Contrast questions

[jwalker12]

Hope all is well. Had a few questions I could not find definitive answers to (probably because there are none) but was hoping for some guidance.

1.) Do some of you use Gadolinium for ESI's (CESI, TFESI, LESI) etc? If so what are your thoughts on case reports of inadvertent intrathecal injection and death?

2.) If someone has anaphylaxis to shellfish are you avoiding omnipaque or are you using a steroid prep?

Thanks!

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[Ferrismonk]

For ESI, I used to use gadolinium if allergy to iodine. Now my new facility just doesn't use contrast if allergy.

I was never too impressed by intrathecal gadolinium data (we're not injecting intrathecal anyway supposedly), but it's a real medico-legal risk I suppose. Even then, small amounts, low dose is fine intrathecal.

Either way, since I do majority TFESI now, thecal puncture is super super rare. If I'm doing a CESI on a person with iodine allergy, I revert back to my LOR days and use CLO to be extra safe. No contrast.

 

[Ducttape]

1. not using Gad. if absolutely necessary, and an ESI is not, I will do anaphylaxis prophylaxis prior to injection.
2. shellfish allergy =/= omnipaque allergy. use with impunity.


edit - cant remember the last time I did prophylaxis. maybe 3 years ago?

 

[BobBarker]

No gad ever.

 

[SommeRiver]

I've never used gadolinium.

LOR with air gives a nice pneumogram. You can test dose with lidocaine and use dexamethasone as well.

 

[Pain Applicant1]

Hope all is well. Had a few questions I could not find definitive answers to (probably because there are none) but was hoping for some guidance.

1.) Do some of you use Gadolinium for ESI's (CESI, TFESI, LESI) etc? If so what are your thoughts on case reports of inadvertent intrathecal injection and death?

2.) If someone has anaphylaxis to shellfish are you avoiding omnipaque or are you using a steroid prep?

Thanks!

Am I wrong??? The way I understand it is there is no correlation whatsoever between iodine-based dyes and a shellfish allergy. Any relationship is a fallacy. Those allergic to shellfish are allergic to the protein it contains. Has new research proved this to be wrong?

 

[deleted131481]

You are correct. Shellfish allergy has nothing to do with dye allergy.

Also many people who report iodine allergy but it's really betadine sensitivity - don't need to worry about.

While we're at it no one is truly allergic to iodine, assuming they had a thyroid at one point.

I never use gad for reasons above. I will use contrast still if IV dye was mild allergic reaction/hives and not anaphylaxis. I may pretreat with steroid or Benadryl. Or just skip the contrast as has been suggested.

FWIW I saw near catastrophic outcome from gad reaction - probably intrathecal. Most bad outcomes don't show up in the literature.

 

[GlowInTheDark]

Near-fatal event due to likely intrathecal gadolinium had thus inspired my intent to never use it. Thankfully I was entirely uninvolved in the case.

Here’s a good article perfecting appropriate for our discussion to digest:

Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review | Regional Anesthesia & Pain Medicine

 

[jwalker12]

Thank you so much for the info. So my patient who has anaphylaxis to shellfish should theoretically be ok with omnipaque and this is something most practioners would then use or would you do no contrast just LOR? This is for a CESI.

 

[pastafan]

https://pubs.rsna.org/doi/full/10.1148/rg.2015150033

It is now well established that there is no specific link between shellfish allergy and allergy to contrast agents; there is an increased risk of adverse reactions to contrast agents in patients with any history of allergy (27). The major allergens in shellfish are tropomyosins, which are unrelated to iodine. Iodine is an essential element with no potential to cause an allergic response. If a patient reports a history of iodine “allergy,” it is important to clarify if the prior reaction was directly related to an iodinated contrast agent. Patients with an allergy to shellfish should be counseled that this does not increase the risk for an adverse reaction to contrast agents any more than do other allergies.

 

[Ligament]

Am I wrong??? The way I understand it is there is no correlation whatsoever between iodine-based dyes and a shellfish allergy. Any relationship is a fallacy. Those allergic to shellfish are allergic to the protein it contains. Has new research proved this to be wrong?

You are not wrong. You are correct.

 

[Ligament]

You are correct. Shellfish allergy has nothing to do with dye allergy.

Also many people who report iodine allergy but it's really betadine sensitivity - don't need to worry about.

While we're at it no one is truly allergic to iodine, assuming they had a thyroid at one point.

I never use gad for reasons above. I will use contrast still if IV dye was mild allergic reaction/hives and not anaphylaxis. I may pretreat with steroid or Benadryl. Or just skip the contrast as has been suggested.

FWIW I saw near catastrophic outcome from gad reaction - probably intrathecal. Most bad outcomes don't show up in the literature.

What reaction did you witness? sounds terrible. I used to use Gad whenever there was standard contrast allergy but have stopped using Gad due to reports of these IT reactions.

 

[callmeanesthesia]

Soapbox issue for me with patients. That and people with “lidocaine allergy” because it made their heart race at the dentist. (And don’t even get me started on people with an “epinephrine allergy”, or the nurses who unquestioningly added that to their chart)
Shellfish allergy is to the protein in the animal (usually crustaceans, not mollusks). Iodine “allergy” is almost always an anaphylactoid reaction triggered by a bolus of iodinated contrast from a CT scan. Anaphylactic reaction is IgE- mediated - a tiny amount of allergen triggers a hugely amplified effect leading to massive degranulation of mast cells. In anaphylactoid reactions an irritant directly triggers mast cell degranulation. It’s more dose-dependent.
always take a detailed history, and you can almost always use contrast. One today told me she had an iodine allergy and it made her throat close up. On further questioning though, it was during an MRI so must have been Gadolinium. Warned her about that, used iodine, monitored her a little extra time after, and she was fine.
I always counsel patients (and document) that even though they shouldn’t be at extra risk, allergic reaction is possible in anyone and we may have to administer epinephrine and send them to the hospital.
I’ve read the case reports of fatalities from Gad and it was enough to scare me off using it.

 

[deleted131481]

What reaction did you witness? sounds terrible. I used to use Gad whenever there was standard contrast allergy but have stopped using Gad due to reports of these IT reactions.

Wa not directly involved but from what I can remember recall there was fairly rapid deterioration in mental status and neuro deficits requiring intubation and ICU for several days.

 

[bpainless]

No gadolinium.

 

[avalon10]

If someone has an allergy to contrast/seafood/iodine- don’t bother with gad or pretreating or whatever. Just get good needle placement on flouro, save AP/lateral pics, negative aspiration, and inject without contrast.

 

[lobelsteve]

If someone has an allergy to contrast/seafood/iodine- don’t bother with gad or pretreating or whatever. Just get good needle placement on flouro, save AP/lateral pics, negative aspiration, and inject without contrast.

Nope

 

[avalon10]

Nope

Yup. Works very very well.

However I was referring to transforaminals, not interlaminars. I guess I’d use loss of resistance without contrast or with gadolinium for interlaminars. However I haven’t done one in years.
And I’d use gadolinium for true transforaminal cervical injections, although the picture sucks.

 

[Baron Samedi]

How would you do a TFESI without contrast? Just accept that its 50/50 whether or not you're there?

I've been using gad for TF since low risk of intrathecal. No contrast if allergy history for IL.

 

[MD87]

Yup. Works very very well.

However I was referring to transforaminals, not interlaminars. I guess I’d use loss of resistance without contrast or with gadolinium for interlaminars. However I haven’t done one in years.
And I’d use gadolinium for true transforaminal cervical injections, although the picture sucks.

Clarify why you wouldn't use contrast with TFESI but you might for an ILESI? If anything, seems like the opposite should be true given intrathecal risk for ILESI as well as having LOR to give you a fairly strong sense of being epidural or not.

 

[pastafan]

If someone has an allergy to contrast/seafood/iodine- don’t bother with gad or pretreating or whatever. Just get good needle placement on flouro, save AP/lateral pics, negative aspiration, and inject without contrast.

If seafood and iodine allergies equals no contrast might as well add drives an SUV. Makes as much sense.

 

[avalon10]

If seafood and iodine allergies equals no contrast might as well add drives an SUV. Makes as much sense.

Technically maybe you’re right, but it’s common practice out there not to use contrast if someone reports those allergies, and people think it makes them allergic to contrast, whether they’re right or not, so I’m not gonna use it.
And who knows what the allergy is? Maybe the patients mother had a true allergic reaction to contrast and told the patient to avoid seafood? Who knows? Why take even the slightest chance?

 

[MD87]

Technically maybe you’re right, but it’s common practice out there not to use contrast if someone reports those allergies, and people think it makes them allergic to contrast, whether they’re right or not, so I’m not gonna use it.
And who knows what the allergy is? Maybe the patients mother had a true allergic reaction to contrast and told the patient to avoid seafood? Who knows? Why take even the slightest chance?

With that line of reasoning you could argue that if someone has an allergy to strawberries you shouldn’t use contrast either... I have just educated patients that the iodine/shellfish thing had been thoroughly disproven and then they are OK with it. Takes an extra 30 seconds of discussion.

 

[avalon10]

With that line of reasoning you could argue that if someone has an allergy to strawberries you shouldn’t use contrast either... I have just educated patients that the iodine/shellfish thing had been thoroughly disproven and then they are OK with it. Takes an extra 30 seconds of discussion.

People’s beliefs about stuff like that don’t change overnight because some study somewhere proved something. If there’s any problem during the procedure, if the patient vasovagals or has a tummy ache the next day or whatever, some neighbor might tell them that the doctor shouldn’t have used contrast since they’re allergic to seafood or whatever, then they’ll think poorly of you.

You do what you want, I’ll do what I want, but I’m not gonna waste my breath “educating” the patient on something that there’s mixed opinions out there about when I can just as easily do the injection without contrast.

 

[callmeanesthesia]

Technically maybe you’re right, but it’s common practice out there not to use contrast if someone reports those allergies, and people think it makes them allergic to contrast, whether they’re right or not, so I’m not gonna use it.
And who knows what the allergy is? Maybe the patients mother had a true allergic reaction to contrast and told the patient to avoid seafood? Who knows? Why take even the slightest chance?

Sounds like you don’t want to take the time to talk to your patients. We use contrast to ensure the injection is accurately delivered. MBB, sure, easy to leave out the contrast if there’s even a shadow of a doubt of an allergy. CESI, you are asking for trouble. Do you just go room to room with your patients already under IV sedation?

 

[SommeRiver]

I use contrast on 100% of pts who describe iodine or shellfish allergies, and when I see them list that as an allergy I actually ignore it outright.

The patient won't get an invite to my house for a low country boil, but they're perfectly fine to get an injection with contrast and don't need all the other BS like Benadryl or SoluMedrol.

Ludicrous discussion IMO.

 

[avalon10]

Sounds like you don’t want to take the time to talk to your patients. We use contrast to ensure the injection is accurately delivered. MBB, sure, easy to leave out the contrast if there’s even a shadow of a doubt of an allergy. CESI, you are asking for trouble. Do you just go room to room with your patients already under IV sedation?

1. Not sure how else to explain it to you, but it has nothing to do with talking to patients.
2. 99.9.% of my injections are without sedation.
3. Why would you use contrast for a MBB?!? Makes no sense. Are you just trying to rule out vascular flow? Do you have that little confidence in your own abilities?? I could have guessed from your posts that you’re anesthesia even before I saw your username.

 

[avalon10]

Haha...You get worse and worse each time you post.

Whatever dude. From your posts it sounds like you don’t know what you’re talking about at all.

 

[SommeRiver]

Whatever dude. From your posts it sounds like you don’t know what you’re talking about at all.

No lie...I am pretty dumb.

 

[callmeanesthesia]

1. Not sure how else to explain it to you, but it has nothing to do with talking to patients.
2. 99.9.% of my injections are without sedation.
3. Why would you use contrast for a MBB?!? Makes no sense. Are you just trying to rule out vascular flow? Do you have that little confidence in your own abilities??

Unless you use nothing put PF dex for your epidurals you are taking a risk. Ok, let’s put it this way: if you accidentally inject intrathecally and cause arachnoiditis, how well do you think that will stand up in court when it comes out that you didn’t safely verify the location of the injectate because the patient hates shrimp so they wrote it down as an allergy?
Regarding contrast for MBB, 1. You’d be surprised how often you get vascular flow with negative aspiration, and little contrast remaining at the site, or flow spreading totally away from the nerve. 2. The Medicare LCD for my area seems to state contrast is required for MBB or facet joint injection.

 

[MD87]

People’s beliefs about stuff like that don’t change overnight because some study somewhere proved something. If there’s any problem during the procedure, if the patient vasovagals or has a tummy ache the next day or whatever, some neighbor might tell them that the doctor shouldn’t have used contrast since they’re allergic to seafood or whatever, then they’ll think poorly of you.

You do what you want, I’ll do what I want, but I’m not gonna waste my breath “educating” the patient on something that there’s mixed opinions out there about when I can just as easily do the injection without contrast.

I don’t mean this to be confrontational, so please don’t take it to be. I’m just really not sure why you would consider it a waste of time educating a patient. That’s part of the job. The only people who still think there is a connection between contrast and shellfish are people who aren’t up on the latest literature, which isn’t even that new. It’s not a controversial idea at this point.

As far as patient opinions, I don’t disagree with you, but I don’t think skipping contrast saves you from it. If you don’t use contrast and it doesn’t work or “made me worse” they can say it might not have been in the right spot, etc.

 

[avalon10]

I don’t mean this to be confrontational, so please don’t take it to be. I’m just really not sure why you would consider it a waste of time educating a patient. That’s part of the job. The only people who still think there is a connection between contrast and shellfish are people who aren’t up on the latest literature, which isn’t even that new. It’s not a controversial idea at this point.

As far as patient opinions, I don’t disagree with you, but I don’t think skipping contrast saves you from it. If you don’t use contrast and it doesn’t work or “made me worse” they can say it might not have been in the right spot, etc.

Did you read my posts above?!? The answer to your question is there.

 

[avalon10]

Unless you use nothing put PF dex for your epidurals you are taking a risk. Ok, let’s put it this way: if you accidentally inject intrathecally and cause arachnoiditis, how well do you think that will stand up in court when it comes out that you didn’t safely verify the location of the injectate because the patient hates shrimp so they wrote it down as an allergy?
Regarding contrast for MBB, 1. You’d be surprised how often you get vascular flow with negative aspiration, and little contrast remaining at the site, or flow spreading totally away from the nerve. 2. The Medicare LCD for my area seems to state contrast is required for MBB or facet joint injection.

1. Again, sounds to me like you don’t have confidence in your abilities.
2. I have never heard of ANYONE using contrast for a MBB. It’s laughable. It’s basically a soft tissue injection onto bone. Do you use contrast for trigger point injections?!? Flu shots?!?

 

[avalon10]

One lesson from this discussion is that there is more than one way to skin a cat. If you work in different areas and with different people, you’ll see a million ways to do things, and none of them are “wrong”. People do epidurals different ways, facets differently, etc. I think generally people think that the way they trained is the “right” way. Some people on this forum (such as sommeriver and lobelsteve) think that THEY know the “right” way to do everything and that everyone else is wrong. The real world doesn’t work like that.

However, using contrast for MBB is just ridiculous.

 

[SommeRiver]

One lesson from this discussion is that there is more than one way to skin a cat. If you work in different areas and with different people, you’ll see a million ways to do things, and none of them are “wrong”. People do epidurals different ways, facets differently, etc. I think generally people think that the way they trained is the “right” way. Some people on this forum (such as sommeriver and lobelsteve) think that THEY know the “right” way to do everything and that everyone else is wrong. The real world doesn’t work like that.
However, using contrast for MBB is just ridiculous.

Risk to the pt - That's the most important aspect and you don't seem to understand that.

 

[callmeanesthesia]

One lesson from this discussion is that there is more than one way to skin a cat. If you work in different areas and with different people, you’ll see a million ways to do things, and none of them are “wrong”. People do epidurals different ways, facets differently, etc. I think generally people think that the way they trained is the “right” way. Some people on this forum (such as sommeriver and lobelsteve) think that THEY know the “right” way to do everything and that everyone else is wrong. The real world doesn’t work like that.

However, using contrast for MBB is just ridiculous.

From my Medicare LCD:
“A hard (plain radiograph with conventional film or specialized paper) or digital copy image or images which adequately document the needle position and contrast medium flow (excluding RF ablations and those cases in which using contrast is contra-indicated, such as patients with documented contrast allergies), must be retained and submitted if requested.”
Contrast is pretty low risk, which gets back to the beginning of this thread. I’m not saying you’re doing it wrong if you don’t use it - I didn’t when I trained, but it’s not ridiculous to use.

 

[avalon10]

Risk to the pt - That's the most important aspect and you don't seem to understand that.

Thank you for proving my point exactly. That YOU think that you know what is the only right way to do things. I think your biggest problem isnt that you don’t know everything, but the fact that you aren’t aware that you don’t know everything.
Risk to the patient from what?? MBB without contrast?!?
Again, do you use contrast for trigger point injections? If not, and you know what you’re doing, you certainly don’t need it for MBB.
Of all the MBB I’ve done in my life, never ONCE have I thought I needed contrast. I guess you could argue it for an intra-articular facet injection, but I don’t do many of those. For those and facet aspirations, I use flouro to get to the joint then do the rest by feel.

 

[SommeRiver]

Thank you for proving my point exactly. That YOU think that you know what is the only right way to do things. I think your biggest problem isnt that you don’t know everything, but the fact that you aren’t aware that you don’t know everything.
Risk to the patient from what?? MBB without contrast?!?
Again, do you use contrast for trigger point injections? If not, and you know what you’re doing, you certainly don’t need it for MBB.
Of all the MBB I’ve done in my life, never ONCE have I thought I needed contrast. I guess you could argue it for an intra-articular facet injection, but I don’t do many of those. For those and facet aspirations, I use flouro to get to the joint then do the rest by feel.

MBB with contrast is unnecessary.

I've never seen that done, and that is not at all what I'm referring to...

 

[Orin]

MBB with contrast is unnecessary.

I've never seen that done, and that is not at all what I'm referring to...

Inadvertent Intrafacet Injection during Lumbar Interlaminar Epidural Steroid Injection: A Comparison of CT Fluoroscopic and Conventional Fluoroscopic Guidance - PubMed

Inadvertent intrafacet injection is identified during CT fluoroscopic-guided interlaminar epidural steroid injection at a rate that is 10-fold greater than the same procedure performed under conventional fluoroscopy guidance.

pubmed.ncbi.nlm.nih.gov

Maybe people should use contrast?

I'm kidding, I wouldn't bother with that.

I've seen gadolinium intrathecally put someone in an ICU for a few days. It's not pretty. It is a dose related phenomena and can be done safely if needed, but I would move forward with air epidurograms or pretreatment if necessary for true allergies.

 

[SommeRiver]

I have 100% confidence in my procedural skills - I do around 200 fluoro shots a month and have yet to hurt anyone.

Having said that - My previous career taught me confidence will get you in big trouble.

Skipping all the steps you were taught bc you think you're better at your job than all the dudes who established the protocols is how you F it all up.

 

[avalon10]

I am neither skipping steps nor do I think I’m better at my job.
Protocols vary. There is nothing universal, despite lobelsteve’s insistence that his way is always the right way.
Some people were taught to MBB with contrast, some without. Some people do cervical facets from posterior approach, some from lateral approach. So that’s what they think is the right way to do it.
Plus I constantly use my judgement and alter things as I see necessary, as I am sure everyone does to some extent.

 

[SommeRiver]

I am neither skipping steps nor do I think I’m better at my job.

You have repeatedly made statements in this thread about people not having confidence in their skills, and in another thread you mentioned ILESI as a procedure only done by those who lacks skills to do a TFESI.

There is a trend in your statements regarding your belief in your skills.

This is why research is so important - To protect pts from ppl who merely trust their skills rather than adhere to best practice guidelines (SIS for example).

The following screenshot is an indictment on you as a physician bc the iodine and shellfish thing was disproven a long time ago, and not a debatable issue in 2020 (there are no "mixed opinions" about this).

You should use contrast as often as possible, and your "feel" is unreliable.

 

[avalon10]

I do think that the only people I see doing lumbar interlaminars out there are people who don’t know much about spine or aren’t high-volume injectionists. As I said, I see neurologists doing them who probably just learned them on the fly or in a weekend course or something. I don't see much use for them in spine, and I am struggling to think of a situation where I’d choose to do a lumbar interlaminar injection over another type of injection.

As far as contrast allergy, yes there are mixed opinions on it, and I won’t use Omnipaque etc on people who report allergies to seafood/iodine etc for the reasons that I listed above, despite what SIS or whoever says. And I certainly don’t need you telling me what I should or shouldn’t be doing.

 

[Orin]

I do think that the only people I see doing lumbar interlaminars out there are people who don’t know much about spine or aren’t high-volume injectionists.

I rarely do transforaminals because there aren't strong data showing benefit over interlaminars for chronic pain. In some cases, the risks do not justify the benefit as in the case of high cervicals, in which case a catheter threaded to the level is sufficient and safer.

I'm not in a model where high-volume is rewarded financially. I suspect when you take the financial part out of it, most TFESIs would become ILESIs.

 

[avalon10]

I wouldn’t switch to lumbar interlaminars from transforaminals if money were taken out of the equation. I think transforaminals are safer, easier, and much more effective.

 

[lobelsteve]

This thread pains me for the sole reason it violates a critical appraisal of all that is known via our literature.

 

[SommeRiver]

I do think that the only people I see doing lumbar interlaminars out there are people who don’t know much about spine or aren’t high-volume injectionists. As I said, I see neurologists doing them who probably just learned them on the fly or in a weekend course or something. I don't see much use for them in spine, and I am struggling to think of a situation where I’d choose to do a lumbar interlaminar injection over another type of injection.

As far as contrast allergy, yes there are mixed opinions on it, and I won’t use Omnipaque etc on people who report allergies to seafood/iodine etc for the reasons that I listed above, despite what SIS or whoever says. And I certainly don’t need you telling me what I should or shouldn’t be doing.

NM...

This is a waste of my time.

 

[Baron Samedi]

Furman actually discusses contrast for MBB. I don't use it personally but I see the merit.

 

[Taus]

Mbb with contrast- trained without. Didn’t use first few years in practice. Articles on vascular uptake rates (creating false negative response, I’m not worried about safety) and some insurance requiring it led me to change my practice. I was shocked how often the contrast did not cover the mb nerve despite textbook needle placement and bevel orientation. I don’t inject it live. Just a quick spot shot after .2-3cc injected per needle. Reposition/re-inject to ensure mb covered. If concern about allergy- I’m fine to skip it as it’s an efficacy, not safety issue.

epidural? Gets contrast. Much prefer pre-medicating over using gad. If I need to use gad it’s tfesi, not interlam. Not worth the risk of IT with gad. I’d be fine to do a lumbar interlam without contrast, not cervical.

tf vs interlam? I was probably 80 tf: 20 il in training and early practice. I’m probably around 50:50 now. One can argue the evidence and what they see clinically..... sometimes it just comes down to suboptimal result with first approach and 2nd esi is with the other. Exception for me is elderly with stenosis. It’s interlam every time. I got sick of having brief relief on bilat tf with dex. I much more consistently get a solid 3-6 months from interlam with depo. Also takes <1 min. Bilat tf with good medial flow in elderly with the usual significant disc collapse, facet hypertrophy, foraminal stenosis.... more time and discomfort for patient.

 

[SommeRiver]

Mbb with contrast- trained without. Didn’t use first few years in practice. Articles on vascular uptake rates (creating false negative response, I’m not worried about safety) and some insurance requiring it led me to change my practice. I was shocked how often the contrast did not cover the mb nerve despite textbook needle placement and bevel orientation. I don’t inject it live. Just a quick spot shot after .2-3cc injected per needle. Reposition/re-inject to ensure mb covered. If concern about allergy- I’m fine to skip it as it’s an efficacy, not safety issue.

epidural? Gets contrast. Much prefer pre-medicating over using gad. If I need to use gad it’s tfesi, not interlam. Not worth the risk of IT with gad. I’d be fine to do a lumbar interlam without contrast, not cervical.

tf vs interlam? I was probably 80 tf: 20 il in training and early practice. I’m probably around 50:50 now. One can argue the evidence and what they see clinically..... sometimes it just comes down to suboptimal result with first approach and 2nd esi is with the other. Exception for me is elderly with stenosis. It’s interlam every time. I got sick of having brief relief on bilat tf with dex. I much more consistently get a solid 3-6 months from interlam with depo. Also takes <1 min. Bilat tf with good medial flow in elderly with the usual significant disc collapse, facet hypertrophy, foraminal stenosis.... more time and discomfort for patient.

Last few months I've started doing lumbar ILESI a little more frequently.

80mg Depo and 3cc NS at L4-5 and you just dropped a bomb on that pt. Big person use 4cc saline and 80mg Depo.

Honestly, it is a rare situation I do that and it doesn't work, unlike TFESI with dexamethasone which has a failure rate of X.

No one complains of neuritis. People are surprised when I tell them I'm done (usually for TFESI too).