Steroids

[drf]

What are people using for ILESI, TFESI, shoulder/hip/knee joints, peripheral nerves (ie occipital, ilioinguinal, lat fem cut), SIJ, MBB (if steroids are used)?

I've generally used Depomedrol 40 for joins and 80 mg for ESI. I more or less switched to Kenalog in the last few months, but mostly stick to the 40 mg dose. For MBB I generally put 80 mg Depo with 3 cc bupi 0.5% and divide over L4, L5, ala, and S1. I understand the controversy here, but simply clinically and anecdotally I've had pts go 3+ months with relief and never needed to go to RF. If diabetic or other significant comorbidity I don't use steroids.

Also, I do a lot of US guided diagnostic procedures of peripheral nerves. For the more difficult blocks I add in stim as well to ensure concordant paresthesia. I've noticed that 5 ml bupi 0.25%/0.5% with 20-40 of Kenalog will turn off the specific nerve for up to a month. I had a rash of pts who still had objective motor weakness 72 hours after procedure (fem/popliteal type blocks) and therefore decrease my steroid from 40 to 20. One case that stands out is an iliopsoas bursa injection with 9 ml bupi 0.25 and 1 cc DepoMedrol 40 mg. This pt needed wheelchair/cane for 3-4 days after the procedure. The 10 ml of solution managed to spread to the femoral nerve, likely due to volume, even with live US guidance and pre-injection visualization of femoral neurovasc bundle. currently have a pt I performed a US guided saphenous nerve block 3 weeks ago with 20 or 40 (dont remember) who still has no pain and numbness remains.

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[SSdoc33]

What are people using for ILESI, TFESI, shoulder/hip/knee joints, peripheral nerves (ie occipital, ilioinguinal, lat fem cut), SIJ, MBB (if steroids are used)?

I've generally used Depomedrol 40 for joins and 80 mg for ESI. I more or less switched to Kenalog in the last few months, but mostly stick to the 40 mg dose. For MBB I generally put 80 mg Depo with 3 cc bupi 0.5% and divide over L4, L5, ala, and S1. I understand the controversy here, but simply clinically and anecdotally I've had pts go 3+ months with relief and never needed to go to RF. If diabetic or other significant comorbidity I don't use steroids.

Also, I do a lot of US guided diagnostic procedures of peripheral nerves. For the more difficult blocks I add in stim as well to ensure concordant paresthesia. I've noticed that 5 ml bupi 0.25%/0.5% with 20-40 of Kenalog will turn off the specific nerve for up to a month. I had a rash of pts who still had objective motor weakness 72 hours after procedure (fem/popliteal type blocks) and therefore decrease my steroid from 40 to 20. One case that stands out is an iliopsoas bursa injection with 9 ml bupi 0.25 and 1 cc DepoMedrol 40 mg. This pt needed wheelchair/cane for 3-4 days after the procedure. The 10 ml of solution managed to spread to the femoral nerve, likely due to volume, even with live US guidance and pre-injection visualization of femoral neurovasc bundle. currently have a pt I performed a US guided saphenous nerve block 3 weeks ago with 20 or 40 (dont remember) who still has no pain and numbness remains.

you are using huge volumes of local anesthetics. im not surprised you are anesthetizing things you dont want to.

why are you using steroid for peripheral nerve blocks?

if your question is how much steroid to use, i would say that i dont use steroid on peripheral blocks or MBBs. 80 mg otherwise for large joints and ESIs

 

[PMR 4 MSK]

80 mg depomedrol for ESIs typically.

40 mg kenalog for large joints, 10 - 20 for smaller joints.

Steroid on nerve block only makes sense to me if there is something inflaming the nerve, such as HNP. I'll use steroid on LFC injections for meralgia paresthetica, for carpal and cubital tunnel injections and similar. MBB is only diagnostic for me, if I want it therapeutic, it's intra-articular or RFA. But yeah, I also get the occasional patient with prolonged relief.

3 cc is not a MBB, that's a larger volume than the facet itself, it'll go everywhere. Try 1/10 that dose.

10 cc for bursa is way too much. I bet the bursa had only 1-2 cc to start with. The local is not what does the action. I did an iliopsoas bursa injection yesterday with 2 cc 2% lido and 1 cc kenalog 40. 90%+ pain relief immediately following the injection.

For joints I use minimal local unless I want a diagnostic nijection also, the it's usually 2-4 cc 2% lido - maximize the lidocaine while minimizing volume.

I always try to use the smallest amount of fluid that I can anywhere. The most I put anywhere is usually 8 cc in a shoulder or hip for an MRI arthrogram.

 

[Tenesma]

dude... your volume of 3cc over 3-4 spots is still a big dose... i do 0.3ml in a tuberculin syringe...

you are definitely going to get femoral nerve blocks w/ iliopsoas injections with that kind of volume.... first of all, that bursa is tough to get into properly and there is a lot of back-flow of the injectate...

and decreasing the steroid amount is not going to shorten the motor block...

you should think of the local as a way to reduce the peri-procedural discomfort... so usually 2-3 cc is more than enough --- it is the steroid that typically ends up doing the trick.

 

[lobelsteve]

dude... your volume of 3cc over 3-4 spots is still a big dose... i do 0.3ml in a tuberculin syringe...

you are definitely going to get femoral nerve blocks w/ iliopsoas injections with that kind of volume.... first of all, that bursa is tough to get into properly and there is a lot of back-flow of the injectate...

and decreasing the steroid amount is not going to shorten the motor block...

you should think of the local as a way to reduce the peri-procedural discomfort... so usually 2-3 cc is more than enough --- it is the steroid that typically ends up doing the trick.

I hate TB syringes. No Luer lock. I use 3 or 5cc for the .3 to .5cc injections volumes.

 

[drf]

Steroid on nerve block only makes sense to me if there is something inflaming the nerve, such as HNP. I'll use steroid on LFC injections for meralgia paresthetica, for carpal and cubital tunnel injections and similar. MBB is only diagnostic for me, if I want it therapeutic, it's intra-articular or RFA. But yeah, I also get the occasional patient with prolonged relief.
--I do many of these procedures at the request of others in my group as I'm the only US guy. Ie Saphenous nerve block in adductor canal with local/steroid. As mentioned, sometimes the patients end up with prolonged relief.

3 cc is not a MBB, that's a larger volume than the facet itself, it'll go everywhere. Try 1/10 that dose.
--This is divided over 4 needles, not each needle. With fellows the needles aren't always 'perfect' so the lil extra 0.8-1 ml makes me feel better about covering the medial branch. Otherwise the procedures would take 30 minutes each, especially in July/August.

10 cc for bursa is way too much. I bet the bursa had only 1-2 cc to start with. The local is not what does the action. I did an iliopsoas bursa injection yesterday with 2 cc 2% lido and 1 cc kenalog 40. 90%+ pain relief immediately following the injection.
--Agreed. My doses have gone down a bunch as I've gotten more comfortable in my target.

Thanks

 

[Ligament]

There are 1cc syringes with luer locks available, I know cause I use them on occasion when I need to pressurize a nasty SI joint...

 

[PMR 4 MSK]

I hate TB syringes. No Luer lock. I use 3 or 5cc for the .3 to .5cc injections volumes.

There are 1cc syringes with luer locks available, I know cause I use them on occasion when I need to pressurize a nasty SI joint...

Yes, I use 1 cc with Luer lock all the time. Much easier to know I was using 0.1, 0.2, whatever.