Stop Sedating Your TFESI

[lobelsteve]

http://onlinelibrary.wiley.com/doi/10.1111/pme.12092/abstract

Audit detailing no need for sedation for TFESI.

CMS gets a hold of this with the right lobbying and all ASC and in office sedation can go away for TFESI.

And I agree with them.

Think of the cost savings.

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[101N]

http://onlinelibrary.wiley.com/doi/10.1111/pme.12092/abstract

Audit detailing no need for sedation for TFESI.

CMS gets a hold of this with the right lobbying and all ASC and in office sedation can go away for TFESI.

And I agree with them.

Think of the cost savings.

Stop being so paternalistic. Let patients decide, and pay for their decision.

 

[PinchandBurn]

I think it depends.

I currently do not sedate for >95% of my TFESI.

However, there are just some people that have legit radic with mri, sx's, but are just so sensitized. Also it depends on what you mean by sedation.

Some people are doing propofol and 'heavier' sedation where the patient is completely unresponsive. I think that's wrong.

Some Midaz , even for just anxiolysis, is I think reasonable. I mean you can't do the procedures on a moving target......

 

[mille125]

I think it depends.

I currently do not sedate for >95% of my TFESI.

However, there are just some people that have legit radic with mri, sx's, but are just so sensitized. Also it depends on what you mean by sedation.

Some people are doing propofol and 'heavier' sedation where the patient is completely unresponsive. I think that's wrong.

Some Midaz , even for just anxiolysis, is I think reasonable. I mean you can't do the procedures on a moving target......

You describe a much more reasonable approach which is what I do in my practice as well. Steve, I agree the heavier sedation (ie propofol) is not necessary for most pain procedure even though several docs do it one hundred percent of the time. As usual if you are doing things 100% of the time (ie no sedation or always propofol), it is probably not serving the patient. With all of that said, my standard for this procedure is to offer valium po 5mg to 10 mg. About 40% of patients refuse the valium. However, I must also say that it is highly unusual for me to do bilateral L4 and L5 blocks as a lot of docs do.

 

[emd123]

The only sedation I do is PO Xanax for a stim trial or disco in office, or for the rare patient that demonstrates they need it for other procedures, which is less than 1%.

I think sedating for patients who demonstrate the need is appropriate. Sedating per routine 100% of the time is an obvious money grab.

 

[lobelsteve]

Stop being so paternalistic. Let patients decide, and pay for their decision.

Exactly, let CMS and all insurers drop it and if patients want they pay cash for sedation. It will end a lot of the nonsense like MAC with a CRNA for $2000 all for a $200 shot of steroid.

 

[mille125]

Exactly, let CMS and all insurers drop it and if patients want they pay cash for sedation. It will end a lot of the nonsense like MAC with a CRNA for $2000 all for a $200 shot of steroid.

which happens a lot in my area.....Several docs employ CRNAs just for this purpose

 

[lobelsteve]

which happens a lot in my area.....Several docs employ CRNAs just for this purpos

And make sure they are OON for your owned ASC.

Anyone can make $2M a year doing pain. Just have to be an ahole and not care about the patient or the systems based practice to do so. You get to keep 3 out of the 6 core competencies while you rape and pillage. Say bye to professionalism, patient care, and systems based practice as long as you can stay OON and sedate all procedures in your owned ASC. Everyone needs a series of 3 cause I got a boat payment.

I know at least a dozen pain docs like this.

 

[mille125]

And make sure they are OON for your owned ASC.

Anyone can make $2M a year doing pain. Just have to be an ahole and not care about the patient or the systems based practice to do so. You get to keep 3 out of the 6 core competencies while you rape and pillage. Say bye to professionalism, patient care, and systems based practice as long as you can stay OON and sedate all procedures in your owned ASC. Everyone needs a series of 3 cause I got a boat payment.

I know at least a dozen pain docs like this.

only a dozen?

 

[spinal]

Its becoming a like a third world country here too!

I came from a third world country. We did no sedation for the injections, no anesthesia for tonsilectomies, no sedation or anesthesia for tonsilar abcess drainage, I and Ds etc.... We did no sedation because the patient could not afford it and most of the time it was not available.
I came here and the patient demended sedation so I did it.
It's humane, we have been called upon as doctors, we should make the injection experience as pleasant as possible for our patients. We call ourselves pain doctors so we should make the injection expericnce as painless as possible. I disagree with heavy sedation- avoid it- it's dangerous.
Its costing me from my pocket to provide light sedation but i do it for the patients.

 

[Ducttape]

I know I'm doing things wrong financially...

For the in-office sensations I am doing, the only charge that is added to the coding is the medication cost. I have not "charged" for other codes...

Just FYI, for those doing sedation, what extra cpt codes are being used?

 

[Pain Applicant1]

Why sedate, I don't get it? I do 99.99% of procedures without sedation. At most, maybe I'll give a couple of tabs of valium. My stim trials don't have pain. I numb the skin, create a track with a 3.5 inch spinal and saturate it with 0.5% lido mixed with some bupi. Works like a charm. Epidurals, both TF and IL rarely have any pain at all. Sedation's not necessary with the right use of local.

 

[lobelsteve]

Why sedate, I don't get it? I do 99.99% of procedures without sedation. At most, maybe I'll give a couple of tabs of valium. My stim trials don't have pain. I numb the skin, create a track with a 3.5 inch spinal and saturate it with 0.5% lido mixed with some bupi. Works like a charm. Epidurals, both TF and IL rarely have any pain at all. Sedation's not necessary with the right use of local.

That's what the article says.

I believe if you routinely need sedation, you need to redo your training. If you sedate 1/100 patients, you have an anxious patient. But you should have to jump through hoops to get them approved for sedation rather than be allowed to bill for sedating everyone unnecessarily for profit.

Sedation is being used more as a revenue generator than to allow compassionate care.

 

[stim4u]

you are correct with your premise, but your delivery is poor.
A small percentage of pain docs are abusing the system. the population is growing and aging. Medicare expanded to include SSD and Medicaid has only been expanded. All adding to costs.
Patients do have the right to opt for sedation.
Insurance companies, like Aetna, tried to deny propofol for colonoscopy procedures for the same cost benefit analysis.
There is a fine balance. Typically 15mg of oral valium is fine for 95% of TFESI procedure. Fusion patients, more advanced procedures (RACZ) , and anxiety prone patients should have the option of MAC sedation.

 

[mille125]

Its becoming a like a third world country here too!

I came from a third world country. We did no sedation for the injections, no anesthesia for tonsilectomies, no sedation or anesthesia for tonsilar abcess drainage, I and Ds etc.... We did no sedation because the patient could not afford it and most of the time it was not available.
I came here and the patient demended sedation so I did it.
It's humane, we have been called upon as doctors, we should make the injection experience as pleasant as possible for our patients. We call ourselves pain doctors so we should make the injection expericnce as painless as possible. I disagree with heavy sedation- avoid it- it's dangerous.
Its costing me from my pocket to provide light sedation but i do it for the patients.

Then why not sedate for TPIs, flu shots, immunizations..................

 

[stim4u]

if you have money, you can pay an anesthesiologist or a rogue cardiologist to give you propofol at night if you like. insurances have some responsibility to pay for colonoscopies, some minor pain procedures.....

 

[Ligament]

Do i really need to redo my training? That sucks! My patients CHOOSE whether to have sedation; i give them the option. Do YOU give them any options for sedation?

 

[lobelsteve]

Do i really need to redo my training? That sucks! My patients CHOOSE whether to have sedation; i give them the option. Do YOU give them any options for sedation?

They should be able to choose, but insurance should not have to pay.

Plain pizza. You pay for the toppings.

 

[Ducttape]

Plain pizza. You pay for the toppings.

isnt pepperoni a topping? where i live, plain and pepperoni pizza are the same price...

 

[Ducttape]

no offense, but i just looked at that study. i dont think you can draw any conclusions from this survey.

how can they make a determination that sedation is not preferred by patients when only 0.1% of patients, 7 out of 6876, got sedation? additionally, 28% of patients did not answer the survey. i do not, in the limited view of the survey that i have, see where they specifically addressed the issue of whether sedation would have been preferable or desired.

this survey is like going to a pizza parlor, having only cheese pizza available, and asking those who ordered cheese pizza "did you like your cheese pizza", then reporting that there is no need for pepperoni pizza.


personally, in the setting im in, there is no cost savings, other than the cost of midazolam and fentanyl, as i am not billing for light-moderate sedation.


EDIT: my concern deals with CMS arbitrarily deciding that sedation is not allowed, not only for TFESI but for any injection. Dont give Sebelius any ideas....

 

[lonelobo]

personally, in the setting im in, there is no cost savings, other than the cost of midazolam and fentanyl, as i am not billing for light-moderate sedation.


EDIT: my concern deals with CMS arbitrarily deciding that sedation is not allowed, not only for TFESI but for any injection. Dont give Sebelius any ideas...
.

If you don't bill for it why do you care?
NO one is going to tell you , you can't give sedation.

 

[powermd]

Then why not sedate for TPIs, flu shots, immunizations..................

tatoos...

 

[bedrock]

If you don't bill for it why do you care?
NO one is going to tell you , you can't give sedation.

I care because it's a waste of time, money, and unnecessary risk.

I don't give patients the option, (unless I feel it is medically indicated, which is rare)

I do ask about a history of anxiety and history with pain procedures. That doesn't mean I just do what the patient wants. I'm the physician, not the patient.

They may not believe me that they will be fine undergoing a lumbar ILESI with PO valium, because some podiatrist previously tortured them with a toe injection. Their belief doesn't change my medical opinion. If they don't trust my medical opinion, they can wait 3-4 weeks to see another physician. My medical opinion doesn't change for their perception, I'm the physician in this relationship.

2-3 have gone elsewhere. What do 95% of the other patients say after the procedure. "That was it? I can't believe I worried about that."

And that response is why I don't worry about what the patient's previous podiatrist has done before I saw them.

 

[PinchandBurn]

Few things:

I think it demands on your market. Where I'm at, there are a ton of pain docs. Patients have been given injections elsewhere and simply have a phobia to needles. Some of them are just hypersensitized for sure. They simply have been soo traumatized that they are not willing to have injections w/o sedation. Otherwise they have a normal psych profile.


Additionally. IF you are in private practice and not in academics, the consumers drive the market. If patients know that they can go to clinic X across the street and get an injection with sedation vs at your place.....where do you think they will go?

I would say that very few of us have ever had an LESI, TFESI or anything. I know I haven't. But if it were you, where would you go? How many times have one of you done a TFESI and had a paresthesia? Especially if now, everyone is moving to this retrodiscal approach. It's not that pleasant to get a sharp paresthesia. None of us can 'see the nerve' and sometimes paresthesias happen...

I know this may look like I'm defending the practice, but as I stated before, I do not sedate for >95% of TFESi.

 

[mille125]

Few things:

I think it demands on your market. Where I'm at, there are a ton of pain docs. Patients have been given injections elsewhere and simply have a phobia to needles. Some of them are just hypersensitized for sure. They simply have been soo traumatized that they are not willing to have injections w/o sedation. Otherwise they have a normal psych profile.


Additionally. IF you are in private practice and not in academics, the consumers drive the market. If patients know that they can go to clinic X across the street and get an injection with sedation vs at your place.....where do you think they will go?

I would say that very few of us have ever had an LESI, TFESI or anything. I know I haven't. But if it were you, where would you go? How many times have one of you done a TFESI and had a paresthesia? Especially if now, everyone is moving to this retrodiscal approach. It's not that pleasant to get a sharp paresthesia. None of us can 'see the nerve' and sometimes paresthesias happen...

I know this may look like I'm defending the practice, but as I stated before, I do not sedate for >95% of TFESi.

Will 2-3 mg of midazolam stop the discomfort from a "sharp paresthesia"?

 

[fentanyl patch]

No, but it may prevent them from remembering the paresthesia and will be less anxious if they need another injection.

I don't do moderate sedation bc it just slows my day down too much, esp when the IV is difficult to place and I have to do it.

 

[pastafan]

Few things:

I think it demands on your market. Where I'm at, there are a ton of pain docs. Patients have been given injections elsewhere and simply have a phobia to needles. Some of them are just hypersensitized for sure. They simply have been soo traumatized that they are not willing to have injections w/o sedation. Otherwise they have a normal psych profile.


Additionally. IF you are in private practice and not in academics, the consumers drive the market. If patients know that they can go to clinic X across the street and get an injection with sedation vs at your place.....where do you think they will go?

I would say that very few of us have ever had an LESI, TFESI or anything. I know I haven't. But if it were you, where would you go? How many times have one of you done a TFESI and had a paresthesia? Especially if now, everyone is moving to this retrodiscal approach. It's not that pleasant to get a sharp paresthesia. None of us can 'see the nerve' and sometimes paresthesias happen...

I know this may look like I'm defending the practice, but as I stated before, I do not sedate for >95% of TFESi.

Valid points. If it was me I know where I would go. I would not receive sedation but I would receive adequate local anesthetic for the procedure.

 

[kstarm]

I was trained in using procedural hypnosis a couple of months ago. Our fellowship is looking at implementing it in a more standardized way, having the nursing staff/ancillary staff trained to do it while we do procedures. I have been very impressed with how well it works to calm people down for the procedures. It also gives an opening to talk about the benefits of health psych, after they have had a positive experience with it. The main issue we are having has to do with workflow and making sure people are getting in and out on time.

 

[SSdoc33]

Valid points. If it was me I know where I would go. I would not receive sedation but I would receive adequate local anesthetic for the procedure.

try a TFESI with no local and a 25g or 23g. maybe some local in the injectate, but a skin wheal, injection of fat, injection of muscle, etc, is multiple different pinches and more time.
if you know what you are doing, just pop it in there and move on. the patients will thank you for it.

 

[pastafan]

try a TFESI with no local and a 25g or 23g. maybe some local in the injectate, but a skin wheal, injection of fat, injection of muscle, etc, is multiple different pinches and more time.
if you know what you are doing, just pop it in there and move on. the patients will thank you for it.

I have never been a believer in a skin wheal. Consider IM injections. With a small needle they are not really painful. Instead of a skin wheal I take a 25 or 27g 1.25" needle, bury it to the hub and then inject on the way out. Fast and it obviates multiple sticks to anesthetize various structures while achieving the same result as a skin wheal.

 

[spinal]

I started doing everything without sedation. Now about half of my injections get sedation. I was the biggest proponent against the sedation a few years back.
I lost some patients because they thought it was cruel to do the injections without sedation. I saw a young guy have seizure like convulsions just from anxiety/vasovagal response(only 2 ml of local injected peripherally). I have seen a few vasovagal reactions that could have lead to a brain contusion if the signs would have been ignored. Had a old guy had an acute coronary syndrome just after the TFESI. I have changed my ways a bit.
Now I give them the option. My current rule is: No sedation for simple procedures. Optional for medium and required for advanced procedures.
I strongly believe that each patient is different-treat the patient-evaluate who needs it and who doesn't. ONE SIZE DOES NOT FIT ALL.

 

[Aether2000]

A chronic pain patient with hypersensitivity to touch is a completely different animal than an acute disc herniation in an otherwise healthy individual. The former may indeed perceive axial injections as torture as their movement during the procedure deflects the needles (especially 25ga) causing multiple passes to be required. Pressurization of the neuroforamen even though the needle is in the posterior neuroforamen, can cause them to come off the table. The sedation is for the comfort and psychological well being of the patient- it is not for the physician. That is why we usually give general anesthesia for brain surgery. It is not necessary at all, but it is humane.

Patient perception of pain is not related to the duration of time the pain occurs but is related to peak intensity, that is modulated by sleep deprivation, chronic anxiety, depression, past experiences with pain physicians giving injections, cultural issues, and genetics. A bad experience with an injection due to this perceived peak intensity (pain, like other neural processes, is logarithmic, not linear) may prevent the patient from ever receiving another injection again. Whereas skin localization may be beneficial for some, in others the skin wheel simply amplifies the fear and hypersensitivity of what is to follow. While it would be nice to be able to hypnotize patients or use progressive desensitization, most chronic intractable pain patients with hypersensitivity respond poorly to this, and it is time intensive.

Financing sedation is an issue, but if if inexpensive sedation agents are used and there is not a protracted post injection monitoring period for which there is another charge, then sedation can be useful. As far as safety and pithing the nerve with a sharp needle- using fluoroscopy in a rational manner can prevent this by maintaining the needle far posterior to the nerve. Blunt needles simply cannot penetrate the nerve therefore when used with sedation, are the least likely to cause nerve damage.

Sedation is not for everyone, but should not be withheld because solely on the basis of physician bias, the erroneous concept that the physician can somehow determine the level of pain the patient is experiencing during the injection, or preconceived ideas based on poorly constructed studies.

 

[lobelsteve]

A chronic pain patient with hypersensitivity to touch is a completely different animal than an acute disc herniation in an otherwise healthy individual. The former may indeed perceive axial injections as torture as their movement during the procedure deflects the needles (especially 25ga) causing multiple passes to be required. Pressurization of the neuroforamen even though the needle is in the posterior neuroforamen, can cause them to come off the table. The sedation is for the comfort and psychological well being of the patient- it is not for the physician. That is why we usually give general anesthesia for brain surgery. It is not necessary at all, but it is humane.

Patient perception of pain is not related to the duration of time the pain occurs but is related to peak intensity, that is modulated by sleep deprivation, chronic anxiety, depression, past experiences with pain physicians giving injections, cultural issues, and genetics. A bad experience with an injection due to this perceived peak intensity (pain, like other neural processes, is logarithmic, not linear) may prevent the patient from ever receiving another injection again. Whereas skin localization may be beneficial for some, in others the skin wheel simply amplifies the fear and hypersensitivity of what is to follow. While it would be nice to be able to hypnotize patients or use progressive desensitization, most chronic intractable pain patients with hypersensitivity respond poorly to this, and it is time intensive.

Financing sedation is an issue, but if if inexpensive sedation agents are used and there is not a protracted post injection monitoring period for which there is another charge, then sedation can be useful. As far as safety and pithing the nerve with a sharp needle- using fluoroscopy in a rational manner can prevent this by maintaining the needle far posterior to the nerve. Blunt needles simply cannot penetrate the nerve therefore when used with sedation, are the least likely to cause nerve damage.

Sedation is not for everyone, but should not be withheld because solely on the basis of physician bias, the erroneous concept that the physician can somehow determine the level of pain the patient is experiencing during the injection, or preconceived ideas based on poorly constructed studies.

My patient's nerves are radiolucent, though I think I know where Netter told them to be. And those blunt needles are magic. Cannot puncture skin, muscle, or nerve. Only if I had a mallet.

 

[bedrock]

try a TFESI with no local and a 25g or 23g. maybe some local in the injectate, but a skin wheal, injection of fat, injection of muscle, etc, is multiple different pinches and more time.
if you know what you are doing, just pop it in there and move on. the patients will thank you for it.

I think you're right. I recently started doing that after you or someone else suggested it on the forum.

I've found that most patients do better just getting it over with. I use 23G quincke for everything (if patient is thin enough), and they do better just getting started with the primary needle for most things.

I am quite liberal with valium. Taking the edge off your nerves helps most people. I require a driver for all axial spine injections other than SIJ. So most patients get 10-20mg of valium, other than the elderly, who don't need it 99% of the time.

 

[clubdeac]

I think you're right. I recently started doing that after you or someone else suggested it on the forum.

I've found that most patients do better just getting it over with. I use 23G quincke for everything (if patient is thin enough), and they do better just getting started with the primary needle for most things.

I am quite liberal with valium. Taking the edge off your nerves helps most people. I require a driver for all axial spine injections other than SIJ. So most patients get 10-20mg of valium, other than the elderly, who don't need it 99% of the time.

I didn't know they made a 23g needle. And bedrock are you still using the BD needles? Does BD make a 23g 3 1/2"?

 

[bedrock]

I didn't know they made a 23g needle. And bedrock are you still using the BD needles? Does BD make a 23g 3 1/2"?

BD needles are great. They are the only brand of quincke needles that I use.

The make 25g needles in 2in, 3.5, and 4.7 in lengths. 22 gauge in 3.5, 5, 7, and 9 inch.
The 23 g needles only come in 3.5 in length unfortunately. I would love a 23G 5in for my thicker patients.

 

[SSdoc33]

BD needles are great. They are the only brand of quincke needles that I use.

The make 25g needles in 2in, 3.5, and 4.7 in lengths. 22 gauge in 3.5, 5, 7, and 9 inch.
The 23 g needles only come in 3.5 in length unfortunately. I would love a 23G 5in for my thicker patients.

no, they make 23g 3.5, 5, and 6 inchers. i think they are expensive, though. let me check the brand, its not BD.

 

[Jcm800]

I think you're right. I recently started doing that after you or someone else suggested it on the forum.

I've found that most patients do better just getting it over with. I use 23G quincke for everything (if patient is thin enough), and they do better just getting started with the primary needle for most things.

I am quite liberal with valium. Taking the edge off your nerves helps most people. I require a driver for all axial spine injections other than SIJ. So most patients get 10-20mg of valium, other than the elderly, who don't need it 99% of the time.

i dod MBBs with a 25 gauge spinal needle with skin/sub q local all the time. In fact, i do one side with local and one without and ask which hurt more. usually it is the local side...

 

[Jcm800]

i argue the below patient should not be having procedures...as likely their issue isnt "pain" but their "interpretation" of pain and they are likely unable to tolerate ANYTHING, and are likely chemical copers. the guy with a little NF stenosis on his MRI, but 10/10 pain, which he has been trying to get disability for for 10 years, needs 6-7 Norco a day... etc...those are ones that jump off the table for me, and are "hypersensitive" and i typically pass on doing any procedure on... sometimes you dont know until the local, but you usually do...

A chronic pain patient with hypersensitivity to touch is a completely different animal than an acute disc herniation in an otherwise healthy individual. The former may indeed perceive axial injections as torture as their movement during the procedure deflects the needles (especially 25ga) causing multiple passes to be required. Pressurization of the neuroforamen even though the needle is in the posterior neuroforamen, can cause them to come off the table. The sedation is for the comfort and psychological well being of the patient- it is not for the physician. That is why we usually give general anesthesia for brain surgery. It is not necessary at all, but it is humane.

Patient perception of pain is not related to the duration of time the pain occurs but is related to peak intensity, that is modulated by sleep deprivation, chronic anxiety, depression, past experiences with pain physicians giving injections, cultural issues, and genetics. A bad experience with an injection due to this perceived peak intensity (pain, like other neural processes, is logarithmic, not linear) may prevent the patient from ever receiving another injection again. Whereas skin localization may be beneficial for some, in others the skin wheel simply amplifies the fear and hypersensitivity of what is to follow. While it would be nice to be able to hypnotize patients or use progressive desensitization, most chronic intractable pain patients with hypersensitivity respond poorly to this, and it is time intensive.

Financing sedation is an issue, but if if inexpensive sedation agents are used and there is not a protracted post injection monitoring period for which there is another charge, then sedation can be useful. As far as safety and pithing the nerve with a sharp needle- using fluoroscopy in a rational manner can prevent this by maintaining the needle far posterior to the nerve. Blunt needles simply cannot penetrate the nerve therefore when used with sedation, are the least likely to cause nerve damage.

Sedation is not for everyone, but should not be withheld because solely on the basis of physician bias, the erroneous concept that the physician can somehow determine the level of pain the patient is experiencing during the injection, or preconceived ideas based on poorly constructed studies.

 

[Aether2000]

And that is exactly why sedation is useful. Those that do respond to TFESI with chronic intractable pain and chronic radiculopathies are not infrequent. Unlike other practices, we do not push patients into interventional procedures. They come to me and ask for them after they are presented with an array of possible treatments. So sedation can indeed permit patients with chronic pain to benefit from injections that would either never be contemplated by the patient or would make it impossible to perform without.

 

[Ducttape]

i dod MBBs with a 25 gauge spinal needle with skin/sub q local all the time. In fact, i do one side with local and one without and ask which hurt more. usually it is the local side...

I'm happy that there are docs that don't use local anesthesia - two in my area don't. Conservatively i estimate I've seen at least 50 of their patients over that past year, self-referred - due to procedural pain...

 

[Pain Applicant1]

I agree with JCM, sometimes local does more harm than good. Something that's helped me was switching to 0.5% lido. Just as effective. I'm not sure why anyone uses 1% other than it being less expensive. Still, even at 0.5%, some pts don't like it.

 

[lord_jeebus]

no, they make 23g 3.5, 5, and 6 inchers. i think they are expensive, though. let me check the brand, its not BD.

We got these at my fellowship program from Kimberly Clark, I remember that they were significantly more expensive than others.

 

[bedrock]

I'm happy that there are docs that don't use local anesthesia - two in my area don't. Conservatively i estimate I've seen at least 50 of their patients over that past year, self-referred - due to procedural pain...

For MBB only, I've found that doing a skin wheel with a 27 gauge needle isn't particularly helpful and often hurts more than just directly doing the entire procedure with a 25 gauge needle. Skin wheels may also contribute to false positive MBB in some patients.

 

[Kwijibo]

I'd take sedation for my colonoscopy and my TESI thank you very much

 

[lobelsteve]

For MBB only, I've found that doing a skin wheel with a 27 gauge needle isn't particularly helpful and often hurts more than just directly doing the entire procedure with a 25 gauge needle. Skin wheels may also contribute to false positive MBB in some patients.

Data please.

 

[PinchandBurn]

For MBB only, I've found that doing a skin wheel with a 27 gauge needle isn't particularly helpful and often hurts more than just directly doing the entire procedure with a 25 gauge needle. Skin wheels may also contribute to false positive MBB in some patients.

I agree with this.

I know Steve wants data. But let's ask him, what's the data to prove the opposite?

I agree, skin wheals can contribute to false positives at times. Furthermore, with a 25G needle its just one poke. Sometimes even using a little ethyl chloride to numb the skin isn't a bad idea either.

 

[lobelsteve]

I agree with this.

I know Steve wants data. But let's ask him, what's the data to prove the opposite?

I agree, skin wheals can contribute to false positives at times. Furthermore, with a 25G needle its just one poke. Sometimes even using a little ethyl chloride to numb the skin isn't a bad idea either.

I believe it's how Lord, Barnsley, Bogduk, Derby, Dreyfuss, and April did it when they were creating all our data.

 

[Ducttape]

to get specific...

are you saying that the false positive means that the skin wheal gives a positive response, i.e. patients have an appropriate reduction in pain?

 

[bedrock]

I believe it's how Lord, Barnsley, Bogduk, Derby, Dreyfuss, and April did it when they were creating all our data.

None of those studies proves that my approach is inferior, only that their MBB did work. Those studies were not all done with the same exact % of lidocaine, same diameter skin wheel etc.

Get real steve, half of your posts on the forum are "this is the way I do it so it is perfect", and you have don't have data to back up 80% of those.

Much of what we do this this forum is share clinical findings/impressions/techniques for which we don't have a double-blinded-randomized-placebo-controlled trial to prove their superiority. Most of your posts aren't supported by papers.