trigger point injections with toradol?

[jonnylingo]

Previous partner was using lido + toradol for TPIs. Anybody used this? Luck with this? Better than steroid?

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[ampaphb]

no reason to use anything but local, and that is just for patient comfort

 

[BobBarker]

We just use saline at my fellowship. Seems to work well. Of course, my attending who I do these with is a trigger point master. I bet he has done more TPIs than anyone in the country.

 

[bedrock]

Disagree. I do my TPIs with toradol/lidocaine.

I see better results than just lido alone.

I don't like using steroid for TPI due to risk of local atrophy and adding to their overall risk of adrenal suppression.

 

[lobelsteve]

Disagree. I do my TPIs with toradol/lidocaine.

I see better results than just lido alone.

I don't like using steroid for TPI due to risk of local atrophy and adding to their overall risk of adrenal suppression.

Got any studies to back it up?

 

[emd123]

Check your local Medicare LCD. Mine says than if you use saline alone you cannot bill for TPI. Must use local or steroids (or both) to bill. (Doesn't mention Toradol, either way).

 

[SSdoc33]

Do you bill for toradol separately?

 

[SSdoc33]

We just use saline at my fellowship. Seems to work well. Of course, my attending who I do these with is a trigger point master. I bet he has done more TPIs than anyone in the country.

Ahh, yes, a myofascist. If it hurts where you poke, it must by myofascial pain, right? Ugh.

If someone does a buttload of trigger point injections, they are probably not very well trained. TPIs don't really work all that well in general, and the patient population is a PITA.

 

[BobBarker]

He injects no more than two at a time. So far good results. He takes his time doing them. I know some don't believe that they really work but already have some good anecdotal evidence that they can work. Pt with chronic left leg pain, not dermatomal. 6 ESI's, stim trial, two surgeries nothing helped. TPIs to gluteus mediums and maximus. Started crying after the procedure because she was so happy to be pain free and didn't understand why the other doctors had not tried this first. Still pain free on follow up visit.

 

[bedrock]

He injects no more than two at a time. So far good results. He takes his time doing them. I know some don't believe that they really work but already have some good anecdotal evidence that they can work. Pt with chronic left leg pain, not dermatomal. 6 ESI's, stim trial, two surgeries nothing helped. TPIs to gluteus mediums and maximus. Started crying after the procedure because she was so happy to be pain free and didn't understand why the other doctors had not tried this first. Still pain free on follow up visit.

Let's see if it lasts more than one follow-up. Lots of people get immediate relief while local is in place. Lots of patients get relief for 3 weeks after the first one, but not repeat injections, when there is less placebo effect.

The last thing you want is a TPI happy practice with patients demanding TPI every 2 weeks. Do you realize just how poorly trigger points reimburse in the private world?

If most TPI could provide durable relief, that's one thing, but crappy reimbursement and very low incidence of durable relief is a bad combination.

 

[bedrock]

Do you bill for toradol separately?

No I don't. I'm not sure that you can. You can bill for toradol with an general IM injection like you get in the ER, but the procedure code pays so poorly you might as well just bill the TPI. Generic toradol is crazy cheap. $1.30 for 2ml 30mg/ml bottle, and I only use 15mg with my TPI.

And no steve, I don't have a study to back it up. You don't have studies to back up half the **** you do.
Adding NSAID does makes sense based on multiple studies of the inflammatory component of muscle triggers.

One of my Harvard attendings was a TPI guru, and myofascial literature expert. I learned TPI from him and that's what he used(toradol), and it seemed work to better than the attendings who only used lido. Since toradol costs a big extra 40cents, I still use it for my patients.

I now do TPI only intermittently. Most of the time, the trigger points are there because we aren't solving the root cause of the problem anyway.

 

[emd123]

We just use saline at my fellowship. Seems to work well. Of course, my attending who I do these with is a trigger point master. I bet he has done more TPIs than anyone in the country.

Trigger points are okay, but nothing great. I don't care how much of a master someone is of them. I do them here and there but I don't expect miracles. But they do play a role.

 

[clubdeac]

Just saw a patient today who had received numerous phenol tpi's from the neurologist down the street!!

She had all these hypopigmented scars over her traps and lower cervical paraspinals. I told her they were probably from the phenol injections. She said they worked.... cra cra

 

[epidural man]

Ahh, yes, a myofascist. If it hurts where you poke, it must by myofascial pain, right? Ugh.

If someone does a buttload of trigger point injections, they are probably not very well trained. TPIs don't really work all that well in general, and the patient population is a PITA.

Apparently you haven't read Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual (2-Volume Set).

Pure blasphemony that TPI's don't work. How could someone write TWO VOLUMES about trigger points if treating them with TPI's doesn't work?

 

[epidural man]

And no steve, I don't have a study to back it up.

Let's do a multi-center study! Seems easy enough.

 

[ampaphb]

The SDN.net working group. Is anyone affiliated with an IRB?

 

[BobBarker]

Yes, I realize his trigger point centric practice doesn't work in the real world.

 

[lonelobo]

Studies show that nothing works any better that just the Mechanical action of the needle, the rest is just one's choice of Voodoo Juice

 

[nvrsumr]

No one even mentioned sarapin. What's wrong with you guys and your choice of magic beans? haha

 

[emd123]

No one even mentioned sarapin. What's wrong with you guys and your choice of magic beans? haha

Traumeel

 

[geauxg8rs]

Traumeel

Succinylcholine works to reduce pain with a statistically significant reduction in VAS but no change in Return to work when compared to placebo.

 

[emd123]

Succinylcholine works to reduce pain with a statistically significant reduction in VAS but no change in Return to work when compared to placebo.

A true hard-core chronic painer will bounce back with a "10+" over 10 after the short duration of action of succs wears off, no problem. Try non-depolarizer.

 

[oreosandsake]

botulinum toxin

not covered. anyone doing this? results?

i posted on here a few years ago about ketoralac into the joint. some studies reported no chondrotoxic effects.

 

[Taus]

botulinum toxin

not covered. anyone doing this? results?

i posted on here a few years ago about ketoralac into the joint. some studies reported no chondrotoxic effects.

Botox covered if it's cervical dystonia.... Depends on how you define dystonia.

 

[SSdoc33]

Botox covered if it's cervical dystonia.... Depends on how you define dystonia.

seems like a big hassle to me, especially when the patients really dont even have dystonia....

 

[Gemrose]

We just use saline at my fellowship. Seems to work well. Of course, my attending who I do these with is a trigger point master. I bet he has done more TPIs than anyone in the country.

I have found saline alone does not work for myofascial pain relief. Traumeel, the best..unfortunately is not covered by insurance.

 

[ampaphb]

I have found saline alone does not work for myofascial pain relief. Traumeel, the best..unfortunately is not covered by insurance.

What do you think agents like Traumeel are adding to your injection? Given that they dissipate within an hour or two, I don't understand why they would have any durable effect.