Large L4-5 extrusion with severe central stenosis ... which level to inject?

[CarabinerSD]

Young woman with L4-5 8-9mm posterior central protrusion with 8mm inferior subligamentous extrusion with severe central stenosis, thecal sac 5.7mm, with severe lateral recess narrowing. Pain is concordant with low back radiating to the hips, squeezing pain. Already doing medications to manage pain. Doesn’t want surgery yet....

Attached MRI images. Foramen doesn’t look too bad but severe L4-5 central stenosis. Inject bilateral L5-S1 TFESI….or go for the L4-5? I know there's going to be tons of opinions but wondering about your rationale.

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[BobBarker]

There is room to inject wherever you want.

 

[RoloTomassi]

L4-5 IL. That's not that tight. Puts needle tip closest to pathology. If not better second shot would be b/l L4-5 TF for different approach/med. Preganglionic better than postganglionic according to one article.

 

[CarabinerSD]

L4-5 IL. That's not that tight. Puts needle tip closest to pathology. If not better second shot would be b/l L4-5 TF for different approach/med. Preganglionic better than postganglionic according to one article.

Wouldn't doing Transforaminal first put the needle tip closest to the pathology as opposed to Interlam?

 

[RoloTomassi]

Wouldn't doing Transforaminal first put the needle tip closest to the pathology as opposed to Interlam?

The way I see it you're right behind the herniation, especially if you're far paramedian. TF subpedicular is a bit higher/lower than the disc. But there's some evidence that TF is better for hot radic too. This is just what I'd do based on my experience and outcomes. Might not really even make a difference if studied.

 

[willabeast]

I would start with a L5S1 IL ESI. Steroid will travel cephalad. Sounds like pain is all above the knees? Is there anything on PE to support radicular pain?

 

[Taus]

I would start with a L5S1 IL ESI. Steroid will travel cephalad. Sounds like pain is all above the knees? Is there anything on PE to support radicular pain?

mri doesn’t look as bad as those measurements sound. This isn’t severe stenosis- nerve roots separated by some csf

think all suggested esi options above are fine.

Personally I do L5-s1 interlam w depo here. Backup plan is L5 tfesi w dex

Failing that, PT, few months time…. Decompression time if pain below waist bad enough to warrant.

The real question here is…. What would a pain surgeon do?

 

[MitchLevi]

Personally, I start with TF and then chase with IL, but no wrong answers IMO. L4-5 is wide open for an IL or TF.

 

[Agast]

I follow the dermatomal pattern of pain. It sounds like you’re describing L5, but since she also has low back pain, I do an L5/S1 interlaminar ESI first.

 

[SSdoc33]

B L5 TFESI

 

[callmeanesthesia]

Caudal. Inject the steroid first then flush it up with some local and saline.

 

[runfastnow]

B L5-1 TFESI if primarily axial + buttocks pain and no clear L4 or L5 radicular symptoms to the foot/feet. Chase 3-4 weeks later with L5-1 ILESI with depo if not improving enough.

 

[DOctorJay]

B L5-S1 TFESI

follow up with L5-S1 LESI if TFESI doesn’t help

 

[pmrmd]

I’d probably do B 5-1 TF and follow with 4-5 IL if second needed.

I wouldn’t do 4-5 TF at any time for this patient.

 

[Agast]

Caudal. Inject the steroid first then flush it up with some local and saline.

Why caudal over L5/S1 interlaminar? I’d consider this if pain was mostly buttock and posterior leg.

 

[callmeanesthesia]

Why caudal over L5/S1 interlaminar? I’d consider this if pain was mostly buttock and posterior leg.

Usually slightly faster, lower risk of dural puncture, if appropriately angled approach it can result in great anterior spread. Higher volume vs interlam should coat the nerve roots at both levels quite well. Nothing wrong with interlam either, this is just my usual go-to for multilevel lower lumbar pathology.

 

[Scottie_Dog]

Bilateral L5-S1 TFESI with depo

 

[gdub25]

This is something that came up with one of my mid-level's who used to work for a surgeon. She really does a bunch of mental gymnastics trying to figure out the very best injection and it really got me wondering about going back to the basics since I've been out of training for a while now. We have a bunch of different suggestions here from the group. Are there any studies that show that it even matters much? Seems like in training we read a paper that compared results of different epidural approaches as well as contrast spread and there was very little difference in outcome. As long as you were getting some kind of steroid in the epidural space somewhat in the region of the pathology you were going to get similar results. If anyone has any literature on this I would like to use it for a journal club with my team.

 

[nvrsumr]

The surgeons ( and their pas) still think an esi is diagnostic to level they want to treat. They always want to target the surgical level even if pain pattern is different. Ie. L4-5 disc with radiation to dorsum L4-5 tfesi rather than more appropriate L5-1

 

[RoloTomassi]

This is something that came up with one of my mid-level's who used to work for a surgeon. She really does a bunch of mental gymnastics trying to figure out the very best injection and it really got me wondering about going back to the basics since I've been out of training for a while now. We have a bunch of different suggestions here from the group. Are there any studies that show that it even matters much? Seems like in training we read a paper that compared results of different epidural approaches as well as contrast spread and there was very little difference in outcome. As long as you were getting some kind of steroid in the epidural space somewhat in the region of the pathology you were going to get similar results. If anyone has any literature on this I would like to use it for a journal club with my team.

The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis - PubMed

The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two...

pubmed.ncbi.nlm.nih.gov

 

[Taus]

The surgeons ( and their pas) still think an esi is diagnostic to level they want to treat. They always want to target the surgical level even if pain pattern is different. Ie. L4-5 disc with radiation to dorsum L4-5 tfesi rather than more appropriate L5-1

yep. When it’s L4-5 pathology compressing L5 nerve root on mri, L5 symptoms and they order “L45” tfesi….. I do an “L5” tfesi and dictate as such. They don’t specify supraneural, infraneural, retroneural or which foramen I went through….. I get the medicine on the target in the way I feel optimal and dictate slightly ambiguous.

 

[MitchLevi]

Do the injxn at the site of compression.

 

[BobBarker]

It doesn’t really matter unless you do a muscadural. Which seems like about half of our peers do routinely.

 

[callmeanesthesia]

It doesn’t really matter unless you do a muscadural. Which seems like about half of our peers do routinely.

Muscadural? Is that like an epidermal?

 

[Laryngospasm]

I bet an L3/4 ILESI Would work as well as any.

 

[BobBarker]

Muscadural? Is that like an epidermal?

Yes, also related to a flavogram.

 

[clubdeac]

I’d do bilateral L4, L5 and S1 TFESI…. Primarily for the boat

 

[bedrock]

I’d do bilateral L4, L5 and S1 TFESI…. Primarily for the boat

LOL,

I'd do bilateral L5-S1 TFESI if bilateral symptoms and unilateral L4-L5, L5-S1 TFESI if unilateral symptoms.

 

[Ducttape]

This is something that came up with one of my mid-level's who used to work for a surgeon. She really does a bunch of mental gymnastics trying to figure out the very best injection and it really got me wondering about going back to the basics since I've been out of training for a while now. We have a bunch of different suggestions here from the group. Are there any studies that show that it even matters much? Seems like in training we read a paper that compared results of different epidural approaches as well as contrast spread and there was very little difference in outcome. As long as you were getting some kind of steroid in the epidural space somewhat in the region of the pathology you were going to get similar results. If anyone has any literature on this I would like to use it for a journal club with my team.

no real difference in approach.

you already know the key is to manage pain while waiting for disc reabsorption, for which people have 60-75% of the time. there are studies that show that even saline or lidocaine may be effective and studies bounce all over the place as to which approach is more efficacious.

 

[CarabinerSD]

I’d probably do B 5-1 TF and follow with 4-5 IL if second needed.

I wouldn’t do 4-5 TF at any time for this patient.

Why no 4-5 TF at all for this patient?

 

[CarabinerSD]

no real difference in approach.

you already know the key is to manage pain while waiting for disc reabsorption, for which people have 60-75% of the time. there are studies that show that even saline or lidocaine may be effective and studies bounce all over the place as to which approach is more efficacious.

Thank you for this. So many opinions on where to or not to inject ... but as long as imaging shows technically possible to inject then whichever way to get medication in will work. Patient pain is adequately managed on some Tramadol so we are in no rush to do surgery.

Regarding disc reabsorption, do you happen to have a figure on how likely it'll happen (you quoted 60-75%) for different age groups (20-30, 30-40, 40-50, 50-60, 65+...etc)

 

[runfastnow]

I quote ~80% resorption at 12-15 months with isolated disc herniations like this. I think there was an old Plastaras or SIS study that quoted that rate. As far as I know any age related difference in resorption rate is not statistically significant but does tilt more in favor of younger, healthy, non-smokers having high rates of resorption (just like anything else) if you lower your p-value standards.

I'm typically aggressive in injecting these people if still symptomatic enough to require daily meds and/or difficulty sleeping at >6 weeks from onset.

 

[MD87]

I quote ~80% resorption at 12-15 months with isolated disc herniations like this. I think there was an old Plastaras or SIS study that quoted that rate. As far as I know any age related difference in resorption rate is not statistically significant but does tilt more in favor of younger, healthy, non-smokers having high rates of resorption (just like anything else) if you lower your p-value standards.

I'm typically aggressive in injecting these people if still symptomatic enough to require daily meds and/or difficulty sleeping at >6 weeks from onset.

Agree age isn’t much of a factor. The most important factor is the type of pathology (large extrusions resorb better than protrusions due to greater inflammatory response/greater surface area for macrophages and other stuff I’ve forgotten to do their thing)

 

[bedrock]

Why no 4-5 TF at all for this patient?

Look at your flow patterns. What percentage of your injectate can you see flow past the affected nerve & affected disc with an L4-L5 vs an L5-S1 TFESI?

80% of your injectate travels cranially, so you want to inject from an inferior injection approach which coats the entire exiting nerve, the entire disc, the neuroforamen, the entire lateral recess, etc.

Other than foraminal stenosis, why would you want to do a TFESI at the “level” of pathology?

 

[Scottie_Dog]

Why no 4-5 TF at all for this patient?

Probably doesn’t matter that much to be honest but I typically inject the level below a large disc extrusion. A lot less painful and lower risk of poking the disc. Steroid will travel up 2ish levels.

 

[Ducttape]

Look at your flow patterns. What percentage of your injectate can you see flow past the affected nerve & affected disc with an L4-L5 vs an L5-S1 TFESI?

80% of your injectate travels cranially, so you want to inject from an inferior injection approach which coats the entire exiting nerve, the entire disc, the neuroforamen, the entire lateral recess, etc.

Other than foraminal stenosis, why would you want to do a TFESI at the “level” of pathology?

just out of curiosity, where did you get the 80% number from? i cant seem to find it on a specific study on pubmed.


not critiquing - wondering, because of the concern that insurance companies may start denying epidurals not at the level of pathology.