CESI, how high

Started by DOctorJay
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Dr. Ice said:
I’ll keep that in mind. I’ll remember next time not to make a joke on this forum cause apparently I’m dealing with a bunch of millennials like my wife or overly sensitive old people trying to be millennials. I never said one should “feel the force.”
I said with time and experience, one may not need to switch back and forth constantly. I brought up Star Wars as more of a joke about experience and time as advice for younger docs. Didn’t know the bots on here devoid of understanding quips were gonna take it sooo literally
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Rule 1: dont take the Sith lords name in vain.
 
lobelsteve said:
Long term relief from ESI is not a thing. 8-12 weeks max. The rest of the relief is not our shots, when they get it.
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Okay so we can agree to disagree on the relief. How about downsides? I’m truly trying to assess risks to see if I need to change my practice. Has there been any published reports of complications due solely to injecting severe central canal stenosis?
 
geauxg8rs said:
The central stenosis that needs surgery? The shot might help with the pain, but what happens when the stenosis progresses or the patient has a MVC and now is a quad. Some jury will blame you no doubt
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Who’s operating on my 89 year old with CAD? How about the 50yo nurse who was referred to me by the neurosurgeon who wants to do annual MRIs to monitor? If you can’t do a CESI then you can’t do stim. MBB likely not helpful since the CESI gave them 100% relief. What else can you offer?
 
oneforfighting said:
Okay so we can agree to disagree on the relief. How about downsides? I’m truly trying to assess risks to see if I need to change my practice. Has there been any published reports of complications due solely to injecting severe central canal stenosis?
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Just go 1 level below to avoid putting a volume of fluid where there is no space.
 
oneforfighting said:
Okay so we can agree to disagree on the relief. How about downsides? I’m truly trying to assess risks to see if I need to change my practice. Has there been any published reports of complications due solely to injecting severe central canal stenosis?
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I also inject moderately severe stenosis in cervical, severe in lumbar. Small volume, slow push. Have not had issues.

I had one patient who had lumbar ESI at an only moderately stenosed level, by another doc at hospital, had immediate severe leg pain, STAT MRI showed signal change at the stenotic area. Admitted, eventually recovered neurologically. Surgeons I work with have seen similar cases, like cauda equina after ESI. Hard to know what went wrong without being there.
 
RoloTomassi said:
I also inject moderately severe stenosis in cervical, severe in lumbar. Small volume, slow push. Have not had issues.

I had one patient who had lumbar ESI at an only moderately stenosed level, by another doc at hospital, had immediate severe leg pain, STAT MRI showed signal change at the stenotic area. Admitted, eventually recovered neurologically. Surgeons I work with have seen similar cases, like cauda equina after ESI. Hard to know what went wrong without being there.
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Thank you for your input.
I only hold off when I can’t see any csf on MRI. Although admittedly, I have injected even in those cases in the past.
I am more liberal with lumbar spinal stenosis but have found more fleeting relief than in cervical. Thankfully no issues so far, knock on wood.
 
oneforfighting said:
Okay so we can agree to disagree on the relief. How about downsides? I’m truly trying to assess risks to see if I need to change my practice. Has there been any published reports of complications due solely to injecting severe central canal stenosis?
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Are you talking about injecting at the level of severe stenosis? In that case, no. I’m always going at C7-T1, which is rarely stenotic. If it is, I move down a level.
Severe stenosis above the site of injection, I don’t worry much. Really bad looking stenosis or any hint of loss of neurological function, and they get a surgical consult, but the local surgeons send me plenty of patients for injection with severe stenosis who are either stable and not imminently surgical, or too sick for surgery, with for CESI.
 
oneforfighting said:
Okay so we can agree to disagree on the relief. How about downsides? I’m truly trying to assess risks to see if I need to change my practice. Has there been any published reports of complications due solely to injecting severe central canal stenosis?
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I am not aware of specific case reports for complications injecting at the level of stenosis. I am also not aware of any evidence injecting at the site provides better relief.

However, I think we'd agree margin of error is significantly smaller with severe stenosis.

If I can see epidural fat I will inject mild to moderate stenosis in lumbar. As stated prior rarely do I see c7t1 stenosis, and if I do I'll move down a level.
 
C7-T1 only, I never do C6-7. If C7-T1 has limited epidural fat on T1, or if I can't seem to get in the space, I'll go down to T1-T2. I use 20G Touhy, CLO immediately after penetration on AP, moving back and forth between the two views at 45-55 degrees. When I get close to Spino-Laminar Line, use LOR syringe, if I don't feel it but reach that line, then straight contrast to see where I'm at.

Obviously we all hate CESI compared to other procedures, but it has to be done, and I feel comfortable and confident in doing the procedure. I just prefer to avoid over Lumbar Procedures or CMBB/CFJ/CRFA.
 
oneforfighting said:
Okay so we can agree to disagree on the relief. How about downsides? I’m truly trying to assess risks to see if I need to change my practice. Has there been any published reports of complications due solely to injecting severe central canal stenosis?
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theoretical increased risk for cord injury. there is less "space".

increased risk of severe pain with procedure. one of the main reasons patients complain of pain during injection is due to putting fluid in a place with little space.

generally speaking, i always go lower on the spine for someone with severe spinal stenosis.

there are multiple documented "case review study" of complications from epidural steroid injections. the rates however are pretty low.
 
Thanks all. Yes, I would not inject at level of severe stenosis but rather at a nicely open level below it (or a couple levels below). Sorry it was not clear. Glad to hear that many others do the same and have had few or none untoward effects.
 
I tend not to touch lamina first during CESI because I'm usually trying to stay midline. Spinous process isn't lamina. I insert just above spinous process of T1 and go CLO early. Advance in CLO. I will toggle back to AP if I've travelled a few cm just to make sure I'm still midline. Puff of contrast outside epidural space, advance, then puff of contrast in epidural space, inject.
 
Ferrismonk said:
I tend not to touch lamina first during CESI because I'm usually trying to stay midline. Spinous process isn't lamina. I insert just above spinous process of T1 and go CLO early. Advance in CLO. I will toggle back to AP if I've travelled a few cm just to make sure I'm still midline. Puff of contrast outside epidural space, advance, then puff of contrast in epidural space, inject.
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To each his own but why go through all the ligaments when you can come in paramedian and avoid them all, even if you like targeting midline?
 
Ferrismonk said:
I tend not to touch lamina first during CESI because I'm usually trying to stay midline. Spinous process isn't lamina. I insert just above spinous process of T1 and go CLO early. Advance in CLO. I will toggle back to AP if I've travelled a few cm just to make sure I'm still midline. Puff of contrast outside epidural space, advance, then puff of contrast in epidural space, inject.
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Type and Gauge of needle you use?
 
DOctorJay said:
Paramedian for me as well and I switch to CLO very quickly.
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Same. Paramedian. No os. When I feel beginning of any resistance I go clo. Advance to just shy of vill. Back to ap to confirm didn’t deviate medial/lateral. Back to clo and lor with a touch of contrast in the lor syringe. With how often false lor in c spine this minimizes syringe/lor exchanges for contrast. Once lor, then confirm proper spread under live.
 
gaspasser127 said:
Let’s say a patient has severe stenosis at C3-4. You see them in clinic and refer them to spine surgery. Surgeon says patient is too high risk for surgery, even for just a single level decompression. You send them for a second opinion who says the same thing. You do a C7-T1 CESI. 3 months later the patient gets in an MVC and is a quad.

You’re gonna get blamed? For what..?
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probably not gonna be found guilty, but you may be named and have to deal with a lawsuit.

in the above scenario, you shouldnt be doing the ESI anyway. not gonna work
 
Ligament said:
I do C7/T1 or T1/T2 ONLY.

Why take the risk going higher? There is zero proven benefit.

Also, why take the risk of running a catheter? You can shear epidural plexi and veins and cause a hematoma. I used to do this, but have rethought it.
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During fellowship I had attendings go higher - C5/6, and ocassionally higher. I never felt comfortable with that. Good to know that others do much lower!
 
20 gauge touhy, LOR, paramedian, CLO. I think the 25g quinke is interesting but I've never felt the need to switch. And in the event of something inadvertent happening a touhy with LOR is probably considered SOC.
 
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If you are uncomfortable going higher, send it to this guy in Atlanta
 
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