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Guidance on Interventional Pain Procedures During the COVID-19 Global Emergency

When planning for interventional pain procedures during the COVID-19 emergency, consider the Centers for Disease Control and Prevention (CDC) statement regarding goals for the U.S. healthcare system in response to COVID-19:

  1. Reduce morbidity and mortality
  2. Minimize disease transmission
  3. Protect healthcare personnel
  4. Preserve healthcare system functioning
In order to achieve these goals, several steps should be taken:

  • STEP 1: PRIORITIZE ALTERNATIVES TO IN-PERSON VISITS
    • Implement telehealth and telephone visits when possible.
    • Penalties will not be imposed on physicians using telehealth in the event of noncompliance with the regulatory requirements under HIPAA. Click here for more information about the specific requirements and see telehealth resources on the SIS COVID-19 webpage.
  • STEP 2: RESCHEDULE ELECTIVE AND NON-URGENT PROCEDURES
    Whenever possible, reschedule non-urgent interventional pain procedures with the goal of reducing interpersonal exposure and potential for disease transmission to patients, staff, and the community.
    • Governmental regulations may apply now or in the future that restrict or prohibit performing interventional pain procedures. Those regulations supersede guidance provided by SIS.
    • While the recommendations of individual hospitals, facilities, and practices may differ, many major hospitals and academic medical centers are cancelling all elective interventional pain procedures in order to limit COVID-19 exposure and to preserve healthcare resources.
    • Corticosteroid injections may contribute to immunosuppression [SIS Glucocorticoid Impact FactFinder, Popescu 2019] and increased risk of viral infection [Sytsma 2018].
    • Information from the COVID-19 outbreak in China demonstrates a significantly higher mortality rate in hospitalized adults using corticosteroids [Zhou 2020].
  • STEP 3: PRIORITIZE PROCEDURES USING A COMPLETE RISK/BENEFIT ANALYSIS
    The final decision regarding the necessity and urgency of performing interventional pain procedure should be made by the treating physician after taking into account all the risks posed to the patient by presence of COVID-19 in the local community, in addition to risks to medical personnel and the public.
    • As with other systemic infections, when considering a procedure for a patient with known COVID-19 infection, suspected COVID-19 infection, recent return from a high-risk area, or a patient who has had close contact with an infected individual, non-urgent interventional pain procedures should be postponed until the patient is no longer contagious or it is confirmed they do not have COVID-19. (See CDC materials relative to identifying at-risk patients and guidance on potential exposure.)
    • A patient’s risk for contracting and surviving COVID-19 infection must be considered, including age and smoking status, as well as co-morbidities such as diabetes, hypertension, cardiopulmonary disease, and immunosuppression.
    • If the alternative to delaying (rescheduling) an interventional pain procedure clearly exposes the patient to increased risk via the alternative treatment option, proceeding with the procedure may be appropriate in select cases with good chances of a favorable outcome from the interventional pain procedure.
    • Consider alternatives and the risk/benefit ratios for the planned interventional pain procedure compared with other available treatments (e.g. home/virtual therapy options, medications, surgical telehealth consultation, etc.) as appropriate.
    • Consider the consumption of healthcare resources, including both PPE and staffing needs, when interventional pain procedures are performed.
    • Consider the prevalence of COVID-19 in your geographic area.
  • STEP 4: PREPARE YOUR PRACTICE
    Prepare your facility and personnel to safely manage patients during the COVID-19 emergency.
    • FACILITY
      • Consider shifting inpatient procedures to outpatient settings, when feasible.
      • Prepare your facility to safely triage and manage patients: patients should be contacted by telephone before coming to your facility to make sure that potential COVID-19 infection symptoms or exposure are identified and addressed appropriately.
      • Ask that family/friends do not accompany the patient into the clinic unless necessary for medical reasons.
      • Make sure that the waiting room, clinic, and procedure areas are appropriately cleaned and disinfected with increased frequency, consistent with the known high-transmission rate of COVID-19.
      • Implement visual alerts (signs, posters) at building entrances and in strategic locations to provide instructions on hand hygiene, respiratory hygiene, cough etiquette, and reporting.
      • Ensure that adequate supplies are available (tissues, waste receptacles, alcohol-based hand sanitizer).
      • Create measures to spatially separate patients in waiting rooms, clinic areas, and procedural settings; and remove reading materials and other shared items.
      • Consider implementing a system to restrict access to a single entrance and screen all patients and medical personnel who enter the clinical building for risk of undiagnosed COVID-19 infection or exposure. Screening measures include assessment for fever (objectively by temperature check), for symptoms of new or worsening cough, for new or worsening shortness of breath, and for contact with an individual diagnosed with COVID-19 infection.
    • PERSONNEL
      • Advise employees to check for any signs of illness before reporting to work each day and to notify their supervisor if they become ill.
  • STEP 5: REDUCE USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE)
    • Procedures involving the nose, mouth, or throat present higher risk for disease transmission and require more stringent PPE. This is not the case for most pain interventions including cervical spine procedures.
    • When performing common pain procedures for patients without symptoms of infection or exposure to COVID-19, use standard protective equipment (standard mask, gloves, eye protection). N95 masks and masks with face shields are not necessary.
    • PPE can be conserved by wearing the same face mask without removal during sequential patient encounters. In addition, sequential scheduling of all procedure patients will reduce staff needs and exposures, and reduce overall PPE use.
  • STEP 6: MANAGE POTENTIAL EXPOSURE
    If you suspect that you, your patients, your medical personnel, or your facility may have been exposed to COVID-19, refer to CDC’s guidance on potential exposure.
 
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olafa

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Approx how many telehealth cases people doing? Do you see any patients declining this, we have some who say they aren't interested. Not only the older ones.
For those still doing select procedural care (with the above guidance) on low risk and those not wanting to wait either due to time or severity of pain etc ; approx how many cases per week are you seeing?
 

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My state medical board has come out and said any physician doing any non-elective procedure will be fined 1K, face up to 180 days in jail, and have license suspended. Those guidelines are great but don't think they would hold up for me :)
 
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My state medical board has come out and said any physician doing any non-elective procedure will be fined 1K, face up to 180 days in jail, and have license suspended. Those guidelines are great but don't think they would hold up for me :)

post it. I read them. That’s not what it states.
 

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My state medical board has come out and said any physician doing any non-elective procedure will be fined 1K, face up to 180 days in jail, and have license suspended. Those guidelines are great but don't think they would hold up for me :)

Pardon me?

If an RFA is elective, and you do it, I find it extremely unlikely you're getting fined 1k bucks for that. No way. LOFL at jail time...

No way your state board (no clue what state you're in) made that threat.

I may be wrong, and maybe I'm out of touch with the reality of this thing, but I don't believe this.
 
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SommeRiver

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So explain how an officer based visit and several other things are allowed but an RFA is not allowed?
 

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Approx how many telehealth cases people doing? Do you see any patients declining this, we have some who say they aren't interested. Not only the older ones.
For those still doing select procedural care (with the above guidance) on low risk and those not wanting to wait either due to time or severity of pain etc ; approx how many cases per week are you seeing?
I’m doing about 15 video visits a day. Almost all for the opioid crowd. None refuse obviously. 99% of the delayed procedure people understand
 
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So explain how an officer based visit and several other things are allowed but an RFA is not allowed?

Cant explain it. Their wording makes it impossible to justify any procedure unless you can call it emergent. They claim other docs have a duty to report you as well. It will devastate pain groups in Texas if it goes on for much longer.
 

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If an office visit with imaging is okay, I would AT LEAST offer MBB/RFA to pts considering there are no corticosteroids involved in the procedure.

You'd be well protected (IMO) from the state board.

I can easily say, "Was the procedure a matter of life and death? No, but Mrs Smith can't stand up longer than 5 min without back pain, and she has difficulty sleeping. Can't do the dishes or laundry. Cooking is difficult. Withholding the procedure is cruel in my professional opinion."
 

ateria radicularis magna

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If an office visit with imaging is okay, I would AT LEAST offer MBB/RFA to pts considering there are no corticosteroids involved in the procedure.

You'd be well protected (IMO) from the state board.

I can easily say, "Was the procedure a matter of life and death? No, but Mrs Smith can't stand up longer than 5 min without back pain, and she has difficulty sleeping. Can't do the dishes or laundry. Cooking is difficult. Withholding the procedure is cruel in my professional opinion."

You can say this, but will your peer reviewers say this? Will your medical board say this? Or will you be painted as a rogue physician practicing dangerously when guidelines across the board are ordering you to stop doing procedures immediately?
 
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You can say this, but will your peer reviewers say this? Will your medical board say this? Or will you be painted as a rogue physician practicing dangerously when guidelines across the board are ordering you to stop doing procedures immediately?

I can't imagine anyone coming to a consensus about this. It will be a debate for the ages.
 

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Our state has forbidden any non emergent procedures. Someone with 15 years of low back pain getting worse, that can’t stand or do chores...can probably survive a quarantine without 2 mbb and then an rfa. Chances are this person is also over 60 with some co morbidities making them in the at risk category for the virus. I think pain is going to get hit particularly hard from this pandemic
 
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SommeRiver

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So, a pt with worsening back pain, difficulty standing and completing ADL's and comes in for an RFA or MBB and I go to jail, get fined, or lose my license and that is reasonable?

That same person can go to Walmart or Chic-Fil-A, but can't get an injxn for back pain?
 
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So, a pt with worsening back pain, difficulty standing and completing ADL's and comes in for an RFA or MBB and I go to jail, get fined, or lose my license and that is reasonable?

That same person can go to Walmart or Chic-Fil-A, but can't get an injxn for back pain?
That is what my governor is telling us. Maybe your state is different. I have a friend in one part of PA whose practice is doing we are doing in terms of no procedures and then I have another colleague Pittsburgh whose practice is doing things on a “case by case” basis and really hasn’t slowed down much. There is no standardization...much like our entire profession
 

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I'm in Georgia and I'm doing procedures, clinic, and telehealth. We're taking a beating overall, hopefully one from which we'll recover without having to fire anyone, but we are doing our best to properly select pts who are "essential vs nonessential." If your sciatica is on fire I'll inject you. Repeat RFA no...
 
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I think they have to be particularly punitive because any surgeon/proceduralist can easily justify why one patient needs that procedure or surgery. “My patient cant walk because of pain and needs this 3-level fusion”. Next thing you know hospital resources are being used up etc.
 
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Cant explain it. Their wording makes it impossible to justify any procedure unless you can call it emergent. They claim other docs have a duty to report you as well. It will devastate pain groups in Texas if it goes on for much longer.
Yes , I agree the language seems extreme... if a patient is demanding an injection and you deny it and they subsequently commit suicide or some other negative act , you are toast as well. Rough situation in Texas...
 

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Medical Acts that are general permitted or prohibited.

The Board’s FAQs identifies the following surgeries or procedures that are generally prohibited under the order:
1. Screening for a nonlife-threatening chronic condition;
2. Most cosmetic procedures;
3. Routine dermatological procedures;
4. Routine ophthalmological procedures;
5. Routine dental procedures;
6. Non-emergent orthopedic surgeries3;
7. Most cosmetic and plastic surgeries;
8. Nonsurgical cosmetic procedures; and
9. An abortion not medically necessary to preserve the life or health of the mother.

The Board expressly identifies the following medical acts as permissible and outside the governor’s order:
1. Office-based visits that do not require surgery or procedures (so long as conducted in accordance with standard protocols, including safety measures that prevent the spread of COVID-19); and
2. Non-procedures (as carved out by the Board’s definition of “procedures”) that involve: a. physical examinations; b. non-invasive diagnostic tests; c. the performing of lab tests; or d. obtaining specimens to perform laboratory tests.



Note: I am not in Texas and there is language in the order that states no procedures should be done with or without potential for depleting PPE.
Intentionally vague document. Also lists possible immediate suspension of license and reporting to NPDB.
 
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If an office visit with imaging is okay, I would AT LEAST offer MBB/RFA to pts considering there are no corticosteroids involved in the procedure.

You'd be well protected (IMO) from the state board.

I can easily say, "Was the procedure a matter of life and death? No, but Mrs Smith can't stand up longer than 5 min without back pain, and she has difficulty sleeping. Can't do the dishes or laundry. Cooking is difficult. Withholding the procedure is cruel in my professional opinion."

Ugh. You gotta stop doing facet procedures. Only thing that passes the sniff test is a hot radic with a new herniation. Nobody is coming after you, like i said before.... but just do the right thing. Yes, you will get killed financially. If you havent noticed, we all are....
 
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Ugh. You gotta stop doing facet procedures. Only thing that passes the sniff test is a hot radic with a new herniation. Nobody is coming after you, like i said before.... but just do the right thing. Yes, you will get killed financially. If you havent noticed, we all are....

"...do the right thing..."

What exactly is the right thing?

You are either completely sheltered in place or you aren't.

If I have a miserable pt I'll treat them.
 

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"...do the right thing..."

What exactly is the right thing?

You are either completely sheltered in place or you aren't.

If I have a miserable pt I'll treat them.

The right thing could be a life and death decision. Not trying to be melodramatic, but does your back pain patient need that mbb bad enough? Dont overvalue yourself. You are not a nephrologist offering dialysis. You are not a trauma surgeon doing a laparotomy. Ill tell you what i tell my patients: just wait
 
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The right thing could be a life and death decision. Not trying to be melodramatic, but does your back pain patient need that mbb bad enough? Dont overvalue yourself. You are not a nephrologist offering dialysis. You are not a trauma surgeon doing a laparotomy. Ill tell you what i tell my patients: just wait

How about giving me the benefit of the doubt and consider that I may not be offering procedures to 100% of my pts right now. My fragile pts are staying home, but I'm not completely closing my doors.

I think shutting down your practice completely is a little ridiculous don't you?
 

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How about giving me the benefit of the doubt and consider that I may not be offering procedures to 100% of my pts right now. My fragile pts are staying home, but I'm not completely closing my doors.
It’s geographic dependent. In jersey we are taking it very very seriously. You may not be
I think shutting down your practice completely is a little ridiculous don't you?
 

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How about giving me the benefit of the doubt and consider that I may not be offering procedures to 100% of my pts right now. My fragile pts are staying home, but I'm not completely closing my doors.

I think shutting down your practice completely is a little ridiculous don't you?

Noop.

Telehealth and no shots. Its what most of us are doing. Please dont kill gramma because you dont want to make less this month.
 
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It's hard to say what will happen in rural, low density, communities with low volume of transients, no subways, fewer elevators, etc. They are doing some measures. They may be somewhat spared the brunt of this.

I think the game changer is these instant tests and also the serology tests coming on line in next few weeks. Quick testing and effective isolation will stop this thing.
 

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Noop.

Telehealth and no shots. Its what most of us are doing. Please dont kill gramma because you dont want to make less this month.

Dude...You're a total *****. This has nothing to do with my "making less this month."

Hitting a bonus ended long ago for me...This is about providing a service for ppl in a reasonable manner. Certain ppl can come in, some can't...

I'm in rural Georgia, not Manhattan.
 

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Dude...You're a total *****. This has nothing to do with my "making less this month."

Hitting a bonus ended long ago for me...This is about providing a service for ppl in a reasonable manner. Certain ppl can come in, some can't...

I'm in rural Georgia, not Manhattan.
Not Phoebe Putnam I hope.
 
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Dude...You're a total *****. This has nothing to do with my "making less this month."

Hitting a bonus ended long ago for me...This is about providing a service for ppl in a reasonable manner. Certain ppl can come in, some can't...

I'm in rural Georgia, not Manhattan.

specifically, doing a MBB or RF is not providing a service for people in a reasonable manner. to use your language, it is a *****ic act.

i guess none of your patients travel to atlanta. i guess their family members dont either. maybe their cashiers at the grocery stores do. maybe your staff does.

you, like clubdeac, just dont seem to get it. you cannot do this in a half-assed manner. maybe our administration isnt setting hte tone correctly. there are certainly some governors who are dropping the ball. as physicians we -- specifically you -- should know better
 
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specifically, doing a MBB or RF is not providing a service for people in a reasonable manner. to use your language, it is a *****ic act.

i guess none of your patients travel to atlanta. i guess their family members dont either. maybe their cashiers at the grocery stores do. maybe your staff does.

you, like clubdeac, just dont seem to get it. you cannot do this in a half-assed manner. maybe our administration isnt setting hte tone correctly. there are certainly some governors who are dropping the ball. as physicians we -- specifically you -- should know better

That's what talking to pts is for, or maybe you can just make the lazy accusation that I'm just trying to make money.

There is ZERO chance I'll get a bonus Q1-Q3. There will be no ASC shares paid any time soon.

My salary will get cut soon in hopes we can save our employees from getting fired.

I will likely be giving my two nurse techs money from my own checking account.

I think I'm doing 3 procedures Tuesday AM, none of which are MBB. I usually do 15 or more that AM. Wed afternoon I'm doing 3 I think, all epidurals. Thursday same as Tuesday.

This little bit of volume does NOT do anything towards my getting paid.
 

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it's your decision based on your specific situation....try to keep your patients out of the ER. If it means a procedure vs a 30 day supply of meds, then that is your decision. But the guidelines are out. They arent mandates unless in certain areas. ssdoc is near ground zero....he speaks about what he sees. You might be in the boonies.
 
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My governor is advocating more psychiatric resources and visits during this pandemic ( per his weekly updates). Are psychiatric visits mandatory ? Maybe, not sure.

30% of our population has psychiatric issues. You take away their pain options , what happens? More depression, mood disturbance, insomnia, despair, ...suicide!

Why are liquor stores open and essential? are we causing more etoh dependence, domestic violence ? Are we reducing stress and anxiety . Not sure. I know I’m drinking more wine daily.

There is a relation between pain, psych, and tx we offer . IMO. I wouldnt close my doors to my patients demanding tx. Those Texas Board rules seem rough, but I’d still stay open for those desperate patients that demand/request IPM care. I’d defend you for a RFA on a VCF, severe stenosis, or essential worker needing pain relief.
 
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Dude...You're a total *****. This has nothing to do with my "making less this month."

Hitting a bonus ended long ago for me...This is about providing a service for ppl in a reasonable manner. Certain ppl can come in, some can't...

I'm in rural Georgia, not Manhattan.

This will hit every region sooner than later. I also live in a rural area. And 100% of elective procedures are cancelled where I am. We’re ready to funnel our extra PPE to our major cities in our state in the next few weeks if we need to. We all have patients that we feel “need” the epidural. The truth is, no one does. We’re an elective speciality.
 
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That's what talking to pts is for, or maybe you can just make the lazy accusation that I'm just trying to make money.

There is ZERO chance I'll get a bonus Q1-Q3. There will be no ASC shares paid any time soon.

My salary will get cut soon in hopes we can save our employees from getting fired.

I will likely be giving my two nurse techs money from my own checking account.

I think I'm doing 3 procedures Tuesday AM, none of which are MBB. I usually do 15 or more that AM. Wed afternoon I'm doing 3 I think, all epidurals. Thursday same as Tuesday.

This little bit of volume does NOT do anything towards my getting paid.

you are not going to like to hear this, but there is NO WAY that you can legitimately have 9 patients this week with acute disc herniations.

some of those are little old ladies with stenosis. i wouldnt be surprised if you have an SIJ or 2. are you really going to bring in those patients with comorbidities with advancing age into your ASC? with god knows what else crawling on the walls, table, C-arms, etc? shameful.

you say you don't care about the financial aspect, then you talk about how you will be getting a pay cut and your employees may get fired. you are completely making treatment decisions based on trying to stay afloat -- rather than what is in the best interest of your patients, staff, local community, and general community.

where NY is right now, florida, georgia, colorado, LA will be next week.

you really need to try to get to where most of us already have.
 
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you are not going to like to hear this, but there is NO WAY that you can legitimately have 9 patients this week with acute disc herniations.

some of those are little old ladies with stenosis. i wouldnt be surprised if you have an SIJ or 2. are you really going to bring in those patients with comorbidities with advancing age into your ASC? with god knows what else crawling on the walls, table, C-arms, etc? shameful.

you say you don't care about the financial aspect, then you talk about how you will be getting a pay cut and your employees may get fired. you are completely making treatment decisions based on trying to stay afloat -- rather than what is in the best interest of your patients, staff, local community, and general community.

where NY is right now, florida, georgia, colorado, LA will be next week.

you really need to try to get to where most of us already have.

You sound like someone who has never signed the front of a paycheck.
 
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you think i like that my bank account is decimated?

cant bring someone back from the dead. can always make more money.
 
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We are all on the same team...

Lets help fellow pain colleagues through these difficult times. Nobody is necessarily right or wrong, just different circumstances.

Making money is important but health is numero Uno.
 

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you are not going to like to hear this, but there is NO WAY that you can legitimately have 9 patients this week with acute disc herniations.

some of those are little old ladies with stenosis. i wouldnt be surprised if you have an SIJ or 2. are you really going to bring in those patients with comorbidities with advancing age into your ASC? with god knows what else crawling on the walls, table, C-arms, etc? shameful.

you say you don't care about the financial aspect, then you talk about how you will be getting a pay cut and your employees may get fired. you are completely making treatment decisions based on trying to stay afloat -- rather than what is in the best interest of your patients, staff, local community, and general community.

where NY is right now, florida, georgia, colorado, LA will be next week.

you really need to try to get to where most of us already have.

I actually DO care about our finances but my doing a few injxns this week has zero impact on our staying afloat.

My decision to do these injxns is NOT based off finances.

That's my last post on this. I'm done. You're FoS...
 
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I actually DO care about our finances but my doing a few injxns this week has zero impact on our staying afloat.

My decision to do these injxns is NOT based off finances.

That's my last post on this. I'm done. You're FoS...

you dont need my authorization, but you didnt list the types of shots you plan on doing this week. why not post them and see what the general consensus of the board happens to be?

"grandpa you were alive during the coronavirus in 2020? wow. what was it like?"

"well, sonny, i did some marginally effective injections that i could have done 3 weeks later, exposing many to unnecessary risk and a longer course of the pandemic."
 

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Canton GA
www.stevenlobel.com
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  1. Attending Physician
you think i like that my bank account is decimated?

cant bring someone back from the dead. can always make more money.

I think you are wrong. And next months journal of stem cells for the walking dead Dr. Russo publishes an article on how he can raise the dead with MSC’s
 
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