Three level transforaminal epidural steroid injections routinely???? Wtf?

[EtherBunny]

Does anyone else on this forum find routine 3 level TFESIs to be inappropriate? Is this the norm for private practice?

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[101N]

$

 

[Taus]

You are correct. That is pure bs


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[Extralong]

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?

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.

 

[lobelsteve]

This crap has to stop. Conplaint to medical board for ethics. Discussed at ISIS. Expert panel where 4 of 6 were 99% 1 level, 1 of 6 was 90% 1 level, 1 of 6 was 6o% 1 level. No one had ever admitted to a 3 level.
I would testify for OIG or medical board against this practice.

 

[DOctorJay]

Did you spend any time observing procedures with this group before you signed on?


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[pmrmd]

I can count on one hand the number of times I've done a two level TFESI this year. Shady group you're in. Hopefully you know the physicians in your area know it too.

 

[willabeast]

although i never did this, i also have never seen a study comparing it to what i would normally do. also - having never done a three level TF ESI i have no idea if it works better than my usual practice. finally - all advances in medicine were originally met with fierce resistance at first. i would not assume this is being done for $$, although it may be.
“The public is wonderfully tolerant. It forgives everything except genius.”
― Oscar Wilde, The Artist as Critic: Critical Writings of Oscar Wilde

 

[Ligament]

Will try one level first, if fails will bracket the HNP with a two level TFESI. This guarantees steroid cranial caudal to the HNP.

Just in t-spine and l-spine. I don't do TFESI in the c-spine.

 

[clubdeac]

EtherBunny if I remember correctly weren't you the one bragging about how many amazingly high paying jobs you found while searching a few years ago? Is this your first gig or second? Based on the question it sounds like your first. Yeah definitely unethical....if the money sounds too good to be true then it probably is... good luck. I hope you can stick to your ethical standards. It'll be hard when you're the lone sheep in a pack of wolves

 

[EtherBunny]

deleted

 

[lobelsteve]

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.

I know. Writing on the wall. Several practices are like this and the FBI and OIG are being active.

 

[deleted185747]

Look for an exit plan ASAP. This is not the norm in PP although it is out there and you have to watch out for it.

 

[Extralong]

It's clear you feel outraged and obviously you have some strong backing in this forum, which is excellent. I don't know anything about the practice that you mentioned; usually, when a private practice gets into a pattern(whether a legal or illegal pattern), that's how the system flows, this can include even the non-prescriber staff.

Obviously the current norm(pattern) of the practice mentioned is not ethical/legal or whatever you want the word to be; and maybe a good proactive step would be to make a systems change in the practice yourself. Two outcomes can happen, one they accept your standard of care, or two, they disagree and you are free.

I have very strong feelings about people doing too many procedures unnecessarily, or prescribing too many opioids. Best patient care is what I strive for, as I hope we all do.

 

[bedrock]

Agree with Spinebound. Start looking for an exit strategy ASAP. Bad practice ethically and medically. You don't want your name affiliated with them, or part of their eventual lawsuit.

The weird thing is they make only a tiny bit of extra money from doing a bilateral 3 level TFESI. You make 80-90% of the money on the facility fee, not the professional fee, and the professional fee is reduced by 50% for each additional procedure done that day, so the third TFESI professional fee is only 25% of the first one so they're only making an extra 5 dollars on that sixth TFESI needle placement.

 

[drpainfree]

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.

 

[101N]

Mission control IPM has a problem.

 

[bedrock]

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.

You could make an arguement for two-level unilateral TFESI in certain clinical scenarios.

However, there is no a reason to do routinely perform three level TFESI, unless it's because you routinely really struggle to identify the pain generator.

I'm sorry but I fear your university based pain fellowship is likely ranked in the bottom half of pain fellowships nationwide.

No one routinely does three level TFESI at Harvard, or other top ranked pain fellowships.

 

[drpainfree]

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.

 

[Taus]

How do you know which nerve is affected? Wtf? History, physical and MRI read. If subarticular and foraminal narrowing and clinical findings in both dermatomes perhaps a 2 level. I think thats entirely reasonable. I'm not going to say absolutely never a role for 3 level, but should be a real rarity. Routine use is either for $ and if not... then complete inability or lack of desire to clinically evaluate a patient and correlate to MRI.


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[drpainfree]

History: dermatomal variation among individual is widely recognized. PE: sensory deficit, mylopathy or DTR might or might not correlate with symptoms, and they can have mixed clinical manifestation. MRI read: multi-level DDD/stenosis is common in elderly and chronic LBP population.

It comes down to how confident you are to pinpoint a particular nerve root being affected, in what patient population and what techniques (IESI vs. TESI) you like to use. As I said, they favored TESI over IESI for unilateral symptoms. If majority of patients have symptoms in multiple dermatome and with concordant or discordant MRI readings, you want to do an unilateral "shotgun" approach, it's natural to consider multi-level TESI. However many levels you decide to do is a clinical decision, or even a practice philosophy, but don't default to $ or ethics.

BTW, here're more information why they are not doing multi-level TESI for money,

- They don't use quincke spinal needle. Everyone uses Sprotte needles, which costs $10 a piece compared, $1 for quincke. Sprotte is atramautic, and safer than quincke. I know most in PP uses regular quincke needles for TESI, but do we judge/criticize this as for $ reason? No, of course, it's clinical judgement of individual physician.

- They do thoracic IESI in 5 minutes, from prep to needle out (all with anesthesia background, super comfortable doing IESI). It would make more sense to do more procedures in a given time to make more money instead of spending more times doing multi-level TESI and taking 50% cut. This is a very busy program, doing 30 cases a day from 8 to 2pm for EACH attending, btw.

 

[bedrock]

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.

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.

You notice there isn't a chorus of physicians on this board defending your position on this topic. I know it can be hard to change practice patterns, particularly after hearing it from so many of your attendings in fellowship, but what you were taught is dead wrong and is not the standard of care, meaning >90% of pain physicians do not practice this way. Your academic docs may not be doing 3 level TFESI for money, but this practice is way outside the standard of care.

And to your final point. If you ask pain fellows and pain attendings across the country what is the best pain fellowship, >80% will reply that Brigham and Womens is the best pain fellowship in the country and >80% will reply that Mass General and Beth Israel are in the top ten of all pain fellowships nationwide.

Go ahead and tell me what is the "best" pain fellowship that 80% of your attendings trained at, if you're so confident its the best one, then be bold enough to say the name.

I didn't mean to personally attack you but the routine three level TFESI thing and Harvard not having the best pain fellowship are light years out of line with the opinions of the vast majority of pain physicians.

 

[lord_jeebus]

Just to add my n = 1, I have never encountered a patient for whom I thought a 3-level TFESI was indicated. This includes patients who had previously had good relief after a different pain doctor did a 3-level (or 4-level!) TFESI.

In fellowship also, I would estimate that 1% of our transforaminals were 2-level and there was not a single 3-level done during my year.

 

[drpainfree]

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.

BTW, to all of you who said that you never thought anything more than single level TESI is indicated, it really implies every single one of your single TESI has been effective to give significant relief to patient's radicular symptoms. Really? Com'on, if you are really that good with treating radiculopathy with single level TESI, you should be publishing on the advantage of TESI over IESL.

Otherwise, have you ever wondered if you have covered all your bases with one needle?

 

[bedrock]

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.

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.

The statistical likelihood of three separate lumbar nerve roots having simultaneous major radicular pain is astronomical and this fact is clear to everyone on this board. There are plenty of studies that demonstrate that epidurals do not provide sustained relief for lumbar DDD without claudication or radicular pain, so there is again no justification for 3 level TFESI 99.9% of the time.

Also, it's time to put on your big boy britches and name the pain fellowship that is the best one in the country, that you said 80% of your attendings trained at. We'll just see if anyone here will support your belief on that point, either.

 

[hyperalgesia]

I agree with the consensus, routine 3 level TFESI strikes me as a $$$ cha-ching sell out move. It's a dramatic risk increase to stick the pt 3 times while simultaneously destroying any theoretical diagnostic value while simultaneously increasing profit. If I want to use a shotgun, I use interlaminar LESI or the paramedian LESI. I've never done a 3 level TFESI in my 9 years including fellowship. There may be a case that comes along some day where I think I need it but definitely not routine.

 

[drpainfree]

- "There are plenty of studies that demonstrate that epidurals do not provide sustained relief for lumbar DDD without claudication or radicular pain, so there is again no justification for 3 level TFESI 99.9% of the time."

Is your rationale for not doing multi-level TESI is that you don't think it's worth of the risk, therefore why put three needles when they don't work for long term anyway?

If it's what you think about TESI or IESI, I think I would rest my case since you don't have conviction of what you do will actually help your patients. I routinely charged cash for patients coming from other countries. I don't bill insurance, or deal with any third party, so there's no questions of being unethical. I would still do two or three levels TESI, because I can sleep better knowing I have covered all possible sources of radicular symptoms if the patient presents that way with multi-level DDD on MRI.

- "The statistical likelihood of three separate lumbar nerve roots having simultaneous major radicular pain is astronomical and this fact is clear to everyone on this board."

I don't know where you get the "statistics" from. Again I'm open to see the data you're quoting as the basis of your assumption of "standard of care". You might have a very different patient population, that don't often have multi-level DDD. I have about 30% failed back and 70% patients medicare patients. These patients often don't have clearly defined single-level dermatomal symptoms. My previous fellowship program has similar patient demographics.

I never said the pain fellowship I referred to is the best in the country. There are multiple factors to consider what's considered as the best, therefore I do not use the word the "best". Cases volumes, diversity of pathology, etc, all play into the strength of the program. I mentioned the program because it's a solid fellowship program and solid pain management department in a academic center, to dispute the fact people would assume PP is unethical when they are doing multi-level TESI.

No, I won't mention the name. If I do, this discussion would quickly degrade down to a pissing contest about which is the "best" fellowship program.

We're on this board not to prove our ego or to express displeasure "wtf". We're here to understand how everyone else practice and why. This board, by no mean represents the standard of care, or in any way represent the quality care. This boards represent opinions of each and we take these opinions with a grain of salt.

 

[drpainfree]

I agree, if you prefer IESI, I would agree it's the best shotgun approach. As I said, the attendings prefer TESI in general, only use IESL for axial LBP, mostly for spinal stenosis. No, no one does bilateral three level TESI, I would agree it doesn't make sense.

In my experience paramedian IESL doesn't work as well as multiple-level TESI for unilateral symptoms.

I'm saying this because I actually had both for myself, paramedian IESL first, then three-level TESI one year later. The first one didn't work, actually seemed to make it worse. The second one helped significantly.

I don't think we're doing TESI for "diagnostic" value. My primary objective is to provide relief to radicular symptoms. If you stick one needle and provide no relief, what do you do?

"Well, I'm sorry, I think it's really your L4 at L4/5 disc that's causing the problem, but your MRI clearly shows DDD in both level, and L5/S1 look much worse on the film, so I decided to do at L5-S1. let's try it again at L4-5 this time".

 

[EtherBunny]

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.

 

[lobelsteve]

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.

You are right. The other guy is defending dogma. And would lose in court.

 

[BobBarker]

how much more money is it? $20 after costs? Let's not throw turn fellow docs and your business partners into the board for being profiteers when there is no profit to doing what they are doing.

 

[Ducttape]

there was profit - a lot - before Medicare changes, what, 3 years ago regarding bilateral or multilevel injections. perhaps the reasons that there has not been a significant shift in the practices of these established practices is that the cost counting of these small private practices is not as "innovative" or aggressive as they should be?

one of the local private insurance carriers allows, in 2016 fee schedule, $116 for non-facility fee for 64484. that isnt chump change.

in fact, now that i think about it, if i were in private practice and financial responsibility were a concern, why would i, using drpainfree's logic, not always and 100% of the time do 2 level TF?

 

[freddydpt]

If you are doing TESI injection, it's either a hit or miss if you focus on one particular level.

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.

 

[Ligament]

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.

Damn Dr. Weiss, you have some serious training, kudos!

 

[nvrsumr]

I think two level unilateral tfesi can make sense. Getting level of disc and descending nerve root. The point of tfesi advocates over IL or caudal is to get as close to level of pathology as possible. If you think that matters.

Also attendings may do things to help teach a fellow or increase procedural volume for that fellow that they wouldn't routinely do in "real world". Wouldn't judge just based on a procedure note.

 

[emd123]

There's a reason Medicare only pays for 2 levels in TFs. Stick to one or two levels and you're fine. If you truly need to hit 3 levels, you should be doing interlaminar for greater spread and more volume, not 3 level TF. 3 level TF in every patient just plain looks bad.

 

[drpainfree]

I agree. Theoretically you get more anteriolateral spread with TESI. This is one of the main reasons most of my attendings preferred TESI over IESI. And you're right, depend on pathology, the volume of injectate, etc, you might be able to get the meds to spread to an adjacent DDD. It's, however, a stretch to say a single level TESI can give you the kind of shotgun coverage as in a paramedian IESI. On the other hand, if all the symptoms are unilateral, multi-dermatomal (or non-dermatomal), or multi-level DDD on imaging, you do want to have a more "shotgun" unilateral coverage to target radiculopathy. It's a very reasonable decision to make on an individual basis. Again how often do you do this, is based on your patient population therefore the complexity and multitude of spinal pathology.

Another example to share, I had a patient today with right-sided L2-3 annular tear, bilateral L4-5 severe DDD, moderate foraminal stenosis, and multi-level mild DDD in other levels. He has no radicular symptoms at this time, 95% symptoms are axial LBP with very intermittent numbness at right big toe. Bilateral MNBB didn't help, concerned of possible discogenic pain due to L2-3. Decided to do bilateral L4-5 TESI, and right-sided L2-3 TESI. I believe this is the best approach to treat his axial LBP with medication delivered to where the pathology is. If this doesn't work, we might need to consider fusion vs. SCS. In another words, this is his last try with minimally-invasive procedures. He is desperate to see something that would work. Therapeutic benefit is what he's looking for, not diagnostic specificity (besides his insurance only approved one procedure, not sure if they would allow us to go again with TESI at another level or two). He appreciated that I spent time and effort to think through the problem and come up with a solution as opposed to offer him a cook book option. In this case, there is actually no standard option I can think of, except defaulting to IESI, obviously with no way to guaranteed meds go to right L2-3 and bilateral L4-5.

IESI is easy and really no-brainer. It's one step ahead of caudal esi. When we had TESI techniques, pain management advanced one step further. You can really tailor your treatment options based on your patient's presentation, physical exam and imaging findings. Not only we need to be open-minded to different practice patterns, but also realize TESI is where individualized treatment plan can be made.

To the OP, it's very reasonable to post your question on the forum to get OPINIONS from more experienced fellow docs what they do. We all do the same. This is how we improve ourselves through a collective mind pool. It is unreasonable on the other hand, to jump to a conclusion that if someone does something differently than what we do, immediately we default to the thinking that others are incompetent or unethical.

Think rationally, talk humbly, and judge carefully!

To guys who have sent me supportive private messages, I appreciate your input. I don't feel being intimated at all. If someone has knowledge and experience to criticize my practice and I think it makes sense, I will gladly adopt it. It's not about my ego, or how I was trained, it's about giving my patient's the best they can get from a competent pain management physician.

If we do not hold high standard (pain relief, it is what I'm referring to) on what we provide to our patients, and with pressure coming from every corner, we ain't going to have a specialty in the near future.

 

[pmrmd]

So...you did B L4-5 TFESI for no real reason at all it seems. Sounds like you are treating an MRI.

 

[Phyzicz]

Let's be real here- if any of us was getting the procedure done we'd do straight up saline and dex high volume in the middle of the pathology and say hell no to the possibility of a lightning bolt / shooting paresthesia during the procedure with a Tfesi. No good study to show superiority one over the other. Just the billing difference...

Agree on BWH bedrock. Sup.

 

[drpainfree]

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.

What would you do? A single-level TESI at L2-3 on the right side for right-sided annular tear to treat possible discogenic pain and hope somehow axial LBP will resolve?

I don't think there's a straight-forward answer to this case. It's a judgement call. I shared the case to show you medicine (specially pain medicine) is not black and white. It's not one-level TESI or no TESI. We gotta take into consideration the complexity of the individual pathology and their financial constraint. I follow the same practice for patients with multi-level DDD/non-specific dermatomal symptoms/multi-dermatomal symptoms, AND they are paying a fixed cash price for TESI, regardless how many levels I do.

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.

 

[drpainfree]

If you only have one procedure to do, and if it fails, it's either multi-level fusion or SCS, what would you do? If it's you, I bet you'd try anything that's possible to avoid the later two, hopefully in one procedure. I'm speaking about this from my personal experience, as a patient.

But if your preference is IESI, I respect your preference. But don't make assumption it's what everyone here wants for themselve, or what's best for your patient.

As for shooting paresthesia, I don't sedate patients and I talk them through. I also use $10 per piece atraumatic sprotte needles, learnt that during my fellowship as every attending also preferred atraumatic needle. If you talk to some, they would actually recommend blunt tip for TESI. Do I hold guys out there doing TESI with sharp Quincke "unethical", "careless" or "cowboy"? Of course not. It's your practice style, nothing beats your clinical judgement.

 

[lobelsteve]

This guy is nuts.

 

[deleted472101]

You have so many different views in Medicine.

In pain one practice population/diagnosis may be different from another due to multiple factors. It's hard to judge others just because you practice one way.

 

[lobelsteve]

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.

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)

 

[Ducttape]

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.

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.

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.

please see the NYT slamming procedures thread. there is a great quote from that so-so article that i copied.

these numbers are no where supported in EBM.

Even Manchikanti will not quote numbers close to yours.


(in case you doubt me, listed below is section from Evicore for 64483)

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

 

[BobBarker]

He hit #4 with the toe numbness.

 

[Papa Lou]

You guys are making too much of the "money" thing. There's no money! You're talking about adding 40-60 dollars for the extra level *IF they pay for it. That's not exactly big dollar. You'd have to do that to every TESI patient you do that year to get money out of it. Say you are a drastic overutilizer and do a third level on half of your TESI patients that week. Let's say that you are highly interventional and inject 60 patients a week and let's say 30 are lumbar TESI. That puts you at 15 of the patients getting 3 levels. That's 750 bucks extra that week. For the year that's 35,000. Congratulations you bought yourself a new Buick. And I'm describing a HIGH injection volume guy who does HALF of his TESI three levels. That's a beastly overutilizer. A confused guy. Make a few adjustments to the math if you want and it doesn't change the overall picture. Nobody's getting rich off that third level.

Now that one level guy is certainly getting poor off that one level. By all means go ahead and go broke if that's your practice. I do one level 25% of the time. If I'm going to have them come in to an ASC for an injection I'm gonna do two levels for them 75% of the time. I have rarely done and will still go ahead and do the rare 3 levels (unilateral only of course).

I do plenty of one level based on HPI/PE/Imaging but I think it's a little silly. No steroid dose has been proven optimal but I'd rather get two levels and the corresponding amount of steroid. Plus every time I'm doing two levels there's an overlap of dermatomes. Often L5 and S1. I don't believe the studies yet and No I would not want a ton of saline injected into my epidural space instead of local and steroid (until more evidence available).

 

[Phyzicz]

"I don't believe the studies yet."
"I do whatever my attendings did."
This is why we have our ****ty MOCA questions every quarter....

 

[EtherBunny]

Wow, and we wonder why interventional pain medicine as a specialty is in deep trouble. If some of the comments on this thread represent practice patterns at large, then insurance abuse is disturbingly common.

This sort of stuff will maintain incomes in the short term but it will just create enormous problems in the long run: more denials of care, more procedures being listed as "investigational," less reimbursement for individual procedures, more erosion of respect for physicians (are we doctors or glorified salespersons?), more insurance audits... I mean, this is crazy! I can see why private practice is dying. It's just not a sustainable model of practice, especially if the truly ethical physicians are struggling to make it financially and you have to resort to some of the ridiculous tactics above to remain financially viable. I just had a conversation with an older pain physician the other day. He had his own practice and tried his absolute best to practice ethically, only performing interventions when indicated and doing the bare minimum to get the job done, as he learned in his fellowship. He almost went bankrupt and had to sell his practice. Yet, there are many practices in my area doing the complete opposite (3 level TFESIs, routine series of 3, and god knows what other medically unnecessary procedures) and they are making a killing--in many cases, THRIVING.

Wtf is going on in interventional pain???? If this is the norm, then I'm genuinely worried about the future of pain medicine as a specialty. Ethics and profits shouldn't be mutually exclusive, but increasingly they seem to be in interventional pain medicine. That's a very sad state of affairs for our field.

At this point, I'm heading back into academia. Less money, but at least I can sleep at night with a clean conscience. I'd rather be a middle class physician devoted to excellence in patient care than a rich doctor compromising my core values. At some point, profit becomes counterproductive for physicians.

 

[Ducttape]

sounds like these guys are high volume injecters who are doing all their TFs as 3 levels. so at least double that amount. $70,000.

fyi, thats $20,000 more than the average american family makes a year.



oh yes, fyi, the last car I bought was a used subaru. i, like most Americans, cant afford a new buick...