Standard injection solutions

[SSdoc33]

its from the package insert, as linked above

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[epidural man]

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?

I do a lot of things that still get bad press.

I'm still heterosexual (really bad press). I feel comfortable with my gender (very bad press). I'm white and still believe in God (horrible press).

 

[NJPAIN]

I do a lot of things that still get bad press.

I'm still heterosexual (really bad press). I feel comfortable with my gender (very bad press). I'm white and still believe in God (horrible press).

That's what Bruce Jenner once said.


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[Timeoutofmind]

I do a lot of things that still get bad press.

I'm still heterosexual (really bad press). I feel comfortable with my gender (very bad press). I'm white and still believe in God (horrible press).

U must be a horrible human being.










Just kidding lol!

 

[painfree23]

I do a lot of things that still get bad press.

I'm still heterosexual (really bad press). I feel comfortable with my gender (very bad press). I'm white and still believe in God (horrible press).

Hope u don't get sued for 13.7 million lol

 

[Tapspatellas]

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

In lumbar I still use a little local, like 0.33% lido after dilution, not in cervical unless it's a "diagnostic" for the surgeons and I'll throw in a whiff of 1% to flush the tubing. I know a lot don't even do cervical TF, but my surgeons will ask, and Medicaid out here deleted 62310 and didn't add 62321, so no ability to do an ILESI in the ASC.

Results are variable as expected. Anecdotally, for a nice hot radic with displacement or contact of the root but not much compression, do great. Not bad but 2 or rarely 3 shots for compression to get them through. I find for foraminal stenosis it is pretty hit or miss. For central stenosis I get my 3-6 months usually, unless it is multilevel then it is also hit or miss.

 

[painfree23]

In lumbar I still use a little local, like 0.33% lido after dilution, not in cervical unless it's a "diagnostic" for the surgeons and I'll throw in a whiff of 1% to flush the tubing. I know a lot don't even do cervical TF, but my surgeons will ask, and Medicaid out here deleted 62310 and didn't add 62321, so no ability to do an ILESI in the ASC.

Results are variable as expected. Anecdotally, for a nice hot radic with displacement or contact of the root but not much compression, do great. Not bad but 2 or rarely 3 shots for compression to get them through. I find for foraminal stenosis it is pretty hit or miss. For central stenosis I get my 3-6 months usually, unless it is multilevel then it is also hit or miss.

TFESI for central stenosis? Why not LESI, I mean unless it's really bad..

 

[Tapspatellas]

TFESI for central stenosis? Why not LESI, I mean unless it's really bad..

A few reasons.

In the lumbar spine I feel covering the offending DRG is more reliable with TFESI, especially going with a b/l TFESI for stenosis rather than ILESI for bilateral pain. Midline ILESI I just don't see as reliable for bilateral spread. If it is unilateral radicular pain even with central stenosis, then I will do a TFESI as my preferred injection anyway.

I don't hold any anticoagulants or antiplatelet agents for my TFESI. ILESI (and S1 TF) I hold all. If they are on one of these agents, I can usually get S1 from a TFESI approach if that is my target with an infraneural L5-S1, unless the inferior aspect of the foramen is filled up with disc or osteophyte. Most of my patients with stenosis are at least on ASA 81mg and unless it is primary prevention without any risk factors, I prefer to keep them on.

If level of stenosis happens to be poorly accessible due to either multilevel stenosis or it is L5-S1, then I am limited in ILESI, due to obliteration of epidural space.

Main benefit I see with ILESI is I don't have a problem using a particulate, if that does actually matter.

The one indication that I will tend towards an ILESI is for posterior annular tears with axial low back pain that does not localize to the facets on MBB. Sometimes I'll give it a go since they are pretty much out of options, and I have some patients who respond reasonably well for 3-4 months with this injection.

 

[lobelsteve]

Trained by dogma, not science. Sounds like your attendings were old asipp guys. Do tour patients a favor and go to SIS meeting and get a copy of their guidelines.

 

[nvrsumr]

Dogma and hubris are the only training methods I have ever seen in pain medicine.

 

[lobelsteve]

Dogma and hubris are the only training methods I have ever seen in pain medicine.

Learn by example of what not to do.

 

[cbest]

A few reasons.

In the lumbar spine I feel covering the offending DRG is more reliable with TFESI, especially going with a b/l TFESI for stenosis rather than ILESI for bilateral pain. Midline ILESI I just don't see as reliable for bilateral spread. If it is unilateral radicular pain even with central stenosis, then I will do a TFESI as my preferred injection anyway.

I don't hold any anticoagulants or antiplatelet agents for my TFESI. ILESI (and S1 TF) I hold all. If they are on one of these agents, I can usually get S1 from a TFESI approach if that is my target with an infraneural L5-S1, unless the inferior aspect of the foramen is filled up with disc or osteophyte. Most of my patients with stenosis are at least on ASA 81mg and unless it is primary prevention without any risk factors, I prefer to keep them on.

If level of stenosis happens to be poorly accessible due to either multilevel stenosis or it is L5-S1, then I am limited in ILESI, due to obliteration of epidural space.

Main benefit I see with ILESI is I don't have a problem using a particulate, if that does actually matter.

The one indication that I will tend towards an ILESI is for posterior annular tears with axial low back pain that does not localize to the facets on MBB. Sometimes I'll give it a go since they are pretty much out of options, and I have some patients who respond reasonably well for 3-4 months with this injection.

Just curious on your thought process behind preferring ILESI vs TFESI for patients with posterior annular fissure with presumed discogenic low back pain.


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[Tapspatellas]

Just curious on your thought process behind preferring ILESI vs TFESI for patients with posterior annular fissure with presumed discogenic low back pain.


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Wouldn't say that I prefer this, better wording probably would have been that I will be more apt to jump to this should relief with a TF be inadequate if the pain generator seems more consistent with a posterior annular tear. Frank radic then it's TF. Theoretically the TF gets to anterior space better and it makes more sense to me. It is a total anecdotal statement. I do about 98% TFESI for lumbar pathology. I don't typically go after "discogenic" pain either, usually they had some radicular distribution at some point in their history and are still having pain intermittently with an incomplete radicular pattern, such as piriformis region pain with referral to calf, and does not localize to SIJ on exam. Most of these are patients who had a marginal duration of response to a TFESI and we try a different route, or a patient who was seeing one of the other pain docs in the area and was getting this periodically with benefit, so we continue.

 

[painfree23]

Do you do bilateral cervical mbnb or one side at a time? Do any steroid for the diagnostic block? How much time between blocks - either 2 (if bilateral) or 4 (if unilateral)?

 

[Tapspatellas]

Do you do bilateral cervical mbnb or one side at a time? Do any steroid for the diagnostic block? How much time between blocks - either 2 (if bilateral) or 4 (if unilateral)?

Will do bilateral CMBB if symmetric and relatively equal. PITA but I'm in ASC and want to save them some $. Will not perform RF bilateral in the C spine. I give it 3-4 weeks. I start with the worst side and if better after first RF, skip the contralateral.

I will do confirmatory blocks as soon as 1 week later if reasonable amount of pain has recurred. If partially therapeutic response, I try to defer until enough pain recurs that we can definitely "tell" the confirmatory helps. I will do a recurrent 4/10 that has improved from 7/10 and dynamic pain, but not a 2/10 on follow up.

I never use steroids for diagnostic MBB. Only very low volume local. If I had a "therapeutic responder" who was going to Africa for a 6 week safari and had a block in the past and wanted a repeat with steroid for a potential therapeutic response since unable to get RF in before departure, I would do, but not consider diagnostic.

 

[painfree23]

Will do bilateral CMBB if symmetric and relatively equal. PITA but I'm in ASC and want to save them some $. Will not perform RF bilateral in the C spine. I give it 3-4 weeks. I start with the worst side and if better after first RF, skip the contralateral.

I will do confirmatory blocks as soon as 1 week later if reasonable amount of pain has recurred. If partially therapeutic response, I try to defer until enough pain recurs that we can definitely "tell" the confirmatory helps. I will do a recurrent 4/10 that has improved from 7/10 and dynamic pain, but not a 2/10 on follow up.

I never use steroids for diagnostic MBB. Only very low volume local. If I had a "therapeutic responder" who was going to Africa for a 6 week safari and had a block in the past and wanted a repeat with steroid for a potential therapeutic response since unable to get RF in before departure, I would do, but not consider diagnostic.

Nice, I like that. Where I trained we would do one sided cervical MBNBs which seemed like such a hassle for the patient...4 trips before an RF. so you normally do C3-C6 (4 medial branches)?

 

[Tapspatellas]

Nice, I like that. Where I trained we would do one sided cervical MBNBs which seemed like such a hassle for the patient...4 trips before an RF. so you normally do C3-C6 (4 medial branches)?

Typically just 2 levels per side, I feel like I can usually narrow it down to 2 levels based upon referral pattern. I would say C4-6 is a common one.

 

[thecentral09]

What volumes are you guys using per level for cervical MBB? 0.3ml?

 

[Tapspatellas]

What volumes are you guys using per level for cervical MBB? 0.3ml?

Up to 1mL total for TON. Above, at, below joint line of 0.3mL. Otherwise I use 0.2-0.3mL