ultrasound guided injections

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The money grubbing ***** comment was a bit strong, that might have been a bad day when I made that post.
However, I firmly defend that statement that ultrasound is greatly overused for spinal procedures, primarily for financial reasons. Some are salaried, but most non-private practice pain docs do have some kind of production/RVU bonus.

Originally posted by epidural guy
Really? I hope that young residents/fellows reading this demand some science behind this claim - because the science actually shows that caudals are more effective than interlaminar epidurals. If that isn't the case, post the science.
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I never claimed that an ILESI was better than a caudal. I said a TFESI was better than a caudal for the vast majority of clinical scenarios. Just try to find me a decent paper proving otherwise.

Originally posted by epidural guy
That is why we don't use personal experience to make clinical decisions. We use good science. Where is the science?
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Where is the science? Exactly where is your science for caudals? I didn't see any papers quoted in your lengthy defense of caudals.

Originally posted by epidural guy
In addition, there are many case reports of severe nerve damage and paralysis from doing transforaminals - even down to S1. Can you say the same about caudals?
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Many? There are a few case reports of significant nerve damage/paralysis from TFESI and I've read those papers. There are only a couple case reports of paralysis with TFESI below L3-L4 and standard fluoro.
What must be considered are the cases of nerve damage and paralysis that occur secondary to surgical complications when patients end up having surgery because their pain physician didn't use the most optimal epidural technique to treat their radiculopathy/stenosis. No one has ever done that study because the surgeons would never allow it.

I do all my TFESI with DSA, and use non-particulate steroids in higher lumbar levels.
Please show me a report of severe nerve damage/paralysis occuring when the physician did a lumbar TFESI with DSA.

DSA takes more time which I'm not reimbursed for, (particularly now that the TFESI guidance code has been dropped), but I do it because it's the best contemporary technique available for these patients,
not what was taught during residency in the 80s.
 
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facets said:
To clarify, I only do caudals on coumadin/plavix patients with a 25 g needle and put it just past the ligament, get a good dye flow and inject 10 cc of saline with 40-80 of kenalog or depo. I would not pass a catheter on a coumadin patient. I appreciate the perspective of those on the forum who are risk adverse due to litigation. I am fortunate to have never been sued (knock on my desk) but some of the best of us have been victims of malpractice suits. I would never make the statement that I am any better than those who have been in litigation, just more fortunate. It must really grind on you, and I would probably be more CYA if this had happened to me, but I still think that the risks of taking these patients off coumadin is greater than the risks of doing a caudal with them on. A lovenex bridge is an option but not for poor underinsured patients. Lovenox is extremely expensive
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i was risk adverse before i got sued, now i am risk paranoid/obsessed...
 
bedrock said:
The money grubbing ***** comment was a bit strong, that might have been a bad day when I made that post.
However, I firmly defend that statement that ultrasound is greatly overused for spinal procedures, primarily for financial reasons. Some are salaried, but most non-private practice pain docs do have some kind of production/RVU bonus.



I never claimed that an ILESI was better than a caudal. I said a TFESI was better than a caudal for the vast majority of clinical scenarios. Just try to find me a decent paper proving otherwise.



Where is the science? Exactly where is your science for caudals? I didn't see any papers quoted in your lengthy defense of caudals.



Many? There are a few case reports of significant nerve damage/paralysis from TFESI and I've read those papers. There are only a couple case reports of paralysis with TFESI below L3-L4 and standard fluoro.
What must be considered are the cases of nerve damage and paralysis that occur secondary to surgical complications when patients end up having surgery because their pain physician didn't use the most optimal epidural technique to treat their radiculopathy/stenosis. No one has ever done that study because the surgeons would never allow it.

I do all my TFESI with DSA, and use non-particulate steroids in higher lumbar levels.
Please show me a report of severe nerve damage/paralysis occuring when the physician did a lumbar TFESI with DSA.

DSA takes more time which I'm not reimbursed for, (particularly now that the TFESI guidance code has been dropped), but I do it because it's the best contemporary technique available for these patients,
not what was taught during residency in the 80s.
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I am unaware of any head to head study that compared caudal to TFESI. Is there some? I'm not trying to be difficult - I'm sincerely asking...is there good quality evidence to show this?

My point about evidence is that I think there is a complete lack of it....and in that setting, I don't think you can criticize one technique over the other, especially if I think I have good reason for choosing it over the other (less radiation exposure for me, etc.)

Here are some other thoughts I have about the reason to do a caudal....I have stopped using particulate steroid even in lumbar TFESI. There is some evidence that particulate steroid works better than non-particulate. And, as you point out, it probably makes a difference where you put that steroid - and probably the difference has to do with getting anterior spread - and my guess is you get more anterior spread with a caudal then you do with interlaminar. So, I want to use a particulate, AND I want anterior spread. I think a caudal may work well for this scenario. And I can use an ultrasound machine to reliably get into the space with image confirmation.
 
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epidural man said:
I am unaware of any head to head study that compared caudal to TFESI. Is there some? I'm not trying to be difficult - I'm sincerely asking...is there good quality evidence to show this?

My point about evidence is that I think there is a complete lack of it....and in that setting, I don't think you can criticize one technique over the other, especially if I think I have good reason for choosing it over the other (less radiation exposure for me, etc.)

Here are some other thoughts I have about the reason to do a caudal....I have stopped using particulate steroid even in lumbar TFESI. There is some evidence that particulate steroid works better than non-particulate. And, as you point out, it probably makes a difference where you put that steroid - and probably the difference has to do with getting anterior spread - and my guess is you get more anterior spread with a caudal then you do with interlaminar. So, I want to use a particulate, AND I want anterior spread. I think a caudal may work well for this scenario. And I can use an ultrasound machine to reliably get into the space with image confirmation.
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how can we even have a reasonable discussion when you are arguing that a caudal under ultrasound is better than a TFESI under fluoro. get with it, man.
 
lonelobo said:
Can you tell me your clinic name?... want to make sure I steer my patients to another in the area if asked.
Click to expand...


sure, PM me.

Just to be sure, you want to steer people away from my clinic because we do caudal's under ultrasound, correct?
 
These U/S vs. fluoro discussions are getting a tad out of hand. Folks, the enemy is not here on the forums.
 
specepic said:
These U/S vs. fluoro discussions are getting a tad out of hand. Folks, the enemy is not here on the forums.
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No Doubt!

I'll certianly think 9 or 10 times before mentioning ultrasound on this forum again - at least for another few years. Then we shall see.

I think it should be archived and referenced however in about 3 years. As was astutely said before (but for completely different reasons) So it was said, so it was written.
 
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epidural man said:
I am unaware of any head to head study that compared caudal to TFESI. Is there some? I'm not trying to be difficult - I'm sincerely asking...is there good quality evidence to show this?
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I have never seen a study directly comparing TFESI to a caudal because it's just so obvious.
Say you have a patient with an L3-L4 disc herniation, if you do a L4-L5 TFESI, your needle tip is already in the anterior epidural space immediately adjacent to the pathology and you can coat the L4 nerve root and L3-L4 disc herniation with highly concentrated steroid, (I would use 2cc of 40mg/cc of kenalog). If I did a caudal ESI with 2cc of 40mg/cc of kenalong mixed in with 6-9cc of saline, then the relative concentration of steroid at the L4 nerve root and the L3-L4 disc would be less than a tenth of the concentration I achieved with the TFESI. because the caudal ESI spread the steroid thin across multiple levels and the ventral and dorsal epidural spaces.

The reason for doing a therapeutic epidural is to deliver concentrated medication to the area of pathology. If we're going to dilute out the medication so much, we might as well just give PO steroids.

My point about evidence is that I think there is a complete lack of it....and in that setting, I don't think you can criticize one technique over the other, especially if I think I have good reason for choosing it over the other (less radiation exposure for me, etc.)
Click to expand...

They're hasn't been a perfectly designed study contrasting TFESI vs caudals, it's just completely clinically obvious which of those techniques is superior for most cases of radiculopathy/stenosis, which is why everyone on the board jumped on your case.

I can respect the fact that you're trying to decrease your radiation exposure, which is certainly a concern, but that can't be your primary reason to do a caudal. And that was why I got on my soapbox. It wasn't aimed at you specifically, but the thought of patients needlessly being exposed to the risks of surgery because their pain doc was greedy or lazy, does boil my blood a bit. We've all seen plenty of ****ed up patients after spinal surgery and I just consider it a moral imperative to do everything possible to spare them those risks.
Here are some other thoughts I have about the reason to do a caudal....I have stopped using particulate steroid even in lumbar TFESI. There is some evidence that particulate steroid works better than non-particulate. And, as you point out, it probably makes a difference where you put that steroid - and probably the difference has to do with getting anterior spread - and my guess is you get more anterior spread with a caudal then you do with interlaminar. So, I want to use a particulate, AND I want anterior spread. I think a caudal may work well for this scenario. And I can use an ultrasound machine to reliably get into the space with image confirmation.
Click to expand...


Again refer to my first paragraph. Yes, you may get anterior spread, but at what concentration?
Yes a caudal works for some patients, but there are lots of patients don't respond to a caudal, that would respond to a TFESI. Simply as that.

Do you do a TFESI on the patients that don't respond to a caudal or do you refer them to a surgeon?

If you start with a caudal because you really believe in caudals and want to avoid radiation, fine, but if the caudal doesn't work, you gotta offer them what 90% of fellowship-trained pain docs would do for recalcitrant radiculopathy/stenosis---a fluoro-guided lumbar TFESI.
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bedrock said:
epidural man said:
Do you do a TFESI on the patients that don't respond to a caudal or do you refer them to a surgeon?
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I rarely refer a patient to a surgeon. I have tons and tons of stuff I can do to try and help a patient, pulsed RF to the DRG of the affected area for one. I highly doubt that people that get paid for procedures are doing that.

By the way, I am sure it is very obvious to you that a TFESI is better than a caudal, but not to me. I am obtuse. For one, I have no idea what the ideal or minimal concentration of the particulate steroid is that needs to be around to get relief. I'm not even sure I know completely why the steroid works. We think it has to do with inflammation and mediators and all that crap that damaged discs and even inflammed facets elude - but can I say that for sure?

There is some data that shows caudals are better than ILESI (at the level).

And by the way, who says I even do that many caudals? I never did. I just said I like to do them (when I do them) under ultrasound - just defending that important imaging modality.

The reason people jumped all over me, is because that is what people do on this forum. I get it. It's kinda fun to be a dick sometimes (not calling you a dick bedrock....).
Click to expand...
 
bedrock said:
I'm not even sure I know completely why the steroid works. We think it has to do with inflammation and mediators and all that crap that damaged discs and even inflammed facets elude - but can I say that for sure?
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Olmarker K, Byord G, Cornfjord M, et al. Effects of methylprednisolone on nucleus pulposusinduced nerve root injury. Spine 1994;19:1803-8.

http://www.ncbi.nlm.nih.gov/pubmed/7973978

What do you think about this study?
 
epidural man said:
I am unaware of any head to head study that compared caudal to TFESI. Is there some? I'm not trying to be difficult - I'm sincerely asking...is there good quality evidence to show this?

My point about evidence is that I think there is a complete lack of it....and in that setting, I don't think you can criticize one technique over the other, especially if I think I have good reason for choosing it over the other (less radiation exposure for me, etc.)

Here are some other thoughts I have about the reason to do a caudal....I have stopped using particulate steroid even in lumbar TFESI. There is some evidence that particulate steroid works better than non-particulate. And, as you point out, it probably makes a difference where you put that steroid - and probably the difference has to do with getting anterior spread - and my guess is you get more anterior spread with a caudal then you do with interlaminar. So, I want to use a particulate, AND I want anterior spread. I think a caudal may work well for this scenario. And I can use an ultrasound machine to reliably get into the space with image confirmation.
Click to expand...

Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trial.Dashfield AK, Taylor MB, Cleaver JS, Farrow D.

http://www.ncbi.nlm.nih.gov/pubmed/15695544


So per the study they both work well.
 
PMR2008 said:
Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trial.Dashfield AK, Taylor MB, Cleaver JS, Farrow D.

http://www.ncbi.nlm.nih.gov/pubmed/15695544


So per the study they both work well.
Click to expand...

Actually, caudals were better in this study. But they were compared to endoscopic ESI and not a 25g tfesi. Outcome measures tell of bizarre results with p values CS for things that don't change at 6 mo.
 
so from re-reading this thread, i think i get what you are trying to say...

only use ultrasound for everything, only do caudals for all issues...is that right...😀 just kidding...


epidural man said:
bedrock said:
I rarely refer a patient to a surgeon. I have tons and tons of stuff I can do to try and help a patient, pulsed RF to the DRG of the affected area for one. I highly doubt that people that get paid for procedures are doing that.

By the way, I am sure it is very obvious to you that a TFESI is better than a caudal, but not to me. I am obtuse. For one, I have no idea what the ideal or minimal concentration of the particulate steroid is that needs to be around to get relief. I'm not even sure I know completely why the steroid works. We think it has to do with inflammation and mediators and all that crap that damaged discs and even inflammed facets elude - but can I say that for sure?

There is some data that shows caudals are better than ILESI (at the level).

And by the way, who says I even do that many caudals? I never did. I just said I like to do them (when I do them) under ultrasound - just defending that important imaging modality.

The reason people jumped all over me, is because that is what people do on this forum. I get it. It's kinda fun to be a dick sometimes (not calling you a dick bedrock....).
Click to expand...
Click to expand...
 
lonelobo said:
Rather underwhelming video, not sure how this is anywhere close to what can be seen under fluoro ?
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This is, in my humble opinion, probably not the best method for performing an US-guided caudal epidural. It's easier to start with a transverse view, which allows you to clearly view the sacral hiatus and sacrococcygeal ligament. You can inject with an out-of-plane approach this way, or then turn the probe longitudinally and perform the injection in-plane.

Here's an article on the topic: http://journals.lww.com/anesthesiol...nd_Guidance_in_Caudal_Epidural_Needle.28.aspx
 
bedrock said:
epidural man said:
I have never seen a study directly comparing TFESI to a caudal because it's just so obvious.
Say you have a patient with an L3-L4 disc herniation, if you do a L4-L5 TFESI, your needle tip is already in the anterior epidural space immediately adjacent to the pathology and you can coat the L4 nerve root and L3-L4 disc herniation with highly concentrated steroid, .
Click to expand...

I'm not sure that is true. We often think we know why something works, or what is important, only to be redirected in our thinking by further imformation. See the attached study - it kinda goes against what you propose here. And by the way, the reason the study hasn't been done is not because it is just so intuitive. It's not for me, and if it isn't for me, it isn't for a lot of other people.

PMR2008 said:
Olmarker K, Byord G, Cornfjord M, et al. Effects of methylprednisolone on nucleus pulposusinduced nerve root injury. Spine 1994;19:1803-8.

http://www.ncbi.nlm.nih.gov/pubmed/7973978

What do you think about this study?
Click to expand...

I can't get the PDF of this article. Can you attach? Many more sophisticated studies have come out - documenting TNF-alpha as a possible huge player, also TGF-beta, IL-8, IL-1alpah, Protoglandin E2 have all been implicated. IL-1B has been shown to leak out of diseased facet joints.
Click to expand...
 

Attachments

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PMR2008 said:
Olmarker K, Byord G, Cornfjord M, et al. Effects of methylprednisolone on nucleus pulposusinduced nerve root injury. Spine 1994;19:1803-8.

http://www.ncbi.nlm.nih.gov/pubmed/7973978

What do you think about this study?
Click to expand...

Librarian dug it up. Anyway, interesting findings. I'm not sure how ketamine could have interfered with the results - they change SSEPS for example.

Also, here is a line from the study - kind of what I was saying before "The pharmacologic mechanism of high-dose steroid treatment are complex and not fully understood."
 

Attachments

By the way, RVU's for using ultrasound for facets, or transforaminals, are considered category III - and have no RVU value assigned to it - so that makes it hard to get any reimbursment for using the practice.

0228T - 0231T (US guided transforaminal injections) and 0213T - 0218T (US guided paravertebral facet joint injections)

"...a set of temporary codes for emerging technology, services, & procedures. Category III codes allow data collection for these services/procedures. Use of unlisted codes does not offer the opportunity for the collection of specific data. If a Category III code is available, this code must be reported instead of a Category I unlisted code. This is an activity that is critically important in the evaluation of health care delivery & the formation of public & private policy. The use of the codes in this section allow physicians & other qualified health care professionals, insurers, health services researchers, & health policy experts to identify emerging technology, services, & procedures for clinical efficacy, utilization & outcomes..........The inclusion of a service or procedure in this section neither implies nor endorses clinical efficacy, safety, or the applicability to clinical practice. the codes in this section may not conform to the usual requirements for CPT Category I codes established by the Editorial Panel. For Category I codes, the Panel requires that the service/procedure be performed by many health care professionals in clinical practice in multiple locations & that FDA approval, as appropriate, has already been received. The nature of emerging technology, services, & procedures is such that these requirements may not be met.............."
 
sblau001 said:
This is, in my humble opinion, probably not the best method for performing an US-guided caudal epidural. It's easier to start with a transverse view, which allows you to clearly view the sacral hiatus and sacrococcygeal ligament. You can inject with an out-of-plane approach this way, or then turn the probe longitudinally and perform the injection in-plane.

Here's an article on the topic: http://journals.lww.com/anesthesiol...nd_Guidance_in_Caudal_Epidural_Needle.28.aspx
Click to expand...

similar to fluoro with AP and lat you should always use mutually orthogonal planes (in and out of plane) when checking and guiding your needle with ultrasound. both machines translate a 3d image into a 2d screen so the same geometry rules apply
 
you did a neuraxial procedure in an anticoagulated patient?

powermd said:
I did an ultrasound guided caudal on Monday.

1. Patient reported a severe contrast dye allergy.
2. On Coumadin for afib.
3. Postlami at the level of interest.
4. Lives hours away, wants procedure today.
5. Fat enough to see the needle enter the hiatus under active guidance.

I guess I'm just a greedy bastard.

btw, my partners do caudals with 10 mL volume and 120 mg depo. I thought it was crazy at first, but this works well for A LOT of patients. Previously I had only ever done caudals with 5 mL and 80 of depo, with very disappointing results.
Click to expand...
 
I think you can find an article here and there supporting caudal esi...but overall if you look at the most recent cochrane review article for esi, there was very little overall support for caudal. My problem is not with caudal, I'll do them if I have to, but more with these con artists trying to teach docs u/s guided esi and facet joint injections over a weekend course in order to increase practice revenue.
 
How is ultrasound guidance vs fluro guidance increasing revenue? and if so by how much?



voltron said:
I think you can find an article here and there supporting caudal esi...but overall if you look at the most recent cochrane review article for esi, there was very little overall support for caudal. My problem is not with caudal, I'll do them if I have to, but more with these con artists trying to teach docs u/s guided esi and facet joint injections over a weekend course in order to increase practice revenue.
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epidural man said:
👎thumbdown👎

How meta-analysis became the highest level of evidence is beyond me.

Anyone that actually reads articles know that meta-analysis lie, lie, lie.
Click to expand...

Gotta agree with epidural man on that one. Meta-analyses don't mean anything and consequently don't alter my management.

Even the best meta-analysis in the world couldn't convince me to start doing caudal ESI on all my patients...... 😀
 
PMR2008 said:
How is ultrasound guidance vs fluro guidance increasing revenue? and if so by how much?
Click to expand...

I am a big U/S user and feel it has a role for many procedures. The main concern here on this forum I believe is that non-pain docs will start doing lots of ESIs in office under U/S. This may be PCPs, Rheum, Sports med, mid levels, etc.

For a practicing pain doc there is really minimal to no financial incentive b/c U/S takes just as long, if not longer, than fluoro, plus having to buy the machine.

For anything vascular and esp where the needle tip cannot be seen well by the U/S,I would have concerns.
 
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Jeff05 said:
you did a neuraxial procedure in an anticoagulated patient?
Click to expand...

I believe this is a gray area, particularly if you only pierce the sacrococcygeal ligament, and don't drive the needle all the way up the hiatus. Have to weigh the risks and benefits, just like anything else.
 
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