Particulate be non-particulate steroids

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Wkrdoc

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I used all depo on my LESI/TESI/CESIs during the first year of training. Then, it seemed as if most everyone switched to decadron exclusively across the board to avoid the rare 1:1M adverse event with particulates. I was a little surprised to hear a lot still use particulates, most of the busier guys have followed suit as well. I know there isn’t blood flow etc etc but I was curious as to what folks are doing

Also, give me the pros you guys see with using depo/Kenalog vs decadron.
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We switched to dexamethasone for several reasons. Safer considering all routes of administration, cheap, comes in 10mg/ml vial and easy to tell MAs every enjection gets one vial, and was shown to have similar length of relief compared to particulate.
 
I think depo works way better in my older stenotic patients. I don't know why and I don't have any data other than my anecdotal experience. I still use depo in all my ILESIs. I bounce back and forth between depo and dexa for my TFESIs depending on the level
 
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Is there really legitimacy to depo lasting longer? I haven’t noticed much of a difference
 
For those of you who switched to all dex, do you do it for joints too? I still do dex for tfesi but particulate for interlam and joints. I’ve been nervous to switch because biochemically it doesn’t make sense that dex would last as long. I’m aware of the clinical evidence but can anyone point me to some basic science evidence that would explain how dex would have long term efficacy? I really want to switch to all dex because it would be simpler but I guess I just need some reassurance.
 
callmeanesthesia said:
For those of you who switched to all dex, do you do it for joints too? I still do dex for tfesi but particulate for interlam and joints. I’ve been nervous to switch because biochemically it doesn’t make sense that dex would last as long. I’m aware of the clinical evidence but can anyone point me to some basic science evidence that would explain how dex would have long term efficacy? I really want to switch to all dex because it would be simpler but I guess I just need some reassurance.
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Clinical evidence shows it works as well. You choose not to believe the evidence.
I still use Celestone for joints. 50/50 for IL-ESI. Dogma. I have no valid reason to use either for IL-ESI
 
lobelsteve said:
Clinical evidence shows it works as well. You choose not to believe the evidence.
I still use Celestone for joints. 50/50 for IL-ESI. Dogma. I have no valid reason to use either for IL-ESI
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Clinical evidence also shows all manner of woo works, even though basic science pretty clearly shows there is no possible mechanism. Publication bias and the power of the p value at work. These conclusions are drawn from a couple somewhat small clinical studies. I’m willing to entertain the idea they could be correct but the extremely rapid metabolism and transient presence of dex compared to particulates gives me pause. I’d like to switch to dex for everything, which is why I at least want to get some input from people who have made the switch.
 
Kennedy's study was 78 people with acute HNP and dex usually required more injections to get the same outcomes as particulate steroid.
Denis's study showed equivalence but the study was underpowered by their own admission.
El-Yahchouchi's study was retrospective and the criteria for non-inferiority don't work for me. In fact, using these criteria would be a failure IMO.

A meta-analysis of this stuff doesn't work for me for stenosis.

A Turkish study a few months ago showed superiority of particulates for long term outcomes. European data shows similar. It seems dex is inferior to particulates over the long term--which is what we would all expect--everywhere except in this country.
 
I use dex for cervical IL, and TF L2 and above. Otherwise I use particulates for most everything. Its dogma and how I was trained mostly.
 
I use Dex for everything. Spine, knees, shoulders, tendons, whatever. Haven't noticed any real difference.

Perhaps, maybe, my Interlaminar ESI doesn't pack quite the same punch I remember in early fellowship (Depo for first third of fellowship, Dexa therafter), but not clinically a big difference in my opinion. Not worth the medico-legal risk for sure.
 
All TFESI are dex for me, ILESI are either Depo or dex, and all joints are Depo.

My anecdote is Depo being clearly superior to dex, but that's probably me looking for something that isn't really there...Depo SHOULD last longer, and I've heard surgeons say they can see Depo a month after an ESI.

Dex in a hip, knee, SIJ, or facet (other than maybe a cervical facet) seems like a poor choice.
 
callmeanesthesia said:
For those of you who switched to all dex, do you do it for joints too? I still do dex for tfesi but particulate for interlam and joints. I’ve been nervous to switch because biochemically it doesn’t make sense that dex would last as long. I’m aware of the clinical evidence but can anyone point me to some basic science evidence that would explain how dex would have long term efficacy? I really want to switch to all dex because it would be simpler but I guess I just need some reassurance.
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I still use depo for joints, even SI
 
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Decadron for most tfesi, will consider switching to particulate for L3 and below if dex didnt last long. All joints kenalog or depo.
Interlaminar i use particulate.
Anecdotal experience is particulates can last much longer but is it worth the increased risk? Dont know..
 
clubdeac said:
I think depo works way better in my older stenotic patients. I don't know why and I don't have any data other than my anecdotal experience. I still use depo in all my ILESIs. I bounce back and forth between depo and dexa for my TFESIs depending on the level
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100% me too. I tell people I'm not crazy, for some reason, Depo works better. Dex doesn't do anything for them. TFESI with Dex only for 20-60 year old herniations causing radiculopathy. Spinal Stenosis age 70+, ILESI with Depo.
 
Wkrdoc said:
You guys doing 80mg depo? What about IL CESI?
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I use 40mg Depo for IL LESI. Dex for all TF ESI and TESI, CESI. For joints I use Depo. For those who are using Dex and not seeing as robust clinical response as Depo, what dose was used? I have Dex 10mg which is the dose I'll use for 1 level TF or ILESI, for 2 level TESI I'll use 7mg per level and seems to work just as well as the Depo days. Wonder if folks are using only 4mg dosing for TFESI?
 
I always thought 4mg was way too low. I use 10 mg dex across the board for ESIs. Two level TFESI 15mg
 
Wkrdoc said:
I always thought 4mg was way too low. I use 10 mg dex across the board for ESIs. Two level TFESI 15mg
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www.ncbi.nlm.nih.gov

Lumbar transforaminal epidural dexamethasone: a prospective, randomized, double-blind, dose-response trial - PubMed

Transforaminal epidural dexamethasone provides statistically significant and clinically meaningful improvement in radicular pain at 12 weeks after injection, with parallel improvements in disability, impression of change, and satisfaction measures. There was no difference in efficacy for...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Then you inject too much.
 
For a single-level lumbar TESI, I use a 3ml syringe with 2mL of 2% lidocaine and 1ml of 4mg/ml dexamethasone. Each side gets 1.5 ml of solution. I'd estimate that 60% of my patients get great relief (>75%) for at least 3 months. If great but short term relief (even for a few days), I'll do a second and usually they'll get even more relief. I don't usually do a third if no sustained relief after two, cause by then I'm thinking about other options. Where I first practiced, we used a lot more steroids (10mg dexa on each side for each level, or celestone 6mg each side each level, or 80mg depo for ILESI), and I don't realize any less benefit from using much less steroids. I do have a lot less phone calls about steroid-related side effects, however.

Also, I've been having to do more and more peer-to-peers for a simple repeat epidural, and it's not because of documentation. Anyone else having similar issues? Idk how some of my friends are able to schedule some of their patients M/W/F for a 'series of 3' epidurals in one week with these insurances.
 
lobelsteve said:
www.ncbi.nlm.nih.gov

Lumbar transforaminal epidural dexamethasone: a prospective, randomized, double-blind, dose-response trial - PubMed

Transforaminal epidural dexamethasone provides statistically significant and clinically meaningful improvement in radicular pain at 12 weeks after injection, with parallel improvements in disability, impression of change, and satisfaction measures. There was no difference in efficacy for...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Then you inject too much.
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Interesting. So by using a higher dose it’s less effective...
 
Medications and almost all other alternative options also stop working after 3 months too, according to 'studies'. Let's just ban those while we're at it.
 
Another guy stating epidurals were ineffective in the past but mine seemed to work well. Wants a TFESI for the other side now two months after his initial visit. Records show he had multiple TFESIs with 10mg dex by the previous physician. Anecdotal, but he isn't alone. For now, I'm just happy he gets to go around saying Mayo Clinic didn't help him but I did.
 
pmrmd said:
Another guy stating epidurals were ineffective in the past but mine seemed to work well. Wants a TFESI for the other side now two months after his initial visit. Records show he had multiple TFESIs with 10mg dex by the previous physician. Anecdotal, but he isn't alone. For now, I'm just happy he gets to go around saying Mayo Clinic didn't help him but I did.
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mayo arizona? those guys arent very impressive
 
pmrmd said:
Another guy stating epidurals were ineffective in the past but mine seemed to work well. Wants a TFESI for the other side now two months after his initial visit. Records show he had multiple TFESIs with 10mg dex by the previous physician. Anecdotal, but he isn't alone. For now, I'm just happy he gets to go around saying Mayo Clinic didn't help him but I did.
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You’re using depo in TFESIs?
 
Far more likely for people to have poor result from epidural with dex and get surgery—with potential bad outcome from that—than have bad result from ESI with particulate.
 
^ Well, catastrophic event from ESI with particulate is exceedingly rare, more rare than 1:500k given the number of catastrophic events and the number of procedures performed.

This poor guy shows the odds of surgery didn't go in his favor. Not my patient before, unfortunately, but is now. Who knows what he may have avoided with that simple laminectomy/discectomy? A fusion most likely.

Are you going to say surgical risks are more rare than 1:500k? Good luck with that.
 

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pmrmd said:
Far more likely for people to have poor result from epidural with dex and get surgery—with potential bad outcome from that—than have bad result from ESI with particulate.
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you are probably right. but you have no liability if there is a surgical complication. you do if there is a complication from a TFESI.
 
Anyone know Of specific cases in the lower lumbar area? I know of one case where a spinal was done and injected Into the cord at l3/4 with a cord that ended abnormally caudad but that was a spinal not an epidural with particulate.
 
Ducttape said:
just to be clear -

I am not arguing against particulates for ILESI.
I would argue against particulates for TF.

speaking of expert witnesses against particulates for TF: Spinal Injection Expert Witness: Risks and Complications-SEAK
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A near consensus was reached on the following:

  1. Cervical and lumbar transforaminal epidural steroid injections should be performed by injecting contrast medium during real-time fluoroscopy or digital subtraction imaging first before consideration to injection of the actual steroid.
  2. A nonparticulate steroid should be used for the initial lumbar transforaminal epidural injections.
  3. Extension tubing should be used during transforaminal epidural injections.
  4. Cervical and lumbar translaminar epidural injections can be performed without contrast in patients with documented contraindication to the use of contrast.
 
Total consensus was reached on the following:

  1. Cervical translaminar epidural steroids are associated with a rare risk of catastrophic neurologic injury.
  2. Spinal transforaminal injections using particulate steroids are associated with a rare risk of catastrophic neurovascular complications.
  3. All cervical translaminar epidural steroid injections should be performed with image guidance and a test dose of contrast medium.
  4. Cervical translaminar epidural steroid injections should not be performed above the C6-7 level.
  5. One must perform a review of imaging to assure there is adequate space for a needle placement before proceeding with a cervical translaminar epidural steroid injection.
  6. Do not use particulate steroids when performing a cervical transforaminal epidural steroid injection.
  7. All lumbar translaminar epidural steroid injections should be performed with imaging and a test dose of contrast medium.
  8. Particulate steroids can be injected in lumbar transforaminal epidural steroid injections.
  9. A face mask and sterile gloves must be worn during the procedure.
  10. The decision to do a translaminar versus a transforaminal epidural steroid injection should be based on the decision of the health care practitioner performing the injection.
  11. When doing a transforaminal epidural steroid injection in a patient with a contrast allergy, you must use a preservative free, particulate-free steroid.
  12. Moderate to heavy sedation for epidural injections is not recommended. If sedation is necessary, use light sedation so that the patient can clearly communicate with the treating physician
 
I’m so confused with everything now lol

Just bc if this thread, I’m now using particulates on interlam lumbar even though I know two academic institutions that have gone away from depo

I hate all of you 🙂
 
Trans could just mean crossing the plane ..but I agree the nomenclature is odd
 
I use depo for all joints and interlaminar lumbars. Thoracic and cervical interlaminar celestone. Trandsforaminal lumbar celestone L3 and below. Decadron above L3 or any hint of vascular uptake under live flouro
 
I started doing some injections at a new location the other month. I always use beta for ILESI, and as I'm drawing it up, I notice it's clear. I double checked the bottle. Apparently it's betamethasone sodium phosphate, not betamethasone sodium phosphate/betamethasone acetate. Any experience with this? Didn't even know it existed.
 
MD87 said:
I started doing some injections at a new location the other month. I always use beta for ILESI, and as I'm drawing it up, I notice it's clear. I double checked the bottle. Apparently it's betamethasone sodium phosphate, not betamethasone sodium phosphate/betamethasone acetate. Any experience with this? Didn't even know it existed.
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Anesthesiology

pubs.asahq.org pubs.asahq.org
 
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