Selective Nerve Root Block and blood thinners

[gdub25]

Curious if anyone has a reference for anticoagulation guidelines for SNRB. My partner and I are having a discussion about if these are seen the same as TFESI from a legal perspective when it comes to blood thinners and risk. ASRA does not list SNRB as an injection type on their guidelines app.

Also, if I'm not mistaken, SIS guidelines say it's ok for TFESI on blood thinner, yeah?

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[SSdoc33]

i cant see how it would be any different from a TFESI from a legal perspective

 

[lobelsteve]

i cant see how it would be any different from a TFESI from a legal perspective

Or a treatment perspective.

ASRA says need to hold.
Science says no need to hold (L-spine).
Many threads on this.
I'm more amazed that people still think there is such a thing as a SNRB.

 

[Scottie_Dog]

Agree with Steve. There’s a good NASS podcast on both of these subjects, I think furman was the guest on both. I’ll try to find link. SNRB probably isn’t a real thing. Holding blood thinners is more dangerous than doing a lumbar tfesi on anti-coagulation.

 

[gdub25]

I agree with all of the above, but have partners working in a group who tell staff differently and thus the discussion.

 

[jwalker12]

So were not holding AC for lumbar TFESI? is this with a 25g or with 22g as well?

 

[lobelsteve]

So were not holding AC for lumbar TFESI? is this with a 25g or with 22g as well?

What is a 22g? Is that the black needle? No thanks.

 

[Dr. Ice]

Haven’t held blood thinners for tfesi in years

 

[bedrock]

Haven’t held blood thinners for tfesi in years

Including S1? Definitely more bleeding there.

 

[Scottie_Dog]

What is a 22g? Is that the black needle? No thanks.

Do you use 25 for everything? What length? I think the longest 25g we have is only 3.5 inches. I use a 22 gauge 5 inch for almost everything because it’s readily available

 

[drmamba]

25G for the majority of injections whenever possible. No topical local needed. No holding of ACs for TFESIs.

 

[BobBarker]

I don’t mentally differentiate or try to do anything different for tfesi vs SNRB. I am not holding anything for them. My partner hangs out with ortho too much and would like to hold everything for everything but I am working on that.

 

[PMROralBoards]

I’m surprised by some of the posts here, but value the discussion and input from those who have been doing this for longer than I’ve had an MD for.

We were taught in fellowship to follow the ASRA recommendations and for TFESI that would be holding AC. If the patient’s cardiology team feels the risk of coming off AC for a few days is low enough for the benefit of an elective procedure to be worth it, how can it be a good idea from a medicolegal perspective to go against the ASRA recs?

 

[BobBarker]

ASRA guidelines are behind the times.

 

[Scottie_Dog]

Risks and Benefits of Ceasing or Continuing Anticoagulant Medication for Image-Guided Procedures for Spine Pain: A Systematic Review

AbstractObjective. To determine the risks of continuing or ceasing anticoagulant or antiplatelet medications prior to image-guided procedures for spine pai

academic.oup.com

https://www.sciencedirect.com/science/article/pii/S2772594423001097

 

[MitchLevi]

I never hold thinners for TFESI at any level, nor caudals, MBB/RFA, SIJ, etc.

I hold them for cervical ILESI and lumbar ILESI, but I am considering doing lumbar ILESI on thinners.

For cervical ILESI, my using a 25g quincke most likely will be perfectly safe on thinners, and that is most likely true for the lumbar spine too. Hard to imagine an L4-5 ILESI on Eliquis causing a compressive hematoma that requires evacuation from a 25g needle.

I never stop aspirin for any procedure.

Scottie_Dog, what is a non-clinically relevent epidural hematoma, and how does one actually test for that? That article mentions only clinically relevant hematomas...What is the difference?

 

[gdub25]

ASRA guidelines are behind the times.

But its also what any court is going to consider the gold standard. As your practice gets bigger you start to think in terms of risk to the company and start bringing in compliance and medical director mentality like every other large institution. Just the way it has to be apparently from a legal/malpractice perspective.

 

[Scottie_Dog]

I never hold thinners for TFESI at any level, nor caudals, MBB/RFA, SIJ, etc.

I hold them for cervical ILESI and lumbar ILESI, but I am considering doing lumbar ILESI on thinners.

For cervical ILESI, my using a 25g quincke most likely will be perfectly safe on thinners, and that is most likely true for the lumbar spine too. Hard to imagine an L4-5 ILESI on Eliquis causing a compressive hematoma that requires evacuation from a 25g needle.

I never stop aspirin for any procedure.

Scottie_Dog, what is a non-clinically relevent epidural hematoma, and how does one actually test for that? That article mentions only clinically relevant hematomas...What is the difference?

I listened to a presentation on that paper a while back, if I can remember correctly I think it means a hematoma that doesn’t require surgical evacuation.

 

[jwalker12]

So I know many of you are using a 25g, but are some of you using a 22g for these TFESI's while maintaining AC?

In addition, has almost everyone stopped holding blood thinners for cervical/thoracic mbbs/rfa as well, despite needle size? I used 18g.

Thanks in advance. You guys always help push me forward

 

[MitchLevi]

I listened to a presentation on that paper a while back, if I can remember correctly I think it means a hematoma that doesn’t require surgical evacuation.

I guess my Q is how would anyone know if a patient developed a clinically insignificant hematoma?

 

[Snowmen96]

But its also what any court is going to consider the gold standard. As your practice gets bigger you start to think in terms of risk to the company and start bringing in compliance and medical director mentality like every other large institution. Just the way it has to be apparently from a legal/malpractice perspective.

You could argue that the SIS guidelines, being more recent and backed by litterature, are a better gold standard to go by.

 

[au bon pain]

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You could argue that the SIS guidelines, being more recent and backed by litterature, are a better gold standard to go by.

Last I checked SIS doesn’t lay things out in a particularly concrete manner. A shame

 

[au bon pain]

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So I know many of you are using a [emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6][emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6][emoji6]]]]]g, but are some of you using a [emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]]g for these TFESI's while maintaining AC?

In addition, has almost everyone stopped holding blood thinners for cervical/thoracic mbbs/rfa as well, despite needle size? I used [emoji[emoji[emoji6]][emoji[emoji6][emoji6]]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6][emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6][emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6][emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]]]]]g.

Thanks in advance. You guys always help push me forward

I do spine RF and pretty much anything else common for pts on AC/AP all the time. One exception are interlams — I still don’t hold for those, I just tell pts they’re not an option.
Haven’t had issues.

 

[SSdoc33]

SIS doesnt want the responsibility, so they have been hedging on this for nearly a decade

 

[drmamba]

So I know many of you are using a 25g, but are some of you using a 22g for these TFESI's while maintaining AC?

In addition, has almost everyone stopped holding blood thinners for cervical/thoracic mbbs/rfa as well, despite needle size? I used 18g.

Thanks in advance. You guys always help push me forward

I don’t for thoracic and lumbar targets — superficial, compressible, and far away from the valuable structures. I do for cervicals.

 

[drmamba]

I never hold thinners for TFESI at any level, nor caudals, MBB/RFA, SIJ, etc.

I hold them for cervical ILESI and lumbar ILESI, but I am considering doing lumbar ILESI on thinners.

For cervical ILESI, my using a 25g quincke most likely will be perfectly safe on thinners, and that is most likely true for the lumbar spine too. Hard to imagine an L4-5 ILESI on Eliquis causing a compressive hematoma that requires evacuation from a 25g needle.

I never stop aspirin for any procedure.

Scottie_Dog, what is a non-clinically relevent epidural hematoma, and how does one actually test for that? That article mentions only clinically relevant hematomas...What is the difference?

Pretty much use 25G without holding for most procedures with the exception of cervical ILESIs.

For lumbar ILSEI, I’ve toyed with 25G but the bad spines with significant osteophytosis have resulted in many bent needles before reaching the target, so I’ve returned to Tuohys. 25G work great for cervical ILESI.

 

[au bon pain]

I keep hearing about this mythical paper that’s been due to come out for last several years about using a quincke for cervical ILESI…anybody aware of anything on the horizon?

 

[lobelsteve]

I keep hearing about this mythical paper that’s been due to come out for last several years about using a quincke for cervical ILESI…anybody aware of anything on the horizon?

Stuck with doing work. N=1200. Lots of pretty pics.

 

[Scottie_Dog]

Stuck with doing work. N=1200. Lots of pretty pics.

This is a stupid question but do you still use loss of resistance? I use a 20 gauge tuohy with contralateral oblique technique. I do use loss of resistance but mostly rely on contrast/imaging.

what is the reasoning to use a 25 gauge spinal needle for interlam? I’d imagine it is less painful but I thought that because tuohy needles are blunt/curved they are supposed to be safer and reduce the risk of dural puncture? Definitely interested in trying the 25 gauge but just want to understand the benefits/risks before switching

 

[Ducttape]

i believe the thought is that the smaller needle causes less damage when it punctures the dura...

 

[lobelsteve]

This is a stupid question but do you still use loss of resistance? I use a 20 gauge tuohy with contralateral oblique technique. I do use loss of resistance but mostly rely on contrast/imaging.

what is the reasoning to use a 25 gauge spinal needle for interlam? I’d imagine it is less painful but I thought that because tuohy needles are blunt/curved they are supposed to be safer and reduce the risk of dural puncture? Definitely interested in trying the 25 gauge but just want to understand the benefits/risks before switching

No LOR. LOR unreliable since forever. CLO and contrast before advancing. Touch lamina 100% of the time before adjusting and going deeper.

 

[BoardingDoc]

Am I completely misreading this thread? Are some of y'all doing lumbar and cervical interlaminar ESIs with quincke needles instead of tuohys?

Help a lowly fellow out here and explain. Advance on CLO and when close start trying to inject contrast... Advance and rinse and repeat until epidurogram obtained?

Why the change from tuohys?

 

[clubdeac]

Am I completely misreading this thread? Are some of y'all doing lumbar and cervical interlaminar ESIs with quincke needles instead of tuohys?

Help a lowly fellow out here and explain. Advance on CLO and when close start trying to inject contrast... Advance and rinse and repeat until epidurogram obtained?

Why the change from tuohys?

It’s all Steve Lobel. They do it bc he did it. Do they make 25g touhys? I thought that’s why he went to quinke bc he couldn’t get his hands on a 25g touhy. Steve?

 

[lobelsteve]

It’s all Steve Lobel. They do it bc he did it. Do they make 25g touhys? I thought that’s why he went to quinke bc he couldn’t get his hands on a 25g touhy. Steve?

Because my training was to use a 25g spinal needle to anesthestize from skin to lamina then use a 17g Tuohy for LOR and shoot contrast. Never a lateral. 4cc 2%, 2cc nss, 2cc Celestone. Necks and backs. 2004-05.

We have come a long way. LOR and hanging drops are unreliable. CLO mandatory.

 

[Ducttape]

hanging drop unreliable. LOR still being used frequently (because of labor epidurals).

my suspicion is that we are semi-consciously still using some amount of LOR - even lobel. my guess is if the needle is appropriately positioned with CLO and there is resistance to contrast, i sure hope that lobel or anyone is not going to ram down on the plunger just to prove that the needle is in the ligament.

i still use Touhy, 22 gauge, and wont switch to quincke for potential safety issues.

 

[Dr. Ice]

Touhy 22 gauge for me

 

[drrosenrosen]

I asked one of the faculty at IPSIS about this - he had given a talk on risk mitigation. He said that he felt that it was within standard of care, but that he might include some language about loss of resistance in the note just in case. Pointed out, as duct did above, that there is a tactile component to it, even if you're not using that as your end point or using a glass LOR syringe, so that it is reasonable to include that wording in the note.

He also said that that's how Bogduk used to do his ESIs, which I thought was interesting.

 

[MitchLevi]

Stuck with doing work. N=1200. Lots of pretty pics.

I'm doing > 10 per week for 3-4 years. Best ever.

 

[jwalker12]

So is the consensus to use a 22g Tuohy? Advance inject, Advance inject? Are we injecting contrast into the needle or via a extension tubing?

 

[au bon pain]

So is the consensus to use a 22g Tuohy? Advance inject, Advance inject? Are we injecting contrast into the needle or via a extension tubing?

I still use a 20g but open to trying a 22g if my place could ever figure out how to order new stuff without sucking the life out of me.

Always extension tubing for every epidural.

 

[hopefulgasman]

Epidurals are precision procedures. Always tubing.

 

[nvrsumr]

I do steve’s 25g quinke.
Mental game to keep it interesting is lor to contrast. Puffs of contrast until firmly in ligament then 1mm advances. When I feel the loss I inject then remove the contrast syringe and attach injectate. Then I shoot the hopefully final image to see if I was right. That way if I screw up I pay the price of longer procedure. Almost never have to reattach contrast syringe.

 

[MitchLevi]

Maintain pressure on contrast syringe plunger when I’m in ligament.

Vast majority of pts do not feel this injection at all. Can’t believe I’m done when I put a Bandaid on them.

 

[CleanUp]

Maintain pressure on contrast syringe plunger when I’m in ligament.

Vast majority of pts do not feel this injection at all. Can’t believe I’m done when I put a Bandaid on them.

Mitch just so I’m understanding correctly you’re using 25 gauge 3.5 inch spinal needle connected to extension tubing and contrast? Thx.

 

[MD87]

Are you guys using local for these? Wondering if the lido hurts worse than the entire procedure.

 

[Taus]

When I use a 20 gauge tuohy with local, patients feel nothing until I get to supraspinous ligament. I add more local at that point and finish clo. I put a drop of contrast in the hub before attaching lor to air. False loss or still in ligament is immediately apparent from that drop of contrast in hub. Loss is often extremely subtle, a slight change. Takes 2 mins. Quickest most comfortable injection I do. I do exact same on lumbar.

I tried this with 25 quinke for a few months several years ago. Agreed very fast and pain-free to get to flavum. I did not like how much force I needed to put on syringe plunger through the extension tubing and 25g to get the contrast and then depo through plus I had a few patterns where looked like mixed epi/subdural. I missed feeling that slight change at loss that I get with the touhy and was also concerned the sharp tip was causing the mixed flow pattern, slightly piercing dura, so I scrapped it and reverted to the above…. Which is kind of a hybrid.

 

[MitchLevi]

Mitch just so I’m understanding correctly you’re using 25 gauge 3.5 inch spinal needle connected to extension tubing and contrast? Thx.

Yep.

Are you guys using local for these? Wondering if the lido hurts worse than the entire procedure.

I do, and yes, the 25g via interlaminar approach is barely felt, but I use local bc I tell the pt I’m numbing them up when I advance the needle.

 

[lobelsteve]

When I use a 20 gauge tuohy with local, patients feel nothing until I get to supraspinous ligament. I add more local at that point and finish clo. I put a drop of contrast in the hub before attaching lor to air. False loss or still in ligament is immediately apparent from that drop of contrast in hub. Loss is often extremely subtle, a slight change. Takes 2 mins. Quickest most comfortable injection I do. I do exact same on lumbar.

I tried this with 25 quinke for a few months several years ago. Agreed very fast and pain-free to get to flavum. I did not like how much force I needed to put on syringe plunger through the extension tubing and 25g to get the contrast and then depo through plus I had a few patterns where looked like mixed epi/subdural. I missed feeling that slight change at loss that I get with the touhy and was also concerned the sharp tip was causing the mixed flow pattern, slightly piercing dura, so I scrapped it and reverted to the above…. Which is kind of a hybrid.

That tactile feeling is just that. A feeling. Trust your eyes and images.

 

[Dr. Ice]

22 gauge touhy thinking of switching back to 20 gauge, cause im just tired. If it hurts them for 10 seconds so be it. My patients can do way way worse than me in my area if they so chose, so be it. If they can tolerate an unnecessary “deep clean” by their dentist, they can deal with a cervical interlam done in 2 minutes or less

 

[MitchLevi]

22 gauge touhy thinking of switching back to 20 gauge, cause im just tired. If it hurts them for 10 seconds so be it. My patients can do way way worse than me in my area if they so chose, so be it. If they can tolerate an unnecessary “deep clean” by their dentist, they can deal with a cervical interlam done in 2 minutes or less

So do it in 60 sec with a 25