CESI, how high

[p1at0]

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I agree that the comparison is imperfect, but what part of the fluoroscopic guidance do you think makes it impossible to cause cord injury?

Quadriparesis and spinal cord stimulation: case report - PubMed

Revision of spinal cord stimulators is usually a safe procedure. However, placement of an electrode within the spinal cord during the revision process is a potential complication resulting in severe neurologic injury.

pubmed.ncbi.nlm.nih.gov

Another imperfect example, but an SCS electrode driven into the cord

Here is the key image from that case report:

 

[MitchLevi]

I agree that the comparison is imperfect, but what part of the fluoroscopic guidance do you think makes it impossible to cause cord injury?

Quadriparesis and spinal cord stimulation: case report - PubMed

Revision of spinal cord stimulators is usually a safe procedure. However, placement of an electrode within the spinal cord during the revision process is a potential complication resulting in severe neurologic injury.

pubmed.ncbi.nlm.nih.gov

Another imperfect example, but an SCS electrode driven into the cord

I did an horrific revision last week.

I implanted this pt maybe 2 yrs ago. Doing well until 3 weeks ago with acute and severe RLE pain.

She somehow fractured both leads and one was swirled around the anchor and completely outside the epidural space.

One lead was replaced completely and I struggled to replace that lead. Epidural scarring, adhesions, restriction...whatever.

Attempted to place a second new lead and spent 45 min being pushed into the gutters. Perfect posterior landing in the epidural space with approach angle textbook.

I quit.

Pt has one lead in place and it was impossible for the second lead to go.

That case you posted was a cervical revision. I'd be very, very careful about revising cervical leads if there's any resistance or restrictions at all when moving the leads.

Personally, I'd probably not do it.

 

[lobelsteve]

I did an horrific revision last week.

I implanted this pt maybe 2 yrs ago. Doing well until 3 weeks ago with acute and severe RLE pain.

She somehow fractured both leads and one was swirled around the anchor and completely outside the epidural space.

One lead was replaced completely and I struggled to replace that lead. Epidural scarring, adhesions, restriction...whatever.

Attempted to place a second new lead and spent 45 min being pushed into the gutters. Perfect posterior landing in the epidural space with approach angle textbook.

I quit.

Pt has one lead in place and it was impossible for the second lead to go.

That case you posted was a cervical revision. I'd be very, very careful about revising cervical leads if there's any resistance or restrictions at all when moving the leads.

Personally, I'd probably not do it.

Skills and knowledge are secondary to humility and frustration tolerance.
You won the day. She will get relief and walk. Better than any alternative.

 

[Ferrismonk]

I agree that the comparison is imperfect, but what part of the fluoroscopic guidance do you think makes it impossible to cause cord injury?

Quadriparesis and spinal cord stimulation: case report - PubMed

Revision of spinal cord stimulators is usually a safe procedure. However, placement of an electrode within the spinal cord during the revision process is a potential complication resulting in severe neurologic injury.

pubmed.ncbi.nlm.nih.gov

Another imperfect example, but an SCS electrode driven into the cord

Oof. Thanks for posting.

However... "This was performed under general anesthesia"

 

[au bon pain]

What are people's cutoff's for "just enough" room on MR to proceed with a CESI? Any wisp of epidural fat? A certain amount of fat? Canal diameter? Something else?

 

[RoloTomassi]

Considering I pretty much only do C7-T1:

At C7-T1, any wisp of epidural fat, mild to moderate stenosis ok if at least a little dorsal CSF so if LF is tenting I'm not pushing into cord.

Will do it if levels above are at most "mod to severe" stenosis to my eyes but not frankly severe if that makes sense.

 

[Tramadeezy]

Oof. Thanks for posting.

However... "This was performed under general anesthesia”

What type of anesthesia do you use for your cervical implant?

 

[Taus]

What are people's cutoff's for "just enough" room on MR to proceed with a CESI? Any wisp of epidural fat? A certain amount of fat? Canal diameter? Something else?

No objective cut off that I measure, but if it’s just a sliver of epidural fat on T1 image there’s always the level below. Also, it’s rare to have pathology causing central stenosis at c7t1….. if there is more than mild I just go T1-2. If significant stenosis above I’ll inject but keep volume low and inject really slow

 

[Ferrismonk]

What type of anesthesia do you use for your cervical implant?

This can be done under local only, but I usually will do mine under conscious sedation.

At the most, lead placement under conscious sedation and then you can drop them down with propofol for creating the pocket.

No one should ever be unresponsive when near the cord, if you insist, you need to do SSEP/MEP.

 

[lobelsteve]

What type of anesthesia do you use for your cervical implant?

I use general for most of my implants, but with a good Anesthesia team, you can sedate deeply so even if you cut outside the lines (of local), they don't jump off the table. But at that point, general is probably safer.

 

[MitchLevi]

General with neuromonitoring.

Never going back...

 

[callmeanesthesia]

I’m not saying one way is right or wrong but what’s the appeal of general, with or without the hassle of neuromonitoring?
I do most of my implants with moderate sedation (truly moderate - the patient can respond and answer questions). The pocket is the only part that gets uncomfortable for them. So what if they wiggle a little?

 

[Analgesia108]

For the last 3 months, have been using 27G 31/2 inch for all shoulders, knees, hips and MBB - patients love it !

 

[Ferrismonk]

For the last 3 months, have been using 27G 31/2 inch for all shoulders, knees, hips and MBB - patients love it !

Do you use an introducer? Quinke?

 

[Analgesia108]

Quinke tip - no introducer - but my MA tells me its about 50% more expensive than the 25G...

 

[bedrock]

Quinke tip - no introducer - but my MA tells me its about 50% more expensive than the 25G...

I’d just use the 25G. that is still tiny, and you won’t run into intermittent issues pushing particulate steroid compared to a 27G.

 

[Drd105]

I hate doing cervical epidurals. I never go above C7-T1, use CLO with 22G toughy, go ridiculously slow, it really slows down my day, and have a low threshold to abort or even go down to T1-T2 if any parasthesias or anything funky.

I feel like I wrote this myself…

 

[Dr. Ice]

I feel like I wrote this myself…

When are they getting paresthesias? When you push the meds? Or before? What other funkiness? I used to hate it, but clo has changed that for me.

 

[Drd105]

When are they getting paresthesias? When you push the meds? Or before? What other funkiness? I used to hate it, but clo has changed that for me.

Sorry- I meant specifically the part about “hate doing them, use CLO w/ 22, go ridic slow, slows down my day.” I haven’t had paresthesias unless pushing meds but even that is rare- it’s more the chest pressure people complain of. I agree- the use of CLO has kept me from losing sleep the night before a CESI which was life-changing. Recently I had a 450 lb guy and I aborted because the neck was so short and shoulders so high I couldn’t see anything on CLO due to the shoulders. I know a lot of people just do the whole thing in AP but I just couldn’t do it - I felt half-blind.

 

[deleted875186]

When are they getting paresthesias? When you push the meds? Or before? What other funkiness? I used to hate it, but clo has changed that for me.

Admittedly only one patient that had a parasthesia, at C7-T1, he had bilateral foraminal stenosis at this level but no canal stenosis or big disc herniation, but as my needle reached the posterior lamina he felt something in his upper arm, couldn’t figure it out as needle didn’t stray lateral or anything and was still posterior, but I just aborted and went T1-2.

I guess by funky I mean any blood, difficulty getting loss but appears in place on CLO, any question on contrast spread, I simply take the whole thing out and go a level below, never fuss around or try to back out and redirect etc.

 

[MitchLevi]

CLO with a 25g needle. Use Depo, the chest pressure is from dexamethasone.

Take the procedure seriously, but it shouldn't slow down your day at all. CESI shouldn't take any longer than anything else.

Paresthesia is just medication spread most likely.

 

[EtherBunny]

what level is your cut off for interlaminar CESI

I don't go above C6-7, always been told the ligament may not be fused above this level for safe CESI

interesting article here: "RESULTS: Our most common spinal level for injection was C5-6, followed closely by C6-7. Hundreds of injections were performed at spinal levels above C5-6 with the most cephalad level C2-3."

C7/T1, rarely t1/t2. CLO for visualization. Touhy with LOR but anatomical landmarks ultimately take precedence over LOR for safety (e.g., ventral interlaminar line). No need to go higher than C7/T1 in my opinion.

 

[Analgesia108]

What is a true CLO view? Cld anyone repost links to resources that may have been discussed/shared earlier? Thx

 

[lobelsteve]

What is a true CLO view? Cld anyone repost links to resources that may have been discussed/shared earlier? Thx

Search the forums and you will find a few threads discussing this and the supporting articles.

Contralateral Oblique View Is Superior to the Lateral View for Lumbar Epidural Access

Abstract. Objective . The purpose of this study was to perform a comparative analysis of the contralateral oblique (CLO) view and the lateral view for lumb

academic.oup.com

 

[NJPAIN]

On the topic of CLO, I typically use 50 deg CLO in the cervical spine and 45 degrees in the lumbar spine. All from true AP. However, at times the cortical margins of the lamina are not sharp. I’m wondering how many of you typically vary the degree of obliquity in order to crisp up those margins. I’ve hesitated to do so fearing the effect on the VLL as an accurate depth marker.

 

[MitchLevi]

On the topic of CLO, I typically use 50 deg CLO in the cervical spine and 45 degrees in the lumbar spine. All from true AP. However, at times the cortical margins of the lamina are not sharp. I’m wondering how many of you typically vary the degree of obliquity in order to crisp up those margins. I’ve hesitated to do so fearing the effect on the VLL as an accurate depth marker.

I use CLO to no specific degree. I go to 45 and adjust as needed. I want a clean lamina but don't always get it. I rarely go past 55, and the vast majority is 45-48ish for me.

If I can see inferior and superior lamina with enough clarity to visualize the anterior margin of both, I proceed.

Contrast is my friend, as is the LF.

 

[RoloTomassi]

Same as Mitch. RT just swings it over with muscle memory probably, and I use LOR when close. If I look deep and don't feel LF, I'll have her oblique a bit more, might spurt a little contrast before advancing.

 

[GoBeers]

On oblique view 45 degree lumbar or 55 degree cervical, Is there ever a chance that contrast can be seen medial to lamina even if needle is not through LF? Or contrast remain lateral to lamina even if needle is in actuality past the LF?

 

[RoloTomassi]

On oblique view 45 degree lumbar or 55 degree cervical, Is there ever a chance that contrast can be seen medial to lamina even if needle is not through LF?

If your needle is midline or crosses midline inadvertently, and you inject in LF and it crosses midline, it can look like your are anterior to lamina but not be, because you are basically doing an ILO not CLO. Won't be vertical dye flow though. Checking an AP can help.

Or contrast remain lateral to lamina even if needle is in actuality past the LF?

I can't think of this happening as it'll take the path of least resistance.

 

[Taus]

If your needle is midline or crosses midline inadvertently, and you inject in LF and it crosses midline, it can look like your are anterior to lamina but not be, because you are basically doing an ILO not CLO. Won't be vertical dye flow though. Checking an AP can help.


I can't think of this happening as it'll take the path of least resistance.

Nerve root flow exiting foramen can have that look. Often though with mixed appearing flow, part epidural on vill, part could be mistaken for dorsal/soft tissue as if the bevel is part through LF, part still out. Don’t advance. Check AP. Can be all epidural, with the dorsal contrast exiting the foramen. Once aware of this… check it out when doing lumbar tf. Check a clo after getting epidural flow in AP with some medial to pedicle some on exiting root

 

[deleted875186]

On the topic of CLO, I typically use 50 deg CLO in the cervical spine and 45 degrees in the lumbar spine. All from true AP. However, at times the cortical margins of the lamina are not sharp. I’m wondering how many of you typically vary the degree of obliquity in order to crisp up those margins. I’ve hesitated to do so fearing the effect on the VLL as an accurate depth marker.

I start at 45 in lumbar and 50 in cervical. Occasionally oblique more in cervical to 50-55 if it doesn’t look crisp, I use whichever onliquidity provides a better view.

 

[MD87]

I always do C7-T1, but maybe it's not any safer than higher levels after all?
Safety of Interlaminar Cervical Epidural Injections: Experience With 12,168 Procedures in a Single Pain Clinic
Schultz et al.
Pain Physician, 2022

 

[lobelsteve]

I always do C7-T1, but maybe it's not any safer than higher levels after all?
Safety of Interlaminar Cervical Epidural Injections: Experience With 12,168 Procedures in a Single Pain Clinic
Schultz et al.
Pain Physician, 2022

2 serious complications of cord stick. C4-5 and C7-T1.
Location is not as important as paying attention.

Technique adequate but not optimal. Going CLO before getting too far in is paramount. Touching the T1 lamina with the needle is MANDATORY before going CLO.

Overall, complications are rare and it took 12000 suboptimal procedures to stick the cord twice. Anything can happen at any time and this rate is still low. But every precaution must be taken. They did not.

 

[DOctorJay]

I always do C7-T1, but maybe it's not any safer than higher levels after all?
Safety of Interlaminar Cervical Epidural Injections: Experience With 12,168 Procedures in a Single Pain Clinic
Schultz et al.
Pain Physician, 2022

Yeah, that’s the study that I posted to start this thread.

 

[oneforfighting]

I've read on other posts that some folks deem it to be unsafe to inject in patients with severe central canal stenosis. However, I couldn't find any literature to support why or reports of complications because of this. I presume it is because there is a concern for spinal cord injury. As a note, I have injected in patients with severe CCS (some at multilevels) and patients have received excellent long term relief without adverse effects. Would appreciate any input on this from the group.

 

[lobelsteve]

I've read on other posts that some folks deem it to be unsafe to inject in patients with severe central canal stenosis. However, I couldn't find any literature to support why or reports of complications because of this. I presume it is because there is a concern for spinal cord injury. As a note, I have injected in patients with severe CCS (some at multilevels) and patients have received excellent long term relief without adverse effects. Would appreciate any input on this from the group.

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.

 

[geauxg8rs]

I've read on other posts that some folks deem it to be unsafe to inject in patients with severe central canal stenosis. However, I couldn't find any literature to support why or reports of complications because of this. I presume it is because there is a concern for spinal cord injury. As a note, I have injected in patients with severe CCS (some at multilevels) and patients have received excellent long term relief without adverse effects. Would appreciate any input on this from the group.

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

 

[gaspasser127]

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

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..?

 

[MD87]

Yeah, that’s the study that I posted to start this thread.

Gotcha. Didn’t see the initial post. Whoops! Thx

 

[MD87]

2 serious complications of cord stick. C4-5 and C7-T1.
Location is not as important as paying attention.

Technique adequate but not optimal. Going CLO before getting too far in is paramount. Touching the T1 lamina with the needle is MANDATORY before going CLO.

Overall, complications are rare and it took 12000 suboptimal procedures to stick the cord twice. Anything can happen at any time and this rate is still low. But every precaution must be taken. They did not.

I don’t agree with this. I never touch lamina intentionally. I just go to contralateral oblique very, very early, (an inch or less if someone frail) and I switch back-and-forth between AP and CLO frequently. This is basically the Furman technique. What does everyone else do? Am I the only one who does not touch bone first?

 

[Ligament]

I don’t agree with this. I never touch lamina intentionally. I just go to contralateral oblique very, very early, (an inch or less if someone frail) and I switch back-and-forth between AP and CLO frequently. This is basically the Furman technique. What does everyone else do? Am I the only one who does not touch bone first?

I do what you do, and do not touch bone first. However, I think I should start touching bone first to save time and radiation. Seems reasonable to do.

 

[MitchLevi]

I don't touch lamina first, but it IS faster to do it that way.

 

[deleted875186]

I don’t agree with this. I never touch lamina intentionally. I just go to contralateral oblique very, very early, (an inch or less if someone frail) and I switch back-and-forth between AP and CLO frequently. This is basically the Furman technique. What does everyone else do? Am I the only one who does not touch bone first?

I don’t typically touch lamina intentionally, I feel more confident just going in 3 cm in a normal sized human, go CLO, advance, if I need to advance a significant amount I will take a shot AP when past lamina to ensure I didn’t veer off, then back to CLO. I inject contrast live in CLO, then take a shot AP to see spread.

The other doc in my group does cervical ESI entirely AP …

 

[Dr. Ice]

I don’t agree with this. I never touch lamina intentionally. I just go to contralateral oblique very, very early, (an inch or less if someone frail) and I switch back-and-forth between AP and CLO frequently. This is basically the Furman technique. What does everyone else do? Am I the only one who does not touch bone first?

No you are not alone, this is how I was trained..by Furman, however, once you get confident enough, you don’t need to constantly switch and create more radiation. You will get a good sense of when you need to switch to oblique.

Some of it is like yoda trying to explain the force to Luke 😝

Just out of curiosity, all you guys that site the “Furman atlas” are you guys anesthesia or pmr trained? Just curious. As a co contributor to Furman’s atlas and pmr trained albeit through the “inferior” non-acgme route..

 

[lobelsteve]

For those relying on feel and the force. You are taking a risk for no benefit. Bone is your friend. Might want to review the dry needling and acupuncture cord stick data. There has never been a spinal cord between skin and lamina. It is a great way to set depth and prepare to go CLO.

 

[MD87]

For those relying on feel and the force. You are taking a risk for no benefit. Bone is your friend. Might want to review the dry needling and acupuncture cord stick data. There has never been a spinal cord between skin and lamina. It is a great way to set depth and prepare to go CLO.

SDN rarely makes me actually laugh out loud. “Feel and the force” did it for me though.

 

[Ligament]

No you are not alone, this is how I was trained..by Furman, however, once you get confident enough, you don’t need to constantly switch and create more radiation. You will get a good sense of when you need to switch to oblique.

Some of it is like yoda trying to explain the force to Luke 😝

Just out of curiosity, all you guys that site the “Furman atlas” are you guys anesthesia or pmr trained? Just curious. As a co contributor to Furman’s atlas and pmr trained albeit through the “inferior” non-acgme route..

I think Furman's atlas is best at documenting this technique.

However, in case you don't know, this technique was first described in the defunct ISIS journal by our own SDN member about 10 years ago (or so). He called it Puttlitz' line or something similar. This technique most likely was disseminated via this forum to the majority of pain docs worldwide, thanks to him.

Here is what i think is the first published case of the CLO technique

algosresearch.org used to be my personal favorite resource for pain procedure techniques.


Here is Dr. Puttlitz:

 

[soccrwz]

Touch os; faster and safer; less radiation, if you just go into the skin the needle can veer more medial or lateral

 

[Dr. Ice]

Puttlitz was a Furman fellow. We all trained the same

 

[Dr. Ice]

For those relying on feel and the force. You are taking a risk for no benefit. Bone is your friend. Might want to review the dry needling and acupuncture cord stick data. There has never been a spinal cord between skin and lamina. It is a great way to set depth and prepare to go CLO.

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

With regards to the os technique, I’ll keep it in mind. Been doing what I do for long enough without an issue, but of course always room to grow and learn..growing and learning is the Jedi way after all..