pars injection-technical aspects

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schmee90

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I feel like my questions have to do with things surgeons ask me to do. I have a pt who is new to me has isthmic spondylolisthesis, prior pain guys RFA the facets with no benefit they referred to surgeon. Patient has 100% axial back pain with surgeon asking for a pars injection prior to possible fusion and thus was referred to me.

Anybody have a paper on technical apsects of the this procedure as well as insights into coding. I have heard about this injection in passing, and felt like some people have talked about them in confrences I attended with respect to injecting peds patients to help with symptoms and avoid surgery, but have never done one.

Any insights as always are much appreciated.
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No indication for this procedure given the RFA failed.
 
There are no technical aspects, its a glorified TPI. Bring the needle down under AP to the pars, check a lateral to make sure you somehow didn't go through it, then inject. I used to get requests for these and just coded them as facet joint injections (I know, that's horrible - report me). Since you can't do FJIs anymore, its either cash pay or no go.
 
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Technically, they are usually pretty easy. Scottie dog view or AP (I tend to find the oblique a little easier to see the lucency), touch down on os with a 25G quinke with a small bend in it and walk it in a mm or two. You can put a smudge of contrast there if you want. Then inject.
 
I've done it without great success. Steroid and PRP. Same technique as Baron. Oblique, walk into the fracture line. Usually a callous that holds contrast like pseudojoint. If RFA was done right with good depth, Intracept if Modic.
 
oblique like a TFESI hit the pars , then inject. Was a flex ex done. Alot of these BL pars defect pt have radicular pain with flexion, which I think do better with fusion per literature vs purely axial unless unstable. If dynamic-> surgery. No role for injection. Looked up billing, wasn't sure how you code it but see below. The issue will be they may have hit their max LMBB/RFA in a year, since you said RFA was done.

Prior to doing the injection you have to figure out what the next step is if it fails. Is this a young patient, as they may heal on their own with activity mod and bracing/core stabiization. Bone scan may show healing. Also of note, i've heard mention injection with steroid can stop the bone healing process along frx line, so may prevent it from coming back together. Just some thoughts outside of technique


Turn To 64493 for Lumbar Pars Injection : Reader Question

Question: For a patient who is diagnosed with lumbar pars defect, can we report code 64493 for a lumbar pars injection? Is this the correct CPT® code? North Carolina Subscriber Answer: You are correct to report code 64493 (Injection[s], diagnostic or therapeutic agent, [...]
www.aapc.com www.aapc.com

Question: For a patient who is diagnosed with lumbar pars defect, can we report code 64493 for a lumbar pars injection? Is this the correct CPT® code?

North Carolina Subscriber

Answer: You are correct to report code 64493 (Injection, diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) for lumbar pars injection.

v
 
Thanks all for the feedback. Older guy in his 60s pain is all axial for years even with flexion no radicular symptoms. flex/ex films with no dynamic instablility. Surgeon sent him to me with the ratioinale that he doesnt want to operate on axial back pain unless he confirms pars is pain generator, and feels a pars injection would be helpful in making this decision.

I'm a fairly new attending seen quite of few isthmic spondys but surgeons I have worked with have never asked for this before. I know this is an area in PM were there is a lot of grey. In addition I dont really see a lot of article on pars injections. Main thing I saw was NASS guidlines for tx of adult spondys saying...no studies to address the role of steroid injections for the treatment of isthmic spondys

Also prior RFAs were from out of state I have no access to procedure images to confirm there was appropriate placment of needles.
 
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schmee90 said:
Thanks all for the feedback. Older guy in his 60s pain is all axial for years even with flexion no radicular symptoms. flex/ex films with no dynamic instablility. Surgeon sent him to me with the ratioinale that he doesnt want to operate on axial back pain unless he confirms pars is pain generator, and feels a pars injection would be helpful in making this decision.

I'm a fairly new attending seen quite of few isthmic spondys but surgeons I have worked with have never asked for this before. I know this is an area in PM were there is a lot of grey. In addition I dont really see a lot of article on pars injections. Main thing I saw was NASS guidlines for tx of adult spondys saying...no studies to address the role of steroid injections for the treatment of isthmic spondys

Also prior RFAs were from out of state I have no access to procedure images to confirm there was appropriate placment of needles.
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in which case i'd repeat the RFA
 
GoBeers said:
in which case i'd repeat the RFA
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i also think that is reasonable, I'm ust curious do you just outwardly say, hey i don trust the technique of your previous doc in a nice way lol. Most patients who have seen other pain docs and i suggest repeating procs are not very receptive to this idea.
 
schmee90 said:
i also think that is reasonable, I'm ust curious do you just outwardly say, hey i don trust the technique of your previous doc in a nice way lol. Most patients who have seen other pain docs and i suggest repeating procs are not very receptive to this idea.
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True
But I would say even more people have no idea what they've had done actually.

play it off , feign ignorance, and at least you are doing something that has high reward and very very low risk
 
Another question, for those who have done these injections, do you feel its difficult to see the fracture line with fluoro? Some of these fx lines are very subtle on Xr. So if you dont see the fracture line (im not sure if that happens often) are you basically doing the injection at the pars and hoping the injectate gets inside the fracture line. Decent amount of these articles (which are very few) I have seen are with IR guys doing CT guided injections.
 
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You can try repeating the RFA, but a pars injection truly adds nothing to the case.

IMO, RFA is the most poorly performed procedure in our entire field, and the main problem I see with it is depth. If you’ve got a spondy, one of those needles will be potentially a lot deeper than the others.
 
schmee90 said:
Thanks all for the feedback. Older guy in his 60s pain is all axial for years even with flexion no radicular symptoms. flex/ex films with no dynamic instablility. Surgeon sent him to me with the ratioinale that he doesnt want to operate on axial back pain unless he confirms pars is pain generator, and feels a pars injection would be helpful in making this decision.

I'm a fairly new attending seen quite of few isthmic spondys but surgeons I have worked with have never asked for this before. I know this is an area in PM were there is a lot of grey. In addition I dont really see a lot of article on pars injections. Main thing I saw was NASS guidlines for tx of adult spondys saying...no studies to address the role of steroid injections for the treatment of isthmic spondys

Also prior RFAs were from out of state I have no access to procedure images to confirm there was appropriate placment of needles.
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Guy has non-specific LBP. Pain in all directions. Pain with flexion - RFA won’t work. Surgery won’t work. PT. Tylenol. Lumbar brace. Maybe celebrex depending on comorbidities. The worst thing that could happen is placebo response from pars injection (just like the placebo he had from the MBBs) which will lead to a failed fusion. These visits are painful but the best thing you can do is to have an honest discussion and move on. IMO repeating RF on patient with flexion pain is a waste of time. Never works with my hands. Patient won’t be happy.
 
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MD87 said:
Guy has non-specific LBP. Pain in all directions. Pain with flexion - RFA won’t work. Surgery won’t work. PT. Tylenol. Lumbar brace. Maybe celebrex depending on comorbidities. The worst thing that could happen is placebo response from pars injection (just like the placebo he had from the MBBs) which will lead to a failed fusion. These visits are painful but the best thing you can do is to have an honest discussion and move on. IMO repeating RF on patient with flexion pain is a waste of time. Never works with my hands. Patient won’t be happy.
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Then SCS.
 
MD87 said:
Yes. And then finally the patient will know what it is like to be truly pain free.
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My SCS pain relief charts are typically 80-90%. But a few have been 110-115% better and can now inflict/transfer pain on others. (The other party can roll a 2d8 with 7+ on both). DM can allow for standard rules: In Dungeons & Dragons, a character's saving throw against a spell is successful if the number rolled equals or exceeds the spell's Spell Save Difficulty Class (DC). The DC is the total number a creature needs to roll to reduce the effects of a spell. The DC is calculated by adding 8 to the character's spellcasting ability modifier and proficiency. The spellcasting ability modifier is based on the ability score that powers the character's spellcasting. The spell also specifies which ability the target uses for the save and what happens if the save is successful or unsuccessful.
 
lobelsteve said:
My SCS pain relief charts are typically 80-90%. But a few have been 110-115% better and can now inflict/transfer pain on others. (The other party can roll a 2d8 with 7+ on both). DM can allow for standard rules: In Dungeons & Dragons, a character's saving throw against a spell is successful if the number rolled equals or exceeds the spell's Spell Save Difficulty Class (DC). The DC is the total number a creature needs to roll to reduce the effects of a spell. The DC is calculated by adding 8 to the character's spellcasting ability modifier and proficiency. The spellcasting ability modifier is based on the ability score that powers the character's spellcasting. The spell also specifies which ability the target uses for the save and what happens if the save is successful or unsuccessful.
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Thanks for the D&D reference
 
schmee90 said:
i also think that is reasonable, I'm ust curious do you just outwardly say, hey i don trust the technique of your previous doc in a nice way lol. Most patients who have seen other pain docs and i suggest repeating procs are not very receptive to this idea.
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I tell them the nerve location is variable and it's not uncommon to miss the nerve, especially if they responded to MBBs. Most are very receptive to trying again, as it is the least invasive of their options.
 
lobelsteve said:
You always wanted to be a paladin, never made it past Bullywug
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I actually usually play a paladin. Part doctor, part fighter, but not really that good at either. Art imitates life….
 
MitchLevi said:
You can try repeating the RFA, but a pars injection truly adds nothing to the case.

IMO, RFA is the most poorly performed procedure in our entire field, and the main problem I see with it is depth. If you’ve got a spondy, one of those needles will be potentially a lot deeper than the others.
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Can you post pics of depth?
Edit: I used my amazing art skills instead. Feel free to create your own, but I am curious how deep on lateral you think the needles should be A, b, or C? Or something else?:

Untitled.png
 
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kstarm said:
Can you post pics of depth?
Edit: I used my amazing art skills instead. Feel free to create your own, but I am curious how deep on lateral you think the needles should be A, b, or C? Or something else?:

View attachment 387164
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Bogduk says in the middle 2/4ths of the posterior elements so I’d say C but B would maybe be ok if no motor stim. A would worry me
 
A is a prob 2mm too deep, but that’s probably just bc the stylet on that art program is too fat. Most ppl are too shallow during RFA IMO.
 
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