Tips on obliquity used to optimize ventral flow with L-TFESI?

[Taus]

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Having a hard time imaging PARS overlapping with TP. Do you have a picture demonstrating it?

Will get one. Caudal tilt until the inferior tp is a straight line and intersects iap with a square corner.

 

[22yis]

Will get one. Caudal tilt until the inferior tp is a straight line and intersects iap with a square corner.

@Taus drop a pic of this when you get a chance! Sounds like an interesting technique

 

[Taus]

@Taus drop a pic of this when you get a chance! Sounds like an interesting technique

Will do. I learned this from a Tim Maus SIS video. I essentially always focus on this, not squaring the endplate on tfesi. Removes any bony obstruction from your path.

 

[paindoc503]

I'm surprised that this thread has so much variation in responses.
In my view, the answer is very simple. You oblique until the SAP does not obscure the area underneath the pedicle at 6oclock. Oblique as little as possible to accomplish this.

 

[powermd]

Does anyone have tricks for getting in when the facet just won't get out of the way? Sometimes I'm dumbfounded that there is an actual exit for the nerve being that I can't seem to get a needle in without going through the kidney.

 

[GoBeers]

Does anyone have tricks for getting in when the facet just won't get out of the way? Sometimes I'm dumbfounded that there is an actual exit for the nerve being that I can't seem to get a needle in without going through the kidney.

fortunately kidneys should be no where near our needle entry site. kidneys being L3 level and you'd have to oblique like 45 degrees lol

 

[Agast]

Does anyone have tricks for getting in when the facet just won't get out of the way? Sometimes I'm dumbfounded that there is an actual exit for the nerve being that I can't seem to get a needle in without going through the kidney.

My trick is going interlaminar 🤪

J/K. I have a patient whose scoliosis DDD and osteophytosis is so gnarly that if I ever attempt another injection it will be a caudal with a catheter

 

[powermd]

fortunately kidneys should be no where near our needle entry site. kidneys being L3 level and you'd have to oblique like 45 degrees lol

 

[22yis]

Will do. I learned this from a Tim Maus SIS video. I essentially always focus on this, not squaring the endplate on tfesi. Removes any bony obstruction from your path.

Ive been looking for that video and cant find it

fortunately kidneys should be no where near our needle entry site. kidneys being L3 level and you'd have to oblique like 45 degrees lol

If you look at a model the kidneys are ventral to the vertebral bodies. Its not just obliquity that youd need to **** up but massively underestimate your depth

 

[RoloTomassi]

Didn't take kidney position for granted, can be variable. Remember when someone speared a kidney doing Minuteman? I've seen some in the way of LSB and Intracept trajectory, had to do the other side or oblique less

 

[22yis]

Will do. I learned this from a Tim Maus SIS video. I essentially always focus on this, not squaring the endplate on tfesi. Removes any bony obstruction from your path.

Found it @anujacket

 

[Baron Samedi]

The real question is why did that spine get an injection.

 

[Status Sciaticus]

The real question is why did that spine get an injection.

fibromyalgia

 

[Scottie_Dog]

Found it @anujacket

View attachment 404206

I still don’t really understand what they are talking about as far as the pedicle and pars being superimposed. The pictures don’t look drastically different other than squaring the superior end plate. I guess I can appreciate more of a “right angle” but it seems like it’s easier to just square the SEP and do the injection the same was as always? What am I missing

 

[22yis]

I still don’t really understand what they are talking about as far as the pedicle and pars being superimposed. The pictures don’t look drastically different other than squaring the superior end plate. I guess I can appreciate more of a “right angle” but it seems like it’s easier to just square the SEP and do the injection the same was as always? What am I missing

The pars is the neck of Scottie dog and is posterior structure to the eye (Pedicle) which we use for targeting our tfesi. If you change the angle of ii to minimize pars obstructing pedicle it’ll be a true trajectory image and less os obstructing entering neuroforamen. Taus was also saying that if you do more caudal tilt you also follow the path of the nerve better

 

[Scottie_Dog]

The pars is the neck of Scottie dog and is posterior structure to the eye (Pedicle) which we use for targeting our tfesi. If you change the angle of ii to minimize pars obstructing pedicle it’ll be a true trajectory image and less os obstructing entering neuroforamen. Taus was also saying that if you do more caudal tilt you also follow the path of the nerve better

Yea, what I’m saying is that in order to get that view you need to square the end plate, so make it easy on yourself and just square the SEP and don’t worry about trying to super impose the pars or whatever. Start low and lateral to the target and drive up and in. Low to high

 

[22yis]

Yea, what I’m saying is that in order to get that view you need to square the end plate, so make it easy on yourself and just square the SEP and don’t worry about trying to super impose the pars or whatever. Start low and lateral to the target and drive up and in. Low to high

The SEP being squared in this example doesnt mean it will be the case every time. Maus is arguing that its more important to have the pars and pedicle lined up (so you can truly target 6 oclock on pedicle without hitting the pars obstruction), not focusing on squaring end plates

edit- i see what youre saying, lined up SEP, as mentioned in the picture. I guess based off what taus described (i havent tried this technique yet - but will on monday) just focus on that more than SEP/IEP as those dont actually affect trajectory

 

[clubdeac]

The SEP being squared in this example doesnt mean it will be the case every time. Maus is arguing that its more important to have the pars and pedicle lined up (so you can truly target 6 oclock on pedicle without hitting the pars obstruction), not focusing on squaring end plates

edit- i see what youre saying, lined up SEP, as mentioned in the picture. I guess based off what taus described (i havent tried this technique yet - but will on monday) just focus on that more than SEP/IEP as those dont actually affect trajectory

The problem is with old degenerative spines and obese patients which make up 90% of my practice, you’re never going to get a nice crisp image like this where you can differentiate the pars from the inferior pedicle