Depo outlawed

[MD87]

Depo is included on the list of steroids. Still unsure what we are even talking about.

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

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Members don't see this ad.

 

[Dr. Ice]

Lol..people are also acting as if there was no particulate mentioned on these LCDs. Beta is particulate and still on there. Just switch over if you need to.

Btw, I totally agree depo is a phenomenal steroid in terms of duration and amount of relief. Been using it for 6 years or more. We used kenalog in fellowship and I still
think kenalog=king.

I also think stim companies have been having wine/cheese/pointy shoes parties if in fact depo has become the outlaw Jessie James

 

[Laryngospasm]

ILESI above.. if lami

 

[nopain1234]

Every day people inject depo into me. Usually just a little dribble. But when someone pumps in 40 of depo, I close my eyes and wait for the end to come. One of these days I’ll meet my maker.

Lol weird

 

[Ducttape]

My anecdotal evidence >>> your studies results. The difference in patient results are profound

this is the most ludicrous statement i have ever read on this forum. in more ways than one.


i believe noone is arguing against disputing using depo for ILESI. the use of particulates for TFESI is the concern.

 

[nopain1234]

this is the most ludicrous statement i have ever read on this forum. in more ways than one.


i believe noone is arguing against disputing using depo for ILESI. the use of particulates for TFESI is the concern.

You clearly missed my point. I’m not saying there isn’t a concern with particulate and TFESI. I’m saying the results are superior to that of dex and at LOWER LUMBAR SEGMENTS/LEVELS the risk is virtually non existent. I have never heard or read a spinal infarct occurring at L5/S1 from TFESI. If someone has some literature/case studies please provide some.

 

[pmrmd]

There is 1 case right? An aberrant S1 artery. So its 1:10m or whatever it is.
There are a couple cases of SCI after dex injection, so that raises questions as well.

I figure I'll just go on using triam/dex both in my TFs and Keep Being That Guy.

 

[MitchLevi]

The AoA can extend to L5; I'm sure DJ Kennedy has published that (Pain Medicine 2009ish).

TFESI with dex can result in paraplegia of course, and we all know the idea regarding vessel injury due to needle friction. Whether that's real or not is a separate debate.

Vascular surgeons do a lot more than rub the carotid during a CEA and I'm not sure how often ppl stroke during that surgery. They're given an infusion of some form of fibrinolytic during the CEA too if I remember correctly.

Either way, doing a TFESI at any level with any medication brings risk.

BTW - I've had a small number of pts go into atrial fib from ESI. Maybe 4 at the most. Each of them were TFESI with dexamethasone except 1 of them, which was a facet injxn with dexamethasone.

The rapid onset of dex is something to consider and take seriously.

Further, I've destabilized 3 bipolar pts, each received dex.

Never had anything like this with Depo.

 

[Laryngospasm]

People have cva all the time during carotid surgery..

 

[Ducttape]

Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports - PubMed

These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis...

pubmed.ncbi.nlm.nih.gov

Segmental Spinal Myoclonus Complicating Lumbar Transforaminal Epidural Steroid Injection - PubMed

Segmental spinal myoclonus is a rare complication after lumbar transforaminal epidural steroid and local anesthetic injection. Pain physicians should be aware of this potential complication.

pubmed.ncbi.nlm.nih.gov

ASRA statement:

Transforaminal Injection of Steroids​

Transforaminal injection of steroids, often used in the treatment of acute radicular pain, has been linked to cases of spinal cord infarction, cortical blindness, paralysis, and death.24,50,61 The presumed mechanism of these complications involves unintentional needle entry into a small artery that traverses the intervertebral foramen to join the arterial supply to the spinal cord or posterior circulation of the brain. This can occur at various levels, including the vertebral artery anterior to the cervical intervertebral foramina, or the spinal medullary or radicular arteries within the foramina at variable levels within the cervical,62,63 thoracic, lumbar, and sacral portions of the spine. Subsequent injection of particulate steroid preparations can result in occlusion of the distal arterioles within the spinal cord or brain and lead to infarction.61 In vitro studies note that methylprednisolone has the largest particles, betamethasone the smallest, and dexamethasone has no particulate matter.64 While evidence of unintended injection into perispinal vessels during transforaminal injection has been reported, direct evidence to confirm or refute the role of particulate steroids in causing subsequent neuronal injury is lacking (Table 6).

ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine

Neurologic complications associated with regional anesthesia and pain medicine practice are extremely rare. The ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine addresses the etiology, differential diagnosis, ...

www.ncbi.nlm.nih.gov

SIS statement:

•A non-particulate steroid (e.g. dexamethasone) should be used for the initial injection in lumbar transforaminal ESIs.
• Dexamethasone should not be mixed with ropivacaine because of the risk of precipitating the steroid so it acts as a particulate.
• There are situations where particulate steroids could be used in the performance of lumbar transforaminal ESIs. However, because transforaminal ESI using particulate steroids is associated with a rare risk of catastrophic neurovascular complications, efforts should be made to minimize their use in transforaminal injections.

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/patient_safety/safety_practices/sis.safety.practices.m1.esi.pdf

neither organization says do not use particulate, but, well, buyer beware.

 

[SSdoc33]

I use depo for TFESIs at lower lumbar segments. Never had any issues

then it MUST be safe........

 

[SSdoc33]

The AoA can extend to L5; I'm sure DJ Kennedy has published that (Pain Medicine 2009ish).

TFESI with dex can result in paraplegia of course, and we all know the idea regarding vessel injury due to needle friction. Whether that's real or not is a separate debate.

Vascular surgeons do a lot more than rub the carotid during a CEA and I'm not sure how often ppl stroke during that surgery. They're given an infusion of some form of fibrinolytic during the CEA too if I remember correctly.

Either way, doing a TFESI at any level with any medication brings risk.

BTW - I've had a small number of pts go into atrial fib from ESI. Maybe 4 at the most. Each of them were TFESI with dexamethasone except 1 of them, which was a facet injxn with dexamethasone.

The rapid onset of dex is something to consider and take seriously.

Further, I've destabilized 3 bipolar pts, each received dex.

Never had anything like this with Depo.

wait, so you are not using dex b/c it send some into afib and makes others crazy?

this is a perfect example of the tail wagging the dog

 

[SSdoc33]

also, @Ferrismonk, there is a some evidence from Riew that says CESI can decrease the need for C-spine surgery. Dont have time to look up the paper right now but, but ill get to it.

i think the S1 paraplegia case was CT guided

betamethasone is (or at least was) significantly more expensive than depo.

 

[MitchLevi]

wait, so you are not using dex b/c it send some into afib and makes others crazy?

this is a perfect example of the tail wagging the dog

As I've said repeatedly in this thread, I use dexamethasone for all TFESI.

 

[RoloTomassi]

Anyone noticed that cervical ILESI is more painful with dex than depo? More intense pressure in neck and chest? Not a big deal since it's transient and less with slow push but is this a known thing?

 

[MitchLevi]

Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports - PubMed

These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis...

pubmed.ncbi.nlm.nih.gov

Segmental Spinal Myoclonus Complicating Lumbar Transforaminal Epidural Steroid Injection - PubMed

Segmental spinal myoclonus is a rare complication after lumbar transforaminal epidural steroid and local anesthetic injection. Pain physicians should be aware of this potential complication.

pubmed.ncbi.nlm.nih.gov

ASRA statement:

ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine

Neurologic complications associated with regional anesthesia and pain medicine practice are extremely rare. The ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine addresses the etiology, differential diagnosis, ...

www.ncbi.nlm.nih.gov

SIS statement:

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/patient_safety/safety_practices/sis.safety.practices.m1.esi.pdf

neither organization says do not use particulate, but, well, buyer beware.

I have kicked around the idea of using dex for the first two TFESI in my old, stenotic pts and after that using Depo for shot #3 and so on...

That to me is a reasonable practice. I've also considered mixing the two, maybe dex 5mg + Depo 20mg.

Dose of the particulate clearly matters, and the lower the dose the lower the risk.

I would never do a straight 80mg Depo TFESI bc I have just recently had to switch to a generic POS formulation of methylprednisolone that I actually cannot inject through a 27 or 25 gauge needle. That's a crazy thing IMO.

 

[MitchLevi]

Anyone noticed that cervical ILESI is more painful with dex than depo? More intense pressure in neck and chest? Not a big deal since it's transient and less with slow push but is this a known thing?

Chest pain in an ILESI with dex not infrequently until I quit using it.

 

[DOctorJay]

Anyone noticed that cervical ILESI is more painful with dex than depo? More intense pressure in neck and chest? Not a big deal since it's transient and less with slow push but is this a known thing?

we've discussed this very phenomenon multiple times

 

[Ferrismonk]

My anecdotal evidence >>> your studies results. The difference in patient results are profound

Do the study and prove it then.

 

[Ferrismonk]

also, @Ferrismonk, there is a some evidence from Riew that says CESI can decrease the need for C-spine surgery. Dont have time to look up the paper right now but, but ill get to it.

i think the S1 paraplegia case was CT guided

betamethasone is (or at least was) significantly more expensive than depo.

Looking forward to it. Thanks.

 

[SSdoc33]

Looking forward to it. Thanks.

its an old study and im sure there will be holes to be poked in it....

The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study - PubMed

Our data demonstrate that selective nerve-root injections of corticosteroids are significantly more effective than those of bupivacaine alone in obviating the need for a decompression for up to thirteen to twenty-eight months following the injections in operative candidates. This finding...

pubmed.ncbi.nlm.nih.gov

 

[nopain1234]

then it MUST be safe........

Has anyone produced a case of spinal infarct at L5/S1 for me?

I’ve been asking for years yet still haven’t seen one

I’ll happily adjust my practice. Merely trying to help my patients get maximal pain relief

 

[SSdoc33]

Has anyone produced a case of spinal infarct at L5/S1 for me?

I’ve been asking for years yet still haven’t seen one

I’ll happily adjust my practice. Merely trying to help my patients get maximal pain relief

not sure how much info you can draw from this as it was from around 20 years ago and it MAY have been a CT guided injection, but ask and you shall receive.....

Paraplegia after lumbosacral nerve root block: report of three cases - PubMed

We present the cases of three patients who had lasting paraplegia or paraparesis after the performance of a nerve root block. We propose that the mechanism for this rare but devastating complication is the concurrence of two uncommon circumstances, the presence of an unusually low origin of the...

pubmed.ncbi.nlm.nih.gov

 

[MitchLevi]

not sure how much info you can draw from this as it was from around 20 years ago and it MAY have been a CT guided injection, but ask and you shall receive.....

Paraplegia after lumbosacral nerve root block: report of three cases - PubMed

We present the cases of three patients who had lasting paraplegia or paraparesis after the performance of a nerve root block. We propose that the mechanism for this rare but devastating complication is the concurrence of two uncommon circumstances, the presence of an unusually low origin of the...

pubmed.ncbi.nlm.nih.gov

To be fair, you cannot compare L5-S1 and S1 as the latter is richly vascular.

Your case report describes two TFESI at L3-4 and one at S1. Neither are L5-S1.

 

[nopain1234]

not sure how much info you can draw from this as it was from around 20 years ago and it MAY have been a CT guided injection, but ask and you shall receive.....

Paraplegia after lumbosacral nerve root block: report of three cases - PubMed

We present the cases of three patients who had lasting paraplegia or paraparesis after the performance of a nerve root block. We propose that the mechanism for this rare but devastating complication is the concurrence of two uncommon circumstances, the presence of an unusually low origin of the...

pubmed.ncbi.nlm.nih.gov

I treat many 5/1 spondy’s with bilateral TFESIs. Patients do amazingly well with them. Would hate to change from something without good evidence to back it up is all.

 

[RoloTomassi]

Has anyone produced a case of spinal infarct at L5/S1 for me?

:::::Pain Physician:::::

 

[oreosandsake]

Agreed.

Depo ILESI is the most effective ESI I do, and IMO clearly outperform TFESI with dex in patients with stenosis, chronic low back and radicular pain.

The surgeons in my group do TFESI with Depo 80mg + 2cc bupi 0.25% and if I see that pt and do a repeat TFESI with dex, despite my better technique they commonly ask why mine didn't work as long.

I don't do TFESI with particulate.

the surgeons in your group...

 

[Ducttape]

Paraplegia after lumbosacral nerve root block: report of three cases - PubMed

We present the cases of three patients who had lasting paraplegia or paraparesis after the performance of a nerve root block. We propose that the mechanism for this rare but devastating complication is the concurrence of two uncommon circumstances, the presence of an unusually low origin of the...

pubmed.ncbi.nlm.nih.gov

Three patients, two women and one man ranging in age from 42 to 64 years, underwent three procedures performed at three different facilities, in the hands of two different injectionists. In each instance, penetration of the dura was not thought to have occurred. In two procedures the needles were placed transforamenally, one at L3-4 on the left and one at L3-4 on the right, and in the third the needle tip was placed immediately lateral to the S1 nerve root.

 

[oreosandsake]

Has anyone produced a case of spinal infarct at L5/S1 for me?

I’ve been asking for years yet still haven’t seen one

I’ll happily adjust my practice. Merely trying to help my patients get maximal pain relief

Digital subtraction angiography does not reliably prevent paraplegia associated with lumbar transforaminal epidural steroid injection - PubMed

Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating...

pubmed.ncbi.nlm.nih.gov

 

[Pain Applicant1]

Every day people inject depo into me. Usually just a little dribble. But when someone pumps in 40 of depo, I close my eyes and wait for the end to come. One of these days I’ll meet my maker.

Lol weird

I like when she or he posts things like this. It's interesting. Ateria the poet.

 

[nopain1234]

its an old study and im sure there will be holes to be poked in it....

The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study - PubMed

Our data demonstrate that selective nerve-root injections of corticosteroids are significantly more effective than those of bupivacaine alone in obviating the need for a decompression for up to thirteen to twenty-eight months following the injections in operative candidates. This finding...

pubmed.ncbi.nlm.nih.gov

The power of SDN. Much appreciate, I’ll adjust accordingly. Unfortunate but probably necessary

 

[clubdeac]

I think it’s interesting they recommend the first TFESI with dex and if short term relief then you can repeat with particulate. I understand it reduces the risk somewhat but still seems like stupid logic. If particulate is that dangerous in the lumbar spine make a firm statement against it in all circumstances. These wishy washy recommendations reflect how exceedingly rare these injuries really are.

 

[MitchLevi]

These wishy washy recommendations reflect how exceedingly rare these injuries really are.

...and the belief of particulate efficacy amongst the authors.

If it's no better and there's significant risk why not flatly reject its use at all?

 

[nopain1234]

...and the belief of particulate efficacy amongst the authors.

If it's no better and there's significant risk why not flatly reject its use at all?

As stated earlier. I went exclusively dex for 6-9 months. My repeat injections who’d had gotten depo in the past not only complained of decreased length of relief, but greatly reduced pain relief. It was quite noticeable. Hence, the reason I switched back and am so resistant to mostly dex.

 

[MitchLevi]

As stated earlier. I went exclusively dex for 6-9 months. My repeat injections who’d had gotten depo in the past not only complained of decreased length of relief, but greatly reduced pain relief. It was quite noticeable. Hence, the reason I switched back and am so resistant to mostly dex.

I only do dex TFESI, and the results are the exact reason I try to do as many ILESI as I can - So I can use Depo.

 

[bedrock]

As stated earlier. I went exclusively dex for 6-9 months. My repeat injections who’d had gotten depo in the past not only complained of decreased length of relief, but greatly reduced pain relief. It was quite noticeable. Hence, the reason I switched back and am so resistant to mostly dex

I only do dex TFESI, and the results are the exact reason I try to do as many ILESI as I can - So I can use Depo.

Agree to do ILESI with depo on patients with intact lami and stenosis, however you guys should really consider caudal ESI or bilateral S2 TFESI with depo for your patients with s/p lami with persistent lateral recess or foraminal stenosis. Or recurrent radiculopathy.

Very helpful options in the previously surgerized patient.

 

[Dr. Ice]

I’m still waiting on the actual “outlaw” to be in clear writing. Guess will wait to see if there is a response to manchikanti’s attempt at clarification.

 

[Ferrismonk]

My anecdotal evidence >>> your studies results. The difference in patient results are profound

 

[MitchLevi]

Agree to do ILESI with depo on patients with intact lami and stenosis, however you guys should really consider caudal ESI or bilateral S2 TFESI with depo for your patients with s/p lami with persistent lateral recess or foraminal stenosis. Or recurrent radiculopathy.

Very helpful options in the previously surgerized patient.

I do caudals with Depo, and S1 with dexamethasone. Someone above linked to a study about an S1 TF resulting in an ischemic event. Anyone doing S1 regularly should know how vascular that area is, and I catch vessels there all the time. Far more frequently than any other level (I think that's true).

Any reason to do S2 over caudal? I don't see a reason other than being a few cm closer to L5-S1.

My hesitation is the fact bilateral S2 is nowhere near as quick as a caudal. Then again, I've done probably one or two S2 ever.

 

[nopain1234]

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