Cervical wet tap- Darn it

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10KHertz said:
Almost Every blood patch article or study or treatment option refers to OB literature. I assumed you knew epidural blood patch evolution, history and background . My bad... Maybe I can get an OB nurse to educate you , they are extremely smart and resourceful...
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You're not the only person in here that's seen a leak.
 
10KHertz said:
I recommended a MRI for persistent post dural puncture headaches, and the trollS unraveled. Read the literature , it should have been a part of your training. I can post 6 review articles to support my opinion. You want them? Or are you another troll ?
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I did a chronic CSF leak clinic, and we ordered MRI and CT myelo on all these patients but I've never heard...ever...of getting an advanced image for an acute leak.

We had to go through the SEEPS SEEPS algorithm for chronic leak pts, but never once have I heard of an acute leak that was clearly provoked as being in need of an MRI.

The problem with this conversation is that you've got a number of medical professionals within your field who disagree with your plan of care, and instead of considering their advice you start recommending they speak with an OB nurse.

I'm an anonymous dude on the internet who disagrees with you.

Edit - You DID say MRI if persistent and not simply acute. I agree with that, but only after a failed patch and conservative care.
 
I think this pain forum has become less medical in nature and more political and biased . It’s obvious from all the threads and harassed contributors in the past. To bad...
 
10KHertz said:
lots of conversations here.

This thread is discussing cervical Epidural blood patches, not lumbar, what are you talking about? Would you do a cervical patch or not? I’d get a brain MRI (without gad first) in this case if the patients symptoms PERSIST.... If it resolves , great, no brainer not a thread worthy issue .

In ones career you are going to get persistent and complicated symptoms post an epidural (c/l) , and getting a MRI prior to a blood patch is totally legit with persistent symptoms. An MRI may steer you towards more conservative care if the csf volume is appropriate. Hence saving costs in the long run. You ever have a patient complain of headaches post CESI that was not clear cut? I have.

As for your facility fee numbers , do you understand that its a professional fee $177, plus $88-120 follow up/consult ($204), plus injectables costs. Then times this by 2-3 fold for typical commercial reimbursement... this is the same Price as an MRI without contrast. Plus it actually guides care.

As for the snide PMR comment, you sound insecure and attention seeking. Most PMR peeps, including my close friend, are reasonable and chill to hang out with. Let me
buy the next beer round, sport, you need it ...
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no, the thread is discussing PDPH after cervical epidural. the OP asked about cervical blood patch, but no one on this thread has suggested doing cervical blood patches. in fact, willabeast, Baron, Lobelsteve, hyperalgesia and Ligament all specifically stated lumbar blood patch. and no one has stated persistent symptoms. the discussion is on the acute management after presumed wet tap.


so you get the MRI. you wait for approval, get approval, and find lo and behold, the patient has a PDPH that you suspected because the headache is positional and occurred 48 hours after your epidural. now, you have a $1000 study, and you are going to spend the same cost to do the blood patch.

and the patient has had severe positional headache for the past week or so waiting for the results of her MRI and the follow up appointment to discuss the MRI and set up the blood patch. congrats. you spent $1000 on delaying her care for several days.

Where there is doubt regarding the diagnosis of post‐dural puncture headache, additional tests may confirm the clinical findings...I recommended a MRI for persistent post dural puncture headaches...
stop changing the goalposts. noones talking about persistent headaches, or headaches that fail SPG/epidural blood patch.


what PMR comment are you talking about?
 
10KHertz said:
Almost Every blood patch article or study or treatment option refers to OB literature. I assumed you knew epidural blood patch evolution, history and background . My bad... Maybe I can get an OB nurse to educate you , they are extremely smart and resourceful...
Click to expand...

The fact that you don't know the difference between a lumbar dural puncture and a cervical dural puncture makes me really question whether or not you respect cervical ESIs enough to safely perform them. It is clear from your comments that you do not understand the physiology or potential consequences.

The advice you are offering deviates from standard of care. You have several other physicians questioning the advice you are giving and your first response isn't to question your own algorithm -- it's to go on the defensive and sling mud.
 
SommeRiver said:
I did a chronic CSF leak clinic, and we ordered MRI and CT myelo on all these patients but I've never heard...ever...of getting an advanced image for an acute leak.

We had to go through the SEEPS SEEPS algorithm for chronic leak pts, but never once have I heard of an acute leak that was clearly provoked as being in need of an MRI.

The problem with this conversation is that you've got a number of medical professionals within your field who disagree with your plan of care, and instead of considering their advice you start recommending they speak with an OB nurse.

I'm an anonymous dude on the internet who disagrees with you.
Click to expand...
Baron Samedi said:
The fact that you don't know the difference between a lumbar dural puncture and a cervical dural puncture makes me really question whether or not you respect cervical ESIs enough to safely perform them. It is clear from your comments that you do not understand the physiology or potential consequences.

The advice you are offering deviates from standard of care. You have several other physicians questioning the advice you are giving and your first response isn't to question your own algorithm -- it's to go on the defensive and sling mud.
Click to expand...
lmao... this is the most nonsensical response I’ve ever heard . My training and volume are pretty top notch brother. Don’t concern yourself too much, I do well. Been in practice 13 years and still learning . No need to take personal jabs , that’s sophomoric.

Recommending a mri for persistent post dural puncture symptoms s/p a cervical or lumbar ESI is “deviating from the standard of care”?
I just posted excerpts indicating it is commensurate with the standard of care, and medical differential, and diagnostic work up ... do you need me to post 3-4 review article like our last argument ? Would you have the etiquette to read them? Is arguing on this thread worth it ? Are people learning something? Why are people becoming addicted to social media and bullying contributors? Were you popular in high school? Do you hate your dad? I do.

We need some fresh blood on this pain forum. too much inbreeding ...
 
I think 10KHertz is a murse... perhaps one of those advanced Dr. Murses (DNP) Just sayin
 
pmrmd said:
I use a 25g spinal like Steve for years and years now. I will never go back to a Tuohy/LOR technique. A bit of contrast dorsal and then in.View attachment 292411
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I totally had this in mind when i did two C7-T1 interlams today. I'm considering making the switch. One of the two had almost nil ligamentum. Still used a 20G Touhy successfully, but I'm trying to convince myself to just use the 25G spinal.

Question though: What do you use for your treatment med/injectate?
 
iwumd07 said:
I totally had this in mind when i did two C7-T1 interlams today. I'm considering making the switch. One of the two had almost nil ligamentum. Still used a 20G Touhy successfully, but I'm trying to convince myself to just use the 25G spinal.

Question though: What do you use for your treatment med/injectate?
Click to expand...

I use 1cc triamcinolone and 3cc dex usually.
 
pmrmd said:
I like the rapid onset of dex that transitions to the longer effect of kenalog.


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Click to expand...
Can you bill for dual steroids? You may be losing some revenue if your volume is high.
 
SommeRiver said:
What doses are you using? Are those dex equivalents 4mg per cc, 10mg?
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Right, but dex is just so temporal I personally don’t see sustained benefit like the studies say. I reduce in a sensitive diabetic but otherwise it seems to just add quicker onset without much consequence.


Sent from my iPhone using Tapatalk
 
Slightly off topic. I use 10 mg dex in my ILCESI. Most of my patients have cervical spondylosis with central and foraminal stenosis. Only indication is radicular pain. I am completely UNDERWHELMED by the number of patients who report significant relief. Some nothing. Some a few days. I’m not enthusiastic about doing the procedure. Honestly, the ones who go on to ACDF or ACDR do great.


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I switched back to Depo in my CESI's. Better results and no more chest pain
 
The Europeans disagree with your literature though and their findings of superiority for particulates reflects the obvious. It doesn’t make any sense for dex to make a significant difference in a stenotic lesion and their recent publications show exactly that.
 
pmrmd said:
The Europeans disagree with your literature though and their findings of superiority for particulates reflects the obvious. It doesn’t make any sense for dex to make a significant difference in a stenotic lesion and their recent publications show exactly that.
Click to expand...

Can you provide a reference?


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Bensler, S., Sutter, R., Pfirrmann, C.W.A. et al. Is there a difference in treatment outcomes between epidural injections with particulate versus non-particulate steroids? Eur Radiol 27, 1505–1511 (2017) doi:10.1007/s00330-016-4498-9
Results
Patients receiving particulate steroids had statistically significantly higher NRS change scores (p = 0.0001 at 1 week; p = 0.0001 at 1 month).

A significantly higher proportion of patients receiving particulate steroids reported relevant improvement (PGIC) at both 1 week and 1 month post injection (p = 0.0001) and they were significantly less likely to report worsening at 1 week (p = 0.0001) and 1 month (p = 0.017).

Conclusion
Patients treated with particulate steroids had significantly greater pain relief and were much more likely to report clinically relevant overall ‘improvement’ at 1 week and 1 month compared to the patients treated with non-particulate steroids.




Bensler, S., Sutter, R., Pfirrmann, C.W.A. et al. Particulate versus non-particulate corticosteroids for transforaminal nerve root blocks: Comparison of outcomes in 494 patients with lumbar radiculopathy. Eur Radiol 28, 946–952 (2018) doi:10.1007/s00330-017-5045-z
Results
A significantly higher proportion of patients treated with particulate steroids were improved at 1 week (43.2 % vs. 27.7 %, p = 0.001) and at 1 month (44.3 % vs. 33.1 %, p = 0.019). Patients receiving particulate steroids also had significantly higher NRS change scores at 1 week (p = 0.02) and 1 month (p = 0.007).

Conclusion
Particulate corticosteroids have significantly better outcomes than non-particulate corticosteroids.

Key Points
• Better pain relief is achieved with particulate steroids.

• Significantly more patients report overall ‘improvement’ with particulate steroids.

• Significantly more patients report ‘worsening’ at 1 week with non-particulate steroids.



Tagowski, M., Lewandowski, Z., Hodler, J. et al. Pain reduction after lumbar epidural injections using particulate versus non-particulate steroids: intensity of the baseline pain matters.Eur Radiol 29, 3379–3389 (2019) doi:10.1007/s00330-019-06108-9
Results
Four weeks post-injection, the overall chance of ≥ 50% pain reduction was lower in the dexamethasone group than that in the triamcinolone group (odds ratio [OR] = 0.55; p < 0.012). In the dexamethasone cohort, the intensity of baseline pain and the presence of a herniated intervertebral disc in the infiltrated segment were both significant and independent predictors of ≥ 50% pain relief. Patients with baseline NRS score ≥ 7 points had markedly less chance of ≥ 50% pain relief than patients with NRS score < 7 (OR = 0.53; p < 0.032), whereas disc herniation increased the chances more than twofold (OR = 2.29; p < 0.044). There was no significant correlation between the effectiveness of triamcinolone and any analyzed concomitant variables.

Conclusions
Triamcinolone was superior for lumbar radiculopathy of severe intensity. For mild to moderate pain, no benefit of using triamcinolone over dexamethasone was found. The effectiveness of dexamethasone was lower for stenotic spinal lesions than for disc herniation.

Key Points
• Triamcinolone is superior to dexamethasone for epidural treatment of severe lumbar radiculopathy.

• For mild to moderate pain, dexamethasone could be equally effective.

• Dexamethasone reduces pain caused by disc herniation much better than it does to pain caused by fixed stenotic spinal lesions.
 
These are some pretty heavy conclusions to draw on some pretty light data

"Key Points
• Triamcinolone is superior to dexamethasone for epidural treatment of severe lumbar radiculopathy.

• For mild to moderate pain, dexamethasone could be equally effective.

• Dexamethasone reduces pain caused by disc herniation much better than it does to pain caused by fixed stenotic spinal lesions. "


FWIW, my sense is that the particulates do work a bit longer, but i really dont think you can say dex is better for a HNP and particulates are better for stenosis. we are not there yet.

i still am leary about particulates anywhere in the neck, but i wouldnt fault someone for using it in a CESI.

pmrmd, any worry that the dex may clump the kenalog when you mix them?
 
pmrmd said:
It doesn’t in the syringe. Been doing both for over 10 years now.
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Need to review under microscope for particulate size.
www.ncbi.nlm.nih.gov

Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids - PubMed

We present a case of quadriparesis and brainstem herniation after selective cervical transforaminal block. We propose a potential role for corticosteroid particulate embolus during unintended intra-arterial injection as a potential mechanism.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

https://watermark.silverchair.com/9-2-227.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAnQwggJwBgkqhkiG9w0BBwagggJhMIICXQIBADCCAlYGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMozn8OpjiKIM0ULx_AgEQgIICJ4BP1-6S6kSmRLnsp_umF1m1vLO0EaYg18x9F9QLUaY-CO5zG3dvDqpJ3-iG9IPC9SUv7jojn0TQpw9RfER_eRZszYeS2zH4WNfFkIPqZ31waip8LyZYXAPFjqwHpyt_-gQkCWftIQD1zxQhNj3uaz89wk8Qr77D0u9eYkg2aZHfiZAOirl-J44ueCQt5yqIMkRF4yaoXWmJe3JKMfc5HphSlQ3f5bbYgtNoaH7J2zRGmJ2Zcu66TTRgk-od8o3SRHyDqkfG9V8p22Fg2sB95VBa2K4DM_bMdjkHm4kEzErM4nKnKkfL59ze6jBL3Am_Gxw8HM4hORa_nqTfcxeEjV_WDgt6KryMRUn3ImY3QYEYJ1-2kKjsye7o2ze-boafXustUaE0Pd0oEXazGi9fOv9bKxd6qsTrmn1uaFnPG_x7HXo-qwMgI4LR39NaC0gZmHDDl8Lh0I2_00SneP35-WPAcbNxos01PuG2pUQziSctHTG5O22Gjl4HBPyH-QXn_ZynSpEE_m0wUyUnrJoPkSZ8WnltAPQjkoe1a5Xxo5lcBuihufXKTTxIxPYuNjNgg2u5rpI-8wlJAsNvdaEwNQbnEsVLgfY-ORRW3tR4tTHPWvQB48LFpU-ry2HhcAdlWrCPWo_Sdj0xKFdrF-alS8YB4doKDgNIi_t9lOjrBPTnzJVFMG9DDDt_EQI73MN5EeDnwWofbBErFlSja-s2dYZ372hd5TOM
 
I believe the European study states most of our “moderate” radiculopathies will have equivalent responses to either steroid class. I tend to agree that severe radiculopathies improve with particulate steroids. I believe most guidelines in the USA, allow particulates after a FAILED trial of non-particulates injectates, assuming the patient accepts the additional risks as lobel mentions above.

Also, on a side note the AMA and CMS LCDs allow billing of steroids . It’s miminal reimbursement but may become worthwhile based on ones volume .
 
Let's take a step back to this CSF leak multi-level/TF blood patch, where's the data on that and who's paying for this?
 
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