Wondering if people would be more open to cervical tfesi with this new series

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interjectionreflection

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None for me thanks. I would need to see a note discussing the MRI and the Freeman that is going to be injected, noting the position of liable artery. This way it is documented that you knew where the artery was and you knew how to avoid it. Even if it’s a stupid template, this would need to be in the note ahead of an injection.
 
i would personally still be worried about vasospasm regardless of the injectate
 
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I’ve always been curious about why folks on the forum feel so strongly against cervical tfesi considering SIS has been supportive of it for a long time (after switch to non particulate) and most SIS folks I’ve talked to believe cervical interlaminars are inherently more dangerous, plus we have lawsuit data to back that up.

In training I ended up doing more cervical transforaminals than interlaminars. I still prefer them more but I’m comfortable with both. Can get cervical tfesi done with a 27G 1.25” needle 90% of the time.
 
paindoc503 said:
i would personally still be worried about vasospasm regardless of the injectate
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“Vasospasm probably isn’t real.”

DJ Kennedy to myself and another 4-5 people at Stanford Pain
 
JFS said:
I’ve always been curious about why folks on the forum feel so strongly against cervical tfesi considering SIS has been supportive of it for a long time (after switch to non particulate) and most SIS folks I’ve talked to believe cervical interlaminars are inherently more dangerous, plus we have lawsuit data to back that up.

In training I ended up doing more cervical transforaminals than interlaminars. I still prefer them more but I’m comfortable with both. Can get cervical tfesi done with a 27G 1.25” needle 90% of the time.
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I use a 2” 25g quincke. Pretty rare not to reach with room to spare.
 
MitchLevi said:
“Vasospasm probably isn’t real.”

DJ Kennedy to myself and another 4-5 people at Stanford Pain
Click to expand...
“Probably” doesn’t sound good enough for me.

Simple risk/benefit profile as well as the fact that I’d never consider having one myself or letting a family member have one - I’m good…
 
Espn123 said:
“Probably” doesn’t sound good enough for me.

Simple risk/benefit profile as well as the fact that I’d never consider having one myself or letting a family member have one - I’m good…
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They’re done every day by the hundreds and thousands in the USA. I don’t do them, but many ppl do and they’re effective. Saying your family can’t have one is a bit hyperbolic.

SIS supports them. Dex 10mg, 1cc saline and 1cc lidocaine isn’t a terrible option in experienced hands.
 
Espn123 said:
“Probably” doesn’t sound good enough for me.

Simple risk/benefit profile as well as the fact that I’d never consider having one myself or letting a family member have one - I’m good…
Click to expand...

Do you also not do lumbar TFESI due to risk of vasospasm? There is a case report of infarct from a lumbar with dex from several years back that has been discussed multiple times on the forum.

I recently started doing cervical TFESI (couple years ago). I always review MRI making sure the artery is not in the way and I measure the angle of the foramen prior to the procedure, as has been published by SIS recently. I have seen decent results in my patients - certainly not being blown away by the results, but some patients do benefit, though of course this is anecdotal. I always offer ILESI first, but in the right patient, I think it’s reasonable prior to a fusion to try TFESI. There are certainly patients who I do not offer TFESI if the artery is in the way or borderline in the way.
 
I use 27 g 1 1/2 inch for ctfesi. Hate doing em on fat necks with needle flopping around
 
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nvrsumr said:
I use 27 g 1 1/2 inch for ctfesi. Hate doing em on fat necks with needle flopping around
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If you don’t do this already, then connecting even a 2.5 or 3.5 inch needle to ~8 inch extension tubing connected to your next injectate before inserting the needle eliminates the flop and gives you precise control
 
JFS said:
If you don’t do this already, then connecting even a 2.5 or 3.5 inch needle to ~8 inch extension tubing connected to your next injectate before inserting the needle eliminates the flop and gives you precise control
Click to expand...
This helps, plus there’s generally not enough purchase in tissue to attach extension tubing when at the target without needle tip jostling, losing position, tickling nerve etc. I attach tube early on these.
 
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MD87 said:
Do you also not do lumbar TFESI due to risk of vasospasm? There is a case report of infarct from a lumbar with dex from several years back that has been discussed multiple times on the forum.

I recently started doing cervical TFESI (couple years ago). I always review MRI making sure the artery is not in the way and I measure the angle of the foramen prior to the procedure, as has been published by SIS recently. I have seen decent results in my patients - certainly not being blown away by the results, but some patients do benefit, though of course this is anecdotal. I always offer ILESI first, but in the right patient, I think it’s reasonable prior to a fusion to try TFESI. There are certainly patients who I do not offer TFESI if the artery is in the way or borderline in the way.
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The risk of cervical TFESI seems to be far greater than lumbar TFESI, which I do all the time. I’ve also never performed a single cervical TFESI in my life. So it doesn’t seem like a good risk/benefit profile in my hands.
 
JFS said:
If you don’t do this already, then connecting even a 2.5 or 3.5 inch needle to ~8 inch extension tubing connected to your next injectate before inserting the needle eliminates the flop and gives you precise control
Click to expand...
I stopped using extension tubing and live Fluoro/dsa when I switched to dex 15 or so years ago.
 
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Espn123 said:
The risk of cervical TFESI seems to be far greater than lumbar TFESI, which I do all the time. I’ve also never performed a single cervical TFESI in my life. So it doesn’t seem like a good risk/benefit profile in my hands.
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Maybe do a few first. It’s a routinely performed procedure. Where I did my residency, that was the only cervical ESI that was performed, and the only time I saw a cervical interlaminar was during the VA rotation.

I get to fellowship and everyone flipped TFO about that.

Many PMR doctors prefer TFESI bc they aren’t doing labor epidurals as an anesthesia resident.
 
A neurosurgeon-turned pain physician was doing them in my area and gave someone Brown Sequard syndrome. I’m sure he was confident in his hand-eye coordination and knowledge of anatomy.
 
Agast said:
A neurosurgeon-turned pain physician was doing them in my area and gave someone Brown Sequard syndrome. I’m sure he was confident in his hand-eye coordination and knowledge of anatomy.
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Im sure he used DSA, dex, looked for artery on mri and had textbook placement…
 
Cervical TFESI are an unnecessary risk if you can reliably achieve strong cervical foraminal flow by other means, and using a far superior steroid (depomedrol). Per the attached photo.

Cervical TFESI are even less of a good idea because of dex. I agree with dex for safety but dex doesn’t last long enough to justify the other risks of CTFESI.
 

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bedrock said:
Cervical TFESI are an unnecessary risk if you can reliably achieve strong cervical foraminal flow by other means, and using a far superior steroid (depomedrol). Per the attached photo.

Cervical TFESI are even less of a good idea because of dex. I agree with dex for safety but dex doesn’t last long enough to justify the other risks of CTFESI.
Click to expand...
I agree with you 100% that depo >>> dex…. However I think that is overlooking the risk from a catheter in the posterior cervical epidural space
 
Taus said:
I agree with you 100% that depo >>> dex…. However I think that is overlooking the risk from a catheter in the posterior cervical epidural space
Click to expand...

As I described in a previous post, 99% of the time I only advance the catheter from T1-T2 to C6-C7. As you can see in the photo, you don’t have to advance to C4 to reliably paint C4 or C5.

The epidural space narrows cranial to C6-C7, and so you are then more likely to cause irritation or injury.
I’ve done thousands of CESI this way with catheter to C6-C7. 98% of the time they feel nothing from the catheter. The only times I’ve had issues have been if trying to drive the catheter cranial to C6.
 
Agast said:
A neurosurgeon-turned pain physician was doing them in my area and gave someone Brown Sequard syndrome. I’m sure he was confident in his hand-eye coordination and knowledge of anatomy.
Click to expand...
do you know if that was with dex or particulate? not sure if you saw the images but if you did anything stick out about placement?
 
interjectionreflection said:
do you know if that was with dex or particulate? not sure if you saw the images but if you did anything stick out about placement?
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No, I saw this patient a few years later after it happened. I believe it was a cord injury. Sensory loss persisted.
 
MitchLevi said:
Maybe do a few first. It’s a routinely performed procedure. Where I did my residency, that was the only cervical ESI that was performed, and the only time I saw a cervical interlaminar was during the VA rotation.

I get to fellowship and everyone flipped TFO about that.

Many PMR doctors prefer TFESI bc they aren’t doing labor epidurals as an anesthesia resident.
Click to expand...
Thanks but I’ll pass. I’m only good enough for C7-T1 ILESI
 
On a somewhat related note how do you guys feel about doing C6-C7 ilesi with 25g quinke technique? I understand the ligament isn't as thick at this level but would think with the quinke technique it doesn't really matter since you're not relying on LOR
 
im not so sure "we" are doing thousands of these in the US. i know for sure out of the 20 or so pain docs in this area, only 2 of them will do cervical tfesi.

it has been pointed out by ASRA and ASA closed claims cases that cervical TFESI was one of the most likely procedure to lead to a pain physician settling a malpractice case.


there are times where i will do C67, if the MRI looks appropriate.
 

retrospective. data mining.

they use big numbers (6967 procedures), but these were "reviewed" by asking the administering doctor if they remembered any complications.
Each procedure was linked to the performing physician. Those physicians were directly contacted and queried about catastrophic complications such as spinal cord injury, stroke, death, infection, or any other concerning event.
Click to expand...
not sure how much stock i would put in to this method of determining safety.

the second part of the study was a limited chart review of 200 cases. no catastrophic episodes.
This limited review involved looking at nursing documentation in recovery (immediate post-procedure), nurse call-back one day after procedure, clinic follow-up notes and urgent clinic visits (ER, urgent care, primary care).
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===

this study showed no benefit of ctfesi over interlaminar.

pubmed.ncbi.nlm.nih.gov

Comparison of Clinical Efficacy of Transforaminal and Interlaminar Epidural Steroid Injection in Radicular Pain due to Cervical Diseases: A Systematic Review and Meta-analysis - PubMed

Comprehensive reviews of selected articles revealed TFESI could not be recommended over ILESI for the sake of a preferential cervical radiculopathy control due to the weak evidential strength.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

it is a meta-analysis, so grains of salt...

===

i personally dont see any benefit of doing catheter to go to C67 vs a traditional C7T1, as there is clearly spread up a level, but in terms of C7T1 with catheter vs ctfesi, there appears - based on this study - no difference in efficacy:

pubmed.ncbi.nlm.nih.gov

One-year results from a randomized comparative trial of targeted steroid injection via epidural catheter versus standard transforaminal epidural injection for the treatment of unilateral cervical radicular pain - PubMed

Both cervical catheter-directed interlaminar epidural injection and cervical transforaminal steroid injection were effective in reducing pain and disability in the majority of participants with refractory unilateral cervical radiculopathy for up to 1 year.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
Espn123 said:
Thanks but I’ll pass. I’m only good enough for C7-T1 ILESI
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I only do ILESI as well, but I trained with several doctors who I’d let perform that injection on me.

I don’t actually see a need for it TBH, and I’d rather get particulate in my neck if I need an ESI.
 
here is FYI from another provider:
If you use non-particulate corticosteroids and follow the guidelines, cervical TESIs are relatively safer than interlaminar ESIs. Since 1998, I have performed over 8,000 cervical TESIs (64479, 64480) as I usually do two levels (with non-particulate steroids only starting in 2005)and have no major complications yet. Like any procedure, I could have been a lucky dog so far, which may be a matter of time. However, the data appears to convince me that cervical TESIs are safe if we use the precautions mentioned above.
 
SC Tian said:
here is FYI from another provider:
If you use non-particulate corticosteroids and follow the guidelines, cervical TESIs are relatively safer than interlaminar ESIs. Since 1998, I have performed over 8,000 cervical TESIs (64479, 64480) as I usually do two levels (with non-particulate steroids only starting in 2005)and have no major complications yet. Like any procedure, I could have been a lucky dog so far, which may be a matter of time. However, the data appears to convince me that cervical TESIs are safe if we use the precautions mentioned above.
Click to expand...
Humblebrag. If routinely doing 2 levels they are ignoring the science.
 
Got to do 2 levels to make it pencil out $ vs IL. heir and a spare could be another way to look at it clinically. That’s how I do it for lumbar tfesi unless far lateral hnp, perfect correlation with symptoms and no severe forminal stenosis. Otherwise always 2 level hit the disc and descending nerve.

I haven’t done a single ctfesi this year which is amazing change in my practice. With clo and steve’s 25 quinke I finally just started to eat the cost of my one major payor that pays me 90 for cesi and 300 for 2 level ctfesi. Its annoying but cesi so fast now that i just see it as a loss leader.

Like sc tian I could be close to 10k levels without a complication. My only real publications were on ctfesi contrast patterns so I feel a bit more confident than most.
 
I do believe that cervical transforaminals are overall safer than cervical interlaminars when non particulate steroids are used, but routinely doing 2 levels ain’t it. I’m generally only doing tfesi for unilateral single level pathology with a clear level, specially if higher than C6-C7. Anything else and ilesi is the better initial choice
 
lobelsteve said:
Humblebrag. If routinely doing 2 levels they are ignoring the science.
Click to expand...
thanks, I wonder how many of us do 2 levels of lumbar transforaminals? I heard Furman routinely did this before.
just a quote from radiology literature for cervical tf esi: Regarding injected vessels, 27/49 (55%) was likely venous, 22/49, (45%) were indeterminate, and none were likely arterial. AJNR Am J Neuroradiol 37:766 –72.
 
Asc vs office can really change one’s clinical perspective
 
SC Tian said:
here is FYI from another provider:
If you use non-particulate corticosteroids and follow the guidelines, cervical TESIs are relatively safer than interlaminar ESIs. Since 1998, I have performed over 8,000 cervical TESIs (64479, 64480) as I usually do two levels (with non-particulate steroids only starting in 2005)and have no major complications yet. Like any procedure, I could have been a lucky dog so far, which may be a matter of time. However, the data appears to convince me that cervical TESIs are safe if we use the precautions mentioned above.
Click to expand...
which most likely suggests to me that he probably isnt actually in the neuroforamen and all of his injections are sham, or he doesnt bother looking for complications.

i find it interesting that you tout this "another provider" as some sort of source, and yet seem to lessen the evidence that has been presented over a procedure that has shown no indication of any benefit over a safer standard procedure.

SC Tian said:
thanks, I wonder how many of us do 2 levels of lumbar transforaminals? I heard Furman routinely did this before.
just a quote from radiology literature for cervical tf esi: Regarding injected vessels, 27/49 (55%) was likely venous, 22/49, (45%) were indeterminate, and none were likely arterial. AJNR Am J Neuroradiol 37:766 –72.
Click to expand...
a 2 level tfesi is most commonly a money grab.

and what was done in the past is not indicative of what should be done in now. typical injection series was bilateral 3 level tfesi once a month x3, billing for 6 tfesi at once.
 
ill do a 2 level lumbar TFESI when there is severe central stenosis, or when 2 nerves are getting dinged. maybe about half the time.

if HNP or NF stenosis, then single level.

a good case could be made for a CTFESI with there is a focal HNP and clear C5 radiculopathy, like as seen on EMG. otherwise, i dont see much benefit. this is MAYBE once or twice a year.
 
Ducttape said:
which most likely suggests to me that he probably isnt actually in the neuroforamen and all of his injections are sham, or he doesnt bother looking for complications.
Click to expand...
Wow, the information is from a single provider who has had an academic and private practice for 20 years, Sham injection, in my opinion, is very judgemental and at least not accurate before you see their needle placement and contrast pattern.
The imaging I posted here in the thread is for your information only, understand the anatomy of the cervical foramen and how needles can be put in an extra, or junctional location where transforaminal epidural injection can be achieved safely with no risk of arterial injections, the same concept from IPSIS last year where posterior S1 foramen was studied.

2 level tfesi is most commonly a money grab

2 levels of lumbar transforaminal epidural injections are commonly done as well with the understanding there is no evidence for literature to support this, clinical judgment plays a certain role in my knowledge like the severity of stenosis, size of disc herniation, etc, and there are many pain procedures that RCTs do not support. Just making a statement that that is a money grab does not reflect the reality of practice. quoting bilateral 3 levels tf esi is not comparable to 2 levels unilateral injections.
 
bedrock said:
As I described in a previous post, 99% of the time I only advance the catheter from T1-T2 to C6-C7. As you can see in the photo, you don’t have to advance to C4 to reliably paint C4 or C5.

The epidural space narrows cranial to C6-C7, and so you are then more likely to cause irritation or injury.
I’ve done thousands of CESI this way with catheter to C6-C7. 98% of the time they feel nothing from the catheter. The only times I’ve had issues have been if trying to drive the catheter cranial to C6.
Click to expand...
which company/catheter do you use?
 
SC Tian said:
Wow, the information is from a single provider who has had an academic and private practice for 20 years, Sham injection, in my opinion, is very judgemental and at least not accurate before you see their needle placement and contrast pattern.
The imaging I posted here in the thread is for your information only, understand the anatomy of the cervical foramen and how needles can be put in an extra, or junctional location where transforaminal epidural injection can be achieved safely with no risk of arterial injections, the same concept from IPSIS last year where posterior S1 foramen was studied.

2 level tfesi is most commonly a money grab

2 levels of lumbar transforaminal epidural injections are commonly done as well with the understanding there is no evidence for literature to support this, clinical judgment plays a certain role in my knowledge like the severity of stenosis, size of disc herniation, etc, and there are many pain procedures that RCTs do not support. Just making a statement that that is a money grab does not reflect the reality of practice. quoting bilateral 3 levels tf esi is not comparable to 2 levels unilateral injections.
Click to expand...
you can talk to anyone and they can tell you that "something has never happened to me so it must be fine." that is an N of 1 and is the lowest level of "clinical evidence". at least if he had someone do a retrospective chart review, that does make it rise in value, but he is making snake oil level statements.

i can boldly proclaim that, for example, i have never had a complication that i can remember from DREZ lesioning or cervical SCS so they must never cause any complication because it has never happened to me, and as such there is no risk ever of doing these procedures. why would you believe that statement and use it in your medical decision making?


there is no 100% safe location for a cervical transforaminal injection. there is in fact probably no 100% safe location for any epidural injection. otherwise, a nursing student could do a cervical transforaminal injection and your clinical acumen of doing such procedures is nil.


you seem to have bought his statement hook line and sinker because it fits your thought pattern. how gullible are you? always test your hypotheses regarding treatment options. i am aware that 90% of this forum is unwilling to do so, but dont be like them.
===
CMS seems to think otherwise.
  1. Transforaminal ESIs (TFESIs) involving a maximum of two (2) levels in one spinal region are considered medically reasonable and necessary. It is important to recognize that most conditions would not ordinarily require ESI at two (2) levels in one spinal region.11
Click to expand...
 
I chose not to return your message anymore, it does not look like we discuss the same topic even, sham injection versus safety procedure, an example of real-world practice to echo that paper at the top of the thread.
 
SC Tian said:
I chose not to return your message anymore, it does not look like we discuss the same topic even, sham injection versus safety procedure, an example of real-world practice to echo that paper at the top of the thread.
Click to expand...
Immature. Learning is best done through discussion. Not denigrating each other (sarcasm aside). Silence is a lost opportunity.
 
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