Why not CESI and LESI at same time?

[studentdocg]

I don't do it, but I don't really have a clear answer when patients ask me why not. "Because we never did in fellowship" doesn't really answer the question. And despite my best google efforts I can't find a straight answer.

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[Ducttape]

double the dose of steroids, double the dose of contrast, double the dose of radiation...

course, the American way is the more the better, right?

ask them how they would feel if they had to eat two Big Mac Meals.



fwiw, the best answer is that Medicare and most private insurances will not pay for 2 separate distinct injections on the same day, barring extenuating circumstances (anticoagulation being probably the primary one).

 

[studentdocg]

The combined contrast and radiation doses for a CESI and a LESI are still far less than for many other procedures. And if they're getting the second procedure in a month anyway, it doesn't seem like you're really reducing the exposure. Same with steroids, although I can definitely see an elderly patient or a diabetic being a different story there.

I know we don't get paid for the second one, but why? If the patient is paying cash, would any of you do both at the same time? Has anybody ever done both? I've done ESI + peripheral joint before, and I guess I don't really see the difference.

 

[dhcofc]

The second procedure may be worth a lower RVU. Not sure if subsequent procedures on the same day are reimbursed less.

 

[unchockey21]

The combined contrast and radiation doses for a CESI and a LESI are still far less than for many other procedures. And if they're getting the second procedure in a month anyway, it doesn't seem like you're really reducing the exposure. Same with steroids, although I can definitely see an elderly patient or a diabetic being a different story there.

I know we don't get paid for the second one, but why? If the patient is paying cash, would any of you do both at the same time? Has anybody ever done both? I've done ESI + peripheral joint before, and I guess I don't really see the difference.

Personal injury needle jockeys do this regularly.

 

[Ferrismonk]

All of the above is true, but basically it's not good medicine. Treat one issue at a time. These are elective procedures. Don't complicate it and muddle your results.

 

[studentdocg]

Many of my patients say that separating the procedures into two separate days complicates their lives unnecessarily. I tell patients that if we do both at once we might not know which one really helped. CESI + shoulder? Sure, I buy that argument. Combining other procedures with SNRB or MBB? Again, sure. But a CESI muddling the results of a LESI? Neck injections never seem to help a lumbar radiculopathy, but maybe I'm doing them wrong. Of course frequently my lumbar injections don't help lumbar radic pain either, so there's that.

 

[painfree23]

Similarly, What’s the real reasoning behind not doing a 3 level bilateral Transforaminal? Is there a reason we can give patients/legal counsel? Not really imho other than it’s just excessive bc we don’t normally do it

 

[lobelsteve]

DO it on one patient. Holds Plavix.

 

[hyperalgesia]

My biggest hesitation is that I don't want to enable unhealthy coping.

The most common requests I get for this are things like TPI to numb up their whole body every week in addition to a CESI for the occasional radicular pain.

Obviously exceptions can be made but the main thing I don't want to do is participate in a "chemical coping" type scenario.

 

[SommeRiver]

One thing at a time.

 

[clubdeac]

I used to do this at the VA because patients often had to wait at least 3 months to get their next procedure and I felt bad... especially if they had significant pathology in both areas. I'd just halve the steroid dose, 40mg depo in both areas. They all did fine and were more than appreciative. I do think it ups the risk somewhat. I don't do it now in private practice primarily b/c I won't likely get paid for the second injection and if something does go wrong, the lawyers may have a field day stating it's not the "standard of care" whatever that is haha

 

[Ducttape]

my question to OP - why would you really want to endanger someone's adrenal glands by giving them such a supra-therapeutic dose of steroids in 1 day? splitting the steroid dose like clubdeac does presuppose that it is the steroid at a particular dose that really helps. ive tried cutting in 1/2, but too often hear that "that last injection didn't work because you didn't use as much meds in there". literature however seems equivocal - theres a lot that say epidurals don't work at all.....

fwiw, I spread apart my epidurals by at least 30 days. even for a hot radic, at most esi's 30 days apart, no sooner.

so, summary here are the reasons I would not do 2 injections at once
1. double the jeopardy of a complication on one day - ie double radiation, double risk of infection, etc.
2. double the steroid dose
3. double the time to do the injections (or close to it)
4. don't get paid for 1 of the injections possibly not both if Medicare patient
5. I don't want to be that guy that does 2 level TF, bilat SI, and MBB 3 levels bilat in one session. under GA. (a scenario that I have seen on at least 100 times)

 

[Ligament]

Complications. Post op neuro deficits. From the neck or low back or both? Do you really need to deal with that for an elective procedure? Also you will get paid less, so screw that.

 

[studentdocg]

For anyone who is not yet an attending reading this, not getting paid and having the consensus of your peers say that it's bad are each good reasons not to do something.

But I'm still not really satisfied as to why.
-Doubling your complications in one day could also be seen as halving the number of days in which you could have a complication.
-The steroid dose can easily be halved with some studies claiming that we should be using only 40 mg depo in the first place like you mentioned, so you'd still be using 80 total as you do now.
- It would actually likely reduce overall injection/procedure/turnover time.
- You got met there; but why is this the case?
- I don't want to be that guy either, but mainly bc the med community frowns on it. And I still can't find a logical reason why

I dunno, I just find it interesting that something that is so universally seen as bad medicine doesn't have a more clear answer as to why.

 

[studentdocg]

Complications. Post op neuro deficits. From the neck or low back or both? Do you really need to deal with that for an elective procedure? Also you will get paid less, so screw that.

Very true, why didn't I think of that? I'm convinced now

 

[Ducttape]

in terms of it being bad medicine, thats because you are showing you have no idea what you are treating.

it will not reduce turnover time for that particular time slot. get paid for the work you do.
fwiw, evicore guidelines:

CMM-200.6: Non-Indications: ESI

 An epidural steroid injection performed with ultrasound guidance is considered experimental, investigational, or unproven.
 An epidural steroid injection is considered not medically necessary for ALL of the following:
 When performed without imaging guidance (i.e., CT, fluoroscopy)
 Transforaminal epidural steroid injection (TFESI) performed at more than two (2) nerve root levels during the same session/procedure.

 An interlaminar epidural steroid injection (ILESI), performed at more than a single level during the same session/procedure

the more you do on someone on a given day, the more likely you will have a complication. KISS...

 

[SommeRiver]

in terms of it being bad medicine, thats because you are showing you have no idea what you are treating.

it will not reduce turnover time for that particular time slot. get paid for the work you do.
fwiw, evicore guidelines:



the more you do on someone on a given day, the more likely you will have a complication. KISS...

God help me for my agreeing with Evicore (they are all going to Hades at Evicore).

 

[studentdocg]

It's absolutely faster to do them together compared to two separate days. 2 turnovers takes longer than 1.

The more days you do something to someone, the more likely you will have a complication. So that cuts both ways.

And I'm pretty sure evicore was targeting the IL L3-4, L4-5 crowd because the spread from one should get both. Not the CESI/Lesi crowd. But that's probably bc the cesi/lesi crowd is so far out there due to what ligament said that it doesn't need refuting.

 

[painfree23]

It's absolutely faster to do them together compared to two separate days. 2 turnovers takes longer than 1.

The more days you do something to someone, the more likely you will have a complication. So that cuts both ways.

And I'm pretty sure evicore was targeting the IL L3-4, L4-5 crowd because the spread from one should get both. Not the CESI/Lesi crowd. But that's probably bc the cesi/lesi crowd is so far out there due to what ligament said that it doesn't need refuting.

Evicore soon, “just inject enough in the LESI so it goes up to the cspine”

 

[Ducttape]

You seem set in your idea that this treatment pattern is acceptable. Read what you wrote. You are here looking for justification for a practice pattern that is not standard of care.

I don’t think anyone on this forum would do what you are advocating, barring extenuating circumstances.

 

[dhcofc]

The more days you do something to someone, the more likely you will have a complication

Not sure I agree with this. I don’t see why doing a CESI and LESI on different days is riskier than doing both the same day.

 

[emd123]

When people ask me for an LESI and CESI on the same day, I just tell them, "We can't do it. Insurance rules. They won't allow it.' I rarely get any blowback from that, for some reason.

 

[studentdocg]

You seem set in your idea that this treatment pattern is acceptable. Read what you wrote. You are here looking for justification for a practice pattern that is not standard of care.

I don’t think anyone on this forum would do what you are advocating, barring extenuating circumstances.

I know it's unacceptable, have never done it, and just wanted to understand why beyond 'somebody said it was bad.' And again, this thread gave me my answer, so thank you all.

 

[Ligament]

Not sure I agree with this. I don’t see why doing a CESI and LESI on different days is riskier than doing both the same day.

Its not so much the overall risk that is an issue (it is an issue by the way), it is figuring out what is wrong in case there is a complication. Do a CESI and LESI on same day. Few hours later complaining of increased leg pain. Now you gotta workup BOTH cervical and lumbar complications. Image BOTH the cervical and lumbar spine urgently.

God forbid you have an infection. Your infection is now in the cervical and lumbar spine.

Etc etc.

Not worth it for that alone.

Add in the fact you will get ripped off on payment, that just makes it worse.

 

[SommeRiver]

Reading the Evicore rules...Has anyone seen or heard of someone doing an interlaminar ESI at more than one level? Like an L4-5 and an L2-3 during one visit.

I've actually never thought about that as a possibility but I GUARANTEE that's been tried before...

 

[painfree23]

Reading the Evicore rules...Has anyone seen or heard of someone doing an interlaminar ESI at more than one level? Like an L4-5 and an L2-3 during one visit.

I've actually never thought about that as a possibility but I GUARANTEE that's been tried before...

I’ve had a few requests for this. Frankly just ignore the request and do the level I think is causing more problems and inject some extra volume

 

[Ducttape]

Reading the Evicore rules...Has anyone seen or heard of someone doing an interlaminar ESI at more than one level? Like an L4-5 and an L2-3 during one visit.

I've actually never thought about that as a possibility but I GUARANTEE that's been tried before...

yes.

block shops were notorious for doing this. 2 level ESI, 4 level FJI, and bilat SI under GA in one sitting was the worst I have seen. 240 mg depo in 1 sitting. repeated 4 weeks x2. cost the patient well nigh $10,000.

 

[SommeRiver]

yes.

block shops were notorious for doing this. 2 level ESI, 4 level FJI, and bilat SI under GA in one sitting was the worst I have seen. 240 mg depo in 1 sitting. repeated 4 weeks x2. cost the patient well nigh $10,000.

...put that practitioner to death...