Transforaminal ESI level question
Started by MustangGtV894
Personally I would do an LESI unless TFESI is indicted by prior surgery.
But to answer your question i would do L4-5 if only 1 level (assuming its the traversing L5 nerve root you are discussing). If failed, consider L5-S1. I also think a 2 level would be appropriate.
But to answer your question i would do L4-5 if only 1 level (assuming its the traversing L5 nerve root you are discussing). If failed, consider L5-S1. I also think a 2 level would be appropriate.
I’m going to piss some people off and say L4 and L5.
I’d do both.
Or L5 and S1..follow the flow..goes up and down
R L5-S1 TFESI is the place to start. Gotta cover the DRG.
i would do L4 - usually easier, it is where the cause of pathology is (the disc herniation at L4), you will be coating the L5 nerve root at that level and it does spread, patients and surgeons can understand better that the injection was for radicular pain from that specific disc herniation.
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?
maybe infraneural at L4, but L5 is the nerve getting dinged. thats what you need to go after. you would do an L4 TFESI for a lateral or foraminal herniation at L4-5, not a paracentral
Do both
Both
Depends on the pain pattern. If its L4 (anterior leg) then L4 TFESI and if its lateral lower leg and lateral hip, then I would do L5 TFESI
I’m a bit surprised that there is any confusion here. If it’s an L5 radic from L4-5 disc compressing traversing L5 (not exiting L4)…. Then why would anything but an L5 injection be done (if doing tfesi). Whether subpedic/supra-neural in L5-s1 foramen or Infra-neural/retro-discal in 4-5 foramen… that’s dealers choice. I prefer the former, but prob doesn’t really matter.
I usually try to address the nerve root impinged by the herniation. In this case I would start off with L5-S1 TFESI. If this doesn’t last at least three months, then I would repeat it and add the L4-L5 level.
Do both. Maximize chances get the patient pain relief.
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The issue is, if doing a single level the patient doesn’t meet the response criteria dictated by whatever insurance you deal with they will likely deny a second injection, even if you try a separate level. More likely to get a response by hitting two levels.
Can you cite any study/literature to support this?
I don’t think it matters as long as you get in the epidural space.
Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study - PubMed
TFESI for lumbosacral radiculopathy with a preganglionic approach is more effective than TFESI with a ganglionic approach at short-term follow-up.
pubmed.ncbi.nlm.nih.gov
The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis - Neurosurgical Review
The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two...
link.springer.com
It would seem that preganglionic ESI, in this case L4-5 TFESI, would be the better option if you only have the option of doing a single level TFESI.
I would still do both levels on the same visit for aforementioned reasons.
Do L4-5 then two level if necessary.Preganglionic TFESI better than ganglionic for short-term follow-up (1 month) while ganglionic was better than preganglionic for midterm follow-up (6 months).Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study - PubMed
TFESI for lumbosacral radiculopathy with a preganglionic approach is more effective than TFESI with a ganglionic approach at short-term follow-up.
Preganglionic ESI has a 2.38 (95% CI 1.12, 5.04) times statistically significantly higher chance of effectiveness when compared to ganglionic ESI.The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis - Neurosurgical Review
The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two...
It would seem that preganglionic ESI, in this case L4-5 TFESI, would be the better option if you only have the option of doing a single level TFESI.
I would still do both levels on the same visit for aforementioned reasons.
Why so adamant on doing one level?
If I do an ESI without new MRI and the patient doesn’t do as well as we hoped, I think I always find out I was doing the pre-ganglionic injection after new imaging.
Unilateral - LTFESI, always two levels.
Insurance pays for both, and its better to hit both preganglionic and ganglionic than trial and error with single shots.
Insurance pays for both, and its better to hit both preganglionic and ganglionic than trial and error with single shots.
depends.
most insurers this area pay 1.5 times of one sided tfesi.
thankfully, facility fees are not doubled.
most insurers this area pay 1.5 times of one sided tfesi.
thankfully, facility fees are not doubled.
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That could be considered insurance fraud. Each level has its own code with its own wRVU and dollar value.
um, not really.
insurers will require that the biller request 64483-50 instead of 64483 RT + 64483 LT. so not fraud.
insurers will require that the biller request 64483-50 instead of 64483 RT + 64483 LT. so not fraud.
I was referring to the post above about a 2 level unilateral TFESI
why would it be fraud?
I follow the allowed rules. Insurance allows it. It is indicated. This is the way.
I was saying if you perform a two level unilateral TFESI and the insurance changes it to single level -50, it’s fraud on the part of the insurance company. I think duct was implying that. Never mind, I caused mass confusion
Agree that 2 level unilateral is not 50 mod. My misunderstanding on the original post.
Technically in the case of 2 level tfesi one is supposed to use 64483 & 64484. The payment for 64484 is about half of 64483.
Technically in the case of 2 level tfesi one is supposed to use 64483 & 64484. The payment for 64484 is about half of 64483.
