Benzos and opioids

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The science suggests that there is no diagnostic utility to local, but as far as i am aware, there is no science that specifically states that local anesthetic in epidural space is contraindicated. if so, then no more labor epidurals....

My rule of thumb is if I (or you) use it, we have to expect that there will be complication risk - and that complication will almost always happen in the worst possible patient.


One of the reasons to coming on to this forum is to challenge our practice pattern against what others do, many with more experience than us. as long as it is based on science. It makes us better doctors that provide better care.

Some come here for a short time because they are sure they are God’s gift to pain, but can’t handle when what they do is exposed to the best science out there. the wise ones are open to evaluating their practice (doesnt mean that they change, but if they dont, they should have some justification for that choice...)
 
I have ppl get up and walk out of a TFESI pain free.

Can't say that has EVER happened with a CESI - Dex and saline only. Obviously, I'm referring to arm pain and not walking.
 
SommeRiver said:
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.
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Lighten up Francis. You were all good until you called some of is liars. You may believe in dx utility of tfesi. There are even some old articles that kind of support that. But the overwhelming conclusion of the literature is that there is no dx utility to epidural injection.
 
lobelsteve said:
Lighten up Francis. You were all good until you called some of is liars. You may believe in dx utility of tfesi. There are even some old articles that kind of support that. But the overwhelming conclusion of the literature is that there is no dx utility to epidural injection.
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I didn't call anyone a liar unless they deny throwing in an epidural in a confusing pt in hopes of something happening. In those pts I believe there certainly IS diagnostic utility, as I clearly illustrated in my post.
 
SommeRiver said:
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.
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Yeah, it's fun going back and forth with the lawyers about this stuff in the depositions. Billable hours.
 
drusso said:
Yeah, it's fun going back and forth with the lawyers about this stuff in the depositions. Billable hours.
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Maybe I get deposed bc a pt signed the consent forms and ignored the education that I have documented in the medical chart about the risks of epidurals. One day that may happen. I hope not, but local stays in my lumbar syringe...
 
Zero problem with a little local in tfesi. Totally within standard of care which gets thrown around a little too loosely on this forum.

But, I agree with local working too well for a short period of time setting up unrealistic expectations. Nothing feels as good as total analgesia. My experience is that adding local is common with docs working closely with surgeons. Patient comes back week later saying injection worked great for the day then most of pain came back. Now has patient has “failed” “therapeutic” phase of injection but “diagnostic” phase positive so off to surgery...

In my practice the patient comes back a week later and says was a bit worse for a day then slowly improved and now maybe 50% improved. I set this expectation pre procedure by stating I do not expect complete relief

Finally, many of the docs on this forum went to the “best” fellowships. My attendings at the ivory tower did a bunch of stupid s***. Student becomes the master.
 
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So a patient, who has been administered a local anesthetic in a TFESI, gets out of the passenger side of the car on the way home and falls- fracturing her hip because she could not perceive proprioception in the leg and had weakness in the leg after the local was administered. Was the pain physician operating outside the standard of care in administering local in a TFESI or was he operating outside the standard of care for failure to monitor the patient post-injection until the weakness and proprioceptive issues resolved?
 
algosdoc said:
So a patient, who has been administered a local anesthetic in a TFESI, gets out of the passenger side of the car on the way home and falls- fracturing her hip because she could not perceive proprioception in the leg and had weakness in the leg after the local was administered. Was the pain physician operating outside the standard of care in administering local in a TFESI or was he operating outside the standard of care for failure to monitor the patient post-injection until the weakness and proprioceptive issues resolved?
Click to expand...

:thinking: Drops the mike.
 
algosdoc said:
So a patient, who has been administered a local anesthetic in a TFESI, gets out of the passenger side of the car on the way home and falls- fracturing her hip because she could not perceive proprioception in the leg and had weakness in the leg after the local was administered. Was the pain physician operating outside the standard of care in administering local in a TFESI or was he operating outside the standard of care for failure to monitor the patient post-injection until the weakness and proprioceptive issues resolved?
Click to expand...

That is exactly why I don’t include any local in any TFESI, unless I’m literally performing a SNRB requested by a surgeon, which is quite rare.
 
algosdoc said:
So a patient, who has been administered a local anesthetic in a TFESI, gets out of the passenger side of the car on the way home and falls- fracturing her hip because she could not perceive proprioception in the leg and had weakness in the leg after the local was administered. Was the pain physician operating outside the standard of care in administering local in a TFESI or was he operating outside the standard of care for failure to monitor the patient post-injection until the weakness and proprioceptive issues resolved?
Click to expand...

Can’t argue with that logic.
 
bedrock said:
That is exactly why I don’t include any local in any TFESI, unless I’m literally performing a SNRB requested by a surgeon, which is quite rare.
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So if a surgeon operates on a spine and the patient falls on the driveway after getting the spine surgeon is liable?
 
SommeRiver said:
Maybe I get deposed bc a pt signed the consent forms and ignored the education that I have documented in the medical chart about the risks of epidurals. One day that may happen. I hope not, but local stays in my lumbar syringe...
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SommeRiver....local or no local, not a huge deal in the lumbar region. By adding some local (which I did for my first 8 years of practice) you may give some nice immediate relief. However, you are also adding another layer of risk albeit small in the lumbar region. As an example, I did a right L3 TFESI on a lady in the office 5 years ago. Contrast pattern was off but I said whatever and still injected my 40mg kenalog w/2cc's 0.25% marcaine. In some unbelievable stroke of luck I was intrathecal even though my needle looked extraforaminal on AP. The lady developed a spinal from the waist down. She started freaking out thinking I had paralyzed her and actually scared me when she said the numbness was traveling up past her belly button! Had to watch her in the office until 6pm that night. We even bought her dinner. Definitely not worth the local....
 
clubdeac said:
SommeRiver....local or no local, not a huge deal in the lumbar region. By adding some local (which I did for my first 8 years of practice) you may give some nice immediate relief. However, you are also adding another layer of risk albeit small in the lumbar region. As an example, I did a right L3 TFESI on a lady in the office 5 years ago. Contrast pattern was off but I said whatever and still injected my 40mg kenalog w/2cc's 0.25% marcaine. In some unbelievable stroke of luck I was intrathecal even though my needle looked extraforaminal on AP. The lady developed a spinal from the waist down. She started freaking out thinking I had paralyzed her and actually scared me when she said the numbness was traveling up past her belly button! Had to watch her in the office until 6pm that night. We even bought her dinner. Definitely not worth the local....
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Is 40mg IT kenalog ok?
 
so to answer the questions raised by your approach, sommeriver:

there appears to be some evidence that a small amount of local at time of injection might actually improve gait, interestingly:
Acute effects of anesthetic lumbar spine injections on temporal spatial parameters of gait in individuals with chronic low back pain: A pilot study. - PubMed - NCBI
TF with 1% lido improves gait - but only if they are 100% pain free after injection...


otoh, use of immediate pain relief (ostensibly through action of LA) does not predict long term efficacy.
Lumbar transforaminal epidural steroid injections: does immediate post-procedure pain response predict longer term effectiveness? - PubMed - NCBI
The efficacy of interlaminar epidural steroid administration in multilevel intervertebral disc disease with chronic low back pain: a randomized, bl... - PubMed - NCBI
Immediate post-TFESI pain relief does not strongly predict longer term effectiveness in pain relief or functional recovery. Response in pain relief or functional recovery at 2 weeks is more strongly associated with 2-month outcomes.
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for cervical TF, use of low dose lido might be more appropriate, if you review this study:
Cervical transforaminal epidural block using low-dose local anesthetic: a prospective, randomized, double-blind study. - PubMed - NCBI

but here is the main reason i dont use local anesthetic for epidural injection:
ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine

Of all claims associated with neuraxial chronic pain management, 25% involved nerve damage. Injuries associated with treatment for chronic pain were most likely to result from an infectious cause, with hematoma and direct needle injury occurring less frequently. The most striking finding stemming from the ASA analysis of chronic pain claims was that use of local anesthetic and/or opioid during epidural steroid injection was associated with 9 deaths or brain damage, while there were no deaths or brain damage when local anesthetic and/or opioid was not used as part of the neuraxial injectate. The authors warn that injection of neuraxial local anesthetic and/or opioid for pain treatment in the ambulatory setting should be accompanied by the same close monitoring, and the ability to perform resuscitative maneuvers that are available to those patients receiving neuraxial local anesthetic and/or opioid in the operating room or obstetric settings.19,20
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There may be a logical reason for that- local anesthetics plus steroids destabilizes the suspension resulting in flocculation of particles to create much larger particulates. The larger particulates can result in embolization of the arteries.
 
painfree23 said:
Is 40mg IT kenalog ok?
Click to expand...
The answer is no it’s not ideal. As Steve alluded to the preservative could cause problems the worst being arachnoiditis. It’s hard to know what the risk of that is though
 
SommeRiver said:
God forbid I ever end up in court and one of yall are brought in as an "expert witness" and tell a judge I'm practicing incorrectly bc I put bupi or ropi in a TFESI.
Click to expand...

I know people use use local in epidurals and maybe it's not "wrong" per se, but honestly, if the patient has a bad outcome due to an inadvertant spinal or had a bad fall due to leg weakness, I would be forced to say that your epidural could have been the cause. I don't know about you, but I don't want to be in that position.

SommeRiver said:
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.
Click to expand...

I only do epidurals for radicular pain. Evidence doesn't support them otherwise. Throwing in a hail-mary ESI, especialy with local, because you're confused, isn't standard of care and I would testify that in court as well.
 
Ferrismonk said:
I know people use use local in epidurals and maybe it's not "wrong" per se, but honestly, if the patient has a bad outcome due to an inadvertant spinal or had a bad fall due to leg weakness, I would be forced to say that your epidural could have been the cause. I don't know about you, but I don't want to be in that position.



I only do epidurals for radicular pain. Evidence doesn't support them otherwise. Throwing in a hail-mary ESI, especialy with local, because you're confused, isn't standard of care and I would testify that in court as well.
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You don’t do epidurals for spinal stenosis? I feel bad for your patients
 
clubdeac said:
You don’t do epidurals for spinal stenosis? I feel bad for your patients
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You are not, as far as your posts suggest, a needle jockey that is doing ESI for what they find on MRI, but a pain physician treating a symptom such as radicular back pain.

I’m wondering if you meant to say that, rather than a blanket statement about using epidurals for spinal stenosis...
 
Ducttape said:
You are not, as far as your posts suggest, a needle jockey that is doing ESI for what they find on MRI, but a pain physician treating a symptom such as radicular back pain.

I’m wondering if you meant to say that, rather than a blanket statement about using epidurals for spinal stenosis...
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Well yes I do epidurals for radicular pain but also for neurogenic claudication secondary to spinal stenosis
 
clubdeac said:
You don’t do epidurals for spinal stenosis? I feel bad for your patients
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Is there any indication for performing an epidural injection for treatment of purely axial pain without any signs or symptoms of either radicular pain or neurogenic claudication? I guess the point of my question is whether or not it is possible for spinal stenosis to cause purely axial pain, and if so, would an epidural injection help with that?
 
No reason not to try. Cheaper for health care system(in my office) than nongeneric meds, PT, yoga, accupuncture, Chiro and surgery.
 
nvrsumr said:
No reason not to try. Cheaper for health care system(in my office) than nongeneric meds, PT, yoga, accupuncture, Chiro and surgery.
Click to expand...

So do something that won't work, but gets you paid.....vs doing something that won't work and not get you paid?
Home exercise program, deal with it. You are billing for a procedure with risk, without benefit, and delivering false hope.
 
Miss every shot you don't take.

Im busy- dont need to gin up biz. Happy to help and treat my patients as I would my family
 
If someone has severe spinal stenosis at a level (ex. l4/l5) , do u go at that level for an interlaminar epidural? Or offer a transforaminal or the level below?
 
lobelsteve said:
Would not go at the tight level. 1 level below.
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Same. Sometimes I get referrals from surgeons specifically for a level that’s super tight. I sometimes don’t know what to do bc don’t want the surgeon to think I’m an idiot going at the wide open level below
 
painfree23 said:
Same. Sometimes I get referrals from surgeons specifically for a level that’s super tight. I sometimes don’t know what to do bc don’t want the surgeon to think I’m an idiot going at the wide open level below
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Surgeon has no idea what or how we do things. They see where it is tightest and say go there. I know many just look at report and send for shots.
 
lobelsteve said:
Surgeon has no idea what or how we do things. They see where it is tightest and say go there. I know many just look at report and send for shots.
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Do u educate the surgeon? Don’t want to sound like a smart ass that stop referrals especially when the “epidural doesn’t work— surgeon may say oh it’s bc they did the wrong level”
 
clubdeac said:
You don’t do epidurals for spinal stenosis? I feel bad for your patients
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Only for radicular pain or neurogenic claudication (i.e. limbs). Not for spinal stenosis.

promethius said:
Is there any indication for performing an epidural injection for treatment of purely axial pain without any signs or symptoms of either radicular pain or neurogenic claudication? I guess the point of my question is whether or not it is possible for spinal stenosis to cause purely axial pain, and if so, would an epidural injection help with that?
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If this helps, the attached file is from my Medicare LCD:

"The data supporting the use of EIs in the treatment of axial low back pain without radicular origin does not strongly support their use in these circumstances and should not be considered part of routine management of non-specific axial low back pain."
 

Attachments

Ferrismonk said:
"The data supporting the use of EIs in the treatment of axial low back pain without radicular origin does not strongly support their use in these circumstances and should not be considered part of routine management of non-specific axial low back pain."
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My routine course of practice is to use epidural steroid injection primarily for radicular symptoms with correlating MRI findings. Notice, however, in the above coverage determination, that the use of the word "routine" implies there may be special exceptions.

"Should not be considered part of routine management of" and
"should not be considered part of management of" are two different sentences with two different meanings.

I see that some people trained in the Land of Absolutes.
There are very few absolutes in Medicine.
 
painfree23 said:
Do u educate the surgeon? Don’t want to sound like a smart ass that stop referrals especially when the “epidural doesn’t work— surgeon may say oh it’s bc they did the wrong level”
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Dont be anybody’s biotch. If anyone questions my technique or medical decision making, i throw a lot of literature at them. I’m in a competitive market. So if you do not like me, use another guy.
 
lobelsteve said:
Dont be anybody’s biotch. If anyone questions my technique or medical decision making, i throw a lot of literature at them. I’m in a competitive market. So if you do not like me, use another guy.
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I actually had an argument with a peer to peer recently where they told me I had to do an ESI prior to doing medial branch block. They wanted to treat everything through a. Algorithm.

Patient had solely axial pain. I tried arguing clinical literature of esi for axial pain, discussed exam findings, etc. all to no avail. i had to do ESI prior to the MBB. Great use of resources!
 
geauxg8rs said:
I actually had an argument with a peer to peer recently where they told me I had to do an ESI prior to doing medial branch block. They wanted to treat everything through a. Algorithm.

Patient had solely axial pain. I tried arguing clinical literature of esi for axial pain, discussed exam findings, etc. all to no avail. i had to do ESI prior to the MBB. Great use of resources!
Click to expand...

This has happened to me repeatedly. Also I have no shortage of pts with severe stenosis and facet arthropathy, pain is axial, fail MBB, take off like a rocket ship with an ESI.
 
Ducttape said:
Probably steroid effect. Happened to some of my patients - who absolutely love MBB with steroids but hate MBB without or RFAs.

Go publish.

Currently,?what is published is counter to what you state.
Click to expand...

Which is why I don't do it "routinely," although my first post sort of reads that I do. Lemme restate it by saying "I have had pts get denied for MBB and have instead done ESI for back pain, and they got better."

I had a huge fight with a guy at Evicore about this. He went against everything I had ever learned. One of the more absurd things he said was pain in the buttocks is stenosis in all cases. WTF.

I did ESI on several ppl bc of him and several had improvement. He pissed me off for 12 weeks.

Do I "routinely" do ESI for axial pain? No, but I have done it and had some get better. Whether it is steroid effect or not I have no idea. You mention MBB with steroids...I do therapeutic MBB for some pts with dexamethasone but see no difference between those with or without dex.

Here's a Q - Do any of you call pain in the back and buttocks stenosis and do ESI? Pt with multilevel stenosis and facet disease with pain in the back and buttocks. Never goes below the glutes. Try an MBB and nothing happens. You do an ESI on that pt? Stenosis is central, lateral recess, and foraminal.
 
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Ferrismonk said:
I only diagnosis stenosis on MRI. It's an imaging diagnosis and not a pain diagnosis.
Click to expand...

I think we all know that.

You ever call radicular pain in the buttocks?
 
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