EruditeDoc

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I have a patient with a true allergy to contrast. I'm planning to perform an SI joint injection for her. What would you guys do:

a) Do injection without contrast and utilize AP / lateral views with fluoro for needle confirmation?
b) Have her undergo pre-treatment for a contrast allergy prior to injection and then perform injection
c) Other

My gut say to just do it without contrast but I am interested in others thoughts/ experiences.
 
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EruditeDoc

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Two people for use of GAD within 10 minutes of the post. Looks like I will probably go ahead and eliminate option A
 

willabeast

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id just do the injection without contrast. so not worth the risk of complications.
I would discuss situation with patient, present options, and proceed with option #1 (whatever that is). if it fails, go to #2.
There are certainly some good protocalls for preventing contrast reactions, they always worked in my hands.
 

bedrock

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would just do SIJ without contrast if performing in the office. If doing at ASC/HOPD, then I would use gad.
 
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oreosandsake

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there are multiple studies that show intra-articular and peri-articular SIJ injection provide very similar results. performed under US, there is no injection of contrast and billed differently. this is anecdotal, but I believe many of the same patients that do well with fluoro based injection also respond to the US guided injection but I am sure i am mostly peri-articular in the bulk of those US guided injections. the reason we use contrast is to confirm intra-articular placement but really because the code 27096 states it. we save images since they are 1) court views and 2) supposedly to protect ourselves from an audit. Not sure who's ever had their images requested by the insurance company after the authorization and then gotten money taken back since the image didn't correspond to the procedure note (you said you were epidural but it's really SNRB contrast pattern), or ? in this case, if no contrast was used. long answer in saying I would just document allergy, and do the procedure without the contrast. state in note contrast not utilized due to allergy, needle placement appropriate on AP and lateral views...
 

drpainfree

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did a bilateral SIJ not too long ago. Struggle a little bit on the right side to get in, then nice linear constrast pattern. Not so lucky on the left side regardless how many times I tried. Eventually did peri-articular.

saw the patient the week after. the patient said the left side helped more. go figure!
 

algosdoc

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We cannot get Gad inexpensively and without ordering in advance in an outpatient office setting, so I would 1. assess whether this was a true allergy- if not, then pre-treat to avoid idiosyncratic reactions and use iodinated contrast 2. if it were a true contrast allergy, would do the injection without contrast.
 

SSdoc33

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never seen a true allergy to contrast. something tells me this patient had a reaction to CT dye years ago and now thinks she is allergic to isovue
 
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onewithpain

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I agree that a contrast allergy is rare and when you consider that you can verify intra-articular spread with a fraction of a ml while CT vascular studies use the whole bottle then the SI joint injection is usually safe. Some patients report a severe reaction and so I will then skip the contrast. In really sclerotic joints I see some weird vascular spreads and I don't know that a steroid injection would cause harm but it would be unlikely to do any good.
 

thecentral09

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This is interesting because in fellowship we used contrast almost never. I have liked getting a true lateral prior to injecting, but it does not rule out intravascular injection. I assume payment is different in certain regions if contrast is used? Still learning the reimbursement ropes
 
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CT tech here. We premed a lot of cases that have allergies as long as they are not true reactions of full anaphylaxis. Some of our docs still premed for true reactions if the study is deemed priority. What did you end up doing?
 
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lonelobo

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This is interesting because in fellowship we used contrast almost never. I have liked getting a true lateral prior to injecting, but it does not rule out intravascular injection. I assume payment is different in certain regions if contrast is used? Still learning the reimbursement ropes
Used contrast almost never? WTF?
 
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SSdoc33

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This is interesting because in fellowship we used contrast almost never. I have liked getting a true lateral prior to injecting, but it does not rule out intravascular injection. I assume payment is different in certain regions if contrast is used? Still learning the reimbursement ropes
no
 

onewithpain

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I thought that the medicare LCD stated that using 27096 means that contrast was injected, unless there is a contra-indication.
 

thecentral09

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Used contrast almost never? WTF?
In response to your WTF? The historic teaching for SI joint volume suggests approximately 1.5mL. Therefore, by wasting 0.5mL to 1.0mL in contrast medication with no medicinal value inside the joint, there is less SI joint volume for the actual medication. Therefore, by not injecting contrast more medication is actually placed within the joint space. Whether that matters is obviously up for debate.
 

lonelobo

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In response to your WTF? The historic teaching for SI joint volume suggests approximately 1.5mL. Therefore, by wasting 0.5mL to 1.0mL in contrast medication with no medicinal value inside the joint, there is less SI joint volume for the actual medication. Therefore, by not injecting contrast more medication is actually placed within the joint space. Whether that matters is obviously up for debate.
By not injecting contrast there is no way to tell if you are in the joint. YOU may think you are in the joint under Xray but without contrast verification there is no way to tell. You might try a little test by using a small amount of contrast and I think you might be very surprised where that contrast goes.
 

thecentral09

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By not injecting contrast there is no way to tell if you are in the joint. YOU may think you are in the joint under Xray but without contrast verification there is no way to tell. You might try a little test by using a small amount of contrast and I think you might be very surprised where that contrast goes.
I have done it both ways many times. What my experience has been is I have yet to not be in the joint utilizing both AP and lateral when I thought I was in, however, even when inside the joint I have been surprised by the amount of intravascular injections I have seen while intra-articular and under a high pressure injection. Im not saying using contrast is a bad idea, but I do understand the reason to not use it if properly utilizing multiple radiographic views.
 
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EruditeDoc

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CT tech here. We premed a lot of cases that have allergies as long as they are not true reactions of full anaphylaxis. Some of our docs still premed for true reactions if the study is deemed priority. What did you end up doing?
A little background: The patient's allergy is listed in her medical chart as "hives and trouble breathing." There are also about 15 other allergies...

I ended up having my nurses call the patient and postpone the case until next week. In the meanwhile, I have access to the following contrast agents: Magnevist, Gadopentetate, and Dimeglumine. I am still trying to determine if I will order one of these and go vs. pretreatment vs. do injection w/out contrast. So essentially I have decided nothing but have enjoyed reading these responses and trying to gain some perspective. o_O
 
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EruditeDoc

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I would discuss situation with patient, present options, and proceed with option #1 (whatever that is). if it fails, go to #2.
There are certainly some good protocalls for preventing contrast reactions, they always worked in my hands.
I will definitely discuss with the patient. This patient in particular likes to be VERY involved in EVERY aspect of the healthcare process...
 

lonelobo

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I have done it both ways many times. What my experience has been is I have yet to not be in the joint utilizing both AP and lateral when I thought I was in, however, even when inside the joint I have been surprised by the amount of intravascular injections I have seen while intra-articular and under a high pressure injection. Im not saying using contrast is a bad idea, but I do understand the reason to not use it if properly utilizing multiple radiographic views.
Contrast is the standard of care in SIJ injections
 

Dr. Ice

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Contrast is the standard of care in SIJ injections
Im not sure I would feel confident about the injection without seeing the "leaf" outlined with contrast. They can always come back and say it didn't work and then you will always guess whether or not you were truly in the joint without a good pic to refer to...
 

lobelsteve

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I have done it both ways many times. What my experience has been is I have yet to not be in the joint utilizing both AP and lateral when I thought I was in, however, even when inside the joint I have been surprised by the amount of intravascular injections I have seen while intra-articular and under a high pressure injection. Im not saying using contrast is a bad idea, but I do understand the reason to not use it if properly utilizing multiple radiographic views.
Then you don't know what you don't know. What does SiS say on the topic?
 

SSdoc33

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I have done it both ways many times. What my experience has been is I have yet to not be in the joint utilizing both AP and lateral when I thought I was in, however, even when inside the joint I have been surprised by the amount of intravascular injections I have seen while intra-articular and under a high pressure injection. Im not saying using contrast is a bad idea, but I do understand the reason to not use it if properly utilizing multiple radiographic views.

Bullsh$t
 

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I've had plenty where I looked in joint on AP, oblique and lateral and had the classic feel of clearly in joint and still had mainly extra-articulate contrast. Don't need much...0.2-3 cc. Still plenty of room for steroid. For that reason on si and facet I use Depo 80 and 2% lido. Nice and concentrated.


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No Pain All gain

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I would do it without contrast and fluoro/haptic feedback. For this patients future benefit it may be worthwhile to better understand reaction and if true allergy or not. I'm guessing she will need procedure that you need contrast for in future.
 
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willabeast

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never seen a true allergy to contrast. something tells me this patient had a reaction to CT dye years ago and now thinks she is allergic to isovue
i did see one major contrast reaction in my career (i am now retired). Of interest - young male with no history of contrast allergy but his MOTHER had a Hx of contrast allergy!
 
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EruditeDoc

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Would you guys believe that after all my deliberation about how to proceed... the patient cancelled the procedure ? !
 

lobelsteve

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It is an SIJ, it hurts a little compared to most of the stuff we see.
 
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