Peer review let me see what you are doing!

[deleted185747]

I did a peer to peer today:

patient is work comp, injured 2 years ago. MRI shows grade 1 spondylolisthesis L4-5 and DDD. Pain is in coccyx.

OP note from last injection: epidural and facet joint injection by orthopod.
caudal epidural, myelogram obtained after 5cc contrast, 40cc PFNS, 80mg depomedrol and hyaluronidase. Then bilat L4/5 facet injected with 20cc EACH, noted steroid solution (containing another 80mg depomedrol) was incrementally injected 5cc at a time into facet joints.

The request was for treatment of the coccyx pain with bilateral L4/5, L5/S1 epidurals.

F-U

Report based on review of work comp records? For the newbies reading this OP note thinking it doesn't make any sense, don't worry; it doesn't make sense to me either.

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[deleted185747]

the note

 

[jonnylingo]

I'm at a loss for words.

 

[lobelsteve]

Ask for images....

This should trigger 10 patients charts being pulled for review.

 

[pmrmd]

20cc into each facet with a 20g quincke. Ouch. Stick to some kind of actual surgery, Dr. Orthopedist.

 

[Doctodd]

Wow....how did wc ever approve that!

 

[SSdoc33]

i bet the guy doing the shot is 60 or 70 years old. time to put him out to pasture.

 

[lonelobo]

I did a peer to peer today:

patient is work comp, injured 2 years ago. MRI shows grade 1 spondylolisthesis L4-5 and DDD. Pain is in coccyx.

OP note from last injection: epidural and facet joint injection by orthopod.
caudal epidural, myelogram obtained after 5cc contrast, 40cc PFNS, 80mg depomedrol and hyaluronidase. Then bilat L4/5 facet injected with 20cc EACH, noted steroid solution (containing another 80mg depomedrol) was incrementally injected 5cc at a time into facet joints.

The request was for treatment of the coccyx pain with bilateral L4/5, L5/S1 epidurals.

F-U

Report based on review of work comp records? For the newbies reading this OP note thinking it doesn't make any sense, don't worry; it doesn't make sense to me either.

So that was you I was talking to on the phone yesterday?

 

[PainDrain]

Ask for images....

This should trigger 10 patients charts being pulled for review.

I agree. Ask for the images because I bet it's a con. He is doing it blind, hence the volume used. I have an old school neurosurgeon hack near me who does "transforaminal epidurals" by palpation. I kid you not, I have his office notes. He was booted from the local hospital so he does it in his office and doesn't use fluoro. Don't know who is paying for this but it's ridiculous.

 

[lobelsteve]

I agree. Ask for the images because I bet it's a con. He is doing it blind, hence the volume used. I have an old school neurosurgeon hack near me who does "transforaminal epidurals" by palpation. I kid you not, I have his office notes. He was booted from the local hospital so he does it in his office and doesn't use fluoro. Don't know who is paying for this but it's ridiculous.

Call medical board now, or coroner later.

 

[deleted185747]

I was asked privately by a newbie what the problem was with the op note so I'm dissecting it here; feel free to chime in

OP note from last injection: epidural and facet joint injection by orthoropod. <- I don't do epidurals and facets at the same time because that would mean that each site gets less steroid (I use 40mg depomedrol at a time and if I divided by 5 different sites then each location would get 8mg). Also, I treat each location separately and document response to each.

caudal epidural, myelogram obtained after 5cc contrast <- If needle is in epidural space then it's an epidurogram. If needle is intrathecal then it's a myelogram.
40cc PFNS, 80mg depomedrol and hyaluronidase <-thats really high volume, what is he trying to target? 5-8cc would get steroid up to L4/5. I don't use hyaluronidase.

Then bilat L4/5 facet injected with 20cc EACH <- volume of facet joint is 0.2-0.5cc I think.

The request was for treatment of the coccyx pain with bilateral L4/5, L5/S1 epidurals. <- coccyx pain is treated with different injections, not lumbar transforaminals. Anyone doing 2 level bilateral transforaminals had better have a really good reason because it looks more than greed/fraud than medically necessary.

 

[SSdoc33]

I agree. Ask for the images because I bet it's a con. He is doing it blind, hence the volume used. I have an old school neurosurgeon hack near me who does "transforaminal epidurals" by palpation. I kid you not, I have his office notes. He was booted from the local hospital so he does it in his office and doesn't use fluoro. Don't know who is paying for this but it's ridiculous.

you might be on to something. he keeps using the term "image intensifier" instead of flouroscope. he may be using a magnifying glass for all we know.

 

[geauxg8rs]

you might be on to something. he keeps using the term "image intensifier" instead of flouroscope. he may be using a magnifying glass for all we know.

Maybe it's a monocle?

 

[SSdoc33]

Maybe it's a monocle?

nice!

 

[chibadriver]

This is a joke... Right?


Sent from my iPhone using SDN mobile app

 

[yankeeh8r]

W. T. F?

 

[Extralong]

I cannot believe that people practice like this and get away with it!

 

[freddydpt]

So, he also wrote down a clear "myelogram" was seen. If he injected steroid at that point, patient would be at risk for arachnoiditis. I doubt he even knows what a myelogram looks like.

- oops, just realized this was said above. my bad.

 

[melancholy]

those are some large facet joints there