Download Perception vs Reality: Epidural Steroids

Perception vs Reality: Epidural Steroids
Jay Joshi, MD
Disclosure
 Nothing to disclose
Learning Objectives
 Describe the etiology of pain in musculoskeletal disease
diagnoses
 Review the pros and cons of treatment with epidural steroid
injections
 Describe scenarios where epidural steroid injection is likely to be
a successful treatment option
Common Causes of Pain
 Low back pain and arthritis account for half of all musculoskeletal disease
diagnoses1
 Low back pain is most commonly reported type of pain2
– Leading cause of disability among Americans <45 years of age2,3
– >26 million adults experience frequent back pain2
– ~15% of Americans experience back pain lasting >2 weeks1
 Arthritis and chronic joint problems affect ~70 million individuals1
– ~18 million affected by osteoarthritis
– ~2 million suffer from rheumatoid arthritis
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Emons MF. Manag Care. 2003;12(8 suppl):2-7.
Pain facts and figures. American Pain Foundation Web site. http://www.painfoundation.org/print.asp?file=Newsroom/PainFacts.htm. Accessed September 12, 2007.
Pai S et al. Orthop Clin North Am. 2004;35:1-5
Services Under the Pain Umbrella
 While pain management crosses the healthcare spectrum, for the
purposes of this assessment we have classified pain treatment
services into 3 generally accepted categories:
– Acute
• Focused on symptomatic relief of acute pain (ie, postoperative, obstetrical)
– Chronic
• Pain that persists beyond the time of normal healing and can last from 6 months
onward (ie, headaches, low back, pelvic pain, arthritis, RSD/CRPS)
– Palliative
• Severe pain in those suffering and dying from progressive diseases (ie, cancer)
Who Provides These Services
 Physician specialties involved with pain treatment include:
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Anesthesiology
Emergency medicine
General surgery
Interventional pain management/anesthesiology
Oncology
Neurology
Neurosurgery
Orthopedics
Physiatry
Psychiatry
Primary care/internal medicine/hospitalists
Radiology
Rheumatology
Trauma surgery
Other Providers
 In addition to physicians, pain management services can be provided by:
– Chiropractors
– CRNAs
– Nurse practitioners
– Physician assistants
– Physical therapists
– Massage therapists
– Acupuncturists
– Holistic/homeopathic “doctors”
– DME providers
– Hospice and home health providers
Interventional Pain Specialist
 Ideally for patients, an interventional pain specialist is:
–Typically anesthesiologist who has done a fellowship in interventional
pain management
–Can skillfully perform over 100 minimally invasive procedures
–Diagnostician first
–Multidimensional treatment options
–Strong fund of multimodal pain knowledge
–Practice with integrity holding patient safety and outcome as the
priority
Reality of Pain Management
 Of all “pain” doctors, over 90% have not had any formal advanced training
in interventional pain management
 Many pain board certifications can be bought (no formal accredited
fellowship is required)
 In the past, interventional pain management training programs had variable
quality of training
 Many unaccredited programs
 Many “trained” and board certified pain physicians have a variable practice
patterns
 Specialty of interventional pain management recognized by Medicare only in
2002
Interventional Pain Management
 Many options available
 Virtually all must be performed under fluoroscopic guidance for
visualization
 Procedures can be diagnostic as well as therapeutic
 There are set limitations to how many procedures can be performed
in the same area for the same condition within a 6-month period
Interventional Pain Options
 Epidural steroid injections (about 25 locations)
 Transforaminal epidural steroid injections
(theoretically over 50 locations)
 Facet medial branch block (approximately 60 locations)
 Radiofrequency ablation (well over 100 locations)
 Joint blocks (multiple area)
 Nerve blocks (multiple areas besides TFESI)
 Ganglion blocks (multiple)
 Intrathecal pumps
 Spinal cord stimulators
 Percutaneous disc decompression
Surgical Referral vs Pain Referral
 Surgical Referral
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Patient cannot move extremities
Lack of bowel control
Lack of bladder control
Failed all other pain management options
 Pain Management Referral
Patient experiences chronic pain
Recent trauma
Chronic neck, thoracic, back pain
Arm or leg pain
CRPS
Whiplash
Chronic neuropathic headaches
Post laminectomy/
failed back surgery syndrome
– Initial radiculopathy (<3 months)
– Increased function and quality of life
desired
– Minimally invasive options/nonsurgical
options desired
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Case Study
 A 65-year-old man presents with lower back pain for the last 2 years. He has tried
NSAIDS, acetaminophen, physical therapy, chiropractic, massage, and acupuncture
with limited relief. He is now on norco 10/325 bid prn. On exam, he has lower
back pain on standing and extension of his lumbar spine. MRI shows degenerative
disc disease, L4-L5 disc bulging, mild central stenosis, mild neuroforaminal
stenosis, and facet arthropathy. What is the most appropriate procedure to order?
a) L4-L5 lumbar epidural steroid injection at bedside
b) L4-L5 lumbar epidural steroid injection under fluoroscopy by a nonfellowship
trained physician
c) L4-L5 lumbar epidural steroid injection by a physician who has completed an
accredited anesthesiology fellowship
d) A diagnostic L3-S1 facet medial branch block
Disc Conditions
Fibromyalgia vs Facet Pain
Lumbar Referred Pain
Epidural Steroid Injections
 Used for radiculopathy
 Not typically for pure back pain
 Typically limited to no more than 3 injections at a specific level
within a 6-month period
 Translaminar vs transforaminal
Cervical Translaminal Epidural
Lumbar Translaminar Epidural
Lumbar Transforaminal Epidural
Lumbar Transforaminal Epidural (cont’d)
Caudal Epidural Steroid Injection
Racz Catheter Procedure
Increasing Utilization
 The increasing utilization of epidural injections adds fuel to
claims that these are overused, abused, and used without
appropriate medical necessity and indications1
 Other claims state that there has not been increase in disc
herniations or radiculitis over the years,2,3 even though disability
and the economic impact of spinal pain continue to increase4-8
Manchikanti, L, et. al, Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011, Pain Physician 2013; 16:E349-E364
Manchikanti, L, et. al, Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011, Pain Physician 2013; 16:E349-E364
Manchikanti, L, et. al, Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011, Pain Physician 2013; 16:E349-E364
Manchikanti, L, et. al, Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011, Pain Physician 2013; 16:E349-E364
Implications of Overutilization
 Inappropriate utilization and/or providing these procedures without
medical necessity are postulated to be the causes for the increase in
the frequency and costs for epidural injections
 The OIG has recommended strengthening program safeguards to
prevent improper payments for epidural injections
 Consequently, the CMS has established local carrier determinations
(LCDs) across the country based on reasonable and necessary criteria
LCDs Backfired
 The establishment of LCDs has not deterred the utilization
patterns of epidural injections
 To the contrary, despite the OIG report, transforaminal epidural
injections explosively increased more than any other modality
 LCDs if inappropriately prepared, could function as a hindrance
Manchikanti, L, et. al, Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011, Pain Physician 2013; 16:E349-E364
Case Study
 A 65-year-old woman presents with lower back pain for the last 2 years. She has tried NSAIDS,
acetaminophen, physical therapy, chiropractic, massage, and acupuncture with limited relief.
She is now on norco 10/325 bid prn. On exam, she has lower back pain on standing, pain in
the left shin and top of the left foot, and pain on flexion of his lumbar spine. MRI shows
degenerative disc disease, L3-L4 and L4-L5 disc bulging, mild central stenosis, mild left
neuroforaminal stenosis at L4 and L5, and moderate right neuroforaminal stenosis at L5, and
facet arthropathy. What is the most appropriate procedure to order?
a)
b)
c)
d)
One L4-L5 lumbar epidural steroid injection under fluoroscopy by a physician who has
completed an accredited anesthesiology fellowship
Series of 3 L4-L5 lumbar epidural steroid injection under fluoroscopy by a physician who
has completed an accredited anesthesiology fellowship
One left L4 transforaminal epidural steroid injection
One diagnostic L3-S1 facet medial branch block
ESI Clinical Effectiveness
 Clinical effectiveness of epidural injections has been demonstrated with
differential evidence for various conditions with randomized trials, systematic
reviews, and guidelines in multiple publications
 The evidence for disc herniations in the lumbar, thoracic, and cervical spine is
fair to good when epidural injections are performed under fluoroscopic
visualization either with caudal, cervical, thoracic, or lumbar interlaminar, or
lumbosacral transforaminal epidural injections
 The evidence is fair for lumbar and cervical spinal stenosis with interlaminar
epidural injections; however, it is limited to fair for lumbar transforaminal
epidural injections
Manchikanti, L, et. al, Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011, Pain Physician 2013; 16:E349-E364
Manchikanti L, et. al. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician 2013; 16:S49-S253
ESI Clinical Effectiveness
 For axial or discogenic pain the evidence is fair for caudal, fluoroscopic
lumbar interlaminar, and cervical interlaminar epidural injections; however,
it is limited with transforaminal epidural injections
 For lumbar postsurgery syndrome the preferred modality appears to be
caudal epidural injection with fair evidence, or approaching the epidural
space above or below the scar with an interlaminar approach (even though
there is no published evidence), or in highly select cases transforaminal
epidural injections with limited evidence
 Evidence for cervical interlaminar epidural injections in post surgery
syndrome is fair
Manchikanti, L, et. al, Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011, Pain Physician 2013; 16:E349-E364
Manchikanti L, et. al. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician 2013; 16:S49-S253
FBSS (Failed Back Surgery Syndrome)
 Neuropathic leg pain and chronic LBP
• Arachnoiditis
• Postlaminectomy syndrome
– Epidural fibrosis and scarred nerve roots
– Instability
• Postfusion syndrome
– Pseudoarthrosis/nonunions
– Adjacent segments disease
– Posterior fusion, may need anterior fusion
– SI joint pain
– Graft site pain (cluneal nerve pain)
– Facet syndrome
– Hardware pain
– End plate pain
Cluneal Nerve
Hardware Injections
Endplate Pain
Facet Joint and Medial Branch
Facet Medial Branch Radiofrequency
Heat vs Pulsed Radiofrequency
 Regular (heat) RF
–Temperature 70-90 degrees centigrade
 Pulsed RF
–Produces an electromagnetic field
–Maximal temperature 42-43 degrees centigrade
–No tissue damage as it is a low heat modality
–Typically not covered by insurance
Sacroiliac Joint Injection
SI “Joint” Injection (Lumbosacral Medial and
Lateral Branch Block)
Our
approach
Lumbar Discogram
Nucleoplasty
Success With ESI
 Keys for improving outcomes for epidural steroid injections:
– Should be performed by fellowship trained interventional pain specialists
– Pain specialist needs to be able to appropriately perform and interpret a
history and physical, be able to translate study findings, and be able to
integrate solid fund of knowledge with the patients presentation
– Pain specialist needs to have proper skills to perform procedures
(ie, hand-to-eye coordination and ability to visualize and translate images
under fluoroscopy)
– Needs to have proper motives in treating the patient
 Lack of these qualities is responsible for the poor outcomes and
sometimes questionable reputation of epidural steroid injections seen
today