TFESI decision making

[PMR 4 MSK]

82 yo female with signs and symptoms c/w L4 radic. Radiologists report of MRI - "Left posterolateral L3-L4 inferior disc extrusion impinging on the left L4 nerve root." (Among the usual 82 yo degenerative spine things).

Which would you prefer to do? :

1) left L3-4 TFESI - HNP is at that level
2) left L4-5 TFESI - L4 in nerve root involved
3) left L4 SNRB
4) interlaminar ESI L3-4

I did the L4-5 TFESI, saw the contrast flow right up along L4 NR to L3-4, should have been an excellent injection. Pt got no relief. I always debate these in my mind as to the best place to put the needle.

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[lobelsteve]

I think anything you do is likely to help given the pathology, but I'd love to see an axial slice.

TF-ESI is more lucrative, no difference in outcomes (to date) between LESi vs TFESI.

How long has it been going on?

I'd do a 2 level TFESI and if no better do an ILESI. If neither worked I'd rethink the generator based on symptoms and imaging.

 

[Tenesma]

i would repeat the injection every week for a total of 10 weeks ...

oh sorry, one of my local competitors has that method patented....

so instead, I would recommend a one-time repeat either TFESI or IESI - if the 2nd one don't help then recommend surgical management plus or minus meds..

 

[drusso]

I try to "bracket" the pathology with my TFESI's. So, for the scenario you outlined, I'd do L3-4 and L4-5 on the same side if unilateral symptoms.

 

[ampaphb]

no difference in outcomes (to date) between LESi vs TFESI

Absence of evidence is not evidence of absence. There is NO DATA, not no difference

 

[ampaphb]

82 yo female with signs and symptoms c/w L4 radic. Radiologists report of MRI - "Left posterolateral L3-L4 inferior disc extrusion impinging on the left L4 nerve root." (Among the usual 82 yo degenerative spine things).

Which would you prefer to do? :

1) left L3-4 TFESI - HNP is at that level
2) left L4-5 TFESI - L4 in nerve root involved
3) left L4 SNRB
4) interlaminar ESI L3-4

I did the L4-5 TFESI, saw the contrast flow right up along L4 NR to L3-4, should have been an excellent injection. Pt got no relief. I always debate these in my mind as to the best place to put the needle.

It is my experience that the 3/4 disc usually catches the L3 root, rather than 4.

I would confirm that the radiology report is correct by reviewing the films myself.

 

[lobelsteve]

Absence of evidence is not evidence of absence. There is NO DATA, not no difference

ISIS kool aid drinker?

Same results reported in case series. Evidence is Grade D, but edible (much like high school hamburgers).

 

[ampaphb]

ISIS kool aid drinker?

Same results reported in case series. Evidence is Grade D, but edible (much like high school hamburgers).

Only studies I am aware of are blind interlams vs fluoroscopically guided TFEs. If there are head to head fluoro studies, I'd love to see them.

 

[MN1]

Only studies I am aware of are blind interlams vs fluroscopically guided TFEs. If there are head to head flouro studies, I'd love to see them.

Two small studies I'm aware of:

Thomas, et al. in Clin Rheumatol (2003)- fluoroscopic guided transforaminal vs. blind interlaminar; trend towards better pain relief with TF, but no difference in # that underwent discectomy at 6 months (N of 31)



Kolsi, et al., Joint Bone Spine 2000; Compared "nerve root injection" vs. interlaminar, both with fluoro, both receiving the same amount of lido and steroid. Pain relief nearly nearly identical throughout the 28 day study. At 8 month F/U, 3 of the "nerve root injection" group and 3 of the interlaminar group had undergone surgery. The other 24 patients were "free of nerve root pain" (N = 30)

 

[ampaphb]

Two small studies I'm aware of:

Thomas, et al. in Clin Rheumatol (2003)- fluoroscopic guided transforaminal vs. blind interlaminar; trend towards better pain relief with TF, but no difference in # that underwent discectomy at 6 months (N of 31)



Kolsi, et al., Joint Bone Spine 2000; Compared "nerve root injection" vs. interlaminar, both with fluoro, both receiving the same amount of lido and steroid. Pain relief nearly nearly identical throughout the 28 day study. At 8 month F/U, 3 of the "nerve root injection" group and 3 of the interlaminar group had undergone surgery. The other 24 patients were "free of nerve root pain" (N = 30)

Thomas is blind vs fluoro. Kolsi does not mention fluoro at all in the abstract, which leads me to believe it is blind vs blind, however, I do not have access to the study itself.

 

[Tenesma]

ampa - you are SO picky

 

[MN1]

Thomas is blind vs fluoro. Kolsi does not mention fluoro at all in the abstract, which leads me to believe it is blind vs blind, however, I do not have access to the study itself.

I'm assumeing the Kolsi article is fluoro vs. fluoro based on the following from the article:

"Patients in both groups reeceived the same mixture composed of 2 mL of iohexol (Omnipaque 180) to allow verification of needle placement, 2 mL (0.10 g) of lidocaine hydrochloride, and 1.5 mL (3.75 mg) of cortivazol."

Each patient also received a "transdermal" injection at the site that was not used to administer the mixture to "blind" the patients.

 

[drusso]

Each patient also received a "transdermal" injection at the site that was not used to administer the mixture to "blind" the patients.

MN1, I've heard that this is how you do all your injections.

 

[MN1]

MN1, I've heard that this is how you do all your injections.

Only if you were my patient.

 

[seaofred]

Steve, would you start with a 2 level TFESI in this patient or just after the one level didn't give much relief? I usually do just one level TFESIs but I know of some guys who are doing 2 levels. How often do you do 1 level vs. 2?

 

[lobelsteve]

It's all case by case.

I'm doing more 2 levels now as I am seeing a more "degenerative" population with radicular pains.

Can't get less scientific than that. I guess for my older folks, I just want a one day fix, follow up in 1-2 weeks, HEP- call me in 3-6 months.

I've been getting some weekend warriors who get single level TF-ESI before going to CO for ski trips, and a semi=pro bowler who gets the GTB's done before tournaments.

 

[Sharps]

If the imaging shows one level pathology the surgeon is gonna chase that. If there is multilevel patholgy, say a protrusion at L34 catching the L4 nerve with L34 foraminal stenosis catching L3, it'd be helpful to do one level SNRB's so the surgeon knows what to do if they fail injections ime.

 

[lobelsteve]

If the imaging shows one level pathology the surgeon is gonna chase that. If there is multilevel patholgy, say a protrusion at L34 catching the L4 nerve with L34 foraminal stenosis catching L3, it'd be helpful to do one level SNRB's so the surgeon knows what to do if they fail injections ime.

OFF-TOPIC:

Prove it with a dyno sheet.

 

[Sharps]

Mwahaha

 

[lobelsteve]

Mwahaha

11.7 @132?

I guess you have a 4500 pound 911T.

I'm done posting off-topic, PM for Road Atlanta info (June 1).

 

[Sharps]

Actually it's about 3100 but didn't want to wreck the tranny for a low et. The new C6Z06 only traps about 125mph... K, sorry OP for the off posts, over and out.

 

[nvrsumr]

The Efficacy of Lumbar Epidural Steroid Injections in
Patients with Lumbar Disc Herniations
William E. Ackerman, III, MD*
Mahmood Ahmad, MD†
INTRODUCTION: Lumbar epidural steroid injection can be accomplished by one of three methods: caudal (C), interlaminar (IL), or transforaminal (TF). In this study we sought to determine the efficacy of these techniques for the management of radicular pain associated with lumbar disk herniations.
METHODS: Ninety patients aged 18–60 years with L5-S1 disk herniations and
radicular pain were randomly assigned to one of these groups to have epidural
steroid injection therapy every 2 wk for a maximum of three injections. Pain relief, disability, and activity levels were assessed.
RESULTS: Pain relief was significantly more effective with TF injections. At 24 wk from the initiation of this study, pain relief was as follows: C: complete pain relief: 1/30, partial pain relief: 16/30, and no relief: 13/30; IL: complete pain relief: 3/30, partial pain relief: 15/30, and no relief: 12/30; and TF: complete pain relief: 9/30, partial pain relief: 16/30, and no relief: 5/30.
CONCLUSIONS: The TF route of epidural steroid placement is more effective than the C or IL routes. We attribute this observation to a higher incidence of steroid placement in the ventral epidural space when the TF method is used.
(Anesth Analg 2007;104:1217–22)

 

[lobelsteve]

The Efficacy of Lumbar Epidural Steroid Injections in
Patients with Lumbar Disc Herniations
William E. Ackerman, III, MD*
Mahmood Ahmad, MD†
INTRODUCTION: Lumbar epidural steroid injection can be accomplished by one of three methods: caudal (C), interlaminar (IL), or transforaminal (TF). In this study we sought to determine the efficacy of these techniques for the management of radicular pain associated with lumbar disk herniations.
METHODS: Ninety patients aged 18–60 years with L5-S1 disk herniations and
radicular pain were randomly assigned to one of these groups to have epidural
steroid injection therapy every 2 wk for a maximum of three injections. Pain relief, disability, and activity levels were assessed.
RESULTS: Pain relief was significantly more effective with TF injections. At 24 wk from the initiation of this study, pain relief was as follows: C: complete pain relief: 1/30, partial pain relief: 16/30, and no relief: 13/30; IL: complete pain relief: 3/30, partial pain relief: 15/30, and no relief: 12/30; and TF: complete pain relief: 9/30, partial pain relief: 16/30, and no relief: 5/30.
CONCLUSIONS: The TF route of epidural steroid placement is more effective than the C or IL routes. We attribute this observation to a higher incidence of steroid placement in the ventral epidural space when the TF method is used.
(Anesth Analg 2007;104:1217–22)

Nice abstract: Problem 1- patient selection- are these representative of my patients, or of anybody's patients? Are these acute/subacute? Because 17/30 = 56.7% and that would make a caudal ESI a risk factor for continued hurting- given the natural time course is 85% are better at 8 weeks.

So we need to look into the patient selection before entertaining the imaging, meds, psychological profiling, etc.

 

[SSdoc33]

havent read the study yet, but given the dearth of research on TYPES of ESIs, this looks to be at least semi-promising.

 

[MN1]

The Efficacy of Lumbar Epidural Steroid Injections in
Patients with Lumbar Disc Herniations
William E. Ackerman, III, MD*
Mahmood Ahmad, MD†
INTRODUCTION: Lumbar epidural steroid injection can be accomplished by one of three methods: caudal (C), interlaminar (IL), or transforaminal (TF). In this study we sought to determine the efficacy of these techniques for the management of radicular pain associated with lumbar disk herniations.
METHODS: Ninety patients aged 18–60 years with L5-S1 disk herniations and
radicular pain were randomly assigned to one of these groups to have epidural
steroid injection therapy every 2 wk for a maximum of three injections. Pain relief, disability, and activity levels were assessed.
RESULTS: Pain relief was significantly more effective with TF injections. At 24 wk from the initiation of this study, pain relief was as follows: C: complete pain relief: 1/30, partial pain relief: 16/30, and no relief: 13/30; IL: complete pain relief: 3/30, partial pain relief: 15/30, and no relief: 12/30; and TF: complete pain relief: 9/30, partial pain relief: 16/30, and no relief: 5/30.
CONCLUSIONS: The TF route of epidural steroid placement is more effective than the C or IL routes. We attribute this observation to a higher incidence of steroid placement in the ventral epidural space when the TF method is used.
(Anesth Analg 2007;104:1217–22)

Thanks for posting this. Very interesting to read through this.....the abstract is somewhat misleading. The patients had symptoms for an average of 35 days before the injections started. Its decent data.....although their injectates are somewhat different than what I would use. For the IL injections, they state that they directed the bevel in the cranial direction.....going in at the L5-S1 interspace for a S1 radic, not sure I would try to send all the medicine that way. Also, they only used 1 cc of Triam, with 3 cc of contrast and 4 cc of normal saline.

For the caudal, they injected 3 cc of contrast, 19 cc of normal saline, and 1 cc of triam. They stated that this is the volume that is required to reach the L5-S1 interspace, which I strongly disagree with. Quite a dilute injectate.

For those of you who have access to this study, I'd like to hear your thoughts.

 

[MN1]

The Efficacy of Lumbar Epidural Steroid Injections in
Patients with Lumbar Disc Herniations
William E. Ackerman, III, MD*
Mahmood Ahmad, MD†
INTRODUCTION: Lumbar epidural steroid injection can be accomplished by one of three methods: caudal (C), interlaminar (IL), or transforaminal (TF). In this study we sought to determine the efficacy of these techniques for the management of radicular pain associated with lumbar disk herniations.
METHODS: Ninety patients aged 18–60 years with L5-S1 disk herniations and
radicular pain were randomly assigned to one of these groups to have epidural
steroid injection therapy every 2 wk for a maximum of three injections. Pain relief, disability, and activity levels were assessed.
RESULTS: Pain relief was significantly more effective with TF injections. At 24 wk from the initiation of this study, pain relief was as follows: C: complete pain relief: 1/30, partial pain relief: 16/30, and no relief: 13/30; IL: complete pain relief: 3/30, partial pain relief: 15/30, and no relief: 12/30; and TF: complete pain relief: 9/30, partial pain relief: 16/30, and no relief: 5/30.
CONCLUSIONS: The TF route of epidural steroid placement is more effective than the C or IL routes. We attribute this observation to a higher incidence of steroid placement in the ventral epidural space when the TF method is used.
(Anesth Analg 2007;104:1217–22)

Another interesting point.....they provided an "intent to treat analysis flow chart" for those patients that did not meet the inclusion criteria (n=202).

For IL: 75/124 had complete relief 12 weeks after last injection, 38/124 had partial relief, and 11/124 had no relief

For TF: 56/75 had complete relief, 12/75 had partial relief, and 7/75 had no relief.

 

[lobelsteve]

Another interesting point.....they provided an "intent to treat analysis flow chart" for those patients that did not meet the inclusion criteria (n=202).

For IL: 75/124 had complete relief 12 weeks after last injection, 38/124 had partial relief, and 11/124 had no relief

For TF: 56/75 had complete relief, 12/75 had partial relief, and 7/75 had no relief.

That is 91% for the 199 reported in the Tf and IL groups for total or partial relief. I guess the partial relief criteria would need further definiation to see if this holds for the magic 85-90% are "better" at 8-10 weeks.

 

[PMR 4 MSK]

So as an update, we decided last week to do an interlaminar L3-4 ESI. Today she reports 95% of the pain is gone, mainly just some residual numbness. Pt very happy.

 

[ampaphb]

So as an update, we decided last week to do an interlaminar L3-4 ESI. Today she reports 95% of the pain is gone, mainly just some residual numbness. Pt very happy.

1) I'm glad she is better

2) Given what I presume is a ratty, stenotic canal due to lots and lots of spondylosis, going AT the level of the lesion seems to me to be asking for a wet tap. I'm sure in your capable hands it did not happen, but as a general rule, I tend to go above or below the level of the herniation unless the MRI shows a LOT of room for error.

 

[PMR 4 MSK]

1) I'm glad she is better

2) Given what I presume is a ratty, stenotic canal due to lots and lots of spondylosis, going AT the level of the lesion seems to me to be asking for a wet tap. I'm sure in your capable hands it did not happen, but as a general rule, I tend to go above or below the level of the herniation unless the MRI shows a LOT of room for error.

That's another thing I always debate - do it at the level or one away. Epidural space is often quite "squished" at the involved level (That's how I explain it to the patient when they ask why I'm doing it at a different level).

 

[olafa]

That's another thing I always debate - do it at the level or one away. Epidural space is often quite "squished" at the involved level (That's how I explain it to the patient when they ask why I'm doing it at a different level).

re: IL how many of you use a catheter to get to a higher level? either at L-spine or c-spine? any more sucessfull with result?

 

[lovebailey2001]

So as an update, we decided last week to do an interlaminar L3-4 ESI. Today she reports 95% of the pain is gone, mainly just some residual numbness. Pt very happy.

many of my patients also c/o heavyness(in the thighs n/or calf region) ever after complete pain relief with either TLESI or TFESI! I usually console them n give some NSAID with MR for a week. but still unknown of the cause of this residual feeling? any thoughts.....😕

 

[SleepIsGood]

Only studies I am aware of are blind interlams vs fluoroscopically guided TFEs. If there are head to head fluoro studies, I'd love to see them.

here it is:


Anesth Analg. 2008 Feb;106(2):638-44, table of contents.

A prospective evaluation of iodinated contrast flow patterns with fluoroscopically guided lumbar epidural steroid injections: the lateral parasagittal interlaminar epidural approach versus the transforaminal epidural approach.

Candido KD, Raghavendra MS, Chinthagada M, Badiee S, Trepashko DW.

Chicago, IL

BACKGROUND: Lumbar midline interlaminar and transforaminal (TF) epidural steroid injections are treatments for low back pain with radiculopathy secondary to degenerative disk disease. Since pain generators are located anteriorly in the epidural space, ventral epidural spread is the logical target for placement of antiinflammatory medications. In this randomized, prospective, observational study, we compared contrast flow patterns in the epidural space using the parasagittal interlaminar (PIL) and transforaminal approaches with continual fluoroscopic guidance. METHODS: Sixty adult patients with low back pain and unilateral radiculopathy from herniated or degenerated discs were enrolled. Subjects were randomly assigned to one of two groups: TF or PIL (30 in each). All procedures were performed using continual fluoroscopic guidance and 5 mL of contrast. Contrast spread was rated (primary outcome measure) by the interventionalist. Spread was scored 0-2, with 0 = no anterior spread; 1 = anterior spread, same level as needle insertion; and 2 = anterior spread at > or = 1 segmental level. The secondary outcome measure was analgesia at 2 wk, 1, 3, and 6 mo. RESULTS: One hundred percent (29 of 29) patients in the PIL group and 75% (21 of 28) patients in the TF group demonstrated anterior epidural spread. The mean spread grade was 1.93 (95% confidence interval [CI], 1.83-2.0) in the PIL group and 1.46 (95% CI, 1.17-1.46) in the TF group (P = 0.003). Mean fluoroscopy time was 28.96 s (95% CI, 23.9-34.1 s) in the PIL group and 46.25 s (95% CI, 36.27-56.23 s) in the TF group (P = 0.003). Visual analog scale scores were equivalent between groups. CONCLUSIONS: The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.

 

[nvrsumr]

Interesting article.

 

[clubdeac]

Yeah I almost always do two level TFESIs when going for a radic unless the imaging correlates perfectly with the dermatomal pain distribution and physical exam. However, I've had a couple cases where the imaging, exam and presentation were classic for an S1 radic and the patients got no relief from an S1 TFESI. They both did great on subsequent injections when I added a TFESI at L5. Anyone else ever experience that? Anyone else doing many S1 TFESIs?

 

[Jcm800]

.

 

[Jcm800]

.

 

[lonelobo]

Yeah I almost always do two level TFESIs when going for a radic unless the imaging correlates perfectly with the dermatomal pain distribution and physical exam. However, I've had a couple cases where the imaging, exam and presentation were classic for an S1 radic and the patients got no relief from an S1 TFESI. They both did great on subsequent injections when I added a TFESI at L5. Anyone else ever experience that? Anyone else doing many S1 TFESIs?

Usually do 2 level TFESIs on all radiculopathy, unless surgeons wanting more of a one level SNRB for diagnostic purposes

 

[lobelsteve]

I think doing 2 levels is overutilizing.

I do one level and start below the pathology, or perceived pain generator.
If that only lasts 3-7 days, I'll go at the level of pathology. This happens about 25% of the time.

If it is purely axial, I offer a 50/50 that it will work at all.
And there is no such thing as a SNRB.
Unless you go intraneural.

 

[SSdoc33]

I think doing 2 levels is overutilizing.

I do one level and start below the pathology, or perceived pain generator.
If that only lasts 3-7 days, I'll go at the level of pathology. This happens about 25% of the time.

If it is purely axial, I offer a 50/50 that it will work at all.
And there is no such thing as a SNRB.
Unless you go intraneural.

ESIs for axial pain is overutilization, IMHO.

I go one level TF, unless I honestly can't determine where the messed up level is, or when the imaging and clinical findinds dont match up (L5 foraminal herniation but S1 dermatome). then i do 2 level TFESI.

 

[nvrsumr]

I do 2 levels pretty often. If they dont get better on first try I dont always get another bite of the apple. Do level of HNP and level below unless far lateral(rare).

 

[murphles]

Hey this is not head to head. Saw him present this data. He was proposing a NEW TYPE OF LESI. It was kinda cool but I haven't tried it. Late for conference.

 

[Jcm800]

Hey this is not head to head. Saw him present this data. He was proposing a NEW TYPE OF LESI. It was kinda cool but I haven't tried it. Late for conference.

he doesnt do this approach anymore...if that tells you anything...

 

[lonelobo]

I think doing 2 levels is overutilizing.

I do one level and start below the pathology, or perceived pain generator.
If that only lasts 3-7 days, I'll go at the level of pathology. This happens about 25% of the time.

If it is purely axial, I offer a 50/50 that it will work at all.
And there is no such thing as a SNRB.
Unless you go intraneural.

If you go back and have to do a 2nd level 25%, Don't really see an advantage
in utilization. Especially in ASC's where pt will be charged a 2nd fee as well as prof fees for sedation,fluro.

I would propose Interventional techniques are over utilized to some degree
by all who practice pain management, even those of us who think we practice a more "ethical" way of treating pain patients.

 

[lobelsteve]

If you go back and have to do a 2nd level 25%, Don't really see an advantage
in utilization. Especially in ASC's where pt will be charged a 2nd fee as well as prof fees for sedation,fluro.

I would propose Interventional techniques are over utilized to some degree
by all who practice pain management, even those of us who think we practice a more "ethical" way of treating pain patients.

I'm all office. The 50% reduction in reimbursement does not make me want to add a level just in case. And if 1 in 4 come back for another shot at full price...well you do the math. The more I've done, the less I do.

 

[lonelobo]

I'm all office. The 50% reduction in reimbursement does not make me want to add a level just in case. And if 1 in 4 come back for another shot at full price...well you do the math. The more I've done, the less I do.

Not sure what you mean by this
"And if 1 in 4 come back for another shot at full price...well you do the math."

Thought we were talking about overutilization

 

[Mister Mxyzptlk]

Not sure what you mean by this
"And if 1 in 4 come back for another shot at full price...well you do the math."

Thought we were talking about overutilization

Like the man said, do the math. The second level is reimbursed 50%, so it generates 1 + 0.5 = 1.5 to do 2 levels at the same time.

4 patients, all get 2 levels done first time and none need a repeat => 1.5 x 4 = 6

4 patients, all get 1 level done the first time => 1 x 4 = 4,
PLUS 1 patient comes back for a repeat => 1 x 1 = 1,
So the total = 4 + 1 = 5.

If 50% of the single-level patients come back for a repeat, it's a tie (6-6). OTOH, if 1 patient in the two-level group also needs a repeat it swings back to single level being cheaper (6 vs 6.5).

This only applies for in-office. If done at a facility you have to take into account the facility fees.

 

[nvrsumr]

I actually try to treat some patients with jobs.... They appreciate only coming in once.

 

[bedrock]

Billing question for you guys-

I've heard that you get paid 50% for doing a second procedure on the same side, as you're discussing in this thread.
What about bilateral procedures? Is one of the sides 50%? Or 25% reduced on both sides?

Thanks,

 

[lonelobo]

Like the man said, do the math. The second level is reimbursed 50%, so it generates 1 + 0.5 = 1.5 to do 2 levels at the same time.

4 patients, all get 2 levels done first time and none need a repeat => 1.5 x 4 = 6

4 patients, all get 1 level done the first time => 1 x 4 = 4,
PLUS 1 patient comes back for a repeat => 1 x 1 = 1,
So the total = 4 + 1 = 5.

If 50% of the single-level patients come back for a repeat, it's a tie (6-6). OTOH, if 1 patient in the two-level group also needs a repeat it swings back to single level being cheaper (6 vs 6.5).

This only applies for in-office. If done at a facility you have to take into account the facility fees.

Ya I know the math, that was not my point.
He had mentioned overutilization, when I said I perform 2 levels at a time as the answer to a posed question.

So by the math it is a wash(in office)
In an ASC(where I perform procedures) or hospital coming back for 2nd procedure is going to cost patient or insurance more.

Not to mention the convenience factor for some of my patients that have to travel a 100 miles or be taken off anticoagulation.

How about we agree that there are different ways to practice pain mgmt, before we infer that someone is Overutilizing procedures