Cervical Epidurals

[Louisville04]

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Could someone comment on interlaminar and transforaminal cervical epidurals. Which is considered harder (more dangerous)?

 

[Ligament]

the transforaminal cervical epidurals by far.

Could someone comment on interlaminar and transforaminal cervical epidurals. Which is considered harder (more dangerous)?

 

[lobelsteve]

Within 24 hours there will be a long post by amphb debating cervical TF. He will claim that using ISIS techniue, no one ever get hurt. He will also report on the big 22 (or 23) cases in litigation where a cervical TF was performed- often without any notable technique being employed and the patient : died, became a quad, stroked, or seized.

When cervical TF's cure cancer of the spinal cord, I'll be first in line to perform them. For now- I'll go in at C7-T1 with a catheter and steer it over to where we think the pan is coming from.

 

[Ligament]

Steve, I'm in general agreement with your reservations on CTFESIs. However, are you aware of any data or studies concerning the same complications in interlaminar CESIs with catheters? I am not, but suspect there may be a higher risk than we imagine....gut feeling.

Within 24 hours there will be a long post by amphb debating cervical TF. He will claim that using ISIS techniue, no one ever get hurt. He will also report on the big 22 (or 23) cases in litigation where a cervical TF was performed- often without any notable technique being employed and the patient : died, became a quad, stroked, or seized.

When cervical TF's cure cancer of the spinal cord, I'll be first in line to perform them. For now- I'll go in at C7-T1 with a catheter and steer it over to where we think the pan is coming from.

 

[lobelsteve]

Steve, I'm in general agreement with your reservations on CTFESIs. However, are you aware of any data or studies concerning the same complications in interlaminar CESIs with catheters? I am not, but suspect there may be a higher risk than we imagine....gut feeling.

Tough it does not make good scientific sense, I have seen catheters inserted in the epidural space and threaded up over 10cm to wind up IV. I cannot explain this adequately- but the pulsatile flow of contrast on fluoro is a pretty good indicator we were intravascular. This was with a caudal epidural catheter (Arrow brand spring tip) through a 17G Tuohy. Could not get blood to flow out the Tuohy, but could not get contrast through the catheter to go anywhere but IV. Pretty cool (wish I had cine), and I have only seen this a handful of times in a few thousand epidurals. I have seen it less cervical than lumbar, but I believe this is due to the FBSS patients and the tortuosity of Batson's plexus psot laminectomy. 2cents.

 

[Mister Mxyzptlk]

I have largely abandoned CTFESI unless I need to get high cervical such as C2. I don't think there will ever be a head-to-head study of CTFESI vs IL or catheter because the incidence of complications is so low you would need a gigantic study population.

I have also seen a few catheters go IV in the c-spine, even a Feth-R-Cath.

 

[ampaphb]

I took a quick, non-scientific survey of Drs. Yin, Dreyfuss, Derby, Bogduk, and Aprill at the recent ISIS meeting.

To date, none of them are aware of a single case of a catastrophic complication subsequent to cervical transforaminal epidural steroid injection when the practitioner followed ISIS Guidelines meticulously (including waiting a full two minutes after administering a test dose of lidocaine) where there are images that show the needle in optimal position in AP, lateral, and oblique planes.

 

[Tenesma]

i don't think your consensus group yields much insight into the problem - transforaminal complications are under-reported (we all know that)

and for those of us who have done transforaminals in the neck we also know that a little twitch of the needle can make something non-intravascular intravascular....

ISIS guidelines just say to be careful - careful doesn't mean diddly.

Look at the increasing number of lumbar transforaminal disasters - i have a colleague in a town 30 miles from here who did an L3 selective nerve root block without steroid and the patient is paretic (and suing both him and the spine surgeon who recommended it)...

last week i shot contrast which showed beautiful neural spread at L4 WITHOUT vascular uptake and just as I was about to inject the medication HEME comes back through a 25 gauge 3.5 inch - i re-do contrast and presto have vascular uptake - so i reposition needle without vascular uptake and it happens again (despite me doing everything humanly possible not to move that darn needle) - so i aborted that level

so bottom line is that ISIS ain't going to be in court when you are getting sued for failing standard of care (remember the standard of care is what other local pain doctors would be doing).

 

[ampaphb]

i don't think your consensus group yields much insight into the problem - transforaminal complications are under-reported (we all know that)

and for those of us who have done transforaminals in the neck we also know that a little twitch of the needle can make something non-intravascular intravascular....

ISIS guidelines just say to be careful - careful doesn't mean diddly.

Look at the increasing number of lumbar transforaminal disasters - i have a colleague in a town 30 miles from here who did an L3 selective nerve root block without steroid and the patient is paretic (and suing both him and the spine surgeon who recommended it)...

last week i shot contrast which showed beautiful neural spread at L4 WITHOUT vascular uptake and just as I was about to inject the medication HEME comes back through a 25 gauge 3.5 inch - i re-do contrast and presto have vascular uptake - so i reposition needle without vascular uptake and it happens again (despite me doing everything humanly possible not to move that darn needle) - so i aborted that level

so bottom line is that ISIS ain't going to be in court when you are getting sued for failing standard of care (remember the standard of care is what other local pain doctors would be doing).

1) tubing makes that less likely
2) what is the proposted mechanism how your colleague caused the injury?
3) you DIDN'T hurt anyone, which is the whole point - healthy respect for the procedure, and a recognition of the possible complications IN ADVANCE of injecting NON-particulate agents is key
4) to reiterate my initial point, To date, there has not been a single catastrophic complication subsequent to cervical transforaminal epidural steroid injection when the practitioner followed ISIS Guidelines meticulously where there are images that show the needle in optimal position in AP, lateral, and oblique planes.

 

[lobelsteve]

1) tubing makes that less likely
2) what is the proposted mechanism how your colleague caused the injury?
3) you DIDN'T hurt anyone, which is the whole point - healthy respect for the procedure, and a recognition of the possible complications IN ADVANCE of injecting NON-particulate agents is key
4) to reiterate my initial point, To date, there has not been a single catastrophic complication subsequent to cervical transforaminal epidural steroid injection when the practitioner followed ISIS Guidelines meticulously where there are images that show the needle in optimal position in AP, lateral, and oblique planes.

Cervical TF ESI can cure cancer.

Until that happens, the risk is greater than the benefit.

 

[ampaphb]

Cervical TF ESI can cure cancer.

Until that happens, the risk is greater than the benefit.

When done meticulously, the risk is 0

 

[Louisville04]

.

 

[greywater]

When done meticulously, the risk is 0

You just called it "a quick, non-scientific survey" (which was quite accurate), but then you draw this conclusion? Isn't that setting the bar a little low - like on the floor?

The plural of "anecdote" is not "data".

Lack of evidence is not evidence of lack.

There is no such thing as a risk of 0.

Just as Racz's motive may be suspect in alleging that this is an unsafe procedure, others - particularly those who have written about and promulgated the technique in the ISIS Guidelines - may have a bias toward denial that their recommendations have harmed people.

Unfortunately scientific endeavor isn't the pure process we would hope. There are biases, primarily due to egos and money. It doesn't have to be the kind of money issues people have attributed to Racz, i.e., that it sells more blunt needles. Two doctors whose NIH-sponsored research findings contradict each other can get very nasty.

 

[ampaphb]

You just called it "a quick, non-scientific survey" (which was quite accurate), but then you draw this conclusion? Isn't that setting the bar a little low - like on the floor?

The plural of "anecdote" is not "data".

Lack of evidence is not evidence of lack.

There is no such thing as a risk of 0.

Just as Racz's motive may be suspect in alleging that this is an unsafe procedure, others - particularly those who have written about and promulgated the technique in the ISIS Guidelines - may have a bias toward denial that their recommendations have harmed people.

Unfortunately scientific endeavor isn't the pure process we would hope. There are biases, primarily due to egos and money. It doesn't have to be the kind of money issues people have attributed to Racz, i.e., that it sells more blunt needles. Two doctors whose NIH-sponsored research findings contradict each other can get very nasty.

Do you do these procedures?

 

[Mister Mxyzptlk]

Yes, as I mentioned above I am mostly doing catheter CESIs now.

Greywater is my old screen name for the forum before I decided to put my name behind my opinions. My browser automatically auto-completes forms and I guess I didn't notice. Sorry for any confusion.

Mike Gorback

 

[drusso]

ISIS guidelines are GUIDELINES not a recipe book. Nothing is fool-proof.

I'm more convinced by Huntoon's and other's anatomical dissections and demonstrations of increased anatomical variability in the cervical spine than "anecdotal data."

Until we can technically reduce and mitigate the risk of misadventure due to anatomical variability in the C-spine, I will only do cervical intralaminar via catheter.

 

[ampaphb]

ISIS guidelines are GUIDELINES not a recipe book. Nothing is fool-proof.

I'm more convinced by Huntoon's and other's anatomical dissections and demonstrations of increased anatomical variability in the cervical spine than "anecdotal data."

Until we can technically reduce and mitigate the risk of misadventure due to anatomical variability in the C-spine, I will only do cervical intralaminar via catheter.

No dissection (not Huntoon's or Willard's) have demonstrated the presence of any radiculomedulary arteries deep in the foramen (they both acknowledge these vessels live in the superficial foramen)

Now that weekend warriors have switched to interlaminar injections, more intraneural cord sticks than ever are being reported, and there is no data to support the assumption that catheters are safe.

Errico reported three catastrophic complications with LUMBAR TF ESIs - are you going to stop doing those too?

Ma reported a series of greater than a thousand performed with meticulous technique, and no complications.

Everything we do is dangerous in incompetent hands.

 

[Tenesma]

the amount of vascularity in the neck is very high - why take these risks for something that may give a month or so of relief (if you are luck).

patient care is about weighing risks versus benefits - if i knew that a transforaminal esi would likely give several years of relief then yes I would do it -... since that isn't the case I ain't going to risk it. I suggest you wait until you do a transforaminal ESI and the patient seizes on the table - i wonder how many more transforaminals you are going to do...