2 level ILESI??

[macman]

OK, saw a new pt today. Looking to establish care. mainly needs new doc for ILESI after moving to our area

prior doc was doing L3-4 AND L4-5 ILESI. what? she claims her insurance had no issue with this (United)

was also test dosing pt and flushing with marcaine.

This does not compute

thoughts?

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[Taus]

Weird. Figured was PI bullsht

 

[MitchLevi]

What do you mean test dosing and flushing?

 

[macman]

What do you mean test dosing and flushing?

Okay, you know how some of us do a test dose before we inject the steroid for a transforaminal. In the procedure report it states a test dose was done during the interlaminar. I have never seen that before and I do not understand the rationale.

What I mean by flushing is when they were done with the procedure they flushed 1 to 2 mL of bupivacaine into the epidural space after the steroid

 

[Agast]

SO in the spirit of the NASS Fellowship thread, what ACGME-certified fellowship did this intrepid soul graduate from

 

[Ferrismonk]

2 level makes no sense. ILESI covers multiple levels even if insurance would pay for it.

Nobody does a test dose ever since they invented fluoroscopy and xray dye.

 

[macman]

2 level makes no sense. ILESI covers multiple levels even if insurance would pay for it.

Nobody does a test dose ever since they invented fluoroscopy and xray dye.

So I know the other physician. We went to med school together. Honestly a super super nice guy. I do not know where he did his fellowship. I have not been in touch with him since medical school but I may have to call him up and give him a hard time 🙂

 

[lobelsteve]

So I know the other physician. We went to med school together. Honestly a super super nice guy. I do not know where he did his fellowship. I have not been in touch with him since medical school but I may have to call him up and give him a hard time 🙂

Is it Dan?

 

[macman]

Is it Dan?

No sir

 

[NJPAIN]

So I know the other physician. We went to med school together. Honestly a super super nice guy. I do not know where he did his fellowship. I have not been in touch with him since medical school but I may have to call him up and give him a hard time 🙂

Nice guys are corrupted every day in pain medicine. As someone said, must be PI. I did two PI IMEs this week. Each patient received an MRI of entire spine, shoulders and knees. Series of three lumbar and cervical epidurals and BS percutaneous cervical decompression.

 

[deleted875186]

What is a percutaneous cervical decompression?

 

[NJPAIN]

What is a percutaneous cervical decompression?

Stryker Dekompressor. I did bunch of lumbar cases >> 15 years ago. The amount of disc removed is ridiculously small.

 

[deleted875186]

One of the people I work with does a two level epidural. Will do an ILESI on the left and one on the right, or one at the bottom of the spine and one at the top. Probably only gets paid for 62323 x 1, extra work for nothing I bet

 

[jsaul]

Was it a L4-5 interlaminer" with spread to L3-4 and L4-5 "

 

[MitchLevi]

Okay, you know how some of us do a test dose before we inject the steroid for a transforaminal. In the procedure report it states a test dose was done during the interlaminar. I have never seen that before and I do not understand the rationale.

What I mean by flushing is when they were done with the procedure they flushed 1 to 2 mL of bupivacaine into the epidural space after the steroid

That's what I thought you meant.

Does anyone actually do test doses?

 

[RoloTomassi]

What is a percutaneous cervical decompression?

Disc-FX is one I've seen

 

[Taus]

That's what I thought you meant.

Does anyone actually do test doses?

Not since I stopped using particulate on tfesi

 

[DrSpine]

Nice guys are corrupted every day in pain medicine. As someone said, must be PI. I did two PI IMEs this week. Each patient received an MRI of entire spine, shoulders and knees. Series of three lumbar and cervical epidurals and BS percutaneous cervical decompression.

Percutaneous Cervical Decompression with Stryker may not work much, but I've seen several patients do very well with Elliquence Disc-Fx. So I wouldn't be quick to knock on it. I wouldn't jump to the procedure, but if justified after failing conservative management, and they don't want an intensive procedure, wouldn't be a bad idea. Obviously as a Pain Doctor, I wouldn't do Cervical, but I actually don't mind that procedure. Biggest issue though I see is some physicians don't take out much of the disc when doing Elliquence.

 

[RoloTomassi]

Percutaneous Cervical Decompression with Stryker may not work much, but I've seen several patients do very well with Elliquence Disc-Fx. So I wouldn't be quick to knock on it. I wouldn't jump to the procedure, but if justified after failing conservative management, and they don't want an intensive procedure, wouldn't be a bad idea. Obviously as a Pain Doctor, I wouldn't do Cervical, but I actually don't mind that procedure. Biggest issue though I see is some physicians don't take out much of the disc when doing Elliquence.

Who's a candidate? Endo/microdiscs are not that intensive to me. Does taking out a bunch of good nucleus lead to accelerated DDD?

 

[deleted131481]

One of the people I work with does a two level epidural. Will do an ILESI on the left and one on the right, or one at the bottom of the spine and one at the top. Probably only gets paid for 62323 x 1, extra work for nothing I bet

Depending on the spread, left and right parasaggital doesn't seem crazy for the same reason one would do bilateral TFESI.

 

[macman]

Was it a L4-5 interlaminer" with spread to L3-4 and L4-5 "

No, both levels injected ILESI

 

[lobelsteve]

No, both levels injected ILESI

Then the doc is a douche.

 

[macman]

So, for I remember this guy, he is a good guy. I do not think he is trying to scam anybody. My guess is:

Someone at some point showed him this idea of doing two-level interlaminar's, I have never seen it but there is someone out there who thinks it is a good idea. It must be his Plan B or plan C if a single level is not working. He probably does not realize he can only bill for one of the levels or he does not care not getting paid for the second level

I guess it is possible he is trying to game the system but I doubt that

 

[lobelsteve]

So, for I remember this guy, he is a good guy. I do not think he is trying to scam anybody. My guess is:

Someone at some point showed him this idea of doing two-level interlaminar's, I have never seen it but there is someone out there who thinks it is a good idea. It must be his Plan B or plan C if a single level is not working. He probably does not realize he can only bill for one of the levels or he does not care not getting paid for the second level

I guess it is possible he is trying to game the system but I doubt that

Either way he is an idiot. Yup, nice guys can be idiots as well.

 

[Ducttape]

many years ago, you could bill for 2 levels.

a local spine pain doc would do 3 level TFESI bilaterally, and bill for 6 level TFESI. he made a killing, and the academic pain docs had to spend hours explaining to us fellows why not to do such practice.

most of us listened...

 

[oneforfighting]

So I have never done a two level ILESI but now contemplating doing so. I understand that it wouldn't get reimbursed but wanted to give the patient the best chance at pain relief.

This patient has posterior L2-L4 fusion with moderate-severe CCS at L1-2 and moderate CCS at L4-5.
I am contemplating doing a T12-L1 ILESI (the L1-L2 epidural space is already violated by prior surgery) at the same time as an ILESI at L5-S1. My concern is that the L5-S1 ILESI would have difficulty traversing up to L1-2 both based off of the lower level stenosis and the distance needed for the medication to travel up. TFESI is not an option as there is severe b/l NFS from L1-2 to L4-5. What do others do in this circumstance?

 

[MitchLevi]

You can TF a severely stenotic foramen.

You should do that and not a two level ILESI. If the pt is severely painful during the injection put 1cc of lido 1-2% in the foramen, let it sit for 30 sec and inject.

This pt sounds like a stim candidate BTW.

 

[SpineandWine]

You can TF a severely stenotic foramen.

You should do that and not a two level ILESI. If the pt is severely painful during the injection put 1cc of lido 1-2% in the foramen, let it sit for 30 sec and inject.

This pt sounds like a stim candidate BTW.

If someone had severely stenotic foramen (T1W MRI, see no fat, just disc/nerve), my approach would not be transforaminal.

I’d do far lateral ILESI

Or do most of you do TFESI for severe foraminal stenosis

 

[deleted875186]

So I have never done a two level ILESI but now contemplating doing so. I understand that it wouldn't get reimbursed but wanted to give the patient the best chance at pain relief.

This patient has posterior L2-L4 fusion with moderate-severe CCS at L1-2 and moderate CCS at L4-5.
I am contemplating doing a T12-L1 ILESI (the L1-L2 epidural space is already violated by prior surgery) at the same time as an ILESI at L5-S1. My concern is that the L5-S1 ILESI would have difficulty traversing up to L1-2 both based off of the lower level stenosis and the distance needed for the medication to travel up. TFESI is not an option as there is severe b/l NFS from L1-2 to L4-5. What do others do in this circumstance?

I would look to see if ligamentum still at L1-2 and do a ILESI at that level. Sounds like you already looked.

 

[MitchLevi]

If someone had severely stenotic foramen (T1W MRI, see no fat, just disc/nerve), my approach would not be transforaminal.

I’d do far lateral ILESI

Or do most of you do TFESI for severe foraminal stenosis

I too go between the lamina in those cases, but I haven't ever gone above and below a fusion construct with an ILESI. Choose above or below IMO. If the pt has back pain go above. If leg pain go below.

Lick your finger and check the wind. Pray to Zeus.

I'd either caudal or do the TFESI.

With lido 2% you absolutely can do it. Valium 5mg and once you get to the foramen if they start squirming or making noise drop some lido in there. It will take the edge off enough for you to do it.

 

[bedrock]

So I have never done a two level ILESI but now contemplating doing so. I understand that it wouldn't get reimbursed but wanted to give the patient the best chance at pain relief.

This patient has posterior L2-L4 fusion with moderate-severe CCS at L1-2 and moderate CCS at L4-5.
I am contemplating doing a T12-L1 ILESI (the L1-L2 epidural space is already violated by prior surgery) at the same time as an ILESI at L5-S1. My concern is that the L5-S1 ILESI would have difficulty traversing up to L1-2 both based off of the lower level stenosis and the distance needed for the medication to travel up. TFESI is not an option as there is severe b/l NFS from L1-2 to L4-5. What do others do in this circumstance?

I think your idea makes perfect sense. Until about 18 months ago, you would get paid (by Medicare only) to do both ILESI on the same day.

I did this in the past, rarely, but it does makes sense for select patients.

I’d suggest you do both ILESI but do them separately two weeks apart. You get paid for all your work and you get some diagnostic information as well regarding which level causes what pain.

 

[lobelsteve]

Pick one. Base it on symptoms not images. If you guess wrong, do the other one.

 

[MitchLevi]

Pick one. Base it on symptoms not images. If you guess wrong, do the other one.

...and then your follow up shot gets denied and you must debate a "peer" with post-CVA aphasia.

There's a dude working for one of the major carriers who can't talk.

 

[bedrock]

...and then your follow up shot gets denied and you must debate a "peer" with post-CVA aphasia.

There's a dude working for one of the major carriers who can't talk.

Wow. That isn’t fair. Sorry for them , but if they can’t easily communicate verbally, they should not be allowed to do the job.

I bet the insurance company is secretly laughing about this bull$hit move they pulled on the physicians trying to help people.

 

[oneforfighting]

You can TF a severely stenotic foramen.

You should do that and not a two level ILESI. If the pt is severely painful during the injection put 1cc of lido 1-2% in the foramen, let it sit for 30 sec and inject.

This pt sounds like a stim candidate BTW.

Yeah I’m thinking stim at some point but pt is new to me and has not had ESI in many years.

Problem is when I look at the MRI, at the most stenotic level, there is a significant posterior broad based disc that looks like it’ll be right where my needle tip would be on a TFESI.

 

[oneforfighting]

I would look to see if ligamentum still at L1-2 and do a ILESI at that level. Sounds like you already looked.

Yep I looked and there’s no LF

 

[oneforfighting]

I think your idea makes perfect sense. Until about 18 months ago, you would get paid (by Medicare only) to do both ILESI on the same day.

I did this in the past, rarely, but it does makes sense for select patients.

I’d suggest you do both ILESI but do them separately two weeks apart. You get paid for all your work and you get some diagnostic information as well regarding which level causes what pain.

I like your suggestion and strongly considering

 

[oneforfighting]

Pick one. Base it on symptoms not images. If you guess wrong, do the other one.

Symptoms are low back and nondermatomal leg pains d/t neurogenic claudication. What injection would you do first?

 

[RoloTomassi]

Symptoms are low back and nondermatomal leg pains d/t neurogenic claudication. What injection would you do first?

I'd probably do the upper one first since it's more stenotic. Especially if there's any anterolateral distribution to the claudication

 

[lobelsteve]

Lower. Higher likelihood of causing sx.

 

[MitchLevi]

Wow. That isn’t fair. Sorry for them , but if they can’t easily communicate verbally, they should not be allowed to do the job.

I bet the insurance company is secretly laughing about this bull$hit move they pulled on the physicians trying to help people.

He overturned a stimulator for me but he can barely speak.

 

[deleted875186]

Yep I looked and there’s no LF

Then I would inject at T12-L1, if no effect then go to the lower lumbar. I would also consider sending to a neurosurgeon for single level decompression if short term relief only from the higher injection, otherwise SCS.

 

[oneforfighting]

Then I would inject at T12-L1, if no effect then go to the lower lumbar. I would also consider sending to a neurosurgeon for single level decompression if short term relief only from the higher injection, otherwise SCS.

In you experience will they do a single level lami above fusion?

 

[SC Tian]

He overturned a stimulator for me but he can barely speak.

I will keep talking to the guy, even I don't speak good English, eventually they will give up as they find it is more challenging talking to me and denying my trial. It was the case for one of our local carriers, they no longer deny my stimulator anymore. Good luck! 🙂

 

[deleted875186]

In you experience will they do a single level lami above fusion?

In my experience no, but I do think it’s at least worth giving the patient the option.

 

[MitchLevi]

If you're fused and then decompress the adjacent level without fusing you're going cause listhesis. Also, fusion to L1 or T12 sux.

 

[bedrock]

If you're fused and then decompress the adjacent level without fusing you're going cause listhesis. Also, fusion to L1 or T12 sux.

Agree that a listhesis will often (not always) happen. I’ve worked with many spine surgeons, some more aggressive than others. Some always fuse in this situation, others would do just the lami and wait.

A simple lami adjacent to lumbar fusion doesn’t necessarily always lead to immediate listhesis. It might take 5-8 years before that happens and you’ve saved stress on the second level up if you postpone a fusion for those 8 years.

Their spine lasts longer overall as result.

 

[MitchLevi]

I've never seen either spine surgeon in my group decompress an adjacent level without extending the fusion. In this case, you're talking about a potential L2-4 fusion with a lami at L1-2, right at the TL jxn. In my group that wouldn't happen.

 

[bedrock]

I've never seen either spine surgeon in my group decompress an adjacent level without extending the fusion. In this case, you're talking about a potential L2-4 fusion with a lami at L1-2, right at the TL jxn. In my group that wouldn't happen.

That’s what I was gently trying to say. It isn’t gospel than every surgeon must always fuse the next segment immediately if stenosis is present and the patient failed non surgical treatment.

Just because the surgeons in your particular group always do this, doesn’t mean that it is always right to do so.

 

[Ducttape]

if they try to decompress above or below, most surgeons will end up extending the fusion, and probably result in a L1-s1 fusion, because the stress on that level is too great, per my prior discussion with conservative surgeons.


also, be careful if you are having to get prior auth for these ESI. doing 2 lumbar ESI may trigger denial. from my experience, 2 lumbar levels is tricky. set these up and ask for them individually 3 months apart, or ask for T12-L1 thoracic epidural spaced 2 weeks apart from L5S1 lumbar epidural so as to get approval. (and straight Medicare "approves" all injections, but you of course run risk of getting it denied on audit)


unfortunately, with no ligamentum flavum, MILD isnt an option. after ESI, seems like stim, or surgery.