RFA complication

[Ducttape]

we do question our practice patterns.

the evidence, however limited, suggest that the higher temperatures do not cause complications and provides better results. this is Grade II-III evidence.

yes, we do not have a placebo controlled randomized double blinded study to verify that 90 degrees is more efficacious than 80 degrees.

likewise, we do not have a placebo controlled randomized doubly blinded study that states that particulate steroids in cervical transforaminal is not safe, but we have data that suggests that this is not the practice pattern that we should be doing.

in fact, in the whole of pain medicine, if you relied solely on Grade I evidence, then we really only have, well, no interventional procedures to do that we can state is clinically indicated (one could counter Dreyfus study from 2000 with the MINT trial more recently to negate each other...)



oh and based on your comment FYI by setting your RF machine at 90deg you are breaching the 90deg threshold due to the machines 1-3degree variance. you cant actually set your RF machine to 80 degrees because you have that 1-3 degree variance under 80 degrees, and cant set to 85 degrees because of same variance. do we want to be that dogmatic that it has to be set at exactly at 82.5 degrees?

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[painfree23]

No rule but I think it's a worthwhile discussion with some good points made.

I used 80C/90sec generally primarily because that's what I learned in fellowship. Getting same efficacy with less is always better. I'd imagine we used less steroid in ESIs etc than 10-20 years ago. I certainly wouldn't claim I'm more right than anyone who does 90C since evidence is not there, but a good question. Maybe we'll use 70C in 20 years, who knows.

Just FYI for those not familiar with cooled RF - probe tip goes to 60C but tissue temp is 80C.

What do you mean by we use less steroid in ESIs?

 

[SommeRiver]

Questioning our own practices is encouraged and you should be looking for little tidbits and pearls to improve our craft and protect pts from medical harm...But there's more than one way to skin a cat.

Less corticosteroids in an ESI...I know that the spine surgeons and one of the other older pain guys in my group use 80mg Depo and 2cc bupi 0.25% in ALL of their TFESI, and I know older guys who use 20mg dexamethasone.

There's no real difference in 4mg or 10mg dexamethasone, and we know very well the risk of excessive use of steroids.

 

[Ronin1]

As a fellow in 1997 we used 120 mg depomedrol for intralaminar esi.... And they would get three epidurals a week apart. One of the local spine guys still uses 120 mg for everything he injects.

 

[deleted131481]

What do you mean by we use less steroid in ESIs?

I think posts above answered but as I understand it used to be more common to use 120mg depomedrol 10-20 years ago then 80, now often 40. I've only been out a couple years but seems to be the experience of older pain docs.

 

[SommeRiver]

120mg Depo - Mrs Smith doesn't get to sleep in 2 weeks.

 

[gaseous_clay]

I know a guy who did 17 perm SCS placements in one day with two rooms.

I don’t think 30-40 simple injections in one day is too many. I saw it all the time in residency and fellowship. With good turnover you can do 4-5 per hour. That’s an 8 hour day.

I usually do 20-30/day. I think my record was 35-38

I was referring to seeing clinic patients

 

[gaseous_clay]

only if you bill using time as a variable, and only if you see 40 medicare patients. not likely

Even if you don’t bill using the time variable, you still have to document a detailed history, a detailed examination and medical decision making of moderate complexity. This cannot be done in the 6 minutes allocated per patient if one is seeing 40 patients in 4 hours. This is also assuming your clinic is running at hyper optimal efficiency. In some parts of the country, it is very realistic to see a 90% government payor mix on a daily basis in this field.

 

[SSdoc33]

Even if you don’t bill using the time variable, you still have to document a detailed history, a detailed examination and medical decision making of moderate complexity. This cannot be done in the 6 minutes allocated per patient if one is seeing 40 patients in 4 hours. This is also assuming your clinic is running at hyper optimal efficiency. In some parts of the country, it is very realistic to see a 90% government payor mix on a daily basis in this field.

i am not advocating for running some sort of mill.

who says you arent doing all of the documentation after hours? nobody knows when you do your work. not CMS, not the big boogieman DOJ..... not even lobelsteve.

as long as you arent super heavy gvt payer, i really dont see the need to be worried about it.

 

[SommeRiver]

65% of my documentation is after hours, both before work and afterwards

 

[gaseous_clay]

i am not advocating for running some sort of mill.

who says you arent doing all of the documentation after hours? nobody knows when you do your work. not CMS, not the big boogieman DOJ..... not even lobelsteve.

as long as you arent super heavy gvt payer, i really dont see the need to be worried about it.

It doesn’t matter when you document your clinical encounters. That’s not the point. You simply cannot take a detailed HPI, address ROS, perform a detailed PE, review diagnostic data, coordinate care, and make moderate to complex medical decisions in 6 minutes while you bill a 99214 or 13. You may be able to do that on a few patients, but not 40 of them in a 4 hour period by yourself. This is excluding all the MIPS stuff you have to address as well on Medicare patients. You don’t have to believe me, but I’m currently reviewing a case exactly like this for the DOJ where a doc was seeing 70 pts a day by himself, so clearly this is on their radar.