CESI

[Papa Lou]

There's still a LOT of ppl who do series of 3 epidurals. It's abhorrent practice when it's done indiscriminately and questionable still when done under select circumstances (large extrusion, otherwise normal L/spine).

...BUT....

The epidurals in the c/s don't have the track record of success that TFESI or LESI have in the lumbar spine. I'm finding more often I wish I'd told the patient I would schedule two CESIs a couple weeks apart (or in some pts a TFESI and CESI). So I'm seeing people go from let's say 7/10 pain with persistent radiculitis to 3-4/10 pain trace radiculitis. No facet pain elicited on exam. I never offer a second one when they come with pain in the low range like that--I just let them leave. But I often regret I didn't automate a second one to see if I could get it to 1-2/10 more routinely. I have no way to gauge an answer b/c I've never been one to do more than 1 at a time and look for a result before proceeding. Anybody have an opinion?

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[ampaphb]

Why not just ask them if their pain is still significant enough to warrant a second injection when you see them at the follow-up visit? What benefit does automating the process provide?

 

[painfree23]

There's still a LOT of ppl who do series of 3 epidurals. It's abhorrent practice when it's done indiscriminately and questionable still when done under select circumstances (large extrusion, otherwise normal L/spine).

...BUT....

The epidurals in the c/s don't have the track record of success that TFESI or LESI have in the lumbar spine. I'm finding more often I wish I'd told the patient I would schedule two CESIs a couple weeks apart (or in some pts a TFESI and CESI). So I'm seeing people go from let's say 7/10 pain with persistent radiculitis to 3-4/10 pain trace radiculitis. No facet pain elicited on exam. I never offer a second one when they come with pain in the low range like that--I just let them leave. But I often regret I didn't automate a second one to see if I could get it to 1-2/10 more routinely. I have no way to gauge an answer b/c I've never been one to do more than 1 at a time and look for a result before proceeding. Anybody have an opinion?

I think if u have 0 pain relieved after one injection, don't know how much it will be help or even make sense to repeat another one in a few weeks , other than financial reasons. If u get some relief , then it makes sense to repeat. U can have the patient call back after a few weeks and if they were a little better, may make sense to do another..but just saying ur gonna do 3 for the sake of doing three doesn't make sense. But just my opinion.

 

[hyperalgesia]

I see nothing wrong with the OP's approach - sounds like pt's best interest in mind. In my situation, scheduling 2 injections allows me to deal with scheduling fluoro space, auth issues and patient travel issues much more efficiently. Doesn't mean I will do both, only that I'm prepared.

When doing this, I always explain to the pt that we are only doing this to be prepared and cut through the red tape. I tell them the best thing in the world is if we can cancel the second shot.

 

[willabeast]

//The epidurals in the c/s don't have the track record of success that TFESI or LESI have in the lumbar spine.// i have always found the opposite if using the same methods - CESI usually works better than LESI all other things being equal. One of my referring surgeons thought the same thing, so it was not just me. No data just personal observation.

 

[painfree23]

I see nothing wrong with the OP's approach - sounds like pt's best interest in mind. In my situation, scheduling 2 injections allows me to deal with scheduling fluoro space, auth issues and patient travel issues much more efficiently. Doesn't mean I will do both, only that I'm prepared.

When doing this, I always explain to the pt that we are only doing this to be prepared and cut through the red tape. I tell them the best thing in the world is if we can cancel the second shot.

Sorry, I agree, wasn't trying to smash OP. Just was offering my opinion. What are you injecting for Cesi? How often do you cancel the second shot? Go c7 T1 usually?

 

[Ducttape]

Personally automating any number of epidural injections ignores the clinical response to the procedure.

It's only my opinion, but why not "automatically" set up a follow up 3 weeks after injection and then determine if first did have some benefit and if a patient might benefit from a second in a week or so?

Much better than trying to explain to a patient at the fluoro suite why you are doing another even though they are a lot better, or had no benefit at all...


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[bedrock]

There's still a LOT of ppl who do series of 3 epidurals. It's abhorrent practice when it's done indiscriminately and questionable still when done under select circumstances (large extrusion, otherwise normal L/spine).

...BUT....

The epidurals in the c/s don't have the track record of success that TFESI or LESI have in the lumbar spine. I'm finding more often I wish I'd told the patient I would schedule two CESIs a couple weeks apart (or in some pts a TFESI and CESI). So I'm seeing people go from let's say 7/10 pain with persistent radiculitis to 3-4/10 pain trace radiculitis. No facet pain elicited on exam. I never offer a second one when they come with pain in the low range like that--I just let them leave. But I often regret I didn't automate a second one to see if I could get it to 1-2/10 more routinely. I have no way to gauge an answer b/c I've never been one to do more than 1 at a time and look for a result before proceeding. Anybody have an opinion?

Very bad idea to do this for CESI, which has much higher potential for devastating complications compared the LESI, although still rare. I would never automatically schedule CESI X 2. I would think it much better to schedule LESI X 2 vs CESI x 2.

Just tell the patient at the initial consult that sometimes they might require a second CESI, depending on the amount of relief. Just have them come back 2 weeks after CESI #1, and make the decision then. Not all of them will need a second CESI, but the ones that went from 8/10 to 4/10 pain will likely take you up on your offer for #2, but the 1-2/10 ones won't need it.

 

[hyperalgesia]

Sorry, I agree, wasn't trying to smash OP. Just was offering my opinion. What are you injecting for Cesi? How often do you cancel the second shot? Go c7 T1 usually?

I think it really depends on the logistics. At my VA, I have to go through an authorization process and then I have to get procedure space which takes another 2-3 weeks.

I don't typically order a "series" - maybe 1:30 cases. Pts are instructed to cancel the second procedure if their pain is significantly improved. To be honest I'm not sure how often this happens. It's not perfect and occasionally a pt is in pre-op saying, "I feel great from the last shot" and I have difficulty convincing them there is no indication for a second one.

I'm just pointing out there are rationales other than greed to schedule a "series". But I think it's great that we're all on here discussing this and keeping each other honest. I have taken criticism on this board and my practice has become safer because of it.

For CESI, I use 10mg dex and 2ml NS and enter at C7/T1. No local in the injectate. If I have trouble getting in at C7/T1, I go lower and at a steeper angle.

 

[Ducttape]

Problem is that we are preaching to the choir here.

The big money making pain clinics where the pain doc is in the OR 4 1/2 days a week are doing series of 3 and will not change because it affects their bottom dollar.


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[bronchospasm]

Very bad idea to do this for CESI, which has much higher potential for devastating complications compared the LESI, although still rare. I would never automatically schedule CESI X 2. I would think it much better to schedule LESI X 2 vs CESI x 2.

Just tell the patient at the initial consult that sometimes they might require a second CESI, depending on the amount of relief. Just have them come back 2 weeks after CESI #1, and make the decision then. Not all of them will need a second CESI, but the ones that went from 8/10 to 4/10 pain will likely take you up on your offer for #2, but the 1-2/10 ones won't need it.

Agree with this. This is what I do. If pain is significantly reduced with just one CESI. Why do another one.

 

[NJPAIN]

Problem is that we are preaching to the choir here.

The big money making pain clinics where the pain doc is in the OR 4 1/2 days a week are doing series of 3 and will not change because it affects their bottom dollar.


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Absolutely. I parted ways with a partner 15 years ago because I couldn't go along with "everyone gets a series of three". That morphed into a mega-PIP practice that goes: failed series of 3 -->discography--> failed endoscopic discectomy --> failed fusion --> failed SCS --> DRG stim. He's a billionaire and I drive a VW.


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[bronchospasm]

Problem is that we are preaching to the choir here.

The big money making pain clinics where the pain doc is in the OR 4 1/2 days a week are doing series of 3 and will not change because it affects their bottom dollar.


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Most patients in THESE BIG PAIN CLINICS are there for the BIG Norco 10/3 or10/4 anyways. They don't care if the epidural worked as long as they get the candy.

 

[bronchospasm]

Absolutely. I parted ways with a partner 15 years ago because I couldn't go along with "everyone gets a series of three". That morphed into a mega-PIP practice that goes: failed series of 3 -->discography--> failed endoscopic discectomy --> failed fusion --> failed SCS --> DRG stim. He's a billionaire and I drive a VW.


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This is exactly what goes on in BIG practices. Nurse practitioner prescribes narcotics. Docs sign scripts and do injection. Most practices that pride themselves in doing more that 100 procedures per week have incorporated similar strategy along with gradual escalation of pain medications. Once everything is exhausted or if the patient is exhausted. Then they are lined up for pills and UDS.

What fun.

 

[ampaphb]

This is exactly what goes on in BIG practices. Nurse practitioner prescribes narcotics. Docs sign scripts and do injection. Most practices that pride themselves in doing more that 100 procedures per week have incorporated similar strategy along with gradual escalation of pain medications. Once everything is exhausted or if the patient is exhausted. Then they are lined up for pills and UDS.

What fun.

Our local thief does every procedure known to man, including the stim trial that fails. Then he either tells them he is no longer accepting their insurance, or there's nothing more he has to offer, and so terminates their care.

As this typically takes a year or two to accomplish, by that point he has jacked them up to 30 or 60 of morphine QID (sometimes 5 or 6x/d).

 

[bronchospasm]

Our local thief does every procedure known to man, including the stim trial that fails. Then he either tells them he is no longer accepting their insurance, or there's nothing more he has to offer, and so terminates their care.

As this typically takes a year or two to accomplish, by that point he has jacked them up to 30 or 60 of morphine QID (sometimes 5 or 6x/d).

Sometimes I wonder how many of these patients would actually be getting procedures if no narcotics were being written.

 

[NJPAIN]

The BIGGEST factor in these personal injury mills is the support of the litigation. Even absent the high dose opioids they will have anything done that they are told including a fusion in order to build a case. They even videotape the discography and surgery for use in litigation. The lawyer and the mandatory chiropractor tell them that if they want a big award they should do EVERYTHING that is recommended. If you play along with the lawyers they will keep you VERY busy.

 

[ampaphb]

I beg to differ. I like working with lawyers. The trick is to not be a *****.

I call it down the middle. I am pro-plaintiff half the time, and pro-defense the other half.

May not make me the most successful doc in town, but maintains my reputation, which is my priority.

Now I know you are gonna say the patient will lie. But very few are smart enough to lie convincingly and consistently (e.g. positive supine SLR, but supine SLR almost always negative)

 

[NJPAIN]

I like working with some attorneys as well. However, most who deal in personal injury in my state are less concerned with the wellbeing of their clients than they are with the wealth of themselves and their clients.


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[Papa Lou]

Escalating opioids with ongoing interventional treatment is a very common occurrence. Not in my practice, but in many others I've seen. The patients themselves innocently (or not) request better pain pill control while undergoing "workup/treatment"
Otherwise releasing patients after trying multiple interventional treatments b/c they did not respond is a very common practice. "There's nothing more I can do for you."
Docs that stick to interventional while letting midlevels do f/u visits and easy refills may be considered most appropriate and efficient use of clinical skill and training.

Do you see what I'm saying?

The intention of a doctor is very hard to know or prove. On paper the little devils can look good too. The key word I think is INTENTION. This is intensely difficult to prove. The best way is to actually work there, or talk to someone credible who actually worked there. And this has to be done in a clever way. ....or to audit many many charts and see what patterns emerge. I would welcome this opportunity. I'm sure most of you would too. Let's raise the standard!

 

[clubdeac]

Escalating opioids with ongoing interventional treatment is a very common occurrence. Not in my practice, but in many others I've seen. The patients themselves innocently (or not) request better pain pill control while undergoing "workup/treatment"
Otherwise releasing patients after trying multiple interventional treatments b/c they did not respond is a very common practice. "There's nothing more I can do for you."
Docs that stick to interventional while letting midlevels do f/u visits and easy refills may be considered most appropriate and efficient use of clinical skill and training.

Do you see what I'm saying?

The intention of a doctor is very hard to know or prove. On paper the little devils can look good too. The key word I think is INTENTION. This is intensely difficult to prove. The best way is to actually work there, or talk to someone credible who actually worked there. And this has to be done in a clever way. ....or to audit many many charts and see what patterns emerge. I would welcome this opportunity. I'm sure most of you would too. Let's raise the standard!

I agree... I think it's often very difficult to know the motives from just looking at the patient's chart. Someone could look at what I've done to/for a patient and think wow, he was just bilking the crap out of him. Patient had axial lbp radiating down left leg to the knee. MRI notable for multilevel lumbar spondylosis and a small left L4-5 disc protrusion. I perform 2-3 left paramedian L4-5 ILESIs with diminishing relief every injection. Patient comes back to clinic still in pain now with predominantly axial lbp. I assume the epidural took care of the radicular component and now he has possibly facet mediated pain. I set him up for comparative mbb's. He reports success from two dual diagnostic blocks. We therefore proceed to ablation. See him in clinic in 6 weeks later. He reports 60% improvement but still has some pain. Decide to increase his tramadol from 50mg tid to 100mg tid.... and on and on. My point is, from the outside looking in someone could say look at all the procedures he received. He must be paying for his new jag. All the while I'm salaried and my volume has nothing to do with my compensation. Just trying to find some relief for the patient