CT scan for low back pain

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Tenesma said:
pinchandburn: when i look at the MRI and the symptoms are not consistent with imaging, then I do more detective work, I don't inject just based on symptoms...
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"Let's say you look at MRI. Disc bulge paracentral at L3/4. However, patient's symptoms are all left sided esentially L5 and s1.

Assume no psych issues.

Where are you going to inject?"


Paracentral means a disc is herniated to one side or another (aka-not central) so in pinch and burns example is the disc paracentral to the left or to the right, if the patient had left leg symptoms and a right disc then you are kind of left scratching your head a little, however.....

If a patient has acute leg pain, a vague dermatomal distribution (in this hypothetical case more of an S1 distribution by patient's history--subjective and again hard for some patients to describe) a normal neuro exam and I see a left paracentral disc at L3-4 on MRI and they have left leg pain (but in a S1 dermatomal pattern) then I am going to do a Left L4 Transforaminal injection, I'm going to then have the patient call me in one hour while the nerve is anesthetized and see if there pain is gone

I think the strict adherence to the "normal" dermatomes is antiquated and often times causes paralysis by analysis. There is a lot of overlap in dermatomes and everyone is wired a little differently.

Remember the L4 root has contributions to the sciatic nerve, hence it can cause "sciatica"

What more detective work do you need in this case??
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PinchandBurn said:
Let's say you look at MRI. Disc bulge paracentral at L3/4. However, patient's symptoms are all left sided esentially L5 and s1.

Assume no psych issues.

Where are you going to inject?
Click to expand...

I agree with SIMS and pinch-

If no psych issues, and they have a disc herniation at L3-L4, (not just a tiny bulge), and complain of posterior leg pain, then yes they get a L4-L5 TFESI.

I'm kinda surprised Tenesma took issue with this, I remember one of his other posts in the last year talking about how the dermatomal maps can't be relied on, and L2-L3 disease can cause pain anywhere, etc......


If someone is sane and has clear pathology at one level significantly worse than all others, that's what I target.

However, if they're got multi-level disease with one level that looks a little worse the others, but another particular level fits the overall clinical picture based on description and exam exam, then I go for # 2 in that situation.

Gotta use all your tools. Shouldn't use exam or MRI imaging as absolute gospel.
 
"However, if they're got multi-level disease with one level that looks a little worse the others, but another particular level fits the overall clinical picture based on description and exam exam, then I go for # 2 in that situation."

Sometimes differentiating the precise lumbar root involved is interesting but probably kinda academic. For example, take a patient who has a grade II or > degen spondy @ L4 with both L4 foraminal stenosis and L4/5 central lateral recess stenosis, their dermatomal distribution, MRI, and exam are equivocal as to L4 or L5. So you shoot L4 then L5 and the results are smutz and each gives a week of relief. Does it really matter? The fix - PLIF or TLIF - will address both roots by decompressing L5 and restoring the intra-pedicular height at L4.

Or take a patient with asymmetric collapse of L3 on L4 to the Rt with big bridging osteophytes L3 foraminal, and L4 lateral recess stenosis. We fret and order an EMG - equivocal - and do selective blocks at both levels and confusing results. Get the CT myelo: more confusing results. Send the patient to the surgeon and they get a laminotomy and decompression at L3/4 and X-LIF.

My point is that while it's fun to diagnose the root level, I'm not sure that it's really necessary given the surgical solutions we have.
 
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101N said:
"However, if they're got multi-level disease with one level that looks a little worse the others, but another particular level fits the overall clinical picture based on description and exam exam, then I go for # 2 in that situation."

Sometimes differentiating the precise lumbar root involved is interesting but probably kinda academic. For example, take a patient who has a grade II or > degen spondy @ L4 with both L4 foraminal stenosis and L4/5 central lateral recess stenosis, their dermatomal distribution, MRI, and exam are equivocal as to L4 or L5. So you shoot L4 then L5 and the results are smutz and each gives a week of relief. Does it really matter? The fix - PLIF or TLIF - will address both roots by decompressing L5 and restoring the intra-pedicular height at L4.

Or take a patient with asymmetric collapse of L3 on L4 to the Rt with big bridging osteophytes L3 foraminal, and L4 lateral recess stenosis. We fret and order an EMG - equivocal - and do selective blocks at both levels and confusing results. Get the CT myelo: more confusing results. Send the patient to the surgeon and they get a laminotomy and decompression at L3/4 and X-LIF.

My point is that while it's fun to diagnose the root level, I'm not sure that it's really necessary given the surgical solutions we have.
Click to expand...


true....although my goal is usually to keep patients away from having to see surgeons;)
 
lobelsteve said:
To get paid less, use a larger needle with more potential discomfort, and possibly less clinical effect?

Not yet.
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You actually are paid more doing lumbar ILESI than lumbar TFESI for two reasons.
1-Now that fluoro isn't paid for TFESI, you get paid more to do ILESI.
Doing them in office 62311 + 77003 pays $20 more than 64493
2-most people can do an ILESI twice as fast a TFESI.

We've discussed this before, but I don't feel dexamethasone works as well or lasts as long as triamcinolone.

So I do a paramedian to far lateral ILESI with triamcinolone/methylprednisolone, this approach works well for many patients, the ILESI is better tolerated than TFESI, and it's safer and quicker.

If they get inadequate relief, then I proceed to TFESI with dex or betamethasone, depending on how high the level is.
 
101N said:
Nope.
Click to expand...

Agree to disagree. I do my ILESI with a 20 gauge touhy, do them in 2 minutes, patients don't feel anything, I'm never going to irritate a nerve root, and I've never a had a wet tap in 3 years of practice.


I do think that from an efficacy standpoint, a lumbar TFESI with kenalog/depo will beat a lumbar ILESI with kenalog/depo 9 times out of 10.

However the relative efficacy of a lumbar TFESI with dex compared to a far lateral lumbar ILESI with kenalog/depo is still up for debate
 
bedrock said:
You actually are paid more doing lumbar ILESI than lumbar TFESI for two reasons.
1-Now that fluoro isn't paid for TFESI, you get paid more to do ILESI.
Doing them in office 62311 + 77003 pays $20 more than 64493
2-most people can do an ILESI twice as fast a TFESI.

We've discussed this before, but I don't feel dexamethasone works as well or lasts as long as triamcinolone.

So I do a paramedian to far lateral ILESI with triamcinolone/methylprednisolone, this approach works well for many patients, the ILESI is better tolerated than TFESI, and it's safer and quicker.

If they get inadequate relief, then I proceed to TFESI with dex or betamethasone, depending on how high the level is.
Click to expand...

unless you do 2 level TFESI. I think in most patients this can be justified. I dont 'routinely' do 2 levels, but if there's 2 level foraminal stenosis or for example 2 dermatomes are effected and I want to get the steroid at the level of the disc and the exiting nerve root.

I'm still on the fence about the efficacy of TFESI with dexamethosone. I'm actually seeing just as good results. If I do a 2 level TFESI its with 6mg of dexamethasone at each level. Initially however I almost always do a ILESI in the way you described it above..
 
i have some legacy patients that had been getting TFESI with depomedrol that i now do TFESI with dexa.

Most have said the injections dont seem to last as long, maybe 1-2 weeks shorter in duration, but obviously there is some degree of bias due to the fact that i told them that they may notice differences in duration as i was switching the steroid for safety reasons...
 
personally I usually getter better results with Candido's approach than with a two level TFESI. I do sometimes however get better results with a TFESI. A paramedian ILESI is so quick and easy and you never risk hitting the nerve root. Ironically I did tons of TFESIs in fellowship and very few ILESIs. Now that I'm in practice however, I favor the paramedian ILESI.... fwiw
 
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