Thoracic Epidural Questions

[jewwithguitar]

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I have two clinical scenarios that I have encountered and have been thinking about next steps in management. I am looking for input for the following:

Scenario 1: 70 y/o Male s/p L2-S1 Posterior Decompression/Fusion presenting with neurogenic claudication. MRI reveals severe central and foraminal stenosis at L1-2. Patient had partial relief after an L1-2 TFESI with Dexamethasone. I am trying to decide on the second injection to try to provide additional relief. I do not like to perform ILESI at a level with severe central stenosis, so am deciding between T12-L1 ILESI and Caudal ESI (both using Betamethasone). Any reason to choose one over the other? Any tips for either in this situation (i.e. required volume of injectate for caudal to reach L1? Tricks to obtain more caudad flow of injectate during ILESI)?

Scenario 2: 42 y/o Female presenting with post-herpetic neuralgia in the LUQ/Left Flank. Cutaneous outbreak and pain began 1.5 months ago. She had short term relief with intercostal blocks at T6-T8. My next thought is a Thoracic ESI. Any preference for paramedian IL vs TF approach in this situation? If performing TFESI, I assume that I should target 2 adjacent levels that approximate the affected dermatome. I usually tend to avoid using local anesthetic in ESIs as I am purely office based, but assume that would be quite helpful for the patient in this situation. Recommendations for volume of 0.25% Bupivacaine to use in Thoracic ILESI vs TFESI?

 

[willabeast]

I have two clinical scenarios that I have encountered and have been thinking about next steps in management. I am looking for input for the following:

Scenario 1: 70 y/o Male s/p L2-S1 Posterior Decompression/Fusion presenting with neurogenic claudication. MRI reveals severe central and foraminal stenosis at L1-2. Patient had partial relief after an L1-2 TFESI with Dexamethasone. I am trying to decide on the second injection to try to provide additional relief. I do not like to perform ILESI at a level with severe central stenosis, so am deciding between T12-L1 ILESI and Caudal ESI (both using Betamethasone). Any reason to choose one over the other? Any tips for either in this situation (i.e. required volume of injectate for caudal to reach L1? Tricks to obtain more caudad flow of injectate during ILESI)?

Scenario 2: 42 y/o Female presenting with post-herpetic neuralgia in the LUQ/Left Flank. Cutaneous outbreak and pain began 1.5 months ago. She had short term relief with intercostal blocks at T6-T8. My next thought is a Thoracic ESI. Any preference for paramedian IL vs TF approach in this situation? If performing TFESI, I assume that I should target 2 adjacent levels that approximate the affected dermatome. I usually tend to avoid using local anesthetic in ESIs as I am purely office based, but assume that would be quite helpful for the patient in this situation. Recommendations for volume of 0.25% Bupivacaine to use in Thoracic ILESI vs TFESI?

Scenario #1. No way is a caudal ESI going to reach/help L1-2 stenosis. To get injectate to flow more caudal after IL ESI might try sitting patient up. Is patient really fused from L2 to S1? Why? Scenario #2. I would first try oral medication for neuropathic pain. Failing that an IL ESI or SubQ infiltration of Local and steroid. Volume of IL injectate determined by dye study, the dye should go towards the head, I liked paraspinal approach but you should do whatever you are familiar with after a look at the MRI. I am retired going on 8 years now 😎

 

[RoloTomassi]

1. IL above, go perpendicular or retrograde (cephalad tilt until IL space is small), then point bevel facing caudal. 5-6 mL.

2. Try one then the other. 2 levels if TF. I'm pretty conservative with local, 2 mL in IL, 1 mL in each level of TF

 

[Ducttape]

1. shared decision making but could consider TFESI with particulate steroid for more durable relief.

otoh, epidurals arent that great for neurogenic claudication.

refer to surgery to extend the fusion and decompress.

2. would suggest parasagittal ESI - easier, technically safe, and would cover more than 1 nerve root.

if she did have really good relief, you could RFA the intercostal nerves...

i still wouldnt use local anesthetic.

 

[SSdoc33]

no caudal. TFESI at L2. no shot for PHN

 

[willabeast]

1. shared decision making but could consider TFESI with particulate steroid for more durable relief.

otoh, epidurals arent that great for neurogenic claudication.

refer to surgery to extend the fusion and decompress.

2. would suggest parasagittal ESI - easier, technically safe, and would cover more than 1 nerve root.

if she did have really good relief, you could RFA the intercostal nerves...

i still wouldnt use local anesthetic.

Am suspicious of RFA of intercostal nerve for PHN especially thermal. AFAICT there are no studies or case reports using thermal RF for PHN.

 

[buddababa]

I have two clinical scenarios that I have encountered and have been thinking about next steps in management. I am looking for input for the following:

Scenario 1: 70 y/o Male s/p L2-S1 Posterior Decompression/Fusion presenting with neurogenic claudication. MRI reveals severe central and foraminal stenosis at L1-2. Patient had partial relief after an L1-2 TFESI with Dexamethasone. I am trying to decide on the second injection to try to provide additional relief. I do not like to perform ILESI at a level with severe central stenosis, so am deciding between T12-L1 ILESI and Caudal ESI (both using Betamethasone). Any reason to choose one over the other? Any tips for either in this situation (i.e. required volume of injectate for caudal to reach L1? Tricks to obtain more caudad flow of injectate during ILESI)?

Scenario 2: 42 y/o Female presenting with post-herpetic neuralgia in the LUQ/Left Flank. Cutaneous outbreak and pain began 1.5 months ago. She had short term relief with intercostal blocks at T6-T8. My next thought is a Thoracic ESI. Any preference for paramedian IL vs TF approach in this situation? If performing TFESI, I assume that I should target 2 adjacent levels that approximate the affected dermatome. I usually tend to avoid using local anesthetic in ESIs as I am purely office based, but assume that would be quite helpful for the patient in this situation. Recommendations for volume of 0.25% Bupivacaine to use in Thoracic ILESI vs TFESI?

scenario 1 needs surgery
scenario 2 start with ILESI, angling to the left

 

[Ducttape]

there actually are case reports on thermal RFA on pubmed.

Thermal RFA for intercostal neuralgia case report (not specifically for PHN):

Radiofrequency Ablation for Treating Resistant Intercostal Neuralgia - PubMed

Our cases suggest that thermal RFA can be safely used to treat patients suffering from intercostal neuralgia. This unique treatment has significant implications for chronic pain physicians and warrants additional studies to elucidate its effectiveness, safety profile, and scope of use.

pubmed.ncbi.nlm.nih.gov

there are articles regarding pulsed RFA for zoster.

a review article:

Progress in Radiofrequency Therapy for Zoster-Associated Pain About Parameters, Modes, Targets, and Combined Therapy: A Narrative Review - PubMed

Zoster-associated pain (ZAP) is a painful condition that significantly impacts a patient's quality of life, often leading to postherpetic neuralgia (PHN). Over 30% of patients with herpes probably experience PHN. However, the understanding and treatment of ZAP remain inadequate. Common...

pubmed.ncbi.nlm.nih.gov

a retrospective study:

Efficacy and safety of pulsed radiofrequency modulation of thoracic dorsal root ganglion or intercostal nerve on postherpetic neuralgia in aged patients: a retrospective study - PubMed

ChiCTR2100044176 .

pubmed.ncbi.nlm.nih.gov

cooled RFA case series:

Cooled Radiofrequency Ablation for Intercostal Neuralgia - PubMed

<span><b>Background:</b> Intercostal neuralgia is pain associated with the intercostal nerves along the rib, chest, and upper abdominal wall. Intercostal neuralgia has various etiologies, and current conventional treatment options include intercostal nerve blocks, nonsteroidal anti-inflammatory...

pubmed.ncbi.nlm.nih.gov

 

[Tboned]

1. Epidural above level of stenosis. ILESI with particulate. Consider surgical referral based off response. Don’t do a caudal, too far away.

Having said that, I recently saw a patient who had an epidural in Japan that was a caudal with 30cc of volume (20cc NS, 10cc 1% and 3.3mg of dex) for an L45 HNP. 🤷‍♂️

 

[clubdeac]

Am suspicious of RFA of intercostal nerve for PHN especially thermal. AFAICT there are no studies or case reports using thermal RF for PHN.

I used to do thermal and pulsed ICN RFA. Thermal is dicey though. Caused a ptx once in a lady with COPD and a bunch of blebs and significant deafferentation pain in another. Finally quit doing them as the juice wasn’t worth the squeeze

 

[pmrmd]

1. L2-3 TF
2. 0.5cc, if at all.