Experience with Intracept.

[Taus]

View attachment 365162
This is a snippet from Benzon, written by Steve Cohen. The best and only reliable PE maneuver is paraspinal tenderness. I am happy to see other literature supporting other PE maneuvers. Can we even claim that extension best exacerbates the most commonly implicated joints of 4-5 and 5-1?

I would love to see the citation on that. I’d bet it’s empirical.

This is from a lecture I put together as a fellow and one I give to residents every year.

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[jwalker12]

For those of you performing intracept are you holding ASA 81? Have an elderly gentlemen, CAD with stents, has been stable for upcoming intracept. ASRA app recommends discussion but wanted to get an idea of what everyone was doing. thanks

 

[Taus]

For those of you performing intracept are you holding ASA 81? Have an elderly gentlemen, CAD with stents, has been stable for upcoming intracept. ASRA app recommends discussion but wanted to get an idea of what everyone was doing. thanks

No

 

[Spine MD]

I believe the data to be clear. It’s all about payment now.

Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results - PubMed

BVN ablation demonstrates significant improvements in pain and function over SC, with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.

pubmed.ncbi.nlm.nih.gov

The ol' open label vs SC model of research doesn't convince the payers. Now less than ever.

 

[bedrock]

Agree. They need to double the professional payment given the time ….(and risk/extra expertise) compared to bread&butter lumbar injections.

Intracept will then be worth performing for non HOPD docs.

I still refer out for it to an HOPD doc 2 hrs away. However many docs don’t bother to refer.

 

[Taus]

For those of you performing intracept are you holding ASA 81? Have an elderly gentlemen, CAD with stents, has been stable for upcoming intracept. ASRA app recommends discussion but wanted to get an idea of what everyone was doing. thanks

No


Would just add that you may want to consider a face shield when malletting, especially when in vert body….. Ive been splashed several times when the marrow is a bit juicy

 

[Taus]

Agree. They need to double the professional payment given the time ….(and risk/extra expertise) compared to bread&butter lumbar injections.

Intracept will then be worth performing for non HOPD docs.

I still refer out for it to an HOPD doc 2 hrs away. However many docs don’t bother to refer.

Agreed… however you need to compare apples to apples. Medicare pro fee vs medicare pro fee. +\-$100 esi pro fee vs +\-$450 pro fee. This now takes me only about 30 mins to access and burn 2 vert bodies. Maybe 45 with turnover if only 1 room. Add 15 mins to access and burn another level, additional 250ish. Not great, but when comparing to medicare pro fee its not a money loser. Dont think its fair to compare to a commercial carrier esi. I think the same argument could be made about Medicare stim trials and vertebral augmentation in Asc.

Also, your asc facility nets >3k/case… not bad if you’re an owner

As commercial approvals are slowly improving Im going to keep a close eye on what they’re paying. Not enough of a sample size at this point.

All that being said, I do cap these 2 per week… to leave plenty a room for those commercial esi.

Ive now done over 50 cases….. outcomes still match the published literature

 

[Taus]

The ol' open label vs SC model of research doesn't convince the payers. Now less than ever.

Definitely agree. Take the bull by the horns and do an independent study. Mine is underway.

 

[SC Tian]

preparing for the intercept in our asc, any recommendations are welcome. thanks.

 

[DrMDAware]

preparing for the intercept in our asc, any recommendations are welcome. thanks.

-S1 is the most challenging.
-It takes longer to do the entire procedure than the reps state
-I’d plan for 45 mins if without S1 and 60 mins if there’s S1 assuming two levels. My RNs do time out twelve times like we’re going on pump and my CRNAs let’s me know if the sats go to 98%
-Use 22g spinal needles to plan the trajectory. Use two. For me I go lateral early to see the trajectory.
-use bupi with epi to numb the tract
-Ask the rep Diamond vs Bevel tip and why one over the other (easier to dock vs easier to steer)
-when in doubt burn 15 mins
-ask the rep to remind you where the skin nick should be. The angle of entry for L4 and L5 should be around 45 degrees. This will be a good estimation of your approach. Once my skin nicks were improved my ability to dock became easier.
-there are more advanced techniques that IMHO make this procedure MUCH easier to do. These can fine tune how anterior you are (the most posterior the better) and how you’re able to get to midline. They are a bit awkward at first but once you get the feel of them you can salvage or optimize your approach. This removes the need to have perfect trajectory off the bat. Don’t be afraid to go to them. You can only take the handle bending so far.


Good luck!!

 

[SC Tian]

-S1 is the most challenging.
-It takes longer to do the entire procedure than the reps state
-I’d plan for 45 mins if without S1 and 60 mins if there’s S1 assuming two levels. My RNs do time out twelve times like we’re going on pump and my CRNAs let’s me know if the sats go to 98%
-Use 22g spinal needles to plan the trajectory. Use two. For me I go lateral early to see the trajectory.
-use bupi with epi to numb the tract
-Ask the rep Diamond vs Bevel tip and why one over the other (easier to dock vs easier to steer)
-when in doubt burn 15 mins
-ask the rep to remind you where the skin nick should be. The angle of entry for L4 and L5 should be around 45 degrees. This will be a good estimation of your approach. Once my skin nicks were improved my ability to dock became easier.
-there are more advanced techniques that IMHO make this procedure MUCH easier to do. These can fine tune how anterior you are (the most posterior the better) and how you’re able to get to midline. They are a bit awkward at first but once you get the feel of them you can salvage or optimize your approach. This removes the need to have perfect trajectory off the bat. Don’t be afraid to go to them. You can only take the handle bending so far.


Good luck!!

thanks, how do you do S1, iliac crest likely prevents from go to much angel lateral

 

[epidural man]

preparing for the intercept in our asc, any recommendations are welcome. thanks.

I have done a couple in the clinic - used to do them in the OR.

I’ve been surprised with how well they tolerate it with mild sedation.

But I do medial branch blocks above and below the level and am very generous with the volume.

 

[SC Tian]

I have done a couple in the clinic - used to do them in the OR.

I’ve been surprised with how well they tolerate it with mild sedation.

But I do medial branch blocks above and below the level and am very generous with the volume.

thanks, how do you do the S1 level?

 

[nvrsumr]

I have done a couple in the clinic - used to do them in the OR.

I’ve been surprised with how well they tolerate it with mild sedation.

But I do medial branch blocks above and below the level and am very generous with the volume.

Intracept is reimbursed as office based procedure?

 

[epidural man]

Intracept is reimbursed as office based procedure?

I get paid to do it. But I get paid if I don’t do it. Go figure….

 

[epidural man]

thanks, how do you do the S1 level?

Honestly, I just do what the rep tells me to do.

It’s kind off embarrassing.

 

[RoloTomassi]

thanks, how do you do the S1 level?

Different ways but here's my approach.
Low crest is easy, do like other levels. High crest a bit trickier.

Ferguson view AP.
Oblique to measured trajectory. 35-40 deg is the sweet spot for S1 in my experience.
If crest in the way, cephalad tilt until you can oblique at least 35 or else you run the risk of ending up too anterior.
Dock in the groove with diamond, switch to bevel and go medial.
Retraction method if still a ways away from midline.
May need to compensate for the cephalad till by curving J North.

 

[MitchLevi]

No idea how yall find these pts. I've been looking for months.

 

[SC Tian]

I am considering a modified infra-pedicular approach for L4 and L5, the wiggle room is larger imo.

 

[RoloTomassi]

I am considering a modified infra-pedicular approach for L4 and L5, the wiggle room is larger imo.

Those pedicles are huge and no crest. Can't imagine you could make it any easier. Transpedicular is the safest, less risk of radiculitis or lumbar artery injury.

 

[RoloTomassi]

No idea how yall find these pts. I've been looking for months.

Haha it boggles my mind how you aren't seeing these everyday given your volume and demographic

 

[SC Tian]

Those pedicles are huge and no crest. Can't imagine you could make it any easier. Transpedicular is the safest, less risk of radiculitis or lumbar artery injury.

Imo, infrapedicular approach, it is easier to redirect the trochar, easier to reach posterior part of vertebra.

 

[MitchLevi]

Haha it boggles my mind how you aren't seeing these everyday given your volume and demographic

RFA and a silver tongue I think.

 

[bedrock]

No idea how yall find these pts. I've been looking for months.

I see a candidate every other week.

Just referred one today to the one doc in the state that does intracept.

 

[Dr. Ice]

No idea how yall find these pts. I've been looking for months.

If you think it they will come..if you ask the questions geared towards anterior column pain without radic, patients will say anything. You can also prolly find some end plate edema somewhere…

 

[DrMDAware]

For me the home runs are 40-50 year olds, active, otherwise healthy spines expect for Modic changes at two levels, not on opioids, very midline pain.

 

[Ducttape]

Haha it boggles my mind how you aren't seeing these everyday given your volume and demographic

we ofttimes see what we want to see and when we specifically look for it, eh? i dont mean that negatively - thats with all procedures.

i spend a lot more time looking for modic changes now even though i am not doing intracept. just like how i look at spinous processes more, even though i never put in any spacers...

 

[SC Tian]

osteoporosis was one of the relative contraindications, did you guys see the problems for Intercept? thanks

 

[RoloTomassi]

osteoporosis was one of the relative contraindications, did you guys see the problems for Intercept? thanks

I have not but I tell pt slightly increased risk of fx but still relatively negligible risk

 

[SC Tian]

I have not but I tell pt slightly increased risk of fx but still relatively negligible risk

is the pacemaker contraindicated for the procedure, i thought it is a bipolar.

 

[RoloTomassi]

is the pacemaker contraindicated for the procedure, i thought it is a bipolar.

No it's bipolar

 

[cameroncarter]

how much sedation does a 2 level case typically need?

 

[BobBarker]

GA

 

[Ferrismonk]

I'm curious why Intracept needs GA but Kypho doesn't. Can you educate me?

 

[fathead88]

As someone who used to do Intracept with only GETA and Kypho with only MAC/moderate sedation, I can assure you that Intracept does not require GETA.

 

[MitchLevi]

As someone who used to do Intracept with only GETA and Kypho with only MAC/moderate sedation, I can assure you that Intracept does not require GETA.

Once you've done a few cases though right?

 

[deleted131481]

The training/reps will call anything Modic changes. I've done 3 cases so far. One seems to be doing pretty good not a slam dunk, one nothing, and one some mild-moderate relief. The one doing the best I actually had to abort a level - bone was too sclerotic and the stylet bent, just couldn't advance.

Supposedly pain relief keeps going til 3 months out so we'll see. I've got 2 more booked this week. 4 of the 5 total so far are Medicare. Several do have mixed pain. I can't make anything of my n=3 so far. All had anterior column pain but mixed presentation. If I'm not getting great results I may limit to those middle age with more isolated anterior column pain.

Once you've done a few cases though right?

We've been doing TIVA starting 2nd case and I'm slow with fellow. We may try true MAC as I get faster.

 

[bedrock]

The training/reps will call anything Modic changes. I've done 3 cases so far. One seems to be doing pretty good not a slam dunk, one nothing, and one some mild-moderate relief. The one doing the best I actually had to abort a level - bone was too sclerotic and the stylet bent, just couldn't advance.

Supposedly pain relief keeps going til 3 months out so we'll see. I've got 2 more booked this week. 4 of the 5 total so far are Medicare. Several do have mixed pain. I can't make anything of my n=3 so far. All had anterior column pain but mixed presentation. If I'm not getting great results I may limit to those middle age with more isolated anterior column pain.


We've been doing TIVA starting 2nd case and I'm slow with fellow. We may try true MAC as I get faster.

Are you doing lumbar MBB and/or RFA to classify the pain generators on your Medicare patients?

If, not it might help narrow your pool to more ideal intracept candidates.

 

[Taus]

The training/reps will call anything Modic changes.

Why are you listening to the reps?

I've done 3 cases so far. One seems to be doing pretty good not a slam dunk, one nothing, and one some mild-moderate relief. The one doing the best I actually had to abort a level - bone was too sclerotic and the stylet bent, just couldn't advance.

Supposedly pain relief keeps going til 3 months out so we'll see.

I found that a bit hard to believe re 3 months in the beginning, but have now seen it multiple times. Done 60 to 70 cases.

I've got 2 more booked this week. 4 of the 5 total so far are Medicare. Several do have mixed pain.

How do you define and quantify mixed pain?

. I can't make anything of my n=3 so far. All had anterior column pain but mixed presentation. If I'm not getting great results I may limit to those middle age with more isolated anterior column pain.


We've been doing TIVA starting 2nd case and I'm slow with fellow. We may try true MAC as I get faster.

Same. TIVA, unless anesthesiologist says airway or other factors not amenable, and they are GETA. I am not an anesthesiologist, so I defer to their expertise. I’ve also learned that anything without an airway is not necessarily MAC…

 

[BobBarker]

@fathead88 If they are getting propofol and are not responding to painful stimuli they are getting GA. The presence or absence of an ETT is irrelevant.

It you have to coach the patient through the procedure it is MAC.

 

[deleted131481]

Are you doing lumbar MBB and/or RFA to classify the pain generators on your Medicare patients?

If, not it might help narrow your pool to more ideal intracept candidates.

How do you define and quantify mixed pain?

I'm looking at primarily axial pain with extension/twisting vs pain with flexion/bending forward.

I would need to look for sure but I think all the Medicare ones have gone down mbb/RFA with either partial relief or failure.

Why are you listening to the reps?

I found that a bit hard to believe re 3 months in the beginning, but have now seen it multiple times. Done 60 to 70 cases.

I know the reps will push the procedure. So far the ones I've signed up are full-blown Modic changes lighting up both sides of the disc. Now that I'm sort of looking for anterior column pain in the clinic, I do see some more subtle Modic changes but not sure if I should be taking these candidates back.

That's encouraging about the 3 months. I think two of mine are six weeks out and another one three weeks out.

 

[DrMDAware]

I'm looking at primarily axial pain with extension/twisting vs pain with flexion/bending forward.

I would need to look for sure but I think all the Medicare ones have gone down mbb/RFA with either partial relief or failure.



I know the reps will push the procedure. So far the ones I've signed up are full-blown Modic changes lighting up both sides of the disc. Now that I'm sort of looking for anterior column pain in the clinic, I do see some more subtle Modic changes but not sure if I should be taking these candidates back.

That's encouraging about the 3 months. I think two of mine are six weeks out and another one three weeks out.

Take ‘em back if indicated. Modic changes are binary. Severity does not reflect pain burden.

 

[SC Tian]

Anyone was able to negotiate down the price of the intracept kit, it is reported $6400? The profit margin for Medicare patients is so low here in ASC?

 

[BobBarker]

I think they were able to negotiate around a $3000 profit. Not sure what that comes out to as far as kit cost.

 

[Taus]

Anyone was able to negotiate down the price of the intracept kit, it is reported $6400? The profit margin for Medicare patients is so low here in ASC?

They still net around 3k. That’s low?

 

[SC Tian]

They still net around 3k. That’s low?

Appreciate the feedback, I was thinking that way as well, however, other costs including our surgical package, room charge, x-ray, and staff charges, all added together so barely can make any profits at all

 

[bedrock]

Get

Anyone was able to negotiate down the price of the intracept kit, it is reported $6400? The profit margin for Medicare patients is so low here in ASC?

you should be able to negotiate the price down. Just tell the rep you won’t do any Medicare cases until they do so.

 

[fathead88]

@fathead88 If they are getting propofol and are not responding to painful stimuli they are getting GA. The presence or absence of an ETT is irrelevant.

It you have to coach the patient through the procedure it is MAC.

Thats not accurate. Like at all. I’m anesthesia trained. MAC means there’s an anesthesia provider in the room. It has nothing to do with the depth of anesthesia.

Patients under general anesthesia at 1 MAC will react to surgical stimuli 50% of the time.

20 mcg/kg/min propofol and 20 cc of 1-2% lidocaine infiltrated is sufficient to do these cases. That is not general anesthesia for the majority of the population. You don’t need 1 MAC of sevo. Cases are quicker this way too because you don’t have flip prone.

 

[Ronin1]

Thats not accurate. Like at all. I’m anesthesia trained. MAC means there’s an anesthesia provider in the room. It has nothing to do with the depth of anesthesia.

Patients under general anesthesia at 1 MAC will react to surgical stimuli 50% of the time.

20 mcg/kg/min propofol and 20 cc of 1-2% lidocaine infiltrated is sufficient to do these cases. That is not general anesthesia for the majority of the population. You don’t need 1 MAC of sevo. Cases are quicker this way too because you don’t have flip prone.

We are not talking about minimal alveolar concentration which non anesthesia guys don’t understand. We are discussing monitored anesthesia care. Most surgeons expect IV general with MAC.

 

[BobBarker]

98% of our PMR colleagues think GA=ETT so I was writing for that audience. Anesthesia is a gradient. Intracept on osteoporotic bone can probably be done with sedation. Difficult or barbaric to drive a spike through non osteoporotic pedicle without GA. I would say the majority of my prone, TIVA cases are clearly GA without an airway.

No offense PMR friends. We don’t understand EMGs very well.