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Percutaneous freezing of sensory nerves prior to TKR?

Discussion in 'Knee Replacement Pre-Op Area' started by robert johnson, Feb 16, 2019.

  1. robert johnson

    robert johnson member
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    I'm being offered the option of freezing nerves prior to surgery and was wondering if anyone has experienced it yet. What I'm being told is that they are doing it more frequently now that the laws have changed regarding the dispensing of opioids, and are having great success controlling pain post-op. It's easy to find info on this by Google, but I'm wondering if anyone has actually experienced it.

    Having AFib, I'm concerned about stress during recovery. Stress is a trigger. I don't know for sure if pain is a trigger, but I suspect being annoyed because I'm in pain due to government overreach will be a stress trigger, so I'm open to this idea of cryoneurolysis.

    I would be very appreciative hearing what anyone knows about it.
     
  2. maryo52

    maryo52 FORUM ADVISOR Forum Advisor

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    Never heard of this. I did find one research study from 2016 which I'll include here. Screen Shot 2019-02-16 at 7.59.26 PM.png
     
  3. robert johnson

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    Yes, I read that one and a couple others like it. I'm interested if anyone has personally heard about this through their own orthopedic surgeons. I'm trying to figure out (understand) if it's so cutting edge that I just happen to be early in having it proposed to me, or if nobody else is doing it for some other reason.
     
  4. maryo52

    maryo52 FORUM ADVISOR Forum Advisor

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    The forum administrator is the best person to tell you the history and practice of this procedure (cryoneurolysis). @Josephine
     
  5. robert johnson

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    I guess I have to assume there's little or no experience with this procedure here. I'll have to rely on my trust in the people who are recommending it. I've been doing a lot of reading and it sounds like the concept has been around for quite some time and that technological advances have made it possible to use in conjunction with TKR. If I'm remembering correctly, the procedure is done 5 days prior to surgery and lasts weeks to months.

    I still have a few questions before I agree to do it, but the more I read, the more I'm leaning towards agreeing to it.

    One obvious question I have is: Since nerves send signals to the brain, don't I need those signals to prevent me from hurting myself? What if I lean my knee against a hot frying pan? Will I know it?
     
  6. maryo52

    maryo52 FORUM ADVISOR Forum Advisor

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    I assume you are writing down questions to ask. Since this falls in the realm of anesthesiology, then that would be the department to talk to.

    You seem to be thinking this out very constructively. It would be very helpful to this forum for you to keep posting through your TKR and the month after, to let us know how it works out.

    I'll tag @Josephine again.
     
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  7. robert johnson

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    Yes, thank you. I plan on asking questions before I submit to it. Like the one I suggested plus how long I would expect it to last, risks, etc.

    If I go forward with it, I will definitely let you know how it goes during and after surgery and when it wears off, what that's like.

    I know I'll be on oxy for a certain amount of time since we already established that. This subject came up when he started discussing the new restrictions that went into effect on Jan 1. I was in the camp that I didn't want any restrictions. He told me and my wife that it was a done deal (the restrictions).

    I read "The STOP Act" myself, so I'd say the jury is still out, although he may be under Washington State guidelines. There is always the option of being referred back to my GP for pain management which would last as long as necessary, but I'm intrigued by this cryo procedure and I trust the OS implicitly.

    I'll let you know.
     
  8. maryo52

    maryo52 FORUM ADVISOR Forum Advisor

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    They went from handing out 30 tabs of narcotics after a tooth extraction, to treating older people with difficult pain as if they're drug seekers. Trouble is, too many doctors cannot seem to figure out the difference between a drug seeker and a person in pain. For crying out loud, we older people have had our share of challenges and pain over our lifetime. We're tough. We don't buckle easily.

    I was shocked in a good way to find that despite the fact that I needed up to 1.5 tablets of oxycodone every 4 hours after my original TKR, I got by on 1/2 a day, or less, starting day one with this revision just 6 weeks ago. I have controlled my pain with tylenol and Aleve. This was possible because I was on a clot prevention protocol that did not involve coumadin.

    You have a great attitude, and how wonderful that you have a surgeon who you trust implicitly.
     
  9. ApricotPie

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    My surgeon mentioned he might do this nerve treatment to help reduce pain in the first few days after the surgery.


    Sent from my iPad using Tapatalk
     
  10. robert johnson

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    @maryo52 I know exactly what you're talking about with the new attitude about drugs. I just don't think it's the doctors so much, other than as a reaction to what the regulators are doing. I had a conversation about it 7 months ago at my GP while getting a cortisone shot. I knew this was going to happen and didn't want to get a TKR even back then. He said he doubted it would affect me, but as it turned out, it affects us all.

    Now that I decided to get one, for other reasons, I'm stuck with it. Although, like I said in the worst case scenario, I'll get referred back to my GP.

    Thanks for the kind words. I trust him because here I am 9 years later and my LTKR is really in good shape. I think most of my early problems were because I was taking Lipitor and it made me much weaker. I switched to a water based statin at 18 months post-op.

    Another question occurred to me. As with the frying pan question, what happens if I'm training myself to ride my bike? Will the fact that the nerves are numb(?) allow me to do too much thereby hurting myself where if they weren't numb I'd proceed with more caution? You can apply that to drugs too, I suppose, so maybe it's a non-issue?

    @ApricotPie Thanks for that. I'll let you know how it goes if I do it, how long it lasts, etc.
     
  11. maryo52

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    Your question about overdoing it is a good one. Since the cryoneurolysis is used only in the initial recovery period, it shouldn't be an issue. It's just not wise to bike in the first few weeks. It's really best to just rest, elevate and ice with a slow transition to activity. This way you get the inflammation and swelling in control, give the tissues a chance to heal, and then you can start slowly adding routines. That's probably more than you wanted to hear. I also think that you'll get some good information when you're in the hospital.
     
  12. robert johnson

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    I understand what you're saying and I appreciate the input and reminders. I had 2 PT "Pre-hab" appointments over the last couple of months and let's just say we have arrived at a mutual understanding. He knows I'm not going to do anything that might hurt me, and he made it clear that's his goal too, and that he knows where I'm coming from. On the other hand, we do want to explore that point without going beyond it.

    So, while you're right about not using the bike too soon, the way we plan on using it falls into the time period of the CPM, which is pretty much the first 2 weeks. That's what I did last time. The main reason I don't want one is that I just don't want to have to deal with having that machine on a bed or couch. Besides, the PT told me there's zero proof that a CPM machine improves outcomes.

    He also told me my OS was the only one left in the group who still uses a CPM. I don't want to use one this time (I did last time), I want to use the bike instead. He gave me a demo on a recumbent how I can simulate the CPM by going back and forth up to the point of resistance, sort of leaning into it a little then back the other way to the same point. He advised me to tell the doctor at my pre-op about our plan, which I did.

    The OS bought off on it, but also advised seated knee slides where you gently lean in with your body. He demo-ed it on my wife.

    So, the point being, aside from this nerve freezing thingy, we're all pretty much on the same page.

    My concern now is whether or not the nerve freezing grays the lines of just where that point is, and I run the risk of hurting myself in spite of having no intentions of hurting myself. That's question #2.
     
  13. robert johnson

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    I'm not sure about that either. I think he said up to 12 weeks or so, and I've read "weeks to months." That's question #3.
     
  14. Jajakio

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    I think your worry about burning you knee on a hot frying pan may not be the issue you imagine. I haven't had the percutaneous freezing of nerves done myself but I've read about it and talked to one person who had it done. I don't think you are going to be completely devoid of feeling and pain free. The woman I talked to was pleased and said it was manageable but it still hurt. Of course, she hadn't had a TKR without it to compared it so it's hard to say if it was more or less painful than with opiods. I think if any method could promise up to 8 painfree weeks, everyone would be on board.
     
  15. robert johnson

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    Yes, @Jajakio , you're right about that. I've been meaning to update this. I got some additional information from my PT and the OS's office. This procedure is meant to be in conjunction with other standard pain relief measures. The implication is that you need less of the powerful meds and it improves the effect of the less powerful meds and icing. I will start out on opiods anyway. It's just a question of what kind of hoops I would have to go through to get more of them after the initial prescription. Plus, there's always the option of being referred back to my GP for pain management.

    So yes, I won't have the worries that I thought I might. In a sense this is good news, because if it was a total painfree effect it would seem like those other worries would come into play.

    I'm scheduled to have it done Tuesday the 26th, 10 days prior to surgery. It should be interesting. I'm getting anxious to get this show on the road.
     
  16. Jajakio

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    I'm very interested in how it goes for you as I will eventually need my second knee done. I'm not going to have it done right away but I'm researching and looking ahead. You will have the advantage of comparison to the first TKR with opiods but I know even for the same person, each surgery might be a different experience. Keep us up on how it goes for you.

    I had never had opiods prior to my knee surgery and I'd love to never have to take them again. I used Percocet for just under 2 weeks full time. Then i started tapering down. After about 10 days of that I was down to half a tablet once or twice a day, replacing with it tyenol. I didn't love the opiods. I was constipated, a little loopy and not a fan. But the real problem came when I quit. I thought given the short time I was on them and the 10 days spent tapering off, I would be fine. Wrong. I honestly went through 3 -4 days of withdrawl; no sleep (not that I slept much for the first few months but this was different), jitteriness, general malaise and more including craving the meds. Then another week where i was essentially okay except for wishing for the meds every now and then. It wasnt about the pain. It was completely unexpected withdrawal. I didn't psych myself into this. In fact I didn't even realize what it was until I was most of the way through it. Possibly it doesn't work this way for everyone but the opiod crisis is real and I suspect I'm not the only one who had this issue. If I can find a way not to take opiods next time, I'm all for it. I've got a reasonably high pain tolerance and while last time was painful, it wasn't unmanageable.
     
  17. robert johnson

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    I took oxy (percocet without the Acetaminophen) for roughly 2-3 weeks post-op, but I also simultaneously had a prescription for 7.5mg hydrocodone (325mg Acetaminophen). Once I stopped oxy, which really can only be justified when in serious pain, I continued taking hydrocodone for a total of about 2 months post-op. Maybe 2 and 1/2 months. Once PT ended and I realized the exercises I was doing were extremely painful without drugs, I went in to see the OS and explained to him that I'm going to have to either stop the exercises or continue hydrocodone. He told me to "stop the exercises and see if you can get this behind you", which I did, and it turned out to be good advice.

    So basically at 2.5 months post-op I stopped opiods when my last prescription ran out. It was no big deal. It was like one day I was taking them and the next day I wasn't.

    I have somewhat of the opposite problem as you do. I have a low tolerance for pain and a high tolerance for drugs. I had a hip injury in the late 90s where I was on crutches for 4 months while taking Lortabs (7.5mg hydrocodone). I stopped taking them after my chiropractor gave me ultrasound treatments for a couple of weeks and the pain in my hip finally started to go away. That took me a couple of days to "withdraw". But again, no big deal.

    I'm not worried about the drugs, I'm worried about being the victim of an overreaction regarding the very real opioid crisis in America. While I understand the issue, what it has to do with elderly TKR patients is beyond me.

    My OS assures me many patients have done quite well with a combination of this cryo procedure and a certain amount of opiods (oxy, tramadol, etc.) and tylenol, ice. So, I'm going in with an open mind, but reserve the right to have him refer me to my GP (who's already told me the opioid epidemic doesn't apply to me) for pain management if I'm having a problem coping. I don't think it will come to that, I think the OS will refill whatever is needed, but just in case.

    I'll keep you updated.
     
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  18. maryo52

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    I was on 1.5 percocet every 4 hours for a month after my original TKR, then weaned down to 1, and on and on. There were also lots of issues. At my pre-op appt. this time (different surgeon), when I asked about pain drugs, he said his preference was tramadol, which I pointed out I cannot take. He looked at me and said I wouldn't have pain. I didn't know what he meant and didn't ask. Well, it turns out I have had very little pain, and I attribute that to a highly skilled surgeon, plus resting with ice and elevation most of the day initially. I've never taken more than a half an oxy in any 24 hour period since my revision. Goes to show you, it's good to have a plan, but sometimes there are nice surprises.
     
  19. robert johnson

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    Just off the top of my head, regarding revision vs original TKR, my guess would be that a lot of it has to do with how much bone sawing they had to do. Broken bone pain is unique.
     
  20. robert johnson

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    @maryo52 I did my Iovera Treatment yesterday. I'll tell you about it later.
     

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