Interlaminar epidural in moderate to severe stenosisinal canal stenosis

[painfre]

Pt is having B/L L4/5 and L5/S1 foraminal stenosis and moderate to severe central stenosis and spinal canal about 8.5 mm. CSF barely seen on the posteriorly side in the sagital view on STIR image. Do you do interlaminar epidurals in this patient ? The pt has ligament flavum thickening. I am not very good in reading MRI films. Does Axial views give good idea about epidural space ?

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[lobelsteve]

Pt is having B/L L4/5 and L5/S1 foraminal stenosis and moderate to severe central stenosis and spinal canal about 8.5 mm. CSF barely seen on the posteriorly side in the sagital view on STIR image. Do you do interlaminar epidurals in this patient ? The pt has ligament flavum thickening. I am not very good in reading MRI films. Does Axial views give good idea about epidural space ?

I would not in the neck, but in the low back:

b/l S1 TFESI. SPine is so tight the med will either shoot up and past it or be blocked by the stenosis. Either way you will see the contrast go where it will go. Stenosis is a surgical problem with a surgical correction. ESI can buy time for some patients. If it were me- I'd go for simple decompression.
But you did not mention symptoms....I've got a guy with a 6mm canal at C5-6 and no symptoms. I'm treating his back, his PCP got the MRI of his neck for ache.

 

[doctorlarry]

Machikanti had a series of papers (RCTs) and one of them looked at caudal ESI for spinal stenosis. What is everyone's thoughts on high volume caudals +/- Racz or Codman cath?

 

[lobelsteve]

Machikanti had a series of papers (RCTs) and one of them looked at caudal ESI for spinal stenosis. What is everyone's thoughts on high volume caudals +/- Racz or Codman cath?

Worthless. Maybe do 5 a year to get a catheter in to target multiple levels, but not for stenosis. High volume is never a good idea except for extra-office activities.

 

[Finally M3]

Pt is having B/L L4/5 and L5/S1 foraminal stenosis and moderate to severe central stenosis and spinal canal about 8.5 mm. CSF barely seen on the posteriorly side in the sagital view on STIR image. Do you do interlaminar epidurals in this patient ? The pt has ligament flavum thickening. I am not very good in reading MRI films. Does Axial views give good idea about epidural space ?

Agree with Steve and bilateral S1 TFESIs...

Not a huge fan of huge-volume any-neuroaxial injection.

 

[SSdoc33]

interlaminars for stenosis is dumb. caudals is dumber. this notion of high-volume so that you can cover "all of the involved levels" is flawed thinking. you end up with a motor block or an ineffective injection

bilateral L5, 1 mL steroid and .5 mL anesthetic at each level and VOILA. put the steroid as close to the stenosis that you can and inject slowly. pt may feel it, esp if there is bad foraminal stenosis, but this wil be the biggest bang for your buck.

 

[PMR 4 MSK]

interlaminars for stenosis is dumb.

Why?

 

[Tenesma]

i don't think it is dumb... but i do agree that I prefer bilateral transforaminal over interlaminar... at least i don't have to deal with spinal headaches as much as i used to...

 

[SleepIsGood]

MILD....if theres neurogenic claudication. Can help out the central stenosis if it's d/t lig flavum hypertrop..

 

[SSdoc33]

Why?

lot of reasons. first of all, in the case above, the patient had both NF and central stenosis. with NF stenosis, you are depositing the steroid right at the level of stenosis and presumed inflammation anteriorly, rather than posteriorly with an interlaminar.

also, patient with stenosis are usually older, sometimes have a calcified ligamentum flavum, and a smaller epidural space. you are asking for a dural puncture in these circumstances.

finally, the little research out there suggests that TFESIs are a bit more efficacious in general, and seems to be significantly better with stenosis (see Riew, 2001).

i do see a role for ILESIs, but its a rare case IMHO

 

[Doctodd]

ditto......MILD if the flavum is big enough on films. Next extension for MILD will be a slight deviation laterally towards the foramen.

 

[bedrock]

interlaminars for stenosis is dumb

MILD....if theres neurogenic claudication. Can help out the central stenosis if it's d/t lig flavum hypertrop..

Agree that transforaminals are needed with notable foraminal stenosis. However, I've gotten great results on a significant proportion of my patients with central lumbar stenosis doing regular ILESI. The literature doesn't overwhelming support TFESI as the only way to treat stenosis. http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2010.00932.x/abstract
I will definitely do TFESI if ILESI doesn't work, but since starting private practice I've been surprised at how many central stenosis patient's get better with just an ILESI.

Regarding MILD-Is anyone getting them paid for? Intriguing, but I thought pain docs were having a hard time getting paid (or credentialed) for MILD procedures.

 

[clubdeac]

interlaminars for stenosis is dumb. caudals is dumber. this notion of high-volume so that you can cover "all of the involved levels" is flawed thinking. you end up with a motor block or an ineffective injection

bilateral L5, 1 mL steroid and .5 mL anesthetic at each level and VOILA. put the steroid as close to the stenosis that you can and inject slowly. pt may feel it, esp if there is bad foraminal stenosis, but this wil be the biggest bang for your buck.

I tend to agree more with bedrock and this is only after being in practice having seen the results myself. In fellowship, TFESIs were the rage and I did very few interlaminars. However I have been impressed by the number of LSS patients that do great with ILESIs above or below the level of stenosis. There is even some evidence that they do better than TFESIs for unilateral radicular pain as well:

http://www.painmedicinenews.com/index.asp?section_id=353&show=dept&issue_id=641&article_id=15372

The other day I did a left paramedian L5-S1 ILESI for left leg pain. Got perfect L5, S1 and S2 neurograms. Was so impressed that I pointed it out to my nurse and tech.

 

[SSdoc33]

I tend to agree more with bedrock and this is only after being in practice having seen the results myself. In fellowship, TFESIs were the rage and I did very few interlaminars. However I have been impressed by the number of LSS patients that do great with ILESIs above or below the level of stenosis. There is even some evidence that they do better than TFESIs for unilateral radicular pain as well:

http://www.painmedicinenews.com/index.asp?section_id=353&show=dept&issue_id=641&article_id=15372

The other day I did a left paramedian L5-S1 ILESI for left leg pain. Got perfect L5, S1 and S2 neurograms. Was so impressed that I pointed it out to my nurse and tech.

sure, you CAN do ILESIs..... but why? a TFESI is generally more efficacious, and not to be a materialistic weasel, but it pays better. the only reason that i can think of why you would do an interlaminar is that may be easier from a technical standpoint.

 

[Dr. Ice]

Pt is having B/L L4/5 and L5/S1 foraminal stenosis and moderate to severe central stenosis and spinal canal about 8.5 mm. CSF barely seen on the posteriorly side in the sagital view on STIR image. Do you do interlaminar epidurals in this patient ? The pt has ligament flavum thickening. I am not very good in reading MRI films. Does Axial views give good idea about epidural space ?

What are the symptoms? What does the PE show? If you solely go off the MRI, you will probably not get the results you want. I think there is utility for ILESI, but certainly not for foraminal stenosis with radicular pain in a particular distribution. I do ILESIs on patients with multilevel mild stenosis with intermittent radiculitis and predominantly axial pain with pretty good results.

Im also a big fan of the b/L S1 TFs. I had a guy with a multilevel posterior fusion with predominatly axial pain and intermittent posterior thigh pain. I did b/l S1 TFs on him, saw him a month later and his pain (both axial and posterior thigh) were markedly better...

 

[PsychoticNerve]

In summary, nobody knows. The literature is crap and we all practice differently. Some injections work in some patients, some injections don't work on some patients. Is that about right?

 

[clubdeac]

sure, you CAN do ILESIs..... but why? a TFESI is generally more efficacious, and not to be a materialistic weasel, but it pays better. the only reason that i can think of why you would do an interlaminar is that may be easier from a technical standpoint.

The entire point of my post was that ILESIs are generally more efficacious. That's why you do it. Maybe you missed that...

 

[SSdoc33]

The entire point of my post was that ILESIs are generally more efficacious. That's why you do it. Maybe you missed that...

i didnt miss it, dude, i just disagree. if you feel that the patients that you have seen have done better with ILESIs, then more power to you. the general concensus (both in the literature and on this forum) is that you are wrong, but whatever floats your boat. i think ill err on the side of science, rather than on your personal annecdotal evidence.

 

[clubdeac]

i didnt miss it, dude, i just disagree. if you feel that the patients that you have seen have done better with ILESIs, then more power to you. the general concensus (both in the literature and on this forum) is that you are wrong, but whatever floats your boat. i think ill err on the side of science, rather than on your personal annecdotal evidence.

First off who you callin dude?!?! Do you have any idea how much I bench? And you're talkin to a guy who trained under one of slipmans protege's. I was trained drinking the TFESI and bilateral TFESI koolaid. It wasn't until I had several LSS patients that didn't respond to bilateral TFESIs but do well with ILESIs that I started to rethink things. That's all

 

[drpainfree]

had a patient like that as well: severe, I mean severe L3 to S1 LSS, and foraminal stenosis and L5/S1 anteriolisthesis essentially wipes out canal space at the level. neurogenic claudication, and bilateral but left-sided dominant buttock aching pain and bilateral plantar paresthesia of both feet.

didn't consider ILESI at L5-S1 due to risk of dural puncture, attempted bilateral L5/S1 TFESI, wasn't successful on the left side due to severe stenosis, eventually did caudal epidural with catheter directed to L5/S1 and right-sided L4/L5, and L5/S1, and left-sided L4/L5.

pt was doing better post-procedure and went on to a long vacation.

i wouldn't do ILESI simply because the risk of dural puncture there due to distorted anatomy.

 

[pjuer]

I also find I get good results with ILESI in stenosis, Have not seen a serious headache from an inadvertant dural puncture in this age group either.

 

[SSdoc33]

First off who you callin dude?!?! Do you have any idea how much I bench? And you're talkin to a guy who trained under one of slipmans protege's. I was trained drinking the TFESI and bilateral TFESI koolaid. It wasn't until I had several LSS patients that didn't respond to bilateral TFESIs but do well with ILESIs that I started to rethink things. That's all

fair enough. i usually think of performing a TFESI if the patient fails an ILESI, when i do an ILESI (which is getting more and more rare)

 

[bedrock]

sure, you CAN do ILESIs..... but why? a TFESI is generally more efficacious, and not to be a materialistic weasel, but it pays better. the only reason that i can think of why you would do an interlaminar is that may be easier from a technical standpoint.

I do 90% of my procedures in-office and I find that patients tolerate a quick lumbar ILESI with 20gauge Touhy easier than a bilateral TFESI. So for patients that may do about as well with an interlaminar, I start with an ILESI (about 30% of my lumbar epidurals). The other 70% of my lumbar ESI patients I start with TFESI.

Yes and no from the reimbursement standpoint. In 2010 (in-office) a bilateral single level lumbar TFESI pays approx twice the amount of two separate lumbar ILESI.

However, I can do a lumbar ILESI twice as fast as bilateral TFESI, so I make as much money per procedural hour doing either. Next year I might get paid more doing ILESI compared to TFESI now that they're bundling fluoro for TFESI, but not for ILESI.

 

[pjuer]

http://www.ispub.com/journal/the_in...s-a-prospective-randomized-control-study.html

 

[SSdoc33]

http://www.ispub.com/journal/the_in...s-a-prospective-randomized-control-study.html

caudals? 16 mL injectate? 160 mg steroid? "whoosh test"? internet journal of pain, symptom control, and palliative care? Teerthankar Mahaveer Medical College?

hmmmmmmmmm..........

 

[bedrock]

yeah, that study seems a bit sketchy.....