ultrasound guided injections

[guptaa3]

I recently went to an ultrasound conference for pain management. Other pain doctors are apparently using ultrasound and doing caudal epidurals in their office. Anyone else doing this? Also if you are , do you bill separately for the ultrasound guidance or is imaging already bundled in with the caudal.

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[Ligament]

I think it is poor practice to do any type of epidural under u/s guidance, unless there are extenuating circumstances.

 

[geauxg8rs]

here we go again

 

[specepic]

In contradistinction to my position regarding ultrasound for sacroiliac joints would definitely agree regarding ultrasound being inappropriate, in general, as an exclusive imaging modality for epidural injections. I do not do caudal injections very often, but assuming there is a potential for vascular uptake, which I would assume there is, doing them under ultrasound would be suboptimal.

Possible applications could be women in her third trimester of pregnancy however. I think this situation is very different from the sacroiliac joint in that you can see vessels just above or within the portion of the joint were your injecting, with an epidural injection there is too much bone hiding where the needle tip needs to be.

I do not wish to resurrect the sacroiliac joint argument however, that can be found on the private forearm for those interested.

 

[bedrock]

I recently went to an ultrasound conference for pain management. Other pain doctors are apparently using ultrasound and doing caudal epidurals in their office. Anyone else doing this? Also if you are , do you bill separately for the ultrasound guidance or is imaging already bundled in with the caudal.

The "other" pain doctors you speak of are money-grubbing ******. Hopefully you aren't using them as role models. Forget the ultrasound question for a minute. Why are they doing all these caudals? Epidurals are more effective the closer you are to the target and indications for caudals are fairly rare. Those "pain doctors" probably aren't even fellowship trained and are just doing the easiest epidural that they can perform and they're billing it with ultrasound to make as much money as possible.

They're money-grubbing ****** disgracing the specialty of pain medicine for two reasons by #1 doing a lot of caudal ESI and #2 doing them with ultrasound. How do they sleep at night?

Didn't we originally get into medicine to help people? I've never seen a caudal ESI help someone more than a transforaminal.

 

[101N]

The "other" pain doctors you speak of are money-grubbing ******. Hopefully you aren't using them as role models. Forget the ultrasound question for a minute. Why are they doing all these caudals? Epidurals are more effective the closer you are to the target and indications for caudals are fairly rare. Those "pain doctors" probably aren't even fellowship trained and are just doing the easiest epidural that they can perform and they're billing it with ultrasound to make as much money as possible.

They're money-grubbing ****** distracing the specialty of pain medicine for two reasons by #1 doing a lot of caudals and #2 doing them with ultrasound. How do they sleep at night?

Didn't we originally get into medicine to help people? I've never seen a caudal ESI help someone more than a transforaminal.

Understand your overall position and respect it. However, a caudal under fluoro with a catheter guided where you want it can be pretty darn effective.

 

[Aether2000]

Agree with Bedrock. There are both safety and accuracy issues with caudal ESI and accuracy issues with SI under ultrasound. My take is that unless you can see the tip of the needle and see the injectate path for any spine interventional technique, it is tantamount to fraud since 1. there are readily available accurate alternatives in every acute care hospital in the US and 2. reeks of laziness/insouciance by the physician. If they really don't care where the injecte goes, then they cannot ethically use US for interventional spine techniques. BTW, one cannot see any blood vessels inside bone or in the SI joint using ultrasound. The echogenicity makes this physically impossible.

 

[bedrock]

indications for caudals are fairly rare.

Understand your overall position and respect it. However, a caudal under fluoro with a catheter guided where you want it can be pretty darn effective.

Agree that caudal ESI with catheter guidance can be quite effective for certain situations, and that is exactly what I had in mind as the only real indication for a caudal ESI.
It's hard to think of a indication for a regular caudal ESI and there certainly isn't any indication for an US guided caudal ESI other than greed, sloth, +/- bad interventional training.

 

[powermd]

Agree that caudal ESI with catheter guidance can be quite effective for certain situations, and that is exactly what I had in mind as the only real indication for a caudal ESI.
It's hard to think of a indication for a regular caudal ESI and there certainly isn't any indication for an US guided caudal ESI other than greed, sloth, +/- bad interventional training.

I did an ultrasound guided caudal on Monday.

1. Patient reported a severe contrast dye allergy.
2. On Coumadin for afib.
3. Postlami at the level of interest.
4. Lives hours away, wants procedure today.
5. Fat enough to see the needle enter the hiatus under active guidance.

I guess I'm just a greedy bastard.

btw, my partners do caudals with 10 mL volume and 120 mg depo. I thought it was crazy at first, but this works well for A LOT of patients. Previously I had only ever done caudals with 5 mL and 80 of depo, with very disappointing results.

 

[101N]

I did an ultrasound guided caudal on Monday.

1. Patient reported a severe contrast dye allergy.
2. On Coumadin for afib.
3. Postlami at the level of interest.
4. Lives hours away, wants procedure today.
5. Fat enough to see the needle enter the hiatus under active guidance.

I guess I'm just a greedy bastard.

btw, my partners do caudals with 10 mL volume and 120 mg depo. I thought it was crazy at first, but this works well for A LOT of patients. Previously I had only ever done caudals with 5 mL and 80 of depo, with very disappointing results.

During fellowship we did some caudals with fluoro and a Stimuplex needle.
If you advance the Stimuplex into the hiatus and stim you get an anal wink as confirmation of epidural placement. We verified it with fluoro.

However, I only do my caudals with a cath as I like to thread it up to 4/5 or 5/1 where the pathology usually is.

 

[lobelsteve]

😱

I did an ultrasound guided caudal on Monday.

1. Patient reported a severe contrast dye allergy.
2. On Coumadin for afib.
3. Postlami at the level of interest.
4. Lives hours away, wants procedure today.
5. Fat enough to see the needle enter the hiatus under active guidance.

I guess I'm just a greedy bastard.

btw, my partners do caudals with 10 mL volume and 120 mg depo. I thought it was crazy at first, but this works well for A LOT of patients. Previously I had only ever done caudals with 5 mL and 80 of depo, with very disappointing results.

Not a greedy bastard. But an idiot- YES. And if he developed an epidural hematoma- no expert for you. Indefensible. Irresponsible. Did you just cure cancer with a caudal? Or perform an ELECTIVE procedure with marginal evidence of effect? Actually, the risk is quite low, but the outcome could have been catastrophic. Boo to you for this.

 

[powermd]

😱

Not a greedy bastard. But an idiot- YES. And if he developed an epidural hematoma- no expert for you. Indefensible. Irresponsible. Did you just cure cancer with a caudal? Or perform an ELECTIVE procedure with marginal evidence of effect? Actually, the risk is quite low, but the outcome could have been catastrophic. Boo to you for this.

Needle tip (25g) was only advanced through the sacrococcygeal ligament- not all the way up the hiatus. The risk for a hematoma in this circumstance is EXCEEDINGLY low. My partners have been doing caudals this way in patients on anticoagulation for >10 years and haven't had a hematoma yet. At a conference with 50 docs present, one got up and asked for a show of hands who does caudals in anticoagulated patients. Lots of hands. How many have seen or heard of a hematoma. None. It's very low risk Steve. I would be more concerned about the risks of stopping anticoagulation. No risk free option here. You explain the risks to the patient, and it's theirs to take. If I am at fault for allowing the patient to take the risk of an epidural hematoma, am I (or the cardiologist, or the internist) not also at risk if I/we allow the patient to stop their anticoagulation?

 

[facets]

I disagree with the above. Taking a patient off coumadin is often more risky than doing a caudal epidural with a 25 gauge needle. I have done this many times and have never had an epidural bleed with this technique. I have had strokes and MI's when taking someone off anticoagulation for other procedures. (22 years of experience) This is the only "spinal procedure" I will do with someone on coumadin. Leaving a patient in terrible pain or taking the risk of a CVA by taking them off coumadin are worse alternatives IMHO. I practice in an area that is mostly elderly and have done thousands of caudals with good results and I've never used 120 mg of depo, I use 40-80. If this does not work I will clear the dc of coumadin with cardio.

 

[101N]

I disagree with the above. Taking a patient off coumadin is often more risky than doing a caudal epidural with a 25 gauge needle. I have done this many times and have never had an epidural bleed with this technique. I have had strokes and MI's when taking someone off anticoagulation for other procedures. (22 years of experience) This is the only "spinal procedure" I will do with someone on coumadin. Leaving a patient in terrible pain or taking the risk of a CVA by taking them off coumadin are worse alternatives IMHO. I practice in an area that is mostly elderly and have done thousands of caudals with good results and I've never used 120 mg of depo, I use 40-80. If this does not work I will clear the dc of coumadin with cardio.

During fellowship a referring doc sent me a patient on ASA for stroke prophylaxis. Prior to restarting the ASA after the ESI the patient died of a CVA. Yes, holding anticoagulation is a REAL risk.

There is no data on this topic- caudals in the context of full anticoag - or the risk of caudals under fluoro vs US guidance. A lot of the vitriol on this thread - and the SIJA thread - is just that.

 

[facetguy]

Agree with Bedrock.... There are both safety and accuracy issues with caudal ESI and accuracy issues with SI under ultrasound. My take is that unless you can see the tip of the needle and see the injectate path for any spine interventional technique, it is tantamount to fraud since 1. there are readily available accurate alternatives in every acute care hospital in the US and 2. reeks of laziness/insouciance by the physician. If they really don't care where the injecte goes, then they cannot ethically use US for interventional spine techniques. BTW, one cannot see any blood vessels inside bone or in the SI joint using ultrasound. The echogenicity makes this physically impossible.

Now this is why I come to this forum! I vow to use that word in a sentence before noon tomorrow. Anyone else with me? 😉

 

[lobelsteve]

1. ASRA guidelines. While not identical or intended for your injection, they still apply.

2. Caudal vs tfesi. Literature exists and does not favor caudals.


Terms like: in my experience, in a room of 50, or for my patients detract from the science of pain medicine. I'm glad no one has realized the risk through complication, but consider the consequences of your actions. ASA need not be stopped for Neuraxial injection, the risk of cva from Afib is 4% per year without anticoagulation and 1 to 1.5% per year on coumadin. These are the known quantities.

 

[101N]

1. ASRA guidelines. While not identical or intended for your injection, they still apply.

2. Caudal vs tfesi. Literature exists and does not favor caudals.


Terms like: in my experience, in a room of 50, or for my patients detract from the science of pain medicine. I'm glad no one has realized the risk through complication, but consider the consequences of your actions. ASA need not be stopped for Neuraxial injection, the risk of cva from Afib is 4% per year without anticoagulation and 1 to 1.5% per year on coumadin. These are the known quantities.

Prior to med school I worked as a grounds keeper in a cemetery. There was a guy there - sweet guy - who was mentally ******ed and dug graves by hand. His overseer made a notch on his shovel to designate the state mandated depth for a grave.

Long story short, the state laws changed from 48 in to 36in - or some such - and the poor dude couldn't adapt. He saw that notch on his shovel and just had to dig the graves to that depth. Finally the overseer thought up a solution, he bought a new shovel, marked the line at 36" and tossed the old one.

Some of you guys remind me of the grave digger of my past🙂

 

[Ligament]

Lets move to private forum?

 

[101N]

Lets move to private forum?

No, lets not. I'm not a member of the private forum and have no intention of joining.

 

[bedrock]

Some of this discussion taken out of context is definitely lawyer fodder. I also vote to move to private forum.


101N- Sounds like you've finished residency. I don't see why you can't join the private forum.

 

[101N]

Some of this discussion taken out of context is definitely lawyer fodder. I also vote to move to private forum.


101N- Sounds like you've finished residency. I don't see why you can't join the private forum.

Yea, I'm way past residency.

This forum is kinda like China in terms of editorial license.

 

[PMR2008]

how do you join the private forum?

 

[powermd]

1. ASRA guidelines. While not identical or intended for your injection, they still apply.

If not identical or intended for my injection, how so? A 25g needle through the sacrococcygeal ligament versus any of the other neuraxial spaces seems like apples and oranges to me. Why get bent out of shape over a theoretical risk that seems to be irrelevant in practice (and a stretch in theory).

2. Caudal vs tfesi. Literature exists and does not favor caudals.

A caudal is not my first choice injection, however there can exist circumstances that favor trying it out for a patient.

 

[lobelsteve]

If not identical or intended for my injection, how so? A 25g needle through the sacrococcygeal ligament versus any of the other neuraxial spaces seems like apples and oranges to me. Why get bent out of shape over a theoretical risk that seems to be irrelevant in practice (and a stretch in theory).



A caudal is not my first choice injection, however there can exist circumstances that favor trying it out for a patient.

It's your practice and your patients. Just not on my mom.

Epidural is epidural, and a plaintiff's attorney would point to the patient and ask if the pain relief was worth the urgent surgical decompression or paralysis.

If it is such a risk and a stretch, why didn't ASRA just say so. No neuroxial procedures unless they are US guided and done with a 25G but not into the hiatus, only through the SC ligament (and not the posterior lower fibers as that would be an impar block).

Differences in opinion is fine, but if you had the complication and violated the standard of care per ASRA guidelines, YOU would be in a hole that would be terribly difficult to extricate yourself out of at time of trial. Where I practice we call it the $1,000,000 epidural. You can do it, but it may cost $1,000,000 as that is all Mag Mutual will pay per occurrence. I tell this to the patients and we reschedule. Anticoagulation risks are stated by me for both continuing and stopping. I say 1 in 10,000 to 100,000 in ESI on thinners for complication and 4% per year CVA risk for AFib off coumadin- and their INR is off for about 5 days total.

Charles April: These are elective procedures. Everybody walks home at the end of the day.

Lobel: We are all the same height horizontally.

 

[lonelobo]

During fellowship a referring doc sent me a patient on ASA for stroke prophylaxis. Prior to restarting the ASA after the ESI the patient died of a CVA. Yes, holding anticoagulation is a REAL risk.

There is no data on this topic- caudals in the context of full anticoag - or the risk of caudals under fluoro vs US guidance. A lot of the vitriol on this thread - and the SIJA thread - is just that.

Lots of pts are old and fragile...hence some die...find it unlikely this ASA
made a world of difference

 

[specepic]

how do you join the private forum?

Kiki takes you through the black curtain in the back, 100 cash up front, you can touch but nothing too kinky, ok; oh you mean the physician only forum, there is a sticky

 

[PMR 4 MSK]

To me, it's all good and well to "do the right thing" and provide the patient pain relief. At least in theory. Poor pt, suffering in pain, who wouldn't want to help him?

However, we live in a world where the slightest hint of a suboptimal outcome raises the possibility of a lawsuit. Do enough cases like this, and that lawsuit will come to you. And one lawsuit can ruin you. Even if it doesn't, it will follow you for the rest of your life, grating on you.

If I choose not to do a caudal ESI on a pt on coumadin, but instead provide pain relief through meds, PT, TENS, etc, I have attempted to help him with out the risk of interventional injection. If it didn't help, at least I tried.

If I choose to forgo those options, jump to the needle and there is a poor outcome, what is my defense? "I was only trying to help him!" Sure, that and a check for $5M will get you off the hook.

So if you go through all the more conservative options, he's still in pain, and then you opt for intervention, you are operating in no-man's land. There are no studies of the comparative safety and efficacy of caudal vs TF ESI in pts on coumadin. You are taking a chance.

If you have ever been sued, or trained and practice defensively, you opt not to endanger the pt with intervention. If not, you stick the needle in and hope for the best. But in the setting of a poor outcome, particularly a catastrophic one, you have no defense. You did the right thing, but you'll pay dearly for it.

I choose to be defensive. I did not set up the system, I just live with it.

And I have been sued.

 

[SSdoc33]

if you are gonna do an ESI, do it the right right way, for gods sake. you may think you are killing 2 birds with one stone by keeping the patients on coumadin and gieing them a caudal. however, what you are REALLY doing, is exposing them to a (albeit small) bleeding risk, and performing a suboptimal injection. dumb, IMHO

 

[facets]

Actually caudals can be extremely helpful, esp in patients with pain low over the sacrum, coccydynia, radiculitis. Do I have studies to back this up? No, only thousands of injections in elderly patients over a career of 22 years. Try it, you may be surprised. They are more cost effective than TFI. IMHO, the reason TFI are so popular among PMR docs is because they are not comfortable with ILEI or caudals.

 

[101N]

IMHO, the reason TFI are so popular among PMR docs is because they are not comfortable with ILEI or caudals.

Thanks for clearing that up for us🙂

 

[Ligament]

IMHO, the reason TFI are so popular among PMR docs is because they are not comfortable with ILEI or caudals.

This is actually true IMHO having done a PMR residency and Anesthesiology fellowship there is a big difference in comfort level with these particular procedures.

On the other hand, most anesthesiologist pain docs are terrified of hip and knee injections. Irrational fear of infection.

 

[SSdoc33]

Actually caudals can be extremely helpful, esp in patients with pain low over the sacrum, coccydynia, radiculitis. Do I have studies to back this up? No, only thousands of injections in elderly patients over a career of 22 years. Try it, you may be surprised. They are more cost effective than TFI. IMHO, the reason TFI are so popular among PMR docs is because they are not comfortable with ILEI or caudals.

well, if "facets" says its true, then it must be!!! if a patient has coccydynia, then do a ganglion impar. if they have stenosis or a hnp, do a TFESI. nto sure what you mean by "radiculitis" -- sounds like a waste-bucket term for non-specific leg pain. i truly see zero indication for caudals, despite the fact that i have been trained to do them. i prefer to put the medication at the site of pathology, rather than 5 inches away, mixed with a crapload of dilutant and hoping that im treating something. by being so non-specific, you are doing your patients a dis-service. if you dont know whats wrong, then dont do a shot at all.

 

[PMR 4 MSK]

Actually caudals can be extremely helpful, esp in patients with pain low over the sacrum, coccydynia, radiculitis. Do I have studies to back this up? No, only thousands of injections in elderly patients over a career of 22 years. Try it, you may be surprised. They are more cost effective than TFI. IMHO, the reason TFI are so popular among PMR docs is because they are not comfortable with ILEI or caudals.

I was taught all 3 approaches. One of my attendings only did caudals. I personally don't like caudals.

I do more IL than TF. I find it easier in stenotic pts.

 

[facets]

I didnt say it was an indisputable fact, only that I have seen it work. If you have a patient who cannot be taken off coumadin, is medicated and has had pt, and is still in pain, do you withhold treatment because because you only are comfortable with TFI and there are "no studies showing the efficacy of caudals over TFI"? Or do you do what you have seen work? A little humility and compassion goes a long way. I don't believe telling a patient to just hurt until they die or clot off their stents is an option. Not in my mother, who I have treated successfully on plavix. Taking her off so she could clot off her stents was not an acceptable risk to me. There are times when you just have to stop being so dogmatic and be a physicain, trying to do whats best in an imperfect world

 

[Ligament]

I certainly have seen caudals help a lot of people. Given the option, I'd prefer TFESIs but nothing wrong with caudals.

 

[SSdoc33]

I didnt say it was an indisputable fact, only that I have seen it work. If you have a patient who cannot be taken off coumadin, is medicated and has had pt, and is still in pain, do you withhold treatment because because you only are comfortable with TFI and there are "no studies showing the efficacy of caudals over TFI"? Or do you do what you have seen work? A little humility and compassion goes a long way. I don't believe telling a patient to just hurt until they die or clot off their stents is an option. Not in my mother, who I have treated successfully on plavix. Taking her off so she could clot off her stents was not an acceptable risk to me. There are times when you just have to stop being so dogmatic and be a physicain, trying to do whats best in an imperfect world

i agree that there are a lot of shades of gray here, and i appreciate your thoughtful response to my needless animosity. i guess the difference is that i simply wouldnt do ANY epidural on plavix or coumadin. therefore, whether its a caudal or not is irrevelant. im all for being a physician, and if it werent for fear of litigation, i may consider your path

 

[lonelobo]

Thanks for clearing that up for us🙂

I am PMR trained , statement maybe true if you are talking about blind IESI or caudal., but otherwise I am very comfortable.

On the other hand I wonder if the older Anesthesia Docs are more comfortable with the IESI than TFESI because they were never trained
and taught themselves?

 

[facets]

Some older anesthesia docs have kept up with the times, myself included. I trained in the 80's with blind ILEI and caudals, switched to fluro guided which made life much easier and learned TFI. I think the point you are making is that years of experience is valuable if you have changed your practice as advances in medical science occurs, rather than staying stuck in the 80's or 90's, a point well taken for any speciality

 

[Aether2000]

I think the other side of the coin that demonstrates the value of being ancient is that one has seen many fads come and go, and age affords one the experience and wisdom to not jump on bandwagons that are clearly less accurate than what is currently available (eg. spinal ultrasound procedures vs fluoroscopy) while understanding the value of the new in context of improved visualization and accuracy in other applications (US for shoulder/cyst/hematoma diagnostics and US for plexus/nerve/peripheral joint injections). Of course in order to appreciate the true value of a new toy, it takes years of practice, continual updating of training, and study. It must also be affordable to patients and not used fraudulently in order to generate revenue.

 

[painMD24]

"First do no harm" applies here. No epidural, regardless of site with a patient on anticoagulation. No one doubts the good intentions of any of the pain physicians here, but to proceed simply because you haven't had a bad outcome, contrary to what our guidelines recommend, I believe is risky practice.

 

[powermd]

If it is such a risk and a stretch, why didn't ASRA just say so.

Maybe they didn't consider this technique.

No neuroxial procedures unless they are US guided

The US guidance had only to do with the patient's dye allergy.

and done with a 25G but not into the hiatus, only through the SC ligament (and not the posterior lower fibers as that would be an impar block).

Incidentally, is there anyone else on this board who does caudal injections this way? I am referring to simply dropping a 25 or 27g needle through the SC ligament at 90 degrees(ish) to the sacrum, and then checking dye spread. Can be quite a bit faster. I only learned of this technique from my current partners. Up until then, I had only ever done the classical technique involving driving a needle into the hiatus.

 

[bedrock]

The US guidance had only to do with the patient's dye allergy.

Ok, I still don't see how the dye allergy some causes US to now be a superior method of guidance for a caudal ESI. You can't see vascular uptake using either method (flouro without contrast) or the US.

Incidentally, is there anyone else on this board who does caudal injections this way? I am referring to simply dropping a 25 or 27g needle through the SC ligament at 90 degrees(ish) to the sacrum, and then checking dye spread. Can be quite a bit faster. I only learned of this technique from my current partners. Up until then, I had only ever done the classical technique involving driving a needle into the hiatus.

This sounds like a ganglion impar block, not a epidural.

I suppose you could get some epidural flow from that but not a high percentage. In this scenario, the 120mg of depo injected into the body is probably causing most of the treatment effect, not a targeted injection site. I'd wager that an IM injection of 120 of depo might work as well as the roundabout SC ligament approach.

And with the butt injection, no worries about compressible vital structures on anticoagulated patients!

 

[lobelsteve]

Maybe they didn't consider this technique.



The US guidance had only to do with the patient's dye allergy.



Incidentally, is there anyone else on this board who does caudal injections this way? I am referring to simply dropping a 25 or 27g needle through the SC ligament at 90 degrees(ish) to the sacrum, and then checking dye spread. Can be quite a bit faster. I only learned of this technique from my current partners. Up until then, I had only ever done the classical technique involving driving a needle into the hiatus.

I only do caudals with catheters. An Arrow theracath can be advanced to L1-2 and I can drag and drop meds from L1 to S3. A Myelotec steerable catheter can be used for a mild adhesiolysis ( not the crap Racz is selling). I use a 18g Tuohy with or without a plastic introducer to enter the hiatus. Putting medicine at S4 doesn't make a lot of sense to me, unless you put them on a vibrating inversion table.

 

[powermd]

I only do caudals with catheters. An Arrow theracath can be advanced to L1-2 and I can drag and drop meds from L1 to S3. A Myelotec steerable catheter can be used for a mild adhesiolysis ( not the crap Racz is selling). I use a 18g Tuohy with or without a plastic introducer to enter the hiatus. Putting medicine at S4 doesn't make a lot of sense to me, unless you put them on a vibrating inversion table.

No wonder you object to caudals on anti coagulated patients!

 

[powermd]

Ok, I still don't see how the dye allergy some causes US to now be a superior method of guidance for a caudal ESI. You can't see vascular uptake using either method (flouro without contrast) or the US.



This sounds like a ganglion impar block, not a epidural.

I suppose you could get some epidural flow from that but not a high percentage.

I'm not talking about passing the needle through the sacrum and out the other side. I'm talking about dropping it in between the sacral cornu, but not driving it up the hiatus (between the anterior/posterior oriented bones). Using this technique you do indeed get good caudal epidural dye flow. I always ask the patients where they feel the pressure from the injection. Invariably it's in the legs, not the buttocks.

Like I said before, it's not my first choice injection. But if a guy traveled 3 1/2 hours to see me, is on coumadin/Plavix, and wants an injection today, it seems like a reasonable compromise. It's quite surprising how effective these can be. I suspect the relief comes as much from the hydrodissection of injecting 10 mL up the epidural space as from the steroids.

 

[Jcm800]

Understand your overall position and respect it. However, a caudal under fluoro with a catheter guided where you want it can be pretty darn effective.

caudals with ultrasound dumb, unless pregnant, maybe an arguement. however, a caudal esi with fluoro sometimes is a good thing. and i only use a catheter...and yes its a racz catheter...but it could be any catheter that steers and is visible...

 

[Jcm800]

1. ASRA guidelines. While not identical or intended for your injection, they still apply.

2. Caudal vs tfesi. Literature exists and does not favor caudals.


Terms like: in my experience, in a room of 50, or for my patients detract from the science of pain medicine. I'm glad no one has realized the risk through complication, but consider the consequences of your actions. ASA need not be stopped for Neuraxial injection, the risk of cva from Afib is 4% per year without anticoagulation and 1 to 1.5% per year on coumadin. These are the known quantities.

while i would not call power an idiot, i will agree with steve, that there will be a line of people waiting to hang you out to dry if you have a problem. It isnt worth it. ASRA guidelines are not gospel, but pretty close in the courtroom. it isnt worth it...if there is a real concern about stopping anti-coagulation, then bridge with lovenox.

also, distance/convenience will get you fried as a reason to do a procedure. no matter what, you were the "greedy doc that did the procedure" regardless of your intention....

do what you want, but i fear complications and am risk adverse, and more lawsuit adverse. 99.9% you wont have a problem, but if it is the 0.1% you are hosed...

 

[facets]

To clarify, I only do caudals on coumadin/plavix patients with a 25 g needle and put it just past the ligament, get a good dye flow and inject 10 cc of saline with 40-80 of kenalog or depo. I would not pass a catheter on a coumadin patient. I appreciate the perspective of those on the forum who are risk adverse due to litigation. I am fortunate to have never been sued (knock on my desk) but some of the best of us have been victims of malpractice suits. I would never make the statement that I am any better than those who have been in litigation, just more fortunate. It must really grind on you, and I would probably be more CYA if this had happened to me, but I still think that the risks of taking these patients off coumadin is greater than the risks of doing a caudal with them on. A lovenex bridge is an option but not for poor underinsured patients. Lovenox is extremely expensive

 

[epidural man]

The "other" pain doctors you speak of are money-grubbing ******.

That is really a very obtuse thing to say. I do caudal epidurals all the time, and I work in a salaried practice. I get paid the same if I do nothing, or I do something - and how I do it doesn't matter.

There are lot of reasons to do a caudal under ultrasound - and a big one for me is to be able to do a safe and effective procedure that cuts down on my radiation exposure - and over a lifetime of doing procedures, that seems like a BIG deal to me.

Epidurals are more effective the closer you are to the target and indications for caudals are fairly rare.

Really? I hope that young residents/fellows reading this demand some science behind this claim - because the science actually shows that caudals are more effective than interlaminar epidurals. If that isn't the case, post the science.

Those "pain doctors" probably aren't even fellowship trained and are just doing the easiest epidural that they can perform and they're billing it with ultrasound to make as much money as possible.

I don't think they are easier at all. An ILESI or even a caudal under fluoro is a piece of cake. Using ultrasound takes a lot of skill acutally - to do it right.

They're money-grubbing ****** disgracing the specialty of pain medicine for two reasons by #1 doing a lot of caudal ESI and #2 doing them with ultrasound. How do they sleep at night?

I sleep well because I am an honest broker of medicine. I do what is right by the patient - I have no thought towards billing and all that other crap you have to think about. I do so much pulsed RF because it works, but I bet you don't because you can't get paid for it.

I've never seen a caudal ESI help someone more than a transforaminal.

That is why we don't use personal experience to make clinical decisions. We use good science. Where is the science?

I'll tell you this much - under ultrasound, I can see my needle tip pass under the ligament. When I inject, I can see the ligament bulge so I know it is in the caudal space - very good confirmation.

In addition, there are many case reports of severe nerve damage and paralysis from doing transforaminals - even down to S1. Can you say the same about caudals?

 

[facets]

Statements like "doctors who do this are money grubbing ******" are outrageous and un-called for. I don't use ultrasound and some may use it for reimburement reasons but one cannot know the motives of another physician. Try assuming the best of people rather than the worst. We already have enough people, lawyers, insurance companies, politicians who do that for us, we don't need to do it to each other.