That probably will happen at some point in all of our careers. That's why it's important that when deviating from established practices that you have a thoughtful rationale for the deviation.
Two very large academic institutions for residency and fellowship and everyone adds local. My fellowship program won the Pain Medicine Fellowship Excellence Award the year I was there, and it won in 2008 and 2012. Never saw one time other than cervical ILESI where there wasn't anesthetic. Not once. I guess they're all wrong. Residency the same thing.
To say I am deviating from the norm is laughable. I am not subjecting my pts to severe risk by putting bupi or ropi 1 or 2 cc total in the epidural space.
Is there added value? I don't know, but I think there is, and it seems other ppl in this thread agree bc they use it for acute radic. I actually can't believe one person here says he doesn't use it bc it creates an unrealistic expectation, which is truly hilarious to me. It works too good...LOL...Don't use it bc it works really good and the pt will expect too much! How is that NOT diagnostic?
How many pts out there are stenotic as can be, but also have severe facet disease, vacuum disk, type 1 Modic changes, etc and you're just not sure what's hurting bc your exam isn't obvious and the HPI is sort of confusing so you do an epidural to see if you can get some utility out of it? I know ALL of you do it, and you're a liar if you say otherwise. I definitely put anesthetic in that injxn. This happens to me all the time where it just isn't obvious bc the pt hurts in several places and has a pan-positive back. Huge % of my pts are farmers, and I have some impressive MRIs.
There are studies that show saline alone doesn't work, anesthetic alone works, and there are studies that show anesthetic plus steroid works.
So why wouldn't I add a little bit of anesthetic if it will break up a pain pathway, which certainly provides diagnostic yield?
No, it doesn't provide selective diagnosis, meaning I can't say this is exclusively L3 vs L4 bc the medication spreads several levels, but it ain't your SI joint ma'am, and it ain't that fat L4-5 facet joint.