Translaminar cervical ESI

[muppttl]

I posted this on another forum, and didn't get any feedback yet, but a responder told me that I would likely get some opinions if I posted it here:

Recently, the hospital I worked for highered a new neurosurgeon who I am sort of at odds with. I have nearly always chosen C7-T1 for ESIs no matter the location of the pathology (occasionally C6-7 if I could see a decent epidural space on MRI). This new guy insists that he has worked with rads who do C5-6 and even C4-5 translaminar ESIs. He insists they were translaminar and not transforaminal. I'm feeling pressure from him to do the level he asks, but I can't find any evidence that it is safe to do these higher levels. Most sources say that there is no appreciable epidural space above C6-7 and above here the ligamentum flavum is closely apposed to the dura. I've even presented him evidence that cervical epidural medication on average travels 3.8 levels above and below the injected space, and that didn't make him happy. I don't have any experience with transforaminal ESI, so I'd have to learn that technique should I want to adopt it. What are your thoughts on translaminar ESI above C7-T1?

Thanks in advance!

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[PinchandBurn]

I posted this on another forum, and didn't get any feedback yet, but a responder told me that I would likely get some opinions if I posted it here:

Recently, the hospital I worked for highered a new neurosurgeon who I am sort of at odds with. I have nearly always chosen C7-T1 for ESIs no matter the location of the pathology (occasionally C6-7 if I could see a decent epidural space on MRI). This new guy insists that he has worked with rads who do C5-6 and even C4-5 translaminar ESIs. He insists they were translaminar and not transforaminal. I'm feeling pressure from him to do the level he asks, but I can't find any evidence that it is safe to do these higher levels. Most sources say that there is no appreciable epidural space above C6-7 and above here the ligamentum flavum is closely apposed to the dura. I've even presented him evidence that cervical epidural medication on average travels 3.8 levels above and below the injected space, and that didn't make him happy. I don't have any experience with transforaminal ESI, so I'd have to learn that technique should I want to adopt it. What are your thoughts on translaminar ESI above C7-T1?

Thanks in advance!

dont do it. The evidence that you presented supports it. He's dumb...plain and simple. Tell him you are not going to tk the risk . If he really insists, maybe thread a catheter to the level he aks.

Final option. Do the TFESI but use local only, so it's only diagnostic. This way no chances of 'embolizing' unless you believe arteries go into 'spasm'.

 

[101N]

Most of us - IMO - won't go above C7/T1 for ILESI due to these articles, particularly Derby's. Compromise and offer to perform TFESIs at the levels above using Dexamethasone.

1. Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports.
Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C.
Source
Chattanooga Orthopaedic Group, Foundation for Research, Tennessee, USA.
Abstract
STUDY DESIGN:
Intrinsic cervical spinal cord damage represents the serious and permanent complications that can occur if cervical epidural steroid injections are administered while the patient is sedated. Two case reports are presented.
OBJECTIVES:
To draw attention to the dangerous consequences that can arise from sedating a patient before administering a cervical epidural steroid injection.
SUMMARY OF BACKGROUND DATA:
Reported complications of cervical epidural steroid injections have been minor and infrequent. No reports of intrinsic cervical cord damage could be found in a comprehensive English language literature search.
METHODS:
Two case reports of permanent intrinsic cervical cord damage in patients who had been administered cervical epidural steroid injections while under intravenous sedation are presented. Magnetic resonance imaging was performed before and after the administration of cervical epidural steroid injections. Each patient had herniated nucleus pulposus before they received cervical epidural steroid injections and intrinsic cord damage on postinjection magnetic resonance images.
RESULTS:
Both patients developed increased pain and neurologic symptoms within 24 hours of injection. To date, these symptoms appear to be permanent. However, Patient 1 had pain relief in her right arm and shoulder after undergoing a microdiscectomy, but pain was still persistent in her left leg, and she has developed a positive Lhermitte's sign.
CONCLUSION:
These case reports indicate fluoroscopic guidance will not insure or prevent intrathecal perforation or spinal cord penetration during the administration of cervical epidural steroid injections. In addition, although intravenous sedations during cervical epidural steroid injections have been used numerous times without reported complications, it appears intravenous sedation in these two cases resulted in the inability of the patient to experience the expected pain and paresthesias at the time of spinal cord irritation. Therefore, the authors conclude that the patient should be fully awake during the administration of cervical epidural steroid injections, with only local anesthetic in the skin used for analgesia.

2. Spine:
1 October 1998 - Volume 23 - Issue 19 - pp 2141-2142
Case ReportPoint of View: Cervical Epidural Steroid Injection With Intrinsic Spinal Cord Damage: Two Case Reports Derby, Richard MD

 

[powermd]

I posted this on another forum, and didn't get any feedback yet, but a responder told me that I would likely get some opinions if I posted it here:

Recently, the hospital I worked for highered a new neurosurgeon who I am sort of at odds with. I have nearly always chosen C7-T1 for ESIs no matter the location of the pathology (occasionally C6-7 if I could see a decent epidural space on MRI). This new guy insists that he has worked with rads who do C5-6 and even C4-5 translaminar ESIs. He insists they were translaminar and not transforaminal. I'm feeling pressure from him to do the level he asks, but I can't find any evidence that it is safe to do these higher levels. Most sources say that there is no appreciable epidural space above C6-7 and above here the ligamentum flavum is closely apposed to the dura. I've even presented him evidence that cervical epidural medication on average travels 3.8 levels above and below the injected space, and that didn't make him happy. I don't have any experience with transforaminal ESI, so I'd have to learn that technique should I want to adopt it. What are your thoughts on translaminar ESI above C7-T1?

Thanks in advance!

Above C6-7 the LF becomes a bit less reliable, enough so that most injectionists do not feel the risk is worth the benefit. Margin for error in needle placement is much smaller than at C7-T1. My partners routinely do C6-7 and haven't had any major complications. I almost invariably do C7-T1. I have done C5-6 once or twice, and both times I got epidural dye flow before any appreciable loss of resistance. I just kept injecting puffs of dye until I was epidural.

There is another pain specialist (non-anesthesia or PMR) in my region who I had the chance to review who had procedure notes indicating injections at C4-5 and C5-6 routinely. Can't say I was able to endorse that.

Don't let this arrogant NS push you into doing procedures you're uncomfortable with. If it matters that much, thread a catheter.

 

[bedrock]

I posted this on another forum, and didn't get any feedback yet, but a responder told me that I would likely get some opinions if I posted it here:

Recently, the hospital I worked for highered a new neurosurgeon who I am sort of at odds with. I have nearly always chosen C7-T1 for ESIs no matter the location of the pathology (occasionally C6-7 if I could see a decent epidural space on MRI). This new guy insists that he has worked with rads who do C5-6 and even C4-5 translaminar ESIs. He insists they were translaminar and not transforaminal. I'm feeling pressure from him to do the level he asks, but I can't find any evidence that it is safe to do these higher levels. Most sources say that there is no appreciable epidural space above C6-7 and above here the ligamentum flavum is closely apposed to the dura. I've even presented him evidence that cervical epidural medication on average travels 3.8 levels above and below the injected space, and that didn't make him happy. I don't have any experience with transforaminal ESI, so I'd have to learn that technique should I want to adopt it. What are your thoughts on translaminar ESI above C7-T1?

Thanks in advance!

To be blunt, I'd tell him to go f@#k himself-

You a physician, not a nurse, not a PA. You make you own medical decisions based on your training and your review of the evidence. You are not his lackey that points a needle wherever he wants it. You are an independent physician that makes your own choices and are liable for your own complications. Will his malpractice cover you if you hurt someone? Will the knowledge that you and he are now "friends" ease your conscience after you paralyze somebody?

The medical evidence clearly states that CESI are always unsafe above C6-C7, and unsafe much of the time at C6-C7, and that medication is spread 4 levels superior to your entry spot, so C7-T1 is fine.

As I said before. Present the evidence, if he doesn't like it, politely agree to disagree, but stand your ground as a physician.
If he continues to hassles you, then tell him to to f@#k himself! He can send all his patients elsewhere.

There are quite a few big egos among neurosurgeons. They are used to people whimpering if they yell, and bowing to them. Don't be one of those. Be a physician.
This blowhard has no evidence to support him, just anecdote. What did we all learn about anecdote in medical school? ----The weakest form of clinical "evidence"

 

[101N]

There are quite a few big egos among neurosurgeons. They are used to people whimpering if they yell, and bowing to them. Don't be one of those. Be a physician.
This blowhard has no evidence to support him, just anecdote. What did we all learn about anecdote in medical school? ----The weakest form of clinical "evidence"

Now, now. I work closely with them and they are human like us. Maybe this guy - the NS - is fresh out of residency/fellowship and worked with a yahoo pain guy who did this stuff and got away with it.I'm in this situation now with a new partner.

IMO, the way to proceed is to get Derby's editorial and then offer Dex TFESIs as a compromise.

Don't get into a pissing contest with referring doc when there is an end around.

 

[Ducttape]

i wouldnt even offer the Dex TFESI, esp if you arent comfortable doing them. what is the difference in morbidity and mortality between a cervical TFESI vs. a ILESI above C6-7?

we all suspect that particulate steroids are the cause of catastrophic events from TFESI. anyone know what studies are out there that show that it is definitely the steroids and not the procedure itself that is associated with these catastrophic events?

 

[PinchandBurn]

i wouldnt even offer the Dex TFESI, esp if you arent comfortable doing them. what is the difference in morbidity and mortality between a cervical TFESI vs. a ILESI above C6-7?

we all suspect that particulate steroids are the cause of catastrophic events from TFESI. anyone know what studies are out there that show that it is definitely the steroids and not the procedure itself that is associated with these catastrophic events?

Well, if hte surgeon is looking mainly for 'diagnostic' purposes, the OP doesnt neceesary need to do a true TFESI. He could just do a diagnostic nerve root block. THe medullary arteries,etc are usually in teh foramen somewhere , not usually by the roots....

 

[docnyc]

To be blunt, I'd tell him to go f@#k himself-

You a physician, not a nurse, not a PA. You make you own medical decisions based on your training and your review of the evidence. You are not his lackey that points a needle wherever he wants it. You are an independent physician that makes your own choices and are liable for your own complications. Will his malpractice cover you if you hurt someone? Will the knowledge that you and he are now "friends" ease your conscience after you paralyze somebody?

The medical evidence clearly states that CESI are always unsafe above C6-C7, and unsafe much of the time at C6-C7, and that medication is spread 4 levels superior to your entry spot, so C7-T1 is fine.

As I said before. Present the evidence, if he doesn't like it, politely agree to disagree, but stand your ground as a physician.
If he continues to hassles you, then tell him to to f@#k himself! He can send all his patients elsewhere.

There are quite a few big egos among neurosurgeons. They are used to people whimpering if they yell, and bowing to them. Don't be one of those. Be a physician.
This blowhard has no evidence to support him, just anecdote. What did we all learn about anecdote in medical school? ----The weakest form of clinical "evidence"

+1. No need to feed his personality by being his lackie. I would let him send referrals elsewhere if he is unwilling to compromise. I have a good relationship with 4 local spine surgeons and when I first started I told them that I do not do CTFESI because of risk and they understood. Go C7-T1, document dye spread or thread catheter. Its not worth the risk for the pay you get for this procedure and also the fact that this NS would likely do nothing to stand up for you if there was a complication.

 

[lobelsteve]

To be blunt, I'd tell him to go f@#k himself-

You a physician, not a nurse, not a PA. You make you own medical decisions based on your training and your review of the evidence. You are not his lackey that points a needle wherever he wants it. You are an independent physician that makes your own choices and are liable for your own complications. Will his malpractice cover you if you hurt someone? Will the knowledge that you and he are now "friends" ease your conscience after you paralyze somebody?

The medical evidence clearly states that CESI are always unsafe above C6-C7, and unsafe much of the time at C6-C7, and that medication is spread 4 levels superior to your entry spot, so C7-T1 is fine.

As I said before. Present the evidence, if he doesn't like it, politely agree to disagree, but stand your ground as a physician.
If he continues to hassles you, then tell him to to f@#k himself! He can send all his patients elsewhere.

There are quite a few big egos among neurosurgeons. They are used to people whimpering if they yell, and bowing to them. Don't be one of those. Be a physician.
This blowhard has no evidence to support him, just anecdote. What did we all learn about anecdote in medical school? ----The weakest form of clinical "evidence"

+2

But you forgot to add where you heard about 4 level spread....

http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/CON_ID_000192

Excerpt:

Practicing pain management physicians offered their own advice for avoiding patient injury when performing cervical epidural injections as follows:
Try to use the C7–T1 space whenever possible. Epidurally injected substances spread up to four interspaces above the site of injection, so most of the cervical discs may be reached from this level while lessening the risk of cord damage.
Use fluoroscopy to ensure accurate identification of the spinal level.
Using the prone position may help to avoid unnecessary patient movement, decreasing the risk of dural puncture.
Avoid particulate steroid injections through the transforaminal approach.
Limit sedation when possible.
Encourage patients to communicate unusual symptoms during the procedure, and question them if they appear uncomfortable.
Avoid injecting the drug or contrast material if neuropathic pain is encountered during needle placement.
As baby boomers age, the incidence of back pain is increasing, and the demand for cervical epidural steroid injections will likely continue to increase.11 As with any invasive procedure, the risks must be weighed against the potential benefits to patients in deciding its appropriateness. We are hopeful that open discussion of clinical experiences, including reviews of medical malpractice claims, will serve to make this a more informed decision for both physicians and their patients.

 

[painstop]

This was interesting from Steve's link:

In the one claim involving a primary complaint of persistent headaches, the procedure report stated that the #18-gauge Tuohy needle was advanced into the epidural space under fluoroscopy using loss of resistance. At the time of the "pop" through the ligamentum flavum, the patient moved violently, and cerebrospinal fluid (CSF) returned through the needle. It was slowly withdrawn until the flow of CSF stopped and then, once contrast injection demonstrated epidural spread, triamcinolone was injected through the needle. In recovery, the patient complained of severe headache and over the next several days complained of neck and back pain and stiffness and numbness of the face. An MRI was unchanged over the preprocedure studies. A neurologist attributed the symptoms to probable arachnoiditis from steroids entering into the subarachnoid space.


What do you guys do when you have an inadvertant dural puncture in the cervical spine? Cancel, go to a different level or pull back until you get an epidurogram with no CSF return and then inject?

 

[NOSfan]

.....maybe thread a catheter to the level he asks.

+1

 

[jettavr6]

NS who has since become a great referral source wanted a two level Cervical TFESI. I put a catheter up there. Patient response was great. His response when I told him later: Cool...hadn't seen that done before.

 

[PMR 4 MSK]

You can also just simply say, "The literature I have reviewed and find credible suggests that CESI above C6-7 presents more risk than can be justified by the benefits. I will not do it." Let him find someone else to do them, and let them fight the lawsuit when the pt infarcts.

 

[onechance]

There is always the option of asking your radiology colleagues to do it under CT.

 

[powermd]

This was interesting from Steve's link:

In the one claim involving a primary complaint of persistent headaches, the procedure report stated that the #18-gauge Tuohy needle was advanced into the epidural space under fluoroscopy using loss of resistance. At the time of the “pop” through the ligamentum flavum, the patient moved violently, and cerebrospinal fluid (CSF) returned through the needle. It was slowly withdrawn until the flow of CSF stopped and then, once contrast injection demonstrated epidural spread, triamcinolone was injected through the needle. In recovery, the patient complained of severe headache and over the next several days complained of neck and back pain and stiffness and numbness of the face. An MRI was unchanged over the preprocedure studies. A neurologist attributed the symptoms to probable arachnoiditis from steroids entering into the subarachnoid space.


What do you guys do when you have an inadvertant dural puncture in the cervical spine? Cancel, go to a different level or pull back until you get an epidurogram with no CSF return and then inject?

Never had one recognized with dye spread. There was one patient where I repeatedly had a little pop and pink fluid with attempts at C7-T1 and C6-7 (two attempts each on two separate days). Suspecting DP, I simply aborted without dye injection. Being more cavalier then, I went C5-6 the next time and she got great relief. Never had a headache from the first two misadventures.

 

[pjuer]

I always personally review the images and make sure there is enough room to place my needle regardless of the level (even at C7-T1).

 

[Jcm800]

Agree to do it. So what's the big deal...just make sure that he will do the surgery of choice you "order" when you send a patient to him. You can do the C4-5 ilesi if he agrees to do the ALIF at L5-S1 but only with a Medtronic implant. And make sure he does his TF discectomies with at lest 45 degrees but no more than 52 degrees...Then I think its fair... Besides, you job is to just wrte the narcs anyway...

What a dummy.

Silly thing, he probably would do all that if asked hahahah

 

[ampaphb]

Goel A, Pollan JJ.
Contrast flow characteristics in the cervical epidural space: an analysis of cervical epidurograms.
Spine 2006 Jun 15;31(14):1576-9.

STUDY DESIGN:
A single-center prospective analysis of cervical epidurograms, using a crossover design.

OBJECTIVES:
To delineate the extent and pattern of spread of epidural contrast during cervical epidural steroid injections. To determine the volume of solution needed for effective cervical epidural steroid injections. To determine the most appropriate neck flexion angles for cervical epidural steroid injections. To determine the relationships between epidural spread, degree of neck flexion, and volume of solution used during cervical epidural steroid injections.

SUMMARY OF BACKGROUND DATA:
The decreased epidural space in the cervical region makes injections here liable to rare, but potentially serious, complications. The lower cervical (C6-C7, C7-T1) levels are thought to be safer because of the increased epidural space here, as compared with higher levels. There is, however, considerable controversy in the scientific literature regarding the levels at which cervical epidural injections should be performed. There is also no consensus regarding the volume of solution needed or the extent of neck flexion required for effective epidural spread. To date, no study has examined these questions.

METHODS:
Patients with lower cervical spine pathology who were referred for cervical epidural steroid injections were randomly assigned to have the injections performed at the C6-C7 or C7-T1 midline level. Volume of solutions used and degree of neck flexion were measured. Characteristics of epidural spread were recorded. Patients requiring repeat injections had the injections performed at the adjacent level with identical volume and angle of neck flexion using a goniometer. Contrast flow characteristics were again recorded. Extent of spread was correlated with the level of injection, volume of injectant, and degree of neck flexion.

RESULTS:
No major or permanent complications were noted. The contrast was found to spread evenly throughout the entire dorsal cervical epidural space, on a consistent basis, in all cases. At C6-C7, it was found to spread an average of 3.61 +/- 0.84 levels; and at C7-T1, it spread an average of 3.88 +/- 1.01 levels. Using a three-way analysis of variance, the level at which the epidural was performed, the amount of contrast used, and the neck flexion angle did not affect the number of levels spread.

CONCLUSIONS:
In cervical epidural steroid injections performed in the midline at C6-C7 and C7-T1, the contrast consistently covers the dorsal cervical epidural space bilaterally, irrespective of the volume used or neck flexion angle used. This suggests that solutions introduced here would cover the dorsal cervical epidural space. This questions the utility of performing potentially more dangerous injections at higher cervical levels or more invasive procedures, such as the use of epidural catheters.

 

[powermd]

volume range?

Goel A, Pollan JJ.
Contrast flow characteristics in the cervical epidural space: an analysis of cervical epidurograms.
Spine 2006 Jun 15;31(14):1576-9.

STUDY DESIGN:
A single-center prospective analysis of cervical epidurograms, using a crossover design.

OBJECTIVES:
To delineate the extent and pattern of spread of epidural contrast during cervical epidural steroid injections. To determine the volume of solution needed for effective cervical epidural steroid injections. To determine the most appropriate neck flexion angles for cervical epidural steroid injections. To determine the relationships between epidural spread, degree of neck flexion, and volume of solution used during cervical epidural steroid injections.

SUMMARY OF BACKGROUND DATA:
The decreased epidural space in the cervical region makes injections here liable to rare, but potentially serious, complications. The lower cervical (C6-C7, C7-T1) levels are thought to be safer because of the increased epidural space here, as compared with higher levels. There is, however, considerable controversy in the scientific literature regarding the levels at which cervical epidural injections should be performed. There is also no consensus regarding the volume of solution needed or the extent of neck flexion required for effective epidural spread. To date, no study has examined these questions.

METHODS:
Patients with lower cervical spine pathology who were referred for cervical epidural steroid injections were randomly assigned to have the injections performed at the C6-C7 or C7-T1 midline level. Volume of solutions used and degree of neck flexion were measured. Characteristics of epidural spread were recorded. Patients requiring repeat injections had the injections performed at the adjacent level with identical volume and angle of neck flexion using a goniometer. Contrast flow characteristics were again recorded. Extent of spread was correlated with the level of injection, volume of injectant, and degree of neck flexion.

RESULTS:
No major or permanent complications were noted. The contrast was found to spread evenly throughout the entire dorsal cervical epidural space, on a consistent basis, in all cases. At C6-C7, it was found to spread an average of 3.61 +/- 0.84 levels; and at C7-T1, it spread an average of 3.88 +/- 1.01 levels. Using a three-way analysis of variance, the level at which the epidural was performed, the amount of contrast used, and the neck flexion angle did not affect the number of levels spread.

CONCLUSIONS:
In cervical epidural steroid injections performed in the midline at C6-C7 and C7-T1, the contrast consistently covers the dorsal cervical epidural space bilaterally, irrespective of the volume used or neck flexion angle used. This suggests that solutions introduced here would cover the dorsal cervical epidural space. This questions the utility of performing potentially more dangerous injections at higher cervical levels or more invasive procedures, such as the use of epidural catheters.

 

[ampaphb]

3ml

 

[101N]

3ml

Go bigger: 3mL Celestone, 2mL Omnipaque, 5mL H20.

 

[ampaphb]

according the study cited below, 3ml of contrast covers 3.88 +/- 1.01 levels. So you can tell your referral source a C7/T1 CESI always covers up to 4/5, and often up to 2/3. I personally find that i get spread to 0/1 about 15% of the time (YMMV)

no need to "go bigger", and certainly no need to dilute with 5ml of distilled water. 18mg of betamethasone also seems like an excessive steroid load

I personally inject 3cc of contrast to document spread, a 1cc lidocaine 1% test dose, and then 1 cc lidocaine 2%, 1cc compounded 9mg/ml betamethasone, and 1cc normal saline.

 

[lobelsteve]

Go bigger: 3mL Celestone, 2mL Omnipaque, 5mL H20.

What if they have canal stenosis? DO you go with less water?

 

[101N]

What if they have canal stenosis? DO you go with less water?

No. I inject SLOWLY and the aliquot inevitably travels the path of least resistance. If there is cervical stenosis then it will go thoracic.

I've also found that my needle position - 90 degrees - sometimes also effects the direction of flow. I do all of my ILESIs by fluoro, not feel. By that I mean that I find the target lamina, drop the II caudad about 10 degrees and then enter specifically there. That places my needle trajectory at or about 90 degrees to the skin. Sometimes with that needle position flow is caudal, not rostral even if you rotate the bevel.

Do you use feel - like DCS lead placement - or fluoro for ILESIs?

 

[101N]

a 1cc lidocaine 1% test dose, and then 1 cc lidocaine 2%,

This is interesting. Lido scares me via the IL approach, I've seen bad things happen with it.

 

[PinchandBurn]

according the study cited below, 3ml of contrast covers 3.88 +/- 1.01 levels. So you can tell your referral source a C7/T1 CESI always covers up to 4/5, and often up to 2/3. I personally find that i get spread to 0/1 about 15% of the time (YMMV)

no need to "go bigger", and certainly no need to dilute with 5ml of distilled water. 18mg of betamethasone also seems like an excessive steroid load

I personally inject 3cc of contrast to document spread, a 1cc lidocaine 1% test dose, and then 1 cc lidocaine 2%, 1cc compounded 9mg/ml betamethasone, and 1cc normal saline.

thats a lot lido......1ml of 1% and then 1ml of lido2% ? In fellowship I've seen it go intrathecal despite nice contrast flow (sometimes needles move even with a tubing attached). Also with tht much lido if it goes caudad, you could affect the cardioaccelerator fibers--->bradycardia. In fellowship, I've seen a patient or two almost need intubation s/p local use in the cervical spine. One of our attendings advocated no local anesthetic use in the C-spine and just PF saline and steroid.

If anything, now I use contrast to confirm spread. Then 3ml of PF saline, 0.5ml of 1%lido, and 80 depomedrol (for ILESI in the cervical spine). Yes, particulate steroid, there's no arteries in the posterior epidural space. If ANY doubt, I'll substitute 6mg of dexamethaone instead of the depomedrol.

 

[lobelsteve]

No. I inject SLOWLY and the aliquot inevitably travels the path of least resistance. If there is cervical stenosis then it will go thoracic.

I've also found that my needle position - 90 degrees - sometimes also effects the direction of flow. I do all of my ILESIs by fluoro, not feel. By that I mean that I find the target lamina, drop the II caudad about 10 degrees and then enter specifically there. That places my needle trajectory at or about 90 degrees to the skin. Sometimes with that needle position flow is caudal, not rostral even if you rotate the bevel.

Do you use feel - like DCS lead placement - or fluoro for ILESIs?

100% fluoro for all neuraxials.

SCS with 14g and 30 degree angle. LOR to air.
ESI with 18g and 20 degree angle. LOR nss

 

[101N]

100% fluoro for all neuraxials.

SCS with 14g and 30 degree angle. LOR to air.
ESI with 18g and 20 degree angle. LOR nss

This is not what I mean. By fluoro guidance I mean find the target lamina - C7 - fluoroscopically and go straight in under it. My goal is to have a 'hub view' in AP all the way to the LOR. This puts the needle near perpendicular to the skin. The technique you are describing is driven by 'feel' and confirmed with LOR, CLO, and then contrast-fluoro. You can't get your C-Arm into a 20 angle to the skin, so it really isn't guiding your needle's trajectory in AP.

I'm not implying that my way is the best, it's just what I adopted after fellowship. I'm a physiatrist but I was taught the technique you describe by anesthesiologists during fellowship. What I try to do is avoid bouncing off of lamina and trajectory readujustments.

 

[SSdoc33]

test dose for an interlaminar injection?

lido for an interlaminar injection?

wha?????? please explain your rationale. being as thoughtful as you are, i'm sure there are reasons behind this.

IMHO mL of steroid of choice and be done with it -- dex for me.

10 mL or however much 101N was talking about seems a bit silly and over-diluting the steroid

 

[lobelsteve]

This is not what I mean. By fluoro guidance I mean find the target lamina - C7 - fluoroscopically and go straight in under it. My goal is to have a 'hub view' in AP all the way to the LOR. This puts the needle near perpendicular to the skin. The technique you are describing is driven by 'feel' and confirmed with LOR, CLO, and then contrast-fluoro. You can't get your C-Arm into a 20 angle to the skin, so it really isn't guiding your needle's trajectory in AP.

I'm not implying that my way is the best, it's just what I adopted after fellowship. I'm a physiatrist but I was taught the technique you describe by anesthesiologists during fellowship. What I try to do is avoid bouncing off of lamina and trajectory readujustments.

99% of Cesi are C7-T1. I touch T1 lamina always before going on to ligament. 2-3mm from midline.

 

[PMR 4 MSK]

99% of Cesi are C7-T1. I touch T1 lamina always before going on to ligament. 2-3mm from midline.

The fun part is explaining to the patient why the entry level is differnt that their pathology level.

"My herniated disk is at C5-6, why are you doing it at C7-T1?"

"Because I want you to be able to stand when we finish..."

 

[Ducttape]

wow, my volumes are horrendously low then...

80 depo and 2 cc preservative free saline (and contrast, of course) is all i use.

 

[clubdeac]

wow, my volumes are horrendously low then...

80 depo and 2 cc preservative free saline (and contrast, of course) is all i use.

👍

 

[PMR 4 MSK]

wow, my volumes are horrendously low then...

80 depo and 2 cc preservative free saline (and contrast, of course) is all i use.

A couple ccs of contrast + 1 cc steroid is all I usually use, yet the post-injection images still show spread for 2-3 levels at least in most cases.

 

[mille125]

To be blunt, I'd tell him to go f@#k himself-

You a physician, not a nurse, not a PA. You make you own medical decisions based on your training and your review of the evidence. You are not his lackey that points a needle wherever he wants it. You are an independent physician that makes your own choices and are liable for your own complications. Will his malpractice cover you if you hurt someone? Will the knowledge that you and he are now "friends" ease your conscience after you paralyze somebody?

The medical evidence clearly states that CESI are always unsafe above C6-C7, and unsafe much of the time at C6-C7, and that medication is spread 4 levels superior to your entry spot, so C7-T1 is fine.

As I said before. Present the evidence, if he doesn't like it, politely agree to disagree, but stand your ground as a physician.
If he continues to hassles you, then tell him to to f@#k himself! He can send all his patients elsewhere.

There are quite a few big egos among neurosurgeons. They are used to people whimpering if they yell, and bowing to them. Don't be one of those. Be a physician.
This blowhard has no evidence to support him, just anecdote. What did we all learn about anecdote in medical school? ----The weakest form of clinical "evidence"

Agreed......If something went wrong, you better believe that the NS would be saying in court...He is a doctor isnt he....He didnt have to listen to me...