Blood Patch Question

[Dansk2011]

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Recently did a Lt L4/L5 TFESI on a 50 y/o lady and felt the procedure went very well with good epidural flow, non-mylegraphic pattern, and negative DSA. Patient started reporting a postural headache the day after the procedure and has now lasted for almost a week. She went to the ER and work-up was negative. Naturally they think she has a PDPH and my PA prescribed her some Fioricet and went through the whole protocol of what to do. Planning on doing a blood patch tomorrow although I know it is rare to get a dural puncture with TFESI if done properly. My question is if I should tackle it from an interlaminar approach as I have read a few articles about a transforaminal approach. Any suggestions greatly appreciated.

 

[callmeanesthesia]

Recently did a Lt L4/L5 TFESI on a 50 y/o lady and felt the procedure went very well with good epidural flow, non-mylegraphic pattern, and negative DSA. Patient started reporting a postural headache the day after the procedure and has now lasted for almost a week. She went to the ER and work-up was negative. Naturally they think she has a PDPH and my PA prescribed her some Fioricet and went through the whole protocol of what to do. Planning on doing a blood patch tomorrow although I know it is rare to get a dural puncture with TFESI if done properly. My question is if I should tackle it from an interlaminar approach as I have read a few articles about a transforaminal approach. Any suggestions greatly appreciated.

Can’t speak to the TFESI approach to EBP, but personally I’d do it interlaminar, paramedian to the side you did the epidural from.

I’d definitely recommend that you try a sphenopalatine ganglion block first though. Lower risk and equivalent or better outcomes. The relief is instant when it works, so you can still do the blood patch if the SPG doesn’t help.

 

[deleted131481]

Can’t speak to the TFESI approach to EBP, but personally I’d do it interlaminar, paramedian to the side you did the epidural from.

I’d definitely recommend that you try a sphenopalatine ganglion block first though. Lower risk and equivalent or better outcomes. The relief is instant when it works, so you can still do the blood patch if the SPG doesn’t help.

Can you comment how specifically you do SPG block? Did a couple in training (not for PDPH) - Qtip bilateral nariz to posterior pharynx and just kinda drip down lidocaine 2% making sure to stay below max dose. I was kind of skeptical how much actually got to target. I know they make specific devices and some use viscous lidocaine?

 

[callmeanesthesia]

Can you comment how specifically you do SPG block? Did a couple in training (not for PDPH) - Qtip bilateral nariz to posterior pharynx and just kinda drip down lidocaine 2% making sure to stay below max dose. I was kind of skeptical how much actually got to target. I know they make specific devices and some use viscous lidocaine?

Anesthesiology

anesthesiology.pubs.asahq.org

This is the technique I use. I position the patient supine with a pillow under their neck and shoulders and head extended. After you get the swabs in inject another 0.25 mL down each one, wait 5 minutes, then another 0.25 mL. There are various devices, all quite expensive. If you are in a hospital, go grab yourself an LMA MADgic LTA atomizer from anesthesia - I haven’t done it that way but I think it would work well in place of the more expensive devices, especially if you can find the pediatric size.
Doesn’t reimburse well regardless of how you do it - have to bill 64999.

 

[soccrwz]

surgi-lube mixed with Lidocaine 2% or only viscous lidocaine 4%, 2 long q tips dipped in your solution per side or one per side lift tip of nose and advance straight back till you hit resistance, then 10-15 minutes later you can drip lidocaine 2% a few drops down the stem of the q tip so it travels to the posterior part. have the patient lay flat for 15-20 minutes. Remove q-tips and give the pt tissues to blow their nose. All done

 

[BobBarker]

You can take a long 14g angiocath or use a sphenocath. Super easy.

 

[painfree23]

Anesthesiology

anesthesiology.pubs.asahq.org

This is the technique I use. I position the patient supine with a pillow under their neck and shoulders and head extended. After you get the swabs in inject another 0.25 mL down each one, wait 5 minutes, then another 0.25 mL. There are various devices, all quite expensive. If you are in a hospital, go grab yourself an LMA MADgic LTA atomizer from anesthesia - I haven’t done it that way but I think it would work well in place of the more expensive devices, especially if you can find the pediatric size.
Doesn’t reimburse well regardless of how you do it - have to bill 64999.

Why 64999? Why not a trigeminal nerve block

 

[Ferrismonk]

Same basic idea, swabs soaked in local then dribble some more down about 10 min late, however I use 0.75% Bupivicaine.

 

[callmeanesthesia]

Why 64999? Why not a trigeminal nerve block

Medicare defines 64400 or 64505 cannot be billed for topical SPG. You are supposed to bill 64999 with comments stating SPG sand the device you used if you are using a sphenocath or something similar.

Wiki - sphenopalatine nerve blocks

My doctor's are wanting to start doing sphenopalatine blocks in our office. I am being told by an outside coding source that you can bill 64505-RT, 64505-LT to Medicare, since 50 modifier isn't allowed by Medicare for this code. I don't see how that can be correct though... anyone have any...

www.aapc.com

https://med.noridianmedicare.com/documents/10546/12461373/Billing+Medicare+for+the+SphenoCath+and+Other+Similar+Devices

 

[Ducttape]

Ok where is any info to suggest that SpG blocks help with PDPH?

Any published case reports (for starters)?

 

[DOctorJay]

Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy - PMC

The sphenopalatine ganglion (SPG) is a parasympathetic ganglion, located in the pterygopalatine fossa. The SPG block has been used for a long time for treating headaches of varying etiologies. For anesthesiologists, treating postdural puncture ...

www.ncbi.nlm.nih.gov

Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review - PubMed

A greater number of patients experienced a quicker onset of headache relief, without any new complications, from treatment with SPGB versus EBP. We believe that SPGB is a safe, inexpensive, and well-tolerated treatment. We hope that clinical trials will be conducted in the future that will...

www.ncbi.nlm.nih.gov

Sphenopalatine ganglion block for treatment of post-dural puncture headache in obstetric patients: An observational study - PMC

Post-dural puncture headache (PDPH) is a consequence of spinal and epidural anaesthesia in approximately 1% of obstetric patients. The gold standard for its treatment is epidural blood patch. Sphenopalatine ganglion block (SPGB) has been proposed as ...

www.ncbi.nlm.nih.gov

https://www.ajemjournal.com/article/S0735-6757(15)00168-0/pdf

 

[callmeanesthesia]

Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy - PMC

The sphenopalatine ganglion (SPG) is a parasympathetic ganglion, located in the pterygopalatine fossa. The SPG block has been used for a long time for treating headaches of varying etiologies. For anesthesiologists, treating postdural puncture ...

www.ncbi.nlm.nih.gov

Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review - PubMed

A greater number of patients experienced a quicker onset of headache relief, without any new complications, from treatment with SPGB versus EBP. We believe that SPGB is a safe, inexpensive, and well-tolerated treatment. We hope that clinical trials will be conducted in the future that will...

www.ncbi.nlm.nih.gov

Sphenopalatine ganglion block for treatment of post-dural puncture headache in obstetric patients: An observational study - PMC

Post-dural puncture headache (PDPH) is a consequence of spinal and epidural anaesthesia in approximately 1% of obstetric patients. The gold standard for its treatment is epidural blood patch. Sphenopalatine ganglion block (SPGB) has been proposed as ...

www.ncbi.nlm.nih.gov

https://www.ajemjournal.com/article/S0735-6757(15)00168-0/pdf

You beat me to it. Yeah, some pretty solid evidence lately. Anecdotally, I’ve done it 3 times for PDPH with excellent relief and about a dozen or so for migraine. The great thing is the relief is instant.

 

[SommeRiver]

Never even heard about SPG as a Tx for PDPH, but I would much rather do an SPG than an EBP.

 

[callmeanesthesia]

Never even heard about SPG as a Tx for PDPH, but I would much rather do an SPG than an EBP.

Even if you don’t get reimbursed for it, if you are managing your own procedural compensation, given the pain in the ass that an EBP is for the measly reimbursement I call it a win. You can still bill for the office visit, the relief is immediate, and no risk of a second dural puncture. Also great for post-stim or pump headache because you won’t be injecting a culture medium into the area of your fresh device.

 

[deleted993114]

You beat me to it. Yeah, some pretty solid evidence lately. Anecdotally, I’ve done it 3 times for PDPH with excellent relief and about a dozen or so for migraine. The great thing is the relief is instant.

I have used it for some patients with "migraine"/cervicogenic headache, SUNCT syndrome, cluster patients, and those with atypical orbital/facial pain. We don't charge anything for placing lidocaine up someone's nose with a q-tip. If it relieves the pain, we will arrange for the patient to self administer maximally 2X per week. You want to use the device that instills lidocaine into the urethra prior to urological procedures. We used to use a 4% lidocaine bottle with a soft extension tube (kind of like WD-40), but I don't think they make it anymore. Sticking Q-tips up the nose often can result in nasal mucosal trauma/bleeds- you need a soft applicator.

Billing for a spehnopalantine block with topical local is fraud. It's just local in the nose, after all.

I have had good luck with sphenopalantine rf for those who would otherwise need to use the lidocaine more frequently, or those with cluster headaches. Our cluster patients get that done every 1-1.5 years. It is kind of fun to do, as it scares some providers. You have to make sure the probe goes posterior enough, otherwise you burn the superior palantine nerves and get a numb palate. Don't think too hard about where you are at anatomically (like when you do trigeminal rf) and it is easier to do.

Interestingly, one of the coolest seizures I have ever seen was at the hands of one my former partners doing a trigeminal rf. I taught him the procedure and emphasized never, never put local through the needle. You ramp up the temps slowly so it doesn't hurt so much. He put in local to be "nice" and it was very interesting!

 

[dmk5n]

(Those of you who have done this) How long do the results from the block last?
The hardest part of EBP is extracting blood from the patient. (BMI >40)

 

[painfree23]

I have used it for some patients with "migraine"/cervicogenic headache, SUNCT syndrome, cluster patients, and those with atypical orbital/facial pain. We don't charge anything for placing lidocaine up someone's nose with a q-tip. If it relieves the pain, we will arrange for the patient to self administer maximally 2X per week. You want to use the device that instills lidocaine into the urethra prior to urological procedures. We used to use a 4% lidocaine bottle with a soft extension tube (kind of like WD-40), but I don't think they make it anymore. Sticking Q-tips up the nose often can result in nasal mucosal trauma/bleeds- you need a soft applicator.

Billing for a spehnopalantine block with topical local is fraud. It's just local in the nose, after all.

I have had good luck with sphenopalantine rf for those who would otherwise need to use the lidocaine more frequently, or those with cluster headaches. Our cluster patients get that done every 1-1.5 years. It is kind of fun to do, as it scares some providers. You have to make sure the probe goes posterior enough, otherwise you burn the superior palantine nerves and get a numb palate. Don't think too hard about where you are at anatomically (like when you do trigeminal rf) and it is easier to do.

Interestingly, one of the coolest seizures I have ever seen was at the hands of one my former partners doing a trigeminal rf. I taught him the procedure and emphasized never, never put local through the needle. You ramp up the temps slowly so it doesn't hurt so much. He put in local to be "nice" and it was very interesting!

I don’t get how it’s fraud? It’s a procedure that you are doing . What’s the definition of a nerve block? Putting local anesthetic next to a nerve right? Isn’t that what’s happening here?

 

[callmeanesthesia]

I don’t get how it’s fraud? It’s a procedure that you are doing . What’s the definition of a nerve block? Putting local anesthetic next to a nerve right? Isn’t that what’s happening here?

Because Medicare has explicitly excluded nerve blocks performed by topical application from the CPT for SPG block. While I agree with you in principle, it is fraud to bill Medicare for things Medicare says you can’t bill for.

 

[Ducttape]

Good explanations in the first article.

Not addressing directly the volume loss but addressing pain due to vasodilation. Definitely worth a try.

Thanks

 

[painfree23]

Because Medicare has explicitly excluded nerve blocks performed by topical application from the CPT for SPG block. While I agree with you in principle, it is fraud to bill Medicare for things Medicare says you can’t bill for.

What about other insurance companies?

 

[callmeanesthesia]

What about other insurance companies?

The Blues generally consider it investigational/not medically necessary.

 

[deleted993114]

What about other insurance companies?

I can tell you from the standpoint of Blue Cross, it is fraud. I would assume that the other companies have a similar view.

You are, after all, just putting local anesthetic in someone's nose, which should not be worth much of anything.. Contrast the skill and time required to do that vs doing a fluro guided sphenopalantine nerve block. If it seems like fraud to you, it probably is.

Where I used to practice, there was a retired OB-Gyn guy running a "headache clinic" in which they billed Blue Cross the actual sphenopalantine block code for squirting local up the noses of patients. He had to pay back the company a boat load of money after they caught on to what he was doing.