Cost Utility Analysis of Cervical Therapeutic Medial Branch Blocks in Managing Chronic Neck Pain

Manchikanti, Laxmaiah; Pampati, Vidyasagar; Kaye, Alan D.; Hirsch, Joshua A

doi:10.7150/ijms.20755

Cited by 33 publications

(29 citation statements)

References 83 publications

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“…The number of blocks needed to best select patients for RFA remains unclear and perhaps there are other factors to consider when creating diagnostic protocols for this treatment modality. Stricter insurance regulations and financial renderings of cost ineffective controlled blocks emphasize the need for improved selection criteria in RFA and further urges improvement in the quality of single diagnostic blocks …”

Section: Discussionmentioning

confidence: 99%

“…Interventional injections for facetogenic pain are the second most frequently performed procedures in pain practices across the United States, with class 2B evidence of effectiveness. These injections have been shown to be more cost effective with less risk than surgery or chronic pharmacologic management . Evidence from numerous reviews, studies, and guidelines has established that the most reliable and appropriate way to identify facet joint pain is by performing diagnostic, image‐guided medial branch blocks (MBBs) with local anesthetic .…”

Section: Introductionmentioning

confidence: 99%

“…Practitioners utilize cervical MBB diagnostic results for the identification and selection of patients who may respond to radiofrequency ablation/neurotomy (RFA), but because of variability in the type and, possibly more important, the volume of local anesthetic used, accuracy is difficult to quantify . Controlled studies have shown that the benefits of subsequent RFA are most apparent in patients who obtained nearly complete pain relief from MBBs . Single MBBs can result in high false positive rates ranging from 27% to 63% .…”

Section: Introductionmentioning

confidence: 99%

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Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

Wahezi¹,

Molina

Alexeev

et al. 2019

PM&R

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Background: Neck pain is one of the most common causes of chronic pain and the fourth leading cause of disability worldwide; it is estimated that between 36% and 67% of this pain is due to facet arthropathy. For patients who have pain refractory to conservative treatments literature supports management with diagnostic cervical medial branch blocks (MBBs) to identify the associated facet innervation as the source of pain followed by therapeutic radiofrequency ablation (RFA) of the identified nerves. Cervical RFA has good published outcomes; however, the procedure is dependent upon the specificity of the diagnostic block to achieve maximal success. Currently, this prerequisite test has false positive rates between 27% and 63% and recent studies have shown that this may, in part, be a consequence of currently accepted injection volumes of 0.50 mL or more, which may decrease the sensitivity of MBBs. Objective: To evaluate the possible differences in volume dispersion between 0.25 and 0.50 mL of injectate during cervical MBBs. Study Design: Cadaveric study. Setting: An academic medical center in the United States. Patients: Not applicable. Methods: This was a cadaveric study in which six subjects were chosen with intact cervical spines. Cervical MBB were performed bilaterally at the midcervical spine, using a posterior approach under fluoroscopic guidance. 0.25 or 0.50 mL of a 9:1 solution of Omnipaque 180 mg iodine/mL and 1% medical grade methylene blue were administered on the left and right sides, respectively. Postinjection computed tomography (CT) imaging and gross dissection were performed to assess injectate spread. Main Outcome Measures: Outcome measures after using commonly injected volumes for cervical MBB, included visualized and measured spread (by CT and gross dissection) of cervical medial branch blocks, coating adjacent structures not targeted by RFA. Results: Postinjection CT imaging and cadaveric dissection demonstrated that, although both volumes adequately coated the medial branches, the 0.50 mL cohort reliably spread dorsally to superficial muscles (splenius) and nerves distant from the targeted nerves (dorsal motor branches to splenius), whereas the 0.25 mL injectate cohort was contained in the deep and intermediate muscular cervical layers directly juxtaposed to the targeted cMBBs. Conclusion: Results suggest that 0.50 mL injections of local anesthetic during cervical MBBs contacts many nonintended targets, thus decreasing the specificity of a targeted diagnostic cervical MBB. Furthermore, we demonstrated that 0.25 mL of injectate reliably bathed the cervical medial branches without extensive extravasation. This indicates that there would potentially be fewer local anesthetic effects on distant tissues, increasing the specificity of cervical MBBs and likely improving RFA planning.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

Wahezi¹,

Molina

Alexeev

et al. 2019

PM&R

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“…The majority of the cervical interlaminar epidural injections performed in controlled settings were active controlled trials with successful results [ 23 ], showing no significant difference between local anesthetic or local anesthetic with steroids. There have been frequent multiple studies performed on low back pain of effectiveness and cost utility analysis in the lumbar spine [ 23 24 25 26 ] for epidural injections and facet joint interventions, and occasionally in the cervical spine [ 20 23 27 ], showing significant evidence of effectiveness and cost utility.…”

Section: Introductionmentioning

confidence: 99%

Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome

et al. 2018

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BackgroundNeck and back pain are leading sources of disability placing substantial burden on health care systems. Surgical interventions in managing chronic neck pain secondary to various disorders continue to increase. Even though surgical interventions are effective, a significant proportion of patients continue to have symptomatology and develop cervical post-surgery syndrome. This study was performed to know the effectiveness of cervical interlaminar epidural injections with or without steroids.MethodsThe effectiveness of fluoroscopic cervical interlaminar epidural injections in post-surgery syndrome was evaluated in a randomized, active controlled trial. The study population included 116 patients assigned to 2 groups. Group 1 received cervical interlaminar epidural injections with local anesthetic alone and Group 2 received injection with local anesthetic and steroids. The main outcomes were defined as significant improvement (greater than 50%) of pain relief using the numeric rating scale and/or functional status improvement using the Neck Disability Index (NDI).ResultsBoth groups had similar results with significant improvement (≥ 50% pain relief and functional status improvement) in 69% of the patients in Group I, whereas, in Group II, 71% of the patients showed significant improvement at the end of 2 years. During a 2-year period, the average number of procedures was 5 to 6, with an average of approximately 12 weeks of significant improvement per procedure.ConclusionsFluoroscopic cervical interlaminar epidural injections administered in cervical post-surgery syndrome using local anesthetic, regardless of the use of steroids, may be effective in approximately 70% of the patients at 2-year follow-up.

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“…Even prior to the proposed rule, interventional techniques have been facing a multitude of issues despite demonstration of clinical and cost effectiveness due to improper evidence synthesis (41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58). Based on the available data, CMS is proposing updated pricing recommendations for supply and equipment items currently used as direct practice expense (PE) inputs.…”

Section: Introductionmentioning

confidence: 99%

Reframing Medicare Physician Payment Policy for 2019: A Look at Proposed Policy

Manchikanti

Singh²,

Benyamin

et al. 2018

Pain Phys

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On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2019 Medicare physician fee schedule and quality payment program, combining these 2 rules for the first time. This occurred in a milieu of changing regulations that have been challenging for interventional pain management specialists. The Affordable Care Act (ACA) continuous to be amended by multiple administrative changes. This July 12th rule proposes substantial payment changes for evaluation and management (E&M) services, with documentation requirements, and blending of Level II to V CPT codes for E&M into a single payment. In addition, various changes in the quality payment program with liberalization of some metrics have been published. Recognizing that there are differing impacts based on specialty and practice type, as a whole interventional pain management specialists would likely see favorable reimbursement trends for E&M services as a result of this proposal. Moreover, in comparison with recent CMS final ruling, this proposed rule has relatively limited changes in procedural reimbursement performed in a facility or in-office setting. CMS, in the new rule, has proposed an overhaul of the E&M documentation and coding system ostensibly to reduce the amount of time physicians are required to spend inputting information into patients’ records. The new proposed rule blends Level II to V codes for E&M services into a single payment of $93 for office outpatient visits for established patients and $135 for new patient visits. This will also have an effect with blended payments for services provided in hospital outpatients. CMS also has provided additional codes to increase the reimbursement when prolonged services are provided with total reimbursement coming to Level V payments. Interventional pain managementcentered care has been identified as a specialty with complexity inherent to E&M associated with these services. Among the procedural payments, there exist significant discrepancies for the services performed in hospitals, ambulatory surgery centers (ASCs), and offices. A particularly egregious example is peripheral neurolytic blocks, which is reimbursed at 1,800% higher in hospital outpatient department (HOPD) settings as compared with procedures done in the office. The majority of hospital based procedures have faced relatively small cuts as compared with office based practice. The only significant change noted is for spinal cord stimulator implant leads when performed in office setting with 19.2% increase. However, epidural codes, which have been initiated with a lower payment, continue to face small reductions for physician portion. This review describes the effects of the proposed policy on interventional pain management reimbursement for E&M services, procedural services by physicians and procedures performed in office settings. Key words: Physician payment policy, physician fee schedule, Medicare, Merit-Based Incentive Payment System, interventional pain management, regulatory tsunami, Medicare Access and CHIP Reauthorization Act of 2015

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Cost Utility Analysis of Cervical Therapeutic Medial Branch Blocks in Managing Chronic Neck Pain

Cited by 33 publications

References 83 publications

Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome

Reframing Medicare Physician Payment Policy for 2019: A Look at Proposed Policy

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