Without ASC access for 6 weeks…which procedures would you advise against performing in an office setting?

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cameroncarter

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I’m thinking of procedures like Cervical ILESI, Cervical RFA, Kyphoplasty, sympathetic nerve blocks that I’ve always done in an ASC (including in fellowship).

* I won’t have access to sedation in my office
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All the above are easily done in office
 
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Not sure how you were trained in fellowship, but the safety margin improves when you stop adding local anesthetic to your epidural solution mix. You should feel comfortable doing cervical ESI in an office, and it’s safer without sedation anyway. You have to wait two weeks between cervical MBB for Medicare so by the time you have someone who needs an RFA you will probably have ASC access. Most private insurance will ask for 6 weeks conservative treatment before authorizing kyphoplasty as well but I would not recommend a fresh grad to start doing in office kypho until they’re comfortable doing it solo in the ASC setting that they’re used to.
 
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cameroncarter said:
I’m thinking of procedures like Cervical ILESI, Cervical RFA, Kyphoplasty, sympathetic nerve blocks that I’ve always done in an ASC (including in fellowship).

* I won’t have access to sedation in my office
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I sedate for SCS and stellates (if I think you're crazy).

CESI and C RFA are done in a clinic by me almost daily.

If you need sedation use Valium.
 
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Agast said:
Not sure how you were trained in fellowship, but the safety margin improves when you stop adding local anesthetic to your epidural solution mix. You should feel comfortable doing cervical ESI in an office, and it’s safer without sedation anyway. You have to wait two weeks between cervical MBB for Medicare so by the time you have someone who needs an RFA you will probably have ASC access. Most private insurance will ask for 6 weeks conservative treatment before authorizing kyphoplasty as well but I would not recommend a fresh grad to start doing in office kypho until they’re comfortable doing it solo in the ASC setting that they’re used to.
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This makes a lot of sense, I have only ever done CESIs with LA+steroid. I’ll give steroid only a try.

I have a couple of cervical RFAs that are waiting and I feel like they can get it done without sedation. Thoughts?
 
MitchLevi said:
I sedate for SCS and stellates (if I think you're crazy).

CESI and C RFA are done in a clinic by me almost daily.

If you need sedation use Valium.
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I’m thinking of oral Valium based on someone’s recommendation…

Do you prescribe it beforehand and have them take it before they come in?
 
cameroncarter said:
This makes a lot of sense, I have only ever done CESIs with LA+steroid. I’ll give steroid only a try.

I have a couple of cervical RFAs that are waiting and I feel like they can get it done without sedation. Thoughts?
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I’ve never sedated for cervical RFA. No local in the CESI.
 
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I do all those in office all the time. Cervical ESI is one of the easiest - usually near-painless, and eliminate the risk of dis-inhibition from sedation. Xanax or Valium if they’re needle-phobic. I do 3 mL saline and 40 mg depomedrol in my CESI. Local for skin/subq only. 90% of my RFs in office. 2 tablets Xanax, 0.25 mg if age 65+, 0.5 if <65. Will also add a 5 mg Norco if they had a little difficulty with the branch blocks. Xanax and Norco for kypho, lots of local. Some patients still don’t tolerate it well. Last one I did didn’t make a peep though.
 
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callmeanesthesia said:
I do all those in office all the time. Cervical ESI is one of the easiest - usually near-painless, and eliminate the risk of dis-inhibition from sedation. Xanax or Valium if they’re needle-phobic. I do 3 mL saline and 40 mg depomedrol in my CESI. Local for skin/subq only. 90% of my RFs in office. 2 tablets Xanax, 0.25 mg if age 65+, 0.5 if <65. Will also add a 5 mg Norco if they had a little difficulty with the branch blocks. Xanax and Norco for kypho, lots of local. Some patients still don’t tolerate it well. Last one I did didn’t make a peep though.
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Do you give them the Xanax in-office? I don’t have that…can you discuss the logistics?

I wanted to give them a script for a Xanax to buy/take pre-RFA, but my supervisor is questioning how I can consent them.
 
callmeanesthesia said:
I do all those in office all the time. Cervical ESI is one of the easiest - usually near-painless, and eliminate the risk of dis-inhibition from sedation. Xanax or Valium if they’re needle-phobic. I do 3 mL saline and 40 mg depomedrol in my CESI. Local for skin/subq only. 90% of my RFs in office. 2 tablets Xanax, 0.25 mg if age 65+, 0.5 if <65. Will also add a 5 mg Norco if they had a little difficulty with the branch blocks. Xanax and Norco for kypho, lots of local. Some patients still don’t tolerate it well. Last one I did didn’t make a peep though.
Click to expand...
How do you block out the noise from the hammering? I feel like that would even get the strongest/toughest patients to be a little weary
 
cameroncarter said:
I’m thinking of procedures like Cervical ILESI, Cervical RFA, Kyphoplasty, sympathetic nerve blocks that I’ve always done in an ASC (including in fellowship).

* I won’t have access to sedation in my office
Click to expand...
Other than kypho, I've done all of those in the office with PO xanax. I've done a couple hundred stim trials on oral xanax, though I will also give them a percocet before hand.
 
Valium 2mg x 2 tabs. They get it at the pharmacy. Take it 30 min prior to the procedure.

Never put local in a CESI.

I would do SCS in the clinic setting, but my ASC situation is very good.
 
We use Xanax/Valium for kyphos and 80% of time it gives smooth enough sedation. 20% of time it’s a pain. Often they do hear the hammering. I have Spotify and good speakers though, so I’ll and ask the patient what music they like. Unfortunately where I am, the answer is usually gospel.
I would love to give IV versed and ketamine for these, but our parent company claims that to give IV sedation I basically have to get my procedure room certified as an ASC.
So for now xanax and gospel works.
 
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I typically only do PO benzo sedation for RFA or patient with a lot of anxiety. No need for sympathetic block or CESI.

Xanax or Valium preop. I prefer Valium, it actually has a fast onset time PO although it is longer acting, and gives the most muscle relaxation. I give 5 mg Valium PO, occasionally two tablets for younger patients or super anxious.

I have them take it at home and still consent them, if you practice manager or hosptial doesn’t allow I suppose you can sign the consent in the office visit when ordering the procedure, or have patient fill Valium and bring it to the procedure, and then take after signing the consent, although they’ll have to sit there at least 15-30 mins for it to kick in.
 
painfree23 said:
How do you block out the noise from the hammering? I feel like that would even get the strongest/toughest patients to be a little weary
Click to expand...
Metallica set to loud?
 
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MitchLevi said:
I sedate for SCS and stellates (if I think you're crazy).

CESI and C RFA are done in a clinic by me almost daily.

If you need sedation use Valium.
Click to expand...

If you can do cervical RFA without sedation you can do SCS trial without sedation.
 
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callmeanesthesia said:
I do all those in office all the time. Cervical ESI is one of the easiest - usually near-painless, and eliminate the risk of dis-inhibition from sedation. Xanax or Valium if they’re needle-phobic. I do 3 mL saline and 40 mg depomedrol in my CESI. Local for skin/subq only. 90% of my RFs in office. 2 tablets Xanax, 0.25 mg if age 65+, 0.5 if <65. Will also add a 5 mg Norco if they had a little difficulty with the branch blocks. Xanax and Norco for kypho, lots of local. Some patients still don’t tolerate it well. Last one I did didn’t make a peep though.
Click to expand...
You do depo for ILESIs? I've only ever used dex for ESIs
 
MitchLevi said:
Depo > Dex

...I'll see myself out...
Click to expand...
I don't doubt it and I'm still in training so I can only do what my attendings are comfortable with. From what I've read particulate can be used in lumbar TFESI (if significant but short improvement w/ non-particulate, lumbar ILESI, or cervical ILESI). What have you seen as the common practice?
 
Zero reason to use Dex in an ILESI.

In the foramen, use Dex but please understand you're more likely to see pts with sustained improvement from your ESI if you drop particulate in there...It's just the truth and yes, I hate to say that.

...but we don't have to derail the thread (which I probably just did).

Clinic procedures are easy with Valium.

BTW - Speaking of clinic procedures and Dex...If you do a CESI with Dex, and the pt startd having chest pain, it is just the Dex. Give it 15 min and don't get an EKG.
 
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MitchLevi said:
Zero reason to use Dex in an ILESI.

In the foramen, use Dex but please understand you're more likely to see pts with sustained improvement from your ESI if you drop particulate in there...It's just the truth and yes, I hate to say that.

...but we don't have to derail the thread (which I probably just did).

Clinic procedures are easy with Valium.

BTW - Speaking of clinic procedures and Dex...If you do a CESI with Dex, and the pt startd having chest pain, it is just the Dex. Give it 15 min and don't get an EKG.
Click to expand...
agree on dex in ILESI. I believe it is borderline malpractice to do ILESI with dex. dex is far inferior to depo, and both are equally safe if given via ILESI. I would agree that depo is even safer than dex, because you don't get the chest pain issue with depo, that you get with dex.
 
MitchLevi said:
Zero reason to use Dex in an ILESI.

In the foramen, use Dex but please understand you're more likely to see pts with sustained improvement from your ESI if you drop particulate in there...It's just the truth and yes, I hate to say that.

...but we don't have to derail the thread (which I probably just did).

Clinic procedures are easy with Valium.

BTW - Speaking of clinic procedures and Dex...If you do a CESI with Dex, and the pt startd having chest pain, it is just the Dex. Give it 15 min and don't get an EKG.
Click to expand...
I see the same with Omnipaque. Even when using Celestone in ILESI.
 
MitchLevi said:
BTW - Speaking of clinic procedures and Dex...If you do a CESI with Dex, and the pt startd having chest pain, it is just the Dex. Give it 15 min and don't get an EKG.
Click to expand...

This is a tricky one!

1. I see periscapular pain and chest pain fairly frequently with cervical ILESI with Dex, zero local. I warn patients a couple times about this prior to the procedure "You may have pain and burning between your shoulder blades as I inject the steroid, we do not know why this happens but it is safe and it will pass."
2. Adding 2-3 cc of saline to the dex prior to injection seems to eliminate or reduce this phenomenon, not sure why.
3. RE: "and the pt startd having chest pain, it is just the Dex." ; I actually had a patient in this situation once and the patient was indeed having an acute MI on the table, just after I injected the steroid. Patient survived.

Lesson; you are fine 99.9% of the time until you are not...then #3 happens.
 
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Back to OP question;

You can do anything in clinic without IV sedation, other than gasserians, high volume LA injections (regional doses), and perhaps sympathectomies such as celiacs where you may see transient hypotension issues. and oddball stuff such as spinal blockade.

PO benzos work fairly well. I like to add phenergan to the mix.
 
Ligament said:
This is a tricky one!

1. I see periscapular pain and chest pain fairly frequently with cervical ILESI with Dex, zero local. I warn patients a couple times about this prior to the procedure "You may have pain and burning between your shoulder blades as I inject the steroid, we do not know why this happens but it is safe and it will pass."
2. Adding 2-3 cc of saline to the dex prior to injection seems to eliminate or reduce this phenomenon, not sure why.
3. RE: "and the pt startd having chest pain, it is just the Dex." ; I actually had a patient in this situation once and the patient was indeed having an acute MI on the table, just after I injected the steroid. Patient survived.

Lesson; you are fine 99.9% of the time until you are not...then #3 happens.
Click to expand...
Why don’t you just switch to depo?

Lasts longer for the patient and no concerning chest pain afterwards?
 
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bedrock said:
What does the phenergan do in this situation? Reduce vagals more than benzos alone?
Click to expand...
Yeah, its sedating as well as an antiemetic, antihistaminic, etc. Lets me use lower dose benzo, less diversion issues.

EDIT: I'm not sure if it reduces vagals more often, good question.
 
Last edited:
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Valium 4-5mg + 25 Phenergan is common.
 
callmeanesthesia said:
I do all those in office all the time. Cervical ESI is one of the easiest - usually near-painless, and eliminate the risk of dis-inhibition from sedation. Xanax or Valium if they’re needle-phobic. I do 3 mL saline and 40 mg depomedrol in my CESI. Local for skin/subq only. 90% of my RFs in office. 2 tablets Xanax, 0.25 mg if age 65+, 0.5 if <65. Will also add a 5 mg Norco if they had a little difficulty with the branch blocks. Xanax and Norco for kypho, lots of local. Some patients still don’t tolerate it well. Last one I did didn’t make a peep though.
Click to expand...
Kypho without sedation is barbaric

I’ve had patients come after one with minimal sedation scared for life
 
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I typically rx opioid with benzo.
1-2 Valium 5 or Xanax 0.5-1.
1-2 Tylenol 3 or tramadol on the light side, oxy 10 on the high side.
 
Patient selection. I had a guy almost pass out from a simple hip injection, I totally misread him. He would not be a PO benzo kypho.
 
Agast said:
Not sure how you were trained in fellowship, but the safety margin improves when you stop adding local anesthetic to your epidural solution mix. You should feel comfortable doing cervical ESI in an office, and it’s safer without sedation anyway. You have to wait two weeks between cervical MBB for Medicare so by the time you have someone who needs an RFA you will probably have ASC access. Most private insurance will ask for 6 weeks conservative treatment before authorizing kyphoplasty as well but I would not recommend a fresh grad to start doing in office kypho until they’re comfortable doing it solo in the ASC setting that they’re used to.
Click to expand...
2 weeks between mbb 1 and 2 and then 2 more before rfa?
 
bedrock said:
agree on dex in ILESI. I believe it is borderline malpractice to do ILESI with dex. dex is far inferior to depo, and both are equally safe if given via ILESI. I would agree that depo is even safer than dex, because you don't get the chest pain issue with depo, that you get with dex.
Click to expand...
Sorry, thread derailed

I’ve never heard of chest pain with dex. Say what?

I’ve had chest pressure with injection of anything but is this supposed to be more a dex issue ??
 
oreosandsake said:
2 weeks between mbb 1 and 2 and then 2 more before rfa?
Click to expand...
It’s 2 weeks between the two diagnostic blocks, but I don’t think you have to wait to do the RFA.

Article Detail - JF Part B - Noridian

This webpage is used to structure an article produced by CMS or Noridian.
med.noridianmedicare.com med.noridianmedicare.com

“
Q4: Is the diagnostic procedure required before the therapeutic procedure?
A4: Yes. Two diagnostic procedures, two weeks apart, with the defined criteria in the policy are required before any additional procedure. “
 
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Agast said:
It’s 2 weeks between the two diagnostic blocks, but I don’t think you have to wait to do the RFA.

Article Detail - JF Part B - Noridian

This webpage is used to structure an article produced by CMS or Noridian.
med.noridianmedicare.com med.noridianmedicare.com

“
Q4: Is the diagnostic procedure required before the therapeutic procedure?
A4: Yes. Two diagnostic procedures, two weeks apart, with the defined criteria in the policy are required before any additional procedure. “
Click to expand...
I always did that anyway. Didn’t realize it was Mandatory. Thanks!
 
oreosandsake said:
Sorry, thread derailed

I’ve never heard of chest pain with dex. Say what?

I’ve had chest pressure with injection of anything but is this supposed to be more a dex issue ??
Click to expand...
Dex and Beta.
 
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TIVAndy said:
who's doing particulate for cervical ILESI?
Click to expand...
Me...

95% of my CESI are 60-80mg Depo.

Bc of availability of certain meds, I went awhile doing 40mg Depo + 5mg Dex.

I mix steroid with 1-2 cc saline.
 
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nopain1234 said:
Kypho without sedation is barbaric

I’ve had patients come after one with minimal sedation scared for life
Click to expand...

lobelsteve said:
Wrong doc doing it. Did 2 in office this week. Woke one up to ask if she was doing ok. 1mg Ativan PO.
Click to expand...

I agree with Steve. Our practice almost completely shifted to in office kyphos a couple of years ago because we were losing money on some insurances by doing them in the ASC. I send in PO Valium (dose depends on age) and 5mg Percocet. I use plenty of local and wait long enough for it to set up. Then I talk them through what I’m doing so there are no surprises. Some of my partners don’t feel comfortable doing them in the office so they send the patients to me or one of our spine surgeons. Between the 3 of us, we’ve had no issues. I’ve had patients forget to take their meds and we’ve done it with just local at their request and they’ve done amazing.
 
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unchockey21 said:
I agree with Steve. Our practice almost completely shifted to in office kyphos a couple of years ago because we were losing money on some insurances by doing them in the ASC. I send in PO Valium (dose depends on age) and 5mg Percocet. I use plenty of local and wait long enough for it to set up. Then I talk them through what I’m doing so there are no surprises. Some of my partners don’t feel comfortable doing them in the office so they send the patients to me or one of our spine surgeons. Between the 3 of us, we’ve had no issues. I’ve had patients forget to take their meds and we’ve done it with just local at their request and they’ve done amazing.
Click to expand...
I do about one yearly scs implant under local only. Medical frailty and anesthesia says no.
 
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Depo 80 for CESI and LESI for me

Tried dex for a while, years ago, and had too many weird complaints of burning pain or chest pain with the injection.
 
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