Pars injection?

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gasgasgas

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What do you guys think.

International patient seen a few weeks ago (those are THE BEST.....) at my hospital outpatient clinic for eval. 35 or so yo F w history of several years of axial back pain with left>right leg pain. Has had injections (probably facet) done in Germany which didn't relieve pain. Didn't really do any PT. Saw her, had shooting pain of L leg posterior aspect w/ SLR, minimal facet loading pain, pain with deep palpation of lumbar paraspinals. CT myelogram done shows pars defect and mild spondylosis. She was seen by neurosurgeon at a different hospital who told her she had bilateral L5 pars fractures and wanted her to get bilateral L5 pars injection. She then had a bone scan, which was negative for pars defect or other fractures. Came back to see me, and told me her left leg was what bothered her the most. I did a lumbar ESI on her and she had 100% pain relief for several days. She went back to see the neurosurgeon who then angrily called me asking me why I didn't do a pars injection like he asked me to (he didn't refer the patient to me, and I have no idea who he is) and I told him I did what I felt was best for her based on my exam.

I have never done a pars injection in my career (short as it may be) and just wanted some input; to be honest, was a little bit frazzled by this neurosurgeon who called and bitched at me for not doing what he wanted me to do. He actually hung up on me! TIA.

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What do you guys think.

International patient seen a few weeks ago (those are THE BEST.....) at my hospital outpatient clinic for eval. 35 or so yo F w history of several years of axial back pain with left>right leg pain. Has had injections (probably facet) done in Germany which didn't relieve pain. Didn't really do any PT. Saw her, had shooting pain of L leg posterior aspect w/ SLR, minimal facet loading pain, pain with deep palpation of lumbar paraspinals. CT myelogram done shows pars defect and mild spondylosis. She was seen by neurosurgeon at a different hospital who told her she had bilateral L5 pars fractures and wanted her to get bilateral L5 pars injection. She then had a bone scan, which was negative for pars defect or other fractures. Came back to see me, and told me her left leg was what bothered her the most. I did a lumbar ESI on her and she had 100% pain relief for several days. She went back to see the neurosurgeon who then angrily called me asking me why I didn't do a pars injection like he asked me to (he didn't refer the patient to me, and I have no idea who he is) and I told him I did what I felt was best for her based on my exam.

I have never done a pars injection in my career (short as it may be) and just wanted some input; to be honest, was a little bit frazzled by this neurosurgeon who called and bitched at me for not doing what he wanted me to do. He actually hung up on me! TIA.




If the neurosurgery provider hung up on you then you were doing the right thing. I Would repeat the ESI
 
Even pharmacists don't just dispense prescriptions without question these days. If you sent him a patient for ACDF and his exam revealed that they had CTS would you expect him to do an ACDF? He is pissed that you screwed up his CASH fusion.
 
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I told him I did the ESI based on the clinical exam. He told me she had a few days of 100% relief and "now we are back to square one when you should have done the injection I asked you to do."

The neurosurgeon in my group told me this guy is a "malignant a**hole" fwiw ;)
 
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I also would have done an L5 tfesi first. But, the surgeon does have a point... You are back to square one.

The problem with pars defects is that it is very difficult to prove they are the pain generator. A fusion is a big leap to take when you only have a picture of the defect and no other idea where the pain may be from. -- especially if there if instability on flex/ext.

I'll do a few pars injectins/year. I'm not really sure if they are diagnostic, I'm not really sure if they are therapeutic. I've done some that seem to be curative. Some work for a week, some don't work at all. The surgeons seem to think that if you give the shot and they feel better, this is a license to fuse. I don't think anyone really knows.
 
How do you guys do your par injection? Directly at the site of the fracture?
 
Did i miss the flex/ext? I woulda done the pars injxn with 0.5 cc. What level did u do the ESI? Was it at least transforaminal with small volume? You gained nothing by a translaminar. No edema on MRI if this is chronic.
 
BUMP. How do you all code this??
 
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I told him I did the ESI based on the clinical exam. He told me she had a few days of 100% relief and "now we are back to square one when you should have done the injection I asked you to do."

The neurosurgeon in my group told me this guy is a "malignant a**hole" fwiw ;)
Of all the biggest pricks I have met in the medical field neurosurgeons would fill the top spots.
 
BUMP. How do you all code this??
Most folks would likely argue 64999 though some would say code it like a facet injection


When I google it, insurances seem to carve out coverage for MBBs/facet interventions for "isolated" pars defects,
 
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