Transforaminal ESI level question

[MustangGtV894]

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Question - for a Right sided L4-5 posterolateral disc herniation with L5 nerve impingement would you guys inject at L4-5 (L5 traverses) or L5-S1 (L5 exits)?

 

[mid|ine]

Personally I would do an LESI unless TFESI is indicted by prior surgery.

But to answer your question i would do L4-5 if only 1 level (assuming its the traversing L5 nerve root you are discussing). If failed, consider L5-S1. I also think a 2 level would be appropriate.

 

[Laryngospasm]

I’m going to piss some people off and say L4 and L5.

 

[callmeanesthesia]

I’d do both.

 

[MitchLevi]

Either one is fine, don’t do both levels as a first injection. I would do L4-5 ILESI or TFESI, if that doesn’t work do the two level TFESI.

 

[Dr. Ice]

I’m going to piss some people off and say L4 and L5.

Or L5 and S1..follow the flow..goes up and down

 

[SSdoc33]

Right L5 TFESI

 

[DOctorJay]

If it looks like the L5 nerve root is being irritated I'd start with an L5-S1 TFESI and consider adding the L4-5 level as well if needed for subsequent procedure.

 

[pmrmd]

R L5-S1 TFESI is the place to start. Gotta cover the DRG.

 

[Ducttape]

i would do L4 - usually easier, it is where the cause of pathology is (the disc herniation at L4), you will be coating the L5 nerve root at that level and it does spread, patients and surgeons can understand better that the injection was for radicular pain from that specific disc herniation.

 

[SSdoc33]

i would do L4 - usually easier, it is where the cause of pathology is (the disc herniation at L4), you will be coating the L5 nerve root at that level and it does spread, patients and surgeons can understand better that the injection was for radicular pain from that specific disc herniation.

?

maybe infraneural at L4, but L5 is the nerve getting dinged. thats what you need to go after. you would do an L4 TFESI for a lateral or foraminal herniation at L4-5, not a paracentral

 

[SpineandWine]

Do both

 

[paindoc007]

Both

 

[spondy14]

Depends on the pain pattern. If its L4 (anterior leg) then L4 TFESI and if its lateral lower leg and lateral hip, then I would do L5 TFESI

 

[Taus]

I’m a bit surprised that there is any confusion here. If it’s an L5 radic from L4-5 disc compressing traversing L5 (not exiting L4)…. Then why would anything but an L5 injection be done (if doing tfesi). Whether subpedic/supra-neural in L5-s1 foramen or Infra-neural/retro-discal in 4-5 foramen… that’s dealers choice. I prefer the former, but prob doesn’t really matter.

 

[paindoc007]

I’m a bit surprised that there is any confusion here. If it’s an L5 radic from L4-5 disc compressing traversing L5 (not exiting L4)…. Then why would anything but an L5 injection be done (if doing tfesi). Whether subpedic/supra-neural in L5-s1 foramen or Infra-neural/retro-discal in 4-5 foramen… that’s dealers choice. I prefer the former, but prob doesn’t really matter.

Bc 83 and 84 pay more than 83 alone.

Woops, did I say that out loud

 

[Kissmyabjj]

Question - for a Right sided L4-5 posterolateral disc herniation with L5 nerve impingement would you guys inject at L4-5 (L5 traverses) or L5-S1 (L5 exits)?

I usually try to address the nerve root impinged by the herniation. In this case I would start off with L5-S1 TFESI. If this doesn’t last at least three months, then I would repeat it and add the L4-L5 level.

 

[nvrsumr]

disc level and impinged nerve level. L4-5-1. If classic radicular pain to dorsum

Usually treat symptoms not mri so if to sole of foot L5-1-2 with same mri.

Plus heir and a spare. blobogram as reasons

 

[oneforfighting]

Do both. Maximize chances get the patient pain relief.

 

[Welcome123]

I’m a bit surprised that there is any confusion here. If it’s an L5 radic from L4-5 disc compressing traversing L5 (not exiting L4)…. Then why would anything but an L5 injection be done (if doing tfesi). Whether subpedic/supra-neural in L5-s1 foramen or Infra-neural/retro-discal in 4-5 foramen… that’s dealers choice. I prefer the former, but prob doesn’t really matter.

 

[Welcome123]

The issue is, if doing a single level the patient doesn’t meet the response criteria dictated by whatever insurance you deal with they will likely deny a second injection, even if you try a separate level. More likely to get a response by hitting two levels.

 

[MD87]

Do both. Maximize chances get the patient pain relief.

Can you cite any study/literature to support this?

 

[MD87]

Can you cite any study/literature to support this?

https://www.sciencedirect.com/science/article/pii/S2772594425000688

 

[BobBarker]

I don’t think it matters as long as you get in the epidural space.

 

[oneforfighting]

Can you cite any study/literature to support this?

Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study - PubMed

TFESI for lumbosacral radiculopathy with a preganglionic approach is more effective than TFESI with a ganglionic approach at short-term follow-up.

pubmed.ncbi.nlm.nih.gov

Preganglionic TFESI better than ganglionic for short-term follow-up (1 month) while ganglionic was better than preganglionic for midterm follow-up (6 months).

The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis - Neurosurgical Review

The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two...

link.springer.com

Preganglionic ESI has a 2.38 (95% CI 1.12, 5.04) times statistically significantly higher chance of effectiveness when compared to ganglionic ESI.


It would seem that preganglionic ESI, in this case L4-5 TFESI, would be the better option if you only have the option of doing a single level TFESI.

I would still do both levels on the same visit for aforementioned reasons.

 

[MitchLevi]

Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study - PubMed

TFESI for lumbosacral radiculopathy with a preganglionic approach is more effective than TFESI with a ganglionic approach at short-term follow-up.

pubmed.ncbi.nlm.nih.gov

Preganglionic TFESI better than ganglionic for short-term follow-up (1 month) while ganglionic was better than preganglionic for midterm follow-up (6 months).

The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis - Neurosurgical Review

The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two...

link.springer.com

Preganglionic ESI has a 2.38 (95% CI 1.12, 5.04) times statistically significantly higher chance of effectiveness when compared to ganglionic ESI.


It would seem that preganglionic ESI, in this case L4-5 TFESI, would be the better option if you only have the option of doing a single level TFESI.

I would still do both levels on the same visit for aforementioned reasons.

Do L4-5 then two level if necessary.

 

[oneforfighting]

Do L4-5 then two level if necessary.

Why so adamant on doing one level?

 

[pmrmd]

If I do an ESI without new MRI and the patient doesn’t do as well as we hoped, I think I always find out I was doing the pre-ganglionic injection after new imaging.