Difficult Lumbar TFESI/Pedicle screw

[Scottie_Dog]

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Anyone have any tips for tricky lumbar TFESI on post-surgical patients with pedicle screws? I've had a few referrals over the last couple months where surgeons request a TFESI at the level of a prior fusion. I usually try to avoid doing a TFESI with a traditional supraneural technique at the level of a fusion and will usually enter at the level below, but often times these patients have multi-level fusions and entering below isnt an option. If they have had a laminectomy, interlam isn't an option. Could always try a caudal (possibly with cath?)but I don't feel like the caudal approach typically reaches L3-4 or L4-5.

I've been told by some colleagues that they use an exaggerated oblique to get the pedicle screw/hardware out of the way but I'm slightly hesitate about doing this because the more oblique you use the higher the chance of dural puncture. I also know that sometimes surgeons pack the foramen during surgery which would make it impossible to get into the foramen anyways. I have a hard time in the lateral view seeing the needle due to the screws.

Any tips? Large oblique? Infraneural at level above. Caudal with or without cath?

Always appreciate the help.

 

[BobBarker]

This is something that I have never been very good at and try to avoid. S1 TFESI usually will also get L5 if that is the nerve he is after.

 

[SSdoc33]

i have heard these concerns before. i dont understand them. at all. scotty, i think you were trained by someone who wasnt comfortable doing them. there is no reason for this.

i dont think ive ever had a dural puncture from a TFESI. done probably 10K or them or more.

just do a normal supraneural TFESI as you otherwise would. maybe oblique a tad more if there are pedicle screws in the way. usually dont need to. you probably would benefit from using a 22g needle, and dont bend the tip. you may need a little more purchase to pop thru the scar tissue at the level of the foramen. bent needle or 25g may kink.

put the medication at the site of the problem, not below, and definitely not a caudal

the fun ones are when you have a non-instrumented posterolateral fusion mass. you can go straight thru that mass to get to the foramen that way, but you may need to just ram that needle thru

 

[TIVAndy]

assuming posterior fusion, just oblique it more to open up the view. the hardest one is S1 on a L5-S1 fusion, other levels should be fine

 

[lobelsteve]

Go AP but start more lateral on skin. Touch down on TP. Pull back and aim inferimedially. Finish under lateral.

 

[camkiss]

Go AP but start more lateral on skin. Touch down on TP. Pull back and aim inferimedially. Finish under lateral.

This is the way

 

[Scottie_Dog]

Thanks for the tips. Not sure why I have trouble with these. I use a 22 gauge but I do bend the tip, wonder if a straight needle is the way to go. Next one I do i'll try this. If it's not going well I'll try the Lobel/Camkiss technique. So you square the SEP and don't oblique and just start lateral to the vertebral body and go towards the TP? I know Lobel has mentioned he likes to do his TFESI in AP, haven't tried this but always looking for tweaks and plan B.

 

[SSdoc33]

Thanks for the tips. Not sure why I have trouble with these. I use a 22 gauge but I do bend the tip, wonder if a straight needle is the way to go. Next one I do i'll try this. If it's not going well I'll try the Lobel/Camkiss technique. So you square the SEP and don't oblique and just start lateral to the vertebral body and go towards the TP? I know Lobel has mentioned he likes to do his TFESI in AP, haven't tried this but always looking for tweaks and plan B.

seems like anyone over 50 likes to do their TFESIs straight down / starting in AP. not recommended, but not the end of the world

 

[pmrmd]

More oblique approach. Otherwise its all the same. Generally will need 5" needle coming so oblique.

 

[MitchLevi]

25g 5" needle, start further lateral and touch down midpoint on the TP. Retract a bit, flatten your needle and walk the needle along the TP until you're something close to the pedicle. You can put contrast there and see if you're still too lateral, then just advance until you're 6 o'clock and you'll be there without much trouble usually.

Patients often hurt worse during this procedure IMO. Granulation tissue will prob be there and you'll get a little neuritis during the contrast and medication being injected.

 

[bedrock]

can't believe you'd used a 25g for this. Post operative scar tissue calls for 22g, IMHO

 

[DrSwede]

Are folks on here routinely using 25g needles for TFESI's in general?

 

[Taus]

Ugh on 25g in lumbar tfesi. With or without scar tissue. So much easier and faster for me, little to no pain, with 22 gauge. Perhaps I just suck.

 

[lobelsteve]

99.9% 25G 3.5 for TFESI and LESI/CESI