Medicare requiring contrast injection for mbb?

[biacuplasty]

Has anyone noticed this in your region?

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[DOctorJay]

I've noticed this as well but haven't been using contrast. I've been thinking about adding contrast to my local and taking one pic at end to document the contrast being there.

Is anyone else doing this?


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[lobelsteve]

Can lead to false negatives with vascular uptaje reported 10 to 30% of time. Leads to less RFs.

 

[deleted472101]

Is that just for IA facet joint injections?

 

[Jcm800]

I always use contrast


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[biacuplasty]

I've never used it for facets/mbb


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[geauxg8rs]

I've never used it for facets/mbb


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If they "require" contrast for mbb, then why is it specifically stated that you don't need contrast for the RFA? Wouldn't the same reasoning for needing contrast apply to
Both MBB and RFA?

 

[DOctorJay]

I use contrast for FJI but not MBBs


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[Extralong]

I used to not use contrast for MBBs but recently in the last several months we were told to start using contrast for reimbursement purposes. I find it a waste of time, waste of contrast, and extends my procedure time.

 

[Ducttape]

like what DoctorJay says... mix 0.5 cc contrast in with bupiv or lido, in a ratio not too dilute (usually i use 0.5 ml contrast with 5 ml bupiv). essentially no difference in time.

 

[Ligament]

like what DoctorJay says... mix 0.5 cc contrast in with bupiv or lido, in a ratio not too dilute (usually i use 0.5 ml contrast with 5 ml bupiv). essentially no difference in time.

This is what I do.

You will be surprised how often you see vascular uptake when you use contrast for MBBs. You will also be surprised how often you see lack of flow over the medial branch. This can be solved with readjusting the needle tip position slightly in most cases.

 

[bedrock]

This is what I do.

You will be surprised how often you see vascular uptake when you use contrast for MBBs. You will also be surprised how often you see lack of flow over the medial branch. This can be solved with readjusting the needle tip position slightly in most cases.

I don't mix the two, but will consider it.

I agree with the Medicare rules in this instance for the two reasons ligament just stated.
If you do your MBB with contrast you will surprised how often the flow isn't over the medial branch or is vascular. It doesn't take long to readjust your needle so your medication is covering the medial branches, and if you're doing it with contrast, you can use just 0.3ml of anesthetic as SIS recommends, because you're right there, on target. You don't have to use larger volumes that have a higher chance of anesthetizing other structures for a false positive.

If you skip contrast, you're missing information which directly impacts your block results. Poor MBB technique is a big reason for RF results that don't match MBB results.

 

[clubdeac]

So are you guys using live fluoro during each mb contrast injection? - you would have to to see vascular uptake I assume

 

[Ligament]

So are you guys using live fluoro during each mb contrast injection? - you would have to to see vascular uptake I assume

I used to, but my radiation was getting to high. So now I do spot images. If there is a neurogram, or contrast over the course of the medial branch, then you can be assured local is there. Yes, there may have been vascular uptake, but there was obviously medial branch blockade as well, so the vascular uptake is ok since we are not injecting particulates. If there is no visible contrast after injection, it was 100% vascular and you need to move the needle.

 

[Ducttape]

no. im not going to risk the patient's life any more than necessary. a single shot when i have injected all 3 nerves...

 

[hyperalgesia]

I don't use contrast for MBBs. But maybe I should start... Not my pic but just found it.

 

[bedrock]

Have to admit I don't do live fluoro for MBB. Just too much radiation.
However, once you start regularly doing MBB with contrast, In addition to knowing if your contrast actually flowed over the MB, you'll notice if your contrast volume looks insufficient because some of the contrast is vascular and you can adjust the needle before injecting anesthetic.

 

[Taus]

I've ever used contrast on mbb. I like that idea of mixing a little in my local and will start doing that if insurers require, not to mention risk false neg.


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[SSdoc33]

i use contrast, but i have no idea why. i really dont learn anything from it and rarely reposition. after a while, you know where you are supposed to be. i take 1 spot shot after the needles are positioned to get all 3 or 6 in 1 view. even if you are vascular, it typically isnt 100% vascular -- maybe semi-venous because you are touching down on bone. block will still have the same outcomes.

to sum up: i use contrast, but i have just outlined why you shouldnt. strong work, ssdoc

 

[freddydpt]

This BS hasn't hit FL yet, thank goodness.

 

[lonelobo]

i use contrast, but i have no idea why. i really dont learn anything from it and rarely reposition. after a while, you know where you are supposed to be. i take 1 spot shot after the needles are positioned to get all 3 or 6 in 1 view. even if you are vascular, it typically isnt 100% vascular -- maybe semi-venous because you are touching down on bone. block will still have the same outcomes.

to sum up: i use contrast, but i have just outlined why you shouldnt. strong work, ssdoc

So you use a separate needle for each injection site?

 

[SSdoc33]

So you use a separate needle for each injection site?

yeah. like throwing lawn darts. sometimes 6 or 8 (rarely). i think i know where you are going with this, and no, i dont buy my own needles.....

 

[Taus]

I never used contrast for any mbb in training, but after reading this thread and newer article in pain medicine I started to use some. Not under live fluoro, but just a drop and then a still shot. I have been SHOCKED at how many times it has flowed completely away from needle tip in the wrong direction (regardless of bevel direction) or partially disappears, i.e. vascular. I would have had a handful of false negative mbb just in the past few weeks. Will always be using contrast going forward....




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[Extralong]

From my end, not much has really changed in terms of needle placement, technique, or results now that I dump a quick amount of contrast into someone for MBBs. There is now increase in cumulative flouro time.
Any ideas on how to speed this nonsense up?

 

[bedrock]

I never used contrast for any mbb in training, but after reading this thread and newer article in pain medicine I started to use some. Not under live fluoro, but just a drop and then a still shot. I have been SHOCKED at how many times it has flowed completely away from needle tip in the wrong direction (regardless of bevel direction) or partially disappears, i.e. vascular. I would have had a handful of false negative mbb just in the past few weeks. Will always be using contrast going forward....




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Right on. Lack of contrast or poor MBB technique is why many RFs don't work out.

I normally hate government mandates, but agree with contrast being required for MBB.

 

[Ducttape]

From my end, not much has really changed in terms of needle placement, technique, or results now that I dump a quick amount of contrast into someone for MBBs. There is now increase in cumulative flouro time.
Any ideas on how to speed this nonsense up?

add 0.5 ml contrast into ~4.5 ml 0.25% bupivicaine, and take 1 spot image after injection of diagnostic local anesthetic before removing all needles. its what, 0.225% bupiv, but should not make statistical difference in assesment.

or, if one is to be dogmatic, mix 0.5% bupiv with contrast in a 1:1 ratio. id rather use less contrast, and the extra contrast may make the machine increase output...

 

[freddydpt]

add 0.5 ml contrast into ~4.5 ml 0.25% bupivicaine, and take 1 spot image after injection of diagnostic local anesthetic before removing all needles. its what, 0.225% bupiv, but should not make statistical difference in assessment.

or, if one is to be dogmatic, mix 0.5% bupiv with contrast in a 1:1 ratio. id rather use less contrast, and the extra contrast may make the machine increase output...

The increase in output of the fluoro machine is almost negligible for a small amount of contrast like that. It shouldn't be a factor in your decision making.

 

[Ducttape]

I'm not the one looking to minimize costs, only making suggestion.

Technically, the 1:1 mixture would cost cents more because of increased cost due to 0.5% bupiv and extra contrast needed, so...


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[Taus]

add 0.5 ml contrast into ~4.5 ml 0.25% bupivicaine, and take 1 spot image after injection of diagnostic local anesthetic before removing all needles. its what, 0.225% bupiv, but should not make statistical difference in assesment.

or, if one is to be dogmatic, mix 0.5% bupiv with contrast in a 1:1 ratio. id rather use less contrast, and the extra contrast may make the machine increase output...

I tried this first, but found that i wasn't able to always clearly see it with such dilute concentration of contrast, especially in my ancient spine population where everything is so sclerotic. I switched to placing all needles, getting all in view on screen, put maybe 0.1-2cc in all then taking a single picture. Doesn't add much time or radiation. I'm now sure that a negative block is negative, not false neg from an easily correctable technical issue.


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[lobelsteve]

All those poor folks not getting rf's. Suffering from moderate discomfort.

Id be happy to have more false negatives and less RFs to do.

 

[Ducttape]

the point to Extralong is that he wanted some way of speeding things up, and had apparently little interest in changing his technique.

combining the local with the contrast accomplishes his goals...

 

[Extralong]

Thanks I appreciate it. I like to hear about ways to be more efficient when a mandate appears.

 

[lobelsteve]

I draw 4cc bupi 0.25% and 2cc omnipaque 240. 0.4 per nerve. Spot film at each nerve.

 

[Ligament]

I draw 4cc bupi 0.25% and 2cc omnipaque 240. 0.4 per nerve. Spot film at each nerve.

This is similar to what I do, but use Omni 300 and .75% bupi mixed together.

 

[Taus]

the point to Extralong is that he wanted some way of speeding things up, and had apparently little interest in changing his technique.

combining the local with the contrast accomplishes his goals...

Ahh... my bad.


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[ampaphb]

So for those of you who are injecting local and contrast simultaneously, are you doing it to meet guideline requirements? Or will you reposition if you see evidence of vascular uptake?