Epidural Technique

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What technique do you guys use for intralaminar epidural needle placement?

I used to love the saline-bubble, drive-with-the-plunger technique for OB patients, however, for good reasons, I can see why that's not commonly done in pain for epidural steroid injections. I asked one of my preceptors what would be wrong with putting constant pressure on the syringe as I advance the needle with my fingertips, and he said "nothing, except your attendings are going to want to see the bouncing." That made me wonder what variations on the basic LOR to air technique are done in private practice. What do you guys do?
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First I spell it interlaminar not intralaminar...:laugh:

Second I use saline topped off with a bit of air...
 
interlaminars are a dying breed - but when i do them i use a hanging drop technique in virgin backs.
 
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Tenesma said:
interlaminars are a dying breed - but when i do them i use a hanging drop technique in virgin backs.
Click to expand...



They are a dying breed. However, I think that some of this is due to greed. I see so many patients who get bilateral L4 and L5 transforaminal injections. A lot of this is obviously $$$ driven which is a shame. I really think that if we were reimbursed more for interlaminars, then transforaminals would not be nearly as common.


To answer the OP, I use LOR to air and saline in lumbar and hanging drop in cervical
 
A dying breed in the back, perhaps, but certainly not in the neck ...
 
With respect to blind epidural steroid injections for pain: it is unethical, substandard care that borders on malpractice to be using these. In this day and age, no orthopedist would ever do blind hip pinnings, although they used to do so. Our profession of pain medicine has advanced far beyond the touchy feely guestimations of our anesthesiogist predecessors and has advanced to precision placement of steroids. If interlaminar is ever used (yes, there are occasionally reasons for these to be used such as severe foraminal stenosis with the lack of ingress of contrast on neurography), then it should only be used with fluoroscopic guidance.
Once the physician has made the decision to practice 21st century medicine, then the controversy becomes saline, saline-air, air, or contrast as the injectate. Air alone can cause subdural and subarachnoid inadvertent injections and has caused massive headaches with seizures. There is no rational reason in this day and age to use air because of the potential for intravascular, subdural, or subarachnoid injection. Epidural air can cause air bubbles to form near the nerve root with significant radicular pain.
Saline or saline-air appears to be a useful alternative if the LOR technique is used. There are other techniques to localize the epidural space including stimulation (stimulating epidural needles insulated are available), pressure measurement via manometer, audio manometer, or using a saline infusion. Ultrasound is not yet ready for prime time for epidural use. CT does not permit eval of partial vascular uptake.
While the hanging drop technique does work, it works through tenting of the dura. The average needle insertion is 3 mm further with hanging drop vs LOR technique. However, there is a long history of using this technique with few complications, and when contrast is used thereafter, it is an excellent technique.
 
algosdoc said:
With respect to blind epidural steroid injections for pain: it is unethical, substandard care that borders on malpractice to be using these. In this day and age, no orthopedist would ever do blind hip pinnings, although they used to do so. Our profession of pain medicine has advanced far beyond the touchy feely guestimations of our anesthesiogist predecessors and has advanced to precision placement of steroids. If interlaminar is ever used (yes, there are occasionally reasons for these to be used such as severe foraminal stenosis with the lack of ingress of contrast on neurography), then it should only be used with fluoroscopic guidance.
Once the physician has made the decision to practice 21st century medicine, then the controversy becomes saline, saline-air, air, or contrast as the injectate. Air alone can cause subdural and subarachnoid inadvertent injections and has caused massive headaches with seizures. There is no rational reason in this day and age to use air because of the potential for intravascular, subdural, or subarachnoid injection. Epidural air can cause air bubbles to form near the nerve root with significant radicular pain.
Saline or saline-air appears to be a useful alternative if the LOR technique is used. There are other techniques to localize the epidural space including stimulation (stimulating epidural needles insulated are available), pressure measurement via manometer, audio manometer, or using a saline infusion. Ultrasound is not yet ready for prime time for epidural use. CT does not permit eval of partial vascular uptake.
While the hanging drop technique does work, it works through tenting of the dura. The average needle insertion is 3 mm further with hanging drop vs LOR technique. However, there is a long history of using this technique with few complications, and when contrast is used thereafter, it is an excellent technique.
Click to expand...

SO when is the draft statement going to be available for Medicare and private carriers so we can eliminate payment for substandard care to practitioners more interested in $$$ than patients?

This needs to be ditto for ESI, MBB, SIJ, IA hips. We need to have ICD9's linked to CPT's that allow use of epidural placement for L&D and OR use separate from Pain Medicine. Anyone opposed?

see my post in the Picture of the Week thread where a blind ESI was in the subQ fat. Anes-Pain guy with 20+ yrs experience. Unacceptable.
 
lobelsteve said:
SO when is the draft statement going to be available for Medicare and private carriers so we can eliminate payment for substandard care to practitioners more interested in $$$ than patients?

This needs to be ditto for ESI, MBB, SIJ, IA hips. We need to have ICD9's linked to CPT's that allow use of epidural placement for L&D and OR use separate from Pain Medicine. Anyone opposed?

see my post in the Picture of the Week thread where a blind ESI was in the subQ fat. Anes-Pain guy with 20+ yrs experience. Unacceptable.
Click to expand...




wow........
 
what are the general thoughts of the forum on lumbar fluoroscopically-guided interlaminar injections?
 
mille125 said:
what are the general thoughts of the forum on lumbar fluoroscopically-guided interlaminar injections?
Click to expand...

They work in selected patients.
I typically do a TFESI first based on clinical exam and correlative imaging. If the patient gets 50+% relief but not long lasting, I'll switch to IL-ESI, or if anatomy precludes this, caudal with catheter.

1. Consent
2. Prep- Hibiclens>Iodine, alcohol unacceptable unless done prior to either of the others listed
3. C-arm scout to pick best place to raise a wheal
4. 25-3.5 through wheal to superior part of lamina at bottom of level of entry (upper L5 lamina for a L4-5 ILESI), paramedian approach
5. Tuohy or Coude RX2 (plug for Racz but at what cost per needle) through anesthetized track to lamina
6. Walk off lamina and advance to ligament while injecting 1cc lidocaine
7. LOR with NSS- I use a 10cc plastic syringe, you can spend more for Epilor or glass if it makes you feel better)
8. attach CLC (cute little catheter) (0.2cc priming volume, 6")
9. Contrast followed first AP, then lateral image obtained during test dose
10. Inject pancake mix or whatever cocktail you like
11. Single image washout obtained

ILESI is still bread and butter of pain medicine. Good for radicular pain, spinal stenosis, fair for DDD at best, worthless for spondylosis, listhesis without root compression or canal stenosis.
 
lobelsteve said:
They work in selected patients.
I typically do a TFESI first based on clinical exam and correlative imaging. If the patient gets 50+% relief but not long lasting, I'll switch to IL-ESI, or if anatomy precludes this, caudal with catheter.

1. Consent
2. Prep- Hibiclens>Iodine, alcohol unacceptable unless done prior to either of the others listed
3. C-arm scout to pick best place to raise a wheal
4. 25-3.5 through wheal to superior part of lamina at bottom of level of entry (upper L5 lamina for a L4-5 ILESI), paramedian approach
5. Tuohy or Coude RX2 (plug for Racz but at what cost per needle) through anesthetized track to lamina
6. Walk off lamina and advance to ligament while injecting 1cc lidocaine
7. LOR with NSS- I use a 10cc plastic syringe, you can spend more for Epilor or glass if it makes you feel better)
8. attach CLC (cute little catheter) (0.2cc priming volume, 6")
9. Contrast followed first AP, then lateral image obtained during test dose
10. Inject pancake mix or whatever cocktail you like
11. Single image washout obtained

ILESI is still bread and butter of pain medicine. Good for radicular pain, spinal stenosis, fair for DDD at best, worthless for spondylosis, listhesis without root compression or canal stenosis.
Click to expand...

In a tangentially related question...are people doing test doses and if so what are they using?
 
i agree that forcing air or potentially forcing air into the epidural space should be avoided - better to stick w/ saline... once you have had a patient w/ pneumocephalus you will understand...

also, while TF are better reimbursed, I find them to be far superior to IL ESI --- primarily because of the issues of spread in the posterior epidural space...

and I will always opt for a bilateral TFESI over IL in a patient w/ previous lami and/or post. instrumented fusion... i find that less complications (ie: inadvertent wet-taps) and benefits favor TFESI in that population
 
Tenesma said:
i agree that forcing air or potentially forcing air into the epidural space should be avoided - better to stick w/ saline... once you have had a patient w/ pneumocephalus you will understand...

also, while TF are better reimbursed, I find them to be far superior to IL ESI --- primarily because of the issues of spread in the posterior epidural space...

and I will always opt for a bilateral TFESI over IL in a patient w/ previous lami and/or post. instrumented fusion... i find that less complications (ie: inadvertent wet-taps) and benefits favor TFESI in that population
Click to expand...




you could also argue that there is a higher risk of spinal cord infarction from vascular spread in these patients and perform ILESI over bilateral transforaminal...
 
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Tenesma said:
i agree that forcing air or potentially forcing air into the epidural space should be avoided - better to stick w/ saline... once you have had a patient w/ pneumocephalus you will understand...

also, while TF are better reimbursed, I find them to be far superior to IL ESI --- primarily because of the issues of spread in the posterior epidural space...

and I will always opt for a bilateral TFESI over IL in a patient w/ previous lami and/or post. instrumented fusion... i find that less complications (ie: inadvertent wet-taps) and benefits favor TFESI in that population
Click to expand...



Have you seen better results clinically? I have not. They seem to be very similar clinically (n>5000). Contrary to popular belief you can get into the anterior epidural space with an ILESI. Think about how many stimulators inadvertantly get into the anterior space during placement.

I am not picking with you tenesma. Just playing devil's advocate...
 
mille125 said:
Have you seen better results clinically? I have not. They seem to be very similar clinically (n>5000). Contrary to popular belief you can get into the anterior epidural space with an ILESI. Think about how many stimulators inadvertantly get into the anterior space during placement.

I am not picking with you tenesma. Just playing devil's advocate...
Click to expand...

I disagree with that. You can not get into the anterior epidural space with an ILESI either reliably or predictably even with lateral epidural needle placement. There are at least three studies that report 35-75% anterior flow, the highest was reported with 10-12 ml of injection volumes.
 
i've been crucified on this forum for saying this, but i think interlaminars are more comfortable for the patient, so i usually start out with them except with post-surgical and usually stenosis patients (?better anterior spread and calcified lig flavum in the older population)
 
SSdoc33 said:
i've been crucified on this forum for saying this, but i think interlaminars are more comfortable for the patient, so i usually start out with them except with post-surgical and usually stenosis patients (?better anterior spread and calcified lig flavum in the older population)
Click to expand...

That hasnt been my experience but I am pretty much been using 25G needles for my TFESIs these days.
 
mehul_25 said:
I disagree with that. You can not get into the anterior epidural space with an ILESI either reliably or predictably even with lateral epidural needle placement. There are at least three studies that report 35-75% anterior flow, the highest was reported with 10-12 ml of injection volumes.
Click to expand...

You can too!!!

But the techniue is uncomfotable-having to go through the posterior and anterior dura to get there. As far as the SCS getting there, well that is a pretty big catheter, not a needle. SOme of the medicine will go anterior, but not enough to make an argument on that end as compared to TFESI, where the needle can be brought in front of the thecal sac (usually stop under the pedicle) in a retrodiscal approach.
 
SSdoc33 said:
i've been crucified on this forum for saying this, but i think interlaminars are more comfortable for the patient, so i usually start out with them except with post-surgical and usually stenosis patients (?better anterior spread and calcified lig flavum in the older population)
Click to expand...

Call the guys at ASIPP, they will test you out for the low proce of $6000 and find out why you think ILESI is better than TFESI. It is more comfortable for you, but probably not your patient. 25G vs 17-20G.
 
lobelsteve said:
Call the guys at ASIPP, they will test you out for the low proce of $6000 and find out why you think ILESI is better than TFESI. It is more comfortable for you, but probably not your patient. 25G vs 17-20G.
Click to expand...


id rather have an interlaminar than a TFESI, if it was done by myself. i dont just spear them with a 17 guage, i numb the skin with a 30, and the track with a 25g. 17-20g touhy goes in and then dont feel a thing, including the injectate, which, in my opinion can sometimes be painful.

id prefer to do TFESIs because of that rare time you go intrathecal really pisses me off, but patients are consistently surprised at how easy the ILESIs are. not as consistently pleased with TFESIs
 
The majority of my patients are evaluated for TFESI procedures...
However in a small subset of patient's with large disc herniations and foraminal narrowing, TFESI don't seem to work or spread well. I was 'advised' by a neurosurgeon once, to perform a IL-esi instead, and the patient did much better. I was quite surprised that the patient improved, but even more surprised that the neurosurgeon took the time to evaluate the situation. I did not attempt a b/l TFESI, so I cannot compare at LESI vs. b/l TFESI in this patient....;)
 
stim4u said:
The majority of my patients are evaluated for TFESI procedures...
However in a small subset of patient's with large disc herniations and foraminal narrowing, TFESI don't seem to work or spread well. I was 'advised' by a neurosurgeon once, to perform a IL-esi instead, and the patient did much better. I was quite surprised that the patient improved, but even more surprised that the neurosurgeon took the time to evaluate the situation. I did not attempt a b/l TFESI, so I cannot compare at LESI vs. b/l TFESI in this patient....;)
Click to expand...
In the situation where you have a large central or paracentral herniation at the object level, my preference would be to perform a TFESI at the adjacent level if I did not see adequate proximal flow with my initial injection, rather than performing an ILESI.
 
I only utilize TFESI, and have so for the past few years. The patient rarely complains that it is painful (you can usually avoid things, thanks to the MRI), and my results have been just fine. I have never felt the need to do an interlam, and only a few times have I needed to go a level below or above in order to get the meds epidural. Just reporting.
 
I sometimes do interlaminars for spinal stenosis because the pathology is not necessarily anterior. I also use high volumes, usually 10 ccs, to try to get as much filling as possible and to wash out all those fancy chemicals algos talks about.

I don't do any cervical TFs except for C2, since I can't get there by IL. I can't tell any difference in clinical response between TFs and ILs in the neck.
 
ampaphb said:
In the situation where you have a large central or paracentral herniation at the object level, my preference would be to perform a TFESI at the adjacent level if I did not see adequate proximal flow with my initial injection, rather than performing an ILESI.
Click to expand...




i find that patient's with large disk herniations tend to have a lot of discomfort when receiving transforaminal injections
 
the question is "does steroid need to get to the anterior epidural space in order to be effective". i would think that the answer is no.....
 
mille125 said:
i find that patient's with large disk herniations tend to have a lot of discomfort when receiving transforaminal injections
Click to expand...

oy; dont open up THAT can of worms.....
 
mille125 said:
the question is "does steroid need to get to the anterior epidural space in order to be effective". i would think that the answer is no.....
Click to expand...

Its kind of a tricky question.

Steroids have some anti-neuropathic pain effects from direct effect on nerves themselves. A membrane stabilizing effect if you will. This, to my knowledge is still in the early stages of investigation. So considering this, if there is a neuropathic or wind-up aspect to the patients pain, it is irrelevant whether the steroid reaches the ventral or dorsal epidural space, as long as it makes contact with the painful nerve.

However, assuming a patient has an HNP with radiculalgia, then one would want to deliver steroid TO the HNP itself to reduce the all the nasty inflammatory chemicals; TNFa, prostaglandins, etc. Since ILESI only delivers medication to the ventral epidural space in roughly 33% of procedures, vs 99% of cases in TFESI, one would think the TFESI would be the better choice.

Like Gorback, I tend to do ILESIs only for dorsal epidural space pain generators. This is pretty rare.

Like Tenesma, I'll do bilateral TFESIs at the same level in cases of post op backs.

Like Dr. Russo, I'll sometimes "bracket" an HNP with a TFESI above and below to be sure I get meds to the HNP itself.

Like Algos, I'll sometimes do his patented lateral recess epidural injection when the above fail...
 
mille125 said:
the question is "does steroid need to get to the anterior epidural space in order to be effective". i would think that the answer is no.....
Click to expand...

funny - i just observed someone use a caudal approach to thread a catheter into the anterior epidural space up to the levels of the disk herniations (L4-L5 and L5-S1) and deposit the steroid/local mix there. will have to wait and see how the patient does - although logically it makes sense to try to get as close to the pathology as possible... then again, i'm still just a fellow :laugh:
 
What's wrong with doing a caudal cath up to the lumbar area?
 
I used to do them a lot. Prettiest Xmas tree patterns I ever saw. Now that I do most of my procedures in the office I don't use the technique very much. The way they reimburse for the catheter and needle I lose so much money on the supplies that I net less than an ILESI.
 
i am probably near 50/50 on TFESI vs ILESI in my practice. I really cant say that I have noticed a difference in efficacy. Interestingly enough, I have seen patients fail one approach and respond favorably to the other....
 
mille125 said:
i am probably near 50/50 on TFESI vs ILESI in my practice. I really cant say that I have noticed a difference in efficacy. Interestingly enough, I have seen patients fail one approach and respond favorably to the other....
Click to expand...

I could have written that exact statement.

Isn't it funny how there are so many ways to achieve the same results...
 
mille125 said:
hanging drop in cervical
Click to expand...

Please explain this one. We just do the same "sterile saline with air and continuous pressure" technique for cervical IL ESI as we do for lumbars. Haven't heard of "hanging drop" yet.

Thanks.
 
http://www.ncbi.nlm.nih.gov/pubmed/18227326

I haven't been able to access the full text of the above article from "Anesthesia & Analgesia", but the abstract is quite interesting. States basically that a parasagittal IL approach had more contrast spread to anterior epidural space than a TF approach.

What do you all think??
 
dc2md said:
http://www.ncbi.nlm.nih.gov/pubmed/18227326

I haven't been able to access the full text of the above article from "Anesthesia & Analgesia", but the abstract is quite interesting. States basically that a parasagittal IL approach had more contrast spread to anterior epidural space than a TF approach.

What do you all think??
Click to expand...



i have read that article as well and it does not surprise me based on my results
 
dc2md said:
Please explain this one. We just do the same "sterile saline with air and continuous pressure" technique for cervical IL ESI as we do for lumbars. Haven't heard of "hanging drop" yet.

Thanks.
Click to expand...



fill the tuohy with saline (i use a 20G tuohy for cervicals) when you are in the epidural space the drop will disappear..it really leaves no doubt that you are in the epidural space
 
i dont have full text either right now, but i agree, it does not make sense. take a spot lateral of a TFESI vs. a ILESI and you tell me where the contrast goes. please post the mechanism they suggest in the article or the full text if you can.
 
I tried uploading the pdf but it exceeds the 300kb limit for pdfs, which is bullcrap. If a mod wants to help out I'd be happy to forward.
 
I reduced the pdf filesize so the images may not be as nice as the original...
 

Attachments

  • interlaminarvstfesicandido.pdf
    191.6 KB · Views: 211
even if you do get ventral epidural flow, you still get dorsal epidural flow, which means less medication delivery to the ventral space
 
In an effort to pro-
vide a suitable and reliable alternative to the TF
approach, we studied the parasagittal interlaminar
(PIL) epidural approach. With this interlaminar ap-
proach, the injection is performed at the lateralmost part
of the interlaminar space instead of the usual midline
interlaminar approach.
 

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  • 1.jpg
    1.jpg
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Ligament said:
even if you do get ventral epidural flow, you still get dorsal epidural flow, which means less medication delivery to the ventral space
Click to expand...



yes...but the efficacy appears to be the same at least in my patients
 
Ligament said:
I reduced the pdf filesize so the images may not be as nice as the original...
Click to expand...




thanks for posting...my technique for ILESI's is very similar to the parasagittal that they describe here (if a patient has right sided L5/S1 pathology put the steroid on the right side (easy to do with flouroscopy))... it does surprise me that they did see anterior epidural spread at a rate of 100%..

makes you really question if TFESI really need to be done 100% of time in the lumbar spine..hopefully it is not solely the monetary influence that is driving this practice...
 
Thanks for the pdf Ligament. I'll use this article for my upcoming journal club too.

Here's the technique used for the parasagittal IL approach from the study:

"For the PIL approach, a 20-gauge 3.5 in. Tuohy-type epidural needle was introduced at the level of demonstrated disk pathology by imaging, at the point corresponding to the lateralmost part of the interlaminar opening at
its midlevel as indicated by the direct AP projection on fluoroscopy (no oblique or cephalo-caudad tilt used) (Figs. 1a and b). The needle was advanced directly perpendicular to the skin in a posterior to anterior
direction, with the use of the loss-of-resistance to air technique in order to identify the epidural space. The parasagittal orientation of the needle was maintained throughout the procedure. Once the loss-of-resistance
was obtained, contrast media, 5 mL (Iohexol-180, Amersham Health, Oslo, Norway) was injected using real-time, continuous fluoroscopy for the entire volume of 5 mL of injectate, and images were obtained in the lateral and AP projections (Figs. 2 and 3). The use of the real-time and continuous imaging was to verify that no contrast attained intravascular, subarachnoid, subdural, or intradiscal spread. Next, the antiinflammatory corticosteroid, methylprednisolone acetate, 80 mg, along with 1 mL of normal saline and 1 mL of lidocaine 1%, was injected into the epidural space (total volume; 4 mL). The saline was added to dilute polyethylene glycol 4000 (28.6 mg/mL), the vehicle added during manufacture of methylprednisolone that has been implicated to be associated with arachnoiditis."
 
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mille125 said:
fill the tuohy with saline (i use a 20G tuohy for cervicals) when you are in the epidural space the drop will disappear..it really leaves no doubt that you are in the epidural space
Click to expand...

Yes, it really does leave a doubt you are in the epidural space.
Thats why we have fluoroscopy and contrast.


And what percent of patients have no ligamentum flavum to give you that first LOR?

Hanging drop through the dura happens.
 
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