IR vs Interventional Pain

[whournameiz]

These both sound like interesting fields since I like quick procedures. I was originally thinking IR but I got interested in pain patients after spending time in neurosurgery where I met a lot of chronic back pains that we referred to clinics for injections before considering surgery.

However I have not been able to find a solo pain doc around here in private practice to rotate with so could a few of you chime in on what a typical day is in private practice. There were only 2 old posts on this from years ago.

Typical patient, # of patients you see per day, time you spend with each patients, # procedures/day and avg time (in office vs SC)

satisfactions? frustrations? regrets? Could you still run a successful practice if all procedure rates where slashed in half?

Also there was a link that showed office visit reimbursements are 20-50$/pt....how do you run a clinic on that? can you take insurance just for the procedures? i.e. cash for office visit. I want to be able to spend some time with these patients and not just 5 min like opthos/derms and at the same time I would like to have a pretty nice run office not run down and gloomy....I'm not talking about having a waterfall but you know..nice. Am I just being a idealistic med student?

Thanx for your help.

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[PMR 4 MSK]

Most IR's I've seen don't do clinic - they're just doing procedures by request. When not doing procedures, they often fill in reading films.

Everyone's experiences in pain are different. Pain docs tend to take more time with patients, often longer than we'd like (psych issues). I schedule 15 min f/u and 30 min new pt.

# procedures per day highly variable. I do 15 - 20/wk under fluoro ave, probably the same average in clinic w/o fluoro. Some pain docs are machines doing ESI's and MBB's q 15 min x 4 hours. I book 1 pt/ half-hour for fluoro generally, bilateral procedures usually 45 min, RFA's 1 hour.

I also fill 1/3rd my time doing EMG's. I do 3 half-days of clinic/wk.

You're too early in your education to really worry about the money, and the whole scene will be different before you're done with training. I'm not being condescending, just brutally honest. Go into a field that interests you and that you feel you can contribute to. It doesn't matter how much they pay you, you'll just spend it. Follow your heart, not your wallet.

And you can't run a clinic for very long getting $50/pt. Eventually you'll want a paycheck too. That's why we stick needles in people...

 

[whournameiz]

thanx for the reply and bump

also how do you take vacation? if your overhead is 25k/mo don't you have to be in some sort of group?

 

[PMR 4 MSK]

I'm in a group, so I take vacation whenever I want. A couple rheumatologists handle anything that can't wait until I get back. However, since our is a "eat-what-you-kill" arangment for salary, the more vacation I take the less I earn.

When I was solo it was hard to take vacation since I had no coverage - my staff would call me with anything that was important, and any patient problems were referred to ER, PCP or urgent care.

 

[freddydpt]

I'm going into radiology but for now intend to practice pain management, primarily procedures. I do plan on having a clinic of some sort but not sure yet if it will be a physical therapy clinic or pain clinic or a mix.

For what its worth, most IR's I know do have clinic, end up doing all sorts of procedures from GI, neuro, MSK, vascular, etc etc. There are some solo IR pain practices, do a google search and you'll find them.

I made the choice of residency based on the bread and butter field I wanted to learn.

Hope that helps!

 

[ampaphb]

I do plan on having a clinic of some sort ...

Right there is the clear difference between IR and pain management - for me, it would be inconceivable to do a procedure on a patient without examining them first to determine the appropriateness of the ordered procedure. It is my sense that that is not the case for IR docs, who largely take their cue from the referring physician.

 

[Tenesma]

this is the classic thing I get from some spine surgeons:

a patient recently brought to me an RX that said

rx: Discogram L2/L3, L3/L4 and SI joint

and they were very upset that i didn't perform these procedures (not to mention that the patient already had their L3/L4 fused 360 degrees) for them on their initial visit.

i would love to (just once) send a patient to the spine surgeon for a L4/L5 TLIF with EBS.

 

[Mister Mxyzptlk]

I feel like the pediatricians when they try to convince Mom that the kid doesn't need antibiotics - it's just easier to go along sometimes.

There is one guy who no matter how much I speak to him about it keeps sending me elderly patients for "facet injections". I have to keep asking what he wants - IA or MBB. Despite repeated attempts at education, he usually wants IA, even in people with uncertain dx.

I finally got to the point where I'd toss in MBBs along with the IA injections. If they have good relief right after the procedure I tell the patient that if they don't get long term relief to get a referral for RF. The freebie MBBs are a good investment because the vast majority come back for RF.

Had another patient recently that I did ESIs on for spinal stenosis. Then she went to another surgeon who wanted her to have 3 level TFESI on one side. When I called him to explain that she already had ESIs he said, "These are different than what you did."

Well I can't argue with that because I don't do contiguous 3-level TFESIs.

The hardest part is when they send someone for a procedure that you know is wrong, like a referral for ESIs in a patient with minimal MRI findings and a concordantly tender SI joint.

 

[ampaphb]

There is one guy who no matter how much I speak to him about it keeps sending me elderly patients for "facet injections". I have to keep asking what he wants - IA or MBB. Despite repeated attempts at education, he usually wants IA, even in people with uncertain dx.

I finally got to the point where I'd toss in MBBs along with the IA injections. If they have good relief right after the procedure I tell the patient that if they don't get long term relief to get a referral for RF.

So does that mean you do a single block before moving forward with an RF?

 

[Mister Mxyzptlk]

Yep.

 

[ampaphb]

So you don't prefer IA facet injections, I presume because they are not borne out in the literature, yet you only do a single block, despite the literature that shows that a double block will yield less false positives.

Or is your rationale purely experiential (ie. "my patients seem to get better", "in my hands", etc) in both instances?

 

[Mister Mxyzptlk]

I try to follow the principles of the scientific method, one of which is that the results must be reproducible. Preferably that is done with subsequent publications, but if not then I have to rely on whether or not I can reproduce the results.

This is a common dilemma in pain management. You might hear stories about how IDET works well but then you can't reproduce it, or someone says SI RF doesn't work but you seem to be making people happy.

Given the quality of the work published I think we are unfortunately still in the position of having to go with personal experience to a large extent. I will discuss this a bit in my lecture in Las Vegas.

I don't do IA injections because I have found they rarely work, which agrees with the literature.

I don't know why there is a difference between what I observe and what has been reported for MBBs. I have not dissected the MBB literature in enough detail to figure out the discrepancy but I have some suspicions.

I suppose I could publish a retrospective case series, but ideally it should be prospective and that will have to wait.

 

[mille125]

I try to follow the principles of the scientific method, one of which is that the results must be reproducible. Preferably that is done with subsequent publications, but if not then I have to rely on whether or not I can reproduce the results.

This is a common dilemma in pain management. You might hear stories about how IDET works well but then you can't reproduce it, or someone says SI RF doesn't work but you seem to be making people happy.

Given the quality of the work published I think we are unfortunately still in the position of having to go with personal experience to a large extent. I will discuss this a bit in my lecture in Las Vegas.

I don't do IA injections because I have found they rarely work, which agrees with the literature.

I don't know why there is a difference between what I observe and what has been reported for MBBs. I have not dissected the MBB literature in enough detail to figure out the discrepancy but I have some suspicions.

I suppose I could publish a retrospective case series, but ideally it should be prospective and that will have to wait.

i think that it is all about technique and patient selection....if you inject 5 cc of 1/4 percent marcaine in either IA's or MBB you will get false information...my experience has been that IA and MBB are identical diagnostically and therapeutically....a few years ago i looked at the results of my patients after RF...i perform about 100 RF's per year....total failure rate was about 5 percent..I have proceeded to RF after successful MBB or IA injection and the results are the same...I have several patients who had 6 months or greater relief for IA injection (reproducibly)..In this case I see no reason to add the expense of performing MBB to confirm a diagnosis that I am already confident of....if I am unsure then I do consider MBB...I think that this says a lot about the pain literature and its flaws...I will not subject a patient to added expense and risk just to prove a diagnosis that i am already aware with....if you want to call it non evidenced based so be it...my patients are happy and that is all the evidence that I need..

 

[radslooking]

....

 

[lobelsteve]

to me it's slightly disturbing that we are allowed to charge money for procedures we don't even know are effective......anyhow....

MBB's are like Xrays or MRI's. Diagnostic.

If you ar eimplying we should not get paid for negative studies, well that would be interesting.

 

[radslooking]

are you doing RF ablations after + MBB's routinely? despite 30-40% false positive rates for MBB's? how much do these procedures cost?

 

[radslooking]

MBB's are like Xrays or MRI's. Diagnostic.

If you ar eimplying we should not get paid for negative studies, well that would be interesting.

...

 

[mille125]

to me it's slightly disturbing that we are allowed to charge money for procedures we don't even know are effective.....it's not like these are low cost procedures.....anyhow...

i am trying to understand your post...

1) are you saying that MBB's are not effective? They are a diagnostic procedure. It is very interesting that a radiologist is implying that we should not get reimbursed for diagnostic procedure (i assume that you are in radiology). I dont understand your false positive comment either. The only reason to do an MBB is to see if someone is a candidate for RF. If you dont think that they are an RF candidate then you have no business doing an MBB. Why would you not act on a positive result? You would just be wasting time.


2) are you saying the RF's are not effective? I dont know if you have any experience with the procedure or not. It is one of the more effective things that I do with high patient satisfaction.



please help me understand with you point is because i may have missed it......

 

[mille125]

No, of course not. It just seems you have to question a test with such a high false positive rate...and for which the evidence for the treatment (RF ablation) isn't exactly robust. If there's an indication for the procedure, diagnostic or therapeutic, you should certainly get paid. It just doesn't seem there's adequate information these procedures work, certainly not for very long. And that seems a bit unfortunate (if true) considering the cost of medical care these days.

Shouldn't we be spending money on stuff we know works???

what "stuff do we know works" when discussing treatment of pain? there is actually rather good evidence for RF....

 

[radslooking]

i think that it is all about technique and patient selection....if you inject 5 cc of 1/4 percent marcaine in either IA's or MBB you will get false information...my experience has been that IA and MBB are identical diagnostically and therapeutically....a few years ago i looked at the results of my patients after RF...i perform about 100 RF's per year....total failure rate was about 5 percent..I have proceeded to RF after successful MBB or IA injection and the results are the same...I have several patients who had 6 months or greater relief for IA injection (reproducibly)..In this case I see no reason to add the expense of performing MBB to confirm a diagnosis that I am already confident of....if I am unsure then I do consider MBB...I think that this says a lot about the pain literature and its flaws...I will not subject a patient to added expense and risk just to prove a diagnosis that i am already aware with....if you want to call it non evidenced based so be it...my patients are happy and that is all the evidence that I need..

your commitment to your patients is laudable. i'm not so sure this is the most rigorous scientific method i'm aware of however.

i am not being an ass, but am curious how do you "know" someone has facet joint pain without doing a diagnostic study (which apparently aren't that great either.) To my knowledge their are no known historical factors that can reliably point to facet induced pain.

 

[mille125]

No, of course not. It just seems you have to question a test with such a high false positive rate...and for which the evidence for the treatment (RF ablation) isn't exactly robust. If there's an indication for the procedure, diagnostic or therapeutic, you should certainly get paid. It just doesn't seem there's adequate information these procedures work, certainly not for very long. And that seems a bit unfortunate (if true) considering the cost of medical care these days.

Shouldn't we be spending money on stuff we know works???

treatment of pain secondary to lumbar spondylosis/facet OA is the indication for MBB transitioning to RF..........i am curious...what is your level of training and are you in academics?

 

[mille125]

your commitment to your patients is laudable. i'm not so sure this is the most rigorous scientific method i'm aware of however.

i am not being an ass, but am curious how do you "know" someone has facet joint pain without doing a diagnostic study (which apparently aren't that great either.) To my knowledge their are no known historical factors that can reliably point to facet induced pain.

if someone gets 6months of relief from a low volume facet block and you are able to reproduce these findings what else do you need? Of course there are some physical exam factors that may suggest the diagnosis as well

 

[radslooking]

what "stuff do we know works" when discussing treatment of pain? there is actually rather good evidence for RF....

i apologize if I am unaware of some of the effectiveness of RF procedures. I'll take that out of my previous post. Either way, you are doing a lot of RF procedures for a lot of false positives. I realize these people are in pain. It just seems like a lot of waste.

 

[radslooking]

if someone gets 6months of relief from a low volume facet block and you are able to reproduce these findings what else do you need? Of course there are some physical exam factors that may suggest the diagnosis as well

Well, here are some things that can be found on the web. I'm not saying there's no evidence...but it just doesn't seem that great. Anyhow, it certainly sounds like more studies are in order.

The first is a metanalysis from 2003. The other is a Cochrane Review from 2002. I know you are all trying to provide the best care for your patients. It just seems like there is more personal experimentation here than i'm personally comfortable with. This isn't EBM the way I'm used to it. The situation is a little similar to Cardiac CT and the cardiologists. They feel it has great usage but there is little evidence. I'd feel more comfortable if the situation was great evidence first...then usage of expensive treatments. Anyhow.

• A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain . The Spine Journal , Volume 3 , Issue 4 , Pages 310 - 316C . Slipman

Abstract

BACKGROUND CONTEXT: Lumbar zygapophysial joints are currently believed to be a cause of axial low back pain. Once this diagnosis is made, decisions about when to institute a particular intervention and which treatment to offer is regionally and specialty dependent.
PURPOSE: To perform a critical review of prior published studies assessing the use of interventional treatment options for the treatment of lumbar zygapophysial joint syndrome.
STUDY DESIGN: Evidence-based medicine analysis of current literature.
METHODS: A database search of Medline (PubMed, Ovid and MDConsult), Embase and the Cochrane database was conducted. The keywords used were low back pain, lumbar zygapophysial joint, lumbar facet joint, radiofrequency denervation, medial branch block, and intraarticular injection. After identifying all relevant literature, each article was reviewed. Data from the following categories were compiled: inclusion criteria, randomization of subjects, total number of subjects involved at enrollment and at final analysis. statistical analysis used, intervention performed, outcome measures, follow-up intervals and results. Guidelines described by the Agency for Health Care Policy and Research were then applied to these data.
RESULTS: This review determined that the evidence for the treatment of lumbar zygapophysial joint syndrome with intraarticular injections should be rated as level III (moderate) to IV (limited) evidence, whereas that for radiofrequency denervation is at a level III.
CONCLUSIONS: Current studies fail to give more than sparse evidence to support the use of interventional techniques in the treatment of lumbar zygapophysial joint–mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint–mediated pain can be made.

Review]
Radiofrequency denervation for neck and back pain

L Niemisto, E Kalso, A Malmivaara, S Seitsalo, H Hurri


Cochrane Database of Systematic Reviews 2008 Issue 2 (Status: Unchanged, commented)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD004058 This version first published online: 20 January 2003 in Issue 1, 2003

This record should be cited as: Niemisto L, Kalso E, Malmivaara A, Seitsalo S, Hurri H. Radiofrequency denervation for neck and back pain. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD004058. DOI: 10.1002/14651858.CD004058.

​

Abstract


Background
The diagnosis of cervical or lumbar zygapophyseal joint pain can only be made by using local anesthesia to block the nerves supplying the painful joint. There is a lack of effective treatment for chronic zygapophyseal joint pain or discogenic pain. Radiofrequency denervation appears to be an emerging technology, with substantial variation in its use between countries.


Objectives
To assess the effectiveness of radiofrequency denervation for the treatment of musculoskeletal pain disorders.


Search strategy
We searched MEDLINE, PsycLIT, and EMBASE from start to February 2002, plus the Cochrane Library 2002, Issue 2. The references of identified articles were checked and three experts in the field of radiofrequency treatment were consulted to identify studies we might have missed.


Selection criteria
Randomized controlled trials (RCTs) of radiofrequency denervation for musculoskeletal pain disorders, with no language or date restrictions.


Data collection and analysis
Two authors selected RCTs that met predefined inclusion criteria, extracted the data, and assessed the main results and methodological quality of the selected trials, using standardized forms. Qualitative analysis was conducted to evaluate the level of scientific evidence.


Main results
We found only nine articles, reporting on seven relevant RCTs. Six of the seven were considered to be high-quality. The selected trials included 275 randomized patients, 141 of whom received active treatment. One study examined cervical zygapophyseal joint pain, two cervicobrachial pain, three lumbar zygapophyseal joint pain, and one discogenic low-back pain. The study sample sizes were small, follow-up times short, and there were some deficiencies in patient selection, outcome assessments, and statistical analyses. The level of scientific evidence for the short-term effectiveness of radiofrequency denervation was limited for cervical zygapophyseal joint and cervicobrachial pain, and conflicting for lumbar zygapophyseal joint pain. There was limited evidence suggesting that intradiscal radiofrequency thermocoagulation was not effective for discogenic low-back pain.


Authors' conclusions
The selected trials provide limited evidence that radiofrequency denervation offers short-term relief for chronic neck pain of zygapophyseal joint origin and for chronic cervicobrachial pain; conflicting evidence on the short-term effect of radiofrequency lesioning on pain and disability in chronic low-back pain of zygapophyseal joint origin; and limited evidence that intradiscal radiofrequency thermocoagulation is not effective for chronic discogenic low-back pain. There is a need for further high-quality RCTs with larger patient samples and data on long-term effects, for which current evidence is inconclusive. Furthermore, RCTs are needed in non-spinal indications where radiofrequency denervation is currently used without any scientific evidence.


Plain language summary
Radiofrequency denervation can relieve pain from neck joints, but may not relieve pain originating from lumbar discs, and its impact on low-back joint pain is uncertain.

Ongoing neck or back pain can be caused by a joint or damaged disc between two vertebral joints. Injections to block these specific joint nerves can pinpoint if this is the source of the pain. Radiofrequency denervation aims to de-activate the nerve responsible by applying electric current to cauterise it (damage with heat).

The review found that radiofrequency denervation can provide short-term pain relief for a small proportion of people with specific joint problems in the neck. There is conflicting

 

[ampaphb]

treatment of pain secondary to lumbar spondylosis/facet OA is the indication for MBB transitioning to RF..........i am curious...what is your level of training and are you in academics?

There is actually virtualy no correlation between what a facet joint looks like on radiographic studies, and its responsiveness to therapeutic modalities (analagous to discs on MRI)

 

[Mister Mxyzptlk]

thanks mille, appreciate the information. i retracted some of the posts i felt may be in error.

Well your heart is in the right place, as is your brain. You're asking the right questions. We've been getting away with a lousy knowledge base for years but the party is over. The specialty is finally waking up to the stark reality that if there aren't some good quality studies we might be EBM'd out of existence. It is not enough for putative experts to make pronouncements any more.

Unfortunately studies take a long time to do and in the meantime we just go to meetings and listen to lectures based on dubious science and then swap recipes based on experience. In that sense pain management is at about the level of medicine in general 100 years ago, when there was a transition from anecdotal medicine to an emphasis on science. We are still transitioning.

It's a very young specialty and so we have to evolve extremely fast to catch up to some our brethren in other specialties. What they did over a couple of centuries we have had to compress into a couple of decades. If you look at the medical literature from 100 or 150 years ago you'll see an amazing mirror of the present in terms of the entire process of thinking, debate and research.

 

[radslooking]

Well your heart is in the right place, as is your brain. You're asking the right questions. We've been getting away with a lousy knowledge base for years but the party is over. The specialty is finally waking up to the stark reality that if there aren't some good quality studies we might be EBM'd out of existence. It is not enough for putative experts to make pronouncements any more.

Unfortunately studies take a long time to do and in the meantime we just go to meetings and listen to lectures based on dubious science and then swap recipes based on experience. In that sense pain management is at about the level of medicine in general 100 years ago, when there was a transition from anecdotal medicine to an emphasis on science. We are still transitioning.

It's a very young specialty and so we have to evolve extremely fast to catch up to some our brethren in other specialties. What they did over a couple of centuries we have had to compress into a couple of decades. If you look at the medical literature from 100 or 150 years ago you'll see an amazing mirror of the present in terms of the entire process of thinking, debate and research.

thanks gorbach. good luck to you all. sorry if i ruffled some feathers. i know you are dealing with a difficult population of patients and using your best clinical expertise in the absence of perfect information, which is difficult to come by. take care.

 

[mille125]

do you actually perform these procedures or are you just quoting the literature? are you in training?

 

[mille125]

There is actually virtualy no correlation between what a facet joint looks like on radiographic studies, and its responsiveness to therapeutic modalities (analagous to discs on MRI)

i dont dispute this.....i was implying that the discussed procedures are used to alleviate facet mediated pain...facet OA on an image is not an indication...

 

[PMR 4 MSK]

There is actually virtualy no correlation between what a facet joint looks like on radiographic studies, and its responsiveness to therapeutic modalities (analagous to discs on MRI)

Except for SPECT possibly

 

[lobelsteve]

Except for SPECT possibly

And fat saturated MRI (Fenton and Cervionke 2008 Pain Medicine)

 

[Mister Mxyzptlk]

"fat saturated MRI" sounds so unhealthy. They could at least make it "chocolate-saturated MRI".