Current standard of care lumbar TFESI- safe triangle vs kambins or other .

[Laryngospasm]

Any one have new thoughts on this? With vessel damage in addition to particulate embolization being implicated has anyone changed their practice? I was taught the (un)safe triangle approach but that has been some time ago. What are the fellowships teaching currently?

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[Baron Samedi]

I graduated two years ago and was taught safe triangle. Also used a fair amount of particulate steroid. I still use safe triangle but dex only.

 

[TheLoneWolf]

Any one have new thoughts on this? With vessel damage in addition to particulate embolization being implicated has anyone changed their practice? I was taught the (un)safe triangle approach but that has been some time ago. What are the fellowships teaching currently?

A partner that I work with does an Interlaminar approach and directs the tuohy toward the pedicle. Once he gets loss threads a catheter and can occasionally get contrast spread along the nerve root or transforaminal spread. Uses depomedrol.

I do the standard TFESI safe triangle approach with dexamethasone.

 

[bedrock]

A partner that I work with does an Interlaminar approach and directs the tuohy toward the pedicle. Once he gets loss threads a catheter and can occasionally get contrast spread along the nerve root or transforaminal spread. Uses depomedrol.

I do the standard TFESI safe triangle approach with dexamethasone.

I don’t take the time to do a catheter for lumbar but I do a far lateral approach with my lumbar ILESI and get good anterior spread 90% of the time. Generally do this first and only do TFESI with dex in safe triangle if the ILESI doesn’t cut it.
(except with acute new radic , for which I do start with TFESI and dex)

 

[deleted131481]

I don’t take the time to do a catheter for lumbar but I do a far lateral approach with my lumbar ILESI and get good anterior spread 90% of the time. Generally do this first and only do TFESI with dex in safe triangle if the ILESI doesn’t cut it.
(except with acute new radic , for which I do start with TFESI and dex)

Can you define 'far lateral'? I'll do this sometimes going roughly midway between spinous process and pedicle on that side. Wondering if I should go even further lateral to get more anterior spread. Any issues, difficulty with LOR?

 

[callmeanesthesia]

I don’t take the time to do a catheter for lumbar but I do a far lateral approach with my lumbar ILESI and get good anterior spread 90% of the time. Generally do this first and only do TFESI with dex in safe triangle if the ILESI doesn’t cut it.
(except with acute new radic , for which I do start with TFESI and dex)

Same.

 

[lobelsteve]

Can you define 'far lateral'? I'll do this sometimes going roughly midway between spinous process and pedicle on that side. Wondering if I should go even further lateral to get more anterior spread. Any issues, difficulty with LOR?

What’s LOR?

 

[Taus]

I don’t take the time to do a catheter for lumbar but I do a far lateral approach with my lumbar ILESI and get good anterior spread 90% of the time. Generally do this first and only do TFESI with dex in safe triangle if the ILESI doesn’t cut it.
(except with acute new radic , for which I do start with TFESI and dex)

Same. Would just add that only time I do tfesi/dex first is with acute/subacute foraminal disc

 

[deleted131481]

What’s LOR?

Loss of resistance

Edit: letter of recommendation?!

 

[SSdoc33]

FWIW, i can usually feel a LOR on a TFESI as well.

for those of you who dont get steve's point, he is arguing for not using LOR, just some puffs of contrast pre and post ligamentum flavum. god forbid he actually types what he is actually trying to say

 

[deleted131481]

FWIW, i can usually feel a LOR on a TFESI as well.

for those of you who dont get steve's point, he is arguing for not using LOR, just some puffs of contrast pre and post ligamentum flavum. god forbid he actually types what he is actually trying to say

Hah should have known.

I do this on CESI per this forum (25g + clo).

Still using LOR on lumbar interlaminar. With a 20g tuoy below the conus and a bigger ligament flavum, the risk and likelihood of dural puncture is much lower as compared to CESI. Plus if I'm going 'far lateral' for ILESI throws off my depth a bit on CLO, but I also haven't used CLO as much for lumbar.

 

[deleted185747]

Loss of resistance

Edit: letter of recommendation?!

It’s when the patient stops fighting you

 

[geauxg8rs]

It’s when the patient stops fighting you

Loss of roxicodone. When patients do a bad bad thing

 

[chibadriver]

If you try hard enough you can find vasculature anywhere....

 

[lobelsteve]

There are no safe triangles or spaces inside the body. Fluoro with contrast and extension tubing to not move the needle tip while injecting under live.

 

[Ferrismonk]

Contrast under live flouro and using Dex virtually eliminates vascular concerns.

 

[Laryngospasm]

Contrast under live flouro and using Dex virtually eliminates vascular concerns.

Agree with the you as a general rule. I think I have read of one with dex. Questions of intimal injury, vasospasm etc just had me wondering if anyone was being trained differently etc. Appreciate all the input from everyone.

 

[callmeanesthesia]

If using dex, do we really need live fluoro? There’s no convincing evidence it would have prevented that one single case of paralysis, and the cumulative radiation exposure is not insignificant over time vs a still shot.

 

[SSdoc33]

If using dex, do we really need live fluoro? There’s no convincing evidence it would have prevented that one single case of paralysis, and the cumulative radiation exposure is not insignificant over time vs a still shot.

you wont cause a problem if you do a vascular injection with dex, but it may not be an optiomal shot. you will miss some vascular uptake and a chance to reposition if you don't go live.

 

[callmeanesthesia]

you wont cause a problem if you do a vascular injection with dex, but it may not be an optiomal shot. you will miss some vascular uptake and a chance to reposition if you don't go live.

Sure, but if the amount of contrast you see on the still is less than expected, you can shoot a live shot. If the still looks good, but there’s a tiny wisp of vascular uptake, you probably aren’t losing much medication anyway. Also eliminates the need for extension tubing, which I never liked much anyway.

 

[Laryngospasm]

Yes interestingly I had a patient ask what I was doing the other day and I asked why and they said they had a painful itching around a certain area. This was after an injection with good contrast spread and dex.

 

[lobelsteve]

Sure, but if the amount of contrast you see on the still is less than expected, you can shoot a live shot. If the still looks good, but there’s a tiny wisp of vascular uptake, you probably aren’t losing much medication anyway. Also eliminates the need for extension tubing, which I never liked much anyway.

If you do not inject under live, you are doing your patients a disservice and missing 1/10 vascular injections. series of 3 should help overcome that.

 

[SSdoc33]

Sure, but if the amount of contrast you see on the still is less than expected, you can shoot a live shot. If the still looks good, but there’s a tiny wisp of vascular uptake, you probably aren’t losing much medication anyway. Also eliminates the need for extension tubing, which I never liked much anyway.

im not as big of a hardo as steve is on this, but it IS better practice to go live on TFESIs. if the rest of your technique is good, i wouldnt say its the worst practice out there.

 

[callmeanesthesia]

If you do not inject under live, you are doing your patients a disservice and missing 1/10 vascular injections. series of 3 should help overcome that.

But why is it a dis-service? The contrast is still very clearly flowing along the nerve root - most of the medication is clearly still staying local as evidenced by most of the contrast staying there. If there is little or no contrast after injection then I inject some under live and see where it went, then adjust as needed. Does it really matter whether I deliver 4 mg epidural or 3.9 mg epidural and 0.1 mg IV? If you are in the camp that all intravascular injection must be detected, then are you recommending DSA for all TFESIs?

 

[DrSpine]

I do safe triangle with Dex. I did the Kambin approach one day, and the day I did it, I was in a vessel. So yeah, that was the end of that. Didn't see how it was any better.

 

[MD87]

But why is it a dis-service? The contrast is still very clearly flowing along the nerve root - most of the medication is clearly still staying local as evidenced by most of the contrast staying there. If there is little or no contrast after injection then I inject some under live and see where it went, then adjust as needed. Does it really matter whether I deliver 4 mg epidural or 3.9 mg epidural and 0.1 mg IV? If you are in the camp that all intravascular injection must be detected, then are you recommending DSA for all TFESIs?

I agree with this. My thought is if you are using live flouro with dex during a TFESI, you aren’t increasing safety and are MAYBE increasing efficacy. With the thought process that live fluoro improves efficacy of TFESI, though, shouldn’t we all then be using live fluoro for MBBs, as they have a relatively high occurrence of vascular as well? Fairly certain most people are not using live or DSA for MBB routinely.

 

[lobelsteve]

But why is it a dis-service? The contrast is still very clearly flowing along the nerve root - most of the medication is clearly still staying local as evidenced by most of the contrast staying there. If there is little or no contrast after injection then I inject some under live and see where it went, then adjust as needed. Does it really matter whether I deliver 4 mg epidural or 3.9 mg epidural and 0.1 mg IV? If you are in the camp that all intravascular injection must be detected, then are you recommending DSA for all TFESIs?

Because you are not doing the procedure correctly. Why be good enough when you can be great? Is it the cost of the Braun 0.2ml priming volume Luer lock catheter? Is it the 1-2 seconds of live fluoroscopy? Is it the 5 seconds total time added to the procedure?

To not do it is a disservice and just plain lazy. Safety first, efficacy second.

 

[callmeanesthesia]

Because you are not doing the procedure correctly. Why be good enough when you can be great? Is it the cost of the Braun 0.2ml priming volume Luer lock catheter? Is it the 1-2 seconds of live fluoroscopy? Is it the 5 seconds total time added to the procedure?

To not do it is a disservice and just plain lazy. Safety first, efficacy second.

Yes, it is the few seconds of live fluoro, when a still shot would do. I get that a still shot is not the SIS manual technique, but can you explain to me physiologically and anatomically rather than dogmatically why it is inferior? The medication is still reaching the nerve as I’ve described and in some percentage of cases a small amount might escape in a vessel but most stays local. It’s not lazy, it’s “as low as reasonably achievable.”

 

[chibadriver]

Yes, it is the few seconds of live fluoro, when a still shot would do. I get that a still shot is not the SIS manual technique, but can you explain to me physiologically and anatomically rather than dogmatically why it is inferior? The medication is still reaching the nerve as I’ve described and in some percentage of cases a small amount might escape in a vessel but most stays local. It’s not lazy, it’s “as low as reasonably achievable.”

I would ask your malpractice carrier about this, ALARA principle > vascular uptake detection...

 

[Ducttape]

the uptake may be fast enough that you miss the vascular uptake on still shot.

and if your needle tip is completely intravascular, you will not see any contrast.

why not still do the injection? I think that you are risking vasospasm if you are injecting and some goes in to the vessel. I believe this was postulated as a possible explanation for one documented case of paralysis after dexamethasone injection.

 

[callmeanesthesia]

https://www.texaspain.org/assets/2019AnnualMeeting/A_Rare_case_of_Paraplegia_Following_Transforaminal_Epidural_Steroid_Injections_with_Dexamethasone_MA_1.pdf

They document using digital subtraction. So even that isn’t foolproof. The biggest risk reduction is to use non-particulate. I’m not sure it’s additive beyond that. The few cases with dex may come from direct needle injury to the vessel, causing vasospasm, which means the damage is already done by the time you inject your contrast.

 

[lobelsteve]

Another live fluoro thread.

 

[Ferrismonk]

Another live fluoro thread.

Agree with live fluoro. Although 2mL Kenalog for the C1/C2 joint probably wasn't the best choice.

 

[MD87]

the uptake may be fast enough that you miss the vascular uptake on still shot.

and if your needle tip is completely intravascular, you will not see any contrast.

why not still do the injection? I think that you are risking vasospasm if you are injecting and some goes in to the vessel. I believe this was postulated as a possible explanation for one documented case of paralysis after dexamethasone injection.

One could argue that repositioning the needle If vascular flow is noted could cause even more trauma to any vasculature by shredding it, more so than injection of a larger volume of medication into the vessel. The truth of the matter is, we just don’t really know. There is no actual evidence that live fluoroscopy makes any difference from a safety perspective when dexamethasone is used.

 

[lobelsteve]

One could argue that repositioning the needle If vascular flow is noted could cause even more trauma to any vasculature by shredding it, more so than injection of a larger volume of medication into the vessel. The truth of the matter is, we just don’t really know. There is no actual evidence that live fluoroscopy makes any difference from a safety perspective when dexamethasone is used.

No. We know. You do not. Per SIS, live fluoroscopy is requisite, DSA recommended if dex not available.

 

[callmeanesthesia]

No. We know. You do not. Per SIS, live fluoroscopy is requisite, DSA recommended if dex not available.

That’s Dogma, not science. I get using DSA if you were using a particulate but thus far you have provided not one shred of evidence to show me why I should do live fluoro for non-particulate steroid beyond “SIS says so.”

 

[NJPAIN]

Agree with Steve - live fluoro a must. You need to know if you are in a vessel because that is the incorrect position. The only reason not to do that is to avoid radiation exposure., I think that the you can justfy that exposure.

I get it, radiation exposure is bad. However, you can't safely perform a procedure without enough fluoro time. Every body wants to boast about doing procedures in a few seconds with a few seconds of fluoro. I don't know how you get the job done safely with a few seconds of fluoro. If you drive your needle in without checking after every advancement you are eventually going to end up somewhere bad. I've seen the 3 second C1-2 that ends up in the brainstem - oops!

 

[MD87]

No. We know. You do not. Per SIS, live fluoroscopy is requisite, DSA recommended if dex not available.

I agree with most of what you say on this board. And I agree with most of SIS. But there are 0 published cases of TFESI with dex that have resulted in infarcts, except for the one report where they used live fluoro anyway. Your “we know” = a lot of very smart people say so. I always use extension tubing and I always inject under live if anything looks at all fishy. Same reason why I would inject under live for an ILESI or a joint injection. Injection of dex should be no more dangerous than injection of contrast.

 

[MD87]

Agree with Steve - live fluoro a must. You need to know if you are in a vessel because that is the incorrect position. The only reason not to do that is to avoid radiation exposure., I think that the you can justfy that exposure.

I get it, radiation exposure is bad. However, you can't safely perform a procedure without enough fluoro time. Every body wants to boast about doing procedures in a few seconds with a few seconds of fluoro. I don't know how you get the job done safely with a few seconds of fluoro. If you drive your needle in without checking after every advancement you are eventually going to end up somewhere bad. I've seen the 3 second C1-2 that ends up in the brainstem - oops!

Based on this thought process, question:
Do you inject under live for MBBs or ILESI or joint injections to ensure you are not in an incorrect position?

 

[DODOCSS]

the uptake may be fast enough that you miss the vascular uptake on still shot.

and if your needle tip is completely intravascular, you will not see any contrast.

why not still do the injection? I think that you are risking vasospasm if you are injecting and some goes in to the vessel. I believe this was postulated as a possible explanation for one documented case of paralysis after dexamethasone injection.

so dex can and contrast cannot cause vasospasm? do tell pray tell

 

[swamprat]

I dont use live - if I injected contrast and I see less than expected or a vascular type pattern I adjust. theres a lot of radiation that would add up to go live with every tfesi. aspirate before u inject as well. seems pretty low risk to me idk. i mean everything we do is elective and we are putting neeldes in peoples spine - this all is high risk. id like to see a study, likely retrospective not expert opinion that shows a stasticially and clinically significant decreased rate of bad outcomes (not lack of efficacy of the shot) by using live fluoro vs still shots as well as compare radiation doses

 

[Laryngospasm]

The problem with any kind of study is there are so few cases of bad outcomes with dex that there is nothing to study.

 

[lobelsteve]

I believe people who do not use life fluoroscopy have no understanding of what they are doing and they are poorly trained. If you did not train under a spinal intervention Society instructor at any point you are likely not knowing exactly what you are doing. I also find people who disagree with the use of life for Oscar be saying there’s no literature fail to use Google. Who is my top hit that took five seconds.

Epidural Steroid Injections: Overview, Mechanisms of Radicular Low Back Pain, Rationale for Use of Steroids in Back Pain

Epidural steroid injections (ESIs) have been endorsed by the North American Spine Society and the Agency for Healthcare Research and Quality (formerly, the Agency for Health Care Policy and Research) of the Department of Health and Human Services as an integral part of nonsurgical management of...

www.medscape.com

To put it in more simple terms it is likely a one in 1 million complication. Should it ever happened to you and you not do it exactly like the textbook or guidelines recommend you were might have a leg to stand on in court. If you think there will be a significant cumulative change in your radiation dosing over your career by the supply fluoroscopy you clearly have no idea about radiation safety. It is sad to think that there are people who are fellowship trained out there and not know anything about what they are doing. My recommendation is you visit Washington DC this summer and go to the SIS meeting.

 

[deleted875186]

Yes, it is the few seconds of live fluoro, when a still shot would do. I get that a still shot is not the SIS manual technique, but can you explain to me physiologically and anatomically rather than dogmatically why it is inferior? The medication is still reaching the nerve as I’ve described and in some percentage of cases a small amount might escape in a vessel but most stays local. It’s not lazy, it’s “as low as reasonably achievable.”

I agree, maybe a still shot is just as good, I don’t think we know.

standard is live Fluoro, but I do think it’s somewhat dogma.

I would place it in t same dogma as “don’t give muscle relaxants with LMAs”.

 

[Taus]

This is actually disappointing to read. If mine or my families spine is being injected I want all the juice on my disc and nerve and I don’t want any of it intra-arterial, dural, thecal, muscular, discal etc. I’d rather not be wondering if my post esi urinary incontinance is due to an infarct, spinal or just local in a radiculomedullary artery that was missed (granted, the lido is the main risk here if used, not dex). Seen plenty of lectures and my own procedures where I saw midline arterial flow and epidural at same time. I’d also bet those not injecting live are not using extension tubing... thus unscrewing syringe from needle hub.... risking moving needle tip after contrast injected.

this is far different then non-esi procedures. Same argument and risk profile doesn’t compute for mbb. Facet SI etc

 

[MD87]

My 2 cents:

SAFETY
We are talking about DEXAMETHASONE. If we are THAT worried about intravascular injections with TFESI because it is so dangerous, even in the setting of dexamethasone, then all TFESI should be done with DSA or the procedure should just be abandoned all-together. Are we really talking about the risk profile of a TFESI with dexamethasone due to vascular pathology? Please tell me - what IS the risk profile of a lumbar TFESI with dex? I still have not seen a well-articulated argument here as to why injecting contrast under live fluoro is safer than injecting dexamethasone.

EFFICACY
If we are talking about efficacy, fine. But if we are talking about efficacy because we want all of the steroid going to the right place, then all procedures should be done under live fluoro, including MBBs.

 

[deleted875186]

My 2 cents:

SAFETY
We are talking about DEXAMETHASONE. If we are THAT worried about intravascular injections with TFESI because it is so dangerous, even in the setting of dexamethasone, then all TFESI should be done with DSA or the procedure should just be abandoned all-together. Are we really talking about the risk profile of a TFESI with dexamethasone due to vascular pathology? Please tell me - what IS the risk profile of a lumbar TFESI with dex? I still have not seen a well-articulated argument here as to why injecting contrast under live fluoro is safer than injecting dexamethasone.

EFFICACY
If we are talking about efficacy, fine. But if we are talking about efficacy because we want all of the steroid going to the right place, then all procedures should be done under live fluoro, including MBBs.

I would agree.

I think the notion that injecting contrast and taking a still shot is inferior is not proven, there is no arguement for safety is using dex, there is an arguement for efficacy.

 

[Baron Samedi]

The difference between an effective TFESI and an ineffective one could be the difference in surgery vs continued non-op care.

 

[SSdoc33]

the efficacy difference is likely very small. those live seconds do add up over a lifetime. i still do live flouro, but i can understand the argument against it

 

[nvrsumr]

I trained very closely under the current president of SIS as a resident. ISIS was important back in the day as there was a lot of variation in procedure techniques. That base of knowledge served me well as a fellow moving onto more advanced procedures and learning other techniques for some common procedures as well. I have never looked back and wished I only learned one way of doing a procedure. The point of good training is to eventually take off the training wheels become the Sensai and to make your own expert informed decisions in the best interest of your patients. I generally do not use live fluoro or DSA since I switched to dex for epidurals. I am open as always to new evidence and will change my practice accordingly if needed in the future.