Epidural sludge?

[ctts]

I have heard about epidural sludge, supposedly from repeated ESI, discovered during spine surgery. Does anyone know if this actually occurs? I can't find anything on pubmed, or google image. Is it just spine surgeon's way of discouraging repeated ESI to steer patient's towards surgery? And if it does occur...does it occur primarily with particulates? If a non-particulate like dexamethasone is used, can this be avoided?

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[PinchandBurn]

I have heard about epidural sludge, supposedly from repeated ESI, discovered during spine surgery. Does anyone know if this actually occurs? I can't find anything on pubmed, or google image. Is it just spine surgeon's way of discouraging repeated ESI to steer patient's towards surgery? And if it does occur...does it occur primarily with particulates? If a non-particulate like dexamethasone is used, can this be avoided?

not sure what 'sludge' means....

tell patient you can get 'sludge' aka scarring from surgery as well.

if he's talking about epidural lipomatosis, sure that can happen, but it's very rare, <1%

 

[oreosandsake]

I have heard of spine surgeons finding particles (presumed to be corticosteroids) when they dissect down, even "long after" the last known ESI

I don't think this is a way to discourage ESI, or to steer towards surgery. As far as I have heard, it is mostly an observation that the injectate persists after the efficacious period has passed

If I had to guess, I would assume it is only with particulates.

Any literature from the ortho joint docs? any "sludge" in the knees when they perform arthrscopy?

 

[ctts]

To pinchandburn: Sludge is not a term I made up for it, but that's what I have heard it referred to as. A chiro mentioned it to me recently. And in the past I heard it from other pain docs who have heard that surgeons refer to it as sludge.

I would agree with oreos comments. I guess no one really know if this sludge is in itself harmful in anyway. I wonder how much volume of sludge actually builds up over time.

I am thinking of going with non-particulate dex for all ESIs and seeing how that goes. I have switched from Kenalog to dex for cervical interlaminar ESIs since early 2013. So far, I don't think I am seeing any particular difference. I hae already been using dex for all lumbar TF ESI. So next is changing lumbar interlaminar ESI from Kenalog to dex. Maybe eventually for joint injections too. Not necessarily just because the question of the sludge issue, but I suppose that is part of it.

 

[SSdoc33]

the "sludge" is due to repeated particulate steroid injection. depo-medrol is the biggest culprit. it generally isnt as bad in the epidural space because the stuff flows all over the place. it is seen a lot in joints like the knee at the time of a knee replacement when patients have had lot of injections. the tissue looks a little funny, but nobody really knows if it means anything

 

[Taus]

To pinchandburn: Sludge is not a term I made up for it, but that's what I have heard it referred to as. A chiro mentioned it to me recently. And in the past I heard it from other pain docs who have heard that surgeons refer to it as sludge.

I would agree with oreos comments. I guess no one really know if this sludge is in itself harmful in anyway. I wonder how much volume of sludge actually builds up over time.

I am thinking of going with non-particulate dex for all ESIs and seeing how that goes. I have switched from Kenalog to dex for cervical interlaminar ESIs since early 2013. So far, I don't think I am seeing any particular difference. I hae already been using dex for all lumbar TF ESI. So next is changing lumbar interlaminar ESI from Kenalog to dex. Maybe eventually for joint injections too. Not necessarily just because the question of the sludge issue, but I suppose that is part of it.

TFESI reason is clear.... but why the switch for interlaminar?

 

[bedrock]

To pinchandburn: Sludge is not a term I made up for it, but that's what I have heard it referred to as. A chiro mentioned it to me recently. And in the past I heard it from other pain docs who have heard that surgeons refer to it as sludge.

I would agree with oreos comments. I guess no one really know if this sludge is in itself harmful in anyway. I wonder how much volume of sludge actually builds up over time.

I am thinking of going with non-particulate dex for all ESIs and seeing how that goes. I have switched from Kenalog to dex for cervical interlaminar ESIs since early 2013. So far, I don't think I am seeing any particular difference. I hae already been using dex for all lumbar TF ESI. So next is changing lumbar interlaminar ESI from Kenalog to dex. Maybe eventually for joint injections too. Not necessarily just because the question of the sludge issue, but I suppose that is part of it.

Sorry but you are going to completely shortchange your patients. If your goal is to increase your billings because all your patients will need repeat injections every 4-6 weeks, you will achieve that goal. If your goal is to offer the best care to your patients then you will fail stupendously, if you use dex for all your injections.

Dexamethasone is a reasonable substitute for particulate steroid in only one situation, a hot new acute/subacute radiculopathy. The duration of effect is almost as good at Kenalog/Depomedrol for acute radiculopathy, but is greatly inferior for every other situation.

For much of what we see in pain management, which is generally not hyperacute, (spinal stenosis, chronic to subacute radiculopathy, joint osteoarthritis, etc), particulate steroids last much longer. I'm shocked that you say you didn't noticed difference when you switched from from Kenalog to dex for cervical interlaminars. I'm sure you had lots of patients who only achieved 1-3 weeks of relief after a CESI with dexamethasone. Did you repeat any of those with Kenalog? If you do, the patients will see what they're missing, and over half with see relief that lasts for months, not days/weeks.

 

[lobelsteve]

Sorry but you are going to completely shortchange your patients. If your goal is to increase your billings because all your patients will need repeat injections every 4-6 weeks, you will achieve that goal. If your goal is to offer the best care to your patients then you will fail stupendously, if you use dex for all your injections.

Dexamethasone is a reasonable substitute for particulate steroid in only one situation, a hot new acute/subacute radiculopathy. The duration of effect is almost as good at Kenalog/Depomedrol for acute radiculopathy, but is greatly inferior for every other situation.

For much of what we see in pain management, which is generally not hyperacute, (spinal stenosis, chronic to subacute radiculopathy, joint osteoarthritis, etc), particulate steroids last much longer. I'm shocked that you say you didn't noticed difference when you switched from from Kenalog to dex for cervical interlaminars. I'm sure you had lots of patients who only achieved 1-3 weeks of relief after a CESI with dexamethasone. Did you repeat any of those with Kenalog? If you do, the patients will see what they're missing, and over half with see relief that lasts for months, not days/weeks.

I am not so sure the literature is supporting your argument.

 

[bedrock]

I am not so sure the literature is supporting your argument.

There is no literature to refute my argument.

Outside of acute radiculopathy, there are no significant head to head comparisons of dexamethasone vs particulate steroid, for other indications such as joint OA, spinal stenosis, chronic/recurrent radiculopathy, etc.

 

[Ducttape]

There is no literature to refute my argument.

Outside of acute radiculopathy, there are no significant head to head comparisons of dexamethasone vs particulate steroid, for other indications such as joint OA, spinal stenosis, chronic/recurrent radiculopathy, etc.

As u are the one postulating that particulates are so much better, so the burden of proof should lie with your stance. Disprove the null hypothesis - that there is no difference. And case reports don't count....

 

[lobelsteve]

http://www.spinalinjection.org/?page=PVNPLFF

 

[bedrock]

As u are the one postulating that particulates are so much better, so the burden of proof should lie with your stance. Disprove the null hypothesis - that there is no difference. And case reports don't count....

Hmm, so if the null hypothesis is that there is no difference, let me ask you this question......... Are u using dex for your joint injections and ILESI?

Didn't think so-

 

[bedrock]

http://www.spinalinjection.org/?page=PVNPLFF

I'm not advocating particulates for TFESI. I am advocating particulate steroid for everything else.

 

[Ducttape]

I'm not advocating particulates for TFESI. I am advocating particulate steroid for everything else.

Forgive me if I am mistaken , but I took your posts to imply that you thought that using anything other than particulates for anything other that TF was doing patients a disservice - ie the treatment of choice is a particulate steroid.

IMHO, Since you are postulating there is a difference, the onus to rule out the null hypothesis (that there is no difference) should lie in you to prove this wrong, not those who are supporting the more commonly thought of notion that there is no difference.

 

[lobelsteve]

How about a glass of truth and data:

http://www.medscape.com/viewarticle/766175_1

No best steroid data exists. Trends toward triamcinolone. I like BSP/BA for everything non TFESI. Where you trained has more to do with your steroid choice than clinical data.

 

[oreosandsake]

J Rheumatol. 1979 Jan-Feb;6(1):7-14.

Electron microscopic study of depot corticosteroid crystals with clinical studies after intra-articular injection.

Gordon GV, Schumacher HR.

Depot corticosteroid crystals and their in vivo handling after intra-articular injection have not been studied by electron microscope (EM). We therefore injected 20 mg of either prednisolone tebuate or triamcinolone hexacetonide into knee joints of 7 patients with osteoarthritis and painful effusions. Six patients had a rise in the synovial fluid leukocyte counts, but only 1 patient had clinical evidence of a post-injection flare. Scanning and transmission EM revealed intra- and extracellular crystals 24 hours and 1 week after the initial injection. These combined EM studies provide an adjunct to compensated polarized microscopy in differentiation of depot steroid from other crystals.