NeedleJockeys Instagram thread

[substanceppp]

Advertisement - Members don't see this ad

I am following needlejockeys instagram feed and seeing a lot of two level bilateral TFESIs. Seems unusual. Just curious

 

[emd123]

What in hell is the point of that IG account?

 

[paindoc007]

I trained under a guy in residency who did that ALL the time. And this was academic acgme too

 

[Ducttape]

But... as a needle jockey, why do 2 levels when you can just as easily do 3?

 

[lobelsteve]

I called him out on it.

 

[clubdeac]

Same results as just doing an interlaminar for triple the cost

 

[painfree23]

I am following needlejockeys instagram feed and seeing a lot of two level bilateral TFESIs. Seems unusual. Just curious

What’s the handle?

 

[swamprat]

Can you bill for 2 levels with modified 50 and get paid for all of it?

 

[Ferrismonk]

I may be old fashioned, but I don't understand why, medically speaking, a bilateral TFESI is better than a simple LESI. Just milking the system?

 

[Ducttape]

Yes. Before, each level and side was independent. So a bilateral 2 level TF could get reimbursed as if 4 levels....

 

[NOSfan]

I may be old fashioned, but I don't understand why, medically speaking, a bilateral TFESI is better than a simple LESI. Just milking the system?

Would you not perform bilateral TFESI vs IESI in a patient with central canal stenosis and B/L signs/symptoms?

 

[Ferrismonk]

Would you not perform bilateral TFESI vs IESI in a patient with central canal stenosis and B/L signs/symptoms?

If they have severe spinal stenosis at a certain level, I don't inject at that level. I'll either do the LESI above or below one level. I suppose you could do B/L TFESI, but that's still a lot of volume in an already tight space.

 

[paindoc007]

Would you not perform bilateral TFESI vs IESI in a patient with central canal stenosis and B/L signs/symptoms?

Any data to suggest bl tfesi with central stenosis is superior to ilesi?

 

[SommeRiver]

Any data to suggest bl tfesi with central stenosis is superior to ilesi?

I can suggest it is safer. Also I don't understand the rationale of going above severe stenosis. You go under the problematic level or at the problematic level.

 

[gdub25]

What don’t you understand about going above the stenotic level? Ever done a spinal or “saddle block”, or myelogram? Inject liquid in the epidural or intrathecal space and with gravity the liquid travels caudal. Inject steroid above the stenotic level and let it flow down to the stenosis. That’s how we were taught, makes sense to me.

 

[SommeRiver]

What don’t you understand about going above the stenotic level? Ever done a spinal or “saddle block”, or myelogram? Inject liquid in the epidural or intrathecal space and with gravity the liquid travels caudal. Inject steroid above the stenotic level and let it flow down to the stenosis. That’s how we were taught, makes sense to me.

I don't equate epidural with intrathecal flow patterns, and I was never taught in residency or fellowship to go above the target level.

 

[spinaltap01]

But... as a needle jockey, why do 2 levels when you can just as easily do 3?

There is evidence that multilevel may be more efficacious than single level for multilevel lateral recess stenosis. And you bring up a great point, what is the magic number? Two level bilateral may be foreign to some people, but there are also those who don't believe transforaminal epidurals offer any added benefit to ILESI.

Pain programs vastly differ on this and many topics, and many comment on how they were trained. Without evidence its all speculation

 

[gdub25]

I don't equate epidural with intrathecal flow patterns, and I was never taught in residency or fellowship to go above the target level.

Not saying intrathecal and epidural flow is the same but it makes logical sense that gravity will effect the injectate to some extent in both locations. If the canal is severely stenotic you gotta make a decision to either go TF, bilateral TF, IL above or below, etc and I’m not sure there is a “best” approach as far as we know. If there is a better argument for not going above I’m open to hearing it. Always looking to better the way I do things.

 

[lobelsteve]

Not saying intrathecal and epidural flow is the same but it makes logical sense that gravity will effect the injectate to some extent in both locations. If the canal is severely stenotic you gotta make a decision to either go TF, bilateral TF, IL above or below, etc and I’m not sure there is a “best” approach as far as we know. If there is a better argument for not going above I’m open to hearing it. Always looking to better the way I do things.

You have a different understanding on gravity than you should. It pulls down only. The epidural space acts like a pump going upward. CSF and blood vessels are heading upward.

 

[Ferrismonk]

If you inject contrast with ILESI, it'll go both cephalad and caudad. If you do anesthesia thoracic epidurals for surgery, you'll usually get coverage 2 levels above and 2 levels below. It's volume dependent. Inject 30cc chloroprocaine in a lumbar epidural, they'll be completely numb from ribcage down.

 

[emd123]

I may be old fashioned, but I don't understand why, medically speaking, a bilateral TFESI is better than a simple LESI. Just milking the system?

If they have midline scar tissue, it's better.

 

[SommeRiver]

If you inject contrast with ILESI, it'll go both cephalad and caudad. If you do anesthesia thoracic epidurals for surgery, you'll usually get coverage 2 levels above and 2 levels below. It's volume dependent. Inject 30cc chloroprocaine in a lumbar epidural, they'll be completely numb from ribcage down.

30cc of thoracic spread is not at all similar to 3 or 4cc in the lumbar spine in a patient with advanced stenosis. Yes, the physics of the epidural space say put the injectate below the pathology or at the pathology.

 

[No_Pain_No_Gain]

Is there a good reason to not inject at the target level of severe stenosis? Is there data which has demonstrated this is not safe? Severe stenosis = B/L TFESI or ILESI at the stenotic level IMO.
A different question was previously asked about what the difference between B/L TFESI vs ILESI at the level would be. You technically get more anterior epidural spread with the B/L TFESI.

 

[SommeRiver]

IL is level below always, and TF is at or below. That's just my practice. No way I'm doing an ILESI directly on top of a stenotic canal bc I can't risk wet tapping the pt (I just don't want to deal with it). I haven't patched a pt since fellowship (blood or glue).

 

[tmvguy03]

Can you bill for 2 levels with modified 50 and get paid for all of it?

I have a lady with broad bulge at L4/5 with bilateral L4 radic. I was going to perform a bilateral L4/5 TFESI but it was denied (she has UHC). Turns out it was ordered as bilateral L4-5, L5/S1 bc of a clerical error. The single level bilateral was approved after P2P.
My assumption is that most other private insurers would also deny multi level bilateral TFESI too. Not sure about Medicare/Medicaid but there have been posts about some guys doing bi/tri-level and they must be getting paid by someone...

 

[Ducttape]

1. Furman's book makes a singular statment "the presence of severe spinal stenosis increases the likelihood of intrathecal administration". i believe i saw a similar statement in Waldman's book

2. this article points out that the area of maximal stenosis may be preferential to a level below, but makes no comment about going above the level of maximal stenosis: Interlaminar Epidural Steroid Injection for Degenerative Lumbar Spinal Canal Stenosis: Does the Intervertebral Level of Performance Matter?

3. in addition, the volume necessary for a single level Tf to reach above and below is at most 4 mL. there is literally no point of doing a second level since, with sufficient volume, based on contrast studies, you will get 93-95% coverage.
Injectate Volumes Needed to Reach Specific Landmarks and Contrast Pattern in Kambin's Triangle Approach with Spinal Stenosis. - PubMed - NCBI
Injectate volumes needed to reach specific landmarks in lumbar transforaminal epidural injections. - PubMed - NCBI

RESULTS:
After 1.1 mL of contrast was injected, 100% of L-TFEIs spread to the medial aspect of the superior pedicle (PED) of the corresponding level of injection. After 2.8 mL of contrast was injected, 95% of L-TFEIs spread to the superior aspect of the superior intervertebral disk (IVD) of the corresponding level of injection. After 3.6 mL of contrast was injected, 95% of L-TFEIs spread to the inferior aspect of the inferior IVD of the corresponding level of injection. After 3 mL of contrast was injected, 88% of L-TFEIs spread to cover both the superior and inferior IVDs of the corresponding level of injection. After 4 mL of contrast was injected, 93% of L-TFEIs spread to cover both the superior and inferior IVDs of the corresponding injection. After 4 ml of contrast was injected, 55% of L-TFEIs spread beyond the midline of the spinous process, but barely.

4. it is rather simplistic to think that medication will "sink" to the level of the stenosis. if you are anesthesia trained, you have been well schooled in the various factors that affect intrathecal and epidural anesthesia, including baricity along with volume.
also, you are doing the injection lying down. by the time you sit the patient up, the fluid has already spread,

unless you stand up these LOL immediately after you do your ESIs. in which case, theres a lot more to worry about than just your injection technique...

 

[SommeRiver]

Single most common intervention in the field and yet here we are debating how to do it on one of the most common patients we all see...I hope we can at least agree Watermelon Bubblicious is an elite chewing experience.

 

[tmvguy03]

Single most common intervention in the field and yet here we are debating how to do it on one of the most common patients we all see...I hope we can at least agree Watermelon Bubblicious is an elite chewing experience.

It is great, but two discontinued flavors were much better, including orange and cherry cola. Man I miss those

 

[Ducttape]

well, technically, there is still some debate as to the long term benefits of said procedures.... but I didn't want to go there.

 

[substanceppp]

In my professional experience, I find that TFESI work significantly better than ILESI for radiculopthy (for spinal stenosis with neurogenic claudication, I typically perform CAUDAL ESI). I have no data to support this to be honest -- but i am shifting towards bilateral TFESI for bilateral radiculopathy.

 

[SommeRiver]

Caudal < Bil S1

 

[lobelsteve]

well, technically, there is still some debate as to the long term benefits of said procedures.... but I didn't want to go there.

There is no debate. This procedure, no matter the angle of attack, has not been shown to be do anything beyond 2 months.

 

[NOSfan]

Not central stenosis, but food for thought.

Pain Physician. 2018 Sep;21(5):433-448.
Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis.
Lee JH1, Shin KH2, Park SJ3, Lee GJ4, Lee CH5, Kim DH6, Kim DH7, Yang HS8.
Author information

Abstract
BACKGROUND:
Epidural injection (EI) is used to treat back or radicular pain from lumbosacral disc herniation (LDH). Although several reports have stated that the transforaminal approach in EI (TFEI) has an advantage in target specificity and yields better clinical efficacy than the interlaminar approach in EI (ILEI), other studies have indicated that the clinical efficacy of ILEI was not inferior to that of TFEI and that ILEI also has the ability to spread medication into the ventral space to a degree similar to that of TFEI. There has been controversy about whether TFEI is superior to ILEI in clinical efficacy.

OBJECTIVES:
This systematic review and meta-analysis aimed to investigate whether TFEI is more useful than ILEI for achieving clinical outcomes in patients with LDH.

STUDY DESIGN:
A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCT).

METHODS:
A literature search was performed in MEDLINE, EMBASE, Cochrane review, and KoreaMed for studies published from January 1996 until July 2017. From those found fulfilling the search criteria, manuscripts that compared the clinical efficacy of steroids and control agents, such as local anesthetics or saline, in terms of pain control and functional improvement were included in this study. Exclusion criteria included a previous history of lumbosacral surgery, non-specific low back pain, severe spinal stenosis, and severe disc degeneration. After reviewing titles, abstracts, and the full text of 6,711 studies; 12 studies were included in the qualitative synthesis. Data including pain scores, functional scores, and follow-up period were extracted from 10 studies and analyzed using a random effects model to obtain effect size and its statistical significance. The quality and level of evidence were analyzed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS:
In terms of pain control, TFEI showed significantly better short-term (2 weeks to 1 month) outcomes and slightly favorable long-term (4 - 6 month) outcomes, but without significance, in comparison with ILEI. In terms of functional improvement, TFEI also showed favorable short- and long-term outcomes, but without significance, in comparison with ILEI. TFEI had target specificity, required no additional cost and resources, and had equal applicability to ILEI. However, TFEI was more associated with a higher frequency of discomfort or adverse events during the procedure. Overall, better results were reported with TFEI over ILEI, but with low-grade evidence due to the inconsistency and imprecision of the selected studies.

LIMITATION:
Analyses of safety or adverse effects could not be performed due to a lack of available data from the included studies.

CONCLUSIONS:
Based on low-grade evidence, TFEI showed significantly better short-term pain control and slightly favorable outcomes in long-term pain reduction and short- and long-term functional improvement in comparison with ILEI.

KEY WORDS:
Epidural injection, interlaminar, transforaminal, meta-analysis, systemic review, pain, function.
PMID: 30282389
[Indexed for MEDLINE] Free full text

 

[Ducttape]

in this study, severe spinal stenosis was an exclusion criteria.

so, this GIGO study (per drusso) is not applicable to that condition.

in addition, the article shows bias. the results clearly state no significance in long term outcomes, and not significant outcomes of TFEI over ILEI - yet the conclusions state "short- and long-term functional improvement" of TFEI. you cant draw that conclusion if it was without significance.