Alternative to cervical interlam esi

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Nonphysiologic

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Hey guys,

So a seasoned colleague of mine who does a ton of Med legal work (defense and plaintiff) doesn't do any cervical interlaminar ever. He only does what he calls "facet overflow" method. Basically he does a facet injection coming from posterior and injects 0.3 cc of contrast to confirm and 1cc of Dex into the facet joint itself so that it "overflows" ventrally. He says it's way safer , he considers Interlam too dangerous as he's seen people with 30 + years paralyze people , and he sent me this article to justify this method. He bills as a cervical TFESI and says it all holds up in court if you're ever deposed for any reason.

I actually tried gowned up with him on a case and saw the patient with him with someone with clear radiculopathy. The patient actually did well.
Thoughts on the efficacy and on billing it as a cervical tfesi?

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I'd believe it. Similar to that ILESI/facet injection paper, if you're coming down around that Z-joint capsule, many are likely within the same space, but more importantly, the steroid effect isn't limited to that specific space. The effectiveness is likely similar.

Still, I would not bill that as a TFESI as that's clearly incorrect coding, despite shared or similar efficacy.

Just do a catheter based ILESI from lower if you're not comfy doing a TFESI there.
 
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Imagine a Doctor who convinces a jury that cervical IL ESI are not needed because there is a safer procedure would be quite an effective plaintiff witness. ?.
 
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I buy that it probably works, but this paper compares TFESI with facets, not ILESI. I would definitely not code a facet injection as a TFESI, why not just code it as a facet, 64490 is also a high paying procedure, makes no sense to code it differently.
 
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he considers Interlam too dangerous as he's seen people with 30 + years paralyze people

Hm, do tell. That’s quite a statement. I’d love to hear about those, see the pre-op MRI, see intra-op pics AP and CLO, hear about sedation being used, etc.

Im willing to venture a guess. When I hear about old school guys and complication, it’s often bad technique. “I stay in AP the entire time, since that’s how I always have done it”. Or “I use propofol for sedation, because that’s how I’ve always done it”

I talked to an older doc recently. He was telling me he’s had a few complications with kypho. When pressed further, I learned he would inject 2 cc of cement and then take a picture. You read that correctly. 1 cc per needle (b/l approach), picture, repeat. When I asked why he doesn’t use the gun and squeeze 0.2cc and picture like I do, he basically said “well that’s the way I’ve always done it.”

Just my 2 cents. Take what you hear with a Grain of salt.
 
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Hm, do tell. That’s quite a statement. I’d love to hear about those, see the pre-op MRI, see intra-op pics AP and CLO, hear about sedation being used, etc.

Im willing to venture a guess. When I hear about old school guys and complication, it’s often bad technique. “I stay in AP the entire time, since that’s how I always have done it”. Or “I use propofol for sedation, because that’s how I’ve always done it”

I talked to an older doc recently. He was telling me he’s had a few complications with kypho. When pressed further, I learned he would inject 2 cc of cement and then take a picture. You read that correctly. 1 cc per needle (b/l approach), picture, repeat. When I asked why he doesn’t use the gun and squeeze 0.2cc and picture like I do, he basically said “well that’s the way I’ve always done it.”

Just my 2 cents. Take what you hear with a Grain of salt.
Billing something that you are not doing is fraud.

Simple enough.
Agree that billing this as a CTFESI is fraud.

also agree that many complications are from docs with old and or terrible technique. The answer isnt to stop doing the procedure but to learn how to do it correctly.
 
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I buy that it probably works, but this paper compares TFESI with facets, not ILESI. I would definitely not code a facet injection as a TFESI, why not just code it as a facet, 64490 is also a high paying procedure, makes no sense to code it differently.

Probably because he wouldn’t get paid or get the facet joint injection code approved. The formularies in my area do not allow for “therapeutic” facet joint injections or facet joint injections done in the presence of radicular pain. You can only do them as a “diagnostic” procedure. But after you do it as a diagnostic procedure you cannot follow it with RFA.
 
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No cervical catheters. They pierce the dura quite easily.
I think that depends on technique and the catheter.

Lately I’ve been doing most of my CESI with cath. I enter at T1-T2 with a shallow angle, 18G touhy, place the tip midline, rotate the bevel to the desired side and then advance a soft 20G catheter to the affected level, using Depomedrol for steroid.

I prefer this technique because, 1-entering at T1-2 provides approx double the epidural space as C7- T1, 2-using the catheter, I’m able to achieve direct the medication unilateral (and ventral) quite consistently, 3- patients tolerate it extremely well, better than standard CESI. 4- It works better than standard C7-T1 ILESI due to concentrated ventral flow 5- catheter is inexpensive only $4, 6-I’m just as fast as a standard CESI, as I would go slow with those due to slim margin of error with a standard C7-T1 CESI.
 
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I think that depends on technique and the catheter.

Lately I’ve been doing most of my CESI with cath. I enter at T1-T2 with a shallow angle, 18G touhy, place the tip midline, rotate the bevel to the desired side and then advance a soft 20G catheter to the affected level, using Depomedrol for steroid.

I prefer this technique because, 1-entering at T1-2 provides approx double the epidural space as C7- T1, 2-using the catheter, I’m able to achieve direct the medication unilateral (and in particular ventral) quite consistently, 3- patients tolerate it extremely well, better than standard CESI. 4- It works better than standard C7-T1 ILESI due to concentrated ventral flow 5- catheter is inexpensive only $4, 6-I’m just as fast as a standard CESI, as I would go slow with those due to slim margin of error with a standard C7-T1 CESI.

What needle and catheter are you using?
 
Are you doing this instead of CTFESI? Like when a surgeon asks you to do a CTFESI for diagnostic reasons?
 
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Are you doing this instead of CTFESI? Like when a surgeon asks you to do a CTFESI for diagnostic reasons?
I no longer offer CTFESI. If a surgeons requests a CTFESI, I inform him that the contemporary medical literature does not support CTFESI due to risks of a catastrophic outcome from a procedure that only provides temporary relief and I kindly remind him that this is very different from the state of the literature when he trained 20 years ago. Just because he could ask for CFTESI in 2000, does not mean he can ask for one in 2020.

Just like it’s not appropriate to do an open appendectomy in 2020 instead of a lap appy.
 
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I've been happy with the Arrow theracath kits. Wire reinforced with a spring tip. Can be as floppy as you need. Good shallow paramedian technique like an SCS lead and drive it wherever you need.

 
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The procedure described may "hold up in court" from a medico-legal stance, but I seriously doubt it'll stand in a Medicare fraud stance. It is being billed incorrectly. It's a bad facet injection (rupturing the facet?), not a TFESI.

I also somehow doubt that facet overloading is safer given the facet you're aiming right toward the vertebral artery. There is reason that people don't do intraarticular cervical facets anymore, and it's not just insurances.

All that being said, It'll probably work. I know a guy who does cervical MBB and adds steroid so it'll "overflow" to the nerve root and possibly help with any radicular pain as well. He at least still bills it as a CMBB though.
 
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The procedure described may "hold up in court" from a medico-legal stance, but I seriously doubt it'll stand in a Medicare fraud stance. It is being billed incorrectly. It's a bad facet injection (rupturing the facet?), not a TFESI.

I also somehow doubt that facet overloading is safer given the facet you're aiming right toward the vertebral artery. There is reason that people don't do intraarticular cervical facets anymore, and it's not just insurances.

All that being said, It'll probably work. I know a guy who does cervical MBB and adds steroid so it'll "overflow" to the nerve root and possibly help with any radicular pain as well. He at least still bills it as a CMBB though.
You don’t have to rupture the facet to get something close to epidural spread.

 
How do people do their CESIs? Prone with arms down and CLO?

I ask because I heard another clinic nearby does all their CESIs with the patient sitting and head rested down in front of them on a pillow, seems crazy to me. XRay comes in lateral for the whole procedure.
 
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How do people do their CESIs? Prone with arms down and CLO?

I ask because I heard another clinic nearby does all their CESIs with the patient sitting and head rested down in front of them on a pillow, seems crazy to me. XRay comes in lateral for the whole procedure.
I do prone, arms down, clo and if I can get it lateral but clo is main view for most people.

Usually start at T1 mid to upper lamina with maybe 5 degrees oblique towards symptomatic side and a few degrees inferior tilt assuming I can see space still. Touch lamina as I work towards midline on ap. Once I direct more superior to lamina I switch to CLO once I'm not touching bone. Usually Im close by then. If I need to move alot more I switch back to AP to ensure I'm close to midline. Typically do contrast spread technique with with 23 or 25 gauge spinal. I prefer this to the LOR technique personally. I always want ap and lateral views. Couldn't imagine using only lateral or ap for a procedure (except maybe caudal using lateral and I still use ap to verify contrast). Epidural space is often tiny if you arent close to midline. I always look at T1 MRI for epidural fat pad to pick level.

I did 2 cervical TFs in fellowship, so needless to say between literature and training I've done none in 3 yrs of practice.
 
How do people do their CESIs? Prone with arms down and CLO?

I ask because I heard another clinic nearby does all their CESIs with the patient sitting and head rested down in front of them on a pillow, seems crazy to me. XRay comes in lateral for the whole procedure.

Patient prone with face in a crappy horseshoe/massage type pillow. Arms wherever they are comfortable - with CLO I can see the ventral interlaminar line clearly regardless of where the arms are positioned. I don’t ever check a true lateral.
 
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Prone.
Arms by the side.
AP and CLO.
I don't use lateral.
40-80mg Depo + 2cc NS
25g Quinke
 
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As expected, everyone does prone.

I don’t understand why someone would do it sitting. I would imagine orient could move very easily as your advancing. Plus the all lateral thing is baffling to me, especially for such a high risk procedure.
 
How do people do their CESIs? Prone with arms down and CLO?

I ask because I heard another clinic nearby does all their CESIs with the patient sitting and head rested down in front of them on a pillow, seems crazy to me. XRay comes in lateral for the whole procedure.

Wait, so are they sitting on the X-ray table hunched over a pillow, or sitting on a chair with their chin resting on the X-ray table? How are they secured?
 
Wait, so are they sitting on the X-ray table hunched over a pillow, or sitting on a chair with their chin resting on the X-ray table? How are they secured?
Literally no idea. My impression was sitting on the table with arms and head hunched over a pillow and stand, sort of positioned like a thoracic epidural at bedside. X-ray comes in from the front full lateral. No way to strap them in. It blew my mind to hear about this.
 
I know guys in my area who put patient in a wheelchair and wheel them up to the OR table where they lay their head down.

Seated position was very common back in the days of blind injections.

I like prone on Oakworks with arms tucked at sides.
 
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I'd rather do a Cervical Facet J injection with overflow versus a TFESI. Of course it'll work, it spreads. I would bill it as CMBB though. Definitely do not bill as TFESI as it would qualify as fraud. Not sure how ILCESI is dangerous though unless someone is wrecklessly just pushing down with the Touhy and puncturing the cord. Cervical Interlaminars are scary, but I go AP and CLO, and the minute I am close to it, I begin squirting contrast till I see uptake. Definitely the scariest procedure for me. Thankfully, cervical issues are probably 20% of the time, and of that 20%, I would say 75% is Facet Oriented pain. Cervical Radiculopathy is the rarest.

On a sidenote, if I got a dollar for every referral that was sent to me by a PCP on a patient with localized neck pain (no radiation, with stiffness of the neck, etc) for an epidural after seeing "foraminal narrowing" and cervical disc bulges, I'd be a millionaire. I get it all the time. Referral for CESI, then I see the patient, and pain is coming from the facets. Or my personal favorite, facet pain, but MRI shows C5-6 disc bulge, and patient is referred to me for epidural. I tell the patient everyday most likely 90% of the adult US population has a bulge at C5-6.
 
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.

I also somehow doubt that facet overloading is safer given the facet you're aiming right toward the vertebral artery. There is reason that people don't do intraarticular cervical facets anymore, and it's not just insurances.
.

Well paint me green and call me Gumby!!
I do a fair number of IA facet blocks from a posterior approach. Explain this Vert Artery thing to me.
 
old fashioned way before fluoroscopy was seated with head bent forward.

use a table, put pillows on table. secure the table (usually a nightstand) so it doesn't move. make sure they don't slump too much - tho slumping is good if you are doing a thoracic epidural - bend should be at the cervical level.

fwiw, its maybe the only way to do it on an inpatient who cant come to the fluoro unit.

its good to know how to do them, but they should be never events.
 
No touhy or LOR? Just relying on contrast spread?
Sometimes a Tuohy, usually not.

Cervical epidural space is not the same as the lumbar space - It is tighter and the risk is higher.

Loss is unreliable and (I have no clue how many CESI you've done) commonly there is no loss.

The 25g is tiny, comfortable, and I can drive that little thing quickly down to the ligament without the pt really knowing what's happening (I tell them what I'm doing of course).

I still use a Tuohy on occasion though, but 95% no.
 
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Why don't you just try a NO NEEDLE EPIDURAL 🤔😳


Can we discuss this. What did I just watch?

favorite line “you have to be careful because it’s off label, but you can do a no needle epidural for PTSD as well”
 
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So I have a question. I’ve had my fair share of CESIs that felt great however looked deep on CLO primarily bc I inadvertently crossed midline. I’ve had a few though that looked deep even though they appeared midline in AP. I chalked this up to not having a true AP or not obliquing enough on my CLO. If the loss felt right I’ll still inject. So my question is, if you’re going slow and using an 18g touhy there’s no way you could pith the cord and or inject into the cord without the patient screaming out in pain? I always inject slowly and if there’s any question I’m talking to the patient the entire time assessing their status
 
1) Don’t wait for loss, grab a quick AP to confirm you’ve crossed midline and inject contrast early/often

2) No one is so metal they don’t flinch when you hit nerve
 
So I have a question. I’ve had my fair share of CESIs that felt great however looked deep on CLO primarily bc I inadvertently crossed midline. I’ve had a few though that looked deep even though they appeared midline in AP. I chalked this up to not having a true AP or not obliquing enough on my CLO. If the loss felt right I’ll still inject. So my question is, if you’re going slow and using an 18g touhy there’s no way you could pith the cord and or inject into the cord without the patient screaming out in pain? I always inject slowly and if there’s any question I’m talking to the patient the entire time assessing their status
I don't think anybody could answer that question...who has experience with injecting the cord? That said, inject dorsal to lig flav, inject inside lig flav itself, advance a few mm then inject ventral to lig flav. You've proven your depth this way. If you have this type of patttern it would be difficult to hit the cord, though I'm sure not impossible. Somebody correct me if my thinking is wrong.
 
Stop using LOR.
 
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I don't think anybody could answer that question...who has experience with injecting the cord? That said, inject dorsal to lig flav, inject inside lig flav itself, advance a few mm then inject ventral to lig flav. You've proven your depth this way. If you have this type of patttern it would be difficult to hit the cord, though I'm sure not impossible. Somebody correct me if my thinking is wrong.

If someone puts the cord too far posteriorly and it is pushing up against ligament, your loss can go into the cord. Uncommon for severe stenosis at C7-T1, but can occur.
 
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Stop using LOR.
Maybe it’s my anesthesia background but I still find it very helpful. I use a 22g tuohy so I still get tactile feedback. I primarily rely on the contrast and inject little puffs as I go, but I can usually feel a slight give or click as the needle tip exits ligament, and also feel a loss of resistance from injecting the contrast.
 
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If someone puts the cord too far posteriorly and it is pushing up against ligament, your loss can go into the cord. Uncommon for severe stenosis at C7-T1, but can occur.
You still wouldn’t know it until it’s too late. Contrast puffs exciting out over lamina until it isn’t and instead in the cord
 
So I have a question. I’ve had my fair share of CESIs that felt great however looked deep on CLO primarily bc I inadvertently crossed midline. I’ve had a few though that looked deep even though they appeared midline in AP. I chalked this up to not having a true AP or not obliquing enough on my CLO. If the loss felt right I’ll still inject. So my question is, if you’re going slow and using an 18g touhy there’s no way you could pith the cord and or inject into the cord without the patient screaming out in pain? I always inject slowly and if there’s any question I’m talking to the patient the entire time assessing their status

so, the cord ITSELF is insensate. but, the meninges around it (pia maybe?) is not. your patient WILL feel a zing into their arm, leg, or both if you touch the cord with your needle. this is why lack of sedation is crucial. it you touch the outside of the cord or enter the cord, as long as you dont inject while you do so, you really shouldnt get into much trouble. just withdraw, monitor the patient, and live to fight another day.
 
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So I have a question. I’ve had my fair share of CESIs that felt great however looked deep on CLO primarily bc I inadvertently crossed midline. I’ve had a few though that looked deep even though they appeared midline in AP. I chalked this up to not having a true AP or not obliquing enough on my CLO. If the loss felt right I’ll still inject. So my question is, if you’re going slow and using an 18g touhy there’s no way you could pith the cord and or inject into the cord without the patient screaming out in pain? I always inject slowly and if there’s any question I’m talking to the patient the entire time assessing their status

Needle should not be at midline for two main reasons. First, lack of fusion of ligamentum flavum at midline in C spine. Second, needle will always look deep on CLO if needle at midline. Needle must be paramedian for CLO to be accurate.
 
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Second time I’ve heard doing an ESI through the facet this week.....first time was from Centeno
 
Second time I’ve heard doing an ESI through the facet this week.....first time was from Centeno
What do you guys think of rupturing the facet capsule in order to get epidural spread? Can't be good for the facet, though may be safer way to do a "selective" epidural...
 
Stop using LOR.
technically we all "use" - some degree - "LOR" when you inject contrast.

I'm sure if you had very high resistance to the contrast, you would stop and recheck everything.

if you are very concerned, do AP view, make sure it has crossed midline, then CLO the opposite direction.... the needle tip should be in a good location if you did cross midline.



using a 22 gauge touhy, I have noticed that it seems at times that I cant infuse any contrast at all until the tip looks pretty deep on CLO. more common in elderly...

with the blunt tip needles, I always wonder if we are, well, tenting the ligamentum flavum rather than going through it with the sharp tip cutting needles. (I'm not interested in changing to sharp needles tho because the anesthesia literature is ripe with information on them causing more PDPH.)
 
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