Private practice is a business, once the business model is in place, it's like a machine, and it's common fall into that model if you mix business with medicine. 3 levels is overkill, but I have done 2 levels and bilateral TFESIs when necessary. But I also do genic. RFAs and don't get paid sometimes. I think it's a trade off between many things.I recently joined a private practice in which I've yet to see a patient who has undergone a single level transforaminal. ALL of the injections are either three level transforaminals on one side or a bare minimum of 2 levels (if the patient has unilateral radicular sx) or two level bilateral TFESIs if patients have bilateral symptoms. Worse yet patients get series of these injections even if the injections only result in a week of relief (in some cases days).
Is this the norm for private practice? Honestly, I'm a bit shocked to see these practice patterns. I'm worried that this is the status quo for private practice in pain. I was trained to focus my interventional efforts in the most targeted manner possible, minimizing the overall risk to the patient and doing only what is medically necessary. Three level TFESIs seem ridiculous--absolute overkill that can only be justified on financial grounds. Am I crazy to think this way? Does anyone else on this forum find routine 3 level TFESIs to be inappropriate?
I know. Writing on the wall. Several practices are like this and the FBI and OIG are being active.I'm actually thinking about reporting the practice for insurance abuse but I'm worried that the practice owner has connections in high places, including the oversight boards. I feel like I joined the Bernie Madoff of pain medicine. The man is filthy rich ( mansion in a prime location of the city, a second house in another area of the city, nice cars, etc).
I already confronted the practice owner about my concerns, and he talked to me like I was from another planet...I mean, from his perspective, OF COURSE you do a 3 level transforaminal for an S1 radiculopathy. And, duration of relief from an epidural is irrelevant in subsequent medical decisionmaking. 2 days of relief? Yep, they qualify for another epidural always.
The entire conversation made me so incredibly angry. Maybe I'm too much an idealist but I still believe that excellence in patient care is the focal point of medicine, not becoming rich by exploiting power and knowledge differentials between physicians and patients.
Sad. Very sad.
You could make an arguement for two-level unilateral TFESI in certain clinical scenarios.How do you determine what level to inject if you insist on doing single level TESI? based on clinical findings of radiculopathy of particular nerve or nerves, or radiological finding of foraminal stenosis? We know that clinical findings don't always correlate with radiological findings, and single level disc herniation can cause multiple nerve irritation. you can do ILESI as a shotgun approach, to cover multiple nerve roots. If you are doing TESI injection, it's either a hit or miss if you focus on one particular level.
To the OP, doing multiple level TESI is not CRAZY. I've seen plenty of ethical pain docs doing unilateral 3 levels TESI. I myself have done 3 levels TESI successfully for patients who had single level TESI done by someone else, but failed to receive any benefit.
Every one of my attendings in fellowship did three level TESI. They in general favored TESI over ILESI. This is not a private practice, it's a ACGME-accredited university pain management department. Everyone of over 10 full-time pain management physicians routinely do three level TESI. I don't think it's a question of ethics. It's what you believe would work best for your patients.
To say three level TFESI should virtually never been done isn't close minded, it means I actually know what I am doing. I don't challenge the ethics of your fellowship attendings, I challenge their competence.I actually think 2 level TESI should be the norm whenever you're doing a TESI, single level is really if you are 100% sure which nerve is precisely affected, and 3 level when you have multiple dermatomal involvement or discordance between imaging findings and clinical impressions.
To say three levels TESI should never be done is really narrow-minded. If you have someone with radicular pain in the knee, calf, and bottom of left foot, don't you want to cover L4, L5 and S1 in one single procedure? Of course, you can bring back the patient and do one level at a time, if it sounds more "ethical" to you.
My point is, don't jump into conclusion just because someone doing something different from how you're trained or what you are used to, he/she is doing it "for profit" and "unethically". In fact, as you said, it'd be more profitable to do single level, one at a time, without 50% reduction.
We might differ on our method, we should rarely judge other's characters.
BTW, Harvard doesn't have the best pain management program. 80% Attendings at my fellowship program were trained at the top-notched program. This is the program that have been offering annual pain management symposium nationally for almost 20 years. You can probably second-guess which program it is. But it's really besides the point, since we don't want direct the thread to a personal attack.
What you've described is totally outside the standard of care. Not a single pain physician on this forum is defending you and >90% of pain physicians would support what I've stated tonight. The onus is on you to prove that you are right, not me to prove that you are wrong. I don't have to prove that homeopathy doesn't work. They have to prove that it does.This is not a competence issue. It's a matter of what you believe is the best option for your patients. I'd be happy to have your patients and repeat 2 or 3 level TESI if you just happened to miss your targets.
To say that it's not indicated to do multi-level TESI is analogous to say one should never do MNBB for more than 2 levels. If there are multi-level DDD and there are multiple dermatomal symptoms, there are reasons to do multi-level unilateral TESI.
Actually, so far besides stating your reasons that you have never done multi-level TESI (therefore no one should be doing it, ever), and accusing other practicing unethically for money, or incompetently, there have been no rationales provided on this discussion so far.
I would challenge you to quote "the standard of care" on TESI. I'm open-minded to see any randomized, controlled study to show any more efficacy of single level TESI vs. two level TESI or three level TESI. I'm even open-minded to hear your rational that one should never or even rarely do multi-level TESI. So far I have heard none.
You are right. The other guy is defending dogma. And would lose in court.The reason why I created this thread was to get a sense of practice patterns vis-a-vis transforaminals. I can tell you that I never did a three level transforaminal ESI at my fellowship program. Two levels were rare birds as well. My practice pattern as an attending physician is very similar.
I don't believe this to be true at all. Depends on the volume, the spread, the degree of stenosis. Mix a minute amount of contrast into the meds one day and watch it go in. You'll watch it spread to multiple levels, especially along the anterolateral epidural space. Gravity also plays a factor when the patient stands up. It's the same principle why a gunshot epidural works sometimes.If you are doing TESI injection, it's either a hit or miss if you focus on one particular level.
Damn Dr. Weiss, you have some serious training, kudos!I don't believe this to be true at all. Depends on the volume, the spread, the degree of stenosis. Mix a minute amount of contrast into the meds one day and watch it go in. You'll watch it spread to multiple levels, especially along the anterolateral epidural space. Gravity also plays a factor when the patient stands up. It's the same principle why a gunshot epidural works sometimes.
80% success at 8 weeks far outstrips all published data and is far better than anyone else, ever. You might not be remembering too well. You trained with fools. I, on the other hand, trained with a ________. Everyone makes mistakes (Hannah Montana)I don't think there's a straight-forward answer to this case. It's a judgement call.
It is, and you have lousy judgement. Pretending that if they do not get relief they are going on to fusion or stim is a false argument to make your self feel like you are saving them from something drastic. It is pain, not cancer. Treating axial low back pain with ESI is unsupported. DDD? Over age 40 it is called normal wear and tear.
I have 80% success rate for lumbar IESI (50% pain relief for over 8 weeks at minimum, but great majority gets more than that), 80-90% for cervical IESI, not great, but fortunately close to 95% for lumbar TESI. 5% is for post-laminectomy patients with chronic radic/myelopathy. So I prefer TESI in general. Again this is my personal opinion, and how I practice and how I saw my attending practiced. I happened to agree with them. Even if I do not, I'd respect their personal belief, preference and practice style.
so you perform TF for axial back pain? the EBM is very scant of benefit in this aspect, and as far as i am aware, most LCDs and Medicare/Medicaid agencies do not support this treatment. i know my local LCD specifically states must have radicular pain for any epidural - TF or ESI.Does bilateral foraminal stenosis from severe DDD (nearly bone on bone) produce only radicular symptoms? Is it possible they also produce axial LBP? I think it's possible, therefore I chose bilateral L4-5 TESI.
please see the NYT slamming procedures thread. there is a great quote from that so-so article that i copied.I have 80% success rate for lumbar IESI (50% pain relief for over 8 weeks at minimum, but great majority gets more than that), 80-90% for cervical IESI, not great, but fortunately close to 95% for lumbar TESI.
C. Radiating pain, loss of sensation, or recurrent tingling in a lumbar spinal nerve distribution, or
D. Physical signs consistent with a clinical diagnosis of radiculopathy
1. Traction signs (Lasègue’s sign/slump test; painful straight leg raise 30-70 degrees), or
2. Absent or diminished ankle, or knee jerk, or
3. Decreased motor strength in the affected area, or
4. Decreased sensation in the affected nerve root distribution