Thoracic ILESI

[Tramadeezy]

Any pro tips from the seasoned gurus. I find myself struggling with these more often than I think I should. I use lots of caudal tilt to try and open up the space but its still a pain sometimes. Any thoughts? Thanks.

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[SommeRiver]

Caudal tilt and ask yourself why you're doing this to begin with, bc the appropriate use of this technique must be rare.

I've never done one in 3 yrs of being an attending. I do a T TFESI maybe 3x a year.

 

[pmrmd]

If you need a thoracic ESI a TF approach is far easier but I have seen the need for this only a few times in 15 years.

 

[willabeast]

Any pro tips from the seasoned gurus. I find myself struggling with these more often than I think I should. I use lots of caudal tilt to try and open up the space but its still a pain sometimes. Any thoughts? Thanks.

Used to do these a fair amount. Reasoning is i can use a better steroid than if i do it TF. Anyway - some parts of T spine are more difficult than others. I would use an AP fluoro shot then go two or three levels lower than target, go straight down until i hit lateral lamina to take a depth reading then walk the needle cephalad and medial until i felt like i was in ligament then switch to lateral view (actually rarely switched to lateral at this time but this is a teaching moment here) then LOR until in epidural space then dye (always got a lateral at this point - documentation). Old timers will recognize this method as how we used to do thoracic IL ESI before SIS and fluoro etc but fluoro does make it easier. Never had a problem with getting in or wet taps or anything else. BTW i fixed someone with a thoracic dural chronic leak that neurology sent me once with this technique using blood patch. Good looking female. 😎

 

[No_Pain_No_Gain]

Any pro tips from the seasoned gurus. I find myself struggling with these more often than I think I should. I use lots of caudal tilt to try and open up the space but its still a pain sometimes. Any thoughts? Thanks.

I am just a few years out of fellowship and had a lot of difficulty at first using the same technique you are using. Over the past 1.5 years I switched my technique to be similar to willabeast's above. I approach this the same way I approach spinal cord stimulator trials now. Line up end plates in AP (no caudal tilt). Start 2-3 levels below on medial pedicle border. Advance towards my target level. If I hit lamina then I usually just aim slightly more cephalad and walk off. Go to lateral or CLO and use LOR. This has really improved my average time spent on these procedure and I no longer dread the thoracic ILESI like I used to.

 

[Tramadeezy]

Ya that technique makes sense, didnt think of it like a stim trial. I will try that out next time. I only do a few a year but didnt think I should be struggling like I was. Thanks!

 

[Orin]

I have been doing the CLO for these. I normally give it a try for PHN/shingles of the chest wall.

 

[Laryngospasm]

Clo definitely helps, as well as getting a feel for walking off. I still do hanging drop sometimes when doing blind catheters. I think I’m the only one.

 

[Orin]

I still do hanging drop sometimes when doing blind catheters. I think I’m the only one.

I always suggest the trainees try it as a confirmatory method but I can't get it to work consistently.

 

[Laryngospasm]

Probably depends on comfort level. I find increased negative pressure in the sitting position. Small drop of saline in the hub. Advance holding wings of hub with both thumbs and forefingers. Rest other fingers against back to prevent suddenly large movements. Drop will only move a few mm usually. Have them take deep breaths to confirm. I find it oddly enjoyable.

 

[Ligament]

I find TF ESI to be much easier in the thoracic spine, I hate doing thoracic IL ESIs.

 

[soccrwz]

Transforaminals are much easier in thoracic spine than IL

 

[SageCraft]

Technique for Thoracic TFESI?

 

[soccrwz]

square off level ips oblique slightly, hit arm pit, make sure your needle has a curve, slowly rotate of bone advance medial and anterior. Lateral, check dye. All done