IL ESIs after laminectomy

[dc2md]

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I had a patient earlier this month swear to me that he used to get lumbar interlaminar epidurals even though he's had a laminectomy. i eventually convinced him to get transforaminals instead. BUT, do any of you that normally do ILESIs refuse to do so in a patient with a laminectomy at the level you'd go into?? or would you do it anyway and just trust your loss of air/water resistance and lateral fluoro for needle depth??

 

[Tenesma]

almost every patient w/ a lami that i have done an IESI on (at the level or the level close to the lami) has ended up with a wet-tap or a seroma-tap.... therefore, as a matter of practice I just don't do it anymore.

 

[PMR 4 MSK]

I had a patient earlier this month swear to me that he used to get lumbar interlaminar epidurals even though he's had a laminectomy. i eventually convinced him to get transforaminals instead. BUT, do any of you that normally do ILESIs refuse to do so in a patient with a laminectomy at the level you'd go into?? or would you do it anyway and just trust your loss of air/water resistance and lateral fluoro for needle depth??

99% of the time I do TF s/p lami, but I had one recently that I had done an IL on a couple years ago and it worked w/o wet tap, so when we got in there this time, I re-reviewed the chart, triple checked it, scatched my head a few times saying "why the hell did I do that?" I did the IL again, worked very well. I sweated it, waiting for him to sit up and go "****, my head hurts!" No problemo.

 

[dc2md]

99% of the time I do TF s/p lami, but I had one recently that I had done an IL on a couple years ago and it worked w/o wet tap, so when we got in there this time, I re-reviewed the chart, triple checked it, scatched my head a few times saying "why the hell did I do that?" I did the IL again, worked very well. I sweated it, waiting for him to sit up and go "****, my head hurts!" No problemo.

so you just used loss of resistance (since the ligamentum flavum is gone)??

btw, if you did get a wet tap followed by headache, would you do another IL to do the blood patch...or then do a TF bilaterally (to make sure you get good flow bilaterally)?

 

[lobelsteve]

so you just used loss of resistance (since the ligamentum flavum is gone)??

btw, if you did get a wet tap followed by headache, would you do another IL to do the blood patch...or then do a TF bilaterally (to make sure you get good flow bilaterally)?

There is not going to be a LOR if the flavum is gone. THere is often no posterior epidural space as this "potential space" has been scarred down onto the dura. Caudal with catheter to the affected area or TFESI are "better" approaches.

 

[SSdoc33]

I had a patient earlier this month swear to me that he used to get lumbar interlaminar epidurals even though he's had a laminectomy. i eventually convinced him to get transforaminals instead. BUT, do any of you that normally do ILESIs refuse to do so in a patient with a laminectomy at the level you'd go into?? or would you do it anyway and just trust your loss of air/water resistance and lateral fluoro for needle depth??

ive done a bunch of ILESIs on post-lami patients. i usually have a LOR, and have not had a wet tap yet. that being said, the chances are much greater to get a wet tap, the LOR is inconsistent at best and sometimes absent, and poking through scar can feel like shoe leather.

TFESIs are a much better approach in post-lami patients.

 

[dc2md]

ive done a bunch of ILESIs on post-lami patients. i usually have a LOR, and have not had a wet tap yet. that being said, the chances are much greater to get a wet tap, the LOR is inconsistent at best and sometimes absent, and poking through scar can feel like shoe leather.

TFESIs are a much better approach in post-lami patients.

then why do ILESIs when you can just do the TFESIs safer?? besides just quicker.

and steve, the LOR i was talking about wasn't the resistance of the needle as it got thru the lig flavum...i meant LOR of resistance of the air/water in the syringe. that'll still be there right?? (i haven't done one s/p laminectomy before).

 

[dc2md]

There is not going to be a LOR if the flavum is gone. THere is often no posterior epidural space as this "potential space" has been scarred down onto the dura. Caudal with catheter to the affected area or TFESI are "better" approaches.

wonder why the epidural space would be missing. shouldn't the posterior epidural fat and vessels still be there??

 

[lobelsteve]

wonder why the epidural space would be missing. shouldn't the posterior epidural fat and vessels still be there??

Stop in on a redo with a spine surgeon.
There is often an engorged batsons plexus laterally with some vessels crossing over but frequently the dura is scarred to the remnants of flavum.
The term obliteration comes to mind when I think about a post-lami posterior epidural space. There are plenty of patients who have inconsistent scarring and will have pockets where the injection can be performed- we just do not know ahead of time who has them and where they are. I have seen tremendous scarring at 6 weeks post-op on a redo paddle of one of my patients. 25 y/o female with no medical history. It took 45 minutes to take down enough scar to get the paddle repositioned.

Scar happens. The LOR through the dura vs the LOR through the fibrous scar tissue cannot be differentiated and is unpredictable (unless the intent is to go IT). Caudal with cath or TFESI make sense.

 

[mille125]

There is not going to be a LOR if the flavum is gone. THere is often no posterior epidural space as this "potential space" has been scarred down onto the dura. Caudal with catheter to the affected area or TFESI are "better" approaches.

agreed....these patients do not have a traditional "epidural space" ... these patients are more of a setup for spinal infarcts with transforaminal approaches...proceed with caution....

 

[Sharps]

I've gotten pt's great relief doing an ilesi above or below the level of their prior surgery.

 

[brori]

Post lumbar lami patient. Never did IL around that level. Used to do TF, but switched to caudal cath to avoid the scar tissue and aberrant vasculature.

 

[lobelsteve]

Post lumbar lami patient. Never did IL around that level. Used to do TF, but switched to caudal cath to avoid the scar tissue and aberrant vasculature.

The problem most folks have with caudal caths is the reimbursement is a contentious issue between 63211 and 62319.

It basically comes down to eating the $20 for the good of the patient.
Then the arguement becomes- prove it better than x or y.

Good science is often trumped by egotistical ramblings.

 

[ampaphb]

then why do ILESIs when you can just do the TFESIs safer?? besides just quicker.

and steve, the LOR i was talking about wasn't the resistance of the needle as it got thru the lig flavum...i meant LOR of resistance of the air/water in the syringe. that'll still be there right?? (i haven't done one s/p laminectomy before).

Chris:

Loss of resistance technique is both of the events you described. In a virgin back, when going through muscle, you will be able to push down on the plunger of your syringe. Once the needle engages the ligament, advancing the syringe is slightly more difficult, and the plunger is almost impossible to depress. Once you advance the tip of your needle deep to the ligament, there is often a give or a pop, and the plunger advances easily.

You can be fooled if the patient's anatomy is anomalous, however. Sometimes, the first structure you engage is not, in fact the ligament, but rather the dura itself. Post-operatively, the dura and the ligament can adhere to one another (e.g from scaring) and so again you can pass directly into the thecal sac when performing an ILESI at the operative level.

I have frequently found that my contrast abruptly stops flowing at the level of the scar when I attempt an ILESI below the operative level. My experience is that this can also be the case with TFESIs, with the dye typically flowing distally, but with a proximal cutoff. In both instances, I will typically go to an adjacent level and perform a second injection. I have found that most insurers wont pay you for a two level ILESI, however.

 

[paindefender]

I have found that most insurers wont pay you for a two level ILESI, however.[/QUOTE]

Did you bill for a two level ILESI?

 

[ampaphb]

Did you bill for a two level ILESI?

Recognizing that you are being a troll, and have no interest in an actual dialogue, please tell me why it would not be justified to do a two level ILESI in the post-operative case described, where the contrast abruptly cut off, and you wanted to get therapeutic solution to bathe the object level both from above and below?

 

[paindefender]

Recognizing that you are being a troll, and have no interest in an actual dialogue, please tell me why it would not be justified to do a two level ILESI in the post-operative case described, where the contrast abruptly cut off, and you wanted to get therapeutic solution to bathe the object level both from above and below?

Most physicians would be unable to sustain any rational dialogue with you.

 

[Finally M3]

I've gotten pt's great relief doing an ilesi above or below the level of their prior surgery.

I have heard that the stripping of the LF can be inconsistent @ the level of the laminectomy, and you can still have changes to the structural integrity of the LF above or below the surgical site.

Thoughts?