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Academia is not so shielded from monetary corruption as I'm sure you will soon see
Three level transforaminal epidural steroid injections routinely???? Wtf?
Started by EtherBunny
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I don't know that fusion or scs are the only other two options here..perhaps MIS in some form. I don't think scs for axial pain is a very good idea despite what metronic st Jude Boston tells you
one might be able to infer that medications at low volumes with TF should be spreading pretty commonly...
http://www.ncbi.nlm.nih.gov/pubmed/25675054
in terms of difference between parasagittal and TF injection - the difference might be minimal.
http://www.ncbi.nlm.nih.gov/pubmed/25054387
http://www.ncbi.nlm.nih.gov/pubmed/25675054
in terms of difference between parasagittal and TF injection - the difference might be minimal.
http://www.ncbi.nlm.nih.gov/pubmed/25054387
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Thank you for quoting the available studies. Let's look at these studies closely.
The first study looks at the spread of medication when doing TESI
"Conclusion: Diagnostic selective nerve root blocks limiting injectate to a single, ipsilateral segmental level cannot reliably be considered diagnostically selective with volumes as low as 0.2 mL. Also, spread of the contrast to the superior nerve root was more likely than spread to the inferior nerve root."
Yes, we know this long ago that "selective nerve root block" is really not selective enough to isolate a particular nerve. The technique for SNR is slightly different from TESI, but I can't tell from the pictures shown on the study they are actually doing SNR. It looks more like TESI. It seems they are using two terms interchangeably. Regardless, the study shows that there is superior and inferior spread of medication when doing TESI. No one dispute this fact, we see it all the time after contrast injection. However, this does not show SINGLE-LEVEL TESI ADEQUATELY AND RELIABLY COVER 2 OR 3 NERVE ROOTS IF YOU INTEND FOR A "SHOTGUN" UNILATERAL PROCEDURE.
The 2nd study compares paramedian IESI and SINGLE-LEVEL TESI.
First the paramedian IESI was done really lateral, according to the study (by the way, this is how it was done exactly for my own 1st paramedian IESI). It's great if you are trained that way to put the needle tip all the way to lateral gutter. But look at epidurogram and see almost 100% of contrast is still centered in midline, slightly towards left. Most of time when I do paramedian IESI, the contrast still travels bilaterally favoring one side, up or down in a irregular pattern.
78% success rate for paramedian IESI in the study, is comparable, about my average for lumbar.
76% for TESI, is low. Then I look at the study and image, they are doing SINGLE-LEVEL TESI. In another words, when you are doing single-level TESI, you are getting the kind of result in the ballpark of paramedian IESI.
If you are quoting this study to prove your point "in terms of difference between parasagittal and TF injection - the difference might be minimal.", I think it only proves you should rarely choose single-level TESI over paramedian ESI.
On the other hand, my point is, when you are selecting TESI or IESL and let's say you decide to go TESI, you should rarely go with single-level. As I said, I believe 2-level should be the norm, and 3-level should be reasonable if you can justify clinically or radiologically.
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MIS, as minimally-invasive spine surgery? for L2-3 annular tear, maybe, but to get to that we need discogram first. For bone on bone severe DDD bilateral foraminal stenosis, do you think it's possible? I don't know since I don't do "MIS". But the patient is adamantly against anything more invasive than injections.
I used to think axial LBP is difficult with SCS, but my recent trials have done great relieving axial LBP, whether it's St. Jude or Boston Scientific.
"wft" again? is it really necessary? com'on! if you don't like PP and want to go back to academia, do as you wish. this is not a forum for you, or any one of us to vent your anger towards your private practice. even if you don't believe multi-level TESI should be done, ask your colleagues why they were doing them. Since you were not trained that way, you might at least hear their rationales and learn something from it. If you disagree, do it the way you do. Just like no one can force to prescribe opioids if you don't feel comfortable with prescribing.
If you can't deal with the minimum deviation you are frustrated about in PP, good luck in academia!
no, those numbers are by far the best i have ever seen for any study, and they do not approach 95%.
additionally, this study suggests that a single level TF injection approaches 76% efficacy.
i have not found a study to suggest that a 2, or 3 level TF injection improves your efficacy rate from 76%, what is close to what one gets with an ILESI with visualized contrast flow across several levels, to 95% benefit.
in fact, reviewing all 560 or so listed studies on pubmed for transforaminal injection, i do not see one specific study that discusses let alone advocates multi level TF - one study does talk about bilateral TF for degenerative lumbar spinal stenosis not being inferior... (there is what seems to be a "letter to the editor" from Furman et al that i cannot access writen in PMR, 2015.
if someone could read and post, Furman argues for two level, Cohen for one. i dont think anyone argues for 3... PM R. 2015 Aug;7(8):883-8)
addendum: i forgot to mention - if one is truly worried about making sure medication gets to appropriate levels, based on your stance, one could make the argument that there is no need to do a 2 or 3 level TF, and run the multiplied risks associated with transforaminals - always go PIL (and im not talking about the band... tho i do think they merit consideration on any playlist)
additionally, this study suggests that a single level TF injection approaches 76% efficacy.
i have not found a study to suggest that a 2, or 3 level TF injection improves your efficacy rate from 76%, what is close to what one gets with an ILESI with visualized contrast flow across several levels, to 95% benefit.
in fact, reviewing all 560 or so listed studies on pubmed for transforaminal injection, i do not see one specific study that discusses let alone advocates multi level TF - one study does talk about bilateral TF for degenerative lumbar spinal stenosis not being inferior... (there is what seems to be a "letter to the editor" from Furman et al that i cannot access writen in PMR, 2015.
if someone could read and post, Furman argues for two level, Cohen for one. i dont think anyone argues for 3... PM R. 2015 Aug;7(8):883-8)
addendum: i forgot to mention - if one is truly worried about making sure medication gets to appropriate levels, based on your stance, one could make the argument that there is no need to do a 2 or 3 level TF, and run the multiplied risks associated with transforaminals - always go PIL (and im not talking about the band... tho i do think they merit consideration on any playlist)
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lobelsteve, I don't think I'm going to respond to your inflammatory response at all. As much as I dislike your post, I'm not here to judge your personality or characters. You are entitled to yours and so is everyone else.
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In another words, we should do more studies on this, right?
We should do more to support multi-level TESI, and you should do more to question the efficacy of multi-level TESI.
Before we get to that point, we should all leave it at that, instead of throwing words like "wft, unethical, incompetent".
As for my success rate, you can question all you want. I do three level TESI on cash, on a monthly basis, provided that they have pathology/symptoms/exam findings supporting TESI over IESI.
My cash rate is $1500 per procedure regardless how many expensive atrumatic needles I put in. I rarely need to do 2nd procedure and instead maintain them on gabapentin/TCA if necessary.
i made updates to my post that i believe came just before you reposted.
i can repost, but to avoid redundancy, noone in the literature argues for 3 level TF, only one article argues for 2 level (only a position paper). the available EBM does not appear to support 3 level TF, based on nonstudy. or, more bluntly, there is no EBM to support 3 level TF. might as well do drg PRP...
my cash rate for ILESI... nm i am employed. it makes no financial difference to me whether i do ILESI or TFESI, 1 or 2 or 3 level. im doing this for, believe it or not, best patient care.
i can repost, but to avoid redundancy, noone in the literature argues for 3 level TF, only one article argues for 2 level (only a position paper). the available EBM does not appear to support 3 level TF, based on nonstudy. or, more bluntly, there is no EBM to support 3 level TF. might as well do drg PRP...
my cash rate for ILESI... nm i am employed. it makes no financial difference to me whether i do ILESI or TFESI, 1 or 2 or 3 level. im doing this for, believe it or not, best patient care.
yes, I saw your updated post.
I realize what you said none of paper argue for multi-level TESI.
If every study out there doing TESI is based on single-level TESI, of course you won't have any studies supporting multi-level TESI.
In fact, if every study comparing TESI to IESI is based on single level TESI, don't you ever wonder if these studies have given TESI a fair shot and under-estimate the efficacy of TESI in general?
I'll contact the program director soon to see if there's way to conduct a head-to-head study on multi-level TESI vs. paramedian IESI for unilateral symptoms.
Before we get to the point, use your clinical judgement. I have provided my rationales about (multi-dermatomal symptoms, multi-level DDD, even discordant imaging findings, etc, unilateral shotgun coverage, etc.). If it makes sense to you in your patient population, do it to benefit your patients, cash or non-cash.
If it doesn't make sense to you, don't do it. But don't accuse others "unethical, incompetent".
I realize what you said none of paper argue for multi-level TESI.
If every study out there doing TESI is based on single-level TESI, of course you won't have any studies supporting multi-level TESI.
In fact, if every study comparing TESI to IESI is based on single level TESI, don't you ever wonder if these studies have given TESI a fair shot and under-estimate the efficacy of TESI in general?
I'll contact the program director soon to see if there's way to conduct a head-to-head study on multi-level TESI vs. paramedian IESI for unilateral symptoms.
Before we get to the point, use your clinical judgement. I have provided my rationales about (multi-dermatomal symptoms, multi-level DDD, even discordant imaging findings, etc, unilateral shotgun coverage, etc.). If it makes sense to you in your patient population, do it to benefit your patients, cash or non-cash.
If it doesn't make sense to you, don't do it. But don't accuse others "unethical, incompetent".
Where are you geographically that you are getting patients to pay $1500 for a three level tranny? I'd like to know so I can move there
to the original poster again,
if you question the ethical nature of the practice, look at their ancillary services, HMO contract, etc. If you question their clinical practice, you'd better make sure you have solid evidence to back you up. In this case of multi-level TESI, there isn't any, to support your accusation of "unethical practice"
In PP, especially for us in solo practice, the result (pain relief) speaks for everything. If you don't have good results, you cannot sustain a private solo practice without doing something else questionable.
I'm in no way implying if you are employed or in academia, you don't care about your results. My point is, in private solo practice, our livelihood depends on good results, which generate referral.
I remember this from a pain management doctor at the time when I finished my fellowship. He had pain management clinic for about 20 years. The only thing he taught me about private practice, was to produce good results.
Every single one procedure we do on a given patient is the trust we are taking away from them, on ourselves, and on IPM itself. If you are doing a procedure for a patient without maximizing the benefit/risk ratio, you are not doing the best for the patient.
In my own practice, zero medicaid, 50% self-referred, 5% on low dose opioid (10-50mg MEQ), 10% cash for procedures (0% cash on opioid), 10% PI (mostly after chiro/pt/whoever else have exhausted their med pay, but the patient still genuinely has pain, and attorney needs someone to actually help with the patient's real problem).
I apply the same objective for all patients including PI: pain relief and functional improvement in the shortest amount of time by maximizing benefit to risk ratio within the constraint of their financial situation.
Put into the context, if for every 4 single-level TESI you do, you are missing one result. You gotta to consider how to improve your score. For some of us, we recognize the complexity of the pathology, variation among patient's presentation, etc, we decide to offer multi-level TESI to get maximum benefit.
There's nothing wrong, or unethical about it, especially your livelihood hangs on your results.
if you question the ethical nature of the practice, look at their ancillary services, HMO contract, etc. If you question their clinical practice, you'd better make sure you have solid evidence to back you up. In this case of multi-level TESI, there isn't any, to support your accusation of "unethical practice"
In PP, especially for us in solo practice, the result (pain relief) speaks for everything. If you don't have good results, you cannot sustain a private solo practice without doing something else questionable.
I'm in no way implying if you are employed or in academia, you don't care about your results. My point is, in private solo practice, our livelihood depends on good results, which generate referral.
I remember this from a pain management doctor at the time when I finished my fellowship. He had pain management clinic for about 20 years. The only thing he taught me about private practice, was to produce good results.
Every single one procedure we do on a given patient is the trust we are taking away from them, on ourselves, and on IPM itself. If you are doing a procedure for a patient without maximizing the benefit/risk ratio, you are not doing the best for the patient.
In my own practice, zero medicaid, 50% self-referred, 5% on low dose opioid (10-50mg MEQ), 10% cash for procedures (0% cash on opioid), 10% PI (mostly after chiro/pt/whoever else have exhausted their med pay, but the patient still genuinely has pain, and attorney needs someone to actually help with the patient's real problem).
I apply the same objective for all patients including PI: pain relief and functional improvement in the shortest amount of time by maximizing benefit to risk ratio within the constraint of their financial situation.
Put into the context, if for every 4 single-level TESI you do, you are missing one result. You gotta to consider how to improve your score. For some of us, we recognize the complexity of the pathology, variation among patient's presentation, etc, we decide to offer multi-level TESI to get maximum benefit.
There's nothing wrong, or unethical about it, especially your livelihood hangs on your results.
Where are you geographically that you are getting patients to pay $1500 for a three level tranny? I'd like to know so I can move there
I'm on west coast, most cash patients found me online after exhausted other options, occasionally referred from other physicians. They either don't have insurance or visiting from other countries.
$1500 is a flat fee for most procedures except SCS trial. I don't offer single-shot IESI or caudal. Either 3 level TESI with atraumatic needles w/o sedation, or IESI with racz/theracath catheter if multi-level, bilateral/axial symptoms.
If your focus is maximizing the benefit to risk ratio, then it makes no sense to routinely do multilevel TFESIs. A three level transforaminal, intuitively, is TRIPLE the risk of a single level. Yet the benefit is likely no better than a thoughtfully selected, single level. By opting for multilevel transforaminal epidural steroid injections you're actually REDUCING the benefit to risk ratio, the exact opposite of your stated goal.
Heck, you could probably achieve the same outcome at a single level but with a higher volume of injectate, if your major concern is maximizing spread of the steroid across multiple levels. If 0.6 ml of injectate at a single transforaminal level typically spreads to two levels, according to published research, then what do you think happens with 3 ml? What about 5 ml?
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It doesn't make sense. It's double or triple the risk and I see none of the reward, based on available EBM. Same theory justifies 3 vs 1 level fusion.
If you cannot make a valid clinical decision and have to use shotgun approach for 3 level TF (please note I do not include 2 level or bilat), then you should be performing Ilesi, for which there is EBM. I can possibly see some logic - as does Furman I understand - for 2 level or bilat, but it should not be standard of care for all procedures.
Of course, I am assuming that you do practice safely and divide the total dose of steroids amongst levels.
Please note that a local practice specialized in 3 and 4 level TF. And used to give 40 depo per level. He had highest doctorm salary in entire area something like 5 years in a row, over 1.3 mill at one point
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If you cannot make a valid clinical decision and have to use shotgun approach for 3 level TF (please note I do not include 2 level or bilat), then you should be performing Ilesi, for which there is EBM. I can possibly see some logic - as does Furman I understand - for 2 level or bilat, but it should not be standard of care for all procedures.
Of course, I am assuming that you do practice safely and divide the total dose of steroids amongst levels.
Please note that a local practice specialized in 3 and 4 level TF. And used to give 40 depo per level. He had highest doctorm salary in entire area something like 5 years in a row, over 1.3 mill at one point
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Anyone else here feel sad for this guy for being wrong on every point made thus far? Failure of education, ego with dogma, lack of insight.
If your argument of not doing multi-level TESI in one procedure is risk, I would suggest you go with atraumatic sprotte needle, even using blunt needles, do not sedate patients ever, use nonparticulate steroids, improve your techniques (if you have done enough), etc. From a couple of thousand TESI my attendings have done during my fellowship that I have known, and what I have done in my own practice, I have not heard or seen any complications. On the other hand, I have had 1 wet tap and PDPH when doing IESI, that fortunately resolved on its own.
Now if you missed your target and had to bring back patient for 2nd TESI, or your intention is to bring back the patient for 2nd TESI anyway (w/o fee reduction), you negate the argument on risk.
And you're correct, if you are trying to use single-level TESI for shotgun unilateral approach with higher volume of injectate, you'd probably get better multi-level coverage. Do you get the kind of coverage at lateral recess/foramina at each level, as you'd have if you've done multi-level TESI, I don't know. It doesn't seem to me personally to have the kind of unilateral specificity.
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Again, as I said in my previous message, if people are doing mutli-level TESI and seeing better success rate of 76%, you should take it with a grain of salt, either do your own study or wait for studies to come out.
If you don't want to wait or do these studies, at least think it rationally.
If we take a poll of how many people doing multi-level MNBB, or bilateral MNBB, I think most would agree it makes senses to do multiple blocks in one procedure. If you are doing a single level TESI, is it similar to doing 2 level, unilateral MNBB to cover only one facet? who says facet arthropathy is always in one joint.
You can argue MRI has better sensitivity to detect foraminal stenosis/DDD than facet arthropathy, therefore you'd rely on MRI to determine which level to do TESI, assuming most of your patients would always have presentation, exam findings and concordant imaging findings. Well, it's great. You gotta it easier than me in patient population.
Then ask yourself, how can I improve my success rate of 76% before jumping into conclusion of local docs making huge salary because he specializes in 3, 4 level TESI. We all know nobody gets rich by doing procedures in IPM nowaday,
I went through a very similar situation and went back to anesthesia and have been extremely happy since. Thats just my preference though. I have always thought that If you want to have a decent pain practice and life, academics is definitely the way to go. That way you are protected from some of this PP sleeze that goes on. However, you dont really make great $$, but you certainly dont starve either.
drpainfree I think if we were to poll 1000 pain docs you'd definitely be on the fringe with the 3 level TFESI thing. However I've only done it once or twice in my career (b/c of multilevel pathology and confusing presentation) so I can't attest to degree of efficacy over a 1 or 2 level. Would be interesting to see a study. It's just hard to imagine that you couldn't get the same results with a far lateral paramedian ILESI with 5cc of injectate. Much less risk, much quicker and less painful and likely just as efficacious. Just my 2cents
My question is how are people getting this stuff authorized? Unless they are doing multiple procedures on Medicare patients? I don't know that many private insurances would authorize for tfesi and sij and whatever else on same patient at same time. Are their contracts just that stellar with the insurance companies? Hard to imagine a solo or small group practice doc would be able to get away with this stuff
See the case posted by ducttape and the image I took from the study. Far lateral IESL doesn't give "transforaminal contrast spread", as shown by the images on the study quoted. Much quicker to do an IESI, I agree. Much less risk, I don't know. Wet tap is not uncommon even in an experienced hand, and with seasoned TESI technique/atraumatic needle/non-particulate steroid, I don't consider the risk is any higher. Less painful, none of my TESI gets sedation, I talk them through, just like my IESI.
Yes, I agree. We need to have studies to compare the efficacy of two-level TESI vs. paramedian IESI and three-level TESI vs. paramedian for multi-level unilateral radicular symptoms.
I have my doubts about the increased effectiveness of 3 level TFESI, but I really feel concern about the three separate invasions of neural foramina, especially if you are doing higher lumbar levels where there is more risk of hitting aberrant spinal blood supply. You're basically tripling the risk of injury for a questionable benefit. Is there any literature that says that using a Sprotte needle is safer than a Quincke needle?
- I would counter that the beauty of the transforaminal is that one puts in a small quantity of medication in a specific location. It is the sharpshooter treatment. A 3 level transforaminal essentially makes it no different from an ilesi because the volume of medication necessary to perform all 3 levels.
You are also overreaching with this argument about the medication being intra vs extraforaminal. Do we not look for spread intraforaminal, and not call it a SNRB that we are trying to perform?
Also, you have to dilute the total amount of medication per each level, unlike the traditional single level TF (unless you don't, in which case the patient may be perceiving benefit from the steroidal effect, not the injection).
- there is triple the risk for complication for this practice, a significant increase in radiation, contrast use, and discomfort to the patient for dubious benefit.
- Speaking of which, one of the main issues on this forum is that there have been other treatments that are unsupported by literature. The issue I have with any of these treatments is that it is the onus of the practitioner to prove that such a practice is not only beneficial, but also safe. Or at least provide literature of any sort - even the lowly case report - to back up their contention.
You have no EBM or data of any sort or source, and - from my review, not your own - no one in the literature to suggest your practice is safe and beneficial. No one has ever written that I can see about doing 3 level TF. I challenge you to search for such. Where did your attendings "learn" that this was the safe and best way?
I don't do prp or stem cell, but at least there is a modicum of data to support. articles from Regenex, as biased as they may be, technically "outnumbers" the data to support your position a thousand fold, ad infinitum......
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You are also overreaching with this argument about the medication being intra vs extraforaminal. Do we not look for spread intraforaminal, and not call it a SNRB that we are trying to perform?
Also, you have to dilute the total amount of medication per each level, unlike the traditional single level TF (unless you don't, in which case the patient may be perceiving benefit from the steroidal effect, not the injection).
- there is triple the risk for complication for this practice, a significant increase in radiation, contrast use, and discomfort to the patient for dubious benefit.
- Speaking of which, one of the main issues on this forum is that there have been other treatments that are unsupported by literature. The issue I have with any of these treatments is that it is the onus of the practitioner to prove that such a practice is not only beneficial, but also safe. Or at least provide literature of any sort - even the lowly case report - to back up their contention.
You have no EBM or data of any sort or source, and - from my review, not your own - no one in the literature to suggest your practice is safe and beneficial. No one has ever written that I can see about doing 3 level TF. I challenge you to search for such. Where did your attendings "learn" that this was the safe and best way?
I don't do prp or stem cell, but at least there is a modicum of data to support. articles from Regenex, as biased as they may be, technically "outnumbers" the data to support your position a thousand fold, ad infinitum......
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With all of the craziness in pain management, does anyone else think that the right thing for doctors compensation is a straight salary? Tying compensation to productivity in a procedural field seems like a setup for insurance abuse, fraud, etc. It fuels unethical practice patterns. If all proceduralists were just salaried, I think we would see a major drop in this sort of behavior.
This productivity based pay scheme, which is so common, is more applicable to sales than medicine.
The annual compensation could simply be the top 3rd percentile nationally with annual increases to account for inflation (or whatever arbitrary benchmark you want to use that seems fair).
I would be for it. Of course, I can't imagine this will ever happen.
This productivity based pay scheme, which is so common, is more applicable to sales than medicine.
The annual compensation could simply be the top 3rd percentile nationally with annual increases to account for inflation (or whatever arbitrary benchmark you want to use that seems fair).
I would be for it. Of course, I can't imagine this will ever happen.
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Ok... let's back up here a minute. What is a level 3 tranny and can they be found outside of Vegas or Bangkok?Where are you geographically that you are getting patients to pay $1500 for a three level tranny? I'd like to know so I can move there
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Your closing paragraph makes me think that you are sincere in wanting to help people, but the first paragraph, particularly the last line suggests that you don't actually know what you're doing or understand the current medical literature.
The hardest thing to do in medicine is admit when there is no good treatment for a particular patient. This patient is one of those. There is no great treatment for multilevel lumbar DDD, but the worst thing you could do to this patient is to do a lumbar fusion! Are you freaking kidding me? Are you not aware of the lack of evidence to do lumbar fusions for axial back pain?, particularly with multiple levels of lumbar DDD?
Similarly, doing an SCS trial on a patient with only low back pain, and no major buttock or leg pain is a cash grab pure and simple. It's total BS to suggest as you did in a subsequent post that you get great axial lumbar coverage with the majority of your MDT and Boston SCS implants.
There's no magic about how you insert your SCS leads, and all of us in practice for several years know that the vast majority of patients don't get good sustained lumbar coverage from traditional SCS systems.
It is completely wrong to propose lumbar fusion or SCS for multilevel lumbar DDD, without signicant radicular pain. Just another example, in addition to 3 level TFESI, of how you are practicing completely outside the standard of care.
so what are you going do, let the patient go to next door spine surgeon who would happily fuse him without a 2nd thought?
yes, I had great experience with SCS covering axial LBP pain, 10 years ago in my fellowship, not as great, in last 2-3 years, yes, have been lucky. you can dispute all you want.
if you run a successful private solo practice, you'd know your result speak for yourself.
If you'd ever have DDD and severe low back pain yourself, you'd take a much more passionate attitude towards what this patient is going through.
so stop talking about "standard of care" when you don't have any support to back you up on "your standard".
anyway, this is my last post to this thread as I have explained different opinions. So at least you are aware that there's a different "standard of care" that you'd never thought make sense to you. Whether or not you agree, it's your business, or loss.
yes, I had great experience with SCS covering axial LBP pain, 10 years ago in my fellowship, not as great, in last 2-3 years, yes, have been lucky. you can dispute all you want.
if you run a successful private solo practice, you'd know your result speak for yourself.
If you'd ever have DDD and severe low back pain yourself, you'd take a much more passionate attitude towards what this patient is going through.
so stop talking about "standard of care" when you don't have any support to back you up on "your standard".
anyway, this is my last post to this thread as I have explained different opinions. So at least you are aware that there's a different "standard of care" that you'd never thought make sense to you. Whether or not you agree, it's your business, or loss.
Typical. What is wrong with pain medicine is the doctors. And the patients. And the lack of effective treatments for disc pain.
New attending on here... Had a patient with spinal stenosis come for a second opinion treated with 5 level bilateral tfesi... For several years I guess the doc was covering every abnormality in his entire lumbar spine
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It's VERY unfair for you guys to criticize someone and call out standard of care. Trust me the guys on this board do not practice in accordance to the VAST majority of other pain doctors. Practice patterns vary widely and it's because it's a young field without great treatment for this pain despite years and years of attempts by pain docs and spine surgeons. Nobody's figured it out. Practice patterns vary there is no standard. If there's a standard it's certainly not the approach you guys espouse. Most people right now are opioid heavy and injection heavy. Intention is hard to prove but it's the fairest way to differentiate a bad pain doctor vs a good one, not talking standards. There's no book written on how to run the clinic patients. There's books on how to do the procedures, and STILL huge variation on procedure technique. So please don't go into court or on this forum and talk about standards not being followed.
I agree that the field is still in somewhat of a "pre paradigmatic" state, but that's not an excuse to commit insurance abuse or do other things that are clearly profit driven as opposed to patient centric. The point of this thread was not to argue about whether doctors should opt for a subpedicular approach or retrodiscal approach on transforaminal ESIs. That's controversial (and I certainly have my own opinion on that front). This discussion has focused on one core issue: the prioritization of money over ethics.
As physicians, we took an oath to "first, do no harm" and to always put the patient's welfare first. Routinely doing unilateral, three level transforaminal epidural steroid injections for patients with commercial insurance or two level bilateral transforaminals for patients with Medicare, even though the same clinical outcome can be achieved with a one level transforaminal ESI...I don't care how you try to "spin" that. That sort of practice pattern is a violation of our professional oath, unethical, and probably illegal. It is CLEARLY driven by profit.
It's sad to hear other physicians support this practice pattern. At best it suggests gross incompetence, at worst it implies corruption of core professional values. Either way, patients are getting shafted. I can see why physicians become increasingly cynical, and even burnout, in practice. The medical system in the United States is just fundamentally broken.
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I don't think it is as clear cut as you say. I'm not so sure taking the extra time to do a tri-level TFESI or b/l bi-level TFESI is worth it from a time and lost facility fee perspective. If the doc owns the ASC, they could have the patient come in for three unilateral one level TFESIs on three separate visits; thats three ASC facility fees right there vs. one facility fee if they do a tri-level on the same day.
The procedures performed appear to be for the comfort and convenience of the physician and not in any way to benefit the patient from a medical standpoint.
This would be my response to the request from the insurance company or the Department of Justice for the medical board when asked to justify anyone's use of a 5 level or 3 level transfer a middle epidural. I don't need to mention the standard of care I can just say that this is pure fraud and not good Medical Practice. I will then present the literature that shows routine use of multi-level transforaminals is worthless.
This would be my response to the request from the insurance company or the Department of Justice for the medical board when asked to justify anyone's use of a 5 level or 3 level transfer a middle epidural. I don't need to mention the standard of care I can just say that this is pure fraud and not good Medical Practice. I will then present the literature that shows routine use of multi-level transforaminals is worthless.
or they could schedule two other people for their 3 level TFESI, get facility fees for all 3 of these procedures in addition to the base TFESI, plus the extra add-on fees of the additional TF...
I don't know the facts but I think if you own the ASC you make much more by bringing someone in 2 or 3 times to "find the right pain generating level" with one TFESI at a time approach. I can speak for myself only.
There's other motivators for doing more than one level. I don't own ASC shares. When I do it for patients it's for two reasons. The first reason is I want what I do to work and for the patient to be impressed and happy with the results. I'll more often do two levels not one to maximize my chances of achieving that primary goal. One visit is much more preferable to patients than two visits. I would prefer being paid for two one level visits and the postprocedure followup. But I still go ahead and do it this way despite that. And I make sure and use plenty of steroid as well for that same reason (might be overkill). The second reason is the financial one.
There's other motivators for doing more than one level. I don't own ASC shares. When I do it for patients it's for two reasons. The first reason is I want what I do to work and for the patient to be impressed and happy with the results. I'll more often do two levels not one to maximize my chances of achieving that primary goal. One visit is much more preferable to patients than two visits. I would prefer being paid for two one level visits and the postprocedure followup. But I still go ahead and do it this way despite that. And I make sure and use plenty of steroid as well for that same reason (might be overkill). The second reason is the financial one.
TFESIs arent selective, einstein.
http://www.ncbi.nlm.nih.gov/pubmed/19057631
what the hell is going on around here?
By that logic, we should be doing 5 level TF on all patients. L1, L2, L3, L4, L5.
Oh I forgot to add S1.
And a few facets.
And an SI injection on the more painful side....
What spine surgeons do not know, for the most part, is how to do only what is necessary. If we all decry how much unnecessary stuff they do, should we also avoid the same tactics?
I'm still trying to find any article that shows or suggests that multilevel TF reduce pain and improve functioning more than single level or ESI.
You make much more money doing a full schedule of multilevel TF than single level TF. Maybe if you aren't running a full schedule....
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Oh I forgot to add S1.
And a few facets.
And an SI injection on the more painful side....
What spine surgeons do not know, for the most part, is how to do only what is necessary. If we all decry how much unnecessary stuff they do, should we also avoid the same tactics?
I'm still trying to find any article that shows or suggests that multilevel TF reduce pain and improve functioning more than single level or ESI.
You make much more money doing a full schedule of multilevel TF than single level TF. Maybe if you aren't running a full schedule....
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Current pain fellow...
I've read some ridiculous stuff in this thread.
A TFESI at 3 consecutive levels means you literally have NO IDEA what is going on, so you're just throwing steroid into the epidural space and hoping it works. We've all been there with patients that are stenotic at multiple levels, but you can't convince me that multilevel stenosis requires an additional few cc's of dexamethasone to make it better. With one level you're gonna cover several root levels. If you're just going to blow up the area with steroid, why not just use an IL approach? You save time and the patient's experience is going to be better because the IL approach is PROBABLY more comfortable, and they will be in the procedure room for a shorter duration. An ILESI allows you to use a particulate steroid as well, which PROBABLY hangs around a little bit longer than a nonparticulate. If you want to make an argument that you're against the IL approach because you want to ensure ventral delivery of the steroid, a bilateral TFESI would be a better idea than a 3 level unilateral. I'm not opposed to like a bilateral L5-S1 TFESI as being an alternative to ILESI, but I am 100% opposed to 3 levels of TFESI.
Any place routinely doing 3 levels per visit is also giving fentanyl and Versed to every patient...I guarantee you that's happening...
TFESI is not a selective procedure due to the fact you get migration of injectate SEVERAL LEVELS, but I am positive that everyone in this thread who routinely practices pain knows that.
Since when is a SCS great for axial back pain, and for that matter when did TFESI's become so successful for axial back pain?
I don't even know where to start with this...
If I had DDD I'd be a little more passionate towards my patients? In the context of this thread I am to interpret that as just throwing procedures on patients and just seeing what works? "Mr Smith, you have DDD in your lower back. Let's schedule an epidural to treat the radicular syndrome that you DON'T HAVE..."
This type of BS right here is what will ruin this field in the next 10 years.
I've read some ridiculous stuff in this thread.
A TFESI at 3 consecutive levels means you literally have NO IDEA what is going on, so you're just throwing steroid into the epidural space and hoping it works. We've all been there with patients that are stenotic at multiple levels, but you can't convince me that multilevel stenosis requires an additional few cc's of dexamethasone to make it better. With one level you're gonna cover several root levels. If you're just going to blow up the area with steroid, why not just use an IL approach? You save time and the patient's experience is going to be better because the IL approach is PROBABLY more comfortable, and they will be in the procedure room for a shorter duration. An ILESI allows you to use a particulate steroid as well, which PROBABLY hangs around a little bit longer than a nonparticulate. If you want to make an argument that you're against the IL approach because you want to ensure ventral delivery of the steroid, a bilateral TFESI would be a better idea than a 3 level unilateral. I'm not opposed to like a bilateral L5-S1 TFESI as being an alternative to ILESI, but I am 100% opposed to 3 levels of TFESI.
Any place routinely doing 3 levels per visit is also giving fentanyl and Versed to every patient...I guarantee you that's happening...
TFESI is not a selective procedure due to the fact you get migration of injectate SEVERAL LEVELS, but I am positive that everyone in this thread who routinely practices pain knows that.
Since when is a SCS great for axial back pain, and for that matter when did TFESI's become so successful for axial back pain?
I don't even know where to start with this...
If I had DDD I'd be a little more passionate towards my patients? In the context of this thread I am to interpret that as just throwing procedures on patients and just seeing what works? "Mr Smith, you have DDD in your lower back. Let's schedule an epidural to treat the radicular syndrome that you DON'T HAVE..."
This type of BS right here is what will ruin this field in the next 10 years.
SCS works for axial. You just have used the wrong system in your several weeks on the job.
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My very first encounter with a SCS was just a few weeks ago, and it was sooooo exciting!
You're either insane or just full of it if you're going to tell me that a SCS is a good option for a patient with primarily axial back pain with no radicular component.
You're either insane or just full of it if you're going to tell me that a SCS is a good option for a patient with primarily axial back pain with no radicular component.
Axial low back pain is sometimes responsive to epidurals when an anular fissure is present.
Anyone who tells you they can not address axial low back pain with a stim simply has not been doing scs for the past 5 yrs. Boston and Nevro both can address axial pain of neuropathic origin a reasonable percentage of the time.
I'm sure your comments are based on your vast weather of experience. Or maybe you should get a few hundred more trials under your belt before spewing your overly arrogant, underwhelming opinions based on an insignificant N to those of us who have been in practice for a decade or more
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This is the weekly Pain Forum reminder to keep things civil. Posts containing or quoting profanity have been removed according to the SDN Terms of Service. This thread will be closed if there are further issues.
darn, missed the profanity. If it was directed at the current world's cockiest pain fellow (OR: lobelsteve WR: lobelsteve) then I fully approve.
What do you mean!!!??? I like to go for the TRIPLE LINDY approach to spinal injections. If a patient comes in with back and leg pain, I ALWAYS do bilateral L1, L2, L3, L4, and L5 transforaminal epidural steroid injections. I couple this with bilateral sacroiliac joint injections. Then, at the very end, I ablate the medial branches of the dorsal rami of L2-L5 bilaterally. My patients love me and so do the referring providers. I tell patients that there's a 50/50 chance of pain relief with this approach, though there's only a 10% chance of that and so I always manage patient expectations appropriately... Every time I walk out of the procedural suite, the staff and patients cheer just like this...
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