$60M Lumbar TFESI Settlement

IPSIS: Formerly the Spine Intervention Society
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Ducttape said:
when i started, the first job i looked at, the pain doc did epidurals blind with no fluoro. including cervical, and she was SURE that they worked better than any image guided procedure.
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I’ve heard stories about these good ol’ days, and this was partly why “series of 3” was so popular (and necessary)
 
lobelsteve said:
Does not have to be depo. I have used Celestone since 2004.
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Celestone will last longer than dex. Depo will sometimes last longer than Celestone and is considerably cheaper than celestone for those of us in PP.

Celestone is more gentle than depo. I will still use celestone for some patient with significant automimmine disease of joints or nerves.
 
I wonder how many pain docs in our communities would still be doing tfesi if reimbursement switched tomorrow and now paid less than interlams. Any takers? My guess is <5%. The worry about anterior spread would just disappear. Hmm
 
paindoc007 said:
I wonder how many pain docs in our communities would still be doing tfesi if reimbursement switched tomorrow and now paid less than interlams. Any takers? My guess is <5%. The worry about anterior spread would just disappear. Hmm
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You meant 2 level tfesi…
 
Taus said:
You meant 2 level tfesi…
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Speaking of which....

I know we addressed this briefly in the other lawsuit thread but people were chiming in all over the place with tons of variation in practice. I'm curious as to what percent of TF injections people are doing as:

Single lvl
2 level (adjacent or not)
BL

I'm omitting BL 2 lvl as I assume this is going to be a vanishingly small number for people but please correct me if I'm wrong.

Relatedly: I looked at my schedule and there is a patient who has sx and MRI confirmation of severe NF stenosis at L5 and S1 who's booked this week for a L5 and S1 TFESI. Will take any and all critiques.
 
BoardingDoc said:
Speaking of which....

I know we addressed this briefly in the other lawsuit thread but people were chiming in all over the place with tons of variation in practice. I'm curious as to what percent of TF injections people are doing as:

Single lvl
2 level (adjacent or not)
BL

I'm omitting BL 2 lvl as I assume this is going to be a vanishingly small number for people but please correct me if I'm wrong.

Relatedly: I looked at my schedule and there is a patient who has sx and MRI confirmation of severe NF stenosis at L5 and S1 who's booked this week for a L5 and S1 TFESI. Will take any and all critiques.
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Just go b/l S1 and feel better about not doing unnecessary levels.
 
BoardingDoc said:
Speaking of which....

I know we addressed this briefly in the other lawsuit thread but people were chiming in all over the place with tons of variation in practice. I'm curious as to what percent of TF injections people are doing as:

Single lvl
2 level (adjacent or not)
BL

I'm omitting BL 2 lvl as I assume this is going to be a vanishingly small number for people but please correct me if I'm wrong.

Relatedly: I looked at my schedule and there is a patient who has sx and MRI confirmation of severe NF stenosis at L5 and S1 who's booked this week for a L5 and S1 TFESI. Will take any and all critiques.
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If there are two roots compressed in the distribution of pain… Then sure. I think it’s only BS/money grab if someone always does two levels, “because they can“ when one level will clearly suffice for the pathology.
 
I've been in PP since 2017 and never done one bilateral, two level TFESI. Think about the dilution of your injectate, and if you're keeping that consistent you're injecting 20mg of dexamethasone. Why? It costs more money and is going to cause more problems physiologically.
 
At the risk of being crucified here, we do bilateral and/or 2 level TFESI all the time. If the patient has radicular pain that corresponds to relevant discs, it's warranted.

I also think that the TFESI is a better injection in general. You get more anterior to the space where the disc is pressing against the nerve root vs interlaminar where the injectant is posterior to the problems. There is also less risk of worsening severe stenosis. Total dex for procedure, no matter how many levels you do should be less than 15mg. I use 10mg max and get good results.
 
In fellowship your attending may schedule things like bilateral 2 level to get your numbers up.

I had a neurosurgeon request bilateral L3-4-5 this week. Just ignored and will do staged bilateral single level starting at 4-5 if needed.

They Also wanted follow up a week later during the “anesthetic phase” ….
 
BoardingDoc said:
Speaking of which....

I know we addressed this briefly in the other lawsuit thread but people were chiming in all over the place with tons of variation in practice. I'm curious as to what percent of TF injections people are doing as:

Single lvl
2 level (adjacent or not)
BL

I'm omitting BL 2 lvl as I assume this is going to be a vanishingly small number for people but please correct me if I'm wrong.

Relatedly: I looked at my schedule and there is a patient who has sx and MRI confirmation of severe NF stenosis at L5 and S1 who's booked this week for a L5 and S1 TFESI. Will take any and all critiques.
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I do 2 level TFESIs not infrequently. That was how I was trained. Oftentimes patient has a combo of lateral recess and NF narrowing causing compression of two nerve roots. Now if its obviously one nerve I'll just do one level
 
I do 2 level uni more than 1. Probably a 2:1 ratio.

If I had to only do TF w/dex or IL w/depo exclusively, based on efficacy alone, I'd choose IL by a slim margin.
 
i dont remember ever doing a 2 level bilateral TFESI. seems like one would be spreading the dose too thin...

i do bilateral TFESI i would say at most 10% of the time, almost all bilateral S1.

i do 2 level TFESI like 1% of the time, and its when i am having an inferiority complex and one of those intermittent moral crises where i fear these procedures dont do anything.


then i remember monty python...
 
clubdeac said:
I do 2 level TFESIs not infrequently. That was how I was trained. Oftentimes patient has a combo of lateral recess and NF narrowing causing compression of two nerve roots. Now if its obviously one nerve I'll just do one level
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Then again I trained under Depalma and now looking back I’m unsure of how much he did was bc it was medically superior or just financially advantageous
 
Any problem injecting dex and ropivicaine separately, ie. not mixing them together in the syringe? Ropi already in the epidural space (or intravascular), then introduce dex epidurally (or intravascular)...
 
Ligament said:
Any problem injecting dex and ropivicaine separately, ie. not mixing them together in the syringe? Ropi already in the epidural space (or intravascular), then introduce dex epidurally (or intravascular)...
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FAFO

Rare complication so it could be your next epidural or take 500 years to occur.
 
Agast, that is some serious ‘Perry Mason’ deep-diving into this interesting case… nice work.
Not to defend this physician, but the Medicare LCDs (2021 lcd) literally quote 2018 ESI studies utilizing particulate steroids as background literature….
Prior Medicare LCDs included particulate steroid as an alternative option due to lack of efficacy up to 2018 I believe, only recently (2021) retracting particulate steroids as an option.
Even though in 2011 case reports were starting to emerge suggesting risk with particular steroids. It took time for the Medicare LCDs to catch up or physicians to change clinical practice.
So in 2019, you can assume that it was still a transitional time. Physicians were phasing out participate steroids.
That being said, I agree there’s no clear transforaminal epidurogram excluding obvious vascular uptake, which is the sentinel tool that we have in mitigating catastrophic injuries… if he lied, in addition, that’s sociopathic .
Finally $60 million settlement is obnoxious. even wrongful death suits pay closer to 6-10 million per human being. This will have to be addressed as an appellate court level.
If you remember a few years ago , there was a cervical RFA case that resulted in a catastrophic cervical injury which paid out a significant amount. This had national ripple effect, and essentially all our insurance premiums went up. Some insurance carriers even tried to stop covering RFA procedures. Not to defend this guy, but you don’t want a settlement this large upheld, as it will destroy our specialty… IMO
 
LaminaV said:
Agast, that is some serious ‘Perry Mason’ deep-diving into this interesting case… nice work.
Not to defend this physician, but the Medicare LCDs (2021 lcd) literally quote 2018 ESI studies utilizing particulate steroids as background literature….
Prior Medicare LCDs included particulate steroid as an alternative option due to lack of efficacy up to 2018 I believe, only recently (2021) retracting particulate steroids as an option.
Even though in 2011 case reports were starting to emerge suggesting risk with particular steroids. It took time for the Medicare LCDs to catch up or physicians to change clinical practice.
So in 2019, you can assume that it was still a transitional time. Physicians were phasing out participate steroids.
That being said, I agree there’s no clear transforaminal epidurogram excluding obvious vascular uptake, which is the sentinel tool that we have in mitigating catastrophic injuries… if he lied, in addition, that’s sociopathic .
Finally $60 million settlement is obnoxious. even wrongful death suits pay closer to 6-10 million per human being. This will have to be addressed as an appellate court level.
If you remember a few years ago , there was a cervical RFA case that resulted in a catastrophic cervical injury which paid out a significant amount. This had national ripple effect, and essentially all our insurance premiums went up. Some insurance carriers even tried to stop covering RFA procedures. Not to defend this guy, but you don’t want a settlement this large upheld, as it will destroy our specialty… IMO
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Do you know the details of the cervical RFA case. May be good to discuss
 
Only way to lesion the cord is to come in interlaminar or do a lateral trajectory with no concept of wigwag/oblique/tilt...

That is so difficult to do you'd have to prove to me it wasn't intentional. Prison IMO.
 
Saw a case locally of an RFA that resulted in cord poke, no lesion. ER referred to us. Pt was in WC
 
Agree that 60 million is ridiculous and not sustainable for medicine in general if these types of verdicts are upheld. Also agree that was a transitional time regarding particulates. Seems like a vengeful verdict for sure. The problem is when you discuss risks including rare catastrophes and one happens and still this verdict. If he discussed risk of nerve/cord injury then this is a baseless verdict. It seems they played the sympathy card as well as the Dr likely altering his notes to obscure the fact that this is not an unheard of issue as well as potentially his bad images. Maybe his tech saved the wrong images? Who knows.
Do heart surgeons get sued and lose every time a patient dies? No… because it’s expected due to the severity the patient’s condition.
However, when something is rare but happens Drs will be sued and lose. I can’t help but think the rarity is part of the problem just like with OB verdicts.
In the past OB m/m was so high it was expected to have bad outcomes..but they are victims of their own success so to speak now and I also feel this way with PM.
 
That seems nearly impossible to do by accident
 
The one I saw was posterior approach. I can only assume bad aim, advanced too far, too fast.
 
It’s a given that that RFA patient was sedated, but you’d have to skip the motor testing as well to move forwards with a cord lesion, right?
 
RoloTomassi said:
The one I saw was posterior approach. I can only assume bad aim, advanced too far, too fast.
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How?! Going too anterior lateral to joint doesn’t get you there. Somehow got rf needle through joint or interlam?! or took some crazy lateral to medial angle and went through foramen?

Earlier in my career, I would sometimes try to walk off os laterally, under lateral view, and tip would slide medially behind posterior joint… but I just can’t reason out how someone gets to the cord on this.
 
Maybe start posterior, make a few small advancements and go lateral view too early?
 
cowboydoc said:
I only saw the slide. Furman presented it in Chicago last year IIRC. Egregious incompetence, the air pressure plummeted from the collective gasp.
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Since everybody's chests expanded with the same volume of air lost to the room, was there really any change in air pressure in the room?
 
Taus said:
How?! Going too anterior lateral to joint doesn’t get you there. Somehow got rf needle through joint or interlam?! or took some crazy lateral to medial angle and went through foramen?

Earlier in my career, I would sometimes try to walk off os laterally, under lateral view, and tip would slide medially behind posterior joint… but I just can’t reason out how someone gets to the cord on this.
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Track looked like it went interlaminar
 
My question is who pays the 60 million? The doc certainly doesn’t have that and his insurance probably is only a few million. In these cases is the doc forced into bankruptcy and they confiscate all of his assets including his home? If so that’s sickening
 
Agast said:
I wonder if they went to the contralateral oblique view before touching down on os, and didn’t realize they were listing medial
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I doubt someone who stuck a needle in the cord is using the CLO view. Probably done under deep sedation with a posterior approach, but with only a lateral fluoro view.
 
callmeanesthesia said:
I doubt someone who stuck a needle in the cord is using the CLO view. Probably done under deep sedation with a posterior approach, but with only a lateral fluoro view.
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I can show you a great AP/Lat with catheter inside the cord at C2. Entered at C7-T1.
 
lobelsteve said:
I can show you a great AP/Lat with catheter inside the cord at C2. Entered at C7-T1.
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You reminded me to check my email. Other case. LESI gone bad. 10000 pages to review. Complications led to surgeries in other parts of the body and severe loss of functional status. Cannot comment further as in process.

Never do an injection that is not absolutely necessary.

 
callmeanesthesia said:
I doubt someone who stuck a needle in the cord is using the CLO view. Probably done under deep sedation with a posterior approach, but with only a lateral fluoro view.
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They would go medial to lateral but inadvertently be interlaminar. Pretty much impossible to do if the patient is not sedated
 
My guess -- moved probes from one level to another using only lateral view in an obese patient. Maybe from C7 which tends to be more lateral to C6.
 
There was a case in my state I reviewed . System errors: heavily sedated, sedated even more per pain Md (additional verbal order to crna), rfa probe midline(transforaminal?), missing images, “FLAME LESION” per radiologist report . Insurance premium hikes locally and nationally. No bueno…
 
Can you expound on what you mean by midline transforaminal?
 
Laryngospasm said:
Can you expound on what you mean by midline transforaminal?
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Tip of RFA needle was paracentral to midline on the AP, likely entered lateral via cervical foramina, seeded tip of rfa cannula at the lateral cord. Patient was ‘doubly sedated’ and unable to inform proceduralist of the piercing excruciating cervical radiculopathy during the rogue placement …
 
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