Procedure did not work doc

[lobelsteve]

It was MBB with lidocaine. So it worked perfectly. Ok to discuss with her the RF.

> From: D****, Tammy RN
> To: Lobel, Steven M MD
> Sent: 9/25/2013 3:02 PM
>
CALLER: PT

CALLBACK: 770-xxx-xxxx

DOCTOR:Lobel (caller made aware Dr Lobel out of office this afternoon, returns 9/26/13)

PHARMACY: Walmart local EHR

CONCERN: PC in low back last week - advised to callback with update...calling to notify Dr Lobel that it did not work...first hour everything felt numb...everything felt good for about 6 hours then it wore off. ****Still can not stand up straight, having pain when tries to walk...same as before PC. *Please advise.








Another day, another call about MBB's. We discuss how it works at consult, first MBB with bupi, 2nd MBB with lido. And the saga continues.

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[Ducttape]

exactly...

what seems to help is when i say, at least 3 times, "its like in the dentist office - they numb up your teeth, then it wears off after a few hours - this shot will wear off".

 

[SSdoc33]

there is NO way to get them to understand. none.

i have them lean back after they get off the table, and if they feel better, i pretty much use that as a reason to do the RF. this is why the "50% vs. 75% vs. 90%" pain relief is so stupid.

 

[mdvol]

I could not agree with these comments and frustration more!

 

[Doctodd]

give them a pre/post procedure instruction sheet and have your MA remind them to look at it. It will save your MA alot of time. Or just send them to me so i can discuss non-RF burn options to regenerate their facet joints.😀

 

[SSdoc33]

give them a pre/post procedure instruction sheet and have your MA remind them to look at it. It will save your MA alot of time. Or just send them to me so i can discuss non-RF burn options to regenerate their facet joints.😀

regenerate? like when you cut off a leg of a starfish? cool. im all ears. it appears that you may have found the cure for arthritis

 

[Doctodd]

regenerate? like when you cut off a leg of a starfish? cool. im all ears. it appears that you may have found the cure for arthritis

naaaaa.....it doesnt work. But ill still talk to your patient for you. They can then follow up with you in a few months.

 

[SSdoc33]

naaaaa.....it doesnt work. But ill still talk to your patient for you. They can then follow up with you in a few months.

fine with me. i have no problems sending a few of those snowbirds your way in the winter.

 

[Jcm800]

there is NO way to get them to understand. none.

i have them lean back after they get off the table, and if they feel better, i pretty much use that as a reason to do the RF. this is why the "50% vs. 75% vs. 90%" pain relief is so stupid.

just got denied from an insurance because i did not document greater than 80%, EIGHTY PERCENT... Patient had 75% relief. and i wrote it... denied!

 

[powermd]

there is NO way to get them to understand. none.

I find it helps to turn the discussion around at the first visit.

I tell them the treatment for their problem is RF and describe that in detail. Then I describe how the MBBs test to see if the joints feel better when blocked. Then I remind them ten times the blocks will wear off in hours.

I haven't had any of these stupid "it didn't work" calls since I turned the discussion around this way.

 

[dc2md]

I don't think Steve was asking for suggestions. Just another example of how some patient's are stupid no matter how many times they're explained the procedure.

 

[Dr. Ice]

I don't think Steve was asking for suggestions. Just another example of how some patient's are stupid no matter how many times they're explained the procedure.

In general, pain patients are not going to be of the upper echelon of intelligence...this frustration doesnt just apply to medial branch blocks and rfa. I spend so much time re-explaining what Ive spent so much time explaining during consultation. Sometimes I feel like tape recording myself, leaving it in the room and then coming back and asking if they have questions...

 

[Ducttape]

I also send them home with a " pain diary". I find it helps them focus on the first few hours. I assume you guys do too...

 

[bedrock]

just got denied from an insurance because i did not document greater than 80%, EIGHTY PERCENT... Patient had 75% relief. and i wrote it... denied!

If patient reports 30-50% relief, i report as is and do RF if insurance approves.

If patient reports anything greater than 50%, I report as 80% relief to ensure no idiot bean counter from the insurance co can deny care that is needed.

 

[dc2md]

If patient reports 30-50% relief, i report as is and do RF if insurance approves.

If patient reports anything greater than 50%, I report as 80% relief to ensure no idiot bean counter from the insurance co can deny care that is needed.

Are you joking? You still do an RFA if the patient only gets 30-50% relief?

We haven't been denied any for 75% relief, but if we did, I don't see a problem relaying to the patient that insurance won't approve their RFA unless they report 80+% relief after they say they got 75%.

 

[PinchandBurn]

what about if with Diagnostic MBB they come back and they have no pain at all ...even at the 2 week mark😎

 

[bedrock]

Are you joking? You still do an RFA if the patient only gets 30-50% relief?

We haven't been denied any for 75% relief, but if we did, I don't see a problem relaying to the patient that insurance won't approve their RFA unless they report 80+% relief after they say they got 75%.

I'm talking about patients with only axial pain, who have failed conservative care and basic medications. If they say the only got 50% relief from a MBB, then of course I offer them RF.

What else are you going to do?

RF is safer, and has better literature support than basically every other treatment in pain medicine.



My post above, was commenting on bean counters from insurance companies try to use specific % relief numbers to decide whether to pay for something, but they don't have the clinical expertise to make that decision, so I take that right back from the insurance company.

When patients report their pain relief after MBB, I give them limited options with this in mind. 0% relief, 30% relief, 50% relief, 80% relief, 100% relief.

My patients aren't given the option to say 60 or 75% percent relief, because I know some idiot insurance companies won't pay for it. I don't lie, I simply let the patient pick from the 5 options. If they are thinking that it helped them more than 50%, but not 100%, then the middle ground is 80%, which fits the criteria of every insurance company, I have met so far.

 

[joshmir]

As much as I can I try to get them to do things that normally reproduce their pain before they leave and decide right then; sometimes I tell them to go walk for a half hour then come back; it is more accurate and cuts down on phone calls, confusion

 

[geauxg8rs]

And no matter how you describe radio frequency ablation they will always refer to it as the laser.

So doc is the next step the laser?

 

[EtherBunny]

Well, the problem of patients not understanding diagnostic medial branch blocks may become a moot point in the near future. I think the standard of practice is going to move away from MBB as a prerequisite for RFA. We should all probably go directly to RFA for suspected facetogenic pain. Cohen's research on this topic (I think) will be a game changer. Only time will tell, I suppose.

 

[dc2md]

And no matter how you describe radio frequency ablation they will always refer to it as the laser.

So doc is the next step the laser?

Laser? That's funny.

My patients seem to really understand the word "cauterize", and they're surprisingly not afraid of that word. I've had so many of them use that word to me that I've started using it.

 

[Ducttape]

i would be concerned reporting some level of pain relief that is trumped up from what the patient said.

On the other hand, under the Carecore guidelines, it discusses "clinically meaningful improvement", with an *, allowing RFA. if you have at least a 2 point drop in VAS, then you could document primarily "the patient's global assessment showed clinically meaningful improvement".


*Clinically meaningful improvement: Global assessment showing at least a 50% improvement or a 2 point drop in the VAS pain scale....


(ps the 1 time i used this line for a Wellcare patient, i still got denied 😉 )

 

[SSdoc33]

Well, the problem of patients not understanding diagnostic medial branch blocks may become a moot point in the near future. I think the standard of practice is going to move away from MBB as a prerequisite for RFA. We should all probably go directly to RFA for suspected facetogenic pain. Cohen's research on this topic (I think) will be a game changer. Only time will tell, I suppose.

wrong

 

[SSdoc33]

Are you joking? You still do an RFA if the patient only gets 30-50% relief?

QUOTE]

absolutely. dont be the only one out there who isnt bending the rules. the insurance companies will rape you with their ridiculous regulations. do whats best for your patient

 

[emd123]

It was MBB with lidocaine. So it worked perfectly. Ok to discuss with her the RF.

> From: D****, Tammy RN
> To: Lobel, Steven M MD
> Sent: 9/25/2013 3:02 PM
>
CALLER: PT

CALLBACK: 770-xxx-xxxx

DOCTOR:Lobel (caller made aware Dr Lobel out of office this afternoon, returns 9/26/13)

PHARMACY: Walmart local EHR

CONCERN: PC in low back last week - advised to callback with update...calling to notify Dr Lobel that it did not work...first hour everything felt numb...everything felt good for about 6 hours then it wore off. ****Still can not stand up straight, having pain when tries to walk...same as before PC. *Please advise.








Another day, another call about MBB's. We discuss how it works at consult, first MBB with bupi, 2nd MBB with lido. And the saga continues.

No matter how much time I spend trying to explain the concept of a diagnostic MBB to patients, I get this comment or call constantly. It drives me insane. People just don't get it.

 

[EtherBunny]

wrong

I don't know, man. The attendings at my institution are convinced that the paradigm is going to change. They think that it's only a matter of time.

Check out the article for yourself. Cohen is a giant in the facet literature (and a truly brilliant guy, by the way). It's a good study. Hard to summarily dismiss the results.

Here's the link: http://www.ncbi.nlm.nih.gov/pubmed/20613471

 

[pmrmd]

absolutely. dont be the only one out there who isnt bending the rules. the insurance companies will rape you with their ridiculous regulations. do whats best for your patient

Amen

 

[dc2md]

I don't know, man. The attendings at my institution are convinced that the paradigm is going to change. They think that it's only a matter of time.

Check out the article for yourself. Cohen is a giant in the facet literature (and a truly brilliant guy, by the way). It's a good study. Hard to summarily dismiss the results.

Here's the link: http://www.ncbi.nlm.nih.gov/pubmed/20613471

The 'n' is just too low for each of those three groups in the study. BUT, in my experience, I have very very very rarely found a successful 1st block that was NOT successful for the second one.

 

[Pacman27]

Why do you guys even bother stating 75% relief, etc

If the patient was numb the first hour after the procedure that is %100 relief. So just say greater then 80% or whatever the insurance company needs. These percentages are so subjective. If they get stuck in traffic their percentage point drops.

Its not as if we are deciding to do a fusion

The 'n' is just too low for each of those three groups in the study. BUT, in my experience, I have very very very rarely found a successful 1st block that was NOT successful for the second one.

 

[ampaphb]

I don't know, man. The attendings at my institution are convinced that the paradigm is going to change. They think that it's only a matter of time.

Check out the article for yourself. Cohen is a giant in the facet literature (and a truly brilliant guy, by the way). It's a good study. Hard to summarily dismiss the results.

Here's the link: http://www.ncbi.nlm.nih.gov/pubmed/20613471

In the article you cite, what Dr. Cohen actually says is:
Using current reimbursement scales, these findings suggest that proceeding to radiofrequency denervation without a diagnostic block is the most cost-effective treatment paradigm.

However, in his most recent writing (Cohen SP, Huang JH, Brummett C. Facet joint pain--advances in patient selection and treatment. Nat Rev Rheumatol. 2013 Feb;9(2):101-16.), what he says is "all studies that have used MBBs as a predictive tool in the lumbar and cervical regions to select patients for radiofrequency denervation treatment have shown that this intervention is beneficial."

Lord, S. M., Barnsley, L., Wallis, B. J., McDonald, G. J. & Bogduk, N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N. Engl. J. Med. 335, 1721–1726 (1996).

van Kleef, M. et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine (Phila Pa 1976) 24, 1937–1942 (1999).

Nath, S., Nath, C. A. & Pettersson, K. Percutaneous lumbar zygapophysial (Facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double-blind trial. Spine (Phila Pa 1976) 33, 1291–1297; discussion 1298 (2008).

Tekin, I., Mirzai, H., Ok, G., Erbuyun, K. & Vatansever, D. A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain. Clin. J. Pain 23, 524–529 (2007).

 

[ampaphb]

Cohen (Facet joint pain--advances in patient selection and treatment. Nat Rev Rheumatol. 2013 Feb;9(2):101-16.) on appropriate loevel of pain relief to move forward with RF:

Success rates of radiofrequency denervation of the lumbar facet, cervical facet or sacroiliac joints do not reportedly differ when patients are stratified for therapy on the basis of nerve-block pain relief thresholds of either 50% or 80%. Moreover, studies evaluating pain relief thresholds for other analgesic procedures, such as spinal cord stimulation and pulsed radiofrequency, have also revealed no difference between using 50% and 80% pain relief as the reference standard. On the basis of these findings, one might argue that lower pain cut-offs might even be justified, as clinical studies have determined that approximately 30% pain relief constitutes a clinically meaningful outcome.

 

[bedrock]

On the basis of these findings, one might argue that lower pain cut-offs might even be justified, as clinical studies have determined that approximately 30% pain relief constitutes a clinically meaningful outcome.

Assuming failure of conservative care, 30% relief from RF is a better option than nothing, with far less risk than fusion.

Just no magic wand for axial spine pain, which is part of my standard discussion with patients.

They think surgical fusion "must" have the same success rates as joint replacements. Explaining that surgery isn't magic, is a hard pill for many to swallow.

 

[Dr. Ice]

Assuming failure of conservative care, 30% relief from RF is a better option than nothing, with far less risk than fusion.

Just no magic wand for axial spine pain, which is part of my standard discussion with patients.

They think surgical fusion "must" have the same success rates as joint replacements. Explaining that surgery isn't magic, is a hard pill for many to swallow.

Thats funny..I use the same "I cant wave my magic wand and make this go away" line all the time for axial pain, especially with the octogenerians with degenerative scoliosis and axial pain. Im sure my "satisfaction scores" take a hit every time I say it, because Im not "curing" them...

 

[SSdoc33]

I don't know, man. The attendings at my institution are convinced that the paradigm is going to change. They think that it's only a matter of time.

Check out the article for yourself. Cohen is a giant in the facet literature (and a truly brilliant guy, by the way). It's a good study. Hard to summarily dismiss the results.

Here's the link: http://www.ncbi.nlm.nih.gov/pubmed/20613471

Is this the same Cohen who thinks we don't need MRIs before injections? But then conveniently fails to mention that we need to order them so we don't get sued? That Cohen? Right, I thought so. With guys like this on you side, we needs lawyers or insurance companies.

I'd be fine with going straight to RF. I'm not sure I'd be fine with shady pain doctor X going straight to RF. Overutilization, and then reimbursements go to sh$t

 

[Ducttape]

Without some objective measure, or some way of weeding out legitimate vs a fly by night (or weekend course) doc, rfas will become so abused as to be eliminated by CMS ASAP.

It's what has happened to epidurals, SCS, everything we do. It's imperative that those of us legitimate docs show some signs we are being prudent and analytical about what we do....

Fudging data and "because I said so" doesn't cut it, IMHO.

 

[epidural man]

Well, the problem of patients not understanding diagnostic medial branch blocks may become a moot point in the near future. I think the standard of practice is going to move away from MBB as a prerequisite for RFA. We should all probably go directly to RFA for suspected facetogenic pain. Cohen's research on this topic (I think) will be a game changer. Only time will tell, I suppose.

He is a good source on the subject - agreed.

However, agree with *ahem* ssdoc33 - that it isn't the whole story. Read Manchikanti's stuff on the subject.

The problem is prevalence or pre--test probability of disease. If your prevalence is 10-20% (like in my population) - Dx MBB absolutely makes sense. If it is closer to 80% as in the case of many of the physicians on this board, maybe right to RF makes sense.

The real answer is SPECT, then Rf - but no pain physician will EVER do that study to prove it.

 

[epidural man]

I don't know, man. The attendings at my institution are convinced that the paradigm is going to change. They think that it's only a matter of time.

Check out the article for yourself. Cohen is a giant in the facet literature (and a truly brilliant guy, by the way). It's a good study. Hard to summarily dismiss the results.

Here's the link: http://www.ncbi.nlm.nih.gov/pubmed/20613471

oh and one more thing about this "giant" you mention with regards to SPECT.

Him, and basically all others that have written on the subject (see Cohen's chapter on facet disease on Raj's textbook) all say imaging is not predictive of facet disease. That is a complete lie, or else a complete lack of understanding the literature.

The radiology literature is PEPPERED with articles that show how SPECT and SPECT/CT are very predictive of facet disease that responds to injections - but again, the pain world will have none of it.

Not sure why we are so afraid....lost revenue perhaps?

 

[Ducttape]

oh and one more thing about this "giant" you mention with regards to SPECT.

Him, and basically all others that have written on the subject (see Cohen's chapter on facet disease on Raj's textbook) all say imaging is not predictive of facet disease. That is a complete lie, or else a complete lack of understanding the literature.

The radiology literature is PEPPERED with articles that show how SPECT and SPECT/CT are very predictive of facet disease that responds to injections - but again, the pain world will have none of it.

Not sure why we are so afraid....lost revenue perhaps?

1. SPECT scans cost, what, $3500?


2. why would you do an additional study above an MRI scan for something that does not have therapeutic value, when you have a less expensive diagnostic study that would be required before initiating a therapeutic one?

ie. why do an MRI then a SPECT then a diagnostic MBB before doing an RFA, compared to MRI then diagnostic MBB then RFA?


3. Finally, i dont think the EBM is as robust as you suggest it to be.

This study - Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy? suggests that the diagnostic value is as low as 65%.

CONCLUSIONS: Hybrid SPECT/CT imaging identified potential pain generators in 92 % of cervical spine scans and 86 % of lumbar spine scans. The scan precisely localised SPECT positive facet joint targets in 65 % of the referral population and a clinical decision to inject was made in 60 % of these cases.

On the other hand, This study - Frequency of Discordance between Facet Joint Activity on Technetium Tc99m Methylene Diphosphonate SPECT/CT and Selection for Percutaneous Treatment at a Large Multispecialty Institution. suggested that there is a lot of discordance between SPECT results of active facet disease and what was clinically found.

CONCLUSIONS:Facet joints undergoing targeted percutaneous treatment were frequently discordant with those demonstrating increased technetium Tc99m methylene diphosphonate activity identified by SPECT/CT at our institution, in many cases because the active facet joint(s) did not correlate with clinical findings. Further prospective double-blinded investigations of the clinical significance of facet joint activity by use of technetium Tc99m methylene diphosphonate SPECT/CT and comparative medial branch blocks are needed.

 

[epidural man]

1. SPECT scans cost, what, $3500?


.

Good point. SPECT is not cheap - but I doubt it is $3500. Interestingly, these researchers discovered that actually using SPECT before injection saved the hospital money.

View attachment CT SPECT and facet injections.pdf

2. why would you do an additional study above an MRI scan for something that does not have therapeutic value, when you have a less expensive diagnostic study that would be required before initiating a therapeutic one?

ie. why do an MRI then a SPECT then a diagnostic MBB before doing an RFA, compared to MRI then diagnostic MBB then RFA?

.

If SPECT is very predictive, one would skip the Dx MBB and do RF based on the scanning. The first article you quote shows that it predicts positively in 65% of the cases. That seems about the same number as responders based on Dx MBB - so not bad at all.

3. Finally, i dont think the EBM is as robust as you suggest it to be.

This study - Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy? suggests that the diagnostic value is as low as 65%.



On the other hand, This study - Frequency of Discordance between Facet Joint Activity on Technetium Tc99m Methylene Diphosphonate SPECT/CT and Selection for Percutaneous Treatment at a Large Multispecialty Institution. suggested that there is a lot of discordance between SPECT results of active facet disease and what was clinically found.

If I suggested that the EBM is so great, I apologize. I did not mean to imply this. I did, however, try to imply that there is PLENTY of literature to SUGGEST that it is a very plausible modality to predict facet disease. Unlike MRI, there has been very little research done to try and correlate SPECT with RFA outcomes (none that I am aware of) and to then suggest in articles and textbooks with a dogmatic and emphatic tone that NO IMAGING is useful in determining facet disease is either a straight up lie, or a complete lack of understanding the literature available. And you have produced a paper that suggest that it may not work so great. I think that is a great step in the right direction to answering the question, but that single article certainly does not negate all the research the proceeds it. There needs to be more done - but my point also was that pain physicians would hate to see SPECT replace DX MBB so it is unlikely to happen.

 

[epidural man]

People have talked about SPECT or bone scanning for years.

I think this article probably was the first real prospective study that showed that it might be useful (too large to attach - but link is to the PDF)

Since then, there have been a lot of retrospective studies - many of them positive, and as has been pointed out - some not positive.

The Koreans did another prospective study. They actually correlated with Dx MBB - so that's kinda cool.

View attachment SPECT and DX MBB Korean J of Pain 2011.pdf

As linked in the above post, in 2006, another prospective study showed good results and showed a cost savings.

So we have lots of retrospective reviews looking at it with many positive, a few negative. Then we have some prospective trials showing positive results. To my knowledge, no prospective trial has been produced showing negative results.

Also, I don't think doing a fused CT/SPECT is needed - probably adds more cost - but the images are cool. Linked is a review of fused CT/SPECT with a cool image of a "hot" facet. I linked for veiwing pleasure.

 

[clubdeac]

Since we're on the subject, hypothetically speaking, does medicare pay for RFA if a mbb hasn't been done first? I know you don't need pre-auths so you theoretically could do it without a problem?