Selection for RF in private practice

[caedmon]

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Looking to establish some guidelines within a practice regarding patient selection for RF. It is a two specialty group with surgeons and interventionalists. Different docs are trained at different times and have different approaches to facet mediated pain, so I'd like to establish some uniformity.

I have trained at different institutions with multiple different approaches for selection as follows.

1) Double block paradigm
2) Single block paradigm with Marcaine
3) Single block with lidocaine/marcaine
4) Single block with 2 or 3 plus steroid
5) Positive response to facet blocks repeated over time

I know ISIS recommends 1.

I've trended towards 4 but in select cases will use 3. I find it hard to instill the double block paradigm as a lot of patients will travel longer distances. In my post procedure pain diary, I place emphasis on the first 8 hours to minimize interference of steroid effect.

Thoughts?

Also, would you proceed with RF on a patient referred from a competent colleague who had a good response with IA facet injections without proceeding with MBBS?

 

[Pain_doc]

Unless you're cash-based, you'll do whatever the insurance dictates. I've never had a patient who received relief from one set of diagnostic injections who didn't get relief the second time. Low volume with good needle placement is the key.

I never RF based on a facet joint injection. I'm not burning the joint.

 

[PMR 4 MSK]

Unless you're cash-based, you'll do whatever the insurance dictates. I've never had a patient who received relief from one set of diagnostic injections who didn't get relief the second time. Low volume with good needle placement is the key.

I never RF based on a facet joint injection. I'm not burning the joint.

I don't have the insurance problem. I have never had a case denied or required to do a certain # of blocks prior to RF.

I do a single block, because I have yet to find an expert who can tell me how to handle the various permutations of responses to multiple blocks.

 

[SSdoc33]

double block only because insurance says i have to.

no steroid

would never RF anything i havent personally done an MBB on because i think most other pain docs are buffoons. (i can only imagine what they think of me...)

 

[mille125]

I don't have the insurance problem. I have never had a case denied or required to do a certain # of blocks prior to RF.

I do a single block, because I have yet to find an expert who can tell me how to handle the various permutations of responses to multiple blocks.

I agree wholeheartedly.

 

[mille125]

double block only because insurance says i have to.

no steroid

would never RF anything i havent personally done an MBB on because i think most other pain docs are buffoons. (i can only imagine what they think of me...)

Come on....there has to be someone in your area who is minimally competent (Of course not better than you). If a patient brings pics from the blocks of the previous doc then I am fine with proceeding to RF based on that.

 

[jj337]

Agree with PMR. Only one insurance carrier in my location requires 2 blocks and so I do it for them. Hardly ever use steroid... And then only because it is my personal voodoo moment.

 

[101N]

i don't have the insurance problem. I have never had a case denied or required to do a certain # of blocks prior to rf.

I do a single block, because i have yet to find an expert who can tell me how to handle the various permutations of responses to multiple blocks.

1+

 

[epidural man]

Looking to establish some guidelines within a practice regarding patient selection for RF. It is a two specialty group with surgeons and interventionalists. Different docs are trained at different times and have different approaches to facet mediated pain, so I'd like to establish some uniformity.

I have trained at different institutions with multiple different approaches for selection as follows.

1) Double block paradigm
2) Single block paradigm with Marcaine
3) Single block with lidocaine/marcaine
4) Single block with 2 or 3 plus steroid
5) Positive response to facet blocks repeated over time

I know ISIS recommends 1.

I've trended towards 4 but in select cases will use 3. I find it hard to instill the double block paradigm as a lot of patients will travel longer distances. In my post procedure pain diary, I place emphasis on the first 8 hours to minimize interference of steroid effect.

Thoughts?

Also, would you proceed with RF on a patient referred from a competent colleague who had a good response with IA facet injections without proceeding with MBBS?

I think what you choose to do depends on your pre-test probability of having facet disease based on many things we doctors base those things on, but primarily age and your belief in prevalance of the disease. If you are like most pain practices, your patient population is older and thus have a much higher incidence of painful facet arthropathy. In this case, do one block. Cohen even argues that you could just proceed with RF if your pre-test probability is high. He also argues that you can use 50% pain relief after your Dx MBB as your cut off. His point is that if you don't, you will miss treating patients that will potentially greatly benefit from this valid treatment.

In my case, facet arthropathy incidence is pretty low, so I am usually starting with a low pre-test probability of facet mediated pain. So I think two tests are probably better - and sometimes you do see one respond, and the second time they don't. Although ideally you should use different local so you can add the time of response to your data (although how you can predict how someone responds to a local is beyond me...). That guy from ASIPP who has a long and hard to type name argues for two differential blocks and using 80% relief as the cutoff. In my population, I think that makes a lot of sense.

A very experienced pain guy just told me this week that he uses 4% lidocaine, because it answer the question - AND - it is neurolytic itself. He gets a lot of patients that respond a LONG time to just the Dx MBB. I would guess that if you are worried about money, you would never try to do this and cut yourself out of the RF money, but it is a good thought.

I wish we could some how incorporate what psych studies are now doing with placebo washouts into pain literature. What a cool idea.....

 

[epidural man]

What is the steroid for?

 

[Tenesma]

i don't RF on another pain doc's patient unless they already had RF with good success - and this is just a repeat RF... If the other pain doc only did MBB, then I absolutely repeat the MBB (even if the needle looks good on AP, it doesn't mean it is in the right spot nor am I comfortable relying on volume of local injected by other pain doc).

I do either
1) Double (low-dose) local only MBB then go to RF if appropriate
2) OR intra-articular joint injection followed by single MBB then go to RF

WHY intra-art facet? that's usually for patients who have horrible axial back pain and have an upcoming vacation/honeymoon/trip/business trip, etc and can't go the MBB route just yet (i don't do MBB and RF on same day).

 

[101N]

2) OR intra-articular joint injection followed by single MBB then go to RF

WHY intra-art facet?

I still occasionally perform IA as well. I don't believe that facet periosteum innervation is exclusively by the medial branch. This is controversial & the APS guidelines explicitly argue against performing IA injections. However, when you look at the articles that they based their recommendations on (1,2) they are very poor quality. Carette's median age was about 40 - much to young to have sig posterior element disease - and Lilius didn't use fluoro
for his trigger point - not facet - study.

IMO the guidelines IA injection would better read: "There is insufficient evidence to determine efficacy. Not clear if the intervention is ineffective, or if patients were not accurately selected for procedures targeting specific spinal structures."

Recommendation 3
In patients with persistent nonradicular low back pain,
facet joint corticosteroid injection, prolotherapy, and in-
tradiscal corticosteroid injection are not recommended
(strong recommendation, moderate-quality evidence).
There is insufficient evidence to adequately evaluate ben-
efits of local injections, botulinum toxin injection, epi-
dural steroid injection, intradiscal electrothermal ther-
apy (IDET), therapeutic medial branch block,
radiofrequency denervation, sacroiliac joint steroid in-
jection, or intrathecal therapy with opioids or other med-
ications for nonradicular low back pain.

1. Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid
injections into facet joints for chronic low back pain. N Engl J Med 1991;
325:1002–7.

2. Lilius G, Lassonen AM, Myllynen P, et al. The lumbar facet joint syn-
drome–significance of inappropriate signs. A randomized, placebo-
controlled trial. French J Orthop Surg 1989;3:479 – 86.

 

[SSdoc33]

Come on....there has to be someone in your area who is minimally competent (Of course not better than you). If a patient brings pics from the blocks of the previous doc then I am fine with proceeding to RF based on that.

first of all, i have never seen a pic from another interventionalist in my area. i dont ask for them (god knows the patients i see would be able to consistently obtain them) and would be even a bigger headache if i tried to get them myself.

if i had a partner or someone I absolutley know does good work, then i might consider it. but you are relying on the other doc AND the patient to tell you that an MBB worked. i usually have trouble getting my patietns to understand the point of an MBB anyway. seems wiser to remove as many variables as i can.

every once in a while, ill read a procedure note from another doc if the patient happens to bring them in. used to make me cringe, now it just makes laugh.