parasaggital ILESI - how far

[deleted131481]

There have been discussions on merits of TFESI vs parasaggital ILESI. My question is how far parasaggital do you go when you are targeting one side on an ILESI? For purposes of discusson I have attached an article with an image describing different zones based on distance from midline to pedicle - divides it into zones 1 through 4.

For me I am probably in zone 2 a bit more often than zone 3. I'm wondering if I should target as far lateral in the opening as possible (lateral zone 3 or zone 3/4 border).

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[SSdoc33]

i saw this guy's talk at a recent SIS meeting. bottom line: does it really matter? we are talking about a matter of millimeters, and we know the fluid travels anywhere it wants to, anyway

 

[Ducttape]

zone 3 close to the border.

 

[macman]

For me, it completely depends on their MRI, in other words how big is the posterior epidural space on axial, how wide is it. If they have relatively severe stenosis in a very very small posterior epidural space that is very narrow I will not stray far from the midline. I think it is completely anatomy dependent on an individual basis with each patient and therefore no rule could be made across the board, IMHO

 

[drrosenrosen]

I usually end up between zones 2 and 3. But I agree that with variations in epidural anatomy, adhesions/septations, it can be very hard to guide the injectate. I've put it square in the middle (zone 1) and had the contrast be more unilateral than parasagittal injections on the border of 2 and 3.

 

[nvrsumr]

almost always zone 2 when doing clo

 

[deleted131481]

i saw this guy's talk at a recent SIS meeting. bottom line: does it really matter? we are talking about a matter of millimeters, and we know the fluid travels anywhere it wants to, anyway

In my experience a few mm can result in significantly different contrast spread. I've had where I think I'm on one side and contrast goes to the other, I move it 1 or 2mm lateral and spread is drastically different. Here's another article attached that looks at midline vs parasaggital.

For me, it completely depends on their MRI, in other words how big is the posterior epidural space on axial, how wide is it. If they have relatively severe stenosis in a very very small posterior epidural space that is very narrow I will not stray far from the midline. I think it is completely anatomy dependent on an individual basis with each patient and therefore no rule could be made across the board, IMHO

So let's say mild-moderate stenosis and decent epidural space - would you try to hit zone 3?

 

[MitchLevi]

All my ILESI are 2 or 3.

 

[RoloTomassi]

Usually 3. But if severe, sometimes all you have is 1. Something else that can make a difference is angulation of needle. Skin entry at zone 1 or 2 and steering lateral with tip ending at 3, bevel facing lateral, seems to spread more lateral than starting at 4 and ending at 3.

 

[MitchLevi]

In my experience a few mm can result in significantly different contrast spread. I've had where I think I'm on one side and contrast goes to the other, I move it 1 or 2mm lateral and spread is drastically different. Here's another article attached that looks at midline vs parasaggital.


So let's say mild-moderate stenosis and decent epidural space - would you try to hit zone 3?

Your study lists ILESI with 80mg Kenalog, 2cc bupi 0.5% + 6cc NS.

They did a 10cc injxn and (GASP) used Kenalog!

 

[manowar rules]

Depends a lot on what part of the spine you’re in. L5-S1 you can hit zone 3 all day, no problem. Cervical ESI, I’m not straying much beyond zone 1

Also, for us paramedian ESI lovers, it’s amazing how sharply the contrast often stops at midline. There has to be some sort of septum in the epidural space. I think back to doing labor epidurals and wonder how unilateral numbness wasn’t more common

 

[deleted875186]

Depends a lot on what part of the spine you’re in. L5-S1 you can hit zone 3 all day, no problem. Cervical ESI, I’m not straying much beyond zone 1

Also, for us paramedian ESI lovers, it’s amazing how sharply the contrast often stops at midline. There has to be some sort of septum in the epidural space. I think back to doing labor epidurals and wonder how unilateral numbness wasn’t more common

Why is it safer to be in zone one on a C7-T1 ESI? In fact the ligament is thicker from a paramedian approach, I’m often o
Parasagital in zone 2 for my CESI.

 

[Taus]

Generally zone 2 or bordering 2/3. Exceptions are mod-severe stenosis at level, where epidural fat only occupies small area close to midline, and zone 3, tap os, walk under, as a salvage for a foraminal disc that failed tfesi/dex.

 

[manowar rules]

Why is it safer to be in zone one on a C7-T1 ESI? In fact the ligament is thicker from a paramedian approach, I’m often o
Parasagital in zone 2 for my CESI.

When I look at T1 axials on the MRI, the epidural fat doesn’t often spread much beyond midline at C7-T1. And while wet taps are quite uncommon, I’ve had them when I venture a bit too far lateral in cervical spine.

Also I used to do a lot more C6-7. There you really have to be midline.

 

[Darkside_]

Why is it safer to be in zone one on a C7-T1 ESI? In fact the ligament is thicker from a paramedian approach, I’m often o
Parasagital in zone 2 for my CESI.

Yes and Zone 1 doesn't work as well if you're using CLO.

 

[Ducttape]

Depends a lot on what part of the spine you’re in. L5-S1 you can hit zone 3 all day, no problem. Cervical ESI, I’m not straying much beyond zone 1

Also, for us paramedian ESI lovers, it’s amazing how sharply the contrast often stops at midline. There has to be some sort of septum in the epidural space. I think back to doing labor epidurals and wonder how unilateral numbness wasn’t more common

there is, particularly cervical.

a study i cant find now suggested that the majority of medication stays on the side of the injection.

Your study lists ILESI with 80mg Kenalog, 2cc bupi 0.5% + 6cc NS.

They did a 10cc injxn and (GASP) used Kenalog!

study was done in Iran. the FDA doesnt have much to say there...

 

[PinchandBurn]

I thnk 2 is good..you start going into 3 and it hurts a patient.