Fluoro vs Blind

[lobelsteve]

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Show me your literature references.

I just got into an argument with the Neurologist in my group (new practice setting) who believes Fluoro is unnecessary. He has been getting CESI blindly for 20 years from the practices old referral for Pain. I told him it was not a good idea and he became irate. I'd like to compile the references for him and educate him on why Fluoro is better than blind.

He won't believe me based on guidelines.

 

[Aether2000]

Steve, send me your email and I will send you an article I wrote on the subject with all the references attached.

 

[Mister Mxyzptlk]

http://www.thedoctors.com/risk/specialty/anesthesiology/J4253.asp

The two major points IMHO are (1) that it ensures proper placement for therapeutic benefit, and (2) that without fluoro you don't know for sure what level you're at and could get into relatively unsafe levels, which in this case appears to be above C7-T1. Every case with cord injury was at either C5-6 or C6-7.

The land mine here is an intellectual one. In this report all but one of the cord injuries happened under fluoro. Naturally we need the denominators to determine the relative risk, but we don't have that. If there were 12 cord injuries out of 2700 fluoro-guided procedures and 1 out of 100 blind procedures then fluoro is conceivably safer.

 

[Doctodd]

algos lives!!!!....glad to have u back...or maybe u never left but finally was able to chime in.

How about in the judge's eyes or a review from his peers if a complication occurs?....wil not using fluoro improve their opinion, or just save evreyone a bunch of time?(redundant question)

T

 

[Tenesma]

have had those conversations before... yawn...

but if he is in your group then i just can't understand why there would be any type of fight - especially since fluoro contributes to reimbursement (above and beyond the fact that it is quicker, more comfortable for the patient, and safer, less needle-sticks/attempts, cooler, etc..)

 

[Ligament]

Show me your literature references.

I just got into an argument with the Neurologist in my group (new practice setting) who believes Fluoro is unnecessary. He has been getting CESI blindly for 20 years from the practices old referral for Pain. I told him it was not a good idea and he became irate. I'd like to compile the references for him and educate him on why Fluoro is better than blind.

He won't believe me based on guidelines.

I got into a similar argument at my last practice. Regarding the need for fluoro to safely do injections into the neck. Ended up contributing to me leaving the practice! Same situation; old experienced doctor, had been doing the injections for 20 years, thought fluoro was a waste of time and in fact the procedures could not be done with fluoro anyway...

my point is that this can boil over into something major if you are not very careful.

 

[ampaphb]

Show me your literature references.

I just got into an argument with the Neurologist in my group (new practice setting) who believes Fluoro is unnecessary. He has been getting CESI blindly for 20 years from the practices old referral for Pain. I told him it was not a good idea and he became irate. I'd like to compile the references for him and educate him on why Fluoro is better than blind.

He won't believe me based on guidelines.

Incorrect Needle Position during Lumbar Epidural Steroid Administration: Inaccuracy of Loss of Air Pressure Resistance and Requirement of Fluoroscopy and Epidurography duringNeedle Insertion
AJNR Am J Neuroradiol 26:502–505, March 2005

Efficacy of transforaminal versus interspinous corticosteroid injection
in discal radiculalgia – a prospective, randomised, double-blind study
Clin Rheumatol (2003) 22: 299–304

The Role of Fluoroscopy in Cervical Epidural
Steroid Injections
An Analysis of Contrast Dispersal Patterns
SPINE (2002) Volume 27, Number 5, pp 509–514

Accuracy of blind versus fluoroscopically guided caudal epidural injection
SPINE (1999) Jul 1;24(13):1371-6.

Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration
AJNR Am J Neuroradiol 1991 Sep-Oct;12(5):1003-7

 

[Doctodd]

i hope you dont waste too much of your time....good luck with a difficult situation. Use lots of sugar!!!

 

[nctxil]

I don't see the reason to do a blind CESI. Is it just for convenience?
I use C6-7 as my ceiling for doing CESI's. Is that too high? Should I be entering at C7-T1?

 

[Tenesma]

there really is no good reason i can think of as far as doing higher cervical ESIs --- i usually stay at or below C6/C7... if you inject contrast (just a tiny bit and you can see how far cephalad it goes... usually one 1cc of contrast goes up 2 levels... so you have to figure 3 ccs of medication should go up quite a bit... and most injuries are C5/6 C6/7 anyway...

alternatively thread a catheter to go a bit further...

 

[Mister Mxyzptlk]

As mentioned above, all of the cord injuries in the insurance carrier review happened above C7/T1. I enter at T1/2 or T2/3 and thread a catheter (Feth-R-Cath).

 

[lobelsteve]

As mentioned above, all of the cord injuries in the insurance carrier review happened above C7/T1. I enter at T1/2 or T2/3 and thread a catheter (Feth-R-Cath).

I believe this to be the safest and best way to approach cervical epidural injections. I like C7-T1 entry, for left bias a start in the right parspinals and enter through the ligament in the midline. I'll shoot contrast and if flow is more left biased and spread to desired interspace, I'll not open a catheter kit. If I want the injectate further superior or into a foramen, I'll use a Portex or Arrow cath and advance like an SCS then let the cath fall into the gutter to get the root and hopefully a little anterior epidural spread.

 

[Aether2000]

Kirk Puttlitz and I have devised a method that uses paramedian starting position over the lamina, then angling towards the midline with the tip under AP. Once the interspinous ligament is entered or the trajectory is assured to the midline, the beam is rotated to 60 deg from the sagittal plane (30 deg to the coronal plane), and further advancement using saline LOR is ued until the posterior foraminal line is reached. At this line, the epidural space posteriorly is reached and contrast cephalocaudad spread is easily assessed. Using this rotation instead of a straight lateral gives an excellent view of the posterior epidural space without having to go through the contortions of obtaining an adequate lateral fluoro view at the C6/7 or C7/T1 level (often impossible). This will be published in an upcoming abstract, but I thought you might want to try it. The LOR with the tip of the needle midline occurs at or within 1mm of the posterior foraminal line. The problem with lateral views is visualization and the lack of definable landmarks with which to advance the needle in the lateral position.

 

[ampaphb]

Kirk Puttlitz and I have devised a method that uses paramedian starting position over the lamina, then angling towards the midline with the tip under AP. Once the interspinous ligament is entered or the trajectory is assured to the midline, the beam is rotated to 60 deg from the sagittal plane (30 deg to the coronal plane), and further advancement using saline LOR is ued until the posterior foraminal line is reached. At this line, the epidural space posteriorly is reached and contrast cephalocaudad spread is easily assessed. Using this rotation instead of a straight lateral gives an excellent view of the posterior epidural space without having to go through the contortions of obtaining an adequate lateral fluoro view at the C6/7 or C7/T1 level (often impossible). This will be published in an upcoming abstract, but I thought you might want to try it. The LOR with the tip of the needle midline occurs at or within 1mm of the posterior foraminal line. The problem with lateral views is visualization and the lack of definable landmarks with which to advance the needle in the lateral position.

Having worked with Charlie Aprill for almost a year now, we do things a bit differently than the above.

As opposed to how I was taught with Dr. Windsor, we do not use the inferior lamina as our initial touchstone, but rather aim straight for the interlaminar notch, initially using a paramedian view to better visualize the target. Aftera skin puncture, we go to straight AP, and advance using a bullseye technique with the needle and hub. Once sufficient purchase is obtained, we go to a straight lateral, and advance to the base of the spinous process, which also typically corresponds with the most inferior and posterior aspect of the facet joint. These are landmarks that are almost always visible, in my experience. At that point you start LOR, recognizing that you may still be minimally posterior of the ligament. There is a small segment of the population where the ligament is incompetent, and so the first thing you engage can be the dura in those patients. THAT is why I would advocate our approach, so you can see reliable epidural spread once you advance from the target site even minimally, and look at your contrast even if you have not engaged the ligament, in the rare event that the ligament is incompetent.

The one caveat is that, if your initial approach is not midline, but you are off to the left or the right, you are entering a curved space, and so you will be somewhat deeper than your landmarks. So long as you know that from the beginning, your sphincter tone need not be increased when you go deeper than you would normally, but you should clearly be checking with contrast in the lateral plane with each advance of the needle once you are anterior to the landmarks.

 

[Aether2000]

Peter, that approach is an excellent method if your fluoroscopy equipment will permit penetration and definition of structures in the lateral views. My old 2003 Pulsera will not reliably reveal definition in many of my "fluffy" patients as Mike calls them, even after tweaking the collimation, and using manual brightness/contrast/kV adjustments. But it is an excellent approach. And of course you and Charlie rock!

 

[Ligament]

Any way algos and paz could post images? Sorry for the bother.