NASS Position paper and coverage policy recommendation on L/S ESIs

[ampaphb]

https://www.spine.org/Documents/PolicyPractice/CoverageRecommendations/LumbarEpiduralInjections.pdf

---

Members don't see this ad.

 

[nvrsumr]

More treatments "guidelines". Great. Yeah we all know ESIs don't work for axial back pain (except for the patients that is does). Obviously our NASS surgeon friends recommend we should never even try an ESI and go straight to fusion for axial back pain.

 

[lobelsteve]

More treatments "guidelines". Great. Yeah we all know ESIs don't work for axial back pain (except for the patients that is does). Obviously our NASS surgeon friends recommend we should never even try an ESI and go straight to fusion for axial back pain.

Neither fusion nor epidurals are recommended for axial LBP.

 

[Ducttape]

i think it is interesting that pregnant women and high level athletes are given exceptions.

does that mean that pregnancy is a high-level athletic activity?

 

[powermd]

i think it is interesting that pregnant women and high level athletes are given exceptions.

does that mean that pregnancy is a high-level athletic activity?

And anyone for whom ESI has "worked in the past".

I guess they get grandfathered in. If you haven't had an ESI yet and don't meet the criteria, you're out of luck. Makes a lot of sense!

 

[ampaphb]

Apparently, the concept of chemical sensitization also is too erudite for surgeons to fully grasp. Only radicular pain with imaging demonstrating nerve root impingement. Squished nerves are legit. Inflamed nerves? Nah.

 

[clubdeac]

Didn't read it but what about an annular tear with sensitization of the sinovertebral nerves? How does the surgeon propose we treat this if not with ESIs? PT, PT and more PT? I guess GRC blocks are an option but I'm sure they've never heard of this

 

[lobelsteve]

Apparently, the concept of chemical sensitization also is too erudite for surgeons to fully grasp. Only radicular pain with imaging demonstrating nerve root impingement. Squished nerves are legit. Inflamed nerves? Nah.

How do you know the nerve is inflamed? Not on MRI. Not on EMG. Epiduroscopy?

I think history and exam would be critical for establishing need for ESI when imaging is discordant and pain is radicular. I dp not see any support for esi for axial LBP.

 

[ampaphb]

Completely agree. How do you know the nerve is inflamed? Symptoms are markedly improved s/p TF-ESI. (Interventional Spine: An Algorithmic Approach (Curtis W. Slipman 2008) - Page 129

Although Decision Making in Spinal Care, edited by David Greg Anderson, Alexander R. Vaccaro, suggest that "axial pain is believed to be produced by a combination of outer anular chemical sensitization (cyclooxegenase, interleukins, and prostaglandins come into contact with the perineural tissues surrounding the outer tissues of the disk. (Page 473)

 

[lobelsteve]

Completely agree. How do you know the nerve is inflamed? Symptoms are markedly improved s/p TF-ESI. (Interventional Spine: An Algorithmic Approach (Curtis W. Slipman 2008) - Page 129

Step into Nik's trap: MOA of Tfesi? Evidence exists that no evidence exists....

 

[ampaphb]

J Neurosurg Spine. 2013 May;18(5):496-503. doi: 10.3171/2013.1.SPINE12483. Epub 2013 Mar 8.
Chemokine profile of disc degeneration with acute or chronic pain.
Schroeder M1, Viezens L, Schaefer C, Friedrichs B, Algenstaedt P, Rüther W, Wiesner L, Hansen-Algenstaedt N.

Abstract
OBJECT:
Disc-related disorders such as herniation and chronic degenerative disc disease (DDD) are often accompanied by acute or chronic pain. Different mediators have been identified in the development of radicular pain and DDD. Previous studies have not analyzed individual cytokine profiles discriminating between acute sciatic and chronic painful conditions, nor have they distinguished between different anatomical locations within the disc. The aim of this study was to elucidate the protein biochemical mechanisms in DDD.

METHODS:
The authors determined expression levels of matrix metalloproteinase-3, transforming growth factor-β (TGF-β), tumor necrosis factor-α, interleukin-1α, and pro-substance P using enzyme-linked immunosorbent assay and Western blot analyses in patients suffering from DDD (n = 7), acute back pain due to herniated discs with radiculopathy (n = 7), and a control group (n = 7). Disc tissue samples from the anulus fibrosus (AF) and nucleus pulposus (NP) were analyzed. Statistical analysis was performed using nonparametric tests.

RESULTS:
A distinct distribution of cytokines was found in different anatomical regions of intervertebral discs in patients with DDD and herniated NP. Increased TGF-β levels were predominantly found in DDD. Matrix metalloproteinase-3 was increased in acute herniated disc material. Increased levels of substance P were found in patients suffering from DDD but not in patients with disc herniation. The data showed significantly higher levels of proinflammatory cytokines in the AF and NP of patients with DDD, and the expression levels in the AF were even higher than in the NP, suggesting that the inflammatory response initiates from the AF.

CONCLUSIONS:
These results highlight the complex mechanisms involved during disc degeneration and the need to distinguish between acute and chronic processes as well as different anatomical regions, namely the AF and NP. They also highlight potential problems in disc nucleus replacement therapies because the results suggest a biochemical link between AF and NP cytokine expression.

 

[nvrsumr]

Steve

I agree that not first line tx but risk benefit analysis is favorable. You have been a busy doc in practice for a long time. You really haven't had any patients with axial back pain respond to an esi?

 

[lobelsteve]

Steve

I agree that not first line tx but risk benefit analysis is favorable. You have been a busy doc in practice for a long time. You really haven't had any patients with axial back pain respond to an esi?

No. It's not good science. It's not good medicine. I dont offer esi for non claudicatory or non radicular back pain. Mbb. Grc on occasion. DLS exercise. Show me data.

I guess I really could have an easy living if I did a series of 3 for failed mbb and axial lbp. As it is I work 20 hrs per week tp make my future by reviewing all your charts.

 

[emd123]

No. It's not good science. It's not good medicine. I dont offer esi for non claudicatory or non radicular back pain. Mbb. Grc on occasion. DLS exercise. Show me data.

I guess I really could have an easy living if I did a series of 3 for failed mbb and axial lbp. As it is I work 20 hrs per week tp make my future by reviewing all your charts.

In other words, he takes money from lawyers to help them sue other doctors.

 

[lobelsteve]

In other words, he takes money from lawyers to help them sue other doctors.

Nope. I work for the state and federal government when they request my services.
I also do 100's of reviews per year on your disability patients.

I do less than 5 per year of private attorney cases. More like 5-10 ever. Only been to court once. For the doctor.

 

[oreosandsake]

No. It's not good science. It's not good medicine. I dont offer esi for non claudicatory or non radicular back pain. Mbb. Grc on occasion. DLS exercise. Show me data.

I guess I really could have an easy living if I did a series of 3 for failed mbb and axial lbp. As it is I work 20 hrs per week tp make my future by reviewing all your charts.

Sorry, what's GRC and DLS?

 

[lobelsteve]

Sorry, what's GRC and DLS?

gray rami comm block and dynamic lumbar stabilization.

 

[emd123]

I also do 100's of reviews per year on your disability patients.

And what does that entail? Review them for what?

 

[lobelsteve]

And what does that entail? Review them for what?

When a patient says they are disabled and a surgeon who has operated must agree because the screw at C7 are coming through the upper endplate in to the disc space. When a pain doc must keep a patient disabled to come back for more series of 3 in the T-spine for axial back pain and normal MRI, already failed SCS trial, and copious narcotics....

I'm there to end the nonsense. No disability, RTW FT with R&L as follows...... And I get asked to comment on treatment of pain within SOC as well as opiate prescribing. Then the carriers stop paying for care and disability.

 

[lonelobo]

gray rami comm block and dynamic lumbar stabilization.

Do you have good studies for the efficacy of GRC blocks? please share

 

[lobelsteve]

Do you have good studies for the efficacy of GRC blocks? please share

Pain Physician. 2005;8:61-65, ISSN 1533-3159
A Case Series
Radiofrequency Lesioning of the L2 Ramus Communicans in
Managing Discogenic Low Back Pain
Thomas T. Simopoulos, MD, Atif B. Malik, MD, Khuram A. Sial, MD,

Also a couple articles on L2 DRG pulsed RF as similar procedure, but not same thing. (For axial LBP).

 

[nvrsumr]

No. It's not good science. It's not good medicine. I dont offer esi for non claudicatory or non radicular back pain. Mbb. Grc on occasion. DLS exercise. Show me data.

I guess I really could have an easy living if I did a series of 3 for failed mbb and axial lbp. As it is I work 20 hrs per week tp make my future by reviewing all your charts.

When I offer an LESI to a patient with an annular tear or modic changes and symptoms consistent with discogenic back pain after failed PT and NSAIDs it is not "bad medicine". We will have to agree to disagree my friend.

 

[bedrock]

When I offer an LESI to a patient with an annular tear or modic changes and symptoms consistent with discogenic back pain after failed PT and NSAIDs it is not "bad medicine". We will have to agree to disagree my friend.

Completely agree NVR,

I have had good success using LESI for axial low back pain with carefully chosen patients. It can be quite effective in the two situations you mentioned, annular tears and modic changes.

Just because it hasn't been included in an RCT, doesn't mean it doesn't work, and these patients don't have other great options.