HNP TFESI Poll

[NOSfan]

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A patient presents with pain in the L5 dermatome. MRI indicates a L4-L5 HNP pressing on L5 spinal nerve. The level of your TFESI is:

1. At the level of the HNP (L4-L5) or
2. At the level of the L5 spinal nerve (L5-S1) formamina or
3. Other

 

[SSdoc33]

L5 tfesi

 

[jsaul]

L5 tfesi

agree- L5 tf esi. or as some say L5-S1 tf esi-- in other words at the L5- S1 interspace.

 

[specepic]

other- I would do L4-5 ILESI first, paramedian to side of pain, only do TFESI if that doesn't work

 

[lobelsteve]

L5-S1 space for L5 TFESI

 

[PMR 4 MSK]

Step 1 - do wallet biopsy. See how many procedures the insurance is likely to pay for.

Step 2 - do a left L4-5 and left L5-S1 fluoro-guides ESI. Bill for 99205, 64483, 64484, 77003, 72275, 62264, plus injectables and kit.

Step 3 - see pt back in 2 days, if no better, repeat injections, billing 99215, 64483, 64484, 77003, 72275, 62264 and injectables again.

Step 4 - see pt back in 2-4 days (depending on weekend) and repeat again.

From what I can tell, that's what the guy down the street (literally two buildings over) does.

If that does not work, do left L1-2, 2-3, 3-4, 4-5, and 5-S1 facet joint injection under fluoro.

If that doesn't work do MBB on L1, L2, L3, L4, L5 and S1 medial branches.

Whether or not that works, RF same nerves.

In the meanwhile, liberally prescribe Oxycontin and Percocet, throwing in some Soma or Flexeril, and some gabapentin.



I'd probably just do a L5-S1 TFESI. I'll only make 1/10th of what the other guy makes.

 

[Gauss]

Standard of care in my area:
L5-S1 ILESI x3
then L4-5-S1 MBB and RFA, bilaterally but separate
then SIJ injections and hip joint injections
then SCS and/or fentanyl pump
Don't forget the methadone!

 

[Dr. Ice]

Step 1 - do wallet biopsy. See how many procedures the insurance is likely to pay for.

Step 2 - do a left L4-5 and left L5-S1 fluoro-guides ESI. Bill for 99205, 64483, 64484, 77003, 72275, 62264, plus injectables and kit.

Step 3 - see pt back in 2 days, if no better, repeat injections, billing 99215, 64483, 64484, 77003, 72275, 62264 and injectables again.

Step 4 - see pt back in 2-4 days (depending on weekend) and repeat again.

From what I can tell, that's what the guy down the street (literally two buildings over) does.

If that does not work, do left L1-2, 2-3, 3-4, 4-5, and 5-S1 facet joint injection under fluoro.

If that doesn't work do MBB on L1, L2, L3, L4, L5 and S1 medial branches.

Whether or not that works, RF same nerves.

In the meanwhile, liberally prescribe Oxycontin and Percocet, throwing in some Soma or Flexeril, and some gabapentin.



I'd probably just do a L5-S1 TFESI. I'll only make 1/10th of what the other guy makes.

I cant imagine that s**t like this can last for too much longer...meaning, get payed for..

 

[knoxdoc]

That's a great question, Nosfan. I would do the L5/S1 TFESI to target the left L5 NR, but I find that the local surgeons think I "got the level wrong" when I do that. They always insist on injecting at the level of the disc pathology (which would more likely cover the L4 nerve root in this case). Anyone else get sh$t from surgeons for this? I need to do an "in-service".

 

[Aether2000]

Far lateral approach anterior epidural space L4-5 directly on the disc herniation using a blunt epimed 20 ga clyde tip needle

 

[facetguy]

Refer to chiropractor.😉🙂

 

[bedrock]

other- I would do L4-5 ILESI first, paramedian to side of pain

A tweak on the original question-
If you couldn't do a transforaminal for whatever reason, they hadn't been invented yet, insurance wouldn't pay, etc....
What level would you use for an interlaminar ESI with this same clinical scenario? (L4-L5 disc with L5 root pain)

 

[Mister Mxyzptlk]

How many angels can dance on the head of a pain doctor? You have no evidence either way so you can argue this forever.

A little volume goes a very long way. Either of those approaches should deliver plenty of medication along the affected area.

 

[mille125]

A tweak on the original question-
If you couldn't do a transforaminal for whatever reason, they hadn't been invented yet, insurance wouldn't pay, etc....
What level would you use for an interlaminar ESI with this same clinical scenario? (L4-L5 disc with L5 root pain)

it doesnt matter, both ways work....

 

[mille125]

A patient presents with pain in the L5 dermatome. MRI indicates a L4-L5 HNP pressing on L5 spinal nerve. The level of your TFESI is:

1. At the level of the HNP (L4-L5) or
2. At the level of the L5 spinal nerve (L5-S1) formamina or
3. Other

If very large HNP, I would do ILESI at L4/L5. Otherwise I would do an L5 transforaminal...

 

[drpainfree]

don't treat the image, treat the patient:

if unilateral L5 predominately LE radic, yes, L5-S1 TFESI
if bilateral L5 LE radic, I'd consider bilateral L5-S1 TFESI
if bilateral axial and L5 LE radic, but predominately axial, L4-L5 IESL

 

[docnyc]

Step 1 - do wallet biopsy. See how many procedures the insurance is likely to pay for.

Step 2 - do a left L4-5 and left L5-S1 fluoro-guides ESI. Bill for 99205, 64483, 64484, 77003, 72275, 62264, plus injectables and kit.

Step 3 - see pt back in 2 days, if no better, repeat injections, billing 99215, 64483, 64484, 77003, 72275, 62264 and injectables again.


62264? Isnt that epidural lysis of adhesions? Is he really doing that for a simple radic in a single dermatome?

 

[PMR 4 MSK]

Step 1 - do wallet biopsy. See how many procedures the insurance is likely to pay for.

Step 2 - do a left L4-5 and left L5-S1 fluoro-guides ESI. Bill for 99205, 64483, 64484, 77003, 72275, 62264, plus injectables and kit.

Step 3 - see pt back in 2 days, if no better, repeat injections, billing 99215, 64483, 64484, 77003, 72275, 62264 and injectables again.


62264? Isnt that epidural lysis of adhesions? Is he really doing that for a simple radic in a single dermatome?

yep, and yep

 

[Jcm800]

Acute radic, often I will do both on the first setting, L4-5 and L5-s1. This hedges the bet. I used to just guess, sometimes I would go at l5-s1 and then others at L4-5, and then I would try both levels. I found that both levels often worked better, and often didn't require a repeat, or guessing at a level to do...not terribly scientific, but when it's a big disc that is acute with a motivated patient trying to get back to work, I do both. Otherwise say it doesn't get what i want, it's another two weeks out of worqk for the patient. You could argue I do it for the increased revenue, but I loose revenue by often not doing the second injection, that i found myself doing when I did only one level, regardless of either L45 or L5-s1...

My two cents

 

[Jcm800]

Can this be moved to private...for obvious reasons...

 

[stim4u]

Can this be moved to private...for obvious reasons...

show us an image please. Your read is different than mine, or my local radiologist. Things are missed/misinterpreted all the time.

 

[Ligament]

Acute radic, often I will do both on the first setting, L4-5 and L5-s1. This hedges the bet. I used to just guess, sometimes I would go at l5-s1 and then others at L4-5, and then I would try both levels. I found that both levels often worked better, and often didn't require a repeat, or guessing at a level to do...not terribly scientific, but when it's a big disc that is acute with a motivated patient trying to get back to work, I do both. Otherwise say it doesn't get what i want, it's another two weeks out of worqk for the patient. You could argue I do it for the increased revenue, but I loose revenue by often not doing the second injection, that i found myself doing when I did only one level, regardless of either L45 or L5-s1...

My two cents

I do the same thing. My target is the disc-nerve interface, not the nerve itself in isolation, If I see good contrast flow on only a L5/S1 TFESI, I will stop there. However, if not sufficient flow at the disc-nerve interface, will add a L4/L5 TFESI.

 

[hyperalgesia]

If the MRI is crystal clear and there are no confounding variables, I would do L5 tfesi, just because it's the most elegant and success would have the most diagnostic value. But if the MRI is not quite so obvious or pain pattern is not so clear, "Doc, it alternates between legs", I would use a more "shotgun" approach, ie ILESI, etc. The main advantage I see with the TFESI is *probably* a slightly increased diagnostic selectivity. If you get a slam dunk with a TFESI, you might consider a pulsed RF or something down the road. Or not... I could go either way.

 

[painstop]

I do the same thing. My target is the disc-nerve interface, not the nerve itself in isolation, If I see good contrast flow on only a L5/S1 TFESI, I will stop there. However, if not sufficient flow at the disc-nerve interface, will add a L4/L5 TFESI.

Agreed

 

[pmrmd]

Acute radic, often I will do both on the first setting, L4-5 and L5-s1. This hedges the bet. I used to just guess, sometimes I would go at l5-s1 and then others at L4-5, and then I would try both levels. I found that both levels often worked better, and often didn't require a repeat, or guessing at a level to do...not terribly scientific, but when it's a big disc that is acute with a motivated patient trying to get back to work, I do both. Otherwise say it doesn't get what i want, it's another two weeks out of worqk for the patient. You could argue I do it for the increased revenue, but I loose revenue by often not doing the second injection, that i found myself doing when I did only one level, regardless of either L45 or L5-s1...

My two cents

This is what I would do also. Get steroid above and below the HNP. Later the L5-S1 TFESI would be the better of the two.

 

[Finally M3]

1) Left L5-S1 TFESI

If that didn't work, I would either try a L4-5 ILESI or left L4-5 TFESI (anterior, abort if there was high-pressure with injectate)

If that didn't work would refer out for diskectomy.

 

[Gauss]

I do the same thing. My target is the disc-nerve interface, not the nerve itself in isolation, If I see good contrast flow on only a L5/S1 TFESI, I will stop there. However, if not sufficient flow at the disc-nerve interface, will add a L4/L5 TFESI.

Same practice - I will consent for both L4-5 and L5-S1 and go for the latter first. I commonly consent for 2 levels or bilaterals giving me the option to abort if I'm happy with the contrast spread in the area of pathology, otherwise how do you change consent when they're on the table and they've had versed & fentanyl?

 

[mille125]

1) Left L5-S1 TFESI

If that didn't work, I would either try a L4-5 ILESI or left L4-5 TFESI (anterior, abort if there was high-pressure with injectate)

If that didn't work would refer out for diskectomy.

It seems like the consensus is TFESI at one or multiple levels even on large disks. Do your patients ever absolutely jump off the table when you go transforaminal on a large disk? (question to the forum at large). This is not a loaded question. I am just curious.

 

[lobelsteve]

It seems like the consensus is TFESI at one or multiple levels even on large disks. Do your patients ever absolutely jump off the table when you go transforaminal on a large disk? (question to the forum at large). This is not a loaded question. I am just curious.

Never happens, because I go at the level below the disk.

 

[101N]

It seems like the consensus is TFESI at one or multiple levels even on large disks. Do your patients ever absolutely jump off the table when you go transforaminal on a large disk? (question to the forum at large). This is not a loaded question. I am just curious.

No, but I tell them: "This might hurt a bit".

 

[mille125]

Never happens, because I go at the level below the disk.

what if the affected disk is at L5/S1 which is the most common scenario?

 

[lobelsteve]

what if the affected disk is at L5/S1 which is the most common scenario?

S1 foramen. Never seen a disk extrude that far down.

 

[Finally M3]

It seems like the consensus is TFESI at one or multiple levels even on large disks. Do your patients ever absolutely jump off the table when you go transforaminal on a large disk? (question to the forum at large). This is not a loaded question. I am just curious.

Yes, happened to me when I started out on my own. Like steve, though, I 90% of the time go the level below.

I really only start at the level of herniation when I see a far lateral disc herniation; typically haven't had a problem with severe pain during tfesi.

 

[Tenesma]

just because the pain is in the "L5 dermatome" doesn't necessarily mean it is L5 nerve root that is involved - as you know, those dermatomal maps are not accurate, and there is a fair amount of cross-mapping.

i'd rather treat the imaging first before i treat the dermatome.

i would do a 2 level TFESI L4 and L5 to soak it from both sides...

 

[Ligament]

just because the pain is in the "L5 dermatome" doesn't necessarily mean it is L5 nerve root that is involved - as you know, those dermatomal maps are not accurate, and there is a fair amount of cross-mapping.

This is very true. If you guys want to see something cool, use RF needles for your TFESIs, and stim the nerve root at 50Hz and ask the patient where they feel it. It is really enlightening to see how variable the dermatomes are and especially the amount of crosstalk.

 

[drpainfree]

Interesting point, treat imaging first before treating dermatome...but imaging can be misleading too. a lot of patients with multi-level stenosis/HNP/DDD presents with severe radicular pain at particular level. Personally, I'd inject at the dermatomal level even though it's not a precise mapping.

Or you can shotgun approach and blast multi-levels and bilaterally. The problem is, you'd never know where the problem is exactly, and don't know what to do the next time if it didn't work.

just because the pain is in the "L5 dermatome" doesn't necessarily mean it is L5 nerve root that is involved - as you know, those dermatomal maps are not accurate, and there is a fair amount of cross-mapping.

i'd rather treat the imaging first before i treat the dermatome.

i would do a 2 level TFESI L4 and L5 to soak it from both sides...

 

[specepic]

S1 foramen. Never seen a disk extrude that far down.

Just did a S1 TF on friday where the disc from 5-1 completely fills the foramen, looks pretty cool on the MR, and no, I cannot post pics due to our PACS not allowing it. The radiologist was pretty surprised, enough to order a f/u with contrast

 

[lobelsteve]

Just did a S1 TF on friday where the disc from 5-1 completely fills the foramen, looks pretty cool on the MR, and no, I cannot post pics due to our PACS not allowing it. The radiologist was pretty surprised, enough to order a f/u with contrast

No, the disc is in the L5 foramen, right? It would have to extrude back, then climb the sacral hump and then occupy the sacral canal to be in the way of S1.

 

[Tenesma]

specepic: in PACS do a printscrn, then go to "paint" in windows and paste, then edit by cropping and deleting patient identifiers, then you have a pic you can poste

ligament: Ken Alo has been doing this for a while - in fact, he has it trademarked for his current practice - i think he calls it spinal mapping.

drpainfree: i have found more success personally treating the imaging instead of the dermatome... however, in the case of global/multi-level disease where any level could be the culprit, then I would agree with starting with the dermatomal level.

re: blasting versus diagnostics... i would agree w/ single level from a diagnostic point of view if it is going to help in surgical planning... in the case of a hot radic w/ an L4 disc, i have found good success with soaking it from above and below - this not only provides decent relief initially, but i rarely have to do a 2nd injection and don't practice series of 3.

 

[Jcm800]

just because the pain is in the "L5 dermatome" doesn't necessarily mean it is L5 nerve root that is involved - as you know, those dermatomal maps are not accurate, and there is a fair amount of cross-mapping.

i'd rather treat the imaging first before i treat the dermatome.

i would do a 2 level TFESI L4 and L5 to soak it from both sides...

dead on!

if someone has a symptoms of an L5 radic, and has a normal spine EXCEPT at L3-4, its gotta be L3-4 disc. and if its smooshing the L4 nerve, thats the nerve I am going after, and i am gonna go it and the offending agent (L3-4 disc).

that is WHY we have images, if we dont use them to guide us, and correlate with the symptoms, why use them at all.

30 or 40 volunteers were used for the "gospel" dermatome maps

 

[specepic]

No, the disc is in the L5 foramen, right? It would have to extrude back, then climb the sacral hump and then occupy the sacral canal to be in the way of S1.

The disc extrusion from L5-S1 extends caudad and follows the S1 root through the sacrum.

 

[Tenesma]

i don't think those were volunteers... i believe those maps were based on autopsies of a handful of patients with shingles, and the eruptions were traced back to the nerve roots.

 

[Jcm800]

i don't think those were volunteers... i believe those maps were based on autopsies of a handful of patients with shingles, and the eruptions were traced back to the nerve roots.

depends on whos map...

im no history expert, but this explains why the maps arent always the same, and why he had arguments during fellowship which dermatome it was when you gave someone the middle finger (the bird) whether it was C7 or C8...

Conflicting Dermatome Maps: Educational and Clinical Implications
Mary Beth Downs, Cindy LaPorte
DOI: 10.2519/jospt.2011.3506

SYNOPSIS: Sensory testing is a common noninvasive method of evaluating nerve function that relies on the knowledge of skin dermatomes and sensory fields of cutaneous nerves. Research to determine the extent of the dermatomes was conducted in Europe during the late nineteenth and early twentieth centuries. Experiments performed on cadavers, monkeys, and human patients prior to 1948 resulted in the creation of similar but somewhat different dermatome maps. A radically different map with long, swirling dermatomes was produced by Keegan and Garrett in 1948. This map was derived largely by examining compression of dorsal nerve roots by vertebral disc herniation. The maps appearing in textbooks are inconsistent. Some books show a version of the early maps, some show the Keegan and Garrett map, and others show maps that are not consistent with either. The purpose of this paper is to discuss the history of dermatome maps, including the experimental procedures by which each was obtained, and to relate the early maps to those found in textbooks commonly used in healthcare education programs. The paper discusses the significance of these maps as used for clinical diagnosis and the need for further research.

 

[Finally M3]

dead on!

if someone has a symptoms of an L5 radic, and has a normal spine EXCEPT at L3-4, its gotta be L3-4 disc. and if its smooshing the L4 nerve, thats the nerve I am going after, and i am gonna go it and the offending agent (L3-4 disc).

that is WHY we have images, if we dont use them to guide us, and correlate with the symptoms, why use them at all.

30 or 40 volunteers were used for the "gospel" dermatome maps

How about when you sprinkle in some exam findings?

Say we have the L3-4 paracentral disc herniation mushing L4, other levels stone-cold normal. L5 radicular symptoms, 4/5 EHL/AT weakness, diminished internal hamstring reflex (I know, not always reliable), + straight leg, seated slump.

Still shoot for L4-5? L5-S1? Further studies?

Not playing devil's advocate, get this occasionally...my bias would be to avoid injection in the above scenario.

 

[specepic]

I would say that a pt with a 'classic' radic where imaging, exam, history all line up per the text book is, in reality, a rare pt

 

[Finally M3]

heh. touche.

 

[101N]

depends on whos map...

im no history expert, but this explains why the maps arent always the same, and why he had arguments during fellowship which dermatome it was when you gave someone the middle finger (the bird) whether it was C7 or C8...

Agreed.

You can see this variability for yourself if you experiment with root stim. A 4&3/4" Stimuplex needle fits right through an 18g 3.5" Kimberly-Clark introducer. This set up allows you to stim roots and ask the patient about the paresthesia. You can also elicity a brisk motor twitch and ask them if it's concordant with the distribution of their pain.

 

[drf]

This is very true. If you guys want to see something cool, use RF needles for your TFESIs, and stim the nerve root at 50Hz and ask the patient where they feel it. It is really enlightening to see how variable the dermatomes are and especially the amount of crosstalk.

At my hospital we use Stimuplex needles for regional anesthesia. No one really does regional blocks with stim only anymore (due to US) but we still stock the needles. They come in 2, 4, and 6 inches and are 21-22g and have a built in catheter for injection. Sometimes when looking for a pain generator I pull one of these out and stim when I get close to the foramen. Rather than doing sequential 2-3 selectives over several days/weeks I simply inject the one with concordant stim. Pts so far can always tell, despite it being at 2 hz.

A bit easier sometimes than dragging out the RF machine.

Just read the post above and see it was already mentioned.