smarterchild

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I’m still trying to figure how best to arrange my schedule and was hoping to get your input. I usually book follow up visits for 15 min and new patients for 30 min. For procedures, any spinal injection, I book in 30 min slots and joints in 15 min slots. Inevitably, I have several no shows (even after confirming them many times as late as 1 day before the procedure). As all of you, I hate having these gaps. I’ve started to double book which isn’t ideal but does eliminate some of the down time caused by no shows. It, however, does lead to some waiting for patients.

I should add that I have separate procedure and office visit days

I’m curious to hear how you all book your days for office visits and injections and What you think is a “reasonable” time for a patient to wait to be seen?
 
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8YearsLate

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I have no idea what's going on here but I felt the need to compliment your username. Nice throwback.
 
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I’m still trying to figure how best to arrange my schedule and was hoping to get your input. I usually book follow up visits for 15 min and new patients for 30 min. For procedures, any spinal injection, I book in 30 min slots and joints in 15 min slots. Inevitably, I have several no shows (even after confirming them many times as late as 1 day before the procedure). As all of you, I hate having these gaps. I’ve started to double book which isn’t ideal but does eliminate some of the down time caused by no shows. It, however, does lead to some waiting for patients.

I should add that I have separate procedure and office visit days

I’m curious to hear how you all book your days for office visits and injections and What you think is a “reasonable” time for a patient to wait to be seen?
Why 30 minutes for a spine injection? Do you do everything in an ASC with really slow turnover and lots of onerous paperwork? For in office injections I do 15 minutes, double-booking 1 per half day otherwise I end up taking extra breaks to wait for patients. 30-45 minutes for RF. I don’t consider myself extremely fast, and still have plenty of time if an injection is more technically difficult.
 
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SommeRiver

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I see 4-6 clinic pts per hour, new vs old. An epidural you should be scheduling for 10 min. Having said that, the TFESI is the injxn that will screw you on occasion. Facets in the way, vascular, pt tolerability, anatomy, can't get on the table...RFA I schedule for 20 min.
 

SSdoc33

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I see 4-6 clinic pts per hour, new vs old. An epidural you should be scheduling for 10 min. Having said that, the TFESI is the injxn that will screw you on occasion. Facets in the way, vascular, pt tolerability, anatomy, can't get on the table...RFA I schedule for 20 min.
this is about what i do as well
 
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I see 4-6 clinic pts per hour, new vs old. An epidural you should be scheduling for 10 min. Having said that, the TFESI is the injxn that will screw you on occasion. Facets in the way, vascular, pt tolerability, anatomy, can't get on the table...RFA I schedule for 20 min.
What’s your procedure setup, ASC or clinic? How many procedure rooms do you work out of?
 

Ferrismonk

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I do 10 min simple injections, including ESI.
I do 20 min facet/MBB
I do 30 min RFA, unilateral or bilateral.
If they get sedation, 20 minutes.

I do run behind, but I can usually make that up with unilateral RFA and any simple injections that the patient requires sedation for.
 

SSdoc33

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no sedation, 5 injections/hour. joints are shorter, RFs longer
 

smarterchild

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wow! i'm impressed by all these numbers!

i'm not the fastest proceduralist by any means but I find that most of my time is taken up in speaking with the patient before the procedure (even though I explain it in detail when scheduling it) and then helping to position the patient and getting the equipment ready. The procedure itself may take me 10 min to complete but its all this other stuff that adds up.

I'm in a fairly small office based practice where I have one MA in the room with me that gets my meds and works the C arm. I don't use sedation for any procedures

For those of you doing 4-5 injections per hour, what type of staffing do you have and how do you keep things moving quickly with one procedure room?
 

SSdoc33

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wow! i'm impressed by all these numbers!

i'm not the fastest proceduralist by any means but I find that most of my time is taken up in speaking with the patient before the procedure (even though I explain it in detail when scheduling it) and then helping to position the patient and getting the equipment ready. The procedure itself may take me 10 min to complete but its all this other stuff that adds up.

I'm in a fairly small office based practice where I have one MA in the room with me that gets my meds and works the C arm. I don't use sedation for any procedures

For those of you doing 4-5 injections per hour, what type of staffing do you have and how do you keep things moving quickly with one procedure room?
rad tech and MA in the room, LPN outside it.
 
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wow! i'm impressed by all these numbers!

i'm not the fastest proceduralist by any means but I find that most of my time is taken up in speaking with the patient before the procedure (even though I explain it in detail when scheduling it) and then helping to position the patient and getting the equipment ready. The procedure itself may take me 10 min to complete but its all this other stuff that adds up.

I'm in a fairly small office based practice where I have one MA in the room with me that gets my meds and works the C arm. I don't use sedation for any procedures

For those of you doing 4-5 injections per hour, what type of staffing do you have and how do you keep things moving quickly with one procedure room?
Instead of talking to the patient before the procedure just ask them “any changes since I saw you last? Do you have any questions about the procedure?” Otherwise their questions can wait until follow up. This doesn’t compromise quality of care; it’s just respect for your time. I used to talk to every patient before bringing them back to the procedure room but it really slowed me down. Now I just talk to them when they come into the procedure room. Having us both standing makes them feel awkward about long chit-chats.
I have one procedure room, no IV sedation. Typically a fluoro tech and my scribe in the room with me, and another MA to check patients in/out and do the paperwork. Tech positions patient while scribe and I draw up meds. Scribe does note while I do injection. During RFs she goes off to answer phone calls or do other tasks. I can keep nearly the same pace without her, with the tech helping draw up meds, but sometimes I have to finish notes later. I typically have 4 15-minute procedure slots per hour - Now I’m looking for tips to make that 10 minute slots.
 
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Ferrismonk

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I have RN in pre/post room who does intake, vitals, pain scores, etc. Starts IV if getting sedation.
I have a separate anesthesiologist to provide sedation if needed.
In the room I have a single MA and myself. MA turns over room, sets up my sterile tray, preps patient, etc. I use this time to do my note. If needed, I'll talk to patient while this is happening and do my note later. I draw meds with MA help while prep dries. When done, I take care of my sharps/etc while MA cleans patient and gets them up. MA takes to recovery for post-vitals. Repeat.
 

SommeRiver

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What’s your procedure setup, ASC or clinic? How many procedure rooms do you work out of?
Clinic - One room. I have an XRAY tech and a nurse tech.

ASC - Two rooms. I have an XRAY tech and nurse tech.

Obviously, we have people involved in intake/discharge.

No sedation other than PO Valium unless I'm doing a case that needs MAC - Stim or stellate.

Common procedures and their needle time:

TFESI/ILESI - 5 to 10 min.
SIJ - 3 min
Lumbar MBB - 3 min
Cervical MBB - 5 min
Lumbar facet (rarely do them) - 5 to 10 min
Lumbar RFA - 15 to 18 min
Cervical RFA - 20 to 22 min (hate them)
Caudal - 3 min
Hip - 2 min
Stim trial - 20 to 25 min
Implant - 60 to 70 min

On and off the table, XRAY scanning, drawing meds, etc...That is what takes time and why no sedation or just Valium PO is the way to do it. The procedures are USUALLY quick, but occasionally there's a mess of a pt that steals your soul.

I did a 45 min cervical RFA 2 months ago, and I did a bilateral L4-5 TFESI this AM that took 20 min. I've had stim trials that took 12 min of procedure time, and I recently did a CESI that took 3 min at the most (25g and no LOR saves time and needle manipulation).
 
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SommeRiver

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I typically have 4 15-minute procedure slots per hour - Now I’m looking for tips to make that 10 minute slots.
I do not recommend pre-injection conversation. I am drawing up meds one-handed while the XRAY tech and nurse tech get the pt on the table. While I am drawing meds I hand the prep to the nurse tech who cleans. I drape. All the while I'm talking to the patient about whatever. Usually lifestyle conversation TBH.

Your conversation is costing you probably one injxn per hour, potentially 3 every two hrs (I would guess).

I used to post injection see pts...That is absurd and worthless.

We're talking about shots, not a chole...

Lemme also add I will absolutely NOT allow one of my pts to feel like they've been "processed." As in, treated like cattle on procedure days. There is a huge ortho machine in Atlanta that does that...I don't pre or post injxn see the pt...So much of their experience is feeling like they have 100% of you while they're with you. I rarely talk pain stuff and I'd say 95% of the time I'm talking to them about where they're from, my military experience, sports, etc...
 
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I barely talk to the patient for procedures. All the talking is done in the office visit. I just say “ how are you today? Any questions before we start ?”
 

so55b

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Clinic - One room. I have an XRAY tech and a nurse tech.

ASC - Two rooms. I have an XRAY tech and nurse tech.

Obviously, we have people involved in intake/discharge.

No sedation other than PO Valium unless I'm doing a case that needs MAC - Stim or stellate.

Common procedures and their needle time:

TFESI/ILESI - 5 to 10 min.
SIJ - 3 min
Lumbar MBB - 3 min
Cervical MBB - 5 min
Lumbar facet (rarely do them) - 5 to 10 min
Lumbar RFA - 15 to 18 min
Cervical RFA - 20 to 22 min (hate them)
Caudal - 3 min
Hip - 2 min
Stim trial - 20 to 25 min
Implant - 60 to 70 min

On and off the table, XRAY scanning, drawing meds, etc...That is what takes time and why no sedation or just Valium PO is the way to do it. The procedures are USUALLY quick, but occasionally there's a mess of a pt that steals your soul.

I did a 45 min cervical RFA 2 months ago, and I did a bilateral L4-5 TFESI this AM that took 20 min. I've had stim trials that took 12 min of procedure time, and I recently did a CESI that took 3 min at the most (25g and no LOR saves time and needle manipulation).
Could you please share how to do 25g technique for a CESI? just with contrast? what about lumbar? any downsides?
 

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For those of you that do procedures in office, are your interlams just steroid or do you mix with saline to get volume? Obviously you aren’t putting local in your mix correct?



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When is consent happening for the people that don't talk to the patients prior to the procedure. Is everyone getting consented in clinic? Also I get a fair amount of outside referrals for injections (show up for injection not clinic visit) are people making exceptions for the no talking pre-procedure for these patients, or some other workflow?
 

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Could you please share how to do 25g technique for a CESI? just with contrast? what about lumbar? any downsides?
I got that from this forum. Saw the pics posted by several dudes, and now that is how I do CESI.

25g needle and take it to the interlaminar depth.

Shallow enough you know you're posterior to the ligament.

Put a 0.25 cc dot of contrast there. It is posterior.

Advance 0.5 mm and put another tiny drop of contrast. It is posterior.

Advance another tiny amount and put contrast there...Keep doing that until you're getting epidural spread.

If you poke a hole in the cervical dura at C7, that is a teeny hole and less likely than a 20g or 22g Tuohy to cause PDPH.

You can also move from skin to interlaminar depth A LOT quicker with the 25g bc it is so small. Rather than smaller advancements with a Tuohy that size, you can straight drive that needle deep in one or two advancements with much less discomfort.

I take the AP with slight ipsilateral oblique, enter skin. Go in a few mm and get purchase in the tissue, go CLO 45 deg and see my depth, don't advance yet...Go back AP with ipsilateral oblique and drive that needle a good distance in one or two movements. Then, CLO and go interlaminar and start my contrast...

Mixtures - CESI for me is either dexamethasone 10mg or Depo 40, along with 2cc saline.

LESI - Depo 40 or 80 and saline 3cc.

I never put local between the lamina, but I occasionally do in the foramen.
 
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clubdeac

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I got that from this forum. Saw the pics posted by several dudes, and now that is how I do CESI.

25g needle and take it to the interlaminar depth.

Shallow enough you know you're posterior to the ligament.

Put a 0.25 cc dot of contrast there. It is posterior.

Advance 0.5 mm and put another tiny drop of contrast. It is posterior.

Advance another tiny amount and put contrast there...Keep doing that until you're getting epidural spread.

If you poke a hole in the cervical dura at C7, that is a teeny hole and less likely than a 20g or 22g Tuohy to cause PDPH.

You can also move from skin to interlaminar depth A LOT quicker with the 25g bc it is so small. Rather than smaller advancements with a Tuohy that size, you can straight drive that needle deep in one or two advancements with much less discomfort.

I take the AP with slight ipsilateral oblique, enter skin. Go in a few mm and get purchase in the tissue, go CLO 45 deg and see my depth, don't advance yet...Go back AP with ipsilateral oblique and drive that needle a good distance in one or two movements. Then, CLO and go interlaminar and start my contrast...

Mixtures - CESI for me is either dexamethasone 10mg or Depo 40, along with 2cc saline.

LESI - Depo 40 or 80 and saline 3cc.

I never put local between the lamina, but I occasionally do in the foramen.
1592965454617.png
 
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SommeRiver

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I really should publish 10 year data on technique/safety.
Deserving of publication, and it has made my life easier dude. Best part is that it doesn't require any training. If you already do CESI the traditional way, you're simply using a smaller needle and skipping a step...That's it.

I've recommended it to other ppl and many scoff at it for reasons unclear to me.

Edit - This pt is following up with me in like 30 min. That injxn took like 4 min at the most. Once I get a few mm into tissue and go CLO (to see how deep the pt is), I go back AP and I drive it long distances (each advance may be an inch or more depending on depth) before going back CLO to finish. Much faster technique, and with a 25g needle it just has to be safer.

Before doing this I only had one PDPH. Since, none. You can argue cervical puncture are usually ASx.
 

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SSdoc33

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i appreciate the technique, but i dont see how it is all that much faster. you can do the same thing by using a touhy and LOR with contrast.

is a 25g safer? probably. i still wouldnt want to puff any contrast in the middle of the cord, though.
 
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i appreciate the technique, but i dont see how it is all that much faster. you can do the same thing by using a touhy and LOR with contrast.

is a 25g safer? probably. i still wouldnt want to puff any contrast in the middle of the cord, though.
One could argue it is less safe using a 25 gauge due to less feel. But given modern techniques used in fluoroscopy with contralateral oblique Imaging that is a moot point. Now we can argue there’s less tissue disruption and pain.
 
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One could argue it is less safe using a 25 gauge due to less feel. But given modern techniques used in fluoroscopy with contralateral oblique Imaging that is a moot point. Now we can argue there’s less tissue disruption and pain.
One issue I have with using the 25g is what I experienced to day. I use a 22g tuohy, but have abandoned the LOR syringe of saline in favor of a 3 mL syringe with 1 ML contrast based on advice from this forum. I had a couple puffs in the ligamentum, then felt a slight click and good loss of resistance to the next puff of contrast, but saw no epidural spread. Without that tactile feedback I might have assumed the contrast was in the ligament and kept advancing. Instead I injected a little under live and saw the venous pattern, and redirected the needle.
 

SommeRiver

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One issue I have with using the 25g is what I experienced to day. I use a 22g tuohy, but have abandoned the LOR syringe of saline in favor of a 3 mL syringe with 1 ML contrast based on advice from this forum. I had a couple puffs in the ligamentum, then felt a slight click and good loss of resistance to the next puff of contrast, but saw no epidural spread. Without that tactile feedback I might have assumed the contrast was in the ligament and kept advancing. Instead I injected a little under live and saw the venous pattern, and redirected the needle.
Here are my thoughts FWIW (not much):

I never rely on loss to tell me anything. It is unreliable, and I would argue that with available fluoro at 45 deg CLO you should NOT put any faith in tactile information. I believe 100% of your safety and information should come from imaging, which never lies.

I am so against LOR I don't use it at all for anything. I do not use it for SCS or ILESI bc it is inconsistent. You save time during SCS just loading the lead 1-2 cm from the tip and using your lead as a form of "contrast."

We've all had false loss and no loss pts. We've all seen epidural contrast patterns with no loss.

So I guess IMO the fluoro is my loss.
 
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Here are my thoughts FWIW (not much):

I never rely on loss to tell me anything. It is unreliable, and I would argue that with available fluoro at 45 deg CLO you should NOT put any faith in tactile information. I believe 100% of your safety and information should come from imaging, which never lies.

I am so against LOR I don't use it at all for anything. I do not use it for SCS or ILESI bc it is inconsistent. You save time during SCS just loading the lead 1-2 cm from the tip and using your lead as a form of "contrast."

We've all had false loss and no loss pts. We've all seen epidural contrast patterns with no loss.

So I guess IMO the fluoro is my loss.
Call me overly cautious, but I don’t fully rely on either - in the situation I described the imaging would have misled. The needle was epidural but the contrast didn’t show, and the tip of the needle was already a little obscured from contrast in the ligamentum. I find that in most cases, I do still get useful information from the tactile feedback. I’d say at least 90% of the time I know I’m in the epidural space by feel and the contrast flow is just confirmatory. Sometimes the tactile feedback is misleading, sometimes the fluoro is misleading, but rarely both at once.
 
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lobelsteve

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LOR is useless.
25g spinal. Touch lamina of T1. Walk off superiorly under AP staying 3-4 mm paramedian. Go CLO. Advance towards target and when 2mm out put in a drop of contrast to show you are not epidural. Advance 1mm at a time with a drop of contrast after each movement. Once in epidural space you will see the vertical spread of contrast. If you get 1mm past the line connecting your footballs, go AP to see that you went more medial/lateral than anticipated.
 

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LOR is useless.
25g spinal. Touch lamina of T1. Walk off superiorly under AP staying 3-4 mm paramedian. Go CLO. Advance towards target and when 2mm out put in a drop of contrast to show you are not epidural. Advance 1mm at a time with a drop of contrast after each movement. Once in epidural space you will see the vertical spread of contrast. If you get 1mm past the line connecting your footballs, go AP to see that you went more medial/lateral than anticipated.
Can you explain your 25G TFESI technique again?
 

lobelsteve

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Back on topic of schedule:

Today, for some reason, I have 27 on my schedule. I like 30-32 scheduled so I can see 27-28 with no shows and cancellations.
Only 5 office visits. Rest are new patients or procedures. COVID ramping back up and either we don't care or we are getting all of it done before apocalypse.
 
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paindoc007

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30 today for me. 15 procedures and 15 office visits.
Dang dude. If that’s a normal day, 5 days a week, 46-47 weeks a year. There is NO way you should only be making 400-450k yearly (I think you said that in a previous post but could be wrong).

That too is my typical volume, and I make way more than that.
 
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Sorry, yes L-spine. I don't do CTFESI either.
Just take a 25g and stick it down 0.5cm lateral to lamina and inferior to the TP. After a few CM go lateral and see how much further up and medial to go to get into foramen. I am not particular about foraminal location as long as there is epidural spread. I usually wind up anterior/superior in foramen. Squirt contrast then go AP for more contrast. Then dex 4mg
 
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painfree23

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Just take a 25g and stick it down 0.5cm lateral to lamina and inferior to the TP. After a few CM go lateral and see how much further up and medial to go to get into foramen. I am not particular about foraminal location as long as there is epidural spread. I usually wind up anterior/superior in foramen. Squirt contrast then go AP for more contrast. Then dex 4mg
U start in AP?
 

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I just want to learn how you guys are so efficient.
Starting a practice in the Covid-era is a little stressful. Who knows when the next elective halt is going to happen.
How are you guys staffing your office?
I was thinking of 2 MA a virtual assistant to do the prior auths, +/- front desk person or have one of the MA do it.
 

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You know what's funny? In fellowship everyone is carried away with stim and sexy stuff. Reality is that the epidural and facet procedures are the vast majority of what you do and you need to be really good at them.
My fellowship director always told us to focus on being really accurate and safe with cervical procedures (CESI, facets, mbbs, RFA). If we were good at that the rest would be easy. He was right.


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I got that from this forum. Saw the pics posted by several dudes, and now that is how I do CESI.

25g needle and take it to the interlaminar depth.

Shallow enough you know you're posterior to the ligament.

Put a 0.25 cc dot of contrast there. It is posterior.

Advance 0.5 mm and put another tiny drop of contrast. It is posterior.

Advance another tiny amount and put contrast there...Keep doing that until you're getting epidural spread.

If you poke a hole in the cervical dura at C7, that is a teeny hole and less likely than a 20g or 22g Tuohy to cause PDPH.

You can also move from skin to interlaminar depth A LOT quicker with the 25g bc it is so small. Rather than smaller advancements with a Tuohy that size, you can straight drive that needle deep in one or two advancements with much less discomfort.

I take the AP with slight ipsilateral oblique, enter skin. Go in a few mm and get purchase in the tissue, go CLO 45 deg and see my depth, don't advance yet...Go back AP with ipsilateral oblique and drive that needle a good distance in one or two movements. Then, CLO and go interlaminar and start my contrast...

Mixtures - CESI for me is either dexamethasone 10mg or Depo 40, along with 2cc saline.

LESI - Depo 40 or 80 and saline 3cc.

I never put local between the lamina, but I occasionally do in the foramen.
while most of this is correct, cutting needles have been shown to have increased risk of PDPH than blunt needles. i dont know if you can definitively state that the size difference is enough to overcome the benefits of blunt needle - ie your assumption a 25 gauge sharp needle is less likely to cause PDPH than a blunt Touhy may not be correct.

if you have direct studies comparing both of these 2 aspects, please post. i did not find any, albeit only a quick search (im on vacation).
 
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I’m still trying to figure how best to arrange my schedule and was hoping to get your input. I usually book follow up visits for 15 min and new patients for 30 min. For procedures, any spinal injection, I book in 30 min slots and joints in 15 min slots. Inevitably, I have several no shows (even after confirming them many times as late as 1 day before the procedure). As all of you, I hate having these gaps. I’ve started to double book which isn’t ideal but does eliminate some of the down time caused by no shows. It, however, does lead to some waiting for patients.

I should add that I have separate procedure and office visit days

I’m curious to hear how you all book your days for office visits and injections and What you think is a “reasonable” time for a patient to wait to be seen?
You have to look at your average % of "no shows" and add that many patients to the schedule each day. Occasionally everyone will show up and you will have to hustle. However, in most instances, your average number of "no shows" will not disappoint.

Of course, your times for procedures will be relative to your speed in doing them, which will be different for everyone.

MOST new patients tend to be referred for a single issue, and thus should not take 30 min.
 
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SommeRiver

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while most of this is correct, cutting needles have been shown to have increased risk of PDPH than blunt needles. i dont know if you can definitively state that the size difference is enough to overcome the benefits of blunt needle - ie your assumption a 25 gauge sharp needle is less likely to cause PDPH than a blunt Touhy may not be correct.

if you have direct studies comparing both of these 2 aspects, please post. i did not find any, albeit only a quick search (im on vacation).
All that is my own little mind theorizing about things that vary depending on my blood glucose at the time.

I think diameter probably matters, assuming you've actually put a hole in the dura. Tuohy might just deform it without poking a hole.
 
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All that is my own little mind theorizing about things that vary depending on my blood glucose at the time.

I think diameter probably matters, assuming you've actually put a hole in the dura. Tuohy might just deform it without poking a hole.
Tuohy still has a cutting tip unless you approach from a steep angle so the rounded part is parallel to the dura. A pencan/pencil point will reduce PDPH but those obviously don’t work for ESI because the opening is quite a bit back from the tip. I tried to get the ER on board with using pencil points for their LPs in residency so we wouldn’t get so many calls to blood patch their meningitis rule outs a day or two later.
 

painfree23

2+ Year Member
Jan 26, 2017
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I don’t think there’s anything wrong with it but I just don’t care for it. I like seeing the midline and knowing that I am lateral to start so I don’t get stuck on a spur or hook off the lamina.
If u have a few min can you share a pic of ur AP with the needle along with ur depth? Just curious bc my AP always has the needle coming in from the side below the pedicle (I start in the 20 ipsi oblique). I may try this way tho to limit fluoro movements
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
15+ Year Member
May 30, 2005
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Canton GA
www.stevenlobel.com
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Attending Physician
If u have a few min can you share a pic of ur AP with the needle along with ur depth? Just curious bc my AP always has the needle coming in from the side below the pedicle (I start in the 20 ipsi oblique). I may try this way tho to limit fluoro movements
No ESI on my schedule today. knees, RFs, kypho. Will do Monday.
 
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