Discogenic lbp

[paindoc007]

I have had a few patients recently, younger guys who have manual construction type jobs, come in with complaints of discogenic low back pain. Imaging confirms that. Obviously I do have them try therapy and NSAIDs‘s first...

The question is from a procedural standpoint where do you begin with these sort of patients ?

My understanding was the more acute a disc problem, the more an inj (such as b/l TFESI at the level of the disc) would help. For patients with more of a chronic discogenic lbp picture, how do you guys approach this? Thx

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[Ducttape]

Injections cure everything!









Where did I put my magenta marker???

 

[willabeast]

I have had a few patients recently, younger guys who have manual construction type jobs, come in with complaints of discogenic low back pain. Imaging confirms that. Obviously I do have them try therapy and NSAIDs‘s first...

The question is from a procedural standpoint where do you begin with these sort of patients ?

My understanding was the more acute a disc problem, the more an inj (such as b/l TFESI at the level of the disc) would help. For patients with more of a chronic discogenic lbp picture, how do you guys approach this? Thx

I would explain the natural history of discogenic low back pain, explain how most if not all interventional procedures (such as fusions) do not make much sense in this setting, and then add some representative (no names of course) examples of patients I have known who typify what happens when docs or patients get aggressive in this setting. Finally some vocational counseling if PT fails.

 

[Dr. Ice]

How bout burst stim

 

[DODOCSS]

ESI x 1, then no more interventions

 

[thecentral09]

ESI x 1, then no more interventions

agree with this. And would repeat in months/ years down road if same pain returns/worsens while suggesting vocational change/safe lifting techniques etc

 

[myrandom2003]

Maybe if there was some Type 1 modic changes on the MRI
Intradiscal steroid may be of benefit to at least try.
The role of intradiscal steroids in the treatment of discogenic low back pain

May give you 3-4 months of relief (similar to other procedures that we do)
Intradiscal Glucocorticoid Injection for Chronic Low Back Pain | Annals of Internal Medicine | American College of Physicians

and if it does help, then maybe consider some prp or BMAC
(https://clinicaltrials.gov/ProvidedDocs/18/NCT03340818/Prot_SAP_000.pdf by the way, have the results of this been published?)

 

[nvrsumr]

I like the heretical to the gospel according to expert opinon (ie. heavenly host) of sis suggestion of intra discal steroid. Have done a couple times after disco at positive level and never helped.

Maybe would help more if tried at modic endplate rather than nucleus?

 

[lobelsteve]

Exercise, exercise, exercise. Avoid loading the disc. Maybe occasional tramadol. No injections, no narcotics.

I admit no useful treatment and patient either does what i recommend or moves on to mu shu elsewhere.

 

[paindoc007]

Exercise, exercise, exercise. Avoid loading the disc. Maybe occasional tramadol. No injections, no narcotics.

I admit no useful treatment and patient either does what i recommend or moves on to mu shu elsewhere.

Haha, funny bc in my head, I knew this was the right answer, just was in denial hoping I was wrong.

Thanks everyone

 

[SSdoc33]

Haha, funny bc in my head, I knew this was the right answer, just was in denial hoping I was wrong.

Thanks everyone

there is rarely a "right answer" to what we do. there are a lot of wrong answers, though. in this case, its PT and thats about it

 

[SSdoc33]

Exercise, exercise, exercise. Avoid loading the disc. Maybe occasional tramadol. No injections, no narcotics.

I admit no useful treatment and patient either does what i recommend or moves on to mu shu elsewhere.

did you give up on the GRC blocks you were advocating for a few years ago?

 

[lobelsteve]

did you give up on the GRC blocks you were advocating for a few years ago?

Will do occasionally. But results of RF were 50/50. Better than placebo, but I have inherent bias and not blinded. That could account for the 17% improvement over placebo I would expect.

 

[clubdeac]

biacuplasty all day! duhhh

 

[drpainfree]

LESI x 1, followed by core muscle strengthening exercise, mechanical spinal decompression.

 

[NJPAIN]

LESI x 1, followed by core muscle strengthening exercise, mechanical spinal decompression.

As in VAX-D, IDD, etc commonly done by chiropractors??


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[thecentral09]

Exercise, exercise, exercise. Avoid loading the disc. Maybe occasional tramadol. No injections, no narcotics.

I admit no useful treatment and patient either does what i recommend or moves on to mu shu elsewhere.

While I wholeheartedly agree with you that we don't have anything significant to offer most patients with discogenic pain, I do find it hard to tell patients that exercise is the answer, but loading the disc (which most every form of exercise does) is a typical provoker. I just have a hard time explaining that to patients.

 

[Ducttape]

swimming
water aerobics
yoga
tai chi
elliptical
rowing
maybe recumbent bike, or recumbent stepper (NuStep)
cross country skiing
or, tell them to start with anything that doesnt hurt too much, like indoor walking at the mall. people get afraid to get out.


my experience is that most of us over age 50 dont shoot hoops, play raquetball/squash, or do competitive dance...

 

[drpainfree]

As in VAX-D, IDD, etc commonly done by chiropractors??


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yes, it's correct. I offer it in my practice on cash basis.

 

[lobelsteve]

yes, it's correct. I offer it in my practice on cash basis.

But do you offer sedation for decompression?

 

[Biohazard685]

Injections cure everything!









Where did I put my magenta marker???

I'm out of the loop what does the magenta text signify?

 

[lobelsteve]

I'm out of the loop what does the magenta text signify?

Dark orchid is the official color of sarcasm on the internet.

 

[drpainfree]

But do you offer sedation for decompression?

you are too stiff, my decompression table can't straighten you up with or without sedation.

 

[lobelsteve]

Do you wear scrubs or this outfit?

 

[SSdoc33]

yes, it's correct. I offer it in my practice on cash basis.

oh, for F@ck's sake

shake my head

you have just lost any shred of credibility that you may have had

 

[pastafan]

yes, it's correct. I offer it in my practice on cash basis.

Do you find it more effective when combined with cold laser therapy?

 

[lonelobo]

I prefer his products
Products for Back Pain- DR-HO'S® Official Website

 

[drpainfree]

oh, for F@ck's sake

shake my head

you have just lost any shred of credibility that you may have had

A few guys on this board is hopelessly narrow-minded of anything and everything remotely within your reach of your comprehension. Regardless, it's not worth of my time wasting on this useless discussion.

 

[SSdoc33]

A few guys on this board is hopelessly narrow-minded of anything and everything remotely within your reach of your comprehension. Regardless, it's not worth of my time wasting on this useless discussion.

Neil Degrasse Tyson Wow GIF by New York Comic Con - Find & Share on GIPHY

 

[thiswonthurtabit]

So one thing that has come up recently is the consideration of interventions targeting the basivertebral nerves for 'vertebrogenic' back pain which seems to have similar characteristics to discogenic back pain (suspect a subset of what gets lumped into discogenic may be vertebrogenic). Neither of these papers really convinced me but it may be something that is on the horizon as a treatment option for these patients.

 

[bedrock]

Not that it works for everyone, and shouldn’t be used willy nilly for generic discogenic back pain, but I’d do a Nevro trial if the patient was otherwise considering a surgical fusion.

 

[paindoc007]

Not that it works for everyone, and shouldn’t be used willy nilly for generic discogenic back pain, but I’d do a Nevro trial if the patient was otherwise considering a surgical fusion.

Why Nevro specifically ?

 

[drpainfree]

So one thing that has come up recently is the consideration of interventions targeting the basivertebral nerves for 'vertebrogenic' back pain which seems to have similar characteristics to discogenic back pain (suspect a subset of what gets lumped into discogenic may be vertebrogenic). Neither of these papers really convinced me but it may be something that is on the horizon as a treatment option for these patients.

without reading your articles first, are you referring to pain caused by Schmorl's node, Modic change, etc. as "vertebrogenic" pain? I don't think when we are talking about discogenic pain, we are referring to those.

 

[drpainfree]

Not that it works for everyone, and shouldn’t be used willy nilly for generic discogenic back pain, but I’d do a Nevro trial if the patient was otherwise considering a surgical fusion.

I've done trials before before with SJ. No go.

 

[DODOCSS]

I've done trials before before with SJ. No go.

try opana, soma and decompression

 

[drpainfree]

try opana, soma and decompression

bad judgement, lumping opana, soma with decompression.

try opana, soma and decompression

if you actually know anything about patients who are interested in spinal decompression, you'd know they would want to have nothing to do with medication. but then again, what can I expect from your inflammatory post? Intelligence? obviously not.

I'm not even interested in writing norco...what's soma? don't you know it's not a muscle relaxant?

 

[bedrock]

Why Nevro specifically ?

Because nevro provides better axial coverage than the other manufacturers. Plenty of reasons to consider SJ or DRG for various pains primarily in a limb but if the majority of the pain is axial, nevro is the clear choice.

I've done trials before before with SJ. No go.

See my answer to paindoc007 above.

 

[drpainfree]

Because nevro provides better axial coverage than the other manufacturers. Plenty of reasons to consider SJ or DRG for various pains primarily in a limb but if the majority of the pain is axial, nevro is the clear choice.



See my answer to paindoc007 above.

will consider Nevro for discogenic axial LBP.

 

[Timeoutofmind]

Because nevro provides better axial coverage than the other manufacturers. Plenty of reasons to consider SJ or DRG for various pains primarily in a limb but if the majority of the pain is axial, nevro is the clear choice.



See my answer to paindoc007 above.

Why not Nevro fir purely limb pain? What makes u think the other companies are better for this?

 

[SommeRiver]

I'll do an epidural or two for discogenic pain. If you're miserable I don't see a reason not to try it once or twice.

 

[DOctorJay]

I'll do an epidural or two for discogenic pain. If you're miserable I don't see a reason not to try it once or twice.

I’ve had them denied if there is no radicular component.


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[epidural man]

I have had a few patients recently, younger guys who have manual construction type jobs, come in with complaints of discogenic low back pain. Imaging confirms that. Obviously I do have them try therapy and NSAIDs‘s first...

The question is from a procedural standpoint where do you begin with these sort of patients ?

My understanding was the more acute a disc problem, the more an inj (such as b/l TFESI at the level of the disc) would help. For patients with more of a chronic discogenic lbp picture, how do you guys approach this? Thx

How about hypoxic cultured stem cells?

 

[bedrock]

Why not Nevro fir purely limb pain? What makes u think the other companies are better for this?

That’s not what I’m saying. I’m saying that for primary limb pain, a reasonable physician might choose SJ, DRG, or Nevro. However if the primary complaint is axial pain, then Nevro is the clearly superior SCS technology.

 

[drpainfree]

so I have a young patient (in 20s) who has clinical discogenic lower back pain from L4/L5 annular tear.

He's facing with 3 options, surgery with artificial disc, the surgeon wants to get a discogram first, but the patient is not sure about surgerical outcome, or paying out of pocket for stem cell injection, or SCS...

What's your thought on this?

 

[lobelsteve]

so I have a young patient (in 20s) who has clinical discogenic lower back pain from L4/L5 annular tear.

He's facing with 3 options, surgery with artificial disc, the surgeon wants to get a discogram first, but the patient is not sure about surgerical outcome, or paying out of pocket for stem cell injection, or SCS...

What's your thought on this?

0 for 3.

 

[drpainfree]

0 for 3.

Yes, I've been holding him off for 2-3 months now, providing him with instruction for aquatic therapy, and psych therapy. He is much more fit now, both mentally and physically, but axial LBP persists, even more pronounced...

let him go under the knife? He is not interested unless there are no more options, but he would, if it's the case.

 

[SSdoc33]

Yes, I've been holding him off for 2-3 months now, providing him with instruction for aquatic therapy, and psych therapy. He is much more fit now, both mentally and physically, but axial LBP persists, even more pronounced...

let him go under the knife? He is not interested unless there are no more options, but he would, if it's the case.

and you should talk him out of it. you cant prevent him from having surgery, but you can give your best advice on the subject.

arent we past fusion for discogenic LBP yet? c'mon

 

[SSdoc33]

I'll do an epidural or two for discogenic pain. If you're miserable I don't see a reason not to try it once or twice.

you should be asking "why", rather than "why not"

casting a spell is also harmless

 

[Timeoutofmind]

so I have a young patient (in 20s) who has clinical discogenic lower back pain from L4/L5 annular tear.

He's facing with 3 options, surgery with artificial disc, the surgeon wants to get a discogram first, but the patient is not sure about surgerical outcome, or paying out of pocket for stem cell injection, or SCS...

What's your thought on this?

Yuk
Yuk
and Yuk

 

[Biohazard685]

If surgery, stem cells, and scs offer little in the way of relief, then what options remain besides Jedi mind tricking your way out of the pain?