CESI, how high

[DOctorJay]

what level is your cut off for interlaminar CESI

I don't go above C6-7, always been told the ligament may not be fused above this level for safe CESI

interesting article here: "RESULTS: Our most common spinal level for injection was C5-6, followed closely by C6-7. Hundreds of injections were performed at spinal levels above C5-6 with the most cephalad level C2-3."

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[deleted131481]

I used to do C6-C7 most commonly since that's what I learned in fellowship. After coming to this forum, I almost exclusively do C7-T1. Will occasionally go down one if it's tough to get in. I often see spread to multiple levels after just 0.5cc of contrast.

Colleagues here go at T1-T2 with a catheter and drive it up.

 

[NJPAIN]

what level is your cut off for interlaminar CESI

I don't go above C6-7, always been told the ligament may not be fused above this level for safe CESI

interesting article here: "RESULTS: Our most common spinal level for injection was C5-6, followed closely by C6-7. Hundreds of injections were performed at spinal levels above C5-6 with the most cephalad level C2-3."

I'm a C7-T1 or T1-T2 guy. Everything in our literature tells you to stay at or below C6-7 due to the integrity of the LF and the size of the epidural space. I think that even going to C6-7 now is practiced mainly by docs who have not embraced CLO and need C6-7 to be above the shoulders on lateral.

My perspective is that it's fine to really push the safety envelope to save life or limb but pushing that same envelope to give short lived pain relief in someone with C4-5 spondylosis that needs and will end up having an ACDF... I'm not so sure. But, conservative and safe doesn't make a good Linkedin post.

 

[Ducttape]

retrospective study.

scary study. but does reflect past practice patterns.

60% of patients got IV sedation 2 versed 100 fentanyl.

2 documented cord injuries with myelomalacia and cord edema. one at C7T1 and one at C56. (of note, the C7T1 had myelomalacia at C45 on MRI scan after the injection, so... someone might have screwed up on the levels)

now the incidence of severe complications are low, but...

 

[Agast]

Oof C2-3

Reading this kind of made me feel like I was reading a study where they peed in the pool and didn’t find an increased incidence of ear infections but like, I really did not want to think about you peeing in the pool and I don’t intend to start myself.

 

[Ferrismonk]

Always C7/T1 or below. I use the 25G quinke technique. Agree 0.5cc contrast goes up 2 levels so 3-5mL of injectate will cover most everything.

Others in my institution still run a catheter up and will deposit meds at the side/level they feel is most important.

And I think 60% getting sedation is likely the true current practice pattern, despite what our evidence says should be done.

 

[callmeanesthesia]

C7-T1, if not accessible anatomically advisable then T1-2, if not doable there either (very uncommon) then C6-7. I trained doing it at C6-7 under AP/Lateral. Taught myself CLO and moved to C7-T1. Feels a lot safer. I use a 22g Tuohy because I like the tactile feedback and can feel engagement in the ligament in most patients. I use a 3 mL syringe of contrast for “loss” and use little puffs of contrast as others have described, but I can usually feel I’m in before seeing the picture. There’s a little pop, and sometimes I see a bubble in the needle hub drop down like a hanging drop. Then I feel LOR as I inject the contrast, then confirm finally with fluoro.

 

[RoloTomassi]

C7-T1. Only had to go lower a handful of times, never gone higher.

 

[Ligament]

I do C7/T1 or T1/T2 ONLY.

Why take the risk going higher? There is zero proven benefit.

Also, why take the risk of running a catheter? You can shear epidural plexi and veins and cause a hematoma. I used to do this, but have rethought it.

 

[MitchLevi]

Always C7-T1

 

[lobelsteve]

C7-T1 then T1-2.
Have gone at C6-7 2x in 16 years due to access and visibility.
If need to go higher, does not need an ESI.

 

[clubdeac]

This was a fun one. Guy had a bunch of C2 pain following surgery. Tried and failed GON blocks and TON RFA. Finally decided to try this. Wouldn’t do it now though. Probably no higher than C6-7

 

[NJPAIN]

Oof C2-3

Reading this kind of made me feel like I was reading a study where they peed in the pool and didn’t find an increased incidence of ear infections but like, I really did not want to think about you peeing in the pool and I don’t intend to start myself.

Love it. This is a keeper.

 

[RoloTomassi]

This was a fun one. Guy has a bunch of C2 pain following surgery. Tried and failed GON blocks and TON RFA. Finally decided to try this. Wouldn’t do it now though. Probably no higher than C6-7

Wow. Did it work?

 

[ghost800]

I’ve been routinely doing c6/7 (and occasionally going lower depending on the MRI ) for a few years and recently switched to c7/t1 for the safety reasons outlined above. I’m just waiting to see if there is any change in results/outcomes from a pain relief standpoint going at that lower level. We know the dye spreads to multiple levels even with low volumes but Id be interested in hearing if anyone has noticed any change in outcomes by switching levels, specifically between c6/7 vs c7/t1.

 

[clubdeac]

Wow. Did it work?

For a bit. He died 9 months later from cancer unfortunately

 

[deleted875186]

I hate doing cervical epidurals. I never go above C7-T1, use CLO with 22G toughy, go ridiculously slow, it really slows down my day, and have a low threshold to abort or even go down to T1-T2 if any parasthesias or anything funky.

 

[Ferrismonk]

This was a fun one. Guy has a bunch of C2 pain following surgery. Tried and failed GON blocks and TON RFA. Finally decided to try this. Wouldn’t do it now though. Probably no higher than C6-7

That's a weird screw for the neck...

 

[clubdeac]

That's a weird screw for the neck...

massive right? I always wondered how the surgeon got it in there at that angle. This was during my VA days when I was fearless. Not worth it now

 

[DubVille]

I go where the epidural space is visualized on T1 MRI sequence. Could be C6-7, C7-T1 (by far most common), or T1-2.

If the visualized space is tiny, I will go down a level. If I only have CT I still want to see epidural space for placement, but it can be tough to see.

 

[Dr. Ice]

Cleveland clinic acgme pain doc at my asc wanted to do cervical esi with catheter. Apparently it was for a C3-4 disc. She can barely do C7-t1 without taking the needle in and out with different views unnecessarily. I was asked to supervise..well..cause the staff is horrified at anything new she wants to try. It was a complete mess from start to finish, not to mention she snowed the guy with an absurd amount of sedation.

Needless to say, no higher than C6-7, and no need for catheter..if there is enough space, 3-4 cc is gonna get to the upper levels.

You may ask, if she sucks so bad, why is she allowed to work there..my answer is, she has never killed anyone, she strokes my ortho partners egos and she has wonderful “credentials.”

 

[stsa84]

Saw a guy in clinic this week who is slowly regaining right sided function after a spinal cord injection at C2-3, from some clown in town. Like most here, I do C7/T1 or not at all.

 

[ghost800]

Cervical epidural steroid injection is often times wonderfuy effective, yet remains one of the most dangerous moves in all of pain management. There are a lot of pearls on this site which I have incorporated into practice, I’d advise anyone performing this procedure to search the forum and learn from those who have improved their technique and have had the generosity to post their experiences on this site for all to learn

 

[MitchLevi]

If you stay at C7-T1 or T1-2, use CLO at 45-50 degrees and use a 25 gauge needle without LOR - This ESI is safe, generally effective and 95% of the time painless.

 

[deleted875186]

If you stay at C7-T1 or T1-2, use CLO at 45-50 degrees and use a 25 gauge needle without LOR - This ESI is safe, generally effective and 95% of the time painless.

I’m debating trying the 25G spinal needle technique, but I as though the tactile feedback of a toughy is helpful.

Any tips for when you switched from a toughy to spinal needle?

 

[Ligament]

I’m debating trying the 25G spinal needle technique, but I as though the tactile feedback of a toughy is helpful.

Any tips for when you switched from a toughy to spinal needle?

You can use a 25g touhy as well, FYI.

I don't use LOR. Just go back and forth from AP to CLO many times. You do not need to struggle with a lateral image, unless you want to document one at the end of the procedure.

I've posted my technique here in the past, I think it has not been changed very much compared to other peers on this forum.

 

[RoloTomassi]

I prefer Tuohy. Theoretically it allows you to stop the instant you pass LF. With the Quincke technique you're only as good as your 1 mm increments, and if it's a thin epidural space it seems like you can be just outside of dura after one advancement, and potentially be through on the next. To know exactly when to stop you'd have to keep constant pressure on the contrast syringe while advancing live. But others seem to do these just fine.

 

[deleted875186]

I prefer Tuohy. Theoretically it allows you to stop the instant you pass LF. With the Quincke technique you're only as good as your 1 mm increments, and if it's a thin epidural space it seems like you can be just outside of dura after one advancement, and potentially be through on the next. To know exactly when to stop you'd have to keep constant pressure on the contrast syringe while advancing live. But others seem to do these just fine.

This is more or less why I haven’t switched. I advance with continuous LOR to saline, theoretically it should push the dura away as soon as you access the epidural space. I find the smaller 25G needle attractive though. Any di LOR with this 25G toughy?

 

[MitchLevi]

You cannot rely on LOR for safety.

 

[fathead88]

LOR (continuous pressure) with saline, C7-T1, 20 g Touhy, contralateral oblique imaging with frequent images once at VILL. Haven’t had an issue *knocks on wood multiple times*

 

[Ferrismonk]

I’m debating trying the 25G spinal needle technique, but I as though the tactile feedback of a toughy is helpful.

Any tips for when you switched from a toughy to spinal needle?

I always did the 17G touhy way until someone here (lobelsteve I think?) reccomended the 25G quinke way. I did a few lumbar ESI this way and was amazed at how simple and painless it was. Wasn't long before I switched my CESI this way too. If you can advance a touhy 1mm, you can advance a quinke 1mm. I never did constant pressure and still don't for my labor epidurals fwiw.

I've also, over time, I've basically switched everything over to 25G. ILESI, CESI, TFESI, MBB, Facets, SIJ, shoulders, knees, etc. Only thing I'm not using 25G for is anything over 3 inches deep and RFA.

 

[NJPAIN]

You cannot rely on LOR for safety.

I agree. The whole reliance LOR and “feel a pop” nonsense is an unfortunate gift from Anesthesiology to pain medicine. Works out of necessity in L&D and the OR. The longer I practice and the older I get the less confidence I have in relying on these tactile techniques.

 

[RoloTomassi]

I agree. The whole reliance LOR and “feel a pop” nonsense is an unfortunate gift from Anesthesiology to pain medicine. Works out of necessity in L&D and the OR. The longer I practice and the older I get the less confidence I have in relying on these tactile techniques.

Not alone, but in combination with CLO it's extremely reliable. Any questionable pop, inject some contrast. Look too deep and no pop yet, inject some contrast. To me, gauge matters. 18 ga with CLO, glass>plastic. Very reliable combination.

 

[Dr. Ice]

20 gauge touhy..clo..”toggle technique” with saline lor..been doing it for a long time..never an issue, most of the time works well if patient actually has radicular pain with imaging correlation and not because the doc is too lazy, or doesn’t want to have the extensive conversation about treatment for facet mediated pain..

 

[NJPAIN]

20 gauge touhy..clo..”toggle technique” with saline lor..been doing it for a long time..never an issue, most of the time works well if patient actually has radicular pain with imaging correlation and not because the doc is too lazy, or doesn’t want to have the extensive conversation about treatment for facet mediated pain..

Toggle technique?

 

[Dr. Ice]

Toggle technique?

Incremental pressure on lor syringe as you advance slowly..Have always used plastic syringe. Never got why people needed the fancy glass syringe. 12 years, over 15k procedures, maybe more, never a wet tap or complication

 

[p1at0]

In a multispecialty consensus statement, 13 of 13 organizations recommended that cervical interlaminar injections not be performed higher than C6/7 level:

James P. Rathmell, Honorio T. Benzon, Paul Dreyfuss, Marc Huntoon, Mark Wallace, Ray Baker, K. Daniel Riew, Richard W. Rosenquist, Charles Aprill, Natalia S. Rost, Asokumar Buvanendran, D. Scott Kreiner, Nikolai Bogduk, Daryl R. Fourney, Eduardo Fraifeld, Scott Horn, Jeffrey Stone, Kevin Vorenkamp, Gregory Lawler, Jeffrey Summers, David Kloth, David O’Brien, Sean Tutton; Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from a Multidisciplinary Working Group and National Organizations. Anesthesiology 2015; 122:974–984 doi: Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from a Multidisciplinary Working Group and National Organizations

 

[nvrsumr]

I know a pain doc whose patient remembered a contrast allergy last week on the table.

Usual 20g touhy and cheap 5cc plastic syringe with lor to saline and air at T1-2 in clo view. That nice pop and feel of plunger going down as if by magic I owe to my anesthesia colleagues. I never did a single intralaminar injection as a resident.

100 ctfesi as a resident but never an intralaminar. Just remembered did do a few cervical hanging drop with patient bent over a chair in an exam room at the VA. Was really a different time

 

[NJPAIN]

I know a pain doc whose patient remembered a contrast allergy last week on the table.

Usual 20g touhy and cheap 5cc plastic syringe with lor to saline and air at T1-2 in clo view. That nice pop and feel of plunger going down as if by magic I owe to my anesthesia colleagues. I never did a single intralaminar injection as a resident.

100 ctfesi as a resident but never an intralaminar. Just remembered did do a few cervical hanging drop with patient bent over a chair in an exam room at the VA. Was really a different time

Do you use the same technique in the lumbar spine (ordinary 5ml syringe)?

 

[nvrsumr]

If I did it … yes 5cc plastic syringe works fine. I trained on glass syringes and they are cool but I’m too cheap in PP.

I haven’t done a lor in 5 years and that was for a stim trial. Now for those I just poke the lead thru in lateral. Don’t know why I don’t use clo for those just haven’t switched over

My usual cervical/lumbar is 20g touhy puff of contrast when close and then I consider the lor to air/contrast in 3cc cheap syringe prior to getting my confirmation shot. It a mental game to keep it interesting. Usually right sometimes wrong

 

[epidural man]

Wow. Cool how people use such different techniques.

I use a 17g touhy. I’d use a 10 gauge if available. The bigger the safer in my opinion.

You guys that use a 25 gauge, you should probably think about using a 32 gauge. You can order those from China. If smaller is much better, don’t stop at 25!
😜

Regarding the catheter, I’d be curious why people are worried about this. It is soft, and easily directed away from danger (meaning I don’t think it is stiff enough to push into something scary). It sure seems safer than sliding a dorsal column stimulator lead. You guys do that don’t you?

I don’t do a catheter often, but on occasion will for a 3/4 disc.

 

[Orin]

Regarding the catheter, I’d be curious why people are worried about this. It is soft, and easily directed away from danger (meaning I don’t think it is stiff enough to push into something scary). It sure seems safer than sliding a dorsal column stimulator lead. You guys do that don’t you?

I don’t do a catheter often, but on occasion will for a 3/4 disc.

I love catheters more than most, but it's a weapon if you're not paying attention. The best ones come with a flexible tip, but even then you've got to have a shallow angle or you'll be intrathecal or intraparenchymal quickly. I don't disagree with using them for things up high, but I would just counsel that I would definitely treat it like a SCS lead for the angle of attack.

I also counsel making sure you don't shear the catheter on the way out, so retract as the catheter/needle assembly as a unit.

Serious Complications After Epidural Catheter Placement: Two Case Reports

Thoracic epidural analgesia (TEA) is a standard procedure in multimodal analgesia applied in major thoracic and abdominal surgeries. Two cases are presented with serious complications related to TEA. In both cases, earlier reaction of the treating physicians ...

www.ncbi.nlm.nih.gov

These are two reports on complications of landmark guided thoracic epidural catheters with an epidural hematoma in one and an intraparenchymal catheter in the other.

Knotting of a Cervical Epidural Catheter in the Patient with Post-Herpetic Neuralgia: A Rare Complication

Epidural block is achieved either by single injection of local anesthetic through an epidural needle or as a continuous block by infusion pump through an epidural catheter. Complications associated with epidural catheters include breakage, entrapment, ...

www.ncbi.nlm.nih.gov

This is a report of a knotted epidural catheter in the cervical spine that was placed for a PHN.

 

[Agast]

I trained using a catheter and continued for a while until one day as I was threading it upwards it got stuck on something. I couldn’t push or pull it past whatever it snagged on and that freaked me out, had to withdraw the whole thing as a unit. In retrospect it probably snagged on the tip of the tuohy but since I didn’t see a difference in outcomes without the catheter, I figured it was one less thing in the c-spine.

 

[drrosenrosen]

I guess I'll try the 25ga technique. I've been reading about it here for years but never had the guts to change up from what I've always done. I do sometimes do LOR with constant pressure with contrast and pigtail. Usually air in a LOR syringe. Usually 18ga Tuohy, 22ga Tuohy when I can get them.

 

[Ferrismonk]

Wow. Cool how people use such different techniques.

I use a 17g touhy. I’d use a 10 gauge if available. The bigger the safer in my opinion.

You guys that use a 25 gauge, you should probably think about using a 32 gauge. You can order those from China. If smaller is much better, don’t stop at 25!
😜

Regarding the catheter, I’d be curious why people are worried about this. It is soft, and easily directed away from danger (meaning I don’t think it is stiff enough to push into something scary). It sure seems safer than sliding a dorsal column stimulator lead. You guys do that don’t you?

I don’t do a catheter often, but on occasion will for a 3/4 disc.

I've actually thought about going smaller, I use 27G spinal needles all the time in OB, but the 25G is wiggly enough. Almost completely bevel control and not very forgiving if you run off course.

 

[MitchLevi]

I've actually thought about going smaller, I use 27G spinal needles all the time in OB, but the 25G is wiggly enough. Almost completely bevel control and not very forgiving if you run off course.

27 g would be annoying IMO. If you bent the tip and steered through an old man's tough neck, each adjustment would take you 6 feet off course!

 

[lobelsteve]

I've actually thought about going smaller, I use 27G spinal needles all the time in OB, but the 25G is wiggly enough. Almost completely bevel control and not very forgiving if you run off course.

We cheat and use fluoroscopy. Move 3-5mm and take a pic.

 

[Ferrismonk]

Do you use a 27g?

 

[epidural man]

I love catheters more than most, but it's a weapon if you're not paying attention. The best ones come with a flexible tip, but even then you've got to have a shallow angle or you'll be intrathecal or intraparenchymal quickly. I don't disagree with using them for things up high, but I would just counsel that I would definitely treat it like a SCS lead for the angle of attack.

I also counsel making sure you don't shear the catheter on the way out, so retract as the catheter/needle assembly as a unit.

Serious Complications After Epidural Catheter Placement: Two Case Reports

Thoracic epidural analgesia (TEA) is a standard procedure in multimodal analgesia applied in major thoracic and abdominal surgeries. Two cases are presented with serious complications related to TEA. In both cases, earlier reaction of the treating physicians ...

www.ncbi.nlm.nih.gov

These are two reports on complications of landmark guided thoracic epidural catheters with an epidural hematoma in one and an intraparenchymal catheter in the other.

Knotting of a Cervical Epidural Catheter in the Patient with Post-Herpetic Neuralgia: A Rare Complication

Epidural block is achieved either by single injection of local anesthetic through an epidural needle or as a continuous block by infusion pump through an epidural catheter. Complications associated with epidural catheters include breakage, entrapment, ...

www.ncbi.nlm.nih.gov

This is a report of a knotted epidural catheter in the cervical spine that was placed for a PHN.

None of these were done with fluoro. There is zero percent chance of placing an

I love catheters more than most, but it's a weapon if you're not paying attention. The best ones come with a flexible tip, but even then you've got to have a shallow angle or you'll be intrathecal or intraparenchymal quickly. I don't disagree with using them for things up high, but I would just counsel that I would definitely treat it like a SCS lead for the angle of attack.

I also counsel making sure you don't shear the catheter on the way out, so retract as the catheter/needle assembly as a unit.

Serious Complications After Epidural Catheter Placement: Two Case Reports

Thoracic epidural analgesia (TEA) is a standard procedure in multimodal analgesia applied in major thoracic and abdominal surgeries. Two cases are presented with serious complications related to TEA. In both cases, earlier reaction of the treating physicians ...

www.ncbi.nlm.nih.gov

These are two reports on complications of landmark guided thoracic epidural catheters with an epidural hematoma in one and an intraparenchymal catheter in the other.

Knotting of a Cervical Epidural Catheter in the Patient with Post-Herpetic Neuralgia: A Rare Complication

Epidural block is achieved either by single injection of local anesthetic through an epidural needle or as a continuous block by infusion pump through an epidural catheter. Complications associated with epidural catheters include breakage, entrapment, ...

www.ncbi.nlm.nih.gov

This is a report of a knotted epidural catheter in the cervical spine that was placed for a PHN.

These complications are not a reason to thread a catheter cervical lymph under fluoroscopy. Apples to oranges.

 

[Orin]

None of these were done with fluoro. There is zero percent chance of placing an
These complications are not a reason to thread a catheter cervical under fluoroscopy. Apples to oranges.

I agree that the comparison is imperfect, but what part of the fluoroscopic guidance do you think makes it impossible to cause cord injury?

Quadriparesis and spinal cord stimulation: case report - PubMed

Revision of spinal cord stimulators is usually a safe procedure. However, placement of an electrode within the spinal cord during the revision process is a potential complication resulting in severe neurologic injury.

pubmed.ncbi.nlm.nih.gov

Another imperfect example, but an SCS electrode driven into the cord