Three level transforaminal epidural steroid injections routinely???? Wtf?

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Blitz2006 said:
I agree with everything you say.

But why is the risk of particulate > non particulate in ILESI? What am I missing anatomically

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Wondering the same myself
 
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For all of you like myself doing a fair amt of 2 level TFESI, how much dex do you put in each hole? 5mg per? What volume?
 
thecentral09 said:
For all of you like myself doing a fair amt of 2 level TFESI, how much dex do you put in each hole? 5mg per? What volume?
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5mg per

10mg + 4cc saline div by 2
 
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emd123 said:
How is someone going to "infarct" the cord with particulate in the posterior epidural space, where there are only veins and no cord-entering arteries that could be infarcted?
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The better question is why do it at all? It hasn't ever been shown to be superior so why do it at all? Are there cord serving arteries in the posterior epidural space? No, but you do acknowledge that only one type of steroid has been shown to reliably cause problems during epidural steroid injection and that particular steroid has never been shown to be more effective than nonparticulates so I have no reason to use it outside of joints.

Also I know for certain that there is evidence that methylprednisolone and triamcinolone intrathecally can significantly increase the risk of adhesive arachnoiditis. In my own mind, rightly or wrongly I assume dex is less likely given how aqueous it is. Obviously all steroids increase that risk but it seems more common in particulates, at least in my reading.

My statement about the guy I work with who caused a cord injury with a TFESI was just to show there are still ppl using particulates in TFESI.
 
i saw some study that Tim maus showed for some SIS lecture series that he did 15mg of dexamethasone compared to 80 of methylpred. 10mg seems adequate to me, but some are doing 15, that doesn't seem routine?
 
4mg as effective as 10mg. No risk of particulate in ILESI.

2 level is money grab when done at adjacent levels. Justified if treating right sided L2-3 disc and left side L5-S1. Or b/l for canal stenosis.
 
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Newbie question #2

Any reasonable evidence that in terms of efficacy, TFESI >ILESI?

I have been told that there were a few meta analyses that confirm this.

True?

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lobelsteve said:
4mg as effective as 10mg. No risk of particulate in ILESI.

2 level is monet grab when done at adjacent levels. Justified if treating right sided L2-3 disc and left side L5-S1. Or b/l for canal stenosis.
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What steroid do you use in your interlam?

And since I assume it’s a particulate (bc I think I’ve read that before), why? Since dex is equivalent per studies you cite.
 
Is everyone going subpedicular supraneural, or are they reviewing the imaging and going suprapedicular subneural? Also anyone ever go straight AP go to the bone under the pedicle withdraw and then medialize to perform the tfesi, another practice does this, never tried it
 
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SommeRiver said:
You don't put local in there too?
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If I'm using a 25g, which is most of the time, I don't use local in the epidural space. I like to let people drive to and from the appointments. 25 gauge needle, no local in the epidural space and no sedation, then there's no reason they can't drive home (after sitting for 15 minutes).

If I have to use a 22 gauge then I'll use local in the mixture, usually. But then they can't drive.

No sedation, no local in the epidural space, works well most of the time for an office based procedure suite, if you can manage. But if they need it, you can give it, they just can't drive.
 
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lobelsteve said:
2 level is monet grab when done at adjacent levels. Justified if treating right sided L2-3 disc and left side L5-S1. Or b/l for canal stenosis.
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Show me level one evidence, that injecting two adjacent levels, both with correlating pathology is a "money grab."
 
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paindoc007 said:
What steroid do you use in your interlam?

And since I assume it’s a particulate (bc I think I’ve read that before), why? Since dex is equivalent per studies you cite.
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Dogma. I use Celestone and I have no valid reason to use it, nor any valid reason to change. I would probably change just to have one less bottle on shelf. But I do use it in joints. Need to research if dex has been used in joints with success?
 
lobelsteve said:
Proving your negative is not proper science.
Ask Nik and Charlie how many 2 level TFESI they have ever done. Then ask why.
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For reference purposes, I'd just like to see the study, the high level evidence proving your point, so I can refer to it for teaching purposes, or in court if I'm asked to give expert witness testimony on this (or any other) subject. I'd like to be able to back up, the blanket assertion that a 2 level, adjacent, TF esi (on levels with pathology) is always fraud.

I've been on this board long enough, I respect your opinion. I honestly want the reference, for my files. Not opinion, but hard data, I can refer to.
 
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lobelsteve said:
Dogma. I use Celestone and I have no valid reason to use it, nor any valid reason to change. I would probably change just to have one less bottle on shelf. But I do use it in joints. Need to research if dex has been used in joints with success?
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I’ve tried to search on pubmed and didn’t come up with much looking at particulate vs nonparticulate. A few study’s where they used dex but no comparator. I did find this in vitro study though that showed that betamethasone is more toxic to chondrocytes than other preparations, and dex is less toxic - https://www.ncbi.nlm.nih.gov/m/pubmed/25187334
 
PMR journal from earlier this year:
Efficacy of Injected Corticosteroid Type, Dose, and Volume for Pain in Large Joints: A Narrative Review.
Cushman et al.

Not much on dex: Plafki et al [40] performed a small study comparing the effects of 10 mg triamcinolone acetonide to dexamethasone 21−palmitate (equivalent of 2.5 mg dexamethasone sodium phosphate) to a control group. The control group treatment was stopped early due to inadequate pain relief compared to the 2 steroid groups. The 2 steroids groups demonstrated equivalent outcomes in a Patte score (which includes “subjective estimation of pain, function, force and overall handicap” [40]).
 
emd123 said:
For reference purposes, I'd just like to see the study, the high level evidence proving your point, so I can refer to it for teaching purposes, or in court if I'm asked to give expert witness testimony on this (or any other) subject. I'd like to be able to back up, the blanket assertion that a 2 level, adjacent, TF esi (on levels with pathology) is always fraud.

I've been on this board long enough, I respect your opinion. I honestly want the reference, for my files. Not opinion, but hard data, I can refer to.
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he called it a money grab. (or, actually, a "monet grab")

fraud might be too harsh a term.
 
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MD87 said:
PMR journal from earlier this year:
Efficacy of Injected Corticosteroid Type, Dose, and Volume for Pain in Large Joints: A Narrative Review.
Cushman et al.

Not much on dex: Plafki et al [40] performed a small study comparing the effects of 10 mg triamcinolone acetonide to dexamethasone 21−palmitate (equivalent of 2.5 mg dexamethasone sodium phosphate) to a control group. The control group treatment was stopped early due to inadequate pain relief compared to the 2 steroid groups. The 2 steroids groups demonstrated equivalent outcomes in a Patte score (which includes “subjective estimation of pain, function, force and overall handicap” [40]).
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Weird. That seems like 1/4 the usual dose of kenalog and 1/2 dose of dex. But both still separated from placebo.
 
two adjacent levels- inject at level of disc protrusion and traversing nerve root.
 
Everything I don't do is a money grab.
 
emd123 said:
Do nothing, see no patients, go broke = Not money grab
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Ha! I do two level TFESI bc it works, not bc I sit down and say to myself, "Okay...Mr Smith needs an epidural and I could just do a one level for his L5-S1 and L4-5 stenosis, but I'll get paid more if I do both levels, so that's what I'll do..."

Yes I realize the medication spreads but I like depositing the medication in specific places for specific pts.

At no point do I sit there and decide that I will make more money by doing two levels. I can do a one level and move on to the next room quickly, or I can do two and it will take longer.
 
SommeRiver said:
Ha! I do two level TFESI bc it works, not bc I sit down and say to myself, "Okay...Mr Smith needs an epidural and I could just do a one level for his L5-S1 and L4-5 stenosis, but I'll get paid more if I do both levels, so that's what I'll do..."

Yes I realize the medication spreads but I like depositing the medication in specific places for specific pts.

At no point do I sit there and decide that I will make more money by doing two levels. I can do a one level and move on to the next room quickly, or I can do two and it will take longer.
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So it is more passive income. You would fill both cups (satisfy both camps) if you did S1 one day, and if still needing more relief and doing PT/exercises, could bring him back for L4 or L5.
 
I have some sympathy for the docs who do different procedures on same patient on same day. As long as not PI "real money grab" and for the patient's convenience. I have an 80 year on the table now who drove 3 hours from kansas to see me and has an appt with his heart transplant surgeon for this afternoon. He is scheduled for an SI and Gr. troch. I lose money and the possible diagnostic utility of the injection but gain patient satisfaction.
 
nvrsumr said:
I have some sympathy for the docs who do different procedures on same patient on same day. As long as not PI "real money grab" and for the patient's convenience. I have an 80 year on the table now who drove 3 hours from kansas to see me and has an appt with his heart transplant surgeon for this afternoon. He is scheduled for an SI and Gr. troch. I lose money and the possible diagnostic utility of the injection but gain patient satisfaction.
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That is caring for the patient, not a money grab. You lose money by combining procedures, but save the patient $50 on gas minimum.
 
I mean it depends on what you are doing. if combining an SI and a GT injection, that helps the patient.

these money grabs are people doing a combination of TF and SI and FJI.
 
I do SIJ and GTB all the time.

I do TFESI and GTB not infrequently.

I do SIJ and TFESI every now and then.

The only procedure I don't combo up is a MBB

I find it relatively rare that a patient has only 1 pain generator. Often times, I will do an SIJ after an RF because there is still axial pain. so, we are talking 2 visits for an mbb and 1 for an RF (at the minimum) then another for the SIJ? That is 4 visits for shot if you do bilateral procedures, 7-8 if unilateral. that'd be insane
 
lobelsteve said:
What you believe is not as relevant as 4-5 peer reviewed journal articles showing no difference. Dex is non-particulate, Depo/Kenalog/Celestone are particulate. Dex is drug of choice in TFESI.
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As I’ve stated a dozen times on this board. The dex studies were only treating acute radiculopathy, not stenosis. This issue was repeatedly skipped as stenosis is harder to study.

Huge difference in duration of effect between dex and depo for stenosis.
 
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bedrock said:
As I’ve stated a dozen times on this board. The dex studies were only treating acute radiculopathy, not stenosis. This issue was repeatedly skipped as stenosis is harder to study.

Huge difference in duration of effect between dex and depo for stenosis.
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So do a study. Rct dex vs depo for claudicatory leg pain on your next 60 consecutive severe stenosis patients with data at weeks 1-4-8-12.
 
bedrock said:
As I’ve stated a dozen times on this board. The dex studies were only treating acute radiculopathy, not stenosis. This issue was repeatedly skipped as stenosis is harder to study.

Huge difference in duration of effect between dex and depo for stenosis.
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Can I see a study to support this clinical impression?

Steve’s idea is a start... but it would have to be expanded greatly to be any more than level 3 evidence.
 
Ducttape said:
Can I see a study to support this clinical impression?

Steve’s idea is a start... but it would have to be expanded greatly to be any more than level 3 evidence.
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Please show me a single study that was NOT done only on acute radiculopathy.

None of the ESI studies were ever done on patients with stenosis or chronic/recurring radiculopathy which most of us see more often than a fresh first time acute radiculopathy.
 
lobelsteve said:
4mg as effective as 10mg. No risk of particulate in ILESI.

2 level is money grab when done at adjacent levels. Justified if treating right sided L2-3 disc and left side L5-S1. Or b/l for canal stenosis.
Click to expand...

Disagree. If patient has lateral HNP contacting traversing root I will inject two level - above and below the HNP. Not a money grab, common sense.

In the end a patient who does well with injections SAVES money.


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No Pain All gain said:
Disagree. If patient has lateral HNP contacting traversing root I will inject two level - above and below the HNP. Not a money grab, common sense.

In the end a patient who does well with injections SAVES money.


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In the dark ages possibly. By meaning sense of the commoner, or those who cannot read or write. Then your theory holds.
 
I’m confused by this. If you have a lateral disc at L4/5 you hit the exiting L4 nerve. I would think it makes more sense to just do a single level at L4 in this case since you could cover both the disc and the nerve. If you have a paramedian L4/5 disc you hit the traversing L5 nerve. In that case it might make more sense to do a 2 level at L4 to cover the disc and L5 to cover the nerve... though no evidence for it and contrast studies refute it.
 
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bedrock said:
Please show me a single study that was NOT done only on acute radiculopathy.

None of the ESI studies were ever done on patients with stenosis or chronic/recurring radiculopathy which most of us see more often than a fresh first time acute radiculopathy.
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ADDENDUM: Edited because of trying to answer 2 threads at once.

okay... here is drusso's fav, a meta-analysis:
Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections. - PubMed - NCBI

There is no statistically significant difference in terms of pain reduction or improved functional outcome between particulate and nonparticulate preparations in cervical ESI and, therefore, the authors recommend using nonparticulate steroid when performing cervical TFESI (Grade of Recommendation: B). In patients with lumbar radiculopathy due to stenosis or disk herniation, TFESI using particulate versus non-particulate is equivocal in reducing pain (Grade of Recommendation: B) and improving function (Grade of Recommendation: C) and therefore the authors recommend the use of nonparticulate steroids for lumbar TFESI in patients with lumbar radicular pain (Grade of Recommendation: B). There is insufficient information to make a recommendation of one steroid preparation over the other in lumbar ILESI (Grade of Recommendation: I). Given the lack of strong data favoring the efficacy of one steroid preparation over the other, and the potential risk of catastrophic complications, all of which have been reported with particulate steroids, nonparticulate steroids should be considered as first line agents when performing ESIs.
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No Pain All gain said:
Disagree. If patient has lateral HNP contacting traversing root I will inject two level - above and below the HNP. Not a money grab, common sense.

In the end a patient who does well with injections SAVES money.


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i might understand injecting at the site of the HNP and at the site of the contacted nerve, but what is the logic for injecting below? unless you mean you are targetting the impacted nerve not the HNP level, which would make more sense. (my initial impression is, for example, an L45 HNP, injecting L3 and S1 makes no sense. but, if you mean injecting at L4 and L5, that does...)
 
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Ducttape said:
ADDENDUM: Edited because of trying to answer 2 threads at once.

okay... here is drusso's fav, a meta-analysis:
Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections. - PubMed - NCBI





i might understand injecting at the site of the HNP and at the site of the contacted nerve, but what is the logic for injecting below? unless you mean you are targetting the impacted nerve not the HNP level, which would make more sense. (my initial impression is, for example, an L45 HNP, injecting L3 and S1 makes no sense. but, if you mean injecting at L4 and L5, that does...)
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This is meta-analysis bothers me less than others because it is at least more "apples to apples" than others.

Here's a curve ball observation: I think particulate versus non-particulate are non-inferior for acute radicular syndromes, but for Medicare population's non-surgical chronically anti-coagulated, home 02-dependent, multi-stenotic-spondylotic-claudicatory-poly-co-morbidotic patients, I think particulate steroids have a longer duration of effect and I have to stop their anti-coagulation less frequently for repeat procedures.
 
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drusso said:
This is meta-analysis bothers me less than others because it is at least more "apples to apples" than others.

Here's a curve ball observation: I think particulate versus non-particulate are non-inferior for acute radicular syndromes, but for Medicare population's non-surgical chronically anti-coagulated, home 02-dependent, multi-stenotic-spondylotic-claudicatory-poly-co-morbidotic patients, I think particulate steroids have a longer duration of effect and I have to stop their anti-coagulation less frequently for repeat procedures.
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So do the right thing and keep them on their antiplatelet or anti coag regimen.
 
Ducttape said:
ADDENDUM: Edited because of trying to answer 2 threads at once.

okay... here is drusso's fav, a meta-analysis:
Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections. - PubMed - NCBI





i might understand injecting at the site of the HNP and at the site of the contacted nerve, but what is the logic for injecting below? unless you mean you are targetting the impacted nerve not the HNP level, which would make more sense. (my initial impression is, for example, an L45 HNP, injecting L3 and S1 makes no sense. but, if you mean injecting at L4 and L5, that does...)
Click to expand...

Exactly. Sorry if worded poorly.


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