S1 TFESI tips

[deleted131481]

Ok pretty basic question - tips on S1 TFESI? For some reason these often take me longer than they should or too much walking off. I use technique from Furman - slight cephalad tilt and slight ipsilateral oblique. Often have trouble seeing the S1 dorsal foramen so sometimes try go just under pedicle.

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[lobelsteve]

Make cranial tilt more than slight. Ipsi rotate more until you can see a clear foramen.
Get in 2-2.5in and get a lateral. Contrast once tip in canal. This will become the easiest TFESI you do.
And get ready for using more contrast, vascular structures abound.

 

[Orin]

Ok pretty basic question - tips on S1 TFESI? For some reason these often take me longer than they should or too much walking off. I use technique from Furman - slight cephalad tilt and slight ipsilateral oblique. Often have trouble seeing the S1 dorsal foramen so sometimes try go just under pedicle.

Sacral foramen are hard. I counsel squaring off the S1 superior end plate if possible and then working on the lateral oblique to line up the dorsal/ventral foramen's medial border if possible. The cephalad tilt can be a bit more than you would expect.

The lateral view is probably the most useful as you can see the angulation of S1 and often get an estimation for the craniocaudal location of the foramen even if you don't see it perfectly.

 

[SommeRiver]

I always think about how easy the anterior foramen is to find, and if I've got a good cephalad tilt with a little ipsilateral oblique, and I clearly see the anterior foramen, the posterior foramen is superior to that, and medial to Charlie's Line (Aprill designated landmark).

Find Charlie's Line and anterior foramen and you're done in 90 sec.

Okay, maybe 90 sec...Occasionally. This AM I did a bilateral in MAYBE 3 min and a unilateral that took 10 min bc I was vascular repeatedly. Repeatedly vascular with a 22g. Big ol boohooka butt...Usually a 25g easy.

 

[pmrmd]

Approach like you are doing an L5-S1 TF with that much obliquity and square off the inferior endplate of L5 and the sacral foramen shows up pretty clearly. Perfect epidurogram every time.

 

[SommeRiver]

Saw an article on that recently.

 

[deleted131481]

Thanks to all for the tips. Did a couple today and it was night and day difference.

 

[painfree23]

Make cranial tilt more than slight. Ipsi rotate more until you can see a clear foramen.
Get in 2-2.5in and get a lateral. Contrast once tip in canal. This will become the easiest TFESI you do.
And get ready for using more contrast, vascular structures abound.

How much cranial tilt usually? If you do L5 and S1 transforaminal together, do u cranially tilt for L5 first , then go past that for the S1?

 

[lobelsteve]

I sont believe in multilevel tfesi because the spread is at least 3 segments.

lay a spine model on table. Cranial tilt until you see the sq foramen open up. Looks like ice cream on a cone.

 

[DOctorJay]

Once I started doing that big time cranial tilt this became my favorite TFESI

 

[painfree23]

Once I started doing that big time cranial tilt this became my favorite TFESI

Hmm. So back to my other question , how much more is “big time tilt ” vs a lumbar tfesi?

 

[Ligament]

Square up the L5-S1 disc space, and usually AP sometimes slight ipsilateral oblique to show the foramen easier. Typically very simple. Of course, the only hard one I've had in the past year was a DRG stimulator trail and it took me 30 mins to enter the damn S1 foramen..crazy.

 

[Orin]

Hmm. So back to my other question , how much more is “big time tilt ” vs a lumbar tfesi?

C-Arm Fluoroscope Angle Settings for Fluoroscopically Guided Lumbar Transforaminal Epidural Injections

Abstract. Background Data . Minimizing fluoroscopy time in spine interventions is critical for time of procedure as well as radiation safety of the patient

academic.oup.com

"""Results . For the L4-5 level, 71% of cases had oblique angle of 30°±5° and 94% of cases had neutral cephalad/caudal tilt (0°±5°) observed. For the L5-S1, 72% of cases had oblique angle of 30°±5° and 62% of cases had cephalad tilt angle of 15°±5° observed. For the S1 level, 73% of cases had oblique angle of 5°±5° and 69% of cases had cephalad tilt angle of 15°±5° observed. """

I find myself doing more like 20-25° cephalad

 

[NJPAIN]

C-Arm Fluoroscope Angle Settings for Fluoroscopically Guided Lumbar Transforaminal Epidural Injections

Abstract. Background Data . Minimizing fluoroscopy time in spine interventions is critical for time of procedure as well as radiation safety of the patient

academic.oup.com

"""Results . For the L4-5 level, 71% of cases had oblique angle of 30°±5° and 94% of cases had neutral cephalad/caudal tilt (0°±5°) observed. For the L5-S1, 72% of cases had oblique angle of 30°±5° and 62% of cases had cephalad tilt angle of 15°±5° observed. For the S1 level, 73% of cases had oblique angle of 5°±5° and 69% of cases had cephalad tilt angle of 15°±5° observed. """

I find myself doing more like 20-25° cephalad

The typical anesthesiologist/PM&R S1 approach is not the most favorable for loop creation for DRG. The technique that the radiologists advocate is the most favorable. I find is really interesting and informative to see how the radiologists approach things different than most of us do. SIS really shines in that realm with great representation from radiology.
From UWisc - Dept of Radiology, Div MSK Radiology. I've still not totally figured this one out in a way that it reliably works for me.

 

[DOctorJay]

Hmm. So back to my other question , how much more is “big time tilt ” vs a lumbar tfesi?

I will have my rad tech start tilting cranial and I go live with the pedal on low dose til I see it open up. Usually once the S1 end plate is squared off. It’s definitely more than an L5-S1.

 

[Ligament]

I will have my rad tech start tilting cranial and I go live with the pedal on low dose til I see it open up. Usually once the S1 end plate is squared off. It’s definitely more than an L5-S1.

Square up the L5-S1 disc space. Thats what you need.

 

[painfree23]

C-Arm Fluoroscope Angle Settings for Fluoroscopically Guided Lumbar Transforaminal Epidural Injections

Abstract. Background Data . Minimizing fluoroscopy time in spine interventions is critical for time of procedure as well as radiation safety of the patient

academic.oup.com

"""Results . For the L4-5 level, 71% of cases had oblique angle of 30°±5° and 94% of cases had neutral cephalad/caudal tilt (0°±5°) observed. For the L5-S1, 72% of cases had oblique angle of 30°±5° and 62% of cases had cephalad tilt angle of 15°±5° observed. For the S1 level, 73% of cases had oblique angle of 5°±5° and 69% of cases had cephalad tilt angle of 15°±5° observed. """

I find myself doing more like 20-25° cephalad

This is great. Is there any study like this for facet injections or is it kind of the same average?

 

[DODOCSS]

S1 line me up 100x a day, takes literally 3 seconds

for certain commies would take longer 2/2 protests

 

[paindoc007]

S1 line me up 100x a day, takes literally 3 seconds

for certain commies would take longer 2/2 protests

Must take a few extra secs to straighten your maga cap before inj though no?

 

[DODOCSS]

Must take a few extra secs to straighten your maga cap before inj though no?

no, takes about 3 seconds to deal w/ typical snow flakes though

 

[SommeRiver]

no, takes about 3 seconds to deal w/ typical snow flakes though

People on either edge bring out the worst in each other.