Interlaminar ESI Injectate Question

[DrSwede]

I was looking at the LCD regarding steroids allowed for ESI's. Dexamethasone can be used with no issue. However, the use of methylprednisolone was eliminated (see below) unless I'm reading this incorrectly.

When it comes to Triamcinolone I am a little confused. Kenalog is not approved for Epidural use, which I presume is due to preservatives? So it appears you can use preservative free Triamcinolone? Is this correct?

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[Ferrismonk]

Can you share where you copied that comment from? I'm curious to see it myself.

Either way, no matter what the LCD says, this is my opinion:

Kenalog should not be used because package insert says not for epidural use. This is different than a warning of side effects or off-label.
Depo and Kenalog shouldn't be used because they're particulate and could lead to cord injury.

Just use dex, studies say results are similar.

 

[lobelsteve]

Can you share where you copied that comment from? I'm curious to see it myself.

Either way, no matter what the LCD says, this is my opinion:

Kenalog should not be used because package insert says not for epidural use. This is different than a warning of side effects or off-label.
Depo and Kenalog shouldn't be used because they're particulate and could lead to cord injury.

Just use dex, studies say results are similar.

Not in Bedrock's hands.

 

[DrSwede]

Thank you for your response.

Here's the Link.

The "Issue Description" as copied/pasted above is towards the top of the page. If you go to the "Limitations" section it lists the steroids in #12.

 

[mid|ine]

It doesn't say you can't use methylprednisolone. It just says dose should not exceed those listed, and interestingly, they include triamcinolone...

I know there is a lot of push back on particulate for TFESI, but are others not using it for ESIs?

What dose of betamethasone(12?) and dexamethasone (15?) are people using?

 

[bedrock]

Not in Bedrock's hands.

depomedrol....."preventing unnecessary spine fusions for you and your family since 2000 "

nice tagline

 

[emd123]

Can you share where you copied that comment from? I'm curious to see it myself.

Either way, no matter what the LCD says, this is my opinion:

Kenalog should not be used because package insert says not for epidural use. This is different than a warning of side effects or off-label.
Depo and Kenalog shouldn't be used because they're particulate and could lead to cord injury.

Just use dex, studies say results are similar.

Dex is cheaper than all the others, too. Isn't it?

 

[DrSwede]

It doesn't say you can't use methylprednisolone. It just says dose should not exceed those listed, and interestingly, they include triamcinolone...

I know there is a lot of push back on particulate for TFESI, but are others not using it for ESIs?

What dose of betamethasone(12?) and dexamethasone (15?) are people using?

I guess that's how I read the "issue description" of the LCD at the top. States a black box warning as reason for removal.

 

[Ferrismonk]

Dex is cheaper than all the others, too. Isn't it?

Honestly, no idea.

It doesn't say you can't use methylprednisolone. It just says dose should not exceed those listed, and interestingly, they include triamcinolone...

I know there is a lot of push back on particulate for TFESI, but are others not using it for ESIs?

What dose of betamethasone(12?) and dexamethasone (15?) are people using?

I use dex for TFESI and ILESI. I also use dex in highly vascular areas such as cervical facets (if I'm using steroid), some peripheral nerves, and sympathetic blocks. I'll use Depo for joints, ligaments/tendons (if I'm doing them), and peripheral nerves not near heavy vascularity.

 

[deleted875186]

Honestly, no idea.



I use dex for TFESI and ILESI. I also use dex in highly vascular areas such as cervical facets (if I'm using steroid), some peripheral nerves, and sympathetic blocks. I'll use Depo for joints, ligaments/tendons (if I'm doing them), and peripheral nerves not near heavy vascularity.

I use dex for cervical facets and TFESI but depo for interlaminar ESIs, and almost any soft tissue or joint or peripheral joint otherwise.

 

[Tramadeezy]

So if you use kenalog for ESI it wont get paid??

 

[pmrmd]

Kenalog ESIs get paid.

 

[Ferrismonk]

Kenalog ESI will get paid and will work, but if there is a bad outcome and you get sued you'll have no defense.

 

[mid|ine]

I don't know anyone in my area using non-particulate for interlaminar epidurals (including myself).

 

[MitchLevi]

Dex for an ILESI = I really love frustrating follow up visits.

 

[pmrmd]

Kenalog ESI will get paid and will work, but if there is a bad outcome and you get sued you'll have no defense.

If something goes wrong from an ILESI it’s not from the steroid.

 

[clubdeac]

it really is sad what has happened to depomedrol. If only we didn't live in a litigious, money hungry society. I truly believe depo works better despite the "studies" apparently showing equivalency. Pshhhhah

 

[TIVAndy]

before i've tried dex/celestone for a while for interlaminar.. at least for me the kenalog yields the best results so i am back at it. i think depo maybe similar to kenalog but it's expensive for me

 

[buddababa]

it really is sad what has happened to depomedrol. If only we didn't live in a litigious, money hungry society. I truly believe depo works better despite the "studies" apparently showing equivalency. Pshhhhah

I still use depo. My hospital compliance department reviewed the LCD guidelines and sicne there's no direct mention to NOT use depo, they said we can use it

 

[MitchLevi]

The war on Depo is BS and largely driven by self-righteous physicians who practice while wearing blindfolds.

L4-5 ILESI with 80mg Depo, 2cc NS and 1cc lido 2% is the most effective ESI in my inventory.

Those are much more likely to result in PRN follow ups than something containing dexamethasone.

For the first few yrs in practice I wouldn't touch particulate bc I was being a "good boy." Everyone around me uses Depo for everything, and I got sick of ppl saying my ESI didn't work as well as the others.

If you put dex in a joint you should be publically-shamed.

 

[clubdeac]

The war on Depo is BS and largely driven by self-righteous physicians who practice while wearing blindfolds.

L4-5 ILESI with 80mg Depo, 2cc NS and 1cc lido 2% is the most effective ESI in my inventory.

Those are much more likely to result in PRN follow ups than something containing dexamethasone.

For the first few yrs in practice I wouldn't touch particulate bc I was being a "good boy." Everyone around me uses Depo for everything, and I got sick of ppl saying my ESI didn't work as well as the others.

If you put dex in a joint you should be publically-shamed.

You’re exactly right

 

[nopain1234]

it really is sad what has happened to depomedrol. If only we didn't live in a litigious, money hungry society. I truly believe depo works better despite the "studies" apparently showing equivalency. Pshhhhah

What exactly is the reason we aren’t suppose to use depo anymore?

I went exclusively dex for about a year. When my regular depo ILESI pts returned whom I’d use depo previously they complained they didn’t work. This was on a large subset of patients. Therefore, I use dex on TFESI and particulate on ILESI

 

[clubdeac]

What exactly is the reason we aren’t suppose to use depo anymore?

I went exclusively dex for about a year. When my regular depo ILESI pts returned whom I’d use depo previously they complained they didn’t work. This was on a large subset of patients. Therefore, I use dex on TFESI and particulate on ILESI

Dex in ILESI makes no sense other than avoiding risk of inadvertent IT injection of preservative as dex is typically preservative free

 

[Ferrismonk]

I use dex because I'm afraid of lawyers and studies show non-inferior.

And for what it's worth, mixing saline and 2% makes absolutely no sense to me.

 

[bedrock]

I use dex because I'm afraid of lawyers and studies show non-inferior.

And for what it's worth, mixing saline and 2% makes absolutely no sense to me.

The studies are all wrong. Dex is crap compared to particulate.

Why are you afraid of lawyers if you use depomedrol for an ILESI or Caudal ?

What studies or legal cases demonstrate a real harm with depomedrol that would increase your liability using depo for those two situations? (ILESI +caudal)

(However, I do agree that routinely adding local to epidural isn’t that valuable and only adds risk)

 

[Norepi]

What do you notice when you add 2 cc of saline to your steroid and local? Why not just keep injectate volume to ~3 cc?

 

[nopain1234]

What difference does it make injecting 6-7 cc vs 5 cc on ILESI?

 

[MitchLevi]

5cc total = 80mg Depo + 2cc saline + 1cc lido. That injectate with IL at L4-5 covers L3-S1, and most of my ppl are stenotic at multiple levels.

Being afraid of lawyers bc you put a particulate in the epidural space using an IL approach is ludicrous and has no anatomical basis.

Exactly why would you get in trouble for that?

 

[Ducttape]

I still use depo. My hospital compliance department reviewed the LCD guidelines and sicne there's no direct mention to NOT use depo, they said we can use it

same here.

 

[PinchandBurn]

The studies are all wrong. Dex is crap compared to particulate.

Why are you afraid of lawyers if you use depomedrol for an ILESI or Caudal ?

What studies or legal cases demonstrate a real harm with depomedrol that would increase your liability using depo for those two situations? (ILESI +caudal)

(However, I do agree that routinely adding local to epidural isn’t that valuable and only adds risk)

Agree with Mitch

Local anesthetic in an ESI at such a low volume may help to reset the sensitization that is chronic that patients have. Sure it maybe psychological to disrupt the pain cycle even briefly but I have found it helpful.

The risk of a "high spinal" is soo miniscule especially if diluted with saline. I used to do anesthesia back in the day and we would do spinals for labor and it required a larger dosing. That stated for a cervical esi I will use only 0.5ml of lidocaine in the injectate. A high spinal at that level maybe slightly more dangerous...

 

[Ferrismonk]

The studies are all wrong. Dex is crap compared to particulate.

Why are you afraid of lawyers if you use depomedrol for an ILESI or Caudal ?

What studies or legal cases demonstrate a real harm with depomedrol that would increase your liability using depo for those two situations? (ILESI +caudal)

(However, I do agree that routinely adding local to epidural isn’t that valuable and only adds risk)

I don't know if you've ever dealt with lawyers in a courtroom, but you don't get to respond with nuances. Being on the stand would go like this:

Prosecutor: Dr. X, were you aware that there have been reports of serious neurological complications, including paralysis and death, from epidural injections of particulate steroid?
Dr. X: Yes, but...
Prosecutor: Just yes or no please.
Dr. X: Yes.
Prosecutor: And were you also aware that there are other steroids available which are not particulate but show similar efficacy?
Dr. X: Yes, but...
Prosecutor: Just answer yes or no please.
Dr. X: Yes.

I don't want to be in the position.


Regarding the local:
Go ahead and add local f you want, but at minimum why mix saline and 2% lido when you could just use 1%? Makes no sense.

 

[MitchLevi]

I don't know if you've ever dealt with lawyers in a courtroom, but you don't get to respond with nuances. Being on the stand would go like this:

Prosecutor: Dr. X, were you aware that there have been reports of serious neurological complications, including paralysis and death, from epidural injections of particulate steroid?
Dr. X: Yes, but...
Prosecutor: Just yes or no please.
Dr. X: Yes.
Prosecutor: And were you also aware that there are other steroids available which are not particulate but show similar efficacy?
Dr. X: Yes, but...
Prosecutor: Just answer yes or no please.
Dr. X: Yes.

I don't want to be in the position.


Regarding the local:
Go ahead and add local f you want, but at minimum why mix saline and 2% lido when you could just use 1%? Makes no sense.

It makes perfect sense when you find out there's only so much 1% in the world, and virtually no one uses 2% in my practice but me. Cutting 2% with saline results in my using the same multiuse 2% vial for many days, meanwhile we're already chewing through 1% in bulk.

Quit putting dex in your ILESI - Your description of the legal process is wrong.

 

[Ducttape]

the truth is somewhere in between.

some attorneys are aggressive about their cross examination. but it can backfire on a jury who then becomes sympathetic to the physician.

it is on your attorney to cross examine and allow you to expound on the "but..." parts of your comments, or to bring expert opinions to counter the cross examination.

 

[MitchLevi]

the truth is somewhere in between.

some attorneys are aggressive about their cross examination. but it can backfire on a jury who then becomes sympathetic to the physician.

it is on your attorney to cross examine and allow you to expound on the "but..." parts of your comments, or to bring expert opinions to counter the cross examination.

It's ridiculous to think you're somehow going down if you put particulate in an ILESI.

What anatomy is this attorney bringing to the table with which I then lose my license and freedom?

 

[bedrock]

I don't know if you've ever dealt with lawyers in a courtroom, but you don't get to respond with nuances. Being on the stand would go like this:

Prosecutor: Dr. X, were you aware that there have been reports of serious neurological complications, including paralysis and death, from epidural injections of particulate steroid?
Dr. X: Yes, but...
Prosecutor: Just yes or no please.
Dr. X: Yes.
Prosecutor: And were you also aware that there are other steroids available which are not particulate but show similar efficacy?
Dr. X: Yes, but...
Prosecutor: Just answer yes or no please.
Dr. X: Yes.

I don't want to be in the position.

I understand your “position” but you’re also dooming hundreds of your patients to unnecessary spine surgery.

If I was one of your patients, I might sue you for sending me off for a surgery that could haven been prevented.

As duct said, any competent attorney on cross examination will ask and clarify that spinal cord infarcts are an issue with TFESI and depo, not ILESI.

If you’re too scared to use a real steroid for ILESI or Caudal, then maybe you shouldn’t do interventional pain.

I’m not trying to insult you personally, but I think your patients are being shortchanged if you do everything with dex.

 

[SSdoc33]

I understand your “position” but you’re also dooming hundreds of your patients to unnecessary spine surgery.

If I was one of your patients, I might sue you for sending me off for a surgery that could haven been prevented.

As duct said, any competent attorney on cross examination will ask and clarify that spinal cord infarcts are an issue with TFESI and depo, not ILESI.

If you’re too scared to use use real steroid for ILESI or Caudal, then maybe you shouldn’t do interventional pain.

thats a pretty strong statement when all available evidence shows equal outcomes with particulate vs. non particulate. i think the white stuff works better, but would never fault someone for using dex.

i use depo in my Lumbar ILESIs, but not cervical or thoracic. i dont think there is a correct answer here.

 

[callmeanesthesia]

Prosecutor: And were you also aware that there are other steroids available which are not particulate but show similar efficacy?

“No”
“But surely you’re familiar with the literature showing that particulate and nonparticulate steroids have equal efficacy for epidural steroid injections”
“This patient was not the studied population”

 

[bedrock]

thats a pretty strong statement when all available evidence shows equal outcomes with particulate vs. non particulate. i think the white stuff works better, but would never fault someone for using dex.

i use depo in my Lumbar ILESIs, but not cervical or thoracic. i dont think there is a correct answer here.

Again, I’m not trying to insult him as I specifically wrote.

As I’ve written here a hundred times, the pathophysiology of stenosis is different from radiculopathy. The studies were done on radiculopathy and not a single one of them was done on stenosis. Apples and oranges.

And you should be using particulate in your CESI/TESI , at least betamethasone.

I wager there is more risk to patient from getting overly frequent CESI and dex, because dex doesn’t last, compared risk of less frequent CESI with particulate.

 

[SSdoc33]

Again, I’m not trying to insult him as I specifically wrote.

As I’ve written here a hundred times, the pathophysiology of stenosis is different from radiculopathy. The studies were done on radiculopathy and not a single one of them was done on stenosis. Apples and oranges.

And you should be using particulate in your CESI/TESI , at least betamethasone.

I wager there is more risk to patient from getting overly frequent CESI and dex, because dex doesn’t last, compared risk of less frequent CESI with particulate.

its possible

 

[MitchLevi]

The studies are conflicting with particulate vs nonparticulate.

The risk of low back or neck surgery dramatically outweighs the risk of Depo in an ILESI.

I don't fault anyone for using dexamethasone in an ILESI, but you should swap it with particulate if you're doing a repeat ILESI.

Dex for TFESI, and on TFESI repeats it is okay to swap to particulate, or cut your dex in half with particulate.

Every pain doctor around me uses Depo in their TFESI. That's the competition I'm up against, and that S works yall.

 

[Ferrismonk]

Again, I’m not trying to insult him as I specifically wrote.

As I’ve written here a hundred times, the pathophysiology of stenosis is different from radiculopathy. The studies were done on radiculopathy and not a single one of them was done on stenosis. Apples and oranges.

And you should be using particulate in your CESI/TESI , at least betamethasone.

I wager there is more risk to patient from getting overly frequent CESI and dex, because dex doesn’t last, compared risk of less frequent CESI with particulate.

That's because you shouldn't do ESI for stenosis without radiculopathy.

 

[Ferrismonk]

It makes perfect sense when you find out there's only so much 1% in the world, and virtually no one uses 2% in my practice but me. Cutting 2% with saline results in my using the same multiuse 2% vial for many days, meanwhile we're already chewing through 1% in bulk.

Quit putting dex in your ILESI - Your description of the legal process is wrong.

I love 2%, and in a shortage situation, I have no problem diluting it out. However, if you're using the same multi-dose vial on different patients on different days, you're the one doing something wrong.

 

[MitchLevi]

I love 2%, and in a shortage situation, I have no problem diluting it out. However, if you're using the same multi-dose vial on different patients on different days, you're the one doing something wrong.

...go on good buddy, tell me another thing I'm doing wrong.

 

[MD87]

I don’t know that any steroid works better than another on average, but it isn’t hard to imagine that some people respond better to one steroid than another. As far as I know, there isn’t incredible evidence saying that ibuprofen is better than naproxen or vice versa, but we all know some patients (myself included) just respond better to one than the other. Even if you are dead set on the notion that non-particulate works as well as particulate steroid, it certainly makes sense to mix things up and try a different steroid before sending a patient off to the surgeon.

 

[pmrmd]

I love 2%, and in a shortage situation, I have no problem diluting it out. However, if you're using the same multi-dose vial on different patients on different days, you're the one doing something wrong.

Uh, no. MDV use is entirely appropriate.

 

[bedrock]

That's because you shouldn't do ESI for stenosis without radiculopathy.

Because you like having your patients continue living with treatable pain?

There are thousands of patients with non classic pain from stenosis, such as L3-L4 stenosis pain that only radiates to beltline, that do great after ESI......with particulate steroid. Injecting dex does only little more than saline for stenosis.

I'm not suggesting ESI for patients with mild stenosis and not as the first treatment option.

But for patients with moderate-severe stenosis, and facets have been ruled out by negative MBB, I certainly am doing ESI with depomedrol and providing major pain relief for 4-6 months.
And making a huge differences for a few dozen patients every year who were told its lumbar fusion or nothing for their spine pain.

Not everything is written in a textbook.

 

[Dr. Ice]

Maybe the negative mbb means they should be signed up for intracept..there is pandemic levels of vertebrogenic back pain these days

 

[deleted131481]

Wow a lot of hate here for dexamethasone considering the equivocal data. I'd go with that rather than anecdote.

I do use depo in my ILESI but I doubt my results are magnitudes better than my colleague who does dex.

I save a lot more patients getting surgery by educating them and managing expectations than the fact I use particulate steroid.

 

[lobelsteve]

Because you like having your patients continue living with treatable pain?

There are thousands of patients with non classic pain from stenosis, such as L3-L4 stenosis pain that only radiates to beltline, that do great after ESI......with particulate steroid. Injecting dex does only little more than saline for stenosis.

I'm not suggesting ESI for patients with mild stenosis and not as the first treatment option.

But for patients with moderate-severe stenosis, and facets have been ruled out by negative MBB, I certainly am doing ESI with depomedrol and providing major pain relief for 4-6 months.
And making a huge differences for a few dozen patients every year who were told its lumbar fusion or nothing for their spine pain.

Not everything is written in a textbook.

Alt.universe
Alt.textbook
Alt.ymmv

 

[MitchLevi]

Because you like having your patients continue living with treatable pain?

There are thousands of patients with non classic pain from stenosis, such as L3-L4 stenosis pain that only radiates to beltline, that do great after ESI......with particulate steroid. Injecting dex does only little more than saline for stenosis.

I'm not suggesting ESI for patients with mild stenosis and not as the first treatment option.

But for patients with moderate-severe stenosis, and facets have been ruled out by negative MBB, I certainly am doing ESI with depomedrol and providing major pain relief for 4-6 months.
And making a huge differences for a few dozen patients every year who were told its lumbar fusion or nothing for their spine pain.

Not everything is written in a textbook.

Moderate to severe stenosis with back and buttock pain and a negative MBB is an ILESI with me, and it is generally effective. More often than not, those pts experience relief for several months.

I can't imagine not doing that injxn for those ppl.