Cervical TFESI

[swamprat]

In fellowship no one did them. Now in pp some of the senior guys (trained 10-15 years ago) do them. I’ve shadowed them and they seem pretty simple to do from a technical standpoint and with non particulate and staying posterior then barely dropping off os im considering giving them a try in some select cases. What do u guys do/think?

---

Members don't see this ad.

 

[No Pain All gain]

Awake patient, DSA, dex.


Sent from my iPhone using Tapatalk

 

[willabeast]

Suggest doing an ISI advanced cervical intervention course first although since i have no idea what your level of competence is it is a blanket suggestion for anyone and everyone who has never done one before.

 

[unchockey21]

Have done them before. Risk:reimbursement steers me to not doing them in PP.

 

[lobelsteve]

Do them for your ego only. Not better than cesi. No dx value.

Or just see what its like to kill accidentally.

 

[paindoc007]

Any reason you wish you tackle this? Are you seeing a lot of post op patients from neurosurg where you can’t do ILESI, or folks who refer and specifically ask for tfesi ?

 

[Ligament]

The reason the older guys in your practice do them is they dont want to "offend" the referring spine surgeons who order them. They should educate the surgeons and stop doing them.

 

[SommeRiver]

The reason the older guys in your practice do them is they dont want to "offend" the referring spine surgeons who order them. They should educate the surgeons and stop doing them.

This right here.

 

[swamprat]

Any reason you wish you tackle this? Are you seeing a lot of post op patients from neurosurg where you can’t do ILESI, or folks who refer and specifically ask for tfesi ?

Well I kinda just browsed my schedule coming up and I noticed a case was placed on my schedule from a prior doc who was doing them. It got me thinking about it. I’ll prob just do an interlam like I’m used to then I just wanted to see what people’s thoughts were outside of my group.

 

[Ducttape]

if you are the kind of person who thinks Evel Knievil was a wimp and does things to confirm it, then go for it.

 

[NOSfan]

Based upon the "conclusions" of this article, cervical epidurals should not be performed at all.

Surg Neurol Int. 2018 Apr 23;9:86. doi: 10.4103/sni.sni_85_18. eCollection 2018.
Major risks and complications of cervical epidural steroid injections: An updated review.
Epstein NE

Abstract
Background:
Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections (CESIs). These include interlaminar (ICESI) and transforaminal ESI (TF-CESI) injections that are not Food and Drug Administration (FDA) approved, have no documented long-term efficacy, and carry severe risks and complications.

Methods:
Here we reviewed recent reports of morbidity and mortality attributed to the various types of CESIS. Major complications included; epidural hematomas, infection (abscess/meningitis), increased neurological deficits due to intramedullary (quadriparesis/quadriplegia), and intravascular injections (e.g., vertebral artery injections leading to cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches.

Results:
Complications of cervical CESI/TF-CESI injections producing epidural hematoma, new neurological deficits (intramedullary injections), or intravascular injections resulting in strokes to the cord, brain stem, and cerebellum are often underreported. Interestingly, several other cases involving adverse events of CESI/TF-CESI may now be found in the medicolegal literature.

Conclusions:
Cervical epidural injecions (e.g., CESI, ICESI, and TF-CESI) which are not FDA approved, provide no long-term benefit, and are being performed for minimal to no indications. They contribute to significant morbidity and mortality, including; epidural hematomas, infection, inadvertent intramedullary cord injections or cord, brain stem, and cerebellar strokes. Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.

Major risks and complications of cervical epidural steroid injections: An updated review

 

[lobelsteve]

Based upon the "conclusions" of this article, cervical epidurals should not be performed at all.

Surg Neurol Int. 2018 Apr 23;9:86. doi: 10.4103/sni.sni_85_18. eCollection 2018.
Major risks and complications of cervical epidural steroid injections: An updated review.
Epstein NE

Abstract
Background:
Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections (CESIs). These include interlaminar (ICESI) and transforaminal ESI (TF-CESI) injections that are not Food and Drug Administration (FDA) approved, have no documented long-term efficacy, and carry severe risks and complications.

Methods:
Here we reviewed recent reports of morbidity and mortality attributed to the various types of CESIS. Major complications included; epidural hematomas, infection (abscess/meningitis), increased neurological deficits due to intramedullary (quadriparesis/quadriplegia), and intravascular injections (e.g., vertebral artery injections leading to cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches.

Results:
Complications of cervical CESI/TF-CESI injections producing epidural hematoma, new neurological deficits (intramedullary injections), or intravascular injections resulting in strokes to the cord, brain stem, and cerebellum are often underreported. Interestingly, several other cases involving adverse events of CESI/TF-CESI may now be found in the medicolegal literature.

Conclusions:
Cervical epidural injecions (e.g., CESI, ICESI, and TF-CESI) which are not FDA approved, provide no long-term benefit, and are being performed for minimal to no indications. They contribute to significant morbidity and mortality, including; epidural hematomas, infection, inadvertent intramedullary cord injections or cord, brain stem, and cerebellar strokes. Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.

Major risks and complications of cervical epidural steroid injections: An updated review

Anone want to post the review on cervical disc replacement and ACDF outcomes?

 

[Ducttape]

GIGO.

a review article from a surgeon.

of note, she mixes LESI data in to justify her arguments pertaining CESI. and mixes CESI with TFCESI.

additionally, this is not the only "review" that she disparages CESI.....

 

[Aether2000]

I would argue the conclusions of Epstein are incredibly stupid. The FDA does not approve or disapprove injections of any kind. The FDA approves drug uses and equipment, not procedures. A saline epidural injection is not FDA approved but neither is a spinal tap. Epstein harps on old data to bolster the conclusions...very few do transforaminal ESI. Also Epstein confuses lack of long term relief with efficacy of the short to medium term treatment resulting from ESI.

 

[NOSfan]

Dr. Epistein's bio states: ' Dr. Epstein, a skilled spine surgeon, has helped countless patients over the years find relief from debilitating spine-related conditions.'

Some of Dr. Epistein's numerous publications:

• Neurological complications of lumbar and cervical dural punctures with a focus on epidural injections.
• Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc: Case discussion and review
• Commentary: Unnecessary preoperative epidural steroid injections lead to cerebrospinal fluid leaks confirmed during spinal stenosis surgery.
• The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature.
• Nursing review of cervical laminectomy and fusion.
• Learning curves for minimally invasive spine surgeries: Are they worth it?
• Discrimination against female surgeons is still alive: Where are the full professorships and chairs of departments?

 

[powermd]

No axe to grind here...

Dr. Epistein's bio states: ' Dr. Epstein, a skilled spine surgeon, has helped countless patients over the years find relief from debilitating spine-related conditions.'

Some of Dr. Epistein's numerous publications:

• Neurological complications of lumbar and cervical dural punctures with a focus on epidural injections.
• Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc: Case discussion and review
• Commentary: Unnecessary preoperative epidural steroid injections lead to cerebrospinal fluid leaks confirmed during spinal stenosis surgery.
• The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature.
• Nursing review of cervical laminectomy and fusion.
• Learning curves for minimally invasive spine surgeries: Are they worth it?
• Discrimination against female surgeons is still alive: Where are the full professorships and chairs of departments?

 

[myrandom2003]

Article request:
Can anyone get me a pdf copy of this article?
A posterior approach to cervical nerve root block and pulsed radiofrequency treatment for cervical radicular pain: a retrospective study

 

[bedrock]

Article request:
Can anyone get me a pdf copy of this article?
A posterior approach to cervical nerve root block and pulsed radiofrequency treatment for cervical radicular pain: a retrospective study

I'd be interested as well

 

[Sadder]

This article?

 

[myrandom2003]

This article?

Much appreciated. Thank you.

I was actually really hoping they had more pictures. I was very curious as to how they did it. It looks like an RF from a posterior approach but just keep advancing the needle till they say ouch.

 

[Paindude11]

We did them in fellowship, supine the traditional approach as described above, DSA, dex. Patients were local or versed sedated

We do many at our PP via the prone, posterior approach. While technically it is more of a snrb with steroid. This article explains a similar approach to what we do.
How Do I Do It: Right C8 Selective Nerve Root Block in Prone Position - American Society of Regional Anesthesia and Pain Medicine

 

[NJPAIN]

Do you have any good pictures of your approach? This article is not terribly helpful if you’re trying to figure out how to use this approach.


Sent from my iPhone using Tapatalk

 

[Paindude11]

Do you have any good pictures of your approach? This article is not terribly helpful if you’re trying to figure out how to use this approach.


Sent from my iPhone using Tapatalk

I will take some next week when I do them.

 

[cbest]

Lecture at SIS this year discussed a study looking at vulnerability of vertebral arteries in pathway of cervical TFESI. It was somewhere between 20-30% of vertebral arteries were posterior enough in foramen that they were susceptible to puncture.


Sent from my iPhone using Tapatalk

 

[lobelsteve]

Lecture at SIS this year discussed a study looking at vulnerability of vertebral arteries in pathway of cervical TFESI. It was somewhere between 20-30% of vertebral arteries were posterior enough in foramen that they were susceptible to puncture.


Sent from my iPhone using Tapatalk

22%.

And US missed many of these....

 

[myrandom2003]

Also, for whatever reason, I can't get this to download.
Anyone want to post this article if they have it? Did they reference this article at SIS this year?
An Alternative to the Transforaminal Cervical Epidural: A Selective Dorsal Epidural
Article (PDF Available)  in Pain Medicine 19(2) · June 2017

EDIT:
Nevermind, I got it. attached.

 

[SommeRiver]

Lecture at SIS this year discussed a study looking at vulnerability of vertebral arteries in pathway of cervical TFESI. It was somewhere between 20-30% of vertebral arteries were posterior enough in foramen that they were susceptible to puncture.


Sent from my iPhone using Tapatalk

One of my old attendings published an article on this. I was somewhat shaken by that, and as a rule I just don't do TFESI in the neck. My spine surgeons in my group haven't complained yet, and if they do I'll simply tell them no. If they have a problem with that they'll have to fire me.