Selective Nerve Root Block and blood thinners

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I have respect for the 25G technique but still prefer CESI with catheter. Best clinical results of my career, which allows me to do less CESI, which is what I prefer.
 

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MitchLevi said:
Yep.



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.
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You know what's interesting.

When I use touhy needles patients never have felt a thing or rarely when I get into the epidural space.

With cutting needles like quinke, its painless until i pas through Lig Flavun. I shoot the dye and they do feel it..
 
PinchandBurn said:
You know what's interesting.

When I use touhy needles patients never have felt a thing or rarely when I get into the epidural space.

With cutting needles like quinke, its painless until i pas through Lig Flavun. I shoot the dye and they do feel it..
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Enter more parallel to the skin. Skinnier needle means higher velocity of medication coming out of the needle.

It’s the opposite for me, and the needle thing????



1729677912809.jpeg
 
This morning I had an obese pt for a LESI…staff couldn’t find a six inch tuohy. I started to get excited to try the Steve approach with a spinal needle. But then staff found a six. Oh wells.
Is anybody aware of any published description of the Steve method?
 
au bon pain said:
This morning I had an obese pt for a LESI…staff couldn’t find a six inch tuohy. I started to get excited to try the Steve approach with a spinal needle. But then staff found a six. Oh wells.
Is anybody aware of any published description of the Steve method?
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Yakov Perper is the only one to have published on this so far, i *think*
 
So I do a mix up of all of the techniques fairly frequently. 20g Tuohy, touch down on lamina, rotate to CLO, tiny bit of contrast to confirm where I am, advance needle in CLO, looking for hanging drop, CLO, LOR, radiographic suspicion, all simultaneously. Typically, I will notice hanging drop about a half a mm before I get lor.
 
BobBarker said:
So I do a mix up of all of the techniques fairly frequently. 20g Tuohy, touch down on lamina, rotate to CLO, tiny bit of contrast to confirm where I am, advance needle in CLO, looking for hanging drop, CLO, LOR, radiographic suspicion, all simultaneously. Typically, I will notice hanging drop about a half a mm before I get lor.
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Same for me but 22g Tuohy. Not exactly hanging drop but the little bubble in the hub that drops in when you pop through ligament.
 
Figured I'd chime in with the highest level of evidence: a single anecdotal data point.

Readers digest version: A few weeks ago I did an ILESI on a patient who denied being on a thinner.
Well, it turns out he was actually on eliquis (though how consistently he takes it remains unclear).
On follow up he says he's doing great and using his Peleton apparently without a clinically significant epidural hematoma.

FWIW, I happened to have done this one with Lobel's 25g spinal technique.
 
jwalker12 said:
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
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I use 23g, smaller than 22g but more maneuverable than 25g
 
Agree with others that 23G quincke is the king of pain needles. I use it for everything I can.

thoracic and lumber TFESI, caudals, lumbar MBB, SIJ, coccyx, hip etc.
 
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gdub25 said:
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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Do not do it, it is probably safe, but if anything goes wrong they will eat you alive!
 
mygalperin said:
Do not do it, it is probably safe, but if anything goes wrong they will eat you alive!
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You’re more likely to cause a CVA or an MI than a significant bleeding event. Saying it a different way, you are more likely going to kill your pt if you stop their AC, especially if it is Coumadin.
 
Haven’t stopped them in years for most things. Unfortunately I have a feeling at my new gig (hopd) I will be stopping them for everything
 
Status Sciaticus said:
is it because of a beaurocracy thing?
What state?
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More like deep pockets rule. I don’t know for sure yet, but I get the feeling that for something where there is no official printed guideline on AC for spinal procedures they are likely to be very cautions and therefore require stopping for all neuroaxial procedures.
 
Dr. Ice said:
More like deep pockets rule. I don’t know for sure yet, but I get the feeling that for something where there is no official printed guideline on AC for spinal procedures they are likely to be very cautions and therefore require stopping for all neuroaxial procedures.
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Yep. Deeper pockets, bigger target on the back. Very familiar.
 
bedrock said:
Including S1? Definitely more bleeding there.
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Dr. Ice said:
Haven’t held blood thinners for tfesi in years
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resurrecting this thread. I'd still like to hear peoples thoughts on the risks of holding blood thinners with an S1 TFESI vs all other lumbar TFESI?

I agree it makes no sense to hold thinners for L1-L5 TFESI, but S1 is much more vascular with more bleeding, and I would think more likely to get a epidural hematoma doing S1 TFESI on thinners vs L1-L5 TFESI on thinners?

Thoughts?
 
bedrock said:
resurrecting this thread. I'd still like to hear peoples thoughts on the risks of holding blood thinners with an S1 TFESI vs all other lumbar TFESI?

I agree it makes no sense to hold thinners for L1-L5 TFESI, but S1 is much more vascular with more bleeding, and I would think more likely to get a epidural hematoma doing S1 TFESI on thinners vs L1-L5 TFESI on thinners?

Thoughts?
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Agree with the vascularity at S1 compared to other levels..still haven’t been holding. Although maybe I should start.

You have been a proponent of using particulate steroid at this level, as have I been. Would you be also be concerned about that given the vascular issue there?
 
having had significantly more incidence of heme with S1 TF over all other TFESI, i hold anticoagulation for S1 TFESI or go L5 instead, when appropriate.
 
Dr. Ice said:
Agree with the vascularity at S1 compared to other levels..still haven’t been holding. Although maybe I should start.

You have been a proponent of using particulate steroid at this level, as have I been. Would you be also be concerned about that given the vascular issue there?
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S1 is more vascular, but typically venous. Unless transitional anatomy, I continue to use depo at S1.
The reason I brought it up is that yes I have often offered S1 TFESI with depo.

In patient on anticoagulation, I start with L5 TFESI and dex and don't hold thinners. Frequently due to dex, the patient gets relief for less than a month and so I then do bilateral S1 TFESI with depo, while holding thinners and then the patient gets 6 months of relief. But I'm now more "justified" to hold thinners for S1

Basically, I'm debating to just blend the two. If a patient is on thinners and its something that I think would better respond to S1 TFESI with depo, I'm debating to just go straight to S1 TFESI with depo and not hold the thinners.
 
bedrock said:
S1 is more vascular, but typically venous. Unless transitional anatomy, I continue to use depo at S1.
The reason I brought it up is that yes I have often offered S1 TFESI with depo.

In patient on anticoagulation, I start with L5 TFESI and dex and don't hold thinners. Frequently due to dex, the patient gets relief for less than a month and so I then do bilateral S1 TFESI with depo, while holding thinners and then the patient gets 6 months of relief. But I'm now more "justified" to hold thinners for S1

Basically, I'm debating to just blend the two. If a patient is on thinners and its something that I think would better respond to S1 TFESI with depo, I'm debating to just go straight to S1 TFESI with depo and not hold the thinners.
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That’s what I do
 
bedrock said:
U mean the L1-L5 with dex, on thinners and then s1 depo on thinners if brief relief from first TFESI with dex?
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No just skip to S1 with depo

Honestly haven’t held thinners for any lumbar tfesi including S1 in a long time
 
At IPSIS winter conference a couple years ago (they ever very anti-holding thinners) this came up. 1 person in the crowd did say he had a symptomatic hematoma after S1 TFESI (honestly can't remember if patient was on a thinner or not).
 
MitchLevi said:
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?
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See them not infrequently associated with disc extrusions. Radiologist sometimes can’t distinguish between a peridiscal hematoma and extrusion
 
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