Cervical facet issues post MVA but nothing on MRI

[Timeoutofmind]

Question:
I have a patient who had no pre-existing chronic pain. Was rear ended. Has had pretty debilitating neck pain for several months now, seems to be getting worse. Has failed all the conservative stuff.
On history and exam, has all the signs of being facetogenic... not even really any myofascial tenderness to speak off, nothing radicular, and worse with neck ROM.
He did have a cervical flex ex that was normal, and no comments about his facets. Also his MRI does not show anything on the facets, and neither did his CT scan from the ED.
Would you guys go ahead with the intra-articular injections? Is there something I am missing here?

---

Members don't see this ad.

 

[cbest]

No studies demonstrating any correlation of between imaging findings (X-ray, CT, MRI) and actual facetogenic pain. Last one evaluated was SPECT to see if stuff lighting up might indicate facet pain... nope. If you think it's facetogenic pain based on history and physical, gold standard diagnostic test is MBB. Pain usually axial and extension based. Patient describe pain in same pattern as the cervical facet pattern diagrams. C5-6 most commonly affected followed by C2-3. Gear your MBB targets based on radiation pattern.


Sent from my iPhone using SDN mobile

 

[101N]

Do they have pending litigation, do they have an attorney, and what is the pain catastrophizing score.
You'll be paid for an intervention whether it changes the outcome or not. So, don't be that guy/gal.

 

[DrCommonSense]

Do they have pending litigation, do they have an attorney, and what is the pain catastrophizing score.
You'll be paid for an intervention whether it changes the outcome or not. So, don't be that guy/gal.

Maybe he should offer the patient gender assignment surgery or acupuncture because those modalities have been proven to be highly effective by Oregon Medicaid to "help" patients.

Thank goodness for Roger's EBM. Cutting one's penis off and changing into a female is very important and has much EBM support! Same for yoga and acupuncture!

 

[SSdoc33]

it will get better if you do nothing, but MBB/intra-articular facets are not unreasonable.

 

[nvrsumr]

I just reviewed some of the whiplash literature (thank you forum). Seemed like a ball park estimate is 50% will still have pain at 6 mos and some small percentage up to 7 years.

 

[neutro]

It's a functional diagnosis - need cervical mbb's to exclude facetogenic component.
You can also do an exam under Fluoro and ask the patient to locate the pain - it's not perfect, but it will show you underlying structures. Could be disc also, which is hard to diagnose

 

[Ligament]

There is significant capsule deformity and intra-articular cartilage fissuring after MVAs in lab and autopsy studies. The pain is arising from these two soft tissues, therefore in general will not see any imaging abnormalities. The method to diagnose this issue are MBBs. I've done plenty of RFAs for whiplash with very normal looking MRIs, but very positive MBBs x 2 with great results from RADIOFREQUENCY ABLATION.

 

[101N]

When you ignore confounding factors like secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing you will damage your reputation in your community with savvy docs. Moreover, you contribute to the impression that most IPM physician's as being avaricious hucksters just looking for an injection.

 

[DrCommonSense]

When you ignore confounding factors like secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing you will damage your reputation in your community with savvy docs. Moreover, you contribute to the impression that most IPM physician's as being avaricious hucksters just looking for an injection.

Wait, so doing a facet joint injection to help a patient with Whiplash will make you seem like an "avaricious huckster"?

If you eliminated all of the above patients for "secondary gain", your whole "disability" system would collapse. Never going to happen thanks to blood sucking lawyer lobbies and Democrats.

 

[nvrsumr]

When you ignore confounding factors like secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing you will damage your reputation in your community with savvy docs. Moreover, you contribute to the impression that most IPM physician's as being avaricious hucksters just looking for an injection.

What is your treatment for whiplash that doesn't respond to time and PT? The 1996 nejm lord c rf study was for whiplash injury in MVA patients some of whom were in litigation. That was a blinded study in a prestigious journal. Not certain anything else comes close to this level of evidence for whiplash injury(not that I want to live or die by ebm)

 

[Timeoutofmind]

There is significant capsule deformity and intra-articular cartilage fissuring after MVAs in lab and autopsy studies. The pain is arising from these two soft tissues, therefore in general will not see any imaging abnormalities. The method to diagnose this issue are MBBs. I've done plenty of RFAs for whiplash with very normal looking MRIs, but very positive MBBs x 2 with great results from RADIOFREQUENCY ABLATION.

But why not just intra-articular? If it is a time-limited condition, that often improvs anyway, it seems this would be the way to go. Especially in younger patients as the RF is not going to last until the end of their life by any means. Isn't it nice generally speaking if they improve within intra-articular not to have to go onto RF? Whether it is a whiplash injury or just chronic cervical facet pain generally…

And also, based on your comments here and some of the comments above, I am trying just to get a general idea here, it seems many of you are OK treating facet pain, even if the imaging shows no pathology? ( again, I am not just talking about dramatic whiplash injuries here, but facet pain in general )

 

[nvrsumr]

there is a 1994 nejm article by barnesly that showed no benefit from intra-articular facet injections for whiplash.

 

[101N]

What is your treatment for whiplash that doesn't respond to time and PT? The 1996 nejm lord c rf study was for whiplash injury in MVA patients some of whom were in litigation. That was a blinded study in a prestigious journal. Not certain anything else comes close to this level of evidence for whiplash injury(not that I want to live or die by ebm)

Your evasiveness pretty much confirms my suspicion.

 

[nvrsumr]

Your evasiveness pretty much confirms my suspicion.

huh?

 

[lobelsteve]

When you ignore confounding factors like secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing you will damage your reputation in your community with savvy docs. Moreover, you contribute to the impression that most IPM physician's as being avaricious hucksters just looking for an injection.

Unfounded attack based on data you do not have. not like you care.

Injection may be reasonable as diagnostic.

 

[Ligament]

But why not just intra-articular? If it is a time-limited condition, that often improvs anyway, it seems this would be the way to go. Especially in younger patients as the RF is not going to last until the end of their life by any means. Isn't it nice generally speaking if they improve within intra-articular not to have to go onto RF? Whether it is a whiplash injury or just chronic cervical facet pain generally…

And also, based on your comments here and some of the comments above, I am trying just to get a general idea here, it seems many of you are OK treating facet pain, even if the imaging shows no pathology? ( again, I am not just talking about dramatic whiplash injuries here, but facet pain in general )

Oh yeah if the whiplash has not been around long or the patient is very young, I'll try intra-articular steroids (does not work too well but I'll try it).

Definitely ok doing MBBs on facets that look pristine on MRI. The MRI does not rule in nor rule out facetogenic pain. The MBBs do. Only the MBBs do.

 

[Taus]

This is actually the only time I'll put steroid in a mbb. Coat capsule and nerve. Much more volume then my standard 0.5 max cc mbb. Younger mva whiplash w persistent and localized axial pain failed conservative care. Not so scientific but I just want help them. For me less then 50% of these go on to needing formal mbb/RFA. Less money and procedures for me, good for patient.


Sent from my iPhone using SDN mobile app

 

[Timeoutofmind]

Oh yeah if the whiplash has not been around long or the patient is very young, I'll try intra-articular steroids (does not work too well but I'll try it).

Definitely ok doing MBBs on facets that look pristine on MRI. The MRI does not rule in nor rule out facetogenic pain. The MBBs do. Only the MBBs do.

I thought lumbar intra articulat facets had poor evidence but evidence was reasonable for cervical?

 

[SSdoc33]

When you ignore confounding factors like secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing you will damage your reputation in your community with savvy docs. Moreover, you contribute to the impression that most IPM physician's as being avaricious hucksters just looking for an injection.

no, it really wont.

PCPs send us patients with neck pain, and we give them shots. sometimes it help, sometimes it doesnt. why do you automatically assume that patients are in it for the above stated reasons? you know, if i think that the patients are looking for disability, etc, guess what? i wont do the shot. GASP.

your act is getting old

 

[clubdeac]

When you ignore confounding factors like secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing you will damage your reputation in your community with savvy docs. Moreover, you contribute to the impression that most IPM physician's as being avaricious hucksters just looking for an injection.

The problem is that it's not clear cut and often times very difficult to distinguish the opioid seekers, secondary gainers and catastrophizers from the legit patients. If it was a simple black/white matter then I think most would agree with you.

 

[Taus]

I thought lumbar intra articulat facets had poor evidence but evidence was reasonable for cervical?

Evidence pretty mediocre for both. The longer I'm in practice the less enthusiasm I have for more than a couple weeks to months relief. I'm very upfront about that now. Many patients still opt for trying that before going to mbb/RFA. No big desk if mcare or other that requires mbb x1, but huge pita if need ia facet, then mbb x2 then rf.


Sent from my iPhone using SDN mobile app

 

[101N]

The problem is that it's not clear cut and often times very difficult to distinguish the opioid seekers, secondary gainers and catastrophizers from the legit patients. If it was a simple black/white matter then I think most would agree with you.

I understand . My intake questionnaire is explicitly designed to try to differentiate the three. We all know that there is no absolutely reliable way to predict a seeker on the questionnaire
if they are savvy, but I ask do you or a first degree relative have a history of addiction and I ask about Hep C in my ROS. I also ask Do you have pending litigation or have you applied for
disability and if so have you acquired an attorney. And I use the pain catastrophizing scale. I will also frequently use the 2012 FMS screen. Before I walk into the room I know a lot about the
patient.

Not you, but some intentionally don't screen if it results in lowered procedural volume. I see it all the time in patients who are on opioids and cut loose from other interventional practices. When
I screen those people - post hoc - with my intake questionnaire I'll often find addiction, catastrophizing, overwhelmingly obvious secondary gain, or that the injections just didn't work and they
stayed for the opioids alone.

 

[neutro]

The problem is that it's not clear cut and often times very difficult to distinguish the opioid seekers, secondary gainers and catastrophizers from the legit patients. If it was a simple black/white matter then I think most would agree with you.

Its not that hard. Just takes time.

1) State PDMP to be checked for all new patients.
2) Rule that no opioids first visit, unless you have a great relationship with your referring provider and there is communication from them already that you will be managing meds - first visit is for consultation only.
3) Dr First HX - will check for meds from other states, and more importantly, which physicians the patient has seen.
4) UDS with GC-MS for ALL suspect patients - important for #2, i.e. not prescribing meds on first visit. If they dont give UDS on first visit, do not book them.
5) All new pts must have a PCP. When I was in PP, I used to give them a "transition of care" form - to be filled out by their current provider to document a few things, which included - rationale for opioid rx, last 4 notes, other treatments offered, etc. 100% of the patients given "transition of care" form never returned as they found it too difficult. I of course gave it to the patients that I suspected of the above.
6) The quality of filling out your pain questionnaire. If they skip any questions on previous treatment with opioids and it shows up on PDMP and Dr First Hx, they are not a candidate for any opioids from me. Interventional modalities only. If on suboxone, and did not disclose, then either discharge or non-narcotic multimodal + injections only. More than 90% of these patients do not return.

 

[lobelsteve]

I understand . My intake questionnaire is explicitly designed to try to differentiate the three. We all know that there is no absolutely reliable way to predict a seeker on the questionnaire
if they are savvy, but I ask do you or a first degree relative have a history of addiction and I ask about Hep C in my ROS. I also ask Do you have pending litigation or have you applied for
disability and if so have you acquired an attorney. And I use the pain catastrophizing scale. I will also frequently use the 2012 FMS screen. Before I walk into the room I know a lot about the
patient.

Not you, but some intentionally don't screen if it results in lowered procedural volume. I see it all the time in patients who are on opioids and cut loose from other interventional practices. When
I screen those people - post hoc - with my intake questionnaire I'll often find addiction, catastrophizing, overwhelmingly obvious secondary gain, or that the injections just didn't work and they
stayed for the opioids alone.

Explains a lot. i auto decline new patients who have been in other pain clinics. PDMP tells all. if their doc calls and there is a reason for change that is acceptable to me, i will consult.

No new patients on over 90 ms meq will get seen for anything other than counseling or procedures.

 

[clubdeac]

Its not that hard. Just takes time.

1) State PDMP to be checked for all new patients.
2) Rule that no opioids first visit, unless you have a great relationship with your referring provider and there is communication from them already that you will be managing meds - first visit is for consultation only.
3) Dr First HX - will check for meds from other states, and more importantly, which physicians the patient has seen.
4) UDS with GC-MS for ALL suspect patients - important for #2, i.e. not prescribing meds on first visit. If they dont give UDS on first visit, do not book them.
5) All new pts must have a PCP. When I was in PP, I used to give them a "transition of care" form - to be filled out by their current provider to document a few things, which included - rationale for opioid rx, last 4 notes, other treatments offered, etc. 100% of the patients given "transition of care" form never returned as they found it too difficult. I of course gave it to the patients that I suspected of the above.
6) The quality of filling out your pain questionnaire. If they skip any questions on previous treatment with opioids and it shows up on PDMP and Dr First Hx, they are not a candidate for any opioids from me. Interventional modalities only. If on suboxone, and did not disclose, then either discharge or non-narcotic multimodal + injections only. More than 90% of these patients do not return.

Neutro you missed the point entirely.... We are discussing reasons to not inject (secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing) We are not discussing reasons to not prescribe opioids. That's easy....So according to you, you will inject these types of patients in contrast to 101N who will not b/c he believes they will most likely not improve - which is unfortunately usually the case

 

[neutro]

Neutro you missed the point entirely.... We are discussing reasons to not inject (secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing) We are not discussing reasons to not prescribe opioids. That's easy....So according to you, you will inject these types of patients in contrast to 101N who will not b/c he believes they will most likely not improve - which is unfortunately usually the case

I primarily have an interventional practice - so I would do diagnostic cervical mbb's for axial neck pain and also possible for cerbicogenic headache. I am not sure what is 101N's practice model.
I responded with that post since the biggest challenge is patient selection and documentation before I can decide to inject. That is my protocol to weed out the drug seekers, vs legit patients as you noted that you find challenging. We subject that protocol to all patients.

often the patients will undergo injections and report no response in hopes that I will rx opioids. I don't ESP. If I know that injections were done properly by looking at fluoro images. I send them for a second opinion.

 

[Ducttape]

I think that 101N is pointing out that a major problem with MVA is that a great many people are looking to get something out of the injury - ie money. there is a group of people with even more reprehensible goals - to get paid.

a commercial that airs in my area has 4 or so people who say something like "I got 4 million when insurance would only pay me $100,000. Thanks Cellino ...!"

in some ways, Drug seekers are better - at least they will admit that they want oxy or Percocet

 

[ampaphb]

Crazy people can still have legitimate pain. People in litigation can still have legitimate pain. Comp patients can still have legitimate pain.

101N may not want to take the time to try and figure out who is legitimate, and who is playing him. That his close minded approach leads him to vilify those who disagree should tell you all you need to know

 

[Agast]

How's this for insurance-based medicine:

Cervical facet joint injections are considered diagnostic and not therapeutic. Therefore I am allowed to do bilateral multilevel cervical facet joint injections with steroid to diagnose facet-mediated pain. After >60% pain reduction I am not supposed to repeat the facet joint injections in the future, I am supposed to do radiofrequency ablation. This is from Aetna and Cigna and numerous discussions I have had on the peer-to-peer approval calls. You can do medial branch blocks if you want, or you can do facet joint injections with steroid for the diagnostic portion. So weird.

 

[Taus]

How's this for insurance-based medicine:

Cervical facet joint injections are considered diagnostic and not therapeutic. Therefore I am allowed to do bilateral multilevel cervical facet joint injections with steroid to diagnose facet-mediated pain. After >60% pain reduction I am not supposed to repeat the facet joint injections in the future, I am supposed to do radiofrequency ablation. This is from Aetna and Cigna and numerous discussions I have had on the peer-to-peer approval calls. You can do medial branch blocks if you want, or you can do facet joint injections with steroid for the diagnostic portion. So weird.

Yes it is Mbb/rf only for these patients. United here as well. Some of the lcd also specify if steroid used on diagnostic injection it's not covered. Patients can pay cash for steroid injection, add it but don't document it (dicey), or its Mbb/rf only.

While I don't agree with this policy, as there are a subset of patients where starting with ia steroid is preferable, the evidence doesn't really support them, whereas it does rf. On the other side it's stupid as it will cost insurer more money with more patients getting 1-2 mbb and RFA vs possibly 1 steroid shot.


Sent from my iPhone using SDN mobile app

 

[Hoya11]

When you ignore confounding factors like secondary gain, disability claims, PIP, attorney involvement, opioid seeking, and catastrophizing you will damage your reputation in your community with savvy docs. Moreover, you contribute to the impression that most IPM physician's as being avaricious hucksters just looking for an injection.

In my nightmare former job I did a LOT of auto accidents. I had it down to a science. Very lucrative. Im sure every situation is different but mine was VERRRY sleazy. Interestingly it was mostly a spanish speaking population surrounded by docs, chiros, others who spoke no spanish aside for a few. So when I spoke with them in spanish I feel like I had a bit of an honest connection. After I would describe the injections to them, without a doubt, the next thing they ask is "will it help my case?" I could offer them a foot injection for neck pain and they would be psyched for it. I think there is more of the above here than many providers may be understanding/appreciating. Or maybe they just dont care..

 

[Hoya11]

The problem is that it's not clear cut and often times very difficult to distinguish the opioid seekers, secondary gainers and catastrophizers from the legit patients. If it was a simple black/white matter then I think most would agree with you.

OK so you have a guy sent to you FROM A LAWYER for an MVA eval... He first went to a lawyer not a doctor
He works at burger King. He is poor. He has a large family. He lives in a poor area in a small house.

He gets into the MVA and the lawyer is telling him about how much money he is going to make from this. 20k!? 50k!? And I may not have to work for months to years? Life changing money to this guy and his family...An opportunity of a lifetime! Oh and SHHH just milk it a little bit to make sure we max out damages on this case....

Then you meet the doctor. Hmmm.. the patient is thinking... this doctor personally knows the lawyer who is going to get me all this money. I better do whatever he says, and I also have to relay the fact that I really WAS indeed hurt in the accident.... otherwise I might not get all that money and Ill have to go back to BK.

"So your MRI was totally normal...."
"Yeah but it still hurts in my neck"

"Does it go down your arm"
"A little"

"Does it hurt when I touch here"
"Yeah"

Let me put you on the schedule for an injection to help with the pain its quick and easy and totally covered by your insurance.
(Your not working anyways so why would you NOT be able to ..?, meanwhile the guy is doing side jobs to earn money while collecting disability from BK)

"Sure sounds good"

"Need stronger pain medicine"
"Yes definitely (Ill sell them), and if I say no hell think Im not really hurting"

Funny that when this same type of person would meet the neurosurgeon...

"Yeah PT and injections have really helped, pain is still there, still cant work, but I dont need surgery"

They are willing to let you do your silly little injection in the ASC, but when it comes to cutting them open, well hey lets not get carried away here I mean after all IM FINE and FAKING!

 

[ampaphb]

That's completely a reasonable scenario. However, do you simply deny this population care altogether? Or do you treat them with dignity and respect until they prove themselves unworthy.

Oh, and what MRI finding do u use to identify facet-based pain? My understanding is that the only reliable way to identify such a pain generator is an appropriate response to MBBs or IA facet jt injections

Sent from my SAMSUNG-SM-N930A using SDN mobile

 

[Hoya11]

That's completely a reasonable scenario. However, do you simply deny this population care altogether? Or do you treat them with dignity and respect until they prove themselves unworthy.

Oh, and what MRI finding do u use to identify facet-based pain? My understanding is that the only reliable way to identify such a pain generator is an appropriate response to MBBs or IA facet jt injections

Sent from my SAMSUNG-SM-N930A using SDN mobile

It shows them respect to NOT do the injections. So are you advocating MBBs for everyone with neck pain? how else can you rule it out? The massive evidence of secondary gain vs nebulous physical exam findings

 

[ampaphb]

Not generalized neck pain. But pain with palpation over facet joints, and referral pattern consistent with those described by bogduk absolutely should undergo diagnostic injections.

I notice you didn't respond regarding MRI findings. I await your reply.

 

[lobelsteve]

That's completely a reasonable scenario. However, do you simply deny this population care altogether? Or do you treat them with dignity and respect until they prove themselves unworthy.

Oh, and what MRI finding do u use to identify facet-based pain? My understanding is that the only reliable way to identify such a pain generator is an appropriate response to MBBs or IA facet jt injections

Sent from my SAMSUNG-SM-N930A using SDN mobile

Fire scan (CT SPECT).
I inherently do not trust lawyers. My brother in las is an immigration attorney and he keeps trying to have me deported. And I trained an attorney once. Once.

 

[ampaphb]

Fire scan (CT SPECT).

Do your radiologists do these? Are they covered by insurance? Are they expensive?

DePalma speaks highly of them in his book, but then says they aren't ready for prime time.



Sent from my SAMSUNG-SM-N930A using SDN mobile

 

[101N]

It shows them respect to NOT do the injections. So are you advocating MBBs for everyone with neck pain? how else can you rule it out? The massive evidence of secondary gain vs nebulous physical exam findings

My, a fortuitous dilemma. Boduk thinks he's created a Gordian knot with "Only the needle knows". We'll see when there is a RCT of MBB vs saline.

 

[lobelsteve]

Do your radiologists. Do. These. Are they covered. By insurance? Are they expensive?

DePalma speaks highly of them in his book, but then says they aren't ready for prime time.



Sent from my SAMSUNG-SM-N930A using SDN mobile

These are good tests. Too costly, not readily available, adds nothing to the diagnosis or treatment that a well performed MBB will not do. It makes money for the system and not the doctor.

 

[Hoya11]

My, a fortuitous dilemma. Boduk thinks he's created a Gordian knot with "Only the needle knows". We'll see when there is a RCT of MBB vs saline.

In this scenario, I would mention the injections as a modality if pain does not resolve spontaneously within a few months. Lots of the pain resolves at the end of the suit. If they come back to you after your mention it initially and bring it up to you specifically then I would entertain it. But put the ball in their court, mention it, explain it, tell them it has nothing to do with their case, and let them think about it. If they bring it up on their own then they may really want it. In my experience, few did.

 

[Hoya11]

My, a fortuitous dilemma. Boduk thinks he's created a Gordian knot with "Only the needle knows". We'll see when there is a RCT of MBB vs saline.

I think another interesting test would be MBBs vs TPIs at the same levels...

 

[SSdoc33]

Fire scan (CT SPECT).
I inherently do not trust lawyers. My brother in las is an immigration attorney and he keeps trying to have me deported. And I trained an attorney once. Once.

 

[SSdoc33]

Do your radiologists. Do. These. Are they covered. By insurance? Are they expensive?

DePalma speaks highly of them in his book, but then says they aren't ready for prime time.



Sent from my SAMSUNG-SM-N930A using SDN mobile

crapload of radiation. i do everything i can to avoid CT scans.

 

[bedrock]

SPECT scans can be useful, but only for the select patients. Most of the time unnecessary but can be useful for a challenging case you just can't figure out. I've seen a few place light up, that look normal on X-ray and MRI but correlate with the patients pain.

 

[epidural man]

101N,

You make a good point - of course rule out secondary gain issues (like pending litigation).

BUT...that wasn't really the point of the question.

You would make a good presidential debator.

The question was very specific - about imaging and facet mediated pain. It wasn't about treatment options. It wasn't about outcomes. It wasn't about healthcare costs, etc.

And the answer isn't confusing - nor controversial. I think all pain physicians agree - the pre-test (injection) probability of a successful result with facet injections (to determine facet mediated pain) is determined by history and physical exam and not at all on imaging. In the case of whiplash, that increases the pre-test probability for facet mediated pain a BUNCH.

Now, a second part question was comparing intra-articular with a pure Dx MBB. However, to answer that, it only makes sense to answer the first question about imaging - which I think we did.

 

[epidural man]

I actually should just say - history. I don't physical exam helps that much.

 

[bedrock]

I actually should just say - history. I don't physical exam helps that much.

disagree, I think it improves the likelihood of a positive response to MBB/RF if they patient has positive facet provocation maneuvers. I also palpate the facet joints which is often helpful with cervical facet issues, less with lumbar, but I still do it, and helps clarify between myofascial and facet pain, and decide which levels to include.

Also, I know you don't deal with this in the military medicine here in CA, but many commercial insurance companies in CA will deny the MBB or RF if you omit facet loading tests in your physical exam.

 

[Taus]

I actually should just say - history. I don't physical exam helps that much.

Disagree. No localized tenderness and no pain on extension/rotation make facet pain very unlikely. Very sensitive, but also very non-specific. Also may not be approved by insurance if not present and documented.


Sent from my iPhone using SDN mobile app

 

[epidural man]

Disagree. No localized tenderness and no pain on extension/rotation make facet pain very unlikely. Very sensitive, but also very non-specific. Also may not be approved by insurance if not present and documented.


Sent from my iPhone using SDN mobile app

You should do a study then to prove this. Because every other study has shown this is not realible in the least. In fact, Cohen showed that facet loading has a negative correlation to responding to RF.