Delayed relief from DPPR?

[Baron Samedi]

Encountered a few of these, inject patient and 4 hours later they get relief and then pain comes back a day or two later. Physiologically it doesn't make much sense given the onset and duration of local anesthetics. Is it essentially a fluoro-guided trigger point injection?

What do you do for these folks? Block again? Burn anyways? Tell them to buy a foam roller?

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[Ferrismonk]

DPPR?

 

[Baron Samedi]

DPPR?

Diagnostic posterior primary ramus block. Sorry, was trained to use that terminology and it's ingrained now. Medial branch block.

 

[Ducttape]

i was thinking DePoPRovera injections....

 

[SSdoc33]

Encountered a few of these, inject patient and 4 hours later they get relief and then pain comes back a day or two later. Physiologically it doesn't make much sense given the onset and duration of local anesthetics. Is it essentially a fluoro-guided trigger point injection?

What do you do for these folks? Block again? Burn anyways? Tell them to buy a foam roller?

in my mind, that is a positive response. you cant split hairs with a lot of these patients.... they just dont get it.

 

[Laryngospasm]

Yeah if you wait for perfect responses you’ll never get any. I think there is some component from multifidus spasm relief which is what happens sometimes.

 

[Ronin1]

Encountered a few of these, inject patient and 4 hours later they get relief and then pain comes back a day or two later. Physiologically it doesn't make much sense given the onset and duration of local anesthetics. Is it essentially a fluoro-guided trigger point injection?

What do you do for these folks? Block again? Burn anyways? Tell them to buy a foam roller?

failed mbb. Not facet mediated. On to the next pain generator

 

[SommeRiver]

failed mbb. Not facet mediated. On to the next pain generator

What?

Burn the pt...I have old pts who get weeks from an MBB on occasion.

I burn them.

 

[Ronin1]

What?

Burn the pt...I have old pts who get weeks from an MBB on occasion.

I burn them.

You rf people with no pain relief in the first few hours? That’s the definition of a failed diagnostic block

 

[deleted875186]

You rf people with no pain relief in the first few hours? That’s the definition of a failed diagnostic block

I would RF. To me I’d rather have a false positive than a false negative, RFA is safe, and when successful gives many months of good pain relief, better than many other injection or intervention we have.

 

[Laryngospasm]

Or heaven help them the spine surgeon fuses them for the disc at l4/5 with moderate canal stenosis and they are worse than before..

 

[Ronin1]

Evidence based medicine lol

 

[SommeRiver]

Dude...What are you talking about?

Why would you withhold an RFA in that situation? If it doesn't work, "on to the next pain generator."

RFA is safe, quick, easy, effective...Virtually zero risk.

I don't get it.

Please God think long term for your axial pts bc the surgeon is right down the road and drives a Porsche.

 

[Ronin1]

I don’t ablate people with zero pain relief from a mbb in the first three hours. Your argument to ablate these people only generates income for yourself and goes against guidelines otherwise why even do diagnostic mbb

maybe you are misreading the original post. He implied that the patients did not get any relief until 4 hours later?

 

[SommeRiver]

If I do an MBB and that pt endorses significant relief the day of the procedure I do the RFA.

I don't care if it takes a few hrs for the pain to go from 7 to 5 to 4 to 2 over 4 hrs.

Your comment about generating income for myself is very dumb.

 

[Agast]

Some people don’t get immediate relief from medial branch blocks because they feel too sore at the injection site to know how they feel about their back pain

 

[deleted875186]

Some people don’t get immediate relief from medial branch blocks because they feel too sore at the injection site to know how they feel about their back pain

Agreed, often need to really grill patients. If they don’t feel any pain relief than obviously a no, but if they’re able to tell a difference that day than I call it positive.

I also feel like a lot of people have multiple pathologies, MBB doesn’t relieve all there pain, makes it harder to tell.

 

[BobBarker]

I don’t ablate people with zero pain relief from a mbb in the first three hours. Your argument to ablate these people only generates income for yourself and goes against guidelines otherwise why even do diagnostic mbb

maybe you are misreading the original post. He implied that the patients did not get any relief until 4 hours later?

True, we should go straight to RFA. But since we can’t, the semantics of when the block took effect in the first 24hrs is pointless.

 

[SommeRiver]

MBB is a pointless procedure that does nothing but expose doctors to an untold amount of radiation over the length of one's career. Think about all those pictures...

It's an RFA not a heart transplant. It worked or didn't work...Doesn't even involve corticosteroids.

Stupid to test first, and doubly stupid to test twice.

 

[lobelsteve]

MBB is a pointless procedure that does nothing but expose doctors to an untold amount of radiation over the length of one's career. Think about all those pictures...

It's an RFA not a heart transplant. It worked or didn't work...Doesn't even involve corticosteroids.

Stupid to test first, and doubly stupid to test twice.

Great science on how to prove RF works. Clinically useless.

 

[Sig123]

Some people don’t get immediate relief from medial branch blocks because they feel too sore at the injection site to know how they feel about their back pain

This. 100% move on to abate people who get relief starting at 4-5 hours post procedure

 

[SommeRiver]

Great science on how to prove RF works. Clinically useless.

Steve...What are you talking about?

Please say what you mean specifically so I can address it instead of playing around...

I do not believe MBB should be required.

Why don't we do epidurals with straight bupi before giving the pt the dex?

Over your entire career there will be an ungodly amount of radiation sent your way bc of MBB.

It is a complete load of BS that I have to go through all that to get to a harmless and simple procedure (RFA).

I have had numerous pts pass two MBB and fail the RFA. It is BS.

This is another example of physicians being too weak to defend themselves against insurance companies and the medical establishment (who doesn't care about you or your health).

 

[BobBarker]

I don’t think that most physicians want the two blocks to go away but most would agree they are useless.

 

[SommeRiver]

I don’t think that most physicians want the two blocks to go away but most would agree they are useless.

I do...I am 40 yo and in my life will have done many thousands of them by the time I retire and I don't need all that radiation.

Physicians like the billing on 3 procedures instead of 1, and I understand that...

At the VA we just burned those pts. No MBB, just the RFA. I much prefer that.

I hate explaining the process to people, especially when I know they don't get it and I'm most likely just delaying their benefit.

 

[lobelsteve]

Steve...What are you talking about?

Please say what you mean specifically so I can address it instead of playing around...

I do not believe MBB should be required.

Why don't we do epidurals with straight bupi before giving the pt the dex?

Over your entire career there will be an ungodly amount of radiation sent your way bc of MBB.

It is a complete load of BS that I have to go through all that to get to a harmless and simple procedure (RFA).

I have had numerous pts pass two MBB and fail the RFA. It is BS.

This is another example of physicians being too weak to defend themselves against insurance companies and the medical establishment (who doesn't care about you or your health).

The double diagnostic paradigm was created as a research tool to prove that radio frequency ablation was an effective procedure. Over in Australia/NZ they have a triple diagnostic paradigm. If you really want to get great science you should do one of the blocks with normal saline. The nurse draws up the medicine and neither you nor the patient will know what injections they are getting on what day. A reasonable cost saving measure would be to provide radio frequency ablation along the spine as an initial procedure. It will be diagnostic (or placebo) if they get relief and if they get prolonged relief it will be therapeutic.

 

[SommeRiver]

The double diagnostic paradigm was created as a research tool to prove that radio frequency ablation was an effective procedure. Over in Australia/NZ they have a triple diagnostic paradigm. If you really want to get great science you should do one of the blocks with normal saline. The nurse draws up the medicine and neither you nor the patient will know what injections they are getting on what day. A reasonable cost saving measure would be to provide radio frequency ablation along the spine as an initial procedure. It will be diagnostic (or placebo) if they get relief and if they get prolonged relief it will be therapeutic.

Okay, soooooooooo...Tell me exactly your point man.

My opinion (as a doctor treating pain in the community) is MBB should not be required given the significant exposure to radiation over several decades of practice.

I am very much aware of the history of RFA.

Triple MBB is a joke, sorry to say that and I revere N Bogduk.

Scientific rigor proving that RFA is effective has been done, and there is no reason that should be carried forward into the community where I'm underwater in geriatric pts lit up with facetogenic back pain.

Again, I'm able to go ahead and inject corticosteroids into the canal of anyone I feel has a radic, and I don't have to first do an injxn of local to prove efficacy.

If I am avg around 30 pts per day of volume (procedures and clinic) over 4.5 days of work per week, and I'm offering MBB/RFA as a treatment in my practice, that is thousands of injxns over my career and it appears to me that a substantial % of those injxns are unnecessary.

Those individuals who proved RFA worked have already done the necessary work - RFA is an effective Tx for certain individuals.

If I jump straight to it and it doesn't work, okay...Let's see what else may help. I have harmed no one in the process.

I would bet more than half of my pts who get set up for MBB/RFA have no idea what we're doing. I wrote an entire 3 page "thing" explaining the process. No one understands it and I wrote it at a middle school reading level.

The number of images over a 30 yr career with multiple MBB is NOT insignificant.

 

[lobelsteve]

Okay, soooooooooo...Tell me exactly your point man.

My opinion (as a doctor treating pain in the community) is MBB should not be required given the significant exposure to radiation over several decades of practice.

I am very much aware of the history of RFA.

Triple MBB is a joke, sorry to say that and I revere N Bogduk.

Scientific rigor proving that RFA is effective has been done, and there is no reason that should be carried forward into the community where I'm underwater in geriatric pts lit up with facetogenic back pain.

Again, I'm able to go ahead and inject corticosteroids into the canal of anyone I feel has a radic, and I don't have to first do an injxn of local to prove efficacy.

If I am avg around 30 pts per day of volume (procedures and clinic) over 4.5 days of work per week, and I'm offering MBB/RFA as a treatment in my practice, that is thousands of injxns over my career and it appears to me that a substantial % of those injxns are unnecessary.

Those individuals who proved RFA worked have already done the necessary work - RFA is an effective Tx for certain individuals.

If I jump straight to it and it doesn't work, okay...Let's see what else may help. I have harmed no one in the process.

I would bet more than half of my pts who get set up for MBB/RFA have no idea what we're doing. I wrote an entire 3 page "thing" explaining the process. No one understands it and I wrote it at a middle school reading level.

The number of images over a 30 yr career with multiple MBB is NOT insignificant.

i agree there is no role for mbb in clinical practice.
1. Increased risk to patient and physician
2. Increased costs to patient and the system.

 

[SSdoc33]

I sort of understand a single mbb. 2 is stupid.

Also, stop doing laterals on tfesi if you are worried about radiation. Start oblique, good flow on AP, then inject. Saves a lot of radiation

 

[SommeRiver]

I sort of understand a single mbb. 2 is stupid.

Also, stop doing laterals on tfesi if you are worried about radiation. Start oblique, good flow on AP, then inject. Saves a lot of radiation

TFESI - Oblique then AP. Done.

 

[Ducttape]

Okay, soooooooooo...Tell me exactly your point man.

My opinion (as a doctor treating pain in the community) is MBB should not be required given the significant exposure to radiation over several decades of practice.

I am very much aware of the history of RFA.

Triple MBB is a joke, sorry to say that and I revere N Bogduk.

Scientific rigor proving that RFA is effective has been done, and there is no reason that should be carried forward into the community where I'm underwater in geriatric pts lit up with facetogenic back pain.

Again, I'm able to go ahead and inject corticosteroids into the canal of anyone I feel has a radic, and I don't have to first do an injxn of local to prove efficacy.

If I am avg around 30 pts per day of volume (procedures and clinic) over 4.5 days of work per week, and I'm offering MBB/RFA as a treatment in my practice, that is thousands of injxns over my career and it appears to me that a substantial % of those injxns are unnecessary.

Those individuals who proved RFA worked have already done the necessary work - RFA is an effective Tx for certain individuals.

If I jump straight to it and it doesn't work, okay...Let's see what else may help. I have harmed no one in the process.

I would bet more than half of my pts who get set up for MBB/RFA have no idea what we're doing. I wrote an entire 3 page "thing" explaining the process. No one understands it and I wrote it at a middle school reading level.

The number of images over a 30 yr career with multiple MBB is NOT insignificant.

a couple of concerns - if you do thousands of injections less (and make hundreds of thousand dollars less), what will you replace those appointments with? I hope not other injections because then the professed saving radiation exposure is not going to occur.

also, the thought of the double diagnostic block is to improve success rate with RFA. without MBB, you might be doing more unsuccessful RFAs... im not sure you will be saving that much in terms of radiation exposure....



I do believe in 1 diagnostic block, because it does provide patients with the thought that maybe the RFA will help. more importantly, a single MBB allows me to weed out those who will not tolerate an RFA due to pain intolerance. and I get a lot of those patients.

 

[lobelsteve]

a couple of concerns - if you do thousands of injections less (and make hundreds of thousand dollars less), what will you replace those appointments with? I hope not other injections because then the professed saving radiation exposure is not going to occur.

also, the thought of the double diagnostic block is to improve success rate with RFA. without MBB, you might be doing more unsuccessful RFAs... im not sure you will be saving that much in terms of radiation exposure....



I do believe in 1 diagnostic block, because it does provide patients with the thought that maybe the RFA will help. more importantly, a single MBB allows me to weed out those who will not tolerate an RFA due to pain intolerance. and I get a lot of those patients.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group | Regional Anesthesia & Pain Medicine

 

[SommeRiver]

a couple of concerns - if you do thousands of injections less (and make hundreds of thousand dollars less), what will you replace those appointments with? I hope not other injections because then the professed saving radiation exposure is not going to occur.

also, the thought of the double diagnostic block is to improve success rate with RFA. without MBB, you might be doing more unsuccessful RFAs... im not sure you will be saving that much in terms of radiation exposure....



I do believe in 1 diagnostic block, because it does provide patients with the thought that maybe the RFA will help. more importantly, a single MBB allows me to weed out those who will not tolerate an RFA due to pain intolerance. and I get a lot of those patients.

Why is an RFA in need of patients being "weeded out?" I really don't understand some of y'all about ablations, and this carries that same feel of IV sedation which is both unnecessary and completely absurd for an RFA - A very simple procedure that I rarely struggle doing in terms of pt tolerability.

My community presence is greater without MBB.

I really do not factor in MBB and it being a money maker into my opinion. It has no role in the conversation IMO.

 

[bedrock]

In general, I am a big fan of providing spine RFA to any reasonable candidate. If it will provide even just relief of 40% of their spine pain, I think its worth it to do so and it is cost effective compared to endless PT/chiro, or heavy meds, etc, or just decreased life function.

That said, I think that physicians should decide whether or not to do 1 or 2 MBB because its not worth it do RFA that doesn't provide any relief at all.
I'd do just one MBB for all the clear 60+yr old candidates with extension based pain, and do two MBB for the questionable candidates.

I used to get many referrals from several local spine surgeons for RFA after their patients neck or low back pain worsened 2-4 years after fusion. This was always disc not facet pain, and I hated doing ablations that would always fail so I used the two MBB with different meds to demonstrate the clear placebo effect in these patients between MBB 1 and MBB 2 and so I would then skip the ablation which would not have worked anyway.

 

[Ducttape]

Why is an RFA in need of patients being "weeded out?" I really don't understand some of y'all about ablations, and this carries that same feel of IV sedation which is both unnecessary and completely absurd for an RFA - A very simple procedure that I rarely struggle doing in terms of pt tolerability.

My community presence is greater without MBB.

I really do not factor in MBB and it being a money maker into my opinion. It has no role in the conversation IMO.

why not?

a 2 level MBB is roughly $270 o ASIPP.org site. that's $30 more than a TF. its $15 more than a CESI.

yes, those are single injections, but im sure you will agree that MBBs are significantly safer than CESI or lumbar TFESI.


in terms of weeded out - I have patients that refuse MBB when they see the 25 gauge needle. these patients would not tolerate an RFA with a 32 gauge at 34 degrees(hypothetically speaking), let alone an 18 gauge at 80 degrees.



I am completely certain that your patient panel is the antithesis of mine.

 

[SommeRiver]

why not?

a 2 level MBB is roughly $270 o ASIPP.org site. that's $30 more than a TF. its $15 more than a CESI.

yes, those are single injections, but im sure you will agree that MBBs are significantly safer than CESI or lumbar TFESI.


in terms of weeded out - I have patients that refuse MBB when they see the 25 gauge needle. these patients would not tolerate an RFA with a 32 gauge at 34 degrees(hypothetically speaking), let alone an 18 gauge at 80 degrees.



I am completely certain that your patient panel is the antithesis of mine.

My point is I can chew through my geriatric community fast and catch a huge percentage of them by just ablating them.

I'd miss some too.

I don't think I should skip an MBB on a 35 yo after an MVC, or other pts that are not straightFWD.

I should be clear and say I am drowning in rural Americans with axial pain, and a huge % of them should just be burned.

The money thing is only to say I am not taking financial incentives into account. I'm just trying to improve the state of my community.

 

[callmeanesthesia]

My point is I can chew through my geriatric community fast and catch a huge percentage of them by just ablating them.

I'd miss some too.

I don't think I should skip an MBB on a 35 yo after an MVC, or other pts that are not straightFWD.

I should be clear and say I am drowning in rural Americans with axial pain, and a huge % of them should just be burned.

The money thing is only to say I am not taking financial incentives into account. I'm just trying to improve the state of my community.

I think we have a similar patient panel. Lots of local and some Xanax and most are fine. Lots of old people with axial pain and big facets. Financially I’m glad for MBBs - keeps me busy, but most of the time it’s unnecessary except from a payor standpoint. For cervical I’d argue MBBs sometimes still have an important role because of the closer joints and overlapping pain patterns. For the low back I don’t really need the MBB.