C4-C5 CESI without prior MRI

[Extralong]

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Agree with this. Why risk it? Nothing wrong with a T1-T2

I agree. Respect the neck. That’s my rap.

 

[painfree23]

Agree with this. Why risk it? Nothing wrong with a T1-T2

Will enough get up to where it is? I don’t typically do high volume injections there.

Also, do you document in your note why u went at T1 instead of c7

 

[SommeRiver]

Will enough get up to where it is? I don’t typically do high volume injections there.

Also, do you document in your note why u went at T1 instead of c7

Put steroid and 2cc of NS in there and you're good. Whether it does or doesn't get where it needs to go doesn't change the fact your pt has a bad neck and you're not going to correct that.

Document what you feel you need to document. Nothing wrong with explaining in your note that the pt has a dangerous neck and you simply can't do an ESI in a tight canal.

Not your fault their neck sucks.

 

[callmeanesthesia]

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)

I assume you mean stenosis at C7-T1? I’d say nbd to go down a level as long as you can see T1-2 on your MRI and it looks ok. Just injec

Will enough get up to where it is? I don’t typically do high volume injections there.

Also, do you document in your note why u went at T1 instead of c7

1 cc of contrast usually spreads 2 levels in either direction so 4 cc of injectate is probably going to get where it needs to go just fine. Did T1-2 the other day because I got venous uptake at C7-T1. Just documented why. It’s the same CPT code so doesn’t matter too much.

 

[lonelobo]

This is pretty fascinating to me that LOR is outdated and not what people are doing.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?

I would guess 90% folks still use LOR, it being outdated is a myth

 

[Ducttape]

You know... technically we still all use LOR to some degree.

If you try to put a little puff of contrast and there is a ton of resistance, do you jam in the contrast with both hands, or think “I must not quite be in yet”...

 

[Nonphysiologic]

In regards to the people who put contrast in LOR. I tried this once. My issue is it obscures seeing where my needle tip is.


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[painfree23]

Hanging drop anyone?

 

[lobelsteve]

Hanging drop anyone?

Rofl

 

[dhcofc]

In regards to the people who put contrast in LOR. I tried this once. My issue is it obscures seeing where my needle tip is.


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Don’t start squirting in contrast until you are close to the epidural space in contralateral oblique. At that point you’re view won’t get obscured because the contrast will be shallow to the ligamentum until you’re past it and get a nice epidurogram.

 

[Ducttape]

diluting out the contrast helps.

 

[Bsb2015]

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

Are you using a coude needle? Your leads stay dorsal with this approach?