Local in TFESIs

[Timeoutofmind]

From what I have seen, pain docs are hit or miss as far as putting local in interlaminar injections. But some local in tfesis seems much more common...why is that?

Is the argument that with the interlaminar injection, so little of the local is going to actually be contacting the interface between the bulging disc and the nerve root... Whereas in tfesi you are literally depositing the local right on the irritated nerve?

Or does have it more have to do with the fact that inadvertent intrathecal injections would be more likely in interlaminar and less likely in tfesis?

Thanks ahead of time!

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[bedrock]

Local not required for any epidural injection. Only lasts for a few hours and some patients get worried when their pain worsens 4 hours later and think something went wrong.

Only time you might consider a little local is when doing a lumbar TFESI for a patient with an extremely painful radiculopathy, so they can tolerate you injecting the full volume of steroid along the nerve.

But rarely needed, 1-3% of Lumbar TFESI.

Local never needed for ILESI at any level and just stupid if you include local with a cervical ILESI.

 

[lonelobo]

Still use lidocaine in lumbar procedures maybe only a 1/2 cc but the pts do like it when they have some immediate relief.
They are always told the pain could come back in a few hrs, so there is no surprise for them.
Have tried it with and without local and anecdotally the ones that have local have a much better experience.

 

[NJPAIN]

I think using local is a remnant of pain medicine originating out of anesthesiology. As an anesthesiologist you associate epidural injections with anesthesia and analgesia thus anesthetic drugs. After a few dead legs and accidental intrathecal injections you wake up and realize there is far more to loose than to gain. Think about the times you look at your contrast pattern and have even the slightest question if some of the contrast if IT or SD. If you inject local you find out, the hard way.


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[bedrock]

I think using local is a remnant of pain medicine originating out of anesthesiology. As an anesthesiologist you associate epidural injections with anesthesia and analgesia thus anesthetic drugs. After a few dead legs and accidental intrathecal injections you wake up and realize there is far more to loose than to gain. Think about the times you look at your contrast pattern and have even the slightest question if some of the contrast if IT or SD. If you inject local you find out, the hard way.


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I think there is truth to your thoughts on the origin of local. It seems that anesthesia-pain trained docs inject local with ESI 10x more often than PM&R-pain trained docs.

And as you said, there is more to lose than be gained by injecting local.

 

[SSdoc33]

i put in a little local for TFESIs, but not ILESIs. TFESIs can hurt, and you can exactly predict which ones will hurt more. if you have a really stenotic foramen, you are gonna get a painful paresthesia even with perfect technique. i little dab of LA makes it more tolerable.

 

[pmrmd]

TFESIs can hurt, and you can exactly predict which ones will hurt more. if you have a really stenotic foramen, you are gonna get a painful paresthesia even with perfect technique.

Exactly. 0.5cc of 0.25% marcaine is just enough to help the patient tolerate the TFESI. Never in CESI. Usually unnecessary in LESI.

 

[Timeoutofmind]

What about the concept of "breaking the pain cycle" and trying to interrupt some of the central sensitization peripheral sensitization etc? The same reason, other than it being diagnostic, we do a peripheral nerve block ...

 

[Timeoutofmind]

And how is Marcaine going to help them tolerate the injection? Takes way too long to set up to be of any use for this

 

[pmrmd]

The effect is near immediate when on top of the dura.

 

[dhcofc]

Many people (and fellowships) use Kenalog and Lidocaine 0.5% for CESI - this thread is making me reevaluate this. Also, there still seems to be a debate on particulate vs dexamethasone for ILCESI. What are your thoughts on using particulate and dilute local in CESIs?

 

[Stim4me]

From the anesthesia literature we know lidocaine and marcaine may be neurotoxic. Many case reports and legal settlements in AsA data base... From my experience they cause more spasms the days later. Add the fact that you can cause transient motor weakness and/or IT spinal anesthesia, I see no reason to add them any more. If you have a very uncomfortable patient , maybe you can make an exception, but the overall benefit is low.

 

[clubdeac]

I use local in ILESIs and have never seen a dead leg. Local in TFESIs often causes fairly dense sensory deficit

 

[lobelsteve]

I use local in ILESIs and have never seen a dead leg. Local in TFESIs often causes fairly dense sensory deficit

Never....
Often.....

Dogma.
Nonsense.

 

[Stim4me]

I use local in ILESIs and have never seen a dead leg. Local in TFESIs often causes fairly dense sensory deficit

If you are caring for a post thoracotomy patient with a PCEA , and are trying to wean them off a ventilator , by all means add the local to the injectate. The benefits out weigh the potential risks. Otherwise I'd read the monthly articles in pain medicine describing local anesthesia as neurotoxic....

 

[SSdoc33]

If you are caring for a post thoracotomy patient with a PCEA , and are trying to wean them off a ventilator , by all means add the local to the injectate. The benefits out weigh the potential risks. Otherwise I'd read the monthly articles in pain medicine describing local anesthesia as neurotoxic....

0.5 cc of local on a spinal nerve root is neurotoxic. o......k

i think you may mean "chrondrotoxic", for which you could theoretically make a legitimate argument -- see doctodd

 

[IN2B8R]

It's all in moderation....


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[oreosandsake]

interesting.

we used 2-3 ml of 1% lidocaine in all of our lumbar TFESI and ILESI during my fellowship. you would think that in a training program you are more prone to getting complications but i don't remember hearing of a "dead leg" all year. (probably bias as the pacu nurses took care of the patients, but we would get called back if there was ever an issue)

I still do the same now, but after reading this thread will need to re-evaluate


i don't put any local in C ILESI

 

[Ducttape]

From the anesthesia literature we know lidocaine and marcaine may be neurotoxic. Many case reports and legal settlements in AsA data base... From my experience they cause more spasms the days later. Add the fact that you can cause transient motor weakness and/or IT spinal anesthesia, I see no reason to add them any more. If you have a very uncomfortable patient , maybe you can make an exception, but the overall benefit is low.

should we be not doing labor epidurals or spinals, if they are neurotoxic?

 

[pastafan]

should we be not doing labor epidurals or spinals, if they are neurotoxic?

The use of high concentration of LA and microbore spinal catheters did lead to problems with neurotoxicity. These were abandoned years ago. I am happily not doing labor epidurals anymore but no, LA is not problematic when used properly.