C4-C5 CESI without prior MRI

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thecentral09

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So I work for a hospital in a relatively rule area. Another pain guy who works For a different hospital approximately one hour away had a patient who left and came to our services. In review of the records the patient was complaining of axial neck pain after a car accident, never obtained an MRI, and I have an op note stating for CESi at c4-c5 without any prior MRI? The patient states it was the worst experience of her life. Would the more senior guys have any input on this. I’m fine with people being aggressive, but when it is grossly unsafe and outside guidelines I feel the need to speak up. Has anyone ever reported something like this?
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Never event. MRI should be done before anything in canal. Entering above C6-7 is the never event. I would never enter above C7-T1. Doing CESI for neck pain without concordant arm pain and MRI is stupid and places patient at risk. The other guy is an a hole.
 
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Completely unsafe and shouldn't happen under any circumstances.
 
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So does anyone suggest doing something about this so that it doesn’t happen again? If so what?
 
thecentral09 said:
The patient states it was the worst experience of her life...but when it is grossly unsafe and outside guidelines I feel the need to speak up. Has anyone ever reported something like this?
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What was bad about the experience? Would an MRI have allowed the provider to avoid it?

I agree about not accessing the epidural space above C7-T1.

I am equivocal regarding the MRI but I would feel better with some cross-sectional imaging to assess canal diameter and to rule out acute surgical needs, but with cost/access in rural areas, I'm not sure what is feasible/reasonable. I'm not sure if it really adds value to the patient's care or just protects the provider in case of problems/complaints down the road.

I'm sure somewhere out there, there are providers that still do these based on physical exam findings using a landmark based hanging drop technique. The real question is what your local standard of care is with the resources in your community. If you have concerns, I would first ask other pain doctors in your area and then do the professional thing to let that specific doctor know this patient raised significant concerns, and asking them about their practice standards on a collegial/personal level.

I don't think this quite rises to medical board level, but the next step is probably a hospital patient safety officer for them to review the complaint internally if you don't get the feedback/interaction you want from that cowboy.
 
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Definitely wouldn’t do a CESI without MRI (CT if they had a pacemaker or something else that precludes MR). I never go above C7-T1. Epidural fat noted on sagittal T1 is rarely demonstrated above that level so safe needle placement would be dicey. Pre-procedure advances imaging necessary to keep both patient and doc safe.


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Ok, I do appreciate that everyone agrees this is bad practice. What I am getting at is if a colleague near you was doing this what would you do about it
 
Contact him/ her directly and state your issues with the practice
 
As a general rule, I don't stick needles in patient's spines without seeing an MRI first. If I ever was going to break that rule, I sure as hell wouldn't do it with a CESI, let alone up at C4/5. That's just nuts.

If you want to be safe: Always make sure you have a recent MRI (or CT if MRI is contraindicated) on new patients you're thinking about doing spinal injections on. You'll find weird stuff like cancers, severe central stenosis with cord impingement, fractures and occasional infections, all of which are things you don't want to stick needles into. Also, with cervical ESIs, don't do TF's, don't go above C7/T1 and use contralateral oblique technique. This is all for risk reduction.
 
was this procedure on in the context of personal injury case on a lien?
 
ill reiterate what everyone else says: CT or MRI before procedure always. never go above C7. I personally never do cervical transforaminals. never use sedation (other than a migratory valium).

CT is available almost everywhere. there is a good chance that the proceduralist viewed the CT scan after the MVC that was done in ER prior to the injection.....
 
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It's bad practice, but I don't think people really get reprimanded by the board if you're not causing harm. What was the bad experience? Professionally, if you're motivated, you could call the person and see why they did what they did. If you don't want to personally get too involved, give your opinion to the patient and the patient can complain to the board if they wish. I've seen all kinds of crazy stuff out there and hospitals/employers don't really care as long as they don't get sued. There is no lawsuit without injury.
 
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Ducttape said:
ill reiterate what everyone else says: CT or MRI before procedure always. never go above C7. I personally never do cervical transforaminals. never use sedation (other than a migratory valium).

CT is available almost everywhere. there is a good chance that the proceduralist viewed the CT scan after the MVC that was done in ER prior to the injection.....
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This idiot unlikely reviewed anything. I do see similar nonsense from IR guys at competing health systems.
 
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I finished fellowship last year. We routinely did CESI at C6-C7 with 20g Tuoy LOR and contrast to confirm appropriate loss. I often feel my LOR up here is not always clear cut so now I go lateral or CLO and once I am getting close switch to contrast every 1mm til good spread. I always review MRI again right before procedure.

Everyone above stated they don't go above C7-T1. I know the epidural space is thought to be thicker here. I may change my practice to C7-T1. Does anyone use a catheter or just tuoy? What volume do you use generally?
 
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pastafan said:
Contrast 1 ml, 2 ml NSS, 1 ml steroid.

Please clarify. Usually you used LOR alone in fellowship without contrast?
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I wasn't clear, we always used LOR and contrast. I edited my post. Generally we relied on LOR initially until loss then did contrast to confirm (or if felt we were going to far anterior).

Thanks for posting the mix
 
I don't know about yall but I take CESI very seriously. I use dex 10mg and 2cc of NS. Contrast in CLO and again AP. I want to see good spread in CLO and epidural fat blobs in AP. Early contrast when I know I'm still posterior. I am more cavalier in the lower back, but still careful obviously. I think as soon as you lose your respect for the CESI you're subjecting your pt to additional risk. I had a young girl on work comp maybe an year and a half ago get a severe headache and cloudy nose about 8 hrs after a C7-T1. Lasted about 6 hrs and resolved. Not sure what that was but I take great care with this bc I don't want to hurt anyone and I do NOT want to be called at 1AM.

I've done C6-7 before, but not in private practice. Did a lot of cervical TFESI in residency but none in fellowship and I'm not doing them now.
 
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I too take CESI very seriously. I never go above C7-T1 and do not see a reason to. I see many op reports on IMEs and our own ASC of routine entry at C6-7. No sure why but that seems to be the go to level for many docs. Obviously it is still being taught in training programs. I don't rely on LOR in the cervical spine because I find MANY times there is barely any resistance ( using saline, not air). I use small amounts of contrast until linear spread at VLL. Sometimes there is quite a bit of contrast posterior to the ligament. Since I started using the CLO view and my needle tip is off of midline, I see a lot of unilateral contrast spread and observe much less "fat globules" on AP despite clear epidural spread on CLO unless I make a major effort to stay really close to the midline.
 
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In my fellowship we did midline at C6-7, because in lateral C7-T1 didn’t show up well, but never above that. Pretty soon after starting on my own I switched to CLO and have never looked back. For interlaminar I do C7-T1, and in the rare cases where there’s no good opening there I do T1-T2. 1 mL of contrast spreads 2-3 vertebral levels in either direction so I’m not too worried about the 4 mL of injectate not making it up to the cervical spine. I do cervical transforaminals but only diagnostic at the request of a surgeon.
 
NJPAIN said:
I too take CESI very seriously. I never go above C7-T1 and do not see a reason to. I see many op reports on IMEs and our own ASC of routine entry at C6-7. No sure why but that seems to be the go to level for many docs. Obviously it is still being taught in training programs. I don't rely on LOR in the cervical spine because I find MANY times there is barely any resistance ( using saline, not air). I use small amounts of contrast until linear spread at VLL. Sometimes there is quite a bit of contrast posterior to the ligament. Since I started using the CLO view and my needle tip is off of midline, I see a lot of unilateral contrast spread and observe much less "fat globules" on AP despite clear epidural spread on CLO unless I make a major effort to stay really close to the midline.
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How do you inject the contrast as you go? LOR syringe? Or you switch back and forth from LOR syringe to contrast syringe? Or dont do LOR syringe at all?
 
Just so it’s clear to everyone, lobelsteve is the god of pain medicine, and anyone who does something he doesn’t approve of is an “a hole” and an “idiot”.
 
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Timeoutofmind said:
How do you inject the contrast as you go? LOR syringe? Or you switch back and forth from LOR syringe to contrast syringe? Or dont do LOR syringe at all?
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Prone position, arms at sides, OakWorks frame. No LOR syringe. About 4 ml of Omnipaque in a 5ml syringe with a 6 inch extension tune loaded with contrast. I advance my needle mainly in CLO view until about 3/4 way to VLL. I attach the syringe and start giving small puffs of contrast. One of three things happen: 1. I start seeing contrast posterior to the ligament and flowing over the lamina ( least desirable but quite frequent ), 2. tiny bit of contrast exits needle tip but plunger sort of bounces back, 3. I can't inject at all and I see no contrast. Regardless, I advance giving small puffs of contrast until I get linear spread at VLL. Once I'm ready to start injecting contrast I check an AP to be certain that I have not crossed the midline. Everyone else who works out of the same facility does hanging drop with patient seated in a wheelchair. Much quicker than I am and much less fluoro time. I used hanging drop for many years but would not go back.
 
NJPAIN said:
Prone position, arms at sides, OakWorks frame. No LOR syringe. About 4 ml of Omnipaque in a 5ml syringe with a 6 inch extension tune loaded with contrast. I advance my needle mainly in CLO view until about 3/4 way to VLL. I attach the syringe and start giving small puffs of contrast. One of three things happen: 1. I start seeing contrast posterior to the ligament and flowing over the lamina ( least desirable but quite frequent ), 2. tiny bit of contrast exits needle tip but plunger sort of bounces back, 3. I can't inject at all and I see no contrast. Regardless, I advance giving small puffs of contrast until I get linear spread at VLL. Once I'm ready to start injecting contrast I check an AP to be certain that I have not crossed the midline. Everyone else who works out of the same facility does hanging drop with patient seated in a wheelchair. Much quicker than I am and much less fluoro time. I used hanging drop for many years but would not go back.
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Hanging drop? Where is this place? I told my kids dinosaurs went extinct. They’d love to see some.
 
AP with a trace amount of ipsilateral oblique. Advance until the base of the spinous process. Intermittent CLO to assess depth and AP to make sure I'm not heading lateral. Hook up contrast and inject 0.5cc posterior to the VLL. Advance a small amount and contrast again...Still posterior or in ligament. Attach LOR with air and advance a touch. If you get loss (which you usually do) then air pushes the contrast and you'll have a linear pattern anterior to the VLL. If no loss advance a touch and add contrast. I always do contrast CLO and AP.

At this point I could probably do away with LOR entirely but I'm not there yet. If something happens I'm basically going against the "norm."

Also, I only advance the needle with two fingers directly next to the skin. I've even put a drop of contrast on my glove in the past bc it makes the tip sticky and you get firm contact and good feel. I don't do the drop of contrast as a routine thing.
 
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You would be VERY surprised at how many people still use the technique (hanging drop).I’m not advocating it but I think if you’re using the seated position and no CLO, it MIGHT be more reliable than LOR in the hands of many. I know the literature states that the needle tip comes closer to the cord. It comes down to reliability of a visual sign vs a tactile one.


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Timeoutofmind said:
Anyone ever tried just putting contrast in the LOR syringe? Best of both worlds?
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Never done it but I've thought about it. Problem is that unlike saline, it is sticky and I worry about it making a mess. Putting 0.5cc into the ligament tends to result in a little contrast getting pushed into the space with air during loss. You can see it in fluoro.
 
Timeoutofmind said:
Anyone ever tried just putting contrast in the LOR syringe? Best of both worlds?
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Every single time I draw up 0.5ml omnipaque and 0.5ml air in a plastic LOR syringe. Once nearing the VLL in CLO I attach LOR syringe with contrast and start with gentle pressure on syringe while making small advancements of the 18g tuohy until I get LOR at the VLL. I always use CLO. I can usually tell you when I’m going to get LOR within 1-2 mm on CLO. I’m pinching the needle tightly at the skin, sometimes even pushing the skin down where the needle enters to ensure there’s no way for me to accidentally advance. CLO is very accurate for me as far as predicting the LOR depth when I make sure my needle stays a few millimeters to the side of the spinous process (i.e don’t get to midline or cross midline using CLO).

Also, I use an 18g tuohy for this not only because I trained with it and am most comfortable with it, but I find the larger 18g tuohy gives me a more crisp LOR. A smaller gauge, especially with more viscous contrast would result in a less crisp and mushy loss. But as I said above I usually know right where I am expecting LOR and if I don’t get it I’m checking in AP etc to make sure im really where I want to be (not too lateral or crossing midline).
 
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callmeanesthesia said:
What do you guys do for CESI in patients with contrast allergy?
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We have gadavist a noniodinated contrast. I use it. If I did not have it I would just not use contrast and use my technique above. If anything didn’t feel right (not getting LOR at expected depth using CLO) I’d abort.
 
This is pretty fascinating to me that LOR is outdated and not what people are doing.
First time I’m heading about these alternative approaches.

Is the consensus the same for SCS? Given 14 G tuohy, resistance in general is spotty at best, so do ya’ll just go lateral, inch forward and gently advance the lead till it goes in?
 
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paindoc007 said:
This is pretty fascinating to me that LOR is outdated and not what people are doing.
First time I’m heading about these alternative approaches.

Is the consensus the same for SCS? Given 14 G tuohy, resistance in general is spotty at best, so do ya’ll just go lateral, inch forward and gently advance the lead till it goes in?
Click to expand...

I use loss or the lead in SCS.
 
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paindoc007 said:
This is pretty fascinating to me that LOR is outdated and not what people are doing.
First time I’m heading about these alternative approaches.

Is the consensus the same for SCS? Given 14 G tuohy, resistance in general is spotty at best, so do ya’ll just go lateral, inch forward and gently advance the lead till it goes in?
Click to expand...

I’ve been told by an attending from fellowship that the Germans do this routinely and have a higher rate of wet taps. Couldn’t quote you a study. Purely anecdotal.
 
For SCS, I touch down on T12/L1 (usually) lamina in AP, walk off, drop angle, hook up LOR syringe and andvance with continuous pressure until LOR. I don’t mess with laterals/CLO, takes more time and not as reliable as what I get simply by feel. Also as little C-arm movement as possible over the patient is a good thing. It’s all sterile but Hypothetically risk of contaminating the field goes up I would guess.

Usually check early lateral to make sure leads are posterior though
 
paindoc007 said:
This is pretty fascinating to me that LOR is outdated and not what people are doing.
First time I’m heading about these alternative approaches.

Is the consensus the same for SCS? Given 14 G tuohy, resistance in general is spotty at best, so do ya’ll just go lateral, inch forward and gently advance the lead till it goes in?
Click to expand...
I find that loss of resistance is anything but spotty with the 14 gauge needle in stim trial kits. 99 out of 100 times the plunger falls with an undeniable clunk, much better than with a 18, 20 or 22g tuohy.
 
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Where's the evidence for cesi?
 
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For SCS, I use LOR and CLO.

I still use LOR for CESI, Since I figure at least the first time I don’t want to put too much pressure in.

Usually mix very small amount of contrast with saline for LOR syringe. Like 0.3 ml in 2 ml saline.
 
been using contrast in my LOR for 7 years now and love it. Saves me a step and you can see it before and after you're int he epidural space
 
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I put pure undiluted omnipaque 240 in the LOR syringe. Just don’t squirt it all in and mess up your image. I’ve never had an issue.
 
Would u offer an epidural at c7 for radiculopathy if stenosis is down to 6mm (no signal changes, no myelopathy, but definite cord flattening almost looks deformed)
 
No.

Go south and get yourself some room.
 
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