Difficult Lumbar TFESIs

[NJPAIN]

Even with more than a few years of experience under my belt, with more and more elderly and obese patients I’m finding that even with basic lumbar TFESI the frequency with which I cannot accomplish “plan A”, such as a L5-S1 TFESI using my go to subpedicular approach has risen. More tilt, more oblique, still giant facet in the trajectory view. A few attempts to corkscrew around the big joints unsuccessful. Move on to retrodiscal/Kambin triangle. Not infrequently with a badly collapsed disc even that fails to produce a satisfactory contrast flow pattern. Now time and radiation exposure is mounting. Two needle approach? Parasagittal interlaminar ( in my setting NOT an option unless specified on consent)? Move to an adjacent level, if possible, and hope for better luck.

Wondering how others manage these situations:
- How long will you persist at a level before going to plan B?
- “Hail Mary” techniques to salvage a difficult TFESI when adjacent levels not an option?









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[painfree23]

Even with more than a few years of experience under my belt, with more and more elderly and obese patients I’m finding that even with basic lumbar TFESI the frequency with which I cannot accomplish “plan A”, such as a L5-S1 TFESI using my go to subpedicular approach has risen. More tilt, more oblique, still giant facet in the trajectory view. A few attempts to corkscrew around the big joints unsuccessful. Move on to retrodiscal/Kambin triangle. Not infrequently with a badly collapsed disc even that fails to produce a satisfactory contrast flow pattern. Now time and radiation exposure is mounting. Two needle approach? Parasagittal interlaminar ( in my setting NOT an option unless specified on consent)? Move to an adjacent level, if possible, and hope for better luck.

Wondering how others manage these situations:
- How long will you persist at a level before going to plan B?
- “Hail Mary” techniques to salvage a difficult TFESI when adjacent levels not an option?









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Yes, I would love to hear opinions on this too. I especially struggle trying to get around fusion rods....not sure why.

 

[Agast]

I just do caudals in those L5-S1 fusion patients. I discovered they were just as happy with the results and it saved me so much time and grief.

 

[Ducttape]

Yes, I would love to hear opinions on this too. I especially struggle trying to get around fusion rods....not sure why.

you shouldnt be struggling if you put the stim leads at T12-L1...

 

[bedrock]

i just do an S1 TFESI which works just as well, and is much easier and quicker.

 

[Timeoutofmind]

I just do caudals in those L5-S1 fusion patients. I discovered they were just as happy with the results and it saved me so much time and grief.

With all the scar tissue and altered anatomy and the large sacral epidural space, I highly doubt anything more than a very minuscule amount of steroid is reaching the actual irritated nerve if no catheter is used

Thus I always do tfesi
And have caudal with cath as a backup on the consent...which I advance to the bottom of but not into the operative area...but even that I think is kinda crap in terms of reaching the actual affected nerve root

 

[NJPAIN]

Although patients with instrumentation and posterolateal fusion masses are certainly a big challenge, my post pertains to virgin backs in those with severe spondylosis and resulting hypertrophic facet joints, disc collapse, foraminal stenosis and the like. I could lie and say it has been years since I had a lumbar TFESI that got the best of me. I have probably had 2-3 in the last four months that I was cursing under my breathe. Certainly related to my patient population with the 30 or 40 year old being an exception rather than a rule.

 

[newbie04]

I’m glad someone is posting about this. I’ve had my fair share of difficult TFESI lately.


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[Aether2000]

Four options I use- 1. blunt needle 20ga coude tip steep cephalad to caudad approach, with a 30 deg bend on the needle tip 2. parallel to the disc and entry at the medial border of the iliac crest with a 20-30 deg bend on the tip of a blunt needle 3. interlaminar lateral epidural space approach 4. caudal approach using a blunt 200mm 20ga blunt tipped double curved needle advanced in the anterior epidural space to the level of the L5S1 disc parasagittal.

 

[Timeoutofmind]

Although patients with instrumentation and posterolateal fusion masses are certainly a big challenge, my post pertains to virgin backs in those with severe spondylosis and resulting hypertrophic facet joints, disc collapse, foraminal stenosis and the like. I could lie and say it has been years since I had a lumbar TFESI that got the best of me. I have probably had 2-3 in the last four months that I was cursing under my breathe. Certainly related to my patient population with the 30 or 40 year old being an exception rather than a rule.

For virgin backs, I always have possible ILESI on my TFESI consents

 

[painfree23]

For virgin backs, I always have possible ILESI on my TFESI consents

Same here , as well as caudal ESI on my consents

 

[epidural man]

Caudal

 

[lobelsteve]

A2+B2=C2

Trajectory is hypotenuse. Adjacent is horizontal from spot on skin lateral to prior starting position. Opposite is vertical depth from skin to anterior foramen.

Use MRI to plot and math to solve.

Or: just start more lateral and inferior than you need with a 22g6 and you can always get there. Unless bony fusion present posteriorly.

 

[ziggyziggy]

A2+B2=C2
just start more lateral and inferior than you need with a 22g6 and you can always get there. Unless bony fusion present posteriorly.

I had my share of these problems. Going back to basics helped. Approach wise, more lateral and aiming for below the eye in scotty dog view has helped. How far medial are you going in AP view (crossing the facet line)? What contrast spread do you look for - laminar or nerve root or both and how much contrast are you putting in?

 

[SSdoc33]

dont bend the needle tip. it will kink when you hit bone or fusion mass or scar. you get more strength with a straight-tipped needle. often times, you can go right thru the fusion mass with a 22g.

dont give up and go caudal. thats bush league

 

[lobelsteve]

I had my share of these problems. Going back to basics helped. Approach wise, more lateral and aiming for below the eye in scotty dog view has helped. How far medial are you going in AP view (crossing the facet line)? What contrast spread do you look for - laminar or nerve root or both and how much contrast are you putting in?

When true AP, 6 under the pedicle. Spread is wrapping the pedicle.

 

[drusso]

I do what Steve does, but I'm not opposed to just bailing at the first signs of a struggle and do a caudal or a bilat S1. I liken it to starting a belly case laparoscopic, discovering bad problems (adhesions, bleeding, etc) and converting to a laparotomy. There is an Modifer for procedures that are "technically more difficult than expected." I don't think we use it enough in our specialty...

Modifier 22 — Increased Procedural Services: Add this modifier to a code when the work required to provide a service is substantially greater than typically required. Documentation must support the additional work and extra payment (e.g., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).

 

[AGDOC09]

I usually use parasagittal interlaminar as my bail out (virgin spine). Mainly do this because I get to use particulate and because it’s how I was trained. What is yall’s opinion on this in regards to effectiveness vs an adjacent level bilateral TFESI with dex? I’ve considered switching.

 

[Orin]

I'm still not sure about the benefit of a TFESI vs far lateral interlaminar vs even a caudal. The literature seems to suggest clinically insignificant, if any, difference, and I can't often give myself a good reason for it other than the $/time.

What am I missing?

 

[SSdoc33]

I'm still not sure about the benefit of a TFESI vs far lateral interlaminar vs even a caudal. The literature seems to suggest clinically insignificant, if any, difference, and I can't often give myself a good reason for it other than the $/time.

What am I missing?

the literature does show a slight preference when comparing TFESI to interlaminars. also, it makes more sense to deposit the medication closer to the site of pathology. caudals should pretty much be scrapped except for rare situations. you might as well inject their toe.

 

[ziggyziggy]

Depends on the pathology and symptoms and where you see your contrast spread to after injection.

In my opinion, Literature (esp meta-analysis) does not do a good job of matching pathology, treatment and outcomes. If we all say it is just a steroid injection then it is no different than oral steroids or narcotics.

I'm still not sure about the benefit of a TFESI vs far lateral interlaminar vs even a caudal. The literature seems to suggest clinically insignificant, if any, difference, and I can't often give myself a good reason for it other than the $/time.

What am I missing?

 

[mid|ine]

the literature does show a slight preference when comparing TFESI to interlaminars. also, it makes more sense to deposit the medication closer to the site of pathology. caudals should pretty much be scrapped except for rare situations. you might as well inject their toe.

Unless Im mistaken it was only 1 small study that showed superiority of TFESI vs IL ESI. Clinically I can't say I notice a difference in outcome, but will say that TFESI tend to be more painful. I primarily use the IL approach.

 

[cowboydoc]

the literature does show a slight preference when comparing TFESI to interlaminars. also, it makes more sense to deposit the medication closer to the site of pathology. caudals should pretty much be scrapped except for rare situations. you might as well inject their toe.

With or without a catheter?

 

[SSdoc33]

With or without a catheter?

i dont see how a catheter would get past your knee.

as far as a caudal with a catheter? just seems like a lot of trouble without much need.

 

[clubdeac]

My main problem with these is the damn nerve root getting in the way. Then I have to withdrawal and try to redirect either superiorly (which I typically can't do b/c I'm as high as possible in the foramen) or laterally. If i go too lateral to miss the nerve then I may not get the good ingress around the pedicle. It's a just a pain in the ass when the nerve is in the way

 

[SageCraft]

i just do an S1 TFESI which works just as well, and is much easier and quicker.

What volume are you using for an S1 TFESI below a multi-level fusion?

 

[Ferrismonk]

I too have been having trouble with TFESI lately. Lots of grief with little benefit it seems. For anyone with bilateral or multi-level issues, which seems to be much of my patient population, I go ILESI. If single (or maybe 2-level) root compressed, unilateral, then I'll go TFESI as first line. If post-fusion, usually caudal then maybe SCS trial. Sometimes will try TFESI on higher level above fusion, but whenever I do at fusion site I just hit dense sheets of scarring and unreliable epidural spread.

Use the sniper rifle to hit single targets, the shotgun when you're hitting a group.

 

[bedrock]

What volume are you using for an S1 TFESI below a multi-level fusion?

Depends on how far I want it to travel. 5ml if I’m trying to reach L4-L5. If pathology is at L3-L4, I usually do infraneural at that level.

 

[lobelsteve]

What volume are you using for an S1 TFESI below a multi-level fusion?

Just don't bother. Unless L5-S1 was not fused and pathology at this level. Then it can be tried but won't make any difference either.

 

[MD87]

Any helpful tips on TFESI at the level of spondylolisthesis with moderate foraminal stenosis? Did 1 the other day and struggled. Contrast was so-so. I squared off the superior endplate and used pretty significant obliquity as I normally do for foraminal stenosis... just wondering if there's anything else to be done given the spondy. Thanks.

 

[cowboydoc]

Any helpful tips on TFESI at the level of spondylolisthesis with moderate foraminal stenosis? Did 1 the other day and struggled. Contrast was so-so. I squared off the superior endplate and used pretty significant obliquity as I normally do for foraminal stenosis... just wondering if there's anything else to be done given the spondy. Thanks.

I don't try to be a hero or protect my ego. Have a plan B and C (Thanks Tim Maus).

 

[NJPAIN]

I don't try to be a hero or protect my ego. Have a plan B and C (Thanks Tim Maus).

Maus is the MAN. Highlight of SIS meeting last week.

 

[deleted993114]

Even with more than a few years of experience under my belt, with more and more elderly and obese patients I’m finding that even with basic lumbar TFESI the frequency with which I cannot accomplish “plan A”, such as a L5-S1 TFESI using my go to subpedicular approach has risen. More tilt, more oblique, still giant facet in the trajectory view. A few attempts to corkscrew around the big joints unsuccessful. Move on to retrodiscal/Kambin triangle. Not infrequently with a badly collapsed disc even that fails to produce a satisfactory contrast flow pattern. Now time and radiation exposure is mounting. Two needle approach? Parasagittal interlaminar ( in my setting NOT an option unless specified on consent)? Move to an adjacent level, if possible, and hope for better luck.

Wondering how others manage these situations:
- How long will you persist at a level before going to plan B?
- “Hail Mary” techniques to salvage a difficult TFESI when adjacent levels not an option?









Sent from my iPhone using Tapatalk

More bend in your needle tip. Also, instead of seeking a direct "in plane" fluoro view, start a little lateral of your "tunnel view".

Getting around hardware- same thing. Those L5 transforaminals can just plain be harder for the same reason that L5/S1 intradiscal approaches are harder. We have our easy things,,,,,,,,,,,,,,,,,,,,, and we have things that will always be a little harder.

Also, using a stiffer needle, like a 22g, can be helpful.

 

[SSdoc33]

More bend in your needle tip. Also, instead of seeking a direct "in plane" fluoro view, start a little lateral of your "tunnel view".

Getting around hardware- same thing. Those L5 transforaminals can just plain be harder for the same reason that L5/S1 intradiscal approaches are harder. We have our easy things,,,,,,,,,,,,,,,,,,,,, and we have things that will always be a little harder.

Also, using a stiffer needle, like a 22g, can be helpful.

more bend in your needle means it kinks easier, especially when you hit bone or scar or harder fibrous tissue. i find little, if any, bend is better in most cases, but more than 1 way to skin a cat.

 

[deleted993114]

more bend in your needle means it kinks easier, especially when you hit bone or scar or harder fibrous tissue. i find little, if any, bend is better in most cases, but more than 1 way to skin a cat.

Yep- more than one way to skin a cat. However, I can't say I have ever had a kink in a needle from bending the tip (which of course you always need to do with a transforaminal so you can steer it) so that I was not able to inject- not once.

Can't say it can't or won't happen, just that I have never seen it. I really could not do a quick, easy transforaminal without a bent needle, as that is the way I have always done it and would think it would be pretty tough to steer otherwise. That, of course, is in my hands and they way I have always taught people, but I am sure there are people out there that can do them just fine without a bent tip needle.

If you do anticipate bumping into things, that is the reason to use a larger gauge needle (like a 22, rather than a 25) when doing the injection.

The caudal suggestion above is another means by which you can avoid the situation all together. I have never been fond of a caudal approach, but I know a number of guys who do them all the time and like that approach for L5/S1 injections.

 

[SSdoc33]

Yep- more than one way to skin a cat. However, I can't say I have ever had a kink in a needle from bending the tip (which of course you always need to do with a transforaminal so you can steer it) so that I was not able to inject- not once.

Can't say it can't or won't happen, just that I have never seen it. I really could not do a quick, easy transforaminal without a bent needle, as that is the way I have always done it and would think it would be pretty tough to steer otherwise. That, of course, is in my hands and they way I have always taught people, but I am sure there are people out there that can do them just fine without a bent tip needle.

If you do anticipate bumping into things, that is the reason to use a larger gauge needle (like a 22, rather than a 25) when doing the injection.

The caudal suggestion above is another means by which you can avoid the situation all together. I have never been fond of a caudal approach, but I know a number of guys who do them all the time and like that approach for L5/S1 injections.

if you bend the needle, and approach a bone -- like a hypertrophic neuroforamen, you wont be able to advance because of the bend. it WILL kink. maybe we arent using the same terminology, but the needle wont have as much ability to continue advance. like a nail with a bend in it. the straight nail will move much easier.

 

[No Pain All gain]

Any helpful tips on TFESI at the level of spondylolisthesis with moderate foraminal stenosis? Did 1 the other day and struggled. Contrast was so-so. I squared off the superior endplate and used pretty significant obliquity as I normally do for foraminal stenosis... just wondering if there's anything else to be done given the spondy. Thanks.

Interlam

 

[deleted993114]

if you bend the needle, and approach a bone -- like a hypertrophic neuroforamen, you wont be able to advance because of the bend. it WILL kink. maybe we arent using the same terminology, but the needle wont have as much ability to continue advance. like a nail with a bend in it. the straight nail will move much easier.

Well................. I agree with what you said. However, the whole purpose of a bent needle is using the bend to allow you to steer the needle, which you cannot do with a straight needle. You can easily steer it up, down, medial or lateral without withdrawing the needle. You NEVER try to forcibly contact bone. I would imagine if you forced it, you could kink the needle. However, I have never had a kink in a bent transforaminal needle in my career. I am talking about a 25-30 degree bend close to the tip. I would offer that it would take a tremendous amount of force to kink such a needle- I don't think I could physically do it. Further up the shaft- certainly. But why in the world would you put a bend there.

I ALWAYS bend my transforaminal needles are really think it would be tough to do injections without the bend. Heck, I put a bend in needles for test blocks so that I can steer them easily.

 

[SSdoc33]

Well................. I agree with what you said. However, the whole purpose of a bent needle is using the bend to allow you to steer the needle, which you cannot do with a straight needle. You can easily steer it up, down, medial or lateral without withdrawing the needle. You NEVER try to forcibly contact bone. I would imagine if you forced it, you could kink the needle. However, I have never had a kink in a bent transforaminal needle in my career. I am talking about a 25-30 degree bend close to the tip. I would offer that it would take a tremendous amount of force to kink such a needle- I don't think I could physically do it. Further up the shaft- certainly. But why in the world would you put a bend there.

I ALWAYS bend my transforaminal needles are really think it would be tough to do injections without the bend. Heck, I put a bend in needles for test blocks so that I can steer them easily.

im sure we have both done tens of thousands of shots in our careers. i just find i can get my needle where it needs to go much easier without the bend. done it both ways, easier to get to the target with out the bend. you can still steer it, you just have to know how.

i dont know how else to say it: when you get to a are of "harder" tissue -- done, scar, etc, if you try to advance a bent tip needle, it will not advance. it will bend or kink further up the shaft, then return to its "natural" position. im not jamming the needle through os, but sometimes you needle a little force, which you cant really get with a bent tip

 

[deleted993114]

im sure we have both done tens of thousands of shots in our careers. i just find i can get my needle where it needs to go much easier without the bend. done it both ways, easier to get to the target with out the bend. you can still steer it, you just have to know how.

i dont know how else to say it: when you get to a are of "harder" tissue -- done, scar, etc, if you try to advance a bent tip needle, it will not advance. it will bend or kink further up the shaft, then return to its "natural" position. im not jamming the needle through os, but sometimes you needle a little force, which you cant really get with a bent tip

Again, I can't think of any harder material I would encounter, as I don't contact bone and scar from surgery is going to be more medial. If there is scar lateral to the facet joint, I think we have had a poor surgeon working there. A fusion mass would be hard material more laterally, so you don't contact that either. If I think I might bump up against a fusion mass (by my being an idiot and not starting far enough lateral), then I'll use a stiffer, 22g.

I am sure you can do your transforaminals well with a non bent needle- its just what you get used to doing. I just don't know how I can make sharp turns with a straight needle, which is why I don't use them. However, I'm sure with enough practice, we could probably all get an injection in position with the barrel of an ink pen if required- its just what you have practiced the most, as reps will make you faster and better.

What gauge needle do you use? I can't use anything smaller than a 25, as they are too floppy. I'll use a 22 if I want a bigger, stiff needle.

 

[SSdoc33]

Again, I can't think of any harder material I would encounter, as I don't contact bone and scar from surgery is going to be more medial. If there is scar lateral to the facet joint, I think we have had a poor surgeon working there. A fusion mass would be hard material more laterally, so you don't contact that either. If I think I might bump up against a fusion mass (by my being an idiot and not starting far enough lateral), then I'll use a stiffer, 22g.

I am sure you can do your transforaminals well with a non bent needle- its just what you get used to doing. I just don't know how I can make sharp turns with a straight needle, which is why I don't use them. However, I'm sure with enough practice, we could probably all get an injection in position with the barrel of an ink pen if required- its just what you have practiced the most, as reps will make you faster and better.

What gauge needle do you use? I can't use anything smaller than a 25, as they are too floppy. I'll use a 22 if I want a bigger, stiff needle.

generally 22s. not trying to toot my own horn, but i have been able to get a lot of L5 TFESIs that others cant get to, and i think it is specifically because i dont bend the tip. you can put a 22g straight needle directly through a fusion mass. i will admit that the steering isnt as good, but then agian, you dont need to take as many flouro pics. your just get a good hubogram and then advance.

 

[HouseofPain]

Majority of time use a 5 inch 22ga and bend tip using 18ga needle. Start a little lateral and inferior of straight on oblique trajectory view and advance until I touch inferior portion of pedicle then walk off. Go to lateral and advance hugging pedicle with bent tip keeping in superior aspect of foramen. Once needle is in posterior/superior aspect of foremen go back to true AP and advance close to 6 o’clock position and inject contrast under live fluoro. I find that starting out a little more lateral and inferior of the trajectory view works better for me in the difficult ones. I’ve also tried Charles Aprill’s technique by touching the pars and walking off but find I get more posterior spread and the needle tip tends to be past the 6 o’clock position on AP sometimes. I’ll also go infraneural at the level above as well if I can’t get good spread using subpedicular

 

[deleted993114]

generally 22s. not trying to toot my own horn, but i have been able to get a lot of L5 TFESIs that others cant get to, and i think it is specifically because i dont bend the tip. you can put a 22g straight needle directly through a fusion mass. i will admit that the steering isnt as good, but then agian, you dont need to take as many flouro pics. your just get a good hubogram and then advance.

I agree that a needle that is not bent will be more firm and easier to pass through a
tougher substance. However, why are you going "through" a fusion mass, as that area should be low probability for neurocompressive pathology; I guess I would expect impingement to occur above or below a fusion.

To each his own- it's whatever you get used to doing.

Question: Discography is not done very much anymore. However, when you did a narrowed L5/S1 disc on a male, did you bend the needle or not?

 

[SSdoc33]

I agree that a needle that is not bent will be more firm and easier to pass through a
tougher substance. However, why are you going "through" a fusion mass, as that area should be low probability for neurocompressive pathology; I guess I would expect impingement to occur above or below a fusion.

To each his own- it's whatever you get used to doing.

Question: Discography is not done very much anymore. However, when you did a narrowed L5/S1 disc on a male, did you bend the needle or not?

i'd occasionally bend for discos

sometimes the only way to access a L5 TFESI is through the mass. that mass will grow wherever it wants, sometimes in the path of my needle.

“There is no body cavity that cannot be reached with a number fourteen needle and a good strong arm.”

― Samuel Shem, The House of God

 

[myrandom2003]

don't forget to add that 22 modifier

 

[Ligament]

Algos doc invented a far lateral transforaminal technique that can work in this situation @algosdoc also can try a discogram needle setup iwth a larger outer bore needle and a higly curved inner needle to swing around osteophytes. Sometimes simply cannot do it so go caudal.

 

[SSdoc33]

Algos doc invented a far lateral transforaminal technique that can work in this situation @algosdoc also can try a discogram needle setup iwth a larger outer bore needle and a higly curved inner needle to swing around osteophytes. Sometimes simply cannot do it so go caudal.

Never a reason to do a caudal.

Why not S1? S2?

 

[Ligament]

Never a reason to do a caudal.

Why not S1? S2?

Tarvlov's cysts or tarlov cyst post surgical repair
Post rectopexy pain
S3-5 radicular pain without dorsal neuroforamen
Coccydynia to catch the coccygeal nerves

I have scenerios 1, 2 and 4 in my active patient rotation right now. Its good to have options. I do TFESIs 99% of the time, but sometimes a caudal is appropriate.

 

[SSdoc33]

Tarvlov's cysts or tarlov cyst post surgical repair
Post rectopexy pain
S3-5 radicular pain without dorsal neuroforamen
Coccydynia to catch the coccygeal nerves

I have scenerios 1, 2 and 4 in my active patient rotation right now. Its good to have options. I do TFESIs 99% of the time, but sometimes a caudal is appropriate.

i stand corrected. im not going to disagree with your pelvic pain treatment prowess.

ill just say that for lumbar spine disorders, caudal ESIs are rarely, if ever, necessary

 

[painfree23]

Tarvlov's cysts or tarlov cyst post surgical repair
Post rectopexy pain
S3-5 radicular pain without dorsal neuroforamen
Coccydynia to catch the coccygeal nerves

I have scenerios 1, 2 and 4 in my active patient rotation right now. Its good to have options. I do TFESIs 99% of the time, but sometimes a caudal is appropriate.

We never really treated tarlov cysts in fellowship. Do you think it’s a pain source ?