-
CycleTrack and SDN are teaming up to make medical school admissions more transparent and accessible! Read the announcement to learn how we’re supporting the future of CycleTrack’s free application-tracking tools .
BCBS RF criteria
Started by mdvol
Get help with your application
Use all the free resources available to you from SDN: articles, guides, expert advising, forums discussions, and school research.
1) Will they be paying for the placebo block?
2) I would point out to them this is NOT standard of care within your local or national community (referencing both ISIS and ASIPP Guidelines)
3) BCBS of NC was amongst the Individual Settling Blue Plans Listed on Settlement Agreement. As such, they agreed to abide by:
Patients will be entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice, and cheaper alternatives are permissible only when they are at least as likely to produce equivalent therapeutic or diagnostic results.
If they continue to refuse coverage of an RF after a standard double block paradigm, I would address the issue with the Joint Compliance Dispute Program (http://is.gd/1tFAv) Advertisement - Members don't see this ad
i had a few RFs with BC/BS of indiana under "review" for like months now. I think it is a tactic to hold onto their money until the bitter end...
Was he naked in those slides? That might be what killed it.😱
If you are basing your decision on the Schwartzer paper, better read it again (or for the first time as the case may be). It was a terrible paper that would never see the light of day today in any decent journal.
For those of you who enjoy appeals to authority, I discussed this issue with Bogduk by email about a year ago and he questioned the concept of MBBs on several grounds. In a similar set of emails, Derby also agreed the paper was invalid regarding MBBs.
I recently had a denial for RF. They wanted me to do two sets of MBBs. Ok, I'll be happy to waste your money. Where does this crap come from?
gorback you should have heard Bogduk's talk at ASIPP --- where he was very much pro 3 diagnostic injections for lumbar spine vs 2 for cervical spine...
i agree that there is a cost to this --- and would rather just proceed w/ RF instead of a 2nd shot --- especially because financially an RF just costs most of my insurers a few hundred dollars more at most...
i agree that there is a cost to this --- and would rather just proceed w/ RF instead of a 2nd shot --- especially because financially an RF just costs most of my insurers a few hundred dollars more at most...
I do not want to provide direct quotes from private emails, but suffice it to say that is not what he told me in a series of emails circa 7/8/08 - barely a year ago. He also claimed to have written several book chapters in which he questioned lumbar MBBs.
Sometimes I think Nik and I live on different planets. He says cervical facet pain is common and lumbar is not. I don't see this at all. I see a lot of lumbar facet disease and quite honestly RF in that area is one of the most consistently successful procedures I do. And I am still using sensory stim and only one set of MBBs. I know, lunatic fringe.
The cervical facet study of MBBs was much cleaner than the lumbar study of 1994, which wouldn't even win a middle school science fair today. In discussions with two of the authors (Bogduk and Derby) both agreed that the 1994 study basically sucked from a design POV. Go back and read it - it was a mess. For example, most of the patients got IA injections, not MBBs. How can you derive any conclusions about MBBs from that?
That is not to say the paper had no value. Those were far less sophisticated days in pain management (and medical publishing) and just the concept of doing diagnostic blocks for facet pain was revolutionary. It was the first time anyone tried to say "don't just go poking needles everywhere - try to be scientific about it."
Here's my algorithm:
Mark the painful levels on the skin.
Do MBBs for whatever is under the skin marks.
Poke them again. Sometimes you get a patient who has little tenderness but a lot of pain with certain activities. I once pulled out the office vacuum cleaner for a lady who said she mostly had pain while vacuuming (solution: hire a maid).
Patient has no pain afterward = confirmed diagnosis.
If they have continued pain you have to re-examine them and see if it's outside of where you anesthetized. Sometimes you have to block another level. Sometimes they have SI tenderness, etc. And sometimes they have persistent pain right where you did the block, indicating that it is not the posterior elements (or your aim is way off).
The main point is to examine them personally right after the block. Do not rely on self-reporting 2 weeks later, pain diaries, etc.
I do not accept 50% relief as a positive result. To me it means you didn't block all the things that hurt. You either blocked the pain generator or you didn't. I have no idea what "50% relief" means anyway. Same as "50% chance of rain" I suppose.
Sometimes I think Nik and I live on different planets. He says cervical facet pain is common and lumbar is not. I don't see this at all. I see a lot of lumbar facet disease and quite honestly RF in that area is one of the most consistently successful procedures I do. And I am still using sensory stim and only one set of MBBs. I know, lunatic fringe.
The cervical facet study of MBBs was much cleaner than the lumbar study of 1994, which wouldn't even win a middle school science fair today. In discussions with two of the authors (Bogduk and Derby) both agreed that the 1994 study basically sucked from a design POV. Go back and read it - it was a mess. For example, most of the patients got IA injections, not MBBs. How can you derive any conclusions about MBBs from that?
That is not to say the paper had no value. Those were far less sophisticated days in pain management (and medical publishing) and just the concept of doing diagnostic blocks for facet pain was revolutionary. It was the first time anyone tried to say "don't just go poking needles everywhere - try to be scientific about it."
Here's my algorithm:
Mark the painful levels on the skin.
Do MBBs for whatever is under the skin marks.
Poke them again. Sometimes you get a patient who has little tenderness but a lot of pain with certain activities. I once pulled out the office vacuum cleaner for a lady who said she mostly had pain while vacuuming (solution: hire a maid).
Patient has no pain afterward = confirmed diagnosis.
If they have continued pain you have to re-examine them and see if it's outside of where you anesthetized. Sometimes you have to block another level. Sometimes they have SI tenderness, etc. And sometimes they have persistent pain right where you did the block, indicating that it is not the posterior elements (or your aim is way off).
The main point is to examine them personally right after the block. Do not rely on self-reporting 2 weeks later, pain diaries, etc.
I do not accept 50% relief as a positive result. To me it means you didn't block all the things that hurt. You either blocked the pain generator or you didn't. I have no idea what "50% relief" means anyway. Same as "50% chance of rain" I suppose.
Hi Gorback I agree with most of your post, and also with the quote below with a question; In many if not most patients past a certain age, there are multiple pain generators.
So if you have an 80 yo patient with axial pain that gets 50% pain relief from MBB, nothing from SI blocks, are you really going to pursue a discogram knowing that they can't get the fusion anyway because they are too frail?
I discuss that if I'd rather have seen 80% pain relief from the MBB but if the patient feels 50% pain relief from rhizo is worth it to them, I'll proceed.
I struggle with this issue every week in my geriatric pain practice.
So if you have an 80 yo patient with axial pain that gets 50% pain relief from MBB, nothing from SI blocks, are you really going to pursue a discogram knowing that they can't get the fusion anyway because they are too frail?
I discuss that if I'd rather have seen 80% pain relief from the MBB but if the patient feels 50% pain relief from rhizo is worth it to them, I'll proceed.
I struggle with this issue every week in my geriatric pain practice.
Informed consent. 50% is better than nothing, and it might not work at all. Little downside to procedure except cost and a few days of soreness. I think discos are worthless except to include an adjacent level for a patient already going to the or.
If MBBs have no validity, why not just go straight to RF?
I personally do double blocks, requiring minimum 80% (and generally 100%) pain relief to move onto RF.
That being said ...
Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis
Spine J. 2008 May-Jun;8(3):498-504
Cohen SP, Stojanovic MP, Crooks M, Kim P, Schmidt RK, Shields CH, Croll S, Hurley RW
BACKGROUND CONTEXT: The publication of several recent studies showing minimal benefit for radiofrequency (RF) lumbar zygapophysial (l-z) joint denervation have led many investigators to reevaluate selection criteria. One controversial explanation for these findings is that the most commonly used cutoff value for selecting patients for l-z (facet) joint RF denervation, greater than 50% pain relief after diagnostic blocks, is too low and hence responsible for the high failure rate.
PURPOSE: To compare l-z joint RF denervation success rates between the conventional greater than or equal to 50% pain relief threshold and the more stringently proposed greater than or equal to 80% cutoff for diagnostic medial branch blocks (MBB).
STUDY DESIGN/SETTING: Multicenter, retrospective clinical data analysis.
PATIENT SAMPLE: Two hundred and sixty-two patients with chronic low back pain who underwent l-z RF denervation at three pain clinics.
OUTCOME MEASURES: Outcome measures were greater than 50% pain relief based on visual analog scale or numerical pain rating score after RF denervation persisting at least 6 months postprocedure, and global perceived effect (GPE), which considered pain relief, satisfaction and functional improvement.
METHODS: Data were garnered at three centers on 262 patients who underwent l-z RF denervation after obtaining greater than or equal to 50% pain relief after diagnostic MBB. Subjects were separated into those who received partial (greater than or equal to 50% but less than 80%) and near-complete (greater than or equal to 80%) pain relief from the MBB. Outcomes between groups were compared with multivariate analysis after controlling for 14 demographic and clinical variables.
RESULTS: One hundred and forty-five patients obtained greater than or equal to 50% but less than 80% pain relief after diagnostic MBB, and 117 patients obtained greater than or equal to 80% relief. In the greater than or equal to 50% group, success rates were 52% and 67% based on pain relief and GPE, respectively. Among patients who experienced greater than 80% relief from diagnostic blocks, 56% obtained greater than or equal to 50% relief from RF denervation and 66% had a positive GPE.
CONCLUSIONS: Using more stringent pain relief criteria when selecting patients for l-z joint RF denervation is unlikely to improve success rates, and may lead to misdiagnosis and withholding a potentially valuable treatment from good candidates.
Spine J. 2008 May-Jun;8(3):498-504
Cohen SP, Stojanovic MP, Crooks M, Kim P, Schmidt RK, Shields CH, Croll S, Hurley RW
BACKGROUND CONTEXT: The publication of several recent studies showing minimal benefit for radiofrequency (RF) lumbar zygapophysial (l-z) joint denervation have led many investigators to reevaluate selection criteria. One controversial explanation for these findings is that the most commonly used cutoff value for selecting patients for l-z (facet) joint RF denervation, greater than 50% pain relief after diagnostic blocks, is too low and hence responsible for the high failure rate.
PURPOSE: To compare l-z joint RF denervation success rates between the conventional greater than or equal to 50% pain relief threshold and the more stringently proposed greater than or equal to 80% cutoff for diagnostic medial branch blocks (MBB).
STUDY DESIGN/SETTING: Multicenter, retrospective clinical data analysis.
PATIENT SAMPLE: Two hundred and sixty-two patients with chronic low back pain who underwent l-z RF denervation at three pain clinics.
OUTCOME MEASURES: Outcome measures were greater than 50% pain relief based on visual analog scale or numerical pain rating score after RF denervation persisting at least 6 months postprocedure, and global perceived effect (GPE), which considered pain relief, satisfaction and functional improvement.
METHODS: Data were garnered at three centers on 262 patients who underwent l-z RF denervation after obtaining greater than or equal to 50% pain relief after diagnostic MBB. Subjects were separated into those who received partial (greater than or equal to 50% but less than 80%) and near-complete (greater than or equal to 80%) pain relief from the MBB. Outcomes between groups were compared with multivariate analysis after controlling for 14 demographic and clinical variables.
RESULTS: One hundred and forty-five patients obtained greater than or equal to 50% but less than 80% pain relief after diagnostic MBB, and 117 patients obtained greater than or equal to 80% relief. In the greater than or equal to 50% group, success rates were 52% and 67% based on pain relief and GPE, respectively. Among patients who experienced greater than 80% relief from diagnostic blocks, 56% obtained greater than or equal to 50% relief from RF denervation and 66% had a positive GPE.
CONCLUSIONS: Using more stringent pain relief criteria when selecting patients for l-z joint RF denervation is unlikely to improve success rates, and may lead to misdiagnosis and withholding a potentially valuable treatment from good candidates.
However ...
Radiofrequency neurotomy for low back pain: evidence-based procedural guidelines
Pain Med 2005 Mar-Apr;6(2):129-38
Hooten WM, Martin DP, Huntoon MA
OBJECTIVE: This review was undertaken to outline the procedural limitations of the randomized controlled trials (RCTs) of radiofrequency (RF) neurotomy for low back pain. Second, the literature related to patient selection, diagnostic testing, and the technique of performing lumbar spine RF neurotomy will be critically reviewed and analyzed. Based on these analyses, diagnostic and procedural guidelines will be proposed.
DESIGN: A Medline and EMBASE search identified three RCTs and two systematic reviews of RF neurotomy for low back pain. A similar search identified pertinent literature related to the method of patient selection for a diagnostic block, the medial branch and L5 dorsal ramus comparative block, and the anatomical and technical parameters of lumbar spine RF neurotomy.
RESULTS: Substantial procedural shortcomings were identified in all three RCTs. In the systematic reviews, these procedural limitations were not accounted for by the quality assessment of study design which resulted in an inaccurate estimate of clinical effectiveness. Analysis using likelihood ratios showed that screening criteria could increase the probability of zygapophysial joint pain before performing diagnostic blocks. Similar analysis showed that comparative medial branch blocks, rather than single blocks, must be used before RF neurotomy. Anatomical studies demonstrated that the shorter distal compared with the circumferential radius of the RF lesion necessitates placement of the electrode parallel to the course of the nerve along the base of the superior articular process.
CONCLUSIONS: The evidence-based procedural guidelines provide consistent criteria for multisite studies that could enroll a sufficiently large homogenous study cohort
Pain Med 2005 Mar-Apr;6(2):129-38
Hooten WM, Martin DP, Huntoon MA
OBJECTIVE: This review was undertaken to outline the procedural limitations of the randomized controlled trials (RCTs) of radiofrequency (RF) neurotomy for low back pain. Second, the literature related to patient selection, diagnostic testing, and the technique of performing lumbar spine RF neurotomy will be critically reviewed and analyzed. Based on these analyses, diagnostic and procedural guidelines will be proposed.
DESIGN: A Medline and EMBASE search identified three RCTs and two systematic reviews of RF neurotomy for low back pain. A similar search identified pertinent literature related to the method of patient selection for a diagnostic block, the medial branch and L5 dorsal ramus comparative block, and the anatomical and technical parameters of lumbar spine RF neurotomy.
RESULTS: Substantial procedural shortcomings were identified in all three RCTs. In the systematic reviews, these procedural limitations were not accounted for by the quality assessment of study design which resulted in an inaccurate estimate of clinical effectiveness. Analysis using likelihood ratios showed that screening criteria could increase the probability of zygapophysial joint pain before performing diagnostic blocks. Similar analysis showed that comparative medial branch blocks, rather than single blocks, must be used before RF neurotomy. Anatomical studies demonstrated that the shorter distal compared with the circumferential radius of the RF lesion necessitates placement of the electrode parallel to the course of the nerve along the base of the superior articular process.
CONCLUSIONS: The evidence-based procedural guidelines provide consistent criteria for multisite studies that could enroll a sufficiently large homogenous study cohort
For those who, like me, are suckers for appeals to authority and statistical analyses, I am attaching Nik's response to the Hooten study.
Last edited:
What's important is that they get 100% relief where you did the block. 50% relief of pain means you missed something. If they report partial pain relief and on exam they have SI tenderness but the tenderness over the blocked facets is gone, that's 100% relief of the facet pain, but overall it's still 50% relief. In my book that's a positive test.
If you rely on the patient's self-reporting you can get terribly misguided since few people can really localize their back pain to a specific structure. The wiring just isn't there. Two-point discrimination in the back is pretty poor (can't recall the number but the shin is 30-40 mm, vs 2-4 mm in the fingertip). People have no trouble telling you which finger joint hurts, but in the lumbar spine they can't tell one joint from another even though it's roughly the same distance.
This is why I underscore the importance of personally examining people before and after the block and comparing it to the baseline exam.
How many times have you had a patient come back after an SI joint injection still complaining of back pain, and on repeat exam you find a nontender SI but the pain and tenderness is now more medial? I see this a lot. If you don't repeat the exam you will conclude that the SI injection failed and miss the facet pain that has been uncovered.
I have the same problem with the way pain studies are done. When you batch process patients and just have them fill out postop questionnaires you miss these things and tend to get false negatives. If you're doing a study of MBBs the patient described above would likely be recorded as a (false) negative response without a careful exam pre- and postop.
Regarding the discogram question, I had a patient today where we did MBBs and they didn't change anything at all. Still with axial tenderness, no SI pain. I told the patient that by process of elimination I thought it was disk pain. I explained that we could do a discogram but if she won't consider another surgery (fusion this time) then I wouldn't do it. before you do a test ask yourself what you will do if it's positive and what you'll do if it's negative. If the answer is the same, don't do the test. I'm not going risk diskitis just for curiosity's sake.
Making authoritative pronouncements based on theoretical extrapolations from flawed studies is just so much mental masturbation. Garbage in, garbage out.
Last edited:
Advertisement - Members don't see this ad
The Cohen study does no such thing.
You might also want to more closely examine Nik's assessment (unless, of course, you are only interested in his views regarding your questions).
Please leave the personal attacks out of the discussion.
That was a generic statement. I can't help it if you saw yourself in it and took it personally.
Of course it was. All evidence to the contrary is purely coincidental.
Last edited:
examining patients post-injection might help determine if the MBBs worked, but ultimately, you are still going by patient report. you still have do go with what they tell you. since when is pain on extension or paraspinal tenderness diagnostic for z-joint pain? any since when is there only 1 pain generator. those out there who are looking for nothing short of 100% are fooling themselves. of course you'll have good RF outcomes with that algorithm. id rather kinda help 100 people than really help 2 or 3.
Gorback thanks for the reply and I actually see we have a very similar approach. I agree with the pre and post exam.
Please offer her a GRC. Minimal risk, better than doing nothing. I've been happy for my folks getting relief. I've gone on to to about 20RF's GRC wise in the last 6 months. Results are promising. I put it like this to the patient: the study I handed you says 80% of patients get relief. I think it will be more like 50% . If you want to try, we do a GRC, if it works we can burn it. It may provide 6-18 months of relief or it may do nothing. My only complication (side effect), is a gentleman with low reserves got quad weakness lasting 1 hour post procedure. 5cc 1% plain lidocaine from skin to spine, 0.5cc 0.5% Marcaine on the GRC. Beats me, but he came back a week later for the RF.
Agree. Give us details. I always thought this procedure was bogus but if you're impressed I'm willing to listen.
1. If you think your patients are lying to you then you shouldn't do any procedures on them and you might as well fire them.
2. No one is talking about any particular maneuver being diagnostic. With diagnostic blocks you are using the patient as their own control. If it hurts to extend before the block but not after the block you have a positive test, but not everybody has to. As I mentioned above I had a lady who said she mostly had pain when she vacuumed so I pulled out the vacuum cleaner and let her have a go, but by no means did I say that everybody has to have pain while using a vacuum cleaner.
3. As mentioned in my post yesterday, the fact that there can be > 1 pain generator is exactly why you need to do a post-block exam. As I said before, what's important is 100% relief of what you blocked. If you block the MBs all you need for a positive test is 100% relief of the joints you blocked. If they still hurt over the SI joint it's irrelevant, other than being a nice demonstration there is more than one problem.
4. It is not too rigorous to require that the pain should go away when you block the nerves to the painful structure. It is the only sensible endpoint. If L4/5 is painful and I block its nerve supply, by what mechanism would L4/5 only experience 50% pain relief?
as i said, i do agree with you, and your conclusions make sense, but it only goes so far.
the point is that there is gray area. what about the L5-S1 joint and SI joint? they are pretty damn close. i think thats hard for both myself and the patients to tell the difference. and there are tons of structures that can theoretically cause pain. i find that Z-joint pain completely in isolation is rare, so the 100% pain relief that you are talking about after a perfect block would also be rare.
and how about the patient who comes back into clinic and says she can stand for longer than she could before without having pain (30-45 minutes). or now she can go to the grocery store and do her shopping without as much pain. or the geezer who can finally shave without back pain. i think you have to include function in the equation. if there is 25 or 50% decreased pain, but now all of a sudden they can wash their car, then im all for that.
i do believe my patients (at least most of them), but i often find that the patients report things that i cant test for and that i certainly wouldnt find on exam.
also, lets not kid ourselves, examing the patient 15 minutes after the procedure buts down on clinic time and increases procedure time. if you make the decision to go to RF right then and there, that is. i prefer to bring them back and actually talk about how things went.
http://www.youtube.com/watch?v=2pG3wjabYGs
iPhone 3gs video.
You cannot see the needle on lateral.
It is mid body from front to back, and at the top of the foramen from top to bottom. Medial to lateral it lays on os.
iPhone 3gs video.
You cannot see the needle on lateral.
It is mid body from front to back, and at the top of the foramen from top to bottom. Medial to lateral it lays on os.
Advertisement - Members don't see this ad
$100 says Bogduk is in the "50% is BS" camp. Takers?
I'm not finding complete relief to be rare, and it's only the [ever-increasing number of] really obese ones that I can't make a distinction. I'm willing to take the hit on the postop exam time to do the best job I can.
120 seconds at 75 F.
Some like it hot.
No motor component, no big risk.
Had a failure come back in today.
12 hours of excellent relief after GRC
2 days of good relief after GRC RF.
Must have been the bupi.
Now off to her facets....
How would you bill the block ad RF?
Currently lab on the block and paravertebral on the rf. My coder feels this is
most appropriate.
