Retrodiscal/infraneural approach

[NJPAIN]

I have made two attempts at this, the most recent this morning. Both without success. Lined up superior endplate of INFERIOR vertebral body. Approx 30 degree oblique. Targeting junction of SAP and superior endplate . Alternating AP and lateral to place tip lateral to 12 o'clock position on pedicle in AP and low in foramen and posterior to disc on lateral. Inject contrast - no flow into epidural space. Advance more and either hit bone (posterior margin of inferior vertebral body) or enter dis annulus.

Do I need more oblique approach? Any suggestions?

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[mdvol]

More oblique. Almost like entry to disc for discogram. Oblique so that SAP is about 50% of distance on inferior endplate of superior vertebral body. As soon as you just get around the facet joint you are in epidural space. Leave it to others to decide if this is ventral epidural space like traditional approach.

 

[SSdoc33]

great way to spear the nerve, btw.

i sometimes inject this way, but only because that is where my needle ends up, rather than where i am trying to get.

what is your rationale to use this approach?

 

[101N]

I have made two attempts at this, the most recent this morning. Both without success. Lined up superior endplate of INFERIOR vertebral body. Approx 30 degree oblique. Targeting junction of SAP and superior endplate . Alternating AP and lateral to place tip lateral to 12 o'clock position on pedicle in AP and low in foramen and posterior to disc on lateral. Inject contrast - no flow into epidural space. Advance more and either hit bone (posterior margin of inferior vertebral body) or enter dis annulus.

Do I need more oblique approach? Any suggestions?

It tends to work best at L5/S1 as there is more of a gutter there below the vertebral body.

But, as SS suggested it's probably not worth the effort.

 

[NJPAIN]

More oblique. Almost like entry to disc for discogram. Oblique so that SAP is about 50% of distance on inferior endplate of superior vertebral body. As soon as you just get around the facet joint you are in epidural space. Leave it to others to decide if this is ventral epidural space like traditional approach.

On lateral to you look to be at the level of the disc or BELOW the level of the disc and posterior to the INFERIOR vertebral body?

 

[NJPAIN]

great way to spear the nerve, btw.

i sometimes inject this way, but only because that is where my needle ends up, rather than where i am trying to get.

what is your rationale to use this approach?

I have a young guy (36 yo) with classic discogenic pain and a radiographically evident HIZ. PT x 4 months doing nothing. Standard TFESI did nothing. Mike Furman told me that the only time he does infraneural approach is in cases of annular fissure where he wants to "place steroid at the disc interface". So I figured I would give it a try. I don't think it will help but not a lot of options. Gave up IDT 10-12 years ago. I guess I could try GRC block.

 

[drrosenrosen]

GRC blocks have been mentioned a few times recently. Does anybody have a writeup on technique/billing/evidence?

 

[Taus]

I have a young guy (36 yo) with classic discogenic pain and a radiographically evident HIZ. PT x 4 months doing nothing. Standard TFESI did nothing. Mike Furman told me that the only time he does infraneural approach is in cases of annular fissure where he wants to "place steroid at the disc interface". So I figured I would give it a try. I don't think it will help but not a lot of options. Gave up IDT 10-12 years ago. I guess I could try GRC block.

I don't do many for this indication, but when I do I typically just go under pedicle below and try to get nice spread medial to pedicle up to disc, use slightly higher volume than usual TFESI. Ie Bilat L5-S1 for a L45 disc. Now that I have a lot of "normal" patients with subacute issues who don't want narcs.... this has been very effective (my huge n=5 or 6).

 

[bedrock]

I don't do many for this indication, but when I do I typically just go under pedicle below and try to get nice spread medial to pedicle up to disc, use slightly higher volume than usual TFESI. Ie Bilat L5-S1 for a L45 disc. Now that I have a lot of "normal" patients with subacute issues who don't want narcs.... this has been very effective (my huge n=5 or 6).

Careful. This board will rip you a new one for daring to suggest, as I have over the years that a decent percentage of non-crazy, non-drug seeking patients with annular tears will respond to TFESI or caudal.

Not like any of the critics have a better option.

 

[Taus]

one ml of iohexol 240 will not box anyone's kidneys. you could get confirmation from patient's nephrologist.

This. Had 2 similar patients recently. I got nephro clearance on both. No problem, though they rec'd a prep w holding diuretic, inc fluids and I think ?mucomyst. I'll prob still request clearance though w each similar pt in future.

 

[Taus]

Careful. This board will rip you a new one for daring to suggest, as I have over the years that a decent percentage of non-crazy, non-drug seeking patients with annular tears will respond to TFESI or caudal.

Not like any of the critics have a better option.

Heh I know. I'd take the injection for my back and rec it for family if still miserable after a few months of good pt, meds etc w single level disc, hiz, modic 1 changes. No question.

 

[powermd]

More oblique. Almost like entry to disc for discogram. Oblique so that SAP is about 50% of distance on inferior endplate of superior vertebral body. As soon as you just get around the facet joint you are in epidural space. Leave it to others to decide if this is ventral epidural space like traditional approach.

I've had this technique in my back pocket for a while. Never had a reason to use it, until today.

Had a surgeon request for a L4 TF/SNRB and she had a weird osteophyte on the L4 TP obstructing a tunnel view. I usually corkscrew from AP as a backup, but this was also blocked by osteophytes around the facet. So I tried retrodiscal as you guys have been discussing- SUCCESS! And no paresthesias.

 

[BobBarker]

I use this approach nearly exclusively. I feel it works well and is technically easy.

 

[fentanyl patch]

I've had this technique in my back pocket for a while. Never had a reason to use it, until today.

Had a surgeon request for a L4 TF/SNRB and she had a weird osteophyte on the L4 TP obstructing a tunnel view. I usually corkscrew from AP as a backup, but this was also blocked by osteophytes around the facet. So I tried retrodiscal as you guys have been discussing- SUCCESS! And no paresthesias.

I do a bilateral retrodiscal TFESI for normal patients with a one level HIZ; decent results in patients where there is no other treatement option. You don't have to go nuts with the oblique as long as you have a decent bend on the needle tip.

 

[cbest]

For those of that perform infraneural/retrodiscal lumbar TFESIs regularly, can you go through your process?

E.g Square off inferior endplate of superior level, oblique until SAP bisects vertebral body, advance until X landmark and Y landmark. Thanks in advance!


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[DOctorJay]

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[Aether2000]

Use a blunt coude tip epimed 8" 20ga needle angling towards the lateral border of thd SAP at the disc level. The angle is 25 degrees to the coronal plane. The needle tip may be placed retro or antero neural. It is possible to displace but not pith the nerve with this approach.

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[Ligament]

Use a blunt coude tip epimed 8" 20ga needle angling towards the lateral border of thd SAP at the disc level. The angle is 25 degrees to the coronal plane. The needle tip may be placed retro or antero neural. It is possible to displace but not pith the nerve with this approach.

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This is Algos' far lateral gutter approach TFESI. Cool technique. He used to have a good writeup on it on his website.

The first time I did it I screwed up big time and entered from the right L4/5 neuroforamen and exited at the LEFT L4/5 neuroforamen!!!!

Yes I traversed the entire lumbar spine from right to left.

Thank god no dural rent...no complication. Could have billed for a b/l TFESI from one entry point...

 

[Aether2000]

lol- I have done the same a couple of times. It is an easy way to access the anterior epidural space directly over the disc displacement or to access the lateral recess or perform an evaluation of where the nerve compression is located by performing serial neurograms (foraminal ligaments, foramen, lateral recess, or central stenosis). It is a fun technique.

 

[Ligament]

lol- I have done the same a couple of times. It is an easy way to access the anterior epidural space directly over the disc displacement or to access the lateral recess or perform an evaluation of where the nerve compression is located by performing serial neurograms (foraminal ligaments, foramen, lateral recess, or central stenosis). It is a fun technique.

Its a fantastic technique and thanks for sharing it with the world. My mistake was due to my naïveté, not a comment on your procedure.

 

[Papa Lou]

I use this approach nearly exclusively. I feel it works well and is technically easy.

3.5inch needles don't reach on ppl where they would reach for infraneural with length to spare. pita. Disc spread worries. Long needle. Too often spread not ideal.

 

[BobBarker]

Haha. I wrote that when I was a fellow. I use the traditional approach now.