TFESI

[sprtsmeddoc]

Struggling to get medial flow on my TFESI lately. Square SEP, oblique 25 degree IPL, but still tend to be lateral. Thoughts/recommendations?

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[GoBeers]

my first thoughts , aim closer to the medial side of infrapedicle when you are going coaxial on ipsilateral oblique view or maybe angle 30 degrees with longer needle ?

 

[bedrock]

Struggling to get medial flow on my TFESI lately. Square SEP, oblique 25 degree IPL, but still tend to be lateral. Thoughts/recommendations?

No offense but based on your username, I assume you did not do a pain fellowship?

If you can’t do a TFESI, you should likely leave all pain procedures to pain physicians, who perform a minimum of several hundred TFESI under close supervision during their year long fellowship.

 

[Greenbayslacker]

several hundred TFESI under supervision during their year long fellowship

 

[Tboned]

Do you look at a lateral? Where is your needle tip based on AP, oblique and lateral views? You should be able to triangulate where you’re at and make adjustment to improve. If you can’t, see @bedrock ‘s comments.


post fluoro pics

 

[Ducttape]

you are making a lot of assumptions based on his username...

but if you read his posts, he is using terms typically used by pain docs appropriately.

currently, i get a lateral with all TFESI and i might suspect you are not driving the needle deep enough, hence end up lateral on AP imaging.

you might want to look at the degree of obliquity you are using.

 

[MitchLevi]

I think most people are too shallow with their needle placement, both in TFESI and/especially RFA.

The 6 oclock needle position on the pedicle is a requirement IMO, and another thing is the level you're choosing to inject. If they're super tight go one level below. I've had very stenotic people try to push my contrast back out.

 

[Baron Samedi]

I think most people are too shallow with their needle placement, both in TFESI and/especially RFA.

The 6 oclock needle position on the pedicle is a requirement IMO, and another thing is the level you're choosing to inject. If they're super tight go one level below. I've had very stenotic people try to push my contrast back out.

Agree with all of this with the addition of saying that an infraneural approach one level above is also a viable option.

 

[lobelsteve]

SIS: 5 saved images. Ap/Lat with and without contrast, washout. Live fluoro to assess contrast flow as well.

 

[Ferrismonk]

SIS: 5 saved images. Ap/Lat with and without contrast, washout. Live fluoro to assess contrast flow as well.

SIS is living in a dream world where money and time must not matter.

 

[SSdoc33]

SIS is living in a dream world where money and time must not matter.

agree. AP and oblique only as long as the flow looks good

 

[MitchLevi]

AP and oblique only. Radiation over the course of my career. Unnecessary lateral IMO.

 

[kstarm]

If you are just starting out after you believe you are in the correct position go back and recheck your oblique, often as you are trying to get epidural space you vere one way or another and realigning with the oblique can help with your medial to lateral issues. Do this before contrast as after it can be messy. I now do it post-contrast if I don't get the flow I want and this often is helpful in getting the procedure completed. As others mentioned there is a lot of anatomy issues that might also be getting in the way as well.

 

[Espn123]

If you touch the SAP below w a bent needle then walk one mm lateral and back 1mm medial you are there. Add 0.25cc lidocaine at that SAP for style points if you want

 

[MD87]

agree. AP and oblique only as long as the flow looks good

I agree with this. I check a lateral maybe 5-10% of the time if initial flow is questionable. Example - I’m in the facet inadvertently and in the AP my needle is looking too medial and makes me uneasy, I will get a lateral and advance til it looks good.

 

[epidural man]

Struggling to get medial flow on my TFESI lately. Square SEP, oblique 25 degree IPL, but still tend to be lateral. Thoughts/recommendations?

to fix this depends on the level.

A good answer for every level - drive all the way to vertebral body. That will likely fix the problem.

 

[lobelsteve]

Facepalm all of this nonsense.

 

[agolden1]

No offense but based on your username, I assume you did not do a pain fellowship?

If you can’t do a TFESI, you should likely leave all pain procedures to pain physicians, who perform a minimum of several hundred TFESI under close supervision during their year long fellowship.

Annoyingly, I can think of several ACGME fellowships where TFESI is avoided as much as possible and interlaminar/caudal is used preferentially resulting in only a handful of TFESI being performed each year…

 

[DOctorJay]

Annoyingly, I can think of several ACGME fellowships where TFESI is avoided as much as possible and interlaminar/caudal is used preferentially resulting in only a handful of TFESI being performed each year…

Name and shame. Bread and butter procedure for our subspecialty.

 

[jwalker12]

Do you guys ever notice sometimes you have to advance past 6 o'clock on the pedicle to get medial contrast flow?

 

[lobelsteve]

Do you guys ever notice sometimes you have to advance past 6 o'clock on the pedicle to get medial contrast flow?

Yes, just rotate the C-arm back to show you were at 6 for final image. Know where the sac is and avoid it.

 

[jwalker12]

Yes, just rotate the C-arm back to show you were at 6 for final image. Know where the sac is and avoid it.

thank you

 

[Ferrismonk]

Yes, just rotate the C-arm back to show you were at 6 for final image. Know where the sac is and avoid it.

What about the other 4 views?

 

[Dr. Ice]

Do you guys ever notice sometimes you have to advance past 6 o'clock on the pedicle to get medial contrast flow?

Doesn’t have to be perfect every time. Maybe there’s a lot of foraminal stenosis, a big foraminal disc or big facets. Sometimes as my illustrious mentor would say, the enemy of good, is your hubris that you can make it better

 

[lobelsteve]

What about the other 4 views?

Save them too. There may come a day when I retire and Medicare hires me to do nothing but look at pictures and payments will stop if the pictures aren’t there or aren’t right.