Cervical TFESI

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Curious if anyone is still doing these? I do them occasionally for some surgeons when they want some additional diagnostic info for surgical planning. Im very conservative with how I approach the injection but am well aware of the potential catastrophic outcomes despite using non particulate, digital subtraction etc. Is this still considered a feasible injection to perform? I’m wondering if it’s fallen out of favor to the degree that if a complication did occur I would find myself in a court room without anything to support providing this injection.

 

[painfree23]

Nope.

 

[SSdoc33]

Curious if anyone is still doing these? I do them occasionally for some surgeons when they want some additional diagnostic info for surgical planning. Im very conservative with how I approach the injection but am well aware of the potential catastrophic outcomes despite using non particulate, digital subtraction etc. Is this still considered a feasible injection to perform? I’m wondering if it’s fallen out of favor to the degree that if a complication did occur I would find myself in a court room without anything to support providing this injection.

your surgeons dont know what they are doing.

hard to tell them that, but explain the non-diagnostic and non-selective nature of a CTFESI.

only time i think it is reasonable, is when there is a clear upper cervical HNP or radiculopathy, and the patient has failed an ILESI. this is for therapeutic reasons, not diagnostic.

ill refer out for a CTFESI maybe once every other year

 

[Gnarvin]

your surgeons dont know what they are doing.

hard to tell them that, but explain the non-diagnostic and non-selective nature of a CTFESI.

only time i think it is reasonable, is when there is a clear upper cervical HNP or radiculopathy, and the patient has failed an ILESI. this is for therapeutic reasons, not diagnostic.

ill refer out for a CTFESI maybe once every other year

Who do you refer the patients out to?

 

[SSdoc33]

Who do you refer the patients out to?

someone with more balls than me. despite the risks, a CTEFI is still safer than an ACDF

 

[willabeast]

TF CESI IMHO is a good procedure with a steep learning curve. Diagnostically cervical SNRB false negatives are going to be rare. Probably lots of false positives. Interesting how the pendulum swings back and forth. I remember when IL CESI were the procedure that had fallen out of favor and TF CESI were the injection of choice. Ideally one should know how to do both but in the grand scheme of things the world would not notice all of these procedures going extinct. Better to spend the money on pre-natal vitamins for the indigent. Especially if that is all there is in the budget.

 

[painfree23]

TF CESI IMHO is a good procedure with a steep learning curve. Diagnostically cervical SNRB false negatives are going to be rare. Probably lots of false positives. Interesting how the pendulum swings back and forth. I remember when IL CESI were the procedure that had fallen out of favor and TF CESI were the injection of choice. Ideally one should know how to do both but in the grand scheme of things the world would not notice all of these procedures going extinct. Better to spend the money on pre-natal vitamins for the indigent. Especially if that is all there is in the budget.

IL CESI fell out of favor for TFESI because u could bill more for a two level TFESI.

 

[lobelsteve]

Would never offer CTFESI.

 

[nvrsumr]

I can neither confirm nor deny that I perform ctesi

 

[oreosandsake]

but am well aware of the potential catastrophic outcomes despite using non particulate, digital subtraction etc.

is this accurate? what kind of injury? needle to the VA? local anesthetic into the VA?

 

[Taus]

Curious if anyone is still doing these? I do them occasionally for some surgeons when they want some additional diagnostic info for surgical planning. Im very conservative with how I approach the injection but am well aware of the potential catastrophic outcomes despite using non particulate, digital subtraction etc. Is this still considered a feasible injection to perform? I’m wondering if it’s fallen out of favor to the degree that if a complication did occur I would find myself in a court room without anything to support providing this injection.

I do them. I’ve posted my technique on this forum a few times over the years. But basically see the VA location on mri, stay posterior and barely in foramen, dsa, dex, min lido.

 

[oreosandsake]

I do them. I’ve posted my technique on this forum a few times over the years. But basically see the VA location on mri, stay posterior and barely in foramen, dsa, dex, min lido.

Do you get good epidural spread with barely in foramen?

 

[Agast]

I never trained on it so I would not try to add that to my toolbox. I met a nice lady who has Brown-Sequard after a neurosurgeon did one on her.

That being said if you’ve done it for years and you’re quite good at it, I wouldn’t judge you for continuing. But if for some reason I absolutely needed one done on myself I would choose an interventional radiologist with their fancy fluoro…

 

[painfree23]

I never trained on it so I would not try to add that to my toolbox. I met a nice lady who has Brown-Sequard after a neurosurgeon did one on her.

That being said if you’ve done it for years and you’re quite good at it, I wouldn’t judge you for continuing. But if for some reason I absolutely needed one done on myself I would choose an interventional radiologist with their fancy fluoro…

I would only chose a IL CESI for myself

 

[Taus]

Do you get good epidural spread with barely in foramen?

I get it on the nerve root. Don’t push my luck. Some literature supporting no difference in outcome.

I always go interlam first except if c3/4 or hnp above a fusion. Majority though are direct referrals from spine surgeons.

 

[nvrsumr]

If I performed ctesi I use 27g 1 1/2 along with other safety measures noted. Maybe less risk of vertebral a. trauma. No/fat necks are a relative contraindication. Also old folks necks

 

[deleted131481]

I don't do these but wonder if there is a role to do them under ultrasound?

 

[pmrmd]

Very rarely will I do them. I also stay lateral. I saw an article about a 60 degree approach so I stay well under the VA.

 

[Taus]

Very rarely will I do them. I also stay lateral. I saw an article about a 60 degree approach so I stay well under the VA.

Won’t save you from VA. Several studies show VA aberrantly within 1-2mm from ideal target in ip to 1/3 patients, highest % with foraminal stenosis.

 

[pmrmd]

Won’t save you from VA. Several studies show VA aberrantly within 1-2mm from ideal target in ip to 1/3 patients, highest % with foraminal stenosis.

I look at MRI first but haven’t seen VA that lateral in a long time.

 

[ED50]

There is a guy in my city that probably does around 40 or more per week plenty are two levels. Many surgeons think it is the standard of care. Hardly saw any during training. To his credit I haven't heard of anything catastrophic happening to one of his patients.

 

[Orin]

I don't do these but wonder if there is a role to do them under ultrasound?

Yeah, there are reports and it's actually an easy visualization, but the billing is only for fluoro guidance if I remember right

 

[Tboned]

I do them regularly. Have to look at MRI first to make sure you can access safely. If advanced neuroimaging shows you can’t safely access due to vert or other more superficial vasculature, Don’t do it! switch to ILESI. DO NOT FORGET, YOURE ILESI ARE NOT WITHOUT DANGER AND THERE ARE PLENTY OF CATASTROPHIC COMPLICATIONS ASSOCIATED WITH THEM - Some from very, very experienced interventionalists. BE SAFE regardless, everyone walks away.

 

[paindoc007]

I always go interlam first except if c3/4 or hnp above a fusion. Majority though are direct referrals from spine surgeons.

Spine surgeons literally don’t have a clue what they’re even ordering. “Please perform a selective c4 nerve root block please”. Just do an interlam and call it a day. They don’t know or care the specifics

 

[bedrock]

There is a guy in my city that probably does around 40 or more per week plenty are two levels. Many surgeons think it is the standard of care. Hardly saw any during training. To his credit I haven't heard of anything catastrophic happening to one of his patients.

I do them regularly. Have to look at MRI first to make sure you can access safely. If advanced neuroimaging shows you can’t safely access due to vert or other more superficial vasculature, Don’t do it! switch to ILESI. DO NOT FORGET, YOURE ILESI ARE NOT WITHOUT DANGER AND THERE ARE PLENTY OF CATASTROPHIC COMPLICATIONS ASSOCIATED WITH THEM - Some from very, very experienced interventionalists. BE SAFE regardless, everyone walks away.

Spine surgeons literally don’t have a clue what they’re even ordering. “Please perform a selective c4 nerve root block please”. Just do an interlam and call it a day. They don’t know or care the specifics

Agree that spine surgeons have no idea what they are ordering. Just do a regular cervical epidural and call it good. ILESI still has risk though.

I agree with first checking the location of the VA. I did many CTFESI in fellowship, but now I will only do a cervical SNRB, and I do this as the nerve exits the foramen only. Not worth the risk to do a CTFESI with dex that will only last for a few weeks at best, and I'd rather avoid the SNRBs unless truly necessary.

I've had to educate some old crusty surgeons who were used to ordering CTFESI. I updated them on the literature and that a cervical ILESI is the 21st century approach, just like surgical techniques becomes outdated with time, so do injection techniques.

 

[NJPAIN]

Agree that spine surgeons have no idea what they are ordering. Just do a regular cervical epidural and call it good. ILESI still has risk though.

I agree with first checking the location of the VA. I did many CTFESI in fellowship, but now I will only do a cervical SNRB, and I do this as the nerve exits the foramen only. Not worth the risk to do a CTFESI with dex that will only last for a few weeks at best, and I'd rather avoid the SNRBs unless truly necessary.

I've had to educate some old crusty surgeons who were used to ordering CTFESI. I updated them on the literature and that a cervical ILESI is the 21st century approach, just like surgical techniques becomes outdated with time, so do injection techniques.

What's the difference in your technique for cervical SNRB vs CTFESI other than minus steroid?

 

[Nodolor]

sounds like ........SNRB =squirting meds along nerve root

 

[painfree23]

What's the difference in your technique for cervical SNRB vs CTFESI other than minus steroid?

Probably just don’t go as deep?

 

[Taus]

What's the difference in your technique for cervical SNRB vs CTFESI other than minus steroid?

Stay lateral. On exiting root. Not medial.

 

[DesertDoc16]

I was never trained on CTFESI and I won’t do them. I get asked occasionally, but I’m not about to try and learn at this point. Several others in the community that are comfortable with them…. I send the patients over.

 

[NJPAIN]

I did many from about 2000-2010. Then, like many others I stopped. I now do 1-2 a year at most at surgeon request. I know a few people who routinely do them after failed CILESI. I don’t know that I agree with the claim that it is safer than an ACDF. Perhaps less risk from a single injection but considering the success rate of ACDF and long term sustained relief I’m not certain what the point is. Failed time, PT, CESI—>surgery. Speaking as someone who had 3 CESI then sustained relief with surgery (posterior foraminotomy/discectomy) x 10 years —> recurrent oain —> 2 more CESI that did nothing and then resolution with time.

 

[bedrock]

What's the difference in your technique for cervical SNRB vs CTFESI other than minus steroid?

Stay lateral. On exiting root. Not medial.

I do the same as Taus. I stay lateral (dorsal), touch down on bone, and then redirect slightly ventral to the exiting root, paint nerve with contrast, then inject lidocaine along the root, but I'm not in the actual foramen.

Even this is something I do rarely, just a few times a year for surgeons that are good referral sources.

 

[bedrock]

I don’t know that I agree with the claim that it is safer than an ACDF. Perhaps less risk from a single injection but considering the success rate of ACDF and long term sustained relief I’m not certain what the point is. Failed time, PT, CESI—>surgery. Speaking as someone who had 3 CESI then sustained relief with surgery (posterior foraminotomy/discectomy) x 10 years —> recurrent oain —> 2 more CESI that did nothing and then resolution with time.

Agree. Since everyone can agree that particulate steroids are a bad idea for CTFESI, then what becomes the point of a CTFESI, because the dex isn't going to last very long even if you put it right on the nerve. So the risk isn't worth it.

The last thing I want is patients requesting a CTFESI every 6 weeks, (because relief doesn't last with dex for foraminal stenosis), and cervical ILESI work just fine for disc herniations.

 

[oreosandsake]

Sometimes

 

[RoloTomassi]

Trained in CTFESI but not worth the risk. High volume IL usually gets cephalad and ventral enough.

Another option is transfacet approach which has been shown to be equal efficacy to TF but much safer.

I do both IL and transfacet. Go deep into the facet, can potentially pass through the ventral capsule with needle or with high volume injection. Use CLO. Can see the foraminal flow. I have had many patients get minimal or no relief with one approach but then high percent with the other so they compliment each other well.

 

[oreosandsake]

Trained in CTFESI but not worth the risk. High volume IL usually gets cephalad and ventral enough.

Another option is transfacet approach which has been shown to be equal efficacy to TF but much safer.

I do both IL and transfacet. Go deep into the facet, can potentially pass through the ventral capsule with needle or with high volume injection. Use CLO. Can see the foraminal flow. I have had many patients get minimal or no relief with one approach but then high percent with the other so they compliment each other well.

I’ve seen that, also the idea of burning the capsule. I don’t think busting through the capsule integrity is a good long term idea

 

[RoloTomassi]

I’ve seen that, also the idea of burning the capsule. I don’t think busting through the capsule integrity is a good long term idea

The loss of resistance I feel from seeing contained facet contrast to seeing extracapsular flow using 3 cc syringe is minimal, if any. Feels less abrupt than ligamentum flavum LOR with 3 cc syringe and 22 ga, so I assume it's a small permeation, not a massive rupture of the capsule, and should heal as easily as a needle puncture. Have had no complaints of worsened axial pain. Again it's a risks vs benefits decision and many are happy their hot radic is gone. Try a few. I do with PRP regularly, if they have a big improvement with steroid but it's not durable, as an alternative to RFA in younger patients.

 

[NJPAIN]

Can you provide a reference for the technique?

 

[RoloTomassi]

Studies I would have to dig around. Technique is basically posterior approach:
Prone with neck flexed to open up posterior facets
AP with caudal tilt enough to see clear facet joint space (degree varies a lot depending on level, angle of facet joints, lordosis)
22 ga 5", insert hub view mid lateral mass, inferior joint line (will be easier to correct steering cephalad than caudal)
When about halfway to joint (deep enough that needle won't go lateral or medial off joint), switch to CLO
CLO should show clear joint space and trajectory
Adjust cephalocaudal trajectory in CLO as needed, and go through the capsule into joint
Contrast in CLO, then check in AP, optional in lateral if not sure but often difficult to see lower levels, and have to adjust wag to superimpose joint lines
Don't go too deep, due to vertebral artery location
When in CLO can switch back to AP periodically to make sure not going medial or lateral

 

[RoloTomassi]

Can you provide a reference for the technique?

Approaches in injections for radicular pain: The transforaminal, epidural and transfacet approaches

 

[RoloTomassi]

Example: left C5 radic from adjacent segment disease above her ACDF. Did not respond to C7-T1 ILESI. Was up for fusion extension, but responded very well to transfacet approach, does not need surgery, and it's been months. TFESI may have been just as good, but more risky.

 

[NJPAIN]

Example: left C5 radic from adjacent segment disease above her ACDF. Did not respond to C7-T1 ILESI. Was up for fusion extension, but responded very well to transfacet approach, does not need surgery, and it's been months. TFESI may have been just as good, but more risky.

View attachment 339670View attachment 339671

Thanks so much for the pics. VERY INTERESTING. How much volume do you usually need? In terms of head position do you turn the head and tuck the chin to open the joint space or does that mess up your CLO? Have you had an instance where you did not get flow into the foramen?

 

[RoloTomassi]

Thanks so much for the pics. VERY INTERESTING. How much volume do you usually need? In terms of head position do you turn the head and tuck the chin to open the joint space or does that mess up your CLO? Have you had an instance where you did not get flow into the foramen?

I use very little contrast, probably 0.25 cc. Doesn't take a lot. If you put enough you'll usually see some foraminal flow, but I try to minimize how much I permeate through. I really just look for clean capsule fill.

Sometimes you see more retrodural space of Okada flow. Feels a lot different, much less resistance, feels like epidural. It shows as more of a thin linear pattern along the plane of mid facet in CLO, and horizonal flow along the lamina on AP. I'll find a pic. I don't mind injecting there, and see comparable efficacy, possibly since it's theorized to contain inflammatory mediators. If doing 2 adjacent levels or when 1 level bilateral, with both needles in place, sometimes injecting in one flows out the other.

Medication volume 1-1.5 cc. Dex + lido. I've had 2 cases of vascular spread while in the joint touching os.

2 pillows under chest, tuck chin as much as possible, though they always scrunch. No head turn. It's a lot of tissue to traverse due to the angle you have to come from, so C2-4 usually 3", C4-T1, 5". Lot of steering on that CLO view so best to start with a good trajectory. Inadvertently going medial is obviously the biggest danger.

 

[RoloTomassi]

Retrodural- perpendicular to facet joint line, not anterior as foraminal flow on CLO, flows medially in plane of lamina on AP. Took a minute to find this pic. Almost all pics had foraminal spread. Needle a bit medial, greater likelihood retrodural.

Foraminal+retrodural, moreso with top needle.

 

[MD87]

Retrodural- perpendicular to facet joint line, not anterior as foraminal flow on CLO, flows medially in plane of lamina on AP. Took a minute to find this pic. Almost all pics had foraminal spread. Needle a bit medial, greater likelihood retrodural.
View attachment 339711
View attachment 339712

Foraminal+retrodural, moreso with top needle.
View attachment 339713
View attachment 339714

Great pics. How do you bill for this, and what is your ICD code? I would think a facet injection would not get covered for an ICD code of radiculopathy?

 

[lobelsteve]

Great pics. How do you bill for this, and what is your ICD code? I would think a facet injection would not get covered for an ICD code of radiculopathy?

Would bill it as a CTFESI for M54.12 as that is the procedure being performed, despite not using the classical foraminal approach.

 

[NJPAIN]

Has anyone seen the Porter McRoberts YouTube video from a while back showing a somewhat similar transforaminal technique?. Not transfacet but he seems to go around the lateral mass . He doesn’t check a lateral and I can’t appreciate transforaminal
flow on the video. Anyone familiar wit the intended technique?

 

[Birdstrike]

I don't do C TF ESIs. You can injure a perforating branch to the anterior spinal artery and cause an irreversible cervical spinal cord infarct. Rare, but devastating. All interlaminars for me in the C spine, CLO at C7/T1. YMMV.