LESI LESI Patient Selection and Contraindications 2 — Questions and Answers
Question 1: A patient allergic to iodinated contrast media who requires fluoroscopic LESI should be:
- Denied the procedure entirely
- Pre-medicated with corticosteroids and antihistamines before contrast use, or procedure performed under ultrasound guidance (Correct answer)
- Given double the steroid dose to compensate
- Scheduled for MRI-guided injection only
Correct answer: Pre-medicated with corticosteroids and antihistamines before contrast use, or procedure performed under ultrasound guidance
Patients with contrast allergy can undergo ESI after standard allergy pre-medication protocol (corticosteroids and antihistamines), or alternative guidance methods such as ultrasound can be used to avoid contrast.
Question 2: Which symptom pattern suggests that a patient is NOT an appropriate candidate for ESI as a primary treatment?
- Unilateral leg pain radiating below the knee with dermatomal distribution
- Moderate neurological deficits that have been stable for 3 months
- Cauda equina syndrome with acute bowel and bladder dysfunction (Correct answer)
- Radicular pain with disc herniation on MRI
Correct answer: Cauda equina syndrome with acute bowel and bladder dysfunction
Acute cauda equina syndrome is a surgical emergency requiring urgent decompression — ESI would cause harmful delay and is contraindicated as primary management.
Question 3: Pregnancy is considered a relative contraindication to fluoroscopic LESI primarily because of:
- Increased risk of disc herniation during pregnancy
- Fetal radiation exposure from fluoroscopy and theoretical steroid teratogenicity (Correct answer)
- Hormonal changes that reduce steroid efficacy
- Increased anaphylaxis risk during pregnancy
Correct answer: Fetal radiation exposure from fluoroscopy and theoretical steroid teratogenicity
Fluoroscopy exposes the fetus to ionizing radiation, and systemic steroid absorption carries theoretical risks to the developing fetus, making fluoroscopic ESI a relative contraindication in pregnancy.
Question 4: A patient with uncontrolled coagulopathy (platelet count 40,000/μL) requires LESI. The appropriate action is:
- Proceed with smaller needle gauge
- Postpone until platelet count is optimized above acceptable threshold (typically 70,000-100,000/μL) (Correct answer)
- Use ultrasound guidance only
- Administer the injection at a higher lumbar level
Correct answer: Postpone until platelet count is optimized above acceptable threshold (typically 70,000-100,000/μL)
A platelet count below 70,000-100,000/μL significantly increases hemorrhagic risk; ASRA guidelines recommend optimizing platelet count before proceeding with neuraxial procedures.
Question 5: In which clinical scenario is LESI best supported by evidence as providing meaningful benefit?
- Chronic axial low back pain without radiculopathy lasting more than 2 years
- Acute disc herniation with radiculopathy of less than 3 months duration (Correct answer)
- Degenerative disc disease without neural compression
- Lumbar spondylosis without canal stenosis
Correct answer: Acute disc herniation with radiculopathy of less than 3 months duration
The strongest evidence supports LESI for acute radiculopathy from disc herniation of shorter duration, where the inflammatory component is active and corticosteroids can provide meaningful short-term benefit.
Question 6: Which psychiatric medication requires special consideration before LESI due to potential for severe hypertensive crisis with epinephrine-containing test doses?
- Selective serotonin reuptake inhibitors (SSRIs)
- Monoamine oxidase inhibitors (MAOIs) (Correct answer)
- Tricyclic antidepressants
- Benzodiazepines
Correct answer: Monoamine oxidase inhibitors (MAOIs)
MAOIs inhibit the metabolism of catecholamines; use of epinephrine-containing solutions in patients on MAOIs can trigger a severe hypertensive crisis.
LESI LESI Patient Selection and Contraindications 2
A patient allergic to iodinated contrast media who requires fluoroscopic LESI should be: