MBB/ IA Facet inj without MRI

[lovebailey2001]

When a pt. present with neck/ back (axial) pain, para sp. tenderness and other usual features of Facet involvement, I always face the dilemma of doing Diag. injections first or going for MRI to ruleout other ominous finndings! What are you guys doing.. plz chime in...

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[pmrmd]

That isn't a dilemma. I do facet blocks everyday without MRI. Common things are common.

 

[lobelsteve]

MRI not indicated if no red flags.

Facets are axial pain. No issue.

 

[Taus]

X-ray first needed I would imagine? Though who doesn't have at least X-rays by the time you're going interventional....

 

[SSdoc33]

i always have an MRI before i will do any spinal interventions.

am i wasting money? yes

am i protecting myself from a legal standpoint? yes

have i found tumors, pars defects, and annular tears that i otherwise may not have? yes

 

[Mister Mxyzptlk]

I don't do any imaging if I suspect mechanical pain. If they don't respond to treatment I'll get imaging.

I've lost patients that way: "He wanted to do a procedure on me without even getting an x-ray!"

 

[PinchandBurn]

i always have an MRI before i will do any spinal interventions.

am i wasting money? yes

am i protecting myself from a legal standpoint? yes

have i found tumors, pars defects, and annular tears that i otherwise may not have? yes

for once SSDOC and I agree on everything

 

[bedrock]

i always have an mri before i will do any spinal interventions.

Am i wasting money? Yes

am i protecting myself from a legal standpoint? Yes

have i found tumors, pars defects, and annular tears that i otherwise may not have? Yes

+1

 

[pmrmd]

have i found tumors, pars defects, and annular tears that i otherwise may not have? yes

if they are relevant pain generators, you would find them by doing the MRI if they don't improve as you would expect. you will see the pars defect and often the tumor on the fluoroscope anyway.

 

[bedrock]

if they are relevant pain generators, you would find them by doing the MRI if they don't improve as you would expect. you will see the pars defect and often the tumor on the fluoroscope anyway.

First time I ever skipped ordering MRI/CT for a patient before a spine intervention, they didn't get better after two injections, so after 8 weeks, I saw the CT results of a moderately large L5-S1 tumor, completely missed on plain films by everyone. Pt died 7 months later.

Subsequently, every patient now gets MRI/CT before spine interventions.

 

[SIIMS]

I almost always get advanced imaging prior to interventional procedures for most of the reasons listed above....

Also if I see gapped facets with fluid in them or they light up on STIR I will start with intra-articular injections, if they are gnarly looking and severely arthrosed on imaging but do not have inflammation I skip the steroid song and dance and do mbb's to RF.

However, I can certainly understand both sides of this debate

 

[knoxdoc]

I had a lady in her mid 60s show up 6 months ago with LBP localized to the left L5/1 facet. Positive stork, positive tenderness over the facet, no radicular symptoms. No F/C/sweats/wt loss, but had been having some nausea recently (no CP). Per my usual protocol I got an MRI (although I debated skipping it because this was so straight-forward).

The MRI lit up an infection at the left L5/S1 facet joint. She had not had any spine interventions, no trauma, no skin infections. Likely had a UTI a few weeks ago.

Had I done that injection, I would have OWNED that infection.

EVERYONE gets an MRI before I do an axial injection.

 

[drusso]

I had a lady in her mid 60s show up 6 months ago with LBP localized to the left L5/1 facet. Positive stork, positive tenderness over the facet, no radicular symptoms. No F/C/sweats/wt loss, but had been having some nausea recently (no CP). Per my usual protocol I got an MRI (although I debated skipping it because this was so straight-forward).

The MRI lit up an infection at the left L5/S1 facet joint. She had not had any spine interventions, no trauma, no skin infections. Likely had a UTI a few weeks ago.

Had I done that injection, I would have OWNED that infection.

EVERYONE gets an MRI before I do an axial injection.

Plus, our Medicare FI requires imaging evidence of spondylosis prior to MBB/RF. I guess an xray would suffice, but MRI gives so much more info.

 

[clubdeac]

What do you guys make of "empty facets"? Our radiologist will occasionally report this as will our neurosurgeons. Does it just mean a diastatic facet? And does it correlate with pain?

 

[Ducttape]

I just love the science on this thread... To wit, "I had one case of something out of what, 50000 patients, so now I always order MRIs"...


God forbid if some of us sees the patient with ribose-5-phosphate isomerase deficiency, and decides to institute genetic testing on all new consults, instead of their brain....

 

[clubdeac]

I just love the science on this thread... To wit, "I had one case of something out of what, 50000 patients, so now I always order MRIs"...


God forbid if some of us sees the patient with ribose-5-phosphate isomerase deficiency, and decides to institute genetic testing on all new consults, instead of their brain....

But Ducttape, what are you gonna do when you're on the witness stand and the attorney is hounding you with questions like, "but doctor wasn't infx in your differential?", "didn't his age, health etc make you think infx/tumor could be a possibility?", "do you frequently not work patients up before injecting?", "How did you know what you were treating without prior imaging?", "Dr XYZ states the standard of care is to only inject after obtaining appropriate imaging. Why did you not do this?"..... and on and on and on

 

[Ducttape]

But Ducttape, what are you gonna do when you're on the witness stand and the attorney is hounding you with questions like, "but doctor wasn't infx in your differential?", "didn't his age, health etc make you think infx/tumor could be a possibility?", "do you frequently not work patients up before injecting?", "How did you know what you were treating without prior imaging?", "Dr XYZ states the standard of care is to only inject after obtaining appropriate imaging. Why did you not do this?"..... and on and on and on

One, there is no consensus, from the above comments. Show me where it is standard of care to do MRIs on all patients.

Two, if it is your sound clinical judgement that you feel a necessity to do imaging on any patient prior to an injection, a CYA $1200 test, so be it.

Just don't base your decision on essentially a case report, a zebra, an "x-file"....

 

[emd123]

My feeling is that if a patient comes to me as a Pain specialists, with chronic pain for years (usually) it's reasonable and helpful if they've had MRI imaging in the past year or two. If the imaging has been fairly recent and their pain hasn't changed much, I don't see any major reason to get a new MRI before an injection. If they've never had MRI imaging, or if there are red flags I want an MRI. If its super clear cut, I may do the injection anyways, and not necessarily wait for the MRI before injecting (if the patient is comfortable with that). However, chronic pain being what it is, at some point the pain will come back and there will be a need for imaging, so I order it.

I think it makes good sense to have quality imaging on all of my patients in the past year or two. I think that's reasonable.

Do I think every low back strain 3 days old in the ER or PCP office needs an MRI? No. But by the time they get to us, they usually deserve an MRI.

I agree that med-mal lawyers are not going to cut any of us any slack for saving money for "the system." They see a weakness in your armor and they go for blood.

 

[SSdoc33]

i dont care that the MRIs cost $1200. it is my personal livelihood, and my family's, on the line. until a lawyer cant sue me for nonsense, i will continue to practice defensively. lets think: cost blue cross some extra money, or risk my son's college fund? not much of a decision in my mind. if you do enough injections -- which most of us do, you will invariably get burned somewhere along the way. the patient probably wont sue you for it....... but are you willing to take that risk?

 

[stim4u]

maybe obama's' pilot programs' addressing defensive medicine costs and medical malpractice cost will pan out and shed some light on the subject someday.... probably not. Since radicals like Nader don't believe 20milliion dollar lawsuits exist.

 

[knoxdoc]

One, there is no consensus, from the above comments. Show me where it is standard of care to do MRIs on all patients.

Two, if it is your sound clinical judgement that you feel a necessity to do imaging on any patient prior to an injection, a CYA $1200 test, so be it.

Just don't base your decision on essentially a case report, a zebra, an "x-file"....

True, no consensus. But this is not about patient care, this is purely about CYA so I'm not advocating for guidelines. I really don't care if I'm the only one ordering MRIs before procedures. My point is, don't assume that axial pain is always benign. Anyone who wants to let their ass hang in the breeze is welcome to do so - you will probably never have any bad outcomes.

 

[clubdeac]

Duct... I was pretty much just joking. I think in most cases it's reasonable to not get an MRI before facet injections provided there are no red flags and it looks like a duck, smells like a duck, etc. However, I think the state of malpractice, frivolous lawsuits and entitled lawyers and patients in our society is disgusting and the tort system needs an overhaul. If I increase healthcare costs to CMA in this litigious environment, then so be it. Obama needs to get a clue and make real, beneficial changes, not just pander to his lawyer lobbyists

 

[Gauss]

patients are happier/more satisfied with more imaging and studies. lawyers are happier with more imaging and studies. Ergo, by ordering everything under the sun I'm happier.
Satisfaction and cost of healthcare are inversely proportional and we are somehow tasked with resolving that equation

 

[Dr. Ice]

patients are happier/more satisfied with more imaging and studies. Lawyers are happier with more imaging and studies. Ergo, by ordering everything under the sun i'm happier.
Satisfaction and cost of healthcare are inversely proportional and we are somehow tasked with resolving that equation

1+

 

[Ducttape]

Duct... I was pretty much just joking. I think in most cases it's reasonable to not get an MRI before facet injections provided there are no red flags and it looks like a duck, smells like a duck, etc. However, I think the state of malpractice, frivolous lawsuits and entitled lawyers and patients in our society is disgusting and the tort system needs an overhaul. If I increase healthcare costs to CMA in this litigious environment, then so be it. Obama needs to get a clue and make real, beneficial changes, not just pander to his lawyer lobbyists

i think we had this discussion before.

that being said, if it is your practice pattern, and you feel that it is important, im not going to change that.

but...

"Dear Patient, before your appointment with Dr. X, because he has seen a couple of zebras throughout his career, we require you have the following testing done before your initial evaluation. Please ensure the following tests are performed prior to calling to schedule your appointment:

MRI of the affected area
CT of the affected area
PET scan of the affected area
3 phase bone scan
EMG/NCV
ESR
CRP
Vitamin D and B level
Thyroid function testing
ANA
RF
VDRL
Alk Phos
Basic metabolic profile
liver function testing
Lyme titer
HgA1C
Arsenic levels
Serum and Urine protein electrophoresis
Serum and/or urine vanilmandelic acid levels
LC/GS Urine test
Caffeine-halothane contracture testing
Muscle Biopsy
HLA-B27 testing
Genetic testing for Opioid resistance
List of misdemeanor/felony arrests
NRA card number
For those with Medicaid/Medicare cards, please Click Here, and wait for instructions."

edit: i know im forgetting a few dozen others... sorry...

 

[emd123]

i think we had this discussion before.

that being said, if it is your practice pattern, and you feel that it is important, im not going to change that.

but...

"Dear Patient, before your appointment with Dr. X, because he has seen a couple of zebras throughout his career, we require you have the following testing done before your initial evaluation. Please ensure the following tests are performed prior to calling to schedule your appointment:

MRI of the affected area
CT of the affected area
PET scan of the affected area
3 phase bone scan
EMG/NCV
ESR
CRP
Vitamin D and B level
Thyroid function testing
ANA
RF
VDRL
Alk Phos
Basic metabolic profile
liver function testing
Lyme titer
HgA1C
Arsenic levels
Serum and Urine protein electrophoresis
Serum and/or urine vanilmandelic acid levels
LC/GS Urine test
Caffeine-halothane contracture testing
Muscle Biopsy
HLA-B27 testing
Genetic testing for Opioid resistance
List of misdemeanor/felony arrests
NRA card number
For those with Medicaid/Medicare cards, please Click Here, and wait for instructions."

edit: i know im forgetting a few dozen others... sorry...

Give me the MRI, and you can keep all the rest.


Edit: just noticed "list of misdemeanor and felony arrests". Since that's free, online and public in my area, I'll take that one, too. If a prospective patient has a past social history involving drug sales, I need to know that. You be amazed at how much of that you'll find, if you had access to it. It's negligent that the DEA does not give all Pain MDs access to this.

 

[ampaphb]

Every patient has an MRI before I do axial injections. Issues like tumors and infections may be rare, but cysts are common, and change my approach.

 

[emd123]

but cysts are common, and change my approach.

How so?

 

[clubdeac]

I had a 76 y/o AAM male on hemodialysis wheeled into my office by is wife who was about 30 yrs his younger. He was crying and screaming asking that somebody help him. "Please doctor help me. Please help me". I couldn't get him out of the wheel chair but did the best exam I could. He was markedly tender over his spinous processes. He had a CT from the ER which was unremarkable. Couldn't get an MRI bc of a pacemaker. I thought he was an over the top drama queen and set him up for an epidural in the next few days. Fortunately for some reason I got an ESR. Low and behold, it was in the 90s. Ended up cancelling the epidural and getting a CT w/contrast which showed a big 'ole epidural abscess. And that's why you get imaging

 

[SSdoc33]

I had a 76 y/o AAM male on hemodialysis wheeled into my office by is wife who was about 30 yrs his younger. He was crying and screaming asking that somebody help him. "Please doctor help me. Please help me". I couldn't get him out of the wheel chair but did the best exam I could. He was markedly tender over his spinous processes. He had a CT from the ER which was unremarkable. Couldn't get an MRI bc of a pacemaker. I thought he was an over the top drama queen and set him up for an epidural in the next few days. Fortunately for some reason I got an ESR. Low and behold, it was in the 90s. Ended up cancelling the epidural and getting a CT w/contrast which showed a big 'ole epidural abscess. And that's why you get imaging

Agree with getting imaging, but your example only proves why you should get a sed rate

 

[pmrmd]

I had a 76 y/o AAM male on hemodialysis wheeled into my office by is wife who was about 30 yrs his younger. He was crying and screaming asking that somebody help him. "Please doctor help me. Please help me". I couldn't get him out of the wheel chair but did the best exam I could. He was markedly tender over his spinous processes. He had a CT from the ER which was unremarkable. Couldn't get an MRI bc of a pacemaker. I thought he was an over the top drama queen and set him up for an epidural in the next few days. Fortunately for some reason I got an ESR. Low and behold, it was in the 90s. Ended up cancelling the epidural and getting a CT w/contrast which showed a big 'ole epidural abscess. And that's why you get imaging

We aren't talking about people in that kind of shape. The topic is FACET BLOCK or FACET INJECTION without imaging. Couldn't get out of the wheelchair because he was so painful and screaming out? That doesn't sound like a facet to me. Someone walking in who has a mild/moderate pain with side bend or ipsilateral rotation does. Nice anecdote, but not germane to the topic and you really made no point here.

 

[lobelsteve]

We aren't talking about people in that kind of shape. The topic is FACET BLOCK or FACET INJECTION without imaging. Couldn't get out of the wheelchair because he was so painful and screaming out? That doesn't sound like a facet to me. Someone walking in who has a mild/moderate pain with side bend or ipsilateral rotation does. Nice anecdote, but not germane to the topic and you really made no point here.

+1.

No different than a guy coming in with cervical facets and a GSW to the neck.

And your guy had imaging.

The hard part is knowing who has low pain thresholds. Not easy at the first visit. I have folks who never complain, but they call saying " I broke T9" with tears streaming. Other folks are ayayayayay, my FMS is flaring....need more Zanaflex.

 

[Ducttape]

I had a 76 y/o AAM male on hemodialysis wheeled into my office by is wife who was about 30 yrs his younger. He was crying and screaming asking that somebody help him. "Please doctor help me. Please help me". I couldn't get him out of the wheel chair but did the best exam I could. He was markedly tender over his spinous processes. He had a CT from the ER which was unremarkable. Couldn't get an MRI bc of a pacemaker. I thought he was an over the top drama queen and set him up for an epidural in the next few days. Fortunately for some reason I got an ESR. Low and behold, it was in the 90s. Ended up cancelling the epidural and getting a CT w/contrast which showed a big 'ole epidural abscess. And that's why you get imaging

you had imaging.

you did an exam that was not consistent with just facet related arthropathy.

you suspected a diagnosis and an uncommon one at that, possibly 0.2-1.2 out of 10,000 hospital admissions.


the caveat to take from this is either 1. everyone must get either an MRI scan or CT with contrast, regardless of the clinical scenario or 2. i used my diagnostic acumen to determine that the CT alone was inadequate, and more imaging was necessary.

you obviously chose 1. i would opt for 2.

 

[clubdeac]

Ok ok ok whatever.... it was a good story. After typing it I realized it wasn't particularly relavant to the situation at hand. But I typed it and figured I would post rather than waste my efforts.

 

[lobelsteve]

Ok ok ok whatever.... it was a good story. After typing it I realized it wasn't particularly relavant to the situation at hand. But I typed it and figured I would post rather than waste my efforts.

It was a good story.

I was once accused of causing L3 osteodiscitis after procedure.

Bx at hospital showed metastatic cancer.
Would rather have been an infection. Glad I didn't cause her cancer.

 

[Ducttape]

agree, it was a good story.

my best story was when i was examining someone for crabs, couldnt find a thing... until i saw it crawling over my hand.


no, wait, that was one of my most disgusting stories...

 

[SSdoc33]

agree, it was a good story.

my best story was when i was examining someone for crabs, couldnt find a thing... until i saw it crawling over my hand.


no, wait, that was one of my most disgusting stories...

What you do on your free time is your business. Let's stick to medical stories, please.

 

[Ducttape]

What you do on your free time is your business. Let's stick to medical stories, please.

That is one of many ED stories, not to be confused with stories that cause ED....