manowar rules

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Hi guys,

Does anyone use betamethasone for their TFESIs? I did in fellowship and I am just starting out in private practice. Right now I am using dexamethasone but wondering if it would be worth stocking beta.

Any experience or anecdotal reports on difference in efficacy between the two?
Anyone think the safety profile warrants sticking with dex no matter what?

Thanks!
 

painfree23

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Hi guys,

Does anyone use betamethasone for their TFESIs? I did in fellowship and I am just starting out in private practice. Right now I am using dexamethasone but wondering if it would be worth stocking beta.

Any experience or anecdotal reports on difference in efficacy between the two?
Anyone think the safety profile warrants sticking with dex no matter what?

Thanks!
I'd say use dex to cover you. I'm sure beta may work better but may not b worth the risk. What r u using for your lumbar esi ?
 
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algosdoc

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I assume you mean betamethasone phosphate rather than the phosphate/acetate suspension (Celestone)?
 
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SSdoc33

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it clumps bigger than kenalog (i think).

also, its more expensive.

some people still use particulates for TFESIs. lawyer fodder if anything goes wrong (even increased pain, infection, arachnoiditis on MRI, etc)
 
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You know, I had never really thought of betamethasone phosphate vs. Celestone, but come to think of it, I think I remember seeing Celestone on the vials for our TFESIs. I think I will stick with dex, thanks for your help!

For my ILESI, I use Kenalog. I used to use dex for cervicals, but I noticed patients would often feel uncomfortable anterior chest pressure upon injection. Another doc told me that this sensation was very common for some reason with dex, and that Kenalog avoided this while also being more efficacious. So far I think he was right, by golly
 
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Speaking of lawyer fodder..may want to consider not using kenalog due to "not for epidural use" label
Yeah I hear you. But I'm in a rural town, and most of my patients are elderly with terrible spine pathology (way worse stenosis than I saw in fellowship). Most of them aren't great surgical candidates, and they just want to be able to walk around better so they can keep supplementing their social security income by working down at the Piggly Wiggly. So I really want my epidurals to work. But I'll keep it in mind, and may change my practice as time goes on.
 

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It's really a double edged sword. You want your practice to grow. You want your treatments to work so you keep getting referrals. But what happens when your patients go to Dr. Joe blow in the next town for a second opinion and he tells them that you were injecting an "unsafe" product into their spines. What will happen to your referrals then? If you are in a less competitive market you may not have to worry as much, but interventionalists are a dime a dozen in most areas so just food for thought.
 
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painfree23

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I was looking at the dex vials in our clinic-- they don't say anything about OK for epidural use; I know kenelogs vials say NOT for epidural use, but just wondering about dex not saying anything on its vials about epidural use
 

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Hi guys,

Does anyone use betamethasone for their TFESIs? I did in fellowship and I am just starting out in private practice. Right now I am using dexamethasone but wondering if it would be worth stocking beta.

Any experience or anecdotal reports on difference in efficacy between the two?
Anyone think the safety profile warrants sticking with dex no matter what?

Thanks!
Particulate or Nonparticulate Steroids for Lumbar Transforaminal Injections | Pain Medicine | Oxford Academic

What some believe is irrelevant, what is true is true.

Dex for tfesi.
 

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At the end of the day I want my treatments to work as best as possible, minimize risk of harm to patients and avoid getting sued. Therefore, for some legit and some bs reasons..... Kenalog is out for any esi and all tfesi get dex. I use mainly depo for interlam.


I am also getting more and more disenchanted with dex/tfesi regardless of what the studies show. Doing more and more interlam/Depo for initial lumbar esi unless the main pathology is in foramen. Empirically far less of my patients have been needing more than one shot for hnp/radic and more of my stenotic elderly patients are getting 3-6 months per shot.


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Taus

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I was looking at the dex vials in our clinic-- they don't say anything about OK for epidural use; I know kenelogs vials say NOT for epidural use, but just wondering about dex not saying anything on its vials about epidural use
ALL steroid is off label for epidural. Kenalog is the only one to say "NOT for epidural use".


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Some of these labels I just don't understand. The 0.5% bupivacaine bottle that my residency and every other anesthesia institution used for spinals had "Not for spinal anesthesia" written on the label.
 
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painfree23

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At the end of the day I want my treatments to work as best as possible, minimize risk of harm to patients and avoid getting sued. Therefore, for some legit and some bs reasons..... Kenalog is out for any esi and all tfesi get dex. I use mainly depo for interlam.


I am also getting more and more disenchanted with dex/tfesi regardless of what the studies show. Doing more and more interlam/Depo for initial lumbar esi unless the main pathology is in foramen. Empirically far less of my patients have been needing more than one shot for hnp/radic and more of my stenotic elderly patients are getting 3-6 months per shot.


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Nice, depo only? 40mg? Do you do any local in the space?
 

paindoc007

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Where I trained for fellowship we'd use depo 80 + bupiv 0.25% 2 cc + 3cc normal saline for all lumbar interlams. Seem to get good results. Been doing it this far in practice as well.
 

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Part of my thoughts on non-particulate vs particulate:
1) Per the data, not really much difference in outcomes.
2) Dex is less likely to cause catastrophic, though rare, complications. I like my job, license, and current malpractice insurance rates as they stand and want to avoid lawsuits as much as possible. Do I want to help as many people as possible and allow them to be as functional as possible? Absolutely! But I'm not willing to do something that may needlessly increase risk of me sacrificing my livelihood and the life I've worked hard to build for a few extra hugs from the little old ladies with stenosis. I've had some patients who get better with TF with dex that didn't do well with IL with depo and vice versa, so who knows what's gonna work for which patient.
3) No need for local with ESI in my opinion. The patient has had pain for weeks, months, or years before seeing me. They can push through for another 2-7 days as the steroid kicks in.


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paindoc007

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What's the consensus cocktail for TFESI then? I've been using 15mg dex (1.5 cc) + 2.5 cc bupiv for my typical 2 level tfesi, 2 cc per level.
 

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10mg max in nss. Local for hot crying radics only.

We dont do 2 levels here, since spread is 3 levels.
 

clubdeac

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Steve their stated little "fact" is a big fat lie.

Fact:
All particulate corticosteroid preparations have been implicated in rare cases of paraplegia, whereas no definitive evidence exists of paraplegia resulting from injection of nonparticulate steroids.

dex has now been implicated in a case, right?
 

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I stopped using anesthetic in the injectate mixture. Bupivacaine can rarely cause a motor block and you don't won't this whether you are asc based or office based for obvious reasons in either scenario. Sometimes if it's a hot radic I will give 0.25-.05 cc of lidocaine prior to the delivery of my injectate mixture. Seems to work well..
 

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I have been using 12mg beta for everything.
 

lobelsteve

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Steve their stated little "fact" is a big fat lie.

Fact:
All particulate corticosteroid preparations have been implicated in rare cases of paraplegia, whereas no definitive evidence exists of paraplegia resulting from injection of nonparticulate steroids.

dex has now been implicated in a case, right?
Dex was used in that one case. An adequate explanation for what happened is what is needed. Might have been something else during the case.
 

cbest

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Dex was used in that one case. An adequate explanation for what happened is what is needed. Might have been something else during the case.
In this month's Pain Medixine's Fact Finders, it discusses non- partic vs partic steroid. At the end, it briefly touches on that case of an L4 TFESI causing conus medullaris infarct. A proposed mechanism was that the dex was mixed with ropivicaine which I guess can cause formulation of a solid state or crystals or something along those lines. More reason not to mix local with your steroid.
 
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SSdoc33

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Some of these labels I just don't understand. The 0.5% bupivacaine bottle that my residency and every other anesthesia institution used for spinals had "Not for spinal anesthesia" written on the label.
epidurals arent "spinal anesthesia".

are you an anesthesiologist?
 
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epidurals arent "spinal anesthesia".

are you an anesthesiologist?
Yes I know the difference. The point of that statement is that in that instance, rightly or wrongly, nobody pays attention to the label. Everyone uses that bupivacaine for spinals anyway. The rationale I heard was that it had not been formally FDA approved for spinals and so was an off-label use:
.5% Bupivicaine **NOT FOR SPINAL**

Yes my background is anesthesia.
 

SSdoc33

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Yes I know the difference. The point of that statement is that in that instance, rightly or wrongly, nobody pays attention to the label. Everyone uses that bupivacaine for spinals anyway. The rationale I heard was that it had not been formally FDA approved for spinals and so was an off-label use:
.5% Bupivicaine **NOT FOR SPINAL**

Yes my background is anesthesia.
ok. fine.

also, the anterior chest pressure is solely from injectate volume and speed with cervical epidurals. it is not the type of medication used. slow down when you inject a CESI and the patients wont feel it as much.


i switched over to dex for TFESIs maybe 4 or 5 years ago. did kenalog work better? seems like it did, but it is really hard to say. sort of like Manowar assuming that the dexamathone causes chest pressure, we tend to jump to conclusions without good data support. we have to try to avoid anecdotal evidence or what we think we see. the Kennedy article is the best evidence we have so far
 

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ok. fine.

also, the anterior chest pressure is solely from injectate volume and speed with cervical epidurals. it is not the type of medication used. slow down when you inject a CESI and the patients wont feel it as much.


i switched over to dex for TFESIs maybe 4 or 5 years ago. did kenalog work better? seems like it did, but it is really hard to say. sort of like Manowar assuming that the dexamathone causes chest pressure, we tend to jump to conclusions without good data support. we have to try to avoid anecdotal evidence or what we think we see. the Kennedy article is the best evidence we have so far
I'm not sure I agree with this. In fellowship and when I first started I was using depo with saline (4cc volume) for CESI and almost never had complaints regarding injectate. I changed my practice based on some comments here as well as changes at my fellowship program to dex with 2 cc of saline (3cc volume) and definitely get more complaints now. Will probably go back to depo.
 
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ok. fine.

also, the anterior chest pressure is solely from injectate volume and speed with cervical epidurals. it is not the type of medication used. slow down when you inject a CESI and the patients wont feel it as much.


i switched over to dex for TFESIs maybe 4 or 5 years ago. did kenalog work better? seems like it did, but it is really hard to say. sort of like Manowar assuming that the dexamethasone causes chest pressure, we tend to jump to conclusions without good data support. we have to try to avoid anecdotal evidence or what we think we see. the Kennedy article is the best evidence we have so far
C'mon man, I acknowledge I'm new and I'm trying to learn. I don't understand the hostility. I have been using dex for TFESIs since I started PP. The chest pressure I had noted from both my own and others' cervical ILESIs during fellowship. I just though it was a common side effect of the injection. Then when I started PP a very experienced pain physician mentioned that happened to him to until he switched from dex. He said it was the chemical composition. I had no reason not to believe him, and since I switched I haven't had that issue. Maybe I'm injecting slower now. I'd be happy to take a look at the cervical epidural/chest pressure paper if you have it.
 

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C'mon man, I acknowledge I'm new and I'm trying to learn. I don't understand the hostility. I have been using dex for TFESIs since I started PP. The chest pressure I had noted from both my own and others' cervical ILESIs during fellowship. I just though it was a common side effect of the injection. Then when I started PP a very experienced pain physician mentioned that happened to him to until he switched from dex. He said it was the chemical composition. I had no reason not to believe him, and since I switched I haven't had that issue. Maybe I'm injecting slower now. I'd be happy to take a look at the cervical epidural/chest pressure paper if you have it.
theres no paper.

and there's no hostility. i apologize if you took offense. im glad you are trying to learn -- you will learn a lot on this board (if you can thicken your skin a bit)

ive seen the chest pressure with saline alone. ive seen it with contrast alone.

particulates for CESI are a gray area. i use dex, but i think it can be reasonably argued that depo could be used. i think we are split about 50/50
 
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theres no paper.

and there's no hostility. i apologize if you took offense. im glad you are trying to learn -- you will learn a lot on this board (if you can thicken your skin a bit)

ive seen the chest pressure with saline alone. ive seen it with contrast alone.

particulates for CESI are a gray area. i use dex, but i think it can be reasonably argued that depo could be used. i think we are split about 50/50
That's fair, and thank you. I've learned a lot from this thread alone!
 

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I'm not sure I agree with this. In fellowship and when I first started I was using depo with saline (4cc volume) for CESI and almost never had complaints regarding injectate. I changed my practice based on some comments here as well as changes at my fellowship program to dex with 2 cc of saline (3cc volume) and definitely get more complaints now. Will probably go back to depo.
This is your bias from treating your own patient. It is not fact and it is not a global reality. It is what you have experienced in your own patient. 223 patient complains of this will sway you forever. If we all pooled our data, we would see that your experience is not the collective experience.
 
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DOctorJay

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appreciate the comment Steve, are you also dex for CESI? I can't recall.
 

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appreciate the comment Steve, are you also dex for CESI? I can't recall.
I do not believe in CTFESI, so I use Celestone for CESI. No vertebral artery reachable from where I start.
 

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just putting this out there... and I use dex + lidocaine for L TFESI.

so anyone know if mixing dex and lidocaine also causes crystalization???

Particulate versus non-particulate corticosteroids for transforaminal nerve root blocks: Comparison of outcomes in 494 patients with lumbar radiculopathy

Particulate versus non-particulate corticosteroids for transforaminal nerve root blocks: Comparison of outcomes in 494 patients with lumbar radiculopathy
11 September 2017

Purpose
We set out to compare outcomes in CT-guided lumbar transforaminal nerve root block patients receiving either particulate or non-particulate corticosteroids.

Materials and methods
This was a retrospective comparative effectiveness outcomes study on two cohorts of lumbar radiculopathy patients. 321 received particulate and 173 non-particulate corticosteroids at CT-guided transforaminal lumbar nerve root injections. The particulate steroid was used from October 2009 until May 2014 and the non-particulate steroid was used from May 2014. Pain levels were collected at baseline using an 11-point numerical rating scale (NRS) and at 1 day, 1 week and 1 month. Overall ‘improvement’ was assessed using the Patients’ Global Impression of Change (PGIC) at these same time points (primary outcome). The proportions of patients ‘improved’ were compared between the two groups using the Chi-square test. The NRS change scores were compared using the unpaired t-test.

Results
A significantly higher proportion of patients treated with particulate steroids were improved at 1 week (43.2 % vs. 27.7 %, p = 0.001) and at 1 month (44.3 % vs. 33.1 %, p = 0.019). Patients receiving particulate steroids also had significantly higher NRS change scores at 1 week (p = 0.02) and 1 month (p = 0.007).

Conclusion
Particulate corticosteroids have significantly better outcomes than non-particulate corticosteroids.

Key Points
Better pain relief is achieved with particulate steroids.

Significantly more patients report overall ‘improvement’ with particulate steroids.

Significantly more patients report ‘worsening’ at 1 week with non-particulate steroids.
 
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lobelsteve

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U do catheters ever in C spine? Or Just C7/T1 regardless of level of pathology?
Catheter once a year or so. C7-T1 covers C4 and lower reliably. No one sees a lot of C3-4 discs with radiculopathy.
 

clubdeac

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just putting this out there... and I use dex + lidocaine for L TFESI.

so anyone know if mixing dex and lidocaine also causes crystalization???

Particulate versus non-particulate corticosteroids for transforaminal nerve root blocks: Comparison of outcomes in 494 patients with lumbar radiculopathy

Particulate versus non-particulate corticosteroids for transforaminal nerve root blocks: Comparison of outcomes in 494 patients with lumbar radiculopathy
11 September 2017

Purpose
We set out to compare outcomes in CT-guided lumbar transforaminal nerve root block patients receiving either particulate or non-particulate corticosteroids.

Materials and methods
This was a retrospective comparative effectiveness outcomes study on two cohorts of lumbar radiculopathy patients. 321 received particulate and 173 non-particulate corticosteroids at CT-guided transforaminal lumbar nerve root injections. The particulate steroid was used from October 2009 until May 2014 and the non-particulate steroid was used from May 2014. Pain levels were collected at baseline using an 11-point numerical rating scale (NRS) and at 1 day, 1 week and 1 month. Overall ‘improvement’ was assessed using the Patients’ Global Impression of Change (PGIC) at these same time points (primary outcome). The proportions of patients ‘improved’ were compared between the two groups using the Chi-square test. The NRS change scores were compared using the unpaired t-test.

Results
A significantly higher proportion of patients treated with particulate steroids were improved at 1 week (43.2 % vs. 27.7 %, p = 0.001) and at 1 month (44.3 % vs. 33.1 %, p = 0.019). Patients receiving particulate steroids also had significantly higher NRS change scores at 1 week (p = 0.02) and 1 month (p = 0.007).

Conclusion
Particulate corticosteroids have significantly better outcomes than non-particulate corticosteroids.

Key Points
Better pain relief is achieved with particulate steroids.

Significantly more patients report overall ‘improvement’ with particulate steroids.

Significantly more patients report ‘worsening’ at 1 week with non-particulate steroids.
Finally a study showing what we all see anecdotally in our practices
 
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1. that study was retrospective, so while it looks good, it isn't quite up to par.
2. curious as to why the groups were so different in size - one group was almost twice the size of the other.
3. there was no information on dosing, etc. which would significantly skew the results (suppose they used 80 mg depo vs. 4 mg dex per level...)
 

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Starting doing paramedian ILESI near the lateral edge of the interlaminar space for some patients that had an inadequate response to a TFESI. I regularly see contrast flow along the nerve root and I get to use particulate steroid. Patients have been coming back reporting better relief with the second shot versus the first. your miles may vary
 
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emd123

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I just re-read the case report of infarction with dex. It was mixed with saline, not local.
Don't assume that particulate clogging and artery and causing an infarct as being the only way a TF esi can cause a cord infarct. The perforating spinal arteries are small and if using a cutting needle (Quinke) and depending on size (22g worse than 25g, obviously) one could tear or cut such an artery simply by hitting it or going through it with the needle, especially if its someone who already has a propensity to vascular disease with atherosclerosis (dissection can be caused by needle trauma to a calcified artery), and especially if a difficult injection with multiple passes with the needle, turning of a bent tip needle or other trauma. Certainly injection particulate into an artery can shut down arterial flow, but certainly isn't the only way to cause arterial trauma or infarct.

I favor using dex in TF ESIs as risk reduction, but I don't assume that risk reduction gets me down to zero risk.
 
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ragnathor

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Don't assume that particulate clogging and artery and causing an infarct as being the only way a TF esi can cause a cord infarct. The perforating spinal arteries are small and if using a cutting needle (Quinke) and depending on size (22g worse than 25g, obviously) one could tear or cut such an artery simply by hitting it or going through it with the needle, especially if its someone who already has a propensity to vascular disease with atherosclerosis (dissection can be caused by needle trauma to a calcified artery), and especially if a difficult injection with multiple passes with the needle, turning of a bent tip needle or other trauma. Certainly injection particulate into an artery can shut down arterial flow, but certainly isn't the only way to cause arterial trauma or infarct.

I favor using dex in TF ESIs as risk reduction, but I don't assume that risk reduction gets me down to zero risk.
I'm curious what you all think regarding infraneural approach. It is less likely to hit artery but higher risk of intradiscal injection. I haven't seen any reports of infarct with infraneural TFESI but granted it is less common.

Needle position analysis in cases of paralysis from transforaminal epidurals: consider alternative approaches to traditional technique.
Atluri S1, Glaser SE, Shah RV, Sudarshan G. Author information
Abstract
BACKGROUND:
Transforaminal technique for epidural steroid injections, unlike other approaches, is uniquely associated with permanent, bilateral, lower extremity paralysis.

OBJECTIVE:
To review the literature and analyze the reported cases of paralysis from lumbar transforaminal epidural steroid injections to possibly establish a cause and to prevent this complication.

STUDY DESIGN:
Eighteen cases of paralysis from transforaminal epidural injection have been reported. We could analyze the position of the needle within the neural foramen based on the available images and/or description among 10 of these 18 cases. Five cases were performed with computed tomography guidance and 12 cases were performed with fluoroscopic guidance [unknown in one case]. Additionally, other variables associated with the procedure, including the technique, were also examined.

METHODS:
Analysis of the needle position in the neural foramen in cases of paralysis from transforaminal epidural steroid injections. This analysis is based on images and/or description provided in published reports.

RESULTS:
Paralysis in these cases seems to be associated with a well performed traditional safe triangle approach with good epidural contrast spreads. Analyzed data shows that 77.7% of the time, the needle was in the superior part of the foramen. In 71.4% of the cases, the needle was in the anterior part of the foramen. This coincides with the location of the radicular artery in the foramen. In 22.2%, the needle was in the midzone (neither in the superior nor inferior zone). No level was spared as this event occurred at every foramen from T12 to S1. Ten of these events happened during a left-sided procedure and 8 during a right-sided procedure. No relation to this complication was noted when other variables like type and size of the needles, side of the injection, local anesthetic, contrast, or volume of injectate were taken into consideration.

LIMITATIONS:
Only 18 cases of paralysis from transforaminal epidurals have been reported. Out of these, only 10 cases included images or descriptions which could be evaluated for our study.

CONCLUSION:
In light of the anatomical and radiological evidence in the literature that radicular arteries dwell in the superior part of the foramen and along with our needle position analysis, we suggest that the traditional technique of placing the needle in the superior and anterior part of the foramen must be reexamined. Alternative, safer techniques must be considered, one of which is described.
 
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