Gadolinium fatality

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There was also a commentary by Tim Maus in a SIS publication about this.
I have used 0.5 ml in the lumbar spine for a TFESI on occasion. Never used in the cervical spine or anywhere that I need more than 0.5 ml because of reported toxicity.

My take away is premedicate and use Omni/iso if you must use contrast. It’s a mistake to automatically just use gad if patient reports a reaction to iodinated contrast.
 
For interlaminar I just use air-o-gram.
For foraminal, use premed with 0.5cc Omni.
I do not inject any local in epidural just saline and dex
 
NJPAIN said:
There was also a commentary by Tim Maus in a SIS publication about this.
I have used 0.5 ml in the lumbar spine for a TFESI on occasion. Never used in the cervical spine or anywhere that I need more than 0.5 ml because of reported toxicity.

My take away is premedicate and use Omni/iso if you must use contrast. It’s a mistake to automatically just use gad if patient reports a reaction to iodinated contrast.
Click to expand...
Have a link to the Maus commentary?
 
I too had been using rarely in patients with Omnipaque allergies. How commonly does serious injury result from IT gadolinium? There are 11 cases reported if I read correctly. Does it happen 100% of the time with IT administration?
 
Timeoutofmind said:
Have a link to the Maus commentary?
Click to expand...
www.ncbi.nlm.nih.gov

Relative Conspicuity of Gadolinium-Based Contrast Agents in Interventional Pain Procedures - PubMed

Gadobutrol is the GBCA with the greatest conspicuity for use in spinal injection procedures. It also has the highest molar concentration of gadolinium, and potential neural toxicity from intrathecal delivery must be considered.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
www.ncbi.nlm.nih.gov

Fact Finders for Patient Safety: Are Gadolinium-Based Contrast Media Safe Alternatives to Iodinated Contrast Agents for the Safe Performance of Spinal Injection Procedures? - PubMed

Fact Finders for Patient Safety: Are Gadolinium-Based Contrast Media Safe Alternatives to Iodinated Contrast Agents for the Safe Performance of Spinal Injection Procedures?
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
They key for me with gadolinium is that there is a dose dependent neuroexcitatory phenomena that happens with it. We use Gadovist epidurally and intrathecally with no events when you aren't slamming in a vial into the CSF.
 
This one was only 1.5mL from an ILESI

1567005688685.png
 
Orin said:
They key for me with gadolinium is that there is a dose dependent neuroexcitatory phenomena that happens with it. We use Gadovist epidurally and intrathecally with no events when you aren't slamming in a vial into the CSF.
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Still not worth the risk, when we're talking about potential death here.

I don't see a reasont to ever use gad for pain procedures. Just skip contrast completely or premedicate and use omnipaque.
 
bedrock said:
Still not worth the risk, when we're talking about potential death here.

I don't see a reasont to ever use gad for pain procedures. Just skip contrast completely or premedicate and use omnipaque.
Click to expand...

I agree- if allergic, just skip the contrast.

"MILD" procedure? One must ask why the patient was not just referred for a lumbar laminectomy, as this would not have required the injection of any contrast. Further, the MILD procedure is one of those in which, when indicated, perhaps a decompression is not indicated at all. Having scrubbed in on many laminectomies, I really cannot see how any significant amount of material can be removed to result in a favorable response.

A laminectomy is an easy, effective procedure. In fact, Jim Weinstein found several years ago that it was superior to conservative care (and Jim hates most spine surgery). Just because we can do things, does not mean we should.
 
So there are 11 cases in the literature where IT gadolinium caused serious reactions. There appears to be 3 total cases where epidural intended admininstration ended up accidentely intrathecal and caused serious reactions. I'm sure there are thousands more that were intended for epidural adminstration and ended up IT without complication.

So we don't really know the full risk here. While I am not advocating for indescriminate use of epidural gadolinium, I dont think I could declare it to be out of bounds for IPM in general. I personally will probably stop using it, simply because I am more risk averse than many others.
 
hawkeye2009 said:
I agree- if allergic, just skip the contrast.

"MILD" procedure? One must ask why the patient was not just referred for a lumbar laminectomy, as this would not have required the injection of any contrast. Further, the MILD procedure is one of those in which, when indicated, perhaps a decompression is not indicated at all. Having scrubbed in on many laminectomies, I really cannot see how any significant amount of material can be removed to result in a favorable response.

A laminectomy is an easy, effective procedure. In fact, Jim Weinstein found several years ago that it was superior to conservative care (and Jim hates most spine surgery). Just because we can do things, does not mean we should.
Click to expand...

U think that argument would hold up in court in the epidural has complications (TFESI paralysis)?
 
painfree23 said:
U think that argument would hold up in court in the epidural has complications (TFESI paralysis)?
Click to expand...

Just to continue this thought experiment (not arguing)...you can cause paralysis with a tf esi in 3 ways...particulate roid in the artery, spasm of the artery by contacting it with the needle, or splaying the nerve root with the needle. We all know that the absence of arterial contrast pattern does not mean the needle is not partially in an artery. So does contrast really prevent any of these 3 scenarios? Or is it mainly dogmatic, to be honest, assuming you are using dex and otherwise appropriate technique?
 
I use Isovue 200. Allergy I'll use prednisone and Benadryl or just do it without contrast. I've done plenty of TFESI without contrast and obviously I'm only talking lumbar. I will occasionally give a 1% lido test dose, but seriously...lumbar TFESI without contrast isn't a heart transplant wearing a blindfold.
 
hawkeye2009 said:
A laminectomy is an easy, effective procedure. In fact, Jim Weinstein found several years ago that it was superior to conservative care (and Jim hates most spine surgery). Just because we can do things, does not mean we should.
Click to expand...

study only followed patients for 2 years, and I'd argue that we are better at doing the shots now, but I digress.....
 
SSdoc33 said:
study only followed patients for 2 years, and I'd argue that we are better at doing the shots now, but I digress.....
Click to expand...

Perhaps- Epidural shots are still epidural shots and have not changed since that time. I am a firm believer in a lumbar lamy for true neurogenic claudication. The trick, of course, is taking enough bone and not destabilizing the segment.

I find it inconceivable that the MILD procedure could remove enough material an a situation of true stenosis to be of any utility. There are often substitutes for lamy that are introduced and have failed, the most notable being X-stop- good in theory, terrible in practice.

As far as the reaction with gadolinium, are the "double plus sure" it was gad and not an ionic contrast injected by mistake?
 
hawkeye2009 said:
Perhaps- Epidural shots are still epidural shots and have not changed since that time. I am a firm believer in a lumbar lamy for true neurogenic claudication. The trick, of course, is taking enough bone and not destabilizing the segment.

I find it inconceivable that the MILD procedure could remove enough material an a situation of true stenosis to be of any utility. There are often substitutes for lamy that are introduced and have failed, the most notable being X-stop- good in theory, terrible in practice.

As far as the reaction with gadolinium, are the "double plus sure" it was gad and not an ionic contrast injected by mistake?
Click to expand...

i agree. if you are 50 with severe stenosis, then a lami is the way to go. if you are 85? not so sure.

i think the caveat is that MILD works better when there is predominantly ligamentum flavum hypertrophy, rather than disc or facet causing the stenosis. that being said, i am also not a big believer
 
SSdoc33 said:
i agree. if you are 50 with severe stenosis, then a lami is the way to go. if you are 85? not so sure.

i think the caveat is that MILD works better when there is predominantly ligamentum flavum hypertrophy, rather than disc or facet causing the stenosis. that being said, i am also not a big believer
Click to expand...

Sounds like a good assessment. I would say that most of the people I see with stenosis have stenosis due to facet hypertrophy and narrowing of the canal dorsally.

I do not see how the MILD procedure can accomplish anything.

It was like when x-stop came out. I went to the training course with one of our neurosurgeons; we were both a little shocked when they showed the "pre-treatment" MRIs. The degree of stenosis was so mild to be non-existant and I would not have even done a steroid injection on them, let alone referred for a lamy. The same thing happened when attending a course on MILD. I guess if you are treating patients with very little, or no pathology, you are probably doing too much.

I think it is best when you are communicating about stenosis in the lumbar and cervical spine by the measurement of the canal in mm. Then we can all hang our hat on something objective and what is universally agreed upon as radiographic stenosis.
 
hawkeye2009 said:
Sounds like a good assessment. I would say that most of the people I see with stenosis have stenosis due to facet hypertrophy and narrowing of the canal dorsally.

I do not see how the MILD procedure can accomplish anything.

It was like when x-stop came out. I went to the training course with one of our neurosurgeons; we were both a little shocked when they showed the "pre-treatment" MRIs. The degree of stenosis was so mild to be non-existant and I would not have even done a steroid injection on them, let alone referred for a lamy. The same thing happened when attending a course on MILD. I guess if you are treating patients with very little, or no pathology, you are probably doing too much.

I think it is best when you are communicating about stenosis in the lumbar and cervical spine by the measurement of the canal in mm. Then we can all hang our hat on something objective and what is universally agreed upon as radiographic stenosis.
Click to expand...
I do it occasionally - for those rare patients where the ligament flavum really is the primary stenosis driver, clearly sticking out into the canal, and the patient is not a surgical candidate. I refer out to a surgeon way more than I do MILD. I’m still not very impressed with the outcome so far though. Definitely not as good as their trial data.
 
callmeanesthesia said:
I do it occasionally - for those rare patients where the ligament flavum really is the primary stenosis driver, clearly sticking out into the canal, and the patient is not a surgical candidate. I refer out to a surgeon way more than I do MILD. I’m still not very impressed with the outcome so far though. Definitely not as good as their trial data.
Click to expand...

Jim Weinstein's article about 8-10 years ago was pretty impressive for surgery over conservative treatment. I agree that if one can be surgically decompressed, that would be a superior treatment to other alternatives.

For some of those folks who no one will operate on and have predominantly leg pain, I will stim them, even if they have not had previous spine surgery. Certainly not optimal, but it serves a niche group of patients.
 
I brought the issue of intrathecal gad to Maus at a meeting. If we are injecting PF dex and even low volumes the risk profile for inadvertent intrathecal therapeutic injectate is almost nothing. I would rather have an ineffective injection over injecting gad into the CSF. The response I got to justify the use of gad was that we need to make sure these injections work. I think we'll just be disagreeing on this one.
 
Vie221 said:
I brought the issue of intrathecal gad to Maus at a meeting. If we are injecting PF dex and even low volumes the risk profile for inadvertent intrathecal therapeutic injectate is almost nothing. I would rather have an ineffective injection over injecting gad into the CSF. The response I got to justify the use of gad was that we need to make sure these injections work. I think we'll just be disagreeing on this one.
Click to expand...

U also inject contrast to make sure it’s not intravascular.
 
IT dex probably as effective as epidural
 
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