Hi,
Can anyone recommend a doc to do an IA facet injection at C1-2? Eastern Iowa, or Madison WI?
Can anyone recommend a doc to do an IA facet injection at C1-2? Eastern Iowa, or Madison WI?
C1-2 IA facet injection Iowa or Madison WI?
- Thread starter wscott
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Are commercial payers still covering IA facet injections? I thought Medicare effectively banned them except for extenuating circumstances
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IMO risk is not worth it at C1-2 or AO. For a steroid that will last how long? Had a patient tell me his prior pain doc at Cleveland Clinic got into med mal trouble after a C1-2 injection on another patient that was catastrophic.
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I do C1-2 and it can be life changing on some pts. There's something especially awful about arthropathy at that level.
Make sure there's no posterior branch off the vertebral artery. Radiology won't read that for you. Come in inferiorly and you'll be underneath the C2 nerve.
It hurts BTW. I do 5mg dex in the joint, then retract just posterior to the joint and put 5mg dex there.
Clinic level procedure. Not ASC.
Def a challenging injection
pubs.asahq.org
Def helpful
Turns out you can ultrasound and visualize the vessels/DRG if you've got a good machine.
Dr Narouze in Ohio has a chapter on this but I can't find the reference right this second.
www.samernarouze.com
I often tell patients I'm happy to try this but they may want to plug in with an interventional radiologist who can do it with CT guidance
Anesthesiology
pubs.asahq.org
Def helpful
Turns out you can ultrasound and visualize the vessels/DRG if you've got a good machine.
Dr Narouze in Ohio has a chapter on this but I can't find the reference right this second.
Atlantoaxial (C1-C2) joint injection - Samer Narouze, MD, PhD
www.samernarouze.com
I often tell patients I'm happy to try this but they may want to plug in with an interventional radiologist who can do it with CT guidance
This brings up an interesting issue on risk vs reward for both the patient and the practitioner. Especially relevant in PP where a lawsuit could literally put you out of business. Is this an important enough, an effective enough and durable enough procedure that you should be doing it? Especially in your in office suite. Or are you and the patient better served by letting IR or similar perform with CT scan or their multimillion dollar biplanar fluoro? I’ve read some legal documents that are public record describing some really catastrophic outcomes.
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Referring to IR is something I've never considered. Maybe I will in the future.
I did a bilateral C1-2 last week. Valium 5mg PO 30 min prior.
Pt had an uneventful procedure and I'm anticipating significant improvement.
I could be totally talking out of my behind right now, but I don't THINK I've seen a C1-2 CSI failure. They virtually always work assuming the joint is gross and the patient has neck and occipital pain.
There are plenty of ppl who PRP that joint.
I did a bilateral C1-2 last week. Valium 5mg PO 30 min prior.
Pt had an uneventful procedure and I'm anticipating significant improvement.
I could be totally talking out of my behind right now, but I don't THINK I've seen a C1-2 CSI failure. They virtually always work assuming the joint is gross and the patient has neck and occipital pain.
There are plenty of ppl who PRP that joint.
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yoU SHOULDT TAKE THAT MUCH vALIUM PRIOR TO AN INJECTION.
One shot of tequila, or 1mg Ativan, or both.
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I do them occasionally. Highly selective when I offer and clear discussion re unique risks and probable short - medium term benefit. Dex only and just a drop of lido, maybe 0.2cc. . Don’t need a seizure. Has to light up on T2/stir, fused c2 down and/or all other structures below ruled out, often also tried gon/Lon first. None of my partners do this procedure, (they’re smarter than me) so I do more than I’d prefer to, but refuse if indications aren’t clear.
The caudal to cephalad trajectory is key for improved safety, tolerability and accuracy, as detailed masterfully by Dr. Maus in the sis case videos.
I should add- asc only “just in case”. 25g. Dsa. Minimal needle tip redirection. Perfect coaxial at shallow depth. Always find the vertebral artery on mri pre injection. If not lateral to joint space then won’t do it. Difficult to see sometimes. The Maus videos help.
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I also question whether the risk reward ratio is favorable here. I’ve seen some catastrophic outcomes and I personally don’t do them. For those of you that do would you keep doing them if you had such an outcome?
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Softening my view on this over time, though still do it as above for now.
Catastrophe from particulate? Seizure from local? Cord stick? High spinal? Vert dissection?
Catastrophe from particulate? Seizure from local? Cord stick? High spinal? Vert dissection?
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I am only considering outcomes with permanent neurologic damage. No judgement here. Just wondering how everyone would handle such an outcome as far as continuing to do the procedure.
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Serious Q - Exactly what anatomy are you worried about? The vasculature, C2 nerve root stimulation, overflow into the canal?
I use no local in that joint.
It is dex 5mg in the joint, and 5mg posterior.
I may start referring to IR (just never thought about it), but this procedure isn't terrifying to me and I'm pretty conservative in my practice.
I use no local in that joint.
It is dex 5mg in the joint, and 5mg posterior.
I may start referring to IR (just never thought about it), but this procedure isn't terrifying to me and I'm pretty conservative in my practice.
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At least the thread crapping is educational for once!
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Hopefully never find out but I’d think I would have a hard time getting right back on the horse…. Would probably take a while, if ever…
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VA needle stick, dissection.
D
deleted131481
For those that do these, can you describe patient selection for this procedure vs superficial occipital nerve block or TON block?
Alaa Abd-Elsayed, MD
Alaa Abd-Elsayed, MD, is a UW Health Pain Services medical director. He treats patients with chronic pain in the back, neck, knees, shoulders and hips.
Yeah, I was thinking he might be a good person, but I'm not sure if he does these. He does some cool stuff though and is generally easy to connect with due to his society engagements.
They get the easy stuff first, including C2/TON/C3 facet joint blocks, greater occipital blocks, trigger points, etc. If that stuff doesn't work and the MRI shows signal in the joint area specifically, then I think about it under duress, but these are not fun blocks to do.
I do warn patients that I could cause complications. I'm pretty frank with them about how bad it could be. I still do it though.
I do think about how will I manage the vertebral dissection. I try to see if it's the dominant vertebral on the MRI. I consider how fast I could get them to a neurosurgeon/VIR. It's a lot to worry about so I'd much rather turf it to interventional radiology if they're okay dealing with another silo.
Then even worse, think about how much you get paid to take this risk and deal with the associated stomach bubbling.
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If you review imaging in detail you can perform this injxn safely. The VA will not be located posteriorly unless you've got wildly abnormal anatomy or a posterior branch.
You’ve identified by MRI prior to procedure there's no post branch of the VA.
You stay posterior to the facet and approach inferiorly in the lateral 1/3rd of the joint.
Never stray lateral to the joint bc the VA is there.
Do not go medial bc that's intrathecal and spinal cord.
Do not use local.
Live fluoro, and if after 3 or 4 runs of tiny amounts of contrast you're not IA and looking good, the procedure is over and you abort. Messy contrast obscuring your view is a potential catastrophic event.
5mg in the joint to prevent overflow.
There is risk with this procedure. I tell pts this is a "big boy shot." I will continue to offer this to select pts only.
I prob should refer to IR, and at some point I may.
You’ve identified by MRI prior to procedure there's no post branch of the VA.
You stay posterior to the facet and approach inferiorly in the lateral 1/3rd of the joint.
Never stray lateral to the joint bc the VA is there.
Do not go medial bc that's intrathecal and spinal cord.
Do not use local.
Live fluoro, and if after 3 or 4 runs of tiny amounts of contrast you're not IA and looking good, the procedure is over and you abort. Messy contrast obscuring your view is a potential catastrophic event.
5mg in the joint to prevent overflow.
There is risk with this procedure. I tell pts this is a "big boy shot." I will continue to offer this to select pts only.
I prob should refer to IR, and at some point I may.
The only other tip I'll add to the above is positioning. Having the patient's head overly flexed makes it very hard. A little flexion is very helpful, but don't let the chin too close to the chest. This isn't a cervical epidural where you're trying to open up the interlaminar spaces. The slight amount of flexion with a patient who can open their mouth makes it much easier to visualize the targets, without obscuring them with the anterior structures.
Always be ready to quit and fight another day. There's no glory here. Have some predefined criteria for quitting based on measurable variables like time, contrast injected, etc, and stick to them.
I do use local.
I agree with low volumes 0.5 - 1 mL max per side.
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Inferior to superior approach is critical as well. Come in superiorly and rub the C2 nerve and I can see the pt lurching about on the table and that's bad. You're deep enough at that point to potentially stick the VA assuming you're lateral enough.
Theoretically, you could argue vasospasm can occur from needle rub (should NEVER happen if you do this correctly) or irritation of the vessel from a steroid bath.
I can imagine violating the joint and your needle tip exiting laterally and you squirt your meds under high pressure (say a 1-3cc syringe instead of a 10cc syringe) and that causes spasm perhaps. Unlikely, but I'm trying to think of worst case scenario.
Theoretically, you could argue vasospasm can occur from needle rub (should NEVER happen if you do this correctly) or irritation of the vessel from a steroid bath.
I can imagine violating the joint and your needle tip exiting laterally and you squirt your meds under high pressure (say a 1-3cc syringe instead of a 10cc syringe) and that causes spasm perhaps. Unlikely, but I'm trying to think of worst case scenario.
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Whats the endpoint for this treatment algorithm? Q3mo steroid injections until...?
High risk procedures can be reasonable when there's an established endpoint(end of life in CA pain) but the only thing that makes me cringe more than doing AA injections is doing them 4x/yr indefinitely.
High risk procedures can be reasonable when there's an established endpoint(end of life in CA pain) but the only thing that makes me cringe more than doing AA injections is doing them 4x/yr indefinitely.
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Rarely needed…. but perc fusion.
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exactly. This is exactly why I never start.
A high risk procedure that pays me $100 and has to be repeated 4 times a year, is not a road I want to go down.
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I feel bad because when I was at my first job, I punted all these C1-C2 injections to the local pain fellowship, which provided training for Taus to get good numbers with this procedure.
Though seems like he is now beginning to understand why I punted these patients!
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You don't do them indefinitely. You do them occasionally, similar to an ESI.
Mr Smith is gonna have to hurt.
Again, arthropathy at C1-2 is especially horrible and those pts are clearly worse than the vast majority of spondylosis pts on your schedule.
Fusion is effective.
Try Dr Narouze even though he's in Ohio. He may be able to connect you with someone in those areas that he has trained.
Home - Samer Narouze, MD, PhD
Why pain physicians should consider becoming headache specialists: bridging the gap in patient care. READ ARTICLE Founder and President of American Interventional Headache Society. Learn More Founder of American Board of Headache Medicine. Learn More President-Elect of American Society of...
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If not, interventional radiology can likely accomplish it at U.Wisc
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Agree. I had a similar experience my first few years in practice and I would likely opt for an injection first before fusion personally.
However, it is ridiculous what you get paid to do one, particularly in an ASC. Medicare needs to increase the pay X 10 for this procedure and specify a unique CPT code, because of the risk.
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that is about right.
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$89 maybe for the ASC. In office should definitely be at least $250
I disappointed a Medicare patient today whose previous pain doc was doing CESI q3 months for cervical DDD. No stenosis or radiculopathy.
I don’t feel that was appropriate given the risk, but the fact I only get paid $100 to do those in the ASC, doesn’t motivate me either.
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remember there are 2 different fee schedules.
physician fee $266 for office based, $105.50 for facility based (plus the facility charges, on top) on 2022 ASIPP.
physician fee $266 for office based, $105.50 for facility based (plus the facility charges, on top) on 2022 ASIPP.
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I just realized that you said Medicaid not Medicare.
Damn. This is why I have researched the payments from all the major payors in the practice for all the procedures I do at least every 3 months. I hate doing something that is not worth my time. I would be so pissed to have wasted as much as that doc you know with the CESI.
Several of the ortho groups here lobbied medicaid hard and insisted on nothing less than medicare rates or they would drop medicaid, and medicaid gave in. All docs should do this in every practice. Medicare rates aren't that great, but they should definitely be the floor of what you accept, nothing lower.
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how does medicaid give in?
its a state run product in conjunction with the federal government. who did they talk to?
its a state run product in conjunction with the federal government. who did they talk to?
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I wasn't lead negotiator. And medicaid rates can really vary from state to state, so there isn't a set national medicaid fee schedule like there is with medicare.
Next city over was 90 minutes away. All the orthopedists in my city refused to see medicaid unless they matched medicare rates. State caved, because otherwise there was literally no one to see medicaid patients.
