Cervical ESI Quinke Style

[MitchLevi]

do you have a preference for which way the bevel is positioned?

No, but normally it's facing towards the skin.

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[drrosenrosen]

I've been doing this technique exclusively for both lumbar and cervical for about a year now. I did have my first wet tap using this technique the other day - L4-5. Kept getting contrast spread in the ligament, needle position didn't look too anterior on CLO, but definitely got clear fluid dripping back. Probably had my angle off (usually use about 45 degrees on lumbar, adjust +/- til the lamina looks right.) I told the pt about it and injected dex after pulling back slightly. Never got intrathecal looking contrast. It's my first misadventure in a year of doing it this way, thought I'd report it.

 

[RoloTomassi]

I've been doing this technique exclusively for both lumbar and cervical for about a year now. I did have my first wet tap using this technique the other day - L4-5. Kept getting contrast spread in the ligament, needle position didn't look too anterior on CLO, but definitely got clear fluid dripping back. Probably had my angle off (usually use about 45 degrees on lumbar, adjust +/- til the lamina looks right.) I told the pt about it and injected dex after pulling back slightly. Never got intrathecal looking contrast. It's my first misadventure in a year of doing it this way, thought I'd report it.

Might just be contrast back flow if you were injecting in ligament

 

[Ferrismonk]

I use 25G quinke for everything that it'll reach. It's a finesse thing, but with a bent tip and deliberate small movements you can put it anywhere you can with a bigger needle (as long as it'll reach).

One advantage not mentioned is that a small cutting needle slides like butter through the ligaments. Sometimes you need to add some force to move a 17G touhy through ligaments and there is always the risk of sliding a bit further than you planned to. To address a comment above, I always use Dex in the epidural space anyway so plunger pressure isn't an issue for me.

 

[drrosenrosen]

Might just be contrast back flow if you were injecting in ligament

I thought contrast back flow at first, but it was dripping back quite a lot, didn't dry tacky like contrast. I just thought safest thing was to assume wet tap and change the steroid in case

 

[lobelsteve]

I thought contrast back flow at first, but it was dripping back quite a lot, didn't dry tacky like contrast. I just thought safest thing was to assume wet tap and change the steroid in case

Safety first. When not sure just do partial myelogram with contrast. Easy to know.

 

[bedrock]

Guy came back to clinic today after two years of great relief following an CESI with cath. He is a thin guy and a bit easier to see compared with my other CESI photos.

 

[epidural man]

No LoR. It's a 25g 3.5" (95% of the time), with ext tubing attached to a syringe full of Isovue-200.

Remove Isovue-200 syringe and replace with 2cc normal saline + 80mg Depo.

I really like this show.

 

[clubdeac]

Guy came back to clinic today after two years of great relief following an CESI with cath. He is a thin guy and a bit easier to see compared with my other CESI photos.

you're CESI w/cath pictures are beautiful. There really should be a separate code that pays more when one uses a cath. it definitely takes more time and could be more risky I suppose so you you should get reimbursed accordingly.

What size touhy are you using when you use a catheter?

 

[bedrock]

you're CESI w/cath pictures are beautiful. There really should be a separate code that pays more when one uses a cath. it definitely takes more time and could be more risky I suppose so you you should get reimbursed accordingly.

What size touhy are you using when you use a catheter?

Thank you.

18G Touhy/20G soft catheter

I agree with any Cath ESI procedure should be paid more than without cath.

It doesn’t take me much longer as I’m faster with entry at T1-T2 because double the epidural space compared to C7-T1, and since I only drive the catheter to C6-C7, that doesn’t take long either.

I feel safe with cath to C6-C7 because the space is so open to that point and patients usually feel nothing. I definitely notice more frequent difference in pressure and patient discomfort if I try to direct a catheter above C6-C7 so I routinely stop there but still get great anterior spread that paints 3 nerve roots.

I feel my T1-T2 to C6-C7 technique is just as safe as standard single touhy needle entry at C7-T1.

I also find that on average patients need repeat CESI less frequently with this technique vs standard CESI and that alone is worth doing it.

 

[Ducttape]

If I remember..,,

There used to be, but the cpt was abused so much, it was eliminated.

 

[RoloTomassi]

Would it be reasonable to not hold blood thinners with this approach? That'd be one significant advantage

 

[MitchLevi]

Would it be reasonable to not hold blood thinners with this approach? That'd be one significant advantage

I'm still holding them for this, but I'd go to bat for you if you didn't and the pt had a bleed.

At some point I'm sure I'll do it.

 

[interjectionreflection]

I've been doing this technique exclusively for both lumbar and cervical for about a year now. I did have my first wet tap using this technique the other day - L4-5. Kept getting contrast spread in the ligament, needle position didn't look too anterior on CLO, but definitely got clear fluid dripping back. Probably had my angle off (usually use about 45 degrees on lumbar, adjust +/- til the lamina looks right.) I told the pt about it and injected dex after pulling back slightly. Never got intrathecal looking contrast. It's my first misadventure in a year of doing it this way, thought I'd report it.

Always curious on advice how do you tell this to the patient? Most people are reasonable and understand however some patients I feel like will not take any news in a good way how do you explain it to them without them being upset

 

[bedrock]

Would it be reasonable to not hold blood thinners with this approach? That'd be one significant advantage

That is intriguing. It would be great if a study could be done on 25G quincke CESI with patients still on blood thinners.

The doc doing the study would need legal protection such as in the VA,
but if safe on thinners that would be a major advantage of the 25G quincke technique used by Steve and Mitch.

 

[MD87]

I hold all blood thinners (including ASA) for cervical ILESI. I have had 3 patients in the last 6 months who could not get cleared to hold their ASA. As a result, I discussed the risks/benefits with the patient, and I performed the procedure with a 25g needle. N=3. They can still move all of their limbs, though I believe some of you guys are doing cervical ILESI even on ASA?

 

[MitchLevi]

I cont aspirin

 

[bedrock]

I hold all blood thinners (including ASA) for cervical ILESI. I have had 3 patients in the last 6 months who could not get cleared to hold their ASA. As a result, I discussed the risks/benefits with the patient, and I performed the procedure with a 25g needle. N=3. They can still move all of their limbs, though I believe some of you guys are doing cervical ILESI even on ASA?

Maybe you should do that study? Or at least publish a case series?

asra and SIS guidelines are to not hold ASA.

For CESI/stim only only, I require patients taking ASA (because they personally just just decided to take it) to completely hold ASA for 7 days.
If they’re on ASA under the direction of a physician then my staff asks for clearance to reduce to 81mg ASA, and no cardiologist or neurologist has fought me on it as long their patient gets some ASA (81mg).

 

[callmeanesthesia]

I’d settle for just having a decent pay differential between a cervical ESI and a caudal.

 

[Ducttape]

I hold all blood thinners (including ASA) for cervical ILESI. I have had 3 patients in the last 6 months who could not get cleared to hold their ASA. As a result, I discussed the risks/benefits with the patient, and I performed the procedure with a 25g needle. N=3. They can still move all of their limbs, though I believe some of you guys are doing cervical ILESI even on ASA?

never hold aspirin.


in case i didnt make it clear, never ever hold aspirin.

 

[bedrock]

I’d settle for just having a decent pay differential between a cervical ESI and a caudal.

Yep. Agree completely!

 

[nvrsumr]

I do my ctfesi with 27g. Still hold blood thinners(not asa)

 

[bedrock]

I do my ctfesi with 27g. Still hold blood thinners(not asa)

Have you found 2 inch length 27G needles?

 

[drrosenrosen]

Always curious on advice how do you tell this to the patient? Most people are reasonable and understand however some patients I feel like will not take any news in a good way how do you explain it to them without them being mad

I just explain the idea of wet tap to the patient briefly, explain that it's something that happens sometime, nothing to be nervous about. I recommend proceeding with a different type of medication that's safe to give in that space, do they want to do that or would they rather stop and reschedule the procedure for another day? Afterwards I explain that while it's unlikely, they may have a PDPH, and to call me if that's the case.

 

[nvrsumr]

1 1/2 in 27g. Try not to do ctfesi on thick necks

 

[MD87]

never hold aspirin.


in case i didnt make it clear, never ever hold aspirin.

Source?

 

[MitchLevi]

Source?

No reason to hold aspirin.

 

[bedrock]

1 1/2 in 27g. Try not to do ctfesi on thick necks

Lol. I use a 25G 2in quincke.

My previous rule of thumb was if they needed a 3.5 for a ctfesi, then ILESI is the only choice I would give them, but you are more strict than me!

 

[MD87]

Maybe you should do that study? Or at least publish a case series?

asra and SIS guidelines are to not hold ASA.

For CESI only, I require patients taking ASA because they just decided it, to completely hold for 7 days.
If on ASA under the direction of a physician then I ask for clearance to reduce to 81mg ASA, and no cardiologist or neurologist has fought me on it as long their patient gets some ASA (81mg).

Per ASRA:
If ASA is being taken for primary prophylaxis, ASA discontinuation is recommended for high-risk procedures in which there is a heightened risk of perioperative bleeding and sequelae. In addition, consideration should be given to the discontinuation of ASA for certain intermediate-risk procedures, including interlaminar cervical ESIs and stellate ganglion blocks, where specific anatomical configurations may increase the risk and consequences of procedural bleeding.

 

[lobelsteve]

Per ASRA:
If ASA is being taken for primary prophylaxis, ASA discontinuation is recommended for high-risk procedures in which there is a heightened risk of perioperative bleeding and sequelae. In addition, consideration should be given to the discontinuation of ASA for certain intermediate-risk procedures, including interlaminar cervical ESIs and stellate ganglion blocks, where specific anatomical configurations may increase the risk and consequences of procedural bleeding.

Asra guidelines are terrible and kill more people than they protect.

 

[bedrock]

Per ASRA:
If ASA is being taken for primary prophylaxis, ASA discontinuation is recommended for high-risk procedures in which there is a heightened risk of perioperative bleeding and sequelae. In addition, consideration should be given to the discontinuation of ASA for certain intermediate-risk procedures, including interlaminar cervical ESIs and stellate ganglion blocks, where specific anatomical configurations may increase the risk and consequences of procedural bleeding.

That’s why I do what I do with ASA in post #68.

 

[MD87]

Asra guidelines are terrible and kill more people than they protect.

Are there any guidelines Or studies that indicate that it is safe to continue aspirin for cervical interlam? I continue ASA for everything else that I do, including cervical RF. I would think of the theoretical risk of a symptomatic hematoma is higher during cervical ILESI than any other bread and butter stuff that we do… but that’s just theoretical. Any actual data or just conjecture that it is safe to continue? Thanks.

 

[lobelsteve]

Are there any guidelines Or studies that indicate that it is safe to continue aspirin for cervical interlam? I continue ASA for everything else that I do, including cervical RF. I would think of the theoretical risk of a symptomatic hematoma is higher during cervical ILESI than any other bread and butter stuff that we do… but that’s just theoretical. Any actual data or just conjecture that it is safe to continue? Thanks.

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/2020/11_ff_antiplatelets&ltfesi.pdf

Lumbar.

Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines

Abstract. Setting. Epidural hematoma rarely complicates interventional spine procedures. While anticoagulant and antiplatelet drugs increase bleeding risk,

academic.oup.com

All procedures.

 

[MD87]

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/2020/11_ff_antiplatelets&ltfesi.pdf

Lumbar.

Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines

Abstract. Setting. Epidural hematoma rarely complicates interventional spine procedures. While anticoagulant and antiplatelet drugs increase bleeding risk,

academic.oup.com

All procedures.

I’ve read both of these before. The second article includes a grand total of 0 cervical interlams where blood thinners were continued.

The authors state “Thus, interlaminar approaches should prompt discontinuation of anticoagulant or antiplatelet agents if feasible.”

 

[lobelsteve]

I’ve read both of these before. The second article includes a grand total of 0 cervical interlams where blood thinners were continued.

The authors state “Thus, interlaminar approaches should prompt discontinuation of anticoagulant or antiplatelet agents if feasible.”

Go read Endres article.

 

[MD87]

Go read Endres article.

I have. And now I reread it.

“In contrast, they were wary about interlaminar injections and radiofrequency neurotomy. Interlaminar injections risk injuring epidural veins; and radiofrequency neurotomy involves stab incisions and the use of large-gauge electrodes in multiple positions. As a result, anticoagulants were not routinely continued for these procedures; they were continued only when they could not be discontinued, or when coagulation status was normal. Consequently, the numbers of patients continuing to take anticoagulants for these procedures are small and artificial, and no conclusions are drawn about the safety of these procedures in anticoagulated patients. ****Likewise, conclusions cannot be drawn for cervical procedures, which only relatively small numbers of patients underwent.****

Firm conclusions, however, can be drawn for lumbar transforaminal injections and lumbar medial branch blocks, which patients were willing to undergo and physicians willing to perform while maintaining anticoagulant therapy. A zero prevalence in 1,600 or 1,800 procedures suggests that these procedures are safe, but this sample size does not exclude a possible of prevalence of complications less than two in 1,000.”

All of his conclusions from his 2017 and 2020 articles are about lumbar procedures, specifically TFESI and MBB.


Again, no one here has provided any data on this. Steve, when you publish your technique, maybe retrospectively go back and see how many were on ASA and include that. Would be great to have some evidence to not hold ASA

 

[lobelsteve]

I have. And now I reread it.

“In contrast, they were wary about interlaminar injections and radiofrequency neurotomy. Interlaminar injections risk injuring epidural veins; and radiofrequency neurotomy involves stab incisions and the use of large-gauge electrodes in multiple positions. As a result, anticoagulants were not routinely continued for these procedures; they were continued only when they could not be discontinued, or when coagulation status was normal. Consequently, the numbers of patients continuing to take anticoagulants for these procedures are small and artificial, and no conclusions are drawn about the safety of these procedures in anticoagulated patients. ****Likewise, conclusions cannot be drawn for cervical procedures, which only relatively small numbers of patients underwent.****

Firm conclusions, however, can be drawn for lumbar transforaminal injections and lumbar medial branch blocks, which patients were willing to undergo and physicians willing to perform while maintaining anticoagulant therapy. A zero prevalence in 1,600 or 1,800 procedures suggests that these procedures are safe, but this sample size does not exclude a possible of prevalence of complications less than two in 1,000.”

All of his conclusions from his 2017 and 2020 articles are about lumbar procedures, specifically TFESI and MBB.


Again, no one here has provided any data on this. Steve, when you publish your technique, maybe retrospectively go back and see how many were on ASA and include that. Would be great to have some evidence to not hold ASA

Hire a student to review 2000 charts looking for an OTC med? I do SCS on ASA all the time. ASA and NSAID bleeding risk is meh.
Antiplatelet therapy and blood thinners is a different story. I still hold Plavix for CESI and implants/kypho.

 

[sdnuser001]

https://www.spineintervention.org/events/EventDetails.aspx?id=1765029&group=

 

[epidural man]

I use 25G quinke for everything that it'll reach. It's a finesse thing, but with a bent tip and deliberate small movements you can put it anywhere you can with a bigger needle (as long as it'll reach).

One advantage not mentioned is that a small cutting needle slides like butter through the ligaments. Sometimes you need to add some force to move a 17G touhy through ligaments and there is always the risk of sliding a bit further than you planned to. To address a comment above, I always use Dex in the epidural space anyway so plunger pressure isn't an issue for me.

Why do you always use dex?

 

[Ferrismonk]

Why do you always use dex?

This has been discussed many times in many other threads, but I always use dex because its equally effective and safer. Arguably standard of care.

 

[bedrock]

This has been discussed many times in many other threads, but I always use dex because its equally effective and safer. Arguably standard of care.

Equally effective my ass.

Yes, Standard of care for TFESI.

Not any other steroid injection

 

[epidural man]

This has been discussed many times in many other threads, but I always use dex because its equally effective and safer. Arguably standard of care.

I am not arguing - just wondering about the statement safer.

Is there any data that shows this? (I am talking about interlaminar)

 

[RoloTomassi]

I am not arguing - just wondering about the statement safer.

Is there any data that shows this? (I am talking about interlaminar)

Marginally, due to lack of preservative not particulate

 

[bedrock]

A small Segway. I decided to do this today for a patient with stenosis and Right L5 symptoms. He can’t have surgery. Get 95% relief after TFESI with dex but only for a week. ILESI gives him 50% relief but that 50% lasted for 4 months. A repeat ILESI was similar.

Depomedrol not always but a very high percentage of the time lasts much longer than dex for patients with stenosis causing their symptoms
(not an acute disc herniation).
Anyone who doesn’t see this difference has their head stuck in the sand.

Anyway, so today I decided to do a ILESI plus catheter for the same patient I mentioned above. As you can see from the photos, I literally painted the entire L5 nerve with depo and this technique also provided excellent anterior epidural spread of depo.



I look forward to his follow up next month.

 

[lobelsteve]

I’ve read both of these before. The second article includes a grand total of 0 cervical interlams where blood thinners were continued.

The authors state “Thus, interlaminar approaches should prompt discontinuation of anticoagulant or antiplatelet agents if feasible.”

Epidural hematoma risks associated with ceasing vs maintaining anticoagulant and/or antiplatelet medications for cervical and thoracic interlaminar epidural steroid injections

There is a lack of substantiated evidence to support or refute the risks of ceasing vs maintaining anticoagulant and/or antiplatelet medications (ACAP…

www.sciencedirect.com

 

[au bon pain]

Epidural hematoma risks associated with ceasing vs maintaining anticoagulant and/or antiplatelet medications for cervical and thoracic interlaminar epidural steroid injections

There is a lack of substantiated evidence to support or refute the risks of ceasing vs maintaining anticoagulant and/or antiplatelet medications (ACAP…

www.sciencedirect.com

Thanks for posting. We need more stuff like this to get some aggregate data going.

While it does show proof of concept that you won't necessarily maim a patient on an antiplatelet and/or thinner getting a CESI, this study won't be changing my practice.
Most folks in this decade who are at a particularly high risk of thromboembolic events aren't on ASA alone, which is the biggest subgroup/largest proportion of the n being studied.
The # of study patients on plavix is pretty legit and if another few studies came out with similar number perhaps a major pain society could issue a statement that plavix doesn't need to be held--which could change how many folks practice.
And I guess change comes slow to some parts of PA...most thinner patients here are on coumadin...2003 wants that med back.
Only 11 patients in the study continued on a DOAC so pretty tough to draw conclusions...and they're the thinners I suspect most of our patients are on these days. And 5 of those patients are on "dapigatran"...not confidence inspiring.