Ease of MBB vs Epidurals

[CleanUp]

I’ve been out of training a few years.

I’ve seen a fair amount of patients who see other pain docs and receive multiple epidurals which unfortunately don’t provide relief.

The imaging shows a very minor disc bulge somewhere not concordant with clear radicular pain.

When I asked them about mbbs rfas the patients act surprised and have never heard about them.

Any thoughts why some pain people don’t do the mbbs/rfas? Are they technically more challenging to run parallel to the nerve? Use up too much Fluoro time? Don’t reimburse as well? RFA machine costs money? Weren’t as popular when they trained? Take too much time to explain the diagnostic part?

PS I know stenosis can cause axial back pain I get it.

---

Members don't see this ad.

 

[TIVAndy]

people not trained. or grandfathered into pain

 

[bedrock]

I’ve been out of training a few years.

I’ve seen a fair amount of patients who see other pain docs and receive multiple epidurals which unfortunately don’t provide relief.

The imaging shows a very minor disc bulge somewhere not concordant with clear radicular pain.

When I asked them about mbbs rfas the patients act surprised and have never heard about them.

Any thoughts why some pain people don’t do the mbbs/rfas? Are they technically more challenging to run parallel to the nerve? Use up too much Fluoro time? Don’t reimburse as well? RFA machine costs money? Weren’t as popular when they trained? Take too much time to explain the diagnostic part?

PS I know stenosis can cause axial back pain I get it.

Yep. RFA is the best treatment tool we have and pays fairly well. Anyone who did a real pain fellowship will offer MBB/RFA for axial spine pain in a non crazy patient.

The only pain clinicians who don’t are noctors and physicians who learn epidural basics from a weekend course or single rotation.

Or VA doctors without an RFA machine.

 

[clubdeac]

Cervical RFAs can be a pain in the ass on old degenerative spines, which are most of the ones I do. Honestly loved it when cervical facets were covered. I could get 3-9 months relief in many patients and never had to do the damn RF

 

[painfree23]

Cervical RFAs can be a pain in the ass on old degenerative spines, which are most of the ones I do. Honestly loved it when cervical facets were covered. I could get 3-9 months relief in many patients and never had to do the damn RF

Do u do any facets anymore?

 

[Agast]

In the case of patients I’ve been seeing, it’s because they got shunted into midlevel management purgatory.

 

[MitchLevi]

Yep. RFA is the best treatment tool we have and pays fairly well.

Agree on that. Longest lasting procedure, and in terms of the spine itself, probably the safest as well.

I too have noticed outside pain doctors rarely do ablations. I'll have ppl sent to me with years and years of CLBP that have never heard of an RFA.

We do it, and they may not be perfect but they're generally better and most of the time happy with the outcome.

 

[Ducttape]

all the pain doctors locally - who are btw all ACGME trained - do plenty of RFAs.

the spine interventionalists - both NASS fellowship or grandfathered otherwise - generally do not.


i not infrequently will get referrals from these providers to discuss facet interventions; it seems that they believe their role is to primarily treat radiculopathy prior to surgery...

 

[au bon pain]

In recent weeks it feels like I’m doing 2-3 mbbs or rfa : 1 epidural. Im also in an area with a wide range of people who “do pain.” Agree with others on getting patients who have had ESIs w/o relief elsewhere to then have good results when I treat their facets and they think I’m a magician.

Outside of a TPI, MBBs may be the easiest procedure we do.

 

[clubdeac]

Do u do any facets anymore?

Not really, can’t get them approved

 

[Dr. Ice]

Outside of training bashing, which is so redundant and unnecessary at this point..the reasons many well trained docs don’t want to offer rfa as an option, is more of a personality problem. I can tell you this, talking about mbb/rfa so that the patient REALLY understands it takes work. Much easier to talk about epidurals. The concept of multiple insurance requirements for “test procedures” each one requiring insurance blessing is challenging not to mention getting them to understand what in fact you are really trying to do.

Docs who are trained to do rfa well..may not offer it because they are likely lazy or impatient or have a personality disorder that doesn’t allow them to be uncomfortable with other people.

Everyone wants to harp on training…the reality is actually much deeper.

 

[GlowInTheDark]

Outside of training bashing, which is so redundant and unnecessary at this point..the reasons many well trained docs don’t want to offer rfa as an option, is more of a personality problem. I can tell you this, talking about mbb/rfa so that the patient REALLY understands it takes work. Much easier to talk about epidurals. The concept of multiple insurance requirements for “test procedures” each one requiring insurance blessing is challenging not to mention getting them to understand what in fact you are really trying to do.

Docs who are trained to do rfa well..may not offer it because they are likely lazy or impatient or have a personality disorder that doesn’t allow them to be uncomfortable with other people.

Everyone wants to harp on training…the reality is actually much deeper.

Summation: patients are too stupid to understand 2 diagnostic blocks then RF it’s not worth my breath



Guilty.

 

[Dr. Ice]

Summation: patients are too stupid to understand 2 diagnostic blocks then RF it’s not worth my breath



Guilty.

That’s what many docs think..regardless of “training.” I know duct and others want to constantly tout acgme at nauseum, but I have seen and known many of those “elite” not offering rfa and doing series of 3 on everyone and then stim and then failure and then narcs galore, UDS, monthly follow ups, level 4 visits for chronic pain, etc etc….I can’t with this group sometimes 😒

 

[Dr. Ice]

Summation: patients are too stupid to understand 2 diagnostic blocks then RF it’s not worth my breath



Guilty.

Btw, it’s funny, but you got holier than thou people on this forum saying stuff about training which is actually not really true.

Those that believe patients are too “stupid” while of course has credence, also should check their ego at the door. Maybe those “docs” are too stupid and too lazy to explain it in a way that anyone can understand it…or even more possible…the supposed doctor doesn’t really understand it themselves…

 

[Taus]

They get “like a root canal”…. Oh you kill the nerve?! Kill that sob good doc…

 

[Dr. Ice]

They get “like a root canal”…. Oh you kill the nerve?! Kill that sob good doc…

I’ve had so many patients ask me about rfa when they clearly have neurogenic Claud with radicular pain. Then I explain in detail that you can’t ablate spinal nerves and then they continue to swear that some pain doc told them that was the next step, blah blah..

But what do I really know at the end of the day according to many on here..ho hum

 

[nvrsumr]

Esi in asc pencils out based on increased volume over rfa is my understanding.

Plus despite some of these amazing humanitarian ortho spine partners everyone has on sdn getting too many patients off the surgeons schedule isn’t always desirable

 

[Dr. Ice]

Esi in asc pencils out based on increased volume over rfa is my understanding.

Plus despite some of these amazing humanitarian ortho spine partners everyone has on sdn getting too many patients off the surgeons schedule isn’t always desirable

Lol..not gonna argue business here dude. I know what pencils and what doesn’t.

The conversation is based on why people don’t offer rfa and training was brought up.

I’m fully aware most of us aren’t really “humanitarian” even those who claim to be the most noble only of course constantly practicing the best of EBM…🤮

 

[Taus]

I’ve had so many patients ask me about rfa when they clearly have neurogenic Claud with radicular pain. Then I explain in detail that you can’t ablate spinal nerves and then they continue to swear that some pain doc told them that was the next step, blah blah..

But what do I really know at the end of the day according to many on here..ho hum

My favorite is when they move to the area, have clearcut chronic radic or neurogenic claudication and swear the prior pain docs RFA helped their leg pain…. Perhaps they were getting pulsed rfa to nerve roots but doubt it.

 

[Dr. Ice]

My favorite is when they move to the area, have clearcut chronic radic or neurogenic claudication and swear the prior pain docs RFA helped their leg pain…. Perhaps they were getting pulsed rfa to nerve roots but doubt it.

Don’t even think pulsed Rf is covered anymore, but yeah that’s a possibility I guess..

I guess if one was to just treat algorithmicly, esi, mbb, rfa, the doc could get lucky sometimes if the patients radic pain was actually just referred facet mediated, but that’s of course just a numbers game and not real medicine which I guess goes back to the whole topic at hand anyway

 

[nvrsumr]

I was giving my opinion on the OP’s question. It’s a biz decision.

 

[callmeanesthesia]

My favorite is when they move to the area, have clearcut chronic radic or neurogenic claudication and swear the prior pain docs RFA helped their leg pain…. Perhaps they were getting pulsed rfa to nerve roots but doubt it.

I’ve had a few patients like that. I tell them I have no idea why but I’m glad it helped.

 

[MitchLevi]

RFA commonly treats leg pain.

 

[TIVAndy]

Thats why we try to distinguish true radic (below knee radiation) vs referred pain. Leg pain treated after rfa is often referred pakn treated. Also it could be overlapping

 

[CleanUp]

Lots of great points!

Glad I’m not the only one noticing this.

 

[Taus]

Thats why we try to distinguish true radic (below knee radiation) vs referred pain. Leg pain treated after rfa is often referred pakn treated. Also it could be overlapping

Never seen it in my decade of practice. Your talking about beyond upper gluteal?

 

[lobelsteve]

Never seen it in my decade of practice. Your talking about beyond upper gluteal?

Lumbar facet referred pain should be back to buttock and outer hip towards GTB. But it can be posterior thigh to knee. And it can also be to ankle.
The hip can do the same stupid thing.

When I was a med student, I learned the hip gave you pain in the groin.
When I was a resident, I learned the hip gave you pain in the inferior gluteal region.
When I was a fellow I learned the hip could give you back pain as high as L4-5.
When I was an attending I learned the hip can give you pain that mimics L5 radiculopathy.
I'm glad there is no more training. Next stop is rule out MI, inject hip.

 

[Taus]

Lumbar facet referred pain should be back to buttock and outer hip towards GTB. But it can be posterior thigh to knee. And it can also be to ankle.
The hip can do the same stupid thing.

When I was a med student, I learned the hip gave you pain in the groin.
When I was a resident, I learned the hip gave you pain in the inferior gluteal region.
When I was a fellow I learned the hip could give you back pain as high as L4-5.
When I was an attending I learned the hip can give you pain that mimics L5 radiculopathy.
I'm glad there is no more training. Next stop is rule out MI, inject hip.

So slipman was right all along…. Only the needle knows?

So all those guys doing esi, mbb/RFA, SIJ on every patient, no history or exam needed, had it right? Maybe that’s why those practices where the doc sits in the OR and noctors do all the clinic had it right after all

 

[lobelsteve]

So slipman was right all along…. Only the needle knows?

So all those guys doing esi, mbb/RFA, SIJ on every patient, no history or exam needed, had it right? Maybe that’s why those practices where the doc sits in the OR and noctors do all the clinic had it right after all

That's Bogduk talking. Pain lies to us. History more helpful then exam. Aggravating/Relieving factors and timing more important than location/radiation.

 

[Ducttape]

Outside of training bashing, which is so redundant and unnecessary at this point..the reasons many well trained docs don’t want to offer rfa as an option, is more of a personality problem. I can tell you this, talking about mbb/rfa so that the patient REALLY understands it takes work. Much easier to talk about epidurals. The concept of multiple insurance requirements for “test procedures” each one requiring insurance blessing is challenging not to mention getting them to understand what in fact you are really trying to do.

Docs who are trained to do rfa well..may not offer it because they are likely lazy or impatient or have a personality disorder that doesn’t allow them to be uncomfortable with other people.

Everyone wants to harp on training…the reality is actually much deeper.

my comment was not meant to be with regards to ACGME.

sorry, let me rephrase:

in certain spine specific programs, especially teaching programs affiliated with an ortho spine service, the focus is on throughput to surgery ie on ESI and TFESI. we know the paradigm - see as many acute radics as possible, do an ESI or TFESI, then send to surgery. there is no time or interest for treating arthritic facet arthropathy. and in fact it reduces the overall volume and throughput.

high volume quick turn around procedures.

in a similar vein, my impression is that those that work in a spine block shop are much more likely to focus on ESI and then quick turnaround through the system than to do an MBB that doesnt pay as well x2, at least 1 if not 3 follow up visits before RFA, all of which take away from New Patient slots...


that means that those of us living in the shadow of such (cough) academic spine programs get a higher percentage of chronic facet syndrome patients.

RFA commonly treats leg pain.

we need studies on this.

especially since insurance refuses this paradigm. several local carriers require ESI prior to MBB if there is any hint of radicular pain, even when it is clearly facet syndrome pattern pain.

 

[Baron Samedi]

I do wonder whether all the "named" Special Tests were ever intended for use in chronic pain. Surely the sensitivity/specificity are different in pts with 6 weeks of symptoms vs 6 years? Once central changes occur, it seems like most of the physical exam is out the window. Really my purpose of the exam is to r/o neurological conditions and build rapport with the patient.

 

[drrosenrosen]

That's Bogduk talking. Pain lies to us. History more helpful then exam. Aggravating/Relieving factors and timing more important than location/radiation.

History can be very helpful, as can exam. But some patients are terrible historians and can't tell you where it hurts or what aggravates or relieves it. I try to avoid leading questions, but sometimes you need to bust out the old "if you're in the store and leaning on the shopping cart..."

 

[drrosenrosen]

That’s what many docs think..regardless of “training.” I know duct and others want to constantly tout acgme at nauseum, but I have seen and known many of those “elite” not offering rfa and doing series of 3 on everyone and then stim and then failure and then narcs galore, UDS, monthly follow ups, level 4 visits for chronic pain, etc etc….I can’t with this group sometimes 😒

Hold up now, what's wrong with level 4 visits for chronic pain?

 

[callmeanesthesia]

That's Bogduk talking. Pain lies to us. History more helpful then exam. Aggravating/Relieving factors and timing more important than location/radiation.

Nothing is reliable - patients give terrible history, physical exam is non-specific, and even injections have a false positive/false negative rate and placebo response. Plus we’ve all seen patients who had great relief for 2-3 weeks after a steroid injection that was nowhere near their pathology. That’s why mid levels result in more treatment - they don’t have the training to put that all together as well.

 

[Ducttape]

I do wonder whether all the "named" Special Tests were ever intended for use in chronic pain. Surely the sensitivity/specificity are different in pts with 6 weeks of symptoms vs 6 years? Once central changes occur, it seems like most of the physical exam is out the window. Really my purpose of the exam is to r/o neurological conditions and build rapport with the patient.

dont say this.

drusso will be pissed.

 

[Dr. Ice]

Physical exam doesn’t have much utility especially for chronic axial non radiating back pain. Oblique extension to rule in facets I guess but that’s about it.

I did see a guy with significant pain and weakness involving hip flexion with a positive stinchfield, that just didn’t match his lumbar mri or hip X-rays. Hip injection didn’t do much, ultrasound revealed large iliopsoas effusion which was aspirated. Pain immediately improved. Sent fluid out, still not sure what caused it

 

[MitchLevi]

Disappointing thread.

 

[Dr. Ice]

Disappointing thread.

Lol

 

[SC Tian]

Disappointing thread.

imo, we are doing too many mbb/rfas.

 

[Taus]

imo, we are doing too many mbb/rfas.

When the only tool is a hammer….. so weird it didn’t work on that 30yo w ddd, flexion based pain without facet tenderness…. but he felt great after the mbb under mac with 5ml lido…

 

[CleanUp]

imo, we are doing too many mbb/rfas.

shots fired!

Interesting take. May I explain why you feel that way? Looking to learn

 

[Taus]

shots fired!

Interesting take. May I explain why you feel that way? Looking to learn

Bc most patients have the trifecta of a spine, pulse and insurance

Many pain docs either don’t know any better, don’t give af and/or stay the OR all day and do whatever nonsense procedure was ordered by the noctor in clinic who refills the patient’s narcotics every three months

 

[Dr. Ice]

I don’t think people have to be in that kind of setup to practice crap medical care. I see countless people that just treat in a tunnel. Esi, then mbb then rfa cause patients don’t get it and it’s subjective, then stim for “no surgical low back pain” then narc ‘em, Mary Jane ‘em, uds em, etc etc. No one likes to think anymore

 

[Agast]

 

[callmeanesthesia]

View attachment 378889

 

[DOctorJay]

View attachment 378889

PCP note: patient had an epidural with pain management.

 

[Agast]

PCP note: patient had an epidural with pain management.

 

[Laryngospasm]

You just need one of those hip si esi things

 

[Ronin1]

Epidermal

 

[Ducttape]

patient: "i dont know what shot they gave me, but it went right in to my spine and was the most painful thing ever! im never getting another injection again! my doc said im getting my percs from you now. i have 1 pill left."