Hospice - Repeat ESI?

[NOSfan]

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72 y/o with h/o LSS responded well to L5-S1 IESI x 2 years. Previous L/S MRI showed LSS at L4-L5. Now on hospice for esophageal CA.

No abdominal pain but LBP described similar to before with a neurogenic claudication component. Requests repeat ESI.

What do you do?

 

[willabeast]

Get a new MRI. Logically one could do a caudal ESI and get away with it but you are needlessly opening yourself up to litigation without a new MRI.

 

[lobelsteve]

Palliative care. Repeat ESI. No additional workup as it would not change care.

 

[willabeast]

Palliative care. Repeat ESI. No additional workup as it would not change care.

If there are mets in the spine at L5S1 would you proceed with a L5S1 IL ESI? I would not. If there was significant bleeding and a hematoma formed causing leg weakness you are stuck legally (as is the patient literally).

 

[Ducttape]

on hospice. he is going to die, and most likely within 3 months.

if you want, and probably overkill, at most get a screening xray to make sure you don't see a lytic lesion at where you are going to do an injection, but you are talking end of life care.

make him feel better. don't delay care to get an MRI scan, lie in a scanner for over an hour because you are not going to do anything different with the information.

 

[lobelsteve]

If there are mets in the spine at L5S1 would you proceed with a L5S1 IL ESI? I would not. If there was significant bleeding and a hematoma formed causing leg weakness you are stuck legally (as is the patient literally).

Yes. I would. If esi fails, palliative xrt can be done if mets show.

 

[SommeRiver]

Out of curiosity, would yall up that Depo to 120mg or just do 80mg?

 

[Laryngospasm]

Going to die.. minimal risk, do the ESi

 

[lobelsteve]

Out of curiosity, would yall up that Depo to 120mg or just do 80mg?

See other thread. No benefit over 40 mg

 

[Orin]

72 y/o with h/o LSS responded well to L5-S1 IESI x 2 years. Previous L/S MRI showed LSS at L4-L5. Now on hospice for esophageal CA.

No abdominal pain but LBP described similar to before with a neurogenic claudication component. Requests repeat ESI.

What do you do?

If they're carving this out of the hospice benefit, proceed as you normally would. I agree the MRI is not critical as probability-wise, esophageal cancer does not commonly spread to the lumbar spine.

If they're putting this under the hospice benefit, and assuming it's at home hospice, I would do this landmark guided in the clinic to minimize costs.

 

[SommeRiver]

See other thread. No benefit over 40 mg

Which thread

 

[lobelsteve]

Which thread

Unsure. Active in last few days talking about steroid dosing.

 

[Orin]

Which thread

Didn't find the thread, small study

Comparison of two doses of corticosteroid in epidural steroid injection for lumbar radicular pain - PubMed

In the case of lumbar radicular pain, ESI with low dose (40 mg) methylprednisolone is as effective as high dose (80 mg) with comparable results and less adverse profile.

pubmed.ncbi.nlm.nih.gov

40 = 80

 

[SommeRiver]

Thanks

 

[pmrmd]

I had a patient in hospice and they wouldn’t allow him to get “treatment”. It was end-of-life care and they said active treatment means booted from hospice. Seemed weird but I stayed away from hospice patients since then. If allowed, inject him. There isn’t a good reason not to.

 

[Orin]

I had a patient in hospice and they wouldn’t allow him to get “treatment”. It was end-of-life care and they said active treatment means booted from hospice. Seemed weird but I stayed away from hospice patients since then. If allowed, inject him. There isn’t a good reason not to.

Yeah, it's the structure of the hospice benefit. In this case, you need to clarify that this is not related to the hospice diagnosis (esophageal cancer). Regardless, a patient can opt out of hospice and re-engage later if desired, although not necessarily with the same hospice agency.

 

[Ligament]

See other thread. No benefit over 40 mg

No analgesic benefit but 120mg of depo is going to give him some pep, vim and vigor in his last days. Might be reasonable if he is not already on oral steroids.

 

[Baron S]

I think the medical term for pep, vim, and vigor is "psychosis".

 

[lobelsteve]

 

[Ferrismonk]

No analgesic benefit but 120mg of depo is going to give him some pep, vim and vigor in his last days. Might be reasonable if he is not already on oral steroids.

Just give him/her ritalin instead. It'll last longer.

 

[Ligament]

Just give him/her ritalin instead. It'll last longer.

Give him that too if not already on it and safe for him. No need for these folks to be miserable.

 

[SommeRiver]

Let them smoke weed.