Bizarre practices

[BloodySurgeon]

I’ve had a lot of patients leaving their pain doctors in the last year to come see me after failed treatment.

First practice is a well known and respected one in my community. Interesting enough, many of his patients had a RACZ procedure. What was more interesting is none of them had back surgery or other procedure prior to his injections. After further testing, none had MRI findings of epidural scaring or nerve clumping. After talking to many of them it sounds like he uses the Racz catheter to inject steroid. Is there any benefit to this or just a ploy to bill for adhesiolysis?? I’m concern that if done multiple times it may cause scarring ironically?

Second practice, all his patients are confused when I ask them to position themselves prone. Apparently their previous pain doc performs ESIs in the sitting position. I am not sure how he does fluoro but the patients confirm there is X-ray in the room.

Thoughts?

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[Baron Samedi]

A lot of IR docs do CESI in seated position. Lumbar sounds like a recipe for my own back pain.

The Racz catheter can be helpful in a caudal approach if you don't want to use a bunch of volume and want to target a specific level, or in an interlaminar approach if the target level is inaccessible for some reason. If he's actually coding for a lysis of adhesions, that's a bit suspicious.

 

[deleted875186]

A lot of IR docs do CESI in seated position. Lumbar sounds like a recipe for my own back pain.

The Racz catheter can be helpful in a caudal approach if you don't want to use a bunch of volume and want to target a specific level, or in an interlaminar approach if the target level is inaccessible for some reason. If he's actually coding for a lysis of adhesions, that's a bit suspicious.

I’ve seen a patient get thyroid failure from too much radiation from an IR doc doing repeated CT guided CESI

 

[BloodySurgeon]

The Racz catheter can be helpful in a caudal approach if you don't want to use a bunch of volume and want to target a specific level, or in an interlaminar approach if the target level is inaccessible for some reason. If he's actually coding for a lysis of adhesions, that's a bit suspicious.

Like I said the patient has no prior surgeries or contraindication for ILESI at any level so I am not sure why you need a catheter instead of approaching where you need to approach.

How much utility is a catheter at the caudal area. I’ve always thought about cervical catheterization for high cervical radiculopathy but I was always too worried about trauma. Not sure how or why he is using it.

 

[bedrock]

I’ve seen a patient get thyroid failure from too much radiation from an IR doc doing repeated CT guided CESI

wow

 

[MitchLevi]

Seated ESI do still occur. Just save a lateral image.

Local doctor was doing propofol for TPI. I have the op notes to prove it. Pretty sure I posted them on here. Same guy built a practice in the late 90s, sold to PE and they fired him.

 

[Ferrismonk]

Honestly, this sounds like it's just an old doc doing things the old way.

Racz catheter can be used several different ways despite the patient not having prior surgery.
1. If he's actually doing adhesionolysis, then the doc should be doing an epidurogram during procedure documenting filling defects which would replace other imaging. Of note this isn't an ESI procedure.
2. Doing ESI with catheter can be used to target specific nerve roots, although most of us would just to TFESI now.
3. Some docs will do ALL lumbar ESI from a caudal approach with a catheter because you don't need to do LOR and it's technically simple.

Doing ESI in the sitting position (like a labor epidural) is a dead giveaway he's an old doc in my opinion.

 

[Agast]

Some of my attendings would do the caudal ESI or cervical ESI with a racz catheter. We didn’t bill extra for it, it was just to direct the meds higher

 

[MitchLevi]

I've seen a catheter shear that stayed in the pt, a woman who I believe had Ehlers Danlos and was already unhinged. Fellowship buddy of mine did it.

I don't know if that's the same catheter or not.

 

[Laryngospasm]

I had an attending that did sitting cervicals!

 

[Ronin1]

I had an attending that did sitting cervicals!

I did them that way all the time in the late 90s blind 17gauge. Time’s change though

 

[bedrock]

I did them that way all the time in the late 90s blind 17gauge. Time’s change though

Wow. That would scare the pi$$ out of me !

 

[Ronin1]

Wow. That would scare the pi$$ out of me !

What really got me going was the time I did a thoracic epidural for post op pain on a 2 year old for a thoracic case as an anesthesia resident with a 17g touhy! Now that really sucked

 

[clubdeac]

What really got me going was the time I did a thoracic epidural for post op pain on a 2 year old for a thoracic case as an anesthesia resident with a 17g touhy! Now that really sucked

Respect

 

[stsa84]

I did them that way all the time in the late 90s blind 17gauge. Time’s change though

Lol. I'd inject 98% of those in paraspinal musculature or LF, too nervous to advance further

 

[Agast]

Lol. I'd inject 98% of those in paraspinal musculature or LF, too nervous to advance further

An older colleague told me he suspected that is why “Series of 3” became so common. Basically 3 attempts, or 3 doses of IM steroid to get you relief…

 

[Ferrismonk]

Some of my attendings would do the caudal ESI or cervical ESI with a racz catheter. We didn’t bill extra for it, it was just to direct the meds higher

That makes some sense if they had prior lumbar surgery, but not in a virgin spine.

I had an attending that did sitting cervicals!

When I was a medical student rotating at different locations, I saw an attending do an in-office hanging drop cervical ESI in a normal exam room with no crash cart available. Needless to say I didn't go there....

 

[nvrsumr]

My fellowship kept the 90s thru the aughts. Haha. Was doing sitting blind cesi in VA clinic with only my neurologist attending who did them as well.

 

[drusso]

Seated CESI with the "hanging drop" method of LOR for the win!

 

[bedrock]

My fellowship kept the 90s thru the aughts. Haha. Was doing sitting blind cesi in VA clinic with only my neurologist attending who did them as well.

Rather disappointing for a Harvard hospital to be at that standard just 15 years ago.

 

[nvrsumr]

Some of it was roundsmanship, some just too many patients and some dinosaurs doin their thang.

Seated ilesi, blind caudals, blind stellate, blind “trigeminals”, hanging drop, Straight ap tfesi with dbl needle technique, Seated cesi with II upside down and reversed and me standing basically in the beam, pulsed rf of every peripheral n., unnecessary catheters for all, US regional blocks for chronic pain, inpatient pump trials, epidural portacaths, Emg guided Botox, can’t even remember it all.

off course fentanyl lollipops for all and industry sponsored sushi 5 nites a week.

It was a heavily surgical and inpatient program. I spent many nites in the hospital. I enjoyed every minute doing dumb stuff under someone else’s license though

 

[Baron Samedi]

Some of it was roundsmanship, some just too many patients and some dinosaurs doin their thang.

Seated ilesi, blind caudals, blind stellate, blind “trigeminals”, hanging drop, Straight ap tfesi with dbl needle technique, Seated cesi with II upside down and reversed and me standing basically in the beam, pulsed rf of every peripheral n., unnecessary catheters for all, US regional blocks for chronic pain, inpatient pump trials, epidural portacaths, Emg guided Botox, can’t even remember it all.

off course fentanyl lollipops for all and industry sponsored sushi 5 nites a week.

It was a heavily surgical and inpatient program. I spent many nites in the hospital. I enjoyed every minute doing dumb stuff under someone else’s license though

I'm going to risk sounding dumb but what's wrong with EMG guided Botox? It's been a long time since I've done any general PM&R stuff.

 

[nvrsumr]

Yes it’s great did some Emg and us guided Botox and phenol as a resident as well. This was with our same neurologist who was faculty in anesthesia dept. Prior to the 31 shots on label migraine protocol we have now. Was a bit ahead of her time.


learned something from all of it.

 

[drusso]

Some of it was roundsmanship, some just too many patients and some dinosaurs doin their thang.

Seated ilesi, blind caudals, blind stellate, blind “trigeminals”, hanging drop, Straight ap tfesi with dbl needle technique, Seated cesi with II upside down and reversed and me standing basically in the beam, pulsed rf of every peripheral n., unnecessary catheters for all, US regional blocks for chronic pain, inpatient pump trials, epidural portacaths, Emg guided Botox, can’t even remember it all.

off course fentanyl lollipops for all and industry sponsored sushi 5 nites a week.

It was a heavily surgical and inpatient program. I spent many nites in the hospital. I enjoyed every minute doing dumb stuff under someone else’s license though

 

[Ferrismonk]

Some of it was roundsmanship, some just too many patients and some dinosaurs doin their thang.

Seated ilesi, blind caudals, blind stellate, blind “trigeminals”, hanging drop, Straight ap tfesi with dbl needle technique, Seated cesi with II upside down and reversed and me standing basically in the beam, pulsed rf of every peripheral n., unnecessary catheters for all, US regional blocks for chronic pain, inpatient pump trials, epidural portacaths, Emg guided Botox, can’t even remember it all.

off course fentanyl lollipops for all and industry sponsored sushi 5 nites a week.

It was a heavily surgical and inpatient program. I spent many nites in the hospital. I enjoyed every minute doing dumb stuff under someone else’s license though

What's the AP TFESI with dbl needle technique?

 

[nvrsumr]

Similar to dbl needle for discogram

6” 25 gauge bent into a U though inserted thru 18g 11/2 that’s is placed a few inches lateral to foramen. Basically a technique if you used xray instead of rotating c arm.

 

[MitchLevi]

People still do AP TFESI regularly.

Knowing that technique is important if you're doing an L5-S1 with a steep pelvis.