Cervical Epidurals

Orin

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    I just want to clarify that contralateral oblique for the view refers with respect to the needle ,right? If you cross over the midline, intentionally or accidentally, the CLO view will lead you wrong for depth. Keep it simple and slide lateral.

    I second the tech part as well. Get your tech to move the C-arm so it is lined up/midline to avoid a large offset in addition to a weird wig/wag angle, get the end plates squared off near the level you're aiming at, and the image collimated.

    I'll also sometimes drop down to T1-T2 and thread a catheter if I'm not in a rush.

    Fear's normal and healthy though
     

    No_Pain_No_Gain

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      You may not be imagining things.
      If you're using a smaller gauge needle than you are used to, the LOR is MUCH less profound.
      If the LOR syringe is wider than you're used to, the LOR is MUCH less profound.

      For CESI, never use sedation. Only use dexamethasone (nonparticulate) and NS.

      What is your reasoning for only using dexamethasone (nonparticulate) for cervical interlaminar ESIs?
       

      cbest

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        There’s some incorrect usages of angles for CLO being discussed recently.

        First, don’t go midline. Ligamentum flavum doesn’t form at midline in cervical spine in a decent chunk of people. No lig = no LOR.

        Second, an angle of 50 (maybe 55 in some cases) should be used for CLO in cervical and upper thoracic spine and 45 in lower thoracic and lumbar spine. A smaller angle (eg 30 CLO) will cause needle tip to look deeper than it actually is compared to a larger angle (eg 60 CLO).

        Third, I’m only a couple years out from fellowship and CESI remains my least favorite procedure to do. Understand your views, take your time, and optimize your fluoro view before you even start with your local. Okay to try a little puff of contrast if you’re near ventral interlaminar line and you think you may have had LOR. I don’t recommend using contrast in place of saline as it is more viscous which means it can dampen the LOR sensation compared to saline.

        Finally, I strongly recommend reading all articles published by Jatinder Gill and/or Tom Simopoulos for discussion of CLO.


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        hyperalgesia

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          What is your reasoning for only using dexamethasone (nonparticulate) for cervical interlaminar ESIs?
          Non-particulate: less risk of embolism (I use dexa in all axial procedures)
          Saline instead of local: less risk of high spinal

          Recognize that even though ESIs are done all the time and we, in the pain world, consider them SOC, they are explicitly NOT FDA approved. There is definite risk and benefits are not well established. This setting does not leave room for complications. So, you want to meticulously select pts and take every reasonable precaution.

          FDA Drug Safety Communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain
           
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          painconfidential

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            Thanks all. Now that I think about it I think I in fellowship my needle was 18G. The other thing I get caught up in is once I hit ligament and puff some contrast and if Im out I become hesitant to go further because often times I need to push with some decent force to get through. Maybe a bigger gauge needle will help.

            Also, one of my associates at the practice I'm at has been practicing for like 35 years. He never ever looks at CLO or Lateral and he almost recklessly hits lamina with the tip of the Touhy curved downwards, then rotates its up and then pushes down until he feels loss. It looks so scary when he does it and I'm almost positive a lot of times he does it he is not actually in epidural space but I've noticed on AP view only its easy to be fooled that contrast is in epidural space which leads me to my next series of questions:

            1. What exactly do you guys look for for good contrast flow especially from AP view? I have a difficult time verbalizing it its more like I just know it when I see it but thats not good enough. I was hoping I could get a precise answer.

            2. What do you guys do if there is contrast allergy?

            3. If someone is on PLAVIX or some other blood thinner and or anticoagulant but the appropriately stopped it as per ASRA guidelines does that change the gauge of needle you would use?
             

            lobelsteve

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              Try contrast instead of saline for your LOR syringe. I use 0.5 mL of contrast in my loss of resistance syringe and then draw up about 0.5 ml of air. I use an 18g tuohy so I feel a crisp LOR. I don’t think smaller needles have quite as crisp LOR. If I have LOR in the epidural space and not false loss the fluoro image will reveal epidural spread. Simple. One step if you just use contrast as the LOR fluid.

              But if you get false loss and drop in 0.5cc contrast you can make it more difficult to see the landmarks.
               
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              dhcofc

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                But if you get false loss and drop in 0.5cc contrast you can make it more difficult to see the landmarks.
                That’s never happened to me. I don’t start checking for loss until the tip is starting to go between the posterior lamina line on contralateral oblique and by then you are probably in ligament and unlikely to get false loss. Also, when I get loss I often put in a very small amount of contrast and take a fluoro image, if it looks good I put in a bit more to fully confirm.
                 

                Ducttape

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                  check and see what else is different. the glass vs plastic LOR syringes are also different in feel. needle size is also important.

                  mix in a little contrast in with your saline for the LOR - I don't inject any air for the possibility that someone will later on get an MRI head and state that the 24+ year history of headaches is due the injection I did last week.

                  if patients are awake, from what I hear, they will verbally tell you that something is wrong when you hit the cord.

                  more likely you are having the yips, per se. realizing that what you are by yourself and what you are doing is potentially dangerous is a revelation that, in actuality, is good for you and your patients. its good to feel a little anxiety when you do a riskier procedure.

                  for contrast allergy, pretreat with Benadryl and steroids. I have on rare occasion done without contrast at all. (if using multidose vial, switch out all the vials and use brand new vials for everything.)

                  I use 22 gauge Touhy for all injections. I don't believe going to 25 gauge non-Touhy and having a completely different feel is worth that risk over the increased risk of injury with the larger needle.
                   

                  swamprat

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                    Maybe it’s just my crappy Fluoro machine but any1 ever go CLO and the contrast pattern is not that fine stripped line but looks kinda blotchy and goes far anterior than you would expect. Definitive loss, needle tip is not too far and on AP it looks like ur typical epidurogram. I always thought maybe it’s in the gutter but it looks directly midline in AP.
                     

                    dhcofc

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                      If your needle tip is midline or ipsilateral to the way you are obliqing the contrast spread pattern will appear to move much more anterior than you expect. If your needle tip is truly contralateral to the midline of the way you are obliqing it will appear as a sharp line just anterior to the lamina. You always get the best image if your needle is a few millimeters off of the midline contralateral to the way you are tilting your fluoro.
                       
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                      cowboydoc

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                        Yoon Sangwon, CEO of Saeum Meditec, said, “Koreans use chopsticks everyday at the kitchen table. Their finger culture may be superior to people in many foreign countries. Because the traditional method is very dependent on the sense of the practitioner (tactile feedback at the finger tips), it is of great help to young doctors all over the world.”

                        Their finger culture is better than our finger culture, I guess.
                         
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                        pastafan

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                          powermd

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                            But if you get false loss and drop in 0.5cc contrast you can make it more difficult to see the landmarks.

                            Not in my experience. Like you, I start injecting contrast early. Typically the contrast flows caudad along the lamina which gives a very confidence-inspiring answer to the question of where my needle tip is NOT. The annoying injections are the ones with several false losses. This is why I draw up at least 2.5 mL contrast for cervical epidurals. It's sub-optimal to redraw contrast with a needle millimeters from the cord. Eventually I reach true engagement with the LF, then true loss. I no longer feel any fear during cervical epidurals, but I do have a very healthy respect for a great many things cervical. If placement is more challenging than expected, or dye flow is confusing, I am quick to stop, withdraw, and re-evaluate. The most common problem I encounter is a sub-optimal starting position. Sometimes (rarely) that's not apparent until after the first needle pass. Once that gets corrected, the most challenging placements suddenly become easy.

                            One caveat I would put out there is to think very hard before applying a lot of force because 'osteophytes' or 'thick ligament'. This sounds like a great prelude to a cord strike.
                             
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                            lobelsteve

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                              Not in my experience. Like you, I start injecting contrast early. Typically the contrast flows caudad along the lamina which gives a very confidence-inspiring answer to the question of where my needle tip is NOT. The annoying injections are the ones with several false losses. This is why I draw up at least 2.5 mL contrast for cervical epidurals. It's sub-optimal to redraw contrast with a needle millimeters from the cord. Eventually I reach true engagement with the LF, then true loss. I no longer feel any fear during cervical epidurals, but I do have a very healthy respect for a great many things cervical. If placement is more challenging than expected, or dye flow is confusing, I am quick to stop, withdraw, and re-evaluate. The most common problem I encounter is a sub-optimal starting position. Sometimes (rarely) that's not apparent until after the first needle pass. Once that gets corrected, the most challenging placements suddenly become easy.

                              One caveat I would put out there is to think very hard before applying a lot of force because 'osteophytes' or 'thick ligament'. This sounds like a great prelude to a cord strike.


                              I do not use LOR technique, but 25G 3.5" under CLO with contrast early. No mistaking epidural flow ligamentous flow. I was referring to 20G or larger Tuohy in AP. Once contrast is in, it takes a few cc lido or saline to wash away to be able to see landmarks.
                               

                              drusso

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                                Yoon Sangwon, CEO of Saeum Meditec, said, “Koreans use chopsticks everyday at the kitchen table. Their finger culture may be superior to people in many foreign countries. Because the traditional method is very dependent on the sense of the practitioner (tactile feedback at the finger tips), it is of great help to young doctors all over the world.”

                                Their finger culture is better than our finger culture, I guess.

                                New SDN challenge: Use the phrase "Finger Culture" at least once per day for a week.
                                 
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                                painfree23

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                                  contralateral oblique is great...but its all about how much oblique you use..hence the article: Optimal Angle of contralateral oblique view in cervical interlaminar epidural injection depending on the needle tip position. Jun Young Park. Pain Physician. 2017.

                                  I did one today where i was past the VLL but clearly not epidural yet. I passed it by few mm then was in based on contrast spread. CLO is good but only if u have the perfect angle which is not always the case.
                                   

                                  dhcofc

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                                    contralateral oblique is great...but its all about how much oblique you use..hence the article: Optimal Angle of contralateral oblique view in cervical interlaminar epidural injection depending on the needle tip position. Jun Young Park. Pain Physician. 2017.

                                    I did one today where i was past the VLL but clearly not epidural yet. I passed it by few mm then was in based on contrast spread. CLO is good but only if u have the perfect angle which is not always the case.
                                    I agree. I have found CLO let’s me very accurately get close to the epidural space before needing to rely totally on LOR/contrast. I don’t use LOR until my tip is about to go between the lamina on CLO. I have never “passed” the epidural space doing this. The times when I don’t get LOR as soon/shallow as I think I should I stop and re-evaluate. Get an AP to make sure you didn’t cross midline. Restylet to make sure the needle isn’t clogged. Usually this helps me figure out why I didn’t get LOR at the normal depth. CLO is a great tool, you just have to know when to step back and make sure there isn’t a problem that you haven’t recognized.
                                     
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                                    hyperalgesia

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                                      Thanks all. Now that I think about it I think I in fellowship my needle was 18G. The other thing I get caught up in is once I hit ligament and puff some contrast and if Im out I become hesitant to go further because often times I need to push with some decent force to get through. Maybe a bigger gauge needle will help.

                                      Also, one of my associates at the practice I'm at has been practicing for like 35 years. He never ever looks at CLO or Lateral and he almost recklessly hits lamina with the tip of the Touhy curved downwards, then rotates its up and then pushes down until he feels loss. It looks so scary when he does it and I'm almost positive a lot of times he does it he is not actually in epidural space but I've noticed on AP view only its easy to be fooled that contrast is in epidural space which leads me to my next series of questions:

                                      1. What exactly do you guys look for for good contrast flow especially from AP view? I have a difficult time verbalizing it its more like I just know it when I see it but thats not good enough. I was hoping I could get a precise answer.

                                      2. What do you guys do if there is contrast allergy?

                                      3. If someone is on PLAVIX or some other blood thinner and or anticoagulant but the appropriately stopped it as per ASRA guidelines does that change the gauge of needle you would use?
                                      I think it's better to get comfortable with a 22 than to use an 18. An 18g spear is not worth a more reassuring LOR. As others have said, LOR is just one tool to use, in addition to fluoro, contrast, etc. I use it but I am not totally reliant on it. You don't know if the LF is fully intact where you are probing.

                                      Confidence is a factor of expectations. When your LOR is not like it used to be, your fluoro images are different, your staff is different, your population might be fatter, etc. Added together, these things can make you less confident.
                                       

                                      No_Pain_No_Gain

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                                        Non-particulate: less risk of embolism (I use dexa in all axial procedures)
                                        Saline instead of local: less risk of high spinal

                                        Recognize that even though ESIs are done all the time and we, in the pain world, consider them SOC, they are explicitly NOT FDA approved. There is definite risk and benefits are not well established. This setting does not leave room for complications. So, you want to meticulously select pts and take every reasonable precaution.

                                        FDA Drug Safety Communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain

                                        I completely agree with most of your points including the saline instead of local and meticulously selecting patients while taking every reasonable precaution. I still don't understand the full reasoning for using non-particulate steroid instead of particulate steroid for an interlaminar epidural steroid injection. What vessel in particular are you afraid of embolizing? Do you do the same in the lumbar spine with interlaminar epidural steroid injections?
                                         
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                                        Dr. Ice

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                                          :soexcited::soexcited::eyebrow::eyebrow:
                                          I completely agree with most of your points including the saline instead of local and meticulously selecting patients while taking every reasonable precaution. I still don't understand the full reasoning for using non-particulate steroid instead of particulate steroid for an interlaminar epidural steroid injection. What vessel in particular are you afraid of embolizing? Do you do the same in the lumbar spine with interlaminar epidural steroid injections?
                                          I too am curious and am wondering if perhaps the stim rates are higher in the non particulate users...
                                           

                                          hyperalgesia

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                                            I completely agree with most of your points including the saline instead of local and meticulously selecting patients while taking every reasonable precaution. I still don't understand the full reasoning for using non-particulate steroid instead of particulate steroid for an interlaminar epidural steroid injection. What vessel in particular are you afraid of embolizing? Do you do the same in the lumbar spine with interlaminar epidural steroid injections?
                                            Like I said, I only use dex on axial procedures, lumbar included. The artery I am afraid of embolizing has no name. Vascular anatomy is predictable in anatomy textbooks but not so in real bodies. Do you have evidence to support particulate steroid over dexamethasone?

                                            99% of my procedures are done at the VA. No malpractice worries, no financial incentives. I do 1-2 SCS trials per year.
                                             
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                                            nvrsumr

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                                              Any studies regarding peripheral joints? Google search wasn't helpful.

                                              Not off the top of my head. I would be interested too. I was definitely in the particulate is better and higher dose better camp several years ago but the literature cuts the other way and I havent really noticed a change in transforaminal efficacy since changing to dex.
                                               
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                                              hyperalgesia

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                                                About 10 years ago, I was doing a kyphoplasty, just a year or so out of fellowship. I was stepping on the fluoro pedal and the machine was beeping and the orange light was on. I was taking a live image as I injected PMMA into my cavity. I turned the crank a few times but no cement was flowing according to the image. I thought the cement might be a little too thick, so I applied more pressure. It only took about 2 seconds before I realized the fluoro machine was malfunctioning and was NOT taking a live image at all, despite the beeping and the "fluoro on" light. I was injecting cement blind.

                                                After breaking out in a sweat and swearing under my breath, a fresh image showed the vertebral fracture filling out nicely, without any cement leakage.

                                                My point is, you can't trust anything 100%. If you can use a medication that has a slightly safer profile (even theoretical), without any clear disadvantage, you should do it.
                                                 
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                                                NJPAIN

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                                                  Don't think this is on the market but played with samples years ago. Made epidurals incredibly easy where almost anyone could perform the procedure but it was expensive.

                                                  Comparative study of Episure AutoDetect syringe versus glass syringe for identification of epidural space in lower thoracic epidural

                                                  Never used them in the cervical spine but had a box of these and used on stim trials. AMAZING. Someone bought the company and never restarted production.


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                                                  NJPAIN

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                                                    Sounds like you are having a confidence crisis. Sort of like Maverick in "Top Gun". My guess is that your co-pilot (the X-ray tech) is no longer your trusted comrade from fellowship. My suggestion is to take the flouro course FOR XRAY TECHS that ISI offers. Best thing that ever happened for my practice, and probably for the x-ray techs where I wound up practicing :)

                                                    Tell me about this X-RAY TECH course. Is it SIS or ISI. I ask because our Techs at ASC are clueless. They need formal training and we just had a discussion about this.


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                                                    clubdeac

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                                                      Try contrast instead of saline for your LOR syringe. I use 0.5 mL of contrast in my loss of resistance syringe and then draw up about 0.5 ml of air. I use an 18g tuohy so I feel a crisp LOR. I don’t think smaller needles have quite as crisp LOR. If I have LOR in the epidural space and not false loss the fluoro image will reveal epidural spread. Simple. One step if you just use contrast as the LOR fluid.
                                                      This right here! Golden advice
                                                       

                                                      epidural man

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                                                        My advice - echoes others.

                                                        Use a big needle.

                                                        Don't worry about a perfect loss. If your pucker-factor is super high, you don't see a great picture, you seem deep, and you get a blob-a-gram....take it. Don't risk going any further just to make sure the patient's next three months are a little bit more pain free. Take the blob-a-gram and get out of dodge.
                                                         
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                                                        ragnathor

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                                                          Maybe it’s just my crappy Fluoro machine but any1 ever go CLO and the contrast pattern is not that fine stripped line but looks kinda blotchy and goes far anterior than you would expect. Definitive loss, needle tip is not too far and on AP it looks like ur typical epidurogram. I always thought maybe it’s in the gutter but it looks directly midline in AP.
                                                          Can anyone else comment on this? I've had this happen a few times, blotchy spread goes anterior than expected. I assumed it was lateral gutter as well, had midline and some lateral spread on AP. I did not feel a great loss though.

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                                                          emd123

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                                                            Can anyone else comment on this? I've had this happen a few times, blotchy spread goes anterior than expected. I assumed it was lateral gutter as well, had midline and some lateral spread on AP. I did not feel a great loss though.

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                                                            When you see this, go back to ap view. You'll usually see that some contrast has crossed collaterally to the opposite side. That will give you that deeper contrast appearance rather than the thin stripe, because it's looped around.
                                                             
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                                                            callmeanesthesia

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                                                              Thanks for the tips, everyone. I trained doing CESIs in AP/lateral. I did my first few in CLO (prompted by reading this forum) today and I loved it. I’m certainly still slow and careful but at least I can see the needle... I tried a couple lumbar that way too and that also worked well.
                                                               
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                                                              NJPAIN

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                                                                Thanks for the tips, everyone. I trained doing CESIs in AP/lateral. I did my first few in CLO (prompted by reading this forum) today and I loved it. I’m certainly still slow and careful but at least I can see the needle... I tried a couple lumbar that way too and that also worked well.

                                                                Been doing this 26 years. Still slow and careful.


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                                                                thecentral09

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                                                                  2 questions, is anyone entering the epidural space above C7/T1?
                                                                  and more importantly, what about C3/C4 disc herniations with radic. are you using cervical with catheter to ensure inject ate placed at level of interest?
                                                                   

                                                                  dhcofc

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                                                                    2 questions, is anyone entering the epidural space above C7/T1?
                                                                    and more importantly, what about C3/C4 disc herniations with radic. are you using cervical with catheter to ensure inject ate placed at level of interest?
                                                                    I stopped going any higher than C7-T1. I am never using a catheter. I see 0.5 mL of Omnipaque spread three levels often. I feel like 4 to 5 mL of injectate will be sufficient…
                                                                     
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                                                                    MD87

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                                                                      2 questions:
                                                                      1) In patients with contrast allergy, are any of you guys doing these with magnevist or do you do a steroid prep and use omnipaque? I did one with magnevist the other day, and though I'm confident it was in the right place, it was not a fun experience.
                                                                      2) I have a patient who can't get an MRI and has a radic and recently had a CT (I don't have the images or report yet - she's getting them for me). I've never done an ILESI in the neck without first checking for epidural fat. I do have colleagues who do cervical TFESI, but I don't. Should I send to them? Should I go down to T1/T2 and do ILESI myself?
                                                                      Thanks
                                                                       

                                                                      Ducttape

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                                                                        Cervical TF prob not worth the risk in your hands, definitely not in others.

                                                                        Do what you are doing - look at the CT yourself. Then talk to the patient about your concerns. She might rather try a round or two of PT, non opioid meds and pain psychology first.

                                                                        If you are worried too much - no CESI, or go T12. steroid prep would be 3rdchoice. Referral for Cervical TF IMO is not a choice.
                                                                         
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