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question re vertebroplasty

jsaul

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    what is the longest time from presumed fracture that you would treat...

    ie a 34 year old man with traumatic fracture 2 ( 40 percent loss of height)years ago and still back pain axial-- would you cement that being so old?? The mri shows no other patholgy.. Now i know he could have facet or myofascial pain etc but would you cement that to see if he got any better?
     

    Tenesma

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      the literature only really supports its efficacy if done within 8 weeks of the fracture... persistent axial pain in the setting of old vertebral fx: i would think of discogenic vs facetogenic. In the elderly it is surprising how a well placed bilateral transforaminal w/ good anterior epidural spread will do the trick...
       

      lobelsteve

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        the literature only really supports its efficacy if done within 8 weeks of the fracture... persistent axial pain in the setting of old vertebral fx: i would think of discogenic vs facetogenic. In the elderly it is surprising how a well placed bilateral transforaminal w/ good anterior epidural spread will do the trick...

        There is an article with N=5 for delayed vertebroplasty being very effective in 3/5, effective in 1/5, and no better in 1/5. All were at least 1 year from the Fx date and none had marrow signal anymore.

        I'd block the facets first, then try a unilateral TF-ESI or b/l without caine.
        If it still hurts, try vertebro or consider disco/grc/pdd.
        Least to most invasive and get the dx first.
        No wrong answer, unless you have some retropulsed mobile fragments-then skip the vertebro.
         
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        lobelsteve

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          what is the success rate just placing a interlaminar thoracic ESI without going transforaminal?

          There is no literature worth mentioning. The success rate would hover around 35%, THE SAME RATE FOR PLACEBO.
           

          Aether2000

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            Oh ho!! You love to stir the pot :)
            There are only a few small comparative studies of which I am aware.
            However, there is significant evidence now that:
            a. doctors doing blind interlaminar injections haven't a clue as to what level they are injecting
            b. doctors that use loss of resistance as the only method of determining entry into the epidural space are wrong 25% of the time
            c. most pain doctors do not use test doses, even if test doses were useful (which is doubtful)
            d. the medication once injected into the epidural space (assuming the doctor is even close to the epidural space) reaches the target anywhere from 25 to 75% of the time
            e. dilution of the steroid presumably reduces the effect at the target
            f. most epidural injections using low volume are unilateral
            g. complications from air loss of resistance techniques can be severe including massive headaches from pneumocephalus, intraventricular air injections, nerve root compression, etc.
            h. hanging drop techniques may have a higher dural penetration rate since the dura is tented by the needle using this technique
            i. most academic centers as recent as a few years ago used blind fluoroscopic epidural steroid injections
            j. fluoroscopy with contrast reduces the risk of a sloppy inaccurate technique and may reduce the complication rate
             

            lobelsteve

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              I didn't say blind IL. Let me clarify: what data supports using fluoro-guided TF over fluoro-guided IL for compression fracture pain?

              If any exists, it would be anecdotal or case series. Hence my tone.....sarcasm.

              Little to no literature exists to support ESI, either IL or TF for vertebral compression Fx related pain. In the eyes of PAZ, then, there is no literature to not support not doing the procedure.

              Triple double negative.

              I have had an elderly female patient with a T12 comp Fx, she told the surgeons at 4 weeks out that she did not want kypho/vertebro. As her surgeons were my largest referral source, I did not offer vertebro at 8 or 12 weeks. She later decided she wanted to get rid of the pain. THe surgeons balked. I did 2 IL-ESI's and her pain was much improved. I attribute that to the instillation of hope more than the instillation of steroid.
               

              drusso

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                If any exists, it would be anecdotal or case series. Hence my tone.....sarcasm.

                Little to no literature exists to support ESI, either IL or TF for vertebral compression Fx related pain. In the eyes of PAZ, then, there is no literature to not support not doing the procedure.

                Triple double negative.

                I have had an elderly female patient with a T12 comp Fx, she told the surgeons at 4 weeks out that she did not want kypho/vertebro. As her surgeons were my largest referral source, I did not offer vertebro at 8 or 12 weeks. She later decided she wanted to get rid of the pain. THe surgeons balked. I did 2 IL-ESI's and her pain was much improved. I attribute that to the instillation of hope more than the instillation of steroid.

                Or, to borrow the form of argument common among some pain doctors I know..."If your elderly patient with a compression got better with ILESI injections, then clearly this is prima facie evidence that her pain generator was successfully treated..."
                 

                Aether2000

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                  I know no self respecting physician here would do blind epidurals....I am on a campaign to wipe them out or to reduce payment as low as they are worth. Fluoro guided ESI may have certain applications.

                  I continue to ponder the double triple negative...or was it triple double negative....
                   

                  Mister Mxyzptlk

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                    Or, to borrow the form of argument common among some pain doctors I know..."If your elderly patient with a compression got better with ILESI injections, then clearly this is prima facie evidence that her pain generator was successfully treated..."

                    Take ownership of successful outcomes wherever and whenever you can. If the patient thinks you helped him, don't argue.

                    There will be plenty of times you are blamed for something that's not your fault so enjoy the acclamation even if it's undeserved. It will all average out.
                     

                    PainDr

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                      Anyone have a limit on the number of levels they'd cement during one session? I have a patient with three levels and am a little hesitant to do all three at once. Seems like alot to put him through with MAC and I don't want to use general.
                       

                      caedmon

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                        Saw a presentation a couple of weeks ago about this procedure. Is anyone out there doing this? If so, how does it compare to vertebroplasty? Seems like the idea is to provide a safer procedure with less chance of a spinal injury.
                         

                        ParaVert

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                          Anyone have a limit on the number of levels they'd cement during one session? I have a patient with three levels and am a little hesitant to do all three at once. Seems like alot to put him through with MAC and I don't want to use general.

                          Our reps with Cardinal Health recommend no more than three levels at a time, although we occasionally exceed this without incident. A big concern appears to be the vasodilatory effect of the PMMA solvent. That being said, it is generally accepted that average volume of injected PMMA in vertebroplasty is significantly less now than when the procedure was new and more complications were occuring. Perhaps this convention of 3 or less should be revisited (may be moot in privates due to reimbursement). Thankfully now people are less goal oriented when it comes to cranking in a pre-determined volume into a vertebral body. The spread is much more important.

                          As far as the MAC goes, I guess it depends. In my fellowship, we probably do more cement procedures than anyone anywhere. We do both vertebroplasty and kyphoplasty under "MAC," but they are pretty much totally out. I don't think that the ISIS recommendations concerning sedation have anything to do with hammering an 8 gauge spike through a person's pedicle.

                          I think the biggest case I've done in fellowship is a 5-level kyphoplasty, but that patient was intubated under GA. We used a little more than 20 cc of PMMA.

                          Speaking of which, are any of you guys out there doing kyphoplasty? Never mind the debate over outcomes vs. vertebro. Just wondering.
                           

                          lobelsteve

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                            Our reps with Cardinal Health recommend no more than three levels at a time, although we occasionally exceed this without incident. A big concern appears to be the vasodilatory effect of the PMMA solvent. That being said, it is generally accepted that average volume of injected PMMA in vertebroplasty is significantly less now than when the procedure was new and more complications were occuring. Perhaps this convention of 3 or less should be revisited (may be moot in privates due to reimbursement). Thankfully now people are less goal oriented when it comes to cranking in a pre-determined volume into a vertebral body. The spread is much more important.

                            As far as the MAC goes, I guess it depends. In my fellowship, we probably do more cement procedures than anyone anywhere. We do both vertebroplasty and kyphoplasty under "MAC," but they are pretty much totally out. I don't think that the ISIS recommendations concerning sedation have anything to do with hammering an 8 gauge spike through a person's pedicle.

                            I think the biggest case I've done in fellowship is a 5-level kyphoplasty, but that patient was intubated under GA. We used a little more than 20 cc of PMMA.

                            Speaking of which, are any of you guys out there doing kyphoplasty? Never mind the debate over outcomes vs. vertebro. Just wondering.


                            We may do these when the codes/reimbursement allows us to do them in the ASC. We would also need patients referred to us that have compression Fx. We see no more than 5 per year currently.
                             

                            ParaVert

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                              Interesting. Is this because the area in which you practice has a number of interventional radiologists who are taking the business, or is it that the internists, oncologists, and geriatricians in your area are not referring pts out for compression fractures at all?

                              Either way, this brings up a great question for the private guys out there -- Marketing. The pain community seems so divided on this issue. Some people live and die by their spine surgeon referrals, others seem to focus on neurology and primary care to catch pts before they get cut. The latter seems similar to how cardiology has become a gatekeeper for CABG.

                              Anyone want to make a comment on their strategy?
                               

                              lobelsteve

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                                Interesting. Is this because the area in which you practice has a number of interventional radiologists who are taking the business, or is it that the internists, oncologists, and geriatricians in your area are not referring pts out for compression fractures at all?

                                Either way, this brings up a great question for the private guys out there -- Marketing. The pain community seems so divided on this issue. Some people live and die by their spine surgeon referrals, others seem to focus on neurology and primary care to catch pts before they get cut. The latter seems similar to how cardiology has become a gatekeeper for CABG.

                                Anyone want to make a comment on their strategy?

                                Treat all of your patients with respect. Be honest. Be aggressive in treeating their pain. Follow the standards of care. You will see a lot of liars, addicts, malingerers, somatisizers, and fibromyalgia. These folks are not treated with opioids or procedures. Call it like you see it, give everyone the benefit of the doubt as they enter the practice, and do due diligence in following these folks. It is a part of pain medicine that requires the most skill and tact. Your referral source will be grateful and you'll have plenty of time for your 721.0, 724.4, 721.3, CRPS, 722.52, 722.81, 722.83, occipital neuralgia, etc.
                                 

                                Mister Mxyzptlk

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                                  I like what lobelsteve said and would emphasize that if you don't take care of the customer someone else will. Both the patient and the referring doctor are your clientele. That means if a surgeon sends you a lot of referrals and he wants help with postop pain management you better damn well do it because someone else who's hungrier will. I have a gentleman's agreement with the referring surgeons that I will help with postop pain on any patient that I have treated. They don't abuse that.

                                  To me it's all about eggs and baskets. As with the stock market, you should diversify. I'd prefer lots of little baskets to a few big ones. If there is one surgeon who sends you half your business that person pretty much owns you.

                                  I also try to be on the "gatekeeper" side of things. Therefore I have emphasized the primary care referral route rather than depend on surgical referrals (although I still have plenty of those). One thing you need to do is break the "back pain -> surgical referral" reflex. You can educate the PCPs about "red flags" that need surgical referrals vs the 99% that can wait and have conservative management first.

                                  I usually try to make my "Impression" and "Plan" sections educational, in the hope that if someone actually reads my note they will learn how to determine what can wait and what needs a surgery evaluation. They also learn that it's not just a prescriptions-and-shots practice, but that a patient with back pain can be sent for initial evaluation and a surgical referral will be made as needed.

                                  As a result of these efforts my referral base is wide and shallow - I get a few referrals each from a lot of people. That also gives me some control over specialist referrals - I can steer patients to the surgeons, neurologists, physiatrists, imaging, etc, that I prefer. There are few better incentives for someone to refer you patients than the fact that you are sending them patients.

                                  The downside, as discussed elsewhere, is that when those PCPs, internists, neurologists, etc, admit a patient that needs pain management you are expected to help out with the dreaded hospital consult. I'd rather do that than be beholden to a couple of surgeons for my livelihood.

                                  I am also not above reminding someone who I have just bailed out with a simple PCA pump or an inpatient LESI that I expect outpatient referrals in exchange for inpatient support. If I know they use someone else routinely and I am being called because that guy won't do the consult I will discuss that situation with them before I do the consult. It's usually along the lines of "I know you like to use Joe Smith, but if he isn't going to be there when you need him and I am, then perhaps you need to re-think your relationship." if I don't see referrals as a result, the next consult is declined.

                                  If I know that doing the consult definitely won't change the referral pattern I will tell the nurses that they need to consult Dr. Joe Smith, who is the referring physician's preferred pain doctor. Usually they will tell me they already tried that, which obviously does not increase my enthusiasm for the consult. I see no need to inconvenience myself to help out someone who will not send me outpatient referrals no matter what I do.

                                  In my area (Houston) everyone is doing deals all the time because there are no certificate of need requirements in Texas and ASCs are crowding crack dealers off of the best street corners. If a surgeon and a pain guy are partners in an ASC then that's where the referrals will go.

                                  Some guys will see patients at the surgeon's office and pay "rent" (aka "kickback"). The problem with financially based relationships is that as soon as someone comes along with a better deal there go your referrals. I prefer not to buy my friends because then they are always going with the highest bidder.

                                  If someone tells me they will refer me patients but they must be done at a certain facility I will do that, but that's as far as I will go.
                                   

                                  mille125

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                                    I like what lobelsteve said and would emphasize that if you don't take care of the customer someone else will. Both the patient and the referring doctor are your clientele. That means if a surgeon sends you a lot of referrals and he wants help with postop pain management you better damn well do it because someone else who's hungrier will. I have a gentleman's agreement with the referring surgeons that I will help with postop pain on any patient that I have treated. They don't abuse that.

                                    To me it's all about eggs and baskets. As with the stock market, you should diversify. I'd prefer lots of little baskets to a few big ones. If there is one surgeon who sends you half your business that person pretty much owns you.

                                    I also try to be on the "gatekeeper" side of things. Therefore I have emphasized the primary care referral route rather than depend on surgical referrals (although I still have plenty of those). One thing you need to do is break the "back pain -> surgical referral" reflex. You can educate the PCPs about "red flags" that need surgical referrals vs the 99% that can wait and have conservative management first.

                                    I usually try to make my "Impression" and "Plan" sections educational, in the hope that if someone actually reads my note they will learn how to determine what can wait and what needs a surgery evaluation. They also learn that it's not just a prescriptions-and-shots practice, but that a patient with back pain can be sent for initial evaluation and a surgical referral will be made as needed.

                                    As a result of these efforts my referral base is wide and shallow - I get a few referrals each from a lot of people. That also gives me some control over specialist referrals - I can steer patients to the surgeons, neurologists, physiatrists, imaging, etc, that I prefer. There are few better incentives for someone to refer you patients than the fact that you are sending them patients.

                                    The downside, as discussed elsewhere, is that when those PCPs, internists, neurologists, etc, admit a patient that needs pain management you are expected to help out with the dreaded hospital consult. I'd rather do that than be beholden to a couple of surgeons for my livelihood.

                                    I am also not above reminding someone who I have just bailed out with a simple PCA pump or an inpatient LESI that I expect outpatient referrals in exchange for inpatient support. If I know they use someone else routinely and I am being called because that guy won't do the consult I will discuss that situation with them before I do the consult. It's usually along the lines of "I know you like to use Joe Smith, but if he isn't going to be there when you need him and I am, then perhaps you need to re-think your relationship." if I don't see referrals as a result, the next consult is declined.

                                    If I know that doing the consult definitely won't change the referral pattern I will tell the nurses that they need to consult Dr. Joe Smith, who is the referring physician's preferred pain doctor. Usually they will tell me they already tried that, which obviously does not increase my enthusiasm for the consult. I see no need to inconvenience myself to help out someone who will not send me outpatient referrals no matter what I do.

                                    In my area (Houston) everyone is doing deals all the time because there are no certificate of need requirements in Texas and ASCs are crowding crack dealers off of the best street corners. If a surgeon and a pain guy are partners in an ASC then that's where the referrals will go.

                                    Some guys will see patients at the surgeon's office and pay "rent" (aka "kickback"). The problem with financially based relationships is that as soon as someone comes along with a better deal there go your referrals. I prefer not to buy my friends because then they are always going with the highest bidder.

                                    If someone tells me they will refer me patients but they must be done at a certain facility I will do that, but that's as far as I will go.



                                    This is a very good quote. I also get many referrals from primary care. It took awhile but I have finally changed their thinking about treating back pain. Greater than 70% of my new patients have had pain for less than three months (a stark contrast from fellowship). I have paired myself with a rather conservative surgeon who is willing to try noninvasive approaches on most patients before surgery. I have had to do an inpatient consult from time to time but it is not particularly onerous (may give you a chance to use epidural morphine). I can also easily point out to the PCP's that the other pain doctors in town do not go to the hospital (which helps with referrals). Overall, I am very happy with the situation and would not change it for anything.
                                     

                                    mille125

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                                      I like what lobelsteve said and would emphasize that if you don't take care of the customer someone else will. Both the patient and the referring doctor are your clientele. That means if a surgeon sends you a lot of referrals and he wants help with postop pain management you better damn well do it because someone else who's hungrier will. I have a gentleman's agreement with the referring surgeons that I will help with postop pain on any patient that I have treated. They don't abuse that.

                                      To me it's all about eggs and baskets. As with the stock market, you should diversify. I'd prefer lots of little baskets to a few big ones. If there is one surgeon who sends you half your business that person pretty much owns you.

                                      I also try to be on the "gatekeeper" side of things. Therefore I have emphasized the primary care referral route rather than depend on surgical referrals (although I still have plenty of those). One thing you need to do is break the "back pain -> surgical referral" reflex. You can educate the PCPs about "red flags" that need surgical referrals vs the 99% that can wait and have conservative management first.

                                      I usually try to make my "Impression" and "Plan" sections educational, in the hope that if someone actually reads my note they will learn how to determine what can wait and what needs a surgery evaluation. They also learn that it's not just a prescriptions-and-shots practice, but that a patient with back pain can be sent for initial evaluation and a surgical referral will be made as needed.

                                      As a result of these efforts my referral base is wide and shallow - I get a few referrals each from a lot of people. That also gives me some control over specialist referrals - I can steer patients to the surgeons, neurologists, physiatrists, imaging, etc, that I prefer. There are few better incentives for someone to refer you patients than the fact that you are sending them patients.

                                      The downside, as discussed elsewhere, is that when those PCPs, internists, neurologists, etc, admit a patient that needs pain management you are expected to help out with the dreaded hospital consult. I'd rather do that than be beholden to a couple of surgeons for my livelihood.

                                      I am also not above reminding someone who I have just bailed out with a simple PCA pump or an inpatient LESI that I expect outpatient referrals in exchange for inpatient support. If I know they use someone else routinely and I am being called because that guy won't do the consult I will discuss that situation with them before I do the consult. It's usually along the lines of "I know you like to use Joe Smith, but if he isn't going to be there when you need him and I am, then perhaps you need to re-think your relationship." if I don't see referrals as a result, the next consult is declined.

                                      If I know that doing the consult definitely won't change the referral pattern I will tell the nurses that they need to consult Dr. Joe Smith, who is the referring physician's preferred pain doctor. Usually they will tell me they already tried that, which obviously does not increase my enthusiasm for the consult. I see no need to inconvenience myself to help out someone who will not send me outpatient referrals no matter what I do.

                                      In my area (Houston) everyone is doing deals all the time because there are no certificate of need requirements in Texas and ASCs are crowding crack dealers off of the best street corners. If a surgeon and a pain guy are partners in an ASC then that's where the referrals will go.

                                      Some guys will see patients at the surgeon's office and pay "rent" (aka "kickback"). The problem with financially based relationships is that as soon as someone comes along with a better deal there go your referrals. I prefer not to buy my friends because then they are always going with the highest bidder.

                                      If someone tells me they will refer me patients but they must be done at a certain facility I will do that, but that's as far as I will go.



                                      This is a very good quote. I also get many referrals from primary care. It took awhile but I have finally changed their thinking about treating back pain. Greater than 70% of my new patients have had pain for less than three months (a stark contrast from fellowship). I have paired myself with a rather conservative surgeon who is willing to try noninvasive approaches on most patients before surgery. I have had to do an inpatient consult from time to time but it is not particularly onerous (may give you a chance to use epidural morphine). I can also easily point out to the PCP's that the other pain doctors in town do not go to the hospital (which helps with referrals). Overall, I am very happy with the situation and would not change it for anything.
                                       
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