Arguments for transforaminals Vs. interlaminar lumbar epidurals?

[Ligament]

Hi all,

I've been trying to convince some of my collegues to start doing lumbar transforaminals more frequently. Some of them will order interlaminars almost exclusively, even if the exact site of nerve root irritation has been localized (ie. a right L5 radic based on EMG/MRI). Some of my arguments for:
1. Better delivery of medication to the target
2. Less incidence of dural puncture and PDPHA
3. Less painful to patient (in my experience with a 25ga needle)
3. Better reimbursement (at least in my state). Don't get the wrong idea, I'm a fellow so I don't see a dime of the reimbursement...

Its funny, at my PM&R residency program we did transforaminals exclusively. Never saw an interlaminar until I started fellowship in the anesthesiology dept.

Would you care to provide some more arguments for me? Counter point appreciated as well. thanks!

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[Aether2000]

I assume you are talking about a fluoroscopically guided interlaminar vs transforaminal
1. Precision injection instead of a shotgun approach
2. Medication delivered in much higher concentration to the target
3. A significant number of interlaminar epidurals are unilateral and it may be the wrong side that gets the juice...transforaminal is a selected approach
4. Less chance of PDPH
5. Less chance of pneumocephalus, which is often the cause of an immediate PDPH
6. Does not tear the interspinous ligaments that has the potential to cause long term pain
7. Less chance of a epidural hematoma
8. Less chance of generalized lower extremity post injection weakness or proprioceptive changes that may lead to falls and fractures

 

[Disciple]

Hi all,

I've been trying to convince some of my collegues to start doing lumbar transforaminals more frequently. Some of them will order interlaminars almost exclusively, even if the exact site of nerve root irritation has been localized (ie. a right L5 radic based on EMG/MRI). Some of my arguments for:
1. Better delivery of medication to the target
2. Less incidence of dural puncture and PDPHA
3. Less painful to patient (in my experience with a 25ga needle)
3. Better reimbursement (at least in my state). Don't get the wrong idea, I'm a fellow so I don't see a dime of the reimbursement...

Its funny, at my PM&R residency program we did transforaminals exclusively. Never saw an interlaminar until I started fellowship in the anesthesiology dept.

Would you care to provide some more arguments for me? Counter point appreciated as well. thanks!

Efficacy of fluoroscopically guided lumbar transforaminals vs. interlaminars. Sounds like a good research project.

Some probably do interlaminars because it's faster (hit the inferior lamina, pull back, readjust, loss of resistance) and it's a technique they already have alot of skill in.

As for some counterpoints:
1. No need for oblique or lateral views
2. Easier to steer the needle when injecting obese patients
3. Option to avoid cervical transforaminals by using a catheter (curved at the tip) through a touhy needle.

 

[lobelsteve]

I think you could stop the argument at better reimbursement.

CPT Description Office ASC Hospital

64483 L/S TFESI 376 108 108

64484 2nd Level 178 67 67

62311 L Interlaminar/Caudal 249 83 83

62310 C/T Interlaminar 260 102 102

 

[drrinoo]

<6. Does not tear the interspinous ligaments that has the potential to cause long term pain>

Algos,

Could you expound on this....I can understand a scenario, such as Baastrups disease, causing interspinous pain...but how would you diagnosis this pain apart from infiltrating local, after an ILESI post procedure pain flare?

Additionally, couldn't this apply to even transforaminals...i.e., damaging the extraforaminal ligaments...and causing a post-procedure TFESI pain flare?

Ironically, sacrificing the extraforaminal ligaments may actually help...as some folk believe the pain is akin to an entrapment neuropathy

In any event, it is kinda interesting that we may be overlooking such pathologies as a sources of pain

 

[spondy14]

lobelsteve, could you explain what the numbers mean for us first timers? ALso, what is the reimbursement like at an ASC if for instance you do a unilateral TFESI vs. a bilateral on the same day, is there some sort of modifier or will you get paid a unilateral procedure times 2?

 

[Aether2000]

Both in disc herniation and in degenerative spinal disorders there exist concurrent posterior ligamentous changes. With degeneration, histologically there exists an enthesiopathy with calcification inferior to the tip of the spinous process. There are other age related changes in the histology in the posterior ligaments (LF, ISL, SSL) . In Baastrum's disease, there have been reported posterior epidural cysts. But in any case, puncture of the interspinous ligament with a needle, and in my experience especially a Tuohy needle, causes pain that can exist long term that is quite focal. I have performed ligament injections with contrast (quite interesting) but usually do a posterior lig infiltration of local plus steroid as a therapy.
The extraforaminal ligaments are located predominately in the inferior 1/3 of the neuroforamen, although there are transverse ligaments at the superior neuroforamen but not nearly so dense. During endoscopic foraminoplasty, these are ligaments that must be divided. As you well know using the blunt coude tip needle, sometimes there is a "pop" felt as one traverses these ligaments, but hopefully using blunt needles we do not transsect the ligaments, although you make a good point....why not?
Any idea what those transverse foraminal ligaments function is other than being a base support for the neurovascular complex exiting at that level?

 

[spondy14]

What is everyone using in their injectate for TFESI vs. ILESI.
celestone 2cc with 1cc lido?
Kenalog 1cc with 2-3 cc lido?

 

[wonthurtabit1]

Both in disc herniation and in degenerative spinal disorders there exist concurrent posterior ligamentous changes. With degeneration, histologically there exists an enthesiopathy with calcification inferior to the tip of the spinous process. There are other age related changes in the histology in the posterior ligaments (LF, ISL, SSL) . In Baastrum's disease, there have been reported posterior epidural cysts. But in any case, puncture of the interspinous ligament with a needle, and in my experience especially a Tuohy needle, causes pain that can exist long term that is quite focal. I have performed ligament injections with contrast (quite interesting) but usually do a posterior lig infiltration of local plus steroid as a therapy.
The extraforaminal ligaments are located predominately in the inferior 1/3 of the neuroforamen, although there are transverse ligaments at the superior neuroforamen but not nearly so dense. During endoscopic foraminoplasty, these are ligaments that must be divided. As you well know using the blunt coude tip needle, sometimes there is a "pop" felt as one traverses these ligaments, but hopefully using blunt needles we do not transsect the ligaments, although you make a good point....why not?
Any idea what those transverse foraminal ligaments function is other than being a base support for the neurovascular complex exiting at that level?

algos, the medial branch also goes further than just to the facet, if you follow it out (per frank willard) it goes to the interspinous ligament. This is why i wonder if such good results were obtained comparing fusion to an injection into the ISL. All this being said, not injuring the ISL is reaching for a good argument for ILESI.

I am having the same issue at my work place. do we have any better evidence that TF ESI works > than ILESI, or just, it gets the meds closer to the proposed target.

I did find this French study that seemed to suggest they were comparing flouro guided TF vs. IL ESIs. Let me know what you thinK.

Kolsi, I. Efficacy of nerve root vs. interspinous (their version of IL)glucocorticoids in rx of disc related sciatica. Pilot, randomized, double blind. Journal Bone and Spine. Fr edition. 2000. Article also in english.

 

[paz5559]

algos, the medial branch also goes further than just to the facet, if you follow it out (per frank willard) it goes to the interspinous ligament. This is why i wonder if such good results were obtained comparing fusion to an injection into the ISL. All this being said, not injuring the ISL is reaching for a good argument for ILESI.

I am having the same issue at my work place. do we have any better evidence that TF ESI works > than ILESI, or just, it gets the meds closer to the proposed target.

I did find this French study that seemed to suggest they were comparing flouro guided TF vs. IL ESIs. Let me know what you thinK.

Kolsi, I. Efficacy of nerve root vs. interspinous (their version of IL)glucocorticoids in rx of disc related sciatica. Pilot, randomized, double blind. Journal Bone and Spine. Fr edition. 2000. Article also in english.

One problem - both types of injections appear to have been done blind, so I think what that proves is that blind TFESIs suck just as much as blind IESIs

Joint Bone Spine. 2000;67(2):113-8. Efficacy of nerve root versus interspinous injections of glucocorticoids in the treatment of disk-related sciatica. A pilot, prospective, randomized, double-blind study.

* Kolsi I,
* Delecrin J,
* Berthelot JM,
* Thomas L,
* Prost A,
* Maugars Y.

Rheumatology Department, Nantes Teaching Hospital, Hotel-Dieu, France.

STUDY OBJECTIVES: Pilot study comparing the short-term efficacy on pain and functional impairment of nerve root sheath versus interspinous glucocorticoid injections in patients admitted to a French rheumatology department for disk-related sciatica or femoral neuralgia. PATIENTS AND METHODS: Thirty patients with refractory nerve root pain (sciatica, n = 29; femoral neuralgia, n = 1) for a mean of four months were randomized to nerve root injection (n = 17) or interspinous injection (n = 13) of the same mixture of 0.10 g of lidocaine hydrochloride and 3.75 mg of cortivazol. Both injection methods were performed under analgesia and benzodiazepine sedation to maintain double blinding. Each patient was evaluated daily during the first seven days of bed rest in the hospital, then after discharge on postinjection day 28. RESULTS: Prompt pain relief was obtained in both groups. On day 1, the mean pain scale score (0-100) fell from 70 +/- 3.9 to 26 +/- 5.6 in the nerve root group and from 63 +/- 4 to 23 +/- 4.7 in the interspinous group. These results were sustained on D7 and D28. CONCLUSIONS: The unusually high level of efficacy of glucocorticoid injection in our study may be ascribable in part to strong placebo and Hawthorne effects and in part to the intrinsic effects of the injections. Whether nerve root injection is superior over interspinous injection remains unproven.

PMID: 10769103 [PubMed - indexed for MEDLINE]

 

[Tenesma]

i think transforaminal is WAY faster... in fact, you can do it in the scotty dog view, then switch to AP - advance a bit, shoot contrast - you are done... fluoro time of less than 5-7 seconds - procedure time (including prep) is less than 4 minutes

 

[wonthurtabit1]

One problem - both types of injections appear to have been done blind, so I think what that proves is that blind TFESIs suck just as much as blind IESIs

Joint Bone Spine. 2000;67(2):113-8. Efficacy of nerve root versus interspinous injections of glucocorticoids in the treatment of disk-related sciatica. A pilot, prospective, randomized, double-blind study.

* Kolsi I,
* Delecrin J,
* Berthelot JM,
* Thomas L,
* Prost A,
* Maugars Y.

Rheumatology Department, Nantes Teaching Hospital, Hotel-Dieu, France.

STUDY OBJECTIVES: Pilot study comparing the short-term efficacy on pain and functional impairment of nerve root sheath versus interspinous glucocorticoid injections in patients admitted to a French rheumatology department for disk-related sciatica or femoral neuralgia. PATIENTS AND METHODS: Thirty patients with refractory nerve root pain (sciatica, n = 29; femoral neuralgia, n = 1) for a mean of four months were randomized to nerve root injection (n = 17) or interspinous injection (n = 13) of the same mixture of 0.10 g of lidocaine hydrochloride and 3.75 mg of cortivazol. Both injection methods were performed under analgesia and benzodiazepine sedation to maintain double blinding. Each patient was evaluated daily during the first seven days of bed rest in the hospital, then after discharge on postinjection day 28. RESULTS: Prompt pain relief was obtained in both groups. On day 1, the mean pain scale score (0-100) fell from 70 +/- 3.9 to 26 +/- 5.6 in the nerve root group and from 63 +/- 4 to 23 +/- 4.7 in the interspinous group. These results were sustained on D7 and D28. CONCLUSIONS: The unusually high level of efficacy of glucocorticoid injection in our study may be ascribable in part to strong placebo and Hawthorne effects and in part to the intrinsic effects of the injections. Whether nerve root injection is superior over interspinous injection remains unproven.

PMID: 10769103 [PubMed - indexed for MEDLINE]

Paz, yeah i was trying to see if they were hiding the flouro details somewhere in the french fine print.