Leg cramps post TFESI--management

[Sharps]

I've always attributed this to placing a foreign body (depomedrol) adjacent to an inflammed nerve.
Interestingly it seems more common in the more healthy younger pt's.
Anyone have luck w/ any specific recommendations to patients w/ this?

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[lobelsteve]

I've always attributed this to placing a foreign body (depomedrol) adjacent to an inflammed nerve.
Interestingly it seems more common in the more healthy younger pt's.
Anyone have luck w/ any specific recommendations to patients w/ this?

Please describe your technique, needle selection, adjuvant medications, and volumes of injectate. Muscle cramps or spasms after TFESI should be a rare occurence.

 

[Tenesma]

i have yet to have anybody with muscle cramps - that's odd -

i have had a few cases of weakness that lasted 20 minutes...
and a few cases of worse radicular pain for a day or two ...

but that is it...

 

[lobelsteve]

i have yet to have anybody with muscle cramps - that's odd -

i have had a few cases of weakness that lasted 20 minutes...
and a few cases of worse radicular pain for a day or two ...

but that is it...

i have had a few cases of weakness that lasted 20 minutes...sensitive to the local- happens at least once every few weeks using a mix of 2cc 2% plain lido, 1cc NS, 1 cc Celestone

and a few cases of worse radicular pain for a day or two ...steroid flare- but I bet when the pain subsides they behave like a regular TFESI with good relief.

BTDT (been there done that)

Had a friend do a left L5 TFESI last week and got a sensory level to T2-T3. Some motor block in the legs as well, altogether lasted 2.5 hours. Walked away with good relief, but a little interesting for awhile. Good thing he is an anesthesiologist- I would have been ready to call 911 if her level kept creeping up. I'm sure I could get the tube in, but I don't want to pay for 3 or 4 teeth to do so.

 

[Mister Mxyzptlk]

I stopped using local in my ESI's years ago because (1) I like my patients to leave after the procedure with the same sensory and motor function that they came in with, and (2) there are dangers associated with intra-spinal LA use, especially in the c-spine.

I just use steroid and saline. I haven't seen any difference in outcome.

As for the T2 sensory level - if that was in the office it doesn't matter what the specialty is, you call 911.

A T2 level can cause respiratory compromise because of loss of the intercostals and leave them with just diaphragmatic breathing. People with COPD and flat diaphragms don't handle that well. At a T2 sensory level you pretty much have complete sympathetic blockade with preload and afterload drops and loss of the cardioaccelerators. They can sink like a stone due to vasodilation and bradycardia.

An anesthesiologist should know better than to try to manage that situation in the office.

 

[lobelsteve]

I stopped using local in my ESI's years ago because (1) I like my patients to leave after the procedure with the same sensory and motor function that they came in with, and (2) there are dangers associated with intra-spinal LA use, especially in the c-spine.

I just use steroid and saline. I haven't seen any difference in outcome.

As for the T2 sensory level - if that was in the office it doesn't matter what the specialty is, you call 911.

A T2 level can cause respiratory compromise because of loss of the intercostals and leave them with just diaphragmatic breathing. People with COPD and flat diaphragms don't handle that well. At a T2 sensory level you pretty much have complete sympathetic blockade with preload and afterload drops and loss of the cardioaccelerators. They can sink like a stone due to vasodilation and bradycardia.

An anesthesiologist should know better than to try to manage that situation in the office.

Thanks. I'm pretty easy going and overly careful with patient safety. I've sent folks to the ER via 911 for vasovagal syncope (pretty sure MBB's with 0.5cc lidocaine don't cause LOC) because of h/o CAD/CHF/CVA.

I've got no problems being a "wimp" when it comes to the right venue to treat patients. I once got yelled at for callling 911 for a patient who developed CP after the procedure. H/o anxiety, 50 y/o AAF with BP 220/105. Silly me.

 

[Louisville04]

I stopped using local in my ESI's years ago because (1) I like my patients to leave after the procedure with the same sensory and motor function that they came in with, and (2) there are dangers associated with intra-spinal LA use, especially in the c-spine.

I just use steroid and saline. I haven't seen any difference in outcome.
As for the T2 sensory level - if that was in the office it doesn't matter what the specialty is, you call 911.

If you don't use a local, how will you be able to tell if the injection was diagnostic or that you found the pain generator?

 

[spondy14]

Thanks. I'm pretty easy going and overly careful with patient safety. I've sent folks to the ER via 911 for vasovagal syncope (pretty sure MBB's with 0.5cc lidocaine don't cause LOC) because of h/o CAD/CHF/CVA.

I've got no problems being a "wimp" when it comes to the right venue to treat patients. I once got yelled at for callling 911 for a patient who developed CP after the procedure. H/o anxiety, 50 y/o AAF with BP 220/105. Silly me.

"Yelled at"?? If someone has a hint of chest pain, they are getting a ride to the ER...period.

 

[Tenesma]

for TFESI i use 0.5cc of lido 1% per level - force of habit i guess - but it does give me useful information - and there is something dramatic about patients coming to me unable to walk and once the lido kicks in they are walking around without a cane - it looks great for the office!

however, there are a few lido junkies who are really disappointed when the steroid kicks in because it didn't feel as good as the lidocaine - however we try to prepare all the patients for the biphasic response

a T2 level?!??! what the?? how much local? even with a bit of lido intrathecal that shouldn't happen...

 

[lobelsteve]

for TFESI i use 0.5cc of lido 1% per level - force of habit i guess - but it does give me useful information - and there is something dramatic about patients coming to me unable to walk and once the lido kicks in they are walking around without a cane - it looks great for the office!

however, there are a few lido junkies who are really disappointed when the steroid kicks in because it didn't feel as good as the lidocaine - however we try to prepare all the patients for the biphasic response

a T2 level?!??! what the?? how much local? even with a bit of lido intrathecal that shouldn't happen...

It's not your local. 0.5cc shouldn't be doing that. Do you use Fenton's technique (are you getting painful paresthesias)? Most folks do oblique, I like a straight AP, tap the TP to set depth, and slide anterior and medial to 6 under the pedicle.

As far as the complication, I was not in the room until I heard the call for help. The patient acted like it was an annoyance to have moust of her body turned off for 2 hours. She was a good sport about it. I helped get her head elevated, stuck around for pinprick testing, and wathced them get a set of vitals. Then I bolted back out to the clinic to get things humming along.

 

[PainDr]

If you don't use a local, how will you be able to tell if the injection was diagnostic or that you found the pain generator?

I don't use local either...for the same reasons as Gorback. For most of my TESI's, based on imaging and the clinical examination (most important part of the evaluation), I almost always know where the pain generator is. The proof is in the outcome. Also, I've found that most patients want conscious sedation and in those situations, using local as a diagnostic tool is pretty much worthless. Lastly, if a patient is comptemplating surgery, the surgeon will usually ask for a discogram...not a TESI.

BTW, lets not start another debate about the pro's and con's of using sedation. We've all got our own opinions.

 

[Mister Mxyzptlk]

I use local if I am looking for pain generators but that is largely confined to the joints, e.g., medial branch blocks, SI, etc. Even with 0.5% lidocaine I sometimes get a gimpy leg after an SI.

As for "diagnostic" TF's - I am a skeptic. A little volume goes a long way and I am not convinced that the local stays in a confined space. In order to get pain relief you must get the local past the point of irritation/compression, which is inside the canal most of the time. Once the medication is in the canal it can pick off other things in the area.

If I want to know if a certain nerve root is the problem I do my TFESI with an RF cannula with a 5 mm active tip. Then I stim and ask the patient if it's the same distribution or not. Then I inject the medication as the treatment arm of the procedure.

I rarely have to do that. It's usually quite obvious from the physical exam and imaging (plus EMG as needed). I only do that for cases where I can't figure it out, or a surgeon has asked me to do a "diagnostic" block. Sensory stim followed by TFESI is my version of a diagnostic block.

When I inject, I paint with a broad brush. I think there is mounting evidence that humoral factors in the epidural space play a significant role in radicular pain, and I want to flood the area and wash it out. Even with TF's I do a 5 cc injection. For SS I have started doing 10 cc IL injections. It might turn out that we need even higher volumes.

I have poked fun at Algos in the past for his love affair with cytokines et al because the quacks are always talking about "washing out the toxins", but he is turning out to be right. I hate when that happens.

 

[Ligament]

I agree with Gorback re; the limitations with SNRB ie. they are not selective! (most of the time)...

I'm going to start using Gorbacks stim with RF generator protocol. Makes a lot more sense. While I have the proble there I'll pulse RF too, won't bill for it but will be curious regarding the results.

I use local if I am looking for pain generators but that is largely confined to the joints, e.g., medial branch blocks, SI, etc. Even with 0.5% lidocaine I sometimes get a gimpy leg after an SI.

As for "diagnostic" TF's - I am a skeptic. A little volume goes a long way and I am not convinced that the local stays in a confined space. In order to get pain relief you must get the local past the point of irritation/compression, which is inside the canal most of the time. Once the medication is in the canal it can pick off other things in the area.

If I want to know if a certain nerve root is the problem I do my TFESI with an RF cannula with a 5 mm active tip. Then I stim and ask the patient if it's the same distribution or not. Then I inject the medication as the treatment arm of the procedure.

I rarely have to do that. It's usually quite obvious from the physical exam and imaging (plus EMG as needed). I only do that for cases where I can't figure it out, or a surgeon has asked me to do a "diagnostic" block. Sensory stim followed by TFESI is my version of a diagnostic block.

When I inject, I paint with a broad brush. I think there is mounting evidence that humoral factors in the epidural space play a significant role in radicular pain, and I want to flood the area and wash it out. Even with TF's I do a 5 cc injection. For SS I have started doing 10 cc IL injections. It might turn out that we need even higher volumes.

I have poked fun at Algos in the past for his love affair with cytokines et al because the quacks are always talking about "washing out the toxins", but he is turning out to be right. I hate when that happens.

 

[Tenesma]

i think the advantage of sensory stimulation is that you quickly learn that dermatomal maps are crap - based on old dissections based on shingles patterns...

i have done sensory stimulation on a person with a HNP at L3 but with S1 distribution of pain - and guess what? his L3 mapped in the S1 territory... that has happened quite a few times...

the problem is that sensory stimulation/mapping is not reimbursed per se, and adds time and effort and cost of needles, etc...

i agree with washing away the humors - however, when i am in the TF space it is amazing how far 1ml of omnipaq will travel... so the concept of 5cc seems a bit of overkill - inject 5ml of omnipaq next time and you will see what i mean.

i agree with diagnostic blocks as well - 0.5ml of lido goes onto many structures - again just inject 0.5ml of contrast the next time you do a medial branch and it is amazing where it goes... now i use 0.2ml (TB syringe) of lido for MBB and have found that my RFs have a higher success rate...

i am surprised with how confident you guys (gorback/paindr) are with your physical exam/imaging/emg/history to know where the pain generator is... i still find that in about 20-30% of the cases I honestly can't figure it out from just the first visit or two... in fact, i thought the premise behind interventional pain was the ability to use diagnostic blocks to better determine the pain generator...

 

[drusso]

It's not your local. 0.5cc shouldn't be doing that. Do you use Fenton's technique (are you getting painful paresthesias)? Most folks do oblique, I like a straight AP, tap the TP to set depth, and slide anterior and medial to 6 under the pedicle.

Steve,

I've heard this technique described by some of your other former fellows. My question is, are you coxial in the AP view when you "set your depth" or is your needle moving obliquely across the screen?...just curious.

What do you do in the common situation where you encounter a honkin, osteophytic SAP in the setting of severe DDD and a narrowed disc space with NF stenosis? How can you possibly "get around" the SAP without going oblique? I can see the AP approach working in a pristine back, but those are not my typical patients!

 

[drusso]

I have poked fun at Algos in the past for his love affair with cytokines et al because the quacks are always talking about "washing out the toxins", but he is turning out to be right. I hate when that happens.

I know what you mean. My question is when do you swing the dead chicken over the patient and chant three times?

 

[Mister Mxyzptlk]

"i am surprised with how confident you guys (gorback/paindr) are with your physical exam/imaging/emg/history to know where the pain generator is... i still find that in about 20-30% of the cases I honestly can't figure it out from just the first visit or two... in fact, i thought the premise behind interventional pain was the ability to use diagnostic blocks to better determine the pain generator..."


IMHO the H&P should give you a good idea of the problem most of the time. The history should give you an idea of what's going on and the physical exam should help narrow down the possibilities. Tests are for pinpointing problems or to differentiate among two or more possibilities.

For instance, spinal stenosis should be pretty obvious from the H&P. Imaging is done to confirm it and to identify what level needs treatment.

When you order the tests you should already have a working diagnosis. Otherwise you're just turning over rocks.

Tests should not be primary diagnostic tools. The primary diagnostic tools are listening to and touching the patient. However, what I see more and more is the following sequence: chief complaint -> imaging -> treatment.

I think that's why patients show up for their first appointment carrying hip xrays when they really have SI pain or spinal stenosis referring to the lower back and gluteal area. Most people call the iliac crest/SI region their "hips".

 

[lobelsteve]

Steve,

I've heard this technique described by some of your other former fellows. My question is, are you coxial in the AP view when you "set your depth" or is your needle moving obliquely across the screen?...just curious.

What do you do in the common situation where you encounter a honkin, osteophytic SAP in the setting of severe DDD and a narrowed disc space with NF stenosis? How can you possibly "get around" the SAP without going oblique? I can see the AP approach working in a pristine back, but those are not my typical patients!

Your vertebral body is upside-down.
The technique involves touching the inferior aspect of the TP, then sliding anteriorly while advancing medially. There is very little superior or inferior advancement of the needle while this is occurring. While learning the technique I would always check a lateral to ensure triplanar needle localization. Now, I'm pretty comfortable shooting the contrast and if I see epidural spread as well as nerve root spread, I'm there. If there are lots of osteophytes, I typicall stay lateral and advance anteriorly first, then steer medial into the foramen. Sometimes its a crapshoot and I bump and run off the osteophytes. I use a 25G 3.5" and it is thin enough to squirt by most anything (except walls of BMP and ground up hip).

It's just another way to skin the same cat. Though I advocate against Fenton's idea of sticking the root sheath, causing pain, then doing the therapuetic or diagnostic injection. How sens/spec can you be in a subjective question after you stab the root sheath?

 

[drusso]

Your vertebral body is upside-down.

...Man, I knew I was doing something wrong...I get it now...

 

[lobelsteve]

...Man, I knew I was doing something wrong...I get it now...

Wasn't trying to be a d1ck, sorry.

Just illustrating the point I go under and not over the TP. Skin wheal is 1cm lateral and 1cm inferior to the junction of the inferior TP to the pedicle.

DP still tries to over the TP, but he's so metro.

 

[Tenesma]

\\
agreed that history and physical is important but there are some pain conditions where there is no perfect diagnostic physical exam maneuver and where history may only imply a condition - i am thinking of SI joint pain..

of course, straightforward classical symptoms are easy - and they represent 70-80% of spine patients in my opinion - the other 20% aren't straight-forward.

hitting nerve root: i strongly advocate against that - i find that to be an antiquated "interventional radiology" habit that is painful to the patient, and can't be good... sorry your nerve root is in pain because of a disc but just for good measure we are going to spear it again... don't like that one bit...

as far as AP or slight oblique approach to nerve root - i find that that technique is easier on younger spines and becomes more and more difficult as the spine degenerates and is almost impossible on a post-fusion patient... plus you are likely to only shoot contrast in the AP projection - which is fine, but i have seen contrast go intra-vascular in the lateral projection without being able to appreciate that in the AP view - so i would suspect that with a strict AP approach that you may miss some intra-vascular uptake...

 

[Mister Mxyzptlk]

Actually I find SI joint pain to be one of the easiest diagnoses to make.

 

[Sharps]

Pretty much do everything consistent w/ ISIS guidelines. Usually AP approach but occasionally from posterolateral if bone is in the way.
Inject about 4cc 1% lidocaine w/ 80mg depomedrol divided bilat.
Usually good omnipaque spread w/ relatively little pt discomfort during the injections (compared to my colleague anyway)
People c/o cramps seem to come/go in waves.
Maybe it's the assistants eliciting the initial histories.
Kinda surprised more folks haven't noticed this.