Cervical procedures and risk

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SIIMS said:
There is a lot of talk about ligamentum flavum location on this thread. Not a lot of talk about cervical epidural fat location. I don't know why anyone would ever attempt a C5-6 CILESI injection unless for some reason you were actually able to appreciate any epidural fat on T1 imaging. In my experience of all the cervical MRI's I have ever viewed there is almost never any fat at this level and almost never any at C6-7 hence C7-T1 and even T1-2 is the target area. Now if you view the images carefully here most of the epidural fat is midline, clearly disappears on sagittal imaging scrolling only a few mm's left and right of midline.

So my question is if you are using Fluoroscopy and comfortable with your views wether it be CLO or lateral wouldn't your best chance of avoiding a bad event (wet tap, pithing cord, pneumocephalus, SCI, etc.) be at midline?? Honest question, please no telling me I'm a dumb***** or anything

Also, out of fellowship now so no access to Pubmed, Scopus, etc., is there any reported case in the literature whatsoever on a bad event from CTFESI using DEX and not the typical particulate steroids used??? I am in an ortho group that does occasionally request this procedure, not often, but does occur. I use DSA and DEX and abort if vascular after reposition one time (just my thing) and live to play a different day. I organized a journal club during fellowship that looked at all the rare but devastating complications and still kind of crap my pants doing them but just wondering if anything published with bad outcomes doing this procedure and using DEX?
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you END midline, but you START paramedian. if you start midline, you may not feel the LOR because the ligament may not continuous there. you will hit it if you stat paramedian
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algosdoc said:
Basic anatomy 101. The dura is innervated but the posterior cord and surface of the brain lack sensory innervation. If the patient felt a needle "tickling the cord", it was due to dural distension, not cord compression or penetration due to inadequate fluroscopic imaging not recognizing where the end of the needle is. Brain surgery does not require any anesthesia once through the dura. SCS does not work because c fibers or a delta fibers are activated. That is not the mechanism.
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that actually makes a lot of sense. :thumbup:
 
SIIMS said:
There is a lot of talk about ligamentum flavum location on this thread. Not a lot of talk about cervical epidural fat location. I don't know why anyone would ever attempt a C5-6 CILESI injection unless for some reason you were actually able to appreciate any epidural fat on T1 imaging. In my experience of all the cervical MRI's I have ever viewed there is almost never any fat at this level and almost never any at C6-7 hence C7-T1 and even T1-2 is the target area. Now if you view the images carefully here most of the epidural fat is midline, clearly disappears on sagittal imaging scrolling only a few mm's left and right of midline.

So my question is if you are using Fluoroscopy and comfortable with your views wether it be CLO or lateral wouldn't your best chance of avoiding a bad event (wet tap, pithing cord, pneumocephalus, SCI, etc.) be at midline?? Honest question, please no telling me I'm a dumb***** or anything

Also, out of fellowship now so no access to Pubmed, Scopus, etc., is there any reported case in the literature whatsoever on a bad event from CTFESI using DEX and not the typical particulate steroids used??? I am in an ortho group that does occasionally request this procedure, not often, but does occur. I use DSA and DEX and abort if vascular after reposition one time (just my thing) and live to play a different day. I organized a journal club during fellowship that looked at all the rare but devastating complications and still kind of crap my pants doing them but just wondering if anything published with bad outcomes doing this procedure and using DEX?
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SIIMS

the epidural fat issue is a big deal. Check out the link I had above from the APSF. Basically the article by abrams states that above C6/7, the fat is almost non existent. So as you mentioned lower that C6/7 is the place to go. The lower, probably the better.
 
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know whether or not your pt has any deformities....i had a black fella (its ok they call me white docta fella) come in with a sore neck....quick xray showed he had no curve where there should be a slight curve. sooo yeah, i checked the rest of him then, really anal about that kind of thing
 
SIIMS said:
There is a lot of talk about ligamentum flavum location on this thread. Not a lot of talk about cervical epidural fat location. I don't know why anyone would ever attempt a C5-6 CILESI injection unless for some reason you were actually able to appreciate any epidural fat on T1 imaging. In my experience of all the cervical MRI's I have ever viewed there is almost never any fat at this level and almost never any at C6-7 hence C7-T1 and even T1-2 is the target area. Now if you view the images carefully here most of the epidural fat is midline, clearly disappears on sagittal imaging scrolling only a few mm's left and right of midline.

So my question is if you are using Fluoroscopy and comfortable with your views wether it be CLO or lateral wouldn't your best chance of avoiding a bad event (wet tap, pithing cord, pneumocephalus, SCI, etc.) be at midline?? Honest question, please no telling me I'm a dumb***** or anything

Also, out of fellowship now so no access to Pubmed, Scopus, etc., is there any reported case in the literature whatsoever on a bad event from CTFESI using DEX and not the typical particulate steroids used??? I am in an ortho group that does occasionally request this procedure, not often, but does occur. I use DSA and DEX and abort if vascular after reposition one time (just my thing) and live to play a different day. I organized a journal club during fellowship that looked at all the rare but devastating complications and still kind of crap my pants doing them but just wondering if anything published with bad outcomes doing this procedure and using DEX?
Click to expand...


I've never found an published article describing a significant permanent neurologic deficit from a CTFESI performed by a fellowship-trained physician, with DSA imaging, using dexamethasone. I've also polled the last several ISIS presidents and they've never heard or had reported any significant neurologic event from a CTFESI performed in that manner.

CTFESI performed as I described above, are just as safe as an interlaminar CESI. (neither are risk-free obviously). I do CTFESI extremely rarely for liability reasons, and the CTFESI farce is an unfortunate shining example of our legal system leading to inferior care for our patients.
 
bedrock said:
I've never found an published article describing a significant permanent neurologic deficit from a CTFESI performed by a fellowship-trained physician, with DSA imaging, using dexamethasone. I've also polled the last several ISIS presidents and they've never heard or had reported any significant neurologic event from a CTFESI performed in that manner.

CTFESI performed as I described above, are just as safe as an interlaminar CESI. (neither are risk-free obviously). I do CTFESI extremely rarely for liability reasons, and the CTFESI farce is an unfortunate shining example of our legal system leading to inferior care for our patients.
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I think you are correct except for the inferior care part. No proof cervical TFESI is any better than CESI.
 
You can often appreciate a midline gap on the lig flavum on a good axial cut CS MRI (the lamina may have a lack of midline fusion too which can be a dead giveway but of course can occur w/o this).

I also often find the MR helpful for knowing ahead of time how much LF I can expect to transverse for any ESI. (esp those folks who have a thin LF at L5-S1 and are wet taps waiting to happen).
 
SIIMS said:
Honest question, please no telling me I'm a dumb***** or anything
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You may get away without being called dumb if SSdoc33 doesn't read it...otherwise, be aware....(but if he does call you dumb or obtuse or something else like that...just take it in stride and check out how many other people he has called dumb or something. I think he has torettes, or he could just be really mean.)

SIIMS said:
is there any reported case in the literature whatsoever on a bad event from CTFESI using DEX and not the typical particulate steroids used???
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yes. Case reports of severe neurological damage from just needle placement without using steroid. I placed one of the case report articles somewhere on this forum.
 
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yes. Case reports of severe neurological damage from just needle placement without using steroid. I placed one of the case report articles somewhere on this forum.
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Can you repost that? I'd like to see that article.
I have heard of cord damage after some ***** put his CTFESI needle way into the cord.

I've never seen a published report of significant permanent neurologic deficit after a CTFESI placed in the neuroforamen by a fellowship-trained physician, with DSA guidance, using dexamethasone.
 
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bedrock said:
I've never seen a published report of significant permanent neurologic deficit after a CTFESI placed in the neuroforamen by a fellowship-trained physician, with DSA guidance, using dexamethasone.
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thats a lot of caveats....
 
SSdoc33 said:
thats a lot of caveats....
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Just asking for the procedure to be performed in the correct way by someone trained to do it:)

Bad outcomes from a PA or someone who learned CTFESI at a weekend course aren't relevant to me, because they don't know what the hell they're doing.

I've just never seen or heard of any poor outcomes after a CTFESI performed the correct way as I described above.
Maybe someone on the forum has seen or heard otherwise, and if so I'd like to know.
 
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bedrock said:
Can you repost that? I'd like to see that article.
I have heard of cord damage after some ***** put his CTFESI needle way into the cord.

I've never seen a published report of significant permanent neurologic deficit after a CTFESI placed in the neuroforamen by a fellowship-trained physician, with DSA guidance, using dexamethasone.
Click to expand...

Here is the article I was referring too. Nothing is stated about training, etc.

Based on both cases and images (CT, Fluoro) - I PROBABLY would have avoided this complication in both cases. When I do CT, my needle is much more posterior and always hits the bone first and I don't advance much beyond this. I think the chance of me hitting the vert is VERY minimal. On the fluoro shots, the needle is WAY beyond where I would go - both in the AP, and oblique view. (I know this isn't the case described, but I'm just saying it is a poor example of a safe injection in this region).
 

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epidural man said:
Here is the article I was referring too. Nothing is stated about training, etc.

Based on both cases and images (CT, Fluoro) - I PROBABLY would have avoided this complication in both cases. When I do CT, my needle is much more posterior and always hits the bone first and I don't advance much beyond this. I think the chance of me hitting the vert is VERY minimal. On the fluoro shots, the needle is WAY beyond where I would go - both in the AP, and oblique view. (I know this isn't the case described, but I'm just saying it is a poor example of a safe injection in this region).
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Thanks for the article. I agree the needle was way too anterior and medial. Two cases like this in one month suggests some local yahoo doesn't know how to proper perform the procedure.

However, unless I missed it, the article didn't mention either case being done with DSA, and being done in 2004, I'd wager they used a particulate steroid.

My statement still stands-
I've never read, heard, or seen a significant neurologic deficit from a CTFESI performed by a pain physician with DSA and dexamethasone.
 
I'm not sure if it was someone here or somewhere else. They suggested essentially lining up your needle in a AP fashion as if you were going to do a cervical MBB. But on lateral you advance more anterior. So basicallyou are are close to the cervical root. Then you 'volumize' and try to get the meds to the root.

Obviously, not text book. Gets the job done. Since the pillars protect you from the Vertebral artery, no issues accidentallly injecting into that. Additionally, no problem with accidentally injecting meds into the radicular arteries feeding the cord, since they are found more medially, w/i the foramen.....


Havent tried it...thought it was an interesting thought...

I have to admit. I 've treated multiple patients now who have cervical radicular pain but their chief complaint is facetgenic. I do my diagnostic MBB with rather low volume (0.75ml) with only local. For whatever reason, their radicular symptoms disappears!! This has happened to me 3 times in a span of 3 mo now....I dont know what to think of it.
 
bedrock said:
Can you repost that? I'd like to see that article.
I have heard of cord damage after some ***** put his CTFESI needle way into the cord.

I've never seen a published report of significant permanent neurologic deficit after a CTFESI placed in the neuroforamen by a fellowship-trained physician, with DSA guidance, using dexamethasone.
Click to expand...

Rathmell posted some pics of cervical medial branch RF gone bad at ASRA in New Orleans. The articular pillars weren't lined up perfectly and the MD aimed for the contra lateral one. The MRI showing a full 90 second burn in the middle of the cord at C5 was impressive.
 
drf said:
Rathmell posted some pics of cervical medial branch RF gone bad at ASRA in New Orleans. The articular pillars weren't lined up perfectly and the MD aimed for the contra lateral one. The MRI showing a full 90 second burn in the middle of the cord at C5 was impressive.
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Wow, talk about being asleep at the wheel...
 
drf said:
Rathmell posted some pics of cervical medial branch RF gone bad at ASRA in New Orleans. The articular pillars weren't lined up perfectly and the MD aimed for the contra lateral one. The MRI showing a full 90 second burn in the middle of the cord at C5 was impressive.
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I still don't understand how that can happen. How can you be that far off?

Full 90 second burn in the middle of cord? Sounds like a case done by a PA under MAC.
 
bedrock said:
Thanks for the article. I agree the needle was way too anterior and medial. Two cases like this in one month suggests some local yahoo doesn't know how to proper perform the procedure.

However, unless I missed it, the article didn't mention either case being done with DSA, and being done in 2004, I'd wager they used a particulate steroid.

My statement still stands-
I've never read, heard, or seen a significant neurologic deficit from a CTFESI performed by a pain physician with DSA and dexamethasone.
Click to expand...

I agree with your statement that with DSA, no case reports.

But I think in this case report, these were done for SNRB - so NO steroid was used, problem both times was from trauma to the vertebral artery.
 
epidural man said:
I agree with your statement that with DSA, no case reports.

But I think in this case report, these were done for SNRB - so NO steroid was used, problem both times was from trauma to the vertebral artery.
Click to expand...

I saw the article called these SNRB, but didn't direct state "steroid given, or no steroid given"

I've seen plenty of doc call something a "SNRB", and then inject steroid as a second medication.

Regarding trauma to the vertebral artery. If that happens, you're way off target, and have never been properly trained to do these. The guy in the article obviously had no clue what he was doing.

The question is= "can trauma to the radicular arteries from a 25 gauge needle(not injection of particulate steroid) cause a permanent neuro deficit?"

I don't know the answer, as I'm still looking for evidence of that one. Again, if you see radicular artery uptake with DSA, you back out and don't inject there, which is likely why I've never seen or read a case report of a problem after this was done with DSA.
 
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PinchandBurn said:
I have to admit. I 've treated multiple patients now who have cervical radicular pain but their chief complaint is facetgenic. I do my diagnostic MBB with rather low volume (0.75ml) with only local. For whatever reason, their radicular symptoms disappears!! This has happened to me 3 times in a span of 3 mo now....I dont know what to think of it.
Click to expand...


.75 mL is not "rather low volume", especially for a cervical mbb. ISIS advocates 0.3mL. most practitioners use 0.5mL, from what ive seen.
 
bedrock said:
I saw the article called these SNRB, but didn't direct state "steroid given, or no steroid given"

I've seen plenty of doc call something a "SNRB", and then inject steroid as a second medication.

Regarding trauma to the vertebral artery. If that happens, you're way off target, and have never been properly trained to do these. The guy in the article obviously had no clue what he was doing.

The question is= "can trauma to the radicular arteries from a 25 gauge needle(not injection of particulate steroid) cause a permanent neuro deficit?"

I don't know the answer, as I'm still looking for evidence of that one. Again, if you see radicular artery uptake with DSA, you back out and don't inject there, which is likely why I've seen or read a case report of a problem after this was done with DSA.
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totally agree. I am confident that disrupting a radicular artery won't affect the cord at that level. The blood supply is very good. (I think i heard that at national meeting too).
 
epidural man said:
totally agree. I am confident that disrupting a radicular artery won't affect the cord at that level. The blood supply is very good. (I think i heard that at national meeting too).
Click to expand...

I remember seeing a nice dissection of the spine with the posterior arteries coming off the aorta wrapping around the vertebral bodies. After probably a hundred celiacs, splanchnics, and lumbar sympathetics I'm amazed at how few arteriographies I've seen. I wonder how many 22g needles have sliced them up a bit when walking ventrally.
 
This has been an interesting discussion and I am eager to learn more about the CLO technique. I appreciate that lateral views are a pita, etc.
My question is why hanging drop has been dismissed offhand. If we posit that the ligamentum flavum is often absent, the hanging drop is a technique that doesn't rely on a ligamentum flavum being intact. It simply requires negative pressure from pushing the dura away from the needle. The drop often moves in a very subtle fashion, sometimes it's just a bubble in the hub that moves slightly, but I've never had a wet tap using this technique.
What are the criticisms of it?
 
NEPain said:
This has been an interesting discussion and I am eager to learn more about the CLO technique. I appreciate that lateral views are a pita, etc.
My question is why hanging drop has been dismissed offhand. If we posit that the ligamentum flavum is often absent, the hanging drop is a technique that doesn't rely on a ligamentum flavum being intact. It simply requires negative pressure from pushing the dura away from the needle. The drop often moves in a very subtle fashion, sometimes it's just a bubble in the hub that moves slightly, but I've never had a wet tap using this technique.
What are the criticisms of it?
Click to expand...

I want to know I'm in the epidural space before I'm touching dura.
 
PinchandBurn said:
I'm not sure if it was someone here or somewhere else. They suggested essentially lining up your needle in a AP fashion as if you were going to do a cervical MBB. But on lateral you advance more anterior. So basicallyou are are close to the cervical root. Then you 'volumize' and try to get the meds to the root.

Obviously, not text book. Gets the job done. Since the pillars protect you from the Vertebral artery, no issues accidentallly injecting into that. Additionally, no problem with accidentally injecting meds into the radicular arteries feeding the cord, since they are found more medially, w/i the foramen.....


Havent tried it...thought it was an interesting thought...

I have to admit. I 've treated multiple patients now who have cervical radicular pain but their chief complaint is facetgenic. I do my diagnostic MBB with rather low volume (0.75ml) with only local. For whatever reason, their radicular symptoms disappears!! This has happened to me 3 times in a span of 3 mo now....I dont know what to think of it.
Click to expand...

Had an attending that did this in my fellowship. Probably did or observed 10 cases. No selectivity as spread cephalad and caudad so no SNRB and not getting most medication anteriorly which is the point of CTFESI.


Alot of this has to do with "hands". I have been to a number of courses and interviewed at a large number of places(fellowships and for jobs) and seen ALOT of fellowship trained docs who are total fumble fingers and would scare ths **** out of me to do a TP.
 
That's a valid point if you're afraid you'll poke a hole in the dura. I suspect it has a lot to do with going slowly and being very observant. I've never had a wet tap but maybe I'm just "lucky".
My point was that the dura is always there, but the l flavum is not. So, it has always seemed like a good technique to me and I was surprised to see it dismissed without an argument.
 
Recent article in Pain Medicine on the CL Ob by Landers, Dreyfuss and Bogduk
 
Just sent it to your yahoo account. Can't upload from iPad SDN app.
 
Agreed -- Landers may be a bit of a curmudgeon in person, but he's a sharp one and very conscientious with technique. Dreyfuss and Bogduk, well... I'd just say that is the kind of paper I'd expect from a group like that.
 
It is a good article. While I was skeptical initially after reading the article and looking at the pictures it appears that this is a real practice improvement.

BTW, and not trying to sound like a competitive d*ckhead, why would someone who post's on this forum not have access to the journal? What do you read if not this and Neuromodulation?
 
101N said:
It is a good article. While I was skeptical initially after reading the article and looking at the pictures it appears that this is a real practice improvement.

BTW, and not trying to sound like a competitive d*ckhead, why would someone who post's on this forum not have access to the journal? What do you read if not this and Neuromodulation?
Click to expand...

sunday funnies, and internet porn, mainly.
 
I still get laterals with CLO and save them regardless if the needle tip can't be seen. Just to show due diligence I guess. I used to save contrast spreads on both CLO and laterals, but I think if you have good flow on CLO you're done
 
Gauss said:
I still get laterals with CLO and save them regardless if the needle tip can't be seen. Just to show due diligence I guess. I used to save contrast spreads on both CLO and laterals, but I think if you have good flow on CLO you're done
Click to expand...

As long as you inject live on AP and watch flow as well.
 
I had my first complication today in my short career (6 months now) on a cervical procedure and saw this so had to post it.

long story short, doing a CESI for generalized neck pain with bulging disc. I had done one on the guy 2 weeks ago (he is a PA at my hospital to top it all off) and he had great relief for about 1 week, but symptoms slowly came back. I decided to repeat the procedure. no issues getting LOR with 20g Touhy with paramedian approach like last time. negative aspiration, injected 1mL of naropin and 10mg dexamethasone. Pt has moderate to severe PTSD, and so the ensuing response was either a vasovagal or intrathecal injection. he felt tingling in his arms within 1 minute, felt his arms tired, then 5 minutes later said he had a heavy chest. At that point, I got IV fluids, ran in 2 liters bolus, and assisted bag mask. he was satting 95% on RA but i just assisted him. he said he felt weak but was conscious the whole time and even managed to shove the bag mask out of his face at one point. he was nauseated, hypotensive, and diaphoretic. the symptoms lasted under 30 minutes, and by 1 hour he had fully recovered. I was 100% it was intrathecal, but my colleagues argued it may have been intravascular or vasovagal more likely. We have a high rate of vasovagal in the Army with PTSD and younger men.

any thoughts?
also, do people put local anesthetic in their CESI? i'm the only one in my group that uses local (1-1.5mL of naropin) and now I may stop. the other guys stated they don't notice a difference. please don't roast me, but I want any critical feedback you have. just being honest :)
 
The lit says inadvertent intrathecal injection during epidurals occurs approx 1% of the time. There is also a possibility of being subdural supraarachnoid given the rapid onset. But the rapid pressurization of the epidural space behind the cord can also give these symptoms. Could have been any of the three..... You handled it well and did not panic, watching the symptoms as they evolved, and responding appropriately. We all get into trouble if we do enough procedures: the true test of a doctor is being able to get themselves out of trouble via responding correctly to changing situations. Kudos! We do not use local anesthesia in any intra spinal canal blocks of any kind because in an outpatient isolated clinic setting, we need to know if a problem occurs is serious or not. If a problem develops immediately after the injection of steroid only or steroid plus saline, we know we have a potentially big problem. Also, one of the other nearby clinics uses local in their epidural injections that has resulted in several post injection fractures of hips and ankles from patients falling getting out of the car at home.
 
Kick save. Nice. But a few things to make it easier in the future.
1. No local in the epidural space is needed.
2. Don't do epidurals for generalized neck pain or headaches.
3. You did not mention contrast or CLO.


sweetalkr said:
I had my first complication today in my short career (6 months now) on a cervical procedure and saw this so had to post it.

long story short, doing a CESI for generalized neck pain with bulging disc. I had done one on the guy 2 weeks ago (he is a PA at my hospital to top it all off) and he had great relief for about 1 week, but symptoms slowly came back. I decided to repeat the procedure. no issues getting LOR with 20g Touhy with paramedian approach like last time. negative aspiration, injected 1mL of naropin and 10mg dexamethasone. Pt has moderate to severe PTSD, and so the ensuing response was either a vasovagal or intrathecal injection. he felt tingling in his arms within 1 minute, felt his arms tired, then 5 minutes later said he had a heavy chest. At that point, I got IV fluids, ran in 2 liters bolus, and assisted bag mask. he was satting 95% on RA but i just assisted him. he said he felt weak but was conscious the whole time and even managed to shove the bag mask out of his face at one point. he was nauseated, hypotensive, and diaphoretic. the symptoms lasted under 30 minutes, and by 1 hour he had fully recovered. I was 100% it was intrathecal, but my colleagues argued it may have been intravascular or vasovagal more likely. We have a high rate of vasovagal in the Army with PTSD and younger men.

any thoughts?
also, do people put local anesthetic in their CESI? i'm the only one in my group that uses local (1-1.5mL of naropin) and now I may stop. the other guys stated they don't notice a difference. please don't roast me, but I want any critical feedback you have. just being honest :)
Click to expand...
 
lobelsteve said:
Kick save. Nice. But a few things to make it easier in the future.
1. No local in the epidural space is needed.
2. Don't do epidurals for generalized neck pain or headaches.
3. You did not mention contrast or CLO.
Click to expand...

I agree with Steve.

Provided you did have what looked like true epidural spread, I suspect this was simply an exacerbated response to pressure in the epidural space. I saw a bunch of these during a phase where I switched to non-particulate Solu-Medrol- one even lasted 1 hr, and sounded very much like your case (I placed and IV, gave ephedrine, ran fluids, didn't need to support ventilation though). Ever since going back to Depo I haven't had one case like this beyond the odd mild vagal here and there.

Regarding local, the other guys in my practice use about 1 mL 0.25% bupi in their 5 mL mix. I don't think I'll ever be able to convince them to change.
 
sweetalkr said:
I had my first complication today in my short career (6 months now) on a cervical procedure and saw this so had to post it.

long story short, doing a CESI for generalized neck pain with bulging disc. I had done one on the guy 2 weeks ago (he is a PA at my hospital to top it all off) and he had great relief for about 1 week, but symptoms slowly came back. I decided to repeat the procedure. no issues getting LOR with 20g Touhy with paramedian approach like last time. negative aspiration, injected 1mL of naropin and 10mg dexamethasone. Pt has moderate to severe PTSD, and so the ensuing response was either a vasovagal or intrathecal injection. he felt tingling in his arms within 1 minute, felt his arms tired, then 5 minutes later said he had a heavy chest. At that point, I got IV fluids, ran in 2 liters bolus, and assisted bag mask. he was satting 95% on RA but i just assisted him. he said he felt weak but was conscious the whole time and even managed to shove the bag mask out of his face at one point. he was nauseated, hypotensive, and diaphoretic. the symptoms lasted under 30 minutes, and by 1 hour he had fully recovered. I was 100% it was intrathecal, but my colleagues argued it may have been intravascular or vasovagal more likely. We have a high rate of vasovagal in the Army with PTSD and younger men.

any thoughts?
also, do people put local anesthetic in their CESI? i'm the only one in my group that uses local (1-1.5mL of naropin) and now I may stop. the other guys stated they don't notice a difference. please don't roast me, but I want any critical feedback you have. just being honest :)
Click to expand...

Vagal response. Drop the local and always have IV access. Young male patients do this all the time. Dont beat yourself up over it.
 
Why put any local in an ESI? What does it really accomplish? Now look at the potential complications from it.

Answer #1 - "I've been doing it for years and never had a problem!"
Answer #2 - "It's what we've always done, why not do it?"
Answer #3 - "It may have a remote risk of complication, but in my capable hands, that never happens."
Answer #4 - "It controls post-injection pain." (Really?)
 
Agree with above - it was vagal. Never put local in a with a cervical interlaminar! I see subdural flow patterns in up to 20% of these injections, so adding local is begging for trouble (having to bag the patient).
 
agree with all of the above. vaso-vagal

that "chest pain" is increased pressure from the volum of fluid. see it all the time and it always goes away in a few minutes. the trick is to inject very slowly
 
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