CSEIs with catheters?

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Timeoutofmind

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Are you guys doing these?

I trained in CTFESI, but I dont offer now really, due to risks associated, except in a very unusual circumstance.

So I am pretty much going at C7/T1. But sometimes I wonder if I would do better with some more cephalad meds.

What size needle/catheter? I really dont like putting some 17G/18G or whatever in someone's C spine, and it seems you need a bigger needle to get the catheter through. If you have a small needle/catheter combo, can you share the brand etc?

Thanks in advance.

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I don't think it is worth it. I have penetrated the dura many times with a caudal catheter.
 
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For C3-4, it is worth CESI first.
If partial response and not tolerating their PT, then C7-T1 with 17G Tuohy and Arrow theracath. Have not had to use it in 2 years.
 
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i had a few CESI that only responded with a catheter vs. without. the key here is that you have a greater choice of steroids to use vs. a TF approach.
we are talking about only a few catheter cases a year. maybe 3% . suggest you do some lumbar first before doing cervical or thoracic, always use fluoro and contrast, and IMHO there are increased risks for both bleeding and infection using a catheter, so i always completely gowned and gloved and had big drapes when i did catheter cases.
if increased risk for infection or bleeding (immunosuppressed, platelet problems etc) probably good idea to refuse doing the procedure. from a technical point of view i thought they were fun. amazing what you see sometimes with dye. sometimes perfect TF flow.
 
I'm not sure a cervical epidural catheter is any safer than a cervical transforaminal steroid injection with a blunt tip (as in epimed) needle. I used to think otherwise, but now not convinced. I don't do either any longer. Not worth it to me.
 
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For C3-4, it is worth CESI first.
If partial response and not tolerating their PT, then C7-T1 with 17G Tuohy and Arrow theracath. Have not had to use it in 2 years.
No data for efficacy or safety
 
We have this for the C5/6 level pathology:

Reg Anesth Pain Med. 2017 Jan/Feb;42(1):82-89. doi: 10.1097/AAP.0000000000000521.
A Prospective Randomized Comparative Trial of Targeted Steroid Injection Via Epidural Catheter Versus Standard C7-T1 Interlaminar Approach for the Treatment of Unilateral Cervical Radicular Pain.
McCormick ZL1, Nelson A, Bhave M, Zhukalin M, Kendall M, McCarthy RJ, Khan D, Nagpal G, Walega DR.
Author information

Abstract
BACKGROUND AND OBJECTIVES:
No study has compared cervical interlaminar epidural steroid injection (CIESI) with epidural catheter advancement to the side and level of pathology versus standard C7-T1 CIESI. This study investigated whether cervical radicular pain is more effectively treated by CIESI with a targeted epidural catheter versus a standard C7-T1 approach.

METHODS:
Prospective, randomized, single-blinded trial.

PRIMARY OUTCOME:
Numerical Rating Scale (NRS) pain at 1 month.

SECONDARY OUTCOMES:
Oswestry Neck Disability Index (ONDI), Pain Disability Index (PDI), McGill Pain Questionnaire (MPQ), Patient Global Impression of Change (PGIC), daily morphine equivalents (DME), and Medication Quantification Scale (MQS) III scores.

RESULTS:
Seventy-six participants with a median age of 48 years (IQR, 40-56 years), 59% female, with C4 (n = 2), C5 (n = 27), or C6 (n = 47) radicular pain were enrolled. At 1 month in the catheter and no catheter groups, respectively: 26 (72%, 95% confidence interval [CI], 57%-87%) and 23 (60%; 95% CI, 45%-75%) participants reported 50% or greater NRS reduction; 24 (67%; 95% CI, 52%-84%) and 23 (58%; 95% CI, 42%-73%) participants reported 30% or greater ONDI reduction. There were no group differences in median NRS, ONDI, PDI, MPQ, PGIC, DME, or MQSIII scores (P > 0.05). Intergroup differences were not observed at any follow-up interval.

CONCLUSIONS:
This trial showed no significant difference in clinical outcomes with CIESI using a targeted epidural catheter compared to a standard C7-T1 approach for the treatment of unilateral cervical radicular pain at the C5 or C6 level. Both techniques were associated with clinically meaningful improvement across outcome domains of pain, function, disability, and medication use. These effects persisted to 6-month follow-up.The study was registered at Clinical Trials.gov (NCT02095197).
 
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And this if you believe there is any validity to the concept of "molding, grafting, or formation of a nerve" (definition of the word neuroplasty) in the absence of prior cervical surgery surgery:

Pain Physician. 2016 Feb;19(2):39-48.
Randomized Controlled Study of Percutaneous Epidural Neuroplasty Using Racz Catheter and Epidural Steroid Injection in Cervical Disc Disease.
Ji GY, Oh CH, Won KS1, Han IB1, Ha Y2, Shin DA, Kim KN2.
Author information

Abstract
BACKGROUND:
The efficacy of lumbar percutaneous epidural neuroplasty (PEN) as a minimally invasive technique has been relatively well investigated, but the clinical effectiveness of cervical PEN (C-PEN) has yet to be established.

OBJECTIVE:
The purpose of this study was to compare clinical outcomes between C-PEN and cervical epidural steroid injection (C-ESI).

STUDY DESIGN:
Randomized control study.

SETTING:
University hospital center.

METHODS:
Eighty patients with neck pain from single level cervical disease with and without radiculopathy were included in this study. Patients were randomly assigned into 2 groups: C-PEN or C-ESI. Clinical outcomes were assessed according to Neck Disability Index (NDI) score and Visual Analog Scale (VAS) score for arm pain until 12 months after treatment.

RESULTS:
All C-PEN and C-ESI groups showed better NDI recovery and greater reduction in VAS score at postoperative 6 months (P < 0.001). The C-PEN group demonstrated better NDI score at postoperative 6 months than the C-ESI group (P = 0.014), while there were no differences at 2, 4, and 12 months. Additionally, the C-PEN group showed lower VAS scores at all follow-up intervals compared to the C-ESI group (P < 0.050). Symptom relief was sustained for a significantly longer duration in the C-PEN group than in the C-ESI group (23.4 vs. 20.5 weeks, P < 0.001).

LIMITATIONS:
The follow-up period was relatively short with a small sample size, and the grade of cervical disc disease, root compression, and disc degeneration grade were could not considered in this study.

CONCLUSIONS:
C-PEN was superior to C-ESI in terms of better NDI recovery (at 6 months) and greater reduction in VAS score (until 12 months) in treating single level cervical disc herniation. Better outcomes with C-PEN may have been achieved via a more localized selective block in the epidural space closer to the dorsal root ganglion and ventral aspect of the nerve root.
 
We have this for the C5/6 level pathology:

Reg Anesth Pain Med. 2017 Jan/Feb;42(1):82-89. doi: 10.1097/AAP.0000000000000521.
A Prospective Randomized Comparative Trial of Targeted Steroid Injection Via Epidural Catheter Versus Standard C7-T1 Interlaminar Approach for the Treatment of Unilateral Cervical Radicular Pain.
McCormick ZL1, Nelson A, Bhave M, Zhukalin M, Kendall M, McCarthy RJ, Khan D, Nagpal G, Walega DR.
Author information

Abstract
BACKGROUND AND OBJECTIVES:
No study has compared cervical interlaminar epidural steroid injection (CIESI) with epidural catheter advancement to the side and level of pathology versus standard C7-T1 CIESI. This study investigated whether cervical radicular pain is more effectively treated by CIESI with a targeted epidural catheter versus a standard C7-T1 approach.

METHODS:
Prospective, randomized, single-blinded trial.

PRIMARY OUTCOME:
Numerical Rating Scale (NRS) pain at 1 month.

SECONDARY OUTCOMES:
Oswestry Neck Disability Index (ONDI), Pain Disability Index (PDI), McGill Pain Questionnaire (MPQ), Patient Global Impression of Change (PGIC), daily morphine equivalents (DME), and Medication Quantification Scale (MQS) III scores.

RESULTS:
Seventy-six participants with a median age of 48 years (IQR, 40-56 years), 59% female, with C4 (n = 2), C5 (n = 27), or C6 (n = 47) radicular pain were enrolled. At 1 month in the catheter and no catheter groups, respectively: 26 (72%, 95% confidence interval [CI], 57%-87%) and 23 (60%; 95% CI, 45%-75%) participants reported 50% or greater NRS reduction; 24 (67%; 95% CI, 52%-84%) and 23 (58%; 95% CI, 42%-73%) participants reported 30% or greater ONDI reduction. There were no group differences in median NRS, ONDI, PDI, MPQ, PGIC, DME, or MQSIII scores (P > 0.05). Intergroup differences were not observed at any follow-up interval.

CONCLUSIONS:
This trial showed no significant difference in clinical outcomes with CIESI using a targeted epidural catheter compared to a standard C7-T1 approach for the treatment of unilateral cervical radicular pain at the C5 or C6 level. Both techniques were associated with clinically meaningful improvement across outcome domains of pain, function, disability, and medication use. These effects persisted to 6-month follow-up.The study was registered at Clinical Trials.gov (NCT02095197).

Catheter aside.... if anything else this adds to the otherwise limited evidence for cesi in general, especially the decent 6 month data


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We have this for the C5/6 level pathology:

Reg Anesth Pain Med. 2017 Jan/Feb;42(1):82-89. doi: 10.1097/AAP.0000000000000521.
A Prospective Randomized Comparative Trial of Targeted Steroid Injection Via Epidural Catheter Versus Standard C7-T1 Interlaminar Approach for the Treatment of Unilateral Cervical Radicular Pain.
McCormick ZL1, Nelson A, Bhave M, Zhukalin M, Kendall M, McCarthy RJ, Khan D, Nagpal G, Walega DR.
Author information

Abstract
BACKGROUND AND OBJECTIVES:
No study has compared cervical interlaminar epidural steroid injection (CIESI) with epidural catheter advancement to the side and level of pathology versus standard C7-T1 CIESI. This study investigated whether cervical radicular pain is more effectively treated by CIESI with a targeted epidural catheter versus a standard C7-T1 approach.

METHODS:
Prospective, randomized, single-blinded trial.

PRIMARY OUTCOME:
Numerical Rating Scale (NRS) pain at 1 month.

SECONDARY OUTCOMES:
Oswestry Neck Disability Index (ONDI), Pain Disability Index (PDI), McGill Pain Questionnaire (MPQ), Patient Global Impression of Change (PGIC), daily morphine equivalents (DME), and Medication Quantification Scale (MQS) III scores.

RESULTS:
Seventy-six participants with a median age of 48 years (IQR, 40-56 years), 59% female, with C4 (n = 2), C5 (n = 27), or C6 (n = 47) radicular pain were enrolled. At 1 month in the catheter and no catheter groups, respectively: 26 (72%, 95% confidence interval [CI], 57%-87%) and 23 (60%; 95% CI, 45%-75%) participants reported 50% or greater NRS reduction; 24 (67%; 95% CI, 52%-84%) and 23 (58%; 95% CI, 42%-73%) participants reported 30% or greater ONDI reduction. There were no group differences in median NRS, ONDI, PDI, MPQ, PGIC, DME, or MQSIII scores (P > 0.05). Intergroup differences were not observed at any follow-up interval.

CONCLUSIONS:
This trial showed no significant difference in clinical outcomes with CIESI using a targeted epidural catheter compared to a standard C7-T1 approach for the treatment of unilateral cervical radicular pain at the C5 or C6 level. Both techniques were associated with clinically meaningful improvement across outcome domains of pain, function, disability, and medication use. These effects persisted to 6-month follow-up.The study was registered at Clinical Trials.gov (NCT02095197).
using a catheter to get C6 is sort of dumb if you are comparing it with a C7T1 IL. C6 is too close to C7T1 to make a difference. i think...
 
The point is, it doesn't make a difference regardless where in the cervical spine your target lies. 3cc of fluid has been demonstrated to fill the entire cervical spine

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The point is, it doesn't make a difference regardless where in the cervical spine your target lies. 3cc of fluid has been demonstrated to fill the entire cervical spine

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you can infer that since 3 cc of fluid has been demonstrated to fill the entire (normal) C spine = no difference where you place the steroid, but there are 2 problems.
1. we never work on normal spines.
2. it is still an inference not a proof.
typically a patient has a herniated disc well cephalad (say C23 or C34) and when dye is injected at C7T1 the dye does not make it up to C23. i have seen dye go completely caudal many times from C7T1. place a catheter up to C3, usually but not always dye flows to the correct spot. have i proved anything? no. but 20 years of doing these i know that catheters sometimes work when C7T1 IL do not. are they worth doing? if not one else where you work does them maybe not - after all, we could probably get rid of all ESI on everyone and i doubt we would get a million people non violently protesting their rights to have an ESI :). sometimes i think the world would be better off if we spent all this procedure money on TV commercials showing the bad outcomes that sometimes result from back surgery. eventually no one would want back surgery anymore and there would then be no need for ESIs.
 
Here are a few links- both show no relationship to volume injected and level with the average ascent 3.88 levels when injected at the C7/T1 level (first study). The second study link is to the full article- fascinating fluoroscopic reconstructed images of the contrast location once injected.
https://www.ncbi.nlm.nih.gov/pubmed/16778691
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089107/
My main concern with catheters is I have seen one case resulting in quadriplegia due to the catheter being passed bilaterally in the lateral gutter, sheering off the veins in the canal, resulting in immediate hematoma and paralysis that was only partially resolved after surgical decompression. The litigation that resulted was an easy win for the plaintiff's lawyer- never went to court and was settled out of court.
 
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Sorry to revisit this topic again but what do you guys do for higher level cervical HNP, Spinal stenosis or radicular pain from bone spur.

I have a patient with a c3-c4 uncovertebral joint spurring and small hnp irritating an exiting nerve. Patient still very functional and only has mild to moderate pain and numbness. Previous doctor recommended tfesi but mutual friend said to see me first. I told her I would attempt snrb but not tfesi and safer to attempt C7-T1 ILESI. I injected 2cc of contrast to see spread at c7-t1 and it travelled maybe 2 level cephalad and 4 levels caudal despite my needle being slightly angled. I gave 5cc of treatment mixture and patient had no relief for any period of time.

I was considering a catheter up until c5-c6 but after reading this thread I’m not so sure.

So are the only options for high cervical pathology who fail conservative management are surgery or nothing?
 
Sorry to revisit this topic again but what do you guys do for higher level cervical HNP, Spinal stenosis or radicular pain from bone spur.

I have a patient with a c3-c4 uncovertebral joint spurring and small hnp irritating an exiting nerve. Patient still very functional and only has mild to moderate pain and numbness. Previous doctor recommended tfesi but mutual friend said to see me first. I told her I would attempt snrb but not tfesi and safer to attempt C7-T1 ILESI. I injected 2cc of contrast to see spread at c7-t1 and it travelled maybe 2 level cephalad and 4 levels caudal despite my needle being slightly angled. I gave 5cc of treatment mixture and patient had no relief for any period of time.

I was considering a catheter up until c5-c6 but after reading this thread I’m not so sure.

So are the only options for high cervical pathology who fail conservative management are surgery or nothing?
No better, send for surgical consult.
Some better, repeat.
All better, no need to repeat.
 
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Sorry to revisit this topic again but what do you guys do for higher level cervical HNP, Spinal stenosis or radicular pain from bone spur.

I have a patient with a c3-c4 uncovertebral joint spurring and small hnp irritating an exiting nerve. Patient still very functional and only has mild to moderate pain and numbness. Previous doctor recommended tfesi but mutual friend said to see me first. I told her I would attempt snrb but not tfesi and safer to attempt C7-T1 ILESI. I injected 2cc of contrast to see spread at c7-t1 and it travelled maybe 2 level cephalad and 4 levels caudal despite my needle being slightly angled. I gave 5cc of treatment mixture and patient had no relief for any period of time.

I was considering a catheter up until c5-c6 but after reading this thread I’m not so sure.

So are the only options for high cervical pathology who fail conservative management are surgery or nothing?
See my posts on transfacet approach in this thread:

 
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I need help understanding this thread.

Some are saying they would have considered a catheter, but because of this thread, are not considering it.

Why?

First - BobBarker mentioned he has had dural puncture with caudal catheters. Well don't use a styleted stiff catheter. Use the soft tip, flimsy regular epidural catheter.

Two - you all are comfortable sliding a very stiff and big stimulator lead - why are you worried about a flimsy soft tip epidural catheter?

Third - are you worried about the large bore needle? Why? We have had many discussion about people using very small gauge, sharp cutting needles in a CLO approach. I applaud the skill and bravery for those who do this. That takes a lot of care and skill. Good job. But why would discussion of this make people more nervous of a larger bore, non cutting tip needle specifically designed to enter the epidural space? Larger bore = safer entry (because of better visualization, AND much better tactile feel, AND much better resistance against ligament, and designed not to puncture dura easily).

I'll use a catheter if the disc is large and higher than C5. Do we really think that the dura is somehow less DURA-ble in the cervical spine? These catheters were designed to be placed into the epidural space. I don't think they puncture dura all by themselves that often.
 
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See my posts on transfacet approach in this thread:

Agreed, would just do facet injection and call it a "transfacet approach TFESI"
 
No better, send for surgical consult.
Some better, repeat.
All better, no need to repeat.

wouldnt send for surgery...C3 radic...does he actually have neuropathic pain in that dermatome as his predominant pain complaint?...pretty unusual

live with it with HEP, traction, lifestyle modifications, low dose qHS topamax as good for headaches and neuropathic pain both if he wants

explain the favorable natural history of radicular pain

if he was really miserable i would do MBB as his axial upper C spine complaints are likely facetogenic
 
wouldnt send for surgery...C3 radic...does he actually have neuropathic pain in that dermatome as his predominant pain complaint?...pretty unusual

live with it with HEP, traction, lifestyle modifications, low dose qHS topamax as good for headaches and neuropathic pain both if he wants

explain the favorable natural history of radicular pain

if he was really miserable i would do MBB as his axial upper C spine complaints are likely facetogenic
Surgery not indicated. I just throw out generic algorithm. Agree with MBB.

Per OP: I have a patient with a c3-c4 uncovertebral joint spurring and small hnp irritating an exiting nerve. Patient still very functional and only has mild to moderate pain and numbness.

How about sprinkle in a wee bit if Lyrica and try home stretches and traction.
 
wouldnt send for surgery...C3 radic...does he actually have neuropathic pain in that dermatome as his predominant pain complaint?...pretty unusual

live with it with HEP, traction, lifestyle modifications, low dose qHS topamax as good for headaches and neuropathic pain both if he wants

explain the favorable natural history of radicular pain

if he was really miserable i would do MBB as his axial upper C spine complaints are likely facetogenic
Agree 100%. Probably actually facet pain, but who knows. Try a facet injection or MBB.
 
I need help understanding this thread.

Some are saying they would have considered a catheter, but because of this thread, are not considering it.

Why?

First - BobBarker mentioned he has had dural puncture with caudal catheters. Well don't use a styleted stiff catheter. Use the soft tip, flimsy regular epidural catheter.

Two - you all are comfortable sliding a very stiff and big stimulator lead - why are you worried about a flimsy soft tip epidural catheter?

Third - are you worried about the large bore needle? Why? We have had many discussion about people using very small gauge, sharp cutting needles in a CLO approach. I applaud the skill and bravery for those who do this. That takes a lot of care and skill. Good job. But why would discussion of this make people more nervous of a larger bore, non cutting tip needle specifically designed to enter the epidural space? Larger bore = safer entry (because of better visualization, AND much better tactile feel, AND much better resistance against ligament, and designed not to puncture dura easily).

I'll use a catheter if the disc is large and higher than C5. Do we really think that the dura is somehow less DURA-ble in the cervical spine? These catheters were designed to be placed into the epidural space. I don't think they puncture dura all by themselves that often.
Agree with you. I do most of my CESI with catheters. 18G touhy needle and a very soft 20G catheter. It does have a soft curved stylet but stylet is directed dorsally so as it advances superiorly, the catheter is in contact with the LF, not the dura. Patients feel very little. Actually, they feel less than a standard CESI, which another reason I use this technique.

98% of my CESI are the same and performed with catheter. I enter at T1-T2 (which has twice the epidural space and more consistent LF than C7-T1) and direct the catheter to C6-C7 while adjusting the catheter to be about half way lateral at the tip when targeting multiple levels, or far lateral for severe foraminal stenosis at a particular level. The catheter definitely drives medication to the anterior epidural space and into the foramen more consistently than standard IL CESI at C7-T1.

I took over for a retiring doc who did standard C7-T1 CESI. Nothing wrong with that and his fluoro images are reasonable. However, several of his previous regular CESI patients have commented on how much better they feel after my technique compared to his.

I will direct the catheter more superior if I'm convinced a C2-C3, C3-C4 disc is involved and they failed the technique I just mentioned. This is rare, but has been very helpful for a few patients that failed standard CESI by other docs.
 
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Agree with you. I do most of my CESI with catheters. 18G touhy needle and a very soft 20G catheter. It does have a soft curved stylet but stylet is directly dorsally so as it advances superiorly, the catheter is in contact with the LF, not the dura. Patients feel very little.

98% of my CESI are the same. I enter at T1-T2 (which has twice the epidural space and more consistent LF than C7-T1) and direct the catheter to C6-C7 while adjusting the catheter to be about half way lateral at the tip when targeting multiple levels, or far lateral for severe foraminal stenosis at a particular level. The catheter definitely drives medication to the anterior space and into the foramen more consistently than standard IL CESI at C7-T1.

I took over for a retiring doc who did standard C7-T1 CESI. Nothing wrong with that and his fluoro images are reasonable. However, several of his previous regular CESI patients have commented on how much better they feel after my technique compared to his.

I will direct the catheter more superior if I'm convinced a C2-C3, C3-C4 disc is involved and they failed the technique I just mentioned. This is rare, but has been very helpful for a few patients that failed standard CESI by other docs.
What’s the difference in procedure time and fluoro exposure? Cost for catheter?
 
Agree with you. I do most of my CESI with catheters. 18G touhy needle and a very soft 20G catheter. It does have a soft curved stylet but stylet is directly dorsally so as it advances superiorly, the catheter is in contact with the LF, not the dura. Patients feel very little.

98% of my CESI are the same. I enter at T1-T2 (which has twice the epidural space and more consistent LF than C7-T1) and direct the catheter to C6-C7 while adjusting the catheter to be about half way lateral at the tip when targeting multiple levels, or far lateral for severe foraminal stenosis at a particular level. The catheter definitely drives medication to the anterior space and into the foramen more consistently than standard IL CESI at C7-T1.

I took over for a retiring doc who did standard C7-T1 CESI. Nothing wrong with that and his fluoro images are reasonable. However, several of his previous regular CESI patients have commented on how much better they feel after my technique compared to his.

I will direct the catheter more superior if I'm convinced a C2-C3, C3-C4 disc is involved and they failed the technique I just mentioned. This is rare, but has been very helpful for a few patients that failed standard CESI by other docs.
Where are you ordering your catheter from?
 
What’s the difference in procedure time and fluoro exposure? Cost for catheter?
catheter reference number 6947-02. Costs $4

2 minutes extra time total. Not much more that standard C7-T1 CESI and I find I do less CESI overall due to this technique because these CESI work better, and so I can spend more time on quick lumbar procedures and less on CESI.

I save a few minutes entering at T1-T2 because I don't have to be as cautious as I would at C7-T1 due to the double size of epidural space and more reliable LF at T1-T2 vs C7-T1.
I lose a few minutes inserting and directing the catheter and take 2-3 extra fluoro shots. Grand total is 2 extra minutes.

This is for my 98% CESI that I mentioned above. When I do the other 2% and direct the catheter up to C4, that does add a few more min.
 
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catheter reference number 6947-02. Costs $4

2 minutes extra time total. Not much more that standard C7-T1 CESI and I find I do less CESI overall due to this technique because these CESI work better, and so I can spend more time on quick lumbar procedures and less on CESI.

I save a few minutes entering at T1-T2 because I don't have to be as cautious as I would at C7-T1 due to the double size of epidural space and more reliable LF at T1-T2 vs C7-T1.
I lose a few minutes inserting and directing the catheter and take 2-3 extra fluoro shots. Grand total is 2 extra minutes.

This is for my 98% CESI that I mentioned above. When I do the other 2% and direct the catheter up to C4, that does add a few more min.
same me 2
 
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