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

[clubdeac]

This is all pretty funny...I think there is definitely abuse and misuse of pain procedures and although I don't agree with a a 3 level trany, I am a little more willing to exhaust procedural options in the veteran population - and I'm salaried. Outcomes not money are the driving force. A lot of them are at the end of their rope and are begging for any help they can get. We're weaning most all these guys down or off their opioids and many of them have failed or had lackluster results with PT, acupuncture, and chiropractics. Of course, I'm using my clinical judgement based on imaging and exam. We did just start an interdisciplinary pain psych program so that should help!

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[Taus]

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.

What characterizes neuropathic back pain for Scs consideration? I've heard a few docs, but mainly stim reps mention this term. Quite rarely do I see numb/tingling/burning/etc in the lumbar region itself... are you referring to the constant nature of pain in the region vs "mechanical"? Truly trying to learn here, as now with new literature, Nevro, etc, I'm considering offering it for purely axial fbss. Never done it.


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[lobelsteve]

If you hurt before you move to get out of bed, it is worth trying.

 

[BobBarker]

If the back hurts all the time Nevro will help. If it hurts only w/ movement, less than 50 percent probability of helping.

 

[Ligament]

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.

SCS can cover back pain reasonably well with developments in the past few years. There is absolutely no doubt that axial pain coverage is realistic with some modern SCS systems. I realize you are new in fellowship and the mantra that axial pain is impossible with SCS is being told to you by your attendings, and that used to be the truth 3-5 years ago, but the reality has changed a lot recently.

 

[BobBarker]

They are probably teaching him stim for legs, pumps for axial, and MDT always.

 

[Stim4me]

For dozens of years Medicare allowed something like six allowable tf Levels every six months... That's like 2 three level or three 2 level tfesis every six Months. That was crazy but was allowed by Medicare..... In the past.

I was aware of practices offering this max number of shots, esp in Florida where a lots of my patients reside. I was always flabbergasted with what my patients told me....
In the last few years Medicare has cracked down on 3 levels period, and limited total procedures levels yearly. Obviously Noridian policies are draconian per Lax's mantra.
This reform was way past due. That being said, you don't want the pendulum swung all the way to nothing. Most would agree 1-2 levels, reasses, consider second procedure as clinically indicated. Three Max Esi's per year not 6. Have patient really pursue weight loss, smoke cessation, and home exercise programs. There is always a fine balance . Not sure why it never translates at a policy level....

 

[Disciple]

I'm unsure if the proponents of routine 3 level TFESIs actually believe the arguments for this practice, or if it subconsciously stems from the old-school culture of Interventional Pain=inject as much as possible.

 

[ampaphb]

Please explain to me why you would ever do a three level TF-ESI preferentially over an interlaminar, other than cause the reimbursement is significantly higher

 

[EtherBunny]

Please explain to me why you would ever do a three level TF-ESI preferentially over an interlaminar, other than cause the reimbursement is significantly higher

That's the $15,000 question, isn't it? When I asked the medical director of a practice about the logic for doing 3 level TFESIs all the time, this is what I was told:

"Well, I've never had a patient that I could get better with just one level. I mean, if you can get a great outcome with a single level, you would have to be a miraculously good doctor. I talked to all of the other pain physicians around here. I look at their charts. This is what everyone is doing. It's the norm. Look, all I care about is the patient. I want them to get better so they keep coming back. This isn't like academics..."

No mention of any profit motive at all because...well, of course you do 3 level TFESIs for radiculopathy!

The whole conversation was just ridiculous and made me want to vomit.

 

[lobelsteve]

That's the $15,000 question, isn't it? When I asked the medical director of a practice about the logic for doing 3 level TFESIs all the time, this is what I was told:

"Well, I've never had a patient that I could get better with just one level. I mean, if you can get a great outcome with a single level, you would have to be a miraculously good doctor. I talked to all of the other pain physicians around here. I look at their charts. This is what everyone is doing. It's the norm. Look, all I care about is the patient. I want them to get better so they keep coming back. This isn't like academics..."

No mention of any profit motive at all because...well, of course you do 3 level TFESIs for radiculopathy!

The whole conversation was just ridiculous and made me want to vomit.

You threw up ON Dean Wormer.

 

[SSdoc33]

etherbunny is on double secret probation.

also, if patients get better, why would they keep coming back?

 

[EtherBunny]

etherbunny is on double secret probation.

also, if patients get better, why would they keep coming back?

Lol. Classic movie.

 

[lonelobo]

Lol. Classic movie.

Yes " Mean Girls" was awesome movie

 

[EtherBunny]

Yes " Mean Girls" was awesome movie

Um, I thought the "double secret" probation was from Animal House. Right?

 

[lonelobo]

Um, I thought the "double secret" probation was from Animal House. Right?

yes , I always get those 2 movies confused

 

[MD87]

Saw a lady last week who had right buttock pain radiating into the groin knee with numbness/tingling. Hip exam was normal and her MRI showed multilevel stuff but most significant is right foraminal stenosis at L3/4. She had had injections at an outside facility, and I wanted to see what she had had done there, and I just got the procedure notes today. She had: right L3/4, L4/5, L5/S1 "diagnostic" facet joint injections with steroid followed by a repeat 2 weeks later. She then had the same series of 2 done on the left side. Then she had a 3-level right L2, L3, L4 TFESI, followed by 3-level right L3, L4, L5 TFESI the next week... with lidocaine and saline... no steroid. This is maybe commonplace but it's the first time I've seen it personally. I felt sick reading it. Now of course she's had 320mg of depo from the facet joint injections already, so I'm not sure what to do! Fun.

 

[emd123]

Saw a lady last week who had right buttock pain radiating into the groin knee with numbness/tingling. Hip exam was normal and her MRI showed multilevel stuff but most significant is right foraminal stenosis at L3/4. She had had injections at an outside facility, and I wanted to see what she had had done there, and I just got the procedure notes today. She had: right L3/4, L4/5, L5/S1 "diagnostic" facet joint injections with steroid followed by a repeat 2 weeks later. She then had the same series of 2 done on the left side. Then she had a 3-level right L2, L3, L4 TFESI, followed by 3-level right L3, L4, L5 TFESI the next week... with lidocaine and saline... no steroid. This is maybe commonplace but it's the first time I've seen it personally. I felt sick reading it. Now of course she's had 320mg of depo from the facet joint injections already, so I'm not sure what to do! Fun.

Not commonplace

 

[tmvguy03]

Saw a lady last week who had right buttock pain radiating into the groin knee with numbness/tingling. Hip exam was normal and her MRI showed multilevel stuff but most significant is right foraminal stenosis at L3/4. She had had injections at an outside facility, and I wanted to see what she had had done there, and I just got the procedure notes today. She had: right L3/4, L4/5, L5/S1 "diagnostic" facet joint injections with steroid followed by a repeat 2 weeks later. She then had the same series of 2 done on the left side. Then she had a 3-level right L2, L3, L4 TFESI, followed by 3-level right L3, L4, L5 TFESI the next week... with lidocaine and saline... no steroid. This is maybe commonplace but it's the first time I've seen it personally. I felt sick reading it. Now of course she's had 320mg of depo from the facet joint injections already, so I'm not sure what to do! Fun.

Man that’s sad- I felt the same way you did reading this. It just goes to show what our patients are willing to go through when they have pain... the fact that you’re concerned about her tells me she’s come to the right place and you’ll keep her safe.
I would agree with cooling it on injections, with the exception of potentially RFA of the facets (no steroid of course) assuming that she had an excellent, distinct improvement in her pain with the MBBs. That may not be documented though.

Ultimately if you felt she was a stim candidate, which sounds like she may be, that could be a good long term solution without exposing her to steroid, and hopefully negate the need for future injections all together. Good luck!

 

[Ducttape]

Not commonplace

you mean "not commonplace any more."

when I started in 2010, it was commonplace to do bilateral 3 level TF. I got ridiculed for doing single level epidurals...

the spine guy at the neighborhood academic center would do 30 of these a day.

if you want to know why there are so many rules and regulations regarding injections, these are the shining examples of why CMS got busy.

 

[emd123]

you mean "not commonplace any more."

when I started in 2010, it was commonplace to do bilateral 3 level TF. I got ridiculed for doing single level epidurals...

the spine guy at the neighborhood academic center would do 30 of these a day.

if you want to know why there are so many rules and regulations regarding injections, these are the shining examples of why CMS got busy.

I'll add, shouldn't be commonplace.

 

[TIVAndy]

Please explain to me why you would ever do a three level TF-ESI preferentially over an interlaminar, other than cause the reimbursement is significantly higher

i usually don't do 3 level TFESI but there are pts who had extensive fusion and laminectomies in the lumbar spine then interlaminar is out of the question. i usually consider two level TFESI in this population. vs caudal ESI if i think the target is lumbosacral. i guess some ppl may argue for 3 level also in this case.

 

[lobelsteve]

i usually don't do 3 level TFESI but there are pts who had extensive fusion and laminectomies in the lumbar spine then interlaminar is out of the question. i usually consider two level TFESI in this population. vs caudal ESI if i think the target is lumbosacral. i guess some ppl may argue for 3 level also in this case.

And those people are charlatans and idiots.

 

[SommeRiver]

I do 2 levels but never done a 3 level. Not in residency, fellowship, or the real world. I can't see how you would justify that procedure. I have pts with severe stenosis throughout the lumbar spine, and they'll come in with what looks like multidermatomal pain. I'll do L5-S1 and L3-4 and it works well in some cases. You have enough spread with a two level to cover everything.

 

[Aether2000]

Excessive levels of simultaneous TFESI injections are painting a very large bullseye on the back of Pain Medicine by CMS and insurers that may consider such excesses to be fraud.

 

[emd123]

CMS only pays for two levels in TF ESIs. So how are people even billing for 3 levels? I don't get it.

 

[TIVAndy]

CMS only pays for two levels in TF ESIs. So how are people even billing for 3 levels? I don't get it.

i believe it's one level bilateral or unilateral two levels. in our region medicaid and commercial insurance still pay for three level.

 

[SommeRiver]

BTW - I saw a 52 yo F this past Friday who is s/p L4-S1 instrumentation and she claimed she had 38 epidurals between 2006 and 2010. New patient to me. She has classic SI pain. Failed PT recently. Worsening over the last 6 months. I'm doing an SI joint injxn and told her under no circumstances would I entertain a 39th epidural, or for that matter a 2nd SI joint injxn. I can't imagine talking to a pt after the 17th epidural and recommending an 18th. What TF?

 

[NJPAIN]

When I started in the early 90s the private practice guys would routinely do multilevel TFESI combined with bilateral SIJ or “psoas muscle injections”. Coming out of 8 years in academics ( in 2000 ) where I would not do an ESI absent radicular pain these guys faulted me for neglecting to treat the “multiple pain generators” during a single session in my patients. It was a hard sell to patients as well who expected to go to sleep and wake up having had 6-8 procedures.


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[emd123]

i believe it's one level bilateral or unilateral two levels. in our region medicaid and commercial insurance still pay for three level.

Yes, CMS pays for two needles. One level bilateral or two levels unilat.

Didn’t know Medicaid or privates pay for three.

 

[Blitz2006]

Hey, so newbie question.

When do you do a single level TFESI? Different attendings have told me different things.

My consensus is, go for TFESI only if there is severe foraminal stenosis at the level, correct? Otherwise, always start with ILESI.

Also, when is caudal the best choice?

 

[lobelsteve]

Hey, so newbie question.

When do you do a single level TFESI? Different attendings have told me different things.

My consensus is, go for TFESI only if there is severe foraminal stenosis at the level, correct? Otherwise, always start with ILESI.

Also, when is caudal the best choice?

I go at level below the concordantvpain generator based on imaging and exam/history. Caudal is never best choice. Last resort for multilevel stenosis after failed b/l S1 tfesi. And i cant see how it would be better.

 

[SSdoc33]

havent done a caudal in a decade. prefer TFESIs in just about all cases except younger patients with HNPs

 

[paindoc007]

Do you believe dex works as well as particulates?
And are you bold enough to put dex in a tfesi?

If no to both, nothing wrong with interlam/caudal approaches

 

[lobelsteve]

Do you believe dex works as well as particulates?
And are you bold enough to put dex in a tfesi?

If no to both, nothing wrong with interlam/caudal approaches

What you believe is not as relevant as 4-5 peer reviewed journal articles showing no difference. Dex is non-particulate, Depo/Kenalog/Celestone are particulate. Dex is drug of choice in TFESI.

 

[nvrsumr]

far lateral lumbar hnp=single level tfesi.

 

[paindoc007]

if all steroids are the same, why isn’t it commonly used for interlams? Because the risk of particulate embolization is lower, as is the efficacy with dex

 

[SommeRiver]

Dex exclusively for TF and IL ESI. If you do otherwise you put yourself and the pt at risk. I know a guy personally who caused a cord infarction with 80mg Depo in a TFESI. I use Depo in joints though...

 

[SommeRiver]

if all steroids are the same, why isn’t it commonly used for interlams? Because the risk of particulate embolization is lower, as is the efficacy with dex

It's used by me for interlams.

 

[Blitz2006]

Dex exclusively for TF and IL ESI. If you do otherwise you put yourself and the pt at risk. I know a guy personally who caused a cord infarction with 80mg Depo in a TFESI. I use Depo in joints though...

How come you don't use Depo for ILESI?

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[Blitz2006]

What you believe is not as relevant as 4-5 peer reviewed journal articles showing no difference. Dex is non-particulate, Depo/Kenalog/Celestone are particulate. Dex is drug of choice in TFESI.

So in your opinion, is efficacy between particulate and non particulate the same? I've been told Dex lasts for 2-3 days only...

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[lobelsteve]

So in your opinion, is efficacy between particulate and non particulate the same? I've been told Dex lasts for 2-3 days only...

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In the opinion of the overwhelming majority of the literature, and after review: the literature supports the use of Dex as just as long lasting and effective as any other steroid. My opinion is with the literature. For those who disagree, pull out the papers. And for those who like the paper where it took 2 injections to get the same benefit, I say get paid for two shots instead of one with more risk. But repeating that study would likely yield no changes between the various steroids.

SML

 

[SommeRiver]

How come you don't use Depo for ILESI?

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Why would I? Do you have evidence it is significantly better than dexamethasone?

 

[SommeRiver]

So in your opinion, is efficacy between particulate and non particulate the same? I've been told Dex lasts for 2-3 days only...

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I've done Depo ILESI that didn't last one day. What's your point? It actually angers me that dudes are still doing particulates in epidurals and it is another example of how effed up our field is where the literature is AVAILABLE to answer ALL of these questions.

I guarantee you that if you took a poll of pain MDs doing particulates I bet it is heavily skewed to anesthesiologists. My residency was PMR and Pain Fellowship was anesthesiology based. All my PMR attendings did things by the SIS protocols and the anesthesia based guys in fellowship did whatever TF they wanted. I didn't know you could actually do particulates in any form of ESI, but day one fellowship I did like 10.

Edit - I know two guys who do TFESI with 80mg Depo and 2cc bupi. Probably 15 per week. Surgeons.

 

[MD87]

I agree with this for the most part. But I'm not so sure I agree with only using non-particulate for interlams. If I do a TFESI with dex and it doesn't provide lasting relief, the idea of doing an ILESI with dex seems pretty unlikely to work to me. I feel like that is destining the patient for surgery, and I have a very hard time believing that an ILESI with beta or depo or any particulate steroid poses as high of a risk as any spine surgery. I'm not saying that particulate is better than dex, but I'm saying that in a SPECIFIC individual (not the general population) that has already failed dex but has not failed particulate, why not try it? The same could be true for someone who already failed an ILESI with particulate - I think it would be reasonable to try a TFESI with non-particulate in this sort of patient.

Additionally, I'm not sure I've seen any evidence for particulate steroid being more dangerous than non-particulate for ILESI. I haven't seen any anatomic studies indicating that arteries would be back in that region either, but please let me know if there is such evidence out there. The Safeguards to Prevent Neurologic Complications After ESI from 2015 recommends non-particulate for TFESI but makes no specific recommendation regarding the type of steroid to be used for ILESI, for what it's worth. And, that's in the context of them not specifically recommending that ILESI be performed with live fluoro, which indicates to me, at least, that the committee's opinion is that the risk of a serious complication from a particulate steroid injected into a vessel during an ILESI is not large enough to even think about.

On a related note, since we are talking about caudals - is there any evidence for doing these without stopping blood thinners? I'm sure the risks if you're using a small 25g 1.5 inch needle are small, but is there actually any evidence for it? In residency I saw people doing these with patients on coumadin, but more recently I haven't...

 

[SommeRiver]

I agree with this for the most part. But I'm not so sure I agree with only using non-particulate for interlams. If I do a TFESI with dex and it doesn't provide lasting relief, the idea of doing an ILESI with dex seems pretty unlikely to work to me. I feel like that is destining the patient for surgery, and I have a very hard time believing that an ILESI with beta or depo or any particulate steroid poses as high of a risk as any spine surgery. I'm not saying that particulate is better than dex, but I'm saying that in a SPECIFIC individual (not the general population) that has already failed dex but has not failed particulate, why not try it? The same could be true for someone who already failed an ILESI with particulate - I think it would be reasonable to try a TFESI with non-particulate in this sort of patient.

Additionally, I'm not sure I've seen any evidence for particulate steroid being more dangerous than non-particulate for ILESI. I haven't seen any anatomic studies indicating that arteries would be back in that region either, but please let me know if there is such evidence out there. The Safeguards to Prevent Neurologic Complications After ESI from 2015 recommends non-particulate for TFESI but makes no specific recommendation regarding the type of steroid to be used for ILESI, for what it's worth. And, that's in the context of them not specifically recommending that ILESI be performed with live fluoro, which indicates to me, at least, that the committee's opinion is that the risk of a serious complication from a particulate steroid injected into a vessel during an ILESI is not large enough to even think about.

On a related note, since we are talking about caudals - is there any evidence for doing these without stopping blood thinners? I'm sure the risks if you're using a small 25g 1.5 inch needle are small, but is there actually any evidence for it? In residency I saw people doing these with patients on coumadin, but more recently I haven't...

Dude, how often do you do a TFESI with dex and nothing happens so you just do it again and the pt comes back and says they're 85% better? That happens all the time. Failing one epidural doesn't mean the next will fail too, and it certainly doesn't mean that you now have to graduate the pt from the JV steroid to the varsity steroid.

For those doing ILESI with particulate are you also doing CESI with particulate?

By the way, I consider fluoro as standard of care and it doesn't matter to me how many blind epidurals someone has done...If my mother received blind epidurals and some fool used that to convince her to get back surgery bc the "shots didn't work" I will be waiting in the parking lot for that doctor.

Also a 1.5" needle into the caudal space? You tryna get the medicine to S3 or L5? I won't do an ESI on Coumadin or any other blood thinning medication. We did all types of weird BS in fellowship but that isn't the real world at all.

Edit - You mentioned the risk of particulate in an ILESI is less than the risk of surgery. That is true, and that is why I know two spine surgeons who use Depo 80mg in all TFESI they do...15 or so per week. But, the risk of particulate is higher than nonparticulate and there is nothing to show it is superior so why would you ever use it?

 

[Blitz2006]

Dude, how often do you do a TFESI with dex and nothing happens so you just do it again and the pt comes back and says they're 85% better? That happens all the time. Failing one epidural doesn't mean the next will fail too, and it certainly doesn't mean that you now have to graduate the pt from the JV steroid to the varsity steroid.

For those doing ILESI with particulate are you also doing CESI with particulate?

By the way, I consider fluoro as standard of care and it doesn't matter to me how many blind epidurals someone has done...If my mother received blind epidurals and some fool used that to convince her to get back surgery bc the "shots didn't work" I will be waiting in the parking lot for that doctor.

Also a 1.5" needle into the caudal space? You tryna get the medicine to S3 or L5? I won't do an ESI on Coumadin or any other blood thinning medication. We did all types of weird BS in fellowship but that isn't the real world at all.

Edit - You mentioned the risk of particulate in an ILESI is less than the risk of surgery. That is true, and that is why I know two spine surgeons who use Depo 80mg in all TFESI they do...15 or so per week. But, the risk of particulate is higher than nonparticulate and there is nothing to show it is superior so why would you ever use it?

I agree with everything you say.

But why is the risk of particulate > non particulate in ILESI? What am I missing anatomically

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[MD87]

The answer to your first question is never. I'm a new attending, and in fellowship if someone got no relief whatsoever from the first injection, we did not repeat that same injection, we would try something different. That's just how I was trained, and I'm still finding my way, so maybe that will change.

I am not implying that dex is JV and particulate is varsity. I'm saying that they are probably equal but definitely different. Hence, my comment regarding failing dex with a TFESI and then moving to particulate with a ILESI OR vice versa. To me, that makes more sense than trying the same thing twice and just hoping that somehow the patient has better results the second time around. It sounds like you have good results with that method, though, and as long as your patients do well, I guess who cares. Though to me, as a patient, it would be a hard sell agreeing to have the same exact thing done to me if the last time it didn't do squat.

The comment I made about the 2015 guidelines is with regards to the use of LIVE fluoro (to detect vascular) during ILESI. They are not suggesting that blind epidurals are the way to go, and that is not what I was suggesting either.

You state that the risk of particulate is higher than non-particulate. In the interlaminar space, to the best of my knowledge, the literature does not support that comment.

 

[emd123]

Do you believe dex works as well as particulates?
And are you bold enough to put dex in a tfesi?

If no to both, nothing wrong with interlam/caudal approaches

Why would it be "bold" to put dex in a tf psi?

 

[emd123]

Dex exclusively for TF and IL ESI. If you do otherwise you put yourself and the pt at risk. I know a guy personally who caused a cord infarction with 80mg Depo in a TFESI. I use Depo in joints though...

How is someone going to "infarct" the cord with particulate in the posterior epidural space, where there are only veins and no cord-entering arteries that could be infarcted?