Difficult TFESI within or adjacent to lumbar fusion- tips or pearls?

[cameroncarter]

Even though I have great needle placement in all views, I often notice that foramen within or adjacent to a lumbar fusion feel “very tight”. Tips on optimizing these procedures?

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[Laryngospasm]

Some of the surgeons pack the facets in bone when they fuse.. this particular thing seems to make the tfesi almost impossible sometimes. I think many would advocate for a caudal here or ilesi above the fusion. If you simply must do it come in from farther lateral and see if you can find the hole without spearing the nerve.

 

[cameroncarter]

Some of the surgeons pack the facets in bone when they fuse.. this particular thing seems to make the tfesi almost impossible sometimes. I think many would advocate for a caudal here or ilesi above the fusion. If you simply must do it come in from farther lateral and see if you can find the hole without spearing the nerve.

What about L3/4 or higher levels where caudal isn’t helpful. How are you treating them?

 

[Taus]

What about L3/4 or higher levels where caudal isn’t helpful. How are you treating them?

Interlam above

 

[cameroncarter]

Interlam above

But in theory, why are these TFESIs so much harder, esp when the foramen look open on MRI?

 

[SSdoc33]

depends on the fusion.

older surgeons like to use a lot of bone stock or some mashed bone product and there is often a large posterolateral fusion mass. you can go THRU the fusion mass with a 22g as long as you dont bend the tip. if you do, it will kink. otherwise, i agree, start a little more lateral. a TFESI is still the best injection in these patients (IMHO). it is exceptionally rare that i am unable to to do TFESI on fusion patients.

with a posterior instrumented fusion, just go below the pedicle screw. no big deal

a lot of fellows learn that you should do a a caudal on these patients, or ILESIs. my personal opinion is that this is ridiculous. just get better at doing the shots.

 

[GlowInTheDark]

depends on the fusion.

older surgeons like to use a lot of bone stock or some mashed bone product and there is often a large posterolateral fusion mass. you can do THRU the fusion mass with a 22g as long as you dont bend the tip. if you do, it will kink. otherwise, i agree, start a little more lateral. a TFESI is still the best injection in these patients (IMHO). it is exceptionally rare that i am unable to to do TFESI on fusion patients.

with a posterior instrumented fusion, just go below the pedicle screw. no big deal

a lot of fellows learn that you should do a a caudal on these patients, or ILESIs. my personal opinion is that this is ridiculous. just get better at doing the shots.

Yea, they don’t teach advancing through fusion masses like they used to.

Infraneural TFESI from the level above is also an option