TFESI decision making

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lonelobo said:
Ya I know the math, that was not my point.
He had mentioned overutilization, when I said I perform 2 levels at a time as the answer to a posed question.

So by the math it is a wash(in office)
In an ASC(where I perform procedures) or hospital coming back for 2nd procedure is going to cost patient or insurance more.

Not to mention the convenience factor for some of my patients that have to travel a 100 miles or be taken off anticoagulation.

How about we agree that there are different ways to practice pain mgmt, before we infer that someone is Overutilizing procedures
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Nope, you are greedy.

It is a patient by patient decision. But if it were a blanket policy to do 2 levels all the time, you'd be a greedy bastard.
 
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lobelsteve said:
Nope, you are greedy.

It is a patient by patient decision. But if it were a blanket policy to do 2 levels all the time, you'd be a greedy bastard.
Click to expand...

Again your own math shows that would make more money if you bring back 1/4 of pts for in office procedures.
So who is greedy ?
"Mr. Ethics > profits"

By the way, be careful with the insults, in case we cross paths at meeting
sometime ( everyone is a tough guy anonymously)
 
lonelobo said:
Again your own math shows that would make more money if you bring back 1/4 of pts for in office procedures.
So who is greedy ?
"Mr. Ethics > profits"

By the way, be careful with the insults, in case we cross paths at meeting
sometime ( everyone is a tough guy anonymously)
Click to expand...

dude, it was in purple (sarcasm).

everything comes across wrong when it is typed. many a fight have been started via a misconstrued email (moat of them by my wife).
 
lonelobo said:
Again your own math shows that would make more money if you bring back 1/4 of pts for in office procedures.
So who is greedy ?
"Mr. Ethics > profits"

By the way, be careful with the insults, in case we cross paths at meeting
sometime ( everyone is a tough guy anonymously)
Click to expand...

Anonymous tough guy?

lobelsteve- even a lone wolf could figure this out. Maybe I put my practices link in the column on the left to hide my identity further. I'm easy to find and very accessible.

And yes, I'm pulling your chain.

But I do not see a rationale for performing 2 levels at a time unless multilevel pathology is supported as pain generators: back pain worse on the right and right thigh posteriorly, leg pain worse on the left into the little toe, MRI shows DDD with rightsided bulge at L4-5 and moderate recess stenosis, L5-S1 shows large dis in the recess abutting to and impinging on the descending left S1 root. This becomes a right L5 and left S1 TFESI.

But a simple L5-S1 disc in the recess? I'd always start S1 and almost always get it done with a single shot. Next question: how many series of three do you wind up doing?

I'm not saying 2 levels is always wrong, but always two levels is wrong.
 
lobelsteve said:
Anonymous tough guy?

lobelsteve- even a lone wolf could figure this out. Maybe I put my practices link in the column on the left to hide my identity further. I'm easy to find and very accessible.

And yes, I'm pulling your chain.

But I do not see a rationale for performing 2 levels at a time unless multilevel pathology is supported as pain generators: back pain worse on the right and right thigh posteriorly, leg pain worse on the left into the little toe, MRI shows DDD with rightsided bulge at L4-5 and moderate recess stenosis, L5-S1 shows large dis in the recess abutting to and impinging on the descending left S1 root. This becomes a right L5 and left S1 TFESI.

But a simple L5-S1 disc in the recess? I'd always start S1 and almost always get it done with a single shot. Next question: how many series of three do you wind up doing?

I'm not saying 2 levels is always wrong, but always two levels is wrong.
Click to expand...


My issue with use is you stated Overutilization, then you proceed to tell me you need to bring back 1/4 of pts to do another level.
So it is about a wash. If you work out of office with math you presented
I know your fees would be higher that me charging 50% for a 2nd level
out of an ASC vs you getting the comprehensive on 1/4 of these pts-so
for that I am greedy?

The pt example you give above is valid, but the great majority of pts fall
into the former catergory.

You didn't respond to comment I made about the hassle of taking people off anticoagulation, or time and distance to travel to bring them back, which is big issue where I am at.

Don't do series of threes and never had.

I dont know your practice and you don't know mine, but I would be willing to bet you perform interventional procedures on a higher % of your pts than I do
based on your posts.

Yes I may be a bastard, but I don't consider myself greedy.
 
Loosen up your skirt.

Of course that was your 69th post.

Doing 2 levels on every patient is over-utilizing and gives us all a bad rep.

Rationalization does not always make it better.

You are right to do it if the need to stop anticoag precludes trying one level and the pathology is uncertain.

Unsure if travel distance makes a difference in my eyes- guess right the first time or go at the bottom level- meds do appear to travel up the spine.

Series of 3 is voodoo and we are on the same page.

I try to do less procedures than where I trained, and I am not under pressure or obligation to offer. Patients usually call back and speak to my nurse to see if I would consider doing a procedure for them. Maybe reverse psychology, maybe procedures are only so useful....Dont know.

More importantly- I am no one from no where. Why would you care?

Caveat: I work for insurance and do a small amount of precert work. Mostly disability evals as a disinterested 3rd party.
 
lobelsteve said:
Loosen up your skirt.

Of course that was your 69th post.

Doing 2 levels on every patient is over-utilizing and gives us all a bad rep.

Rationalization does not always make it better.

You are right to do it if the need to stop anticoag precludes trying one level and the pathology is uncertain.

Unsure if travel distance makes a difference in my eyes- guess right the first time or go at the bottom level- meds do appear to travel up the spine.

Series of 3 is voodoo and we are on the same page.

I try to do less procedures than where I trained, and I am not under pressure or obligation to offer. Patients usually call back and speak to my nurse to see if I would consider doing a procedure for them. Maybe reverse psychology, maybe procedures are only so useful....Dont know.

More importantly- I am no one from no where. Why would you care?

Caveat: I work for insurance and do a small amount of precert work. Mostly disability evals as a disinterested 3rd party.
Click to expand...

Not sure what 69th post has to do with anything
have been on this site for couple years and yes I don't usually post 10x/day like others.

But I don't think I give us a bad name, I think more people on this site probably do 2 levels than you think.
Again what overutilization are you talking about-If You bring back your pts 1/4 of time this ends up costing the pt and insurance company more.

I guess when you refer to someone as a greedy bastard, you should know a little more about them, instead of making a blanket statement based on what I do with one type of procedure.

"
 
OMG, STFU..... I CAN'T READ THIS ANYMORE. WHO CARES..... I just pulse the DRG at 4 levels and call it a day 😀 .... and of course bill it as a 4 level RFA
 
Just wanted to apologize for my vulgarity in the previous post; it wasn't directed at any one person, just the general argument .... I had been drinking again. Damn it.
 
group_hug.jpg



🙂
 
PMR 4 MSK said:
82 yo female with signs and symptoms c/w L4 radic. Radiologists report of MRI - "Left posterolateral L3-L4 inferior disc extrusion impinging on the left L4 nerve root." (Among the usual 82 yo degenerative spine things).

Which would you prefer to do? :

1) left L3-4 TFESI - HNP is at that level
2) left L4-5 TFESI - L4 in nerve root involved
3) left L4 SNRB
4) interlaminar ESI L3-4

I did the L4-5 TFESI, saw the contrast flow right up along L4 NR to L3-4, should have been an excellent injection. Pt got no relief. I always debate these in my mind as to the best place to put the needle.
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I would do both L3-L4 and L4-L5 TFESI as it would help the disc inflammation at one level and nerve inflammation at the other;usually have excellent results;But anyother suggestions....?
 
I see the original post was in 2008....but I have always struggled with this as well

As I see it the medication should land as close to the disc-nerve interface as possible

I was taught for a right PC L4-5 disc herniation (compressing the right traversing L5 nerve) to do a right L5 TFESI (L5-S1 foramen) and hope your contrast tracks up....which it does quite frequently

What I haven't been happy with, on occasion, is when you apply this to an L5-S1 disc with an S1 TFESI, many times despite several cc's of contrast, repositioning (or without cannulating a vessel for that matter) I can't seem to get it to track up to the disc space, no way the one cc of kenalog I inject here is making it.

This is when I wonder if the so called "preganglionic" approach at the L5-S1 foramen or an ILESI would be better

But then other docs read your report and wonder why you did an L5 TFESI for an S1 radiculopathy

Thoughts????
 
This was a very enlighting and revealing post.

Thank you for finding it. I taught me a lot about a few of my fellow posters.

Some of you should run for office.
 
ampaphb said:
It is my experience that the 3/4 disc usually catches the L3 root, rather than 4.

I would confirm that the radiology report is correct by reviewing the films myself.
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your experience is wrong
 
mille125 said:
Okay there is no difference....
Click to expand...
The quote was referencing a claim that "no difference in outcomes (to date) between LESi vs TFESI"

Could you provide the literature citation that supports your claim that there is no difference?
 
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mille125 said:
your experience is wrong
Click to expand...
The quote dates back to 2008. Three years later, I would suggest that lateral L3/4 disc displacement catches the L3 nerve, while posteriorly displaced L3/4 discs are more likely to come in contact with L4 or L5.
 
ampaphb said:
The quote dates back to 2008. Three years later, I would suggest that lateral L3/4 disc displacement catches the L3 nerve, while posteriorly displaced L3/4 discs are more likely to come in contact with L4 or L5.
Click to expand...

I would agree with that. Same generalization lower down also.
 
ampaphb said:
The quote dates back to 2008. Three years later, I would suggest that lateral L3/4 disc displacement catches the L3 nerve, while posteriorly displaced L3/4 discs are more likely to come in contact with L4 or L5.
Click to expand...

i would agree
 
ampaphb said:
The quote was referencing a clain that "no difference in outcomes (to date) between LESi vs TFESI"

Could you provide the literature citation that supports your claim that there is no difference?
Click to expand...

Can you provide a literature citation that says that there is a difference?
 
ampaphb said:
What part of "there is no data" did you not understand?
Click to expand...

ampaphb,

Why do you insist there is not data?

Here are several studies that compare the two. I am not saying anything about the quality of these studies, nor if there is a difference....just saying that it IS data.
 

Attachments

The original quote dates back to 2008. Please note that only one of your studies predates the comment.

What I should have said was that, in 2008, when I claimed there was no data, I was incorrect. There was was one case controlled pilot study, which concluded:
" ...transforaminal epidural steroid injections for the treatment of symptomatic lumbar disc herniation resulted in better short term pain improvement and fewer long term surgical interventions than interlaminar epidural steroid injection"​
 
ampaphb said:
The original quote dates back to 2008. Please note that only one of your studies predates the comment.

What I should have said was that, in 2008, when I claimed there was no data, I was incorrect. There was was one case controlled pilot study, which concluded:
" ...transforaminal epidural steroid injections for the treatment of symptomatic lumbar disc herniation resulted in better short term pain improvement and fewer long term surgical interventions than interlaminar epidural steroid injection"​
Click to expand...

Oh. my bad. I get the dates know.
 
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