1. Basic interventional techniques using treatment algorithms. Although many new procedures are showing promise at treating pain, Dr. Glaser advocates a back-to-the-basics concept. "A lot of times people just want to do the sexiest procedure, the new kid on the block, and they forget about the time tested utility of the basic procedures," he says.
These are the bread-and-butter procedures that have been around — and successfully treating pain — for decades. "Doctors should be familiar with the algorithm of lower back pain," Dr. Glaser says. "The vast majority of patients with lower back pain can be adequately controlled using basic interventional techniques such as facet joint injections, medial nerve blocks, radiofrequency ablation, and interlaminar, transforaminal, and caudal epidural steroid injections."
2. Peripheral joint, ligament and nerve injections using ultrasound guidance. Dr. Glaser says adding peripheral joint and nerve injections using ultrasound guidance in his office has really enhanced his practice in terms of patient satisfaction, convenience, and safety. "With the ultrasound guidance, you increase your success rate because you can visualize exactly where you're putting the needle," he says.
Because the ultrasound equipment is expensive and the CPT code for ultrasound guidance will most likely be bundled into the code for certain injections, Dr. Glaser advises against thinking of these procedures as a "revenue enhancer" but rather another treatment option to offer to patients who do not respond to traditional treatment.
3. Neuromodulation. Although neuromodulation has been around since the 1980s, Dr. Glaser says the software and hardware of the implants gets better every year. Late last year, the FDA approved a Medtronic implant that automatically adjusts the level of stimulation depending on whether the patient is lying down, sitting or standing up. Older devices had to be manually changed. Another device approved last year from St. Jude allows physician to place leads for neuromodulation through a single entry point. This make the procedure even more minimally invasive, Dr. Glaser says.
Although the treatment is gaining popularity, the devices are expensive and treatment can be hard to gain pre-approval from insurers. "That doesn't change the fact that it's fantastic," he says. "The cost and difficulty in getting pre-approved should not dissuade pain physicians from doing these techniques in their practice. We are seeing amazing results with peripheral nerve stimulation especially for headaches.”
4. Decompressive techniques. Dr. Glaser says two new procedures — minimally invasive lumbar decompressions and laser endoscopic techniques — have the potential to become "huge." He says the exciting thing about these techniques is that they are minimally invasive procedures but accomplish the goals of more invasive procedures without the risks. These more advanced procedures are good for patients who are not responding to the basic interventional procedures like injections.
5. Vertebroplasty. As the population ages and remains active, Dr. Glaser predicts an increase in vertebral compression fractures, which are often treated with vertebroplasty. During the procedure, bone cement is injected into the collapsed or fractured vertebra using an introducer needle. Dr. Glaser says patients undergoing this procedure are frequently admitted to the hospital but that it's really an outpatient procedure.
While some controversy surrounding its efficacy exists, Dr. Glaser says the studies questioning it have some serious flaws and were questioned by many in the specialty. "This procedure is here to stay," he says.
Additionally, payors are often reluctant to cover the procedure based on that research, he says. One key point is to make sure the procedure is used to treat a recent fracture and obtain proof of that to give to insurers. Dr. Glaser says insurers have become very aggressive about denying this procedure unless proof is present of its acuity.
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