ASIPP conference

[Extralong]

Did anyone go to ASIPP?

I was in Dallas for the weekend and was pretty surprised. I saw pretty cool(and ballsy) procedures that were discussed and promoted. For example, there was discussion about endoscopy, and I was pretty surprised that there are pain physicians that are doing this. I wonder if this is pissing off neurosurgery. I also heard discussion about TFESI neurolysis; I was like wow, I don't think I have the balls to do that. Also, if you aren't aware, the MILD procedure is making a comeback. Per my understanding reimbursement was cut, unless you were doing "research," and a couple of big name guys are getting ready to publish the efficacy of the MILD procedure. CMS is reviewing this information and has opened a comments section, and the lecturer requested that if you have something to say about the MILD procedure, to go on the CMS website and add a comment.
There was also buzz about advancement about PRP, but I missed that lecture. And whats really surprising, SI-Bone is still trying to recruit Pain physicians. I remember them from last years meeting, and it totally seemed like an ortho/neurosurg procedure, but, I maybe wrong.
Lastly, there was a pretty interesting lecture for anyone doing celiac plexus blocks. Apparently(and I did not know this), GI is trying to take over this by doing an Endoscopic ultrasound guided plexus block. They have published data claiming that their procedure is way better and safer.

So that was like 20% of the stuff. I'm sure there is more I cannot think off, but figured I would share.
Anyone have any thoughts?

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[drpainfree]

I was there as well. Not a fan of Dallas, but the meeting met its objectives.

I'm glad MILD is making a comeback and at least from the data presented it seems to have a good chance to get covered. I do have a large percentage of elderly medicare patients with spinal stenosis. It would be great to offer this safe and effective alternatives to them.

The lecture on SI fusion was a completely waste of time, IMHO. Not only the presenter did not present the different aspects of the procedures, it seems he unintentionally (or intentionally) downplayed the utility of SI injection and RFA for SI dysfunction.

Endoscopic discectomy/foraminotomy is very interesting. Will look more into it.

 

[Ducttape]

I wouldn't mind giving up celiacs. it is very hit or miss... (especially with the aorta)

 

[lobelsteve]

When I think big name guys and MILD I think conflict of interest and misrepresenting data.

 

[willabeast]

Suggestion clear cutting edge procedures with referring doc first

 

[Extralong]

When I think big name guys and MILD I think conflict of interest and misrepresenting data.

I guess, since I not trained in MILD and did not get exposure, I haven't really looked into the data. What data is being misrepresented? Supposedly (not my opinion, but just per lecture), its cheaper to get the MILD procedure done compared to open surgery. But then again, its just want I heard, and it may be incorrect.

 

[Aether2000]

Insurers have blocked coverage for endoscopic discectomy and unless the intracanal fragment is addressed (making it neurosurgery) then it is no more than an APLD, LASE, PL3D, DiscFx, coblation, or other of the many variants. Foraminoplasty is definitely a neurosurgical procedure and is not covered by insurance. I did both from 2001 to 2010.

 

[Extralong]

Insurers have blocked coverage for endoscopic discectomy and unless the intracanal fragment is addressed (making it neurosurgery) then it is no more than an APLD, LASE, PL3D, DiscFx, coblation, or other of the many variants. Foraminoplasty is definitely a neurosurgical procedure and is not covered by insurance. I did both from 2001 to 2010.

Wow, thats pretty awesome. How does one even get privileges to do them, especially if insurance does not cover them.

 

[drpainfree]

seems mostly worker comp, from what the presenter said.

 

[lobelsteve]

I guess, since I not trained in MILD and did not get exposure, I haven't really looked into the data. What data is being misrepresented? Supposedly (not my opinion, but just per lecture), its cheaper to get the MILD procedure done compared to open surgery. But then again, its just want I heard, and it may be incorrect.

http://www.ncbi.nlm.nih.gov/pubmed/24308292

http://forums.studentdoctor.net/threads/mild.1104878/#post-15826079

See pastafan post in thread above.

 

[drpainfree]

what else do you offer to these 70 to 90-years old patient who have central canal stenosis, either unwilling to undergo general anesthesia for open decompression or medically high-risk for such open surgeries?

think about it, if the r/b/a of the MILD is clearly explained to the patient, the patient would prefer to go MILD instead of open decompression, why does it matter who sponsored the study?

it becomes "evidence-based" when an insurance payer is involved.

 

[lobelsteve]

This is the new study (along with additional 1 year f/u data) that was shown at ASIPP. Thoughts

http://www.ncbi.nlm.nih.gov/pubmed/26815247

Mild vs esi. Prior data strongly suggests neither works.

 

[lobelsteve]

what else do you offer to these 70 to 90-years old patient who have central canal stenosis, either unwilling to undergo general anesthesia for open decompression or medically high-risk for such open surgeries?

think about it, if the r/b/a of the MILD is clearly explained to the patient, the patient would prefer to go MILD instead of open decompression, why does it matter who sponsored the study?

it becomes "evidence-based" when an insurance payer is involved.

Risks may outweigh benefits especially if the procedure isnt proven to work any better than ESI at 6 mo.

Sponsored study imparts bias. No way around it.

 

[Ligament]

Wow, thats pretty awesome. How does one even get privileges to do them, especially if insurance does not cover them.

It helps if you are one of the most badass pain docs in the USA.

 

[oreosandsake]

Did anyone go to ASIPP?


There was also buzz about advancement about PRP, but I missed that lecture.
So that was like 20% of the stuff. I'm sure there is more I cannot think off, but figured I would share.
Anyone have any thoughts?

you missed a great talk Friday afternoon on regenerative medicine.

 

[DOctorJay]

hahaha

 

[Extralong]

It helps if you are one of the most badass pain docs in the USA.

Noted. I will attempt to commence the badassery right away.

 

[Extralong]

you missed a great talk Friday afternoon on regenerative medicine.

Yea I know! It was hard to decide because many topics were great options.

 

[bedrock]

Insurers have blocked coverage for endoscopic discectomy and unless the intracanal fragment is addressed (making it neurosurgery) then it is no more than an APLD, LASE, PL3D, DiscFx, coblation, or other of the many variants. Foraminoplasty is definitely a neurosurgical procedure and is not covered by insurance. I did both from 2001 to 2010.

Algos,

Is lack of coverage the main reason you stopped offering these procedures?

How were the outcomes compared to open surgery?

 

[bedrock]

what else do you offer to these 70 to 90-years old patient who have central canal stenosis, either unwilling to undergo general anesthesia for open decompression or medically high-risk for such open surgeries?
.

There was an academic neurosurgeon in the tri-state area doing lumbar laminectomies on elderly patients with epidural anesthesia, that were considered too risky for general.

I know this isn't common practice, not sure why, maybe the anesthesia folks can comment. I expect a big concern is that these patients might move during the surgery?
I don't know how effective is the anesthesia component.

 

[PinchandBurn]

There was an academic neurosurgeon in the tri-state area doing lumbar laminectomies on elderly patients with epidural anesthesia, that were considered too risky for general.

I know this isn't common practice, not sure why, maybe the anesthesia folks can comment. I expect a big concern is that these patients might move during the surgery?
I don't know how effective is the anesthesia component.

That, and also you typically have to do the epidural around the same level (1 or 2 levels away) from where the lami is done. If there's a bad outcome around the cord. Who's fault, anesthesia or surgery? I think this is partially why it fell out of favor.