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

IPSIS: Formerly the Spine Intervention Society
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DODOCSS said:
so dex can and contrast cannot cause vasospasm? do tell pray tell
Click to expand...
technically the injection of any substance could cause vasospasm.

why risk causing spasm twice?

if you are intravascular, and you realize that, why would you risk further vasospasm and continue with the procedure?

MD87 said:
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.
Click to expand...
yes. I have abandoned cervical TFESI because the risk is not worth any additional perceived benefit over an interlaminar cervical epidural.

your second line is a nonsequitor. see above.

as a matter of course, how do you respond when the plaintiff's attorney asks "so you knew that you were in the vessel and could cause an injury... why did you go ahead and give what, 4 times the volume of what you just gave, in the exact same spot?"

------
dex may not be completely safe:

pubmed.ncbi.nlm.nih.gov

Conus Medullaris Infarction After a Right L4 Transforaminal Epidural Steroid Injection Using Dexamethasone - PubMed

The spinal cord infarction with TFESI's may occur related to various mechanisms, regardless of the type of particulate or non-particulate steroid used during these procedures.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

this case is FUBAR but they did use dex:
www.ncbi.nlm.nih.gov

Paraplegia after transforaminal epidural steroid injection in a patient with severe lumbar disc herniation - A case report -

Transforaminal epidural steroid injection (TFESI) is a conservative treatment for patients with lumbar disc herniation (LDH). However, there are reports of various complications that can occur after TFESI; among these, paraplegia is a serious complication. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Members don't see this ad.
 
DODOCSS said:
so dex can and contrast cannot cause vasospasm? do tell pray tell
Click to expand...
technically any injection can cause vasospasm.

why risk causing spasm twice?

fwiw, if you are intravascular, and you realize that, why do you not abort?

MD87 said:
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.
Click to expand...
yes. I have abandoned cervical TFESI because the risk is not worth any additional perceived benefit over an interlaminar cervical epidural.

your second line is a nonsequitor. the purpose of the contrast is to determine if injection of anything is safe. makes no sense to inject something else if you get intravascular injection. you stop, pull out to avoid further damage.

if you don't, the opposing lawyer asks "so you knew that you could cause an injury... why did you go ahead and give what, 4 times the volume, in the exact same spot?"

pubmed.ncbi.nlm.nih.gov

Conus Medullaris Infarction After a Right L4 Transforaminal Epidural Steroid Injection Using Dexamethasone - PubMed

The spinal cord infarction with TFESI's may occur related to various mechanisms, regardless of the type of particulate or non-particulate steroid used during these procedures.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
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Ducttape said:
technically any injection can cause vasospasm.

why risk causing spasm twice?

fwiw, if you are intravascular, and you realize that, why do you not abort?


yes. I have abandoned cervical TFESI because the risk is not worth any additional perceived benefit over an interlaminar cervical epidural.

your second line is a nonsequitor. the purpose of the contrast is to determine if injection of anything is safe. makes no sense to inject something else if you get intravascular injection. you stop, pull out to avoid further damage.

if you don't, the opposing lawyer asks "so you knew that you could cause an injury... why did you go ahead and give what, 4 times the volume, in the exact same spot?"

pubmed.ncbi.nlm.nih.gov

Conus Medullaris Infarction After a Right L4 Transforaminal Epidural Steroid Injection Using Dexamethasone - PubMed

The spinal cord infarction with TFESI's may occur related to various mechanisms, regardless of the type of particulate or non-particulate steroid used during these procedures.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...
I appreciate what you are saying about lawyers, but I am talking about what actually makes sense from an evidence stand point, not a legal perspective. We know depo is fine for ILESI but kenalog "isn't" for legal purposes even though they are basically equivalent. I'm pretty sure that if you have a complication, you are screwed no matter what. Why didn't you use DSA, doctor? Did you know that sometimes vascular injections can be missed using only live fluoroscopy? Are you saying it's impossible that you missed vascular flow during the injection? From a legal perspective, I think it may be smarter to use live fluoro, but I'm not trying to argue that point.

The only thing I disagree with you about is when you say "avoid further damage." My whole point is that there are no cases of ANY damage using dex that would have been prevented by live fluoro (the link you sent, as you know, is a case where dex was used after live fluoro and an infarct still took place). Do we know that injecting more medicine is more dangerous/more likely to cause vasospasm than repositioning the needle slightly, which could slice through more vessel(s)?
 
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from an evidence based standpoint, you can justify using live fluoro and not DSA because studies - and as a result, the pain societies - have not determined significant benefit of DSA over live fluoro.

you will not cause "further" damage if you withdraw the needle, and either abort the procedure or go at a different level or different approach. you could cause damage by continuing to perseverate on using the site that you have documented clear vascular injury. why would you do that?

even withdrawing and then readvancing a needle in the same tract does not seem logical or safe.
 
The hubris in this thread. Every time I go to a meeting or look at church I realize that every single one of us thinks he’s the worlds greatest pain physician. There’s a lot of it will never happen to me type thinking out there and a lot of I trained here and I’ve seen this and all kinds of things that if we could just step back he could look at from 10,000 feet and realize the field is bigger than us and our patience. We have minuscule careers that mean nothing. The biggest problem is when everyone does their own thing and a complication happens no one has any idea why. Maybe it’s just chance. Maybe it’s bad luck. What happens after the next patient becomes paralyzed from an aberrant placed needle. Sure it’s probably no one on this board as there are clearly folks that have no clue what they’re doing. Maybe one of these folks will become famous for the last guy to ever do an epidural because it will no longer be acceptable due to the lack of proof and benefit and the risks. Our field and these procedures have paralyzed and killed over 100 people. Think about that. Everything we can do to be a safer and better doctor is what we should be doing.
We need to be better stewards for the future of pain medicine.
 
Ducttape said:
from an evidence based standpoint, you can justify using live fluoro and not DSA because studies - and as a result, the pain societies - have not determined significant benefit of DSA over live fluoro.

you will not cause "further" damage if you withdraw the needle, and either abort the procedure or go at a different level or different approach. you could cause damage by continuing to perseverate on using the site that you have documented clear vascular injury. why would you do that?

even withdrawing and then readvancing a needle in the same tract does not seem logical or safe.
Click to expand...

This brings up an interesting point: do the majority of you abort the procedure if you see vascular flow or do you reposition? I believe SIS recommends reposition if venous and aborting if arterial, though it’s not always so easy to tell which is which.
 
MD87 said:
This brings up an interesting point: do the majority of you abort the procedure if you see vascular flow or do you reposition? I believe SIS recommends reposition if venous and aborting if arterial, though it’s not always so easy to tell which is which.
Click to expand...
It gets easier when you inject under live.
 
My name is in the list of references for the review article steve posted. It’s possible to have the same information and reach a different conclusion.

I respect Steve’s opinion and think it’s reasonable and has his patients safety at heart
 
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pubmed.ncbi.nlm.nih.gov

The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data - PubMed

In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Big review of similar topic. Access to lots of data and EBM gurus for SIS.
 
lobelsteve said:
The hubris in this thread. Every time I go to a meeting or look at church I realize that every single one of us thinks he’s the worlds greatest pain physician. There’s a lot of it will never happen to me type thinking out there and a lot of I trained here and I’ve seen this and all kinds of things that if we could just step back he could look at from 10,000 feet and realize the field is bigger than us and our patience. We have minuscule careers that mean nothing. The biggest problem is when everyone does their own thing and a complication happens no one has any idea why. Maybe it’s just chance. Maybe it’s bad luck. What happens after the next patient becomes paralyzed from an aberrant placed needle. Sure it’s probably no one on this board as there are clearly folks that have no clue what they’re doing. Maybe one of these folks will become famous for the last guy to ever do an epidural because it will no longer be acceptable due to the lack of proof and benefit and the risks. Our field and these procedures have paralyzed and killed over 100 people. Think about that. Everything we can do to be a safer and better doctor is what we should be doing.
We need to be better stewards for the future of pain medicine.
Click to expand...
Church?
 
nvrsumr said:
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.
Click to expand...
I also trained under a past SIS president as a fellow. I agree that the SIS base of knowledge and standards are such that every pain physician should know.

I also agree that you have to be able to adapt and be able to do procedures more than one way and look at the global picture both for safety of all involved and to optimize patient outcomes. You need to first start with a solid foundation, as this also gives you the knowledge base and ability to not follow various guidelines like a sheep, unless there is truly valid data to support a certain protocol.

If we look at the evidence, we know that live fluoro misses arterial uptake very frequently and although certainly superior, even DSA is not a suit of armor as some catastrophic outcomes have occurred despite DSA. And DSA uses 4X the radiation of live fluoro which takes a toll on the physician and staff.

I think those on a pedestal saying that you are a bad pain physician unless you do all your procedures with live flouro, should reflect on all of their practices and see if there is some hypocrisy. Because unless you use DSA for every single injection procedure....all of your ESI (TF or IL), and DSA for MBB, particularly cervical MBB/facets, then you are missing some vascular uptake, (particularly arterial uptake). Same thing with IA hip, sympathetic blocks, etc. The list goes on and on.

If a physician uses DSA for all of their injection procedures (so not RFA/stim), then I can respect their position even if I disagree with it. If they use for some injections but not others, or if they call for live fluoro on every ESI, but not DSA, then I can't understand them going halfway but disparging those who don't go halfway, because those physicians aren't truly sacrificing themselves to protect the patient at all costs, either.

Personally, since I stopped doing cervical TFESI I have completely stopped using DSA or live fluoro for injections other than for sympathetic blocks.
I use dex for TFESI and I virtually never add local to an ESI. If the single fluoro shot looks off for ESI/facet/MBB, peripheral joint etc, I readjust and take a second shot.

I'm committed to helping my patients, but I'm not going to triple my cancer risk for unproven and theoretical concerns.
 
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1. there is insufficient evidence already cited that the risk benefit ratio of DSA is that much superior to live fluoro.
2. please post any Society guidelines/ position statements about the requirement of using live fluoro for non-transforaminal epidural injections.



the purpose of using live fluoro is to prevent injury. but even if you do get vascular uptake in an MBB, the likelihood of vertebral artery spasm or other vascular injury causing paralysis is so extraordinarily low that there is no benefit towards using live fluoro. you can still see capsular injury without live fluoro.

if you disagree, please post articles and case reports of patients who had appropriately placed MBB or ILESI or hip injection that resulted in significant vascular injury.

(i use live fluoro for LSBs and celiacs).
 
Maybe a little off topic here.

I have recently interviewed at about 4 practices and have shadowed the docs during procedures.
These were all experienced ACGME fellowship trained pain docs both PMR and Anes. They are all part of well run practices
but their interventional skills were down right crappy. Blobs of contrast not near the target , a CESI at C2-3!, among other things.

I have been in practice for about 15 years, but I can not believe how shoddy their procedures were for supposedly " well trained pain docs"

I guess my point is there is a lot of finger pointing on these blogs in regards to the downfall of pain medicine on poorly trained physicians.

But over the last several weeks, I have learned that is probably not the biggest issue.
 
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You can go to best fellowship and be awful or conversely one of the poorest and be amazing. I try to focus on keeping my own house in order before criticizing and I can always improve so I don’t have a lot of time to criticize lol but a CESI at c2? Geez
 
Nodolor said:
Maybe a little off topic here.

I have recently interviewed at about 4 practices and have shadowed the docs during procedures.
These were all experienced ACGME fellowship trained pain docs both PMR and Anes. They are all part of well run practices
but their interventional skills were down right crappy. Blobs of contrast not near the target , a CESI at C2-3!, among other things.

I have been in practice for about 15 years, but I can not believe how shoddy their procedures were for supposedly " well trained pain docs"

I guess my point is there is a lot of finger pointing on these blogs in regards to the downfall of pain medicine on poorly trained physicians.

But over the last several weeks, I have learned that is probably not the biggest issue.
Click to expand...
I don’t know what to say about a C2-3 epidural.
 
Perhaps we need a Step 2 CS analog for pain medicine? I'm seeing the accrediting boards $alivating over that thought...
 
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