therapeutic genicular nerve blocks for chronic knee pain ... · • auriculo-temporal nerve block...
Post on 21-Dec-2018
221 Views
Preview:
TRANSCRIPT
Therapeutic genicular nerve blocks for chronic knee pain
Ian Zhao, Ph.D.
July 26, 2018
Genicular Nerve
Blocks
May be used for several purposes
o To determine the source of pain
o To predict how pain will respond to long-term treatments
o To treat painful acute conditions
o For short-term pain relief after some surgeries/procedures
o For anesthesia during some procedures, such as finger surgery
and foot surgery
Are also used to treat chronic pain by some providers
o Peripheral nerve blocks are being used to treat chronic pain
o The practice is controversial
Peripheral nerve blocks
2
Genicular Nerve
Blocks
64400 – trigeminal nerve
64402 – facial nerve
64405 - greater occipital nerve
64408 – cranial (vagus) nerve
64410 – upper spinal (phrenic) nerve
64413 – cervical plexus
64415 – brachial (arm) nerve bundle
64417 – underarm (axillary) nerve
64418 – suprascapular nerve (collar bone)
64420 – intercostal nerve (rib)
64421 – multiple rib nerves
64425 – ilioingubal iliohypogastric nerves
(groin)
64430 – pudental nerve (external genital)
64435 – paracervical nerve (uterine)
64445 – sciatic nerve
64447 – femoral nerve
64448 – thigh nerve
64449 – lumbar plexus nerve bundle,
posterior approach
64450 - Injection, anesthetic agent; other
peripheral nerve or branch
64455 – plantar common digital nerve
64461 – paravertebral block - thoracic
G9770 - Peripheral nerve block (new)
CPT and HCPCS codes for PNBs
3
Genicular Nerve
Blocks
On peripheral somatic nerve blocks for long-term treatment
ASA: the American Society of Anesthesiologists;
ASRA: the American Society of Regional Anesthesia and Pain Medicine
Rosenquist et al., 2010. Anesthesiology; 112:1–24
A Survey by the American Society of Anesthesiologists
4
N Strongly Agree
Agree Equivocal Disagree Strongly Disagree
ASRA 170 15.3% 30.6% 34.7% 15.3% 4.1%
ASA 298 17.4% 28.2% 34.6% 17.1% 2.7%
Genicular Nerve
Blocks
Practice Guidelines for Chronic Pain Managemento An Updated Report by the American Society of Anesthesiologists Task
Force on Chronic Pain Management and the American Society of
Regional Anesthesia and Pain Medicine – 2010
o Recommendation for blocks - Peripheral somatic nerve blocks
should not be used for long-term treatment of chronic pain
Rosenquist et al., 2010. Anesthesiology; 112:1–24
Treatment guidelines
5
Genicular Nerve
Bocks
Therapeutic genicular nerve block (TGNB) for chronic
knee pain
o Exclusions
Diagnostic genicular nerve block
Treating painful acute conditions
Perioperative analgesia
Anesthesia for surgery/procedures
Genicular nerve ablation is outside the scope
o It will be addressed in an HTCC topic: “Peripheral nerve
ablation for lower limb pain”
Is TGNB effective and safe for chronic knee
pain?
6
Genicular Nerve
Blocks
The genicular nerves injected
7
SMG
IMG
SLG
Common peroneal nerve Tibial nerve
Genicular Nerve
Blocks
Cochrane Database of Systematic Reviews
o None
Hayes’ database o Genicular nerve blocks for knee pain (Search & summary, Hayes, Inc. 2015,
updated 2017)
PubMedo Two (2) RCTs
o Two (2) case studies
The evidence – therapeutic genicular nerve block
for chronic knee pain
8
Genicular Nerve
Blocks
Outcome F/U RCTs N Results/Conclusion Quality
RF neurotomy of GN vs. GN block (After TKA)
Pain, function
(OKS, KSS),
AE, disability,
QoL (SF-36),
analgesic use
3, 6 and
12
months
Qudsi-
Sinclair
2016
28 No sham control; poor design and data analyses; “as
treated” analysis instead of ITT; high differential attrition
rate > 10%
The authors showed statistically significant reduction in
pain (NRS) and an improvement in joint function during
the first 3 to 6 months and concluded that no difference
found compared to GN block in pain and function.
The changes in NRS and function scales, however, were
so small that they were not clinically important. For
example, the mean NRS value at the baseline was 6.43
(±1.56) for the GNB group. The value dropped to 5.30
(±1.80) at 3 months and 5.50 (±3.51) at 6 months post
treatment. The differences in the NRS scores compared
to the baselines were 1.1 and 0.9, respectively. Overall
we are unable to draw any conclusion from the RCT
because of the low quality of the study.
●○○○
Very low
RCT on therapeutic GN blocks
9
Qudsi-Sinclair, S., E. Borrás-Rubio, J. F. Abellan-Guillén, M. L. Padilla del Rey, and G. Ruiz-Merino. 2017. Pain Practice, 17: 578-88.
Genicular Nerve
Blocks
Outcome F/U RCTs N Results/Conclusion QualityGNB with local anesthetic vs. local anesthetic + corticosteroid (Knee OA patients)
VAS; Oxford
knee score
(OKS)
1, 2, 4
and 8
weeks
Kim 2018 48
The VAS scores were significantly lower in the lidocaine
plus TA group than that in the lidocaine alone group at 2
weeks and 4 weeks after GNB. The authors concluded
that when combined with a local anesthetic and
corticosteroid, GNB can provide short-term clinically
significant pain relief (up to 2 weeks). However, the
clinical benefit of corticosteroid administration was not
clear in comparison with local anesthesia alone (1 week).
Given the potential adverse effects, corticosteroids might
not be appropriate as adjuvants during a GNB for chronic
knee OA
●●●○
Moderate
RCT on therapeutic GN blocks – cont.
10
Kim, D. H., S. S. Choi, S. H. Yoon, S. H. Lee, D. K. Seo, I. G. Lee, W. J. Choi, and J. W. Shin. 2018., Pain Physician, 21: 41-51.
Genicular Nerve
BlocksKim et al. 2018
11
TA = triamcinolone
Genicular Nerve
BlocksKim et al. 2018
12
Genicular Nerve
Blocks
Summary
13
The evidence regarding genicular nerve block is scant
Some evidence showed that GNB may provide short-
term pain relief (one week with lidocaine alone and up to
2 weeks with lidocaine plus steroid)
The effectiveness of this procedure on chronic knee pain
has not been established
The safety of repetitive anesthetic/steroid injections is
unproven
Genicular Nerve
Blocks
Payer Policy Note
CMS No NCD identified on the CMS website
Aetna Not covered for cluneal, ganglion, genicular, and obturator nerve blocks for
chronic pain or for repetitive peripheral nerve blocks for chronic non-malignant
pain
2018
Blue Cross
Blue Shield
Florida
Nerve block injection of the genicular nerve for the treatment of chronic knee
pain is considered experimental or investigational. The available scientific
evidence remains insufficient to permit conclusions concerning the effect of
this procedure on net health outcomes.
4/15 2018
Anthem Genicular nerve blocks and genicular nerve ablation are considered
investigational and not medically necessary for the treatment of chronic knee
pain, including but not limited to any of the following:
Degenerative joint disease;
Osteoarthritis of the knee;
As a treatment prior to knee replacement;
As a treatment following knee replacement;
As a treatment for individuals who are not candidates for knee
replacement surgery
3/29/2018
Selected payers’ policy on therapeutic genicular
nerve blocks
14
Genicular Nerve
Blocks
Coverage decision: Not Covered (Effective date: xx/xx/2018)
o Genicular nerve block for treating chronic knee pain is not a covered
benefit.
o The knee joint is innervated by the articular branches of several nerves
including the femoral, common peroneal, saphenous, tibial and
obturator nerves. These articular branches around the knee joint are
known as genicular nerves.
o Genicular nerve block for treating chronic knee pain is controversial.
The effectiveness of the procedure on relieving chronic knee pain is not
established. The safety of repetitive anesthetic/steroid injections to the
genicular nerves is unproven.
Therapeutic genicular nerve block for chronic
knee pain – draft coverage decision
15
Genicular Nerve
Blocks
Upper extremity blocks Lower extremity blocks
• Interscalene block• Supraclavicular block• Infracalvicular block• Axillary block • Intercostal nerve block• Supascapular nerve block • Ulnar nerve block• Median nerve block• Radial nerve block• Wrist nerve block
• Lumbar plexus block• Femoral nerve block• Fascia iliaca block• Obturator nerve block• Cluneal nerve blocks• Genicular nerve blocks• Sciatic nerve block• Popliteal block• Saphenous nerve block • Adductor canal block• Ankle block• Digital nerve block
Peripheral nerve blocks
16
Genicular Nerve
BlocksPeripheral nerve blocks – cont.
17
Nerve blocks of the scalp, neck and trunk
• Scalp block• Cervical plexus block• Intercostal nerve block• Thoracic paravertebral nerve block• Interfascial plane blocks• Transverse abdominis plane (TAP) block• Rectus sheath block• Ilioinguinal and iliohypogastric nerve
block• Transversalis plane block• Pudental and paracervical blocks
• Greater occipital nerve block• Lesser occipital nerve block• Auriculo-temporal nerve block• Supra-trochlear and supraorbital
nerves block• Spheno-palatine ganglion• Trigeminal nerve block (for headaches)• Ganglion impar block• Dorsal rami blocks
top related