Does this actually happen?

[mille125]

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Had a patient that I saw last week. Came over from another local pain practice. Essentially normal cervical MRI and got cervical MBBs but that is for another conversation.

The thing that was interesting is that the patient claimed that the MBBs were performed by a rad tech and not the doctor. He said that they doctor was not even in the room (they do procedures in a different office). He was very adamant and says that he was fully awake because no sedation was given. The procedure note is clearly signed by the doctor.

I found this hard to believe but the patient is convincing. Have any of you seen anything like this.

 

[Dr. Ice]

Had a patient that I saw last week. Came over from another local pain practice. Essentially normal cervical MRI and got cervical MBBs but that is for another conversation.

The thing that was interesting is that the patient claimed that the MBBs were performed by a rad tech and not the doctor. He said that they doctor was not even in the room (they do procedures in a different office). He was very adamant and says that he was fully awake because no sedation was given. The procedure note is clearly signed by the doctor.

I found this hard to believe but the patient is convincing. Have any of you seen anything like this.

Wouldn’t be surprised the way this field is going..but never actually seen that

 

[callmeanesthesia]

Had a patient that I saw last week. Came over from another local pain practice. Essentially normal cervical MRI and got cervical MBBs but that is for another conversation.

The thing that was interesting is that the patient claimed that the MBBs were performed by a rad tech and not the doctor. He said that they doctor was not even in the room (they do procedures in a different office). He was very adamant and says that he was fully awake because no sedation was given. The procedure note is clearly signed by the doctor.

I found this hard to believe but the patient is convincing. Have any of you seen anything like this.

I’d say most likely new patient visit with NP, then procedure done by doctor.

 

[willabeast]

could not have been an x-ray tech, they are taught not to do that. probably a PA or RN or a Radiologist Assistant. Radiologist Assistants (RAs): These are highly trained technologists with a master's-level credential who can perform advanced clinical tasks—such as evaluating images for completeness, performing specific non-surgical procedures, and making initial observations—under the supervision of a radiologist.

 

[1 Up]

There was this guy who said he murdered someone. Probably can't be true because murder is illegal. Nobody would ever do something illegal.

 

[SpineandWine]

Do you require MRI findings of facet disease before scheduling mbb?

 

[PinchandBurn]

Do you require MRI findings of facet disease before scheduling mbb?

No...for example whiplash

Most of the time there's some sort of spondylosis or facet stuff though

 

[interjectionreflection]

No...for example whiplash

Most of the time there's some sort of spondylosis or facet stuff though

Our rads never comment on facet arthrosis for cervical spine and about half do for lumbar

 

[SSdoc33]

Do you require MRI findings of facet disease before scheduling mbb?

yes. or ct

 

[Agast]

Had a patient that I saw last week. Came over from another local pain practice. Essentially normal cervical MRI and got cervical MBBs but that is for another conversation.

The thing that was interesting is that the patient claimed that the MBBs were performed by a rad tech and not the doctor. He said that they doctor was not even in the room (they do procedures in a different office). He was very adamant and says that he was fully awake because no sedation was given. The procedure note is clearly signed by the doctor.

I found this hard to believe but the patient is convincing. Have any of you seen anything like this.

Does the procedure note say that sedation was given?

I had a patient who claimed that she was fully awake and I never touched her. She got versed/fentanyl IV sedation and complained the whole time while she was falling asleep and waking up. She had hurt her back scooping kitty litter for her 11 cats…

 

[callmeanesthesia]

Does the procedure note say that sedation was given?

I had a patient who claimed that she was fully awake and I never touched her. She got versed/fentanyl IV sedation and complained the whole time while she was falling asleep and waking up. She had hurt her back scooping kitty litter for her 11 cats…

I’ve had a couple patients who were adamant they didn’t have a procedure (usually it was a RFA following up after a year or two though). Even after I pulled up the fluoro images from their file and compared it to their regular imaging for confirmation they remained unconvinced.

 

[MitchLevi]

I’ve had a couple patients who were adamant they didn’t have a procedure (usually it was a RFA following up after a year or two though). Even after I pulled up the fluoro images from their file and compared it to their regular imaging for confirmation they remained unconvinced.

Been there…Printed procedure pics with their patient identification sticker on the image and handed it to them. Gave them copies of their signature on the consent, showed the bill, showed where we got their blood pressure, procedure note, etc.

They doubled down and said it never happened.

Had a few go so far as to argue with the spouse who agrees with me and was the person who drove them that day,

PO Valium 5mg, no propofol, Versed or fentanyl.

 

[clubdeac]

a doc I did fellowship with trained his Xray techs to do mbb’s im one room so he could do other procedures in another. Billed for both. Complete scum

 

[mille125]

I’d say most likely new patient visit with NP, then procedure done by doctor.

New patient visit was done by NP. That part is clear.

 

[mille125]

Do you require MRI findings of facet disease before scheduling mbb?

I do not if it fits clinically with what I would expect. I see it as a clinical arthritic condition.

The patient that I describe had an xray and MRI and both were essentially normal.

I would not do an MBB in the setting that I describe with normal films but I know that some disagree.

 

[mille125]

Does the procedure note say that sedation was given?

I had a patient who claimed that she was fully awake and I never touched her. She got versed/fentanyl IV sedation and complained the whole time while she was falling asleep and waking up. She had hurt her back scooping kitty litter for her 11 cats…

Procedure note does say no sedation.

 

[mille125]

a doc I did fellowship with trained his Xray techs to do mbb’s im one room so he could do other procedures in another. Billed for both. Complete scum

still doing it?

 

[Dr. Ice]

Do you require MRI findings of facet disease before scheduling mbb?

My hopd will not allow any neuroaxial procedure without an MRI or CT if mri is contraindicated. I used to do mbb on patients with just X-rays. Never had an issue

 

[SpineandWine]

I do not if it fits clinically with what I would expect. I see it as a clinical arthritic condition.

The patient that I describe had an xray and MRI and both were essentially normal.

I would not do an MBB in the setting that I describe with normal films but I know that some disagree.

I know off topic here but you have let’s say 35 year old (not very old), normal MRI, normal X-ray.
Has done 2 years of conservative care (PT, dry needling, massage)- continues to suffer from axial back pain which starts in middle of her low back and goes out in belt like fashion. Leaving back hurts and forward makes it better. Better when sitting.
You do TPI and NSAIDs. No relief.


Offer MBB?

 

[SpineandWine]

My hopd will not allow any neuroaxial procedure without an MRI or CT if mri is contraindicated. I used to do mbb on patients with just X-rays. Never had an issue

I follow LCDs. Question I’m asking is if MRI is normal but clinically seems arthritis in younger patient without centralized pain

 

[SpineandWine]

Had a patient that I saw last week. Came over from another local pain practice. Essentially normal cervical MRI and got cervical MBBs but that is for another conversation.

The thing that was interesting is that the patient claimed that the MBBs were performed by a rad tech and not the doctor. He said that they doctor was not even in the room (they do procedures in a different office). He was very adamant and says that he was fully awake because no sedation was given. The procedure note is clearly signed by the doctor.

I found this hard to believe but the patient is convincing. Have any of you seen anything like this.

Seems like fraud if it occurs. Sometimes patients may not know if doctor did injection because they are positioned, doctor gets in and does injection while music is playing and leaves.
They see doc for like 10 seconds pre op with mask on

 

[Dr. Ice]

I follow LCDs. Question I’m asking is if MRI is normal but clinically seems arthritis in younger patient without centralized pain

LCDs are garbage but I’m forced to follow them. Yes, I’ve done many mbb and rfa in this type of patient population with success. I tell them they are young and if necessary to repeat, the chance of multifidus atrophy but even the anti rfa regen guys are basically just telling these people to “exercise more”

 

[Dr. Ice]

I know off topic here but you have let’s say 35 year old (not very old), normal MRI, normal X-ray.
Has done 2 years of conservative care (PT, dry needling, massage)- continues to suffer from axial back pain which starts in middle of her low back and goes out in belt like fashion. Leaving back hurts and forward makes it better. Better when sitting.
You do TPI and NSAIDs. No relief.


Offer MBB?
Yes all the time

 

[SpineandWine]

MRI is a poor predictor of facet-mediated pain, and medial branch blocks (MBBs) can be performed without MRI evidence of facet arthropathy. Multiple guidelines explicitly state that MRI should not be required prior to diagnostic facet blocks.

Per open evidence
Furthermore….


• Facet pain can arise from capsular inflammation, synovitis, or microinstability that may not manifest as visible arthropathy on structural imaging.


• MRI and CT detect structural degeneration, but facet-mediated pain is a functional diagnosis best confirmed by the physiologic response to diagnostic medial branch blocks.


• Interestingly, patients referred based on clinical palpation rather than imaging findings actually reported better improvement after cervical facet interventions in one prospective study.

 

[Dr. Ice]

MRI is a poor predictor of facet-mediated pain, and medial branch blocks (MBBs) can be performed without MRI evidence of facet arthropathy. Multiple guidelines explicitly state that MRI should not be required prior to diagnostic facet blocks.

Per open evidence
Furthermore….


• Facet pain can arise from capsular inflammation, synovitis, or microinstability that may not manifest as visible arthropathy on structural imaging.


• MRI and CT detect structural degeneration, but facet-mediated pain is a functional diagnosis best confirmed by the physiologic response to diagnostic medial branch blocks.


• Interestingly, patients referred based on clinical palpation rather than imaging findings actually reported better improvement after cervical facet interventions in one prospective study.

Yes clinical people know this..in many cases people making the rules don’t know this..

 

[SpineandWine]

Yes clinical people know this..in many cases people making the rules don’t know this..

Lot on this forum would argue you need MRI evidence

 

[callmeanesthesia]

I follow LCDs. Question I’m asking is if MRI is normal but clinically seems arthritis in younger patient without centralized pain

You’re following the Medicare LCD on a healthy 35 year old?

 

[SSdoc33]

MRI is a poor predictor of facet-mediated pain, and medial branch blocks (MBBs) can be performed without MRI evidence of facet arthropathy. Multiple guidelines explicitly state that MRI should not be required prior to diagnostic facet blocks.

Per open evidence
Furthermore….


• Facet pain can arise from capsular inflammation, synovitis, or microinstability that may not manifest as visible arthropathy on structural imaging.


• MRI and CT detect structural degeneration, but facet-mediated pain is a functional diagnosis best confirmed by the physiologic response to diagnostic medial branch blocks.


• Interestingly, patients referred based on clinical palpation rather than imaging findings actually reported better improvement after cervical facet interventions in one prospective study.

MRI shows modic changes of discs, active facet arthroparthy, annular tears, facet cysts, etc.

Your 35 year old absent trauma and a normal mri isn’t going to respond to the mbb. Yes, you CAN do it, but it’s not gonna help

You probably should know this by now

 

[Gnarvin]

MRI shows modic changes of discs, active facet arthroparthy, annular tears, facet cysts, etc.

Your 35 year old absent trauma and a normal mri isn’t going to respond to the mbb. Yes, you CAN do it, but it’s not gonna help

You probably should know this by now

Agreed. Or they will say the 2 sets of MBB helped but then say the RFA didn’t help and complain their pain is even worse now…

 

[PMROralBoards]

Agreed. Or they will say the 2 sets of MBB helped but then say the RFA didn’t help and complain their pain is even worse now…

I usually find that the patients who don’t have immediate same day relief with mbb but say it feels better the next day and a few days after that generally have myofascial pain rather than facetogenic pain. Basically just a bunch of deep trigger point injections.

 

[callmeanesthesia]

MRI shows modic changes of discs, active facet arthroparthy, annular tears, facet cysts, etc.

Your 35 year old absent trauma and a normal mri isn’t going to respond to the mbb. Yes, you CAN do it, but it’s not gonna help

You probably should know this by now

Some of the manual laborers who’ve been abusing their bodies since they were teenagers do. Also some of the hypermobile people.

 

[SpineandWine]

MRI shows modic changes of discs, active facet arthroparthy, annular tears, facet cysts, etc.

Your 35 year old absent trauma and a normal mri isn’t going to respond to the mbb. Yes, you CAN do it, but it’s not gonna help

You probably should know this by now

MRI is clean (none of what you mentioned. No facets or discs)
What’s your next step in CLEAN mri?
Hurts axial back when they stand, gets better when sit. Goes out in belt like fashion (no annular tear, facets, etc.)

They’ve done PT, massage, yoga, dry needling, TPI
I know what I’d do in my practice with good results

 

[SpineandWine]

You’re following the Medicare LCD on a healthy 35 year old?

I get MRIs on everyone with back pain who is not responding to conservative care and I want a better look.
I’m asking if then stated MRI is completely clean- what’s next step?

 

[adiradirim]

I see these situations all the time in kids and young adults.

The answer is med management, education, functional restoration and pain psych. It’s most likely either myofascial or nociplastic.

MBB on these patients are just fancy TPIs.

Preventing them getting deconditioned and giving it time and generally it gets better over 2-5 years.

 

[callmeanesthesia]

I see these situations all the time in kids and young adults.

The answer is med management, education, functional restoration and pain psych. It’s most likely either myofascial or nociplastic.

MBB on these patients are just fancy TPIs.

Preventing them getting deconditioned and giving it time and generally it gets better over 2-5 years.

What’s worse is when they have a few tiny findings and latch on to it. “I was diagnosed with disintegrating disc disease, that’s why I’ve been on oxy for 20 years.”

 

[SpineandWine]

What’s worse is when they have a few tiny findings and latch on to it. “I was diagnosed with disintegrating disc disease, that’s why I’ve been on oxy for 20 years.”

They’ve tried all of it, didn’t work. They tried NSAIDs, muscle relaxants, various non opiate pharmacotherapy, do PT
Functional restoration and PT don’t work all the time
I’d do mbb at that time. Not opiates
MRI findings are not necessary for mbb

For younger patients, I offer intra-articular steroid vs PRP (cash if not covered) if they’ve demonstrated everything else

 

[callmeanesthesia]

They’ve tried all of it, didn’t work. They tried NSAIDs, muscle relaxants, various non opiate pharmacotherapy, do PT
Functional restoration and PT don’t work all the time
I’d do mbb at that time. Not opiates
MRI findings are not necessary for mbb

I agree with you, I’d certainly try an MBB. Unfortunately those are often the same patients who scream so loud the waiting room can hear when you touch them with a 25g. 20 years of smoking a pack a day, laying on the couch, opiate-induced hyperalgesia, and learned helplessness behavior.
I treat them respectfully, take their pain seriously, but thankfully they usually don’t schedule the procedure once they find out I’m not going to prescribe them opiates.
It’s not too often I get these though. I think word has gotten around that I’m not dispensing pills.

 

[SpineandWine]

I agree with you, I’d certainly try an MBB. Unfortunately those are often the same patients who scream so loud the waiting room can hear when you touch them with a 25g. 20 years of smoking a pack a day, laying on the couch, opiate-induced hyperalgesia, and learned helplessness behavior.
I treat them respectfully, take their pain seriously, but thankfully they usually don’t schedule the procedure once they find out I’m not going to prescribe them opiates.
It’s not too often I get these though. I think word has gotten around that I’m not dispensing pills.

Agree, no opiates

 

[Welcome123]

Had a patient that I saw last week. Came over from another local pain practice. Essentially normal cervical MRI and got cervical MBBs but that is for another conversation.

The thing that was interesting is that the patient claimed that the MBBs were performed by a rad tech and not the doctor. He said that they doctor was not even in the room (they do procedures in a different office). He was very adamant and says that he was fully awake because no sedation was given. The procedure note is clearly signed by the doctor.

I found this hard to believe but the patient is convincing. Have any of you seen anything like this.

I will almost always focus on clinical presentation as dominating factor in my treatment decisions. MRI is useful as a tool but in cases of facet mediated pain not that helpful, especially in the younger population who will often have no mention of facet pathology on MRI, on personal review there may be some widening or increased T2 w possible effusion(or not) my outcomes are usually quite good in the scenario of axial pain with facetogenic pain patterns.
As far as a rad tech doing the procedure-haven’t heard/seen that before. What i have seen are patients being poor historians.

 

[SSdoc33]

They’ve tried all of it, didn’t work. They tried NSAIDs, muscle relaxants, various non opiate pharmacotherapy, do PT
Functional restoration and PT don’t work all the time
I’d do mbb at that time. Not opiates
MRI findings are not necessary for mbb

For younger patients, I offer intra-articular steroid vs PRP (cash if not covered) if they’ve demonstrated everything else

you are using a flow chart

Algorithms are for clipboard nurses or PAs.

And if you are gonna do it that way, make sure it is right. Yours is not.

No mbbs and for effs sake, don’t charge them 1k for PRP. wtf?

You be a big boy and You tell them you can’t help them outside of what you have already told them or prescribed. Thats ok

First do no harm

If it sounds like I am being condescending, its bc I am.

 

[SpineandWine]

you are using a flow chart

Algorithms are for clipboard nurses or PAs.

And if you are gonna do it that way, make sure it is right. Yours is not.

No mbbs and for effs sake, don’t charge them 1k for PRP. wtf?

You be a big boy and You tell them you can’t help them outside of what you have already told them or prescribed. Thats ok

First do no harm

If it sounds like I am being condescending, its bc I am.

You’re wrong

 

[SSdoc33]

I

You’re wrong

I’m right.

You wouldn’t be asking if you were confident you were right.

It’s not the end of the world if you do this mbb….. but you are not helping this patient

 

[SpineandWine]

I

I’m right.

You wouldn’t be asking if you were confident you were right.

It’s not the end of the world if you do this mbb….. but you are not helping this patient

Neither are you.
More on board here would practice what I would.
I’m asking because people on this board have previously stated they would never but I’ve had good success with it in clean MRIs

Open evidence AI agrees with this as well

 

[Ducttape]

MRI is clean (none of what you mentioned. No facets or discs)
What’s your next step in CLEAN mri?
Hurts axial back when they stand, gets better when sit. Goes out in belt like fashion (no annular tear, facets, etc.)

They’ve done PT, massage, yoga, dry needling, TPI
I know what I’d do in my practice with good results

if young, then core exercises, HEP daily, they can consider home traction units if it makes them happy.

heck, if they want to go to chiro, thats an option for them if they seek it out themselves - im not generating a referral.

but no interventional spine treatment.

 

[SpineandWine]

if young, then core exercises, HEP daily, they can consider home traction units if it makes them happy.

heck, if they want to go to chiro, thats an option for them if they seek it out themselves - im not generating a referral.

but no interventional spine treatment.

I don’t know why everyone falls back into chiro/PT/dry needling. I am stating these didn’t work
Hopefully you’re not hanging your hat only on MRI

 

[SSdoc33]

Neither are you.
More on board here would practice what I would.
I’m asking because people on this board have previously stated they would never but I’ve had good success with it in clean MRIs

Open evidence AI agrees with this as well

incorrect, i AM helping the patient by not offering them a bogus procedure that will give them false hope and costs them $$$.

the scenario you portray: 35 y/o with back pain, normal MRIs, and pain with standing/extension isnt all that common. i find those patients have pain mostly if they sit for a long time, or when they awaken in the morning.

i dispute that "more in this board would practice what I would"

i dont GAF what open evidence AI says about it either.

 

[Ducttape]

i hope you are not offering some injection for the sake of doing something, espcially something not backed by science.

if HEP/PT and alternative therapies dont work, then other injection alternatives wont work.

then we talk about CBT, EAAT, ACT, and no one else on this forum wants to discuss those therapies.

 

[clubdeac]

still doing it?

Not sure but I would guess unless he got caught. He makes a lot more money than I too

 

[clubdeac]

I

I’m right.

You wouldn’t be asking if you were confident you were right.

It’s not the end of the world if you do this mbb….. but you are not helping this patient

I’m sorry but cmon ssdoc. I too think mbb’s in a 35 yo is low yield but after exhausting everything else it’s not unreasonable. Plus you know as well as anyone that imaging findings do not correlate with response to mbb and RFA. This is pain 101. Were you asleep for that lecture? Get off his back

And since when does ethics enter your treatment paradigm? I’m actually kinda impressed as misguided as you often are

 

[RoloTomassi]

I'm with @SpineandWine
Axial back pain without disc/endplate changes and not presenting like SIJ gets MBB. Regardless of age or facet appearance. Moderate yield. Even some where I was sure it would be disc/endplate and just doing a facet rule out comes back positive. RFA or PRP. Same algorithm with C and T.