cervical selective nerve root block

[SpineandWine]

Hi,

Surgeon booked the following procedure on my schedule "L C4-C5 and C5-C6 SNRB." In fellowship, I never did transforaminal epidural steroid injections at the cervical region, nor did I do SNRB at those (only CESI at C7-T1).

1) Does anyone do TFESI OR SNRB at cervical region. If show, what's the technique/how to do it
2) Should I just communicate I don't do them? Or just go with the flow?

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[lobelsteve]

What could go wrong? Just jab em in the side of the neck. No worries. Do you book fusions and paddles for him?

 

[SSdoc33]

So much wrong here.

Neither the suegeon, nor you know what you are doing. But ill help out.

Just do the C7-T1 ILESI. Communicate with the surgeon that SNRBs in the neck arent specific, especially if you do 2 levels. He is trying to decide whether to do a single or 2 level ACDF. There is no injection that can make that determination.

My guess is that the surgeon doesnt know what hes doing, or more likely, his PA 'ordered' the injection.

Next time, see this patient in clinic first. If you have to see them just for the shot, only do the ILESI. Do not just 'wing it' with a TFESI

 

[SpineandWine]

They’re a friendly group. Okay, I’ll just communicate with surgeon that snrb of cervical region is not standard of care. That’s what I figured but just wanted to make sure no one else does this and believes it is safe.

I just started so I don’t think they know what I can do/what boundaries are.

 

[callmeanesthesia]

If you want to learn it, start with reading the SIS procedure manual and an anatomy atlas. That said, if you’re not comfortable with this injection, best get some hands on guidance, like at an SIS course, before attempting.

First, need to clarify whether they are truly asking for a diagnostic procedure. Some surgeons use SNRB and TFESI interchangeably. Second, is the purpose a diagnostic or therapeutic injection? If therapeutic, is almost all circumstances you can substitute an interlaminar at C7-T1 with at least equal efficacy and better safety profile and patient comfort.

If diagnostic, what is the question being asked? If it’s “Should I fuse both these levels?” Then an injection won’t really help. If it’s “should I include this level in the fusion?” Then I may have some utility. With that in mind, as SSdoc33 says, a 2 level SNRB is unlikely to be indicated.

 

[SSdoc33]

Only time i see a rationale for ctfesi, which is very rare, is when there is a high cervical radic, and they have failed a ilesi. Happens once every 2 years or so

 

[SpineandWine]

Based on what I'm gathering, it seems I'll stick with my C7-T1 ILESIs.
PHEW!

I'll definetely review that SIS procedure manual.

 

[SpineandWine]

Another booking - "C1-C2 Facet" I assume no one does these as well. I am just going to have these direct procedures seen in clinic and book myself.

 

[Tboned]

Definitely would not wing it doing a CTFESI/ SNRB with zero experience

Some people do C1-2 joint injections, others don’t. Wouldnt recommend winging that either.

Need to be good at reviewing MRI for both so you don’t skewer a vert.

 

[willabeast]

Hi,

Surgeon booked the following procedure on my schedule "L C4-C5 and C5-C6 SNRB." In fellowship, I never did transforaminal epidural steroid injections at the cervical region, nor did I do SNRB at those (only CESI at C7-T1).

1) Does anyone do TFESI OR SNRB at cervical region. If show, what's the technique/how to do it
2) Should I just communicate I don't do them? Or just go with the flow?

Suggest this procedure is a bad one for you to attempt without training. Pick an excuse. So much can go wrong....For training SIS probably good start. https://www.spineintervention.org/events/EventDetails.aspx?id=1704445

 

[clubdeac]

This is hilarious. I think you’re getting punked by one of the surgeons. Hopefully no one ends up paralyzed

 

[bedrock]

Unfortunately both procedures they asked for are ones that can’t really be learned in a course. You need to have learned them in fellowship, while you were proctored. They have higher than normal risk and require very particular technique.

btw, unless they have a ct scan with flagrant c1-C2 pathology, u should never start with a C1C2 facet injection. Always try GON blocks and C2,C3,C4 MBB first. C1-C2 facet/articulation injection is always last and rarely needed.

And you need to have a talk with your surgeons about direct injection referrals. They should be saved for patients in severe pain. Everyone else should first see you for a consult on a different day. (So you can then order and auth, the correct procedure)

 

[Taus]

Another booking - "C1-C2 Facet" I assume no one does these as well. I am just going to have these direct procedures seen in clinic and book myself.

I do both c1-2 and ctfesi. Most do not. As others have stated, do not attempt to wing it with either one of these. Either send to somebody else in the group or specifically tell the surgeons and schedulers you do not do these 2 specific procedures.

 

[Orin]

This is a good time to sit with them and understand their needs. If you can't do it, then help them find a solution while you work on getting comfortable/good at it. As an academic doc, I know how easy it is to punt but eventually that leads to loss of confidence/faith in your ability to execute.

As far as winging it, definitely not something you do without having reviewed a bunch of papers with a clear grasp of the procedural steps, fluoro/ultrasound images, and ideally some cadaver time. I started doing both after fellowship as an attending and I'm not the best needler in the West by any stretch, so I'm sure you can do it safely if you're comfortable with that learning curve.

If/when you do start, you want these procedures scheduled with extra time as rushing the first few times is never fun.

Modification of the Cervical Transforaminal Epidural Steroid Injection Technique Based Upon the Anatomic Angle of the Superior Articular Process on MRI

AbstractObjective. A modification of the conventional technique for cervical transforaminal epidural steroid injection (CTFESI) has been developed. This te

academic.oup.com

Anatomic Considerations for Injection of the Lateral Atlanto-Axial Joint

AbstractObjective. We aimed to define the potential complications of intra-articular steroid injections into the lateral C1-2 articulations and safety marg

academic.oup.com

 

[SpineandWine]

This is a good time to sit with them and understand their needs. If you can't do it, then help them find a solution while you work on getting comfortable/good at it. As an academic doc, I know how easy it is to punt but eventually that leads to loss of confidence/faith in your ability to execute.

As far as winging it, definitely not something you do without having reviewed a bunch of papers with a clear grasp of the procedural steps, fluoro/ultrasound images, and ideally some cadaver time. I started doing both after fellowship as an attending and I'm not the best needler in the West by any stretch, so I'm sure you can do it safely if you're comfortable with that learning curve.

If/when you do start, you want these procedures scheduled with extra time as rushing the first few times is never fun.

Modification of the Cervical Transforaminal Epidural Steroid Injection Technique Based Upon the Anatomic Angle of the Superior Articular Process on MRI

AbstractObjective. A modification of the conventional technique for cervical transforaminal epidural steroid injection (CTFESI) has been developed. This te

academic.oup.com

Anatomic Considerations for Injection of the Lateral Atlanto-Axial Joint

AbstractObjective. We aimed to define the potential complications of intra-articular steroid injections into the lateral C1-2 articulations and safety marg

academic.oup.com

Thanks for the article.

 

[MitchLevi]

If you do either procedure and you have a bad outcome you're cooked bro.

I used to do clinic C1-2 facet CSI, including bilaterals. I've given them up bc that procedure is best done under CT. If you wanted your mother to get a C1-2 CSI you'd prefer she got it under CT. Don't deny your pts the same level of care you'd want for your mother.

Do NOT allow a surgeon to put a C1-2 facet on your schedule. EVER.

Know how to read C1-2 MRIs ahead of time bc the vert has a posterior branch in some ppl, and if you're not sure how to find it on MRI and you hit it there could be prproblems. You should also look at the spinal nerve location before as well.

As you approach the joint, if you rub that spinal nerve and the pt lurches off the table there can be problems.

Talk to these surgeons. There's no rationale for C SNRB. That's been disproven repeatedly.

Good luck.

 

[RoloTomassi]

C7-T1 ILESI or transarticular/transfacet approach

The Fluoroscopic-Guided Cervical Transarticular Epidural Steroid Injection - PubMed

The epidural space is commonly accessed via an interlaminar or transforaminal approach to administer corticosteroids for radicular pain. An alternative is a transarticular approach, which may be considered when conventional access to the epidural space is either not desired or contraindicated...

pubmed.ncbi.nlm.nih.gov

 

[lobelsteve]

Another booking - "C1-C2 Facet" I assume no one does these as well. I am just going to have these direct procedures seen in clinic and book myself.

I do C1-2. If your needle veers laterally you hit the vertebral artery and the needle can dissect it causing stroke and death. If the needle veers medially you can hit the cord at C1-2 causing spinal cord injury, paralysis, and death. The procedure pays under $100.
I do them rarely. After reviewing CT scan as MRI does not have the necessary frontal cuts to make me happy.

 

[MitchLevi]

I don't know why anyone would still do them under fluoro. They pay nothing.

I felt like I was being a good Dr by offering them. I now feel otherwise.

It is hard to justify fluoro-guided C1-2 when CT is available.

You won't do my mother's C1-2 Steve. I wouldn't offer do yours either.

Last one I did was in the clinic, and it was bilateral. I feel like I got away with it TBH. Contrast slightly obscured laterally after the first side was done. It was stupid.

CT is available everywhere.

 

[bedrock]

I don't know why anyone would still do them under fluoro. They pay nothing.

I felt like I was being a good Dr by offering them. I now feel otherwise.

It is hard to justify fluoro-guided C1-2 when CT is available.

You won't do my mother's C1-2 Steve. I wouldn't offer do yours either.

Last one I did was in the clinic, and it was bilateral. I feel like I got away with it TBH. Contrast slightly obscured laterally after the first side was done. It was stupid.

CT is available everywhere.

But who is the clinician doing them under ct guidance? A radiologist who has done far less c1-C2 injections than a good pain physician?

Many radiologists are mediocre at pain procedures.

 

[MitchLevi]

But who does they under ct guidance? A radiologist who has done far less c1-C2 injections than a good pain physician?

Many radiologists are mediocre at pain procedures.

Many pain physicians are mediocre at pain procedures.

The benefit of CT eliminates quite a bit of risk.

 

[DrMDAware]

Am I wrong in a rare patient who has a noted C5 radic on emg to try out a IESI at C7-T1 and then if failed try a c4-5 TFESI?

I get it is not in everyone’s bag of tricks and the consequences can be dire.

However, I thought with a short unbent needle, live fluoro, 90 second lido test, understanding of the hourglass concept, multiple views and non particulate steroid the risk is reduced.

I have colleagues who swear a cervical TFESI is the devil but routinely do cervical SCS or thread a catheter with an entry point of C7-T1. What I’m saying is I’m not sure why cervical TFESI seem to get an overdue amount of caution.

Edit: here’s a nice link talking about the risks and data

Complications of Cervical Transforaminal Epidural Steroid Injections - The Pain Source - Makes Learning About Pain, Painless

thepainsource.com

 

[Centurion38]

OP: I just booked a retrograde Cervical SCS trial onto your schedule. My PA ordered it. Pull the leads after 2 days so I can place a paddle in the ASC I own. She takes Plavix and Eliquis, I told her no problem.

 

[Laryngospasm]

Both procedures are quite dangerous and reimbursement is simply not worth the risk. Try to avoid risky procedures that Don’t pay enough for a tank of gas after taxes. But seriously having done ctfesis would not wing it.. and honestly just not worth it. Same goes for c1/2 facet.. just hell no.

 

[gaseous_clay]

BCBS in our state only pays for C2/3 and below.

 

[SpineandWine]

OP: I just booked a retrograde Cervical SCS trial onto your schedule. My PA ordered it. Pull the leads after 2 days so I can place a paddle in the ASC I own. She takes Plavix and Eliquis, I told her no problem.

Benefit of having surgeons book procedures is that you can bill for new patient and procedures on same visit, which maximizes revenue.

But then how do you politely give feedback that you won’t do a certain procedure they booked. Still working on this piece. It’s day 3 on the job so I’m sure I’ll get it hopefully streamlined as time goes on.

 

[Taus]

Benefit of having surgeons book procedures is that you can bill for new patient and procedures on same visit, which maximizes revenue.

But then how do you politely give feedback that you won’t do a certain procedure they booked. Still working on this piece. It’s day 3 on the job so I’m sure I’ll get it hopefully streamlined as time goes on.

So… In the middle of a busy procedure day, you were planning on doing a full history and physical, Dictation, decide to do the procedure that is already scheduled and authorized, and then bill for the procedure and consult with a 25 modifier? On multiple levels I don’t know how that is going to work out.

 

[MitchLevi]

Benefit of having surgeons book procedures is that you can bill for new patient and procedures on same visit, which maximizes revenue.

Oh yeah?

 

[lobelsteve]

Oh yeah?

I smell a lot of denials for this type of care.

 

[MitchLevi]

I smell a lot of denials for this type of care.

It's gonna be P2P time IMO.

 

[SpineandWine]

It's gonna be P2P time IMO.

Procedures they book already have prior authorization so no denials or P2P to do.
Surgeons have already taken care of it at this point.

I just can’t change the procedure so if they book a cervical TFESI, I cannot change to CESI unless they are Medicare/Medicaid or NAR.
So I am going to look ahead of time and change procedures I don’t offer to clinic visit.

The one thing I didn’t know how to approach this was whether to just “man up” and do it after reading sis book. I think based on talking to other people, I won’t do it and see them in clinic

 

[SpineandWine]

So… In the middle of a busy procedure day, you were planning on doing a full history and physical, Dictation, decide to do the procedure that is already scheduled and authorized, and then bill for the procedure and consult with a 25 modifier? On multiple levels I don’t know how that is going to work out.

Level 3 visit, mod 25
It’s all MDM now, so as long as I evaluate for a problem and prescribe med, it should cover it.
My partners had a template at my last job that justified level 3 billing

 

[Taus]

Procedures they book already have prior authorization so no denials or P2P to do.
Surgeons have already taken care of it at this point.

I just can’t change the procedure so if they book a cervical TFESI, I cannot change to CESI unless they are Medicare/Medicaid or NAR.
So I am going to look ahead of time and change procedures I don’t offer to clinic visit.

If you take direct referrals for procedures, as I do, I see it as a must to review your schedule ahead of time, about a week or so. You’ll catch the occasional issues with contrast allergies and no prep, interlam at level of fusion, procedures you don't do, etc and have time to get it corrected before day of. Much better than having a clusterf during procedure day and canceling someones procedure after they already arrived, got a driver, took off work, fasted, held thinners, etc. Also, gives you time, not in middle of a busy procedure day, to review imaging.


One minute of work per direct referral procedure ahead of time… you’re getting paid enough for the procedure to make it worth it imho

 

[SC Tian]

My two cents, for adjacent level disease from lower cervical spinal fusion, interlaminar epidural will not spread up enough, by reviewing transforaminal injection papers from different specialties, especially from radiologists, the Injection is safely achievable, the key points: where is the target of needle placement, remain posterior, remain on the bone, chances of injuring vertebral artery is extremely low imo.

 

[SC Tian]

Benefit of having surgeons book procedures is that you can bill for new patient and procedures on same visit, which maximizes revenue.

But then how do you politely give feedback that you won’t do a certain procedure they booked. Still working on this piece. It’s day 3 on the job so I’m sure I’ll get it hopefully streamlined as time goes on.

If this in Asc, imo this is not billable, office visit with office procedure might be more reasonable to bill.

 

[SpineandWine]

If this in Asc, imo this is not billable, office visit with office procedure might be more reasonable to bill.

It's HOPD- you sure? If not billable, i'll definitely make them all clinic visits first.
I'll find out when my first bill will come in I guess but my understanding was that anytime you see new patient, you can do procedure that day with modifier 25. Most people do not as they don't have someone that gets prior authorizations for them.
Let me know- as this will change how I approach this job completely.

 

[MitchLevi]

Procedures they book already have prior authorization so no denials or P2P to do.
Surgeons have already taken care of it at this point.

Dude.

You better be careful.

 

[SC Tian]

It's HOPD- you sure? If not billable, i'll definitely make them all clinic visits first.
I'll find out when my first bill will come in I guess but my understanding was that anytime you see new patient, you can do procedure that day with modifier 25. Most people do not as they don't have someone that gets prior authorizations for them.
Let me know- as this will change how I approach this job completely.

My understanding is you have to see patients in the office first, then move them to hopd for procedures. If you see patients in HOPD and do procedures, you cannot bill an office visit at the same time, no matter what it is risky to be audited by medicare imo, i might be wrong.

 

[SpineandWine]

My understanding is you have to see patients in the office first, then move them to hopd for procedures. If you see patients in HOPD and do procedures, you cannot bill an office visit at the same time, no matter what it is risky to be audited by medicare imo, i might be wrong.

I’ll clarify with group/billing department. Thank you!

 

[MitchLevi]

I’ll clarify with group/billing department. Thank you!

Have you spoken with the previous doctor who filled this position?

 

[SpineandWine]

Have you spoken with the previous doctor who filled this position?

There is no previous pain doctor - i'm the first one they're bringing on board.

 

[MitchLevi]

There is no previous pain doctor - i'm the first one they're bringing on board.

Bingo!

So they have no clue WTF they're doing.

Don't let these ppl add to your schedule. Don't double dip on your billing.

Are you a fellow, or are you already an attending?

Edit - Let me explain my situation...I'm in an ortho group that's never had a real pain doctor prior to me. Practice established in the 1960s BTW...It's established, we're strong regionally. Our staff are quite intelligent and orthopedically we're an extremely well oiled machine...

Despite there having been a few pain docs come and go, THEY HAVE NO FREAKING CLUE WHAT WE DO AND HOW TO PROPERLY UTILIZE OUR SKILLS.

That's specifically the surgeons, midlevels and administrative ppl.

I've made fantastic progress in that regard, but it took years to figure things out...

Those ppl in charge of billing and collecting and compliance don't have a clue what they're doing.

 

[SpineandWine]

Bingo!

So they have no clue WTF they're doing.

Don't let these ppl add to your schedule. Don't double dip on your billing.

Are you a fellow, or are you already an attending?

Attending, albeit recent- working for about a year and half.

 

[MitchLevi]

Attending, albeit recent- working for about a year and half.

See above...Edit.

Surgery groups don't know anything about pain. I wouldn't let them put procedures on your schedule until you've been there awhile and you've spoken with them about it.

I went through this myself.

 

[bedrock]

Benefit of having surgeons book procedures is that you can bill for new patient and procedures on same visit, which maximizes revenue.

What maximizes revenue is to have a streamlined procedure process, with a very predictable procedure and anesthesia time.

1-That's how you see 30 pts on a clinic day AND do 40 procedures on a procedure day.

2- And you can bill those clinic patients as level 4 new patient instead of a 3 with 25 modifier.

3-And most importantly, while you make additional money due to improved efficiency, your patients also benefit because you took the time to decide the optimal pain procedure for them, not whatever the surgeon thinks should be done, which is often wrong.

 

[drrosenrosen]

What maximizes revenue is to have a streamlined procedure process, with a very predictable procedure and anesthesia time.

1-That's how you see 30 pts on a clinic day AND do 40 procedures on a procedure day.

2- And you can bill those clinic patients as level 4 new patient instead of a 3 with 25 modifier.

3-And most importantly, while you make additional money due to improved efficiency, your patients also benefit because you took the time to decide the optimal pain procedure for them, not whatever the surgeon thinks should be done, which is often wrong.

This x100

 

[Tboned]

Benefit of having surgeons book procedures is that you can bill for new patient and procedures on same visit, which maximizes revenue.

But then how do you politely give feedback that you won’t do a certain procedure they booked. Still working on this piece. It’s day 3 on the job so I’m sure I’ll get it hopefully streamlined as time goes on.

Unfortunately puts you in a bad position. If the patient likes their surgeon but you tell them no, easy for them to go somewhere else or bad mouth you in any way shape and form. I have found that patients who think “they are right” regarding their diagnosis or ordered procedure and you disagree, it’s hard to change their mind.

 

[Tboned]

Procedures they book already have prior authorization so no denials or P2P to do.
Surgeons have already taken care of it at this point.

I just can’t change the procedure so if they book a cervical TFESI, I cannot change to CESI unless they are Medicare/Medicaid or NAR.
So I am going to look ahead of time and change procedures I don’t offer to clinic visit.

The one thing I didn’t know how to approach this was whether to just “man up” and do it after reading sis book. I think based on talking to other people, I won’t do it and see them in clinic

Don’t “man up”
🤦‍♂️

 

[nvrsumr]

See if someone in the community will proctor to you on how to do as safely as possible. You are not going to change the surgeons minds on what they want and they will refer out then eventually replace you.

 

[MitchLevi]

See if someone in the community will proctor to you on how to do as safely as possible. You are not going to change the surgeons minds on what they want and they will refer out then eventually replace you.

I've had the opposite experience.