Epidural/tfe

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smarterchild

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Hi all,

I was wondering if you all had any tips or tricks to reducing the pressure sensation patients experience during epidurals and tfe injections?

I usually go at the level below for patients with significant central stenosis, but they inevitably still feel quite a bit of discomfort. I do everything without sedation.

for interlam epidurals, my injectate is 1cc lidocaine, 2 cc normal saline, and then 1ml of either dex or methylpred. For tfe, I just inject 1.5 ml of a mixture Made up of 0.5 cc of lidocaine and 1 cc of dexamethasone 4mg.

appreciate any suggestions you guys may have. Thanks and stay safe!
 
Not sure if the catheter does anything directly, but I do it like Steve above. The catheter definitely seems to make it easier to inject slowly. Sometimes I feel like injecting during patient's exhalation helps.

Sent from my Pixel 4 XL using Tapatalk
 
Oh yes! I always use a catheter for all of my injections. I don’t know how some can safely aspirate and inject directly through a needle. I’ve tried the deep breathing method and that works on occasion

My concern is that I don’t want to inadvertently inject intraneurally thinking it’s just pressure from the patients stenosis. I would assume that would be excruciating but the way some patients react during injections, You would never know.
Thanks for the input!
 
smarterchild said:
Oh yes! I always use a catheter for all of my injections. I don’t know how some can safely aspirate and inject directly through a needle. I’ve tried the deep breathing method and that works on occasion

My concern is that I don’t want to inadvertently inject intraneurally thinking it’s just pressure from the patients stenosis. I would assume that would be excruciating but the way some patients react during injections, You would never know.
Thanks for the input!
Click to expand...
Oooooh. If it's THAT painful, I just abort and go for another level (usually below it).

Sent from my Pixel 4 XL using Tapatalk
 
If there is a lot of stenosis, it hurts. Aome docs fo out of their way to avoid this. I inject at the problem level regadless
 
smarterchild said:
Hi all,

I was wondering if you all had any tips or tricks to reducing the pressure sensation patients experience during epidurals and tfe injections?

I usually go at the level below for patients with significant central stenosis, but they inevitably still feel quite a bit of discomfort. I do everything without sedation.

for interlam epidurals, my injectate is 1cc lidocaine, 2 cc normal saline, and then 1ml of either dex or methylpred. For tfe, I just inject 1.5 ml of a mixture Made up of 0.5 cc of lidocaine and 1 cc of dexamethasone 4mg.

appreciate any suggestions you guys may have. Thanks and stay safe!
Click to expand...
Don’t try and slam it all in in two seconds
 
Thanks for all the hint!

how do you guys determine that the discomfort the patient is feeling is from their disease Versus the needle being somewhere it shouldn’t be? I guess this applies more for tfe. I often second guess myself and get concerned I’m intraneural or something bad like that.
 
smarterchild said:
Thanks for all the hint!

how do you guys determine that the discomfort the patient is feeling is from their disease Versus the needle being somewhere it shouldn’t be? I guess this applies more for tfe. I often second guess myself and get concerned I’m intraneural or something bad like that.
Click to expand...
I just look for "zing" vs localized pain

Sent from my Pixel 4 XL using Tapatalk
 
smarterchild said:
Hi all,

I was wondering if you all had any tips or tricks to reducing the pressure sensation patients experience during epidurals and tfe injections?

I usually go at the level below for patients with significant central stenosis, but they inevitably still feel quite a bit of discomfort. I do everything without sedation.

for interlam epidurals, my injectate is 1cc lidocaine, 2 cc normal saline, and then 1ml of either dex or methylpred. For tfe, I just inject 1.5 ml of a mixture Made up of 0.5 cc of lidocaine and 1 cc of dexamethasone 4mg.

appreciate any suggestions you guys may have. Thanks and stay safe!
Click to expand...

Decrease the volume
 
Inject slowly is the only thing I can tell you. It's a function of mechanics right? You're putting volume somewhere that has lost volume.

Decreasing stimulation on the front end helps IMO - No IV or NPO night prior (WTF). Mix bicarb into your local. Valium PO 5mg 75 min prior and again 30 min prior (call that into their pharmacy). Play music in the procedure room (albums NOT singles). Have fun and engage the pt during the procedure (Where you from originally?).

End of the day - You're putting volume somewhere that has lost volume and it might hurt regardless of your technique.
 
SommeRiver said:
Inject slowly is the only thing I can tell you. It's a function of mechanics right? You're putting volume somewhere that has lost volume.

Decreasing stimulation on the front end helps IMO - No IV or NPO night prior (WTF). Mix bicarb into your local. Valium PO 5mg 75 min prior and again 30 min prior (call that into their pharmacy). Play music in the procedure room (albums NOT singles). Have fun and engage the pt during the procedure (Where you from originally?).

End of the day - You're putting volume somewhere that has lost volume and it might hurt regardless of your technique.
Click to expand...

Why albums not singles
 
So I typically do Interlaminar. I don't have a catheter, I just inject away. There was one patient who was almost crying once b/c of the pain, I did not expect that. I just always in general inject slowly. DO NOT RUSH the injectate. Even for the very stenotic patients, I find going slow isn't that bad.
 
curious if someone has severe stenosis, where do y'all inject? Say the stenosis is at L3/4. I generally do a level above or below depending on other discs etc
 
paindoctor2014 said:
curious if someone has severe stenosis, where do y'all inject? Say the stenosis is at L3/4. I generally do a level above or below depending on other discs etc
Click to expand...
B L4 tfesi
 
paindoctor2014 said:
curious if someone has severe stenosis, where do y'all inject? Say the stenosis is at L3/4. I generally do a level above or below depending on other discs etc
Click to expand...
Paramedian L4-5 on the more symptomatic side. You’ll get the same result as B L4-5 TF if severe stenosis.
 
paindoctor2014 said:
curious if someone has severe stenosis, where do y'all inject? Say the stenosis is at L3/4. I generally do a level above or below depending on other discs etc
Click to expand...

I’ve always gone the level below. Had a patient recently who I had done bilateral TFESI below and didn’t get much relief. Had prior surgery so couldn’t do ILESI level below.

Went to see one of our surgeons who requested I do ILESI above level of stenosis. I’d never done that before but the patient got fantastic relief.


Sent from my iPhone using SDN
 
DOctorJay said:
I’ve always gone the level below. Had a patient recently who I had done bilateral TFESI below and didn’t get much relief. Had prior surgery so couldn’t do ILESI level below.

Went to see one of our surgeons who requested I do ILESI above level of stenosis. I’d never done that before but the patient got fantastic relief.


Sent from my iPhone using SDN
Click to expand...

I'd argue in that scenario any injxn would have helped.
 
pmrmd said:
Paramedian L4-5 on the more symptomatic side. You’ll get the same result as B L4-5 TF if severe stenosis.
Click to expand...

Really? Maybe, but how do you know? TFESI>ILESI via literature.
 
DOctorJay said:
I’ve always gone the level below. Had a patient recently who I had done bilateral TFESI below and didn’t get much relief. Had prior surgery so couldn’t do ILESI level below.

Went to see one of our surgeons who requested I do ILESI above level of stenosis. I’d never done that before but the patient got fantastic relief.


Sent from my iPhone using SDN
Click to expand...
Surgeons have some weird ideas about these shots. They really have no clue about the best approach -- they just think they do.

I had one who demanded an ilesi cephaled to the stenosis bc he thought it would 'drip down'. Not a horrible thought, but also no the best initial plan.
 
Ducttape said:
use a larger syringe.

the pressure you create using a 3 ml syringe is significantly greater than a 10 ml syringe.
Click to expand...

...at the risk of your thumb/finger over time.
 
If patient feels a zinger during TFESI. Stop, let it resolve, then try again. If it is not resolving immediately, you're too close.

Larger syringes do provide less pressure overall, but you can titrate better with a small syringe. Whatever you use, inject slowly.

In general:
1. Inject slower
2. Use less volume
3. Use extension tubing to mitigate movements.

I would also argue to remove the local from your epidural. No clinical benefit, more risk, and can confuse the picture if something weird happens.
 
SommeRiver said:
...at the risk of your thumb/finger over time.
Click to expand...
really?

I assume you are being facetious.


if not, factor the extra time you need to inject with the 3 cc syringe vs the 10 cc syringe in your equation and it will even out.

better yet then, don't do the injection at all if you are worried about your poor liddle thumb...
 
I spent years hitting things with my fists. I worry about my hands at 70.
 
DOctorJay said:
I’ve always gone the level below. Had a patient recently who I had done bilateral TFESI below and didn’t get much relief. Had prior surgery so couldn’t do ILESI level below.

Went to see one of our surgeons who requested I do ILESI above level of stenosis. I’d never done that before but the patient got fantastic relief.


Sent from my iPhone using SDN
Click to expand...

I also have always gone one level below unless only mild stenosis at affected level. I don’t do TFESI very often for stenosis unless they fail ILESI, because TFESI with dex rarely lasts as long.

Similar to you, I always did one level below for most stenosis. A few years ago, I started doing the level above for some cases where there was no intact level below, and it works most of the time.

I’ve had several stenosis patients who were not safe for surgery, did not have intact lamina below the stenotic level, had only 1-2 weeks of relief after TFESI with dex, but who obtained 4+ months of relief after ILESI at the level above.
 
bedrock said:
I also have always gone one level below unless only mild stenosis at affected level. I don’t do TFESI very often for stenosis unless they fail ILESI, because TFESI with dex rarely lasts as long.

Similar to you, I always did one level below for most stenosis. A few years ago, I started doing the level above for some cases where there was no intact level below, and it works most of the time.

I’ve had several stenosis patients who were not safe for surgery, did not have intact lamina below the stenotic level, had only 1-2 weeks of relief after TFESI with dex, but who obtained 4+ months of relief after ILESI at the level above.
Click to expand...

Does it work well enough that you would choose above the level as a 1st option?
 
I recently saw a Young 33 year old lady with severe right L5 foraminal stenosis from a herniated disc. No significant spinal stenosis at L5-s1 or any level for that matter. Pretty unremarkable mri otherwise.

tried to get a tfe approved through her insurance but the doctor I did the peer to peer with was adamant I try an interlaminar first as it “is much safer”. I tried to quote some of the literature posted here but he refused to buy into it. I appealed it and the original doctors decision was upheld.

Given all this, Do you all recommend doing an right paramedian esi at l5-s1 or at l4-5? She came into the office crying saying she was in such excruciating pain and just wanted it surgically repaired but no surgeon would see her as this “wasn’t urgent”

thanks in advance
 
smarterchild said:
I recently saw a Young 33 year old lady with severe right L5 foraminal stenosis from a herniated disc. No significant spinal stenosis at L5-s1 or any level for that matter. Pretty unremarkable mri otherwise.

tried to get a tfe approved through her insurance but the doctor I did the peer to peer with was adamant I try an interlaminar first as it “is much safer”. I tried to quote some of the literature posted here but he refused to buy into it. I appealed it and the original doctors decision was upheld.

Given all this, Do you all recommend doing an right paramedian esi at l5-s1 or at l4-5? She came into the office crying saying she was in such excruciating pain and just wanted it surgically repaired but no surgeon would see her as this “wasn’t urgent”

thanks in advance
Click to expand...

Paramedian L5-S1.
 
L5-S1 and what a sad and dumb story. In that situation I would personally do an S1 TFESI with 1cc normal saline, 1cc 0.25% bupi, and 10mg dexamethasone. That 3cc volume would cover that pathology nicely. If it is an acute herniation I may just do 2cc of bupi and hold the saline (if she's miserable).

I am now (bc of this forum) only using anesthetic in my epidurals for acute herniations, and long standing stenotic pts just get steroid and saline.

Edit - I would add that if I did an S1 and she got good relief but it didn't last long I would consider repeating with an additional level (L4-5 + S1). I occasionally do that and I'll bracket the level. Occasionally I'll just repeat the single level with particulate (maybe once a year).
 
smarterchild said:
I recently saw a Young 33 year old lady with severe right L5 foraminal stenosis from a herniated disc. No significant spinal stenosis at L5-s1 or any level for that matter. Pretty unremarkable mri otherwise.

tried to get a tfe approved through her insurance but the doctor I did the peer to peer with was adamant I try an interlaminar first as it “is much safer”. I tried to quote some of the literature posted here but he refused to buy into it. I appealed it and the original doctors decision was upheld.

Given all this, Do you all recommend doing an right paramedian esi at l5-s1 or at l4-5? She came into the office crying saying she was in such excruciating pain and just wanted it surgically repaired but no surgeon would see her as this “wasn’t urgent”

thanks in advance
Click to expand...

L5-S1 intralaminar as an initial approach for me in this instance.
 
id be tempted to do the L5 TFESI anyway. Its the kost appropriate injection. Ive never had a reviewer ok one TYPE of ESI vs another
 
SSdoc33 said:
id be tempted to do the L5 TFESI anyway. Its the kost appropriate injection. Ive never had a reviewer ok one TYPE of ESI vs another
Click to expand...
Me either. I’ve never heard of an insurer getting so involved. I would probably do a paramedian IL if it is as stenotic as you say, she’s already acute and hypersensitive, and I don’t have IV sedation. This is a case appropriate for IV sedation if you want TF.
 
thanks for the input everyone. unfortunately, this hasn't been the first issue I've had with this particular payer, which is a small insurance company here in the new england area. one other issue I had a few months ago was for a patient for whom I was requesting a repeat lumbar RF. She had a whole year of relief from the last one. They demanded I repeat at least one MBB to confirm that her pain was facet-mediated even though the patient said the pain was exactly the same as it was before the last RF.

I do really like the TFE idea but unfortunately I don't have access to IV sedation as I do them in the office with just local. Will do the interlam and hope for the best.

thanks again
 
smarterchild said:
thanks for the input everyone. unfortunately, this hasn't been the first issue I've had with this particular payer, which is a small insurance company here in the new england area. one other issue I had a few months ago was for a patient for whom I was requesting a repeat lumbar RF. She had a whole year of relief from the last one. They demanded I repeat at least one MBB to confirm that her pain was facet-mediated even though the patient said the pain was exactly the same as it was before the last RF.

I do really like the TFE idea but unfortunately I don't have access to IV sedation as I do them in the office with just local. Will do the interlam and hope for the best.

thanks again
Click to expand...

What? Are you saying you won't do transforaminal because no sedation available?
 
smarterchild said:
thanks for the input everyone. unfortunately, this hasn't been the first issue I've had with this particular payer, which is a small insurance company here in the new england area. one other issue I had a few months ago was for a patient for whom I was requesting a repeat lumbar RF. She had a whole year of relief from the last one. They demanded I repeat at least one MBB to confirm that her pain was facet-mediated even though the patient said the pain was exactly the same as it was before the last RF.

I do really like the TFE idea but unfortunately I don't have access to IV sedation as I do them in the office with just local. Will do the interlam and hope for the best.

thanks again
Click to expand...
I think the insurer was being reasonable wanting a block for the repeat RF. A whole year later it may be coming from other levels.
 
smarterchild said:
thanks for the input everyone. unfortunately, this hasn't been the first issue I've had with this particular payer, which is a small insurance company here in the new england area. one other issue I had a few months ago was for a patient for whom I was requesting a repeat lumbar RF. She had a whole year of relief from the last one. They demanded I repeat at least one MBB to confirm that her pain was facet-mediated even though the patient said the pain was exactly the same as it was before the last RF.

I do really like the TFE idea but unfortunately I don't have access to IV sedation as I do them in the office with just local. Will do the interlam and hope for the best.

thanks again
Click to expand...

You don't need IV sedation for any epidural, whether it is foraminal or interlaminar. If your pt is nervous give them Valium PO.
 
SommeRiver said:
You don't need IV sedation for any epidural, whether it is foraminal or interlaminar. If your pt is nervous give them Valium PO.
Click to expand...
I disagree. It isn’t anxiety but discomfort. Plenty of times people with severe foraminal stenosis have no pain with the needle in place but jump when the contrast slowly starts flowing. Some pre-procedure hydrocodone helps those people I guess but they would still prefer an IV. I might sedate 1-2 people in a month for a TFESI.
 
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