CESIs

[swamprat]

How do you guys approach these?

Particulate or non particulate?

What gauge tuohy ? I find the 18 gauge or 20 gauge ones to be easier to use but I'm told are more dangerous. Maybe it is just bc I am used to them from LESIs etc.

Do you walk of lamina or just go right in ?

Whats the highest level you would target?

How do you do your LOR? Continuous or intermittent? Or something else?

Do you utilize the contralateral oblique ?

I'm nearing the end of my fellowship and we have faculty that do all different various techniques. I don't know which one I will adopt but I have an idea and since a lot of people trained and stayed at my institution im curious as to what you guys do to get outside perspective.

Thanks

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[No Pain All gain]

Interlaminar epidurals - doesn’t matter which tuohy. I use a 20 in the office and an 18 in the ASC. With good technique needle not important. You should be able to do with any needle. For cervical SCS I typically use a Coude needle and enter 7-1 or T1-2.

Depomedrol for Interlaminar injections. Dexamethasone for foraminal injections.

Always contralateral oblique for interlaminar injections, lumbar or cervical. Engage needle AP then switch to CLO for LOR. Continuous LOR.

Highest level I target is C6-7. If needed I use a perifix epidural catheter to reach higher levels.


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[pastafan]

Particulate or non particulate?
Depomedrol

What gauge tuohy ? I find the 18 gauge or 20 gauge ones to be easier to use but I'm told are more dangerous. Maybe it is just bc I am used to them from LESIs etc.
20 gauge. Stick the cord or put meds in wrong place and needle size is no longer so important.

Do you walk of lamina or just go right in ?
Head for target. Place needle AP then switch to CLO.

Whats the highest level you would target?
C7-T1

How do you do your LOR? Continuous or intermittent? Or something else?
Continuous with LOR syringe

Do you utilize the contralateral oblique ?
Best thing to ever happen to CESI technique evolution.

 

[lobelsteve]

Going above C7-T1 is asking for trouble.
Steroid: dex=celestone=depo=kenalog (per the literature, YMMV)
LOR: no.
CLO: yes.
25g 3.5" Touch lamina of T1, walk superiorly under AP and turn bent tip en pointe. Go CLO and advance to behind CLO pedicle line and inject contrast to show posterior to epidural space. Advance 1mm at a time and add contrast until you can see epidural flow. Inject cocktail of choice. 2cc NSS, 1cc 6mg Celestone (or 4-6mg dex).

 

[painfree23]

Question about the CLO..I never understood what u are contralateral to if ur aiming straight down on AP. The papers say anywhere from 40-50 degrees oblique...but depending on how much u oblique within that range ur needle tip will change drastically.

 

[pmrmd]

Paramedian at C7-T1. 25g spinal needle with tubing. Steve and I have the same technique it seems. CLO at 45-50 degrees to see the ipsilateral lamina and then the epidural space is at the posterior foraminal line.

 

[Ducttape]

paramedian approach, usually patients left side, 99% of the time C7T1. rest of time it is T1-T2. 20 gauge Touhy. advance under CLO targetting the ventral margin of the ventral interlaminar line using CLO with mixture of saline and contrast. usually 45 degrees. finish off with AP image and a Diet Dew chaser.

4 cc total volume, 80 mg depo + PF NS. for the patient, not me.

 

[Ligament]

Going above C7-T1 is asking for trouble.
Steroid: dex=celestone=depo=kenalog (per the literature, YMMV)
LOR: no.
CLO: yes.
25g 3.5" Touch lamina of T1, walk superiorly under AP and turn bent tip en pointe. Go CLO and advance to behind CLO pedicle line and inject contrast to show posterior to epidural space. Advance 1mm at a time and add contrast until you can see epidural flow. Inject cocktail of choice. 2cc NSS, 1cc 6mg Celestone (or 4-6mg dex).

I basically do this as well with a 25ga 3.5" touhy. Always at T1-T2. I use dex.

 

[NJPAIN]

paramedian approach, usually patients left side, 99% of the time C7T1. rest of time it is T1-T2. 20 gauge Touhy. advance under CLO targetting the ventral margin of the ventral interlaminar line using CLO with mixture of saline and contrast. usually 45 degrees. finish off with AP image and a Diet Dew chaser.

4 cc total volume, 80 mg depo + PF NS. for the patient, not me.

I do this with the following differences:
- 18 ga Hustead needle. I’m a creature of habit and want to the variables to a minimum ( aka too old to change ).
- Dexamethasone
- I too go left paramedian usually from the left ( most comfortable for right handed proceduralist ). However, since I find that the contrast spread is then usually left sided I will usually go right paramedian If symptoms predominantly right sided.
- I attach short extension and 5ml syringe containing contrast. Give “puffs” of contrast as I approach VLL. In most cases can’t inject until LOR past VLL. Sometimes there is a bit of a mess of contrast along the lamina before the VLL but if I used LOR that is where I would be getting a false LOR.


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[Ferrismonk]

I'm a bit embarrassed to say this here, but in the interest of showing differing options, I still do 18G midline interlaminar LOR. Use contrast after LOR. Dex and saline. That was the way I was trained (well, we didn't use contrast in fellowship), although once I read up about the details, I plan on switching to CLO.

 

[244913]

Going above C7-T1 is asking for trouble.
Steroid: dex=celestone=depo=kenalog (per the literature, YMMV)
LOR: no.
CLO: yes.
25g 3.5" Touch lamina of T1, walk superiorly under AP and turn bent tip en pointe. Go CLO and advance to behind CLO pedicle line and inject contrast to show posterior to epidural space. Advance 1mm at a time and add contrast until you can see epidural flow. Inject cocktail of choice. 2cc NSS, 1cc 6mg Celestone (or 4-6mg dex).

In fellowship we did 18g interlaminar, touch lamina, walk off, LOR to air, contrast and depo+local

Now, I do 20 g with same technique, but LOR with CLO. Dex and saline nowadays.

Steve- when doing CLO I find if I come in slightly paramedian sometimes the needle tip can look more ventral on CLO. What angle of CLO do you use every time and how do you mitigate against this? Try to come in as midline as possible?

Thanks

 

[lobelsteve]

In fellowship we did 18g interlaminar, touch lamina, walk off, LOR to air, contrast and depo+local

Now, I do 20 g with same technique, but LOR with CLO. Dex and saline nowadays.

Steve- when doing CLO I find if I come in slightly paramedian sometimes the needle tip can look more ventral on CLO. What angle of CLO do you use every time and how do you mitigate against this? Try to come in as midline as possible?

Thanks

Never midline. Raphe exists in up to half patients and no LOR until IT. CLO angle depends on many things. Good articles on depth/angle/approach:
But I am usually 55 degrees to start and adjust until I can see those footballs clearly. If I am skiving too far left to right (for right arm symptoms) I will rotate up to 70 deg.

Optimal Angle of Contralateral Oblique View in Cervical Interlaminar Epidural Injection Depending on the Needle Tip Position. - PubMed - NCBI
Contralateral oblique view is superior to lateral view for interlaminar cervical and cervicothoracic epidural access. - PubMed - NCBI
Fluoroscopic Contralateral Oblique View in Interlaminar Interventions: A Technical Note | Pain Medicine | Oxford Academic
Reliability and Accuracy of MRI Laminar Angle Measurements to Determine Intra-Procedural Contralateral Oblique View Angle for Cervical or Thoracic Interlaminar Epidural Steroid Injections | Pain Medicine | Oxford Academic

 

[NJPAIN]

Never midline. Raphe exists in up to half patients and no LOR until IT. CLO angle depends on many things. Good articles on depth/angle/approach:
But I am usually 55 degrees to start and adjust until I can see those footballs clearly. If I am skiving too far left to right (for right arm symptoms) I will rotate up to 70 deg.

Optimal Angle of Contralateral Oblique View in Cervical Interlaminar Epidural Injection Depending on the Needle Tip Position. - PubMed - NCBI
Contralateral oblique view is superior to lateral view for interlaminar cervical and cervicothoracic epidural access. - PubMed - NCBI
Fluoroscopic Contralateral Oblique View in Interlaminar Interventions: A Technical Note | Pain Medicine | Oxford Academic
Reliability and Accuracy of MRI Laminar Angle Measurements to Determine Intra-Procedural Contralateral Oblique View Angle for Cervical or Thoracic Interlaminar Epidural Steroid Injections | Pain Medicine | Oxford Academic

Steve, when you are rotating up to 70 degrees what visual endpoint are you using to determine you final angle?



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[lobelsteve]

Steve, when you are rotating up to 70 degrees what visual endpoint are you using to determine you final angle?

ventral interlaminar line VILL. If you can't see it and have super c or work in a room where c arm can be brought in from left, then use 55 on CLO. Ie: c arm on right of prone patient, rotate over top



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