MBB and RFAs

[deleted875186]

New fellow. Would like to know what other people do for MBBs and moving on to RFAs for lumbar and cervical.

One block, two blocks? What do you use with your blocks, local plus steroid? How much pain relief and for how long are you looking for to predict success with RFA? Anyone ever just go straight to RFA?

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[cowboydoc]

New fellow. Would like to know what other people do for MBBs and moving on to RFAs for lumbar and cervical.

One block, two blocks? What do you use with your blocks, local plus steroid? How much pain relief and for how long are you looking for to predict success with RFA? Anyone ever just go straight to RFA?

This is mostly dictated by insurance. Medicare changed their guidelines in 2016, and most private insurances have followed suit, requiring 2 diagnostic blocks.

I will do one diagnostic block if clear results and second block is not required by insurance. I cannot imagine any insurance would allow you to go straight to RFA. You could make the argument to do this for a cash paying patient.

 

[Laryngospasm]

They should be teaching you theses things. No steroid. Insurances will deny RFA.

 

[Espn123]

How far apart do you all separate mbb 1 from mbb 2, and RFA L from RFA R.

Is this informed by a 10 day global for all these procedures or can you do them closer together?

thanks in advance

 

[lonelobo]

Could do one day apart, global would not pertain to what you are asking

 

[deleted875186]

They should be teaching you theses things. No steroid. Insurances will deny RFA.

Why no steroid?

 

[painfree23]

Why no steroid?

better question: why?

 

[buddababa]

Why no steroid?

try to read guidelines and insurance/payer explanations. Why aren't they teaching you this in fellowship?

 

[soccrwz]

Alot of this is dictated by insurance; you should be trying to learn CPT and ICD coding in fellowship; and look up LCD like actually read them; most require two, >80% relief documented on a follow up, some will let you document it via telephone, or >50-60% relief with documented improvement with specific ADLs. Some insurance will let you do two levels only, some will let you do 3 levels BL; Trad medicare is reRFA every 12 months, some are 6 months with commericial or adv plans. Make good friends with your coder. Steroid is not allowed for most insurances. If you do IA facets you will likely be blocked from RFA by many insurances. Thoracic and cervical you may have to pick; Lumbar or sacral you may have to choose between two. The things you don't learn in fellowship but should have, will be a rapid learning process your first year out. Listen to the sage wisdom on this board, it was hard earned

 

[deleted993114]

Why no steroid?

1. There is no point- you are looking for the effect of local anesthetic on the nerves you plan to ablate.
2. Steroids may give a systemic effect which will render the test blocks useless
3. intravascular particulate steroid, if entering a radicular artery or the vertebral will result in quadriplegia or death
4. there is no evidence whatsoever for intra-articular cervical facet injections nor steroid to medial branch nerves.
5. the insurance company will deny the rf if test blocks are performed in this manner.

This issue brings up one of my pet peeves- the academic departments, as they are often inbred and do not do as many procedures as private practice, are not training fellows adequately. The quality of those coming out of training programs has had a linear decline over time, which is a direct reflection of those training them. It is a case of "one upmanship" at universities as to who can be the most conservative, not the most helpful. This often results in university programs doing absolutely nothing for a patient and being damn proud of it.

The blind leading the blind.

 

[Espn123]

1. There is no point- you are looking for the effect of local anesthetic on the nerves you plan to ablate.
2. Steroids may give a systemic effect which will render the test blocks useless
3. intravascular particulate steroid, if entering a radicular artery or the vertebral will result in quadriplegia or death
4. there is no evidence whatsoever for intra-articular cervical facet injections nor steroid to medial branch nerves.
5. the insurance company will deny the rf if test blocks are performed in this manner.

This issue brings up one of my pet peeves- the academic departments, as they are often inbred and do not do as many procedures as private practice, are not training fellows adequately. The quality of those coming out of training programs has had a linear decline over time, which is a direct reflection of those training them. It is a case of "one upmanship" at universities as to who can be the most conservative, not the most helpful. This often results in university programs doing absolutely nothing for a patient and being damn proud of it.

The blind leading the blind.

100% truth. Not every case, but an accurate general trend