Title: Fluoroscopy Is Medically Necessary for the Performance of Epidural Steroids
Abstract: Although it seems that Manchikanti et al. support the use of fluoroscopy, we disagree with the conclusion that fluoroscopy is medically necessary in all cases of “failed back surgery syndrome” (FBSS). Furthermore, in our opinion, they do not provide convincing evidence to support their preference. Manchikanti et al. criticize the fact that we have not “drawn the conclusion that fluoroscopy is medically necessary to perform epidural steroids in the treatment of [FBSS].” However, our data do not support such an emphatic conclusion. Rather, as stated in our original manuscript, in patients who have undergone surgical “procedures associated with extensive tissue trauma or in which the posterior spinous processes are removed, fluoroscopy may ensure more accurate epidural space identification.” Thus, we suggest that “the surgical records may be vital when analyzing the cost-benefit of fluoroscopic guidance.” Manchikanti et al. conclude that, in the absence of fluoroscopy, epidural steroid administration would be associated with a “16% success rate.” However, our study demonstrates that simple mathematical proportions are not reliable when predicting the success rate of epidural steroid placement in FBSS. Although blind needle placement was accurate in 47% of patients, spread of contrast medium within the epidural space reached the level of pathology in only 26% of patients. Because, in FBSS, the limited spread of contrast medium (or depot-steroids) is likely caused by surgically induced adhesions, in our opinion, it is doubtful that fluoroscopy would significantly improve target tissue penetration. Brian Fredman MB, BCh Robert Jedeikin MB, BCh, FFA(SA)