DSA and TFESI

[epidural man]

I know we have talked about this - and if I weren't so lazy I would go look for it -

But instead, I'm asking again.

What is the value of DSA in the lumbar region for a TFESI?

I used to get one every time - then started thinking about the amount of exposure. I also realized that I have never yet seen a vessle on DSA that I didn't already notice on the regular live fluoroscopy. I'm sure that is from my ability to look or use DSA (studies show that DSA has a much increased sensitivity to pick up vasculature - but that likely isn't from pain literature).

But since DSA didn't seem to help me, and WAS hurting me, I stopped using it for lumbar TFESI.

What is your practice?

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[RoloTomassi]

Not needed if using dex

 

[callmeanesthesia]

Never have. I see no convincing reason either, if using dex. For that matter, I don’t even really see much need for live fluoro if using dex.

One attending when I was in fellowship said he used to do DSA when he first started out, until the radiology staff asked him why his exposure levels were consistently several times higher than the other pain doctors.

 

[bedrock]

I know we have talked about this - and if I weren't so lazy I would go look for it -

But instead, I'm asking again.

What is the value of DSA in the lumbar region for a TFESI?

I used to get one every time - then started thinking about the amount of exposure. I also realized that I have never yet seen a vessle on DSA that I didn't already notice on the regular live fluoroscopy. I'm sure that is from my ability to look or use DSA (studies show that DSA has a much increased sensitivity to pick up vasculature - but that likely isn't from pain literature).

But since DSA didn't seem to help me, and WAS hurting me, I stopped using it for lumbar TFESI.

What is your practice?

DSA provides 4X the radiation of live fluoro and live fluoro is already much more radiation than a static image.

DSA have been shown not to be foolproof, such as the L5 TFESI in a Chicago academic center about 10 years ago, that had a clear DSA sequence but their L5 TFESI with particulate caused an immediate severe SCI.

I now only use DSA with stellate blocks and cervical SNRBs.

I only use dex for TFESI in the spinal column.

 

[SC Tian]

Do not use dsa, our c arm does not have this function

 

[epidural man]

I only use dex for TFESI in the spinal column.

Me too!

But most of my colleagues use dex for interlaminar in cervical and some for everything.

I have asked them - "what artery are you worried about back there? Has there ever been an artery described? How about case reports? Has there every been a single case report of harm coming from particulate steroid from an interlaminar injection (not needle harm or misplacement)? What am I missing here?"

 

[clubdeac]

Me too!

But most of my colleagues use dex for interlaminar in cervical and some for everything.

I have asked them - "what artery are you worried about back there? Has there ever been an artery described? How about case reports? Has there every been a single case report of harm coming from particulate steroid from an interlaminar injection (not needle harm or misplacement)? What am I missing here?"

I agree. I wonder if they use dex in ILESIs bc it’s preservative free whereas Depo and kenalog aren’t?

 

[MitchLevi]

The other pain guy in my group does all lumbar TFESI with Depo 80, and all cervicals (ILESI) with dexamethasone 10.

It makes no sense.

FTR - Two spine surgeons in our group both do a few dozen lumbar TFESI per month. Unilateral one level with Depo 80 + bupi 2cc.

 

[bedrock]

I

The other pain guy in my group does all lumbar TFESI with Depo 80, and all cervicals (ILESI) with dexamethasone 10.

It makes no sense.

FTR - Two spine surgeons in our group both do a few dozen lumbar TFESI per month. Unilateral one level with Depo 80 + bupi 2cc.

agree none of those make sense from either the other pain doc or the spine surgeons.

Everyone here knows how much I prefer using depo when safely possible.

However, we also have a local spine surgeon (unaffiliated) who does his own lumbar TFESI with particulate, but his technique is so terrible that some of these same patients do better after I repeat the TFESI with dex.

 

[Barleycorn]

Me too!

But most of my colleagues use dex for interlaminar in cervical and some for everything.

I have asked them - "what artery are you worried about back there? Has there ever been an artery described? How about case reports? Has there every been a single case report of harm coming from particulate steroid from an interlaminar injection (not needle harm or misplacement)? What am I missing here?"

Arachnoiditis because the ligament may be discontinuous up there? Thats how Ive justified it to myself at least.

 

[bedrock]

Arachnoiditis because the ligament may be discontinuous up there? Thats how Ive justified it to myself at least.

I’m not criticizing you as cervical ILESI is stressful for all of us.

But I’d suggest doing T1-T2 with depo or C7-T1 with Celestone, over C7-T1 with dex if you don’t feel comfortable using depo at C7-T1.

 

[Dr. Ice]

after 14 years of work, with contralateral oblique, cervical Ilesi is one of the easiest and quickest procedures I do. No fear of particulate. Review mri in detail beforehand, easy peasy.. never an issue or complication. Probably about 5 minutes total. If I was hopd employed, would have to want to drink lots of coffee for the hour time slot I would get to do a super simple shot

 

[bedrock]

after 14 years of work, with contralateral oblique, cervical Ilesi is one of the easiest and quickest procedures I do. No fear of particulate. Review mri in detail beforehand, easy peasy.. never an issue or complication. Probably about 5 minutes total. If I was hopd employed, would have to want to drink lots of coffee for the hour time slot I would get to do a super simple shot

after a similar time in practice, I'm the same, but I expect barleycorn doesn't have that level of confidence/experience yet.

 

[epidural man]

Arachnoiditis because the ligament may be discontinuous up there? Thats how Ive justified it to myself at least.

Post case reports please. If it is dangerous, there probably are tons of case reports, probably even a large series of them.

 

[DrMDAware]

after 14 years of work, with contralateral oblique, cervical Ilesi is one of the easiest and quickest procedures I do. No fear of particulate. Review mri in detail beforehand, easy peasy.. never an issue or complication. Probably about 5 minutes total. If I was hopd employed, would have to want to drink lots of coffee for the hour time slot I would get to do a super simple shot

That’s great. Good for you! I’m not being sarcastic by the way.

For the less experienced and those willing to learn what exactly are you reviewing on the mri? Depth? Largest space? Angle of entry? Or are you saying a solid CLO really helps you do this quickly and safely?

 

[Ducttape]

I agree. I wonder if they use dex in ILESIs bc it’s preservative free whereas Depo and kenalog aren’t?

preservative free is kind of a misnomer.

dex contains citric acid, which is a preservative, but since it is considered a food substance, it isnt labelled as a preservative.

 

[lobelsteve]

preservative free is kind of a misnomer.

dex contains citric acid, which is a preservative, but since it is considered a food substance, it isnt labelled as a preservative.

Also a natural flavor enhancer. A little dex on toast. Delish.

 

[Biohazard685]

No DSA where I do procedures.

Mix up between Celestone or Dex.

Depends on what we have available for the week.

Anecdotally, see better results with betamethasone.

 

[bedrock]

No DSA where I do procedures.

Mix up between Celestone or Dex.

Depends on what we have available for the week.

Anecdotally, see better results with betamethasone.

betamethasone definitely works better than dex.

However, the reason betamethasone works better is that it is not truly non particulate. It is not safe for TFESI. Fine for everything else.