Did any one tried this alternate method of doing Lumbar TFESI ?

[painfre]

Did any one tried this alternate method of doing TFESI ? I tried on couple of patients but did not get characteristic epidurogram you get by going under "safe triangle"

http://www.painphysicianjournal.com/2011/july/2011;14;331-341.pdf

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[101N]

Did any one tried this alternate method of doing TFESI ? I tried on couple of patients but did not get characteristic epidurogram you get by going under "safe triangle"

http://www.painphysicianjournal.com/2011/july/2011;14;331-341.pdf

AKA the preganglionic TFESI. Yes, I've used it.

1. Preganglionic approach to transforaminal epidural steroid injections.
Lew HL, Coelho P, Chou LH. Am J Phys Med Rehabil. 2004 May;83(5):378. No abstract available.

2. Transforaminal epidural steroid injection for lumbosacral radiculopathy: preganglionic versus conventional approach. Lee JW, Kim SH, Choi JY, Yeom JS, Kim KJ, Chung SK, Kim HJ, Kim C, Kwack KS, Kwon JW, Moon SG, Jun WS, Kang HS. Korean J Radiol. 2006 Apr-Jun;7(2):139-44.

3. Transforaminal epidural steroid injection via a preganglionic approach for lumbar spinal stenosis and lumbar discogenic pain with radiculopathy. Kabatas S, Cansever T, Yilmaz C, Kocyigit OI, Coskun E, Demircay E, Akar A, Caner H. Neurol India. 2010 Mar-Apr;58(2):248-52.

 

[lurkingrue]

Could someone really briefly explain the subtleties in the difference between the "retrodiscal" approach and the "preganglionic" approach? I haven't really investigated these options yet, and was about to start looking into them...

Clearly, there's reason to think the "safe triangle" isn't so, and also there's a question of efficacy of TFESI using different approaches. I know some who swear by the retrodiscal approach as being superior for discogenic pain relief.

Any input from the audience?

 

[101N]

Could someone really briefly explain the subtleties in the difference between the "retrodiscal" approach and the "preganglionic" approach? I haven't really investigated these options yet, and was about to start looking into them...

Clearly, there's reason to think the "safe triangle" isn't so, and also there's a question of efficacy of TFESI using different approaches. I know some who swear by the retrodiscal approach as being superior for discogenic pain relief.

Any input from the audience?

There is no difference between the preganglionic and "retrodiscal approach".

The positioning for the preganglionic is similar to disc puncture. Not surprisingly, the risk with the preganglionic is inadvertant disc puncture so use a two needle tecnique.

 

[lurkingrue]

Appreciate that confirmation. I thought I was going mad for a while there. Puzzling why there's no agreed-upon terminology. It seems that this approach has been "discovered" by someone else every few months for the last several years, too.

Anyway, thank you for clearing that up.

 

[101N]

The guys that wrote the 1st preganglionic article are friends of mine. They originally submitted it in poster form to NASS in 2001 or 2002 and it got rejected.

What stimulated them devise the technique was a desire to get medicine more reliably into the lateral recess, proximal to the foramen, where the pathology often is. Realize that this is an area - the lateral recess - cephalad to the axilla and root sleeve take off. The principle was working on this at about the time that the Houten article came out. But, it wasn't a safety issue that drove the technique.

Another buddy of mine who did his fellowship at UCSF told me that he was taught the technique there, they just didn't write it up.

The fact that the current authors in Pain Physician didn't do their research into the prior description of this technique doesn't surprise me at all.

1. Paraplegia after lumbosacral nerve root block: report of three cases.
Houten JK, Errico TJ. Spine J. 2002 Jan-Feb;2(1):70-5.

 

[epidural man]

Did any one tried this alternate method of doing TFESI ? I tried on couple of patients but did not get characteristic epidurogram you get by going under "safe triangle"

http://www.painphysicianjournal.com/2011/july/2011;14;331-341.pdf

Try this approach.

At least according to this article, you have as good, if not better, anterior spread than with TFESI.

It might be safer as well.

View attachment far lateral ILESI.pdf

 

[deleted79235]

Try this approach.

At least according to this article, you have as good, if not better, anterior spread than with TFESI.

It might be safer as well.

View attachment 17635

Dr. Glaser wrote an editorial with some comments about Dr. Candido’s paper.

A 5ml volume was required for the ILESIs to achieve the spread patterns with anterior epidural flow. Thus, this route (compared to transforaminal approach) requires larger volumes, lacks target specificity, and results in dilution of the steroids.

Dr. Glaser also compared pics in Candido's paper and felt contrast spread into the foramen and ventral epidural space occurred more consistently via the transforaminal approach.

- Pain Physician: July/August 2010: 13:395-400

 

[specepic]

Did any one tried this alternate method of doing TFESI ? I tried on couple of patients but did not get characteristic epidurogram you get by going under "safe triangle"

http://www.painphysicianjournal.com/2011/july/2011;14;331-341.pdf

what is up with the needles they are using? how the hell do you advance a needle like that in any kind of a straight line/path?

 

[facets]

what is up with the needles they are using? how the hell do you advance a needle like that in any kind of a straight line/path?

I say WTF! They are using the triangle of Rinoo (sp) approach but making it very complicated. Why not just go lateral to the tip of the scotty ear like Rinoo described, go lateral and make sure you don't get in the disc. This technique seems FUC*** UP

 

[bedrock]

Try this approach.

At least according to this article, you have as good, if not better, anterior spread than with TFESI.

It might be safer as well.

View attachment 17635

I'd agree with the safer part. No way in hell do you get better anterior spread than a TFESI! How can you get better anterior spread than if your needle is already in the anterior epidural space? Looking at those pictures I though the anterior flow was superior with TFESI.

I do agree that you can get decent anterior spread with far lateral ILESI. And it's still more target specific than a caudal......

Even though I'm a big proponent of lumbar TFESI, I do worry enough about arterial uptake with TFESI, even at lower levels, that my first lumbar ESI on someone is usually a far lateral ILESI (with particulate steroid) to the side of pathology. Many patients do great with far lateral ILESI, if not, they get a TFESI.

I'm finding this approach all the more applicable recently, now with some prominent ISIS board members suggesting doing all levels of TFESI with dex and the fluoro code removed for TFESI.

I think you get more sustained effect doing a far lateral ILESI with particulate steroid compared to TFESI with dex, and it's easier, faster, safer, and(with flouro)now reimburses very similar to TFESI.

 

[lovebailey2001]

is this technique not really similar to ' Retro Neural Approach' given in ISIS book, only with more complicated procedural description in this article! with presumed safety of Intra-arterial injection with conventional Sub-pedicular TFESI, but without evidence of efficacy, because all supportive evidence for TFESI is with Sub Pedicular approach.

 

[mille125]

I'd agree with the safer part. No way in hell do you get better anterior spread than a TFESI! How can you get better anterior spread than if your needle is already in the anterior epidural space? Looking at those pictures I though the anterior flow was superior with TFESI.

I do agree that you can get decent anterior spread with far lateral ILESI. And it's still more target specific than a caudal......

Even though I'm a big proponent of lumbar TFESI, I do worry enough about arterial uptake with TFESI, even at lower levels, that my first lumbar ESI on someone is usually a far lateral ILESI (with particulate steroid) to the side of pathology. Many patients do great with far lateral ILESI, if not, they get a TFESI.

I'm finding this approach all the more applicable recently, now with some prominent ISIS board members suggesting doing all levels of TFESI with dex and the fluoro code removed for TFESI.

I think you get more sustained effect doing a far lateral ILESI with particulate steroid compared to TFESI with dex, and it's easier, faster, safer, and(with flouro)now reimburses very similar to TFESI.

i agree with you and this reflects my practice pattern...it is especially useful for large disks (tfesi hurts a lot)..the days of the bilateral L5 and S1 transforaminals are clearly numbered as medicare is rumored to be contemplating paying for one level only on the entire 60000 series. Some surgery centers in my area have been getting denials over the last few weeks.

 

[deleted185747]

Any pearls as to WHEN when to do a subpedicular TFESI vs a retroneural TFESI?

 

[pastafan]

Any pearls as to WHEN when to do a subpedicular TFESI vs a retroneural TFESI?

Others may disagree but I usually do subpedicular. Retroneural occurs when needle is inserted for subpedicular but first fluoro shows that tissue has directed needle retroneural. Then I just go with the flow.

 

[pmrmd]

When there is osteophyte blocking the usual sub-pedicular path I will go farther oblique and try the other approaches. The epidurograms are generally not very pretty and I like pretty pictures for my notes. The patients don't feel the paresthesia as much either. They seem to be effective though.

 

[drusso]

When there is osteophyte blocking the usual sub-pedicular path I will go farther oblique and try the other approaches. The epidurograms are generally not very pretty and I like pretty pictures for my notes. The patients don't feel the paresthesia as much either. They seem to be effective though.

Ditto. I some-times "end up" here if there's osteophytosis. I accept it if the epidurogram looks okay. Patient outcome seems to be the same.

 

[lobelsteve]

I start on the skin in the back ang in the little hole over to the side of the spine. AP/lateral views confirm I finish by onjecting into the epidural space. 6 oclock under the pedicle. Not IT, or IM, or vascular.