Spine Surgeons: Please Read!

[101N]

Please don't order interlaminar epidurals in patients who have had a previous laminectomy at or near the site you want injected. When you - or the surgeon before you - performs the laminectomy/laminotomy you remove the injectionist's landmark - the ligamentum flavum - for our loss of resistance. Interlaminars in this instance frequently result in wet taps and subsequent headaches that we then have to patch.

Please order either a caudal ESI with catheter or TF ESI as an alternative in patients who have had a previous decompression at the desired injection site. Thanks!

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[lonelobo]

Please don't order interlaminar epidurals in patients who have had a previous laminectomy at or near the site you want injected. When you - or the surgeon before you - performs the laminectomy/laminotomy you remove the injectionist's landmark - the ligamentum flavum - for our loss of resistance. Interlaminars in this instance frequently result in wet taps and subsequent headaches that we then have to patch.

Please order either a caudal ESI with catheter or TF ESI as an alternative in patients who have had a previous decompression at the desired injection site. Thanks!

please don't order a caudal with cath I make $40

 

[pmrmd]

Please post this in some surgeon forum.

 

[Jcm800]

please don't order a caudal with cath I make $40

Please don't "order" an injection. I am not McDonalds. I will not supersize or offer fries with the desired injection. Please feel free to request a consultation...

 

[lobelsteve]

Please don't use the word instability in your note unless you are reviewing the flexion/extension xrays. It makes you look cheap.

 

[Pain Applicant1]

Please don't "order" and injection. I am not McDonalds. I will not supersize or offer fries with the desired injection. Please feel free to request a consultation...

 

[lord_jeebus]

I got a 2 word referral faxed yesterday from a rheumatologist for "Epidural 45." No other documentation provided. My assistant calls the patient to schedule a new patient clinic visit and the patient says that he just wants the injection that his rheumatologist ordered. He scheduled the clinic appointment, but then cancelled today because he got one of the other pain doctors in town to agree to do the injection same-day today. It did not sound like the patient had a prior relationship with that doctor although I am not certain.

Am I just naive or is this not normal? One of the spine surgeons in town sends me referrals for specific injections, but he sends me detailed documentation and imaging and I am comfortable with him to just schedule the injection with some time beforehand for history/physical/consent/etc. All the other surgeons just send patients for clinic evaluation with a note suggesting that I consider a particular procedure.

 

[JoBreeze]

Please don't use the word instability in your note unless you are reviewing the flexion/extension xrays. It makes you look cheap.

f**k yes

 

[TripleH]

To OP: I get this all the time. Orders for interlaminar injections at the site of previous disectomy/laminectomy/fusion. Very frustrating. Because of the set up here - it's expected that the surgeon will see patient in office and than send patient for a injections directly. I've sat down with them and talked to them numerous times and no change. they say injections at the site allows them to determine the pain generator and to determine if the patient needs a repeat surgery at that site.

My questions: Are there any guidelines/articles that show the risk in interlaminar injections at previous surgical sites? Are there any articles that provide or disprove the statement that an interlaminar injection at a previous site of surgery helps to locate a pain generator there?

 

[lobelsteve]

To OP: I get this all the time. Orders for interlaminar injections at the site of previous disectomy/laminectomy/fusion. Very frustrating. Because of the set up here - it's expected that the surgeon will see patient in office and than send patient for a injections directly. I've sat down with them and talked to them numerous times and no change. they say injections at the site allows them to determine the pain generator and to determine if the patient needs a repeat surgery at that site.

My questions: Are there any guidelines/articles that show the risk in interlaminar injections at previous surgical sites? Are there any articles that provide or disprove the statement that an interlaminar injection at a previous site of surgery helps to locate a pain generator there?

There are no studies supporting use of SNRB or ESI as diagnostic that have any merit. MBB and IA SIJ with low volume may be Dx.

 

[clubdeac]

There's an orthospine guy in town that narc's up all his patients on whatever they want and then cuts on 'em and punts to pain management. I've now seen 3 of his freaking train wrecks! All addicts getting insane amounts of opioids. Last patient I saw received a total of 6 scripts of roxy 15's following his ACDF for a total of #240 pills in a 2 week period. That was in addition to the 75mcg fentanyl patch he is takign. He shows up in my office out of all of the above needing refills b/c his surgeon drug dealer would no longer prescribe. So I call the surgeon up and am ready to ream his ass when he answers the phone with his southern good 'ole boy accent and says, "Was just talking to your partner Dr. ..... the other day. He was telling me what a great addition you've been to the practice" blah blah blah... Being the new guy in town with no clout, I of course puss out. Instead of laying into him, I nicely say how concerned I was about the patient's excessive opioid use and multiple scripts... Ughhh. It blows my mind the crap some of these surgeons get away with!!

 

[101N]

We're physiatrists, we're bred for passivity

 

[hyperalgesia]

.

 

[emd123]

There's an orthospine guy in town that narc's up all his patients on whatever they want and then cuts on 'em and punts to pain management. I've now seen 3 of his freaking train wrecks! All addicts getting insane amounts of opioids. Last patient I saw received a total of 6 scripts of roxy 15's following his ACDF for a total of #240 pills in a 2 week period. That was in addition to the 75mcg fentanyl patch he is takign. He shows up in my office out of all of the above needing refills b/c his surgeon drug dealer would no longer prescribe. So I call the surgeon up and am ready to ream his ass when he answers the phone with his southern good 'ole boy accent and says, "Was just talking to your partner Dr. ..... the other day. He was telling me what a great addition you've been to the practice" blah blah blah... Being the new guy in town with no clout, I of course puss out. Instead of laying into him, I nicely say how concerned I was about the patient's excessive opioid use and multiple scripts... Ughhh. It blows my mind the crap some of these surgeons get away with!!

What's the point in reaming him out? Just refuse to take over any of his BS scripts and write in every consult "risks of med doses outweigh the gains" then when the fit hits the shan it's his arse, not yours. Problem solved, no confrontation had. Pretty soon he won't send you his BS.

 

[bedrock]

There's an orthospine guy in town that narc's up all his patients on whatever they want and then cuts on 'em and punts to pain management. I've now seen 3 of his freaking train wrecks! All addicts getting insane amounts of opioids. Last patient I saw received a total of 6 scripts of roxy 15's following his ACDF for a total of #240 pills in a 2 week period. That was in addition to the 75mcg fentanyl patch he is takign. He shows up in my office out of all of the above needing refills b/c his surgeon drug dealer would no longer prescribe. So I call the surgeon up and am ready to ream his ass when he answers the phone with his southern good 'ole boy accent and says, "Was just talking to your partner Dr. ..... the other day. He was telling me what a great addition you've been to the practice" blah blah blah... Being the new guy in town with no clout, I of course puss out. Instead of laying into him, I nicely say how concerned I was about the patient's excessive opioid use and multiple scripts... Ughhh. It blows my mind the crap some of these surgeons get away with!!

Dude. Don't don't puss out. You are enabling the drug dealer. If no one will see his train wrecks on mountains of opioids, he might have to alter his practice.

Plus seeing patients like that all time, will suck the life and joy out of you.

 

[hyperalgesia]

It is frustrating as hell.

 

[lobelsteve]

We're physiatrists, we're bred for passivity

Not those under the line of Windsor.

 

[ampaphb]

There's an orthospine guy in town that narc's up all his patients on whatever they want and then cuts on 'em and punts to pain management. I've now seen 3 of his freaking train wrecks! All addicts getting insane amounts of opioids. Last patient I saw received a total of 6 scripts of roxy 15's following his ACDF for a total of #240 pills in a 2 week period. That was in addition to the 75mcg fentanyl patch he is takign. He shows up in my office out of all of the above needing refills b/c his surgeon drug dealer would no longer prescribe. So I call the surgeon up and am ready to ream his ass when he answers the phone with his southern good 'ole boy accent and says, "Was just talking to your partner Dr. ..... the other day. He was telling me what a great addition you've been to the practice" blah blah blah... Being the new guy in town with no clout, I of course puss out. Instead of laying into him, I nicely say how concerned I was about the patient's excessive opioid use and multiple scripts... Ughhh. It blows my mind the crap some of these surgeons get away with!!

John:

My staff has all referrals send records and MRIs, and pull a PMP prior to scheduling an appointment. I review each case in advance of seeing them. I let the patient know that if they don't have an MRI, I am happy to see them, but I won't be able to write for meds. I personally have a list of meds I don't write for (soma, methadone, anxiolytics, and sleepers other than TCAs). I also am not willing to write for more than 3-4 short-acting opioids a day. Patient is advised of my policies, and are then given the option of being seen under the above rules of the game.

In the case of the above-mentioned patient, I would punt. You have nowhere to go with his pain meds, and his current regimen is clearly a huge red flag. In this case, I would tell the patient that your clinic is simply not equipped to handle someone with his complicated pain picture. Luckily, your community is served by a wonderfully sophisticated academic pain clinic (http://www.carolinashealthcare.org/pmr), and your best recommendation is that he be seen by the world-renowned mavens there.

 

[ampaphb]

We're physiatrists, we're bred for passivity

Pain docs are not typical physiatrists. They are the most driven, self-assured, entrepreneurial, and least retiring members of the field. Whole different breed from the in-patient folks.

 

[ssmallz]

To OP: Would the surgeon actually care or notice if you did a TFESI instead of an ILESI? Why even bother arguing with him, just evaluate the patient and do what you want

 

[emd123]

To OP: Would the surgeon actually care or notice if you did a TFESI instead of an ILESI? Why even bother arguing with him, just evaluate the patient and do what you want

Agree. I doubt most would spend > 10 sec reading your note (if at all) to discern the difference enough to care. They're just checking a box: "Injection tried". Check

"Therefore, more surgery needed". Check.

 

[ampaphb]

You are picking examples that are too easy.. What if he ordered a C4 snrb, and I changed it to a C7/T1 mid line injection? What if he ordered a lumbar disco, but the facets had never been evaluated as potential pain generators? There are times when surgeons order a specific injection for a reason. You may disagree, but if I change the plan, they may decide to send future referrals to the guy down the street.

I tend to do the procedure requested, unless it is a stupid request (eg. L2/3 request when the pain is in an S1 distribution) and then recommend the appropriate injection as the next thing to do.