Definitely oof'd, possibly even audibly during the procedure. The patient ended up being totally fine afterwards so I can laugh about it now but definitely not one of my proudest moments. It's also probably the most compelling example I've had where the "puffs of contrast" technique advocated here would have prevented it.
I reviewed a case where the injectionist used gadolinium for the contrast. Chose gad becasue the chart had the patient having a "dye allergy"
Air epidurogram if IL, no contrast if TF w/dex
Spoken to a few difference specialties. Most of the rads never use contrast for IL or TFESI. Never done this before. How can you tell your epidural and not intrathecal or out?
I love blowing their mind with
I know someone who did this, shoot you probably reviewed their case. They were an all-around bad clinician. They’re now a fellowship PD.
This, although pneumoceohalus is no joke if you get IT w the air. I saw a case during fellowship… Not in my hands… to the ER with essentially a thunderclap headache… ultimately nothing else found but air in the ventricles. Admitted, monitored with serial CT. Patient was miserable. I still do loss the air… But occasionally think about that case….
Any merit and just converting the ilesi to tfesi? I've seen some some docs abandon the ilesi and they tell me no difference in offices
Need both of these tools in the box.
Sorry for my ignorance...as I don't deal with reimbursement -
Every day. Bread n butter. At level below.
As above couldn’t one argue that air IT is as bad as gad?
I don’t believe in allergies.
No experience here - just thinking out loud.
Not at the level….unless they have a preserved epidural space.
Same, however, regarding MRI… the only time I will do an esi with an older MRI like that is if they are elderly with known stenosis, having flareup/recurrence of their typical neurogenic claudication in identical distribution as the last time I personally saw them. Just about anything else gets a new MRI for ESI.
This. I draw back maybe 1/4- 1/2 cc max of air.
True anaphylactic reactions to iodinated contrast are rare but yes, they would definitely react to even such a small amount. The vast majority of patients have an anaphylactoid reaction - direct mast cell irritation by the substance. They don’t in general react to a small amount that is not administered IV.
anyone not PM&R that doesnt use LOR for ESI/SCS? I know anesthesia folks might feel more familiar with LOR from the several hundred labor epidurals during residency but wonder if any of the anesthesia folks converted to not using LOR once they started practicing pain medicine
You use contrast for your SCS cases?
No. CLO, leads placed in the needle when I’m 1-2mm from the LF. Gentle pressure and the needle bites into the LF, and the lead goes in safely with no issues. I’ll use LOR if I’m struggling, but prob 95% of trials and implants I don’t use it.
In my 20th year in practice. Not sure labor epidurals in training equal what I have done in practice. But your post is telling about you as a physician. Direct visualization is superior to your feels. Didn't Lobel get his name on a blind vs image guided paper years ago/
pubmed.ncbi.nlm.nih.gov
air causes PDPH headache.
yes. it might be as small as a local skin reaction that leads to pruritis and thats it for the initial exposure.
I do not think labor epidurals are in anyway similar to what we do, and I did a lot of thoracic catheters for CT surgery and trauma during my fellowship. We did acute pain, and yes I went in at 0300 to place bedside catheters in polytrauma pts. It has nothing to do with our field IMO.In my 20th year in practice. Not sure labor epidurals in training equal what I have done in practice. But your post is telling about you as a physician. Direct visualization is superior to your feels. Didn't Lobel get his name on a blind vs image guided paper years ago/
The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data - PubMed
In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical...
