For those who put anesthetic in their epidurals, why?

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cameroncarter

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(sincere question following the TX paralysis case.)

Seems like excluding local may help with earlier identification of nerve/cord injury post-procedure in patients who reports numbness/weakness.
 
willabeast said:
One reason to put local in is it confirms you targeted the pain generator (or missed it). Another reason is that I remember some studies done in the past using only local that showed a benefit in pain relief longer than the duration of the local. Lack of Superiority of Epidural Injections with Lidocaine with Steroids Compared to Without Steroids in Spinal Pain: A Systematic Review and Meta-Analysis - PubMed
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Agreed with this.

Also depends on how much put in. 40mg of triamcinolone, 3 normal saline, and 1ml of 1%lidocaine combo will not cause a profound blockade. As an anesthesia resident for certain. Surgeries we would out in 1 to 1.5ml of lidocaine intra thecal for surgeries/c sections.

Reasons to give local. There is a nocebo response. Also if someone is miserable and had acute on chronic pain, I recall studies showing giving immediate relief helps the patient psychologically. Also I understand lidocaine should last 30min. But sometimes after desensitizating the nerves it lasts longer. Think why do MBBs last longer than the 3hr window?

I wouldn't put in 4mL of lidocaine. I think it's dose and volume specific. Unfortunately bad things will always happen.
 
PinchandBurn said:
Agreed with this.

Also depends on how much put in. 40mg of triamcinolone, 3 normal saline, and 1ml of 1%lidocaine combo will not cause a profound blockade. As an anesthesia resident for certain. Surgeries we would out in 1 to 1.5ml of lidocaine intra thecal for surgeries/c sections.

Reasons to give local. There is a nocebo response. Also if someone is miserable and had acute on chronic pain, I recall studies showing giving immediate relief helps the patient psychologically. Also I understand lidocaine should last 30min. But sometimes after desensitizating the nerves it lasts longer. Think why do MBBs last longer than the 3hr window?

I wouldn't put in 4mL of lidocaine. I think it's dose and volume specific. Unfortunately bad things will always happen.
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I have to agree with the nocebo response Pinch, you’re absolutely right.

I’m going to take a page out of lobelsteve’s book and switch to Lido 1-2% though. Everyone in my fellowship and area uses 0.25cc bupi - must be creatures of habit.
 
No local in cervicals, but all lumbar IL and TF I use lido 1% or 2%.

Typical lumbar ILESI for me 80mg Depo, 2cc saline and 1cc lido 2%.

TF generally dexamethasone 10mg, 1cc saline and 1cc lido 1-2%.

It is an almost never event where my pts get leg anesthesia or gait dysfxn. They all walk out of the building under their own power.

If my pt is super old and fragile, or young and crazy or in any way they make me feel nervous or suspicious...No local.
 
PinchandBurn said:
Agreed with this.

Also depends on how much put in. 40mg of triamcinolone, 3 normal saline, and 1ml of 1%lidocaine combo will not cause a profound blockade. As an anesthesia resident for certain. Surgeries we would out in 1 to 1.5ml of lidocaine intra thecal for surgeries/c sections.
Click to expand...
Triamcinolone has black box warning for epidural use.
 
I only use local in my TFESI because my partners do and if last time they got a numb leg and this time they didn't I'm apparently a bad doctor.

Edit: I don't use local in CESI and don't do cervical TFESI.
 
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This is good all, thanks!

I never do local for cervical or thoracic cases. For L-ILESI and L-TFESI, I’m going to just do 1 cc of Lido 1%. Per Mitch’s thoughts, will avoid this too for the old+fragile/young+crazy.

No more bupi for me.
 
I personally educate my patients to wait 10-14 days until they peak effect.

I tell them they will not have relief right after and that is normal.

The problem with “only” adding 1 cc of local is you and I know that’s not enough to realistically cause any motor weakness. However I’m paranoid. If the patient falls or something like that there’s no way a lawyer or jury will understand how small 0.5-1cc of local is.
 
I personally educate my patients to wait 10-14 days until they peak effect.

I tell them they will not have relief right after and that is normal.

The problem with “only” adding 1 cc of local is you and I know that’s not enough to realistically cause any motor weakness. However I’m paranoid. If the patient falls or something like that there’s no way a lawyer or jury will understand how small 0.5-1cc of local is.
 
DrMDAware said:
I personally educate my patients to wait 10-14 days until they peak effect.

I tell them they will not have relief right after and that is normal.

The problem with “only” adding 1 cc of local is you and I know that’s not enough to realistically cause any motor weakness. However I’m paranoid. If the patient falls or something like that there’s no way a lawyer or jury will understand how small 0.5-1cc of local is.
Click to expand...
That’s a shame. 94% of patients reached peak effect on day 5.
 
This Texas case is sad.

Should someone be sued for it? Probably not. That is the risk. The real question is should we be doing them? I would argue, yes.

But what is the absolute risk of epidural hematoma with in inter laminar, vs neurological damage from a transforaminal?

I do a lot of caudals. They seem to work great AND I suspect the risk for these problems is even smaller.
 
epidural man said:
This Texas case is sad.

Should someone be sued for it? Probably not. That is the risk. The real question is should we be doing them? I would argue, yes.

But what is the absolute risk of epidural hematoma with in inter laminar, vs neurological damage from a transforaminal?

I do a lot of caudals. They seem to work great AND I suspect the risk for these problems is even smaller.
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For which clinical scenarios are you using caudals?
( I took a lot of flak recently for my use of caudals)
 
bedrock said:
For which clinical scenarios are you using caudals?
( I took a lot of flak recently for my use of caudals)
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Anything someone would do an ILESI or TFESI - I would do a caudal.

From what I remember from old Manchikanti data, order of efficacy was TFESI > Caudal > ILESI, but difference was very small. Also, level of placement for TFESI OR ILESI made no difference (doesn’t need to be at level of pathology).

What I took from that was caudals work pretty well for anyone who would benefit from epidurally placed steroid.
 
Caudal is my go to for L4/5 pathology or below for patients on antithrombotics. I will also sometimes do it for patients with bad L5/s1 spondy or prior surgery.

pubmed.ncbi.nlm.nih.gov

Caudal Epidural Steroid Injections in the Setting of Remaining on Antithrombotics: A Retrospective Study - PubMed

We conclude that caudal epidural steroid injections can be performed safely in patients while taking antithrombotic medications. Catastrophic events have been observed in patients who have discontinued antithrombotic agents preceding procedures. Thus, discontinuing antithrombotic medications may...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
Simply put the risk doesn’t outweigh the benefit
 
epidural man said:
From what I remember from old Manchikanti data, order of efficacy was TFESI > Caudal > ILESI, but difference was very small.
Click to expand...
My experience is that ILESI is the best. Definitely choose approach on case by case basis but if I hypothetically had to choose 1 approach for the rest of my career, I'd go IL
 
DrMDAware said:
Thanks. I didn’t know this. If you’re being serious I’ll modify what I patients
Click to expand...
Anything over a week is wrong to tell a patient for a steroid injection.
My post procedure instructions say——- relief in 2-5 days (covers dex at 2 days and depo at 3-5)
 
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RoloTomassi said:
My experience is that ILESI is the best. Definitely choose approach on case by case basis but if I hypothetically had to choose 1 approach for the rest of my career, I'd go IL
Click to expand...
Tough because some cases one approach does little while another works better.

Sometimes ILESI with depo does so much more than TFESI with dex, but I’ve seen the reverse many times as well. I generally do one and then the other for a second ESI if the first approach does little.

In contrast to many of you, I still do S1 TFESI with depomedrol, (though any TFESI superior to S1, I do with dex)

If I was forced to use only one technique and level for all lumbar ESI, S1 TFESI with depomedrol would be it.
 
Ferrismonk said:
Fyi, you cannot legally bill a LESI without fluoro (or CT).
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You can bill, but it may not be covered. I generally down code it to 62322 for a landmark guided lumbar/caudal epidural. I think it was just a year or so ago they took out the ultrasound guided TFESI 0228T-0231T
 
Ferrismonk said:
Fyi, you cannot legally bill a LESI without fluoro (or CT).
Click to expand...
Think baron works for the VA. Billing may not be an issue.

Or malpractice suits. Only situation in which I’d ever offer a pregnant woman an epidural steroid injection, would in the VA system, because you’re safe from being sued.
 
Baron Samedi said:
Been doing caudals under ultrasound lately. Really nice when bone density is poor, fluoro not available, or in pregnant patients.
Click to expand...
Agreed. But I have been burned a few times with larger patients. Can’t see the cornu clearly.
 
bedrock said:
Anything over a week is wrong to tell a patient for a steroid injection.
My post procedure instructions say——- relief in 2-5 days (covers dex at 2 days and depo at 3-5)
Click to expand...
Ah cmon man “wrong” is a bit strongly worded don’t ya think?

Maybe I’m wrong but I thought steroids affect transcription processes intracellularly (as opposed to GPCR) and work on endocrine processes thus take longer to work given the immune modulating effects.
 
DrMDAware said:
Ah cmon man “wrong” is a bit strongly worded don’t ya think?

Maybe I’m wrong but I thought steroids affect transcription processes intracellularly (as opposed to GPCR) and work on endocrine processes thus take longer to work given the immune modulating effects.
Click to expand...
Wrong is wrong. Not trying to be mean but I’m also not a woke educator coddling everyone, at the expense of actual education.

If your skin is so thin, then next time I won’t teach you.

You’ll notice that none of the experienced docs here, stated a cortisone time frame effect anywhere close to what you’ve been incorrectly telling your patients.
 
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There are similar papers to the one below that state: "Improvement 2 weeks after the injection when the corticosteroid anti-inflammatory effect is engaged predicts long-term benefit." I think there is another out there by Plastaras that has similar statement, but those are mostly for helping us determine longevity of efficiacy. I think that has gotten misconstrued as "benefit will occur by two weeks."

I generally tell people two days for ESI to start working, should continue to improve over the first two weeks (with most benefit in first week), and where your pain is at two weeks is where we expect it to stay for 3 months (hopefully longer) and should further improve with McKenzie PT, lifestyle changes, etc.

Academically my statement may be wrong, but in practice it holds true for me.

Diagnostic and therapeutic spinal interventions: Epidural injections - PMC

Epidural injections of local anesthetic or a corticosteroid are frequently given to diagnose and treat patients with radicular pain originating from any spinal level. The best-quality evidence supports a transforaminal approach in the lumbar spine. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
I’ll squirt a little 1% lido on the nerve if they’re having a lot of pain during a TFESI due to NF narrowing. Helps them tolerate the injection. Other than that I don’t use anesthetic in my epidurals
 
bedrock said:
Wrong is wrong. Not trying to be mean but I’m also not a woke educator coddling everyone, at the expense of actual education.

If your skin is so thin, then next time I won’t teach you.

You’ll notice that none of the experienced docs here, stated a cortisone time frame effect anywhere close to what you’ve been incorrectly telling your patients.
Click to expand...

Woke educator? The guy clearly learned from the feedback he got from Steve and you piled on for no reason. MDAware then politely pushes back and you go full boomer on him. Pipe down.
 
bedrock said:
Wrong is wrong. Not trying to be mean but I’m also not a woke educator coddling everyone, at the expense of actual education.

If your skin is so thin, then next time I won’t teach you.

You’ll notice that none of the experienced docs here, stated a cortisone time frame effect anywhere close to what you’ve been incorrectly telling your patients.
Click to expand...
Woke educator? What? That has nothing to do with this.

No, please teach me. That’s not the issue.

I’m looking for scientific evidence that the onset is much sooner. Not debating you. Looking for some evidence. That’s all. If we can see sooner onset then that’s more important than what experienced docs on sdn say or what I say.

If the onset is much shorter what do you tell your patients when it doesn’t work and their insurance company tells them to wait 14 days?
 
runfastnow said:
There are similar papers to the one below that state: "Improvement 2 weeks after the injection when the corticosteroid anti-inflammatory effect is engaged predicts long-term benefit." I think there is another out there by Plastaras that has similar statement, but those are mostly for helping us determine longevity of efficiacy. I think that has gotten misconstrued as "benefit will occur by two weeks."

I generally tell people two days for ESI to start working, should continue to improve over the first two weeks (with most benefit in first week), and where your pain is at two weeks is where we expect it to stay for 3 months (hopefully longer) and should further improve with McKenzie PT, lifestyle changes, etc.

Academically my statement may be wrong, but in practice it holds true for me.

Diagnostic and therapeutic spinal interventions: Epidural injections - PMC

Epidural injections of local anesthetic or a corticosteroid are frequently given to diagnose and treat patients with radicular pain originating from any spinal level. The best-quality evidence supports a transforaminal approach in the lumbar spine. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
Great post. I tell the full effect is in 10-14 days. Full effect =/= onset.
 
Kissmyabjj said:
Woke educator? The guy clearly learned from the feedback he got from Steve and you piled on for no reason. MDAware then politely pushes back and you go full boomer on him. Pipe down.
Click to expand...
I’m no boomer but you’re clearly a millennial.

I have no idea how you millennial pansies survived medical training, however GFY.
 
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C'mon folks. We can disagree without getting douchey. If light hearted or sarcastic, please note in dark orchid (purple).
Easy enough to argue steroids for anything other than acute radic don't work well enough to be paid for. The route, type, dose, timing, frequency, adjuvants, equipment- it is pedantic nonsense if the procedure itself gets abandoned by payors.
 
of course this came up for me today....small L4-5 disc herniation right in foramen. Pressure from TF almost made the grown man cry.....worse than delivering a baby i speculate. Had some Rope in there and it gradually eased up. Ended up putting another 3-4 cc of Rope in the facet capsule to help ease the pain. Thought about a TL but decided to punt and hope the facet spill over would help.

So yes i will always use a bit of anesthetic.
 
Doctodd said:
of course this came up for me today....small L4-5 disc herniation right in foramen. Pressure from TF almost made the grown man cry.....worse than delivering a baby i speculate. Had some Rope in there and it gradually eased up. Ended up putting another 3-4 cc of Rope in the facet capsule to help ease the pain. Thought about a TL but decided to punt and hope the facet spill over would help.

So yes i will always use a bit of anesthetic.
Click to expand...

injecting a tight foramen hurts. but it is the injection of choice. i do the same -- add a little more lido in those cases

and severe NF stenosis in a LOL can indeed cause motor block with 1 mL of 1% lido. really not the end of the world (especially in the lumbar spine)
 
lobelsteve said:
C'mon folks. We can disagree without getting douchey. If light hearted or sarcastic, please note in dark orchid (purple).
Easy enough to argue steroids for anything other than acute radic don't work well enough to be paid for. The route, type, dose, timing, frequency, adjuvants, equipment- it is pedantic nonsense if the procedure itself gets abandoned by payors.
Click to expand...

1672250597036.png
 
On the note of epidurals, anyone routinely do retroneural approach and feel like sharing some tips and/or pics? I primarily do subpedicular or infraneural, but was reading about retroneural approaches and would be interested in trying.
 
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