Spine Surgeons doing epidurals.....

[PinchandBurn]

Regardless of whether they are a spine surgeon (ortho versus neuro), if they do back surgeries, isn't it a huge conflict of interest to be doing subcutaneous steroid injections....I mean epidural steroid injections?

Especially, when they do not 'work', fusion/laminectomy is the next step?

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[lobelsteve]

Regardless of whether they are a spine surgeon (ortho versus neuro), if they do back surgeries, isn't it a huge conflict of interest to be doing subcutaneous steroid injections....I mean epidural steroid injections?

Especially, when they do not 'work', fusion/laminectomy is the next step?

See it all the time.

Case in OH where surgeon did 3 blind ESI in surgery center, 22G Tuohy, seated position.
They didn't help so he performed L4-S1 fusion. 1 month later I&D and picc for infection, 3 months later removal of hardware for ongoing infection.

MRI with mild foraminal compromise, no canal stenosis, no nerve compromise.
Exam was 5/5, normal reflexes, normal sensation.

 

[drf]

I previously complained about a nearby ortho spine surgeon doing caudals with lidocaine 1% 10 ml, NS 10 ml, and dexamethasone 10 mg. to be followed by fusion when it doesnt work.

 

[PMR 4 MSK]

In my former practice, I had a neurosurgeon nearby who did his own spinal procedures, would fuse, and then when they still had pain would put a pump in them and then send them to a home health agency that did all the pump refills and adjusting of doses - essentially an RN decided what dose they got.

I saw patients all the time who had had ESIs by him who were scared to death when I suggested they have a real one done by me. "Oh God no! I had a headache for 2 weeks when he did mine!" That was a common thing to hear.

I had one lady he literally paralyzed with a pump. She was walking before the pump, not after. So much metal in her back I could not figure out why, neither could the neuologist I sent her to for another opinion. She refused referral to another spine doc. All I could do was refill her pump. It worked very well for her suprisingly.

Another patient he put in a pump for me (before I figured out he was a yahoo, medtronics rep recommended him) and the patient came back to me a week later with an obvious spinal headache. I called him and he said send her right over. A few days later I get his note and he says it's a tension-type HA and he prescribed ibuprofen. A week later she still cannot sit up. I told her husband to take her right over to the surgeons office. He finally agreed it was aspinal HA, did a blood patch and she walked out HA-free.

Now we have a newly-trained ortho spine guy starting this summer with us. He plans to do his own lumbar injections but not cervical. I can't wait to see if he plans to use fluoro or not...

 

[Louisville04]

I saw patients all the time who had had ESIs by him who were scared to death when I suggested they have a real one done by me. "Oh God no! I had a headache for 2 weeks when he did mine!" That was a common thing to hear.

I had one lady he literally paralyzed with a pump. She was walking before the pump, not after. So much metal in her back I could not figure out why, neither could the neuologist I sent her to for another opinion. She refused referral to another spine doc. All I could do was refill her pump. It worked very well for her suprisingly.

Another patient he put in a pump for me (before I figured out he was a yahoo, medtronics rep recommended him) and the patient came back to me a week later with an obvious spinal headache. I called him and he said send her right over. A few days later I get his note and he says it's a tension-type HA and he prescribed ibuprofen. A week later she still cannot sit up. I told her husband to take her right over to the surgeons office. He finally agreed it was aspinal HA, did a blood patch and she walked out HA-free.

Now we have a newly-trained ortho spine guy starting this summer with us. He plans to do his own lumbar injections but not cervical. I can't wait to see if he plans to use fluoro or not...

Did the patient come to see you for a 2nd opinion after having poor results with the surgeon or did he refer her to you for chronic pain management?

Do spinal headaches always have to be treated with a blood patch or are some self limiting (2-3 days vs 2 weeks)?

Isn't fluoro the standard of care for spinal procedures and no one does them blindly?

 

[Jcm800]

we had an ortho out here that did them, but only in work comp...hmmmm.
they all go rip-roaring paraesthesias, per the patients i saw...

 

[PinchandBurn]

Did the patient come to see you for a 2nd opinion after having poor results with the surgeon or did he refer her to you for chronic pain management?

Do spinal headaches always have to be treated with a blood patch or are some self limiting (2-3 days vs 2 weeks)?

Isn't fluoro the standard of care for spinal procedures and no one does them blindly?

see it's because of Yahoo surgeons like this and others that the data for ESIs is jaded. Think of how many Fusions/Lamis that COULD have been prevented by a properly guided (with fluro) injection and correct medications.

The trick is trying to get to these patients before they fall on the knives of these surgeons. That's always the toughest task though. Also, once the surgeons start finding out that your ESIs actually work, they sort of stop referring to you on cases they really want to operate on, is what I heard......really awful.

 

[painstop]

see it's because of Yahoo surgeons like this and others that the data for ESIs is jaded. Think of how many Fusions/Lamis that COULD have been prevented by a properly guided (with fluro) injection and correct medications.

The trick is trying to get to these patients before they fall on the knives of these surgeons. That's always the toughest task though. Also, once the surgeons start finding out that your ESIs actually work, they sort of stop referring to you on cases they really want to operate on, is what I heard......really awful.

The Hippocratic Oath at its finest...what has medicine turned to (I'm thinking a used car dealership but maybe a brothel is a more appropriate analogy)

 

[onewithpain]

There are 2 ortho spines in my town. They both used to refer to me and now only one does. The other didn't like that I did MBB/RFA and the patients didn't go back to him, so he took a PASSOR class and now does his series of 3 ESIs and then cuts.

 

[stim4u]

ortho in my town, has patients curl into a fetal position, and uses an 'xray' to put the needle in the back. Most have headaches, and 1 weeks of relief.
when they get to me, and have a standard procedure in the prone position, they are surprised.
pretty scary out there.

 

[PMR 4 MSK]

Did the patient come to see you for a 2nd opinion after having poor results with the surgeon or did he refer her to you for chronic pain management?

Do spinal headaches always have to be treated with a blood patch or are some self limiting (2-3 days vs 2 weeks)?

Isn't fluoro the standard of care for spinal procedures and no one does them blindly?

Most came to me for another opinion. Most spinal HAs are self-limited - rest, caffeine, liquids, tylenol or ibuprofen.

Many docs still do ESIs blind. Older docs were trained before fluoro was in wide use for pain, and all anesthesiologists are trained to do epidurals for surgery. Many therefore believe since they can do them for surgery, an ESI is easy to do blind.

 

[lobelsteve]

Most came to me for another opinion. Most spinal HAs are self-limited - rest, caffeine, liquids, tylenol or ibuprofen.

Many docs still do ESIs blind. Older docs were trained before fluoro was in wide use for pain, and all anesthesiologists are trained to do epidurals for surgery. Many therefore believe since they can do them for surgery, an ESI is easy to do blind.

I'd readily argue that performing a blind ESI for purpose of treating pain is outside the standard of care. I believe Algos has an article that may or may not be published on a review of the data. We do have a decent battery of articles on how poor and unsafe the procedure can be when done by improperly trained docs using antiquated techniques.

 

[epidural man]

Do spinal headaches always have to be treated with a blood patch or are some self limiting (2-3 days vs 2 weeks)?

the data suggest this....but the data isn't based on 14 gauge holes in the dura.

 

[Jcm800]

Let's admit, the spine surgeons should do everything that makes money, we should just sit around and see in patients and write narcotics