Cervical epidurals with catheter

IPSIS: Formerly the Spine Intervention Society
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painfre

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DO you use catheters for crvical epidurals. I am seeing lot of pts with previous neck surgeries coming with bilateral forminal stenosis extending up to C7.
I would like to try catheters in these pts.
Ayn experiencing using the arrow Kits with catheters.
AK-05000
Epidural Catheterization Kit with TheraCath® Catheter

Thanks
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Be very careful with these catheters: they can sheer the veins in the epidural space causing complications.
 
algos, do you never perform cervical ESI with cath or do you just avoid it when possible? I respect your opinion on such things.
I only did a couple cervical ESI + cath during fellowship, and I still debate the risk/reward ratio of doing cervical ESI that way.
 
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Is there any better way of doing an epidurals if Pt has a previous surgeries with hardware extending below up to C6 or C7 or In pts with high cervical disc lesions with radicular pain other than TFESI ?
 
Typically the hardware is not a major impeding issue for transforaminal approach since for an ACDF, it lies on the anterior vertebral bodies, and with a posterior decompression and fixation, it lies on the lamina or pedicles. If for some reason an interlaminar approach is necessary for pathology superior to C4, then sometimes I use a catheter...
 
Softest possible. I like the Arrow flex-tip without a stylette. There are very few things to obstruct its advancement in the posterior epidural space...
 
Only theracath in my hospital. I withdraw theracath stylette out about 1-2cm, and advance slowly to the target area.
 
algosdoc said:
Softest possible. I like the Arrow flex-tip without a stylette. There are very few things to obstruct its advancement in the posterior epidural space...
Click to expand...

The hospital previously only had arrow nerve catheter kits available for these. 17g tuohy and spring loaded catheter. Impossible to steer, but soft.

I now use both Neurotherm catheters as well as Epidmed. I mainly use the Epimed introducer and catheter for caudals. With a bit of a bend on the catheter tip it is reasonable steerable. I tried a cervical ESI with this system once, but it was too stiff. I ended up having to take the stylette out, which defeated the entire purpose of a steerable catheter.

The Neurotherm catheters are much softer, steerable, and work great for ILESIs.
 
Probalby discussed elsewhere, but if you are directing a catheter via an interlaminar needle to a foramen, inject dye and see it spread out foramen, can this be billed as transforaminal injection?
 
Lumbago said:
Probalby discussed elsewhere, but if you are directing a catheter via an interlaminar needle to a foramen, inject dye and see it spread out foramen, can this be billed as transforaminal injection?
Click to expand...

Yes it can be billed that way. Use the code for fraudulent services
 
speaking of

Just did a peer review of a doc in the most bankrupt state of our union. For a diagnosis of low back pain, NOS and completely normal physical examination the doc performed and billed the following on the same DOS: bilateral L5 TFESI (actually documented as an ILESI), caudal ESI, lumbar TPI, sciatic/piriformis block with nerve stimulator coded as US guidance, and a post procedure TENS unit "analgesic" session. Separately, anesthesia billed their services along with "EEG" monitoring during the case. The facility also billed an SI injection but the provider apparently forgot to throw that one in too.

The bunch is being spoiled as we speak.
 
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Duly noted. Sounds like catheter directed ILESI should be billed as simple ILESIs. Anyone doing otherwise?
 
Lumbago said:
Duly noted. Sounds like catheter directed ILESI should be billed as simple ILESIs. Anyone doing otherwise?
Click to expand...

the fact that it is an ILESI, is the reason why i would call it an ILESI...
seems logical to me.
 
To those who use Epimed catheters, which one do you use? At our facility, we use 21g Versa-Kath with 16 or 18 gauge Epimed Rx needle. I can't help but feel that the Versa-Kath is a little stiff though, to be working in the cervical region...

For those who have tried Epimed catheters, but have decided on another brand, is there any particular reason why?
 
Any of you guys do Cervcial epidurals in the sitting position using a flouroscope as the pt is comfortable flexing the neck and resting on some support? Any thoughts?
 
Did this way in fellowship. Not a bad way but worry about vagal in this position.
 
Surveys show up to 30% of folks do this. I have not personally seen it and think it unusual, and allows the patient the ability for too much movement to make me comfortable. I'd stick with ISIS guidelines for how to.
 
nvrsumr said:
Did this way in fellowship. Not a bad way but worry about vagal in this position.
Click to expand...

Done it. DOnt do it anymore. I have actually done blind sitting CESI...

I Dont like the lack of AP in the sitting position. prone is just better all around i think...my 2 cents
 
1x on a CHFer. Never again. PITA.
 
Any opinions? Where I train, we perform CESI's in an outpatient facility with no IV access or procedural patient monitoing other than pre/post. Is this fairly standard for private practitioners?
 
MedZeppelin said:
Any opinions? Where I train, we perform CESI's in an outpatient facility with no IV access or procedural patient monitoing other than pre/post. Is this fairly standard for private practitioners?
Click to expand...

Iv debatable but nice to have. Monitor is essential for spinal procedures.
 
MedZeppelin said:
Any opinions? Where I train, we perform CESI's in an outpatient facility with no IV access or procedural patient monitoing other than pre/post. Is this fairly standard for private practitioners?
Click to expand...

where I trained, no IV, no Monitors...
many people I know do not use any monitors for routine procedures...
 
No IV, pre-post BP, O2 sat. Can monitor during procedures, but tubes get in the way often.
 
I use a Feth-R-Kath for CESI's but with the Medicare reductions I am cutting that out of the equation. Tired of eating $12 losses on the catheters. They will get an ILESI and if it doesn't go high enough, oh well. You get what you pay for.

I use monitoring and a saline lock on everyone. It's rare to need the IV for emergencies (usually vaso-vagal episodes) but I subscribe to the airline pilot's adage that it's better to be on the ground and wish you were in the the air than vice-versa.
 
Mister Mxyzptlk said:
I use a Feth-R-Kath for CESI's but with the Medicare reductions I am cutting that out of the equation. Tired of eating $12 losses on the catheters. They will get an ILESI and if it doesn't go high enough, oh well. You get what you pay for.

I use monitoring and a saline lock on everyone. It's rare to need the IV for emergencies (usually vaso-vagal episodes) but I subscribe to the airline pilot's adage that it's better to be on the ground and wish you were in the the air than vice-versa.
Click to expand...

The only time I use a monitor and IV is on patients that will have a complication. Thanks pre-cogs.
 
If worried about Vaso-vagal responses shouldn't you put in saline lock for every office injection - shoulder, knee, and even trigger point?
 
lonelobo said:
If worried about Vaso-vagal responses shouldn't you put in saline lock for every office injection - shoulder, knee, and even trigger point?
Click to expand...

That is my exact arguement against those who would call it the "standard" for non-sedated fluoro cases. Aside from being in or around the CNS, an injection is an injection. Pts vaso-vagal largely, IMHO, due to anxiety. I've never had a female pass out. I've had a couple teen girls come close. Every syncopal episode I have had has been on a male. All have recovered shortly with laying them down +/- trendelenberg, cold cloths on the head and a few minutes.

I've seen rheumtology pts down the hall have their husbands pass out when the wife was getting an injection. Several needed EMS due to prolonged syncope. Should we heplock everyone in the room?
 
I've seen rheumtology pts down the hall have their husbands pass out when the wife was getting an injection. Several needed EMS due to prolonged syncope. Should we heplock everyone in the room?[/QUOTE]


yes. i believe it is standard of care to heplock all individuals within 1 mile radius of any injection, anywhere.
 
Anyone using the neurotherm tru-cath for the cervical TF ESI to get better more localized results than IL ESI?
 
QUOTE=painfre;10221566]DO you use catheters for crvical epidurals. I am seeing lot of pts with previous neck surgeries coming with bilateral forminal stenosis extending up to C7.
I would like to try catheters in these pts.
Ayn experiencing using the arrow Kits with catheters.
AK-05000
Epidural Catheterization Kit with TheraCath® Catheter

Thanks[/QUOTE]

59 yo male with left cervical radic.
T1-2 IL ESI 20% relief for 30 days
T1-2 IL ESI with catheter (theracath ref ec-05000) made by arrow through a #17 gauge tuohy 90% relief for 9 months.
 
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In training we always used the Epimed versa-caths (21g cathter, 18g needle). Can't bill for catheter so you have to just bill for regular cervical ESI. Cost of catheter is ~60 bucks, and for the needle is ~15 bucks. IV was plus/minus. At our main facility we put IVs in all cervical procedures. At the VA we didn't unless the patient was really antsy. Of course I can count at least 2-3 patients we were doing cervical procedures who vagal'ed during the procedure and subsequently ended up having to get an IV.

Epimed has more economical catheters, I think called econo-caths but requires a 16g needle and I'm not putting a huge ass needle in someone's neck.
 
[

[/QUOTE]

59 yo male with left cervical radic.
T1-2 IL ESI 20% relief for 30 days
T1-2 IL ESI with catheter (theracath ref ec-05000) made by arrow through a #17 gauge tuohy 90% relief for 9 months.[/QUOTE]

Is this supposed to be an endorsement for CESI with cath?
This also happens sometimes when you do the exact same procedure on the same patient.
 
It is not possible to attribute long term results to any epidural steroid technique beyond the antiinflammatory effects of the particular steroid. Any long term results are due to metalloproteinases or reduction in the biomechanical production of continued inflammatory based pain.
 
lonelobo said:
[
Click to expand...

59 yo male with left cervical radic.
T1-2 IL ESI 20% relief for 30 days
T1-2 IL ESI with catheter (theracath ref ec-05000) made by arrow through a #17 gauge tuohy 90% relief for 9 months.[/QUOTE]

Is this supposed to be an endorsement for CESI with cath?
This also happens sometimes when you do the exact same procedure on the same patient.[/QUOTE]

not endorsing anything. just saying. :naughty:
 
Jcm800 said:
I've seen rheumtology pts down the hall have their husbands pass out when the wife was getting an injection. Several needed EMS due to prolonged syncope. Should we heplock everyone in the room?
Click to expand...



yes. i believe it is standard of care to heplock all individuals within 1 mile radius of any injection, anywhere.[/QUOTE]

I tried this once. It significantly increased the suboxone patients for the next month.
 
I suppose it depends on risks and alternatives. If you use a test dose with local or use local intentionally in the epidural cervical injection then if you accidentally inject subdural or subarachnoid then are you prepared to deal with the respiratory arrest, loss of conciousness, and hypotension? Can you handle this without an iv? What if you could not get an iv? Same for contrast reactions...can you handle these without an iv if one cannot be placed after theanaphylaxis occurs? Also iv placement is a repetition dependent skill. If you never start ivs for procedures, can you place one into the capillaries of a chemo patient in a patient with a blood pressure of zero? Just considerations....
 
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