occipital nerve block

[jonnylingo]

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with or without steroid?

 

[drusso]

with.

 

[lobelsteve]

with

 

[Lecithin5]

Without

 

[SSdoc33]

without

 

[DOctorJay]

with

 

[NOSfan]

With --> therapeutic

 

[Biohazard685]

Done with and without.

Had better results with.

 

[dhcofc]

What do you guys do as a next step for occipital neuralgia if the block helps but doesn’t last long enough? Occipital RFA is tough to get reimbursed, same for pulsed. I have a hard time knowing what to do besides the blocks. TON, C3 RFA?

 

[Ducttape]

with primarily.

TON next step, for RFA if benefit.

 

[AGDOC09]

Same as above but without steroids for the ONB

 

[pmrmd]

ONB? Pick a different procedure to do.

 

[oreosandsake]

with, dex, performed under ultrasound, above the C2 lamina. you can reliably RF here as well if you chose to

 

[painfree23]

new article came out saying doing with local only every month is beneficial

with primarily.

TON next step, for RFA if benefit.

do you do a TON diagnostic block first? C2/3 junction, any other nerves u hit during that block?

 

[Orin]

Just put an ice pack there and quit trying to be a crazy needle-jock with your occipital nerve blocks!

I'm not a fan but I'll do local +/- nonparticulate steroid for an initial but low volume local only if they're proceeding to stimulation/ablation

 

[oreosandsake]

GON at C2 lamina

 

[Ducttape]

I like US... but sometimes pics just don’t “translate” as well as fluoro pics...

Yes to diagnostic block first, and Icall it C23 block/mbb for insurance purposes...

 

[painfree23]

I like US... but sometimes pics just don’t “translate” as well as fluoro pics...

Yes to diagnostic block first, and Icall it C23 block/mbb for insurance purposes...

Do you do bilateral 64490, but only do one block (C2/3 junction) on each side?

 

[nvrsumr]

Since fluoro guidance is bundled with facet interventions should not bill this as a facet block

 

[Ducttape]

who is billing for separate fluoro guidance for these injections?

 

[nvrsumr]

who is billing for separate fluoro guidance for these injections?

The cervical facet injection code 64490 bundles Fluoroscopic guidance. My understanding is u can’t bill 64490 if done blindly or even with us guidance. You could bill an occipital block with the us code

 

[painfree23]

Since fluoro guidance is bundled with facet interventions should not bill this as a facet block

ohh, i see. so you bill it as
64450 + fluoro guidance?

 

[nvrsumr]

64405 + 76942 - occipital n block and US guidance.

No 77003 with 64990 as the fluoro is bundled as mentioned previously

 

[Ducttape]

Or bill it for what it is - a facet joint injection. I bill 64490. And only 64490 - Rarely there is a -50 modifier.

Somewhere, you made the assumption that I did this under ultrasound. I never stated that.

 

[PainDrain]

What do you guys do as a next step for occipital neuralgia if the block helps but doesn’t last long enough? Occipital RFA is tough to get reimbursed, same for pulsed. I have a hard time knowing what to do besides the blocks. TON, C3 RFA?

I personally would never do an RFA of the occipital nerve. I had a patient who developed deafferentation pain following an occipital RFA and she was left in unrelenting constant pain. Consider Botox or referral to a neurosurgeon for physical decompression.

 

[drusso]

Dexamethasone Injected Perineurally is More Effective than Administered Intravenously for Peripheral Nerve Blocks: A Meta-Analysis of Randomized Controlled Trials

Zorrilla-Vaca, Andres BSc*; Li, Jinlei MD, PhD†

The Clinical Journal of Pain: March 2018 - Volume 34 - Issue 3 - p 276–284
doi: 10.1097/AJP.0000000000000519
Review Articles

• Abstract
• In Brief
• Author Information

Introduction: Peripheral nerve blocks (PNBs) are widely and increasingly used for better acute perioperative pain control for a variety of procedures. Clinically preservative-free dexamethasone is arguably the most commonly used adjuvant and offers the most optimization effects on PNBs yet with the least side-effects noted. Our aim was to compare the effectiveness of intravenous versus perineural dexamethasone on the effectiveness and safety of PNBs.

Methods: Major databases (PubMed, EMBASE, Cochrane library, ISI Web of Science, Google Scholar) were systematically searched for randomized controlled trials comparing the effectiveness of intravenous versus perineural dexamethasone on PNBs. Study characteristics, intraoperative events, and postoperative outcomes including duration of analgesia, duration of sensory block, duration of motor block, pain score at 24 hours, opioid consumption, and postoperative nausea and vomiting, were extracted from the articles. Meta-analysis was performed using random-effect models.

Results: Thirteen randomized controlled trials comprising a total of 937 patients (intravenous: 464 patients; perineural: 473 patients) were included in this meta-analysis. Perineural dexamethasone significantly prolonged the duration of analgesia (standardized mean difference [SMD], 0.48 h; 95% confidence interval [CI], 0.18-0.79) and sensory block (SMD, 0.74; 95% CI, 0.53-0.94). In subgroup of studies that used 4 to 5 mg we found that perineural dexamethasone was universally more effective to prolong analgesia as compared with intravenous dexamethasone (SMD, 0.48 h; 95% CI, 0.24-0.72), but there was no significant difference between intravenous versus perineural dexamethasone when using a dose of dexamethasone ≥8 mg (SMD, 0.33 h; 95% CI, −0.11 to 0.77). Perineural dexamethasone had similarly more benefits in terms of prolongation of motor block duration, decreasing pain score, reducing opioid consumption, and less postoperative nausea and vomiting.

Conclusions: This investigation not only confirmed the better analgesic effects of perineurally administered dexamethasone as compared with its intravenous injection, but also implicitly supported the hypothesis of local interaction between dexamethasone and the nerve as one of the pain modulation mechanisms of dexamethasone, because systemic absorption alone could not explain the superior quality of PNBs.

 

[Ducttape]

I know a guy that says meta-analysis is GIGO.....

 

[drusso]

I know a guy that says meta-analysis is GIGO.....

It mostly is. But, this actually satisfies the criteria for a legitimate meta-analysis: You're studying one intervention (dexamethasone) across a series of related circumstances (different nerve blocks). No one believes there is any biological reason why dexamethasone would work differently on the occipital nerve versus the median nerve, but one can still be open to the possibility of that.

Compare that to how meta-analysis mostly gets used in Pain Medicine: Treatment X for conditions A, B, C lumped together (ie low back pain).

Uses and abuses of meta-analysis. - PubMed - NCBI

Big Data: The Danger in Knowing Less and Less about More and More | The Lund Report

 

[Aether2000]

I block with steroid using US and target halfway between the "GCC Institute" labels that appear on my ultrasound

 

[drpainfree]

I believe Aetna is not paying occipital nerve block either.

 

[SeniorWrangler]

Anecdotally, I've done local-only ONB's for pregnant ladies and they worked well but not as long.
Occipital cryotherapy works well but is getting very hard to get authorized.

 

[mid|ine]

WITH

Was taught not to RF because of deafferentation pain. I have done a few stims, which worked really well, but hard to get approved.