Cervical TFESI

[sweetalkr]

Any thoughts on Cervical TFESI? Safe or dangerous? Do you do them? or just use a catheter?

If you do them, any tips?
if you don't, what do you do otherwise?

can you have a successful practice without doing them, or is that a disservice to your patients?

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[mid|ine]

I don't do them, and believe the trend is to not do them.

You can have a very successful practice without doing them.

I do ILESI at C7-T1. The cervical space is tight and you get good spread through the cervical epidural space with this approach.

 

[Aether2000]

The cervical TFESIs have associated complications of nerve injury via direct trauma, spinal cord injury due to direct trauma/injection into the cord/or vascular infarction ostensibly due to particulates injected into the radiculomedullary arteries, cerebellar or cerebral infarction due to the same. Using non-particulates will eliminate the vascular complications via particulate injection but not the complication of hematoma or direct trauma. Usng a catheter may cause direct trauma to the nerve or cord, and may lacerate vessels. Given the spread from an interlaminar low volume injection, I cannot believe TFESI have much utility. Still do some...selected cases.

 

[lobelsteve]

Never did them. Trained not to do them. Risks seem to outweigh benefits when CESI is available. I do use catheters for C3-4 and always enter at C7-T1 based on anatomy. AP/Lat images saved on all cases- I'll fudge the lateral to the football view if shoulders in way.

 

[PMR 4 MSK]

2 recent reviews in (I think) Pain Medicine News looked at studies which purport to improve CESI safety - one interlaminar, one transforaminal. I'd have to look at them for the citations.

My last TFCESI got blood 2 tries in a row, and that's when I gave up on them - about 5 years ago.

I only do interlaminar C6-7 or C7-T1.

 

[nvrsumr]

I often get requests for ctfesi from spine surgeons trying to figure out which level to fuse or disc to replace. They actually want an snrb and I do my best to accomodate them though there is almost always epidural spread. I have interviewed with some spine groups who specifically wanted ctfesi and cervical discos in their pain docs bag of tricks.

 

[SSdoc33]

I often get requests for ctfesi from spine surgeons trying to figure out which level to fuse or disc to replace. They actually want an snrb and I do my best to accomodate them though there is almost always epidural spread. I have interviewed with some spine groups who specifically wanted ctfesi and cervical discos in their pain docs bag of tricks.

i dont think there is such thing as a cervical SNRB.

 

[lobelsteve]

i dont think there is such thing as a cervical SNRB.

There isn't. The literature demonstrates it. I think it was Furman who published that article.

 

[sweetalkr]

well that is the consensus i hear from the guys I know and my program. We will do catheters from c7-t1 but only if electively necessary

thanks for the input as always.

young grasshopper

 

[bedrock]

The cervical TFESIs have associated complications of nerve injury via direct trauma, spinal cord injury due to direct trauma/injection into the cord/or vascular infarction ostensibly due to particulates injected into the radiculomedullary arteries, cerebellar or cerebral infarction due to the same. Using non-particulates will eliminate the vascular complications via particulate injection but not the complication of hematoma or direct trauma. Usng a catheter may cause direct trauma to the nerve or cord, and may lacerate vessels.

Both IL and TF cervical ESI have potentially serious risks as Algos nicely outlined. The one thing he didn't mention is there has never been a published case (or even reported to ISIS leadership) of a significant complication from a cervical TFESI performed with DSA and using a true non-particulate steroid (dexamethasone).

I did a lot of IL and TF cervical ESI during fellowship, but since entering practice, I do >95% IL CESI, more for legal reasons than anything else. I offer cervical TFESI to patients who have focal cervical pathology, have failed cervical ILESI, and they're otherwise going for surgery. I've saved quite a few of those patients from going under the knife.
I have yet to find evidence anywhere that a cervical TFESI (performed with DSA & dexamethasone) is riskier than cervical surgery.

 

[Jcm800]

when i do them, i do them with DSA and Dex as well. And i document very carefully. Again rare cases, posterior laminectomies..."SNRB" requests from surgeons...
maybe 2 a month...

Both IL and TF cervical ESI have potentially serious risks as Algos nicely outlined. The one thing he didn't mention is there has never been a published case (or even reported to ISIS leadership) of a significant complication from a cervical TFESI performed with DSA and using a true non-particulate steroid (dexamethasone).

I did a lot of IL and TF cervical ESI during fellowship, but since entering practice, I do >95% IL CESI, more for legal reasons than anything else. I offer cervical TFESI to patients who have focal cervical pathology, have failed cervical ILESI, and they're otherwise going for surgery. I've saved quite a few of those patients from going under the knife.
I have yet to find evidence anywhere that a cervical TFESI (performed with DSA & dexamethasone) is riskier than cervical surgery.

 

[dc2md]

Has anyone done a typical TF approach, but then stop just lateral to the foramen and thread a catheter to the "safe zone"?? Apparently the VA pain docs in my area have started doing it this way...though I haven't seen it.

 

[dc2md]

1. Minimal to no sedation
2. Guide needle tip towards the posterior foramen (ant. aspect of SAP) to recognize the depth, then slowly advance under LIVE fluoroscopy
3. Use extension tubing to minimize needle movement
4. Contrast-enhanced LIVE fluoroscopy with digital subtraction
5. Test dose of lidocaine --> sensorimotor testing in 2 minutes
6. Use non-particulate steroids
7. Consider alternate routes to transforaminal space

 

[Aether2000]

Hypothetically 2,3, and 5 may make the procedure safer but these are speculative (but somewhat logical). The sedation issue is interesting....but in general, either minimally sedated or very deeply sedated would be preferred over moderate (no mans land) sedation with the patient becoming uncooperative or thrashing about dangerously. The posterior foramen is definitely what I use, but with the caveat that the radiculomedullary arteries via recent dissections are present all throughout the neuroforamen. The lidocaine test dose is predicated on the needle tip not moving a fraction of an inch nor rotating for the 2 minutes during the test dose. This type of absolutely immobility of the needle doesn't happen in my patients....

 

[dc2md]

I just gave a presentation on this exact topic to the LSU pain fellows and attendings (and a few other residents) this past Friday.

ALGOS, good point about the moderate sedation possibly allowing for more of that aggressive/uninhibited coming out of sedation effect. We typically don't use any at all where I've trained, but the argument is just that too much sedation will not allow for the nausea/dizziness/headache to be reported until the sedation wears off; which, in the unfortunate event of an infarct, may be precious minutes.

And after Dreyfus' and Lee's recent studies showing equivalent effectiveness of triamcinolone (kenalog) and dexamethasone (decadron) with C-TFESIs, why would anyone take a chance with using particulates. EVERY case report I found was either kenalog or depo-medrol (though some didn't report the steroid used). No case reports with celestone soluspan, but then with Tiso's and Derby's "particle size/aggregation" studies showing depo-medrol, kenalog, and celestone (in the Derby one) forming large aggregates in blood, Celestone probably isn't worth taking a chance on either.

 

[Ligament]

I urge y'all to reconsider the utility of the 2 minute local anesthetic "test dose" for the reasons Algos mentions below. I used to think that the "test dose" was of no use. Lately, I think it is simply dangerous.

No patient and no needle will stay absolutely still for 2 minutes, unless the patient is DEAD. Especially if you are doing any form of motor exam at the 2 minute mark.

Now if you do a test dose with LA, and a few seconds later inject steroid, this may or may not be useful to r/o cerebral uptake. The needle tip should move less in a few seconds.

Hypothetically 2,3, and 5 may make the procedure safer but these are speculative (but somewhat logical). The sedation issue is interesting....but in general, either minimally sedated or very deeply sedated would be preferred over moderate (no mans land) sedation with the patient becoming uncooperative or thrashing about dangerously. The posterior foramen is definitely what I use, but with the caveat that the radiculomedullary arteries via recent dissections are present all throughout the neuroforamen. The lidocaine test dose is predicated on the needle tip not moving a fraction of an inch nor rotating for the 2 minutes during the test dose. This type of absolutely immobility of the needle doesn't happen in my patients....

 

[dc2md]

No patient and no needle will stay absolutely still for 2 minutes, unless the patient is DEAD. Especially if you are doing any form of motor exam at the 2 minute mark.

Now if you do a test dose with LA, and a few seconds later inject steroid, this may or may not be useful to r/o cerebral uptake. The needle tip should move less in a few seconds.

But the neurologic reaction to the test dose of lidocaine happened at 90 seconds (I believe) in this case report, so just waiting a few seconds is worthless....but maybe that's your point. Should probably just use nonparticulates and forget about the test dose.

Karasek M, Bogduk N. “Temporary neurologic deficit after cervical transforaminal injection of local anesthetic.” Pain Med. 2004 Jun;5(2):202-5

 

[SleepIsGood]

But the neurologic reaction to the test dose of lidocaine happened at 90 seconds (I believe) in this case report, so just waiting a few seconds is worthless....but maybe that's your point. Should probably just use nonparticulates and forget about the test dose.

Karasek M, Bogduk N. “Temporary neurologic deficit after cervical transforaminal injection of local anesthetic.” Pain Med. 2004 Jun;5(2):202-5

I think Algos' point of using some sedatino may have some point here.

While I see the point that sedatio may 'mask' some intra arterial injections...on the flip side under careful sedation the patient is less likely to move. As Ligament points out, moving just a tad can redirect the medicine that once was NOT intravascular.

having said that, the few times I've done a CTFESI, it's been w/o sedation. Under careful sedation pt's can still tell you if they are light headed or have a 'sense of doom'. At the same time you can preserve their ability to let you know if motor function is intact. Again,this requires careful sedation.

 

[Jcm800]

of all the procedures we do, this i think requires the LEAST sedation if any. I do them all awake. the distance from the skin to the foramen is not far, and in general, the tissue isnt too painful (although i have never had it done to me)
with a 24 or 25 gauge needle, i find it almost silly to sedate for this, and i like the awake patient.

but i still do 98% of my procedures without sedation. Including RF, stim trials, and discograms. i know im mean.

 

[clubdeac]

I did more C-TFESIs in fellowship than C-ILESIs. Now that I'm out, like DocShark and Bedrock, I only offer it after failed ILESI and focal pathology possibly amenable to TFESI. Agree with dig subtraction, test dose, dexa etc. I've used Smith and Nephew's trucath needle too but it was a little awkward to manipulate.

Just to clarify, everyone's argument against the test dose is b/c of the long wait time of 2 min. Is that right? Shorter time is ok? Otherwise we could argue that contrast injection is useless due to needle mov't b/w injections....

Oh and dc2md, I'm familiar with all the literature except the Dreyfus and Lee's recent studies on equivalency of dexa and kenalog in the cervical spine. I'm aware of a study that showed clinical but not statistical significance for improved outcomes with triamcinolone compared to dexa but I thought this was in the lumbar region. Can you post those articles for me

Sweets when you gonna rotate at the VA spa? I'll show ya what's up

 

[PMR 4 MSK]

Is there is a single study showing TFCESI superior to ILCESI in any patient population?

 

[dc2md]

Oh and dc2md, I'm familiar with all the literature except the Dreyfus and Lee's recent studies on equivalency of dexa and kenalog in the cervical spine. I'm aware of a study that showed clinical but not statistical significance for improved outcomes with triamcinolone compared to dexa but I thought this was in the lumbar region. Can you post those articles for me

Here are the two articles comparing dexa to triamcinolone in the C-spine:

Dreyfuss P, Baker R, Bogduk N. “Comparative effectiveness of cervical transforaminal injections with particulate and nonparticulate corticosteroid preparations for cervical radicular pain.” Pain Med 2006;7:237-42

Lee et al. “Cervical transforaminal epidural steroid injection for the management of cervical radiculopathy: a comparative study of particulate versus non-particulate steroids.” Skeletal Radiol 2009;38:1077–1082

And here's one comparing dexa to triamcinolone in the L-spine, BUT I believe they only used 8mg of dexa, instead of the 12mg used in the Dreyfuss study above.
O’Donnell C, Cano W, Eramo G. Comparison of triamcinolone to dexamethasone in the treatment of low back pain and leg pain via lumbar transforaminal epidural steroid injection. Spine J. 2008;8:65S