TIPS for ILESI - difficult arthritic back

IPSIS: Formerly the Spine Intervention Society
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SpineandWine

SpineandWine

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Had a patient that had extremely arthritic spine, difficult to see due to OA/osteophytes
Is there some technique to orient yourself in the spine with this type of back (sorry, no pictures saved, but in future if I see them, i'll post it).
My thought was to square end plate (and try to aim between pedicles - if unable to see opening).

Any way people have to try and optimize this?
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Yeah - try a different approach. You can spend 30 minutes trying to get in through a ligament.

Or you can do a TFESI in 3 minutes (or a Caudal).
 
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epidural man said:
Yeah - try a different approach. You can spend 30 minutes trying to get in through a ligament.

Or you can do a TFESI in 3 minutes (or a Caudal).
Click to expand...
Do u get approval for a different approach (diff CPT) after u do it or just document why u couldn’t do the old CPT code and why u had to change to the new CPT
 
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The handful of lumbar ILESIs I could not get in I've talked with the patient on table and got approval to switch to different approach.
Bill the aborted procedure modifier (-53) for the ILESI and switched to either bilateral TFESI or TFESI on symptomatic side.
Happened maybe 3-4 times - all in very old (i.e. Medicare) patients.

No idea if they got paid or not. Happens so rarely that makes no difference to me.
 
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i just go to caudal and call it a day. then if no benefit, trial tfesi next time.
 
Multiple pillows under stomach. Caudal tilt on c-arm to find lucency. Then usually have to start even lower on skin and angle cephalad. CLO can help with the angle. May have to come in on the other side and cross over. May have to go in the level above or below.
 
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I do not understand the inability to get into the spinal canal while using fluoroscopy.
Go between the lamina above and below. If you cannot see this space, adjust your Xray.
If you still cannot see this space, go TFESI.
 
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L5-S1 is pretty easy to get into even with the most degenerative spines. However, there was someone who had so much osteophytes all over the place, I felt like I had to wiggle inside a 2mm space with my Touhy. The epidurogram is generally thin and brutal with these patients with contrast; so stenotic. If for some reason I couldn't, and there was someone whom I couldn't, I'd opt for Caudal Approach and call it a day.

I wouldn't do TFESI with Dex, because the likelihood of Dex working for these stenotic patients is almost 0.
 
Caudal tilt a good bit. Sometimes I’ll oblique like 5 or 10 degrees. To open up one side of interlaminar space a bit better off Fluoro while taking an angle to end up midline.
 
Treat it like a mid to upper thoracic. Tilt to the feet until you see an opening. Oblique ipsilateral a little bit if needed. Enter paramedian, but aim under the nose of the spinous process, ending with needle tip more midline than typical paramedian approach. Once get purchase, go to contralateral oblique to confirm and adjust the trajectory. Swing back to AP and clo several times to confirm all is on track as needed. If there is a thick ligament to add to the challenge, I put a drop of contrast in the hub before my lor under clo.

If you can’t get in with that, go to the level below or caudal.

Before all this, confirm on MRI that there actually is some epidural fat on T1 at the desired level. Even a sliver should be fine, think about the small target in C-spine.
 
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have to be careful with switching in some insurances, because the new cpt may generate a denial.

doing a caudal wont ever generate a denial as it is still same cpt.

agree with above, tilt upper part caudally.

in addition, before injecting, go CLO. sometimes i can see the interlaminar opening on CLO and know where the needle tip should ultimately head toward.
 
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Taus said:
Treat it like a mid to upper thoracic. Tilt to the feet until you see an opening. Oblique ipsilateral a little bit if needed. Enter paramedian, but aim under the nose of the spinous process, ending with needle tip more midline than typical paramedian approach. Once get purchase, go to contralateral oblique to confirm and adjust the trajectory. Swing back to AP and clo several times to confirm all is on track as needed. If there is a thick ligament to add to the challenge, I put a drop of contrast in the hub before my lor under clo.

If you can’t get in with that, go to the level below or caudal.

Before all this, confirm on MRI that there actually is some epidural fat on T1 at the desired level. Even a sliver should be fine, think about the small target in C-spine.
Click to expand...
This technique, but no caudal tilt. Start AP a level below and drive needle paramedian out of plane like an SCS trial, hit lamina of level below and walk off. CLO once near lamina to get into the space. 20G toughy is small enough it bends a little to get in easier. Make sure several pillows under the stomach. If difficulty just do the level above or below, or a caudal.
 
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Agree with Taus and dipri. come in at that trajectory and if tight just twist the needle and muscle it in. Can't count the number of times I've done this with good results in a seemingly closed off space. it's so rewarding
 
1680545979834.png
 
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anujacket said:
went in, couldn't get good CLO (given it's on right side and i have GE c-arm, but slipped in with good contrast in lateral) - more luck than anything
Click to expand...
You can still get a right sided CLO. You have to flip the c-arm. Because this puts the x ray tub above the table, I only use this trick if I really really need to get a right sided CESI.
 
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anujacket said:
You mean move the c arm on other side of table?
Click to expand...
No, on most C arms you can flip the "C" upside down, so the xray tube is on top and the II is below. Then you can rotate the way you need to get a CLO on the right side.
 
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For those of you that do caudals, why not just enter at BL s1 or s2 foremen’s?
 
How’s an epidural gonna help this poor chap
 
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Just by looking at the Fluoro, that person likely has axial pain predominantly with transitional movement issues
 
MitchLevi said:
I still can't get over some of the backs I see that don't hurt.
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Agreed. I see plenty of elderly patients with terrible looking spines and severe stenosis, who do very well for a solid 3 to 6 months with a caudal or interlam w depo. Plenty also do well with facet RF and intracept when indicated for axial pain. Can be very technically demanding procedures in these patients, but very rewarding if you take the time to do it right.
 
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