Weird case

[epidural man]

"permanent neurological injury" is more likely in lumbar TFESI vs. ILESI?

I've never heard of permanent neurological injury from an ILESI below L3. There are case reports all the way down to S1 from permanent neurological injury with TF route.

---

Members don't see this ad.

 

[SSdoc33]

I've never heard of permanent neurological injury from an ILESI below L3. There are case reports all the way down to S1 from permanent neurological injury with TF route.

with particulates

 

[MD87]

There’s one case report after TFESI with non-particulate, if you believe it. I’ve seen patients (I think 2) with new onset weakness after TFESI at a level of severe foraminal stenosis. Likely due to compression of the nerve from the medication. Both patients had horrible pain during the injection. Neurologic damage after an interlaminar can still happen if they have a hematoma and you’re unlucky, of course. Pick your poison.

 

[deleted875186]

another reason to nearly all lumbars transforaminally

Transforaminal don’t offer as long lasting pain relief as interlaminar, you need multiple injections or bilateral to cover both sides, and they are undeniably more uncomfortable for the patient.

the factthat they are so much more uncomfortable for the patient is reason enough not to do them routinely.

 

[kstarm]

Maybe those with more experience can help me with the time course. My experience for the few wet taps I've been apart of is that the patient is noting a headache pretty much right after the procedure or the next day they are calling me. I'm struggling with the patient had the procedure.....does fine.....now a week later wet tap?? Is this a time course others have seen?

 

[Dr. Ice]

Can’t say from experience but that is not in the literature. It’s also not described as intermittent spanning 2 days with no headache and then all of sudden incapacitating headache. But this is what this guy is telling me

 

[deleted875186]

From anesthesia experience, typically headache starts the next day. I seen in consult a few people with headaches from C section spinals (25G Whitaker punctures) that started with a headache several days later, basically after discharged from the hospital so 4 days after CS.

 

[deleted875186]

For sure, frank wet tap the headache would not be delayed. The frank wet taps I’ve heard about all had a terrible headache that might or the next day.

 

[SommeRiver]

Can’t say from experience but that is not in the literature. It’s also not described as intermittent spanning 2 days with no headache and then all of sudden incapacitating headache. But this is what this guy is telling me

...because your pt doesn't have a PDPH.

Sadly, I don't have another Dx and I can guarantee you that if you were to patch him he would be miraculously "cured," but not bc he had a PDPH.

Sorry to hear about this BTW, sucks...

 

[Ducttape]

I hate to bring this up.... might there be ulterior motives from the sickness?

this isn’t, say, a comp case, or did he request opioid pain meds post procedure?

 

[Dr. Ice]

I hate to bring this up.... might there be ulterior motives from the sickness?

this isn’t, say, a comp case, or did he request opioid pain meds post procedure?

No..he’s seemingly normal. No medical issues, active guy, has a job. Not comp, no known history of substance abuse.

 

[lobelsteve]

No..he’s seemingly normal. No medical issues, active guy, has a job. Not comp, no known history of substance abuse.

Wait for it.

 

[epidural man]

Regarding epidural space at different levels. I have noticed over the years that there doesn't seem to be much space (but i'm sure there is plenty of potential space) at L5 - at least while the person is lying supine in an MRI scanner.

Here are two random l-spine MRIs on the scanner from today, T1 IMAGES to highlight the fat so epidural space is well visualized. This pattern is very reproducible.

PATIENT #1

PATIENT #2

 

[lobelsteve]

Meh. Potential space. You can still go ILESI and put in 100cc of fluid. It will track to the C-spine and cause blindness, but it will go in there.

 

[deleted875186]

Meh. Potential space. You can still go ILESI and put in 100cc of fluid. It will track to the C-spine and cause blindness, but it will go in there.

Agreed, should still have space. If people can do epidurals on the cervical spine which is undoubtedly much more narrow, there should always be enough space in e lumbar spine.

 

[Dr. Ice]

Wait for it.

Trust me I know..everyone is cray until proven otherwise..and even then..

 

[Taus]

Agree there’s often less at L5-s1. That said, If you can routinely do a cesi, then I don’t understand the concern about l5-s1. It’s by far the most common injection I do

 

[SommeRiver]

Agree there’s often less at L5-s1. That said, If you can routinely do a cesi, then I don’t understand the concern about l5-s1. It’s by far the most common injection I do

The MC injxn you do is IL at L5-S1? I'd say the most MC I do is TF at L5-S1 or L4-5...Bilateral L4-5 or L5-S1 for me...Seems like 80% of my pts are stenotic L3-S1.

 

[bedrock]

The MC injxn you do is IL at L5-S1? I'd say the most MC I do is TF at L5-S1 or L4-5...Bilateral L4-5 or L5-S1 for me...Seems like 80% of my pts are stenotic L3-S1.

Most common patient I see for a lumbar esi is someone with moderate-severe stenosis and/or spondylolisthesis at L4-L5.

Those patients all get L5-S1 ILESI with depo.
They generally do very well averaging 5-6 months of relief and I’ve had only one wet tap in over a decade of medical practice.

 

[SSdoc33]

The MC injxn you do is IL at L5-S1? I'd say the most MC I do is TF at L5-S1 or L4-5...Bilateral L4-5 or L5-S1 for me...Seems like 80% of my pts are stenotic L3-S1.

Same

 

[SommeRiver]

Most common patient I see for a lumbar esi is someone with moderate-severe stenosis and/or spondylolisthesis at L4-L5.

Those patients all get L5-S1 ILESI with depo.
They generally do very well and I’ve had only one wet tap in over a decade of medical practice.

I really do ILESI like...Once a month.

 

[deleted875186]

The MC injxn you do is IL at L5-S1? I'd say the most MC I do is TF at L5-S1 or L4-5...Bilateral L4-5 or L5-S1 for me...Seems like 80% of my pts are stenotic L3-S1.

Why do bilateral TFESI in this situation. ILESI will get better spread, is less uncomfortable for patient, and depo lasts longer. Canal stenosis is not a contraindication.

Are people doing it simply because a two level TFESI pays better?

 

[lobelsteve]

Why do bilateral TFESI in this situation.

ILESI will get better spread, -no evidence

is less uncomfortable for patient, - no evidence

depo lasts longer. -weak to no evidence

Canal stenosis is not a contraindication. Not ci for wither injection.

Are people doing it simply because a two level TFESI pays better?

 

[deleted875186]

I understand there are no RCTs demonstrating some of these statements.

better spread with ILESI - anecdotally true. Can’t deny that contrast spreads more on a ILESI than on a TFESI. Whether it is important I guess is a different question.

more comfortable for patient - not sure how anyone can argue this one, parasthesias with injecting Are definitely less with ILESI, plus you have a chance of touching the root with your needle with a TFESI.

Depo lasts longer - again, even with no good RCT, anecdotaly this is 100%, and makes logical sense with the pharmacokinetics of the two drugs.

TFESI pays better - asking this because I’m not sure of the answer in practice. The CMS fee schedule and RVUs suggests this is the case.

 

[paindoc007]

Why do bilateral TFESI in this situation. ILESI will get better spread, is less uncomfortable for patient, and depo lasts longer. Canal stenosis is not a contraindication.

Are people doing it simply because a two level TFESI pays better?

In my opinion it doesn’t make a damn bit of difference. Do your epidural whichever the way you please. It’ll either work or won’t. But people very shortly will start rambling about anterior epidural spread being incredibly superior to posterior therefore transfor esi should be done in the lumbar spine.

 

[Orin]

I suspect small leaks may show up later as conceptually the fibers get nicked, the patient coughs, and a symptomatic leak happens. The major factor for me with questionable PDPHs is whether there is positional worsening. Rarely, I consider brain MRI to rule out things like cerebral venous thrombosis, especially with late presenting headaches, but it's not something I've seen outside of rare cases around labor epidurals.

 

[deleted875186]

I suspect small leaks may show up later as conceptually the fibers get nicked, the patient coughs, and a symptomatic leak happens. The major factor for me with questionable PDPHs is whether there is positional worsening. Rarely, I consider brain MRI to rule out things like cerebral venous thrombosis, especially with late presenting headaches, but it's not something I've seen outside of rare cases around labor epidurals.

To that end, it’s not always true that PDPHs are benign. Small percentage will get chronic headaches as a result, and a smaller percentage can end up with neurological deficits from cerebral venous thrombosis. So always worth it to give the patients symptoms the benefit of the doubt.

 

[SommeRiver]

Why do bilateral TFESI in this situation. ILESI will get better spread, is less uncomfortable for patient, and depo lasts longer. Canal stenosis is not a contraindication.

Are people doing it simply because a two level TFESI pays better?

Nothing at all to do with payment.

I did a few hundred blood and glue patches as a fellow, and the risk of me wet tapping a pt with a TFESI is dramatically lower than an ILESI. I've yet to have a leak in private practice, and I hope to keep it that way.

Neither is superior, and you should do whichever procedure you feel is better for that pt. I am not saying you're doing anything wrong at all...Neither of us is providing better care than the other.

Depo working longer simply isn't true by the way. In my group our spine surgeons do epidurals frequently, and they use 80mg Depo and 2cc bupi in every pt...You know how often I'm told my epidurals work better? Frequently...

 

[bedrock]

Nothing at all to do with payment.

I did a few hundred blood and glue patches as a fellow, and the risk of me wet tapping a pt with a TFESI is dramatically lower than an ILESI. I've yet to have a leak in private practice, and I hope to keep it that way.

Neither is superior, and you should do whichever procedure you feel is better for that pt. I am not saying you're doing anything wrong at all...Neither of us is providing better care than the other.

Depo working longer simply isn't true by the way. In my group our spine surgeons do epidurals frequently, and they use 80mg Depo and 2cc bupi in every pt...You know how often I'm told my epidurals work better? Frequently...

sorry but surgeons doing the other epidural is the worst example possible. They are terrible at epidurals and all other interventional spine procedures that they attempt.

Try comparing two fellowship trained pain physicians, one doing a unilateral TFESI with dex and another doing a paramedian to far lateral ILESI with depo for patients with a similar amount of lumbar stenosis and leg pain and see which procedure lasts longer most of the time.....spoiler, its not the TFESI with dex.

I agree that a wet tap is more likely with ILESI, but still very rare in good hands (not a surgeon). The tiny chance of a wet tap isn't the risk I worry about. I worry about the risk of the patient having unecessary spine surgery after their TFESI with dex only provides 2 weeks of relief.

 

[SommeRiver]

sorry but surgeons doing the other epidural is the worst example possible. They are terrible at epidurals and all other interventional spine procedures that they attempt.

Try comparing two fellowship trained pain physicians, one doing a unilateral TFESI with dex and another doing a paramedian to far lateral ILESI with depo for patients with a similar amount of lumbar stenosis and leg pain and see which procedure lasts longer most of the time.....spoiler, its not the TFESI with dex.

I agree that a wet tap is more likely with ILESI, but still very rare in good hands (not a surgeon). The tiny chance of a wet tap isn't the risk I worry about. I worry about the risk of the patient having unecessary spine surgery after their TFESI with dex only provides 2 weeks of relief.

Our surgeons do TFESI and they do them very well. The Depo doesn't work any better than my dexamethasone.

I have this internal belief Depo is superior to dex but it simply isn't...

 

[deleted875186]

Our surgeons do TFESI and they do them very well. The Depo doesn't work any better than my dexamethasone.

I have this internal belief Depo is superior to dex but it simply isn't...

How do surgeons do TFESI? In the office with fluoro?

 

[SommeRiver]

How do surgeons do TFESI? In the office with fluoro?

OR days they basically schedule them in a bunch before they start operating.

They'll do 10-15 one level unilateral TFESI, and when that's done they start their surgical cases.

 

[deleted875186]

OR days they basically schedule them in a bunch before they start operating.

They'll do 10-15 one level unilateral TFESI, and when that's done they start their surgical cases.

Fascinating. I

OR days they basically schedule them in a bunch before they start operating.

They'll do 10-15 one level unilateral TFESI, and when that's done they start their surgical cases.

so why do the surgeons use depomedrol? Seems like an unnecessary risk.

 

[SommeRiver]

Fascinating. I

so why do the surgeons use depomedrol? Seems like an unnecessary risk.

The thought is Mr Smith comes to see you with a problem and if it doesn't get better with PT and it looks like it may be time for surgery, go ahead and try this shot.

They don't believe dexamethasone has an effect, and while Depo has higher risk than dexamethasone, the risk is lower than back surgery.

A surgeon is NOT trained to manage anything.

By the way, spine surgeons do shots all over the nation. It isn't uncommon at all.

 

[deleted875186]

Our surgeons do TFESI and they do them very well. The Depo doesn't work any better than my dexamethasone.

I have this internal belief Depo is superior to dex but it simply isn't...

Also, I think there is a lot of inter patient variability. I for one have had lots of patients that have had both TFESI and ILESI, most say the ILESI lasts longer. I have yet to have any patients say the TFESI lasts longer, although I have had the few patients were ILESI doesn’t help and than we move to a TFESI, presumably too severe formainal stenosis and steroid doesn’t reach the affected root.

 

[SommeRiver]

Also, I think there is a lot of inter patient variability. I for one have had lots of patients that have had both TFESI and ILESI, most say the ILESI lasts longer. I have yet to have any patients say the TFESI lasts longer, although I have had the few patients were ILESI doesn’t help and than we move to a TFESI, presumably too severe formainal stenosis and steroid doesn’t reach the affected root.

Like I said a few posts up...I'll probably start doing IL epidurals a little more often. I rarely do them in the lumbar spine.

 

[Espn123]

Like I said a few posts up...I'll probably start doing IL epidurals a little more often. I rarely do them in the lumbar spine.

dont you want to be the ones doing the in office injections ?

 

[SommeRiver]

dont you want to be the ones doing the in office injections ?

I do office and ASC injxns depending on which location I'm at...

 

[epidural man]

It’s sure funny and interesting how our ideas change.

Many years ago on here, I was very critical of ya alll for doing TFESI over ILESI because I assumed the only reason to do such was for greed, but I do more TFESI over ILESI (because I am greedy now. Jk. I am salaried).

I was super critical of my colleagues who did caudals. Now I do even more caudals them TFESI and just love doing them.

I made fun of people that put local mixed with their causal or lumber ILESI - but do every time now.

Let’s see what another 10 years brings.

 

[lobelsteve]

You need to question why you made those changes and what SIS, ASIPP, etc recommends as best practices...

 

[epidural man]

You need to question why you made those changes and what SIS, ASIPP, etc recommends as best practices...

Asipp Data shows TFESI>Caudal>ILESI.

But you state that like there is a clear distinction and crystal clear path.

As my friend once put it - we pain physicians bicker back and forth about the best way to do an epidural and have huge discussions and literature battles, and the rest of the medical community just recognizes none of it works anyway.

I know very well why I made the changes. They are good justifications for me at least.

 

[lobelsteve]

Asipp Data shows TFESI>Caudal>ILESI.

But you state that like there is a clear distinction and crystal clear path.

As my friend once put it - we pain physicians bicker back and forth about the best way to do an epidural and have huge discussions and literature battles, and the rest of the medical community just recognizes none of it works anyway.

I know very well why I made the changes. They are good justifications for me at least.

Ok. So share why you made those changes. Ongoing learning is a core competency

 

[Espn123]

Asipp Data shows TFESI>Caudal>ILESI.

But you state that like there is a clear distinction and crystal clear path.

As my friend once put it - we pain physicians bicker back and forth about the best way to do an epidural and have huge discussions and literature battles, and the rest of the medical community just recognizes none of it works anyway.

I know very well why I made the changes. They are good justifications for me at least.

At least not bickering about the newest and more dangerous ways to block the same nerve such as done routinely in regional anesthesia meetings
(not bias or anything)

 

[NJPAIN]

Regarding epidural space at different levels. I have noticed over the years that there doesn't seem to be much space (but i'm sure there is plenty of potential space) at L5 - at least while the person is lying supine in an MRI scanner.

Here are two random l-spine MRIs on the scanner from today, T1 IMAGES to highlight the fat so epidural space is well visualized. This pattern is very reproducible.

PATIENT #1
View attachment 320128View attachment 320129View attachment 320130

PATIENT #2

View attachment 320131View attachment 320132
View attachment 320133

Very interesting observations and images of L5-S1. Thanks for posting.
I go back and forth with ILESI. I do think it often works well in setting of TFESI that works well for short duration. I credit Taus for offering that advice.
I do find myself often at L5-S1 for ILESI as it lures you in with that wide open interlaminar window. I often can’t see any interlaminar space at L4-5 because of all of the pathology commonly there. However; perhaps because of the smaller epidural space and thin LF, I see a lot of mixed epidural and intradural spread of contrast.

 

[Ducttape]

Asipp Data shows TFESI>Caudal>ILESI.

But you state that like there is a clear distinction and crystal clear path.

As my friend once put it - we pain physicians bicker back and forth about the best way to do an epidural and have huge discussions and literature battles, and the rest of the medical community just recognizes none of it works anyway.

I know very well why I made the changes. They are good justifications for me at least.

ASIPP data tends to be heavily influenced by what comes out of Paducah, Kentucky

 

[10KHertz]

I’d Get an updated lumbar and brain MRI. Look for real volume loss and menigeal traction signs.
If that all looks good , discuss and reassure the patient.
If they are still burdened, then do the EBP.
A routine epidural can cause a transient headache -NOS.

 

[Baron Samedi]

The two reasons I do ILESI are:
- Sizeable far lateral disc herniation
- I have no idea what level is symptomatic

Neither are probably really good reasons.

 

[deleted875186]

The two reasons I do ILESI are:
- Sizeable far lateral disc herniation
- I have no idea what level is symptomatic

Neither are probably really good reasons.

fair points, what about bilateral symptoms?

to me, patient experience matters a lot, I have no illusions that I’m fixing anyone with an epidural. If I was the patient I would prefer one midline injection that two needles in an oblique view that is undeniably less comfortable.

 

[Baron Samedi]

fair points, what about bilateral symptoms?

to me, patient experience matters a lot, I have no illusions that I’m fixing anyone with an epidural. If I was the patient I would prefer one midline injection that two needles in an oblique view that is undeniably less comfortable.

The evidence supports bilateral TFESI over ILESI.

Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis - PubMed

Bilateral TF epidural injection allowed the higher concentration of injectates to be delivered into ventral epidural space bilaterally. The IL approach can be more affected by tissue fibrosis, scarring, or hypertrophy, which is more prominently featured in SS than in HIVD; these prevent the...

pubmed.ncbi.nlm.nih.gov

I would argue comfort level is probably the same. Smaller needle and less nerve wracking crunchy sounds as you're going in -- especially in older patients with calcified ligaments there's all sorts of gross sounds. I am personally more comfortable with TFESIs as well, so its a generally quicker procedure.

 

[Ducttape]

OTOH:

Comparison of treatment outcomes in lumbar central stenosis patients treated with epidural steroid injections: interlaminar versus bilateral transforaminal approach - PubMed

Both ILESI and TFESI are reliable treatment options for LCSS. ILESI might be preferred because of easier application and more effectiveness. However, TFESI might be a better option in patients with more prominent neuropathic pain.

pubmed.ncbi.nlm.nih.gov

Or this (tho I would not recommend CTFESI):

A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results - PubMed

Both C-CIESI with triamcinolone and CTFESI with dexamethasone are effective in reducing pain and disability associated with refractory unilateral cervical radiculopathy in a substantial proportion of participants for at least six months.

pubmed.ncbi.nlm.nih.gov