Imaging before injections

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NeuroGuyIP

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I am fresh out of pain fellowship and want to get some advice regarding when to image. If patient's clinical history and exam are suggestive of a radiculopathy and you are planning on doing an epidural (interlaminar or transformainal), do you first get an MRI or do you complete an injection first and then if no improvement, get imaging? I have heard of several insurances denying an MRI initially but approving an injection. Thanks for any insight!


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I am currently a fellow, just started and I suggested on a patient to do a cervical epidural on a patient with cervical radic and was told by my attending that he never injects without some imaging, whether it be CT or MRI to know or get an idea of what the pathology is that is going on. But would like to hear other peoples opinions as well!
 
And this is exactly how we handled things while I was a fellow, but as you know, academic practice does not always reflect how things are done in the real world. I don't think I will be doing cervical epidurals without and MRI or CT first.


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This really should have been taught during your fellowship. Agree with what DoctorJay said above. And it doesn't matter if insurance will approve an injection without imaging, they could give a flying fart less about the best interest of the patient or your liability.

A tip for your future peer to peers, ask their name, primary specialty, and if they're still practicing. Let them know you're documenting that in the chart and it tends to put them in their place a little quicker.
 
Refer to 28.2 million dollar lawsuit thread on this forum. Image everything. The law is pro plaintiff until the cows come home. It's your ass (and your patients) on the line.
 
I saw a 65 y/o F patient a few years ago with a presentation classic for facet mediated pain. I got an MRI as I routinely do before injections and as it turns out she had a facet abscess in the absence of any prior low back surgery or injections. Had I just done the injections and later sent her for an MRI when she returned to say she was worse, it would have been my fault she was infected.

Some on this forum will not order an MRI for facet pain and just do the injections - that's fine, but you are accepting some risk.
 
knoxdoc said:
I saw a 65 y/o F patient a few years ago with a presentation classic for facet mediated pain. I got an MRI as I routinely do before injections and as it turns out she had a facet abscess in the absence of any prior low back surgery or injections. Had I just done the injections and later sent her for an MRI when she returned to say she was worse, it would have been my fault she was infected.

Some on this forum will not order an MRI for facet pain and just do the injections - that's fine, but you are accepting some risk.
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what's the cause of "facet abscess"? was there systemic infection that made you suspect a "facet abscess"? if not, are you routinely doing MRI for axial low back pain with paramedian tenderness and positive facet loading test?

wondering what other guys do on this forum?

I don't require MRI before MNBB if I suspect the axial LBP is facetogenic.
 
I will never perform an epidural injection without MRI>CT. Unless I do- which is administering a caudal block for a person in extreme agony from a L5 or S1 radiculopathy on physical exam, only to be followed by an MRI within a day or two. I will never perform a TFESI or interlaminar without a MRI/CT because I don't know what is there and do not know the best approach/needle set without knowing the size of the neuroforamen or the spinal canal. 70 years ago, sacroiliac infection was not uncommon with TB and staphylococcus, but today those are rare, so injection into the SI seems prudent without anything but an xray. Facets are more complex, but if there is axial back pain alone without any referred pain to the foot or calf, and SLR is neg, then I would perform a facet injection, but not a RF without MRI/CT. Anyone with red flag signs significant weight loss, unexplained fevers, night sweats, worsening pain at night in the back, significant coexisting abdominal pain, loss of bowel or bladder control, lower extremity numbness or weakness without pain will get a MRI before doing anything to the patient. A MRI within the last year is acceptable for anyone without red flag signs. I nearly always view the old MRI personally on the second visit (with instructions for the patient to obtain this) and all new MRIs are viewed personally. I do this in the room with the patient demonstrating that they have pathology, but also emphasize that all pathology on MRI does not translate to pain or disease. I also made the distinction between overt disc herniation and disc bulges since some patients are erroneously told by their physician they have 5 disc herniations when in fact they have none, and certainly none causing symptoms.
 
Last edited:
knoxdoc said:
I saw a 65 y/o F patient a few years ago with a presentation classic for facet mediated pain. I got an MRI as I routinely do before injections and as it turns out she had a facet abscess in the absence of any prior low back surgery or injections. Had I just done the injections and later sent her for an MRI when she returned to say she was worse, it would have been my fault she was infected.

Some on this forum will not order an MRI for facet pain and just do the injections - that's fine, but you are accepting some risk.
Click to expand...
OK but an ESR costing 10 dollars would have alerted you to the abscess.
 
NeuroGuyIP said:
I am fresh out of pain fellowship and want to get some advice regarding when to image. If patient's clinical history and exam are suggestive of a radiculopathy and you are planning on doing an epidural (interlaminar or transformainal), do you first get an MRI or do you complete an injection first and then if no improvement, get imaging? I have heard of several insurances denying an MRI initially but approving an injection. Thanks for any insight!


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Click to expand...
Key here is "fresh out of pain fellowship". Be conservative in your clinical decision making for a few years. You have a lot to learn at this point. BTW this forum is usually a good one.
 
Thanks for all the great information. If insurance is denying MRI, do you personally complete peer to peer review to get it approved? If so, does it take much justification to get the MRI approved? I never saw this side of medicine during fellowship since the attendings were the ones dealing with denials and peer to peer reviews.


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Much of the time the peer to peer is just a hastle that will not take much of your time and the study will get approved. Some of the time you will be on the phone with some jackoff who is power tripping and will read back to you verbatim your note and then try to enforce the irrational conservative management mandate "6 weeks of conservative manangement blah blah" and they will deny the study. If that happens I will ask for their name and speciality and tell them that I will make the patient aware that Dr soandso from the insurance company denied your study without ever having seen you and is requiring that you suffer in pain for 6 the next 6 weeks. Usually I get a call back saying the test was approved.
 
An elevated ESR is present with polymyalgia rheumatica, rheumatoid arthritis, psoriatic arthritis, sometimes in gout, temporal arteritis, headaches, neck or shoulder pain, pelvic pain, anemia, poor appetite, unexplained weight loss, joint stiffness, arthritis, aging, cancer, multiple myeloma or Waldenstrom's macroglobulinemia, SLE, etc. Lots of causes, not a very specific test, and means something physically is wrong with the patient.
 
Well... you can get an elevated ESR from infections. In one study, 71% of children with adenovirus had a send rate >30.

I'm not sure I would say that these individuals have something seriously wrong tho.


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the problem of getting a MRI before MNBB is most commercial carriers in my area would require minimum 6 weeks of conservative treatment, blahblahblah. So instead of doing PA for MRI, get an ESR to r/o cancer/infection in a nonspecific manner is much quicker and reasonable.

I mean what you are looking for if your clinical diagnosis for axial LBP is clearly facetogenic when you are ordering a spinal MRI. Cancer and infection at the site of planned injection, right? MRI seems to be a misused resource if you can order an ESR/CRP to r/o these two concerns.
 
Ligament said:
Be honest; in 99% of the cases the MRI you order is to protect you from the lawyers. Just order it and CYA.
Click to expand...
Of course. But this is the way it will be unless there is actual tort reform in this country
 
drpainfree said:
the problem of getting a MRI before MNBB is most commercial carriers in my area would require minimum 6 weeks of conservative treatment, blahblahblah. So instead of doing PA for MRI, get an ESR to r/o cancer/infection in a nonspecific manner is much quicker and reasonable.

I mean what you are looking for if your clinical diagnosis for axial LBP is clearly facetogenic when you are ordering a spinal MRI. Cancer and infection at the site of planned injection, right? MRI seems to be a misused resource if you can order an ESR/CRP to r/o these two concerns.
Click to expand...


But then again, many insurances require some sort of imaging before approving an injection- the whole system is messed up
 
in terms of prescreening, there may be some validity.

and in one study, the sensitivity for postoperative spinal infection was kind of poor - 78%. (http://www2.aaos.org/shoulder/OC/Mart/MartLinks/ESR in Orthopaedics.pdf)

another study looking for epidural abscess suggests however 100%. i only have the abstract, however, but it used risk stratification, CRP and ESR in combination, and was highly sensitive. An Error Occurred Setting Your User Cookie
http://thejns.org/doi/abs/10.3171/2011.1.SPINE1091?journalCode=spi
however, the purpose of these studies was to determine presence of suspected epidural abscess, not for determining the appropriateness of injection. and ESR and CRP may not have the same validity for ruling out malignancy.
 
If it has been a relatively benign course of axial low back pain for longer than 6 months without any red flags, then I will do the MBB with plain films, MR if inadequate response. Any radicular pain, recent onset, or severe pain beyond what I would anticipate and I will get MR or CT before proceeding. Even with SIJ I had one referred by our surgeons that ended up due to invasion of bony met. Glad I imaged first. I always err on the side of imaging and very clearly discuss with my patients that by not doing this we are potentially, but very unlikely, missing something sinister.
 
I definitely have not routinely been ordering plain films before MBNB and SI joint injections. Guess I will start doing this!
 
Aren't you using fluoroscopy for procedure sake if you planned to do an SI joint/facet injection? Why insist on an x-ray prior to your X-ray?!


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EruditeDoc said:
I definitely have not routinely been ordering plain films before MBNB and SI joint injections. Guess I will start doing this!
Click to expand...

don't order a test/study unless you know what you're looking for, or you know what you might be surprised to find in which case you are looking for incidental findings.
 
How do you diagnose lumbar spondylosis or facet arthropathy without at least an X-ray? I don't think my carriers will approve MBB for "back pain".


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IN2B8R said:
Aren't you using fluoroscopy for procedure sake if you planned to do an SI joint/facet injection? Why insist on an x-ray prior to your X-ray?!


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Click to expand...
A couple of reasons.
1. Confirm diagnosis for lumbar spondylosis, otherwise I am submitting for m54.5, low back pain, which is non-specific and may not be approved. Can't call spondylosis without imaging before.
2. No surprises in the fluoro suite when I shoot

I try not to over-image, but I don't want to under-image as well. Radiation and wasted money are bad, but not having the information that I need to increase my diagnostic probability before doing a procedure with very real risk is worse in my mind.
 
Tapspatellas said:
A couple of reasons.
1. Confirm diagnosis for lumbar spondylosis, otherwise I am submitting for m54.5, low back pain, which is non-specific and may not be approved. Can't call spondylosis without imaging before.
2. No surprises in the fluoro suite when I shoot

I try not to over-image, but I don't want to under-image as well. Radiation and wasted money are bad, but not having the information that I need to increase my diagnostic probability before doing a procedure with very real risk is worse in my mind.
Click to expand...

I call it cervical/lumbar spondylosis all time in people over 30 because we all have it after our twenties if you look hard enough. No insurance has ever raised an issue with it.

I only order X-rays and the radiation/cost that goes with them, if the MRI is suggestive of transitional anatomy. In these cases, I agree it's nice to have the x ray ahead of time for planning your procedure and later explaining to the patient about their extra/funny vertebra as no one else ever tells them.

With this approach I just get x rays on about 5% of my patients.
 
bedrock said:
I call it cervical/lumbar spondylosis all time in people over 30 because we all have it after our twenties if you look hard enough. No insurance has ever raised an issue with it
Click to expand...

I agree with that statement, but if I do not have any imaging, then I am not able to justify a diagnosis of spondylosis based solely upon examination, thus without the minimum of a plain film, I am unable to assign a diagnosis that the insurance will consider as an indication for MBB.
 
wait, am I missing something? I have not seen a lumbar spine x-ray reads out facet arthropathy. MRI, yes, but not all the time.

Facet arthropathy as an axial LBP generator is a clinical diagnosis, hence DIAGNOSTIC medial nerve branch block is offered to CONFIRM the diagnosis.
 
Yeah my radiologists comment on it so it may be a regional difference. Not saying you're wrong at all and I agree it's a clinical dx that we confirm with MBB.


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drpainfree said:
wait, am I missing something? I have not seen a lumbar spine x-ray reads out facet arthropathy. MRI, yes, but not all the time.

Facet arthropathy as an axial LBP generator is a clinical diagnosis, hence DIAGNOSTIC medial nerve branch block is offered to CONFIRM the diagnosis.
Click to expand...

Yes, I would like to hear more about this as well. Is it true that you cannot diagnose someone with spondylosis unless there is imaging?
 
There was a bmj study that concluded docs that order more tests are sued less.

I order lumbar obliques all the time and specifically ask about facets. If no mention I request overread. I do not think mild/moderate facet arthrosis is something rads really thinks is an issue and/or treatable
 
drpainfree said:
wait, am I missing something? I have not seen a lumbar spine x-ray reads out facet arthropathy. MRI, yes, but not all the time.

Facet arthropathy as an axial LBP generator is a clinical diagnosis, hence DIAGNOSTIC medial nerve branch block is offered to CONFIRM the diagnosis.
Click to expand...

You can see facet hypertrophy on plain films, hence diagnose spondylosis. To confirm that you clinical suspicion of facet arthropathy is causing the pain, then MBB. While non-hypertrophic facets can hurt, spondylosis is the typical diagnosis that I will use to justify the MBB to the insurance company.
 
NeuroGuyIP said:
I am fresh out of pain fellowship and want to get some advice regarding when to image. If patient's clinical history and exam are suggestive of a radiculopathy and you are planning on doing an epidural (interlaminar or transformainal), do you first get an MRI or do you complete an injection first and then if no improvement, get imaging? I have heard of several insurances denying an MRI initially but approving an injection. Thanks for any insight!


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Click to expand...

Lawyers would love for you to be injecting without MRIs.
 
Tapspatellas said:
You can see facet hypertrophy on plain films, hence diagnose spondylosis. To confirm that you clinical suspicion of facet arthropathy is causing the pain, then MBB. While non-hypertrophic facets can hurt, spondylosis is the typical diagnosis that I will use to justify the MBB to the insurance company.
Click to expand...
so if you have whiplash injury from an MVC with classic location and distribution of facet mediated arthropathy (ie classic cause/classic symptoms/classic location), but "normal" xrays, you would not try a diagnostic MBB?
 
Ducttape said:
so if you have whiplash injury from an MVC with classic location and distribution of facet mediated arthropathy (ie classic cause/classic symptoms/classic location), but "normal" xrays, you would not try a diagnostic MBB?
Click to expand...

I would, as I mentioned non-hypertrophic facets can hurt, in particular whiplash syndrome there need not be any degenerative changes, which is your point. My point as well is that while facet arthropathy as a diagnosis is 100% clinical, to play the game most payers require some type of imaging with a diagnosis of spondylosis, lucky if you can get away without advanced imaging nowadays.
 
Last week I got a referral from oncology for "acute disk herniation with sciatica". The patient was incorrectly scheduled into my procedure clinic as opposed to a new patient visit. Patient had a h/o colon CA in remission. Presented with acute posterior left leg pain starting in the buttock. No lbp. I examined him and told him I'd do an epidural assuming it was an L5/S1 radic but I was going to get an MRI to confirm my suspicions. MRI came back negative. With his history I decided to order a pelvic MRI. Bilateral hip xrays were already done and were negative. Welp, pelvic MRI came back positive for bony pelvic mets. Lesson learned
 
clubdeac said:
Last week I got a referral from oncology for "acute disk herniation with sciatica". The patient was incorrectly scheduled into my procedure clinic as opposed to a new patient visit. Patient had a h/o colon CA in remission. Presented with acute posterior left leg pain starting in the buttock. No lbp. I examined him and told him I'd do an epidural assuming it was an L5/S1 radic but I was going to get an MRI to confirm my suspicions. MRI came back negative. With his history I decided to order a pelvic MRI. Bilateral hip xrays were already done and were negative. Welp, pelvic MRI came back positive for bony pelvic mets. Lesson learned
Click to expand...
Great job following your better instincts
 
clubdeac said:
Last week I got a referral from oncology for "acute disk herniation with sciatica". The patient was incorrectly scheduled into my procedure clinic as opposed to a new patient visit. Patient had a h/o colon CA in remission. Presented with acute posterior left leg pain starting in the buttock. No lbp. I examined him and told him I'd do an epidural assuming it was an L5/S1 radic but I was going to get an MRI to confirm my suspicions. MRI came back negative. With his history I decided to order a pelvic MRI. Bilateral hip xrays were already done and were negative. Welp, pelvic MRI came back positive for bony pelvic mets. Lesson learned
Click to expand...

Did the epidural help?
 
lobelsteve said:
Did the epidural help?
Click to expand...
No of course it didn't help. I thought something was amiss from the get go when he said he had really no back pain to speak of. The lumbar MRI with only age appropriate degenerative changes is what sent me searching as his pain was seemingly pretty severe
 
clubdeac said:
No of course it didn't help. I thought something was amiss from the get go when he said he had really no back pain to speak of. The lumbar MRI with only age appropriate degenerative changes is what sent me searching as his pain was seemingly pretty severe
Click to expand...
Despite the pathology, there was a 1 in 3 chance of about 2 months relief. Regardless of pathology.
 
51189417593__D58296B7-A95D-4A5C-8F5F-BD8B7387CC19.JPG I found this on a patient sent by partner for hip injection...
 
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