TFESI via AP approach?

[CleanUp]

I'm pain trained. I know there is supra and infraneural and the whole Kambin's triangle bit. I use oblique to get in.

However, I am wondering, why aren't TFESIs performed via the AP approach?

The spine guys do kyphos and Intracept in AP view.

Go down -> touch pedicle -> walk caudad a bit-> turn needle and go cephalad.

Obviously one shouldn't go lateral b/c there is no backstop. And one of course shouldn't go medial.

What am I missing? I'm just curious.

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[swamprat]

You def can - it's just not typically taught that way. Theres many ways to skin a cat. I do a lot of endoscopic decompression transforaminal approach and use AP and lateral to guide my needle placement before seldinger technique to introduce the scope. Go AP - (if you miss - miss dorsal not ventral). Hit bone, go lateral most of the time your on SAP - back up the needle and angle more ventral and your in. Now that I just typed this I will say its easier to oblique and AP then AP and lateral which is another reason I do TFESI via oblique approach.

 

[MD87]

Big facets would make an AP approach very difficult.

 

[MitchLevi]

I sometimes do AP at L5-S1 if the pelvis is steep.

 

[Bostonspine]

The AP 2 needle technique is how the do it at HSS where you bend the 2nd needle

 

[DoYouEvenLiftBro]

attending we had in training did everything from solely AP with the c arm fixed.. bc when he taught himself it couldn’t move
Essentially you see the TP
Numb your tract inferior to the lateral part of the TP
Put a bend on the needle tip
Drive it down to the inferior medial aspect of the TP, touch Os, now you know depth
Pull it back go inferior and medial
You’re in, confirm with contrast
would do tfesis with 2 secs of fluoro time, save time not having to move for laterals/obliques etc
I practiced on a cadaver a few times in training and would check laterals, it was pretty much always codmans triangle
He would get paresthesias occasionally

 

[MitchLevi]

What's the purpose of two needles? Just bend one needle and do the same shot

 

[CleanUp]

The AP 2 needle technique is how the do it at HSS where you bend the 2nd needle

Could you please explain? The first needle finds the pedicle and the second needle does what?

 

[CleanUp]

attending we had in training did everything from solely AP with the c arm fixed.. bc when he taught himself it couldn’t move
Essentially you see the TP
Numb your tract inferior to the lateral part of the TP
Put a bend on the needle tip
Drive it down to the inferior medial aspect of the TP, touch Os, now you know depth
Pull it back go inferior and medial
You’re in, confirm with contrast
would do tfesis with 2 secs of fluoro time, save time not having to move for laterals/obliques etc
I practiced on a cadaver a few times in training and would check laterals, it was pretty much always codmans triangle
He would get paresthesias occasionally

Neat! Thanks. He pulled it out or just back? Was it a big bend or something imperceptible?

 

[redchyvak]

I sometimes do AP at L5-S1 if the pelvis is steep.

I came across a comment by lobel saying the same thing about 4 or 5 months ago. Hadn’t ever heard of it thought about it in fellowship, but the next day tried one on a difficult obese female with really high crests. Made a world of a difference.

 

[RoloTomassi]

I've seen it done this way but not my preference. You're more likely to end up in dorsal epidural space and more lateral than mid pedicle, but if you're ok with dorsal and down the root flow you can do it.

 

[DoYouEvenLiftBro]

Neat! Thanks. He pulled it out or just back? Was it a big bend or something imperceptible?

Would pull it back about quarter of an inch then in one fell swoop would advance
If you do any cadaver courses just grab a touhey or a spinal and try
More of a hockey stick type bend
I use it when can’t see anything from hardware on obliques

 

[lobelsteve]

I do all my TFESI starting AP with not more than 10 degrees oblique. THen go lateral when close to target, then AP to get 6 under the pedicle. Save 5 views SIS.

 

[Ducttape]

It is important to do a lateral with this technique.

A single AP image is not adequate to assess proper placement.

This point was pushed in during my fellowship. One of the other fellows did the procedure. Looked good to us fellows. Attending asked fellow if he was sure. He and I said yes.

Lo and behold on lateral the fellow was a good inch short of the TF opening.

 

[SSdoc33]

I do all my TFESI starting AP with not more than 10 degrees oblique. THen go lateral when close to target, then AP to get 6 under the pedicle. Save 5 views SIS.

5 views for a TFESI = cancer

i dont care what SIS says

 

[bedrock]

5 views for a TFESI = cancer

i dont care what SIS says

Any more that two views is a waste of time and radiation

 

[MitchLevi]

5 views for a TFESI = cancer

i dont care what SIS says

ESI is 1-2 saved images. To say 5 views are required is hilarious. Why on Earth is that a thing?

 

[SC Tian]

Oblique to plan the path, ap to finalize the location, and check lateral as needed.

 

[lobelsteve]

Failure to document a lateral is failure to do the procedure correctly.
I can live with saved pics x2 (oblique or AP, and a true lateral) and documented washout of live fluoro is adequate.

 

[SSdoc33]

Failure to document a lateral is failure to do the procedure correctly.
I can live with saved pics x2 (oblique or AP, and a true lateral) and documented washout of live fluoro is adequate.

no. no lateral, esp if perfect spread with AP and oblique

 

[lobelsteve]

no. no lateral, esp if perfect spread with AP and oblique

Then you fail SIS standards.

 

[MitchLevi]

My epidurals rarely involve laterals.

I start oblique and finish AP.

If it looks weird I'll go lateral, but that's rare.

Insane to require 5 views when you consider an entire career within a field of radiation.

 

[callmeanesthesia]

My epidurals rarely involve laterals.

I start oblique and finish AP.

If it looks weird I'll go lateral, but that's rare.

Insane to require 5 views when you consider an entire career within a field of radiation.

For that matter, if using dex, do you really need live fluoro? I realize “SIS says so” but clinically what value does it add, and does that value justify the added radiation exposure?

 

[clubdeac]

Lateral seems unnecessary if classic spread in AP.

 

[RoloTomassi]

I do lateral but don't go live. I know how much 0.5 mL contrast should look on a spot film. If it looks like less than that I adjust slightly, inject again, contrast stays, inject steroid.

 

[SSdoc33]

Maybe this is why SIS has standards. Everyone has their own way of doing it. Lateral just seems unnecessary

 

[MD87]

SIS also is big on cervical TFESI, which many on here are not. Can’t have your cake and eat it too.

 

[Bostonspine]

Could you please explain? The first needle finds the pedicle and the second needle does what?

So the want to introduce a clean needle for the 2nd one. This is what they explained when I rotated there in residency. I do the the standard way oblique the AP to the 6 o’clock. I must admit if the flow on live is picture perfect I don’t check a lateral

 

[lobelsteve]

SIS also is big on cervical TFESI, which many on here are not. Can’t have your cake and eat it too.

When certain folks high up on the ISIS platform love these procedures, they find a way to influence the guidelines towards certain procedures that are not better than safer techniques.
When we are considering risks, catastrophic complications start at 1:150,000 and go towards 1:1,000,000

 

[MitchLevi]

When certain folks high up on the ISIS platform love these procedures, they find a way to influence the guidelines towards certain procedures that are not better than safer techniques.
When we are considering risks, catastrophic complications start at 1:150,000 and go towards 1:1,000,000

What about our risk? If I'm going to practice for 30 years (I'm certainly not), that's so much unneccessary radiation man. Sooooo much more than any of us or our staff need.

 

[lobelsteve]

What about our risk? If I'm going to practice for 30 years (I'm certainly not), that's so much unneccessary radiation man. Sooooo much more than any of us or our staff need.

Then you should be using CT.

https://ajronline.org/doi/full/10.2214/AJR.10.6102

 

[Ducttape]

hence the emphasis on ALARA - pulse, low dose, wear lead, stand back, and what most pain docs dont do, collimate.

 

[SSdoc33]

hence the emphasis on ALARA - pulse, low dose, wear lead, stand back, and what most pain docs dont do, collimate.

alaRa

R = reasonably

5 views is not reasonable.


also, collimation makes me step on the pedal more times than i otherwise would

 

[lobelsteve]

alaRa

R = reasonably

5 views is not reasonable.


also, collimation makes me step on the pedal more times than i otherwise would

Come for a visit. We can get you better pictures with less radiation. And lunch is on me.

 

[SSdoc33]

Come for a visit. We can get you better pictures with less radiation. And lunch is on me.

Im not sure its possible to do as many shots as i do with lower radiation. I do hips and shoulders and only step on the pedal twice. Sounds like a challenge to me.

 

[lobelsteve]

Im not sure its possible to do as many shots as i do with lower radiation. I do hips and shoulders and only step on the pedal twice. Sounds like a challenge to me.

You can improve your technique if this is the case.

 

[Ducttape]

what is your typical fluoro time for a TFESI?

i average 6.7 seconds for a normal bmi patient.

 

[Laryngospasm]

I'm pain trained. I know there is supra and infraneural and the whole Kambin's triangle bit. I use oblique to get in.

However, I am wondering, why aren't TFESIs performed via the AP approach?

The spine guys do kyphos and Intracept in AP view.

Go down -> touch pedicle -> walk caudad a bit-> turn needle and go cephalad.

Obviously one shouldn't go lateral b/c there is no backstop. And one of course shouldn't go medial.

What am I missing? I'm just curious.

Because it’s more difficult than traditional due to large facets and there’s not any benefit. Don’t make things harder than they need to be.

 

[CleanUp]

Because it’s more difficult than traditional due to large facets and there’s not any benefit. Don’t make things harder than they need to be.

The benefit would be for whatever reason not being able to get in via an oblique approach. Always good to have other tricks in the bag. I’m not recommending this is the standard approach

 

[NEA]

The Kumar Technique: A Novel and Effective Approach to Transforaminal Epidural Steroid Injections

Background Transforaminal epidural steroid injections (TFESIs) are widely used as a minimally invasive treatment for lumbar radicular pain. This study presents an alternative approach for lumbar TFESI, the Kumar Technique, which utilizes a more lateral and inferior needle starting point to...

www.cureus.com

 

[Ducttape]

technique wise, im failling to really appreciate a signficant difference between the kumar approach vs traditional, other than the entry point is inferior and lateral to the standard technique.

issues:
it is a retrospective study.

i also wonder about the statistician that did the analysis. the graphs showing pain relief are remarkably similar. all the graphs overlap significantly.

at least they admit that the kumar patients were statistically younger and statistically more likely to have disc herniation and less likely to have foraminal stenosis, so there is bias built in to a retrospective study...

 

[RoloTomassi]

technique wise, im failling to really appreciate a signficant difference between the kumar approach vs traditional, other than the entry point is inferior and lateral to the standard technique.

Entry point isn't really even special. They start lateral relative to a 30 deg oblique, but sometimes I'll oblique 35+ so there's no difference there. And looking the the lateral fluoro example the needle is parallel with endplates, not seeing a significant cephalad angle by starting a little inferior.

Biggest difference is on AP they are going to medial pedicle instead of mid pedicle, which I don't know how they can argue is equally as safe.

 

[DoctorInScrubs]

I do all my TFESI starting AP with not more than 10 degrees oblique. THen go lateral when close to target, then AP to get 6 under the pedicle. Save 5 views SIS.

With the low obliquity, do you find it hard to get to 6 o'clock in patients with disc height loss and hypertrophic facets? With these patients, I find I am barely able to get to 6 o'clock in AP even with an oblique of 30 degrees with a strong bend on the needle with the needle ending relatively anterior in the foramen.

In that case, do you find that you are able to still get medial pedicle spread with the needle a bit more lateral that the 6 o'clock position?