Multi-Jurisdictional CAC Meeting Transcript - Peripheral Nerve Blocks - February 3, 2025 - JF Part A
Multi-Jurisdictional CAC Meeting Transcript - Peripheral Nerve Blocks - February 3, 2025
Note: Please refer to the recording (time stamps are notated throughout) for an accurate representation of this transcription.
Note:The recording of the Multi-Jurisdictional Peripheral Nerve Blocks Contractor Advisory Committee Meeting February 3 is available on the PalmettoGBA YouTube channel.
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Olatokunbo Awodele
We have just started the recording of this CAC meeting and in compliance with CMS, for the record, prior to doing so, I announced that we would make an audio recording of the CAC meeting and consented on behalf of all participating MACs.
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Olatokunbo Awodele
So once again, good afternoon, everyone, and thank you for joining us today for the MultiJurisdictional Peripheral Nerve Blocks Contractor Advisor Advisory Committee Meeting.
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Olatokunbo Awodele
I'm Dr. Ola Awodele, one of the contractor medical directors at National Government Services.
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Olatokunbo Awodele
The participating MACs for today's CAC are Palmetto GBA, CGS Administrators, National Government Services, and Noridian Healthcare Solutions.
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Olatokunbo Awodele
I am co-moderating this CAC with several contractor medical directors.
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Olatokunbo Awodele
Dr. Moynihan, can you introduce yourself please?
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Eileen Moynihan
Yes. Hi. Eileen Moynihan from Noridian Healthcare Solutions.
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Eileen Moynihan
And my background is as a rheumatologist. Thank you.
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Olatokunbo Awodele
Thank you, Dr. Durden, can you please introduce yourself?
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Marc Duerden
Certainly this is Mark Durden.
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Marc Duerden
I'm a physical medicine rehabilitation physician and I am a medical director at National Government Services.
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Olatokunbo Awodele
Thank you.
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Olatokunbo Awodele
Dr. Volker, can you please introduce yourself?
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Judy Volkar
Hi, my name is Dr. Judith Volker.
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Judy Volkar
I'm an OB GYN and I am a chief medical officer at Palmetto GBA.
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Olatokunbo Awodele
Thank you.
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Olatokunbo Awodele
Dr. Hopkins, can you please introduce yourself?
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Michael Hopkins
Hi, this is Mike Hopkins.
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Michael Hopkins
I'm a medical director from Palmetto GBA and my background is in emergency medicine.
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Olatokunbo Awodele
And last but certainly not least, Dr. Loveless, can you please introduce yourself?
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Meredith Loveless
Yes. I'm Dr. Meredith Loveless. And I also an OBGYN and medical director with CGS Administrators.
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Olatokunbo Awodele
As MACs, we would like to extend a special thank you to Palmetto GBA and Melissa J. Robinson for all her work in hosting this meeting and ensuring everything runs smoothly. Now the purpose of today's meeting is outlined in the CMS Program Integrity Manual 100-08, Chapter 3, Section 13.2.4.3.
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Olatokunbo Awodele
This committee is designed to provide a formal mechanism for healthcare professionals to be informed about the evidence used in developing the LCD and to promote communications between MACs and the healthcare community.
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Olatokunbo Awodele
Our panel consists of subject matter experts from various fields of medicine who will discuss the quality of evidence in the medical literature regarding peripheral nerve blocks.
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Olatokunbo Awodele
This discussion may potentially lead to the development of a peripheral nerve block LCD.
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Olatokunbo Awodele
The CAT members serve in an advisory capacity as representatives of their constituency to review the quality of the evidence used in the development of an LCD. Since the CAC is advisory in nature, the final decision for all issues resides with the MACs.
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Olatokunbo Awodele
Accordingly, the advice rendered by the CAC is most useful when it results from a process of full scientific inquiry and thoughtful discussion in this public forum.
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Olatokunbo Awodele
Subject matter experts (SME), please introduce yourselves by briefly stating your name, profession, affiliation, and any conflicts of interest, if any.
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Olatokunbo Awodele
We recognize that each SME has submitted a written conflict of interest form.
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Olatokunbo Awodele
But please verbally present any conflicts or disclosures that may be relevant to our audience.
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Olatokunbo Awodele
Our SMEs include Dr. Benjamin Northrop.
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Olatokunbo Awodele
Could you please introduce yourself?
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Ben Northrup
Hi, yes, I'm Ben Northrop from Washington University St. Louis, Missouri. I'm a radiologist and no conflicts.
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Olatokunbo Awodele
Thank you, Sir. Dr. Alexander Bautista.
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Alex Bautista
Hi. I'm Dr. Alex from University of Louisville. I'm a pain management and physiologist.
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Alex Bautista
No conflict of interest.
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Olatokunbo Awodele
Thank you, Dr. Deepak Azad.
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Deepak Azad
I'm an internist and occupational medicine. That's my expertise and I have no conflict.
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Olatokunbo Awodele
Thank you, Dr. Marzena Buzanowska.
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Marzena Buzanowska, MD
I am a PM&R pain management physician, and I have no conflicts of interest.
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Olatokunbo Awodele
Thank you, Dr. Laxmaiah Manchikanti.
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Laxmaiah Manchikanti
Thank you.
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Laxmaiah Manchikanti
I'm Laxmaiah Manchikanti.
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Laxmaiah Manchikanti
I'm the chairman of the Board of American Society of Interventional Pain Physicians.
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Laxmaiah Manchikanti
I'm an interventional pain physician.
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Laxmaiah Manchikanti
I also serve on the Career Advisory Committee for CGS Kentucky.
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Laxmaiah Manchikanti
I also have affiliations with University of Louisville and University of Louisiana in Shreveport.
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Olatokunbo Awodele
Any conflicts, Sir, to disclose, OK.
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Laxmaiah Manchikanti
No, I have no conflict.
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Olatokunbo Awodele
Thank you. Dr. Michelle Poliak-Tunis,
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Michelle Poliak-Tunis
Hi, I'm Michelle Poliak-Tunis,
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Michelle Poliak-Tunis
I am a PM&R pain physician at the University of Wisconsin, Madison, and I have no conflicts.
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Olatokunbo Awodele
Thank you Dr. Brian Paquette.
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Brian Paquette
Yes, my name is Dr. Brian Paquette. I'm a neurologist and interventional pain physician located in Indianapolis, IN.
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Brian Paquette
No conflicts of interest.
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Olatokunbo Awodele
Thank you, Sir. Dr. Steven Barrett.
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Steven Barrett
Yes, Steven Barrett.
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Steven Barrett
I'm a podiatric surgeon and also the chairman of the board of trustees for the Association of Extremity Nerve Surgeons.
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Steven Barrett
I have no conflicts of interest.
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Olatokunbo Awodele
Thank you, Dr. Erin Nelson.
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Erin Nelson
I'm Dr. Erin Nelson practice in Ames, IA.
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Erin Nelson
I have no conflicts of interest.
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Olatokunbo Awodele
Thank you, Dr. Anne Moscony.
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Anne Moscony
Hi. I'm Anne Moscony.
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Anne Moscony
I'm an occupational therapist and a certified hand therapist, and I'm representing the American Occupational Therapy Association, and I'm pleased to be here today.
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Anne Moscony
And I have no conflicts to report.
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Olatokunbo Awodele
Thank.
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Olatokunbo Awodele
Thank you. Mary Walsh-Sterup.
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Mary Walsh-Sterup
Yes, I'm Mary Walsh-Sterup.
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Mary Walsh-Sterup
I'm also an occupational therapist, certified hand therapist within American Occupational Therapy Association, and I currently practice in mid-state, Nebraska.
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Olatokunbo Awodele
Thank you, Dr. Michael Schneider.
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Olatokunbo Awodele
Sorry, Dr. Michael Schneider.
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Olatokunbo Awodele
Dr. Kevin Vorenkamp.
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Olatokunbo Awodele
Dr. Kevin Vorenkamp.
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Olatokunbo Awodele
Melissa, can we please make sure that check whether they are on the call and volume stuff. OK, so while we're doing that prior to this meeting, the MACs conducted a multi-jurisdictional workgroup to discuss pre-decisional concepts and the medical literature preparing a list of topics and.
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Olatokunbo Awodele
Questions for the experts to address. This allows them to supplement their presentations with their own medical literature reviews.
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Olatokunbo Awodele
Today's meeting will run from 2:00 to 4:00 PM Eastern Time and it will be recorded. As I stated earlier and placed on each respective MACs website as we conduct this session via teleconference and webinar, please focus on the strength of the medical evidence rather than personal experience. Should the medical evidence be silent or inconclusive on a topic we encourage our SMEs to highlight these areas found in the literature.
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Olatokunbo Awodele
Please adhere to the time limits for each agenda topic to ensure smooth dialogue when you begin speaking, state your name so we can accurately capture contributions from all participants. To maintain order, we want our experts to speak uninterrupted. I there are questions from MAC medical directors after your presentation, please use the raised hand icon to indicate your question and the moderators will acknowledge you prior to speaking.
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Olatokunbo Awodele
Likewise, if an SME has additional comments or concerns, please raise your hand for acknowledgement.
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Olatokunbo Awodele
Ms. Robinson may also recognize and facilitate raised hand icons to allow you to be acknowledged.
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Olatokunbo Awodele
All speakers are asked to mute themselves when not speaking.
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Olatokunbo Awodele
To minimize background noise or feedback, we will encourage a meeting of civility when addressing an issue. Please focus on the topic rather than the individual or practice behind an opinion.
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Olatokunbo Awodele
The moderators reserve the privilege to ensure a smooth meeting, additional comments or questions should be submitted in writing as time constraints may limit in in meeting discussion.
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Olatokunbo Awodele
Thank you again for your participation and dedication.
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Olatokunbo Awodele
Let's have a productive and insightful discussion.
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Olatokunbo Awodele
I'll now hand over to Dr. Moynihan, the questioner for the first section, Dr. Moynihan.
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Eileen Moynihan
Hi could I know whether?
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Eileen Moynihan
Two of the speakers are on the call, Dr. Schneider and.
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Eileen Moynihan
Dr. Vorenkamp.
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Eileen Moynihan
Did we find out if they're on because they are involved in this section?
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Alex Bautista
I usually don't.
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Alex Bautista
Dr. Warren, this is Alex.
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Alex Bautista
What you said Vorenkamp asked you resend the link to him again. He says he was not able to, like make it.
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Alex Bautista
I can send a link.
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Eileen Moynihan
How about?
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Eileen Moynihan
How about Dr. Schneider?
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Melissa J Robinson
I don't see him on.
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Eileen Moynihan
OK.
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Melissa J Robinson
I'll resend both of them the link and hopefully they'll join within the next few minutes.
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Eileen Moynihan
OK so.
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Eileen Moynihan
Let me ask any of the others if they can answer the first question, which is what is the evidence and or societal guidelines concerning the provision of non-surgical conservative care prior to proceeding with therapeutic genicular nerve blocks or related procedures like radiofrequency ablation or cryo NE?
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Eileen Moynihan
Would anyone answer since the speaker is not on?
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Laxmaiah Manchikanti
This is Dr. Manchikanti.
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Laxmaiah Manchikanti
Carte if you want me to, I would.
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Eileen Moynihan
I'll take any answers at this point on what the evidence on conservative therapy or what the societal guidelines are.
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Eileen Moynihan
If no one knows for sure, I can put it at the end to see if Dr. Shadier comes in.
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Eileen Moynihan
I realized you weren't assigned this question, but if someone can answer that would be great.
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Olatokunbo Awodele
I think we have a volunteer.
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Olatokunbo Awodele
I don't, I don't.
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Olatokunbo Awodele
Not sure if you heard Eileen.
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Olatokunbo Awodele
One of our SMEs was volunteering.
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Olatokunbo Awodele
So, Sir, could you go ahead?
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Laxmaiah Manchikanti
This is Dr. Laxmaiah Manchikanti.
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Eileen Moynihan
OK.
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Eileen Moynihan
Yes.
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Laxmaiah Manchikanti
OK.
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Laxmaiah Manchikanti
So there is no specific evidence or societal guidelines for the non-surgical or conservative care prior to proceeding. Therapeutic genicular nerve block.
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Laxmaiah Manchikanti
Are related procedure. However, as we go with all the conservative measures, non-stereo antiinflammatory agents.
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Laxmaiah Manchikanti
Exercise program.
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Laxmaiah Manchikanti
Physical therapy.
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Laxmaiah Manchikanti
All of these should be considered for certain period of time, three months or so.
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Laxmaiah Manchikanti
And after that we should consider a genicular nerve block. And if we are successful with the genicular nerve block, we can consider radio frequency ablation.
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Eileen Moynihan
Thank you, Dr.
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Douglas Beall
So this this is Doug Beall, if I could add to so agreed with Manchikanti.
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Douglas Beall
If I could add to that.
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Douglas Beall
So there's two level one.
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Douglas Beall
There's two level one trials; one compares is by Davis et all comparing genicular nerve RF versus steroid injection.
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Douglas Beall
The other one is by Chin with en comparing ready frigates. Ablation to.
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Douglas Beall
Visigo supplementation.
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Douglas Beall
So there's two level one trials on this.
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Eileen Moynihan
All right.
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Eileen Moynihan
Thank you, Dr. Bell.
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Eileen Moynihan
Dr. Azad, is there any evidence to support a minimum trial duration and number of therapies of conservative care before proceeding with Genicular nerve block?
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Laxmaiah Manchikanti
There should be six weeks of.
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Laxmaiah Manchikanti
Trial conservative management just like what we do for facet joint injections or other types of treatments.
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Laxmaiah Manchikanti
That should be with the non-steroidal anti-inflammatory agents and any other drugs, plus physical therapy.
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Laxmaiah Manchikanti
And structured exercise program.
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Eileen Moynihan
Should they be occurring simultaneously?
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Eileen Moynihan
Provide if there's no.
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Eileen Moynihan
Problem with the drugs.
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Laxmaiah Manchikanti
I didn't understand the question.
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Eileen Moynihan
Well, you mentioned that you could try certain medications.
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Eileen Moynihan
Or structured.
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Eileen Moynihan
Program physical therapy.
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Eileen Moynihan
So I'm wondering, are you suggesting that they be in serially or in conjunction with each other?
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Eileen Moynihan
Provided there's no problem with the picking up medication.
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Laxmaiah Manchikanti
Any of the medications, I don't think there should be a problem, and it can be provided in conjunction with each other so.
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Eileen Moynihan
OK.
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Eileen Moynihan
Thank you.
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Eileen Moynihan
Dr. Poliak-Tunis.
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Eileen Moynihan
Could you share insights into the absolute and relative contraindications for receiving a genicular nerve block, particularly informed by studies like McCormick in 2018 or any others that you have found?
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Michelle Poliak-Tunis
Sure. So based on this McCormick study in 2018, the contraindications for genicular nerve block.
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Michelle Poliak-Tunis
Included active infections, bleeding disorders.
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Michelle Poliak-Tunis
Current anticoagulation or antiplatelet medication use.
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Michelle Poliak-Tunis
For this study specifically, allergies and medication used in their protocol as well as pregnancy and pacemaker.
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Michelle Poliak-Tunis
Again, this was based on this study.
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Eileen Moynihan
Thank you.
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Eileen Moynihan
Dr. Northrup, what does the evidence indicate regarding the efficacy and safety of various genicular block techniques such as using anatomical landmarks versus fluoroscopic or ultrasound guided methods?
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Ben Northrup
Yes, thank you.
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Ben Northrup
So this is really a couple questions ruled into one, the first being landmarks versus imaging guidance. And then the difference between those two.
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Ben Northrup
So to answer the first portion of those.
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Ben Northrup
Just simply using anatomic landmarks is quite rare now in most of the studies.
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Ben Northrup
Just don't have much information on that, mainly because at this point, if you were to create a trial, it would be unethical to use a control arm, so to speak, with only anatomic landmarks.
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Ben Northrup
So essentially everything is fluoro versus ultrasound. What we do see in the evidence when they've surveyed providers is that essentially nobody does it without imaging guidance of some type 2024 study, very recent show that 85 approximately 85% use fluoroscopic guidance 7.2.
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Ben Northrup
Percent use ultrasound and a little under 7% use the hybrid method ultrasound plus fluoroscopic guidance.
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Ben Northrup
Is 0 used anatomic landmark so.
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Ben Northrup
Very little evidence for that out there, and certainly when you look at how the procedure is done and how these landmarks were created for imaging guidance, you simply you couldn't do it very well without imaging guidance.
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Ben Northrup
So it's really something that that isn't an issue of note, since we are talking about coverage, there is no difference in payment.
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Ben Northrup
So whether we're talking about the block or the ablation?
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Ben Northrup
Code 64454 and 64624 both say including.
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Ben Northrup
Imaging guidance when performed so whether or not imaging guidance is performed you code it the same way and it will make no difference in you know in certainly with how one would code it or how it would be reimbursed. Now to your next question concerning Flora versus ult.
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Ben Northrup
This is where it gets a little bit more complicated.
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Ben Northrup
So there is one study non-us that compares fluoro and ultrasound guidance from Kim at all.
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Ben Northrup
I can send you the citation if you'd like in the comments, and that showed that the outcomes were not significantly different.
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Ben Northrup
There is another, smaller study from Turkey that shows a slightly greater pain reduction with ultrasound guidance.
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Ben Northrup
But it was a much smaller study.
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Ben Northrup
And then.
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Ben Northrup
Then the next topic here in terms of, so that was in terms of the efficacy of it in terms of safety. So, all the major studies have shown very similar safety profiles between fluoro and ultrasound. However, there is no question that you can with ultrasound better localize things.
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Ben Northrup
Like the pest insurinous tendon, the joint capsule, adjacent vessels, etcetera.
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Ben Northrup
And you could in theory reduce the risk of these rare but reported.
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Ben Northrup
Complications such as pest and Bursitis or pest insurinus tendonitis, tendon injury, Bursitis, periarticular hematoma, septic arthritis, etcetera. These are of course very, very, very rare.
0:19:0.618 --> 0:19:8.578
Ben Northrup
And not likely with either method. But in theory the ultrasound method ultrasound guidance could potentially reduce those risks.
0:19:12.398 --> 0:19:13.558
Eileen Moynihan
Well, thank you very much.
0:19:15.98 --> 0:19:27.338
Eileen Moynihan
Dr. Manchacane, what factors might influence genicular nerve block outcomes? Considering variables like the number of needles, nerves, blocked, needle size, etcetera.
0:19:27.618 --> 0:19:31.978
Eileen Moynihan
Additionally, could you address the lack of direct comparisons?
0:19:34.178 --> 0:19:35.418
Eileen Moynihan
Among techniques.
0:19:38.48 --> 0:19:42.368
Laxmaiah Manchikanti
Yes, there are no comparative studies.
0:19:42.368 --> 0:19:45.728
Laxmaiah Manchikanti
There are no society guidelines generally.
0:19:45.728 --> 0:19:52.608
Laxmaiah Manchikanti
These are performed on three nerves, superomedial, superolateral and infer medial.
0:19:53.8 --> 0:20:1.528
Laxmaiah Manchikanti
Some have used other nerves like medial retinacular in proper telr, but that it is not a common practice.
0:20:2.418 --> 0:20:7.458
Laxmaiah Manchikanti
The CPT code insists on are involves 3 genicular nerves.
0:20:8.638 --> 0:20:14.838
Laxmaiah Manchikanti
So those are the three nerves should be done. If it is not done, then it is not considered a genicular nerve.
0:20:15.358 --> 0:20:17.478
Laxmaiah Manchikanti
It will go into a peripheral nerve block.
0:20:19.18 --> 0:20:21.178
Laxmaiah Manchikanti
In reference to number of needles.
0:20:23.688 --> 0:20:46.848
Laxmaiah Manchikanti
In nerve blocks, there are no studies at all. Looking at different number of needles. But for radio frequency neurotomy there is a study which is used 3 needles versus one needle per nerve. That may make some sense because it can produce a larger longer type of lesion. But.
0:20:46.848 --> 0:20:48.488
Laxmaiah Manchikanti
For genicular nerve block.
0:20:49.298 --> 0:20:53.658
Laxmaiah Manchikanti
There is no need for any more needles and there are no studies at all.
0:20:54.648 --> 0:20:58.48
Laxmaiah Manchikanti
The nurse blocked. I just described that.
0:20:59.618 --> 0:21:0.498
Laxmaiah Manchikanti
Size of the needles so.
0:21:2.168 --> 0:21:3.928
Laxmaiah Manchikanti
It really doesn't matter.
0:21:3.928 --> 0:21:8.48
Laxmaiah Manchikanti
Some use 22 gauge; some use 25 gauge.
0:21:8.678 --> 0:21:17.118
Laxmaiah Manchikanti
I prefer personally 22 gauge. Most of the studies used 22-gauge needles and KL grading.
0:21:19.488 --> 0:21:33.488
Laxmaiah Manchikanti
All the studies used in grade two or higher, as you know, Grade 0 means no pathological futures grade. One is doubtful. Narrowing of joint space and possible us to fight lipping.
0:21:34.208 --> 0:21:39.888
Laxmaiah Manchikanti
Grade two is definite osteophytes and possible narrowing of joint space.
0:21:40.488 --> 0:21:43.368
Laxmaiah Manchikanti
Then grade 3 moderate multiple osteophytes.
0:21:44.498 --> 0:21:48.258
Laxmaiah Manchikanti
Grade 4 is large, osteophytes mark, narrowing of joint.
0:21:48.648 --> 0:21:54.848
Laxmaiah Manchikanti
Space with severe sclerosis and definite deformity of bone ends so.
0:21:56.418 --> 0:22:8.978
Laxmaiah Manchikanti
Based on the literature, they are recommending these to be performed in patients over grade two, grade two or higher, not grade 0 or not grade one.
0:22:13.128 --> 0:22:18.728
Laxmaiah Manchikanti
And since there is not a direct comparison between these techniques in the literature.
0:22:21.128 --> 0:22:25.8
Laxmaiah Manchikanti
It is not hard to answer the question, but.
0:22:26.578 --> 0:22:28.418
Laxmaiah Manchikanti
It may not make any difference at all.
0:22:30.98 --> 0:22:32.338
Laxmaiah Manchikanti
How many needles he uses and three nerves?
0:22:32.338 --> 0:22:37.818
Laxmaiah Manchikanti
You block because that is what the CPT code says. Size of the needles does not matter.
0:22:38.58 --> 0:22:39.938
Laxmaiah Manchikanti
KL grading is important.
0:22:41.578 --> 0:22:43.98
Laxmaiah Manchikanti
Because if we are using.
0:22:44.778 --> 0:22:50.138
Laxmaiah Manchikanti
Any clinical blocks other than osteoarthritis then it is important.
0:22:51.288 --> 0:22:59.488
Laxmaiah Manchikanti
We have to remove the restriction on tail grading and just do with the go with the chronic pain.
0:23:1.58 --> 0:23:8.178
Laxmaiah Manchikanti
Which is disabling or severe enough to be affecting their ability to function.
0:23:10.188 --> 0:23:10.668
Laxmaiah Manchikanti
Thank you.
0:23:14.158 --> 0:23:17.638
Eileen Moynihan
Thanks very much for that answer, Dr. Batista.
0:23:17.638 --> 0:23:25.838
Eileen Moynihan
What is the current evidence surrounding the efficacy of genicular nerve blocks compared to placebo or sham procedures?
0:23:29.38 --> 0:23:31.758
Alex Bautista
So there is.
0:23:33.298 --> 0:23:43.218
Alex Bautista
Literature out there. However, individual studies have shown like result. It's limited to timeframe of like evaluation.
0:23:43.218 --> 0:23:50.298
Alex Bautista
Some other are just like 12 weeks and some of them are different like ranges of like osteoarthritis.
0:23:50.378 --> 0:23:58.218
Alex Bautista
However, there is a recent publication January 2025 published in the Journal of Pain Research, where they did.
0:23:59.418 --> 0:23:59.938
Alex Bautista
A analysis.
0:24:1.478 --> 0:24:4.838
Alex Bautista
Of 13 randomized control trials with seven.
0:24:6.538 --> 0:24:17.978
Alex Bautista
And they have found out that genicular nerve blocks are found to be superior to other analgesic regimen. But currently there's no societal guideline.
0:24:18.498 --> 0:24:24.298
Alex Bautista
And again, with a lot of mixed results from individual studies, but those studies are limited to.
0:24:25.858 --> 0:24:35.58
Alex Bautista
Are limited because of the randomization. May not be that accurate and some of them may not be reproducible, but overall, in this meta-analysis it's showing that.
0:24:36.568 --> 0:24:42.648
Alex Bautista
Block is superior to any analgesic regimen or knee pain.
0:24:47.108 --> 0:24:48.268
Eileen Moynihan
Thank you very much.
0:24:49.818 --> 0:25:2.858
Eileen Moynihan
Dr. Buzanowska, could you explain any guidelines or evidence related to the frequency of therapeutic genicular nerve blocks and whether repetition of these injections is advised?
0:25:4.778 --> 0:25:7.258
Marzena Buzanowska
Hello. Yes, this is Dr. Marzena Buzanowska.
0:25:7.618 --> 0:25:16.218
Marzena Buzanowska
And so I was a little bit confused about this question because therapeutic blocks in my understanding.
0:25:16.648 --> 0:25:22.968
Marzena Buzanowska
Those are blocks where you inject local anesthetic combined with a steroid.
0:25:22.968 --> 0:25:25.128
Marzena Buzanowska
So some sort of therapeutic agent?
0:25:26.698 --> 0:25:33.778
Marzena Buzanowska
And there are no society guidelines or studies that look at the efficacy of therapeutic gene kill nerve blocks.
0:25:34.178 --> 0:25:36.538
Marzena Buzanowska
The studies looking at gene kill nerve blocks are.
0:25:38.258 --> 0:25:45.538
Marzena Buzanowska
Ones where the nerve blocks are used as diagnostic tool to see and predict the outcomes of radiofrequency ablation.
0:25:47.88 --> 0:25:54.248
Marzena Buzanowska
And so I am not aware of any studies that or societal guidelines that look at therapeutic blocks.
0:25:55.818 --> 0:25:57.378
Marzena Buzanowska
That include steroids. I'm welcome.
0:25:57.378 --> 0:25:58.418
Marzena Buzanowska
I welcome other people's input.
0:26:3.28 --> 0:26:3.908
Eileen Moynihan
Thank you very much.
0:26:5.458 --> 0:26:9.538
Eileen Moynihan
Is Dr. Bornkamp able to be on at this point?
0:26:11.138 --> 0:26:12.138
Eileen Moynihan
Or still having trouble?
0:26:11.458 --> 0:26:17.98
Kevin Vorenkamp
I'm I think I'm in the I think I'm in the general audience, but I am listening.
0:26:16.868 --> 0:26:18.388
Eileen Moynihan
I hear you.
0:26:19.188 --> 0:26:19.988
Eileen Moynihan
I hear you.
0:26:20.28 --> 0:26:31.708
Eileen Moynihan
So could I ask you to respond to what does the evidence say about diagnostic genicular nerve blocks prior to radiofrequency ablation procedures?
0:26:33.258 --> 0:26:38.698
Eileen Moynihan
Referencing works like McCormick in 2017 and Jameson in 2018.
0:26:39.98 --> 0:26:41.978
Eileen Moynihan
Are there particular criteria for selection?
0:26:44.148 --> 0:26:46.148
Kevin Vorenkamp
Yeah, I think it's a bit limited.
0:26:46.148 --> 0:26:55.188
Kevin Vorenkamp
The original McCormick study he showed very comparable findings whether you proceeded directly to radio frequency ablation.
0:26:56.738 --> 0:27:2.378
Kevin Vorenkamp
Or did the diagnostic block and in the original with his original study, he was looking at?
0:27:4.138 --> 0:27:8.458
Kevin Vorenkamp
I think 50% relief and 1ML volume.
0:27:9.18 --> 0:27:10.538
Kevin Vorenkamp
He did a subsequent study.
0:27:10.538 --> 0:27:13.978
Kevin Vorenkamp
A couple years ago, when he looked at being more restrictive.
0:27:14.928 --> 0:27:38.128
Kevin Vorenkamp
Using only half a milliliter at each location, and actually, even if he graded to, I think they looked back, their study and even if he used 80% or 90% as a selection criteria, it didn't make much difference in terms of outcomes with RFA. So.
0:27:38.128 --> 0:27:39.448
Kevin Vorenkamp
Kind of the general.
0:27:40.258 --> 0:27:44.258
Kevin Vorenkamp
Sense is that the genicular nerve blocks have very limited.
0:27:45.128 --> 0:27:45.888
Kevin Vorenkamp
Utility.
0:27:47.418 --> 0:27:47.738
Kevin Vorenkamp
In predicting.
0:27:48.48 --> 0:27:51.608
Kevin Vorenkamp
Response to limited prognostic value.
0:27:53.278 --> 0:28:1.718
Kevin Vorenkamp
But they still may be indicated for specific patients, but do not necessarily increase the success of radio frequency ablation.
0:28:6.898 --> 0:28:7.338
Eileen Moynihan
All right.
0:28:7.338 --> 0:28:8.18
Eileen Moynihan
Thank you.
0:28:8.18 --> 0:28:12.138
Eileen Moynihan
We're going to move on to radio frequency ablation.
0:28:13.688 --> 0:28:16.408
Eileen Moynihan
And I'm I can't see who's on.
0:28:16.408 --> 0:28:19.368
Eileen Moynihan
Is Dr. Snyder still not on?
0:28:21.648 --> 0:28:22.688
Eileen Moynihan
Could someone answer?
0:28:27.418 --> 0:28:29.778
Judy Volkar
I sent him an e-mail and re sent him the link.
0:28:28.118 --> 0:28:28.478
MELISSA J ROBINSON
Crystal.
0:28:32.968 --> 0:28:33.408
Eileen Moynihan
OK.
0:28:34.968 --> 0:28:39.688
Eileen Moynihan
Maybe I'll leave that question till after the others are asked.
0:28:41.368 --> 0:28:44.648
Eileen Moynihan
And then we'll come back and see if he was able to get on.
0:28:45.168 --> 0:28:49.928
Eileen Moynihan
So I'm going to move to Dr. Polyak Tunis.
0:28:51.878 --> 0:29:5.198
Eileen Moynihan
Do different genicular RFA techniques compare in terms of safety and efficacy, such as conventional RFA versus cooled RFA and anatomical landmark versus guided procedures?
0:29:6.768 --> 0:29:13.408
Michelle Poliak-Tunis
Sure. So, with regards to efficacy and safety and with different canalicular radio frequency techniques.
0:29:15.48 --> 0:29:18.488
Michelle Poliak-Tunis
Based on a study published in 2022, the Capital study.
0:29:20.88 --> 0:29:21.368
Michelle Poliak-Tunis
Noticed that cooled radio frequency.
0:29:21.678 --> 0:29:39.998
Michelle Poliak-Tunis
Provided better short term improvement in VA scores rather than traditional radio frequency with a time interval of pain relief greater than 50%, pain decreased an average of only 2.6 months for the traditional radio frequency group, whereas it was 11.1 months for the cool.
0:29:39.998 --> 0:29:41.38
Michelle Poliak-Tunis
Radio frequency ablation group.
0:29:42.608 --> 0:29:51.808
Michelle Poliak-Tunis
And the study also noted that long term positive outcomes greater than six months really depended on the size of the lesion. And This is why cold radio frequency.
0:29:52.238 --> 0:29:55.318
Michelle Poliak-Tunis
As well as larger traditional radio frequency ablated.
0:29:55.318 --> 0:30:15.798
Michelle Poliak-Tunis
Treated patients received longer time intervals of pain relief, which is likely due to larger volume of denervation area that's captured greater number of articular branches, and by creating a larger angle independent lesion, the likelihood of ablating the target nerves increased, which could explain the success of cold rad.
0:30:15.798 --> 0:30:18.398
Michelle Poliak-Tunis
Frequency, when compared to traditional.
0:30:19.208 --> 0:30:20.8
Michelle Poliak-Tunis
Radio frequency.
0:30:20.478 --> 0:30:27.518
Michelle Poliak-Tunis
Now, with regards whether ultrasound vasopylaio guided radiofrequency, excuse me, radiofrequency ablation techniques.
0:30:29.48 --> 0:30:32.888
Michelle Poliak-Tunis
And again, this is now based on a study published in 2021 that you mentioned there.
0:30:34.488 --> 0:30:49.448
Michelle Poliak-Tunis
Fluoroscopy guidance can easily identify nerve targets as they run adjacent to the CURIOSTEIN and offer better needle visualization regardless of tissue depth and needle gauge. Whereas in contrast, ultrasound guidance offers the benefit of in office.
0:30:50.88 --> 0:30:58.608
Michelle Poliak-Tunis
Based usually cheaper alternatives with no radiation exposure and improved safety due to better visualization of adjacent soft tissue structures.
0:30:58.808 --> 0:31:13.288
Michelle Poliak-Tunis
However, it is the authors did state, and the literature does support that the choice of technique should be based on the availability of the set up as well as the individual experience and comfort with imaging modalities.
0:31:18.538 --> 0:31:19.18
Eileen Moynihan
Thank you.
0:31:20.568 --> 0:31:35.848
Eileen Moynihan
Dr. Manchikanti it's not going to be finally, but could you provide insights into the frequency of genicular RFA procedures as per current evidence and what guides these decisions in the absence of firm evidence?
0:31:37.928 --> 0:31:38.488
Laxmaiah Manchikanti
Thank you.
0:31:39.678 --> 0:31:43.318
Laxmaiah Manchikanti
All the most of the systematic reviews and.
0:31:44.888 --> 0:31:48.968
Laxmaiah Manchikanti
The randomized controlled trial is providing the evidence that.
0:31:50.688 --> 0:31:59.208
Laxmaiah Manchikanti
They are effective for about 6 months, some have said 12 months, but that is a small number considering the radio frequency.
0:32:0.808 --> 0:32:5.528
Laxmaiah Manchikanti
Effectiveness for six months for other conditions such as facet joint pain.
0:32:7.288 --> 0:32:9.448
Laxmaiah Manchikanti
I think repeating after six months.
0:32:10.758 --> 0:32:17.598
Laxmaiah Manchikanti
If one obtains greater than 50% relief for six months.
0:32:21.358 --> 0:32:24.118
Laxmaiah Manchikanti
And that is based on the evidence.
0:32:24.158 --> 0:32:29.198
Laxmaiah Manchikanti
There are multiple systematic reviews on it if you want, I will be happy to go over that.
0:32:33.448 --> 0:32:33.568
Eileen Moynihan
Umm.
0:32:36.898 --> 0:32:39.18
Eileen Moynihan
Well, well, you mean right now.
0:32:39.18 --> 0:32:40.898
Eileen Moynihan
You can summarize those.
0:32:41.438 --> 0:32:43.478
Eileen Moynihan
Yes, or you're going to send them.
0:32:43.478 --> 0:32:44.838
Eileen Moynihan
Oh, OK. Go ahead.
0:32:45.58 --> 0:32:45.98
Laxmaiah Manchikanti
I.
0:32:46.408 --> 0:32:53.248
Laxmaiah Manchikanti
There is a systematic review published in 2024 by Sateho in pain physician.
0:32:53.248 --> 0:33:5.808
Laxmaiah Manchikanti
They performed meta-analysis of radio frequency and pulsed radio frequency and cooled radio frequency. They identified about 11 publications with 604 patients.
0:33:6.688 --> 0:33:13.208
Laxmaiah Manchikanti
They showed that both cooled and pulsed RFA procedures targeting the genicular nerve resulted in considerable pain reduction.
0:33:14.438 --> 0:33:35.718
Laxmaiah Manchikanti
Hit three, six and 12 months. However, there was no significant improvement in physical and functional outcome for the cooled RFA technique in follow up visits. There was significant improvement in physical function outcomes for the pulsed RFA technique at one month and three month follow up visit so overall at.
0:33:35.718 --> 0:33:39.958
Laxmaiah Manchikanti
Six month follow a total of nine studies were included with five studies of.
0:33:40.768 --> 0:33:42.928
Laxmaiah Manchikanti
Cool RFA and four studies of pulsed RFA.
0:33:43.798 --> 0:33:46.358
Laxmaiah Manchikanti
Showing significant improvement from baseline.
0:33:47.928 --> 0:33:52.648
Laxmaiah Manchikanti
So 12 months was questionable, with only four studies meeting the criteria.
0:33:54.288 --> 0:33:58.208
Laxmaiah Manchikanti
The second systematic review and meta-analysis by Chen et all.
0:33:58.528 --> 0:34:3.128
Laxmaiah Manchikanti
It was published in Annals of Medicine and Surgery in 2023.
0:34:3.528 --> 0:34:11.848
Laxmaiah Manchikanti
They included nine randomized control trials with 714 participants in this evaluation.
0:34:11.848 --> 0:34:14.368
Laxmaiah Manchikanti
Some studies utilized genicular nerve block.
0:34:15.238 --> 0:34:19.38
Laxmaiah Manchikanti
Others performed RFA directly.
0:34:19.158 --> 0:34:35.518
Laxmaiah Manchikanti
The result showed that meta-analysis revealed that RFA demonstrated a significant short-term efficacy in reducing pain compared to the control group at six months as indicated by the pain scores of reductions of 2.69.
0:34:36.198 --> 0:34:41.758
Laxmaiah Manchikanti
Similarly, Western and Ontario and McMaster Universities Osteoarthritis index.
0:34:42.568 --> 0:34:45.368
Laxmaiah Manchikanti
Our Womack scores had six months favored the RFA.
0:34:45.758 --> 0:34:49.118
Laxmaiah Manchikanti
Group with a reduction of scores of 4.4.
0:34:51.658 --> 0:34:56.698
Laxmaiah Manchikanti
Based on this evidence, which is moderate.
0:34:58.808 --> 0:35:11.208
Laxmaiah Manchikanti
We believe that repeating them every six months would be appropriate, provided they do obtain 6 months of pain relief with improvement in their functional status.
0:35:14.488 --> 0:35:15.48
Laxmaiah Manchikanti
Thank you.
0:35:16.478 --> 0:35:17.758
Eileen Moynihan
Thank you very much.
0:35:18.518 --> 0:35:41.118
Eileen Moynihan
I'm going to go back to the first question. If Dr. Schneider is not on, would one of you possibly be able to talk about the evidence regarding the efficacy of genicular RFA compared to genicular nerve blocks, placebo sham or other interventions? And are there societal guidelines?
0:35:41.888 --> 0:35:42.448
Eileen Moynihan
To consider here.
0:35:44.298 --> 0:35:46.978
Laxmaiah Manchikanti
This is Dr. Manchikanti again, I think the.
0:35:45.898 --> 0:35:48.738
Alex Bautista
I can take that crush, OK.
0:35:48.778 --> 0:35:49.818
Laxmaiah Manchikanti
Go ahead please.
0:35:51.688 --> 0:35:52.208
Eileen Moynihan
Yes.
0:35:52.448 --> 0:35:53.888
Alex Bautista
Go ahead, Dr. Manchikanti.
0:35:55.918 --> 0:36:16.878
Laxmaiah Manchikanti
OK, so as I described just now in reference to the systematic reviews, there is good evidence for or moderate evidence. I won't say good, but moderate evidence for radio frequency neurotomy cooled radio frequency is difficult to perform in clinical settings because of the expense is more expensive. So.
0:36:16.878 --> 0:36:19.358
Laxmaiah Manchikanti
It is not available in many settings.
0:36:19.718 --> 0:36:22.118
Laxmaiah Manchikanti
Maybe in the hospital settings but not outside.
0:36:23.488 --> 0:36:25.8
Laxmaiah Manchikanti
Now the there are not.
0:36:25.318 --> 0:36:27.758
Laxmaiah Manchikanti
Not that many placebo-controlled studies.
0:36:27.758 --> 0:36:33.318
Laxmaiah Manchikanti
So it is hard to decide on the placebo control trials now.
0:36:33.318 --> 0:36:43.918
Laxmaiah Manchikanti
Radiofrequency neurotomies definitely better than genicular nerve blocks it has been compared, and the results are shown clearly.
0:36:45.488 --> 0:36:46.968
Laxmaiah Manchikanti
Other active interventions.
0:36:48.968 --> 0:36:54.568
Laxmaiah Manchikanti
There is one study where they compared the active intervention like usual.
0:36:55.128 --> 0:37:2.368
Laxmaiah Manchikanti
Treatment the radio frequency was better, so overall radio frequency comes out to be better.
0:37:4.808 --> 0:37:16.448
Laxmaiah Manchikanti
When they compare active controls with the like radio conventional radio frequency with cool radio frequency, our pulsed radio frequency. There is no difference.
0:37:16.888 --> 0:37:21.768
Laxmaiah Manchikanti
But if you look at the placebo or from the baseline to the monitoring level?
0:37:23.408 --> 0:37:25.248
Laxmaiah Manchikanti
The radio frequency is superior.
0:37:25.598 --> 0:37:27.678
Laxmaiah Manchikanti
To other modalities of treatments.
0:37:28.478 --> 0:37:34.998
Laxmaiah Manchikanti
So radio frequency lasts 6 months and genicular nerve blocks had best may last about three months.
0:37:41.208 --> 0:37:41.728
Eileen Moynihan
Thank you.
0:37:41.218 --> 0:37:58.698
Alex Bautista
So to add on to Dr. J&T, there is one consensus guideline from the American Society of Pain in Neuroscience that has issued consensus for all Rfa's for virus pain condition, and one of them is chronic knee pain, and that guideline supports the use of Gen.
0:37:58.768 --> 0:38:4.328
Alex Bautista
For our face, an effective treatment option for chronic knee pain.
0:38:9.878 --> 0:38:10.558
Eileen Moynihan
Thank you.
0:38:11.158 --> 0:38:12.38
Eileen Moynihan
Any other comments?
0:38:19.728 --> 0:38:27.648
Eileen Moynihan
I would presume that nobody would be doing any of this in an unstable knee for osteoarthritis.
0:38:27.648 --> 0:38:29.648
Eileen Moynihan
Is that one of the contraindications?
0:38:36.238 --> 0:38:37.718
Eileen Moynihan
If a knee is unstable.
0:38:39.208 --> 0:38:45.168
Kevin Vorenkamp
Yes, that is in in at least one of the studies that was listed as an exclusion criterion.
0:38:39.878 --> 0:38:40.318
Eileen Moynihan
OK.
0:38:48.378 --> 0:38:49.578
Eileen Moynihan
Thank you for that.
0:38:51.338 --> 0:38:52.18
Eileen Moynihan
Are there any?
0:38:51.728 --> 0:38:53.888
Kevin Vorenkamp
Sorry, I was sorry.
0:38:53.928 --> 0:39:3.128
Kevin Vorenkamp
I was on mute before, but there is a multi-society guideline on genetic blocks and RFA in process which will likely be.
0:39:4.698 --> 0:39:6.218
Kevin Vorenkamp
Submitted in the next few months here.
0:39:8.908 --> 0:39:9.148
Eileen Moynihan
OK.
0:39:9.148 --> 0:39:10.108
Eileen Moynihan
That's good to know.
0:39:11.858 --> 0:39:25.18
Eileen Moynihan
I had another question whether anyone would proceed with radiofrequency by some other choice than by seeing whether someone responded to a genicular block.
0:39:28.598 --> 0:39:33.278
Eileen Moynihan
Was there some other way that you might choose a patient?
0:39:34.818 --> 0:39:34.898
Eileen Moynihan
Or.
0:39:36.618 --> 0:39:36.658
Eileen Moynihan
Not.
0:39:38.858 --> 0:39:39.138
Ben Northrup
Hi.
0:39:38.928 --> 0:39:45.648
Eileen Moynihan
I did notice about the tenicular blocks maybe not being so predictive.
0:39:40.738 --> 0:39:40.818
Geoghan, Susan
Guys.
0:39:45.648 --> 0:39:47.328
Eileen Moynihan
So that was my question.
0:39:48.898 --> 0:39:49.778
Ben Northrup
Yeah, this is Ben Northrop.
0:39:49.858 --> 0:40:5.458
Ben Northrup
There are occasionally times where you would do it without a block, particularly if it was a patient who had responded very well to a prior genicular nerve RFA. And then, you know, say, a year or two down the line, they have recurrent pain. Then you might simply perform.
0:40:5.458 --> 0:40:8.18
Ben Northrup
That again without doing a block in between.
0:40:8.648 --> 0:40:15.328
Ben Northrup
We do see this particularly in neat arthroplasty patients with chronic pain due to synovitis, for example.
0:40:17.58 --> 0:40:22.258
Ben Northrup
And they responded well before, and there's no need to do another block when you're doing essentially a repeat later on.
0:40:24.738 --> 0:40:29.618
Laxmaiah Manchikanti
The study this is Dr. Manchikanti again. The study performed by Snyder.
0:40:29.618 --> 0:40:35.498
Laxmaiah Manchikanti
I think Snyder, it showed that there was no difference.
0:40:35.938 --> 0:40:37.698
Laxmaiah Manchikanti
Predictability was not.
0:40:39.258 --> 0:40:49.698
Laxmaiah Manchikanti
Certain and there are systematic in randomized control trials where they have performed the RFA without a diagnostic block.
0:40:50.218 --> 0:40:53.898
Laxmaiah Manchikanti
I was reviewing an article they were questioning that.
0:40:54.408 --> 0:40:58.288
Laxmaiah Manchikanti
Well, they don't do any diagnostic blocks before they do a total knee.
0:40:58.688 --> 0:41:3.368
Laxmaiah Manchikanti
Why do you have to do a diagnostic block before you do radio frequency neurotomy?
0:41:7.178 --> 0:41:11.898
Eileen Moynihan
Are you suggesting we would have logic in medicine, Dr. Manchikanti?
0:41:12.498 --> 0:41:14.258
Laxmaiah Manchikanti
No, I'm not suggesting at all.
0:41:14.258 --> 0:41:18.178
Laxmaiah Manchikanti
I'm in favor of actually doing the diagnostic blocks.
0:41:18.778 --> 0:41:20.698
Laxmaiah Manchikanti
I'm honest not doing that.
0:41:21.338 --> 0:41:31.978
Laxmaiah Manchikanti
Diagnostic blocks. But I'm just saying that it there are studies doing radio frequency directly without diagnostic blocks.
0:41:29.858 --> 0:41:30.18
Eileen Moynihan
And.
0:41:30.688 --> 0:41:30.968
Eileen Moynihan
Yeah.
0:41:33.658 --> 0:41:34.98
Eileen Moynihan
Yes, I know.
0:41:34.98 --> 0:41:38.18
Eileen Moynihan
I saw some of them, which is why I was asking you guys the question of what you thought about that.
0:41:38.18 --> 0:41:40.18
Eileen Moynihan
But thanks very much.
0:41:40.98 --> 0:41:41.458
Eileen Moynihan
I think my section.
0:41:42.168 --> 0:41:47.8
Eileen Moynihan
Is out of time and I want to thank you all for participating.
0:41:48.578 --> 0:41:53.298
Eileen Moynihan
In this and I'm going to pass it off, Mark, I think it's you next.
0:41:53.298 --> 0:41:54.858
Eileen Moynihan
But I've lost my notes.
0:41:54.858 --> 0:41:57.458
Eileen Moynihan
Is the Dr. Durden? Yes.
0:41:55.648 --> 0:41:55.808
Marc Duerden
Yep.
0:41:57.388 --> 0:41:58.308
Marc Duerden
Thank you.
0:41:57.438 --> 0:41:57.998
Judy Volkar
It is.
0:41:58.308 --> 0:41:59.868
Marc Duerden
Thank you. Thank you, Eileen.
0:42:1.978 --> 0:42:5.418
Marc Duerden
So this first question is to Dr. Vorenkamp.
0:42:6.298 --> 0:42:9.418
Marc Duerden
I'd like to discuss intercoastal nerve blocks.
0:42:9.618 --> 0:42:26.218
Marc Duerden
Is there any robust evidence supporting the use of perioperative analgesia in thoracic surgery, such as the video assisted therapy, or the thoracotomies compared to other regional anesthetic techniques?
0:42:29.728 --> 0:42:35.848
Kevin Vorenkamp
And I'll ask my other colleagues to add in intercoastal nerve blocks today.
0:42:37.418 --> 0:42:58.138
Kevin Vorenkamp
Are less commonly used in in the world of ultrasound and the thoracic facial plain blocks and epidural catheters are still for the mainstay for open Thor economies. But intercoastal nerve blocks there is supportive evidence it's not superior.
0:42:58.488 --> 0:43:5.208
Kevin Vorenkamp
Evidence to an epidural, a thoracic paravertebral block, the thoracic vascular plain blocks.
0:43:5.568 --> 0:43:7.88
Kevin Vorenkamp
But you would.
0:43:7.288 --> 0:43:11.288
Kevin Vorenkamp
There may be reasons why you would do it, either because of.
0:43:12.898 --> 0:43:14.98
Kevin Vorenkamp
Local contraindications?
0:43:15.778 --> 0:43:20.18
Kevin Vorenkamp
In in that area where you need may need to do a more anterior lateral approach.
0:43:20.538 --> 0:43:27.858
Kevin Vorenkamp
So there is some supportive evidence, but it would not be superior to the other blocks listed like epidural.
0:43:28.408 --> 0:43:32.848
Kevin Vorenkamp
Roller recti spinney in the perioperative population.
0:43:36.168 --> 0:43:37.8
Marc Duerden
Excellent. Thank you.
0:43:38.578 --> 0:43:53.298
Marc Duerden
Dr. Batista does the current literature support intercoastal nerve blocks in reducing postoperative opiate consumption and things like improving patient centered outcomes such as their recovery and their satisfaction.
0:43:56.378 --> 0:43:56.818
Alex Bautista
So.
0:43:59.858 --> 0:44:5.658
Alex Bautista
As I said, like there are a lot more options than intercles for prior operative views.
0:44:5.658 --> 0:44:17.378
Alex Bautista
However, it still showed a decrease in or because shouldn't be a discussion but not superior to thoracic epidural, pervert, table boss or erector spine blocks.
0:44:20.958 --> 0:44:24.358
Alex Bautista
But if the question if it does it decrease oblige assumption, the answer is yes.
0:44:21.168 --> 0:44:21.688
Marc Duerden
Thank you.
0:44:25.898 --> 0:44:26.58
Marc Duerden
OK.
0:44:29.198 --> 0:44:31.998
Marc Duerden
And for what period of time were you? They do?
0:44:31.998 --> 0:44:34.518
Marc Duerden
They measure that reduction in opiate consumption.
0:44:38.668 --> 0:44:48.748
Alex Bautista
For all the studies, is like short term for the duration of admission, usually for within a week. OK.
0:44:51.678 --> 0:44:53.598
Marc Duerden
Back-to-back to Dr. Vornkamp.
0:44:53.598 --> 0:45:5.358
Marc Duerden
Dr. Vorenkamp, could you discuss the limitations and potential risks associated with an intercostal nerve block for postoperative analysis? And does the evidence address any of these concerns?
0:45:7.848 --> 0:45:15.328
Kevin Vorenkamp
So the biggest risk in terms of performance certainly weren't close proximity to the plura.
0:45:15.448 --> 0:45:17.248
Kevin Vorenkamp
So risk of pneumothorax.
0:45:17.248 --> 0:45:19.328
Kevin Vorenkamp
Risk of intravascular injection.
0:45:20.408 --> 0:45:23.808
Kevin Vorenkamp
Like anything, risk of bleeding and in infection as well.
0:45:26.58 --> 0:45:31.378
Kevin Vorenkamp
This. Yeah, these would typically be done in the setting of thoracic surgery.
0:45:33.298 --> 0:45:38.178
Kevin Vorenkamp
Does the evidence adequately address these concerns? I.
0:45:40.148 --> 0:45:40.588
Kevin Vorenkamp
I think so.
0:45:40.588 --> 0:45:53.348
Kevin Vorenkamp
I mean, all of these are kind of risk benefit when we place a thoracic epidural were millimeters from the from the spinal cord. When we do an intercostal nerve block or millimeters from the pleura.
0:45:54.28 --> 0:45:55.868
Kevin Vorenkamp
So it it's always risk benefit.
0:45:58.858 --> 0:46:12.338
Kevin Vorenkamp
So yeah, like I said, in terms of widespread adoption, that's not where we are currently. And that's not the direction the field of regional anesthesia is going to with intercoastal nerve blocks.
0:46:12.498 --> 0:46:14.98
Kevin Vorenkamp
Their role is really for.
0:46:15.858 --> 0:46:21.538
Kevin Vorenkamp
A rare or unusual situation, typically for patients with thoracic surgery.
0:46:22.288 --> 0:46:24.728
Kevin Vorenkamp
Now, when we're talking about intercoastal blocks.
0:46:26.298 --> 0:46:32.698
Kevin Vorenkamp
In RFA for chronic pain, that's a different field, but I know this is focusing on postoperative analgesia.
0:46:36.98 --> 0:46:36.898
Marc Duerden
Thank you too.
0:46:36.938 --> 0:46:38.458
Marc Duerden
I appreciate your input.
0:46:39.98 --> 0:46:49.138
Marc Duerden
I'm going to shift gears a little bit and like to now talk about ganglion empire blocks for coccydynia and this is to the group.
0:46:49.738 --> 0:47:0.738
Marc Duerden
Is there enough high-quality evidence or robust evidence to support a ganglion empire block as an effective treatment for chronic coccydynia?
0:47:1.578 --> 0:47:5.18
Marc Duerden
Particularly in patients not responding to conservative management.
0:47:13.338 --> 0:47:14.738
Alex Bautista
You know, it's very hard to.
0:47:17.18 --> 0:47:22.938
Alex Bautista
Is #1A lot of insurance will not approve it, so it's very hard, but I think there is utility for that.
0:47:25.368 --> 0:47:44.128
Marc Duerden
But looking at the evidence of what you've been out there, so you have Swain Sangar Nasiri. You have a number of small studies that are out there of those studies do is there enough evidence to support the use of these M par blocks for the treat?
0:47:44.128 --> 0:47:46.448
Marc Duerden
Of chronic coccydynia and.
0:47:48.18 --> 0:47:51.138
Marc Duerden
And broadening the question just to make sure I was clear that.
0:47:52.858 --> 0:47:53.58
Marc Duerden
And.
0:47:54.698 --> 0:48:4.458
Marc Duerden
Would you do the impar block, particularly in patients that are not responding to conservative management? And what would that conservative management really entail?
0:48:12.578 --> 0:48:18.938
Kevin Vorenkamp
In terms of indications you know would be chronic pain, which hasn't responded to.
0:48:20.538 --> 0:48:31.298
Kevin Vorenkamp
Conservative measures, which typically is going to be your medications, often using the different cushions, different ways of offloading that that area.
0:48:32.938 --> 0:48:39.258
Kevin Vorenkamp
Maybe some physical therapy, although the kind of them, whether that's pelvic floor, physical therapy or.
0:48:41.338 --> 0:48:42.218
Kevin Vorenkamp
Back direct.
0:48:43.408 --> 0:49:2.728
Kevin Vorenkamp
So yeah, this would be for patients that have failed conservative studies or conservative measures. And I think there is a role for this, whether it's a gang related part block or a coxagel trigger kind of local injection there. But it there are limited studies, it's a pretty.
0:49:2.728 --> 0:49:9.8
Kevin Vorenkamp
Limited volume of patients that we're looking for typically. Yeah. For chronic oxidenia or?
0:49:10.218 --> 0:49:11.218
Kevin Vorenkamp
Chronic pelvic pain.
0:49:15.388 --> 0:49:15.788
Marc Duerden
Thank you.
0:49:15.788 --> 0:49:20.228
Marc Duerden
That has been my experience as well as I've been reviewing the literature.
0:49:20.508 --> 0:49:27.428
Marc Duerden
Is anybody else like to add anything else before I turn the time over to Dr. Volker?
0:49:32.708 --> 0:49:34.548
Laxmaiah Manchikanti
This is Dr. Manchikanti again.
0:49:32.868 --> 0:49:33.268
Marc Duerden
OK.
0:49:35.398 --> 0:49:43.398
Laxmaiah Manchikanti
Sure. The evidence is limited, but condition is significant.
0:49:35.888 --> 0:49:36.8
Laxmaiah Manchikanti
Oh.
0:49:43.398 --> 0:49:51.918
Laxmaiah Manchikanti
People may have significant pain and empire block is performed for other painful conditions in the perineum and pelvis.
0:49:53.458 --> 0:49:58.418
Laxmaiah Manchikanti
There is only one randomizer trial. I think that is, so evidence is very limited.
0:50:0.608 --> 0:50:7.888
Laxmaiah Manchikanti
But and it is very uncommon, very uncommon to procedure to be performed so.
0:50:9.458 --> 0:50:9.698
Laxmaiah Manchikanti
It is.
0:50:11.728 --> 0:50:18.448
Laxmaiah Manchikanti
So if it is not a very common procedure, does it will require LCD? It would be another consideration.
0:50:23.758 --> 0:50:24.598
Marc Duerden
Yes, thank you.
0:50:27.948 --> 0:50:28.308
Marc Duerden
OK.
0:50:28.308 --> 0:50:33.388
Marc Duerden
This concludes my section of the CAC, and I'll now turn the time over to Dr. Volker.
0:50:34.308 --> 0:50:35.228
Judy Volkar
Thank you, Dr. Duarte.
0:50:35.228 --> 0:50:49.388
Judy Volkar
All right. Dr. Batista, what does the evidence suggest about using curedental nerve blocks for reducing postoperative pain in adult patients undergoing perineal surgeries? Compared to standard anesthesia?
0:50:49.668 --> 0:50:55.308
Judy Volkar
Usually my familiarity is used for that in your gynecologic surgeries.
0:50:58.878 --> 0:51:2.238
Alex Bautista
So there's quite a bit of like somatic reviews that.
0:51:4.338 --> 0:51:13.458
Alex Bautista
Look into the utility of potential nerve block and hemorrhoidectomy and those reviews have shown like significant improvement of their pain.
0:51:15.258 --> 0:51:16.738
Alex Bautista
There is for.
0:51:19.378 --> 0:51:35.178
Alex Bautista
Sure. And then again, there's also very limited like randomized control trial, but all those trials have shown evidence that it decreases poster pain for patients undergoing gynecologic.
0:51:36.128 --> 0:51:36.528
Alex Bautista
Searcher.
0:51:41.488 --> 0:51:41.928
Alex Bautista
But.
0:51:43.738 --> 0:51:54.298
Alex Bautista
Overall, I think it's a good option if this open consumption and if exhausted all analgesic resid.
0:51:57.798 --> 0:52:10.838
Judy Volkar
Thank you. If I could expand that just a smidge. And do you have any evidence using prudential nerve blocks for chronic pelvic pain, particularly dyspareunia?
0:52:12.368 --> 0:52:14.368
Judy Volkar
Do you know of any evidence for that?
0:52:14.368 --> 0:52:19.608
Judy Volkar
I know a lot of people use it, but I didn't know if you were aware of any evidence that would support or refute that.
0:52:27.308 --> 0:52:37.28
Alex Bautista
So the strength for King control for chronic pain? Again, it's very limited we there are like.
0:52:38.618 --> 0:52:48.458
Alex Bautista
Small studies that look at randomized control trial and it definitely showed reduced pain scores for a brief time period.
0:52:50.858 --> 0:53:6.738
Alex Bautista
Currently, our group and the gynecologic group urogyne group are doing a study to see the efficacy of peripheral nerve potential nerve block using ultrasound infaroscopy.
0:53:7.248 --> 0:53:10.208
Alex Bautista
And longevity of the pain relief.
0:53:10.528 --> 0:53:22.648
Alex Bautista
So again the IT has been a lot of people are doing that for chronic pain and there's some limited studies that show that it is beneficial.
0:53:25.658 --> 0:53:26.538
Judy Volkar
Thank you very much.
0:53:27.488 --> 0:53:30.288
Judy Volkar
And now I'm going to switch subjects a little bit.
0:53:30.568 --> 0:53:41.528
Judy Volkar
And Dr. Manchikanti is there compelling evidence supporting the use of cryo neurolutions over radiofrequency ablation for chronic pain conditions such as facet joint pain?
0:53:44.948 --> 0:53:50.108
Laxmaiah Manchikanti
There definitely there is no compelling evidence.
0:53:50.628 --> 0:53:53.988
Laxmaiah Manchikanti
The evidence is not even equal and leave alone.
0:53:55.538 --> 0:53:56.818
Laxmaiah Manchikanti
Superior and it is.
0:53:56.858 --> 0:54:1.218
Laxmaiah Manchikanti
There is no evidence showing that it is not inferior.
0:54:3.178 --> 0:54:12.778
Laxmaiah Manchikanti
There, there is evidence showing that cryoneuralices is inferior to radio frequency neurotomy in almost all conditions.
0:54:16.568 --> 0:54:18.928
Laxmaiah Manchikanti
Perineurial license may be preferable.
0:54:21.168 --> 0:54:29.568
Laxmaiah Manchikanti
There is no evidence again, so preferable in the knee neurulations procedures.
0:54:31.138 --> 0:54:37.778
Laxmaiah Manchikanti
There is, so the answer is the evidence is not superior and not equivalent to radiofrequency ablation.
0:54:39.538 --> 0:54:41.58
Laxmaiah Manchikanti
In chronic painful conditions.
0:54:42.698 --> 0:54:43.898
Laxmaiah Manchikanti
It may have a selective use.
0:54:45.658 --> 0:54:48.458
Laxmaiah Manchikanti
Specifically for knee pain, it's used for facet.
0:54:48.458 --> 0:54:50.58
Laxmaiah Manchikanti
Joint pain is laborious.
0:54:50.668 --> 0:54:52.468
Laxmaiah Manchikanti
With suboptimal results.
0:54:54.718 --> 0:54:55.158
Judy Volkar
All right.
0:54:55.158 --> 0:55:1.478
Judy Volkar
Thank you very much and we will move now to nerve entrapment and peripheral nerve blocks.
0:55:1.958 --> 0:55:19.958
Judy Volkar
So, Dr. Nelson, what does the literature say about using peripheral nerve blocks versus conservative therapies for nerve entrapment syndromes such as anterior cutaneous nerve entrapment, or lateral femoral cutaneous nerve intraven?
0:55:19.958 --> 0:55:20.718
Judy Volkar
Which I believe.
0:55:21.498 --> 0:55:23.18
Judy Volkar
Is known as Miraglia paresthetica.
0:55:25.958 --> 0:55:29.198
Erin Nelson
Our section is the lower extremity like below the knee.
0:55:29.198 --> 0:55:31.798
Erin Nelson
So this area wouldn't be my area.
0:55:32.38 --> 0:55:33.158
Erin Nelson
Ours is a little further down.
0:55:35.548 --> 0:55:37.68
Erin Nelson
For the peripheral nerves.
0:55:39.218 --> 0:55:39.658
Judy Volkar
OK.
0:55:39.818 --> 0:55:42.378
Judy Volkar
Does anybody else have anything to opine on that?
0:55:46.678 --> 0:55:47.238
Kevin Vorenkamp
I would, yeah.
0:55:47.238 --> 0:55:49.918
Kevin Vorenkamp
Certainly for the morale of a static.
0:55:51.658 --> 0:56:12.778
Kevin Vorenkamp
You're only you were attempting this after conservative measures have failed and these have been treatments that have been kind of the mainstay for those patients that have failed conservative therapy for several decades. And as our imaging techniques with ultrasound have gotten.
0:56:14.608 --> 0:56:17.528
Kevin Vorenkamp
Become prevalent over the last 1020 years.
0:56:18.288 --> 0:56:27.728
Kevin Vorenkamp
I would say our success of treating these nerves like the lateral thermal cutaneous is much higher. Most of the literature is limited to K series.
0:56:29.298 --> 0:56:38.898
Kevin Vorenkamp
I'm not aware of any placebo-controlled, but yeah, many of those do show very positive outcomes in K Series case reports.
0:56:41.508 --> 0:56:42.68
Judy Volkar
Thank you.
0:56:43.618 --> 0:56:54.418
Judy Volkar
And then the final question would be to Dr. Barrett and Dr. Nelson. If you could provide any insights into the role of peripheral nerve blocks in managing conditions of the lower extremity based on current evidence.
0:56:56.378 --> 0:56:57.738
Steven Barrett
Yeah, this is Stephen Barrett.
0:56:58.898 --> 0:57:4.858
Steven Barrett
There's not a lot in the literature as far as the efficacy of lower extremity peripheral nerve blocks.
0:57:4.858 --> 0:57:9.98
Steven Barrett
However, there are three studies that are listed on this outline.
0:57:10.8 --> 0:57:11.888
Steven Barrett
They have.
0:57:13.898 --> 0:57:17.18
Steven Barrett
Very good potential for aiding in the diagnosis of.
0:57:18.858 --> 0:57:25.58
Steven Barrett
Certain specific nerve entrapment such as common perineal nerve at the fibular neck and tarsal tunnel.
0:57:25.258 --> 0:57:27.98
Steven Barrett
The one study from.
0:57:28.818 --> 0:57:39.498
Steven Barrett
Ebura et al. Actually, compared it to EMG findings and found that it was able to pick up nerve entrapments much earlier than with traditional.
0:57:39.848 --> 0:57:46.288
Steven Barrett
Electrophysiological diagnostic methods, it's also being very.
0:57:47.858 --> 0:57:50.978
Steven Barrett
Significantly implemented in mapping out different.
0:57:52.818 --> 0:58:2.18
Steven Barrett
Nerve involvement with different traumatic areas such as like if it if there's an injury on the dorsal aspect of the foot, which nerve is it?
0:58:2.18 --> 0:58:5.98
Steven Barrett
Is it superficial, perineal or deep?
0:58:6.818 --> 0:58:9.618
Steven Barrett
Perineal or is it even a softness and by using?
0:58:9.688 --> 0:58:13.288
Steven Barrett
Using lidocaine you can do mapping but there is not a lot of literature.
0:58:13.288 --> 0:58:15.608
Steven Barrett
Quite frankly for this.
0:58:21.488 --> 0:58:23.928
Judy Volkar
Hey, anybody else have anything?
0:58:24.688 --> 0:58:27.48
Judy Volkar
Otherwise I will yield my time.
0:58:28.618 --> 0:58:29.258
Judy Volkar
To Dr. Lovelace.
0:58:29.258 --> 0:58:39.738
Judy Volkar
So thank you all for your insights. And Dr. lobos. I will now pass the baton to you for Section 3, which is head Neck and upper extremity. Thank you so much.
0:58:41.848 --> 0:58:49.568
MEREDITH LOVELESS
And so we'll move forward with carpal tunnel syndrome and Dr. Azad. We'll start with you.
0:58:49.608 --> 0:58:56.8
MEREDITH LOVELESS
Is there evidence supporting the use of blocks or steroids for managing acute pain in carpal tunnel syndrome?
0:58:59.358 --> 0:59:2.518
Deepak Azad
You know, as I told you, I'm as present.
0:59:2.518 --> 0:59:4.38
Deepak Azad
I'm far away from.
0:59:5.578 --> 0:59:21.98
Deepak Azad
The US and I forgot to assemble my some of this review, so if somebody else want to help out on this question, I'm in India at this time and it's middle of the night and I have misplaced my all the paperwork.
0:59:21.98 --> 0:59:23.658
Deepak Azad
So if somebody can help us out, that'll be great.
0:59:23.658 --> 0:59:24.138
Deepak Azad
Thank you.
0:59:29.238 --> 0:59:31.398
Meredith Loveless
Any volunteers to take this question?
0:59:32.688 --> 0:59:37.368
Meredith Loveless
The question is the do blocks or steroids?
0:59:37.608 --> 0:59:44.8
Meredith Loveless
Are they useful in managing acute pain in carpal tunnel syndrome or referring to steroid injections?
0:59:49.448 --> 0:59:49.848
Marzena Buzanowska, MD
I can.
0:59:49.848 --> 0:59:51.48
Marzena Buzanowska, MD
This is Dr. Buzanowska.
0:59:51.48 --> 0:59:54.688
Marzena Buzanowska, MD
I can make a comment about this question.
0:59:54.118 --> 0:59:54.638
Meredith Loveless
Yes, please.
0:59:56.258 --> 0:59:56.418
Marzena Buzanowska, MD
And.
0:59:58.778 --> 1:0:7.978
Marzena Buzanowska, MD
In general, studies looking at carpal tunnel syndrome look at chronic carpal tunnel related pain and or median nerve compression pain.
1:0:9.698 --> 1:0:10.378
Marzena Buzanowska, MD
Not acute.
1:0:10.858 --> 1:0:19.538
Marzena Buzanowska, MD
So if you're if this question specifically referring to acute pain less than six weeks, then there is no evidence to that.
1:0:19.848 --> 1:0:25.8
Marzena Buzanowska, MD
Looks at that, but when it comes to chronic pain, and I guess that's your next question.
1:0:25.8 --> 1:0:27.48
Marzena Buzanowska, MD
So I'm going to leave that to the next person.
1:0:29.68 --> 1:0:31.828
Meredith Loveless
Well, that one's geared towards the group because we didn't.
1:0:32.108 --> 1:0:41.748
Meredith Loveless
So if you want to comment further on the chronic, that would be wonderful or if anyone else wants to contribute to the use of injections for chronic carpal tunnel syndrome.
1:0:44.98 --> 1:0:47.458
Alex Bautista
So several studies have looked into.
1:0:49.218 --> 1:0:53.538
Alex Bautista
Court procedure injections and it provide transient relief of symptoms.
1:0:55.138 --> 1:0:58.898
Alex Bautista
No long-term evidence of longevity of pain relief.
1:1:0.328 --> 1:1:7.408
Alex Bautista
However, patients who would qualify for stero injection should have failed conservative management, the.
1:1:10.898 --> 1:1:15.18
Alex Bautista
And physical therapy as part of their noninvasive treatment.
1:1:19.108 --> 1:1:32.508
Meredith Loveless
And if they respond with those injections, be repetitive management or would that be something done as a diagnostic before going on to a surgical treatment if anyone wants to?
1:1:34.58 --> 1:1:36.138
Meredith Loveless
Elaborate just for our understanding.
1:1:39.38 --> 1:1:40.598
Marzena Buzanowska, MD
So this my question.
1:1:40.678 --> 1:1:42.798
Alex Bautista
So the thing with chronic steroid injections?
1:1:42.138 --> 1:1:42.778
Marzena Buzanowska, MD
Question 3.
1:1:45.658 --> 1:1:48.858
Marzena Buzanowska, MD
So question #3 is about frequency of.
1:1:51.98 --> 1:1:54.138
Marzena Buzanowska, MD
Repetition of steroid injections for carpal tunnel syndrome.
1:1:54.738 --> 1:2:2.378
Marzena Buzanowska, MD
So there is no study that looks at that specifically how frequently should their steroid injection be repeated for carpal tunnel before?
1:2:4.98 --> 1:2:5.618
Marzena Buzanowska, MD
And surgical approach is.
1:2:7.458 --> 1:2:8.218
Marzena Buzanowska, MD
Considered.
1:2:9.858 --> 1:2:15.858
Marzena Buzanowska, MD
In the way that carpal tunnel syndrome is addressed in the literature is evaluated based on.
1:2:16.208 --> 1:2:18.208
Marzena Buzanowska, MD
On the severity of symptoms.
1:2:20.138 --> 1:2:35.778
Marzena Buzanowska, MD
As reported on an EMG study, so if the carpel tunnel syndrome seems to be mild or moderate in conservative management is exhausted then steroid injection does seem to be provide excellent relief for between one and 12 months.
1:2:35.778 --> 1:2:41.178
Marzena Buzanowska, MD
So different studies look at look at different report, different results and that seems to be.
1:2:42.898 --> 1:2:46.578
Marzena Buzanowska, MD
Dependent on the predisposing factors and causes of carpal tunnel.
1:2:47.328 --> 1:2:56.368
Marzena Buzanowska, MD
Patients who have underlying diabetes tend to have less shorter duration of relief and more.
1:2:57.938 --> 1:3:10.978
Marzena Buzanowska, MD
Recurrent symptoms patients who have other sources of carpal tunnel syndrome may be related to occupational repetitive stress that can be.
1:3:12.658 --> 1:3:18.978
Marzena Buzanowska, MD
Maybe addressed in some ways those patients tend to report symptoms or have relief from those symptoms of the symptoms.
1:3:19.568 --> 1:3:22.928
Marzena Buzanowska, MD
For much longer and can be up to even 12 months.
1:3:22.928 --> 1:3:29.48
Marzena Buzanowska, MD
But most studies look at outcomes at 4 or 12 weeks or 24 weeks.
1:3:30.578 --> 1:3:35.138
Marzena Buzanowska, MD
But there is no study that look at exactly how many times you have to repeat steroid injections before you give up.
1:3:38.128 --> 1:3:39.768
Meredith Loveless
Thank you for your answer.
1:3:39.768 --> 1:3:45.528
Meredith Loveless
Appreciate that. And from the radiological perspective, Dr. Northrop, what is your thought?
1:3:45.728 --> 1:3:51.888
Meredith Loveless
What is the evidence say about the if ultrasound guidance is necessary to perform these injections for carpal tunnel?
1:3:53.698 --> 1:3:54.258
Ben Northrup
Yes, thank you.
1:3:54.258 --> 1:4:0.858
Ben Northrup
This is definitely an excellent question, and one for which the evidence and current clinical practice is a little bit incongruent.
1:4:0.858 --> 1:4:5.58
Ben Northrup
So First off, thank you for including those eight references in the packet.
1:4:5.58 --> 1:4:6.538
Ben Northrup
Are reviewing those.
1:4:7.88 --> 1:4:13.568
Ben Northrup
There are four of those eight studies in which all injections used ultrasound guidance.
1:4:13.568 --> 1:4:19.448
Ben Northrup
There were two in which it was not mentioned, so we have to assume that it was either intermittently used or not used.
1:4:19.448 --> 1:4:32.488
Ben Northrup
There was a systemic review from Dong at all in which many most of the studies used ultrasound guidance and then a final one, ceramet, which compared ultrasound guided versus blind steroid injection.
1:4:32.488 --> 1:4:35.48
Ben Northrup
So let's start with that one, because that's the most direct comparison.
1:4:35.818 --> 1:4:38.658
Ben Northrup
So that one compared the effectiveness and the safety of each approach.
1:4:39.168 --> 1:5:1.88
Ben Northrup
It did find that both groups did show improvement in both the Boston Symptom Severity Scale as well as the functional status scale. However, the ultrasound group saw significantly greater relief and that relief came a bit earlier. Another study not included in the packet from 2013 H.
1:5:1.528 --> 1:5:4.848
Ben Northrup
And I can send you the link for that or the reference for that if you like.
1:5:5.658 --> 1:5:9.18
Ben Northrup
So that compared anatomic based blind injections.
1:5:9.368 --> 1:5:18.928
Ben Northrup
To ultrasonography and they showed that the ultrasonography guided injections were more accurate, more effective and had less error genetic injuries.
1:5:19.368 --> 1:5:32.168
Ben Northrup
Both groups did demonstrate improvement, but once again the ultrasound guided group showed an earlier onset of relief, and they showed more improvement or a greater improvement in terms of symptom severity scores.
1:5:32.328 --> 1:5:33.408
Ben Northrup
So that's efficacy.
1:5:33.408 --> 1:5:35.288
Ben Northrup
Let's go on to safety here so.
1:5:36.98 --> 1:5:39.858
Ben Northrup
Ultrasound is going to allow for more accurate assessment of the safe zone.
1:5:40.488 --> 1:5:47.728
Ben Northrup
For intervention and the anatomic area that is relatively devoid of major neurovascular structures can be better evaluated.
1:5:48.208 --> 1:6:3.368
Ben Northrup
Very important, not only for the ones you think of, like the superficial Palmer Arch on their nerve on their artery, etc. But some patients, a small but significant number have a persistent meeting artery, and you certainly don't want to inject that so ultrasound and there's a few studies.
1:6:3.408 --> 1:6:5.368
Ben Northrup
That show that just simply.
1:6:6.178 --> 1:6:12.138
Ben Northrup
The effectiveness of ultrasound in identifying those structures and avoiding them, and I can send you the citations for those.
1:6:12.328 --> 1:6:13.168
Ben Northrup
If you would like.
1:6:14.738 --> 1:6:29.938
Ben Northrup
So then there's another study that was not just looking at, can you see them and can you avoid them, but the actual outcomes and that one showed this is also from the Houston study from 2013, another portion of that study that did show that there was indeed.
1:6:30.298 --> 1:6:38.458
Ben Northrup
Less estrogenic injury, so better outcomes from a safety standpoint. In addition to the prior study, which showed you can see it better and avoid it.
1:6:39.58 --> 1:6:41.858
Ben Northrup
And then the final thing to talk about here just in the.
1:6:42.288 --> 1:7:0.488
Ben Northrup
In the interest of Full disclosure here, as I said, there is some incongruence between the evidence and clinical practice. Medicare databases do show that only about 14% of the time are these performed with ultrasound guidance. 86% of the time they are performed blind.
1:7:4.428 --> 1:7:7.548
Ben Northrup
And let me know if you have any further radiology related questions.
1:7:5.88 --> 1:7:6.808
Meredith Loveless
Thank you for your thorough answer.
1:7:7.548 --> 1:7:26.378
Meredith Loveless
Mm hmm. And we would greatly appreciate you sharing the evidence that you mentioned with us and as well As for all of our speakers who have mentioned literature evidence that was not included in the in our in our bibliography list. We would greatly appreciate if you can share that.
1:7:26.428 --> 1:7:31.868
Meredith Loveless
With us as well as any additional comments that you have on you on the questions after our meeting.
1:7:33.928 --> 1:7:40.728
Meredith Loveless
And I'm going to move forward into our neurological world with a question for Dr. Paquette.
1:7:41.408 --> 1:7:47.328
Meredith Loveless
Is there supporting evidence for the use of blocks as a diagnostic tool for occipital neuralgia?
1:7:48.898 --> 1:7:52.18
Brian Paquette
Hi yes, this is Dr. Brian Paquette. So, I'll take this one.
1:7:53.698 --> 1:7:57.898
Brian Paquette
Is there evidence to support blocks as a mechanism to diagnose occipital neuralgia?
1:7:58.378 --> 1:7:59.698
Brian Paquette
And the answer is yes.
1:8:1.338 --> 1:8:5.98
Brian Paquette
In conjunction with a thorough history and physical examination.
1:8:6.8 --> 1:8:11.968
Brian Paquette
And there is good evidence, and in fact, the American Academy of Neurology has guidelines in support of this.
1:8:13.938 --> 1:8:29.218
Brian Paquette
You know, initial treatment should focus on conservative measures, of course like medication including anti-inflammatory drugs, muscle relaxants, sometimes anticonvulsants. I'd say as an interventional headache specialist, I actually believe.
1:8:30.768 --> 1:8:33.248
Brian Paquette
That employing a block earlier in the.
1:8:35.88 --> 1:8:43.8
Brian Paquette
Sequence is probably safer and more effective, but that's my opinion and so I'm relegated to what the American Academy of Neurology guidelines.
1:8:43.398 --> 1:8:53.798
Brian Paquette
Tell me to report here, which is that we will use them for refractory cases, but ultimately these occipital nerve blocks can be used as a diagnostic and therapeutic tool.
1:8:57.438 --> 1:8:58.358
Meredith Loveless
Thank you so much.
1:8:59.928 --> 1:9:1.488
Meredith Loveless
And to follow up with that Dr. Bautista does the current evidence support the use of block applications to relieve occipital neuralgia pain compared to standard of care, and any guidelines on frequency?
1:9:18.728 --> 1:9:28.8
Alex Bautista
So there are studies that shows like there are block relief for individual neurology.
1:9:30.328 --> 1:9:47.208
Alex Bautista
Use of light dexameth with other creative syndrome have found to have reduced pain after again a steroid injection in the study meta-analysis study by Evans at Ali, 2023.
1:9:47.758 --> 1:9:49.598
Alex Bautista
They tried to investigate a change in headache.
1:9:49.598 --> 1:9:58.758
Alex Bautista
Severity and frequency following those nerve blocks and those are like 12 randomized control trials with a total number of.
1:10:0.328 --> 1:10:2.608
Alex Bautista
Almost 600 patients and found that.
1:10:7.208 --> 1:10:10.928
Alex Bautista
Frequency, hospital sculpting or tenderness?
1:10:12.528 --> 1:10:17.888
Alex Bautista
As to the optimal number and frequency of nerve blocks for effective pain relief.
1:10:18.278 --> 1:10:19.118
Alex Bautista
Typical neural rate.
1:10:19.118 --> 1:10:23.518
Alex Bautista
It's not very well established due to the limited high-quality evidence.
1:10:25.208 --> 1:10:27.48
Alex Bautista
Clinical practice. We often tailor the frequency.
1:10:29.168 --> 1:10:30.928
Alex Bautista
Individual responses.
1:10:31.808 --> 1:10:36.208
Alex Bautista
The duration of Relief and usually typically in.
1:10:39.48 --> 1:10:39.728
Alex Bautista
Is or so.
1:10:41.328 --> 1:10:47.968
Alex Bautista
Lasted less than two months, so the clinician should consider all headache medications or other interventions.
1:10:51.588 --> 1:10:58.908
Meredith Loveless
Thank you so much for your answer and we're going to now focus on stellate ganglion box. And this question is for the group.
1:10:59.348 --> 1:11:11.268
Meredith Loveless
Is there any evidence to support the use of stellate ganglion blocks for hot flashes as compared to standard therapies, and if so, any recommendations on frequency?
1:11:22.658 --> 1:11:25.778
Meredith Loveless
And if there's no volunteers, I'll move forward with the next question.
1:11:25.778 --> 1:11:27.378
Meredith Loveless
And will we?
1:11:27.538 --> 1:11:28.858
Meredith Loveless
We have very limited.
1:11:30.408 --> 1:11:36.488
Meredith Loveless
Papers on this, and as you can see in the bibliography, but we just wanted to seek if there was any additional input.
1:11:36.488 --> 1:11:42.168
Meredith Loveless
So we'll refer to the papers there and if anyone has any additional to contribute, please send our way.
1:11:42.688 --> 1:11:45.88
Meredith Loveless
So the next question is for Dr. Paquette.
1:11:45.728 --> 1:11:50.728
Meredith Loveless
Is there evidence supporting the effectiveness of stellate ganglion blocks for spasticity?
1:11:51.198 --> 1:11:53.358
Meredith Loveless
And does it include any guidance on frequency?
1:11:55.388 --> 1:12:13.428
Brian Paquette
Yeah, there's a paucity of evidence on this particular topic, and this is outside of my specific area of expertise, so I'll welcome my PM and our colleagues to chime in if they have further information. There is a study by Janet all discussing the clinical efficacy of ultrasound Gu.
1:12:13.508 --> 1:12:19.268
Brian Paquette
Steth block combined with extra corporeal shockwave therapy on limb spasticity in patients with.
1:12:20.128 --> 1:12:23.888
Brian Paquette
Ischemic stroke. And they looked at 60 patients.
1:12:24.518 --> 1:12:28.278
Brian Paquette
Diagnosed with ischemic stroke by lymph spasticity.
1:12:29.848 --> 1:12:31.8
Brian Paquette
And this study was done in.
1:12:32.688 --> 1:12:32.888
Brian Paquette
China.
1:12:34.528 --> 1:12:42.128
Brian Paquette
Where they administered 3 to 4 milliliters of lidocaine as their block, and they did this every three days for a month.
1:12:43.968 --> 1:12:50.608
Brian Paquette
And their conclusion was that yes, there is evidence to support the use of Stella ganium blocks for spasticity compared to standard of care.
1:12:52.688 --> 1:12:53.408
Brian Paquette
Ultimately.
1:12:54.238 --> 1:12:54.958
Brian Paquette
They.
1:12:58.218 --> 1:12:58.338
Brian Paquette
Umm.
1:13:0.278 --> 1:13:8.678
Brian Paquette
Looked at those who were receiving the combination of Stella ganglion block, plus the extracorporeal shockwave therapy, as.
1:13:10.248 --> 1:13:12.968
Brian Paquette
The more superior group.
1:13:14.608 --> 1:13:14.928
Brian Paquette
And.
1:13:17.818 --> 1:13:19.338
Brian Paquette
Obviously also.
1:13:21.368 --> 1:13:22.528
Brian Paquette
This would be done.
1:13:24.368 --> 1:13:24.568
Brian Paquette
After.
1:13:26.168 --> 1:13:33.448
Brian Paquette
Standard of care for lymph spasticity is performed, such as oral muscle relaxants, Botox injections, physical therapy, occupational therapy.
1:13:35.248 --> 1:13:35.728
Brian Paquette
Even.
1:13:37.368 --> 1:13:43.568
Brian Paquette
Considering also intrathecal Baclofen therapy may be a nice option if.
1:13:45.438 --> 1:13:52.558
Brian Paquette
If there was more reliable data, as Stella ganglion blocks in the right hands are a safe procedure.
1:13:55.808 --> 1:13:58.208
Brian Paquette
But otherwise, this study really.
1:13:59.768 --> 1:14:1.48
Brian Paquette
There weren't too many other studies that.
1:14:3.358 --> 1:14:4.438
Brian Paquette
Looked at this.
1:14:6.8 --> 1:14:9.128
Brian Paquette
But despite those limitations, the limitations of the single study.
1:14:10.768 --> 1:14:13.168
Brian Paquette
This could be potential option.
1:14:16.998 --> 1:14:17.958
Meredith Loveless
Thank you for your answer.
1:14:20.128 --> 1:14:30.88
Meredith Loveless
And Dr. Poliak-Tunis. What does the evidence suggest regarding stellate ganglion blocks for PTSD? And again, any recommendations for number and frequency?
1:14:31.618 --> 1:14:40.658
Michelle Poliak-Tunis
Sure. So again, not a whole lot of evidence here too, but the Canadian Journal of Health Technologies actually published a review article in March 2021.
1:14:42.208 --> 1:14:45.968
Michelle Poliak-Tunis
And they were summarizing findings from studies coming from 1 systematic review.
1:14:47.728 --> 1:15:1.408
Michelle Poliak-Tunis
Notifying that the Stella Gang unlocked for treatment of PTSD versus Sham did not provide clinically significant improvement in comparison to sham, and they also noted and the other study, which was a primary randomized control trial.
1:15:2.638 --> 1:15:6.998
Michelle Poliak-Tunis
Which you guys listed here is the Ray Olmsted study.
1:15:8.568 --> 1:15:19.688
Michelle Poliak-Tunis
This one actually was comparing the effects of two rounds of static blocks versus sham, and this did show improvement of a Caps 5 total system severity score at 8 weeks.
1:15:22.48 --> 1:15:27.728
Michelle Poliak-Tunis
But those were the two that were thought I was able to find.
1:15:29.368 --> 1:15:30.8
Michelle Poliak-Tunis
So again.
1:15:31.198 --> 1:15:33.878
Michelle Poliak-Tunis
Again, based on the systematic review.
1:15:35.648 --> 1:15:40.968
Michelle Poliak-Tunis
There did not provide significant benefit, but then the randomized control trial did show some improvements.
1:15:42.978 --> 1:15:43.938
Meredith Loveless
Thank you very much.
1:15:43.938 --> 1:15:46.178
Meredith Loveless
Appreciate your looking into that.
1:15:47.728 --> 1:15:51.808
Meredith Loveless
And our next question is for Anne Moscony and Mary Walsh-Sterup.
1:15:51.808 --> 1:16:3.928
Meredith Loveless
And we're inquiring about evidence for stellate ganglion blocks for complex regional pain syndrome in adults as compared to standard of care. And again, if any evidence about frequency.
1:16:5.528 --> 1:16:5.968
Anne Moscony
Thank you.
1:16:5.968 --> 1:16:7.328
Anne Moscony
This is Anne Moscone.
1:16:8.48 --> 1:16:9.208
Anne Moscony
I'm happy to answer that.
1:16:9.208 --> 1:16:26.768
Anne Moscony
The standard of care for persons with CRPS is outlined by Hardin at all in the 5th edition of the CRPS Practical Diagnostic and treatment guidelines, which was published in 2022 on behalf of the American Academy of Pain Medicine, and these guidelines advocate for a multidisciplinary appro.
1:16:27.248 --> 1:16:31.48
Anne Moscony
Emphasizing the importance of specific evidence-based interventions.
1:16:31.848 --> 1:16:36.488
Anne Moscony
In occupational therapy and physical therapy, with a primary focus on functional restoration.
1:16:36.918 --> 1:16:56.678
Anne Moscony
It does support the use of medications, including sympathetic nerve blocks, but only when the patient is unable to initiate or progress in therapy and in those cases, a short course of steth ganglion blocks should be considered only within combination with OT and PT interventions. Per this manual with.
1:16:56.678 --> 1:17:5.398
Anne Moscony
Regard to the question, is there evidence to support number and frequency of block applications to effectively relieve pain? I couldn't find anything specifically in the literature that.
1:17:6.168 --> 1:17:7.128
Anne Moscony
Definitively answered this query.
1:17:7.918 --> 1:17:25.678
Anne Moscony
Overall, the studies were limited by small sample size and large amounts of variability between the studies, making it really hard to generalize any findings for a broader population. But in general, the articles that we have do suggest that it is blocks can assist in situations in which the.
1:17:25.678 --> 1:17:29.718
Anne Moscony
Patient is having trouble participating in occupational and physical therapy.
1:17:33.78 --> 1:17:35.918
Meredith Loveless
Thank you very much and for the reference as well.
1:17:37.488 --> 1:17:41.448
Meredith Loveless
And Dr., yeah, if you could provide that, that'd be wonderful.
1:17:37.508 --> 1:17:38.748
Anne Moscony
Welcome. I'll happy to upload it.
1:17:41.928 --> 1:17:50.568
Meredith Loveless
And Dr. Paquette, what evidence exists regarding stalking ganglion blocks for Bell's palsy? And any guidance on how they should be applied?
1:17:53.138 --> 1:18:0.938
Brian Paquette
Yeah. So, Bell's palsy. It can be a difficult condition to treat a current treatment strategies are.
1:18:2.568 --> 1:18:3.408
Brian Paquette
Not very effective.
1:18:3.528 --> 1:18:13.768
Brian Paquette
Typically heals with time, but for some people it can be a chronic, disfiguring, debilitating condition with ophthalmologic impact as well.
1:18:14.318 --> 1:18:29.518
Brian Paquette
Stella ganglion Block is a sympathetic nerve block. While it's commonly used for conditions like CRPS and vascular insufficiency, certain other types of face pain and other pain syndromes, its use in Bell's palsy is really less well established.
1:18:31.88 --> 1:18:42.208
Brian Paquette
However, the rationale may be enhanced microcirculation of the facial nerve and reduced reduction in edema and inflammation and ultimately leading to improved nerve healing.
1:18:42.718 --> 1:18:45.38
Brian Paquette
So what we do have is some limited case reports.
1:18:46.608 --> 1:18:47.448
Brian Paquette
We do lack large.
1:18:49.928 --> 1:18:50.488
Brian Paquette
Scale studies.
1:18:53.398 --> 1:18:57.558
Brian Paquette
However, there is one randomized trial.
1:18:59.568 --> 1:19:1.368
Brian Paquette
By Lou et al.
1:19:3.208 --> 1:19:16.888
Brian Paquette
Who in his small randomized single blinded clinical trial involving 96 diabetic patients with Bell's palsy randomly divided into control and treatment with equal.
1:19:19.168 --> 1:19:22.208
Brian Paquette
Severity of the Bell's P policy prior to treat.
1:19:22.678 --> 1:19:25.998
Brian Paquette
Meant there was a significant.
1:19:27.568 --> 1:19:34.528
Brian Paquette
Improvement in their functional disability scores between the two groups.
1:19:36.208 --> 1:19:36.328
Brian Paquette
And.
1:19:37.838 --> 1:19:41.838
Brian Paquette
The safety they commented was.
1:19:47.708 --> 1:19:55.348
Brian Paquette
They had good safety data regarding this, and I think that holds true with other conditions that respond to Stella ganglion block.
1:19:57.48 --> 1:19:57.688
Brian Paquette
One interesting.
1:20:2.518 --> 1:20:22.598
Brian Paquette
Study that was not in this section but may be applicable is Kawabata et al. Describes prolonged blockade of the cervical sympathetic nerve by Stella ganglion block accelerating therapeutic efficacy in trigeminal neuropathy and the purpose of that study.
1:20:24.168 --> 1:20:26.8
Brian Paquette
Was to investigate the relationship between.
1:20:27.688 --> 1:20:30.168
Brian Paquette
The blockade of Stella ganglion and.
1:20:32.368 --> 1:20:33.88
Brian Paquette
Improvement in.
1:20:33.318 --> 1:20:36.718
Brian Paquette
Trigeminal neuropathy after orthonautic surgery.
1:20:37.378 --> 1:20:46.498
Brian Paquette
The study aims to determine if this blockade would help in that recovery and what they found was that there is therapeutic efficacy.
1:20:49.288 --> 1:20:55.288
Brian Paquette
And I thought maybe this was also applicable to the healing of the facial nerve in Bell's palsy.
1:20:58.288 --> 1:21:3.248
Brian Paquette
But otherwise small and positive data overall for the use in Bell's palsy.
1:21:6.718 --> 1:21:7.638
Meredith Loveless
Thank you so much.
1:21:7.728 --> 1:21:8.248
Brian Paquette
That's it.
1:21:10.538 --> 1:21:10.938
Meredith Loveless
And.
1:21:12.568 --> 1:21:24.808
Meredith Loveless
Dr. Manchikanti can you explain to us the evidence to support the use of Stella ganglia blocks for post herpetic neuralgia and also any recommendations on number and frequency?
1:21:26.808 --> 1:21:27.488
Laxmaiah Manchikanti
Thank you.
1:21:27.968 --> 1:21:29.888
Laxmaiah Manchikanti
There are no society guidelines.
1:21:30.688 --> 1:21:38.808
Laxmaiah Manchikanti
There are few studies and multiple systematic reviews evaluating the role of stellate, gangly and block and post herpetic neuralgia.
1:21:39.608 --> 1:21:43.648
Laxmaiah Manchikanti
However, the systematic reviews included multiple treatments.
1:21:45.208 --> 1:21:49.288
Laxmaiah Manchikanti
These systematic reviews included one or two studies in the entire picture. So.
1:21:50.968 --> 1:21:51.928
Laxmaiah Manchikanti
They're not very useful here.
1:21:53.608 --> 1:21:56.408
Laxmaiah Manchikanti
Of importance is that a randomized control trial.
1:21:56.798 --> 1:22:4.358
Laxmaiah Manchikanti
Was published by Makarita in Pain physician in 20/20/12.
1:22:5.38 --> 1:22:22.398
Laxmaiah Manchikanti
This randomized trial evaluated the effect of early Stella ganglion block for facial pain from acute hepaster and incidence of post herpetic neuralgia. They included 64 patients to receive either astelit ganglion block using 8ML of sodium chloride solution.
1:22:23.208 --> 1:22:24.728
Laxmaiah Manchikanti
Or 6ML of bupivacaine.
1:22:25.438 --> 1:22:32.398
Laxmaiah Manchikanti
With eight milligrams of dexamethasone in a total volume of eight ML, all procedures were performed under fluoroscopy.
1:22:33.138 --> 1:22:44.618
Laxmaiah Manchikanti
All patients received pre gambling in a dose of 150 milligrams twice daily, along with Tylenol pain assessment was performed using VAS up to six months.
1:22:45.58 --> 1:23:0.458
Laxmaiah Manchikanti
Group 2 receiving bhopiva, Kane and Dexamethasone showed significant reduction in pain and satisfaction at three and six months by the 4th week, 29 patients in Group Two reported no pain at three months compared to 22 patients.
1:23:1.248 --> 1:23:2.688
Laxmaiah Manchikanti
In the sodium chloride group.
1:23:3.288 --> 1:23:14.328
Laxmaiah Manchikanti
Further mild pain was reported in two patients at three months, with none of them reporting moderate or severe pain, whereas 8 patients reported moderate pain in placebo group.
1:23:15.678 --> 1:23:28.398
Laxmaiah Manchikanti
So this is a reasonably well conducted placebo-controlled trial with significant improvement in the treatment group. However, significant improvement was also seen in the placebo group even though less than treatment group.
1:23:29.198 --> 1:23:37.38
Laxmaiah Manchikanti
The question here comes is if sodium chloride solution into the stellate ganglion block was truly a placebo.
1:23:37.318 --> 1:23:39.918
Laxmaiah Manchikanti
There are multiple studies in epidural injections.
1:23:40.728 --> 1:23:44.488
Laxmaiah Manchikanti
And facet joint injection showing the effectiveness of sodium chloride solution.
1:23:45.458 --> 1:23:53.658
Laxmaiah Manchikanti
As a therapy, does injection of sodium chloride solution which is an inactive solution but into an active structure?
1:23:54.168 --> 1:23:56.488
Laxmaiah Manchikanti
May provide false positive results.
1:23:57.168 --> 1:23:59.488
Laxmaiah Manchikanti
A true placebo would have been injecting.
1:24:0.118 --> 1:24:3.998
Laxmaiah Manchikanti
The sodium chloride solution outside the stellate ganglion block.
1:24:4.438 --> 1:24:7.358
Laxmaiah Manchikanti
Still a ganglion into subcutaneous tissues.
1:24:8.998 --> 1:24:16.198
Laxmaiah Manchikanti
There is another study published adding extra carports, shockwave therapy, ultrasound, guided stelae, ganglion block.
1:24:17.768 --> 1:24:22.408
Laxmaiah Manchikanti
In this they studied 36 patients into three groups, very small number.
1:24:24.88 --> 1:24:39.48
Laxmaiah Manchikanti
So they basically showed that Stella ganglion block with shockwave therapy works the best, but they repeated this every week for six weeks. I don't see much of clinical use with this.
1:24:39.478 --> 1:24:52.918
Laxmaiah Manchikanti
30 they also compared another study, pan it all compared lidocaine andropubicane in treating postherpetic neuralgia in 252 patients.
1:24:53.158 --> 1:24:56.638
Laxmaiah Manchikanti
And they did not see any difference between both.
1:24:56.638 --> 1:24:58.438
Laxmaiah Manchikanti
It is an active control style.
1:25:1.238 --> 1:25:2.558
Laxmaiah Manchikanti
And to control file.
1:25:4.128 --> 1:25:19.88
Laxmaiah Manchikanti
So overall there is Level 3 evidence with one randomized placebo-controlled trial and one retrospective compared to study prophylacane and lidocaine. I would say with moderate recommendation in reference to the frequency.
1:25:20.728 --> 1:25:30.248
Laxmaiah Manchikanti
These can be performed frequently for three times with at least two to four weeks four-week intervals.
1:25:30.558 --> 1:25:41.598
Laxmaiah Manchikanti
Preferably 4-week intervals. Then if they respond to that and the pain returns, they may be performed once in three months provided they.
1:25:44.108 --> 1:25:50.588
Laxmaiah Manchikanti
Show three months of improvement in pain relief as well as functional status.
1:25:52.88 --> 1:25:52.368
Laxmaiah Manchikanti
Thank you.
1:25:54.78 --> 1:26:6.518
Meredith Loveless
Thank you. And the final question in this section is for Dr. Vorenkamp. And is there evidence supporting the use of stellate ganglion blocks for relieving acute postoperative pain and would there be any indication to repeat that?
1:26:9.668 --> 1:26:17.28
Kevin Vorenkamp
And I don't have much to add beyond that article that's included which I think is the final reference 16.
1:26:17.28 --> 1:26:30.508
Kevin Vorenkamp
But yeah, they have a meta-analysis of seven small studies showing improvement in pain compared to either a placebo or to no intervention at 8 and 24 hours.
1:26:30.508 --> 1:26:33.228
Kevin Vorenkamp
A couple of the studies tracked it out to 48 hours.
1:26:34.8 --> 1:26:37.768
Kevin Vorenkamp
I am not aware of any literature showing repeat injection.
1:26:39.728 --> 1:26:42.688
Kevin Vorenkamp
Either subsequent to that time.
1:26:43.368 --> 1:26:51.8
Kevin Vorenkamp
So yeah, my impression is that this has limited evidence for use in the acute postoperative period.
1:26:51.8 --> 1:26:56.288
Kevin Vorenkamp
And I'm not familiar with any literature showing repeat of the Stella block.
1:26:58.598 --> 1:26:59.878
Meredith Loveless
Thank you very much.
1:27:0.438 --> 1:27:13.598
Meredith Loveless
And the next section addresses trigeminal neuralgia and for each of these questions, if you can comment on the number and frequency of applications, the 1st is for Dr. Paquette for trigeminal neuralgia.
1:27:13.598 --> 1:27:16.958
Meredith Loveless
Is there evidence supporting peripheral nerve blocks for short term use?
1:27:18.958 --> 1:27:32.398
Brian Paquette
Yes. So trigeminal neuralgia, it's a rare condition like many of these conditions we're talking about. And so, the number of patients required to adequately power a randomized controlled trial makes this particularly difficult.
1:27:32.398 --> 1:27:35.558
Brian Paquette
But there is some data to support its use.
1:27:35.558 --> 1:27:42.758
Brian Paquette
El Sheikh Moore and de Stefani are the studies that I looked at more at all demonstrated in.
1:27:43.728 --> 1:27:46.568
Brian Paquette
Their study a systematic review.
1:27:48.168 --> 1:28:2.488
Brian Paquette
For rescue, analgesic strategies and acute exacerbations of primary trigeminal neuralgia 2019 and they used Prisma preferred reporting items for systematic reviews and meta-analysis as their flow diagram to.
1:28:4.408 --> 1:28:6.328
Brian Paquette
Report on 17 studies.
1:28:10.338 --> 1:28:23.298
Brian Paquette
That offered analgesic therapy within 24 hours of administration for trigeminal neuralgia and ultimately the evidence supports the use of blocks.
1:28:23.368 --> 1:28:28.968
Brian Paquette
In acute trigeminal neuralgia, but they.
1:28:30.738 --> 1:28:37.18
Brian Paquette
Suggest further studies are warranted, whereas El Sheikh at all in their study.
1:28:39.458 --> 1:28:46.138
Brian Paquette
Local anesthetic and steroid injection using a modified coronoid approach in trigeminal neuralgia 2016.
1:28:46.298 --> 1:28:49.858
Brian Paquette
Yes, there is evidence to support the use of peripheral nerve blocks.
1:28:50.618 --> 1:28:56.858
Brian Paquette
The study detailed evaluated the effect of adding calcitonin to the local anesthetic.
1:28:56.858 --> 1:29:7.898
Brian Paquette
It's not something that I use in my practice, but in this study, they showed that the addition of calcitonin significantly prolonged the duration of effective pain relief.
1:29:8.468 --> 1:29:14.708
Brian Paquette
Compared to the control group specifically, the duration of effective Pain relief was significantly longer.
1:29:16.258 --> 1:29:19.778
Brian Paquette
34 weeks as compared to the control group of 16 weeks.
1:29:20.418 --> 1:29:30.578
Brian Paquette
Fewer patients in the calcitonin group require repeated blocks, and there were no serious adverse events. And so, we talked about number and frequency of blocks.
1:29:33.438 --> 1:29:38.758
Brian Paquette
There's no specific guidance on this, however, in this particular study.
1:29:41.178 --> 1:29:41.778
Brian Paquette
Every.
1:29:44.18 --> 1:29:45.738
Brian Paquette
16 to 34 weeks seems.
1:29:48.498 --> 1:29:52.338
Brian Paquette
The duration that they were going for in de Stefani.
1:29:54.418 --> 1:30:2.18
Brian Paquette
Their study on the combination of pharmacotherapy and lidocaine, analgesic block of the peripheral trigeminal branches.
1:30:2.608 --> 1:30:17.208
Brian Paquette
Fortran General Neuralgia 2015. Their primary objective was to evaluate the therapeutic effect of combining pharmacotherapy with lidocaine analgesic block which is more common in in our practices to combine therapies.
1:30:18.778 --> 1:30:31.498
Brian Paquette
On the peripheral trigeminal branches, so specifically the study aims to assess the reduction in frequency of pain episodes in a month measured at 30 and 90 days after the treatment and what they found out.
1:30:32.88 --> 1:30:37.88
Brian Paquette
13 patients with classic trigeminal neuralgia were involved in the study.
1:30:37.288 --> 1:30:52.688
Brian Paquette
So the small study the patients were divided into two groups, 7 patients received only pharmacologic treatments, and the second group was six patients received pharmacologic treatment in addition to lidocaine analgesic block.
1:30:53.288 --> 1:30:55.688
Brian Paquette
Lidocaine injected was administered.
1:30:56.898 --> 1:30:58.738
Brian Paquette
To the area of most intense pain.
1:31:1.768 --> 1:31:8.768
Brian Paquette
And the pharmacologic treatment included the typical medicines carbamazepine oxcarbazepine as well as gabapentin and lamotrigine.
1:31:9.808 --> 1:31:23.168
Brian Paquette
The authors concluded that the combination of pharmacologic therapy and lidocaine analgesic block of the peripheral branches resulted in a significantly lesser frequency of pain.
1:31:24.778 --> 1:31:30.738
Brian Paquette
And additionally, the combination led to a consistent reduction in pain and improvement in quality of life.
1:31:31.168 --> 1:31:32.848
Brian Paquette
Life over there.
1:31:32.848 --> 1:31:34.528
Brian Paquette
Observation period of 90 days.
1:31:37.368 --> 1:31:42.288
Brian Paquette
And so the study suggests that this combination therapy is beneficial overall.
1:31:44.8 --> 1:31:47.448
Brian Paquette
So small sample size. Of course. It's a rare disorder.
1:31:47.448 --> 1:31:54.568
Brian Paquette
Difficult to study, but there are some reasonably good studies to support its use for.
1:31:56.138 --> 1:31:59.378
Brian Paquette
Acute trigeminal neuropathic pain.
1:32:2.128 --> 1:32:4.88
Meredith Loveless
Well, thank you for that thorough answer.
1:32:4.88 --> 1:32:5.328
Meredith Loveless
That's very helpful.
1:32:5.888 --> 1:32:14.648
Meredith Loveless
And for Dr. Batista, how about the use of peripheral nerve blocks diagnostically for trigeminal neuralgia?
1:32:16.748 --> 1:32:26.548
Alexander Bautista
The I you know, based on the studies that it can assist and agnostic neurology by temporarily alleviating the pain.
1:32:26.948 --> 1:32:41.188
Alexander Bautista
So it therefore kind of help helps confirm the involvement of specific nerve branches like for instance like blocking the peripheral branch of the trigeminal nerve can help identify affected division responsible for the pain.
1:32:41.978 --> 1:32:47.298
Alexander Bautista
And also this can aid in distinguishing trigeminal neurology from other facial pain syndrome.
1:32:48.488 --> 1:32:51.8
Alexander Bautista
However, beyond the diagnosis.
1:32:52.578 --> 1:33:8.458
Alexander Bautista
The use of the utility of nerve block for neurology showed, like very limited studies again as what the former expert have said, it's very difficult to study.
1:33:9.58 --> 1:33:13.938
Alexander Bautista
So there's very limited data but.
1:33:15.578 --> 1:33:22.538
Alexander Bautista
You doing those nerve blocks have reported significant reduction of pain severity and frequency over a period of six months period.
1:33:23.8 --> 1:33:23.968
Alexander Bautista
For some studies.
1:33:26.728 --> 1:33:27.848
Meredith Loveless
Thank you so much.
1:33:28.408 --> 1:33:31.408
Meredith Loveless
And we're heading back to Dr. Piquette to discuss.
1:33:32.978 --> 1:33:38.338
Meredith Loveless
Refractory trigeminal nerve cases and if peripheral nerve blocks have a role in that scenario.
1:33:40.998 --> 1:33:45.238
Brian Paquette
Yes, yes, peripheral nerve blocks have a role in this scenario.
1:33:45.358 --> 1:33:48.878
Brian Paquette
Trigeminal nerve patients, as many of us, we treat these people.
1:33:48.878 --> 1:33:53.118
Brian Paquette
These are people that are highly debilitated.
1:33:53.238 --> 1:33:55.358
Brian Paquette
This is a terrible condition.
1:33:55.358 --> 1:33:58.838
Brian Paquette
We don't have many tools to help them once they become refractory.
1:34:0.378 --> 1:34:2.858
Brian Paquette
These nerve blocks are, in my view, critical.
1:34:4.578 --> 1:34:9.18
Brian Paquette
Unfortunately, there is limited, high quality scientific studies for the reasons I mentioned earlier.
1:34:10.628 --> 1:34:16.548
Brian Paquette
In the publications that are available to me through the American Academy of Neurology.
1:34:18.338 --> 1:34:29.218
Brian Paquette
June 2021 there is recommendation in Continuum lifelong learning and neurology to provide trigeminal nerve blocks.
1:34:33.258 --> 1:34:41.458
Brian Paquette
Not only for an acute exacerbation, but also potentially on a scheduled basis for preventive therapy.
1:34:43.18 --> 1:34:52.858
Brian Paquette
A systematic review published in Pain Medicine 2021 found that local anesthetic blocks provide immediate relief and although long term efficacy remains uncertain.
1:34:54.538 --> 1:34:57.338
Brian Paquette
For repeated blocks is recommended.
1:35:2.888 --> 1:35:8.488
Brian Paquette
So this question you know is its refractory trigeminal neuralgia?
1:35:8.488 --> 1:35:14.168
Brian Paquette
Is there evidence to employ periodic nerve blocks for the treatment of refractory trigeminal nerve blocks?
1:35:14.168 --> 1:35:18.208
Brian Paquette
Is this acute flare ups or are we employing this as?
1:35:19.778 --> 1:35:22.58
Brian Paquette
A scheduled maintenance therapy.
1:35:22.58 --> 1:35:26.738
Brian Paquette
So these are in my view two different scenarios, but in both scenarios.
1:35:29.808 --> 1:35:40.208
Brian Paquette
Patients respond favorably to these peripheral nerve blocks, and several blocks may be necessary to achieve adequate pain control and improve central and peripheral sensitization.
1:35:41.778 --> 1:35:44.218
Brian Paquette
More at all in their review.
1:35:45.978 --> 1:35:52.618
Brian Paquette
Treatment was drained, was deemed effective if it resulted in better than 50% overall pain reduction in 24 hours.
1:35:54.338 --> 1:36:1.298
Brian Paquette
After administration and they use the VAS scale NRS and verbal pain rating scale.
1:36:1.568 --> 1:36:5.768
Brian Paquette
In their review, overall, the quality of evidence.
1:36:9.498 --> 1:36:11.458
Brian Paquette
Is low.
1:36:11.858 --> 1:36:13.338
Brian Paquette
The sample sizes are small.
1:36:13.338 --> 1:36:17.938
Brian Paquette
The study designs don't include many randomized control trials.
1:36:17.938 --> 1:36:19.658
Brian Paquette
Again, for the reasons that I mentioned.
1:36:21.578 --> 1:36:27.858
Brian Paquette
However, the use of these blocks is highly effective.
1:36:36.888 --> 1:36:46.648
Brian Paquette
So that is the current recommendation is to include these blocks in conjunction with.
1:36:48.338 --> 1:36:50.378
Brian Paquette
Traditional pharmacologic therapy.
1:36:52.58 --> 1:36:54.858
Brian Paquette
For the overall treatment of this patient population.
1:36:57.128 --> 1:37:15.208
Meredith Loveless
Thank you so much. And we are on our final section of our meeting today. And if this is on radio frequency for trigeminal neuralgia and this question is directed to the group, is there evidence to support radio frequency of lation for decreasing pain for patients with TR?
1:37:15.448 --> 1:37:16.8
Meredith Loveless
Neuralgia.
1:37:30.798 --> 1:37:31.918
Kevin Vorenkamp
I'm happy to go first.
1:37:31.918 --> 1:37:39.878
Kevin Vorenkamp
Yeah, this this was actually the first application of radio frequency ablation for chronic pain.
1:37:39.878 --> 1:37:44.998
Kevin Vorenkamp
And so I believe it was 1967 when the original article came out.
1:37:44.998 --> 1:37:55.798
Kevin Vorenkamp
So yeah, there's many decades of supportive evidence in a subset of patients, certainly those that are more elderly with comorbidities for those that don't.
1:37:58.138 --> 1:38:0.618
Kevin Vorenkamp
Have the indications for microvascular decompression?
1:38:1.128 --> 1:38:8.328
Kevin Vorenkamp
Or failed at so as a palliative treatment, there is decades of supportive evidence.
1:38:11.478 --> 1:38:14.878
Meredith Loveless
Thank you so much for that answer and.
1:38:16.418 --> 1:38:24.858
Meredith Loveless
Dr. Paquette, how about the does radio frequency ablation help reduce the need for surgery in these patients with trigeminal neuralgia?
1:38:26.728 --> 1:38:32.368
Brian Paquette
Yeah, I think really this is a follow-up question to what we just talked about.
1:38:33.938 --> 1:38:36.418
Brian Paquette
Radiofrequency ablation can be very effective.
1:38:38.178 --> 1:38:44.178
Brian Paquette
The data are pretty clear that if someone has a compressive lesion.
1:38:47.108 --> 1:38:50.788
Brian Paquette
Identified causing the patient's trigeminal neuralgia.
1:38:50.788 --> 1:38:55.988
Brian Paquette
That microvascular decompression is likely the treatment of choice.
1:38:57.538 --> 1:39:1.618
Brian Paquette
That's barring if the patient has any reservations or contraindications.
1:39:3.258 --> 1:39:15.658
Brian Paquette
In in short of that, if there is no definite compressive lesion discovered, then microvascular decompression is really not an option and.
1:39:17.298 --> 1:39:19.538
Brian Paquette
The evidence is clear that radiofrequency ablation.
1:39:20.8 --> 1:39:24.208
Brian Paquette
A minimally invasive procedure can be very effective.
1:39:28.388 --> 1:39:29.388
Meredith Loveless
Thank you very much.
1:39:29.38 --> 1:39:32.158
Brian Paquette
I have plenty of literature to share with you on this.
1:39:32.198 --> 1:39:34.38
Brian Paquette
I can do that at a later date.
1:39:33.98 --> 1:39:33.938
Meredith Loveless
Yes, please do.
1:39:35.938 --> 1:39:39.658
Meredith Loveless
And our final question, which is for the panel.
1:39:41.378 --> 1:39:45.378
Meredith Loveless
How frequently would the radiofrequency ablation be performed in these cases?
1:39:45.378 --> 1:39:53.658
Meredith Loveless
Is it the do we expect pain release for six months like in other areas that we've discussed or is there some variation in this area?
1:40:5.568 --> 1:40:10.608
Kevin Vorenkamp
And I think that's a similar reasonable expectation.
1:40:12.138 --> 1:40:12.778
Kevin Vorenkamp
There are some.
1:40:15.108 --> 1:40:16.588
Kevin Vorenkamp
Situation certainly.
1:40:17.628 --> 1:40:24.508
Kevin Vorenkamp
Trigeminal neuralgia in some subsets of particular Ms. May be more refractory.
1:40:24.508 --> 1:40:39.668
Kevin Vorenkamp
So you may need to use more aggressive lesioning parameters, so you may start with the more standard Ms. Protocol and if you don't get significant relief, you may modify your treatment modalities. But.
1:40:40.458 --> 1:40:43.898
Kevin Vorenkamp
In general, I think 6 months is kind of the.
1:40:44.328 --> 1:40:50.288
Kevin Vorenkamp
Target where we would want to repeat it, but there may be some exceptions and certain patient subsets.
1:40:52.278 --> 1:41:4.118
Meredith Loveless
Thank you. And in follow up to some of your responses for this head neck and upper extremity section at one point, Dr. Northrup, you mentioned that the block, the Steli gangling block is safe in the right hands.
1:41:5.698 --> 1:41:10.698
Meredith Loveless
Do what does the panelist consider the appropriate training for these head and neck?
1:41:12.338 --> 1:41:21.218
Meredith Loveless
Or requirements for training for these procedures and my additional question is really geared towards Dr. Northrop. Are there any recommendations regarding image guidance for these?
1:41:21.808 --> 1:41:24.48
Meredith Loveless
Head, neck and upper extremity procedures.
1:41:30.508 --> 1:41:40.468
Ben Northrup
Yeah, I can go first. Concerning imaging guidance, I do not have it in front of me, but there are several papers I can look up later and provide references concerning imaging guidance.
1:41:40.468 --> 1:41:51.428
Ben Northrup
There are even a few that use fluoroscopy, but I would say the majority of people, particularly for the head and neck interventions, are going to use CT guidance for it.
1:41:52.68 --> 1:41:54.188
Ben Northrup
Some of the other upper extremity ones.
1:41:54.628 --> 1:41:57.708
Ben Northrup
In some cases, fluoro could work for certain nerve blocks.
1:41:58.578 --> 1:42:0.338
Ben Northrup
Ultrasound is probably most common.
1:42:1.168 --> 1:42:15.328
Ben Northrup
There's evidence for all these it would be a very long reference list, but yes, as a general statement, most of these will use imaging guidance of some type and some of the more dangerous ones, particularly those in the head neck. You'll definitely need CT.
1:42:17.128 --> 1:42:18.128
Meredith Loveless
Thank you so much.
1:42:20.288 --> 1:42:45.8
Kevin Vorenkamp
In terms of basic training requirements, I'm not aware of any reference of anything we've looked at today that of any procedure performed by non-physicians. So, everything we've discussed is our procedures in literature performed by physicians. The majority of these are provide provided by anesthesiologists, physiatrists, neurologists, rad.
1:42:46.298 --> 1:42:49.738
Kevin Vorenkamp
Neurosurgeons orthopedic surgeons, that typically have a minimum of.
1:42:50.168 --> 1:42:57.728
Kevin Vorenkamp
Four years of post-medical school training, but I am not aware of any reform by non-physicians.
1:43:1.818 --> 1:43:13.218
Meredith Loveless
Thank you so much. And that concludes our question section. I just want to thank everyone for your insightful and valuable contributions to this discussion. And I'm going to turn things back over to our moderators, our other moderators.
1:43:19.368 --> 1:43:21.8
Michael Hopkins
Yes, that ends our question section. I'll leave a few minutes for many of our panel if there's any sort of final comments or anything to add from anyone.
1:43:36.628 --> 1:43:37.428
Michael Hopkins
And if.
1:43:36.908 --> 1:43:38.708
Ben Northrup
Yeah, I do have a quick question here.
1:43:38.708 --> 1:43:39.588
Ben Northrup
This is Ben Northrop.
1:43:40.28 --> 1:43:55.658
Ben Northrup
So I noticed at the end of your document you had a final question that we didn't get to hear. It said. Are there additional peripheral nerve blocks that we did not include in the discussion, and you know, certainly kind of a loaded question because you can always.
1:43:56.28 --> 1:44:3.708
Ben Northrup
You can always find something minor, but I just did want to point out and some of these might be included in some of the general categories such as.
1:44:4.458 --> 1:44:6.378
Ben Northrup
Upper extremity, pelvic, lower extremity etcetera.
1:44:6.768 --> 1:44:30.848
Ben Northrup
But just as a point of reference, ones that were not specifically mentioned but have met the very high criteria for category one, CPT codes include Vegas brachial, Plexus superscapular, axillary paraservical, or uterine sciatic iliyainguanol. Ileohypogastric femoral and digital nerve blocks.
1:44:30.848 --> 1:44:36.488
Ben Northrup
So all of those do have category one CPT codes needed. The evidence and widespread UT.
1:44:37.48 --> 1:44:40.288
Ben Northrup
To achieve that category 1CT code that is.
1:44:40.288 --> 1:44:45.328
Ben Northrup
And those were not mentioned. So just wanted to point those out. I can include those in an e-mail if you want the full list.
1:44:46.618 --> 1:44:54.338
Michael Hopkins
Yeah, I think that would be helpful. Just to make sure that we have everything that we talked about, an e-mail would be helpful and thank you for bringing that up.
1:44:55.898 --> 1:44:56.298
Michael Hopkins
Is there?
1:44:56.858 --> 1:44:59.18
Michael Hopkins
I'll leave it open for another minute.
1:44:59.18 --> 1:45:1.178
Michael Hopkins
Anybody else with another comment or concern?
1:45:9.628 --> 1:45:19.748
Michael Hopkins
Hearing nothing there, I believe that concludes our contractor Advisory Committee meeting. On behalf of the contractors, I would like to thank everyone for their participation and very constructive comments.
1:45:20.348 --> 1:45:22.388
Michael Hopkins
Your involvement is an invaluable part of our process.
1:45:22.388 --> 1:45:36.748
Michael Hopkins
We greatly appreciate you sharing your knowledge and expertise. The information that was shared today will be carefully considered as we move forward. Just to reiterate, if there are references mentioned that are not included in our references list, please send them so we. So, we are all you know, thinking about and talking about the same literature.
1:45:42.138 --> 1:45:45.178
Michael Hopkins
And to conclude, thank you again and everyone have an excellent afternoon.
1:45:47.898 --> 1:45:48.418
Michael Hopkins
Thank you all.
1:45:49.558 --> 1:45:50.358
Meredith Loveless
Thank you everybody.
1:45:51.128 --> 1:45:51.648
Ben Northrup
Thank you
