Lumbar MBB with AP approach?

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CarabinerSD

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I've been doing Lumbar MBBs using ipsi-lateral oblique (25 degrees) for L4 and L5 levels, switching to AP view for sacral ala. For the heavier patients sometimes I won't be able to reach the groove without much effort. Thinking about doing the entire thing in AP approach, but placing L4 and L5 levels slightly lateral of pedicle first and driving out of plane towards the groove. I understand facet hypertrophy might get in the way but I'm very comfortable driving out of plane. Anyone doing this and efficacy vs oblique?
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I oblique 10 to the left, then once placed I oblique 10 to the right and they to get my target points on the right lined up, plus the needle tips on the left to verify position from a second angle. Even if they looked great in the first view the second does often show them to be a little too shallow or too inferior.
 
If you are using contrast dye and the spread looks good along the medial branch nerve you should be fine
 
I oblique 10-15 for everyone and then come back to AP for the L5 DR only if the crest is in the way.
 
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Fox800 said:
Not doing contrast for MBBs or RFA.

Can you do all 3 targets in the oblique view? Skip the AP?
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I only use contrast for MBB's now that our medicare LCD requires it. started about 4 years ago. double check yours to make sure they also dont require that
 
CarabinerSD said:
I've been doing Lumbar MBBs using ipsi-lateral oblique (25 degrees) for L4 and L5 levels, switching to AP view for sacral ala. For the heavier patients sometimes I won't be able to reach the groove without much effort. Thinking about doing the entire thing in AP approach, but placing L4 and L5 levels slightly lateral of pedicle first and driving out of plane towards the groove. I understand facet hypertrophy might get in the way but I'm very comfortable driving out of plane. Anyone doing this and efficacy vs oblique?
Click to expand...
I will often do this procedure exactly in this fashion.
 
Multimodal said:
I only use contrast for MBB's now that our medicare LCD requires it. started about 4 years ago. double check yours to make sure they also dont require that
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How are you looking this up? When I search for MBB LCD for example, I don't get 20 different results for different states. I get one result.
 
look up the LCD for where you live. you are looking up the Medicare guidelines. you need to go to the specific LCD.

if you are not sure, look at a recent denial or approval form from a patient's insurer. for example, in my area of NY, it is mostly eviCore.


in one of my patients approval form, this line:
Excellus BCBS contracts with eviCore healthcare MSI, LLC d/b/a eviCore healthcare, an independent entity, to determine whether certain health care services are medically necessary and appropriate for the plan's members.
Click to expand...


in the eviCore (and Cigna) LCD, no contrast is required.
 
cowboydoc said:
How many needles do you go through for a tpi? 6 needles for skin wheals before 6 RF cannulae?
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For whatever reason the nurses are fine with me doing skin wheals with one needle. I got reported the first week in my ASC when I was doing three spinals for bl mbb and three RF needles for bl rfa. TPI are done in clinic without nurses in the room.
 
What kind of RF needles are you using? Please, please tell me they are having you waste 3 $35 venom needles on every ablation. Then you can have them pull how many facet RF’s they are doing and present how much money they have wasted over the past few years. 😂
 
BobBarker said:
What kind of RF needles are you using? Please, please tell me they are having you waste 3 $35 venom needles on every ablation. Then you can have them pull how many facet RF’s they are doing and present how much money they have wasted over the past few years. 😂
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I get away with three needles for my RF, but I use disposable probes because they don’t want to deal with the paperwork of using an autoclave.
 
lobelsteve said:
I get away with three needles for my RF, but I use disposable probes because they don’t want to deal with the paperwork of using an autoclave.
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I’d bet you wouldn’t use the disposables if the probe costs were coming out of your pocket. Only paperwork on autoclave is the maintenance log
 
Are they billing as office or HOPD?
There isn’t enough money to pay for the probes if billing as an office.
 
BobBarker said:
Are they billing as office or HOPD?
There isn’t enough money to pay for the probes if billing as an office.
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I can’t see anywhere outside HOPD using disposables. You are working basically for free and costing your practice money if done that way in an office when you subtract out all the other overhead associated
 
Correct. $350 minimum on rf specific and general procedure supplies per case.

$500 with venoms and not watching costs on the general supplies.
 
BobBarker said:
What kind of RF needles are you using? Please, please tell me they are having you waste 3 $35 venom needles on every ablation. Then you can have them pull how many facet RF’s they are doing and present how much money they have wasted over the past few years. 😂
Click to expand...
Yup venom
 
PMROralBoards said:
For whatever reason the nurses are fine with me doing skin wheals with one needle. I got reported the first week in my ASC when I was doing three spinals for bl mbb and three RF needles for bl rfa. TPI are done in clinic without nurses in the room.
Click to expand...
got reported... that's ridiculous. what a nonsensical ridiculous policy. Too many uneducated people running the show
 
Baron Samedi said:
When I was an intern on medicine night float I got reported by a nurse for refusing to trim a patient's toenails at 2am. I wish I was kidding.
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why do nurses go after physicians... it happens not infrequently
 
clubdeac said:
got reported... that's ridiculous. what a nonsensical ridiculous policy. Too many uneducated people running the show
Click to expand...
Also got reported for not wiping the top of just opened vials with an alcohol pad before drawing up meds. Just silly nursing things but what can you do. I think the ASC just has a giant stock of venom needles from a past pain doc who had left so it’s nbd right now. When they run out I’ll probably switch to regular ones and just do the typical two burns with 180* twist in between. I haven’t bought in yet so for me it doesn’t matter at this point.
 
Baron Samedi said:
When I was an intern on medicine night float I got reported by a nurse for refusing to trim a patient's toenails at 2am. I wish I was kidding.
Click to expand...

Somehow I made it through med school and residency without ever trimming a patients toenails.

Seems like the job of a nurse to me. Or a podiatry resident, but certainly not that of a medical doctor.
 
Had a diabetic wound foot clinic as part of our amputee rotations. Gross
 
I'll be curious to what you guys think of this, maybe I'm a prima donna. I work for a private practice ortho group and we own an ASC, but for whatever reason the ASC does not use the same EMR that we use (we have epic). When I'm doing procedures at the ASC, the flouro pics are PRITNED and then I have to collect them all and take them to an office staff member who scans them into our chart. I don't know if this is common but it seems insane that the files aren't digitally saved and uploaded (its 2025...)

I typically use three 25 gauge needles for MBB (unilateral or bilateral) because the thought of printing 6 individual pictures and scanning them in the chart seems so ridiculous to me. I've actually used 6 needles before to avoid being responsible for hundreds of printed pictures.

Anyone else living in the stone age or just me?
 
Scottie_Dog said:
I'll be curious to what you guys think of this, maybe I'm a prima donna. I work for a private practice ortho group and we own an ASC, but for whatever reason the ASC does not use the same EMR that we use (we have epic). When I'm doing procedures at the ASC, the flouro pics are PRITNED and then I have to collect them all and take them to an office staff member who scans them into our chart. I don't know if this is common but it seems insane that the files aren't digitally saved and uploaded (its 2025...)

I typically use three 25 gauge needles for MBB (unilateral or bilateral) because the thought of printing 6 individual pictures and scanning them in the chart seems so ridiculous to me. I've actually used 6 needles before to avoid being responsible for hundreds of printed pictures.

Anyone else living in the stone age or just me?
Click to expand...
Take pic with phone then upload?
I am on Novarad and going to Intellipacs. Auto loads to chart.
 
Scottie_Dog said:
I'll be curious to what you guys think of this, maybe I'm a prima donna. I work for a private practice ortho group and we own an ASC, but for whatever reason the ASC does not use the same EMR that we use (we have epic). When I'm doing procedures at the ASC, the flouro pics are PRITNED and then I have to collect them all and take them to an office staff member who scans them into our chart. I don't know if this is common but it seems insane that the files aren't digitally saved and uploaded (its 2025...)

I typically use three 25 gauge needles for MBB (unilateral or bilateral) because the thought of printing 6 individual pictures and scanning them in the chart seems so ridiculous to me. I've actually used 6 needles before to avoid being responsible for hundreds of printed pictures.

Anyone else living in the stone age or just me?
Click to expand...
My ASC is still on paper charts, but their (antiquated) c arm has a connection to upload directly to our PACS. surely that’s possible.
 
lobelsteve said:
Take pic with phone then upload?
I am on Novarad and going to Intellipacs. Auto loads to chart.
Click to expand...
I'm hoping in the near future we can get something to auto load the pictures to the chart. Not familiar with Novarad but I'll look into it. Honestly shocked my partner has been doing it this way for 10-15 years, the quality of the photos is often pretty poor after being printed and then scanned. I'll have to look in to a way to take pictures on my phone and upload them myself. More work for me but it's a liability issue.
 
PMROralBoards said:
Also got reported for not wiping the top of just opened vials with an alcohol pad before drawing up meds. Just silly nursing things but what can you do. I think the ASC just has a giant stock of venom needles from a past pain doc who had left so it’s nbd right now. When they run out I’ll probably switch to regular ones and just do the typical two burns with 180* twist in between. I haven’t bought in yet so for me it doesn’t matter at this point.
Click to expand...
the wiping off the top is from CDC guidelines - i believe the case taht prompted this was from Arizona?

Scottie_Dog said:
I'm hoping in the near future we can get something to auto load the pictures to the chart.
Click to expand...
there are a lot of PACS out there to choose from. a quick google search brought up this one (i cant verify its benefits - the heatlhcare system has a PACS that works with Epic):


www.medicai.io

PACS (Picture Archiving and Communication System): A Comprehensive Guide

Picture Archiving and Communication Systems (PACS) have revolutionized the field of radiology by enabling the storage, retrieval, management, and sharing of medical images digitally. This comprehensive guide will delve into the various aspects of PACS, including its definition, evolution, cost...
www.medicai.io www.medicai.io
 
With regard to wiping tops off at the ASC, that is the easiest thing to fix. Make the scrubs and nurses do it from now on. I’m sure they have 4-5 people in the room standing around doing very little.
 
so many ASC’s all have the same problems. Then the staff wanders why it failed and they are out of jobs. Look in the mirror…
 
If I am ever annoyed or aggravated with someone or something in my practice, I can just read this thread and realized how good I have it.
 
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