Discogenic pain case

[deleted875186]

26 yo healthy guy, comes in with many years of low back pain, hurt himself when he was 18 lifting something. MRI with an L5-S1 disc protrusion, maybe big enough to call a herniation, mild canal and left formainal stenosis, annular tear in the disc. Rest of the MRI is pristine. Main complain is left sided back pain. Has occasional aching in the left lateral thigh and calf, occasionally aching in the left anterior groin, positive SLR, pain with rotation and side bending, very limited ROM.

What would you guys do for him?

He has tried PT, NSAIDS, no injections.

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[swamprat]

Why not an epidural ?

 

[deleted875186]

Offered him an epidural.

I guess the question is if he doesn’t get much relief from the epidural, or pain continues to return, or back pain isn’t relieved much from the LESI, what do you guys do next.

he was sent over from the surgeon. I assume he would be a surgical candidate, but would hate to fuse a 26 yo.

 

[MD87]

I find that when patients have a positive SLR, even when their pain is mostly axial, that they tend to do pretty well with ESI (if back pain is worse when dorsiflexing the foot). However, given this has been going on since he was 18, I think it’s unlikely to work.

Education is key. I tell them it’s unlikely that anything is going to make them perfect. Get an inversion table. Lose weight if need. NSAIDs PRN.

I tell them about intradiscal options, even though I don’t do them, and I tell them that the evidence isn’t great, but if they insist on “doing something” to do that before getting a fusion. I tell them that they should never get a fusion unless their pain is completely debilitating, and even then, with positive discogram, at best 70% chance of relief, and then they will likely have other issues down the road.

These patients suck. I had one today. But spending extra time with them, telling them they have a problem that isn’t cancer and won’t kill them, telling them not to get a million shots and surgery, is probably the best thing we can do for them.

 

[deleted875186]

What indradiscal options do people do, anyone have any experience to share?

Disc RFA?
Intradiscal PRP?
Endoscopic discectomy?

 

[lobelsteve]

What indradiscal options do people do, anyone have any experience to share?

Disc RFA?
Intradiscal PRP?
Endoscopic discectomy?

Literature does not support any intradiscal procedure or surgery. Home exercise program, acceptance, mindfulness. You can make him a pincushion, a failed back surgery patient, or dependent on drugs. But you cannot fix this. No one can. Treatment benefits the doctor more than the patient. Do the above, nothing more.

 

[Taus]

Agree with above but after giving the spiel and stressing hep, core, procedures are not great for this etc, if seems like a reasonable person I’d offer a left L5-s1 interlam esi x1. Straight up state 50:50 chance it helps at all for 3-6 months. His call then. Most decline. If not crazy and failed all else I’d refer to a colleague doing intradiscal prp also stating 50:50 chance it helps 50%, will be cash. Only consider fuse if miserable all fails and has a spondy at same level.

 

[deleted875186]

Literature does not support any intradiscal procedure or surgery. Home exercise program, acceptance, mindfulness. You can make him a pincushion, a failed back surgery patient, or dependent on drugs. But you cannot fix this. No one can. Treatment benefits the doctor more than the patient. Do the above, nothing more.

So, I have seen similar patients get an ALIF with good results. Obviously I would never recommend such a young patient get fused, but what are your thoughts on older patients getting an ALIF for discogenic pain?

 

[NJPAIN]

So, I have seen similar patients get an ALIF with good results. Obviously I would never recommend such a young patient get fused, but what are your thoughts on older patients getting an ALIF for discogenic pain?

During the dark days of the pandemic I spent slot of time listening to some of the greatest minds in academic spine surgery on NASS and Seattle Science Foundation podcasts. My takeaway was fusion for axial low back pain in the presence of a black disc - poor outcome. Fusion for axial LBP in presence of collapsed disc and Modic 1 or 2 changes -reasonable outcome.

 

[Gnarvin]

I would most certainly offer an epidural for him in addition to usual conservative care.

I am not a spine surgeon, but I don’t see why he wouldn’t be a candidate for a microdiscectomy rather than a full on fusion. If his disc herniation is causing the canal and foraminal stenosis then I think a discectomy would be reasonable. I get that most of his pain is axial but I would still probably send him to a good surgeon that I know is conservative if he fails epidurals.

 

[Laryngospasm]

Please no fusion on a 20 something unless he is becoming incapacitated. Just no.

 

[Taus]

I would most certainly offer an epidural for him in addition to usual conservative care.

I am not a spine surgeon, but I don’t see why he wouldn’t be a candidate for a microdiscectomy rather than a full on fusion. If his disc herniation is causing the canal and foraminal stenosis then I think a discectomy would be reasonable. I get that most of his pain is axial but I would still probably send him to a good surgeon that I know is conservative if he fails epidurals.

Completely disagree. microdiscectomy would not be reasonable. That is treating an mri not patient. There is no expectation for axial pain to improve with a decompressive procedure.

 

[lobelsteve]

When 4+ doctors all recommended vastly different treatment ……

we lack the technology to make him better. Validate the pain in words not action. Tell him 4 or more colleagues said injections, surgeries, experiments with prp are not better than flipping a coin. No consensus, no procedure.

 

[DrSpine]

If it’s primarily back pain and axial; try a diagnostic MBB on the left. Everything is mechanical, perhaps disc derangement causing some instability and more pressure on the facets with mechanical loading. If relief, consider with steroids periodically or RFA (but I am more apprehensive about Ablating young people). Simple blocks with steroids help - but If he comes back, then I’d consider an ablation versus constant steroids.

 

[MD87]

When 4+ doctors all recommended vastly different treatment ……

we lack the technology to make him better. Validate the pain in words not action. Tell him 4 or more colleagues said injections, surgeries, experiments with prp are not better than flipping a coin. No consensus, no procedure.

I agree that this is really the right thing. Every time I have done an injection on these patients because they have begged, (less than 10 definitely, so not a huge sample size), the results have been disappointing and I’ve regretted it. In other words, my experience is consistent with the literature. I’ve never been surprised by the results.

 

[Laryngospasm]

I also plant a seed with these folks and tell them 70% or so will get better in a year. I feel like a lot of lower back pain In Younger pop is catastrophizing.

 

[thecentral09]

I have seen a number of these patients recently. It’s always such a long conversation that ends with frustration as essentially getting to the point that there’s not a whole lot that can be done for the specific problem. I am extremely hopeful that basivertebral nerve ablation demonstrates future significant efficacy for the specific problem down the road as it seems very easy to do, is focusing predominately on non-myelinated nerves hopefully leading to significant and long-term improvement. I guess all we can do is hope that it pans out as hoped

 

[Orin]

I agree with lobelsteve that doing a procedure will validate that this is a pain that requires an intervention, eventually leading to surgery in a patient where PT and acceptance may be sufficient.

I'm also a bit confused as if you feel this is discogenic axial or radicular pain based on the imaging description, the pain pattern, and the proffered treatment. I'm not confident the data are great for ESIs for axial discogenic pain, such as that might be treated by BVN ablation or intradiscal injections.

 

[nvrsumr]

I see patients whose untreated radicular pain centralizes over time and is more in the buttock or periscapular eventually. I’d give him an epidural depending on his personality

 

[deleted875186]

I agree with lobelsteve that doing a procedure will validate that this is a pain that requires an intervention, eventually leading to surgery in a patient where PT and acceptance may be sufficient.

I'm also a bit confused as if you feel this is discogenic axial or radicular pain based on the imaging description, the pain pattern, and the proffered treatment. I'm not confident the data are great for ESIs for axial discogenic pain, such as that might be treated by BVN ablation or intradiscal injections.

Patient had some radical pain for sure, but the leg was very intermittent, not that bothersome, it was reproducible with SLR. Primary complaint was low back pain that was much more severe.

MRI was not bad, correlates with a Yoj g patient feeling radicular pain, but if it was an old person I might not even think it was very significant. He has an annular tear, and his symptoms sounded more discogenic. He could barely bend forward, maybe 60 degrees forward flex ion, pain with any type of flex ion or rotation, and had some radiation to the anterior groin that didn’t really correlate with radicular symptoms.

 

[Doctor_anonymous]

I have seen a number of these patients recently. It’s always such a long conversation that ends with frustration as essentially getting to the point that there’s not a whole lot that can be done for the specific problem. I am extremely hopeful that basivertebral nerve ablation demonstrates future significant efficacy for the specific problem down the road as it seems very easy to do, is focusing predominately on non-myelinated nerves hopefully leading to significant and long-term improvement. I guess all we can do is hope that it pans out as hoped

Who is capable of doing this procedure? I’ve never heard of it and am interested in seeing the research/consider pursuing some research.

 

[Doctor_anonymous]

I see patients whose untreated radicular pain centralizes over time and is more in the buttock or periscapular eventually. I’d give him an epidural depending on his personality

Can you elaborate on your thoughts of the mechanism behind this?

 

[Laryngospasm]

We don’t understand half of pain conditions. That’s the mechanism.

 

[nvrsumr]

Myotomes and dorsal rami

 

[BobBarker]

Yes, I think you can certainly try an ESI and then left sided Mbb/rfa. I have a similar patient and I have been able to help him.

 

[deleted875186]

Who is capable of doing this procedure? I’ve never heard of it and am interested in seeing the research/consider pursuing some research.

I too am hopefully about basovertebral RFA, intracept. Per the company, only people with modic changes qualify, my guy does not have modic changes, otherwise I honestly may have offered it after a LESI.

Not sure if modic changes actually mean anything, or if the company just picked it as a bio marker to facilitate research and patient selection.

 

[lobelsteve]

Anyone who gets relief by doing procedures on this type of patient: was it the procedure? Was it the timing? Was it the placebo response?

you are profiting from false hope, essentially flipping a coin or worse odds. I couldn’t practice like that.

 

[SSdoc33]

Anyone who gets relief by doing procedures on this type of patient: was it the procedure? Was it the timing? Was it the placebo response?

you are profiting from false hope, essentially flipping a coin or worse odds. I couldn’t practice like that.

You could when to you were doing GRC blocks on these folks. Hows the view from up their on your equine?

FFS, no surgery at all on these patients. Shots arent a great idea either. I hold out some home for intradiscal biologic goo of some sort in the future, but we are not there yet

 

[sloh]

When 4+ doctors all recommended vastly different treatment ……

we lack the technology to make him better. Validate the pain in words not action. Tell him 4 or more colleagues said injections, surgeries, experiments with prp are not better than flipping a coin. No consensus, no procedure.

It's the "art" of medicine!

 

[lobelsteve]

You could when to you were doing GRC blocks on these folks. Hows the view from up their on your equine?

FFS, no surgery at all on these patients. Shots arent a great idea either. I hold out some home for intradiscal biologic goo of some sort in the future, but we are not there yet

Grc had better literature than mbb for disc as well as esi for axial lbp

 

[lobelsteve]

Grc had better literature than mbb for disc as well as esi for axial lbp

I offer a copy of the literature and let them know it is like flipping a coin. My lack of enthusiasm usually seals the deal.
I think I have done 1 this past year.

 

[bedrock]

26 yo healthy guy, comes in with many years of low back pain, hurt himself when he was 18 lifting something. MRI with an L5-S1 disc protrusion, maybe big enough to call a herniation, mild canal and left formainal stenosis, annular tear in the disc. Rest of the MRI is pristine. Main complain is left sided back pain. Has occasional aching in the left lateral thigh and calf, occasionally aching in the left anterior groin, positive SLR, pain with rotation and side bending, very limited ROM.

What would you guys do for him?

He has tried PT, NSAIDS, no injections.

Patient had some radical pain for sure, but the leg was very intermittent, not that bothersome, it was reproducible with SLR. Primary complaint was low back pain that was much more severe.

MRI was not bad, correlates with a Yoj g patient feeling radicular pain, but if it was an old person I might not even think it was very significant. He has an annular tear, and his symptoms sounded more discogenic. He could barely bend forward, maybe 60 degrees forward flex ion, pain with any type of flex ion or rotation, and had some radiation to the anterior groin that didn’t really correlate with radicular symptoms.

26 yo healthy guy, comes in with many years of low back pain, hurt himself when he was 18 lifting something. MRI with an L5-S1 disc protrusion, maybe big enough to call a herniation, mild canal and left formainal stenosis, annular tear in the disc. Rest of the MRI is pristine. Main complain is left sided back pain. Has occasional aching in the left lateral thigh and calf, occasionally aching in the left anterior groin, positive SLR, pain with rotation and side bending, very limited ROM.

What would you guys do for him?

He has tried PT, NSAIDS, no injections.

Completely disagree. microdiscectomy would not be reasonable. That is treating an mri not patient. There is no expectation for axial pain to improve with a decompressive procedure.

When 4+ doctors all recommended vastly different treatment ……

we lack the technology to make him better. Validate the pain in words not action. Tell him 4 or more colleagues said injections, surgeries, experiments with prp are not better than flipping a coin. No consensus, no procedure.

I see patients whose untreated radicular pain centralizes over time and is more in the buttock or periscapular eventually. I’d give him an epidural depending on his personality

I agree with taus that a discetomy is a bad idea. A fusion is the worst idea in the universe for this patient. Given his age and symptoms, MBB/RFA is doomed to failed, but I would consider it if he were 46, but not at age 26. Certainly better odds for RFA over age 50.

Why is everyone getting their panties in a bunch about offering this patient an epidural? Not the end of the world. Worst thing that can happen realistically in a young healthy patient is that it does nothing, the best thing that can happen is that he is 90% better overall.
The most likely outcome is that his mild radicular pain resolves and his axial pain improves by 40%, most patients would accept if you tell them that ahead of time before they undergo an easy, quick 5 minute injection.

A left S1 TFESI is reasonable depending on the location of the annular tear. Or a left S2/caudal with particulate steroid. Personally, I would do a left S2 TFESI with Depo, unless the tear was truly lateral.

Because he has an annular tear, if only his leg pain resolves, but back pain is unchanged on f/u, I would offer him a left S1/S2 TFESI with PRP. I would not sell him on the PRP, but I would discuss the pros and cons and try it if he wants to .
I personally do this and I see PRP improve axial pain by 50% or more in 50% of patients with lumbar annular tear, particularly younger patients. All were happy for the 50% or more relief. I've had several patients achieve 90% sustained relief after PRP for annular tear. (I'm not doing TFESI PRP for generic DDD, only for annular tears)

Very low risk to do TFESI with PRP. As long as you are honest with the patient before hand that the PRP has only a 50/50 chance of working they are ok with the outcome either way. For a young patient like this, I would definitely try it if he completely fails an epidural. A TFESI with PRP is very low risk compared to an intradiscal injection.

Not trying to call out steve in particular, but I disagree with no consensus no procedure. I agree with that sentiment if the procedure is risky such as surgery or if you have to "sell" the patient on a procedure. But if a procedure has minimal risk, and the patient is reasonable, you might as well give them a chance, particularly with a simple left S1 TFESI.

I would want a chance to get better or at least to hear some options besides "live with it" if I were the patient.

I can understand if some of you don't feel comfortable offering PRP injection, but it is ridiculous not to offer this young patient a quick left S1 TFESI unless he has psychological red flags.

 

[nikolaite]

Read this with a grain of salt as I am neither physician nor surgeon. While I went through the premed program at university, my main focus has been in the business of medical records archiving, pharma, animal lab and other research, medical device design and manufacturing, and mechanical engineering. So, from specifically my mechanical engineering and medical device background, is there any possibility that an external/ambulatory rib cage to thigh rig would work to support or help support the weight of his upper body, perhaps with a slight traction on the spine, to relieve L5-S1 disc protrusion and stop the worsening or exacerbation of the stenosis? Is there any possibility of pain relief in that?

I know the body weight is not meant to be supported on the thigh as proposed, but in defense of my consideration, the fellow has an immediate problem with quality of life...so, just saying.

 

[deleted875186]

Read this with a grain of salt as I am neither physician nor surgeon. While I went through the premed program at university, my main focus has been in the business of medical records archiving, pharma, animal lab and other research, medical device design and manufacturing, and mechanical engineering. So, from specifically my mechanical engineering and medical device background, is there any possibility that an external/ambulatory rib cage to thigh rig would work to support or help support the weight of his upper body, perhaps with a slight traction on the spine, to relieve L5-S1 disc protrusion and stop the worsening or exacerbation of the stenosis? Is there any possibility of pain relief in that?

I know the body weight is not meant to be supported on the thigh as proposed, but in defense of my consideration, the fellow has an immediate problem with quality of life...so, just saying.

And the thread died ….

 

[DrSpine]

I wouldn’t go crazy with a lot of procedures but an MBB at least offers him something instead of being told “deal with it you’ll get better with time.” Imagine if this was yourself for a second. We have to play empathetic but at the same time be logical physicians. A series of MBB and if successful an RFA, or a TFESI would be fair. Nothing crazier though. Inform him that it’s diagnostic and therapeutic; can’t guarantee anything and MRI/Symptoms make it a little difficult and vague. Assure them that over time they will heal; but given the fact that it’s been ongoing for years with this gentleman, wouldn’t hurt to try. PT is most important. Perhaps mechanically he is off. These patients are some of the hardest ironically but I’ve found that being sincere, honest, and logically explaining And thinking it through goes a long way.

 

[DrSpine]

Read this with a grain of salt as I am neither physician nor surgeon. While I went through the premed program at university, my main focus has been in the business of medical records archiving, pharma, animal lab and other research, medical device design and manufacturing, and mechanical engineering. So, from specifically my mechanical engineering and medical device background, is there any possibility that an external/ambulatory rib cage to thigh rig would work to support or help support the weight of his upper body, perhaps with a slight traction on the spine, to relieve L5-S1 disc protrusion and stop the worsening or exacerbation of the stenosis? Is there any possibility of pain relief in that?

I know the body weight is not meant to be supported on the thigh as proposed, but in defense of my consideration, the fellow has an immediate problem with quality of life...so, just saying.

Thanks - this awakened all of us and solved the issue!

 

[NJPAIN]

I agree with taus that a discetomy is a bad idea. A fusion is the worst idea in the universe for this patient. Given his age and symptoms, MBB/RFA is doomed to failed, but I would consider it if he were 46, but not at age 26. Certainly better odds for RFA over age 50.

Why is everyone getting their panties in a bunch about offering this patient an epidural? Not the end of the world. Worst thing that can happen realistically in a young healthy patient is that it does nothing, the best thing that can happen is that he is 90% better overall.
The most likely outcome is that his mild radicular pain resolves and his axial pain is improves by 40%, most patients would accept if you tell them that ahead of time before they undergo an easy, quick 5 minute injection.

A left S1 TFESI is reasonable so it is right on the annular tear. Or a left S2/caudal with particulate steroid. Personally, I would do a left S2 TFESI with Depo.

Because he has an annular tear, if only his leg pain resolves, but back pain is unchanged on f/u, I would offer him a left S1/S2 TFESI with PRP. I would not sell him on the PRP, but I would discuss the pros and cons and try it if he wants to .
I personally do this and I see PRP improve axial pain by 50% or more in 50% of patients with lumbar annular tear, particularly younger patients. All were happy for the 50% or more relief. I've had several patients achieve 90% sustained relief after PRP for annular tear. (I'm not doing TFESI PRP for generic DDD, only for annular tears)

Very low risk to do TFESI with PRP. As long as you are honest with the patient before hand that the PRP has only a 50/50 chance of working they are ok with the outcome either way. For a young patient like this, I would definitely try it if he completely fails an epidural. A TFESI with PRP is very low risk compared to an intradiscal injection.

Not trying to call out steve in particular, but I disagree with no consensus no procedure. I agree with that sentiment if the procedure is risky such as surgery or if you have to "sell" the patient on a procedure. But if a procedure has minimal risk, and the patient is reasonable, you might as well give them a chance, particularly with a simple left S1 TFESI.

I would want a chance to get better or at least to hear some options besides "live with it" if I were the patient.

I can understand if some of you don't feel comfortable offering PRP injection, but it is ridiculous not to offer this young patient a quick left S1 TFESI unless he has psychological red flags.

Very Interesting even if there is no evidence to support it. The reason being that although the majority of my patients are elderly, I have had a few in the 16-18 year old age group come in the last 3-6 months. All sent by general ortho, most also having seen a spine surgeon. All participants in high level gymnastics or cheerleading. All with predominantly axial low back pain of 6wk to 6 mo vintage. All with little improvement with PT. All with central disc protrusion with associated annular fissure. All with parents looking for a treatment and not open to hearing that this is likely to be a long term relapsing and remitting symptom complex that we don’t have a treatment for. I generally will unenthusiastically offer a retrodiscal/ infraneural TFESI if they feel that something must be done. Most will decline given that I tell them that absent radicular symptoms it’s unlikely to help.
Have you had luck with TF PRP in this population??

 

[Orin]

Come on, the thigh/rib brace might have more face validity than injecting magic sauce. It reminds me of those inflatable spine braces that provide support and distraction.

Is there a thought that the ventral steroid in a retrodiscal/ infraneural TFESI does better for discogenic pain?

 

[NJPAIN]

Come on, the thigh/rib brace might have more face validity than injecting magic sauce. It reminds me of those inflatable spine braces that provide support and distraction.

Is there a thought that the ventral steroid in a retrodiscal/ infraneural TFESI does better for discogenic pain?

I don’t know that there is any research evidence that retrodiscal steroids are more effective for discogenic pain. However, I visited Mike Furman a few years back and when I asked when/if he uses that approach for TFESI he commented “I generally use the infraneural approach in the setting of axial low back pain when I want to deposit steroid at the epidural/disc interface”. Since then I’ve done it a bunch of times and > 50% of the time I seem to get a response.

 

[Dr. Ice]

I agree with taus that a discetomy is a bad idea. A fusion is the worst idea in the universe for this patient. Given his age and symptoms, MBB/RFA is doomed to failed, but I would consider it if he were 46, but not at age 26. Certainly better odds for RFA over age 50.

Why is everyone getting their panties in a bunch about offering this patient an epidural? Not the end of the world. Worst thing that can happen realistically in a young healthy patient is that it does nothing, the best thing that can happen is that he is 90% better overall.
The most likely outcome is that his mild radicular pain resolves and his axial pain improves by 40%, most patients would accept if you tell them that ahead of time before they undergo an easy, quick 5 minute injection.

A left S1 TFESI is reasonable depending on the location of the annular tear. Or a left S2/caudal with particulate steroid. Personally, I would do a left S2 TFESI with Depo, unless the tear was truly lateral.

Because he has an annular tear, if only his leg pain resolves, but back pain is unchanged on f/u, I would offer him a left S1/S2 TFESI with PRP. I would not sell him on the PRP, but I would discuss the pros and cons and try it if he wants to .
I personally do this and I see PRP improve axial pain by 50% or more in 50% of patients with lumbar annular tear, particularly younger patients. All were happy for the 50% or more relief. I've had several patients achieve 90% sustained relief after PRP for annular tear. (I'm not doing TFESI PRP for generic DDD, only for annular tears)

Very low risk to do TFESI with PRP. As long as you are honest with the patient before hand that the PRP has only a 50/50 chance of working they are ok with the outcome either way. For a young patient like this, I would definitely try it if he completely fails an epidural. A TFESI with PRP is very low risk compared to an intradiscal injection.

Not trying to call out steve in particular, but I disagree with no consensus no procedure. I agree with that sentiment if the procedure is risky such as surgery or if you have to "sell" the patient on a procedure. But if a procedure has minimal risk, and the patient is reasonable, you might as well give them a chance, particularly with a simple left S1 TFESI.

I would want a chance to get better or at least to hear some options besides "live with it" if I were the patient.

I can understand if some of you don't feel comfortable offering PRP injection, but it is ridiculous not to offer this young patient a quick left S1 TFESI unless he has psychological red flags.

I hope you are using lysate prp

 

[Taus]

I don’t know that there is any research evidence that retrodiscal steroids are more effective for discogenic pain. However, I visited Mike Furman a few years back and when I asked when/if he uses that approach for TFESI he commented “I generally use the infraneural approach in the setting of axial low back pain when I want to deposit steroid at the epidural/disc interface”. Since then I’ve done it a bunch of times and > 50% of the time I seem to get a response.

I’ve probably had more discograms in my career trying to do that vs the ones I did on purpose…

 

[Dr. Ice]

I try not to use that technique solely based on having more discograms inadvertently with retrodiscal tfesi than I’ve done on purpose in my career…

Yeah you end up using more fluoro time with the approach to avoid that

 

[NJPAIN]

I’ve probably had more discograms in my career trying to do that vs the ones I did on purpose…

I definitely have not mastered the approach either.

 

[SSdoc33]

Read this with a grain of salt as I am neither physician nor surgeon. While I went through the premed program at university, my main focus has been in the business of medical records archiving, pharma, animal lab and other research, medical device design and manufacturing, and mechanical engineering. So, from specifically my mechanical engineering and medical device background, is there any possibility that an external/ambulatory rib cage to thigh rig would work to support or help support the weight of his upper body, perhaps with a slight traction on the spine, to relieve L5-S1 disc protrusion and stop the worsening or exacerbation of the stenosis? Is there any possibility of pain relief in that?

I know the body weight is not meant to be supported on the thigh as proposed, but in defense of my consideration, the fellow has an immediate problem with quality of life...so, just saying.

this would work great on robots

 

[SSdoc33]

I offer a copy of the literature and let them know it is like flipping a coin. My lack of enthusiasm usually seals the deal.
I think I have done 1 this past year.

wait a minute. you JUST said you couldnt practice by profiting off of patients when a procedure outcome is like flipping a coin, then you offer GRC to patients and tell them it is like flipping a coin. ummmm.....

for the record, i think both GRC blocks and ESIs could be reasonably offered, yet the outcomes for both are overall very poor.

i dont have a huge problem offering up shots, I'd probably do a L L5-S1 ILESI with particulate if the patient was in agony. but just dont play the holier than thou card.

 

[Ducttape]

i dont offer epidurals for axial back pain that is discogenic.

1. false hope
2. steroid effect may confuse benefit.
3. if they do get steroid effect, they come to rely on this rather than focusing on management, be it CBT, ACT, back exercises, stretches, etc.

 

[kstarm]

He has had the pain for 8 years and has tried multiple things. What of all the different things has actually helped?

You have ruled out SI joint?

 

[painfree23]

He has had the pain for 8 years and has tried multiple things. What of all the different things has actually helped?

You have ruled out SI joint?

View attachment 338843

I hate this drawing . I’ve seen it many times, how validated is it and radiating into the lateral calf?

 

[DrSpine]

I've had SI Pain. Can confirm that lateral calf discomfort.

 

[deleted875186]

He has had the pain for 8 years and has tried multiple things. What of all the different things has actually helped?

You have ruled out SI joint?

View attachment 338843

He has a little SIJ tenderness, I actually did all the maneuvers on him. His SLR was very positive and reproduced the leg symptoms though, so I don’t think it’s the primary generator. The groin pain is a little suspect though.