SNRB vs TFESI

[PMR 4 MSK]

When doing a lumbar SNRB, how often do you seen cephalad contrast flow into the epidural space (at least laterally) vs how often should you see this?

Conversely, what about doing TFESI and seeing a wonderful neurogram of the same nerve root, extending out both caudal and cephalad for a couple inches or more?

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[Mister Mxyzptlk]

IMHO, selective nerve root blocks are anything but selective. You have to get medication proximal to the lesion in order to block the pain. This usually means getting medication well into the canal. Once you're there, it's no longer selective since the passing nerve roots are so close by.

I would also venture to say that the extent of visible spread is less than the extent of actual spread. As the leading edge of the fluid gets thinner you will lose the ability to distinguish dye from tissue, so the edge will probably be beyond where you think it is.

 

[SSdoc33]

i think the goal is to try to get as little LA as possible proximally try to keep it selective. hence the term "selective nerve block". there really is no such thing as a "selective nerve root block" because you are not blocking the nerve root. once the medication has gone to the root, it is no longer selective.

to the OP, i try to inject as little contrast as possible and stay relatively farther from the foramen than in a TFESI.

and i disagree with gorback; even though the pathology is proximal, you are blocking the nerve distal to its pathology. if you get the right nerve and you have you pain relief, you're good to go.

please correct me if i am missing something.

 

[Mister Mxyzptlk]

I always thought you had to be between the pain and the brain for local anesthesia to work. If a HNP is crushing the DRG and I apply LA to the nerve root outside the foramen how will that provide pain relief?

 

[SSdoc33]

I always thought you had to be between the pain and the brain for local anesthesia to work. If a HNP is crushing the DRG and I apply LA to the nerve root outside the foramen how will that provide pain relief?

if you are feeling radicular pain in a particular nerve distribution, blocking the nerve WILL provide pain relief. this isnt me, its ISIS talking. i was halfway to the ISIS guidelines book to quote the actual text, but that is more like something ampa would do.

i am not 100% sure of the exact mechanism, but i believe that radicular pain is "downstream" from its pain generator. so, blocking the distal transmission will provide pain relief and/or paresthesia relief. i agree that it is counter-intuitive, but it works.

a disc crushing the DRG is not a true radiculopathy, so a selective nerve block would do nothing. however, when the disc hits the nerve/radicle it will provide pain relief

 

[Mister Mxyzptlk]

Let me make sure I have this straight:

If I block your sciatic nerve you won't feel it if I put a clamp across the L5 nerve root because the sciatic nerve is "downstream" from the pain generator.

I guess I could do a wrist block and then operate on your elbow because the block is "downstream" from the pain generator.

Maybe we could fix cervical radiculopathy with a brachial plexus block.

 

[SSdoc33]

Let me make sure I have this straight:

If I block your sciatic nerve you won't feel it if I put a clamp across the L5 nerve root because the sciatic nerve is "downstream" from the pain generator.

I guess I could do a wrist block and then operate on your elbow because the block is "downstream" from the pain generator.

Maybe we could fix cervical radiculopathy with a brachial plexus block.

i think you reversed my upstream/downstream analogy. or maybe i wasnt clear. what i was trying to say is that the efferent impulses from the site of injury (disc-nerve interface) to the painful area (leg) get blocked. you would think that the pain would only go proximally, but it shoots down your leg, so there must be a neural relay there. that is what i THINK is getting blocked.

my mechanism may be completely wrong, but are you trying to tell me that selective nerve blocks "don't work". if so, i think ISIS and a buttload of surgeons would disagree with you.

 

[Mister Mxyzptlk]

Ok, I will keep trying to understand. Bear with me because I am old and slow.

I believe you're saying that efferent pain impulses run down the nerve from the site of the spinal nerve root insult, producing pain in the leg. Hence, blocking the nerve outside of the foramen will block the radicular pain in the leg.

You also posit that this entails a "neural relay".

Is that correct? If so, I have some questions.

1. I could not find a description of any sensory ganglia or plexuses in the extremities in my anatomy book. According to the same book, it's pretty much one uninterrupted axon straight on down. Where is the relay?

2. I was unable to find the efferent sensory pathway from the spine to the leg. I even looked on PubMed. Is this one of the remaining frontiers of neuro-anatomy that Tony Yaksh must conquer? If germs can cause ulcers I suppose anything is possible so I won't say that it's completely out of the question.

Also, let's talk about what we know about the body and the laws of nature and try to extrapolate from that what makes sense, not what someone else may or may not believe.

I don't understand why you would allow anyone else to do your thinking for you, whether it's ISIS or "surgeons" (now there's an enlightened scientific community).

 

[SSdoc33]

Ok, I will keep trying to understand. Bear with me because I am old and slow.

I believe you're saying that efferent pain impulses run down the nerve from the site of the spinal nerve root insult, producing pain in the leg. Hence, blocking the nerve outside of the foramen will block the radicular pain in the leg.

You also posit that this entails a "neural relay".

Is that correct? If so, I have some questions.

1. I could not find a description of any sensory ganglia or plexuses in the extremities in my anatomy book. According to the same book, it's pretty much one uninterrupted axon straight on down. Where is the relay?

2. I was unable to find the efferent sensory pathway from the spine to the leg. I even looked on PubMed. Is this one of the remaining frontiers of neuro-anatomy that Tony Yaksh must conquer? If germs can cause ulcers I suppose anything is possible so I won't say that it's completely out of the question.

Also, let's talk about what we know about the body and the laws of nature and try to extrapolate from that what makes sense, not what someone else may or may not believe.

I don't understand why you would allow anyone else to do your thinking for you, whether it's ISIS or "surgeons" (now there's an enlightened scientific community).

allright, i hear what you are saying. my "mechanism" was me trying to extrapolate the laws of nature and what makes sense.

"neural relay" is laman's term for a synapse in my book. apparently that is not neurophysiologically correct. my bad.

i dont think that the exact mechanism of neuropathic radicular pain is completely understood (especially by myself), but those blocks DO work. rather than point out why my posings are wrong, please tell me why these blocks work. or, please explain why you think they dont.

 

[Tenesma]

i agree w/ gorback - there is no difference between SNRB and transforaminal ESI - they are one and the same...

however, i use the term SNRB occasionally to spice up my notes and make it sound like i have diversified my skills 😀

 

[SSdoc33]

i agree w/ gorback - there is no difference between SNRB and transforaminal ESI - they are one and the same...

however, i use the term SNRB occasionally to spice up my notes and make it sound like i have diversified my skills 😀

no such thing as a SNRB or "selective nerve root block". it is a SNB or "spinal nerve block".

Spine Procedural Terminology

Epidural injections are not “blocks”. The word "block" should only be utilized when one specifically places local anesthetic onto a nerve or nerve branch for the sole purpose of stopping transmission of sensation or motor function (i.e., medial branch block)
Interlaminar epidural injection – Not translaminar
Transforaminal injection – Not nerve root block. Not selective nerve root block. Not selective epidural. Not transforaminal selective epidural.
Spinal nerve block – Not root block. Not spinal nerve root block.
Ventral ramus block – Targeted more distally and anteriorly to avoid blocking innervation of the posterior elements
Zygapophysial joint intra-articular injection – Not facet block
Medial branch neurotomy – Not “rhizotomy” which refers to cutting a “root”
Lesion- Recently added to Webster’s Dictionary through our specialties’ lobbying efforts. It now refers to both a verb (to cut) and its previous noun form.
L5 dorsal ramus neurotomy – Not L5 medial branch neurotomy

Sacroiliac joint intra-articular injection – Not SIJ block

Medial branch and L5 dorsal ramus block – Not paramedian nerve block (remember: only two medial branches per joint)
Provocation discography – Not provocative discography

IDEA (intradiscal electrothermal annuloplasty) is a “generic” term for the trademarked name
IDET (intradiscal electrothermal therapy)
Disc biologic – One of the newer therapeutics which causes the repair of tears and fissures within the anulus fibrosis and alters the chemical milieu of the intervertebral disc.
These suggestions may appear trivial, however your incessant application of these terms is necessary to "raise the standard" of our field.
Kevin J. Pauza, MD, Chair, PASSOR Educational Guidelines Task Force

Updated 2005

 

[Mister Mxyzptlk]

The blocks "DO work"? Mere assertion doesn't work for me. Cite your evidence.

I don't doubt that they can produce pain relief. What I contest is that they are reliable diagnostic tools.

Pull out your ISIS book to page 13 and look at fig 10. There is contrast running up & down medially. The passing S1 nerve root will be exposed to the local anesthetic. How can you know for certain that given the spread seen in that figure that you aren't anesthetizing S1 as it passes by?

And the dye spread goes farther than you can see. What you see on a neurogram is the LEAST amount of spread, not the maximum.

In my practice I don't use the term SNRB at all. I do TFESIs. But who died and made Pauza God? He doesn't get to define the terms for everyone.

 

[SSdoc33]

The blocks "DO work"? Mere assertion doesn't work for me. Cite your evidence.

I don't doubt that they can produce pain relief. What I contest is that they are reliable diagnostic tools.

Pull out your ISIS book to page 13 and look at fig 10. There is contrast running up & down medially. The passing S1 nerve root will be exposed to the local anesthetic. How can you know for certain that given the spread seen in that figure that you aren't anesthetizing S1 as it passes by?

And the dye spread goes farther than you can see. What you see on a neurogram is the LEAST amount of spread, not the maximum.

In my practice I don't use the term SNRB at all. I do TFESIs. But who died and made Pauza God? He doesn't get to define the terms for everyone.

I agree that the S1 is may be getting anesthetized in that particular figure. i think the anesthetic should be a bit more "extraforminal" to maintain any semblance of selectibility.

"I don't doubt that they can produce pain relief. What I contest is that they are reliable diagnostic tools. "

this seems to be a shift in your argument. you previously stated that you had to inject the anesthetic between the pain generator and the brain for it to work.

whether or not they are reliable is a bit more dicey. i couldnt even pull up anything other than abstracts from the references list in ISIS b/c the studies are so old. the evidence for their validity is weak, at best, i do admit.

i think the idea behind getting uniform nomenclature is for the very reason that we are having these disagreements on this board. it is intended to attempt to standardize what we do. just because it has someone's name behind it doesnt mean it is wrong or a bad idea.

 

[Mister Mxyzptlk]

It's not a shift in the argument at all. My initial reply said:


"IMHO, selective nerve root blocks are anything but selective. You have to get medication proximal to the lesion in order to block the pain. This usually means getting medication well into the canal. Once you're there, it's no longer selective since the passing nerve roots are so close by."

My argument has not deviated from that statement. Note that I did not say the blocks can't anesthetize anything - just that the pain relief is of dubious diagnostic value.

As a side argument, I dispute your assertion that if you anesthetize a nerve distal to the lesion you will get relief. You support your argument by introducing heretofore undiscovered sensory pathways and synaptic junctions outside of the spine.

 

[PMR 4 MSK]

I was taught that SNRB (if you accept that it is "Selective" on the "Nerve Root" or even a "Block"...) is performed similar to TFESI, but that the needle is placed more inferior and lateral, so as to get on the nerve after it has exited the neuroforamina and the epidural outpouching along the root has ended.

My experience has taught me that it doesn't matter - it spreads cephalad anyways, usually into the epidural space, despite my wishes. And converesly, the TFESI often outlines one or more nerves out of the neuroforamina.

This is the reason that I find the idea of routinely doing multi-level TFESI, such as someone doing right L3-4, L4-5 and L5-S1 all at the same time, absolutely ridiculous, and little more than a scheme to get paid more by doing more procedures unneccesarily, with the added bonus of giving way too much steroid.

 

[SSdoc33]

It's not a shift in the argument at all. My initial reply said:


"IMHO, selective nerve root blocks are anything but selective. You have to get medication proximal to the lesion in order to block the pain. This usually means getting medication well into the canal. Once you're there, it's no longer selective since the passing nerve roots are so close by."

My argument has not deviated from that statement. Note that I did not say the blocks can't anesthetize anything - just that the pain relief is of dubious diagnostic value.

As a side argument, I dispute your assertion that if you anesthetize a nerve distal to the lesion you will get relief. You support your argument by introducing heretofore undiscovered sensory pathways and synaptic junctions outside of the spine.

whoops. looks like the entire clinic is staring at me because i was laughing at your response. (because it made fun of me).

diagnostic value of SNBs is questionable -- agreed -- moving on.

i think i made clear that my mechanism may not be (or probably IS not) correct. however, i stand by the pain relief aspect of a SNB. you block the nerve distal to the lesion and get pain relief.

"Blockade of unmyelinated C and small, myelinated A-delta fibers is the objective as these fibers transmit acute sharp pain and delayed-onst dull aching pain in radicular pain. The goal fo the diagnostic injection is to anesthetize these fibers at the spinal nerve, DRG, and/or dorsal nerve root" -- from Slipman, pg 197, with a reference to Nygaard, Spine 1998.

 

[Tenesma]

i disagree with your interpretation of your results...

i do a lot of extra-foraminal TFESIs - not always on purpose, but it is usually in patients with very difficult anatomy (ie: osteosarcoma in the way, or tons of bony fragments from previous failed fusion, etc...)...

those extra-foraminal TFESIs which you call SNBs have relatively good results (often when i see where i get the needle tip, and see the contrast spread, and realize that this is the best I am going to be able to achieve - I curse myself because i feel like I have failed the patient - only for them to come back 2 weeks later loving me) ... however, i have noticed that frequently when i inject 1 to 1.5 ml of contrast (the usual amount of volume that i use for my injectate of steroid +/- local) the contrast spreads into the spinal canal...

so there are several explanations

1) your theory: blocking pain distal to the lesion

2) possibility that the nerve absorbs the steroid and then via some type of unclear intra-cellular mechanism moves the steroid to the site of nerve injury or irritation

3) possibility that the steroid causes shrinkage of the nerve distally and that shrinkage decreases the strain on the nerve at the site of nerve injury

4) that the medication moves medially and gets into the spinal canal and works on the site of injury

5) systemic absorption of steroids

6) powerful placebo

7) relaxation of interspinous,multifidus muscles that were contributing to some foraminal narrowing by being in spasm???

8) voodoo

but i still agree with gorback

and thank you for the Pauza posting - i loved that one - in fact, during fellowship we had that posted everywhere in the fellows room... but there is no way you are going to get me to say Zygapoph.... block - it will still be a facet block (just less of a mouth-ful).

 

[mille125]

I was taught that SNRB (if you accept that it is "Selective" on the "Nerve Root" or even a "Block"...) is performed similar to TFESI, but that the needle is placed more inferior and lateral, so as to get on the nerve after it has exited the neuroforamina and the epidural outpouching along the root has ended.

My experience has taught me that it doesn't matter - it spreads cephalad anyways, usually into the epidural space, despite my wishes. And converesly, the TFESI often outlines one or more nerves out of the neuroforamina.

This is the reason that I find the idea of routinely doing multi-level TFESI, such as someone doing right L3-4, L4-5 and L5-S1 all at the same time, absolutely ridiculous, and little more than a scheme to get paid more by doing more procedures unneccesarily, with the added bonus of giving way too much steroid.

go to the head of the class...

i agree with every word said here

 

[ampaphb]

Fluoro your SNBs again right before they leave you facility, after they have been up and moving around a while - you will be amazed how much more proximally the contrast has extended.

 

[drusso]

This is the reason that I find the idea of routinely doing multi-level TFESI, such as someone doing right L3-4, L4-5 and L5-S1 all at the same time, absolutely ridiculous, and little more than a scheme to get paid more by doing more procedures unneccesarily, with the added bonus of giving way too much steroid.

Yes and no.

Sometimes, especially if there is a lot osteophytosis/stenosis at one level and/or a less than completely satisfying epidurogram, the level adjacently inferior can be a good "salvage" injection if you get nice cephalad flow. You never get a second change to make a first impression! 😀

Since the government payors and workman's comp seem Hell-bent on making me work for free most of the time anyway, I accept honest reimbursement for honest effort.

 

[ampaphb]

Yes and no.

Sometimes, especially if there is a lot osteophytosis/stenosis at one level and/or a less than completely satisfying epidurogram, the level adjacently inferior can be a good "salvage" injection if you get nice cephalad flow. You never get a second change to make a first impression! 😀

Since the government payors and workman's comp seem Hell-bent on making me work for free most of the time anyway, I accept honest reimbursement for honest effort.

two levels, given a reasonable rationale like drusso's, seems perfectly acceptable, IMHO.

I think PMR is referring more to the pigs like the ones on the Northshore in my area, who do BILATERAL L3/4, 4/5, and 5/1 TFESIs routinely.

 

[Tenesma]

bilateral multi-level TFESIs --- crazy....

in some states the medical boards allow you to report physicians who don't conform to standard of care (ie: in texas) --- in those states, that can have a huge impact (for the better)...

however, our standard of care is so murky it may actually backfire?

 

[Disciple]

i think i made clear that my mechanism may not be (or probably IS not) correct. however, i stand by the pain relief aspect of a SNB. you block the nerve distal to the lesion and get pain relief.

"Blockade of unmyelinated C and small, myelinated A-delta fibers is the objective as these fibers transmit acute sharp pain and delayed-onst dull aching pain in radicular pain. The goal fo the diagnostic injection is to anesthetize these fibers at the spinal nerve, DRG, and/or dorsal nerve root" -- from Slipman, pg 197, with a reference to Nygaard, Spine 1998.

😕

SSdoc,

There's no efferent sensory pathway. The reason people with radicular pain feel pain in the leg is because of the somatotopic organization of the central nervous system.

Remember the homunculus and the somatosensory cortex?

The reason you get pain relief with a SNRB (or SNB as you called it) is that the anesthetic is tracking proximally. If the site of impingement happens to be a foraminal herniation/foraminal stenosis, lateral recess stenosis or even a far lateral herniation, then the anesthetic doesn't even have to track that far proximally. You're doing the same thing as a TFESI, but probably getting less anesthetic/medication into the epidural space.

Another possibility is that other structures which may be referring pain down the leg are being anesthetized.

 

[SSdoc33]

😕

SSdoc,

There's no efferent sensory pathway. The reason people with radicular pain feel pain in the leg is because of the somatotopic organization of the central nervous system.

Remember the homunculus and the somatosensory cortex?

The reason you get pain relief with a SNRB (or SNB as you called it) is that the anesthetic is tracking proximally. If the site of impingement happens to be a foraminal herniation/foraminal stenosis, lateral recess stenosis or even a far lateral herniation, then the anesthetic doesn't even have to track that far proximally. You're doing the same thing as a TFESI, but probably getting less anesthetic/medication into the epidural space.

Another possibility is that other structures which may be referring pain down the leg are being anesthetized.

well, the reason i call it a spinal nerve block is because it IS a spinal nerve block. ISIS, PASSOR, and other bodies are very clear in this distinction.

also very clear is that the goal of the SNB is to anesthetize the spinal nerve alone, and that the medication does NOT track proximally in order to maintain specificity.

the goal is to anesthetize the nerve that is mediating the pain. practice guidelines pg 3 "the procedure is used as a diagnostic test to determine if the nerve or nerves anesthetized is, or are, responsible for mediating a patient's symptoms".

example: take your typical L4-L5 paracentral herniation, causing an L5 radic. is your contention that you are actually injecting local anesthetic to the disc-nerve interface? this is the site of the lesion, and thus the source of the pain, and therefore that is what we anesthetize?

i just frankly disagree with that. i DONT know the exact mechanism, and i cant find an explanation yet (most likely because one has not been clearly hypothesized). im trying to get some of the references quoted in ISIS, but they are not that easy to find.

what would be the point in blocking the nerve at all if what you are really interested in is the exact point of disc herniation?

 

[Tenesma]

i believe that SNRB (SNBs if you will) evolved for the same reason that discography has evolved.... a surgeon asks for it, hoping to better delineate the source of pain and maybe fake-out the crazies, and we have gladly complied....

but just because a procedure is described in ISIS or in Steve Waldman's new books, doesn't mean it is the right procedure for the right reason...

this is also the same reason that i find medial branch blocks to not be VERY specific for medial branches... even when i inject 0.3ml of contrast over the MBB, some of it can be seen extending around the ventral surface of the joint (ie: near the DRG and some sensory fibers close to the dura)....

 

[Disciple]

also very clear is that the goal of the SNB is to anesthetize the spinal nerve alone, and that the medication does NOT track proximally in order to maintain specificity.

the goal is to anesthetize the nerve that is mediating the pain. practice guidelines pg 3 "the procedure is used as a diagnostic test to determine if the nerve or nerves anesthetized is, or are, responsible for mediating a patient's symptoms".

example: take your typical L4-L5 paracentral herniation, causing an L5 radic. is your contention that you are actually injecting local anesthetic to the disc-nerve interface? this is the site of the lesion, and thus the source of the pain, and therefore that is what we anesthetize?

i just frankly disagree with that. i DONT know the exact mechanism, and i cant find an explanation yet (most likely because one has not been clearly hypothesized). im trying to get some of the references quoted in ISIS, but they are not that easy to find.

what would be the point in blocking the nerve at all if what you are really interested in is the exact point of disc herniation?

Since we're referencing the ISIS Guidelines, page 12 paragraph 4 states “The injection should continue until the contrast medium fully outlines the spinal nerve and its dorsal root ganglion where they lie in the intervertebral foramen (Figure 10). Contrast medium does not need to be driven beyond the inferior end of the lateral recess that contains the roots of the target nerve.”

Figure 8 and 9 both show contrast tracking under the pedicle and through the foramen.

Nowhere does it state that the contrast flow should remain “extraforaminal”, and figure 10 clearly shows contrast in the epidural space, at the level below the targeted nerve. The foramen and lateral recess, that’s 2 possible sites of neural impingement. And what about all those inflammatory mediators in the epidural space from a disc herniation?

 

[Mister Mxyzptlk]

As an aside:

While the ISIS Guidelines are useful, they were not brought down the mountain carved on stone tablets. Indeed, a good proportion of the ISIS leadership doesn't follow them, which is a sore point when it comes to the ISIS courses where the instructors will often deviate from the Guidelines.

The ISIS Guidelines, like law and sausage, are something you'd rather not see being made. They are like the output of wide dynamic range neurons - there are multiple inputs that are integrated into a single output. The inputs often reflect personal bias and non-medical (e.g., economic) agendas rather than evidence. In the final analysis a lot of the literature can be argued either way so people can justify their agendas on an EBM basis. I think Nik does a good job sorting it all out and keeps it as intellectually honest as he can, but the final product has to be acceptable to the Board, not just him.

So although we can reference them and they are useful for practicing according to "acceptable standards", they are not a substitute for thought, although people do use them that way.

 

[ampaphb]

As an aside:

While the ISIS Guidelines are useful, they were not brought down the mountain carved on stone tablets. Indeed, a good proportion of the ISIS leadership doesn't follow them, which is a sore point when it comes to the ISIS courses where the instructors will often deviate from the Guidelines.

The ISIS Guidelines, like law and sausage, are something you'd rather not see being made. They are like the output of wide dynamic range neurons - there are multiple inputs that are integrated into a single output. The inputs often reflect personal bias and non-medical (e.g., economic) agendas rather than evidence. In the final analysis a lot of the literature can be argued either way so people can justify their agendas on an EBM basis. I think Nik does a good job sorting it all out and keeps it as intellectually honest as he can, but the final product has to be acceptable to the Board, not just him.

So although we can reference them and they are useful for practicing according to "acceptable standards", they are not a substitute for thought, although people do use them that way.

Mike:

Let's assume for a second that you and I are both ethical reasonable people. We both know lots of other docs out there who don't practice that way. Not ever accepting articles or allowing for minimum standards or benchmarks is nihilistic and allows for every doc to practice the way they see fit, regardless if their motives are financial or in the best interests of the patient.

So, if articles are imperfect, and guidelines not not rise to the level of acceptable minimum standards, how do you propose the ferals be domesticated?

 

[Tenesma]

ampa

simple answer to that...

1) Medicare/Medicaid/Private insurers stop paying for spine procedures unless they are done by a Board-Certified Interventionalist
2) Medicare/Medicaid/Private payers stop paying once you have reached X amount of injections per region per time period.... ie: you can't do SI injections every 2 weeks...

the only way to get the quacks out of this process is to eliminate the reimbursement....

GI had to go through this when FPs were billing colonoscopies and weren't going beyond the sigmoid colon or even the rectum -

the quacks will then find another procedure/specialty they can pilfer...

 

[ampaphb]

ampa

simple answer to that...

1) Medicare/Medicaid/Private insurers stop paying for spine procedures unless they are done by a Board-Certified Interventionalist
2) Medicare/Medicaid/Private payers stop paying once you have reached X amount of injections per region per time period.... ie: you can't do SI injections every 2 weeks...

the only way to get the quacks out of this process is to eliminate the reimbursement....

GI had to go through this when FPs were billing colonoscopies and weren't going beyond the sigmoid colon or even the rectum -

the quacks will then find another procedure/specialty they can pilfer...

Maximum number per time period has already been implemented by a number of LCDs

WTF is a board certified interventionist? Is that the same thing as a board certified pain doc? 'cause if that is the case, some of the worst thieves in my area would continue to get paid.

Additionally, as most PM&R fellowships lost their accreditation, that would skew payment to anesthesia-trained docs at the expense of those trained at top notch, but non-ACGME accreditied PM&R based fellowships.

 

[Mister Mxyzptlk]

I don't think we need guidelines to identify bad apples. Just because there's twilight doesn't mean you can't tell night from day. The medical boards do this all the time. You can lose your license because of your opioid prescribing habits even in the absence of any standards for same.

Be careful what you wish for. Do you really want a set of guidelines to become the de facto standard? What if they* decide to use ACOEM? Will you start practicing that way or will you develop a new-found sense of relativism?

Guidelines are promulgated by many organizations (e.g., ISIS, ASIPP, ODG, and ACOEM) - all of them disagreeing to some extent or another, and each of them claiming to be based on "best evidence" as interpreted by "experts". Which set is correct?


*Whoever "they" are. I just know I am not one of them, although I would like to be as "they" appear to have a lot of power and influence.

 

[Mister Mxyzptlk]

Additionally, as most PM&R fellowships lost their accreditation, that would skew payment to anesthesia-trained docs at the expense of those trained at toop notch, but non0-ACGME accreditied PM&R based fellowships.

Works for me.

Perhaps ACGME thought they were weeding out the riff-raff the same way you would like to use standards to do the same in IPM. After all, ACGME is a standard-setting entity.

How can you argue for standards in one post as a mechanism for debriding bad actors and then argue against a well-established standard-setting organization in another?

As an aside, why did these programs lose accreditation? Seems to me that a top-notch program shouldn't have that problem.

 

[ampaphb]

I don't think we need guidelines to identify bad apples. Just because there's twilight doesn't mean you can't tell night from day. The medical boards do this all the time. You can lose your license because of your opioid prescribing habits even in the absence of any standards for same.

Be careful what you wish for. Do you really want a set of guidelines to become the de facto standard? What if they* decide to use ACOEM? Will you start practicing that way or will you develop a new-found sense of relativism?

Guidelines are promulgated by many organizations (e.g., ISIS, ASIPP, ODG, and ACOEM) - all of them disagreeing to some extent or another, and each of them claiming to be based on "best evidence" as interpreted by "experts". Which set is correct?


*Whoever "they" are. I just know I am not one of them, although I would like to be as "they" appear to have a lot of power and influence.

Impressive dodging of the issue - if you don't respect the academic literature, and you can't abide ISIS or AAPM setting MINIMUM standards (although I do like how that adjective magically dropped out of your restating my position), what meausre's would you use to determine physicians practicing below minimum competency levels? Or is this akin to Justice Potter Stewart's "I can't define it, but I know it when I see it"

 

[ampaphb]

Works for me.

Perhaps ACGME thought they were weeding out the riff-raff the same way you would like to use standards to do the same in IPM. After all, ACGME is a standard-setting entity.

How can you argue for standards in one post as a mechanism for debriding bad actors and then argue against a well-established standard-setting organization in another?

As an aside, why did these programs lose accreditation? Seems to me that a top-notch program shouldn't have that problem.

WOW - thanks Mike, that confirms you shoot from the hip when you don't have a clue what you are talking about.

Rules regarding fellowships were changed recently, and one of the rules implemented was one fellowship per institution. A number of the best PM&R fellowships (Emory, Sinai, Temple) were peripheral to their institutions, while the anesthesia fellowships were more directly connected. Others (UC Davis, Stanford) got swallowed up by their larger anesthesia counterparts. The vast majority (Northwestern, University of Washington, Penn, Washington University, HSS, Beth Israel in NY) never bothered to jump through the ACGME's hoops in the first place.

Might want to actually find out the facts before smearing a large number of your colleagues in futue, Dr. G. Oh, and just to reiterate my original pioint I made to Tenesma, the ACGME DOES NOT accredit interventionists, so NONE of us are board certified in THAT area of specialization.

I never advocated literature or guidelines as minimum standards, what I asked was, if you don't accept those, what DO you use as a measure of competency?

 

[Disciple]

Most of these PM&R fellowships lost pain accreditation, or were never accredited in the first place, because they're not pain fellowships.

In a nutshell, these fellowships teach detailed evaluation of musculoskeletal disorders, EMG, ultrasound, procedures (to varying degrees), etc.

Call it Advanced Physical Medicine, whatever.

The problem is that there's no recognized certification for this type of training/expertise and that these fellowships are themselves standardized very loosely.

Hopefully the ABPMR will take care of this problem in the near future.

 

[lobelsteve]

Most of these PM&R fellowships lost pain accreditation, or were never accredited in the first place, because they're not pain fellowships.

In a nutshell, these fellowships teach detailed evaluation of musculoskeletal disorders, EMG, ultrasound, procedures (to varying degrees), etc.

Call it Advanced Physical Medicine, whatever.

The problem is that there's no recognized certification for this type of training/expertise and that these fellowships are themselves standardized very loosely.

Hopefully the ABPMR will take care of this problem in the near future.

I'm hoping ABPMed and ASIPP can combine and adopt ISIS as their crazy old uncle. THen we stand a fighting chance of shutting down the charlatans, developing appropriate standards of care and training, and better treating patients in pain.

 

[Tenesma]

ampa - did you miss your xanax dose tonight? why do you alway start frothing at the mouth?

regarding my comment regarding board certified interventionists - i still stand by that comment. the problem is we don't have a true acgme-accredited board certification for interventional pain (other than FIPP, ABIPP)... that hopefully would be ideal in bringing most people on the same page...

interestingly, I know of some folk who were trained at great programs with a strong emphasis on good evidence, etc... and what do they do in private practice, series of 3 ESIs, TONS of intra-articular facets, TONS of discograms regardless of whether potential surgery is considered, nucleoplasty on PI cases, etc... their motivation: productivity to make partner...

it is sad... so maybe my plan is pointless as long as there are financial motivators...

 

[Jcm800]

I am really late to this topic, so excuse me for that...

But back to the original topic of is there a SNRB vs. TFESI. Here is my comment, and do with it what you will. But i have asked this question a thousand times to a thousand people, and nobody seems to answer it the same. I, similar to Gorback, agree that the pain generator is proximal, and have never understood how blocking something peripheral will improve the pain.

Ie, the example of a patient with radic pain who gets a sciatic block, their leg is numb (at least in the distribution of the sciatic nerve) and you can do surgery (depending on the surgery obviously) but they still have radicular pain. I have seen this. I have done anesthesia for a total knee with sciatic block and continuous femoral block... they are in there hammering and sawing with no incisional pain, but their back pain and radic pain exisited.

Also, explain this one to me. I do a brachial plexus block, lets say axillary, say it fails. try to do a rescue block proximal, supraclavicular or interscalene... you cant get a twitch. BUT you can distal. so rescue blocks have to be at the ulnar or median nerve or whatever. Again, i have done this...
I think this has to be the same phenomena as the "extraforaminal nerve block" regardless of whether the local anesthetic tracks proximal. I just cant understand based on science how it could work, if it was truly "selective." if the pain generator is proximal, you are not blocking the signal by blocking it distal to that site, IMHO. So for a "SNRB" to work Ie, it must track proximal. I dont even try and make a distinction because im rarely looking for a true diagnostic block, im treating their symptoms, so epidural, unselective is ok for my goals.

Ok, my two cents. Please rip to shreds.

 

[Disciple]

I think the notion of an "extraforaminal" block must have come from the idea of trying to get a nice neurogram. I mean, who doesn't like to see that. I think it makes us feel like we did the procedure well when we have a nice image to save for our records and to send to the surgeon.

We've been quoting the ISIS Guidelines, which themselves don't say anything about keeping the contrast outside the foramen.

In fact, their pictures show the opposite.

 

[Disciple]

I'm hoping ABPMed and ASIPP can combine and adopt ISIS as their crazy old uncle. THen we stand a fighting chance of shutting down the charlatans, developing appropriate standards of care and training, and better treating patients in pain.

I think the ABPMR is brainstorming on how to dig up enough content to create a new subspecialty. I don't see it being that difficult, they've already got PASSOR procedure guidelines based on the ISIS Guidelines, and Slipman's book is almost as thick as Braddom.

With an interventional pain certification, I think it depends on how high you want the standards to be. Interventional Cardiologists take the Cardiology boards and then Interventional Cards exam 1-2 years after that.

We can probably agree that not all accredited fellowships provide good interventional training. Should we require ABIPP as a second board exam?

If a pain residency forms, should it be ABPM, followed by ABIPP 6-12 months later?

Is that too much of a pain in the ass for the vast majority of practicing pain physicians?

interestingly, I know of some folk who were trained at great programs with a strong emphasis on good evidence, etc... and what do they do in private practice, series of 3 ESIs, TONS of intra-articular facets, TONS of discograms regardless of whether potential surgery is considered, nucleoplasty on PI cases, etc... their motivation: productivity to make partner...

it is sad... so maybe my plan is pointless as long as there are financial motivators...

Anybody have any inkling if Interventional Cardiologists are doing many unecessary procedures? What about GI, Derm, or any other specialty for that matter? I think we've talked about spine surgeons enough in the Laser Spine Institute thread.

 

[Tenesma]

well cardiology groups would do TONS of "diagnostic" caths.... so they started clamping down on cath labs - stating that if >20% of diagnostic caths are normal than they are "Over-doing" caths... but the cardiologists just adjusted and are now diagnosing some type of disease even if it is pretty normal.... insane

 

[Mister Mxyzptlk]

I think the indication for EGD/colonoscopy ("choke 'n' poke") is a referral for any abdominal complaint and/or anemia. And I can't recall seeing one done w/o at least one biopsy.

The indication for excisional skin biopsy appears to be "any spot that is a different color than the rest of the skin".

 

[jsaul]

I think the indication for EGD/colonoscopy ("choke 'n' poke") is a referral for any abdominal complaint and/or anemia. And I can't recall seeing one done w/o at least one biopsy.

The indication for excisional skin biopsy appears to be "any spot that is a different color than the rest of the skin".

i have seen patients sent to GI for liver issues, Hep C whatever... they always ended being scoped.

Just like when I send a patient to a spine surgeon for back pain that has failed all conservative treatment, the patient ends up getting a cervical fusion. This has happened several times and is becoming more common.

 

[Tenesma]

well cervical fusions pay better... and are easier and faster to do - so that makes sense

my local GI guys will do EGD/Colonoscopies for ANY GI complaint - even if it is for reflux - that's because they can bill for screening endoscopies...

the GI guys are making >800k in my neck of the woods with this paradigm -