Which Corticosteroid for Epidurals?

If one monitors water soluble contrast agents over time after an injection into the epidural space, one sees a rapid dissipation of the contrast density, whether transforaminal or interlaminar. Non-particulate agents such as dexamethasone suffer the same fate and are rapidly washed away. Therefore, if dexamethasone works at all, it does so by rapid but brief contact with the cellular membranes of the disc and the neurons, stabilizing them temporarily, or it works via systemic effect. My experience is that dexamethasone epidurally is little better than doing nothing. The premise behind sustained relief of epidural steroids is that particulates literally precipitate out onto the nerve roots, providing a long term release of the drug. Neurosurgeons who operate within a week after the administration of steroids will often encounter the steroid particles on the nerve root.

Yes...celestone is a particulate corticosteroid suspension composed of betamethasone phosphate and acetate mixture. The overall particulate content however is low compared to triamcinolone which contains half the particulate solid compared to depomedrol. It does appear to be efficacious but the deposition of particulate is clearly less than the other two suspensions.

CTFESIs continue to get a bad rap....

Ludwig, Michael A. MD *; Burns, Stephen P. MD *+ Spinal Cord Infarction Following Cervical Transforaminal Epidural Injection: A Case Report. Spine. 30(10):E266-E268, May 15, 2005.

For the non-anesthesiologists in the group (understandably, the authors had space limitations for their article and may not have been able to describe the resuscitation efforts)....can you describe your train of thought on this case....specifically, is spinal cord infarction the only feasible possibility based on the patient's presentation 10 minutes following the injection...here is the pertinent excerpt:


"The patient received conscious intravenous sedation and remained alert while undergoing a left C6 transforaminal injection under fluoroscopic guidance. Localization of the 2.5" 25-gauge needle was obtained with both anteroposterior and lateral fluoroscopic confirmation of left C6 nerve root sheath spread of injectable Omnipaque-240 contrast without evidence of vascular uptake on live fluoroscopy. Aspiration revealed no hematogenous return and was followed by injection of 0.75 cc of 0.75% bupivacaine and 0.75 cc of triamcinolone. The patient tolerated the procedure well and transferred to a stretcher without assistance. Approximately 10 minutes post-procedure, the patient noted weakness in the left arm and bilateral lower limbs. The initial post-procedure cervical MRI revealed no cord signal change, but subsequent studies 24 hours later revealed patchy increased T2 and short [tau] inversion recovery signal in the cervical cord at C2–C5 vertebral levels as well as the upper thoracic cord, involving both anterior and posterior spinal cord arterial territories (Figures 2 and 3). The patient's neurological examination showed incomplete tetraplegia, classified as American Spinal Injury Association Impairment Scale score C, with loss of pain and temperature sensation and preservation of proprioception."

drrinoo said:

CTFESIs continue to get a bad rap....

Ludwig, Michael A. MD *; Burns, Stephen P. MD *+ Spinal Cord Infarction Following Cervical Transforaminal Epidural Injection: A Case Report. Spine. 30(10):E266-E268, May 15, 2005.

Click to expand...

1) No use of DSA
2) No mention of oblique views to confirm needle position adjacent to the posterior wall of the foramen
3) No images from the procedures to confirm proper needle position or aberrant arterial anatomy

lobelsteve said:

A court case is ongoing for a similar complication on a similar procedure.
The procedure took place over 5 years ago and was a C TF ESI.

Expert witness testimony was provided by Robert Windsor and Curtis Slipman for the opposing sides.

I'm in Windsor's camp- I can enter C7-T1 and run a spring tip to the desired level and side without having to deal with intravascular uptake or the needle tip moving during the injection.

BTW,

Windsor's testimony supposedly blew away Slipman's.

Click to expand...

Steve, when you post something quite so one-sided, don't you think it might be important to mention that you are currently one of Dr. Windsor's fellows? After all - it might bias your opinion just a tad!

As there are no studies comparing vascular uptake with epidural catheter placement vs. the extraforaminal cervical transforaminal approach, it is simply presumption and suppostion that the epidural catheter approach is safer.

algosdoc said:

As there are no studies comparing vascular uptake with epidural catheter placement vs. the extraforaminal cervical transforaminal approach, it is simply presumption and suppostion that the epidural catheter approach is safer.

Click to expand...

Algos, whe you say "vascular" uptake, would it be safe to assume that what you mean is arterial?

Interestingly I see both during neurography. The venous pattern is generally in Batson's plexus and has a slower outflow and image decay than the arterial. Arterial tends to demonstrate a flash of contrast on injection without any ghosting of imagry. Arterial flow is sometimes connected to the vertebral artery and I have seen clear evidence on a few occasions of vertebral artery filling during transforaminal cervical injections with absolutely positive placement within the posterior neuroforamen at the mid pedicular line.
My sense is that venous uptake is far more common than arterial based on my own practice, on the lack of valves in the foraminal veins, the tendency to venous congestion with foraminal stenosis or positioning. I am working on a paper now with a description of this. So....how does one develop cord infarction from venous particulate injection? Possibly cord edema due to venous engorgement below the level of particulate induced obstruction? Or could the infarction be just as likely from an errantly placed needle (into the cord or anterior spinal artery)?
Of course the traditional approach of maximizing the neuroforaminal size on xray using a 45 degree oblique angulation places the vertebral and carotid arteries directly in the line of fire of the needle....

I tried dexamethasone for a while instead of my usual Kenalog. The results were immediately apparent: dexamethasone did not work well at all.

paz5559 said:

1) No use of DSA
2) No mention of oblique views to confirm needle position adjacent to the posterior wall of the foramen
3) No images from the procedures to confirm proper needle position or aberrant arterial anatomy

Click to expand...

4) No evidence that any of the above matter when it comes to avoiding catastrophic intra-arterial injections.

greywater said:

4) No evidence that any of the above matter when it comes to avoiding catastrophic intra-arterial injections.

Click to expand...

1) There is little evidence that most of what we do works, we do a good deal of what we do cause it makes sense in theory

2) There is no edidence that taking images as documentation of proper needle position doesn't improve saftey and efficacy? Then why bother with fluro altogether? C'mon, the literature is replete with documentation that fluro makes your needle position more accurately placed (drrinoo's citation of the recent AJNR article is the most current one - Stojanovic et al Spine Spine 27(5):509-14 documents it specifically in cervical cases ), and both keeping the images and showing them to the rest of the scientific community merely confirms technical competency in the setting of catestrophic sequelae. Not providing images makes it far more likely people will believe your needle WASN'T within the posterior neuroforamen at the mid pedicular line when viewed with the beam at a 45 degree oblique angulation. Afterall, as Rathmell et all close their most recent pronouncement on the subject, "Critical to the safety of this technique is an understanding of the anatomy coupled with disciplined and accurate use of imaging." Anesthesiology 100(6):1595–1600.

Actually, I wasn't thinking about the technical aspects of the procedure...as with my discussion with Dr. Gilula...there are a multitude of ways to get into the foramen....

I was thinking about an alternate differential...imagine that you were at the patients bedside

1. subdural injection (delayed onset of neuro sxs)
2. subarachnoid injection (relatively quick onset of neuro sxs)

the above are unlikely, because the patient was still breathing and apparently conscious and I am assuming that they did not become hypotensive

1. intravascular...

unlikely because the patient did not seize or become obtunded

in any event, I do not know why they would use 0.75% bupivacaine...at least if you are going to use such a high concentration use levo-bupivacaine or ropivacaine or use a lower concentration of bupivacaine

as far as the technical aspects of the procedure:

nothing in the cervical foramen is safe..it is a busy area...I emailed Huntoon and apparently, even the dorsal inferior cervical foramen is vulnerable....(see the abstract below) and I would encourage you to read an article in Spine 1996 by Oga regarding the tortuosity of the vertebral artery.

although efforts to CTFESIs safer, such as optimal views and DSA, seem logical....we will never be able to see every image/technical approach that every practitioner in the USA...one must assume that not all these practitioners are experts and not all their patients are ideal...thus, the fact that complications are not approaching a 10-20% rate, but probably are in the .001% range, suggests that our bodies are very forgiving to foreign insults. Grey Water is correct that there is no evidence...but there never will be evidence that optimal views/DSA are the way to go...you are asking to perform a study wherein we want to reduce the rate of complications from 0.001% to 0.00001%.

additonally, the recognition of vascular uptake ultimately depends on the resolution of the human eye...DSA is not a microscope looking at blood vessels....it depends on the mag capabilities of the fluoroscope...hence, really small vessels, smaller than the caliber of a 25 or 27 gauge needle may be responsible for complications..and these could be missed...criticising a practioner for not using DSA is like being a monday morning quaterback

think about all the other things one can use to criticise a practitioner who has a complication:

If you have a heavy smoker, multilevel cervical spinal stenosis without myelopathy but vague non discrete radicular signs, and a short thick neck or a patient with a multilevel anterior fusion....odds are the vascular anatomy will be abnormal and that there will be some vascular disease....now if you do a cervical transforaminal....you will need someone to pull down the shoulders and you will probably need a swimmer's view....also if you use a small caliber needle (25 gauge), it will be deflected from dense fibrous (in these patients) tissue and will be more difficult to steer the deeper you go...common sense suggests that we should not perform CTEFSIs in this population..but we do, don't we? Now, if a complication occurs, can the practitioner be faulted or are we being speculative and trying to create a story for the events that led to the complication.

should we demand the use of needles with calibers in the 18-22 gauge range

should we demand the use of blunt needles

should we demand a posterior approach

should we also demand the use of a stimulating needle with impedance checks...high impedance fluctations suggest intravascular injection? low voltage stimulation may suggest intraneural injections?

should we demand a test dose with epinephrine?

should we use the auscultatory test, such as described by Leighton to detect intravascular injections in OB patients...auscultate the heart to listen for air bubbles...I can't remember if she used portable dopplers

even then, complications may not occur even when all these safety stops are removed...the ISB approach ala Winnie with paresthesia elicitation (sharp needle in the brachial plexus) rarely results in disastrous complications...imagine an intraneural injection of high doses of local anesthetic

also, is imaging needed?...Boezaart's new approach to the brachial plexus...in volves advancing a sharp stimulating needle in an upright patient, blindly, till the needle hits the distal C6 transverse process and then injecting high dose local

common sense to one individual may be different to another...and common sense should not be codified into standards

so, should we be dogmatic about our common sense and then show up as an expert witness and slam the practitioner's incompetence (didn't use optimal views, didn't use DSA), when we know that the vast majority of practitioners are probably practicing in the same way as the defendent..or should we fess up as a community of pain doctors at large and say.....

cervical transforaminal procedures are potentially dangerous, but we advocate them anyway...in fact the irony is that even 'monkeys' can do it, but dangers can occur, independent of whether you are a monkey or an expert monkey.

it is hypocritical to endorse a technique that can be taught at a weekend course and then state that this procedure should only be performed by 'experts' and in only specific ways..also it is irresponsible to demand that practitioners rigorously understand anatomy...knowing the anatomy in a cadaver cannot prepare you with every possible anatomic variation...even then, fluoroscopy cannot provide all the information needed to make CTFESIs safe all the time...

at some point, we have to have faith in fellow physicians that they are trying their best...and assuming there wasn't gross or malicious incompetence, we have to assume they did the best they could in order to avoid complications and we should exercise an open mind that there are a number of ways to do the procedure safely.

t
<snip>
A-1140
October 26, 2004
3:30:00 PM - 5:00:00 PM
Room Hall C2-4
The Ascending and Deep Cervical Arteries Are Vulnerable to Injury during Cervical Transforaminal Epidural Injections: An Anatomic Study
Marc A. Huntoon, M.D.
Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota, United States.
Background: Corticosteroids are commonly injected in the cervical epidural space as a treatment for radiculitis. Traditionally, epidural corticosteroid has been injected via an interlaminar approach, but the transforaminal approach has become prevalent. Recent case reports (1,2) of anterior spinal cord infarct and death have elicited safety concerns for the transforaminal approach.

Methods: In this prospective anatomic study of 10 embalmed cadavers, the relationships of the spinal roots, blood supply from the vertebral, ascending cervical and deep cervical arteries supplying radicular or segmental medullary anastamoses were examined. Specific areas of vulnerability to needle trauma in the posterior (dorsal ) foramen were examined. Arterial origin , outer diameter, location and foraminal distribution were documented.

Results: In 5 dissected cadavers of 10 planned, 3 of the 5 have arteries that are vulnerable to needle injury during a standard dorsal middle transforaminal injection. In a female cadaver a large branch of the deep cervical artery arising directly from the subclavian arch on the right passes ventral to the C7 nerve root before diving under the C6 root in the dorsal aspect of the intervertebral foramen. This vessel is vulnerable to needle injury from transforaminal placement. The vessel measures 1.6 mm, compared to the 3.0 mm vertebral artery . The deep cervical supplies segmental medullary blood to the anterior spinal artery. In a second (male) cadaver, an ascending cervical branch from the right thyrocervical trunk passes ventral to the C7 root then passes through the dorsal aspect of the C6 foramen, continues ascending to the dorsal aspect of the C5 foramen then trifurcates into a segmental medullary vessel as well as ascending branches. The artery is 1.0 mm compared to the 3.5 mm vertebral artery , and appears to be very vulnerable at C5 and C6. In a third male cadaver, a radicular branch of the deep cervical artery is vulnerable at the dorsal aspect of the C7 root.

Discussion: A recent case described a near -miss during a C7 transforaminal injection in which a segmental medullary pattern of contrast spread caused the authors to abort the procedure.These authors are aware of 6 more cases of spinal cord injury that are sub judice and not yet reported. (3) Previously, Brouwers et.al. had described a fatal transforaminal injection at C6.(1) More recently, Ludwig et. al. reported an anterior cord ischemic event associated with a C6 root injection (2). A prospective study of 504 transforaminal cervical injections documents a 19.4% incidence of contrast confirmed intravascular injection. (4) It is known that the inferior cervical segmental medullary blood supply may come from branches of the ascending and deep cervical arteries, and that some variability exists.(5) Our study demonstrates that the C5, C6 and C7 areas may be most vulnerable to needle injury, with ascending and deep cervical arteries in the presumed safe area of injection, dorsal to the nerve root and vertebral artery. As blood supply is variable, transforaminal injections in these cervical foramina may be innevitably high risk.

References:

1. Brouwers, et.al. Pain 2001; 91:397

2. Ludwig, et.al. Arch Phys Med Rehab 2003; 84:E37

3.Baker, et.al. Pain 2003;103:211

4.Furman et.al. Spine 2003;28:21

5. Gillilan. J Comp Neurol 1958;110:75

Anesthesiology 2004; 101: A1140

paz5559 said:

2) There is no edidence that taking images as documentation of proper needle position doesn't improve saftey and efficacy? Then why bother with fluro altogether? C'mon, the literature is replete with documentation that fluro makes your needle position more accurately placed

Click to expand...

The literature is pretty much silent on whether imaging makes the procedure safer. That includes the alleged superiority of DSA.

paz5559 said:

Afterall, as Rathmell et all close their most recent pronouncement on the subject, "Critical to the safety of this technique is an understanding of the anatomy coupled with disciplined and accurate use of imaging." Anesthesiology 100(6):1595–1600.

Click to expand...

This type of statement is a well-known logical fallacy called "appeal to authority":

Person A is an authority on subject S.
Person A makes claim C about subject S.
Therefore, C is true.

paz5559 said:

we do a good deal of what we do cause it makes sense in theory

Click to expand...

Particulate antacids during labor also made good sense in theory, and antibiotics for peptic ulcer disease used to make no sense in theory.

Originally Posted by paz5559
There is no evidence that taking images as documentation of proper needle position doesn't improve saftey and efficacy? Then why bother with fluro altogether? C'mon, the literature is replete with documentation that fluro makes your needle position more accurately placed

Click to expand...

Originally posted by Greywater
The literature is pretty much silent on whether imaging makes the procedure safer. That includes the alleged superiority of DSA.

Click to expand...

That's a neat little trick - I say more accurate, you misquote me and say safer in order to prove your point. Nice debate tactic. Still doesn't disprove my initial statement

greywater said:

This type of statement is a well-known logical fallacy called "appeal to authority":

Person A is an authority on subject S.
Person A makes claim C about subject S.
Therefore, C is true.

Click to expand...

This is where we may well have our fundamental disagreement. I give deference to those authorities in our field (in this case, Rathmell, Aprill, and Bogduk) unless they are factually in error. Perhaps that is due to my lack of experience in practice (afterall, I am only a fellow). On the other hand, perhaps it is due to my lack of arrogance (afterall, I am only a fellow ).

There is no such thing as an 'expert' in any discipline in pain management, as long as you have a waiting area full of pain patients....

there is already too much self congratulation in our field....the problem of pain management won't be solved for several lifetimes....when it is...then and only then can we proclaim ourselves as experts....

all we are doing is shifting around mud...and whether my mud is better than your mud....lies in the eyes of the beholder

paz5559 said:

That's a neat little trick - I say more accurate, you misquote me and say safer in order to prove your point. Nice debate tactic. Still doesn't disprove my initial statement

Click to expand...

No trick. Ironically you accuse me of switching subjects when the guilty party is yourself. You responded to this statement by me about SAFETY:

"4) No evidence that any of the above matter when it comes to avoiding catastrophic intra-arterial injections."

And in your answer YOU changed the argument to accuracy (although unlike yourself I made no allegations of ill intent in my response). In my reply I merely brought you back on topic - safety.

I missed this article when it first came out...but I was fortunate to read the letter to the editor in this months RAPM...nice discussion between two icons in regional anesthesia...hadzic and selander.

I think this article would be excellent for discussion...imagine what a 25 gauge needle can do to an extremely large nerve....

it is compelling, because it not only has implications for complications in spinal/interventional pain procedures...but it has implications for the comparative local anesthestic methodology to reduce false postives (which I think is a bunch of BS)...e.g., 5 mm length small caliber nerve twig (lumbar medial branch) pinched underneath mamillo-accessory ligament....place a sharp needle right there....significant hemming and hawing about exact needle placement...wow! you get pain relief...neurolysis vs. temporary neuropraxia vs. temporary conduction block due to local anesthetic or temporary conduction block due to high injection pressures...ISIS standards only believe one of the previous hypotheses: temporary conduction block due to LA....

that is why some of the original data in the early 90s by Bogduk on the relevance of comparative local anesthetics were never completely clean...lidocaine produced pain relief beyond the duration of the local anesthetic (1-2 hours) in some patients..this was attributed to placebo...and hence, one reason for a false positive

comparative local anesthetic blocks need to be done away with or better optimized

<snip>

Reg Anesth and Pain

September-October 2004 • Volume 29 • Number 5

Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs

Admir Hadzic, M.D., Ph.D b * [MEDLINE LOOKUP]
Faruk Dilberovic, M.D., Ph.D c [MEDLINE LOOKUP]
Shruti Shah, M.D. b [MEDLINE LOOKUP]
Amela Kulenovic, M.D. c [MEDLINE LOOKUP]
Eldan Kapur, M.D. c [MEDLINE LOOKUP]
Asija Zaciragic, M.D. d [MEDLINE LOOKUP]
Esad Cosovic, M.D. e [MEDLINE LOOKUP]
Ilvana Vuckovic, M.D. c [MEDLINE LOOKUP]
Kucuk-Alija Divanovic, M.D. d [MEDLINE LOOKUP]
Zakira Mornjakovic, M.D. e [MEDLINE LOOKUP]
Daniel M. Thys, M.D. a [MEDLINE LOOKUP]
Alan C. Santos, M.D., M.P.H. b [MEDLINE LOOKUP] • Previous article in Issue
• Next article in Issue
• View full-text version
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Abstract TOP

Background Unintentional intraneural injection of local anesthetics may cause mechanical injury and pressure ischemia of the nerve fascicles. One study in small animals showed that intraneural injection may be associated with higher injection pressures. However, the pressure heralding an intraneural injection and the clinical consequences of such injections remain controversial. Our hypothesis is that an intraneural injection is associated with higher pressures and an increase in the risk of neurologic injury as compared with perineural injection.

Methods Seven dogs of mixed breed (15–18 kg) were studied. After general endotracheal anesthesia, the sciatic nerves were exposed bilaterally. Under direct microscopic guidance, a 25-gauge needle was placed either perineurally (into the epineurium) or intraneurally (within the perineurium), and 4 mL of lidocaine 2% (1:250,000 epinephrine) was injected by using an automated infusion pump (4 mL/min). Injection pressure data were acquired by using an in-line manometer coupled to a computer via an analog digital conversion board. After injection, the animals were awakened and subjected to serial neurologic examinations. On the 7th day, the dogs were killed, the sciatic nerves were excised, and histologic examination was performed by pathologists blinded to the purpose of the study.

Results Whereas all perineural injections resulted in pressures &#8804;4 psi, the majority of intraneural injections were associated with high pressures (25–45 psi) at the beginning of the injection. Normal motor function returned 3 hours after all injections associated with low injection pressures (&#8804;11 psi), whereas persistent motor deficits were observed in all 4 animals having high injection pressures (&#8805;25 psi). Histologic examination showed destruction of neural architecture and degeneration of axons in all 4 sciatic nerves receiving high-pressure injections.

Conclusions High injection pressures at the onset of injection may indicate an intraneural needle placement and lead to severe fascicular injury and persistent neurologic deficits. If these results are applicable to clinical practice, avoiding excessive injection pressure during nerve block administration may help to reduce the risk of neurologic injury.

greywater said:

I tried dexamethasone for a while instead of my usual Kenalog. The results were immediately apparent: dexamethasone did not work well at all.

Click to expand...

I can only reply as a recipient of dexamethasone block. I could not walk for 3 weeks, and lost control of bladder. 3 years later, I am only now beginning to get control of b and blddr functions. Walking is still extremely problematic. As far as pain relief, there may have been an hours worth. Maybe.

This is a very interesting thread by the way.

Regards,

The A guy

The A guy said:

I can only reply as a recipient of dexamethasone block. I could not walk for 3 weeks, and lost control of bladder. 3 years later, I am only now beginning to get control of b and blddr functions. Walking is still extremely problematic. As far as pain relief, there may have been an hours worth. Maybe.

This is a very interesting thread by the way.

Regards,

The A guy

Click to expand...

Wow. Care to give more details? Hard to believe it was the dexamethasone that did all that. There wasn't anything else, like a cord injection?

CTFESI may have no benefit.


Transforaminal steroid injections for the treatment of cervical
radiculopathy: a prospective and randomised study
Leif Anderberg Eur Spine J 2006

Abstract Steroid injections are often employed as an
alternative treatment for radicular pain in patients with
degenerative spinal disorders. Prospective randomised
studies of the lumbar spine reveal contradictory results
and non-randomised and most often retrospective
studies of the cervical spine indicate pain reduction
from steroid injections. No prospective randomised
study on transforaminal steroid injections for the
treatment of radicular pain in the cervical spine
focusing on short-term results has been performed.
Forty consecutive patients were employed for the
study. The inclusion criteria were one-sided cervical
radiculopathy with radicular distribution of arm pain
distal to the elbow and corresponding significant
degenerative pathology of the cervical spine at one or
two levels on the same side as the radicular pain and
visualised by MRI. A transforaminal technique was
used for all injections. A positive response to a diagnostic
selective nerve root block at one or two nerve
roots was mandatory for all patients. The patients were
randomised for treatment with steroids/local anaesthetics
or saline/local anaesthetic. Only the neuroradiologist
performing the blocks was aware of the
content of the injection; all other persons involved in
the study were blinded. Follow up was made 3 weeks
after the randomised treatment by a clinical investigation
and with a questionnaire focusing on the subjective
effects from the injections. At follow up, there
wereno differences in treatment results in the two
patient groups. Statistical analysis of the results confirmed
the lack of difference in treatment effect.
Further studies have to be performed before excluding
steroids in such treatment and for evaluating the
influence of local anaesthetics on radiculopathy in
transforaminal injections.

Dexamethasone maybe as efficacious as Triamcinalone.

Comparative Effectiveness of Cervical Transforaminal Injections
with Particulate and Nonparticulate Corticosteroid Preparations for
Cervical Radicular Pain
Paul Dreyfuss, MD,* Ray Baker, MD,† and Nikolai Bogduk, Pain 2006

Objectives. Cervical transforaminal epidural injections of corticosteroids have been used in the
treatment of radicular pain. Particulate agents have been associated with rare adverse neurological
outcomes. It is unknown whether nonparticulate preparations are any less effective than particulate
preparations. Therefore, a study was designed to determine whether there is a basis for promoting
a theoretically safer nonparticulate corticosteroid preparation.
Design. Volunteer patients were randomized to receive a single cervical transforaminal epidural
injection with one of two corticosteroid preparations.
Setting. This study was undertaken in a private practice setting.
Patients. Those with single-level, unilateral radicular pain with advanced imaging demonstrating
single-level neural compression.
Interventions. Patients received a single cervical transforaminal epidural injection with either dexamethasone
or triamcinolone.
Outcome Measures. Ratings were obtained by an independent unbiased assessor at 4 weeks via a
telephone interview. A visual analog pain scale was used preprocedurally and a verbal integer scale
was used at 4 weeks to assess the severity of the patient’s radicular pain. As a secondary outcome
measure, a patient-specified functional outcome measure was obtained.
Results. Both groups exhibited statistically and clinically significant improvements in pain at
4 weeks. Although the triamcinolone group exhibited a somewhat greater improvement, the difference
between groups was not significantly different.
Conclusion. The study found that the effectiveness of dexamethasone was slightly less than that of
triamcinolone, but the difference was neither statistically nor clinically significant. A theoretically
safer nonparticulant agent appears to be a valid alternative to particulate agents that have been used
to date, and which have been associated with hazard.

Interesting.

I have had several, make that many, lumbar procedures (depo medrol and aristicort forte, and one celestone) and all the ones that have been done on the left side, have encountered extreme difficulty. As in trying to knock a wood nail into concrete. All were done with flouroscopy to guide, which indicated a straight shot, which was not to be. For the record, all approaches from the right side (over 10) were a cinch. Floro or not.

A recent MRI/CT myelo combination I had done revealed significant pedicle and facet defects on my left lumbar side. Wonder why the flouro did not pick up on this? Any ideas?

the A guy

paz5559 said:

That's a neat little trick - I say more accurate, you misquote me and say safer in order to prove your point. Nice debate tactic. Still doesn't disprove my initial statement

Click to expand...

for those using dex for CTFESI, what concentration and total volume are you using for the cervicals?

http://www.ncbi.nlm.nih.gov/pubmed/23370580





Am J Phys Med Rehabil. 2013 Jan 30.

Comparison of Pain Score Reduction Using Triamcinolone vs. Dexamethasone in Cervical Transforaminal Epidural Steroid Injections.

Shakir A, Ma V, Mehta B.


Source

From the Vertical Spine & Sports Medicine, Barberton, Ohio (AS); Case Western Reserve University School of Medicine, Cleveland, Ohio (VM); and Western Reserve Spine and Pain Institute, Kent, Ohio (BM).


Abstract


OBJECTIVE:

This study aimed to compare the effectiveness of triamcinolone vs. dexamethasone used in transforaminal epidural steroid injections for the treatment of cervical radiculopathy.

DESIGN:

This is a retrospective cohort study of patients with cervical radiculopathy who underwent cervical transforaminal epidural steroid injections performed by a single physician from February 2005 through January 2010. Data from the subjects were divided into two groups on the basis of the type of corticosteroid preparation used during treatment. A two-sample t test with equivalent variance was used to compare the effectiveness of dexamethasone to triamcinolone.

RESULTS:

Triamcinolone (40 mg per injection) was used in 220 subjects during the period of February 2005 through August 2007, with a mean reduction in pain score of 2.33 points on a 10-point scale. Dexamethasone (15 mg per injection) was used in 221 subjects during the period of September 2007 through January 2010, with a mean reduction in pain score of 2.38 points on a 10-point scale. A two-sample F test for variance showed no statistically significant difference in the variance of these two groups. The two-sample t test with equivalent variance showed no statistically significant difference in the mean reduction in pain score between the two groups.

CONCLUSIONS:

The mean reduction in pain score in this set of 441 patients with cervical radiculopathy treated with transforaminal epidural steroid injections was independent of the type of corticosteroid formulation used. Triamcinolone (40 mg) and dexamethasone (15 mg) produced similar benefits as measured by the patients' self-reported pain scores

Triamcinolone 40mg &#8800; dexamethasone 15mg, but still an interesting result. I'd also like to know the follow up time.

Nothing new. The original study by baker and dreyfuss demonstrated similar initial efficacy.

HOWEVER, they didn't measure long-term outcome. By that I mean six or twelve month outcome.

This newest study didn't change anything. If someone ever measures dex vs depo/kenalog and follows the patients for at least 6 months, they will see significantly less duration of effect with dex, just like we all see in our clinics every day.

kinda reminds me of all the american car companies quoting that they were rated #1 by JD power for "initial" quality.
They cite that reference, not the ones for durability or reliability, because they know the japanese cars are more reliable.


(Although over the last decade, the reliablity of american cars has improved greatly, so they are now equal to european cars, but still somewhat worse than the japanese.)

the study definitely has its limitations.

I'm sure most people would prefer a randomized prospective study with N of a few hundred, and 6 month follow up.

this data was collected from 2005 to 2010. comparing before, and after they switched from triamcinolone to dex.

in this current environment I doubt anyone would be able to perform this as PROspective study, even though some people are still out there doing CTFESI with particulate steroids.

I thought most studies report that TF or IL ESI are good for short term pain relief, and min/moderate evidence for long term (>6M) pain relief. I would guess at anything greater than 6M and they would both be at the same place.

Interesting but I don't know what it means. 40mg kenalog = 7.5mg dexa so all this study is telling me is that if you use double the equivalent dose of kenalog you get equivalent outcomes. Or dexa has half the efficacy as kenalog.....a lot can be inferred but nothing conclusive.

I would gladly double my dexamethasone dose for a couple epidurals if I could get the same efficacy and the more favorable risk profile of nonparticulate. I'd do all my lumbars with dex. I think this is a very informative study that as mentioned wont done prospectively, though a study with dsa might mitigate some concerns. I have to say the the results do not correspond to my clinical experience.

I love reading this thread. This group was so on top of this issue.

bedrock said:

Nothing new. The original study by baker and dreyfuss demonstrated similar initial efficacy.

HOWEVER, they didn't measure long-term outcome. By that I mean six or twelve month outcome.

This newest study didn't change anything. If someone ever measures dex vs depo/kenalog and follows the patients for at least 6 months, they will see significantly less duration of effect with dex, just like we all see in our clinics every day.

Click to expand...

Nothing ruins good outcomes or biased impressions like 100% follow-up. Just 'cause something should logically happen doesn't mean your assumptions will necessarily be demonstrated by well designed studies.

And I was told that Lax's studies show that we only need to use saline, not steroids

I know this has been discussed before somewhere on here but wanted to get a consensus. I was told by another physician that since kenalog has come out its black box warning or whatever it was, no one is using kenalog in cervical interlaminars and if you do, you are putting yourself at an increased risk of litigation. He said lumbar was fine. True?

Anything TF in our institution gets Dex and this is what other academic centers seem to be doing based on lecture this morning at AAPM.

DOctorJay said:

Anything TF in our institution gets Dex and this is what other academic centers seem to be doing based on lecture this morning at AAPM.

Click to expand...

Since day 1 post fellowship, all my TFs get dex (99.9%), with rare exceptions. I don't care if cord infarct is extremely rare, I don't want any patient (even if its only one in a whole career) leaving my office a paraplegic in an ambulance over an elective procedure that might relieve some pain for a while.

I can live with the fact that the duration of action might be shorter and that I may have to do more interlaminars with a particulate (and make less money per patient). I can live with the fact that if a patient has a cord infarct from a TF with dex, it's the first one reported, EVER (correct me if wrong on that). I can live with the risk of a wet tap. Cord infarct? Not for me.

Also, post fellowship I haven't used kenalog for an epidural, ever. Is the black box warning stupid? Yes, but why use it, when there are other choices without a lawyer-bait black box warning, ie, celestone? At some point when they've black boxed everything (which I wouldn't put past them) then it's a different story.

It's for the same reason I look for opportunities to lower opiates, or to not start opiates in patients, as opposed to a default of "when in doubt, start opiates; when in doubt, increase dose." Thats asking for trouble. It's all about risk management. Just because it can be done, doesn't mean it should be done.

I don't want to find out that a particulate in a TF is dangerous by causing paraplegia. I also don't want to find out a patient's opiate dose is too high by them having an overdose, either.

Being risk averse in the field of Pain Medicine (and Medicine in general) is a very smart thing in this day and age.

clubdeac said:

I know this has been discussed before somewhere on here but wanted to get a consensus. I was told by another physician that since kenalog has come out its black box warning or whatever it was, no one is using kenalog in cervical interlaminars and if you do, you are putting yourself at an increased risk of litigation. He said lumbar was fine. True?

Click to expand...

That physician is an idiot. Either you are worried about a black box warning or not regarding epidural administration. Cervical or lumbar makes no difference.

As many have mentioned, the FDA warning against epidural kenalog is ridiculous. The people making the warning are not pain physicians and don't understand the issue. Might as well have accountants discussing risks of gingivitis. I prefer kenalog, believe it's no more dangerous than depomedrol and I feel it works better than depo.

I don't use it just because of the national legal situation. I'd use kenalog in the VA or europe.

emd123 said:

Since day 1 post fellowship, all my TFs get dex (99.9%), with rare exceptions. I don't care if cord infarct is extremely rare, I don't want any patient (even if its only one in a whole career) leaving my office a paraplegic in an ambulance over an elective procedure that might relieve some pain for a while.

I can live with the fact that the duration of action might be shorter and that I may have to do more interlaminars with a particulate (and make less money per patient). I can live with the fact that if a patient has a cord infarct from a TF with dex, it's the first one reported, EVER (correct me if wrong on that). I can live with the risk of a wet tap. Cord infarct? Not for me.

Also, post fellowship I haven't used kenalog for an epidural, ever. Is the black box warning stupid? Yes, but why use it, when there are other choices without a lawyer-bait black box warning, ie, celestone? At some point when they've black boxed everything (which I wouldn't put past them) then it's a different story.

It's for the same reason I look for opportunities to lower opiates, or to not start opiates in patients, as opposed to a default of "when in doubt, start opiates; when in doubt, increase dose." Thats asking for trouble. It's all about risk management. Just because it can be done, doesn't mean it should be done.

I don't want to find out that a particulate in a TF is dangerous by causing paraplegia. I also don't want to find out a patient's opiate dose is too high by them having an overdose, either.

Being risk averse in the field of Pain Medicine (and Medicine in general) is a very smart thing in this day and age.

Click to expand...

I agree with 90% of what you said. Two exceptions----

1-You don't lose money on ILESI, you make more money.
The total reimbursement for 62311 +77003 is more than the total reimbursement for 64483.
Plus most people can do a lumbar ILESI faster than a TFESI.

2-I agree with dex for transforaminals. However, I stilll do S1 TFESI with depomedrol. I can think of hundreds of post lami patients with radiculopathy or stenosis at mid-lower lumbar levels who had very brief relief after TFESI with dex, but achieved significant long-term relief after S1 TFESI with particulate steroid, and who I spared from surgery. You can't forget that people get @#$@#ed up with neurologic deficits after spinal surgery as we all have seen many times in our clinics.

There is only one case of a spinal cord infarct after an S1 TFESI and that was done with horrible technique. No live fluoro, the fluoro images just showed a blob of contrast. He should not have injected with those pictures. I don't even know if it was a fellowship-trained physician.

bedrock said:

That physician is an idiot. Either you are worried about a black box warning or not regarding epidural administration. Cervical or lumbar makes no difference.

As many have mentioned, the FDA warning against epidural kenalog is ridiculous. The people making the warning are not pain physicians and don't understand the issue. Might as well have accountants discussing risks of gingivitis. I prefer kenalog, believe it's no more dangerous than depomedrol and I feel it works better than depo.

I don't use it just because of the national legal situation. I'd use kenalog in the VA or europe.

Click to expand...

Yeah. How is lumbar okay, and cervical not? The block box says "not approved for epidural use." It does not say "okay for lumbar."

This is so sad that kenalog is rarely being used now due to the black box warning. I'm headed to the private sector and saw superior results with kenny in the VA. Only used dexa for high lumbars, thoracic and cervical TFESIs which I rarely performed. To clarify, was the black box warning due to anaphylaxis or cord infarct from emboli? We all know kenalog is no more worse than any other particulate and is superior to any nonparticulate in regard to pain relief. I would like to keep using it when out in the private sector. Is PF kenlog better medicolegally?

bedrock said:

I agree with 90% of what you said. Two exceptions----

1-You don't lose money on ILESI, you make more money.
The total reimbursement for 62311 +77003 is more than the total reimbursement for 64483.
Plus most people can do a lumbar ILESI faster than a TFESI.

2-I agree with dex for transforaminals. However, I stilll do S1 TFESI with depomedrol. I can think of hundreds of post lami patients with radiculopathy or stenosis at mid-lower lumbar levels who had very brief relief after TFESI with dex, but achieved significant long-term relief after S1 TFESI with particulate steroid, and who I spared from surgery. You can't forget that people get @#$@#ed up with neurologic deficits after spinal surgery as we all have seen many times in our clinics.

There is only one case of a spinal cord infarct after an S1 TFESI and that was done with horrible technique. No live fluoro, the fluoro images just showed a blob of contrast. He should not have injected with those pictures. I don't even know if it was a fellowship-trained physician.

Click to expand...

I practice just like what bedrock .

except two exceptions. I will use depomedrol for L5/s1 TFESI and for s1 TFESI. That's it for the most part. RARE RARE occasions I will use depomedrol for L4/5.or L3/4. But only on the right.

I never use kenalog for anything spine related.

clubdeac said:

This is so sad that kenalog is rarely being used now due to the black box warning. I'm headed to the private sector and saw superior results with kenny in the VA. Only used dexa for high lumbars, thoracic and cervical TFESIs which I rarely performed. To clarify, was the black box warning due to anaphylaxis or cord infarct from emboli? We all know kenalog is no more worse than any other particulate and is superior to any nonparticulate in regard to pain relief. I would like to keep using it when out in the private sector. Is PF kenlog better medicolegally?

Click to expand...

It was based on nothing other than a smart pre-emotive legal CYA move along the lines of, "We know lawyers will start baseless class action lawsuits at some point, so lets slap a disclaimer on there saying, 'told ya so, shouldn't have used it for that!'

Sad? Maybe.

Smart defensive move? In our medical legal sesspool: probably.

DOctorJay said:

Anything TF in our institution gets Dex and this is what other academic centers seem to be doing based on lecture this morning at AAPM.

Click to expand...

I missed this due to the workshop. Can you give a little more nformation on who/where and any stats?

All the state academic programs I polled a year ago had switched to decadron. I'm wondering if it is more nation wide now.

emd123 said:

Since day 1 post fellowship, all my TFs get dex (99.9%), with rare exceptions. I don't care if cord infarct is extremely rare, I don't want any patient (even if its only one in a whole career) leaving my office a paraplegic in an ambulance over an elective procedure that might relieve some pain for a while.

I can live with the fact that the duration of action might be shorter and that I may have to do more interlaminars with a particulate (and make less money per patient). I can live with the fact that if a patient has a cord infarct from a TF with dex, it's the first one reported, EVER (correct me if wrong on that). I can live with the risk of a wet tap. Cord infarct? Not for me.

Also, post fellowship I haven't used kenalog for an epidural, ever. Is the black box warning stupid? Yes, but why use it, when there are other choices without a lawyer-bait black box warning, ie, celestone? At some point when they've black boxed everything (which I wouldn't put past them) then it's a different story.

It's for the same reason I look for opportunities to lower opiates, or to not start opiates in patients, as opposed to a default of "when in doubt, start opiates; when in doubt, increase dose." Thats asking for trouble. It's all about risk management. Just because it can be done, doesn't mean it should be done.

I don't want to find out that a particulate in a TF is dangerous by causing paraplegia. I also don't want to find out a patient's opiate dose is too high by them having an overdose, either.

Being risk averse in the field of Pain Medicine (and Medicine in general) is a very smart thing in this day and age.

Click to expand...

We used depomedrol for ILESI for years until switching to kenalog for medicolegal reasons. The depomedrol package insert had a prohibition against intrathecal use while triamcinolone did not so we were advised to switch. How ironic that the worm has turned.

I use Kenalog for ILESI due to some unique local factors that mitigates the malpractice issue but Dex for all TFESI.

drf said:

I missed this due to the workshop. Can you give a little more nformation on who/where and any stats?

All the state academic programs I polled a year ago had switched to decadron. I'm wondering if it is more nation wide now.

Click to expand...

I think it was Mahajan who made the statement during his QA session. No specific stats, lots of head nodding in the room. He also stated that DSA is essentially standard of care at least in the neck.

Michna made it very clear in his talk regarding his work with closed claims that the problems with paraplegia and tetraplegia were a result of particulate steroid and heavy sedation. He went so far to say that if a patient "requires" sedation for our injection procedures that pt is not an appropriate candidate for injection therapies. His own opinion.

Some really good sessions so far and looking forward to today's programs.