Local in ESI

[PAINISGOOD]

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Anyone using local anesthetic in ILESI or TFESI with steroid? I've been using local in ILESI and saline in TFESI with steroid.

 

[SSdoc33]

Anyone using local anesthetic in ILESI or TFESI with steroid? I've been using local in ILESI and saline in TFESI with steroid.

Reverse that, then you will have it right

 

[PinchandBurn]

Anyone using local anesthetic in ILESI or TFESI with steroid? I've been using local in ILESI and saline in TFESI with steroid.

Yes I use local in both cases, ILESI and TFESI.

Patients get some immediate relief and they appreciate it.

Now, If I'm doing a cervical ILESI I will never use local, just steroid and saline.

Also, if it's a very elderly patient and I'm using local, I might dilute it down to like 0.2% ropi/bupi.

So for example in Lumbar ESI. I will give 2mL of 0.25% bupi or 2ml of 1% lido plus 5ml of PF saline, plus 80mg dep.

As you can see, this is very diluted local, having a motor block is almost impossibe, those of us that did anesthesia can attest to that.

 

[NEA]

yes i use local in both cases, ilesi and tfesi.

Patients get some immediate relief and they appreciate it.

Now, if i'm doing a cervical ilesi i will never use local, just steroid and saline.

Also, if it's a very elderly patient and i'm using local, i might dilute it down to like 0.2% ropi/bupi.

So for example in lumbar esi. I will give 2ml of 0.25% bupi or 2ml of 1% lido plus 5ml of pf saline, plus 80mg dep.

As you can see, this is very diluted local, having a motor block is almost impossibe, those of us that did anesthesia can attest to that.

+1

 

[pastafan]

Yes I use local in both cases, ILESI and TFESI.

Patients get some immediate relief and they appreciate it.

Now, If I'm doing a cervical ILESI I will never use local, just steroid and saline.

Also, if it's a very elderly patient and I'm using local, I might dilute it down to like 0.2% ropi/bupi.

So for example in Lumbar ESI. I will give 2mL of 0.25% bupi or 2ml of 1% lido plus 5ml of PF saline, plus 80mg dep.

As you can see, this is very diluted local, having a motor block is almost impossibe, those of us that did anesthesia can attest to that.

I use 4ml Lido 1% for LIESI and 2ml LIdo 2% for TFLESI. No local for CESI. Many are adamant about no local for ILESI but as pointed out, patients appreciate immediate relief. Odds of motor block are extremely low and I believe that most object due to efficiency issues more than clinical issues with the practice.

 

[Jcm800]

1 cc 1% in Tfesi in 20-30% of patients. I am amazed at how the "immediate" relief still happens with only saline and steroid...

 

[PinchandBurn]

1 cc 1% in Tfesi in 20-30 patients. I am amazed at how the "immediate" relief still happens with only saline and steroid...

washing away of the inflammatory cytokines and interleukins my friend😀

 

[lobelsteve]

Nothing but steroid and saline.

Unless you come in crying with acute radic, then I'll swap local for 2 %lido.

 

[bedrock]

nothing but steroid and saline.

Unless you come in crying with acute radic, then i'll swap local for 2 %lido.

+1

 

[SSdoc33]

Yes I use local in both cases, ILESI and TFESI.

Patients get some immediate relief and they appreciate it.

Now, If I'm doing a cervical ILESI I will never use local, just steroid and saline.

Also, if it's a very elderly patient and I'm using local, I might dilute it down to like 0.2% ropi/bupi.

So for example in Lumbar ESI. I will give 2mL of 0.25% bupi or 2ml of 1% lido plus 5ml of PF saline, plus 80mg dep.

As you can see, this is very diluted local, having a motor block is almost impossibe, those of us that did anesthesia can attest to that.

9 mL fluid for an ILESI? Plus contrast?

 

[Jcm800]

9 mL fluid for an ILESI? Plus contrast?

that i crazy talk... CESI (ILESI) gets 2 cc of celestone, and 1-2 cc of saline

LESI (ILESI) gets 2 cc of celestone maybe 1 cc of lido, and 1 cc of saline

TFESI gets 1 cc of celestone 1 cc of saline per level. So if i do a 7 level TFESI, thats 7 ccs of saline...

 

[Aether2000]

I use saline and steroid only. There may not be a motor block with small doses of local anesthetics, but there very well may be a proprioceptive block. I fear falls, especially in the elderly....and especially once they get back home.

 

[Ducttape]

that i crazy talk... CESI (ILESI) gets 2 cc of celestone, and 1-2 cc of saline

LESI (ILESI) gets 2 cc of celestone maybe 1 cc of lido, and 1 cc of saline

TFESI gets 1 cc of celestone 1 cc of saline per level. So if i do a 7 level TFESI, thats 7 ccs of saline...

you do a 7 level TFESI???


for ILESI, 2 cc depo, 2.5 cc saline and 0.5 cc 1% lido... or 2 cc depo and 3 cc saline if i am concerned about falls. will also cut to 2cc additive total for cervicals.

 

[clubdeac]

9 mL fluid for an ILESI? Plus contrast?

Yeah I think you'll get better results pinch if you concentrate your steroid down. I get great results with 2cc of 40mg kenalog and 1cc 0.25% marcaine (3cc's total) for ILESIs. Appropriately selected patients usually get 3-4 mos relief

 

[Jcm800]

you do a 7 level TFESI???


for ILESI, 2 cc depo, 2.5 cc saline and 0.5 cc 1% lido... or 2 cc depo and 3 cc saline if i am concerned about falls. will also cut to 2cc additive total for cervicals.

Sarcasm. No. I will do 2 levels, or bil.

 

[lovebailey2001]

I hv stopped mixing steroid (Kenalog) with LA, mainly due to ?risk of larger perticle formation with this mixture. Only saline with steroid now.

 

[PinchandBurn]

9 mL fluid for an ILESI? Plus contrast?

what's your point? I dont inject more than about 1 ml of contrast, usually about 0.5ml of contrast. I use a few other confirmation techniques to make certain I'm in the epidural space.

Unless you have personally written a randomized, prospective, observational study like Candido has, I think that much volume is not unreasonable.

Read this, he uses a total of 9ml of fluid (including contrast). . Read his rational for diluting down with saline. Others use up to 10ml of fluid in the LUMBAR space.


http://www.anesthesia-analgesia.org/content/106/2/638.long

BACKGROUND: Lumbar midline interlaminar and transforaminal (TF) epidural steroid injections are treatments for low back pain with radiculopathy secondary to degenerative disk disease. Since pain generators are located anteriorly in the epidural space, ventral epidural spread is the logical target for placement of antiinflammatory medications. In this randomized, prospective, observational study, we compared contrast flow patterns in the epidural space using the parasagittal interlaminar (PIL) and transforaminal approaches with continual fluoroscopic guidance.

METHODS: Sixty adult patients with low back pain and unilateral radiculopathy from herniated or degenerated discs were enrolled. Subjects were randomly assigned to one of two groups: TF or PIL (30 in each). All procedures were performed using continual fluoroscopic guidance and 5 mL of contrast. Contrast spread was rated (primary outcome measure) by the interventionalist. Spread was scored 0–2, with 0 = no anterior spread; 1 = anterior spread, same level as needle insertion; and 2 = anterior spread at ≥1 segmental level. The secondary outcome measure was analgesia at 2 wk, 1, 3, and 6 mo.

RESULTS: One hundred percent (29 of 29) patients in the PIL group and 75% (21 of 28) patients in the TF group demonstrated anterior epidural spread. The mean spread grade was 1.93 (95% confidence interval [CI], 1.83–2.0) in the PIL group and 1.46 (95% CI, 1.17–1.46) in the TF group (P = 0.003). Mean fluoroscopy time was 28.96 s (95% CI, 23.9–34.1 s) in the PIL group and 46.25 s (95% CI, 36.27–56.23 s) in the TF group (P = 0.003). Visual analog scale scores were equivalent between groups.

CONCLUSIONS: The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.


Previous SectionNext Section

IMPLICATIONS: Transforaminal and parasagittal interlaminar epidural steroid injections are methods of placing medication into the anterior epidural space to provide analgesia for inflammatory conditions of the lumbar spine. In this study, the parasagittal interlaminar technique was more reliable in placing dye in the ventral epidural space, and did so in less time, than the transforaminal technique. Outcomes were similar between the two groups of patients.


Previous SectionNext Section

Midline interlaminar and transforaminal (TF) lumbar epidural steroid injections (LESI) are two accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease. It is thought that the inflammatory response may be localized at the nerve root/intervertebral disk interface, which is in proximity to the anterior epidural space.1 Previous studies have demonstrated that with the midline interlaminar epidural injections, the injectate spreads into the anterior epidural space only 36% of the time.1 As a result, practitioners are increasingly performing TF ESI instead of standard midline interlaminar ESI. The TF approach is a proven technique and has shown analgesic effectiveness in multiple studies.2–6 Although effective, TF injections sometimes lead to complications including spinal cord injury and permanent paralysis.7 In an effort to provide a suitable and reliable alternative to the TF approach, we studied the parasagittal interlaminar (PIL) epidural approach. With this interlaminar approach, the injection is performed at the lateralmost part of the interlaminar space instead of the usual midline interlaminar approach. No study has compared the two techniques (PIL and TF) in terms of the contrast flow patterns and utility for driving medication into the anterior epidural space. In this randomized, single-blind, prospective study, we investigated the spread of contrast media in the anterior epidural space using fluoroscopic guidance. We also studied the analgesic benefit of choosing the PIL or the TF technique.

 

[emd123]

what's your point? I dont inject more than about 1 ml of contrast, usually about 0.5ml of contrast. I use a few other confirmation techniques to make certain I'm in the epidural space.

Unless you have personally written a randomized, prospective, observational study like Candido has, I think that much volume is not unreasonable.

Read this, he uses a total of 9ml of fluid (including contrast). . Read his rational for diluting down with saline. Others use up to 10ml of fluid in the LUMBAR space.


http://www.anesthesia-analgesia.org/content/106/2/638.long

BACKGROUND: Lumbar midline interlaminar and transforaminal (TF) epidural steroid injections are treatments for low back pain with radiculopathy secondary to degenerative disk disease. Since pain generators are located anteriorly in the epidural space, ventral epidural spread is the logical target for placement of antiinflammatory medications. In this randomized, prospective, observational study, we compared contrast flow patterns in the epidural space using the parasagittal interlaminar (PIL) and transforaminal approaches with continual fluoroscopic guidance.

METHODS: Sixty adult patients with low back pain and unilateral radiculopathy from herniated or degenerated discs were enrolled. Subjects were randomly assigned to one of two groups: TF or PIL (30 in each). All procedures were performed using continual fluoroscopic guidance and 5 mL of contrast. Contrast spread was rated (primary outcome measure) by the interventionalist. Spread was scored 0–2, with 0 = no anterior spread; 1 = anterior spread, same level as needle insertion; and 2 = anterior spread at ≥1 segmental level. The secondary outcome measure was analgesia at 2 wk, 1, 3, and 6 mo.

RESULTS: One hundred percent (29 of 29) patients in the PIL group and 75% (21 of 28) patients in the TF group demonstrated anterior epidural spread. The mean spread grade was 1.93 (95% confidence interval [CI], 1.83–2.0) in the PIL group and 1.46 (95% CI, 1.17–1.46) in the TF group (P = 0.003). Mean fluoroscopy time was 28.96 s (95% CI, 23.9–34.1 s) in the PIL group and 46.25 s (95% CI, 36.27–56.23 s) in the TF group (P = 0.003). Visual analog scale scores were equivalent between groups.

CONCLUSIONS: The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.


Previous SectionNext Section

IMPLICATIONS: Transforaminal and parasagittal interlaminar epidural steroid injections are methods of placing medication into the anterior epidural space to provide analgesia for inflammatory conditions of the lumbar spine. In this study, the parasagittal interlaminar technique was more reliable in placing dye in the ventral epidural space, and did so in less time, than the transforaminal technique. Outcomes were similar between the two groups of patients.


Previous SectionNext Section

Midline interlaminar and transforaminal (TF) lumbar epidural steroid injections (LESI) are two accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease. It is thought that the inflammatory response may be localized at the nerve root/intervertebral disk interface, which is in proximity to the anterior epidural space.1 Previous studies have demonstrated that with the midline interlaminar epidural injections, the injectate spreads into the anterior epidural space only 36% of the time.1 As a result, practitioners are increasingly performing TF ESI instead of standard midline interlaminar ESI. The TF approach is a proven technique and has shown analgesic effectiveness in multiple studies.2–6 Although effective, TF injections sometimes lead to complications including spinal cord injury and permanent paralysis.7 In an effort to provide a suitable and reliable alternative to the TF approach, we studied the parasagittal interlaminar (PIL) epidural approach. With this interlaminar approach, the injection is performed at the lateralmost part of the interlaminar space instead of the usual midline interlaminar approach. No study has compared the two techniques (PIL and TF) in terms of the contrast flow patterns and utility for driving medication into the anterior epidural space. In this randomized, single-blind, prospective study, we investigated the spread of contrast media in the anterior epidural space using fluoroscopic guidance. We also studied the analgesic benefit of choosing the PIL or the TF technique.

Sure, you can use less volume with an ILESI, but you increase the chances that you may not get the steroid to your target. The whole point of an ILESI is to use more volume since its less targeted. Plus you need more volume to get your steroid where you need it to go, either bilateral, to more than one nerve root and/or to the anterior epidural space. I don't use 9 ml. I usually use 5-6cc plus a little contrast, with 1 cc being 1% lido, 2 cc celestone and the rest saline 3cc (for lumbar). Sure I could use less, but if I'm going to try to be that targeted, I'm going TF with less volume anyways. With 1/5 to 1/6 of the mixture being local you will almost never (if ever) get a motor block (roughly 0.2% lidocaine), and if you did it would be super short lived. They do seem to get enough sensory block to walk out of the office feeling a little better, and that the injection got to where the pain is. That being said, is local necessary? No.

For cervical ILESI, always at C7/T1 with 2cc celestone and 2cc saline. Slow injection, less volume if significant stenosis (and tighter epidural space). Never any local in cervicals. No cervical TF.

 

[clubdeac]

Sure, you can use less volume with an ILESI, but you increase the chances that you may not get the steroid to your target. The whole point of an ILESI is to use more volume since its less targeted. Plus you need more volume to get your steroid where you need it to go, either bilateral, to more than one nerve root and/or to the anterior epidural space. I don't use 9 ml. I usually use 5-6cc plus a little contrast, with 1 cc being 1% lido, 2 cc celestone and the rest saline 3cc (for lumbar). Sure I could use less, but if I'm going to try to be that targeted, I'm going TF with less volume anyways. With 1/5 to 1/6 of the mixture being local you will almost never (if ever) get a motor block (roughly 0.2% lidocaine), and if you did it would be super short lived. They do seem to get enough sensory block to walk out of the office feeling a little better, and that the injection got to where the pain is. That being said, is local necessary? No.

For cervical ILESI, always at C7/T1 with 2cc celestone and 2cc saline. Slow injection, less volume if significant stenosis (and tighter epidural space). Never any local in cervicals. No cervical TF.

Did you read the article you attached in your post? Parasagital ILESIs get the medication to the anterior epidural space more frequently than TFESIs with less fluoro time and little to no risk of hitting a radiculomedullary artery. It suggests that properly placed ILESIs can be more target specific than TFESIs

 

[emd123]

.

 

[emd123]

Repeat post

 

[emd123]

Did you read the article you attached in your post? Parasagital ILESIs get the medication to the anterior epidural space more frequently than TFESIs with less fluoro time and little to no risk of hitting a radiculomedullary artery. It suggests that properly placed ILESIs can be more target specific than TFESIs

Yes I read it. Let me clarify: I interpret "target specific" as the medication going where I want it to go, but nowhere else. They didn't look at that in this study. I'm pleased to hear that ILESIs (at last by this one study) get more medication to the anterior epidural space. That's not to say 5ml goes to the anterior epidural space only at that one level and nowhere else. I'm sure plenty stays posterior, and a significant amount goes to the contra lateral side. I'm okay with that. I think the trend to do TFs has more to do with the ability to do multiple levels, bill for them and get reimbursed much more than for a single ILESI. Of course in response, CMS has been slashing TF reimbursement much more than 62311, with private insurers to follow.

I do a fair amount of ILESIs. They're quicker than TFs, easier to do, the patient has practically no pain at all. I'm okay with the fact that some steroid goes to nerve roots that might not need it, as long as plenty goes where I want it to. That being said, I do think there is a role for TF, depending on the situation.

 

[SSdoc33]

I rarely do a tfesi.

For me, they are quicker, use less flours and not appreciably more painful. Plus, I think they work better, and there is virtually no risk of a wet tap. More dangerous? If you say so, I suppose.

 

[SSdoc33]

what's your point? I dont inject more than about 1 ml of contrast, usually about 0.5ml of contrast. I use a few other confirmation techniques to make certain I'm in the epidural space.

Unless you have personally written a randomized, prospective, observational study like Candido has, I think that much volume is not unreasonable.

Read this, he uses a total of 9ml of fluid (including contrast). . Read his rational for diluting down with saline. Others use up to 10ml of fluid in the LUMBAR space.


http://www.anesthesia-analgesia.org/content/106/2/638.long

BACKGROUND: Lumbar midline interlaminar and transforaminal (TF) epidural steroid injections are treatments for low back pain with radiculopathy secondary to degenerative disk disease. Since pain generators are located anteriorly in the epidural space, ventral epidural spread is the logical target for placement of antiinflammatory medications. In this randomized, prospective, observational study, we compared contrast flow patterns in the epidural space using the parasagittal interlaminar (PIL) and transforaminal approaches with continual fluoroscopic guidance.

METHODS: Sixty adult patients with low back pain and unilateral radiculopathy from herniated or degenerated discs were enrolled. Subjects were randomly assigned to one of two groups: TF or PIL (30 in each). All procedures were performed using continual fluoroscopic guidance and 5 mL of contrast. Contrast spread was rated (primary outcome measure) by the interventionalist. Spread was scored 0–2, with 0 = no anterior spread; 1 = anterior spread, same level as needle insertion; and 2 = anterior spread at ≥1 segmental level. The secondary outcome measure was analgesia at 2 wk, 1, 3, and 6 mo.

RESULTS: One hundred percent (29 of 29) patients in the PIL group and 75% (21 of 28) patients in the TF group demonstrated anterior epidural spread. The mean spread grade was 1.93 (95% confidence interval [CI], 1.83–2.0) in the PIL group and 1.46 (95% CI, 1.17–1.46) in the TF group (P = 0.003). Mean fluoroscopy time was 28.96 s (95% CI, 23.9–34.1 s) in the PIL group and 46.25 s (95% CI, 36.27–56.23 s) in the TF group (P = 0.003). Visual analog scale scores were equivalent between groups.

CONCLUSIONS: The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.


Previous SectionNext Section

IMPLICATIONS: Transforaminal and parasagittal interlaminar epidural steroid injections are methods of placing medication into the anterior epidural space to provide analgesia for inflammatory conditions of the lumbar spine. In this study, the parasagittal interlaminar technique was more reliable in placing dye in the ventral epidural space, and did so in less time, than the transforaminal technique. Outcomes were similar between the two groups of patients.


Previous SectionNext Section

Midline interlaminar and transforaminal (TF) lumbar epidural steroid injections (LESI) are two accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease. It is thought that the inflammatory response may be localized at the nerve root/intervertebral disk interface, which is in proximity to the anterior epidural space.1 Previous studies have demonstrated that with the midline interlaminar epidural injections, the injectate spreads into the anterior epidural space only 36% of the time.1 As a result, practitioners are increasingly performing TF ESI instead of standard midline interlaminar ESI. The TF approach is a proven technique and has shown analgesic effectiveness in multiple studies.2–6 Although effective, TF injections sometimes lead to complications including spinal cord injury and permanent paralysis.7 In an effort to provide a suitable and reliable alternative to the TF approach, we studied the parasagittal interlaminar (PIL) epidural approach. With this interlaminar approach, the injection is performed at the lateralmost part of the interlaminar space instead of the usual midline interlaminar approach. No study has compared the two techniques (PIL and TF) in terms of the contrast flow patterns and utility for driving medication into the anterior epidural space. In this randomized, single-blind, prospective study, we investigated the spread of contrast media in the anterior epidural space using fluoroscopic guidance. We also studied the analgesic benefit of choosing the PIL or the TF technique.

My point is that you are using too much fluid. You want to concentrate your medication at the exact area of pathology. Comparative studies might not show a difference, but common sense tells you that.

Ask ligament, jcm, Steve, and tenesma what they use. Then copy it. You are better listen to them than candido.

 

[Jcm800]

I rarely do a tfesi.

For me, they are quicker, use less flours and not appreciably more painful. Plus, I think they work better, and there is virtually no risk of a wet tap. More dangerous? If you say so, I suppose.

did you mean, "i rarely do an ILESI"

 

[SSdoc33]

did you mean, "i rarely do an ILESI"

Yes. Thanks

 

[bedrock]

Yes I read it. Let me clarify: I interpret "target specific" as the medication going where I want it to go, but nowhere else. They didn't look at that in this study. I'm pleased to hear that ILESIs (at last by this one study) get more medication to the anterior epidural space. That's not to say 5ml goes to the anterior epidural space only at that one level and nowhere else. I'm sure plenty stays posterior, and a significant amount goes to the contra lateral side. I'm okay with that. I think the trend to do TFs has more to do with the ability to do multiple levels, bill for them and get reimbursed much more than for a single ILESI. Of course in response, CMS has been slashing TF reimbursement much more than 62311, with private insurers to follow.

I do a fair amount of ILESIs. They're quicker than TFs, easier to do, the patient has practically no pain at all. I'm okay with the fact that some steroid goes to nerve roots that might not need it, as long as plenty goes where I want it to. That being said, I do think there is a role for TF, depending on the situation.

I think the article is ridiculous and biased. How can a needle that starts in the anterior epidural epidural space (TF), cause medication flow to the anterior epidural space less often than a needle that starts in the dorsal epidural space(IL). Makes no anatomic sense.


That said, I start with an ILESI whenever possible, because depomedrol works way longer than dex, I can do an ILESI faster than TFESI, and ILESI hurt less. I get way more vagals with lumbar TFESI than lumbar ILESI.

 

[Aether2000]

The answer may be foraminal ligaments that criss cross the neuroforamen impeding flow. These are not present in the canal or lateral recess.

 

[nvrsumr]

No local. Office based suite so too much hassle. Also patients never experience as good of relief as the local provides so they end up chasing total analgesia and arent as satisfied with 80% better, etc..

 

[bedrock]

Also patients never experience as good of relief as the local provides so they end up chasing total analgesia and arent as satisfied with 80% better, etc..

I couldn't agree more

 

[mdvol]

small test dose with trans esi and just saline for interlams for the reasons already mentioned unless the person is absolutely in misery with radic pain. Total volume for interlam for me is 4mls.

 

[emd123]

No local. Office based suite so too much hassle. Also patients never experience as good of relief as the local provides so they end up chasing total analgesia and arent as satisfied with 80% better, etc..

Good thought.

 

[Ligament]

patients never experience as good of relief as the local provides so they end up chasing total analgesia and arent as satisfied with 80% better, etc..

Hmm, makes a lot of sense! Never thought of that.

 

[Ducttape]

No local. Office based suite so too much hassle. Also patients never experience as good of relief as the local provides so they end up chasing total analgesia and arent as satisfied with 80% better, etc..

thats ironic. some of my patients use that same thought process in reverse ie "that first day is terrific, thats why i come back for the injections, to feel normal even if for a day, even if it is only 50% better the next 3 months."