C7-1 vs C6-7 CESI

[jwalker12]

Hello everyone,

I see some people doing C6-7 ILESI's and these physicians swear they get better relief. I know the ligament things as we move further superior but they say C6-7 is still ok. I saw a patient I did 2 C7-1 ESI's and she got a third from another at C6-7 with 100% relief as opposed to only moderate relief with mine. Are other people doing C6-7? I know in theory the epidural space is small enough that volume does get up the spine but wanted to see what others are doing. Thank yall!

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[SSdoc33]

Hello everyone,

I see some people doing C6-7 ILESI's and these physicians swear they get better relief. I know the ligament things as we move further superior but they say C6-7 is still ok. I saw a patient I did 2 C7-1 ESI's and she got a third from another at C6-7 with 100% relief as opposed to only moderate relief with mine. Are other people doing C6-7? I know in theory the epidural space is small enough that volume does get up the spine but wanted to see what others are doing. Thank yall!

doesnt matter

stay at C7-T1

 

[willabeast]

When you do your CESI under flouro you can see where the dye goes. Which I.S. you place your needle is part of the equation. If you look at where the dye went you probably will get your answer. Other factors include what steroid was used, the volume, what else was mixed in with the steroid. Many times I have done two identical injections and gotten very different results. In terms of avoiding litigation suggest staying with C7T1 unless you have a good reason.

 

[SpineandWine]

Can potentially use catheter from c7-T1 and sneak it higher level if you need to.

 

[DrSpine]

C7-T1 CESI only for me. Not worth the risk anything higher. C6-7 should be ok in theory, but I'm not taking that risk. Honestly, Epidurals are largely crapshoots anyway. The space is small and tight anyway, I've done Epidurals where patient's felt it on the opposite side as well presumably because of how tight the spacing is. I know someone that went C4-5 CESI. I told him I wouldn't do it, and he told me that he's been "trained well in it" and saw another Physician doing the same in training. Seems like playing with fire.

 

[lobelsteve]

Hello everyone,

I see some people doing C6-7 ILESI's and these physicians swear they get better relief. I know the ligament things as we move further superior but they say C6-7 is still ok. I saw a patient I did 2 C7-1 ESI's and she got a third from another at C6-7 with 100% relief as opposed to only moderate relief with mine. Are other people doing C6-7? I know in theory the epidural space is small enough that volume does get up the spine but wanted to see what others are doing. Thank yall!

Personal bias clouds their judgement and risks patients cords. These are what we call bad doctors. Stick with the guidelines. Have already been to court twice for CESI related complications. Stay at C7-T1, no sedation.

 

[bedrock]

Personal bias clouds their judgement and risks patients cords. These are what we call bad doctors. Stick with the guidelines. Have already been to court twice for CESI related complications. Stay at C7-T1, no sedation.

Care to share (in general terms) what was done incorrectly with those CESI?

 

[lobelsteve]

Care to share (in general terms) what was done incorrectly with those CESI?

Cord stick and then worse. Possibly still open case.
CESI at C5-6 with poor technique, poor documentation- infection, cord damage. Closed.

 

[DubVille]

Look for an epidural space on T1 MRI. I use contrast spread technique and not LOR. I've always hated the feeling of breaching ligament with a larger tuohy. I use 25 g spinal for all IL ESIs. I think I saw Lobel post about it and tried. Never going back.

Very, very rarely I may go C6-7 if a big epidural space is seen. Probably 90% C7-T1, 9% T1-2 because no or miniscule epidural seen on MRI at C7-T1, 1% C6-7. Don't think I've ever gone above that even if I see some epidural space.

 

[SpineandWine]

Look for an epidural space on T1 MRI. I use contrast spread technique and not LOR. I've always hated the feeling of breaching ligament with a larger tuohy. I use 25 g spinal for all IL ESIs. I think I saw Lobel post about it and tried. Never going back.

Very, very rarely I may go C6-7 if a big epidural space is seen. Probably 90% C7-T1, 9% T1-2 because no or miniscule epidural seen on MRI at C7-T1, 1% C6-7. Don't think I've ever gone above that even if I see some epidural space.

Can you please describe this 25G technique. Seems as if it’d be hard to tell loss (would love to know and if I like it, can start incorporating it)

 

[DubVille]

I tend to aim at inferior lamina (usually a tad of cephelad tilt to see the interlaminar space) just a bit lateral to not hit spinous process/ligaments. Touch down on superior lamina (about in line with c-arm to have close to hubogram) and slide up along lamina. Once my needle is just above lamina I go to a big CLO. And get to spinolaminar line.

Get just barely beyond it. Put in contrast looking for organized line epidural in front of spinolaminar line. I almost always get inital spread posterior (I'd always rather be a weenie). Move it a millimeter or 2. Push another touch of contrast.


It's CLO so usually it looks more anterior than reality. But if I get a touch nervous, I go back to AP and ensure I'm very close to midline. Re-insert stylet, and just barely move it forward.

Such a sharp and small needle usually little pain. And I never get that rebound from the ligament. I hated that feeling.

Only LOR syringe I use is for scs trials now.

You can see already one and one with some posterior spread, then a nice (but faint) line on the other. That one looks pretty anterior as I admittedly should have a bigger oblique. If I didnt get that line I would definitely get a bigger CLO for reassurance. I have much better examples but not accessible now.

 

[painfree23]

Look for an epidural space on T1 MRI. I use contrast spread technique and not LOR. I've always hated the feeling of breaching ligament with a larger tuohy. I use 25 g spinal for all IL ESIs. I think I saw Lobel post about it and tried. Never going back.

Very, very rarely I may go C6-7 if a big epidural space is seen. Probably 90% C7-T1, 9% T1-2 because no or miniscule epidural seen on MRI at C7-T1, 1% C6-7. Don't think I've ever gone above that even if I see some epidural space.

Could you share some images of what is a “big” enough epidural space to consider C6/C7? I’m at like 99% C7/T1 but may consider going up to C7/T1 if surgeon requests it specifically

 

[DubVille]

Could you share some images of what is a “big” enough epidural space to consider C6/C7? I’m at like 99% C7/T1 but may consider going up to C7/T1 if surgeon requests it specifically

I wish I could say I had some measurement guidelines I use but I don't. I need to see more than a paper thin white line on T1 sequence for sure, but otherwise it's kind of just "eyeballing it."

 

[SpineandWine]

I tend to aim at inferior lamina (usually a tad of cephelad tilt to see the interlaminar space) just a bit lateral to not hit spinous process/ligaments. Touch down on superior lamina (about in line with c-arm to have close to hubogram) and slide up along lamina. Once my needle is just above lamina I go to a big CLO. And get to spinolaminar line.

Get just barely beyond it. Put in contrast looking for organized line epidural in front of spinolaminar line. I almost always get inital spread posterior (I'd always rather be a weenie). Move it a millimeter or 2. Push another touch of contrast.


It's CLO so usually it looks more anterior than reality. But if I get a touch nervous, I go back to AP and ensure I'm very close to midline. Re-insert stylet, and just barely move it forward.

Such a sharp and small needle usually little pain. And I never get that rebound from the ligament. I hated that feeling.

Only LOR syringe I use is for scs trials now.

You can see already one and one with some posterior spread, then a nice (but faint) line on the other. That one looks pretty anterior as I admittedly should have a bigger oblique. If I didnt get that line I would definitely get a bigger CLO for reassurance. I have much better examples but not accessible now.

That’s seems similar technique to my touhy with LOR except you use 25G.
Do you feel any loss with this or just based on imaging and slow guidance?

 

[DubVille]

That’s seems similar technique to my touhy with LOR except you use 25G.
Do you feel any loss with this or just based on imaging and slow guidance?

Occasionally I feel it but it's based on imaging and contrast really.

 

[fathead88]

I commonly do C6/7. 20 gauge touhy. Always CLO. Advance to VILL, then small advancements, continuous LOR pressure. Haven’t had any issues. This is a very common injection site in my local practice area.

 

[drrosenrosen]

That’s seems similar technique to my touhy with LOR except you use 25G.
Do you feel any loss with this or just based on imaging and slow guidance?

I've recently started doing this technique for cervical and lumbar interlaminars. It's similar to the way you've been doing it, you're just replacing the LOR "feel" for a visual inspection. Getting the angle right on that CLO is very important. Usually about 40-45 for lumbar and 50-55 for cervical.

 

[RoloTomassi]

I commonly do C6/7. 20 gauge touhy. Always CLO. Advance to VILL, then small advancements, continuous LOR pressure. Haven’t had any issues. This is a very common injection site in my local practice area.

Do you feel it's significantly more effective than C7-T1? i.e. high percentage of patients who fail C7-T1 do well with repeat at C6-7?

Any increase in subdural pattern?

 

[painfree23]

I wish I could say I had some measurement guidelines I use but I don't. I need to see more than a paper thin white line on T1 sequence for sure, but otherwise it's kind of just "eyeballing it."

Makes sense. But whenever you get the chance can you send a snap of the T1 sequence where you feel there’s an adequate amount? I just was curious to get a baseline. Thanks

 

[fathead88]

I haven’t noticed any change in efficacy. I was taught C6/7 is fine but not to go higher so I don’t think much of doing an injection at 6/7.

I can think of one subdural contrast spread in the last 6 months. Not sure if that was 6/7 or 7/1. That patient of course did great.

 

[RoloTomassi]

That patient of course did great.

Interesting, you find subdural more efficacious?

 

[fathead88]

Interesting, you find subdural more efficacious?

I have no idea if it is or not. That patient did well. I don't know how that could ever be studied except retrospectively. If I get a subdural pattern in the C spine I will typically inject the dex and call it a day. Not sure if that is right or wrong - one layer closer to the nerves I guess.

 

[RoloTomassi]

I have no idea if it is or not. That patient did well. I don't know how that could ever be studied except retrospectively. If I get a subdural pattern in the C spine I will typically inject the dex and call it a day. Not sure if that is right or wrong - one layer closer to the nerves I guess.

That's funny I do the same. I'll try to redirect a couple times but if I keep getting subdural, I'll toss the Depo, draw up dex only and inject. They do seem to do just fine. I wonder if he 25ga contrast method has less incidence of subdural. I get it very rarely. Do you get subdural ever @lobelsteve @DubVille @Ferrismonk @MitchLevi ?

 

[SSdoc33]

That's funny I do the same. I'll try to redirect a couple times but if I keep getting subdural, I'll toss the Depo, draw up dex only and inject. They do seem to do just fine. I wonder if he 25ga contrast method has less incidence of subdural. I get it very rarely. Do you get subdural ever @lobelsteve @DubVille @Ferrismonk @MitchLevi ?

i wasnt included in the call out, but ill inject subdural as well. or if its half and half, which is usually the case

 

[RoloTomassi]

i wasnt included in the call out, but ill inject subdural as well. or if its half and half, which is usually the case

Thanks didn't remember if you were one of the big proponents of 25ga

 

[lobelsteve]

Have not had s subdural with 25g. If I fid i would pull back a mm and reinject omni. Repeat until epidural. Use dex so if it follows subdural from epidural because of the track I made, so what.

 

[clubdeac]

That's funny I do the same. I'll try to redirect a couple times but if I keep getting subdural, I'll toss the Depo, draw up dex only and inject. They do seem to do just fine. I wonder if he 25ga contrast method has less incidence of subdural. I get it very rarely. Do you get subdural ever @lobelsteve @DubVille @Ferrismonk @MitchLevi ?

what's the thought on dex instead of depo if subdural? Don't want to inject benzyl alcohol or PEG into the subdural space? Is this the same risk as injecting it into the IT space?

 

[RoloTomassi]

what's the thought on dex instead of depo if subdural? Don't want to inject benzyl alcohol or PEG into the subdural space? Is this the same risk as injecting it into the IT space?

Yes. Not sure of the risk but it's one step closer to where I don't want it to be

 

[MitchLevi]

Can't recall subdural patterns using the 25g technique. There have been times I've tossed the Depo and used dexamethasone...I've def done that.

I hate dex CESI in general. The chest pain I've seen repeatedly.

 

[lobelsteve]

Can't recall subdural patterns using the 25g technique. There have been times I've tossed the Depo and used dexamethasone...I've def done that.

I hate dex CESI in general. The chest pain I've seen repeatedly.

I think that is from the Omni.

 

[MitchLevi]

I think that is from the Omni.

I use Isovue

 

[SpineandWine]

Have not had s subdural with 25g. If I fid i would pull back a mm and reinject omni. Repeat until epidural. Use dex so if it follows subdural from epidural because of the track I made, so what.

If you're utilizing 25 G to gain cervical epidural entry and mainly using contrast flow patterns rather than loss of resistance feel, do you really need intact ligamentum flavum?
Just for my education, why would you be opposed to going at higher levels?

 

[DubVille]

If you're utilizing 25 G to gain cervical epidural entry and mainly using contrast flow patterns rather than loss of resistance feel, do you really need intact ligamentum flavum?
Just for my education, why would you be opposed to going at higher levels?

Look at the MRI. Often no epidural space.

 

[SC Tian]

imo, no or minimal lor is more common than thoracic and lumbar levels, especially adjacent to surgery levels. Fluoroscopic guided needle depth is critical at this time, I use hang-drop technique, from my observation, it is slightly more consistent and sensitive, i can use two hands to control needles, especially when patient is moving and irritated, my one hand is constantly holding the needle, the other hand grabbing meds to inject.

 

[lobelsteve]

If you're utilizing 25 G to gain cervical epidural entry and mainly using contrast flow patterns rather than loss of resistance feel, do you really need intact ligamentum flavum?
Just for my education, why would you be opposed to going at higher levels?

Closed claim data, guidelines, anatomy. Education, training, experience.
In that order.

 

[SC Tian]

The training and experience are so important, especially if you are doing cervical stim, every angle matters, last year i heard a guy practicing for more than 10 years, got severe complications from cervical stimulation.

 

[lobelsteve]

The training and experience are so important, especially if you are doing cervical stim, every angle matters, last year i heard a guy practicing for more than 10 years, got severe complications from cervical stimulation.

Any time in that area is always the first time in that area in that patient. Nothing we do is scarier.

 

[Ferrismonk]

imo, no or minimal lor is more common than thoracic and lumbar levels, especially adjacent to surgery levels. Fluoroscopic guided needle depth is critical at this time, I use hang-drop technique, from my observation, it is slightly more consistent and sensitive, i can use two hands to control needles, especially when patient is moving and irritated, my one hand is constantly holding the needle, the other hand grabbing meds to inject.

Nothing is going to be more consistent or sensitive (and specific) than contrast spread.

 

[SC Tian]

Nothing is going to be more consistent or sensitive (and specific) than contrast spread.

Thanks, our procedure is normally considered as fluoroscopic guided contrast confirmed the injection, contrast certainly will be more specifically confirmed epidural spread, can also show intra-cord spread, we actually compare lor syringe to hang drop side by side, this is purely technical discussion.

 

[Ferrismonk]

Not trying to be snarky.

With the 25G quinke, I advance in CLO. Needle tip is advanced until close, puff of contrast shows still outside ligaments. Advanced 1mm, feel tight ligamentum flavum on needle and resistance to contrast, then advance 1mm and release of resistance to contrast injection. See contrast in epidural spread. Any deviation you withdraw, reassess, and try again. Hanging drop or LOR with contrast at the end just for confirmation just isn't as good.

If you're afraid of a sharp needle, I get that, but if I'm anywhere near a cord injection, a lot has gone wrong.

FWIW, I use saline and dex only in CESI. Never had any chest pressure complaints.
Dex concerns with benzoyl alcohol/PEG are avoided altogether by using preservative-free dex.

 

[deleted875186]

Not trying to be snarky.

With the 25G quinke, I advance in CLO. Needle tip is advanced until close, puff of contrast shows still outside ligaments. Advanced 1mm, feel tight ligamentum flavum on needle and resistance to contrast, then advance 1mm and release of resistance to contrast injection. See contrast in epidural spread. Any deviation you withdraw, reassess, and try again. Hanging drop or LOR with contrast at the end just for confirmation just isn't as good.

If you're afraid of a sharp needle, I get that, but if I'm anywhere near a cord injection, a lot has gone wrong.

FWIW, I use saline and dex only in CESI. Never had any chest pressure complaints.
Dex concerns with benzoyl alcohol/PEG are avoided altogether by using preservative-free dex.

I think hanging drop works pretty well. I don’t see it as unsafe, so long as you go slow and take frequent images in CLO. I do LOR alone with 20G toughy. I usually inject contrast if any doubt of at the VLL, see posterior in the ligament, then do as Yoj describe above, essentially the same technique as yours, just with 20G toughy. Question is if it is safer to slowly advance a 25G Quincy versus a 20G toughy.

 

[SC Tian]

Not trying to be snarky.

With the 25G quinke, I advance in CLO. Needle tip is advanced until close, puff of contrast shows still outside ligaments. Advanced 1mm, feel tight ligamentum flavum on needle and resistance to contrast, then advance 1mm and release of resistance to contrast injection. See contrast in epidural spread. Any deviation you withdraw, reassess, and try again. Hanging drop or LOR with contrast at the end just for confirmation just isn't as good.

If you're afraid of a sharp needle, I get that, but if I'm anywhere near a cord injection, a lot has gone wrong.

FWIW, I use saline and dex only in CESI. Never had any chest pressure complaints.
Dex concerns with benzoyl alcohol/PEG are avoided altogether by using preservative-free dex.

I guess i use 18 gauge needle for all interlaminar and caudal, making the difference.
Imo, testing needle localization with injection of contrast is interesting concept, for complicated case like presence of anterior and posterior fusion with bmi over 50, it can be challenging to fine tune the needle.

 

[RoloTomassi]

I guess i use 18 gauge needle for all interlaminar and caudal, making the difference.
Imo, testing needle localization with injection of contrast is interesting concept, for complicated case like presence of anterior and posterior fusion with bmi over 50, it can be challenging to fine tune the needle.

Why 18 ga for caudal??

 

[lobelsteve]

I guess i use 18 gauge needle for all interlaminar and caudal, making the difference.
Imo, testing needle localization with injection of contrast is interesting concept, for complicated case like presence of anterior and posterior fusion with bmi over 50, it can be challenging to fine tune the needle.

Colimate in tight to see flow. Then open it up and save a pic.

 

[SC Tian]

Why 18 ga for caudal??

Perifix catheter, use this for epidural, lysis of adhesions etc, same ****

 

[seamonkey]

80% of the time the contrast flows caudal when I inject at C7/T1 and patients dont get relief - no matter how low an angle I take to approach it, whereas 90% of the time it flows cephalad when I inject at C6/7.
C7/T1 just is not effective. I'd use that level every time if it actually helped my patients, but in this era where you get one try and thats it, I try to balance safety and efficacy and go C6/7

 

[MitchLevi]

Colimate in tight to see flow. Then open it up and save a pic.

I save the collimated CLO pic, opened up AP pic. I always collimate in CLO. Skinny or "weighty."

 

[RoloTomassi]

80% of the time the contrast flows caudal when I inject at C7/T1 and patients dont get relief - no matter how low an angle I take to approach it, whereas 90% of the time it flows cephalad when I inject at C6/7.
C7/T1 just is not effective. I'd use that level every time if it actually helped my patients, but in this era where you get one try and thats it, I try to balance safety and efficacy and go C6/7

Your reasoning makes sense but 80% is excessively high. There are studies that show pretty consistent flow to C3-4 I believe. You doing these seated? I'm assuming not but that's unusual. I would say vast majority of the time after I inject contrast, about 2/3 goes cephalad, 1/3 caudal. 2 pillows under chest, chin tucked, needle parallel to footballs

 

[MitchLevi]

80% of the time the contrast flows caudal when I inject at C7/T1 and patients dont get relief - no matter how low an angle I take to approach it, whereas 90% of the time it flows cephalad when I inject at C6/7.
C7/T1 just is not effective. I'd use that level every time if it actually helped my patients, but in this era where you get one try and thats it, I try to balance safety and efficacy and go C6/7

I somehow didn't see this post.

LOL

 

[lobelsteve]

80% of the time the contrast flows caudal when I inject at C7/T1 and patients dont get relief - no matter how low an angle I take to approach it, whereas 90% of the time it flows cephalad when I inject at C6/7.
C7/T1 just is not effective. I'd use that level every time if it actually helped my patients, but in this era where you get one try and thats it, I try to balance safety and efficacy and go C6/7

Post pics. Your personal bias does not jive with the collective literature or experience of 1000s of colleagues. But C6-7 is still acceptable so who cares.