Dural puncture avoidance

[epidural man]

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L5-S1 IL is also the least likely potential for wet tap if you go paramedian. Nerve is the backstop, not the sac. Look at all that fat past the LF, doesn't matter if none dorsally midline.

Needle tip is right behind site of compression, do not need to worry about if flow is going up/down/medial enough, you are closer to target than any other injection and can use depo.
View attachment 409159

I disagree with this.

You can’t tell by MRI where the medial edge of the lamina/inferior articulating process is so when doing not on fluoro - you really have no idea exactly where the needle is in relation to this picture.

 

[RoloTomassi]

I disagree with this.

You can’t tell by MRI where the medial edge of the lamina/inferior articulating process is so when doing not on fluoro - you really have no idea exactly where the needle is in relation to this picture.

L5-S1 usually has the widest window. You can see where the facet is. If you are just medial to facet you should be fine. Even more so if your needle is angling medial to lateral.

 

[bedrock]

everyone who is stil doing caudals b/c they were trained that way: stop. just do an S1 TFESI. quicker, easier, and closer to the pathology. hardware is never in the way

You need to be more open minded, about medicine and other things.

As I’ve posted a couple dozen times before on SDN, shallow angle caudals, (when you drive the needle tip cranially up to the S3-S4 level, not just barely through sacral hiatus) will
1- most reliably direct medication to the central third of the disc than other ESI techniques, which is particularly important with central disc herniations and annular tears.
2- caudals also more reliably cover the center right or center left portions of a disc vs a TFESI, and will safely cover it with depo instead of dex. Depo doesn’t always work better than dex, but it is never worse than dex if injected with same ESI technique.

Below are the lumbar spine MRI images of a staff member. First 3 photos are the MRI done in 2021, the second 3 images are from 2025 MRI.

Patient initially presented with right lumbar pain and right lumbar radiculopathy. Pain extended to knee only.
Did a right L5-S1, right S1 TFESI (depomedrol at S1, dex at L5-S1) This provided 95% relief for a year. Pain returned a year later. Repeated the same TFESI with same excellent sustained clinical results.

18 months later (this year) the pain returned in a fairly similar distribution but more intense. Repeated same right L5-S1, S1 TFESI (dex at L5, depo at S1). She had 50% relief for 10 days, then all pain returned. That TFESI worked really well historically so I again repeated the TFESI, but again it provided her only with a similar modest and brief 50% relief for a week.

Staff member is not able to function at work or home so I get a new lumbar mri. (Second series of photos) which reveal new modic changes at L4-L5 and also that the L4-L5 HD is now central instead of right paracentral as was seen in previous MRI. Pain radiates to buttock/thigh in a similar distribution, but a bit more central vs lateral, now

Again, despite a TFESI previously providing 95% relief for a year (twice) the staff member can now barely function despite recently repeating two TFESI with same technique that worked so well with the first two ESI. Now I suggest a caudal and discuss the MRI with the patient (nurse) and that I wanted to cover central to central right portion of the part of HD.

I perform a shallow angle caudal with depomedrol at S3-S4 with the tip slightly right. The patient now achieves 90% sustained relief (she is currently in post procedure month 4)
The past 4 months she has been able to sit at work, bend at home, and resume exercise, etc. Clinical result after the caudal ESI is slightly less than the initial TFESI 4 years ago 90% vs 95% relief, but dramatically more effective than repeating the same (previously effective) TFESI twice this year with only mediocre results x 2.

Caudals don’t fix everything,and in
many clinical scenarios are less effective than TFESI. But it is short sighted to just say it’s virtually always incorrect to perform a caudal, as you just did.

There are some spine issues which respond better to a caudal with depomedrol vs any other ESI technique.

 

[lobelsteve]

You need to be more open minded, about medicine and other things.

As I’ve posted a couple dozen times before on SDN, shallow angle caudals, (when you drive the needle tip cranially up to the S3-S4 level, not just barely through sacral hiatus) will
1- most reliably direct medication to the central third of the disc than other ESI techniques, which is particularly important with central disc herniations and annular tears.
2- caudate also more reliably cover the center right or center left portions of a disc vs a TFESI, and will safely cover it with depo instead of dex. Depo doesn’t always work better than dex, but it is never worse than dex if injected with same ESI technique.

Below are the lumbar spine MRI images of a staff member. First 3 photos are the MRI done in 2021, the second 3 images are from 2025 MRI.

Patient initially presented with right lumbar pain and right lumbar radiculopathy. Pain extended to knee only.
Did a right L5-S1, right S1 TFESI (depomedrol at S1, dex at L5-S1) This provided 95% relief for a year. Pain returned a year later. Repeated the same TESI with same excellent sustained clinical results.

18 months later (this year) the pain returned in a fairly similar distribution but more intense. Repeated TFESI. 50% relief for 10 days, then all pain returned. That TFESI worked really well historically so I repeated the TFESI, but again this provided her with only the same modest and brief relief of 50% relief for a week.

Staff member is not able to function at work or home so I get a new lumbar mri. (Second series of photos) which reveal new modic changes at L4-L5 and also that the L4-L5 HD is now central instead of right paracentral as was seen in previous MRI. Pain radiates to buttock/thigh in a similar distribution, but a bit more central vs lateral, now

Again, despite a TFESI previously providing 95% relief for a year (twice) the staff member can now barely function despite repeating two TFESI with same technique that worked so well in the past (twice). So I now suggest a caudal and discuss the MRI with the patient (nurse) and that I wanted to cover central to central right portion of the part of HD.

I perform a shallow angle caudal with depomedrol at S3-S4 with the tip slightly right. The patient now achieves 90% sustained relief (she is currently in post procedure month 4)
The past 4 months she has been able to sit at work, bend at home, and resume exercise, etc. Clinical result after the caudal ESI is slightly less than the initial TFESI 4 years ago 90% vs 95% relief, but dramatically more effective than repeating the same (previously effective) TFESI twice this year with only mediocre results x 2.

Caudals don’t fix everything,and in
many clinical scenarios are less effective than TFESI. But it is short sighted to just say it’s virtually always incorrect to perform a caudal, as you just did.

There are some spine issues which respond better to a caudal with depomedrol vs any other ESI technique.

Making a post longer doesn’t make it scientifically correct.

You exhibited a lot of magical thinking. No ESI can last a year. That’s not how it works.

 

[bedrock]

Making a post longer doesn’t make it scientifically correct.

You exhibited a lot of magical thinking. No ESI can last a year. That’s not how it works.

Whatever.

I just know that I help a lot of people that you and ssdoc can’t help. And this lady wouldn’t be able to work or function if I was as close minded as you guys.

It takes 4 minutes to do a shallow angle caudal with depo. Extremely low risk injection which requires far less time than a discussion with a frustrated patient telling them that they have to live with their pain, take meds chronically, or have surgery.

 

[SSdoc33]

Whatever.

I just know that I help a lot of people that you and ssdoc can’t help. And this lady wouldn’t be able to work or function if I was as close minded as you guys.

It takes 4 minutes to do a shallow angle caudal with depo. Extremely low risk injection which requires far less time than a discussion with frustrated patient telling them that they have to live with their pain, take meds chronically, or have surgery.

more magical thinking. no way you can know that.

nothing on that MRI tells me that "this lady cant work".

i admit i need to be more open minded. now you admit that you arent as good at this as you think you are.

 

[Ducttape]

um... your TFESIx2 lasted a year.

does that by itself imply that TFESI work very well?

 

[bubaghanush]

You need to be more open minded, about medicine and other things.

As I’ve posted a couple dozen times before on SDN, shallow angle caudals, (when you drive the needle tip cranially up to the S3-S4 level, not just barely through sacral hiatus) will
1- most reliably direct medication to the central third of the disc than other ESI techniques, which is particularly important with central disc herniations and annular tears.
2- caudals also more reliably cover the center right or center left portions of a disc vs a TFESI, and will safely cover it with depo instead of dex. Depo doesn’t always work better than dex, but it is never worse than dex if injected with same ESI technique.

Below are the lumbar spine MRI images of a staff member. First 3 photos are the MRI done in 2021, the second 3 images are from 2025 MRI.

Patient initially presented with right lumbar pain and right lumbar radiculopathy. Pain extended to knee only.
Did a right L5-S1, right S1 TFESI (depomedrol at S1, dex at L5-S1) This provided 95% relief for a year. Pain returned a year later. Repeated the same TFESI with same excellent sustained clinical results.

18 months later (this year) the pain returned in a fairly similar distribution but more intense. Repeated same right L5-S1, S1 TFESI (dex at L5, depo at S1). She had 50% relief for 10 days, then all pain returned. That TFESI worked really well historically so I again repeated the TFESI, but again it provided her only with a similar modest and brief 50% relief for a week.

Staff member is not able to function at work or home so I get a new lumbar mri. (Second series of photos) which reveal new modic changes at L4-L5 and also that the L4-L5 HD is now central instead of right paracentral as was seen in previous MRI. Pain radiates to buttock/thigh in a similar distribution, but a bit more central vs lateral, now

Again, despite a TFESI previously providing 95% relief for a year (twice) the staff member can now barely function despite repeating two TFESI with same technique that worked so well in the past (twice). So I now suggest a caudal and discuss the MRI with the patient (nurse) and that I wanted to cover central to central right portion of the part of HD.

I perform a shallow angle caudal with depomedrol at S3-S4 with the tip slightly right. The patient now achieves 90% sustained relief (she is currently in post procedure month 4)
The past 4 months she has been able to sit at work, bend at home, and resume exercise, etc. Clinical result after the caudal ESI is slightly less than the initial TFESI 4 years ago 90% vs 95% relief, but dramatically more effective than repeating the same (previously effective) TFESI twice this year with only mediocre results x 2.

Caudals don’t fix everything,and in
many clinical scenarios are less effective than TFESI. But it is short sighted to just say it’s virtually always incorrect to perform a caudal, as you just did.

There are some spine issues which respond better to a caudal with depomedrol vs any other ESI technique.

Do you have any fluoro pics showing spread to that disc? Curious why you think caudal will give better spread than interlaminar for a central disc?

I used to do more what you're referring to as shallow angle caudals with depo. My colleagues routinely use caudal with catheter up.

I do a lot less caudals now. They didn't work any better in my hands than interlaminar or transforaminal, and usually worse. Anyone getting a year of relief I chalked up to placebo or improvement that would've happened anyways.

 

[MitchLevi]

Making a post longer doesn’t make it scientifically correct.

You exhibited a lot of magical thinking. No ESI can last a year. That’s not how it works.

You’re saying an ESI can’t provide a year of relief? That’s absurd.

 

[Ducttape]

its not the esi that is providing the year of relief.

it is the underlying pathology improving on its own.

 

[lobelsteve]

You’re saying an ESI can’t provide a year of relief? That’s absurd.

Believing it was the ESI that did it is the absurd part.

 

[MitchLevi]

Why do you give anyone an ESI? This is a crazy conversation IMO.

 

[lobelsteve]

Why do you give anyone an ESI? This is a crazy conversation IMO.

To get them 2 months of relief and to get more agressive with the home exercise program or restart PT.

 

[geauxg8rs]

You’re saying an ESI can’t provide a year of relief? That’s absurd.

What if the esi provides 2 months of relief but the flare was going to get better in 6 weeks (shot or not) and not flare again for a year.

 

[MitchLevi]

What if the esi provides 2 months of relief but the flare was going to get better in 6 weeks (shot or not) and not flare again for a year.

Sure, happens all the time.

 

[MitchLevi]

To get them 2 months of relief and to get more agressive with the home exercise program or restart PT.

…treatments with a perfect track record.

 

[oneforfighting]

To get them 2 months of relief and to get more agressive with the home exercise program or restart PT.

And how many of these patients adhere to their home exercise program

 

[bedrock]

Do you have any fluoro pics showing spread to that disc? Curious why you think caudal will give better spread than interlaminar for a central disc?

I used to do more what you're referring to as shallow angle caudals with depo. My colleagues routinely use caudal with catheter up.

I do a lot less caudals now. They didn't work any better in my hands than interlaminar or transforaminal, and usually worse. Anyone getting a year of relief I chalked up to placebo or improvement that would've happened anyways.

Unfortunately it seems you didn’t understand the step by step clinical scenario I described, or basic spinal anatomy.

 

[bedrock]

To get them 2 months of relief and to get more agressive with the home exercise program or restart PT.

its not the esi that is providing the year of relief.

it is the underlying pathology improving on its own.

Believing it was the ESI that did it is the absurd part.

Why do you give anyone an ESI? This is a crazy conversation IMO.

The absurd part is Steve thinking that all epidurals last two months or less.

Maybe if you do all of them with dex….

Mitch, I agree with you.
If these guys think ESI doesn’t do anything, then why do they perform them?

 

[bubaghanush]

Unfortunately it seems you didn’t understand the step by step clinical scenario I described, or basic spinal anatomy.

What I don't understand is your magical thinking. I get you think your caudal gets you better anterior spread. Perhaps 0-10% of your injectate gets up there from S3. Show some pictures of your fluoro images showing the anterior spread.

 

[lobelsteve]

It's not what I think that matters, it is what the literature reports.
My patients routinely come back for another S1 TFESI at a year saying it just wore off.
If I was not an educated physician who knew the science, I would believe them too.

 

[Ducttape]

do steroids cure knee pathology?

do steroids cure rotator cuff disease?

do steroids cure carpal tunnel?


in every other body part, certain doctors are pushing for regenerative medicine to cure an underlying condition because the steroid does not.

but the spine is different?

 

[SSdoc33]

Unfortunately it seems you didn’t understand the step by step clinical scenario I described, or basic spinal anatomy.

let me get this straight: you are literally making sh$t up and then being condescending when people legitimately question what you are doing.

strong work

 

[epidural man]

What I don't understand is your magical thinking. I get you think your caudal gets you better anterior spread. Perhaps 0-10% of your injectate gets up there from S3. Show some pictures of your fluoro images showing the anterior spread.

It’s not magical thinking. Lots has been written on caudals and anterior spread.

I’m not here to convince anyone to do them.

I will speak up when someone tries to argue NOT to do them because at worst, it performs on par with ILESI and at best, it performs better.

Years ago when everyone was doing particulate steroid for every approach, Manchikanti clearly showed that in order of efficacy was TFESI>Caudal>ILESi.

Now with everyone using Dex which gives about 6 weeks of pain relief in almost everyone, I suspect caudals perform better. But even if they perform on par, they are quick and very very safe. And to argue against that seems odd.

I get people don’t want to do them. I know all the reasons. And I don’t judge anyone for never wanting to do another caudal. If you don’t do them all the time, they can be very very challenging in some.

 

[lobelsteve]

Impact of Different Approaches of Epidural Steroid Injection on Outcome of Patients Treated for Low Backache - PMC

The objective of this study was to evaluate the clinical efficacy of epidural steroid injections through different approaches using pain relief and improvement in functional capacity as outcome measures. Sixty patients with low backache and ...

pmc.ncbi.nlm.nih.gov

https://www.sciencedirect.com/science/article/pii/S2772594424000165

and:

https://www.sciencedirect.com/science/article/pii/S2772594422001479

So- nope.

 

[SSdoc33]

It’s not magical thinking. Lots has been written on caudals and anterior spread.

I’m not here to convince anyone to do them.

I will speak up when someone tries to argue NOT to do them because at worst, it performs on par with ILESI and at best, it performs better.

Years ago when everyone was doing particulate steroid for every approach, Manchikanti clearly showed that in order of efficacy was TFESI>Caudal>ILESi.

Now with everyone using Dex which gives about 6 weeks of pain relief in almost everyone, I suspect caudals perform better. But even if they perform on par, they are quick and very very safe. And to argue against that seems odd.

I get people don’t want to do them. I know all the reasons. And I don’t judge anyone for never wanting to do another caudal. If you don’t do them all the time, they can be very very challenging in some.

????

manchikanti?

caudal better than ILESI?

 

[bubaghanush]

It’s not magical thinking. Lots has been written on caudals and anterior spread.

I’m not here to convince anyone to do them.

I will speak up when someone tries to argue NOT to do them because at worst, it performs on par with ILESI and at best, it performs better.

Years ago when everyone was doing particulate steroid for every approach, Manchikanti clearly showed that in order of efficacy was TFESI>Caudal>ILESi.

Now with everyone using Dex which gives about 6 weeks of pain relief in almost everyone, I suspect caudals perform better. But even if they perform on par, they are quick and very very safe. And to argue against that seems odd.

I get people don’t want to do them. I know all the reasons. And I don’t judge anyone for never wanting to do another caudal. If you don’t do them all the time, they can be very very challenging in some.

Thanks for replying. I have changed my practice patterns before based on the collective wisdom of this forum.

I would love to see if there is evidence that caudal has on par or better performance than ILESI. Or, barring that, that it has more consistent anterior flow. I consistently get anterior spready with ILESI with parasagittal approach:

A prospective evaluation of iodinated contrast flow patterns with fluoroscopically guided lumbar epidural steroid injections: the lateral parasagittal interlaminar epidural approach versus the transforaminal epidural approach - PubMed

The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.

pubmed.ncbi.nlm.nih.gov

Can you post the Manchikanti studying shows caudal is better than ILESI? Here is a meta-analysis saying TFESI is better, but didn't state ILESI or caudal is better. They do site a Manchikanti study in there that showed no difference.

:::::Pain Physician:::::

And here is the Manchikanti study showing no difference. I take his results with a grain of salt as apparently his epidural work 2-4x longer than the dozens of pain physicians I've met:

Comparison of the Efficacy of Caudal, Interlaminar, and Transforaminal Epidural Injections in Managing Lumbar Disc Herniation: Is One Method Superior to the Other? - PMC

Epidural injections are performed utilizing 3 approaches in the lumbar spine: caudal, interlaminar, and transforaminal. The literature on the efficacy of epidural injections has been sporadic. There are few high-quality randomized trials performed ...

pmc.ncbi.nlm.nih.gov

Regarding epidural spread, I'm not saying caudal epidural can't have anterior spread. My opinion is it is routinely minimal. This study says you need 20mL to reliably get to L5-S1. Is that the volume you use or greater? 10mL is not enough.

MR epidurography: distribution of injectate at caudal epidural injection - PubMed

Firstly, MR epidurography is a safe technique that allows excellent visualization of the distribution of gadolinium in the epidural space following injection via the caudal hiatus. Secondly, a volume of 10 ml is unlikely to treat L5/S1 disease in almost half of patients at caudal epidural...

pubmed.ncbi.nlm.nih.gov

I said maybe 0-10% of the injectate gets to the anterior epidural space. Perhaps I will revise it to 20% max if you are using 20mL.


I do maybe 1-2 caudals a month. Not because they reimburse less or are technically harder, but because I find they don't have any better efficacy.

 

[SSdoc33]

i dont understand how putting the medication 4 inches away is better.

as steve would say "does not compute"

 

[lobelsteve]

i dont understand how putting the medication 4 inches away is better.

as steve would say "does not compute"

Homeopathic principles.

 

[clubdeac]

I’ve seen great results with caudals in the right situation. Usually in a patient with varying degrees of central canal and lateral recess and NF stenosis at L4-5 and L5-S1 and primarily buttock and posterior thigh pain, very little lbp

 

[MitchLevi]

I do caudals. They’re effective like everything else is effective. Really dumb to say otherwise.

 

[hopefulgasman]

I also peform caudals and patients desire them for a variety of reasons. While they don't seem to subjectively offer the same duration as other more targeted ESIs, they take a minute to perform and elicit zero pain. The majority of my patients quite literally lay on the table stunned and echo "done?! Didn't even know the procedure started, wow"

 

[SSdoc33]

News flash: if you don’t agree with MitchLevi, you are an idiot

Of course caudals ‘work’. We just have better tools to use than an outdated injection.

A lot of the teaching of caudals wears baked in to old school spine care. I see people always do them when there is fusion hardware. Why? Why not an L5. Or an S1? Pedicle screws are never in the way on an S1 TFESI. And the medication is way closer. It is also farther from your b-hole, so less risk of an infection. You won’t get blamed for the colonial cyst that was already there.

Just a lot of reasons to NOT do a caudal

 

[epidural man]

i dont understand how putting the medication 4 inches away is better.

as steve would say "does not compute"

Try it! You will see -

0.5-1 ml of contrast gets to L5/S1. I do 10 mls for the injection. It gets there.

 

[epidural man]

News flash: if you don’t agree with MitchLevi, you are an idiot

Of course caudals ‘work’. We just have better tools to use than an outdated injection.

A lot of the teaching of caudals wears baked in to old school spine care. I see people always do them when there is fusion hardware. Why? Why not an L5. Or an S1? Pedicle screws are never in the way on an S1 TFESI. And the medication is way closer. It is also farther from your b-hole, so less risk of an infection. You won’t get blamed for the colonial cyst that was already there.

Just a lot of reasons to NOT do a caudal

You haven't really named a good reason in my mind (not to do it) . S1 - do you use particulate? Case report(s) of spinal injury from this.

No case report of spinal injury from caudal with particulate.

 

[SSdoc33]

You haven't really named a good reason in my mind (not to do it) . S1 - do you use particulate? Case report(s) of spinal injury from this.

No case report of spinal injury from caudal with particulate.

That case report was bogus as bedrock will tell you. And if you are diluting your steroid that much, then what’s the point?

 

[callmeanesthesia]

That case report was bogus as bedrock will tell you. And if you are diluting your steroid that much, then what’s the point?

I put a little lidocaine, then the steroid, then flush it in with saline. I figure that will wash the steroid up into the lumbar canal. I’ve definitely seen vascular uptake from S1. I don’t really see it being that big of an advantage unless it’s specifically S1 you’re trying to reach.

 

[bedrock]

let me get this straight: you are literally making sh$t up and then being condescending when people legitimately question what you are doing.

I'm not making anything up. I shared this case, as I have shared many others because it was a situation where the usual approach didn't help the patient, and if I followed dogma, I'd just have to tell the patient to "deal with it" Instead I gave the patient her life back. Just saw her yesterday and she is doing great.

bugabunaush was not asking questions, he was openly challenging the concept and the results, despite my long post describing the history and results of each of the 4 previous ESI before the caudal. If someone attacks me, I attack them back.

 

[bedrock]

That case report was bogus as bedrock will tell you.

I'm glad to see that you seem to finally believe something I posted!

 

[bedrock]

Speaking of making things up, that is how many new procedures and treated are "invented" You can't be completely cavalier about this of course. If a particularly pathology has a great treatment, no physician has justification to invent or use a new treatment without prospective studies. However, if a particular ailment doesn't have any very effective treatments, THEN it makes sense for a physician scientist to think a bit and sometimes invent a new treatment to help the patient more than the current ineffective methods.

I was never taught this, but I invented a technique for reduce the symptoms of chronic brachial plexopathy. I do a facet injection with a posterior approach at the affected root levels (and trunk levels). I withdraw from the facet and then direct the needles to the lateral aspect of the neuroforamen but a full cm lateral to ensure no arterial uptake. I then inject depo and lido along those nerves. Makes a big difference in 2/3 of patients for 3-6 months.

Saw a patient back today. Brachial plexus injury at birth. Patient is now 40 and has suffered from a severely painful right brachial plexopathy her entire life. Failed multiple attempts at therapy and multiple meds. I did the injection for the brachial plexus which I described above. She has been 85% better for six weeks full and her 85% relief is still holding as of today.
She broke down crying during our visit today, because she is 40 years old, and I'm the only clinician who has ever significantly decreased her brachial plexus symptoms during her entire 40 years on this earth, and thanked me three times.

This is why I think outside the box.

And I post about these treatments and patients not for self aggrandizement, but to share clinical information with other physicians so they can might consider something new to help patients with similar diagnoses in the future, instead of just throwing up their hands and telling the patient to just "deal with it".

 

[SSdoc33]

Speaking of making things up, that is how many new procedures and treated are "invented" You can't be completely cavalier about this of course. If a particularly pathology has a great treatment, no physician has justification to invent or use a new treatment without prospective studies. However, if a particular ailment doesn't have any very effective treatments, THEN it makes sense for a physician scientist to think a bit and sometimes invent a new treatment to help the patient more than the current ineffective methods.

I was never taught this, but I invented a technique for reduce the symptoms of chronic brachial plexopathy. I do a facet injection with a posterior approach at the affected root levels (and trunk levels). I withdraw from the facet and then direct the needles to the lateral aspect of the neuroforamen but a full cm lateral to ensure no arterial uptake. I then inject depo and lido along those nerves. Makes a big difference in 2/3 of patients for 3-6 months.

Saw a patient back today. Brachial plexus injury at birth. Patient is now 40 and has suffered from a severely painful right brachial plexopathy her entire life. Failed multiple attempts at therapy and multiple meds. I did the injection for the brachial plexus which I described above. She has been 85% better for six weeks full and her 85% relief is still holding as of today.
She broke down crying during our visit today, because she is 40 years old, and I'm the only clinician who has ever significantly decreased her brachial plexus symptoms during her entire 40 years on this earth, and thanked me three times.

This is why I think outside the box.

And I post about these treatments and patients not for self aggrandizement, but to share clinical information with other physicians so they can might consider something new to help patients with similar diagnoses in the future, instead of just throwing up their hands and telling the patient to just "deal with it".

wow. amazing results.

where was this published again?

if not this case, then your caudal technique MUST be in publication somewhere.

you have an unhealthy god complex.

i have no doubt you are good at what you do. but your continued anecdotal cases are pretty silly and generate an immediate eyeroll from anyone in the the peanut gallery who has been doing this for a while