Standard injection solutions

[painfree23]

I have seen so many things over the years, just was wondering if we could get some kind of survey out for what everyone does..I bring this up bc an ASC in Colorado was recently sued ($14 mil) bc one of the pain docs used kenelog in the epidural space.

http://www.bizjournals.com/denver/news/2017/04/06/colorado-paralyzed-woman-wins-14-9-million.html

I don't ever use it in the epidural space, but have def seen people do it..so thought I'd throw this question out.

In GENERAL...normal patient, no significant comborbidities what do you inject for the following: and this is it not to criticize people's technique or approach, just to learn different styles

Cervical MBNB (diagnostic)
-bupi 0.25% only

Cervical MB RFA (before and after burn)
-lido 2% before burn, dex + bupi after

Cervical ESI
-dexamethsone 10mg + PF normal saline

Lumbar MBNB (diagnostic)
-bupi 0.25%

Lumbar MB RFA
-lido 2% before burn, kenelog+ bupi after

Lumbar ESI
-dex 10mg + 1cc 0.25% bupi + saline

Caudal ESI
-Dex 10mg + 1cc 0.25% bupi + saline

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[bedrock]

I don't use kenalog for epidurals just for this reason, even though I don't think it's any riskier than depo, which I continue to use.

Regarding your other injection solutions, there is no good clinical reason to add local anesthetic to pain epidurals, you just increase your legal risks by doing so.

 

[powermd]

Depo + Saline for ILESI, usually 5 mL.
For caudals, 1-2 mL lido 1%, then 10 mL depo + saline. The lido seems to help with patient complaints of pressure at the injection site, and hasn't caused any issues with mobility. I'm not a fan of unnecessary local.
TF Saline + dex
SNRB 2% lido + dex

MBB #1 - bupi 0.25; MBB #2 lido 2%
Lumbar RF - lido 2% + depo
Cervical RF - lido 2% + dex

Medium size tendon sheaths/bursae (like supraspinatus), 5-10 mL bupi 0.25% + depo
Larger tendons like lumbar ES, or large bursae 10 mL 0.125% bupi + 20 depo each

Piriformis/ONB (don't want higher potency local) 10 mL 0.125% bupi + depo.

 

[lonelobo]

Depo + Saline for ILESI, usually 5 mL.
For caudals, 1-2 mL lido 1%, then 10 mL depo + saline. The lido seems to help with patient complaints of pressure at the injection site, and hasn't caused any issues with mobility. I'm not a fan of unnecessary local.
TF Saline + dex
SNRB 2% lido + dex

MBB #1 - bupi 0.25; MBB #2 lido 2%
Lumbar RF - lido 2% + depo
Cervical RF - lido 2% + dex

Medium size tendon sheaths/bursae (like supraspinatus), 5-10 mL bupi 0.25% + depo
Larger tendons like lumbar ES, or large bursae 10 mL 0.125% bupi + 20 depo each

Piriformis/ONB (don't want higher potency local) 10 mL 0.125% bupi + depo.

Please explain the difference

 

[lonelobo]

Same warning is on label of Depo against Epidural use.All the steroids I have ever used for epidurals have only been labeled for intramuscular and intravenous use.......if bad sh't happens this case will be used by future attorneys

 

[powermd]

Please explain the difference

In theory, you intersect the nerve lateral to the foramen and use less volume. At least that's what I learned in fellowship, which I believe is ISIS technique. In practice I just do a TFESI and note both the location of the pressure paresthesia, as well as numbness in the ordinarily painful dermatome if applicable. To me, the pressure paresthesia is the more useful diagnostic tool. I only do SNRBs at the request of a surgeon.

 

[powermd]

Same warning is on label of Depo against Epidural use.All the steroids I have ever used for epidurals have only been labeled for intramuscular and intravenous use.......if bad sh't happens this case will be used by future attorneys

Would be instructive to have the details of the incident. I don't think there's anything wrong with patients being compensated for "bad effing luck", it's just a question of who does the paying- and how much! We have a national vaccine compensation program to cover unusual sequelae of vaccine use, how are catastrophic complications of ESI any different?

 

[Blitz2006]

Anyone uses betamethasone?

 

[painfree23]

I don't use kenalog for epidurals just for this reason, even though I don't think it's any riskier than depo, which I continue to use.

Regarding your other injection solutions, there is no good clinical reason to add local anesthetic to pain epidurals, you just increase your legal risks by doing so.

Ive heard adding local to your epidural allows for something to work on the drg (hopefully it makes it that far out...)

Thoughts?

 

[lord_jeebus]

Anyone uses betamethasone?

I do, for ILESI

 

[Blitz2006]

Safer than kenalog and depot?

Sent from my SM-N910V using Tapatalk

 

[bedrock]

Same warning is on label of Depo against Epidural use.All the steroids I have ever used for epidurals have only been labeled for intramuscular and intravenous use.......if bad sh't happens this case will be used by future attorneys

I agree that epidural use has always been off-label, however brand name kenalog (and by extension the generic version) has a specific warning against epidural use.

Please show me a picture of a depo bottle specifically stating that epidural use is forbidden, otherwise your premise that both steroids leave you as legally vulnerable is incorrect.

 

[cowboydoc]

I use Dex for all epidurals, saline (and 1mL 1% lido for Lumbar TFESI)

Cervical MBB 1% lido or 0.5 % bup

Lumbar MBB 2ml 1% lido, 1ml 6mg/ml beta (I know, roast me for this, but I don't think it affects diagnostic value of block, and 75% of time gives weeks of relief, and I'm 5 weeks out to get them back for second block or RF. FWIW, in my residency, our VA pain clinic did this mix every 3 months for "therapeutic" MBB, on to RF only if diminishing benefit...)

RF 2% lido and 0.5% bup. I've been considering adding a bit of steroid...

Large joints 2 mL 1% lido, 1 ml beta.

 

[lonelobo]

I agree that epidural use has always been off-label, however brand name kenalog (and by extension the generic version) has a specific warning against epidural use.

Please show me a picture of a depo bottle specifically stating that epidural use is forbidden, otherwise your premise that both steroids leave you as legally vulnerable is incorrect.

I suggest you you take that little piece of paper out of the box of Depo-medrol and read it

Under section C
Warnings
Epidural Injections is first on the list and the Warning is even stronger that that of Kenalog

( If I wasn't so terminologically inept I would have sent picture)

FDA Won’t Change Warning Label for Steroid Injections

 

[Pain Applicant1]

I suggest you you take that little piece of paper out of the box of Depo-medrol and read it

Under section C
Warnings
Epidural Injections is first on the list and the Warning is even stronger that that of Kenalog

( If I wasn't so terminologically inept I would have sent picture)

FDA Won’t Change Warning Label for Steroid Injections

Is this what you're looking for? It's called a PI

http://labeling.pfizer.com/ShowLabeling.aspx?id=551


https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/011757s103lbl.pdf

 

[SSdoc33]

Is this what you're looking for? It's called a PI

http://labeling.pfizer.com/ShowLabeling.aspx?id=551


https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/011757s103lbl.pdf

"Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke. These serious neurologic events have been reported with and without use of fluoroscopy. The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use."


it doesnt say "don't use depo-medrol" for epidural use. the packet insert is purposely vague, instead referring to all "corticosteroids" in general, rather than depo-medrol in particular

 

[pmrmd]

MBB: dex + bupi, sometimes phenol + dex
ILESI: 2cc kenalog + 3cc dex
TFESI: 1cc kenalog, 2.5cc dex, 0.5cc bupi
Lg joint = TFESI cocktail
Tendons: dex + bupi
CT: 1cc celestone + 2cc dex

I use a ton of dex.

 

[SSdoc33]

MBB: dex + bupi, sometimes phenol + dex
ILESI: 2cc kenalog + 3cc dex
TFESI: 1cc kenalog, 2.5cc dex, 0.5cc bupi
Lg joint = TFESI cocktail
Tendons: dex + bupi
CT: 1cc celestone + 2cc dex

I use a ton of dex.

2 diff steroids? kenalog in a TFESI? dont let steve read this.....

 

[epidural man]

I use kenalog for ESI.

 

[lonelobo]

A lot of what we do is Voodoo with the different mixtures of medications....think the take home is if sh't hits the fan there are multiple reasons we can get sued

 

[BobBarker]

What about for joint injections in the office? I do 4ml .25% Marcaine and 80mg of depomedrol.

 

[cowboydoc]

I don't do any marcaine IA. Some old Ortho literature suggesting chondrotoxicity, though certainly debatable.

I thought pmrmd was joking about his special sauces.

 

[DrCommonSense]

I have seen so many things over the years, just was wondering if we could get some kind of survey out for what everyone does..I bring this up bc an ASC in Colorado was recently sued ($14 mil) bc one of the pain docs used kenelog in the epidural space.

http://www.bizjournals.com/denver/news/2017/04/06/colorado-paralyzed-woman-wins-14-9-million.html

I don't ever use it in the epidural space, but have def seen people do it..so thought I'd throw this question out.

In GENERAL...normal patient, no significant comborbidities what do you inject for the following: and this is it not to criticize people's technique or approach, just to learn different styles

Cervical MBNB (diagnostic)
-bupi 0.25% only

Cervical MB RFA (before and after burn)
-lido 2% before burn, dex + bupi after

Cervical ESI
-dexamethsone 10mg + PF normal saline

Lumbar MBNB (diagnostic)
-bupi 0.25%

Lumbar MB RFA
-lido 2% before burn, kenelog+ bupi after

Lumbar ESI
-dex 10mg + 1cc 0.25% bupi + saline

Caudal ESI
-Dex 10mg + 1cc 0.25% bupi + saline

Was the paralysis from the actual properly performed injection or potential direct trauma from the Touhy needle?

Outside of particulate steroid usage in TFESI (particularly cervical, although a lumbar cases have been reported out of literally 10s of millions of injections by this time) how many documented cases do we have that the properly performed injection caused paralysis from an ILESI that wasn't due to a hematoma or infection or perforation of the cord using a Touhy?

 

[SageCraft]

Resurrecting this thread. For years our practice had considered shifting from Kenalog to Dexa for all TFESI's. The Colorado incident made the decision final. However, since switching to Dexa all three of us have noticed drastically reduced relief duration. With Kenalog we could get at least 2 months and longer. With Dexa we are noticing relief lasting for around 5 days...maybe a couple of weeks if we're lucky. This isn't happening with every patient but it has certainly become worrisome. Thoughts?

 

[lobelsteve]

Resurrecting this thread. For years our practice had considered shifting from Kenalog to Dexa for all TFESI's. The Colorado incident made the decision final. However, since switching to Dexa all three of us have noticed drastically reduced relief duration. With Kenalog we could get at least 2 months and longer. With Dexa we are noticing relief lasting for around 5 days...maybe a couple of weeks if we're lucky. This isn't happening with every patient but it has certainly become worrisome. Thoughts?

Folie a trois.

Read the literature. What you see is your bias, what your patients feel is your bias induced nocebo. The literature makes it equivalent.

 

[epidural man]

Folie a trois.

Read the literature. What you see is your bias, what your patients feel is your bias induced nocebo. The literature makes it equivalent.

Not quite equivalent, but close.

 

[Dr. Ice]

Resurrecting this thread. For years our practice had considered shifting from Kenalog to Dexa for all TFESI's. The Colorado incident made the decision final. However, since switching to Dexa all three of us have noticed drastically reduced relief duration. With Kenalog we could get at least 2 months and longer. With Dexa we are noticing relief lasting for around 5 days...maybe a couple of weeks if we're lucky. This isn't happening with every patient but it has certainly become worrisome. Thoughts?

Dex sucks
Paralysis sucks
Lawyers suck
Working in a field based largely on subjective complaints sucks

But what's worse:
Loss of job
Loss of earning potential
Guilt of causing harm

Perception based on practice bias should matter but it doesn't

I struggle with this everyday

 

[bedrock]

Resurrecting this thread. For years our practice had considered shifting from Kenalog to Dexa for all TFESI's. The Colorado incident made the decision final. However, since switching to Dexa all three of us have noticed drastically reduced relief duration. With Kenalog we could get at least 2 months and longer. With Dexa we are noticing relief lasting for around 5 days...maybe a couple of weeks if we're lucky. This isn't happening with every patient but it has certainly become worrisome. Thoughts?

This what I see as well. The literature that Steve references, was only done on acute radiculopathy patients, not the recurrent/chronic radiculopathy and stenosis patients that we actually see 90% of the time.

Dex is decent for acute radiculopathy, and I do lumbar TFESI w dex for acute radios, but dex TFESI generally do not provide durable relief for other diagnoses.

I do a fair number of lumbar ILESI and caudals with depomedrol for everything but acute radics.
I also still do S1 TFESI with depo, but that's another discussion.

 

[painfree23]

Really surprising to still see the number of people using kenelog in epidurals. Not trying to criticize but just to learn..how do you justify this knowing all this bad press about it is out there?

 

[painfree23]

This what I see as well. The literature that Steve references, was only done on acute radiculopathy patients, not the recurrent/chronic radiculopathy and stenosis patients that we actually see 90% of the time.

Dex is decent for acute radiculopathy, and I do lumbar TFESI w dex for acute radios, but dex TFESI generally do not provide durable relief for other diagnoses.

I do a fair number of lumbar ILESI and caudals with depomedrol for everything but acute radics.
I also still do S1 TFESI with depo, but that's another discussion.

How much dex?

 

[bedrock]

How much dex?

4mg for diabetic or fragile patient. 8mg for regular patient.

 

[lord_jeebus]

One of my attendings did a little prospective study on dex dosing for TFESI:

Lumbar transforaminal epidural dexamethasone: a prospective, randomized, double-blind, dose-response trial. - PubMed - NCBI

CONCLUSIONS:
Transforaminal epidural dexamethasone provides statistically significant and clinically meaningful improvement in radicular pain at 12 weeks after injection, with parallel improvements in disability, impression of change, and satisfaction measures. There was no difference in efficacy for dexamethasone 4 mg compared with 8 or 12 mg. The optimal dose of epidural dexamethasone may be lower than 4 mg, further increasing the long-term safety and tolerability of this treatment. Current data are reassuring with regard to the safety of dexamethasone for transforaminal epidural steroid injection.

 

[Phyzicz]

Dex I purchase comes 10mg/vial so I may need to start doing organic chem titrations for each tfesi. Are you saying 4-8mg total dose or per nerve root???
Also isn't equivalent of 80mg depo a little less than 20mg dex??? Are you under dosing dex therefore giving shorter duration efficacy?

 

[painfree23]

Dex I purchase comes 10mg/vial so I may need to start doing organic chem titrations for each tfesi. Are you saying 4-8mg total dose or per nerve root???
Also isn't equivalent of 80mg depo a little less than 20mg dex??? Are you under dosing dex therefore giving shorter duration efficacy?

So you normally do the whole vial at each nerve root?

 

[bedrock]

Dex I purchase comes 10mg/vial so I may need to start doing organic chem titrations for each tfesi. Are you saying 4-8mg total dose or per nerve root???
Also isn't equivalent of 80mg depo a little less than 20mg dex??? Are you under dosing dex therefore giving shorter duration efficacy?

As Jeebus pointed out, studies have demonstrated 4mg to be sufficient for lumbar TFESI. One thing you notice about dex ESIs is there are a number of dose dependent side effects, glucose spikes obviously, but more than with particulates. Patients will also have cardiovascular side effects, such as elevated BP, HA, feel jittery etc, more often with dex than with particulate, because dex is absorbed so quickly. So I would advise against using 20mg of dex.

10mg is the other common size for dex vials. If you get 10mg dex vials, it's pretty easy to just use half of it (5mg) for a unilateral TFESI, and use the whole 10mg vial for a bilateral or two level TFESI.

 

[clubdeac]

Dex I purchase comes 10mg/vial so I may need to start doing organic chem titrations for each tfesi. Are you saying 4-8mg total dose or per nerve root???
Also isn't equivalent of 80mg depo a little less than 20mg dex??? Are you under dosing dex therefore giving shorter duration efficacy?

7.5mg dex is equivalent to 40mg depomedrol. You should know this if you're a pain physician

 

[Timeoutofmind]

As Jeebus pointed out, studies have demonstrated 4mg to be sufficient for lumbar TFESI. One thing you notice about dex ESIs is there are a number of dose dependent side effects, glucose spikes obviously, but more than with particulates. Patients will also have cardiovascular side effects, such as elevated BP, HA, feel jittery etc, more often that with particulate, because dex is absorbed so quickly. So I would advise against using 20mg of dex.

10mg is the other common size for dex vials. If you get 10mg dex vials, it's pretty easy to just use half of it (5mg) for a unilateral TFESI, and use the whole 10mg vial for a bilateral or two level TFESI.

How would dex cause elevated BP given the fact that it has no mineralcorticoid activity?

 

[cowboydoc]

How would dex cause elevated BP given the fact that it has no mineralcorticoid activity?

Mechanism of delivery. (3.5in spinal needle)

 

[Dr Manhattan]

As Jeebus pointed out, studies have demonstrated 4mg to be sufficient for lumbar TFESI. One thing you notice about dex ESIs is there are a number of dose dependent side effects, glucose spikes obviously, but more than with particulates. Patients will also have cardiovascular side effects, such as elevated BP, HA, feel jittery etc, more often with dex than with particulate, because dex is absorbed so quickly. So I would advise against using 20mg of dex.

10mg is the other common size for dex vials. If you get 10mg dex vials, it's pretty easy to just use half of it (5mg) for a unilateral TFESI, and use the whole 10mg vial for a bilateral or two level TFESI.

this is a great dialogue to have. makes me think about reconsidering my formulation. for me, i often use 10mg dexamethasone for my elderly/diabetic patient, while using 20mg dexamethasone for the other "healthy" patients. may switch to 15mg as the "max dose"

would like to hear others opinions regarding this.

 

[DOctorJay]

I've been using 10 of dex for single level TFESI and CESI, 15 of dex total for 2 level TFESI (I get the 10 mg/cc vials)

am also watching this thread closely and considering changing

 

[DODOCSS]

6 or 12 (2-level) here

 

[NJPAIN]

10mg of dex either at a single level or split between two. I found 20mg no more effective but did see more complaints of HA in the postprocedure period.

 

[DODOCSS]

corrections vials are 4mg, so its single = 8mg, 2-level = 12mg split

 

[kstarm]

I've been using 10 of dex for single level TFESI and CESI, 15 of dex total for 2 level TFESI (I get the 10 mg/cc vials)

am also watching this thread closely and considering changing

This is what I do currently but am also considering lowering the dose.

 

[lobelsteve]

4mg single, 10mg max.

 

[thecentral09]

Does anyone use Dexamethasone for a TFESI initially, and hypothetically have a great response for <1-2months and then attempt repeating the procedure with depo?

 

[Tapspatellas]

this is a great dialogue to have. makes me think about reconsidering my formulation. for me, i often use 10mg dexamethasone for my elderly/diabetic patient, while using 20mg dexamethasone for the other "healthy" patients. may switch to 15mg as the "max dose"

would like to hear others opinions regarding this.

Most Medicare LCD have switched or are changing to max of 15mg dex per injection session.

I use 5mg/injection site, 10 mg for 2 level/bilateral.

Does anyone use Dexamethasone for a TFESI initially, and hypothetically have a great response for <1-2months and then attempt repeating the procedure with depo?

DJ Kennedy told me he was doing this before his study came out (edit: if surgery was the next step since the risk of a particulate is much lower than surgery), I believe he isn't any more. I don't ever use particulate in TF, I'll use in ILESI for lumbar, but have contemplated switching to full dex for any ESI.

 

[Timeoutofmind]

4mg single, 10mg max.

Same

 

[painfree23]

Most Medicare LCD have switched or are changing to max of 15mg dex per injection session.

I use 5mg/injection site, 10 mg for 2 level/bilateral.



DJ Kennedy told me he was doing this before his study came out (edit: if surgery was the next step since the risk of a particulate is much lower than surgery), I believe he isn't any more. I don't ever use particulate in TF, I'll use in ILESI for lumbar, but have contemplated switching to full dex for any ESI.

What kind of results r u seeing with just dex for tfesi? Any local ?

 

[painfree23]

"Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke. These serious neurologic events have been reported with and without use of fluoroscopy. The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use."

Wait where is this from? Does this scare anyone else from a legal point of view...