Quick ESI question

[SSdoc33]

patient shows up with a local anesthetic allergy AND a contrast allergy. lets assume both are legit (anaphylaxis).

any way to do an ESI?

transforaminal is out.

interlaminar really needs good LOR without contrast and it would be pretty uncomfortable without local

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[Ronin1]

See if it’s an amide vs an ester allergy. I’ve done a few without local. They all lived to tell. I probably actually did a few thousand ESIs without contrast or image guidance back in the day

 

[gdub25]

I’d do transforaminal with dex and no contrast. No way to confirm good spread but definitely better than telling the patient you have no options.

 

[SSdoc33]

I’d do transforaminal with dex and no contrast. No way to confirm good spread but definitely better than telling the patient you have no options.

just did it they way you proposed. i advanced a little farther than i otherwise would have and the patient felt a mild paresthesia in the leg. thats good enough for me.

this is the type of patient that will complain of something if i blinkthe wrong way

 

[Bostonspine]

I would probably needle exchange from 25g to 20g then LOR no contrast the initial pinch would be the worse then it should pretty much be the same

 

[SSdoc33]

I would probably needle exchange from 25g to 20g then LOR no contrast the initial pinch would be the worse then it should pretty much be the same

20g would not feel very good

 

[paindoc007]

this is the type of patient that will complain of something if i blinkthe wrong way

No one requires a shot of steroid. If you sense this behavior in office, in light of allergy list, you are way better off not injecting. PT, weight loss, non opioid medications. And be done with it. They won’t be back. Someone else’s problem now.

 

[SSdoc33]

No one requires a shot of steroid. If you sense this behavior in office, in light of allergy list, you are way better off not injecting. PT, weight loss, non opioid medications. And be done with it. They won’t be back. Someone else’s problem now.

sigh. wrong. im not a noob.

she has a radic diagnosed via EMG and an HNP.

patients that have a real back problem and are not crazy are easy to treat
patients that dont have a real back problem and are crazy are easy to treat
patients that have a real back problem AND are crazy are heard to treat.

 

[paindoc007]

sigh. wrong. im not a noob.

she has a radic diagnosed via EMG and an HNP.

patients that have a real back problem and are not crazy are easy to treat
patients that dont have a real back problem and are crazy are easy to treat
patients that have a real back problem AND are crazy are heard to treat.

I don’t agree with that just bc she has a real radic. That doesn’t necessitates a steroid injection, in a crazy patient, with an allergy list that makes standard of care of using contrast not possible. I hope she does well, with no drama afterwards, but man, you couldn’t pay me enough to do that.

 

[SSdoc33]

I don’t agree with that just bc she has a real radic. That doesn’t necessitates a steroid injection, in a crazy patient, with an allergy list that makes standard of care of using contrast not possible. I hope she does well, with no drama afterwards, but man, you couldn’t pay me enough to do that.

i hear what you are saying. this wasnt the type who was vindictive. just a little bit crazy. and she was struggling. ill post back again if there is any drama. you are correct that no good deed goes unpunished.

 

[Centurion38]

20g would not feel very good

Can advance interlaminar carefully with 22G or 25G as well using saline "puffs" and detect resistance change once you are epidural. I would do that before a TFESI, if no contrast allowed, even with Dexamethasone.

 

[lobelsteve]

Take to OR, intubate prophylactically. Solumedrol drip, Tagamet, IV Benadryl, Run some epi in her IV. Albuterol in the tube.

 

[Ferrismonk]

Plan is based on risk/benefit discussion with the patient.

1. Non-injection treatment is reasonable if patient on board.
2. Doing LOR interlaminar ESI without local or contrast is fine, but 20G touhy may be a little painful. Could argue sedation warranted.
3. Doing TFESI with 25G without local or contrast is fine too, but discuss risk of not being 100% sure you're in the correct spot.
4. Switching to chloroprocaine okay for skin if you want to play that game, although I probably wouldn't if anaphylaxis with amides and I don't have a confirmed ester-free allergy test.

 

[callmeanesthesia]

Why is TFESI out? With preservative-free dex, worst case they just got an IV dose of steroid. That would be my first move in that situation. If lower lumbar might do caudal. I use a 22g for interlaminar and can generally feel a decent LOR. For a lumbar, between that and CLO technique I think it would be enough for me.

 

[Baron Samedi]

I think others have posted better options but I've done a fair amount of US guided caudals and you can get away with a small needle doing that. Never tried a 25G but a 22G is pretty easy.

 

[bedrock]

Lumbar TFESI with dex only, no local, no contrast, and 25G needle.

Not the end of the world.

 

[au bon pain]

In the non-crazy* and otherwise known and compliant patient, depending upon the level of their pathology, I would likely start with a caudal. If no relief would consider a trans.

Ice pack to the back for 15 to 20 minutes right before procedure. 25g or if patient very thin, 27g.

*I, like most of us, think my crazy detector is pretty good. But it still failed me with one of these patients who messaged a week after a trans I did without contrast. Said her legs “were numb and no longer worked” and wanted me to repeat an injection (!?). Instead of just telling me about it, new MA decides to save this insane note to the patient’s chart and alert me. I called patient within an hour of the alert, and she was cheerful and said all was well with her legs and her pain was down by 60%. She could not give a clear explanation for why she had sent that message. Several months later, she saw me again saying the epidural was wearing off and wanted it repeated. Declined.

 

[paindoc503]

I feel like caudal would be the best first move (least likely to harm, also least likely to work). I usually get in with the 25G 1.5" skin needle

 

[RoloTomassi]

Just do ILESI with air. 20 ga shouldn't be that bad after initial poke. PO sedation with opioid and benzo should be plenty to withstand a quick 20 ga jab, but can do IV if needed

 

[lobelsteve]

I feel like caudal would be the best first move (least likely to harm, also least likely to work). I usually get in with the 25G 1.5" skin needle

First best move is to say no injections. Treat however you want from there.

 

[hyperalgesia]

i hear what you are saying. this wasnt the type who was vindictive. just a little bit crazy. and she was struggling. ill post back again if there is any drama. you are correct that no good deed goes unpunished.

I wonder if you can send her to an allergist/immunologist to assess magnevist/omnipaque and various local anesthetics. Never done this but it's a hard life if you're allergic to ALL anesthetics. I totally don't buy it.

You would help this patient a lot more by getting some clarity on this than by squirting steroid in the canal.

 

[MitchLevi]

Some of yall are kind of ridiculous. Give the poor lady a shot FFS. I can guarantee yall would want one if your leg was screaming with a radic.

I'd TFESI with saline and dex using a 25g needle, or I'd do an ILESI with dex and saline using LOR.

This is small potatoes, and some of yall act like it's a big deal.

 

[Agast]

You could always sit a bag of ice on her back before you prep. For some patients that probably numbs them more than lidocaine since the lido doesn’t go that deep anyway

And two Valium. One for the patient and one for you

 

[CleanUp]

SCS

 

[Ducttape]

we used to do epidurals blind... or sitting epidurals...

yes, you can get allergy testing done to local anesthetics. ive done it several times.

give patient a bottle of lido and and a bottle of bupiv, send referral to allergist, and have him skin test the patient.

only problem is that this will take a while...

1. confirm allergy was not the "i got numbing in dentist and heart racing".

2. use an ester anesthetic

3. premedicate with benadryl and prednisone.


if she refuses the contrast, then premedicate for the ester anesthetic and get it done under fluoro with saline for LOR.

 

[SSdoc33]

little back story:

i had seen the patient once for an EMG.

sent directly for an ESI by surgeon colleague.

yeah, i could have got immunology involved. i could have not done the shot, i could have dug much further into her past history. just seems like a lot of work for a simple injection with very little risk.

 

[PMROralBoards]

Side questions about TFESI related to this thread: do most people do steroid with lido for their tfesis (without an allergy), or do you primarily do steroid with saline? Our fellowship program did steroid with saline, but all of my partners now do steroid with lido. Thanks!

 

[MitchLevi]

Use a little local.

 

[paindoc503]

Side questions about TFESI related to this thread: do most people do steroid with lido for their tfesis (without an allergy), or do you primarily do steroid with saline? Our fellowship program did steroid with saline, but all of my partners now do steroid with lido. Thanks!

personally I feel that steroid with lido is ok if you are doing a single level TFESI. I would avoid using lido for multiple level TFESI due increased potential for developing weakness.

 

[Ducttape]

i use dex and saline unless they are inpatients. so there is no risk for weakness post injection that would prevent them from walking out.


for inpatients with severe radic, i will use dex and bupiv

 

[RoloTomassi]

Dex and lido

 

[kstarm]

I used dex and saline, though I am still a little surprised by the number of patients who complain of numbness/tingling/weakness after the procedure.

 

[Dansk2011]

Sorry another question...using contrast for injections in patients with severe renal disease. I figure it's not enough volume to have any effect on kidneys but am curious as to what, if anything, do folks do differently?

 

[buddababa]

Sorry another question...using contrast for injections in patients with severe renal disease. I figure it's not enough volume to have any effect on kidneys but am curious as to what, if anything, do folks do differently?

nothing different

 

[specepic]

I have seen several patients over the years who claimed to have a local anesthetic allergy. I have also had patient's claim to have a steroid allergy. In almost every case, and I cannot think of any exceptions at this time, these allergies ended up not really being allergies. The way we usually handle this is we have them consult with an allergist who does formal testing in a controlled environment. They then give us the results and we know what we can inject safely

If the patient did not want to see the allergist, and assuming they have a copious posterior epidural space I would do an interlaminar with a 20-gauge tuohy with no local and no contrast and consent them extensively about possible increased risks and they agreed to assume those risks because they would rather not see the allergist or wait to see the allergist

 

[hyperalgesia]

little back story:

i had seen the patient once for an EMG.

sent directly for an ESI by surgeon colleague.

yeah, i could have got immunology involved. i could have not done the shot, i could have dug much further into her past history. just seems like a lot of work for a simple injection with very little risk.

I definitely wouldn't have delayed care for the allergist. I just think that would be helpful for the pt in the long term. What happens when they're in the ER and tell the doc they're allergic to everything?

I love Agast's idea for mechanical anesthetic, like ice or ethyl chloride. For contrast, I would normally use magnevist as an alternate but, using dex and NS, I would not really have an issue with using no contrast.

 

[hyperalgesia]

we used to do epidurals blind... or sitting epidurals...

yes, you can get allergy testing done to local anesthetics. ive done it several times.

give patient a bottle of lido and and a bottle of bupiv, send referral to allergist, and have him skin test the patient.

only problem is that this will take a while...

1. confirm allergy was not the "i got numbing in dentist and heart racing".

2. use an ester anesthetic

3. premedicate with benadryl and prednisone.


if she refuses the contrast, then premedicate for the ester anesthetic and get it done under fluoro with saline for LOR.

Interesting and good to know.

 

[DOctorJay]

in response to @PMROralBoards
steroid with saline
all my partners use lidocaine in their TFESIs, my nurses hate when their patients have a weak leg and love that mine don't