Weird case

[deleted875186]

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.

If your argument is TFESI is the same comfort as ILESI, I unfortunately call bologna. Midline is far less uncomfortable. ILESI take but a minute, Patients don’t feel when your in the ligament. Patients do feel when you get close to the neuroforamin, and the paraspinal muscles are undoubtedly more sensitive than midline.

---

Members don't see this ad.

 

[Baron Samedi]

If your argument is TFESI is the same comfort as ILESI, I unfortunately call bologna. Midline is far less uncomfortable. ILESI take but a minute, Patients don’t feel when your in the ligament. Patients do feel when you get close to the neuroforamin, and the paraspinal muscles are undoubtedly more sensitive than midline.

Maybe. Neither seem that uncomfortable for the vast majority of patients, to be honest. I've never had either done on myself so I can't tell you which hurts more.

 

[SommeRiver]

Maybe. Neither seem that uncomfortable for the vast majority of patients, to be honest. I've never had either done on myself so I can't tell you which hurts more.

It is pretty obvious IMO the TFESI hurts more...

 

[Baron Samedi]

Their pain is 10/10 at baseline anyways? *shrug*

I don't know. My patient population is very different from most, though. Very, very rarely do I have people complain about the pain.

 

[deleted875186]

Maybe. Neither seem that uncomfortable for the vast majority of patients, to be honest. I've never had either done on myself so I can't tell you which hurts more.

I’m probably biased since I’m anesthesia trained and have done a lot of ILESIs before pain, but still think it’s more comfortable.

 

[lobelsteve]

If your argument is TFESI is the same comfort as ILESI, I unfortunately call bologna. Midline is far less uncomfortable. ILESI take but a minute, Patients don’t feel when your in the ligament. Patients do feel when you get close to the neuroforamin, and the paraspinal muscles are undoubtedly more sensitive than midline.

Do you just do anesthesia or do you do pain as a side gig? You clearly have no idea what you’re talking about.

 

[gdub25]

Since there appears to be debate on the matter I guess I’ll go ahead and throw my vote out there that clearly ILESI is less painful, almost never the patient complaint of pain down the leg with injecting.

 

[Baron Samedi]

Is either procedure more painful than an acutely herniated disc? If not, then who cares?

 

[deleted875186]

Do you just do anesthesia or do you do pain as a side gig? You clearly have no idea what you’re talking about.

Pain fellow

 

[lobelsteve]

ILeai are always paramedian.
Discomfort for either is completely controlled by the performing physician by use of LA.
Both procedures take under 5 min. Superiority of one technique over another is theoretical and not absolute. Literature is not strong either way.

 

[epidural man]

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

Okay I will - but please note - I didn't before because these ideas are easily criticized and toppled with a few swift reasonable statements...and I am thin skinned and hate criticism. I am not a Millennial, but have taken on their persona and am easily triggered and need a safe space frequently.

So - I do more TFESI than ILESI for two reasons. #1 - I kept hearing fellows nearing the end of fellowship say they didn't have much experience with TFESI, so I started always doing them to get them more experience. #2. I had an anesthesia staff once tell me "Every time I watch a resident do an epidural (he was referring to the labor deck), a part of me dies." I thought that was so funny, and very true. I think it happens for me watching a psych fellow (for example) with little experience doing an ILESI. I know they aren't dangerous, and wet tap is only an inconvenience, but nonetheless, watching them is a little anxiety provoking. It is interesting, that as I get older, I get less patient with these learners. I thought it should have worked the other way with time and experience, but it hasn't. I have no idea why.

Regarding local anesthetic - When I came out of fellowship, I was the smartest guy on the block. I made a lot of noise about all my colleagues who put local in their cadaul/ILESI. I would say "No one that trained in the last 30 years, or who isn't in the military puts local in their Caudal/ILESI" and think I was so important and smart.

I suspect the reason that this is partly true is because of liability issues. But I don't have the same liability issues that those who are in private practice. I have to practice smart and safe, but I can make good decisions without that hanging over my head at least.

Anyway, a much wiser, and brilliant pain physician would smile at my retorts. One day, he told me..."let me tell you why I do local. I want the patient getting up off the bed feeling 100% better immediately. I want them to walk out of the clinic thinking they are cured and life is going to be that much better." I have thought about that idea a lot. Considering the complexity of chronic pain and the toll on the psyche, I have come to believe how important that might be in a person's experience. I put very little local (maybe 1ml or less of 1% lidocaine in my 10ml solution for caudal, less for ILESI).

If I were in private practice - I would never do caudal unless clinical picture highly dictated that. That is because they can be very uncomfortable. Patient's are going to go to the guy next door if their last epidural from them didn't hurt, and my caudal was very uncomfortable. However, I have a "trapped" patient population. They can't go anywhere else. And see above (TFESI vs ILESI) about why my first choice is usually caudal (super safe, fast, easy). Plus, I get a huge kick out of the contrast pattern on a caudal each time. It's fun and cool watching the contrast spread in the anterior epidural space.

 

[clubdeac]

In my hands lumbar ILESIs are almost always painless and typically take < 30 seconds. TFESIs OTOH can take anywhere from 30 second to 5 minutes depending on the anatomy and they are painful 30-50% of the time. I always drop in a little 1% lido now as I approach the opening of the foramen. Adds a little time but it's worth it.

 

[epidural man]

For all your TFESI's, do you guys try to put the needle tip all the way anterior (basically touch the vertebral body in a lateral view)? I mean, as long as you don't pass the medial pedicle border (in an AP view)?

 

[Gnarvin]

I do not. I will advance in lateral until the needle tip is is about in the middle of the neural foramen. Then go AP and check needle position and contrast spread.

If I remember correctly, the vasculature is usually more in the anterior part of the foramen so I try to avoid going all the way anterior if possible.

 

[Ligament]

For all your TFESI's, do you guys try to put the needle tip all the way anterior (basically touch the vertebral body in a lateral view)? I mean, as long as you don't pass the medial pedicle border (in an AP view)?

I often do. Provides definitive endpoint. Hit bone, check lateral. Contrast under DSA. It's seems true more vessles are in the anterior foramen but I'm injecting dex anyway and using DSA.

 

[epidural man]

I often do. Provides definitive endpoint. Hit bone, check lateral. Contrast under DSA. It's seems true more vessles are in the anterior foramen but I'm injecting dex anyway and using DSA.

I don't think this is true. I mean, I know people write about this.

But when I look at Sagitals in the MRI, vessels are EVERYWHERE and not predictable.

 

[bedrock]

In my hands lumbar ILESIs are almost always painless and typically take < 30 seconds. TFESIs OTOH can take anywhere from 30 second to 5 minutes depending on the anatomy and they are painful 30-50% of the time.

agree with this. ILESI are far less painful, though i wouldn’t say they are always painless. And much quicker.

I still take the time to do a TFESI for acute lumbar radiculopathy, but an ILESI with depo is my first choice for everything else.

 

[Taus]

I used to do way more tf than il. I’m opposite now. I do interlam with depo first unless I have a reason I really can’t or shouldn’t ie foraminal hnp or prior lami at level. The evidence says what it says but I got sick of routinely having a few weeks relief on tfesi with dex followed by problem resolution with il/depo with hnp or 3-6 months with stenosis. Rarely saw the opposite. I do what I feel gives my patients the best chance at only needing one shot. Yes it’s also generally faster and less uncomfortable.... but that had nothing to do with my change in practice.

 

[swamprat]

I did TFESI exclusive my first year out now I mix and match. Essentially if I need a spray and pray method as they have multiple discs and unclear which one is pain generator I do ILESI otherwise TFESI. I do not go lateral I drive in oblique then advance to 6 o’clock position in AP. I do think TFESI hurts more than interlaminar in my opinion especially if significant stenosis is present

 

[MD87]

A lot of you guys mention using depo for your ILESI. I use beta (only out of habit, it’s how I’ve been trained). Any rationale for the depo?

 

[bedrock]

A lot of you guys mention using depo for your ILESI. I use beta (only out of habit, it’s how I’ve been trained). Any rationale for the depo?

Several reasons. Depo is complete particulate instead of half and half like beta, so it lasts a bit longer than betamethasone.

also betamethasone is much more expensive than depo, which is important in private practice.

Also a small percentage of patients will have side effects from the quick onset of beta, (the same patients that react that way to dexamethasone), so you get less calls about side effects with depo compared to beta