Pain Procedures- Injection Solutions

[Dawkter]

I tried bumping a previous thread on this topic but for some reason SDN wouldn't let me. I would like to know what others are doing in 2019.

Standard injection solutions

Cervical MBB (2 diagnostic):
-bupi 0.5% 1 ml per level

Cervical MB RFA (before and after burn)
-lido 2% before burn, dex + bupi after

Cervical ESI C7 T1 only
-depomedrol 80 mg + 1 cc saline + 0.5 cc 1% lido

Lumbar MBB (2 diagnostic)
-bupi 0.5% 1 ml per level

Lumbar MB RFA
-lido 2% before burn, dex + bupi after

Lumbar ESI
-80 mg depo + 2 ml saline + 1 ml 1% lido

Lumbar TFESI
-10 mg dex + 0.5 ml saline + 0.5 ml 1% lido for one level. For 2 levels I use 15 mg dex.

Caudal ESI
-80 mg depo + 1cc 0.25% bupi + 6-8 ml saline

Joints
-40 mg depo + 3-4 ml 0.5% bupi

I use 0.5% bupi for my mbb (0.5- 1 cc per level) but noticed no one else really is. Any particular reason?

Should I transition my lumbar IL ESIs to dexamethasone in place of particulate steroid? If using particulate I can't seem to find a real difference regarding safety in depomedrol vs. kenalog.

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[Pain_doc]

Seems like a lot of local for a diagnostic block. In most of the cervical, I'll use 0.2 -0.25, lumbar never more than 0.5. Put 0.2ml contrast in before your local in a cervical MBB and notice the spread I like depo 80mg for IL ESI. I typically use triamcinolone for joints, 20-40mg depending on joint.

 

[SommeRiver]

I tried bumping a previous thread on this topic but for some reason SDN wouldn't let me. I would like to know what others are doing in 2019.

Standard injection solutions

Cervical MBB (2 diagnostic):
-bupi 0.5% 1 ml per level

Cervical MB RFA (before and after burn)
-lido 2% before burn, dex + bupi after

Cervical ESI
-depomedrol 80 mg + 1 cc saline + 1 cc 1% lido

Lumbar MBB (2 diagnostic)
-bupi 0.5% 1 ml per level

Lumbar MB RFA
-lido 2% before burn, dex + bupi after

Lumbar ESI
-80 mg depo + 2 ml saline + 1 ml 1% lido

Lumbar TFESI
-10 mg dex + 0.5 ml saline + 0.5 ml 1% lido for one level. For 2 levels I use 15 mg dex.

Caudal ESI
-80 mg depo + 1cc 0.25% bupi + 6-8 ml saline

Joints
-40 mg depo + 3-4 ml 0.5% bupi

I use 0.5% bupi for my mbb (0.5- 1 cc per level) but noticed no one else really is. Any particular reason?

Should I transition my lumbar IL ESIs to dexamethasone in place of particulate steroid? If using particulate I can't seem to find a real difference regarding safety in depomedrol vs. kenalog.

I would urge you to read the latest PMR journal which reviewed joint injections with anesthetic. Seems that ropi is safer for the cartilage so in your joints you may consider swapping.

I use dex 10mg for all epidurals. I buy 10mg vials and that's all the steroid that you get, whether it is ILESI or TFESI (one or two level). I don't think you're getting anything extra by going to 15mg.

I don't use steroid after an RFA.

I use bupi 0.5% for MBB, and it is between 0.5 and 1.0 cc.

At the end of the day these little details don't matter bc you can do a perfect injxn and the pt may come back and ask why you didn't make them better.

 

[thecentral09]

Per SIS guidelines you are too high volume on MBBs. Probably causing many false pos

 

[Dawkter]

I would urge you to read the latest PMR journal which reviewed joint injections with anesthetic. Seems that ropi is safer for the cartilage so in your joints you may consider swapping.

I use dex 10mg for all epidurals. I buy 10mg vials and that's all the steroid that you get, whether it is ILESI or TFESI (one or two level). I don't think you're getting anything extra by going to 15mg.

I don't use steroid after an RFA.

I use bupi 0.5% for MBB, and it is between 0.5 and 1.0 cc.

At the end of the day these little details don't matter bc you can do a perfect injxn and the pt may come back and ask why you didn't make them better.

I used to use steroid after RFA to prevent neuritis while training. Seems like it may not be necessary?

The Impact of Local Steroid Administration on the Incidence of Neuritis following Lumbar Facet Radiofrequency Neurotomy - PubMed

Radiofrequency neurotomy, radiofrequency ablation, neuritis, corticosteroid, lumbar facet pain, post neurotomy neuritis.

www.ncbi.nlm.nih.gov

 

[callmeanesthesia]

Seems like a lot of local for a diagnostic block. In most of the cervical, I'll use 0.2 -0.25, lumbar never more than 0.5. Put 0.2ml contrast in before your local in a cervical MBB and notice the spread I like depo 80mg for IL ESI. I typically use triamcinolone for joints, 20-40mg depending on joint.

I second that on the cervical MBBs. 1 mL is waaay to high. I used to do 0.5, then I tried injecting 0.2 mL contrast and was shocked by how far it spreads. I started doing 0.3 mL. 0.5 easily spreads to adjacent levels and other structures and reduces specificity.

I don’t use any steroid for RF. Did in fellowship and a few months of practice then stopped. Haven’t had any increase in neuritis. Has been studied and never found to reduce neuritis.

 

[callmeanesthesia]

How common is local in CESI? I’ve been scared to do it because one attending from fellowship said he gave someone a high spinal once with local in a CESI.

 

[lobelsteve]

How common is local in CESI? I’ve been scared to do it because one attending from fellowship said he gave someone a high spinal once with local in a CESI.

Completely unnecessary and potentially dangerous.

 

[SommeRiver]

How common is local in CESI? I’ve been scared to do it because one attending from fellowship said he gave someone a high spinal once with local in a CESI.

It is crazy. Yesterday I did a C7-T1 and with 1cc of Isovue I got up to C5. Tight neck. So if I mix local into my injectate and I flood that pt's neck and lido is in there who is to say I'm not bagging her shortly thereafter?

 

[SSdoc33]

you will get a lot of disagreement here over exactly which combinations are "best".

FWIW, id rather have more false positives than false negatives when doing a MBB. you may get some patients who dont do as well with the RF, but you also may get more who benefit because you "capture" more of these patients. (doesnt hurt to bill more RFs, btw). i dont want to miss some of these patients b.c my technique may be off a tiny bit. as good as we all think we are, we are not perfect. so, a little "extra" local is not a bad thing, IMHO.

1 mL for lumbar, 0.5mL for cervicals. literature be damned

 

[pmrmd]

For mbb I use bupi, .25% for years but lately .5% because it’s all that’s around. I’ll use dex with it. The diagnostic/confirmatory aspect is right after they get off the table and the dex helps for at least a few days which is better than a few minutes. No steroid post RF. No local in CESI—ever. That’s just dumb. I use kenalog in CESI/LESI. I’ve tried Celestone and Medrol and just don’t like either as much. I spread my kenalog with dex instead of saline so I guess I make my triamcinolone version of betamethsasone. Dex only for tendons or ligaments. End stage joint kenalog because it needs an arthroplasty anyway but otherwise just dex for the synovitis.

 

[SSdoc33]

you will get a lot of disagreement here over exactly which combinations are "best".

FWIW, id rather have more false positives than false negatives when doing a MBB. you may get some patients who dont do as well with the RF, but you also may get more who benefit because you "capture" more of these patients. (doesnt hurt to bill more RFs, btw). i dont want to miss some of these patients b.c my technique may be off a tiny bit. as good as we all think we are, we are not perfect. so, a little "extra" local is not a bad thing, IMHO.

1 mL for lumbar, 0.5mL for cervicals. literature be damned

if it makes you feel any better, steve, i only do mbbs on patients that i have a very high clinical suspicion of facet pain. rarely patients in their 40's, basically never in their 30's, never when there is a clear annular tear, or i suspect discogenic pain. these are patients that i would go straight to RF if insurance let me. for a relatively innocuous procedure like an RF, i dont want to miss someone i can help. if that means that some get an unnecessary RF..... ill live with that

 

[painfree23]

For mbb I use bupi, .25% for years but lately .5% because it’s all that’s around. I’ll use dex with it. The diagnostic/confirmatory aspect is right after they get off the table and the dex helps for at least a few days which is better than a few minutes. No steroid post RF. No local in CESI—ever. That’s just dumb. I use kenalog in CESI/LESI. I’ve tried Celestone and Medrol and just don’t like either as much. I spread my kenalog with dex instead of saline so I guess I make my triamcinolone version of betamethsasone. Dex only for tendons or ligaments. End stage joint kenalog because it needs an arthroplasty anyway but otherwise just dex for the synovitis.

How many of your patients have Cushings?

 

[thiswonthurtabit]

Here's what we're generally using where I'm training

Standard injection solutions

Cervical MBB :
-bupi 0.25% .5 ml per level

Cervical MB RFA (before and after burn)
-.5-1 ml lido 1% before burn vs .5-1mL 50/50 mix 1% lido/.25% bupi
dex 5 mg +2.5 mL .25% bupi after vs no post if bupi mix used before

Cervical ESI C7 T1 only
-10 mg dex (10mg/ml) + 1 mL NS vs 8mg dex (4mg/mL)

Lumbar MBB (2 diagnostic)
-bupi 0.5% 0.5 ml per level

Lumbar MB RFA
-.5-1 ml lido 1% before burn vs .5-1mL 50/50 mix 1% lido/.25% bupi,
dex 5 mg +2.5 mL .25% bupi (per side if bilateral) after vs no postablation steroid/local if bupi mix used before

Lumbar ILESI
-10 mg dex + 2 ml saline + 1 ml .25% bupi

Lumbar TFESI
-10 mg dex + 1ml .25% bupi for one level, 10 mg dex +2 mL .25% bupi for two levels vs 4mg dex +1ml 1% lido per level, in general don't do more than two levels.

Caudal ESI
-10 mg dex + 1.5cc 0.25% bupi + 2.5 ml saline

SI Joints
-40 mg kenalog+ 2 ml 0.25% bupi

 

[lobelsteve]

if it makes you feel any better, steve, i only do mbbs on patients that i have a very high clinical suspicion of facet pain. rarely patients in their 40's, basically never in their 30's, never when there is a clear annular tear, or i suspect discogenic pain. these are patients that i would go straight to RF if insurance let me. for a relatively innocuous procedure like an RF, i dont want to miss someone i can help. if that means that some get an unnecessary RF..... ill live with that

It doesn't. If doing a procedure, do it to spec. No validity or adequate reason to do things however you see fit. Wild west cowboy medicine may result. Maybe not for you, but for those who lurk and read and think 1cc why not 3cc.

 

[pmrmd]

How many of your patients have Cushings?

Lol. The effects of dex last one day. HPA axis back after one day. You have to inject quite often to get that kind of outcome.

 

[Dawkter]

you will get a lot of disagreement here over exactly which combinations are "best".

FWIW, id rather have more false positives than false negatives when doing a MBB. you may get some patients who dont do as well with the RF, but you also may get more who benefit because you "capture" more of these patients. (doesnt hurt to bill more RFs, btw). i dont want to miss some of these patients b.c my technique may be off a tiny bit. as good as we all think we are, we are not perfect. so, a little "extra" local is not a bad thing, IMHO.

1 mL for lumbar, 0.5mL for cervicals. literature be damned

This is my rationale for using 1 ml as well, to account for any procedural variation.

 

[lobelsteve]

This is my rationale for using 1 ml as well, to account for any procedural variation.

Sounds like you inject to create false positives to keep the procedure train rolling. I know this is not the case, but on the face of it ....

 

[callmeanesthesia]

This is my rationale for using 1 ml as well, to account for any procedural variation.

If you are that un-confident in your needle placement that you need 1 mL of local to get the nerve, how are you going to get an RF cannula onto the nerve? Seriously, inject a little contrast sometime and see how far it spreads.

 

[Dawkter]

All fair points, will decrease the amount of local.

 

[Ferrismonk]

For mbb I use bupi, .25% for years but lately .5% because it’s all that’s around. I’ll use dex with it. The diagnostic/confirmatory aspect is right after they get off the table and the dex helps for at least a few days which is better than a few minutes. No steroid post RF. No local in CESI—ever. That’s just dumb. I use kenalog in CESI/LESI. I’ve tried Celestone and Medrol and just don’t like either as much. I spread my kenalog with dex instead of saline so I guess I make my triamcinolone version of betamethsasone. Dex only for tendons or ligaments. End stage joint kenalog because it needs an arthroplasty anyway but otherwise just dex for the synovitis.

Not to highjack this thread, and I may throw my 2c in later, but the package insert of kenalog states clearly that you should not use it in the epidural space. All the others say something to the effect of "not approved for". Using Kenalog in the epidural space opens you up to some legal liability.

 

[thecentral09]

If you are that un-confident in your needle placement that you need 1 mL of local to get the nerve, how are you going to get an RF cannula onto the nerve? Seriously, inject a little contrast sometime and see how far it spreads.

Yeah. If your going to use more than 0.5 ml, Might as well just use 10ml. Same result. And now more patients who had more procedures that didn’t work. When I see/hear these things I no longer wonder why insurance companies make me do a peer to peer before I tie my shoes

 

[nvrsumr]

Do u want to make a type one or type two error on a screening test? Should be sensitive not necessarily specific. The rf is the specific confirmatory test as well as treatment if considered properly.

False negative mbb can lead to a fusion in the real world. High cost and significant morbidity. False positive results in funded 529 for kids.

 

[callmeanesthesia]

Do u want to make a type one or type two error on a screening test? Should be sensitive not necessarily specific. The rf is the specific confirmatory test as well as treatment if considered properly.

False negative mbb can lead to a fusion in the real world. High cost and significant morbidity. False positive results in funded 529 for kids.

I get what you are saying about fusion, but MBB is supposed to be a diagnostic test, not a screening test. Screening is your history and physical exam. False positive MBBs result in unnecessary invasive procedures and unhappy patients. If your needle placement is accurate you shouldn’t need 1 mL local.

 

[Ducttape]

Do u want to make a type one or type two error on a screening test? Should be sensitive not necessarily specific. The rf is the specific confirmatory test as well as treatment if considered properly.

False negative mbb can lead to a fusion in the real world. High cost and significant morbidity. False positive results in funded 529 for kids.

no. should be sensitive and specific. you should be limiting the type of error on all tests, not accepting a higher degree of type 2 error as compensation.

RFA is not confirmatory. it is not a diagnostic procedure. someone somewhere quoted a significant (? 10-15% failure rate) on perfectly done procedures, but I didn't find that study on a quick glance on pubmed.

 

[nvrsumr]

Yes it would be perfect for all tests to be sensitive and specific. That is not the case and screening tests are supposed to be sensitive. At least that what my undergrad stats prof thought.