TFESIs and segmental artery injection

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chibadriver

chibadriver

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I have tried to move toward a infraneural/suprapedicular approach for my TFESIs but seem to be finding more trouble more often... On two occasions now my dye flow does not look as expected and I go lateral only to find it whisked away by what I presume to be the lumbar segmental arteries. Just me? Any thoughts?
IMG_6010.jpg

Retrodiscal RM Artery.PNG
 
I can think of a way to be 50% less likely to get vascular uptake.

Those vessels seem to be in variable positions in the foramen on mri. I don’t know of analysis of incidence in Supraneural vs infraneural approach, but it is a good argument for live fluoro/DSA and using dex.
 
You simply spear the nerve and get into disc more often with infraneural. I do think there is less vasculature infraneurally, but are vessels that big of a deal with live flouro and dex? Move the tip a bit and you are free
 
Agree, live always; I don't always use digital subtraction for TFs but I need to change that. On both occasions there was a faint neurogram (not proportional to what I was expecting) and less obvious vascular uptake (probably based on plane of vascular uptake relative to AP view).

@SSdoc33: that was the other thing, I reposition the needle and same result, I only feel comfortable doing that a couple/few times before I just pull the needle out. Doesn't really seem like a risk mitigation strategy... in my hands anyway
 
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MRI/MRA study showed that most of the time it is in the superior anterior quadrant of the NF. that being said, it can be anywhere... and once the disc collapses the morphology changes and pushes things around... take the bullet out of the barrel and use dex.

DSA is 4x the radiation. is not infallible.
 
What ssdoc said. Annulogram galore with that approach. Stay posterior but high in the foramen if you're apprehensive.
 
I’ll take my chances with 1 case of paralysis in however many hundreds of millions of epidurals with dex, and spare myself the cataracts and cancer from doing DSA for every transforaminal.
 
I like infraneural in thoracic TFESI, but hate it lumbar.

Just use dex and stay high in the hole. Absolutely no to DSA.
 
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Ligament said:
The lead author of that paper is highly suspect.
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. Too many publications. Too much Japanese whisky. Too big a lobster. You mean the 2nd author. Ken doesnt play nice. He got in a prolonged argument with Ampa years ago. SIS vs ASIPP. I can live with out Kenny. We all need GCC.
 
lobelsteve said:
. Too many publications. Too much Japanese whisky. Too big a lobster. You mean the 2nd author. Ken doesnt play nice. He got in a prolonged argument with Ampa years ago. SIS vs ASIPP. I can live with out Kenny. We all need GCC.
Click to expand...

I do not know what "Too big a lobster." means.

What was the AMPA Candido arguement?
 
DOctorJay said:
I have DSA and no longer use it because I only use dex for TFESI. DSA isn't fool proof.

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Back to medicine for a minute. I agree with Jay and Somme.

I no longer use DSA (even though I have it) because it isn't foolproof and I'm not going to expose myself to 4X the radiation for procedures that provide temporary relief. I use dex for my lumbar TFESI above S1 and I don't do cervical or thoracic TFESI any longer.
 
bedrock said:
Back to medicine for a minute. I agree with Jay and Somme.

I no longer use DSA (even though I have it) because it isn't foolproof and I'm not going to expose myself to 4X the radiation for procedures that provide temporary relief. I use dex for my lumbar TFESI above S1 and I don't do cervical or thoracic TFESI any longer.
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interesting. I was never trained in cervical tfesi. Watched my big shot attending perform 3 as a fellow. We never got great epidural spread. Lot of contrast spreading around the vert artery and up and down the outside of the artery . Looking at the approach on the SIS procedure book and doing them on a cadaver makes me think it’s still a good option compared to IL in the C spine. For those that do them or did lots of them, what’s the deal? Is the fear unfounded? Do you think the risk is due to the historic use of particulate steroids? Possibly combined with poor hands ? Just curious. I’vebeen considering adding them to my practice
 
oreosandsake said:
interesting. I was never trained in cervical tfesi. Watched my big shot attending perform 3 as a fellow. We never got great epidural spread. Lot of contrast spreading around the vert artery and up and down the outside of the artery . Looking at the approach on the SIS procedure book and doing them on a cadaver makes me think it’s still a good option compared to IL in the C spine. For those that do them or did lots of them, what’s the deal? Is the fear unfounded? Do you think the risk is due to the historic use of particulate steroids? Possibly combined with poor hands ? Just curious. I’vebeen considering adding them to my practice
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I did only a couple in fellowship but basically taught myself by the SIS book in practice because a neurosurgeon sent them to me occasionally. Because of that I’ve almost exclusively done them with lidocaine only, so there’s minimal risk. Still counsel patients risk of stroke/seizure from vert injection, and regarding the positive/negative predictive value issues. Generally feel I get good epidural spread. Procedure isn’t hard really.
 
oreosandsake said:
interesting. I was never trained in cervical tfesi. Watched my big shot attending perform 3 as a fellow. We never got great epidural spread. Lot of contrast spreading around the vert artery and up and down the outside of the artery . Looking at the approach on the SIS procedure book and doing them on a cadaver makes me think it’s still a good option compared to IL in the C spine. For those that do them or did lots of them, what’s the deal? Is the fear unfounded? Do you think the risk is due to the historic use of particulate steroids? Possibly combined with poor hands ? Just curious. I’vebeen considering adding them to my practice
Click to expand...

I did lots of cTFESI in fellowship, half of my cases, though my fellowship was one of the last actively teaching it at the time. My first couple years in PP, I did a far amount of them. They were most useful for high radiculopathy due to severe foraminal stenosis like C4, C5 radic, particularly above a fusion, and for patients with cervical lamis. But just like lumbar TFESI with dex for stenosis, I didn't get long lasting results. Also DSA is obligatory for these IMHO, as radicular artery uptake is so common and missed on live fluoro. Also took longer than C ILESI. And more papers kept coming out, including vertebral artery dissection causing stroke, in a case performed with DSA and dex. More papers showing inconsistent cervical vertebral artery anatomy.

So for all of those reasons combined I gave them up and starting doing standard CESI or CESI with catheter if I needed to reach a high level (both with depo). Quicker, safer, good results and those results actually last due to the depo.
 
My partner taught himself, has done them for several years. About 6 mos ago I got pulled into the room to help him with CPR for unresponsive pulseless 40ish yo woman which occurred immediately after bandaids placed following CTFESI with dex/saline (no lido, no DSA ever). After about 2 minutes we got a weak pulse and she started mumbling about angels while staring through us. Soon after she was responsive and appropriate, EMS arrived and took her to ED. Partner called cardiology friend who said, “it couldn’t have been anything you did and doesn’t sound cards-related...does she have a psych history?” “Yes she is bipolar.” “Sounds like a ‘psychiatric episode.’” Patient had neuro already who ordered MRI brain because the patient asked him to and idk the results of that.
 
oreosandsake said:
interesting. I was never trained in cervical tfesi. Watched my big shot attending perform 3 as a fellow. We never got great epidural spread. Lot of contrast spreading around the vert artery and up and down the outside of the artery . Looking at the approach on the SIS procedure book and doing them on a cadaver makes me think it’s still a good option compared to IL in the C spine. For those that do them or did lots of them, what’s the deal? Is the fear unfounded? Do you think the risk is due to the historic use of particulate steroids? Possibly combined with poor hands ? Just curious. I’vebeen considering adding them to my practice
Click to expand...
To me the results of the interlams are good enough to not justify the tf approach.
 
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