Anxiety

IPSIS: Formerly the Spine Intervention Society
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dipriMAN said:
from the evicore guidelines
62323
Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT)
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64483 says something similar and doesn’t include the word contrast, yet obviously you need contrast for a TFESI. If you read deeper into their definitions, they say contrast needs to be used. See this link-


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MD87 said:
64483 says something similar and doesn’t include the word contrast, yet obviously you need contrast for a TFESI. If you read deeper into their definitions, they say contrast needs to be used. See this link-


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I’d be curious if anyone knows the actual answer to this? I’ve seen lots of pain physicians stop using contrast for ILESI, never heard any problem about reimbursement.
 
dipriMAN said:
Not sure why everyone prefers TFESI. An ILESI with depomedrol will last much longer than the 10 mg decadron in your TFESI. You don’t need contrast for your ILESI, and it’s much faster and less radiation than a TFESI.

Am I missing something?
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Epidural Steroid Injections: Overview, Mechanisms of Radicular Low Back Pain, Rationale for Use of Steroids in Back Pain

Epidural steroid injections (ESIs) have been endorsed by the North American Spine Society and the Agency for Healthcare Research and Quality (formerly, the Agency for Health Care Policy and Research) of the Department of Health and Human Services as an integral part of nonsurgical management of...
emedicine.medscape.com

Would hate for a complication to occur in your ILESI and then documentation shows no contrast used. Docs would be lining up to go to court against that egregious deviation from standard of care. This is pain and not OB/OR. But I think if that were to occur it would need to be settled before trial, because there is no good chance of winning. Indefensible.
 
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My understanding, and correct me if I'm wrong, is that chronic radiculopathy from facet arthrosis and disc bulge-osteophytes is a mechanical problem and not an inflammatory process, opposed to an acute HNP.

If thats true, why would I expect a corticosteroid to significantly help? It doesn't increase he available real estate in the area. Sure, there's some anti-nociceptive properties to it but oral medications do the same thing.

Yoga and structured walking programs works wonders for these people.
 
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My guess would be that their charts haven’t been audited. And most people’s charts don’t get audited. Just like there are people out there doing garbage shots, like the one that Steve posted the pic of - I’m sure he got reimbursed for an ILESI. Call the insurance company and ask. They will tell you you you need to use contrast. That’s the fraud perspective.

From a patient care perspective, there’s no reason to not use contrast unless they have a severe allergy to it. Even if you are “certain” you are in the epidural space based on LOR, how are you certain you weren’t in a vessel within the epidural space and that none of the meds were delivered where you intended? Aspiration of blood isn’t accurate. Neither is a test dose. Seeing the contrast in the epidural space though, is.

Only reason to not use contrast is it saves money and saves about 20 seconds. Our field is already Wild West enough. Contrast is a basic part of a fluoro injection.
 
dipriMAN said:
What do you do for your chronic radic people from facet hypertrophy / osteophytes / disc bulg / formainal stenosis etc.
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lobelsteve said:
Topamax and dynamic stabilization exercises. Will do esi if acute exacerbation or if they are going to wedding, cruise, etc.
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ED50 said:
You are using topamax for elderly patients with neuropathic pain? Curious what your dosing and success looks like?
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Steve,
I love ya man but you can't ever admit when you're just wrong. You're a great guy in person, I don't know why you are so stubborn online.

You are really going to suggest that topomax and core exercise is a better option for all the middle aged to elderly people out there with chronic radiculopathy secondary to recurrent disc bulges/foraminal stenosis or lumbar stenosis with neurogenic claudication? Seriously, Topomax compared to just feeling better?

Just because a level one study hasn't yet been completed demonstrating that all these millions of patients usually obtain 3-5 months of relief after ILESI or S1 TFESI with particulate steroid for these conditions, doesn't mean that it doesn't work, it just means that no one has take the extreme time and money necessary to demonstrates in on paper in a study.

I"m certainly not going to make all these patients suffer in the meantime.
 
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lobelsteve said:

Epidural Steroid Injections: Overview, Mechanisms of Radicular Low Back Pain, Rationale for Use of Steroids in Back Pain

Epidural steroid injections (ESIs) have been endorsed by the North American Spine Society and the Agency for Healthcare Research and Quality (formerly, the Agency for Health Care Policy and Research) of the Department of Health and Human Services as an integral part of nonsurgical management of...
emedicine.medscape.com

Would hate for a complication to occur in your ILESI and then documentation shows no contrast used. Docs would be lining up to go to court against that egregious deviation from standard of care. This is pain and not OB/OR. But I think if that were to occur it would need to be settled before trial, because there is no good chance of winning. Indefensible.
Click to expand...

Agree there is no reason not to use contrast in an epidural unless the patient is allergic
 
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lobelsteve said:

Epidural Steroid Injections: Overview, Mechanisms of Radicular Low Back Pain, Rationale for Use of Steroids in Back Pain

Epidural steroid injections (ESIs) have been endorsed by the North American Spine Society and the Agency for Healthcare Research and Quality (formerly, the Agency for Health Care Policy and Research) of the Department of Health and Human Services as an integral part of nonsurgical management of...
emedicine.medscape.com

Would hate for a complication to occur in your ILESI and then documentation shows no contrast used. Docs would be lining up to go to court against that egregious deviation from standard of care. This is pain and not OB/OR. But I think if that were to occur it would need to be settled before trial, because there is no good chance of winning. Indefensible.
Click to expand...
I strongly agree with what Steve is saying. I have had more than a few occasions of performing an ILESI on an elderly patient with a big thick ligament and not so well defined LOR. Contrast is then injected and I get a lobular centrally accumulating (on AP), sharply demarcated collection of contrast. I can then aspirate back almost all of the contrast. This is characteristic of an INTRAdural injection. If you don't recognize that you can end up with cauda equina syndrome. Tim Maus at Mayo Clinic has an excellent lecture on the this and how the flimsy inner dural border cell layer will easily dissect as you inject contrast steroid, etc.
I trained as an anesthesiologist and was taught to heavily rely on the "feel" of procedures. Things like LOR, feeling "two pops" of the needle for II/IH block. After years of using imaging my opinion is that your hands are FAR LESS reliable than your eyes.
 
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bedrock said:
Steve,
I love ya man but you can't ever admit when you're just wrong. You're a great guy in person, I don't know why you are so stubborn online.

You are really going to suggest that topomax and core exercise is a better option for all the middle aged to elderly people out there with chronic radiculopathy secondary to recurrent disc bulges/foraminal stenosis or lumbar stenosis with neurogenic claudication? Seriously, Topomax compared to just feeling better?

Just because a level one study hasn't yet been completed demonstrating that all these millions of patients usually obtain 3-5 months of relief after ILESI with particulate steroid for these conditions, doesn't mean that it doesn't work, it just means that no one has take the extreme time and money necessary to demonstrates in on paper in a study.

I"m certainly not going to make all these patients suffer in the meantime.
Click to expand...

Or maybe all of the above don't really work.
 
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Nothing wrong with occasional epidurals (IL or TF) in stenotic pts to buy them relief for a few months.

Pain "management." It isn't a cure, and isn't marketed as such.

Withholding an occasional epidural is just cruel IMO. You can do it; it helps somewhat for some duration of time; if I'm the pt I'll take 2 to 3 per year for as long as I can avoid surgery.
 
These patients do not get long term relief from their baseline pain as Steve has said. I typically reserve ESIs in these patients for flares of pain here and there for them and I also do them when they have a big event such as a family wedding or vacation and just want to enjoy their life for a few days. And as much as I hate the term pain management that’s what is. Very rarely do we do anything other than management. And yes use contrast. You may get away with it your whole career without it or it could end your career and disable a patient. But it’s definitely below the standard of care. But yes if they get several months of relief I will do 2-3 a year as long as they are getting reasonable relief.
 
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lobelsteve said:
25 bid, increase to 50 bid after a week if needed. I have younger folks go to 100 bid if no side effects.

pubmed.ncbi.nlm.nih.gov

Topiramate in chronic lumbar radicular pain - PubMed

The anticonvulsant topiramate might reduce chronic lumbar nerve root pain through effects such as blockade of voltage-gated sodium channels and AMPA/kainite glutamate receptors, modulation of voltage-gated calcium channels, and gamma-aminobutyric acid agonist-like effects.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

pubmed.ncbi.nlm.nih.gov

The rationale and use of topiramate for treating neuropathic pain - PubMed

Topiramate acts on neuronal transmission in at least five ways: by modulating voltage-gated sodium ion channels, potentiating gamma-aminobutyric acid inhibition, blocking excitatory glutamate neurotransmission, modulating voltage-gated calcium ion channels, and by inhibiting carbonic anhydrase...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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dafuq?
 
if the LOL has documented relief q3 months with an ESI, i am fine repeating it. TBH, sometimes its 2-3x/year, sometimes they skip a year or 2.

i dont like to do it forever, but there are worse things
 
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Other option is what I have, a VA gig, where I am pmr spine doing ILESI, facet SI and caudals, and my partner is anesthesia pain fellowship trained doing everything else, is comfortable pace, full schedule is usually 8-12 on a procedure day, we are in the process of getting prp and prolotherapy so I can start on peripheral joints, plus I get a pmr resident rotating with me, plus no malpractice issue since we are under federal tort
 
AndyDufrane said:
Other option is what I have, a VA gig, where I am pmr spine doing ILESI, facet SI and caudals, and my partner is anesthesia pain fellowship trained doing everything else, is comfortable pace, full schedule is usually 8-12 on a procedure day, we are in the process of getting prp and prolotherapy so I can start on peripheral joints, plus I get a pmr resident rotating with me, plus no malpractice issue since we are under federal tort
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yeah that's how my pain attending at va in residency did it - almost exact set up you are describing.
 
Fwiw, Medicare also requires contrast for epidural steroid injections. It's not just evicore.
 
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i used to have a patient who would come in 4 times a year for a caudal ESI. He was in his late eighties lived alone and would do all his house and yard work during the 3 weeks relief he got from an ESI. Then he would basically sit for the next 2 months. He was a retired Marine Corp sniper and still went to the range. I told him i had troubles sighting in my Mini-14 and next time i saw him he handed me a box of hand loaded .223 ammunition and said "this will fix your problem". Back surgery did not help him.
 
AndyDufrane said:
Other option is what I have, a VA gig, where I am pmr spine doing ILESI, facet SI and caudals, and my partner is anesthesia pain fellowship trained doing everything else, is comfortable pace, full schedule is usually 8-12 on a procedure day, we are in the process of getting prp and prolotherapy so I can start on peripheral joints, plus I get a pmr resident rotating with me, plus no malpractice issue since we are under federal tort
Click to expand...

This sounds incredibly easy. What is the salary and full benefits?
 
MD87 said:
In fellowship, whenever a patient had a lumbar TFESI, it was a 2-level TFESI. For every 1 patient who got an ILESI, 8 or 9 got TFESI. As a result, I felt confident in TFESI, but lumbar ILESI made me anxious when I graduated. Initially, I scheduled a lot of my patients for TFESI rather than ILESI. As I became more comfortable, I started scheduling more ILESI. Now, I'm 2 years out, and ILESI are my favorite procedure because they are quick, easy, and you pretty much always get great contrast flow.

I echo what everyone is saying. Anxiety is normal, especially when you are first starting, but even later on. If the anxiety becomes a major point of stress for you and doesn't decrease over time, then it may be worthwhile sending those procedures elsewhere. Some of the anxiety will decrease as your procedure volume increases. Anxiety means you likely won't hurt a patient. Being overly confident at this point in your training would be a problem.
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why would you do interlaminars?? Once you're out in the real world, they are basically for people who don't know how to do transforaminals. I see a lot of neurologists doing them - I'd guess that the contrast flow on flouro wouldn't be great if I saw their pictures.
 
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avalon10 said:
It is not dumb. It is true.
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Incorrect on both sides of the period.

The period after the word dumb is an amazing piece of grammar - It is a fulcrum upon which a seesaw of ignorance is taking place.
 
20201209_134003.jpg
 
Thread was originally posted by someone who got banned, died for a couple of months and was bumped by a spammer... and now has devolved into insults and memes.

I think this thread has a number of reasons to be closed.
 
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