Difficult Lumbar TFESIs

[lobelsteve]

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

Only when it hurts.

But really. No.

 

[deleted993114]

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

I agree- Tarlov's cysts are not pain generators.

 

[deleted993114]

Never a reason to do a caudal.

Why not S1? S2?

I rarely, if ever, do caudals anymore and agree with doing a transforaminal. MANY docs still do them with apparently good results, so I don't see a problem with it at all.

I really think it is in the area of personal preference and not a big issue. We used to do caudals all the time back in the 90s when Racz catheters were in vogue. I think the realization that a transforaminal does about the same thing with less hassle really killed the Racz catheter.

 

[Ligament]

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

Very rarely. But yes, they can be pain generators. When you have patients with Tarlov's cysts and pelvic neuralgias and or S1/S2 radiculalgias, consider the cysts. Otherwise ignore them.

Most assume they dont cause symptoms because nobody treats pelvic pain that looks at the spine. The GYNs dont look at the spine but treat pelvic pain. The pain docs look at the spine but dont treat pelvic pain. Anyway this is a rare cause of pain.

 

[Baron S]

I do caudals under ultrasound for OB patients

 

[lobelsteve]

I do caudals under ultrasound for OB patients

That is not pain.

 

[Baron S]

That is not pain.

Pregnant ladies can get lumbar radiculopathy as well?

 

[lobelsteve]

Pregnant ladies can get lumbar radiculopathy as well?

Not that require ESI.

 

[Baron S]

We have very different patient populations

 

[MD87]

This was briefly touched on previously, but I have a question regarding TFESI in fusion patients. The question isn’t regarding efficacy, which is certainly an important issue, but rather getting the needle in the right spot. I’ve done a lot of these, and the contrast usually isn’t perfect, but after checking a few views I’m usually confident it’s epidural. Today, I had a patient with L4-S1 lami/fusion with moderate canal stenosis at L3/4, no significant L4/5 NFS. All left-sided pain, sent for left L4 TFESI. I tried from 2 different starting points and both times failed (second time more inferolateral, though my first attempt was already somewhat inferolateral to the target). I kept hitting what I think was fusion mass, not a screw - couldn’t get medial enough. I couldn’t push through the fusion mass (22g needle). I wasn’t even close.

My question is - is it sometimes literally just impossible to do these in patients with fusions? Any way to determine this prior to attempting the injection other than getting a CT? Certain things to look for on an XR?

 

[bedrock]

This was briefly touched on previously, but I have a question regarding TFESI in fusion patients. The question isn’t regarding efficacy, which is certainly an important issue, but rather getting the needle in the right spot. I’ve done a lot of these, and the contrast usually isn’t perfect, but after checking a few views I’m usually confident it’s epidural. Today, I had a patient with L4-S1 lami/fusion with moderate canal stenosis at L3/4, no significant L4/5 NFS. All left-sided pain, sent for left L4 TFESI. I tried from 2 different starting points and both times failed (second time more inferolateral, though my first attempt was already somewhat inferolateral to the target). I kept hitting what I think was fusion mass, not a screw - couldn’t get medial enough. I couldn’t push through the fusion mass (22g needle). I wasn’t even close.

My question is - is it sometimes literally just impossible to do these in patients with fusions? Any way to determine this prior to attempting the injection other than getting a CT? Certain things to look for on an XR?

often impossible to do TFESI on posterior fusion patients at the level of the fusion. You should educate your referral sources. Once they muck up that level with hardware and post op scarring and post op bone formation, that level can't be reliably treated with an epidural at the level of the fusion.

This patient you describe above should get an L3-L4 TFESI not an L4-L5 TFESI.

 

[Agast]

I’ve had patients where I was successfully doing their TFESI and then one day just couldn’t get near the foramen anymore. Sometimes on fluoro you can see the osteophytosis. At that point I might switch to caudal and start the discussion on neuromodulation.

 

[SommeRiver]

I work with two spine surgeons and I don't usually do the injxn at the level they request. Well, 50% of the time I do...

They've never said a word to me about it.

Some fusion pts simply can't be injected at certain levels.

S1 TFESI with high volume is a great shot, or go above the fusion.

 

[NJPAIN]

Agree with everything said above. It's probably unnecessarily difficult to perform the procedure ordered. Better to use supra-adjacent level infraneural approach or sub-adjacent subpedicular or similar. Yes, you could use cross sectional imaging and plan trajectory using both axial and sagittal images to find a location in both planes that you might be able to sneak a needle in. But you would be doing a lot of work to fulfill an order that never took into consideration anything other than the symptom location or an MRI finding.

 

[SSdoc33]

i agree it can sometimes be difficult. if you are bending your 22g on these patients, then stop. it will kink when you hit the fusion mass. you can usually push through the mass with a straight 22, but not always.

also, try going a bit more anterior/deep then you otherwise would, and start a bit more lateral that you otherwise would.

i would have attempted the same injection you did --L4 TFESI

 

[manowar rules]

I would love to hear advice on how to avoid getting pressure parathesias from TFESI with a tight neuroforamen. I know some people say they do these routinely and the patient never feels a thing, but I just don’t see how this is physically possible. Even when I inject REALLY slowly. I can always get through the procedure, but that dermatomal discomfort is common. The only thing I have found helpful when the foramen shows nothing but nerve root, is that retrodiscal is better tolerated than subpedicular. Otherwise, I am one of those people who will go to an adjacent level.

But there are plenty of docs with more experience than me, so I would love to learn your tricks...

 

[NJPAIN]

If I see nothing but root on T1 sagittal then I don’t inject at that level. If you do, you risk intraneural injection and most flow is distal to foramen. If there is fat above or below the root, supraneural vs infraneural respectively.

 

[myrandom2003]

Don’t forgot to document why it was difficult and add the -22 modifier on

 

[lobelsteve]

Never inject a foramen with more than moderate stenosis. True in fellowship, true still.

 

[NJPAIN]

There is a great video from SIS made by Tim Maus from the Department of Radiology at Mayo on the topic of "Planning Lumbar TFESI-based on Imaging" that addresses this issue. Very enlightening.

 

[SSdoc33]

Never inject a foramen with more than moderate stenosis. True in fellowship, true still.

Absolute nonsense.

The stenosis is the nidus of pain. That is exactly where you should go

 

[lobelsteve]

Absolute nonsense.

The stenosis is the nidus of pain. That is exactly where you should go

So it is not just political stupidity on your part?

Radiographic finding is not clinical symptoms. Pain from sensory nerve to cord to brain.

Whether from mechanical etiology: bone, ligament, disc. Or from chemical etiology from tear in disc. Medicine in the epidural space travels 1 down and 3 up. Putting a needle where no extra space exists might be why lots of doc’s patients have painful injections and why people spear roots.

No thanks.

 

[swamprat]

So it is not just political stupidity on your part?

Radiographic finding is not clinical symptoms. Pain from sensory nerve to cord to brain.

Whether from mechanical etiology: bone, ligament, disc. Or from chemical etiology from tear in disc. Medicine in the epidural space travels 1 down and 3 up. Putting a needle where no extra space exists might be why lots of doc’s patients have painful injections and why people spear roots.

No thanks.

Where r u getting this 1 down 3 up deal?

 

[SommeRiver]

Absolute nonsense.

The stenosis is the nidus of pain. That is exactly where you should go

Disagree.

Epidural spread is multilevel with even modest volume of injectate and the reason neither of the spine surgeons in my group ever send me a SSNB.

One level below with 3-4 cc of volume.

Studies support this.

 

[SSdoc33]

Where r u getting this 1 down 3 up deal?

Furman.

The whole idea why TFESI works better is because you put the medication closest to the area of pathology. Severe right L5S1 NF stenosis get a right L5 TFESI. Yes, you will feel paresthesias but you will get the bedt chance of pain relief with me. Or, you could go to lobel and he will inject your foot and hope some medication gets to the stenosis

This is medicine, not politics. Be a big boy and stick to the subject

 

[lobelsteve]

Furmans data. Lots published. It was posted as attachment in a few older threads here.

 

[SommeRiver]

Furman

 

[SommeRiver]

Furman.

The whole idea why TFESI works better is because you put the medication closest to the area of pathology. Severe right L5S1 NF stenosis get a right L5 TFESI. Yes, you will feel paresthesias but you will get the bedt chance of pain relief with me. Or, you could go to lobel and he will inject your foot and hope some medication gets to the stenosis

This is medicine, not politics. Be a big boy and stick to the subject

You can S1 and drown that L5 nerve with no pain...Same outcome.

 

[SSdoc33]

You can S1 and drown that L5 nerve with no pain...Same outcome.

S1 will definitely get there, but why not L5? Bc there 'might' be pain or paresthesia? L5 will work better. Has to. There is no research on this, just annecdotes. Try going right at the problem and i bet you will see better outcomes. The shot will be marginally more painful and the outcome marginally better

 

[SSdoc33]

There is a great video from SIS made by Tim Maus from the Department of Radiology at Mayo on the topic of "Planning Lumbar TFESI-based on Imaging" that addresses this issue. Very enlightening.

Maus loves going infraneural. Talk about spearing a nerve, thats where you would do it

 

[pmrmd]

The whole idea why TFESI works better is because you put the medication closest to the area of pathology. Severe right L5S1 NF stenosis get a right L5 TFESI. Yes, you will feel paresthesias but you will get the bedt chance of pain relief with me.

I'll go to the stenosed level too, slowly and stay a bit lateral or posterior or if TF approach blocked then lateral IL at that level.

 

[clubdeac]

I'll just do a two level. If L5 is severely stenosed try going at L5 cautiously and then if you only get egress add S1 and make sure you get good superior flow

 

[Taus]

I’ll inject any foramen. With a tight foramen- Take a more caudal to cephalad trajectory, coming in more parallel to nerve root. Stay high and tight to pedicle. Go lateral earlier than usual. Barely/minimally enter the foramen on lateral. go back to ap. Even if lateral to 6 o’clock on the pedicle shoot contrast.... very slowly. Tell patient what they may feel. Nerve root flow? Done. No? Advance a touch more ventrally and repeat prn. No need to get flow medial to pedicle when the pathology is in the foramen.
And yes the maus lecture is excellent. Discussed this at sis a few years ago. Use your mri to plan. T1 sag. Go lateral earlier. This is also crucial when doing any approach other than sub-pedicular. From my recollection those were my key take home points.

Also keep in mind that if it’s foraminal stenosis from arthritic joint and disc height collapse.... you’re not curing jack. I dont expect more than brief relief. A large acute or subacute foraminal disc compressing the root/drg..... good chance to spare them surgery so I’ll be more aggressive with the tfesi at that level.

that said...... if minimal relief or very short term from the tfesi— I’ll go far lateral interlam

 

[NJPAIN]

Looks like we are all not going to agree on this. In my patient population the vast majority of foraminal stenosis is due to disc collapse and what surgeons like to call up-down stenosis. I rarely see a big piece of disc occupying the entire foramen with no epidural fat visible. I frequently see no epidural facet in an 80 yo with disc collapse. I agree with Taus that the relief is very brief in that setting. I am often chanting silently to myself "why am I doing this" as I struggle past the giant facets in the ancient twisted spine.

On the topic of what is an adequate flow pattern, please see the last item on the following excerpted from the MAUS lecture.

 

[bedrock]

You may all consider it blasphemous, but if I see a patient with radicular pain from severe foraminal stenosis, I first try a far lateral ILESI with dep. It often works well, and most importantly the particulate steroid provides months of relief, not weeks (from dex).
If the far lateral ILESI doesn’t provide complete relief. I still find that I have more success then following up with a TFESI with dex as the second procedure because the nerve isn’t as swollen due to effects of the 1st ILESI, and I achieve more consistent foraminal flow in these patients with severe foraminal stenosis.

 

[Ligament]

I would love to hear advice on how to avoid getting pressure parathesias from TFESI with a tight neuroforamen. I know some people say they do these routinely and the patient never feels a thing, but I just don’t see how this is physically possible. Even when I inject REALLY slowly. I can always get through the procedure, but that dermatomal discomfort is common. The only thing I have found helpful when the foramen shows nothing but nerve root, is that retrodiscal is better tolerated than subpedicular. Otherwise, I am one of those people who will go to an adjacent level.

But there are plenty of docs with more experience than me, so I would love to learn your tricks...

I do not belief there is any way to avoid this all the time. One option is to put in .25cc - .5 cc of 4% lidocaine if it is very stenotic and wait a minute. That helps. but you are often going to get a weak leg.

 

[Ligament]

How do I find this Maus video you speak of, internet?

 

[NJPAIN]

How do I find this Maus video you speak of, internet?

PM me your email address and I will send you the video. I don’t know if it is still on their website or YouTube

 

[Gnarvin]

I would be interested in the video, as well.

 

[Dawkter]

Anyone able to post pics of their needle entry point(s) for L5 and S1 TFESIs? I have been getting poor epidural spread lately and need to look at my technique again.

 

[gaseous_clay]

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.

Especially when combined with threading a catheter through the needle to the level of L5/S1, this injection works well.

 

[Baron S]

Anyone able to post pics of their needle entry point(s) for L5 and S1 TFESIs? I have been getting poor epidural spread lately and need to look at my technique again.

Click attached pics. Couple S1 TFs I've done recently.

 

[runfastnow]

Awesome flow.

Where do you find these good looking spines?

 

[Baron S]

Awesome flow.

Where do you find these good looking spines?

My average pt in the military is like 30 years old.

 

[Ducttape]

can we trade?


please???????

 

[drrosenrosen]

My average pt in the military is like 30 years old.

Do you get involved in all the disability determinations, or is that another department?

 

[Baron S]

can we trade?


please???????

Trust me, it's not any better. It's probably the biggest motivator for me leaving the military. They have unrealistic expectations, poor procedural tolerance, and lots of secondary gain issues.

I much prefer my 85 year old retired generals who show up in suit and tie.

 

[Baron S]

Do you get involved in all the disability determinations, or is that another department?

Thankfully no. Every now and then I get asked for my "expert opinion" to which I almost universally respond "pt's pain is unlikely to improve while they remain in the military."

 

[paindoc503]

How far ventral are you guys going for the S1 TFESI on lateral view? Furman says "base of the sacral canal", but almost every picture I see shows the needle ventral to that point

 

[Agast]

My dumb@ss not taking my own advice on sticking to caudals. Still 95% improved two weeks later. Never again.

I looked at her X-ray and thought it would be ok but forgot about the IPG getting in the way on oblique. SCS from me, vertiflex and fusion from the neurosurgeon.