Buying new C arm. Do I need DSA?

[thecentral09]

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Hey team,

I am buying a new C arm. I am being quoted by GE 75k for a used without DSA, 85k for WITH DSA. I do not believe I need DSA as I havent used it. Is this something that I need added?

 

[Ferrismonk]

No.

 

[pmrmd]

Doesn't seem like it

 

[Ligament]

It is 10K to "prove" you were not intravascular during your epidurals, which could provide invaluable defense to you in court. To me, that is worth it.

 

[SSdoc33]

No

 

[callmeanesthesia]

Only if you’re doing

It is 10K to "prove" you were not intravascular during your epidurals, which could provide invaluable defense to you in court. To me, that is worth it.

You do DSA on all your epidurals? That’s a lot of radiation.

 

[Ferrismonk]

It is 10K to "prove" you were not intravascular during your epidurals, which could provide invaluable defense to you in court. To me, that is worth it.

You can prove the same thing by injecting contrast under live fluoro which is cheaper and less radiation than DSA.

 

[manowar rules]

Nay. Are there any examples of DSA making or breaking a tort case? Probably not

 

[bedrock]

Nay. Are there any examples of DSA making or breaking a tort case? Probably not

And there was the case of the L5 TFESI with particulate steroid causing SCI despite being done properly with DSA at a university.

DSA gives 4x the radiation and yet still isn’t a guarantee of avoiding intravascular flow.

I’ll still use DSA for my very rare cervical SNRB but that is it.

 

[mid|ine]

I’ll still use DSA for my very rare cervical SNRB but that is it.

If its an SNRB, im not sure DSA is helpful. If injecting results in vascular spasm, then contrast may do it as well. As long as you aren't injecting particulate steroid, Im not sure DSA helps...

 

[bedrock]

If its an SNRB, im not sure DSA is helpful. If injecting results in vascular spasm, then contrast may do it as well. As long as you aren't injecting particulate steroid, Im not sure DSA helps...

Depends on where I am. I’d rather not inject anesthetic into a radicular artery.

Agree that if not injecting particulate steroid, then 99% of the time DSA is not needed

 

[epidural man]

Tough question.

Very useful to have (maybe) when you need it. But when will you need it? Likely never.

I used to use it a lot (I hardly ever do anymore). Truth be told, those times there WAS vascular uptake, I could see it already. I don't think I ever saw something that I failed to see with live fluoroscopy but then picked it up on DSA.

 

[docpain]

For cervicals DSA is a must.

 

[MitchLevi]

For cervicals DSA is a must.

Correction, when doing cervical TFESI...

Which are slower, carry greater risk, force one to use nonparticulate and are no more effective than ILESI.

 

[Ligament]

Correction, when doing cervical TFESI...

Which are slower, carry greater risk, force one to use nonparticulate and are no more effective than ILESI.

I have told all the surgeons I work with that I don't do cervical TF ESI, they acknowledge it, but keep sending me cervical TF ESI. I just tell patient I no longer do those and change to interlaminar. I can see there could be some diagnostic utility in a cervical TF ESI but not worth the risk.

 

[lobelsteve]

I get referrals for C3-4 and C4-5 CESI.
Always seem to go at C7-T1 though.
They don't have our literature.
And I don't tell them where to put the screws.

 

[MitchLevi]

I have told all the surgeons I work with that I don't do cervical TF ESI, they acknowledge it, but keep sending me cervical TF ESI. I just tell patient I no longer do those and change to interlaminar. I can see there could be some diagnostic utility in a cervical TF ESI but not worth the risk.

Yeah...I just do the C7-T1 IL and no one knows the difference.

 

[Taus]

Yeah...I just do the C7-T1 IL and no one knows the difference.

Prior auth issues?

I do ctfesi on direct referral. Mri is reviewed. Arteries located. 25g needle tip only to lateral border of foramen. dex w 0.2cc lido. DSA. Exiting root flow obtained. done.

 

[MitchLevi]

Prior auth issues?

I do ctfesi on direct referral. Mri is reviewed. Arteries located. 25g needle tip only to lateral border of foramen. dex w 0.2cc lido. DSA. Exiting root flow obtained. done.

No one sends anymore to me for CTFESI, but when they did we just submitted new procedures orders and did the C7-T1.

In my residency, all we did was CTFESI. In my fellowship, don't even mention CTFESI.

 

[lobelsteve]

Prior auth issues?

I do ctfesi on direct referral. Mri is reviewed. Arteries located. 25g needle tip only to lateral border of foramen. dex w 0.2cc lido. DSA. Exiting root flow obtained. done.

Utility of diagnostic SNRB, or is this a therapeutic inj?

 

[MD87]

I don’t disagree with anything being said here… But according to Tim Maus, when’s performed prudently, the literature does not really support that TFESI has more significant adverse events an ILESI. The key obviously being that dex is used here.

 

[lobelsteve]

I don’t disagree with anything being said here… But according to Tim Maus, when’s performed prudently, the literature does not really support that TFESI has more significant adverse events an ILESI. The key obviously being that dex is used here.

And MRI reviewed showing VA is not near your path.
No thanks. Not worth the wrvu.

 

[MD87]

And MRI reviewed showing VA is not near your path.
No thanks. Not worth the wrvu.

Correct. Fair.

 

[nvrsumr]

I have told all the surgeons I work with that I don't do cervical TF ESI, they acknowledge it, but keep sending me cervical TF ESI. I just tell patient I no longer do those and change to interlaminar. I can see there could be some diagnostic utility in a cervical TF ESI but not worth the risk.

Im surprised lig. I know you can do ctfesi in ur sleep.

 

[Ligament]

Im surprised lig. I know you can do ctfesi in ur sleep.

I can and have done many in the past, but stopped about 5 years ago or so. Good doc nearby had a terrible complication from one.

 

[MD87]

I can and have done many in the past, but stopped about 5 years ago or so. Good doc nearby had a terrible complication from one.

Do you know the details?

 

[NJPAIN]

Spine surgeons are creatures of habit. If they trained in an institution where CTFESI/SNRB was utilized for planning surgery, they don’t care about the hazards and lack of specificity. It’s like telling a 10 yo he can’t have a BB gun.

 

[medking]

I get referrals for C3-4 and C4-5 CESI.
Always seem to go at C7-T1 though.
They don't have our literature.
And I don't tell them where to put the screws.

Much appreciated if you’re able to post the literature you’re referring to.

 

[lobelsteve]

Much appreciated if you’re able to post the literature you’re referring to.

Avoiding Catastrophic Complications from Epidural Steroid Injections

Epidural steroid injections are frequently performed for patients with lumbar and cervical radiculopathy, the accepted indications. A review of Medicare

www.apsf.org

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/patient_safety/safety_practices/sis.safety.practices.m1.esi.pdf

Never do any epidural:

http://surgicalneurologyint.com/wp-content/uploads/2018/04/8843/SNI-9-86.pdf