Why not mbb's?

[clubdeac]

So as there are no pathognomonic historical symptoms, physical exam signs or radiographic findings to suggest facet mediated pain, why not perform medial branch blocks on everyone over 50 y/o with axial lbp, assuming they don't have a significant amount of psychosocial overlay or ongoing substance abuse? Let's discuss....

---

Members don't see this ad.

 

[101N]

So as there are no pathognomonic historical symptoms, physical exam signs or radiographic findings to suggest facet mediated pain, why not perform medial branch blocks on everyone over 50 y/o with axial lbp, assuming they don't have a significant amount of psychosocial overlay or ongoing substance abuse? Let's discuss....

For the same reason you would not perform prostate screening on every male over 50, you end up with a bunch of false positives, increased cost and iatrogenic complications.

 

[clubdeac]

However some studies report a prevalence of up to 45% among individuals over 50. Your false positives decrease as prevalence increases

 

[bedrock]

However some studies report a prevalence of up to 45% among individuals over 50. Your false positives decrease as prevalence increases

I mostly agree with clubdeac.

If someone over 50 has purely axial low back pain, doesn't have major psych issues, has failed a good PT program, basic meds, and their function is still significantly limited---------MBB time

Clear discogenic pain on exam or imaging would obviously preclude MBB for those patients.

 

[101N]

An excellent read. And yes, I perform mbbs.

Spine J. 2007 Jan-Feb;7(1):27-31. Epub 2006 Nov 20.
The pyrite standard: the Midas touch in the diagnosis of axial pain syndromes.
Carragee EJ, Haldeman S, Hurwitz E.

 

[PMR 4 MSK]

I mostly agree with clubdeac.

If someone over 50 has purely axial low back pain, doesn't have major psych issues, has failed a good PT program, basic meds, and their function is still significantly limited---------MBB time

Clear discogenic pain on exam or imaging would obviously preclude MBB for those patients.

axial, worse with extension, not enough relief with meds or PT, certainly consider MBB, regardless of radiologic exams.

Neither xrays nor MRI correlate well with facet pain. SPECT might.

 

[pmrmd]

Anyone else feel lumbar facet pain is far more prevalent than the accepted ISIS numbers? To say facet pain is far less common in the lumbar spine than cervical spine, even though its the same process and the joints are forced to bear more weight and move more weight, makes no sense to me.

 

[SSdoc33]

forget age and imaging findings. you should generally know which patients will benefit from a MBB with history and a cursory exam...

 

[clubdeac]

forget age and imaging findings. you should generally know which patients will benefit from a MBB with history and a cursory exam...

And that history and cursory exam involve what? And your evidence supporting the use of these as reliable indicators of facet mediated pain is ....

 

[SSdoc33]

And that history and cursory exam involve what? And your evidence supporting the use of these as reliable indicators of facet mediated pain is ....[/QUOTE

the art of medicine, my man.

its from me saying "hmmmm, this sounds like facetogenic pain to me", then doing an MBB, and seeing the results. im not perfect at it, but you just get a sense after a while. algorithms are for bozos

 

[hyperalgesia]

So as there are no pathognomonic historical symptoms, physical exam signs or radiographic findings to suggest facet mediated pain, why not perform medial branch blocks on everyone over 50 y/o with axial lbp, assuming they don't have a significant amount of psychosocial overlay or ongoing substance abuse? Let's discuss....

The only thing I would add to this is that this should be pain that is severe enough to interfere with QOL or function. I have lots of patients that come in just because they are concerned about what the pain is telling them. I hate it when I hear a pt say that they had some intervention done b/c a doc or chiropracter told them that's what they "needed". "Did it help your pain?" "No but I needed it."

Don't mean to be nit-picky but I would not agree that everyone with LBP who fails conservative measures should have MBBs. I would say that those with pain that have significantly compromised QOL or function could be offered MBBs as a potentional dx/tx.

 

[101N]

"the art of medicine, my man."

Unfortunately, the "art" often leads to big disparities in terms of procedural volume variation. A few years ago Doug Merrill wrote about this in Regional Anesthesia and Pain Medicine. Variation isn't sustainable and it isn't good medicine.

Maybe art with some benchmark standards to ensure that there isn't a 15 fold difference in MBB rate from one geographic region to another. Variation isn't explained by disease prevalence or chance.

Who’s in the driver's seat? The influence of patient and physician enthusiasm on regional variation in degenerative lumbar spinal surgery: a population-based study.
Bederman SS, Coyte PC, Kreder HJ, Mahomed NN, McIsaac WJ, Wright JG.
Source Department of Orthopaedic Surgery, University of California at Irvine, Orange, CA, USA. [email protected]

Abstract
STUDY DESIGN:
Cross-sectional population-based study using administrative databases, census data, and surveys of orthopedic/neurosurgeons, family physicians (FPs) and patients in Ontario, Canada.

OBJECTIVE:
To determine the influence of the enthusiasm of patients, FPs, and surgeons for surgery on the regional variation in surgical rates for degenerative diseases of the lumbar spine (DDLS), such as spinal stenosis and degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA:
Rates of surgery and healthcare costs for treating DDLS have been increasing. Regional variation in spinal surgical rates has been observed and it is thought that the enthusiasm of patients and physicians for surgery contributes to this variation.

METHODS:
Using population-based administrative databases, we included all patients aged 50 years and older who underwent DDLS surgery (i.e., decompression/laminectomy, fusion) from 2002 to 2006 and calculated standardized utilization rates across counties. We measured regional "enthusiasm for surgery" for surgeons, FPs, and patients, using responses from a province-wide survey. Small-area variation analysis and multivariate Poisson regression models were performed calculating incidence rate ratios (IRRs) controlling for county demographics, socioeconomic measures, prevalence of disease, and community resources.

RESULTS:
We identified 10,318 DDLS surgeries (mean age 65 years, 50.6% female). Significant regional variation was observed (extremal quotient 5.0, coefficient of variation 28.0). Counties with higher rates of surgery had higher surgeon enthusiasm for surgery (IRR: 1.26, P < 0.013), older (IRR: 2.17, P < 0.0001) male patients (IRR: 1.19, P < 0.0001), lower income (IRR: 0.89, P < 0.0015), more knowledge of official languages (IRR: 1.12, P < 0.0003), and the presence of magnetic resonance imaging scanners (IRR: 1.30, P < 0.004). FP and patient enthusiasm for surgery, physician supply, and prevalence of disease were not statistically associated with higher surgical rates.

CONCLUSION:
Prior studies have not addressed the role of patient enthusiasm for surgery. Although patients and FPs had variable enthusiasm for surgery, surgeon enthusiasm was the dominant potentially modifiable factor influencing surgical rates. Prevalence of disease and community resources were not related to surgical rates. Strategies targeting surgeon practices may reduce regional variation in care and improve access disparities.

 

[Mister Mxyzptlk]

To me MBBs are a test like Dopplers, and EKG, or an MRI. You have a clinical impression and you want to verify it, maybe see if a treatment will work. You do a test.

You see someone with pain radiating down their leg. SLR is positive. Your working diagnosis is HNP so you test it. How? An MRI test.

You see someone with axial back pain and negative neuro exam. Tender over the lower facets. You have a working diagnosis of facet pain, now test it. With what? An MBB test.

Same principle. I can't overstate the value of "numb it up and see if the pain goes away" as a diagnostic tool.

 

[SSdoc33]

do you inject the sixty year old woman who smokes 2 packs a day, is crying in your office, has no job, is depressed, and has LBP all the time, regardless of what she does? no

do you inject the 55 y/o who has pain when he stands and get relief with sitting and isnt crazy? sure.

thats the art of medicine. you cant set an algorithm, but you shouldnt inject everyone. the last think you want is some sort of checklist to decide who gets the injection.

 

[mdvol]

Ok from a cost to benefit ratio, instead of MBB's in this situation just go directly to the "burn"? Discuss.

 

[SSdoc33]

Ok from a cost to benefit ratio, instead of MBB's in this situation just go directly to the "burn"? Discuss.

hey, i am all for that. but then you'd get a bunch of yahoo's RFing everyone, and it wouldnt pay squat. this may sound conceited, but i would feel comfortable if I would have the ability to do this. i would not feel comfortably if EVERY pain doc out there had that ability. correction: that DID sound conceited.

 

[Mister Mxyzptlk]

Unless the results of RF are as reliable as MBBs then you could conceivably go straight to RF, have a technical failure, and think you did the wrong thing since the pt didn't feel better.

I don't know of any study that has looked at relative sensitivity/specificity of MBB vs RF.

Even though the results of RF are usually commensurate with what I see on the MBBs, I do get some treatment failures. Then I go back and pick off the burn I missed. So in my hands I'd have to say that it looks like MBBs are more sensitive.

In summary, I think I'm more comfortable with the LA reliably blocking the MBB than RF as a diagnostic tool. OTOH, from a cost standpoint going straight to RF might be more efficient if the false negative rate is small compared to MBBs. A few people would suffer due to missed diagnosis I guess.

I wouldn't worry about the yahoos. They are already our of control and we will eventually get paid squat no matter what.

 

[PMR 4 MSK]

Same principle. I can't overstate the value of "numb it up and see if the pain goes away" as a diagnostic tool.

This is the most ignored part of an injection I see from many docs, including most orthos.

If a structure may be causing pain, and is accessible by needle, and you reasonably need to know if that is the pain generator, block it. Observe the response to the local anesthetic.

All the time I see joint injection reports where they document that the pt received 1 cc steroid + 5-10 cc local in a joint, with instructions to f/u in 6 weeks. WTF? What happened with the local? Did it help? How much? For how long? Why did you put so much local in and then not gauge the effect of it?

 

[epidural man]

SPECT might.

Unbelievably, no one has ever looked at this.

SPEC has CLEARLY been shown to help delineate what facet joints benefit from an facet injection.

No one has ever even looked at SPEC and RF - i don't understand why not since the data is clear that SPEC essentially rules out a facet that WON'T respond to an intra-articular injecton. No hot joint on SPEC - no response to facet injection.

I assume it is a money thing. Why would anyone do a study that essentially did away with medial branch blocks?

SPEC is the only radiological finding that helps. (Maybe increased fluid in the joint on MRI - soft finding for this). I use SPEC a lot. Although one could argue that making someone sit for 3 to 4 hours for a radiological study is kinda cruel when you can easily inject 3 small needles in 5 minutes and get your answer. That's probably true.

Physical exam, the only finding is paraspinal tenderness. In fact, some of the 'common' positive findings on exam that many think need to exist have a NEGATIVE correlation to response to RF.

 

[epidural man]

For your Dx MBB, use 50% decrease in pain for a positive, or 80%?

 

[epidural man]

This is the most ignored part of an injection I see from many docs, including most orthos.

If a structure may be causing pain, and is accessible by needle, and you reasonably need to know if that is the pain generator, block it. Observe the response to the local anesthetic.

All the time I see joint injection reports where they document that the pt received 1 cc steroid + 5-10 cc local in a joint, with instructions to f/u in 6 weeks. WTF? What happened with the local? Did it help? How much? For how long? Why did you put so much local in and then not gauge the effect of it?

This is why I want to start using functional discography - makes a whole lot a sense to me - like it was said above - numb it up - see if pain goes away.

I don't know why it isn't use more - again, probably a money thing.

 

[Mister Mxyzptlk]

For your Dx MBB, use 50% decrease in pain for a positive, or 80%?

100% relief OF THE ANESTHETIZED PART. IOW, if you do facet MBB and they still hurt over the SI joints those don't count. I think that is one of the biggest design flaws in the literature. Percent reduction in pain, changes in pill count, change in pain scale, etc all are contaminated by the presence of other pain generators. You have to focus the patient on what was blocked. Most won't do that themselves.

I examine them before the blocks and mark the tender spots on the skin. Then I block whatever is under those spots. Postop, I re-check those spots for pain. No other locations count.

 

[epidural man]

100% relief OF THE ANESTHETIZED PART. IOW, if you do facet MBB and they still hurt over the SI joints those don't count. I think that is one of the biggest design flaws in the literature. Percent reduction in pain, changes in pill count, change in pain scale, etc all are contaminated by the presence of other pain generators. You have to focus the patient on what was blocked. Most won't do that themselves.

I examine them before the blocks and mark the tender spots on the skin. Then I block whatever is under those spots. Postop, I re-check those spots for pain. No other locations count.

Do you send a pain diary?

 

[101N]

Do you send a pain diary?

Excellent point: RECALL BIAS. Without a formal written pain diary and interrogation of the results, you don't know what you've done.

 

[SIIMS]

To Epidural Man

There are very cool studies out there on SPECT/CT fusion (different than just SPECT), those images are like eye candy, looks very cool....studies are on a variety of orthopedic issues

During fellowship we had this imaging capability. One of my patients had chronic low back pain, right sided, pinpoint, no relief from multiple other therapies. She was a teacher and she was about as normal as they come for a pain fellowship at a tertiary care academic center

Order the CT/SPECT, the only thing that lights up is her right L3-4 facet. I looked at it a hundred times and was totally geeked.

Set her up for an IA facet injection (made sure no transitional segment, etc.) Perfect IA spread....took my time with the procedure.

NO relief at all...........bubble effectively burst!!!

Only an N of 1

Still love the cool pics though.......Fenton and Czervionke (Mayo Jax) did a study with Fat-suppressed MR correlating to side of patients pain a while back which is kind of similar physiologically to what would light up on a SPECT

 

[SSdoc33]

For your Dx MBB, use 50% decrease in pain for a positive, or 80%?

i use "did your back feel better" and "count you stand for longer" and "could you cook dinner without any pain", these percentages are ludicrous. then make up some number so the insurance approves it

 

[SSdoc33]

Unbelievably, no one has ever looked at this.

SPEC has CLEARLY been shown to help delineate what facet joints benefit from an facet injection.

No one has ever even looked at SPEC and RF - i don't understand why not since the data is clear that SPEC essentially rules out a facet that WON'T respond to an intra-articular injecton. No hot joint on SPEC - no response to facet injection.

I assume it is a money thing. Why would anyone do a study that essentially did away with medial branch blocks?

SPEC is the only radiological finding that helps. (Maybe increased fluid in the joint on MRI - soft finding for this). I use SPEC a lot. Although one could argue that making someone sit for 3 to 4 hours for a radiological study is kinda cruel when you can easily inject 3 small needles in 5 minutes and get your answer. That's probably true.

Physical exam, the only finding is paraspinal tenderness. In fact, some of the 'common' positive findings on exam that many think need to exist have a NEGATIVE correlation to response to RF.

im not getting a CT on my back unless its really gonna change something. zapping people with all that unnecessary radiation is a big deal when you can just fry the nerves without any major adverse consequences.

 

[bedrock]

Unbelievably, no one has ever looked at this.

SPEC has CLEARLY been shown to help delineate what facet joints benefit from an facet injection.

No one has ever even looked at SPEC and RF - i don't understand why not since the data is clear that SPEC essentially rules out a facet that WON'T respond to an intra-articular injecton. No hot joint on SPEC - no response to facet injection.

I assume it is a money thing. Why would anyone do a study that essentially did away with medial branch blocks?

SPEC is the only radiological finding that helps. (Maybe increased fluid in the joint on MRI - soft finding for this). I use SPEC a lot. Although one could argue that making someone sit for 3 to 4 hours for a radiological study is kinda cruel when you can easily inject 3 small needles in 5 minutes and get your answer. That's probably true.

Physical exam, the only finding is paraspinal tenderness. In fact, some of the 'common' positive findings on exam that many think need to exist have a NEGATIVE correlation to response to RF.

Is there a particularly well-designed study you're referring to on SPECT?

I've never believed that a normal facet joint on SPECT "rules out" facet pain.

I've done RF on many a facet joint with normal SPECT scan (ordered by our local surgeons), and those patients have had significant relief.

 

[sweetalkr]

if you believe facet pain can be from "micromotion", does anyone else think facet fusions might be a good idea? i've been training on some minimally invasive spinei stuff and trufuse looked like a good one for people not getting long term relief after rftc

 

[Mister Mxyzptlk]

Do you send a pain diary?

"I examine them before the blocks and mark the tender spots on the skin. Then I block whatever is under those spots. Postop, I re-check those spots for pain."

No diary needed. I evaluate them 15 mins after the block and make a decision.

 

[SIIMS]

"I examine them before the blocks and mark the tender spots on the skin. Then I block whatever is under those spots. Postop, I re-check those spots for pain."

No diary needed. I evaluate them 15 mins after the block and make a decision.

Devils advocate:

What are you really testing with your method??

Facets are joints and presumably cause pain with motion (bending, twisting, extension etc.), you block the mbb's which innervate the z-joints and multifidi and then press on their skin (3 inches above the joints) when they are in a static position......I just don't see what you are accomplishing with this

 

[bedrock]

Hey epidural guy,

I'm not trying to be antagonistic, but can you tell me what your reference is for that "great" SPECT study that shows a normal SPECT study rules out facet pain? I'm open to considering every piece of information out there, but clinical experience and Paul Dreyfuss has taught me otherwise regarding the relative utility of SPECT vs MBB for ruling in/out facet pain.

 

[Mister Mxyzptlk]

Devils advocate:

What are you really testing with your method??

Facets are joints and presumably cause pain with motion (bending, twisting, extension etc.), you block the mbb's which innervate the z-joints and multifidi and then press on their skin (3 inches above the joints) when they are in a static position......I just don't see what you are accomplishing with this

Devil's answer: Does it matter? If the painful structure is innervated by the MB then a MBB should block the pain temporarily and RF should block it long term.

It doesn't have scientific purity but it's certainly closer than a pain scale, a diary, subsequent pill use, etc. You have an immediate before-and-after assessment of the painful part by the same examiner. I have simplified the discussion somewhat in that it's not just a matter of poking them again. After the blocks we place them in an exam room for 15 mins or so and and tell them while they are waiting to do things that usually hurt (I draw the line at sex).

I had one lady who said she only hurt when she vacuumed so I got our vacuum cleaner out and had her push it up and down the hall. She was able to go through the motions w/o pain and we proceeded to a successful RF.

The important thing to remember is that the only relevant part of the assessment is resolution of pain in the blocked area. How you want to assess that is up to you.

 

[pjuer]

Anyone else feel lumbar facet pain is far more prevalent than the accepted ISIS numbers? To say facet pain is far less common in the lumbar spine than cervical spine, even though its the same process and the joints are forced to bear more weight and move more weight, makes no sense to me.

I do. I think many people may have multiple pain generators. The problem with most of the algorithms is that they assume there is only one pain generator where it may be multifactorial.

 

[ccldoc]

As a big horse-person I can attest to your post: If your horse is lame and you suspect the hock, inject the hock. If the horse stops limping....... you know the rest. The key is to trot the horse after the MBB's. Use NO opioids and despite what your well-meaning surgery center nurses say, have the patient resume their daily activities and not just lie around all day "recovering" from their procedure. Have them keep a 24-48 hour pain diary. And yes, I do occasionally use steroids for a MBB. It's surprising how many patients actually improve for several weeks afterward, especially those with axial pain after a surgical decompression.....

 

[epidural man]

Hey epidural guy,

I'm not trying to be antagonistic, but can you tell me what your reference is for that "great" SPECT study that shows a normal SPECT study rules out facet pain? I'm open to considering every piece of information out there, but clinical experience and Paul Dreyfuss has taught me otherwise regarding the relative utility of SPECT vs MBB for ruling in/out facet pain.

Bedrock,

I just saw this.

I'll find the articles I am referring to and post next week. Also, I think you wanted the cervical SNRB case reports as well on another thread. Hopefully, I can find that too.

As far as the SPECT, no one that I am aware of has done a study looking at SPECT and MBB, or RF. The studies are done by radiologists and they did facet injections. It has been a while that I have looked at them, but it seemed the SPECT did a great job at predicting which joints would respond to an injection - but I don't remember how it did at ruling OUT the facets. We shall see.

As far as getting a CT scan of the back - SPECT (although the term computer tomography is in the name), uses no x-ray. It is gamma radiation so I am pretty sure it is much safer.

It is true that some have written about a CT/SPECT fusion scan, and these images are way beautiful - but also way overkill for what is needed. Bone scan with SPECT of the posterior elements in the lumbar region is all that is needed.

 

[epidural man]

Hey epidural guy,

I'm not trying to be antagonistic, but can you tell me what your reference is for that "great" SPECT study that shows a normal SPECT study rules out facet pain? I'm open to considering every piece of information out there, but clinical experience and Paul Dreyfuss has taught me otherwise regarding the relative utility of SPECT vs MBB for ruling in/out facet pain.

Here are two. One of them correlated SPECT with response to injections. The other just talks about SPECT and facet pain. There are more of these but I won't post.

I haven't seen a great study on the topic that shows it isn't useful. But in the abscence of great evidence disproving hypothesis A, it probably isn't horrible to entertain hypothesis A when there exists some evidence for its validity.