IL ESI Through a ligament fissure?

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praskal

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When I do an IL ESI, I always get a contralateral oblique. When I’m in the interlaminar ligament, I give a very small amount of lidocaine just to keep the needle tip patent and for a bead a fluid for a hanging drop. But in this case, the ligament was very hard and no fluid could come out. I pushed a little harder and then suddenly about 1/2 cc lidocaine came out. Patient experienced no sensation. On the oblique I could tel that I was still quite a bit posterior to the epidural space. But I decided to give a small amount of contrast anyway. And guess what? You can see the oblique and lateral. There is a good posterior epidurogram. With the needle tip way back. I guess I must have caused a ligament fissure? Anyway, I did not advance the needle any more. I just gave the dexamethasone and got out of there. Has anyone seen this?
 
praskal said:
View attachment 252664View attachment 252665View attachment 252666

When I do an IL ESI, I always get a contralateral oblique. When I’m in the interlaminar ligament, I give a very small amount of lidocaine just to keep the needle tip patent and for a bead a fluid for a hanging drop. But in this case, the ligament was very hard and no fluid could come out. I pushed a little harder and then suddenly about 1/2 cc lidocaine came out. Patient experienced no sensation. On the oblique I could tel that I was still quite a bit posterior to the epidural space. But I decided to give a small amount of contrast anyway. And guess what? You can see the oblique and lateral. There is a good posterior epidurogram. With the needle tip way back. I guess I must have caused a ligament fissure? Anyway, I did not advance the needle any more. I just gave the dexamethasone and got out of there. Has anyone seen this?
Click to expand...

Switch to depo/ken
 
Dorsal raphe. No ligament in midline sometimes. Your technique makes it so if this happens, it doesn’t matter. Hanging drop? Small g needle and you are shooting contrast early enough. All good. And dont change your steroid based on anonymous internet comments. The literature supports you.
 
lobelsteve said:
Dorsal raphe. No ligament in midline sometimes. Your technique makes it so if this happens, it doesn’t matter. Hanging drop? Small g needle and you are shooting contrast early enough. All good. And dont change your steroid based on anonymous internet comments. The literature supports you.
Click to expand...

literature for equivalency in ILESI?
 
lobelsteve said:
Very limited data available.
Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update

Conclusion: the author of this review abandoned particulates in all ESI.
Click to expand...

Currently use depomedrol for interlaminer Cervical, thoracic and Lumbar. Dex for TFESI....dont do cervical TF....may go to all dex...what dose do you use for TF and IL with dex? Im using 8mg dex for single level TF and would use 16mg for IL dex..
 
PAINISGOOD said:
Currently use depomedrol for interlaminer Cervical, thoracic and Lumbar. Dex for TFESI....dont do cervical TF....may go to all dex...what dose do you use for TF and IL with dex? Im using 8mg dex for single level TF and would use 16mg for IL dex..
Click to expand...

4mg is best dose, though lower may prove useful.
 
I do 10mg dex for everything that isn't a joint. Dex 4mg is the same as 10mg if I remember correctly, but I get dex in 10mg vials so it is easier and quicker to just take the entire 10mg vial. If two level TFESI it gets split into each level. My mixture is dex 10mg, NS, and 0.25% bupi. I occasionally use Depo for lumbar ILESI but I don't do a lot of lumbar ILESI as I'd rather do TFESI. I especially don't do ILESI if the pt has a Hx of lumbar surgery.

Of course, I'm sure there are people on this forum that will read this post and find a way to whine about it.
 
SommeRiver said:
I do 10mg dex for everything that isn't a joint. Dex 4mg is the same as 10mg if I remember correctly, but I get dex in 10mg vials so it is easier and quicker to just take the entire 10mg vial. If two level TFESI it gets split into each level. My mixture is dex 10mg, NS, and 0.25% bupi. I occasionally use Depo for lumbar ILESI but I don't do a lot of lumbar ILESI as I'd rather do TFESI. I especially don't do ILESI if the pt has a Hx of lumbar surgery.

Of course, I'm sure there are people on this forum that will read this post and find a way to whine about it.
Click to expand...
So injecting 4mg has been effective as 8 or 10mg dex per level for TF? What do u inject for interlaminer?
 
Does anyone have the study available that says 4mg is equivalent to higher doses of dexa, I've heard this before, but haven't seen the paper. 80mg of depomedrol is equal to 15mg of dexamethasone. Less steroid would be nice.
 
soccrwz said:
Does anyone have the study available that says 4mg is equivalent to higher doses of dexa, I've heard this before, but haven't seen the paper. 80mg of depomedrol is equal to 15mg of dexamethasone. Less steroid would be nice.
Click to expand...

4mg is equivalent to EITHER 8mg, 10mg, or 12mg of dex - I don't remember which. There are studies on this.
 
PAINISGOOD said:
So injecting 4mg has been effective as 8 or 10mg dex per level for TF? What do u inject for interlaminer?
Click to expand...

ILESI is always 10mg dex and 1.5 to 2cc of NS. Occasionally for lumbar I'll add 0.5 to 1cc of bupi 0.25%. Cervical volume will never exceed 3cc and lumbar never exceed 4cc. Oh, if a pt has received a previous ESI and I'm repeating it I will occasionally do Depo 40 or 80mg as my steroid.
 
soccrwz said:
Does anyone have the study available that says 4mg is equivalent to higher doses of dexa, I've heard this before, but haven't seen the paper. 80mg of depomedrol is equal to 15mg of dexamethasone. Less steroid would be nice.
Click to expand...
Ahadian FM, McGreevy K, Schulteis G. Lumbar transforaminal epidural dexamethasone: a prospective, randomized, double-blind, dose–response trial. Reg Anesth Pain Med. 2011;36:572–8.
 
I used 8mg Dex + 3ml Saline for ILESI and 4mg Dex with 1ml Saline for each level in TFESI. I don't bother with PF Dex since I'm not going intrathecal, although I think it's reasonable if you want to be super super safe.
 
Ferrismonk said:
I used 8mg Dex + 3ml Saline for ILESI and 4mg Dex with 1ml Saline for each level in TFESI. I don't bother with PF Dex since I'm not going intrathecal, although I think it's reasonable if you want to be super super safe.
Click to expand...
What’s the point of using dex for your ILESI if it’s not PF? Isn’t that the whole point in using dex for interlaminars?
 
I use Dex for ESI because its non-particulate. The epidural space is highly vascular and I don't want some lawyer quoting how particulates in the epidural space have caused paralysis if something happens. The whole idea of PF is just in case you go intrathecal, so I just don't go intrathecal.
 
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