Which fellowships are teaching the "Series of 3"

[PMR 4 MSK]

---

Members do not see this ad.

Someone is teaching these yahoos that ESIs are always done as a "series of 3", often a week or less apart. Are there attendings at ACGME fellowships doing this? Or is it only non-ACGME ones? Or is it just docs get out of training, get greedy and decide to subject every patient to an unproven and potentially dangerous theory?

There is a guy in my town who does 3 ESIs in 1 week - M-W-F. Other docs set pts up for 3 ESIs right away - as in "Ok, well do one today, the next one a week from today and the third in 2 weeks."

Most every patient who comes to me from other towns or states has had ESIs in multiples of 3. It's always 3,6, 9, 18, 36.No one ever says "I had 2 ESIs, but they didn't help so we moved on to something else."

Instead, its "How many epidurals did you have?"
"6"
"Did they help?"
"No"
"Then why did you keep havin them done?"
"Because my doctor told me I should"

WTF? Shouldn't this be an automatic beotch-slapping offense?

While I'm on this rant, what about the needle monkey who does the "Series of 3" LESIs, followed by 3 CESis, then bilateral 5-level FJI, Bilateral SIJI and a caudal ESI all on the same day? Can we just appoint someone to come sodomize them with a 60 cc syringe?

 

[nwbgn]

I often see this as well. I tell my patients that the "series of 3" is no longer recommended. I actually schedule an office follow up about 10 days after every spinal injection as I want to make sure the patient is responding appropriate and has not developed any complications or other medical issues which preclude them from having another procedure if one were needed. Is this overkill? How are others scheduling their injections / follow ups?

 

[Jitter Bug]

In my neighborhood its always the surgeons (both neurosurg and ortho spine) who order a series of 3 and get their buddies to just follow the script.

The pain docs (anes, PM&R) don't do this.

Not sure what it's like in other cities.

 

[Taus]

Just saw a patient today for 4 limb EMG ordered by his pain doc (at a major academic hospital). Middle age, chronic 4 limb parasthesias, mild neck/back pain, h/o heavy etoh abuse. C/L MRI w/ mild degen changes and no smoking guns.

In the last 3 years he has had "6-8 series of 3" C&L ESI's by the referring doc. Occasional relief for a few days.

EMG (legs only): Peripheral polyneuropathy likely due to etoh. Not one damn finding in a myotomal pattern. A 1 minute motor and sensory physical exam would have told you the same thing.

 

[PinchandBurn]

I am not a proponent of a routine series of 3.

Having said that, we also have to really dwell into what our patients say and what they mean. I cant imagine a patient woudl subject themselves to 3 of anything if it didnt help at all.

Also, let's say year ONE they have 3 ESIs andthen year TWO they have another 3 ESI. These were all 4 months apart. Is that a bad thing (assume no cushingoid issues, no hyperglycemia issues and well controlled pain).

I do think doing 3 back to back 1 week apart is concerning. I think doing 3, perhaps 4 months apart (only if symptoms come back) is reasonable. I think the context is important.

 

[Uncovert]

I saw a pediatric patient with proximal RLE pain/paresthesias being seen in the outpatient Pain clinic after inguinal hernia repair and diagnosed with CRPS. To make it even more ridiculous, they were about to do a series of 3 epidurals. The clinic would not allow an EMG, which the parents paid for on their own at outside hospital. This, along with 40 sec exam demonstrated meralgia.......

 

[101N]

Surgeon: This patient doesn't need surgery. I'll send them to the pain guy for a series of 3. Hopefully, they'll go away (regress to the mean).

Pain Guy: This patient needs three epidurals because I can bill 3x as much.

 

[Ligament]

There are a number of lowlife pain docs around here that routinely schedule a series of 3 epidurals. They ALWAYS schedule a series of three if they also own the surgery center these epidurals will be performed in.

There are even more physicians that tell their patients they can ONLY have "3" epidurals per year, or 3 steroid injections of any sort, for whatever folk tale they base this info on.

 

[lobelsteve]

http://www.stevenlobel.com/procedures.html

Click on the link at bottom of page "Series of 3" for the abstract.

 

[PMR2008]

There are a number of lowlife pain docs around here that routinely schedule a series of 3 epidurals. They ALWAYS schedule a series of three if they also own the surgery center these epidurals will be performed in.

There are even more physicians that tell their patients they can ONLY have "3" epidurals per year, or 3 steroid injections of any sort, for whatever folk tale they base this info on.

What guidelines do you follow Ligament for the number of steroid injections per year?

 

[Dr. Ice]

What guidelines do you follow Ligament for the number of steroid injections per year?

My favorite is when I see the patient who have already had the series and it failed, and Im left to clean up the mess of improper diagnosis and no other treatments offered. I just saw a woman who came in sobbing cause some needle jockey said she "had to" have the series of injections or she had to go somewhere else. The best is when they call me after they have gotten a series from some other a**clown and then ask me for what they should do next.

Of course these guys are making 2x my salary and are all driving bentleys.

I know I may open up a can of worms here...but it seems...just seems that a lot of these guys are..well...anesthesia trained pain docs.

Let the flood gates open.......

 

[Dr. Ice]

I also think that these guys dont want to bother to take the time to actually listen to patients or do an exam and just go by whats on the imaging.

So they recommend the series and when the third injection doesnt work..they ship the patient to the next guy saying "sorry my treatment didnt work." That way..they get the billings outta doing the shots and they dont have to worry about what happens to the patients when their bs treatment fails.

 

[Jcm800]

i think you are mistaken. this has never happened with an anesthesia trained doctor. It has only occured with PMR trained docs.

Wait maybe, it is only with Neuro trained...blah blah


it happens with the bad eggs regardless of training. I know plenty of PMR"pain" docs that do the same. There are just MORE anesthesia "pain" docs out there...

My favorite is when I see the patient who have already had the series and it failed, and Im left to clean up the mess of improper diagnosis and no other treatments offered. I just saw a woman who came in sobbing cause some needle jockey said she "had to" have the series of injections or she had to go somewhere else. The best is when they call me after they have gotten a series from some other a**clown and then ask me for what they should do next.

Of course these guys are making 2x my salary and are all driving bentleys.

I know I may open up a can of worms here...but it seems...just seems that a lot of these guys are..well...anesthesia trained pain docs.

Let the flood gates open.......

 

[PinchandBurn]

i think you are mistaken. this has never happened with an anesthesia trained doctor. It has only occured with PMR trained docs.

Wait maybe, it is only with Neuro trained...blah blah


it happens with the bad eggs regardless of training. I know plenty of PMR"pain" docs that do the same. There are just MORE anesthesia "pain" docs out there...

exactly. In my area, even for L3 radics, the local PMR pain guy does S1 and L5TFESI (series of 3 btw) on ALL patients !!

I agree with JCM, I think there are just bad apples out there regardless of the primary specialty.....

 

[lobelsteve]

exactly. In my area, even for L3 radics, the local PMR pain guy does S1 and L5TFESI (series of 3 btw) on ALL patients !!

I agree with JCM, I think there are just bad apples out there regardless of the primary specialty.....

PM me his name. I sit on the AAPMR. I'll call him on it.

 

[emd123]

What if your fellowship teaches a series of 4?













(just kidding). 🙂

 

[PMR 4 MSK]

Most of those cases of the So3 where I've been able to find out the time b/w injections, it was under 2 weeks. 1 week seems to be most common.

I remember asking one guy for whom the So3 didn't work,"what did the other doc tell you (about why you 'needed' 3 injections in a row)? " He said he was told that the first 2 injections didn't count, that it was the third one that worked. My only thought was the doc was applying the Synvisc principle - it takes 3 injections, 2 don't do it.

 

[nvrsumr]

I think the original reason for the series of three was that blind ESIs got to the correct level only 33% of the time.

 

[emd123]

i think the original reason for the series of three was that blind esis got to the correct level only 33% of the time.

lol!

 

[PMR 4 MSK]

I think the original reason for the series of three was that blind ESIs got to the correct level only 33% of the time.

But I bet you are not far from the the truth.

 

[epidural man]

http://www.stevenlobel.com/procedures.html

Click on the link at bottom of page "Series of 3" for the abstract.

Cool. I tell patients all the time that the only people doing 3 shots in a row are ones getting paid and don't care about outcomes.

I like how you use literature to support your conclusion. Very wise of you.

By the way, just curious, can you do the same (on here...but cool if you can add it to your webpage as well) that supports your claim that a caudal is the least useful?

(We have had this discussion before....I'm just asking, not claiming anything...sheesh.)

 

[lobelsteve]

Cool. I tell patients all the time that the only people doing 3 shots in a row are ones getting paid and don't care about outcomes.

I like how you use literature to support your conclusion. Very wise of you.

By the way, just curious, can you do the same (on here...but cool if you can add it to your webpage as well) that supports your claim that a caudal is the least useful?

(We have had this discussion before....I'm just asking, not claiming anything...sheesh.)

http://general-medicine.jwatch.org/cgi/content/full/2011/1013/1

 

[epidural man]

http://general-medicine.jwatch.org/cgi/content/full/2011/1013/1

Nice effort. 😉

Any studies that compare the different ways to access the epidural space that I can take a gander at?

 

[101N]

I think the original reason for the series of three was that blind ESIs got to the correct level only 33% of the time.

Not far from the truth...



WHITE, ARTHUR H. MD 1; DERBY, RICHARD MD 2; WYNNE, GAR MD 1




Institution

(1)Drs. White and Wynne are in private practice in San Francisco, California
(2)Dr. Derby is an anesthesiologist at St. Mary's Hospital in San Francisco




Title

Epidural Injections for the Diagnosis and Treatment of Low-Back Pain.[Article]




Source

Spine. 5(1):78-86, January/February 1980.




Abstract

Three hundred four consecutive patients with low-back pain were given epidural anesthetic and steroid injections. A prospective study demonstrated that selected patients had 87% short-term success and 34% relief of pain for as long as 6 months. No patient was cured by these injections. Needle placement during epidural injections was incorrect 25% of the time in experienced hands.