NJPAIN

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To make long story short:
56 year old with axial LBP worse in AM, will standing and with extension. MRI with diffuse "severe disc degeneration. Has bilateral L3 to sacrum MBB with 0.5% bupivacaine and has > 80% relief for what he describes as a day. Confirmatory block done with 2% lidocaine and reports no relief. Of note, due to insurance limitations procedure done in hospital. Anesthesiologist snows patient with propofol and when I go to examine him he is out cold. As it happens he is discharged via wheelchair 2 hours latter and I do not get to see him until today when he reports no relief at all on the day of the procedure.

Aside for initial procedure being a false positive, is it reasonable to postulate that his PACU stay outlived the LA duration or am I just dreaming?
 

No Pain All gain

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To make long story short:
56 year old with axial LBP worse in AM, will standing and with extension. MRI with diffuse "severe disc degeneration. Has bilateral L3 to sacrum MBB with 0.5% bupivacaine and has > 80% relief for what he describes as a day. Confirmatory block done with 2% lidocaine and reports no relief. Of note, due to insurance limitations procedure done in hospital. Anesthesiologist snows patient with propofol and when I go to examine him he is out cold. As it happens he is discharged via wheelchair 2 hours latter and I do not get to see him until today when he reports no relief at all on the day of the procedure.

Aside for initial procedure being a false positive, is it reasonable to postulate that his PACU stay outlived the LA duration or am I just dreaming?
Why would you do the second block with lido and not bupi?


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Dr. Ice

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To make long story short:
56 year old with axial LBP worse in AM, will standing and with extension. MRI with diffuse "severe disc degeneration. Has bilateral L3 to sacrum MBB with 0.5% bupivacaine and has > 80% relief for what he describes as a day. Confirmatory block done with 2% lidocaine and reports no relief. Of note, due to insurance limitations procedure done in hospital. Anesthesiologist snows patient with propofol and when I go to examine him he is out cold. As it happens he is discharged via wheelchair 2 hours latter and I do not get to see him until today when he reports no relief at all on the day of the procedure.

Aside for initial procedure being a false positive, is it reasonable to postulate that his PACU stay outlived the LA duration or am I just dreaming?
Did the patient really need sedation for the mbb? Would you have not been able to do it at the hospital unless they got the sedation? I used to work in a hospital type setting where the anesthesia staff told physicians that they didn't want to be involved if something happened to the patients if they weren't directly involved with patient care from
the onset, i.e. providing sedation for the patients. Where I am as I have mentioned before, we are told that there is no insurance coverage for "pain management procedures." So if people want it they can either pay for it or they don't get it and I make a point to say that a procedure like mbb which is meant to be diagnostic won't be reliable if they are sedated and still feel the effects of the sedation for longer than the diagnostic anesthetic block. If they don't like that answer they can go somewhere else.
 
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NJPAIN

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Why would you do the second block with lido and not bupi?


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I normally do. However YOU PEOPLE (LOL) made me feel like I should be using two anesthetics with different duration to be more scientific.


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lobelsteve

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Sedation contraindicated for dx block. And anes got paid more than you.

0/2.

No soup for you.
 
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NJPAIN

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Did the patient really need sedation for the mbb? Would you have not been able to do it at the hospital unless they got the sedation? I used to work in a hospital type setting where the anesthesia staff told physicians that they didn't want to be involved if something happened to the patients if they weren't directly involved with patient care from
the onset, i.e. providing sedation for the patients. Where I am as I have mentioned before, we are told that there is no insurance coverage for "pain management procedures." So if people want it they can either pay for it or they don't get it and I make a point to say that a procedure like mbb which is meant to be diagnostic won't be reliable if they are sedated and still feel the effects of the sedation for longer than the diagnostic anesthetic block. If they don't like that answer they can go somewhere else.
I could certainly do it without sedation and would prefer to. I have never had my arm twisted by the anesthesia group although their pain guys give sedation for everything and that is what I compete against. However I sometimes am too exhausted with life to beat my head against the wall and explain to patients why I want to do this under local even though all of their friends had it done "asleep" by Drs. , Y and Z.


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NJPAIN

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Sedation contraindicated for dx block. And anes got paid more than you.

0/2.

No soup for you.
STEVE
Please don't sugar coat things just to make me feel good.
I'll skip the Muligatawny soup


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Ducttape

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Sedation contraindicated for dx block. And anes got paid more than you.

0/2.

No soup for you.
depends on LCD, but i dont believe that any of my local insurance carriers pay for the anesthesia services for an MBB. ive been quoted guidelines from the local LCD, Evicore:

"When performing facet joint injections/medial branch blocks, the use of intravenous sedation may be grounds to negate the results of a diagnostic block and; therefore, should be reserved for only those individuals with severe anxiety issues. Due to the risk of potential complications, the routine use of intravenous sedation is considered not medically necessary." (bolded by Evicore, not me)



now, technically, you could go back and ask him "did you have any pain before you left the hospital? cause if you had no pain, then that means the injection was completely effective, but sadly wore off as you left. so RFA!"
 
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Tapspatellas

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To make long story short:
56 year old with axial LBP worse in AM, will standing and with extension. MRI with diffuse "severe disc degeneration. Has bilateral L3 to sacrum MBB with 0.5% bupivacaine and has > 80% relief for what he describes as a day. Confirmatory block done with 2% lidocaine and reports no relief. Of note, due to insurance limitations procedure done in hospital. Anesthesiologist snows patient with propofol and when I go to examine him he is out cold. As it happens he is discharged via wheelchair 2 hours latter and I do not get to see him until today when he reports no relief at all on the day of the procedure.

Aside for initial procedure being a false positive, is it reasonable to postulate that his PACU stay outlived the LA duration or am I just dreaming?
Yes, definitely effect may be gone at 2 hours. If they aren't 80% when I come sauntering up to them immediately post-op, it is failed. Many are worn off at or close to 2 hours on diary review at follow up. Standard is 2 different locals, so I think you're doing the right thing.

I would call it an inconclusive trial and try to figure out a way to spin it to get a repeat approved again and make sure no deep sedation. May also be that it isn't facet pain and the first was placebo, or it hit an unintended target. Shoot the studies prove that not all respond to RFN even with 2 positive blocks, so not moving forward after the second block should be an occurrence at times.
 

lobelsteve

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STEVE
Please don't sugar coat things just to make me feel good.
I'll skip the Muligatawny soup


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:poke: Hello.......Newman.
 

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I don't know what the best solution to the specific situation above is.... 3rd block? Go to rf anyway understanding that it may fail? No further intervention offered as axial pain?


Though, for the rare patient who "needs" sedation for mbb - I use bupivicaine on that block to make certain it outlasts the initial sedation. I also request no opioid in the anesthesia.


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Ducttape

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no one cares about my opinion, but here it is anyways - any patient that needs anything more than reassurance (or possibly a low dose benzo) for a median branch block is not a good candidate for RFA and has already declared that the likelihood of failure with RFA is high.
 

SSdoc33

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no one cares about my opinion, but here it is anyways - any patient that needs anything more than reassurance (or possibly a low dose benzo) for a median branch block is not a good candidate for RFA and has already declared that the likelihood of failure with RFA is high.
yup.

at this point, unless you are a newbie, you really should know which patients are going to respond well to a MBB. im not 100% on this, but it is rare that i offer a patient a MBB that doesnt go on to RF.

you should know the profile: at least 50, facet arthropathy on imaging, pain with standing. younger, crazier, ugly looking discs usually dont respond.

that being said, i will massage the MBB results to get an RF approved if i think it will help the patient. evicore, cigna, all those a-holes can go S a D
 
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lobelsteve

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yup.

at this point, unless you are a newbie, you really should know which patients are going to respond well to a MBB. im not 100% on this, but it is rare that i offer a patient a MBB that doesnt go on to RF.

you should know the profile: at least 50, facet arthropathy on imaging, pain with standing. younger, crazier, ugly looking discs usually dont respond.

that being said, i will massage the MBB results to get an RF approved if i think it will help the patient. evicore, cigna, all those a-holes can go S a D
S a D?

Scale a dragon?

 
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NJPAIN

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In the end another lesson learned in life after many years in practice. I need to remind myself to practice what I preach - mainly - don't let the tail wag the dog. That's sometimes very difficult in a day and age when patients want to dictate treatment. Had an obese PITA lady who I am getting ready for a stim trial argue with me for 30 minutes over the fact that she wanted to be asleep for the trial and implant.
Exhausting.
 

lobelsteve

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In the end another lesson learned in life after many years in practice. I need to remind myself to practice what I preach - mainly - don't let the tail wag the dog. That's sometimes very difficult in a day and age when patients want to dictate treatment. Had an obese PITA lady who I am getting ready for a stim trial argue with me for 30 minutes over the fact that she wanted to be asleep for the trial and implant.
Exhausting.
Send her to me for explant in 2018. I collect batteries. Could use another 4 port BS...
 
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NJPAIN

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We had that conversation yesterday after discussing the failed confirmatory block.


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algosdoc

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Ultrashort acting agents such as propofol, methohexital, or remifentanil do not affect the outcome of MBB. Midazolam and fentanyl do appear to affect the outcome of the MBB. That being said, 25ga quincke needles are not painful for most patients having MBB, even without local in the skin. If they are exquisitely painful, on insertion and the patient cannot tolerate the needle placement, then you have your answer- RF will not be effective.
 
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NJPAIN

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Send her to me for explant in 2018. I collect batteries. Could use another 4 port BS...
I never use BS. Going to be a NEVRO trial and then off to NS if she needs an implant. Too fat and too much of a PITA for me to deal with an implant on her. She is very high maintenance. Opioids for 15 years by a doc who "retired". So high maintenance that the chief spine surgeon at HSS who did her lami 20 years ago didn't offer a fusion when her back pain worsened postop. He fused everyone in those days. Instead he sent her to someone for COT, for "nerve damage"to keep her happy.


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BobBarker

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I'm talking about the lady who wanted to be asleep for trial
 

lobelsteve

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I never use BS. Going to be a NEVRO trial and then off to NS if she needs an implant. Too fat and too much of a PITA for me to deal with an implant on her. She is very high maintenance. Opioids for 15 years by a doc who "retired". So high maintenance that the chief spine surgeon at HSS who did her lami 20 years ago didn't offer a fusion when her back pain worsened postop. He fused everyone in those days. Instead he sent her to someone for COT, for "nerve damage"to keep her happy.


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Why would you waste your time trialing her?
 
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