Is it the end of 'Safe Triangle Approach!

[lovebailey2001]

Latest article in Pain Physiciaan. Seems to be impressive! Has anybody seen new ISIS guidelines! What is their opinion abt Safe Triangle approach....

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[lobelsteve]

Latest article in Pain Physiciaan. Seems to be impressive! Has anybody seen new ISIS guidelines! What is their opinion abt Safe Triangle approach....

"All patients received particulate steroids."

Case closed.

 

[DOctorJay]

55. Murthy NS, Maus TP, Behrns CL. Intra- foraminal location of the great anterior radiculomedullary artery (artery of Adamkiewicz): A retrospective review. Pain Med 2010; 11:1756-1764.

Maus is the ISIS education chair. He does inferior and posterior.

 

[Ducttape]

It's interesting that the authors basically ignored this fact. Better to avoid the area, to paraphrase, than change an offending substance that was noted in all their cases. Also, what influence did dr. Manchikanti play in that decision?

Well, there are parts of town I should avoid, but I'm not going to deny myself a good bowl of pho. I'll just not drive a Mercedes down there...

 

[Aether2000]

Easy to avoid the artery: blunt needle placed medial to the pedicle and lateral to the traversing nerve in the anterior epidural space at the disc level.

 

[dc2md]

Easy to avoid the artery: blunt needle placed medial to the pedicle and lateral to the traversing nerve in the anterior epidural space at the disc level.

Which blunted needle is this?

 

[Aether2000]

Epimed coude tip 20ga

 

[lovebailey2001]

"All patients received particulate steroids."

Case closed.

Dr Lobel! Do you mean that no particulate steroids should be used for TFESI at any level? But there is ample evidence that 'Particulate' are more effective than the dex. I use dex for TF above L3 level.

 

[lobelsteve]

Dr Lobel! Do you mean that no particulate steroids should be used for TFESI at any level? But there is ample evidence that 'Particulate' are more effective than the dex. I use dex for TF above L3 level.

And that is the risk you take.

The risk is minimal and well documented. Realizing that risk can be catastrophic.

My take on epidural injections is that they are indicated for acute radicular pain or exacerbation of chronic radicular pain and offer no more than a gateway of restoring normal movement patterns or to begin an appropriate exercise program or PT. I don't care if my ESI lasts more than 8 weeks.

ESI not for chronic pain, back pain, asymptomatic stenosis (no hug the buggy = no dex), or findings on imaging that are not concordant with root encroachment/compression.

 

[ampaphb]

Dr Lobel! Do you mean that no particulate steroids should be used for TFESI at any level? But there is ample evidence that 'Particulate' are more effective than the dex. I use dex for TF above L3 level.

Not sure where you get the idea that there is any kind of "ample evidence" that particulates are more effective that dex. Three papers were presented at ISIS earlier this month that all demonstrated equal efficacy going out as long as 3 months.

That, in combinatiuon with the original Dreyfuss paper (Pain Med. 2006 May-Jun;7(3):237-42), the Park article (Pain Med. 2010 Nov;11(11):1654-8), and the Kim paper of 2011 (Clin J Pain. 2011 Jul-Aug;27(6):518-22) were enough to convince me to switch to non-particulate steroids for all TF-ESIs.

 

[ampaphb]

Easy to avoid the artery: blunt needle placed medial to the pedicle and lateral to the traversing nerve in the anterior epidural space at the disc level.

I thought the blunt needle discussion had been definitively addressed by Dr. Bogduk's white paper Sharp vs Blunt Needles; International Spine Intervention Society White Paper Interventional Spine Newsletter Vol 5, Number 4, p07-17, refuting the Haevner findings.

Even if that wasn't sufficient, these findings were confirmed this year in a prospective study of patients undergoing lumbar transforaminal injections that found no difference in inadvertent vascular injection rates between the sharp beveled needles, whitacre needles and blunt-tip needles. Patel A, Martinez-Ith A, Smuck M. A prospective analysis of alternative needles for lumbosacral transforaminal epidural injections. Pain Med. 2012;13(8):1103.

 

[Jcm800]

I thought the blunt needle discussion had been definitively addressed by Dr. Bogduk's white paper Sharp vs Blunt Needles; International Spine Intervention Society White Paper Interventional Spine Newsletter Vol 5, Number 4, p07-17, refuting the Haevner findings.

Even if that wasn't sufficient, these findings were confirmed this year in a prospective study of patients undergoing lumbar transforaminal injections that found no difference in inadvertent vascular injection rates between the sharp beveled needles, whitacre needles and blunt-tip needles. Patel A, Martinez-Ith A, Smuck M. A prospective analysis of alternative needles for lumbosacral transforaminal epidural injections. Pain Med. 2012;13(8):1103.

this is also my understanding. I gave up on blunt needles a couple of years ago...

 

[Jcm800]

ive always done POSTERIOR superior, or am i missing something...why go anterior, unless spread is no good, why advance?

 

[101N]

Latest article in Pain Physiciaan. Seems to be impressive! Has anybody seen new ISIS guidelines! What is their opinion abt Safe Triangle approach....

Dumb arse newby post

 

[Aether2000]

Bogduk is hell bent on using sharp needles with a long curve. Blunt needles avoid intraarterial injections, not intravenous injections since they can sheer veins that bridge, but as in the prior papers, do not penetrate arteries. If the needle is parallel to the radiculomedullary artery it cannot penetrate it, but merely moves it aside. Having done over 5000 blunt needle injections transforaminal under DSA I have never seen an arterial injection, but there are plenty of intravenous injections possible. But intravenous injections are not hazardous.

 

[oreosandsake]

Not sure where you get the idea that there is any kind of "ample evidence" that particulates are more effective that dex. Three papers were presented at ISIS earlier this month that all demonstrated equal efficacy going out as long as 3 months.

That, in combinatiuon with the original Dreyfuss paper (Pain Med. 2006 May-Jun;7(3):237-42), the Park article (Pain Med. 2010 Nov;11(11):1654-8), and the Kim paper of 2011 (Clin J Pain. 2011 Jul-Aug;27(6):518-22) were enough to convince me to switch to non-particulate steroids for all TF-ESIs.

there are a few retrospective papers that have been recently published (see below). shortly a Prospective multi-center trial comparing dex/triamcinolone for Lumbar TFESI will be published


Pain Med. 2013 Jul 30.
The Noninferiority of the Nonparticulate Steroid Dexamethasone vs the Particulate Steroids Betamethasone and Triamcinolone in Lumbar Transforaminal Epidural Steroid Injections.
El-Yahchouchi C, Geske JR, Carter RE, Diehn FE, Wald JT, Murthy NS, Kaufmann TJ, Thielen KR, Morris JM, Amrami KK, Maus TP.
SourceDepartment of Anesthesia, American University of Beirut, Beirut, Lebanon.

Abstract
OBJECTIVE: To assess whether a nonparticulate steroid (dexamethasone, 10 mg) is less clinically effective than the particulate steroids (triamcinolone, 80 mg; betamethasone, 12 mg) in lumbar transforaminal epidural steroid injections (TFESIs) in subjects with radicular pain with or without radiculopathy.

DESIGN: Retrospective observational study with noninferiority analysis of dexamethasone relative to particulate steroids.

SETTING: Single academic radiology pain management practice.

SUBJECTS: Three thousand six hundred forty-five lumbar TFESIs at the L4-5, L5-S1, or S1 neural foramina, performed on 2,634 subjects.

METHODS/OUTCOME MEASURES: Subjects were assessed with a pain numerical rating scale (NRS, 0-10) and Roland-Morris disability questionnaire (R-M) prior to TFESI, and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R-M score. Noninferiority analysis was performed with δ = -10% as the limit of noninferiority. Continuous outcomes (mean NRS, R-M scores) were analyzed for noninferiority with difference bounds of 0.3 for NRS scores and 1.0 for R-M scores.

RESULTS: With categorical outcomes, dexamethasone was demonstrated to be noninferior to the particulate steroids in pain relief and functional improvement at 2 months. Using continuous outcomes, dexamethasone was demonstrated to be superior to the particulate steroids in both pain relief and functional improvement at 2 months.

CONCLUSION: This retrospective observational study reveals no evidence that dexamethasone is less effective than particulate steroids in lumbar TFESIs performed for radicular pain with or without radiculopathy.

 

[PinchandBurn]

Bogduk is hell bent on using sharp needles with a long curve. Blunt needles avoid intraarterial injections, not intravenous injections since they can sheer veins that bridge, but as in the prior papers, do not penetrate arteries. If the needle is parallel to the radiculomedullary artery it cannot penetrate it, but merely moves it aside. Having done over 5000 blunt needle injections transforaminal under DSA I have never seen an arterial injection, but there are plenty of intravenous injections possible. But intravenous injections are not hazardous.

a former teacher of mine also advocated using blunt needles. But man they hurt patients! Are you making a skin knick first? Using an introducer? When I first started, I used blunt tip needles, but they were just tooo painful and I'm not in academics.....

 

[Aether2000]

I do make a skin wheel first and use a 16ga introducer. There is some discomfort as you pop through the muscle fascia and sometimes the foraminal ligaments. If there is inflammation around the posterior or posteriolateral disc then you can usually tell it right away . I use blunt needles because I can go places sharp needles do not dare....

 

[PinchandBurn]

I do make a skin wheel first and use a 16ga introducer. There is some discomfort as you pop through the muscle fascia and sometimes the foraminal ligaments. If there is inflammation around the posterior or posteriolateral disc then you can usually tell it right away . I use blunt needles because I can go places sharp needles do not dare....

do you use dexamethasone ? Or a particulate?

Reason is, if you are going to go through all that trouble, and then use a non particulate, is there a point? I agree you probably can go places where I wouldn't with a blunt needle.

 

[Aether2000]

Depomedrol + digital subtraction from L3 and distal.

 

[lobelsteve]

 

[Aether2000]

True, but an old one that will not ride much longer

 

[epidural man]

Latest article in Pain Physiciaan. Seems to be impressive! Has anybody seen new ISIS guidelines! What is their opinion abt Safe Triangle approach....

First off, why would anyone ever go TFESI again? (maybe rarely depending on previous surgery, etc).

http://www.anesthesia-analgesia.org/content/117/1/219.short (can't attach--to big)

and

View attachment Far lateral ESI better contrast flow than TFESI A&A 2008.pdf

Secondly, what a silly paper - as ANY discussion is about a SAFE place in the foramen where there are no vessels. Anyone that spends anytime looking at foramen in the sagital plane on MRI can contest that vessels are seen ALL OVER THE PLACE and there has NEVER been a place where they don't exist at any low frequency.

 

[emd123]

First off, why would anyone ever go TFESI again? (maybe rarely depending on previous surgery, etc).

http://www.anesthesia-analgesia.org/content/117/1/219.short (can't attach--to big)

and

View attachment 24669

Agree. That's what I've been doing for a while now. Paramedian IL Esi with celestone, or if too much scar tissue in the midline, then TF with Dex, never particulate. For Cervicals, CLO at C7/T1 with celestone, never TF, and never higher. Conservative, but cord infarction is catastrophic and I want no part of it. No triangle is safe.

That's just one man's 2 cents.

 

[mille125]

First off, why would anyone ever go TFESI again? (maybe rarely depending on previous surgery, etc).

http://www.anesthesia-analgesia.org/content/117/1/219.short (can't attach--to big)

and

View attachment 24669

Secondly, what a silly paper - as ANY discussion is about a SAFE place in the foramen where there are no vessels. Anyone that spends anytime looking at foramen in the sagital plane on MRI can contest that vessels are seen ALL OVER THE PLACE and there has NEVER been a place where they don't exist at any low frequency.

Now that is a smart man..............


Really calls into question all of the bilateral L5 and S1 transforaminal blocks that are an epidemic in my area...................

 

[emd123]

Now that is a smart man..............


Really calls into question all of the bilateral L5 and S1 transforaminal blocks that are an epidemic in my area...................

That's just a way to get paid for four injection when you really only need to do one.

 

[clubdeac]

I am the biggest fan of paramedian ILESIs there is but I do have a few patients that for unknown reasons to me do better with a bilateral tfesi than an ILESI. Its rare but it happens

 

[bedrock]

First off, why would anyone ever go TFESI again? (maybe rarely depending on previous surgery, etc).

Secondly, what a silly paper - as ANY discussion is about a SAFE place in the foramen where there are no vessels. Anyone that spends anytime looking at foramen in the sagital plane on MRI can contest that vessels are seen ALL OVER THE PLACE and there has NEVER been a place where they don't exist at any low frequency.

I think that your second paper is silly. It is impossible for contrast to reach the anterior epidural space more often after ILESI than after TFESI. When you do a TFESI(unless you do them retroneural), your needle is already in the anterior epidural space. How the heck can a paramedian ILESI injection spread contrast to the anterior epidural space more often than a TFESI where your needle is already in the anterior epidural space? I doubt the intellectual integrity of that paper.

That said, I agree than paramedian ILESI with depo is the way to go whenever possible. I do this as my first epidural most of the time and generally don't need to do a TFESI with dex.

I am the biggest fan of paramedian ILESIs there is but I do have a few patients that for unknown reasons to me do better with a bilateral tfesi than an ILESI. Its rare but it happens

Agree. I love far lateral ILESI and feel they work just as well and last longer than dex TFESI most of the time, but I never let a patient go to a surgeon without doing a TFESI.

The big local pain group in my town are all gas-pain guys, I'm pmr-pain. Like many anesthesia-pain docs, then really, really, love ILESI, but to their detriment sometimes.
Quite a few times, I've seen patients for a second opinion after they failed various epidurals, facet/SIJ injections, etc. I do a targeted TFESI and the patient gets better for the first time in months.

 

[Taus]

How far lateral are people going? All paramedians I've done in training have been within 1cm or so of midline. Any issues getting a reliable LOR when very lateral w ILESI?

 

[oreosandsake]

I think that your second paper is silly. It is impossible for contrast to reach the anterior epidural space more often after ILESI than after TFESI. When you do a TFESI(unless you do them retroneural), your needle is already in the anterior epidural space. How the heck can a paramedian ILESI injection spread contrast to the anterior epidural space more often than a TFESI where your needle is already in the anterior epidural space? I doubt the intellectual integrity of that paper.

QUOTE]

per the methods section of the paper -- "The needle was advanced until the needle tip was at the posterior and superior aspect of the intervertebral neural foramen..."

for clarification, is the posterior-superior neuroforamen the same as retroneural?

 

[Jcm800]

I would not hold that paper as gospel....

I think that your second paper is silly. It is impossible for contrast to reach the anterior epidural space more often after ILESI than after TFESI. When you do a TFESI(unless you do them retroneural), your needle is already in the anterior epidural space. How the heck can a paramedian ILESI injection spread contrast to the anterior epidural space more often than a TFESI where your needle is already in the anterior epidural space? I doubt the intellectual integrity of that paper.

That said, I agree than paramedian ILESI with depo is the way to go whenever possible. I do this as my first epidural most of the time and generally don't need to do a TFESI with dex.



Agree. I love far lateral ILESI and feel they work just as well and last longer than dex TFESI most of the time, but I never let a patient go to a surgeon without doing a TFESI.

The big local pain group in my town are all gas-pain guys, I'm pmr-pain. Like many anesthesia-pain docs, then really, really, love ILESI, but to their detriment sometimes.
Quite a few times, I've seen patients for a second opinion after they failed various epidurals, facet/SIJ injections, etc. I do a targeted TFESI and the patient gets better for the first time in months.