbar spine: At least 5ml local at each level. Wait at least 90 seconds before placing cannula. Talk to patient. Tell them In advance what they will feel. Tell them how you prefer local because it is safer for them.


Sent from my iPhone using Tapatalk

I’ve done this.

 

[Ronin1]

I stopped doing cooled RF for this reason as well as length of procedure time. Patients really had a lot of procedural pain. Switched to the Stryker venom with similar results at least in my anecdotal practice experience

 

[DODOCSS]

I do a lot of cooled RF with 16G needles. I use 1% lido and versed/fent/prop (1-3 cc). The patients are EXTREMELY uncomfortable. I’ve tried using minimal sedation/no sedation and it’s simply too stimulating for the patients to handle.

I’m curious as to how you guys pull this off without sedation? I can pull off standard RF with minimal sedation/no sedation (local only) using 18/20G needles. But never with 16G

5cc local and 2cc at MB

must wait 3 minutes for local to take

 

[Wkrdoc]

5cc local and 2cc at MB

must wait 3 minutes for local to take

just to clarify, so for bilateral three levels, 42 cc of LA?

clearly we all calculate LA toxicity doses

 

[DODOCSS]

just to clarify, so for bilateral three levels, 42 cc of LA?

clearly we all calculate LA toxicity doses

unilateral, 2 weeks apart

 

[10KHertz]

When you flame lesion the cord , you are off line... case reports and Med-mal cases are out there. Malpractice carriers are aware of these payouts . If your state has an event, trust me your coverage can change or may exclude the technique. It comes down to Excessive sedation , bad technique/training and high thermal lesions. Trifecta.

actually isn’t it the burden of the forum to provide a randomized control trial(at least more than 2) to justify RF lesions at 90deg?
Me posting dozens of randomized studies supporting 80-85deg is a waste of time... it’s already the standard of care .
Dreyfus, Halbrook, Pauza 2000, classic Spine study ...

 

[10KHertz]

I do a lot of cooled RF with 16G needles. I use 1% lido and versed/fent/prop (1-3 cc). The patients are EXTREMELY uncomfortable. I’ve tried using minimal sedation/no sedation and it’s simply too stimulating for the patients to handle.

I’m curious as to how you guys pull this off without sedation? I can pull off standard RF with minimal sedation/no sedation (local only) using 18/20G needles. But never with 16G

A 16g needle is a harpoon. There is no true way to place this wide bore needle with consistent patient comfort. Are you getting much better results with cooled rf vs traditional thermal?

 

[Ducttape]

When you flame lesion the cord , you are off line... case reports and Med-mal cases are out there. Malpractice carriers are aware of these payouts . If your state has an event, trust me your coverage can change or may exclude the technique. It comes down to Excessive sedation , bad technique/training and high thermal lesions. Trifecta.

actually isn’t it the burden of the forum to provide a randomized control trial(at least more than 2) to justify RF lesions at 90deg?
Me posting dozens of randomized studies supporting 80-85deg is a waste of time... it’s already the standard of care .
Dreyfus, Halbrook, Pauza 2000, classic Spine study ...

no, the forum is not a police enforcement agency.
We post studies that are intertpreted by each doctor independently. Nothin I or others post is a rule or guideline.

There is, as far as I am aware, no gold standard as to RFA lesion temperature. Definitely not by insurance rules other than it cannot be pulsed or cooled.

Please post the gold standard you are touting for the rest of us to see. Dreyfus et al from 2000... the duration of lesion and the temperature are not listed in the abstract. And.. That is19 years ago.
There is, in fact, a clinical trial being done I believe from Cleveland Clinic regarding temperature.

ClinicalTrials.gov

clinicaltrials.gov

And this retrospective study suggests you are wrong about optimal temperature.

Optimal Temperature for Radiofrequency Ablation of Lumbar Medial Branches for Treatment of Facet-Mediated Back Pain - PubMed

There seems to be significant functional improvement associated with temp of 90°C compared to 80°C, with no added risk of complications. Randomized controlled studies are warranted.

www.ncbi.nlm.nih.gov

Yes retrospective. Bias.

 

[Baron Samedi]

If we are limiting our treatments to only things with multiple large RCTs, then I'm not sure what's left and why we did fellowships.

Do you perform ESIs?

 

[Wkrdoc]

A 16g needle is a harpoon. There is no true way to place this wide bore needle with consistent patient comfort. Are you getting much better results with cooled rf vs traditional thermal?

I get good results with both, but it seems cooled yields better results more consistently (Is use standard in office cooled in hospital). More room for error and larger lesion

 

[gaseous_clay]

I think you missed my point.

People get zinged during procedures all the time, and with an RFA it's virtually impossible to completely lesion a spinal nerve bc the patient simply won't allow it, even with Versed and fentanyl running.

Propofol is out of my league and I don't know when you're giving it or how you're using it but you're doing motor testing right? So at some point that patient is talking to you.

If you're doing that many procedures over 5 yrs you've surely had an adverse event and seen this exact scenario right?

You've caused neuritis several times or tickled someone nerve root but you're simply not able to ablate a spinal nerve for multiple reasons.

What I meant by my post isn't that you're a bad proceduralist, it's just I'd expect someone with that much volume to see this kind of thing occasionally.

Edit - Regarding volume...I know people who see 3 to 4 dozen patients per day, and I know a guy who sees that many in an afternoon. I personally won't go over 30 in a whole day bc I don't want to...

I hope whoever is seeing 40 pts in an afternoon is not taking government insurance. CMS can audit the clinic schedule and determine that a 99203/13 or 99204/14 is being billed fraudulently due to sheer inability to complete that many detailed clinical evaluations in such a short period of time.

 

[painfree23]

I hope whoever is seeing 40 pts in an afternoon is not taking government insurance. CMS can audit the clinic schedule and determine that a 99203/13 or 99204/14 is being billed fraudulently due to sheer inability to complete that many detailed clinical evaluations in such a short period of time.

What if you see 20??

 

[Wkrdoc]

I hope whoever is seeing 40 pts in an afternoon is not taking government insurance. CMS can audit the clinic schedule and determine that a 99203/13 or 99204/14 is being billed fraudulently due to sheer inability to complete that many detailed clinical evaluations in such a short period of time.

I know a guy who did 17 perm SCS placements in one day with two rooms.

I don’t think 30-40 simple injections in one day is too many. I saw it all the time in residency and fellowship. With good turnover you can do 4-5 per hour. That’s an 8 hour day.

I usually do 20-30/day. I think my record was 35-38

 

[SommeRiver]

I hope whoever is seeing 40 pts in an afternoon is not taking government insurance. CMS can audit the clinic schedule and determine that a 99203/13 or 99204/14 is being billed fraudulently due to sheer inability to complete that many detailed clinical evaluations in such a short period of time.

There is a very well known and well published neuromodulator who I've met several times who gave me some really good advice during fellowship about how to schedule and how to grow your practice.

He sees 40 a half day - From what he told me.

I know people who see more than that in a total day, and most of these types use scribes and midlevels for HPI...

They walk in and do a brief PE and make up a plan that is dictated by the scribe or midlevel.

Edit - I want to point out that I don't think it's cool to brag about volume. Quite the contrary actually. I have much more respect for physicians who see a reasonable number of pts per day and actually sit down and listen to pts as they talk.

 

[10KHertz]

no, the forum is not a police enforcement agency.
We post studies that are intertpreted by each doctor independently. Nothin I or others post is a rule or guideline.

There is, as far as I am aware, no gold standard as to RFA lesion temperature. Definitely not by insurance rules other than it cannot be pulsed or cooled.

Please post the gold standard you are touting for the rest of us to see. Dreyfus et al from 2000... the duration of lesion and the temperature are not listed in the abstract. And.. That is19 years ago.
There is, in fact, a clinical trial being done I believe from Cleveland Clinic regarding temperature.

ClinicalTrials.gov

clinicaltrials.gov

And this retrospective study suggests you are wrong about optimal temperature.

Optimal Temperature for Radiofrequency Ablation of Lumbar Medial Branches for Treatment of Facet-Mediated Back Pain - PubMed

There seems to be significant functional improvement associated with temp of 90°C compared to 80°C, with no added risk of complications. Randomized controlled studies are warranted.

www.ncbi.nlm.nih.gov

Yes retrospective. Bias.

I just posted our best rfa study to date.... it’s a gold standard article in our field and referenced in every subsequent study or insurance guideline(read below commentary). Furthermore its a good randomized and controlled study you can be proud of. It’s a part of our RFA history. Don’t demean the study because it’s older. Actually our expansion of studies in this area is lagging.

Read this:

Redirect Notice

Now you post a randomized study showing 90deg is clinically effective. You can’t . Doesn’t exist. The literature is limited. If you read the commentary above , your
reliance on observational studies may make you feel confident but it doesn’t support your practice. So instead, rely on the real albeit limited data we have. Because overutilization(read the article) and rfa injuries and lack of efficacy only harms our field .IMO...

I await your study for thermal rfa lesions at 90deg(randomized, controlled)so I may consider a change of my understanding and practice of RFA protocol. Otherwise, I maintain that 80-85deg is the accepted range of thermal RFA in this country (maybe not in Korea/NZ where they have more medical tribunals).

 

[10KHertz]

I get good results with both, but it seems cooled yields better results more consistently (Is use standard in office cooled in hospital). More room for error and larger lesion

By more room for error you are referring to a partial anxonometisis with cooled rfa? Technically cooled should be less effective and less prolonged , but safer. However using a 16g in any patient increases risks of bleeding/hematoma formation and may offset any added benefit of the cooled rf. You have any studies comparing cold V’s thermal rf for the spine? Also I’d be careful using 16g needles in any anticoagulated patients cervical or lumbar .

 

[Wkrdoc]

By more room for error you are referring to a partial anxonometisis with cooled rfa? Technically cooled should be less effective and less prolonged , but safer. However using a 16g in any patient increases risks of bleeding/hematoma formation and may offset any added benefit of the cooled rf. You have any studies comparing cold V’s thermal rf for the spine? Also I’d be careful using 16g needles in any anticoagulated patients cervical or lumbar .

This guy is a total buzzkill

 

[lobelsteve]

This guy is a total buzzkill

Here is SIS 2017:


Radiofrequency neurotomy is indicated if there has been significant pain relief with medial
branch blocks with local anesthetic. Lumbar medial branch radiofrequency neurotomy is
performed by placing a radiofrequency cannula parallel to the medial branch along the neck of
the superior articular process. A thermocouple electrode is inserted into the cannula. A lesion is
created by heating the electrode to 80-90 degrees for 60 to 90 seconds. Factors that maximize
lesion size include large diameter cannula, maximum temperature of 90 degrees, long duration
of lesion at 90 seconds, and accuracy of cannula placement. Multiple lesions may be created at
a single level to ensure coagulation of the...

 

[clubdeac]

By more room for error you are referring to a partial anxonometisis with cooled rfa? Technically cooled should be less effective and less prolonged , but safer. However using a 16g in any patient increases risks of bleeding/hematoma formation and may offset any added benefit of the cooled rf. You have any studies comparing cold V’s thermal rf for the spine? Also I’d be careful using 16g needles in any anticoagulated patients cervical or lumbar .

60 degrees (cooled) and 90 degrees are going to procedure the same degree of axonotmesis (I think that's the word you meant above)and therefore equal efficacy and duration. Actually cooled should result in a longer duration due to the larger lesion size as duration and lesion size are directly correlated. There is no data showing an increased risk with larger lesions created by 16g needles or cooled technology. You're spouting a bunch of hypotheticals as dogma

 

[Ducttape]

I just posted our best rfa study to date.... it’s a gold standard article in our field and referenced in every subsequent study or insurance guideline(read below commentary). Furthermore its a good randomized and controlled study you can be proud of. It’s a part of our RFA history. Don’t demean the study because it’s older. Actually our expansion of studies in this area is lagging.

Read this:

Redirect Notice

Now you post a randomized study showing 90deg is clinically effective. You can’t . Doesn’t exist. The literature is limited. If you read the commentary above , your
reliance on observational studies may make you feel confident but it doesn’t support your practice. So instead, rely on the real albeit limited data we have. Because overutilization(read the article) and rfa injuries and lack of efficacy only harms our field .IMO...

I await your study for thermal rfa lesions at 90deg(randomized, controlled)so I may consider a change of my understanding and practice of RFA protocol. Otherwise, I maintain that 80-85deg is the accepted range of thermal RFA in this country (maybe not in Korea/NZ where they have more medical tribunals).

technically, if you only want to use randomized gold standards for interventional spine care, then we would not be doing any procedures at all. (as an example, look at the MINT trial).

in fact, we would be doing what Dr. Malanga specifically states:

In terms of what alternatives can be offered: first, patients should be given positive messages. Rather than focusing on incidental findings on X-rays and MRI scans, they should be directed to the many self-empowering activities they can do (rather than being passive recipients of care).

Treatment should emphasize the role of exercise programs that patients can do on their own, controlling weight, stretching, biofeedback, and other cognitive behavioral treatments. Simple measures that include being aware of our thoughts and how stress can manifest in physical ailments is something that few people want to address but can provide great rewards for very little cost and without negative effects. Receiving treatments that are invasive, not evidence-based and unlikely to be of benefit should be avoided!


and Wkrdoc - I take your 30-40 simple injections to mean TPI, SI injections.

ESI, MBB, and TF should not be construed as simple injections. if you classify ESI, MBB, etc as simple injections, then NP and PA can rightfully state that they should be allowed to perform them.

Procedures we do have significant potential complications (see Anesthesia Closed Claims case files) and need to be done with at least a modicum of care.

 

[Baron Samedi]

As an aside I just met a young guy who developed erectile dysfunction immediately following lumbar RFA. Unless some freak accident occurred and the probe ended up epidural and zapped a descending sacral root, I can't physiologically explain why that would be. Maybe it's just a coincidence or psychogenic?

 

[Baron Samedi]

Here's my question about cooled RFA -- I know the supposed benefit is a larger lesion size but why should this matter for lumbar RFA? If you are doing pre-burn testing and getting excellent responses, why would a larger lesion make any difference? The goal is axonotmesis which will result in Wallerian degeneration anyways, so wouldn't even the smallest possible lesion if placed properly still produce the same results as a larger lesion? Wouldn't a larger lesion lead to more potential complications, like ablating some fibers of a nearby root?

The only application I've really appreciated for cooled RFA is for recurrent SIJ pain. Since I am doing an anatomic rather than physiologic burn pattern for that it makes sense to have a larger lesion size to increase the likelihood that I am getting those tiny nerve fibers. That being said, I hate that procedure and don't offer it(thankfully my clinic does not have the capability).

 

[SSdoc33]

I hope whoever is seeing 40 pts in an afternoon is not taking government insurance. CMS can audit the clinic schedule and determine that a 99203/13 or 99204/14 is being billed fraudulently due to sheer inability to complete that many detailed clinical evaluations in such a short period of time.

only if you bill using time as a variable, and only if you see 40 medicare patients. not likely

 

[SSdoc33]

As an aside I just met a young guy who developed erectile dysfunction immediately following lumbar RFA. Unless some freak accident occurred and the probe ended up epidural and zapped a descending sacral root, I can't physiologically explain why that would be. Maybe it's just a coincidence or psychogenic?

i had one who said that as well, but i think he is FOS. doesnt make sense from a physiologic standpoint. plus, he is diabetic, and weights 350 lbs.

 

[paindoc007]

only if you bill using time as a variable, and only if you see 40 medicare patients. not likely

Hmm, I have come to understand the opposite. >25 pts/daily CAN raise flags, regardless of billing for time or medical complexity, and they do NOT have to be all Medicare pts. Can someone else weigh in? I’d love to get clarity on this as well

 

[SSdoc33]

Hmm, I have come to understand the opposite. >25 pts/daily CAN raise flags, regardless of billing for time or medical complexity, and they do NOT have to be all Medicare pts. Can someone else weigh in? I’d love to get clarity on this as well

CMS doesnt know if you are seeing blue cross patients

 

[lobelsteve]

CMS doesnt know if you are seeing blue cross patients

but the DOJ does.

 

[10KHertz]

technically, if you only want to use randomized gold standards for interventional spine care, then we would not be doing any procedures at all. (as an example, look at the MINT trial).

in fact, we would be doing what Dr. Malanga specifically states:

In terms of what alternatives can be offered: first, patients should be given positive messages. Rather than focusing on incidental findings on X-rays and MRI scans, they should be directed to the many self-empowering activities they can do (rather than being passive recipients of care).

Treatment should emphasize the role of exercise programs that patients can do on their own, controlling weight, stretching, biofeedback, and other cognitive behavioral treatments. Simple measures that include being aware of our thoughts and how stress can manifest in physical ailments is something that few people want to address but can provide great rewards for very little cost and without negative effects. Receiving treatments that are invasive, not evidence-based and unlikely to be of benefit should be avoided!


and Wkrdoc - I take your 30-40 simple injections to mean TPI, SI injections.

ESI, MBB, and TF should not be construed as simple injections. if you classify ESI, MBB, etc as simple injections, then NP and PA can rightfully state that they should be allowed to perform them.

Procedures we do have significant potential complications (see Anesthesia Closed Claims case files) and need to be done with at least a modicum of care.

I prefer to base as much of my practice on the best literature out there. Otherwise you’d be changing your practice weekly with every observational study that comes out in Pain Medicine ...
FYI RFA has the strongest literature in our field. So use it the literature correctly. Why not burn at 95deg if 90deg works? 100deg?
Our field needs to catch up to other evidence based specialists, not just regress or justify retrospective-observational- case cohort studies we see every week. Just because a study is published doesn’t mean you burn at 90deg.

 

[lobelsteve]

I prefer to base as much of my practice on the best literature out there. Otherwise you’d be changing your practice weekly with every observational study that comes out in Pain Medicine ...
FYI RFA has the strongest literature in our field. So use it the literature correctly. Why not burn at 95deg if 90deg works? 100deg?
Our field needs to catch up to other evidence based specialists, not just regress or justify retrospective-observational- case cohort studies we see every week. Just because a study is published doesn’t mean you burn at 90deg.

basic science and early data shows you that as you approach 100degC, the tissue will char and increase risk of infection. Above 90, you increase risk without significantly increasing lesion size.

we learn every day.

 

[10KHertz]

This guy is a total buzzkill

Read more....

https://www.painphysicianjournal.com/current/pd

Water cooled doesn’t cause more axonotmetesis than thermal. A larger lesion means nothing and causes more extra tissue effects. Plus it’s still experimental .

This goal is not to kill the medial branch nerve.

16g catheters can cause more injury in anticoagulant patients.

There is no literature supporting over 85deg.

Sorry that the literature/truth hurts...buzzkill

 

[10KHertz]

basic science and early data shows you that as you approach 100degC, the tissue will char and increase risk of infection. Above 90, you increase risk without significantly increasing lesion size.

we learn every day.

https://www.painphysicianjournal.com/current/pd

Read and we can discuss when your done.... We don’t look to destroy the mbn... for obvious reasons

 

[lobelsteve]

https://www.painphysicianjournal.com/current/pd

Read and we can discuss when your YOU'RE done.... We don’t look to destroy the mbn... for obvious reasons

Dead link, but appreciate your arrogance. 1-2 years out of fellowship now? And I do my best to destroy 5-8mm of the nerve every time I do an RF with a 10mm exposed tip.

 

[10KHertz]

So obviously this tread is going now where...fast

It seems the consensus is that 90deg thermal ablation and cooled rfa with larger probes is acceptable. I see them as experimental. So, can somebody post some reasonable studies to support these practices?

thanks in advance

 

[10KHertz]

Dead link, but appreciate your arrogance. 1-2 years out of fellowship now? And I do my best to destroy 5-8mm of the nerve every time I do an RF with a 10mm exposed

Lol...

More like 12-13 yrs out. Or was that 13months out. I forgot.
“Destroy the nerve”... lol.
Read the article big time. You need a refresher .

 

[lobelsteve]

2 articles posted in this thread as well as SIS position on the topic. Cosman. Costandi.

No refresher needed. I know who I am and so does everyone else. Good day sir.

 

[10KHertz]

2 articles posted in this thread as well as SIS position on the topic. Cosman. Costandi.

No refresher needed. I know who I am and so does everyone else. Good day sir.

Thanks for the debate. Enjoying it. I’m glad you have people who respect you. Must make you proud. I hope to gain more of your knowledge base in the future.

However in this case, your position is wrong and your interpretation of the literate incorrect.

I have previously posted a sentinel rfa article and a great anatomical study. But that wasn’t enough...
Now I have posted the pain physician guildelines for spinal injections. As you must know, this guideline incorporates all society guidelines (sis, ASIPP, etc). Call it the ultimate practice management guideline for our specialty if you like. Please Review it, if you have time . If you’re too busy , let me summarize it for you:


2.2.1 Radiofrequency Neurotomy
Radiofrequency lesioning is performed utilizing either a heat lesion or pulsed mode radiofrequency. A thermal radiofrequency neurotomy lesion for facet denervation is performed at 80° to 85°C.

https://www.painphysicianjournal.com/2013/april/2013;16;S49-S283.pdf

Here’s the link to the guidelines. Enjoy it, and good day to you my humble lifetime moderator friend.

 

[lobelsteve]

Yawn.

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/patient_safety/safety_practices/safetypractices_module2.3_fa.pdf

 

[10KHertz]

Yawn.

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/patient_safety/safety_practices/safetypractices_module2.3_fa.pdf

If you post something, maybe you should read it first... or maybe you were just dozing off . Sorry to disturb you .

The SIS short-form summary link makes no recommendation on RFA lesioning. NO thermal range recommendations are provided or recommended...

It simply warns not to burn above 90deg due to major risks. Which is the reason for this debate in the first place. (Ie. I stated catastrophic rfa risks)
It references articles that lesion at 80-85deg.

SiS is one source , the pain physician guideline incorporates many sources...sorry Yoda , I must respectfully disagree with your voluminous well intentioned posts...

 

[SommeRiver]

This debate is really stupid.

 

[10KHertz]

This debate is really stupid.

Its like a bad MVA, you can’t look away.

 

[lobelsteve]

If you post something, maybe you should read it first... or maybe you were just dozing off . Sorry to disturb you .

The SIS short-form summary link makes no recommendation on RFA lesioning. NO thermal range recommendations are provided or recommended...

It simply warns not to burn above 90deg due to major risks. Which is the reason for this debate in the first place. (Ie. I stated catastrophic rfa risks)
It references articles that lesion at 80-85deg.

SiS is one source , the pain physician guideline incorporates many sources...sorry Yoda , I must respectfully disagree with your voluminous well intentioned posts...

You're incorrect on several things, and it is clear in your tone throughout this thread that you do not care for the advice of others, and that you are by default correct. I post for those more open to science and truth.

My take on the topic: Factors affecting lesion size: tip probe: larger increases lesion size- 22G in the face, 20-16g elsewhere in the body. Time of lesion: 60 sec minimum, no significant benefit over 180 sec. Temp: thermocoagulation over 50deg in liver studies, 62deg about the spine is acceptable. Range from 80-90.
My settings: 20g10mm except face 22g5mm. 90 sec. 80deg neck, gasserian. 90deg lumbar, 90deg peripheral nerves.

Internal Skin Burn Due to Novel Radiofrequency Ablation Technology

Myth: Internal skin burns do not occur during radiofrequency ablation of medial branch nerves or sacral lateral branch nerves because the lesions produced

doi.org

Radiofrequency ablation has been used to denervate painful joints for more than 40 years, predominantly the zygapophysial and sacroiliac joints [1,2]. The size of RFA lesions depends on the gauge of the electrode used, the length of its active tip, lesion duration, and lesion temperature. A typical monopolar RFA lesion has a volume of 0.7 cm3 and a diameter of 0.9 cm [3]. Even when cannula size and duration/temperature parameters are maximized, monopolar lesions are not likely to expand beyond 0.9 cm3 and 1.1 cm [3].

I believe the best data is presented above. This is how I choose my probes, time, and temp.

Local anesthetic: My technique: 1%lido from skin to site, 0.25%bup, 2cc per nerve. Acceptable to use 1/2/4% lido, .25/.5% marcaine. Volumes needed to anesthetize the joint without LAST or motor weakness is appropriate.

Motor and sensory testing is unnecessary, I test motor for additional safety, but I trust my placement under fluoroscopy.

Attacking SIS AS ONLY ONE SOURCE, bad idea. SIS is truth and science. ASIPP is how to get paid.

 

[SSdoc33]

This debate is really stupid.

never stopped us before

 

[paindoc007]

Mildly acrimonious, but not stupid. People are reading this, and learning something, or at the very least forcing them to think about something they haven’t before.

I’ll take this debate over the garbage political debates we often see. Like anyone gives a **** what dudes on sdn think about Bernie vs Trump. No thanks

 

[SommeRiver]

What's stupid is that people think there is some rule about temperature.

 

[Ligament]

What's stupid is that people think there is some rule about temperature.

Obviously, the temp must remain between 80-85C, or you will be banned by all insurance panels.

 

[10KHertz]

You're incorrect on several things, and it is clear in your tone throughout this thread that you do not care for the advice of others, and that you are by default correct. I post for those more open to science and truth.

My take on the topic: Factors affecting lesion size: tip probe: larger increases lesion size- 22G in the face, 20-16g elsewhere in the body. Time of lesion: 60 sec minimum, no significant benefit over 180 sec. Temp: thermocoagulation over 50deg in liver studies, 62deg about the spine is acceptable. Range from 80-90.
My settings: 20g10mm except face 22g5mm. 90 sec. 80deg neck, gasserian. 90deg lumbar, 90deg peripheral nerves.

Internal Skin Burn Due to Novel Radiofrequency Ablation Technology

Myth: Internal skin burns do not occur during radiofrequency ablation of medial branch nerves or sacral lateral branch nerves because the lesions produced

doi.org

Radiofrequency ablation has been used to denervate painful joints for more than 40 years, predominantly the zygapophysial and sacroiliac joints [1,2]. The size of RFA lesions depends on the gauge of the electrode used, the length of its active tip, lesion duration, and lesion temperature. A typical monopolar RFA lesion has a volume of 0.7 cm3 and a diameter of 0.9 cm [3]. Even when cannula size and duration/temperature parameters are maximized, monopolar lesions are not likely to expand beyond 0.9 cm3 and 1.1 cm [3].

View attachment 291143

View attachment 291144
I believe the best data is presented above. This is how I choose my probes, time, and temp.

Local anesthetic: My technique: 1%lido from skin to site, 0.25%bup, 2cc per nerve. Acceptable to use 1/2/4% lido, .25/.5% marcaine. Volumes needed to anesthetize the joint without LAST or motor weakness is appropriate.

Motor and sensory testing is unnecessary, I test motor for additional safety, but I trust my placement under fluoroscopy.

Attacking SIS AS ONLY ONE SOURCE, bad idea. SIS is truth and science. ASIPP is how to get paid.

I am calling for a good randomized controlled trial supporting 85-90deg lesioning.
That is our ideal scientific state , yet I am called unscientific ... wtf, did I just enter the twilight zone. Pain medicine isnt exempt of critical thinking.

FYI by setting your RF machine at 90deg you are breaching the 90deg threshold due to the machines 1-3degree variance. Hence you are violating your precious SIS guidelines(cavitation issues, asymmetric lesions, excessive axonometesis v s partial). Since this is your gold standard ‘true science’ guideline, you just violated your own recommendations. Turn your machine down to 85deg.

As you know , a physician should never state that one guideline dictates their practice patterns. It sets you up for liability. You should know this from you PI and Med Mal experiences. Best to incorporate ASIPP, ASP, Acoem(I hate OEM obviously), national cleaning house, Asra, and CMS in your understanding and practice of science and Medicine.

Finally, to those that think that this debate is nonsensical, why wouldn’t you question your practice patterns? Why wouldn’t you examine what you are actually doing everyday? Rfa is an amazing technology in our field and having an intimate understanding of its principles is key. Sorry I’m the purest on this forum.

Happy Holidays. I’m off.

 

[deleted131481]

What's stupid is that people think there is some rule about temperature.

No rule but I think it's a worthwhile discussion with some good points made.

I used 80C/90sec generally primarily because that's what I learned in fellowship. Getting same efficacy with less is always better. I'd imagine we used less steroid in ESIs etc than 10-20 years ago. I certainly wouldn't claim I'm more right than anyone who does 90C since evidence is not there, but a good question. Maybe we'll use 70C in 20 years, who knows.

Just FYI for those not familiar with cooled RF - probe tip goes to 60C but tissue temp is 80C.

 

[SommeRiver]

I don't feel that ppl using 90 degrees are doing anything wrong or practicing outside the norm, and this thread has devolved into the contrary.

The 90 degree target has been in textbooks for years. The egg yolk study is old, and we've all seen those pics.