Struggling to get medial flow on my TFESI lately. Square SEP, oblique 25 degree IPL, but still tend to be lateral. Thoughts/recommendations?
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TFESI
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No offense but based on your username, I assume you did not do a pain fellowship?
If you can’t do a TFESI, you should likely leave all pain procedures to pain physicians, who perform a minimum of several hundred TFESI under close supervision during their year long fellowship.
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you are making a lot of assumptions based on his username...
but if you read his posts, he is using terms typically used by pain docs appropriately.
currently, i get a lateral with all TFESI and i might suspect you are not driving the needle deep enough, hence end up lateral on AP imaging.
you might want to look at the degree of obliquity you are using.
but if you read his posts, he is using terms typically used by pain docs appropriately.
currently, i get a lateral with all TFESI and i might suspect you are not driving the needle deep enough, hence end up lateral on AP imaging.
you might want to look at the degree of obliquity you are using.
I think most people are too shallow with their needle placement, both in TFESI and/especially RFA.
The 6 oclock needle position on the pedicle is a requirement IMO, and another thing is the level you're choosing to inject. If they're super tight go one level below. I've had very stenotic people try to push my contrast back out.
The 6 oclock needle position on the pedicle is a requirement IMO, and another thing is the level you're choosing to inject. If they're super tight go one level below. I've had very stenotic people try to push my contrast back out.
Agree with all of this with the addition of saying that an infraneural approach one level above is also a viable option.
SIS: 5 saved images. Ap/Lat with and without contrast, washout. Live fluoro to assess contrast flow as well.
SIS is living in a dream world where money and time must not matter.
agree. AP and oblique only as long as the flow looks good
If you are just starting out after you believe you are in the correct position go back and recheck your oblique, often as you are trying to get epidural space you vere one way or another and realigning with the oblique can help with your medial to lateral issues. Do this before contrast as after it can be messy. I now do it post-contrast if I don't get the flow I want and this often is helpful in getting the procedure completed. As others mentioned there is a lot of anatomy issues that might also be getting in the way as well.
I agree with this. I check a lateral maybe 5-10% of the time if initial flow is questionable. Example - I’m in the facet inadvertently and in the AP my needle is looking too medial and makes me uneasy, I will get a lateral and advance til it looks good.
to fix this depends on the level.
A good answer for every level - drive all the way to vertebral body. That will likely fix the problem.
Facepalm all of this nonsense.
Annoyingly, I can think of several ACGME fellowships where TFESI is avoided as much as possible and interlaminar/caudal is used preferentially resulting in only a handful of TFESI being performed each year…
Name and shame. Bread and butter procedure for our subspecialty.
Do you guys ever notice sometimes you have to advance past 6 o'clock on the pedicle to get medial contrast flow?
Yes, just rotate the C-arm back to show you were at 6 for final image. Know where the sac is and avoid it.
thank you
What about the other 4 views?
Doesn’t have to be perfect every time. Maybe there’s a lot of foraminal stenosis, a big foraminal disc or big facets. Sometimes as my illustrious mentor would say, the enemy of good, is your hubris that you can make it better
Save them too. There may come a day when I retire and Medicare hires me to do nothing but look at pictures and payments will stop if the pictures aren’t there or aren’t right.
