Thoracic TFESI and anticoagulation

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No. But are you sure the patient needs the esi?
 
Why do TFESI instead of interlaminar?

There’s a local guy who did an accidental arterial injection using TFESI in the thoracic region, used Kenalog of course….major lawsuit for spinal cord injury going on right now
 
Agast said:
Why do TFESI instead of interlaminar?

There’s a local guy who did an accidental arterial injection using TFESI in the thoracic region, used Kenalog of course….major lawsuit for spinal cord injury going on right now
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1. Assuming unilateral dermatomal distribution of pain.
2. Assuming lower risk of clinical hematoma via transforaminal approach if continuing AP/AC

I always use dex for TFESIs
 
If it's PHN, an ESI is reasonable IMO.

What's the reason for the anticoagulation?

I'd do it off Plavix but on apixaban. TFESI.
 
oneforfighting said:
I'm thinking this would be most reasonable. Would you do them with above AP/AC on board?
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For sure. Especially diffusion technique since you’re just landing on the superficial side of the rib. Easily compressible. Also I think I’m about 0 for 5 with thoracic epidurals helping with PHN…
 
Not Steve but I do 3 consecutive levels, with a total injectate of dex 10mg with 4cc bupivacaine 0.5%. Split the injectate into each level.

Unless it clear which dermatome. I think isolating the dermatome is hard, so I bracket.
 
Mark off a rib in the approximate center of the pain, drop a 25g onto the center of the rib shadow until it touches bone. Put a finger on each side of the needle oriented cephalad/caudad, and apply pressure to constrain the spread in a superior/inferior direction, and inject about 10 mL lido/steroid.
 
callmeanesthesia said:
Mark off a rib in the approximate center of the pain, drop a 25g onto the center of the rib shadow until it touches bone. Put a finger on each side of the needle oriented cephalad/caudad, and apply pressure to constrain the spread in a superior/inferior direction, and inject about 10 mL lido/steroid.
Click to expand...
Why center of rib though? Easy enough to touch inferior aspect safely, especially with caudal tilt, it's the walking off that gets riskier. Would seem like you'd more likely diffuse to intended target if starting closer
 
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RoloTomassi said:
Why center of rib though? Easy enough to touch interior aspect safely, especially with caudal tilt, it's the walking off that gets riskier. Would seem like you'd more likely diffuse to intended target if starting closer
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Minimize risk. Definitely more diffuse - I’ve added contrast to it to see, and one shot hits 2-3 intercostal levels.
 
I like US.

Rumors are that Putin had an MI today. In other news...
 
How close to the spine do you catch the intercostal nerve?
 
callmeanesthesia is using the omiguoi technique.

i will use that and traditional technique, under fluoro.

target and hit lower 1/3rd of rib. lots of local anesthetic, up to 5 ml on to each rib.

then angle downwards until off edge of bone, advance 1mm, no more, and reimage. then give 2 ml 025% bupiv and dex.

i get a lot of inpatient rib fracture patients, so the 1% on rib helps a lot, and want subjectively faster effect from that and dex and dont need longer term effect of depo.
 
Qutenza it?

I'm okay with a 25g spinal based TFESI here or proximal intercostal at the medial angle of the rib.
5 mL there will get back to the DRG.

Omoigui may as well be an ESP
 
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