Cervical ESI with catheter

[epidural man]

Folks,

Background -

for pathology higher up in the cervical region, I have sometimes entered into the usually space (C7/T1) and threaded a catheter to get a more target specific injection. I use the regular epidural catheter we use in the OR - so soft tip, single orifice - non styleted catheter.

However, some of you have voiced concern over threading a catheter in this space.

Rather than me spend a bunch of time searching old threads trying to determine which thread this subject was addressed - can those of you who are against threading the catheter re-voice that opinion and reasons why? What are the known and described dangers and complications?

I am asking because I had never thought it was a concern previously until I read some of your thoughts and it has me concerned enough to rethink my practice. I was asked by the surgeon today to do a TFESI cervical for a patient who has C5 nerve root impingement. The surgon wants this done to PREVENT surgery, not for diagnostic purposes. The patient has had previous extensive neck surgery from an MVA years before so I can't do an ILESI - or don't want to. My options are 1) don't do it. 2)TFESI under CT with fluoro and DSA with non-particulate or just fluoro/DSA 3) ILESI at T2 or so - thread a catheter.

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[emd123]

Why not just paramedian interlaminar at c7/T1? 9 times out of 10 you'll see your contrast go up at least 2 levels anyways.

And, are you sure the surgeon really cares if it's TF vs Interlaminar vs Interlaminar with catheter?

Or does he just care to check off the "tried epidural" box?

 

[Taus]

wait a sec... I'm missing something. You can't do an interlaminar bc had prior neck surgery, but can thread a catheter up the posterior epidural space? That doesn't make much sense. If it was posterior decompression... no interlam, catheter or not. ACDF- either route is fine. I am, however, young and stupid enough to say that I'd just do the TFESI, keeping needle barely in foramen off os of SAP, like an SNRB.

Risk with catheter is potential for epidural hematoma. Though I'd imagine same w/ a cervical SCS trial, and I don't hear as many people hesitate to do those.

 

[epidural man]

Why not just paramedian interlaminar at c7/T1? 9 times out of 10 you'll see your contrast go up at least 2 levels anyways.

And, are you sure the surgeon really cares if it's TF vs Interlaminar vs Interlaminar with catheter?

Or does he just care to check off the "tried epidural" box?

He has a large scar - midline from base of neck to bottom of neck...and no records what was done. As a general rule, any place the ligament has possibly been removed, I won't do an inter laminar.

The surgeon doesn't care. I just want to be safe.

 

[emd123]

He has a large scar - midline from base of neck to bottom of neck...and no records what was done. As a general rule, any place the ligament has possibly been removed, I won't do an inter laminar.

Oh, okay. I wouldn't do interlam either, unless below the scar. At some point, when a patient's had ESIs, then their neck has been filet'ed open, sometime you have to just leave somebody alone.

How many of these people that have had their neck or back operated on, one, two, three times and had a bunch of injections and are still hurting are going to get better with another operation when the first one, two or three didn't take the pain away?

Some of these people you've gotta just leave alone.

 

[SSdoc33]

Oh, okay. I wouldn't do interlam either, unless below the scar. At some point, when a patient's had ESIs, then their neck has been filet'ed open, sometime you have to just leave somebody alone.

How many of these people that have had their neck or back operated on, one, two, three times and had a bunch of injections and are still hurting are going to get better with another operation when the first one, two or three didn't take the pain away?

Some of these people you've gotta just leave alone.

in this case, if you do indeed believe that the problem is from supra-adjacent level disease, id farm it out to someone who will actually do the TFESI at C5. happens maybe once or twice a year, but it seems to be justified in this case

 

[ampaphb]

+1 TF-ESI with non-particulate

 

[deleted472101]

Catheter wouldn't be a bad option. Send to someone if you don't do it

 

[willabeast]

IMHO infection is an increased risk with catheter ESI over non catheter. no idea how much, but i tell patients.