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This is how I was taught as well. In retrospect, I wonder how many fascial plane/venous injections we were doing🙂
Cervical injections
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This is how I was taught as well. In retrospect, I wonder how many fascial plane/venous injections we were doing🙂
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That is sad. Your training does not meet the standard of care. Good luck with that.
i cant see how you'd have LESS vaso-vagals with the patient sitting. physics and physiology would argue against this.
this sentence "Sometimes even using contrast to confirm" is also pretty disturbing
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I heard about someone getting very lateral using this approach, injecting into a vertebral artery, and causing a posterior circulation stroke.
Hard to defend continuing this practice given the widespread availability of fluoroscopy.
Hard to defend continuing this practice given the widespread availability of fluoroscopy.
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When I first started doing them we used sharpened quills and we had to mine our own radium to do the xrays. The main postop complication was tetanus.
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Let me amend that...we always use contrast. But the positioning,etc is the same.
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Says who the guy that is running a NON-ACGME accredited fellowship..you?
I'm at an ACGME accredited fellowship. At a high volume place, very academic place. I have attendings that have been doing this >15 years or so with no catastrophic complications like the ones described in last month's APSF newsletters or in the recent Anesthesiology article by Rathmell. In fact, lots of the "greats" in pain medicine STILL do it this way (with contrast usage of course).
Give me evidence based research that shows it's worse than the way you do it. We'll talk about Standard of Care then. Otherwise it's merely opinion, which you have a right to.
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Not sure if you were referring to my post? But we do use fluro for this.
Not sure how people were getting into the vertebral artery doing this. To get to the vertebral artery you have to be not only lateral, but anterior which is a ways off ...
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I'll just say if it is not via ISIS, the injection technique can be improved upon.
Not sure how your arguments hold water.
I trained ACGME in an ISIS house at Emory.
I am training my fellow through the same school of thought.
Your attendings have years of experience and have not had catastrophe.
Russian roulette works the same way.
Ok with me- you can practice however you want. Just not on my mother....
And the data is pretty good against your way of doing things. Closed claims, ISIS guidelines, Curr Rev Musculoskelet Med. 2009 March; 2(1): 3042.
Published online 2009 January 7. doi: 10.1007/s12178-008-9041-4.
PMCID: PMC2684951
Copyright © The Author(s) 2008
Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar versus transforaminal. A review
Christopher W. Huston
Pain Med. 2011 May;12(5):726-31. doi: 10.1111/j.1526-4637.2011.01077.x. Epub 2011 Mar 10.
Incidence and characteristics of complications from epidural steroid injections.
McGrath JM, Schaefer MP, Malkamaki DM.
And on and on.
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Isn't there pretty solid anesthesia literature that hanging drop has a higher incidence of wet taps than saline LOR?
I just finished training with Furman and helped him with a couple chapters of his Atlas. It is coming out in a few months and is OUTSTANDING for doing SAFE procedures. The whole thing is based on utilizing safety views and includes bad dye patterns to recognize too which you never see in books.
I just finished training with Furman and helped him with a couple chapters of his Atlas. It is coming out in a few months and is OUTSTANDING for doing SAFE procedures. The whole thing is based on utilizing safety views and includes bad dye patterns to recognize too which you never see in books.
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Give me evidence that ACGME-trained fellows have fewer complications or better outcomes than non-ACGME accredited🙂
This is turning into another pissing contest.
it must be nice to live in a world where your sh$t dont stink.
What will be the name of the book? The bad dye patterns is a great idea.
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You are missing the point.
There are different ways to do procedures. There's no 'one' right way. I think someone that did a real ACGME accredited fellowship with oversight by experienced staff can do things as long as they are competent and knowledgeable about all the risks, benefits, etc.
I think this is VASTLY different from someone that doesnt do a formal ACGME accredited fellowship and/or attends a weekend course at some random meeting and learns how to do cervical injections. Additionally, again please take a look at those recent catastrophic events that have occurred with cervical injections. A vast majority of them were done the "ISIS" way. Or look at the TFESI's done the "ISIS" (per Steve the "standard of care") way causing ischemia to the Art of Adam...
I'm not discounting the ISIS way. It's a great organization and they have some great educational material. There are some really great academic guys on it as well. The bottom line is complications unfortunately happen. You do things the way you were trained, especially if it's safe and you strive to perfect that technique--that's how you increase safety.
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"Additionally, again please take a look at those recent catastrophic events that have occurred with cervical injections. A vast majority of them were done the "ISIS" way."
Calling your bluff. Provide peer reviewed evidence for your perspective.
You are in deeper than you know.
In my area there is a spine surgeon doing sitting cervicals as well as lateral RF and SCS trials (somehow) after a one day weekend course. Needless to say that I have stopped referring to him and I pray for his patients....
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http://www.ncbi.nlm.nih.gov/pubmed/21386702
read the full version of it. It's hard to tease out which technique was used for the various injections. You non -ACGME accredited 'spine' folks are very quick to altercate. There is no clear indication that one technique is the "standard of care", that's my point. Both techniques have their limitations..
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Fluoro and contrast are the main criteria for standard of care with cervical ESI. Doing CESI with hanging drop technique but without fluoro and contrast is definitely substandard care in today's pain medicine. Even though I don't like doing CESI that way, I'd argue that for Pinch to do hanging drop (but with fluoro and contrast) is a reasonable variation of the standard of care.
I know this had been discussed before, but comparing the procedural training from a weekend course to a year-long fellowship (non-ACGME) is ridiculous. I have residency friends who did ACGME and non-ACGME fellowships, and many of the non-ACGME fellowship trained guys have better procedural skills than the ACGME trained ones (but definitely goes both ways).
An ACGME fellowship certainly provides superior training as an all-around pain physician, but it's ridiculous to compare the procedural training of a 16 hr weekend cadaver course to year-long fellowship with thousands of clinical hours and hundreds of procedures on live patients. Not even in the same ballpark.
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im not missing the point at all. the above post is a bunch of crap that doesnt really say anything.
i know some on this board can seem sanctimonious (myself included). the reason is that there are a lot of shall we say "less than perfect" pain practitioners out there. doesnt matter if they are your attending from an "ACGME-accredited fellowship". oooooooh, look out. the standards to be teaching fellows is not exactly a high bar.
do yourself a favor, and listen to the members of this board. dollars to doughnuts, they know more than your attendings. and when they say you shouldn't be doing cervical epidurals with the patient sitting, you should probably at least listen.
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PD at U Pitt still does blind seated CESI.
That's ACGME and that's wrong. Besides this, I really like Dr. Cope.
That's ACGME and that's wrong. Besides this, I really like Dr. Cope.
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might as well stir it up some more.
This question really does not matter, and probably is not answerable base on the rare 'reported' complications we encounter among ACGME and non-ACGME physicians. IN the eyes of a jury and plaintiff attorney you are not ABMS certified and the same. Most attorneys go after new grads, even board-eligible ACGME candidates can be targeted.... So there is a difference.
From my perspective, I was trained to doing hanging drop for lumbar epidurals as a 'historical' and alternative approach. The attendings were I train still teach this technique more as a novelty. If you have the confidence to do this in the cervical spine, god speed. As long as you are using contrast to map the epidural spread and obtain some long term benefit you must be doing something right...
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It can easily be argued ACGME fellowships are NOT necessarily a sign of good or even adequate training. The requirement for matriculation from an ACGME pain fellowship is that one do 20 interventional procedures. Thats it...20 for the entire fellowship. With a bar set that low, it is impossible to assure adequate quality based on certification alone.
There certainly are many ways to perform procedures and the standard ISIS method, while in general has the longest track record of safety, other techniques may be necessary in some patients due to anatomical constraints. There will always be some fool who is arrogant and incompetent enough to claim the ISIS technique caused the complication they had when in fact it is much more likely to be sloppy technique and rushing through a day, not using real time contrast injection, not appreciating the flow pattern aberration, or moving the needle after the contrast injection. It is THAT proclamation that will not hold up in court.
There certainly are many ways to perform procedures and the standard ISIS method, while in general has the longest track record of safety, other techniques may be necessary in some patients due to anatomical constraints. There will always be some fool who is arrogant and incompetent enough to claim the ISIS technique caused the complication they had when in fact it is much more likely to be sloppy technique and rushing through a day, not using real time contrast injection, not appreciating the flow pattern aberration, or moving the needle after the contrast injection. It is THAT proclamation that will not hold up in court.
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That 20 procedure per fellowship requirement is nuts. I did 20 per day in fellowship very frequently.
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I totally agree. The basal level is ridiculously low and provides significant non-uniformity between programs given this latitude...
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Unfortunate but true. You have to take a closer look at the individual training as there are plenty of substandard ACGME and non-ACGME fellowships out there. Procedure logs should be the main requirement for insurance and facility credentialing, not ACGME status.
Procedural volumes much higher than 20 should be part of ACGME credentialing for individual fellowships. This would motivate the lesser programs to provide appropriate procedural training for their fellows.
Procedural volumes much higher than 20 should be part of ACGME credentialing for individual fellowships. This would motivate the lesser programs to provide appropriate procedural training for their fellows.
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Didn't ISIS preach for years about the "safe triangle" for lumbar tfesi? which turned out to be BS (considering all of the major vascular structures are in this region
as for the CESI, it is hard to argue that the hanging drop technique is less accurate or safe based on the literature.
as for sitting vs standing, there is probably no data, but logically it sounds like if the patient's neck is relatively more stable in the head down position, it would be safer? You can argue either way, but where I trained (ACGME certified) at tx tech and from the major interventional ACGME fellowship trained drs i know (UCLA, brigham womens, cleveland clinic), no one did them in the seated positions, and definitely not using hanging drop. for what it's worth.
touching lamina, walking off and finding LOR, using lateral fluoro as well as AP fluoro, all these things add minimal time and the epidural space can be safely accessed under 90 seconds in skilled hands safely with good results.
as for the CESI, it is hard to argue that the hanging drop technique is less accurate or safe based on the literature.
as for sitting vs standing, there is probably no data, but logically it sounds like if the patient's neck is relatively more stable in the head down position, it would be safer? You can argue either way, but where I trained (ACGME certified) at tx tech and from the major interventional ACGME fellowship trained drs i know (UCLA, brigham womens, cleveland clinic), no one did them in the seated positions, and definitely not using hanging drop. for what it's worth.
touching lamina, walking off and finding LOR, using lateral fluoro as well as AP fluoro, all these things add minimal time and the epidural space can be safely accessed under 90 seconds in skilled hands safely with good results.
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the only standard pain physicians have are ACGME accredited fellowships, the only fellowships recognized by the American Board of Medical Specialties. Not abiding by these rules opens doors for mid-level health providers that claim they get similar if not superior training as nurse pracs, etc. We as a specialty need to enforce board certification if we will ever rid ourselves of the troubles of pill mill docs, docs doing blind SI joints, docs not using contrast.
look at cardiologists and how they were able to protect their field. Anesthesiologists trained with CT anesthesia fellowships are unable to bill for TEE's unless they get a separate certification in addition to their fellowship. this extra hurdle does not make them more qualified, but protects their field. similarly our field needs protection. ensuring board certification for A) reimbursement and B) legal advertisement as a pain physician is critical for our specialty moving forward.
anyone arguing against is either trained many decades ago and will be grandfathered in, or could not get into an ACGME-accredited fellowship.
arguing that an ACGME fellowship is not a sign of a well-trained physician is simply asinine. I guess you can throw away your medical license, your GME residency training certificates, and your USMLE Step I scores because they don't mean much either then
look at cardiologists and how they were able to protect their field. Anesthesiologists trained with CT anesthesia fellowships are unable to bill for TEE's unless they get a separate certification in addition to their fellowship. this extra hurdle does not make them more qualified, but protects their field. similarly our field needs protection. ensuring board certification for A) reimbursement and B) legal advertisement as a pain physician is critical for our specialty moving forward.
anyone arguing against is either trained many decades ago and will be grandfathered in, or could not get into an ACGME-accredited fellowship.
arguing that an ACGME fellowship is not a sign of a well-trained physician is simply asinine. I guess you can throw away your medical license, your GME residency training certificates, and your USMLE Step I scores because they don't mean much either then
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Safe triangle was a term used to describe a triangular area where the exiting nerve would not be pithed if the needle was placed as described. This terminology existed long before in depth vascular dissections had been made and long before the reports of lumbar catastrophic disasters. The term was accurate for its time, but it was also accompanied by the proviso of real time fluoro injections and analysis followed by steroid injection without needle movement. It is the lacking of the latter two components that made the injection rarely unsafe in the triangle, not the presence of vasculature.
As for the hanging drop technique, the literature demonstrates a positive cervical epidural pressure in the prone position and usually is frequently positive in the sitting position making the hanging drop technique inappropriate for identification of the epidural space (Anesthesiology. 2010 Sep;113(3):666-71.
). Another article found the epidural space was 2mm more anteriorly identified with the hanging drop technique compared to the LOR technique and that there is a diminished risk of dural damage with LOR vs hanging drop technique ( Br J Anaesth. 1999 Nov;83(5):807-9.).
The ACGME fellowships have been around since 1993 and it would be difficult to argue the experiences throughout the fellowship programs over the past 20 years have been homogenous. The only significant standards for these fellowship programs were developed and implemented over the past 3 years. Prior to that, it was a hodge podge of experiences available. But the CRNAs are knocking at the door, attempting to cajole the University of New England into granting them a "pain fellowship" training program, so you might as well throw away your certificates if that occurs.
As for the hanging drop technique, the literature demonstrates a positive cervical epidural pressure in the prone position and usually is frequently positive in the sitting position making the hanging drop technique inappropriate for identification of the epidural space (Anesthesiology. 2010 Sep;113(3):666-71.
). Another article found the epidural space was 2mm more anteriorly identified with the hanging drop technique compared to the LOR technique and that there is a diminished risk of dural damage with LOR vs hanging drop technique ( Br J Anaesth. 1999 Nov;83(5):807-9.).
The ACGME fellowships have been around since 1993 and it would be difficult to argue the experiences throughout the fellowship programs over the past 20 years have been homogenous. The only significant standards for these fellowship programs were developed and implemented over the past 3 years. Prior to that, it was a hodge podge of experiences available. But the CRNAs are knocking at the door, attempting to cajole the University of New England into granting them a "pain fellowship" training program, so you might as well throw away your certificates if that occurs.
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no, arguing that SOLELY because a doc does a ACGME pain fellowship, therefore that doc is a good pain physician is asinine.
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Exactly my point. Pain fellowship training just isn't standarized enough to be able to uniformly trust every doc who did a pain fellowship.
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the point of acgme fellowships is to keep out quack docs that do blind interlaminar ESI's (which we all know are not equivalent to a transforaminal; just call yourself dr. crna) and mid-level health providers from cashing in on the system.
it also helps keep health care costs down if we can keep out these non-board certified physicians that charge for procedures that they never did or did incorrectly. the state of Ohio is on the right track by only allowing "certified pain clinics" to administer opioids. Eventually, we need to limit all reimbursement of interventional procedures to pain medicine board certified physicians. the last thing we need are people doing what they did to the IDET and render SCS and MILD to be experimental and not work because untrained physicians do the procedure on anyone to make $.
no one said that ACGME fellowships make a pain physician competent anymore than and MD or DO make a person a competent physician. It should be used to enforce guidelines to save our country money and ensure good and ethical care
it also helps keep health care costs down if we can keep out these non-board certified physicians that charge for procedures that they never did or did incorrectly. the state of Ohio is on the right track by only allowing "certified pain clinics" to administer opioids. Eventually, we need to limit all reimbursement of interventional procedures to pain medicine board certified physicians. the last thing we need are people doing what they did to the IDET and render SCS and MILD to be experimental and not work because untrained physicians do the procedure on anyone to make $.
no one said that ACGME fellowships make a pain physician competent anymore than and MD or DO make a person a competent physician. It should be used to enforce guidelines to save our country money and ensure good and ethical care
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We do need a high standard for pain medicine, certainly higher than the free for all that now exists. Interestingly I submitted an article to Anesthesiology around 4 years ago reviewing all the reasons and literature surrounding why blind epidurals should be obsolete. It was rejected outright, largely due to the fact many OR anesthesiologists continue to do blind epidural steroid injections. Perhaps it is these individuals that should be barred from practicing pain medicine as well as noctors....
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I just want to say a few things......
I don't care what PinchandBurn says, I like his moniker
Sweets quit acting like you didn't just graduate
I hope you were able to get that wine out of your suit and got it covered by Freddy... that sucked!
I think we need as much protection as possible. Grandfather in the guys now doing pain and require board certification to practice from here on out!! I don't need anyone else tryin to get ma monay
And finally my favorite quote from the ASIPP meeting, "No matter how severe and intractable the pain, it can always be made worse by surgery" ... Amen
I don't care what PinchandBurn says, I like his moniker
Sweets quit acting like you didn't just graduate
I hope you were able to get that wine out of your suit and got it covered by Freddy... that sucked!I think we need as much protection as possible. Grandfather in the guys now doing pain and require board certification to practice from here on out!! I don't need anyone else tryin to get ma monay
And finally my favorite quote from the ASIPP meeting, "No matter how severe and intractable the pain, it can always be made worse by surgery" ... Amen
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I just want to say a few things......
I don't care what PinchandBurn says, I like his moniker
Sweets quit acting like you didn't just graduate
I think we need as much protection as possible. Grandfather in the guys now doing pain and require board certification to practice from here on out!! I don't need anyone else tryin to get ma monay
And finally my favorite quote from the ASIPP meeting, "No matter how severe and intractable the pain, it can always be made worse by surgery" ... Amen
Algos:
So what if only 20 ESI's are necessary for an ACGME program. You also need a component of didactics from radiology, psych, practice Management, ortho, and neurology and so forth. We had additional time for research in my program. This many be minimal in your book, but still exists.
Clearly, ACGME programs do NOT guarantee good physicians. But what field does??? At least there is a minimal bar that needs to be met. Non-ACGME programs do not, which is even scarier....
In the end, patients need to look at the doctor's medical/residency/fellowship institution, credentials, malpractice claims, accreditations, and so forth. There are a lot of quacks out there in all fields, at least ACGME forces physicians to do the basics.
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The problem is rolling standards that change over time cause patients to be misled rather than insuring confidence. The ACGME fellowship trained board certified doc sounds great on paper but what if they trained in 1994 doing blind interlaminar epidurals, trigger points, and methadone treatment and have largely maintained the same practice since without advancement (I know of several physicians in this boat). Or docs that trained having 20 interventional procedures under their belts for the entire fellowship and now enter practice...is that doctor really competent to be credentialled by a hospital or surgery center or have enough experience to be doing complex stimulator procedures? Of course not, but many credentials committees don't know the difference and even worse, neither do the patients. How many new grads that have done two stim implants are going to confess to their patients before scheduling them for a stim that they have done only two?
What about docs that have vast experience and are outstanding clinicians but do not have ACGME fellowship training because they do not need it....they long ago surpassed what fellowships could offer....is their lack of ACGME training to be held as a yardstick by patients who may elect to not see these docs on that basis?
Of course we need to transition to a higher training program but what happens when we have 2 year ACGME programs or a residency....does that make the one year trainees inferior to those who have are board certified and pain residency trained? Certainly they will have better education than you....why should they not be rewarded for their time investment in education and be able to point out to the public they are better because they are better trained? And the MOCs...if you do not have MOC in pain medicine are you less qualified than a person who does or are these really artifices to garner hundreds of millions of dollars more in income by the specialty boards since the MOC value is simply speculative and has not been proven? You see there is no end to the brinksmanship that can occur when ever escalating requirements with questionable educational value are introduced. There is a tacit assumption made that each level of increased training translates defacto into a better physician or should be used as a facade to the public that the additional training makes the person a better physician. I am nearing the end of my career and really do not have a dog in this fight but would caution holding anything out to the patients or general public using a certification as a measure of competency is erroneous since the entire concept is unproven. From pain board certification to ACGME training, there have been huge variations in quality, requirements, and outcomes over the past 2 decades that still persist today. The effort in additional training is appreciated but where we are today is only part of a continuum that will make current graduates certificates obsolete in a decade or two.
What about docs that have vast experience and are outstanding clinicians but do not have ACGME fellowship training because they do not need it....they long ago surpassed what fellowships could offer....is their lack of ACGME training to be held as a yardstick by patients who may elect to not see these docs on that basis?
Of course we need to transition to a higher training program but what happens when we have 2 year ACGME programs or a residency....does that make the one year trainees inferior to those who have are board certified and pain residency trained? Certainly they will have better education than you....why should they not be rewarded for their time investment in education and be able to point out to the public they are better because they are better trained? And the MOCs...if you do not have MOC in pain medicine are you less qualified than a person who does or are these really artifices to garner hundreds of millions of dollars more in income by the specialty boards since the MOC value is simply speculative and has not been proven? You see there is no end to the brinksmanship that can occur when ever escalating requirements with questionable educational value are introduced. There is a tacit assumption made that each level of increased training translates defacto into a better physician or should be used as a facade to the public that the additional training makes the person a better physician. I am nearing the end of my career and really do not have a dog in this fight but would caution holding anything out to the patients or general public using a certification as a measure of competency is erroneous since the entire concept is unproven. From pain board certification to ACGME training, there have been huge variations in quality, requirements, and outcomes over the past 2 decades that still persist today. The effort in additional training is appreciated but where we are today is only part of a continuum that will make current graduates certificates obsolete in a decade or two.
it is not used to enforce guidelines. it doesnt save our country money. it doesnt ensure good care. it doesnt ensure ethical care.
your heart is in the right place, but your head isnt there. id love a billion dollars and a wife who doesnt give me sh$t, but thats not the situation.....
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The guy is learning two image guided techniques for CESI and two nonimgage guided methods to confirm epidural space. Both fluoro guided with contrast confirmation. I question his observations(hes a fellow so he should be having varying observations) but seems to be reasonable training.
I dont use hanging drop, catheters(much), blind seated or image guided seated anymore. In fact I primarily use the contralat oblique approach, when not doing CTFESIs, that I was first introduced to on SDN. I think knowing 5-6 different methods of accessing the same place hopefully taught by 10 to 15 different attendings will make him a better doc.
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Algos as always great posts
1) As I mentioned in my original posts on here, I agree I think ISIS does have some great guidelines. People that follow these guidelines may or my not get complications. My contention was to reject Lobel's assertion that following ISIS guidelines is the only way to go. Bottom line is that complications can happen no matter what. It's all about risk mitigation. ISIS has some great educational material as I've always mentioned in my previous posts. I think one could do cervical injections in multiple different manners as long as you have checks and balances (fluro, contrast, LORTA/saline, hanging drop,change in respiration, fluid column to gravity, contralateral, oblique, etc). Whether you do it sitting, prone, LORTA, hanging drop, I think as long as contrast and fluro are used, it can be safe.
2) As sweetalkr mentioned, some of us ACGME accredited fellowship grads who have done things the right way get furious when these quacks out there overutilize therapies. As he mentioned, I do not want SCS and MILD to have the same life expectancy as IDET did. Why, because they are good therapies in the right patient population. The problem we have is when any random guy in private practice decides to create a "fellowship" to essentially create revenue for his practice. If one wants to be an educator then go into academics--there's nothing wrong with it. Creating these "spine fellowships" or whatever someone wants to call them is a problem. Why create them when they already exist? We are just diluting the concept of a fellowship then. Furthermore, these 'weekend' courses, no matter which organization does it, should not be open to anyone. There should be regulation and it should be for docs that want to hone in on the skills they learned in fellowship and wanted to perfect.
3) I agree, the 20 procedure requirement is not a lot. But I would also present to you that almost no ACGME accredited fellowship gives fellows only 20 procedures. Having said that, there are only a few fellowships that give fellows adequate training for more advanced procedures like SCS, mild, Intrathecal drug delievery,etc (texas tech, BWH, cleveland clinic, etc). I would agree that if you did only 2 SCS's as a fellow, being an implanter is a stretch.
4) The bottom line is there needs to be restriction as to who goes into pain medicine. Creating MORE fellowships is not the answer. The ACGME fellowship is atleast a guideline, or a minimum. I would submit to you that almost anyone that is looking to start a fellowship always applies to an ACGME accredited one first, and then goes to a non-ACGME accredited one as a back up. One may not admit that, but it is fact from what I've observed.
5) The concept of a pain residency is a good one. But the issue becomes how can one be constructed so that one is not a 'jack of all traits and a master of none". Presumably these residents would do a few months with anesthesiology, PMR, neuro, neurosurg, ortho, psych, IM, etc. How can someone that just did a little of each of these become proficient enough to be a proceduralist/implanter? Anyone can write opioids, refer patients to PT, write non-opioids,etc--all you need is a pen/or a keyboard these days. The technical skills could be lacking if one is not properly exposed to procedures. I dont want someone sticking a 14G needle close to someone's spine that's just seen/done 10 epidurals while on their anesthesia rotation. If these sort of differences could be resolved, then a pain residency is a great idea.
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Discussing MILD in the context of IDET is prescient as it is destined for the same fate.
Open & endoscopic decompression both work well, are the standard of care, and will continue to be. We don't need an alternative as the problem is solved. MILD - like X-stop & IDET - merely increases the cost of spine care and place patients at an unnecessary risk do to the procedure's lack of direct visual guidance. You won't do this on my momma.
If patient injuries do not kill MILD, outcome studies will. Stay tuned.
Open & endoscopic decompression both work well, are the standard of care, and will continue to be. We don't need an alternative as the problem is solved. MILD - like X-stop & IDET - merely increases the cost of spine care and place patients at an unnecessary risk do to the procedure's lack of direct visual guidance. You won't do this on my momma.
If patient injuries do not kill MILD, outcome studies will. Stay tuned.
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your procedural methods, medical knowledge, and medical technology will be obsolete in 5 years or less essentially negating whatever fellowship you did.
ACGME does nothing to ensure safety, efficacy, or outcomes when you're out in practice for years/decades because you have to constantly adapt and update your skills. The guy who does the most and best stims in my area is self-trained because it didn't exist in his training era. Same with pumps. Most of these guys never even had a formal fellowship available to them. Look at Aprill, Bogduk, Derby, etc.
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like i said, older docs get grandfathered in
for the 1994 docs getting their acgme fellowship training, hopefully they get their CME credit yearly (isn't that what it's for?)
and a patient should go into an office with face, neck, ankle, arm, phantom limb, or phantom testicle (i saw this) pain and have an option of treatment. people should not be going to "spine only" docs. pain doctors should treat all pain.
and for old outdated docs, well they will eventually retire before better trained docs, and hopefully they are continuing to learn right?
we need a baseline to protect our field. NO ONE can argue that. argue the validity of ACGME, argue the trianing requriements, but NO ONE can argue that requiring an ACGME fellowship protects our specialty. try it.
for the 1994 docs getting their acgme fellowship training, hopefully they get their CME credit yearly (isn't that what it's for?)
and a patient should go into an office with face, neck, ankle, arm, phantom limb, or phantom testicle (i saw this) pain and have an option of treatment. people should not be going to "spine only" docs. pain doctors should treat all pain.
and for old outdated docs, well they will eventually retire before better trained docs, and hopefully they are continuing to learn right?
we need a baseline to protect our field. NO ONE can argue that. argue the validity of ACGME, argue the trianing requriements, but NO ONE can argue that requiring an ACGME fellowship protects our specialty. try it.
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Do you have any thoughts on using a Weiss needle as opposed to the Touhy? The blunted tip and wings might help a bit.
Also, can any of you private guys please tell me how you get access to journal articles? Are you paying for each article you read?
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The reason the saline is sucked in during the hanging drop technique is frequently due to tenting the dura into the cord. The pressure in the cervical epidural space is frequently positive, therefore the ONLY way the hanging drop method can work in such cases is through displacement of some anatomical element in the epidural space that enlarges the space. The only structure possible to be so displaced is the dura since there is virtually no fat in the posterior cervical epidural space. Displacement of the dura anteriorly towards the cord or touching the cord is not exactly the safest idea, and given a dural puncture rate 3 times as high for hanging drop vs loss of resistance, it is not surprising. The hanging drop method should be abandoned. It is an anachronism practiced by those in the past that did not understand the anatomy or physiology of the epidural space.
I wont advocate a method I no longer use(hanging drop) but I do routinely confirm cervical epidural space after LORTS with a fluid column drop. If the fluid drops I always get a good contrast pattern. Period. This is performed in the prone position. Maybe I tent the dura every day or maybe there is something going on regarding epidural pressures that arent fully understood?
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Depends on the position: in the prone position, the cervical epidural pressures are positive, and fluid drops can move down the needle via gravity into the epidural space, overcoming small positive pressures during LOR placement. In the sitting position, if the needle is horizontal, and the cervical epidural pressures are positive, then the only way a drop of fluid would enter the epidural space is if the dura is tented....
So you are correct, there are some physiological explanations for the loss of the fluid that may vary with position of the patient, needle position, etc.
Many of us, including me, first learned the hanging drop technique as the only means of accurately predicting epidural space entry. But given the advancement in knowledge, it exists as an archaic (but fun) historical technique.
So you are correct, there are some physiological explanations for the loss of the fluid that may vary with position of the patient, needle position, etc.
Many of us, including me, first learned the hanging drop technique as the only means of accurately predicting epidural space entry. But given the advancement in knowledge, it exists as an archaic (but fun) historical technique.
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I have read the studies about the variable pressures associated with the cervical region. As you mentioned they can be positive. However, this is why I personally would not do it "blind" w/o fluro so that you just advancing. However, I think with the utilization of fluro you can decrease this. Secondly, all/most issues surrounding cord related injuries that were severe were associated with injecting contrast/saline/air INTO the cord. With the hanging drop technique you are not injecting into the cord. The drop goes into the area with the least resistance (it's not being injected in). With hanging drop, the two common ways for the "drop" to disappear is if you are in the intrathecal space or the epidural space. If you are in the intrathecal space, then on fluro that should be detected (again reason for using fluro).
In terms of 'wet taps', sure it can happen. I think this year in my fellowship combined amongst all our fellows at a highly interventional program, we had a total of 1 wet tap. The time it did happen was when they were doing LORTA....As an anesthesiologist I can tell the reader that wet taps happen, as long as you do enough of these, even if you use LORTA in the lumbr/thoracic regions as well.
Again, I think as long as one is using both fluro/contrast/ and have other methods (can be discussed in the private forum) to verify the space you are in, CESI can be done using either technique, respectfully refuting it's anachronism. Again, being younger and having first learned the LORTA technique, and hesistant about the hanging drop technique. I am quite convinced now that the hanging drop technique, when done correctly can be just as good.
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It would only take one screw-up using a hanging drop technique regardless of the cause, and you would be toast in court. With several papers touting the decreased safety of the technique, you would be arguing your case against the medical literature and against the vast global experience of anesthesiologists. I would not play with fire knowing how close to the cord the tip of the needle has to be in order to get hanging drop to work. Intrathecal placement in the sitting position definitely will not cause the drop to "disappear" since there is a column of CSF fluid with positive pressure to prevent that. In the prone position, yes, one can have a negative pressure or neutral pressure or positive pressure with a wet tap cervical. Too many variables with hanging drop, higher wet tap rate, much closer to the cord....all reasons to not use the technique...
