ILESI level in moderately severe stenosis

[clubdeac]

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For ILESIs (not TFESIs) in patients with moderately severe central stenosis, do you all go at the level or one level below and do you see a difference in results?

I used to go at the stenotic level even in severely stenotic patients but started going one level below 8 yrs ago as I became more conservative. I’m now wondering if I used to get better results going directly at the stenotic level

 

[Taus]

I go level below if treating neurogenic claudication.
Sometimes get direct referrals for at level of max stenosis. Ligament is often thick, target very small, dead midline. More uncomfortable with injectate. Have not seen differences in outcome. ain’t worth it imo, but not wrong to do at level.

 

[DODOCSS]

b/l tesi below


same IL below

 

[willabeast]

If someone put their needle into a central stenosis with very little room and a hematoma developed and neurological damage resulted it might look bad. Would look less bad if needle was below or above the stenosis.

 

[RoloTomassi]

I've always gone at stenotic level. Below, seems like flow takes path of least resistance and bulk of medicine goes down

If very severe it's usually only at the caudal aspect of the IL space so I'll do a more cephalad trajectory to hit the mid or upper part, use smaller volume 3 cc

 

[bubaghanush]

Usually level below. If I see decent epidural space at the level of stenosis I'll go there. In general, my results aren't very good doing ILESI for central stenosis.

 

[ScawtyDawg]

i personally use 1cc dex (10mg) for ILESI at the stenotic level, have had good results thus far but durability remains an issue

from IPSIS Fact Finder:

"Milburn et al. reported on 57 study participants with LSS who had interlaminar ESI with 6 mL of injectate at the level of maximal central stenosis or two levels cephalad with less stenosis (14). The mean degree of LSS at the most stenotic level was 6.1 mm (range, 2.5-9.1 mm). The most common maximally stenotic intervertebral level was L4-L5, followed by L3-L4 and L5-S1. No complications were reported. Injection at the level of maximal stenosis was associated with better outcomes. No subjects were reported to be lost to follow-up.
Another study retrospectively evaluated 128 subjects who received ESI in the setting of moderate to severe central LSS and did not report any injection-related complications (15). Of note, all subjects received ESI at the most stenotic level, using the interlaminar approach N R I A with an injectate volume of 8 mL. "

 

[clubdeac]

i personally use 1cc dex (10mg) for ILESI at the stenotic level, have had good results thus far but durability remains an issue

from IPSIS Fact Finder:

"Milburn et al. reported on 57 study participants with LSS who had interlaminar ESI with 6 mL of injectate at the level of maximal central stenosis or two levels cephalad with less stenosis (14). The mean degree of LSS at the most stenotic level was 6.1 mm (range, 2.5-9.1 mm). The most common maximally stenotic intervertebral level was L4-L5, followed by L3-L4 and L5-S1. No complications were reported. Injection at the level of maximal stenosis was associated with better outcomes. No subjects were reported to be lost to follow-up.
Another study retrospectively evaluated 128 subjects who received ESI in the setting of moderate to severe central LSS and did not report any injection-related complications (15). Of note, all subjects received ESI at the most stenotic level, using the interlaminar approach N R I A with an injectate volume of 8 mL. "

This is exactly what I was looking for. Thank you. My gestalt was I was getting better outcomes 8 yrs ago

 

[clubdeac]

Usually level below. If I see decent epidural space at the level of stenosis I'll go there. In general, my results aren't very good doing ILESI for central stenosis.

Central stenosis is one of the most responsive diagnosis I treat with ILESI. I use particulate and it works very well, consistently at least 3 months and sometimes 6 months

 

[Taus]

i personally use 1cc dex (10mg) for ILESI at the stenotic level, have had good results thus far but durability remains an issue

from IPSIS Fact Finder:

"Milburn et al. reported on 57 study participants with LSS who had interlaminar ESI with 6 mL of injectate at the level of maximal central stenosis or two levels cephalad with less stenosis (14). The mean degree of LSS at the most stenotic level was 6.1 mm (range, 2.5-9.1 mm). The most common maximally stenotic intervertebral level was L4-L5, followed by L3-L4 and L5-S1. No complications were reported. Injection at the level of maximal stenosis was associated with better outcomes. No subjects were reported to be lost to follow-up.
Another study retrospectively evaluated 128 subjects who received ESI in the setting of moderate to severe central LSS and did not report any injection-related complications (15). Of note, all subjects received ESI at the most stenotic level, using the interlaminar approach N R I A with an injectate volume of 8 mL. "

i personally use 1cc dex (10mg) for ILESI at the stenotic level, have had good results thus far but durability remains an issue

from IPSIS Fact Finder:

"Milburn et al. reported on 57 study participants with LSS who had interlaminar ESI with 6 mL of injectate at the level of maximal central stenosis or two levels cephalad with less stenosis (14). The mean degree of LSS at the most stenotic level was 6.1 mm (range, 2.5-9.1 mm). The most common maximally stenotic intervertebral level was L4-L5, followed by L3-L4 and L5-S1. No complications were reported. Injection at the level of maximal stenosis was associated with better outcomes. No subjects were reported to be lost to follow-up.
Another study retrospectively evaluated 128 subjects who received ESI in the setting of moderate to severe central LSS and did not report any injection-related complications (15). Of note, all subjects received ESI at the most stenotic level, using the interlaminar approach N R I A with an injectate volume of 8 mL. "

first study put it at worst level or CEPHALAD, not caudal to max level

Granted, I used to think this was BS or voodoo, the “drip/trickle down technique”, but occasionally will do this with adjacent level stenosis when tfesi fails and severe central above fusion without epidural fat or prominent listhesis or lami at level above fusion. Ilesi/depo at level above that…. Does seem to work better than adjacent level tfesi/dex. It is also a heck of a lot easier and faster and less uncomfortable for adjacent level fusion patients.


And if you’re concerned about the durability of ilesi…. It is probably your dex. I would suggest switching to Depo 40 for around six months and reassessing. It is unusual not to get 3 to 6 months on these elderly claudicators

 

[bubaghanush]

Central stenosis is one of the most responsive diagnosis I treat with ILESI. I use particulate and it works very well, consistently at least 3 months and sometimes 6 months

Hmm, what volume and steroid do you use? I use 5 ml with 40 to 80 of Depo depending if they are diabetic.


Edit: Thinking about this now. I do think my responders tend to be closer normal range BMI and previously functional. Obese obviously not responding as well.

Going to keep a tally of my next ten and how they do. I'll try to remember to update here.

 

[clubdeac]

Hmm, what volume and steroid do you use? I use 5 ml with 40 to 80 of Depo depending if they are diabetic.


Edit: Thinking about this now. I do think my responders tend to be closer normal range BMI and previously functional. Obese obviously not responding as well.

Going to keep a tally of my next ten and how they do. I'll try to remember to update here.

3-4 ml

 

[BoardingDoc]

with an injectate volume of 8 mL.

What? They injected at the level of severe stenosis with EIGHT ml? Did the pain of the injection simply make them think that their back pain wasn't so bad once the pressure from that much volume wore off?

I use 3cc for CESIs and 4 for LESIs. (2NS + 1 of DEPO vs 2NS + 1 lido + 1 depo).

 

[Ducttape]

Central stenosis is one of the most responsive diagnosis I treat with ILESI. I use particulate and it works very well, consistently at least 3 months and sometimes 6 months

you said this, so why change?

What? They injected at the level of severe stenosis with EIGHT ml? Did the pain of the injection simply make them think that their back pain wasn't so bad once the pressure from that much volume wore off?

I use 3cc for CESIs and 4 for LESIs. (2NS + 1 of DEPO vs 2NS + 1 lido + 1 depo).

from the article:
"The injectate consisted of 2 mL of 40 mg/mL methylprednisolone (Pfizer), 2 mL of bupivacaine 0.25% (Hospira), and 2 mL of normal saline for a total injectate volume of 6 mL."



they were followed 12 weeks out. initially assessed at 1 and 4 weeks, there was a statistically significant difference in pain with ambulation - 4.5 vs 6.3 at 4 weeks. but at 12 weeks, there were "those who dropped out" and the difference was 6.7 vs 7.0, so p=0.08 and not statistically significant at 12 weeks. i included that phrase because the authors did, seemingly as a reason that the data was not

of note, at 5 min no difference in pain between 2 groups.

also of note, 57 enrolled. at 12 weeks, 15 of the group that got injection at stenosis level dropped out, and 14 of the ones that got injection 2 levels cephalad dropped out, so 1/2 of the study was gone at 12 weeks. dropped out because they got additional steroids or they elected surgery. it does not make a distinction, which could be significant

 

[clubdeac]

you said this, so why change?


from the article:
"The injectate consisted of 2 mL of 40 mg/mL methylprednisolone (Pfizer), 2 mL of bupivacaine 0.25% (Hospira), and 2 mL of normal saline for a total injectate volume of 6 mL."



they were followed 12 weeks out. initially assessed at 1 and 4 weeks, there was a statistically significant difference in pain with ambulation - 4.5 vs 6.3 at 4 weeks. but at 12 weeks, there were "those who dropped out" and the difference was 6.7 vs 7.0, so p=0.08 and not statistically significant at 12 weeks. i included that phrase because the authors did, seemingly as a reason that the data was not

of note, at 5 min no difference in pain between 2 groups.

also of note, 57 enrolled. at 12 weeks, 15 of the group that got injection at stenosis level dropped out, and 14 of the ones that got injection 2 levels cephalad dropped out, so 1/2 of the study was gone at 12 weeks. dropped out because they got additional steroids or they elected surgery. it does not make a distinction, which could be significant

I didn’t change whether I do an ILESI for stenosis. I just changed the level from most stenotic to one level caudad. Did that as I’ve become more conservative in my latter years

 

[Ducttape]

so if you have good results, then continue.

if not, go back to the prior method, but i wouldnt necessarily base it on that marginal study.



i avoid going at levels with severe stenosis if i cannot see anything and go 1 level caudal. i dont expect it to do much and when the stenosis is severe, it usually doesnt for me, whether (previously) going at the level, 1 above or 1 below.

 

[interjectionreflection]

3-4 ml

What's the dose of depo you use? Any local?

 

[mille125]

I saw the 8 ml too..

 

[Orin]

Two issues with it are difficulty/risks of access and risk of worsening pressure neuropraxia. One is mitigatable by your skill and the other by your technique. I generally prefer TFESI in severe central stenosis as I don't think my hands are that good, but y'all might be better at it.

Slow injections in an awake patient let you know how much volume they can tolerate. I do steroid/local first and then chase with saline till they say ouch.

Link for FF: www.ipsismed.org/resource/resmgr/factfinder/24/05-FF-Lumbar-Stenosis.pdf
Link for study with 8 mL in severe stenosis: Changes in pain scores and walking distance after... : Medicine

 

[clubdeac]

What's the dose of depo you use? Any local?

Used to be 80 mg depo but gonna start using 40 mg. Mix it with saline, no local.

 

[joshmir]

For those who perform ILESI at the level of moderate-severe central canal stenosis

Do you feel that’s where you may have the highest occurrence of wet taps (when you go directly at that level)?

Or is it at levels where the curvature is altered (ie levels with listhesis or L5/S1)?

 

[Ducttape]

those most likely to have severe spinal stenosis are those who are least likely statistically to develop PDPH ie elderly.

i cant remember the last time i had a wet tap. the last time i had a patient with PDPH was a couple of years ago, and almost all of them have been in younger (<35) females.

 

[MitchLevi]

those most likely to have severe spinal stenosis are those who are least likely statistically to develop PDPH ie elderly.

i cant remember the last time i had a wet tap. the last time i had a patient with PDPH was a couple of years ago, and almost all of them have been in younger (<35) females.

I’ve not had one since becoming an attending in 2017. I also go a level below if severe stenosis. I’ll do moderate.

I think some ppl forget what it is we do for a living, manage pain not cure it.

 

[nvrsumr]

Jinx

 

[clubdeac]

those most likely to have severe spinal stenosis are those who are least likely statistically to develop PDPH ie elderly.

i cant remember the last time i had a wet tap. the last time i had a patient with PDPH was a couple of years ago, and almost all of them have been in younger (<35) females.

Wet tap and PDPH are two separate things. You can have one without the other.

 

[hopefulgasman]

Has anyone ever seen PDPH from a TFESI? Again similar demographic as that mentioned above, <40y female with a raging radic from disc herniation. She was adamant about IV sedation and I steadfast refused because she was new and my spider sense said don't do it with (I do IV case-by-case), so I referred out to another interventionalist who doesn't care. She ended up obtaining zero relief and reported a non-positional headache for weeks after. I saw her back in clinic, benign clinical exam, and reassured. It eventually subsided on its own. Could have been due to the steroid (they used depo), could have been a PDPH; I'll never know as I didn't perform the procedure.

 

[clubdeac]

Has anyone ever seen PDPH from a TFESI? Again similar demographic as that mentioned above, <40y female with a raging radic from disc herniation. She was adamant about IV sedation and I steadfast refused because she was new and my spider sense said don't do it with (I do IV case-by-case), so I referred out to another interventionalist who doesn't care. She ended up obtaining zero relief and reported a non-positional headache for weeks after. I saw her back in clinic, benign clinical exam, and reassured. It eventually subsided on its own. Could have been due to the steroid (they used depo), could have been a PDPH; I'll never know as I didn't perform the procedure.

Have surprisingly injected IT once or twice in my career via TFESI but neither got PDPH

 

[MitchLevi]

Has anyone ever seen PDPH from a TFESI? Again similar demographic as that mentioned above, <40y female with a raging radic from disc herniation. She was adamant about IV sedation and I steadfast refused because she was new and my spider sense said don't do it with (I do IV case-by-case), so I referred out to another interventionalist who doesn't care. She ended up obtaining zero relief and reported a non-positional headache for weeks after. I saw her back in clinic, benign clinical exam, and reassured. It eventually subsided on its own. Could have been due to the steroid (they used depo), could have been a PDPH; I'll never know as I didn't perform the procedure.

Non positional HA + demanding IV sedation + reduced risk using TF approach = Unlikely PDPH.

 

[Ducttape]

Wet tap and PDPH are two separate things. You can have one without the other.

yes about 2/3 of female peripartum patients get PDPH after wet tap.

it is possible to be blithely unaware that one has caused a wet tap...

 

[mille125]

Has anyone ever seen PDPH from a TFESI? Again similar demographic as that mentioned above, <40y female with a raging radic from disc herniation. She was adamant about IV sedation and I steadfast refused because she was new and my spider sense said don't do it with (I do IV case-by-case), so I referred out to another interventionalist who doesn't care. She ended up obtaining zero relief and reported a non-positional headache for weeks after. I saw her back in clinic, benign clinical exam, and reassured. It eventually subsided on its own. Could have been due to the steroid (they used depo), could have been a PDPH; I'll never know as I didn't perform the procedure.

You just said non positional headache

TFESI uses the same sized needle as spinal taps.

Very Very Very unlikely that this was a PDPH

 

[SSdoc33]

Has anyone ever seen PDPH from a TFESI? Again similar demographic as that mentioned above, <40y female with a raging radic from disc herniation. She was adamant about IV sedation and I steadfast refused because she was new and my spider sense said don't do it with (I do IV case-by-case), so I referred out to another interventionalist who doesn't care. She ended up obtaining zero relief and reported a non-positional headache for weeks after. I saw her back in clinic, benign clinical exam, and reassured. It eventually subsided on its own. Could have been due to the steroid (they used depo), could have been a PDPH; I'll never know as I didn't perform the procedure.

never seen it. done i dont know, 10-20K if them.

it is described in the literature, but i think that is BS

 

[Orin]

I have done spinal injections via the TF approach, but no PDPH noted. Small N, baclofen/deformity/spinal fusion cases

 

[FSQT]

never seen it. done i dont know, 10-20K if them.

it is described in the literature, but i think that is BS

Looking at the boundaries of the thecal sac on 1000's of MRIs, I can't imagine how it would happen. You would have to be at least at the very medial border of the pedicle when advancing in AP at the end, well past the "6 o'clock on the pedicle" position.

If I'm missing something, can someone please let me know!

 

[CB1Antagonist]

Dural puncture can happen with the accidental puncture of a large dural diverticulum traveling with the exiting nerve root, using standard TFESI techniques (subpedicular/retroneural etc)

 

[CB1Antagonist]

The incidence of large dural diverticulae in lumbar lumbar nerve roots is around 4%

 

[FSQT]

Dural puncture can happen with the accidental puncture of a large dural diverticulum traveling with the exiting nerve root, using standard TFESI techniques (subpedicular/retroneural etc)

Thanks. Are these just Tarlov cysts, or something different? I see those in the sacral region, but haven't really noticed it in the lumbar foraminal. I don't think I've been seeing these on lumbar MRIs, but I'll be looking more closely now!

 

[BobBarker]

I have a beautiful tfesi that got a PDPH. Blood patch resolved everything. Let me find a pic.

 

[BobBarker]

 

[lobelsteve]

View attachment 423721

Clearly IT.

JK

 

[mille125]

I have a beautiful tfesi that got a PDPH. Blood patch resolved everything. Let me find a pic.

22 or 25 G spinal?

 

[BobBarker]

I use 23g

 

[bedrock]

Back to the original question, I don’t think the potential results are worth the potential risk of doing ILESI at level with severe stenosis. Mild stenosis yes, no to severe.