Transitional L5-S1 Anatomy Procedure Approach

[jwalker12]

Hello,

I always have trouble with these patient's when I do get them so was looking for some guidance. I always count from the top (starting at L1) below last rib. Then if I am to do a TFESI is it correct to assume if there is Sacralization of L5 my approach should be similar to doing a traditional S1 but at the L5 level to target the L5 nerve root? Same goes for lumbarization of S1 is it correct to assume my approach for a S1 TFESI should be similar to a traditional L5 TFESI to target the S1 nerve root? Lastly, does this transitional anatomy have any effect on the development of the ligamen or is it safe to do a Interlaminer injection between a L5-S1 transitional level? Thank you as always for everyones help, much appreciated.

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[Clean7795]

Hello,

I always have trouble with these patient's when I do get them so was looking for some guidance. I always count from the top (starting at L1) below last rib. Then if I am to do a TFESI is it correct to assume if there is Sacralization of L5 my approach should be similar to doing a traditional S1 but at the L5 level to target the L5 nerve root? Same goes for lumbarization of S1 is it correct to assume my approach for a S1 TFESI should be similar to a traditional L5 TFESI to target the S1 nerve root? Lastly, does this transitional anatomy have any effect on the development of the ligamen or is it safe to do a Interlaminer injection between a L5-S1 transitional level? Thank you as always for everyones help, much appreciated.

I'm not in pain but FYI there is no 100% method to know if there is a transitional vertebrae unless you have full spine imaging or at least imaging from the thorax down. You can have rare hypoplastic 12th ribs, anatomic variants with 13th ribs, etc. But your method works the vast majority of the time and it would be overkill to get full spine imaging to look for a transitional vertebrae.

 

[callmeanesthesia]

Variant anatomy can be so variable that it’s a case by case basis. Did L5-S1 MBBs today on a guy with absent 12th ribs, and a partially sacralized L5. He had an L4-5 fusion that looked like an L5S1 fusion. CT scan showed fully formed facet joints at the L5-S1 level.

 

[Laryngospasm]

Yes lots of variation.. usually can be figured out from various radiology reports and using c arm if any question. I had a patient the other day with C7 ribs.. confused the hell out of me for a bit

 

[kstarm]

If it looks like a lumbar VB I will do a traditional TFESI with oblique starting position and aiming under the pedicle . IF there is sacralization of L5 it depends a little as this can be a spectrum of partial to fully. Often it will work to do the same oblique approach as above. I always correlate with MRI as sometimes you get different counting based on the scan and sometimes it will vary between radiologists and I just try to be clear in my note what I am calling what based on what scan I am using. If it is a referral from neurosurgery for surgical planning I will call them to clarify if need be which is very rare. The idea is to get the medicine where the pathology is. On rare occasion I have put down a marker needle especially if there is variant anatomy and significant scoliosis/degenerative changes.