which level do you inject for stenosis

[myrandom2003]

I typically go at or below the level of stenosis.
do you guys do the same?

for example in the picture attached, since there is epidural space, i went at the level of stenosis at the L4/5 level.
patient had some discomfort while injecting the medication (2cc celestone, 2cc saline 2cc marcaine) while on stomach.
- before anyone says it, patient does not want decomrpession (in her 40s) and either shot or live it are the options she will entertain.

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[SSdoc33]

I typically go at or below the level of stenosis.
do you guys do the same?

for example in the picture attached, since there is epidural space, i went at the level of stenosis at the L4/5 level.
patient had some discomfort while injecting the medication (2cc celestone, 2cc saline 2cc marcaine) while on stomach.
- before anyone says it, patient does not want decomrpession (in her 40s) and either shot or live it are the options she will entertain.

View attachment 347065

ILESI or TFESI? like to see the axials. unilateral or bilateral pain?

with the limited info you have given, i would do an L5 TFESI.

you will get a lot of opinions, and also some who will question your use of local.

 

[runfastnow]

If bilateral or stenotic type symptoms would do L5-S1 ILESI with 20 dex+2 cc saline/contrast. If on blood thinners bilateral L5-S1 TFESI with 20 dex split bilaterally.

 

[myrandom2003]

ILESI or TFESI? like to see the axials. unilateral or bilateral pain?

with the limited info you have given, i would do an L5 TFESI.

you will get a lot of opinions, and also some who will question your use of local.

I did an ILESI

The tighter space is the L4/5 level
I use local because of the dogma I was trained with 10 years ago. I find that it helps at least for a day or so of relief even if the steroid does not. also helps with any post procedure discomfort. Again, just dogma, doesnt mean its correct.
She had bilateral pain with standing and walking.

I picked the L4/5 level for an ESI because of the stenosis at the level above as well with contrast spreading to that level. I was not confident my medication would spread beyond the L4/5 level with an TFESI/ILESI at the L5/S1 level.

 

[Dr. Ice]

Intradiscal PRP for annular tear at L5-S1…I kid, I kid..😝

 

[Dr. Ice]

Furman’s flow studies suggest that injectate volume will spread to cephalad levels. Just look at what happens in the c spine with C7-T1. You would have been fine with L5-S1 Ilesi

 

[Ducttape]

its hard... looking at that axial, i would have considered going to L5S1. not much space.

i usually only use 4 ml of volume. probably still would have gone L45.

 

[SSdoc33]

Furman’s flow studies suggest that injectate volume will spread to cephalad levels. Just look at what happens in the c spine with C7-T1. You would have been fine with L5-S1 Ilesi

wasnt that for TFESI?

 

[DOctorJay]

I would do L5-S1 ILESI here. I never go at the level of stenosis. almost always below.

I've done a couple above a degenerating segment above a fusion at the request of a spine surgeon and was surprised it gave some relief as well.

 

[Dr. Ice]

wasnt that for TFESI?

I believe there were separate studies, but I might be mistaken

 

[callmeanesthesia]

Probably get crucified for this on here but I’d start with a caudal. I’ve found injecting 2-3 mL lidocaine then letting it sit for 30 seconds or so before injecting the saline/steroid helps a lot with the injection discomfort. Looking at how far the 1 mL contrast usually spreads, I’m pretty sure the 10 mL injectate is easily reaching L4-5, and probably L3-4.

 

[pmrmd]

L4-5 IL with particulate is what I’d do as well. IL at the level of the lesion when possible.

 

[fathead88]

level of the stenosis if you think there is room. It’s fine to put some local in there if the dye looks good. It’s also fine not to. I would have done 4/5 as well.

 

[RoloTomassi]

L4-5 ILESI, Depo. That's plenty of space to me. There's a moderately large amount of epidural fat. As long as I see any amount of little white triangle, I'm good. The tighter it is the smaller volume, slower push. I'd do 3-4 cc for that one.

If that doesn't work I'd do b/l L4-5 TFESI, as that's in between the two stenotic levels, should spread to both.

 

[10KHertz]

The axial cuts suggests possible MILD procedure at this single level central stenosis …

2.5mm HLF+ neurogenic clarification+s/p TFESI(maybe times 2) =MILD.

TFESI for radicular lateral stenosis .

 

[MitchLevi]

L4-5 ILESI - Depo 80, 2.5cc saline, 0.5cc lidocaine 2%.

ILESI x 2 and if not keeping that pt afloat I'd do MILD. That LF looks 4-5mm if I had to guess.

 

[painfree23]

Stim it

 

[MitchLevi]

Stim it

Def not

 

[deleted875186]

L5-S1, 80mg depo, 1 cc bupi, 2 cc saline.

Or L4-5 with less volume. Moderate canal stenosis, appears to be room for ILESI.

 

[khankjkhan]

i would do L5-1 TFESI, considering if L4-5 disk is causing paracentral effacement of descending L5 root, but just recently I read an article which concludes that injecting at L4-5 (Pre-ganglionic-for L5) has better outcomes.

 

[maskman]

If it is really stenotic at L4-5, what are the thoughts in performing an interlaminar at the proximal level L3-4 with the hopes that gravity can move the medication distally? Also, as with peripheral nerve blocks, wouldn't there be an advantage to blunting nociceptive activation at the more proximal axon segments?

 

[Agast]

I choose depending on the dermatomal distribution of pain. Stenotic at L4-5 but symptoms at L5 buttocks/hips I will do an L5/S1 ESI. I did have one lady who started screaming for me to stop at 1cc of volume, I’m assuming cephalad flow. She got about 50% better but I’m never doing that one again.

For symptoms at the level of stenosis if it’s very severe I do TFESI.

 

[drusso]

This sounds vertebrogenic. Is there a Tinel's sign over the posterior iliac crest with deep palpation?

 

[fathead88]

i would do L5-1 TFESI, considering if L4-5 disk is causing paracentral effacement of descending L5 root, but just recently I read an article which concludes that injecting at L4-5 (Pre-ganglionic-for L5) has better outcomes.

Can you link that paper? Would like to read it.

 

[SSdoc33]

I find it interesting that everyone is trying to avoid injecting at the level of stenosis -- either central or neuroforaminal, TFESI or ILESI.

the whole point is to put the medication at the site of pathology. you will still get a higher concentration of injectate the closer you go to the problem. just inject slow. the patients will do fine and the outcomes will be better

furman's data was really meant to show that there is no such thing as a "selective" nerve root block. the conclusions have morphed into rationale for deciding where to inject. that is an error, IMHO

 

[khankjkhan]

Can you link that paper? Would like to read it.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667587/pdf/kjr-7-139.pdf

 

[NJPAIN]

I find it interesting that everyone is trying to avoid injecting at the level of stenosis -- either central or neuroforaminal, TFESI or ILESI.

the whole point is to put the medication at the site of pathology. you will still get a higher concentration of injectate the closer you go to the problem. just inject slow. the patients will do fine and the outcomes will be better

furman's data was really meant to show that there is no such thing as a "selective" nerve root block. the conclusions have morphed into rationale for deciding where to inject. that is an error, IMHO

We have discussed this before. People I respect at SIS, that perhaps others would label
overly cautious, would examine the target foramen on T1 sagittal and if true severe stenosis with little to no supra and infraneural epidural fat would not put a needle in there. I believe reasoning is three fold
- risk of nerve injury
- extra foraminal flow likely > intraforaminal flow thus missing the target DRG. The debate then becomes what is the more important target; the DRG or the compressive lesion in the foramen in the setting of multifactorial degenerative foraminal stenosis.
- if you are using LA, the risk of prolonged motor block of the compressed spinal nerve

Following the above I find many fewer patients that are very uncomfortable during injection but maybe fewer having a positive outcome?

 

[SSdoc33]

We have discussed this before. People I respect at SIS, that perhaps others would label
overly cautious, would examine the target foramen on T1 sagittal and if true severe stenosis with little to no supra and infraneural epidural fat would not put a needle in there. I believe reasoning is three fold
- risk of nerve injury
- extra foraminal flow likely > intraforaminal flow thus missing the target DRG. The debate then becomes what is the more important target; the DRG or the compressive lesion in the foramen in the setting of multifactorial degenerative foraminal stenosis.
- if you are using LA, the risk of prolonged motor block of the compressed spinal nerve

Following the above I find many fewer patients that are very uncomfortable during injection but maybe fewer having a positive outcome?

there is no stenosis i wont inject. except in the neck.

and yeah, it can hurt.

 

[MitchLevi]

There is more than enough room at L4-5 on these axial MRI cuts.

To put medication at another level would be reasonable if the pathologic level was severely stenotic...But it isn't.

 

[Ferrismonk]

I don't inject stenosis without radicular symptoms, evidence says it doesn't work.

If radicular, I'll usually try to inject that level plus one below TFESI. If severe stenosis, I'll go low-volume. If patient complains while injecting, I'll milk it in slow enough they don't complain.

 

[oreosandsake]

Didn’t read all the other responses

Bilateral L3-S3 tfesi



performed with a caudal catheter and 10 ml of contrast




Kidding. Don’t take this seriously

 

[oreosandsake]

TLDR

I always inject level that reflects the radiculopathy. If this is stenotic I push slowly as long as I get midline flow I’m happy. Multiple papers showing concordant pain on tfesi has NO better outcomes. (edit)
Sometimes infra neural sometimes Supra. Often will go the level below and inject Supra neural as well.

When i first started It didn’t make sense to me to treat at s1 if the disc issue was at L5. Then got people who would come back and say the pain to the top of the foot or big toe was gone but the calf/ankle/lateral foot was still numb or painful. Started doing more s1 tfesi and got better pain relief

 

[oreosandsake]

What’s evidence that 80mg depo is better than 40mg?


What’s minimum effective dose?

 

[Ferrismonk]

What’s evidence that 80mg depo is better than 40mg?


What’s minimum effective dose?

I don't have the papers, but 80 isn't better than 40.

 

[oreosandsake]

I don't have the papers, but 80 isn't better than 40.

AGREED

 

[10KHertz]

I don't inject stenosis without radicular symptoms, evidence says it doesn't work.

If radicular, I'll usually try to inject that level plus one below TFESI. If severe stenosis, I'll go low-volume. If patient complains while injecting, I'll milk it in slow enough they don't complain.

If the patient reports confirmatory dysethesias during the injection , you are targeting the correct level , with likely overall better outcomes . Several studies reflect this injection sensation as meaningful and diagnostic…

 

[Ducttape]

i thought we discussed this and studies have shown that subjective dysethesias during procedure did not portend benefit from procedure.

if i remember, ssdoc posted a study...

 

[Taus]

If the patient reports confirmatory dysethesias during the injection , you are targeting the correct level , with likely overall better outcomes . Several studies reflect this injection sensation as meaningful and diagnostic…

Can Someone please link the studies. My recollection is that it doesn’t really make a difference, anesthetic response is more “diagnostic”, despite the lack of great specificity.

 

[lobelsteve]

Can Someone please link the studies. My recollection is that it doesn’t really make a difference, anesthetic response is more “diagnostic”, despite the lack of great specificity.

Concordant pain provocation during transforaminal epidural steroid injection for lumbosacral radiculopathy: effect on pain outcome and predictive factors - PubMed

Provocation of concordant radicular pain does not predict pain relief at short-term follow-up after a transforaminal ESI. Foraminal stenosis, nerve root impingement, and lack of a medial-superior contrast flow pattern are associated with pain during the transforaminal ESI. Thus, clinicians...

pubmed.ncbi.nlm.nih.gov

Conclusions: Provocation of concordant radicular pain does not predict pain relief at short-term follow-up after a transforaminal ESI. Foraminal stenosis, nerve root impingement, and lack of a medial-superior contrast flow pattern are associated with pain during the transforaminal ESI. Thus, clinicians should be aware of these radiologic and procedural risk factors for inciting pain during transforaminal ESI.

The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain: Combination of pain provocation with effectiveness results - PubMed

In this follow-up study, transforaminal epidural steroid injection was found to be effective in both the early period and in the mid-term. Pain provocation was not clinically predictive for better outcome according to the results.

pubmed.ncbi.nlm.nih.gov

Conclusion: In this follow-up study, transforaminal epidural steroid injection was found to be effective in both the early period and in the mid-term. Pain provocation was not clinically predictive for better outcome according to the results.

 

[gaspasser127]

Def not

I would agree that based on limited history + imaging that we have that the pt is prob a good candidate for MILD but she’s 40, likely has some commercial insurance plan, and they prob won’t cover mild. Stim is her best option if no durable benefit with ESI and she’s exhausted all other conservative tx. If she does in fact have Medicare then Vertiflex is another option for her as well.

I’m curious as to why she’s adamantly opposed to surgery. Seems like she has a single level of stenosis that may be amenable to Micro discectomy or a single level laminectomy. Has she at least spoken to a surgeon?

 

[bedrock]

I wouldn’t do MILD for two reasons.

1- there is no medical reason she can’t have a lami so if you have a complication from MILD, you are particularly vulnerable legally.
2- she needs to live with it or have surgery. She will eventually give in and have surgery which is the correct option. If she fails epidurals You shouldn’t accommodate her craziness and dictating of her care. You are the physician.

If a patient ignore my expert recommendations, they are free to look up random craziness on the internet but it’s not my problem

 

[10KHertz]

I’d disagree friends… Many studies published supporting concordant relief . the interesting thing is that IL approach may be more correlated to outcomes than TFESI .

Concordant pressure paresthesia during interlaminar lumbar epidural steroid injections correlates with pain relief in patients with unilateral radicular pain - PubMed

This study showed that the lateral parasagittal interlaminar approach was more effective than the midline interlaminar approach in targeting low back pain with unilateral radicular pain secondary to degenerative lumbar disc disease. It also showed that pressure paresthesia occurring...

pubmed.ncbi.nlm.nih.gov

Furthermore the IL parasagital approach has the best correlation evidence :

Is Procedural Pain Prognostic in Lumbar Epidural Injection?

Studies are divided on the optimistic indication of concordant procedural pain.

www.medscape.com

 

[10KHertz]

I wouldn’t do MILD for two reasons.

1- there is no medical reason she can’t have a lami so it you have a complication from MILD, you particularly vulnerable legally.
2- she needs to live with it or have surgery. She will eventually give in and have surgery which is the correct option. If she fails epidurals You shouldn’t accommodate her craziness and dictating of her care. You are the physician.

If a patient ignore my expert recommendations, they are free to look up random craziness on the internet but it’s not my problem

Technically a lateral foraminotomy is not indicated with nonradicular symptoms . A MILD is equivalent to a posterior Lami for NEUROGENIC CLAUDICATION symptoms … thus your logic is reversed IMO. Ie Less is best …FYI Vertos has pretty decent literature for its technique and was well accepted by Medicare nationwide.

 

[deleted875186]

I wouldn’t do MILD for two reasons.

1- there is no medical reason she can’t have a lami so it you have a complication from MILD, you particularly vulnerable legally.
2- she needs to live with it or have surgery. She will eventually give in and have surgery which is the correct option. If she fails epidurals You shouldn’t accommodate her craziness and dictating of her care. You are the physician.

If a patient ignore my expert recommendations, they are free to look up random craziness on the internet but it’s not my problem

I would agree with this. If the patient declines surgery and ESI is ineffective, we should not just “offer a MILD”, it’s not correct treatment, it delays the correct care, it’s more risk for everyone involved.

 

[lobelsteve]

Technically a lateral foraminotomy is not indicated with nonradicular symptoms . A MILD is equivalent to a posterior Lami for NEUROGENIC CLAUDICATION symptoms … thus your logic is reversed IMO. Ie Less is best …FYI Vertos has pretty decent literature for its technique and was well accepted by Medicare nationwide.

Mild equal to open decompression? Anything not published by Vertos?

 

[Orin]

Patient refusal is the the only absolute reason you shouldn't operate or do a procedure. Physician refusal is more of an opinion issue.

With that said, insurance won't cover it outside Medicare so unless the patient is going to pony up cash, you're better off offering SCS for pain.
Document everything well if this is your circus.

I offer mild and tell patients it won't fix the issue as good as a real surgery, but it won't keep them from having a real one if they want later. It's just another tool to avoid the bigger whack if possible.

 

[NJPAIN]

Technically a lateral foraminotomy is not indicated with nonradicular symptoms . A MILD is equivalent to a posterior Lami for NEUROGENIC CLAUDICATION symptoms … thus your logic is reversed IMO. Ie Less is best …FYI Vertos has pretty decent literature for its technique and was well accepted by Medicare nationwide.

Is there evidence that MILD is equivalent to a laminectomy for NIC? I have no issue with MILD and VERTIFLEX for the correct indication in the correct patient but I find it hard to believe that either is equivalent to surgical decompression.

 

[NJPAIN]

…
I offer mild and tell patients it won't fix the issue as good as a real surgery, but it won't keep them from having a real one if they want later. It's just another tool to avoid the bigger whack if possible.

EXACTLY

 

[10KHertz]

I’m not a Vertos rep or surgical cowboy… . But I do believe MILD has a place prior to formal decompressive open surgery , foraminotomies, and disc decompression.

Study Demonstrates mild® Procedure Five-Year Durability | Vertos

According to a recent study, the mild® Procedure significantly decreased the incidence of surgical decompression during five-year follow-up.

www.vertosmed.com

Literature is decent for this procedure , not great , but decent . My outcomes on appropriate patient is pretty good. Post op pain is minimal . I can understand the hesitation for some

 

[bedrock]

Technically a lateral foraminotomy is not indicated with nonradicular symptoms . A MILD is equivalent to a posterior Lami for NEUROGENIC CLAUDICATION symptoms … thus your logic is reversed IMO. Ie Less is best …FYI Vertos has pretty decent literature for its technique and was well accepted by Medicare nationwide.

I’m worried about your reading comprehension as no where did I mention a lateral foraminotomy, only a laminectomy.

So you have things backwards , not I.

And as NJPain stated, there is no good data demonstrating that MILD is equal to a surgical posterior laminectomy, only data that MILD is better than no decompression at all in old sick patients.