The Rise of Cryoanalgesia

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Long-lasting effectiveness and versatility are leading to the emergence of this opioid-reducing pain reliever.


IN THE MEANTIME When COVID-19 shut down elective procedures, the use of cryo treatments allowed Proliance Orthopaedic Associates to give patients much-needed pain relief while they waited for surgeries to resume.  |  Jana Flener

William P. Barrett, MD, had a patient scheduled for a knee revision surgery when he ran into a problem. The patient’s joint pain was so great that they desperately needed some relief in the weeks leading up to the procedure. “This patient had a very loose tibial component, and could barely walk,” says Dr. Barrett, a surgeon with Proliance Orthopaedic Associates, an orthopedic provider with several locations in the Seattle area.

That’s when Jana L. Flener, PA-C, OPA-C, COT, a physician assistant at Proliance, suggested Dr. Barrett try cryoanalgesia, a procedure that freezes targeted nerves with carbon dioxide or nitrous oxide to provide weeks or even months of pain relief. “Admittingly, I was a bit skeptical at first,” says Dr. Barrett. “But after we treated the patient, she felt good enough to literally hop on the injured leg. It was that dramatic.”

Instant and effective pain relief is one of the major selling points of cryo. Another is its versatility. The analgesic technique can be used to provide a conservative, non-surgical treatment option to patients who don’t yet need a total joint replacement or who aren’t candidates for surgery due to inhibiting factors such as a high BMI.

Cryo can also be used to control pain in patients undergoing treatments intended to optimize their health before surgery — such as losing weight to meet a BMI cutoff, lowering blood glucose levels and quitting smoking. “Once we identify patients who are at risk of complications, we keep them comfortable as we ready them for a perioperative journey that increases successful outcomes,” says Ms. Flener.

Proliance providers also used cryo to provide much-needed relief to patients during the surgical shutdown caused by the pandemic. “When COVID-19 hit, cryo was very effective in treating the pain of patients while we waited for the green light to get back to operating,” says Ms. Flener.

Another benefit of cryo that can’t be overstated given the fact that we’re in the midst of a nationwide opioid crisis: It allows providers to treat pre- and post-op pain without using habit-forming narcotics that are rife with negative side effects. “It’s a non-pharmaceutical form of analgesia,” says Ms. Flener. “It gives us one more thing to add to multimodal regimens.”

Advanced care

Proliance providers currently perform around eight cryo procedures per month, a number that is already growing rapidly thanks to word of mouth. “Other local practices have been finding out we offer this intervention and send patients for treatment prior to surgery,” says Dr. Barrett. Proliance is also starting a prospective, controlled study during which patients will be randomized into cryo and non-cryo treatment groups. The results of the study could lead to a further influx of patients.

The practice’s cryo treatments are performed by Ms. Flener, as opposed to Dr. Barrett, a practice she views as both a benefit and potential growth factor of the technique. “Nurse practitioners and other advanced practice providers can perform the procedure effectively,” she explains. “I don’t think many orthopedic surgeons will want to take the time to administer the treatments.”
Other providers, however, might jump at the opportunity to expand their skill sets. “I think cryo makes a whole lot of sense if you have an advanced practice provider in your clinic,” says Ms. Flener. “If you have a provider who would be interested in learning the technique and going through the training, I think you’ll find this is not only really beneficial to your patients, but also to your practice.”

 
Effective Ways to Achieve Targeted Pain Relief
HITTING THE MARK
SURE SHOTS Ultrasound guidance allows providers to find individual nerves in order to provide direct treatments.

Cryoanalgesia procedures are performed in one of two ways, says Jana L. Flener, PA-C, OPA-C, COT, a physician assistant who administers the treatments at Proliance Orthopaedic Associates in the Seattle area:

Anatomical landmarks. Providers measure the expected location of anatomical landmarks and mark the patient’s skin to create a treatment line. They then numb the skin’s surface with lidocaine and work along the line, pushing the cryo probe underneath the skin to freeze the targeted nerves. 

Ultrasound guidance. This technique allows providers to locate individual superficial genicular nerves and direct the probe to the exact locations in order to provide targeted pain relief. Ms. Flener says the learning curve is a bit steeper for this technique if the provider isn’t familiar with using ultrasound, but the necessary skills are learned fairly easily. In fact, she had never used ultrasound guidance prior to her experience with cryo. “I took a machine home and said to my nurse friends, ‘I’ll offer wine to anyone who lets me scan their leg,’” says Ms. Flener. “It was an extremely useful hands-on experience for me — and we had quite the party.” — JB

Mitigating the misconceptions

SWEET RELIEF Cryo can be used to alleviate the discomfort of knee replacement patients before and after surgery.

Cryo isn’t yet a widely used intervention, so there are plenty of questions about what this form of analgesia actually is and what it can do. Even Dr. Barrett had some misgivings about the technique early on. “When we started looking into the technology five years ago, my biggest concern was that freezing the nerve would permanently damage it,” he says. “But the research has shown that while the nerve gets stunned, you don’t destroy its anatomical structure.”

The freezing effects of cryo could provide pain relief for several weeks or several months, depending on how close you get to the nerve’s structure while administering the treatment, according to Dr. Barrett, a factor he says leads to variability in the results.

If you’re skeptical about the potential of cryo, Dr. Barrett suggests visiting a facility where the treatments are used to watch how it’s done and see how patients react. “There’s nothing quite like seeing the technology in action and learning how the providers are incorporating it into their practice,” he says. “The results are dramatic. If it works, it works right away.”
Ms. Flener says facilities should apply the same tried-and-true checkmarks they use when deciding to implement any type of technology:

• Is it efficacious?
• Does it improve efficiencies?
• Is it affordable?
• Does it improve patient outcomes?

“I believe cryo would get a checkmark in all the boxes,” she says. “But most importantly, cryo is an effective non-pharmaceutical option for pain control.”

There’s something inherently rewarding about relieving a patient’s pain. For Ms. Flener, the greatest benefit of cryo is watching patients stand up immediately after treatments. “They put their foot down with great trepidation because they know how bad their knee hurt when they walked in the door,” she says. “But when they begin to put weight on their leg, the look of joy on their face screams relief. That’s so rewarding.”

That instantaneous pain relief — without having to prescribe opioids — is what providers are constantly striving to provide for their patients. Cryo can help them achieve that important goal. “From my standpoint, cryo is just one more arrow in the quiver of multimodal pain management,” says Dr. Barrett.

When you’re treating debilitating pre- and post-op pain, the more treatment options you have at your disposal, the better. OSM

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