Lumbar radicular pain in patients with severe NF stenosis who failed ILESI…

[cameroncarter]

Do you offer a TFESI? Any procedural modifications you suggest?

Is surgical decompression appropriate if central canal isn’t significantly compromised?

Would SCS be a good option?

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[Ducttape]

surgery, though you would hvae to find someone that likes foraminotomies.

you could try TF but prob not likely to help


if surgery not an option, could consider MILD or spacer. Minuteman i guess is the current craze.



im more likely to tell someone that they have to manage the pain than SCS, but it is an option...

 

[SSdoc33]

you should have started with TFESI

 

[DrSpine]

How stenotic is the neuroforamen? That could be quite painful, and the problem is, when its stenotic elderly patients, I personally find TFESI with Dex is awful and not likely to help. I recommend Depo with ILESI instead so the particulates sit there a bit more and 'shotgun' the approach. These people have multi-faceted causes of pain. TFESI with Dex is great for younger people, with one direct nerve root impingement from a disc herniation. Again, no science or evidence behind this, this is just my anecdotal exprience and preference. You can try directing the ILESI more laterally if you wish?

If that fails, then you could try MILD or Vertiflex to help open the space up if they're not willing to live with it and it's affecting their quality of life. Assuming they're not a candidate for more extensive surgery.

 

[RoloTomassi]

Do you offer a TFESI? Any procedural modifications you suggest?

Definitely. Either before or after IL. Stay right under pedicle, go slow, might need to be more lateral than 6 o'clock of pedicle

Is surgical decompression appropriate if central canal isn’t significantly compromised?

Potentially, fusion more likely than foraminotomy

Would SCS be a good option?

Not going to get approved pre surgery

 

[cowboydoc]

surgery, though you would hvae to find someone that likes foraminotomies.

you could try TF but prob not likely to help


if surgery not an option, could consider MILD or spacer. Minuteman i guess is the current craze.



im more likely to tell someone that they have to manage the pain than SCS, but it is an option...

MILD for NF stenosis without much central narrowing? Does not compute.

TFESI is reasonable. I like technical recommendations of Dr. Rolo. Foraminotomy in the right hands is probably the right answer.

Stim for an ongoing mechanical compression of a nerve has never made much sense to me, but I do not wear pointy shoes.

 

[Ducttape]

there is some suggestion that nf stenosis can benefit from MILD

mild® Treatment in the Presence of Foraminal Narrowing

Dr. Navdeep Jassal shares why mild® should be considered for patients impacted by the presence of foraminal narrowing.

www.vertosmed.com

Though the amount of pain improvement between groups was not significantly different, this study confirms that by debulking the HLF and reducing compression on the nerves, patients with foraminal narrowing can benefit from a relief in pressure and should not be excluded from patient selection.

my N of 1 did benefit from this approach...

 

[DrSpine]

MILD for NF stenosis without much central narrowing? Does not compute.

TFESI is reasonable. I like technical recommendations of Dr. Rolo. Foraminotomy in the right hands is probably the right answer.

Stim for an ongoing mechanical compression of a nerve has never made much sense to me, but I do not wear pointy shoes.

I assumed the patient has central narrowing as well. MILD without central narrowing is worthless, don't come close to touching the foramen. Vertiflex spacer might be better in that case. The patient should do well with the block though.

 

[lobelsteve]

there is some suggestion that nf stenosis can benefit from MILD

mild® Treatment in the Presence of Foraminal Narrowing

Dr. Navdeep Jassal shares why mild® should be considered for patients impacted by the presence of foraminal narrowing.

www.vertosmed.com

my N of 1 did benefit from this approach...

You getting paid like Jassal to spout that nonsense?

 

[Baron Samedi]

It all depends on what is causing the stenosis.

Big ole herniated disc that is likely to improve over the next 6-12mo? Sure, try a TFESI.

A big ole disc-osteophyte complex with associated height loss and bad facet arthrosis that's progressively worsened over the years? Sure, you can try a TFESI but it's probably not going to help much. Maybe it buys the pt time before they get surgery.

 

[MitchLevi]

there is some suggestion that nf stenosis can benefit from MILD

mild® Treatment in the Presence of Foraminal Narrowing

Dr. Navdeep Jassal shares why mild® should be considered for patients impacted by the presence of foraminal narrowing.

www.vertosmed.com

my N of 1 did benefit from this approach...

What?

You're doing exactly what you accuse sooooo many people of when you post in this forum.

 

[Taus]

Definitely. Either before or after IL. Stay right under pedicle, go slow, might need to be more lateral than 6 o'clock of pedicle

Potentially, fusion more likely than foraminotomy

Not going to get approved pre surgery

Agreed 100%. Do the shot. Stay high n tight. Go to lateral early and just barely get into posterior foramen. Get meds on the root without worrying about medial flow.

If not responsive to meds, pt, occasional tfesi…. See surgeon. Anything else is bs.

 

[cameroncarter]

Agreed 100%. Do the shot. Stay high n tight. Go to lateral early and just barely get into posterior foramen. Get meds on the root without worrying about medial flow.

If not responsive to meds, pt, occasional tfesi…. See surgeon. Anything else is bs.

Thanks [mention]Taus [/mention][mention]RoloTomassi [/mention][mention]cowboydoc [/mention] I do my TFESIs in these patients just like that. I find that I’m able to place my needle at the NF entrance comfortably but they experience severe pain with even the contrast injection. More than that, I’d say that only <5% of my contrast flows epidurally.

 

[bedrock]

Definitely. Either before or after IL. Stay right under pedicle, go slow, might need to be more lateral than 6 o'clock of pedicle

Potentially, fusion more likely than foraminotomy

Not going to get approved pre surgery

Agreed 100%. Do the shot. Stay high n tight. Go to lateral early and just barely get into posterior foramen. Get meds on the root without worrying about medial flow.

If not responsive to meds, pt, occasional tfesi…. See surgeon. Anything else is bs.

Both Rolo and Taus are on the money. Agree with what they said.

Particularly agree that with a TFESI your goal is just to get meds on the root and not try to get a perfect picture if technically limited by the foraminal stenosis.

Surgically, I definitely prefer a true foraminotomy vs a fusion, but neurosurgeons who still offer foramniotomies are become few and far between, generally are near retirement.

Finally, if a patient fails both ILESI with depo and TFESI with dex and is otherwise facing a lumbar fusion, I will do an S1 TFESI with depomedrol if severe foraminal stenosis at L4-L5 or L5-S1

The S1 TFESI with depo will spare about 50-60% of patients from a fusion. But it certainly doesn't work for everyone.

 

[interjectionreflection]

Both Rolo and Taus are on the money. Agree with what they said.

Particularly agree that with a TFESI your goal is just to get meds on the root and not try to get a perfect picture if technically limited by the foraminal stenosis.

Surgically, I definitely prefer a true foraminotomy vs a fusion, but neurosurgeons who still offer foramniotomies are become few and far between, generally are near retirement.

Finally, if a patient fails both ILESI with depo and TFESI with dex and is otherwise facing a lumbar fusion, I will do an S1 TFESI with depomedrol if severe foraminal stenosis at L4-L5 or L5-S1

The S1 TFESI with depo will spare about 60% of patients from a fusion. But doesn't work for everyone.

That's interesting idea, I'd be curious to try it usually all just to the ILESI or TFESI at the impinged level. I typically don't go to levels below for fear of extra scrutiny even though potentially this could help the patient I just don't know how defensible that would be but if I have solid reason I'm happy to try it is the main goal just to get the med to flow more superior?

 

[bedrock]

That's interesting idea, I'd be curious to try it usually all just to the ILESI or TFESI at the impinged level. I typically don't go to levels below for fear of extra scrutiny even though potentially this could help the patient I just don't know how defensible that would be but if I have solid reason I'm happy to try it is the main goal just to get the med to flow more superior?

Goal is to try to inject particulate steroid next to the foremen. We all know that dex is the only safe option for a TFESI at the actual foremen, but it rarely lasts long.

ILESI with depo often helpful for central stenosis, but frequently less so for foraminal stenosis.

S1 TFES with depo often provides particulate steroid to a stenotic neuroforamen more reliably than an ILESI at the exact level.

 

[DrMDAware]

Someone please correct me if I’m wrong but if the patient has anterior column pain *worse* with forward flexion then a Vertiflex would not be indicated. My understanding is a Vertiflex is better for NIC and RELIEF with bending forward. Maybe I’m being too theoretical here and missing out a lot of Vertiflex candidates.

 

[pmrmd]

You aren’t wrong.

For me severe NF stenosis gets TF staying lateral to 6oclock on the pedicle and then depending on the patient a Vertiflex/Inspan or surgical referral.

MILD for NF stenosis is zany.

Minuteman is so…..yesterday.

 

[cameroncarter]

Both Rolo and Taus are on the money. Agree with what they said.

Particularly agree that with a TFESI your goal is just to get meds on the root and not try to get a perfect picture if technically limited by the foraminal stenosis.

Surgically, I definitely prefer a true foraminotomy vs a fusion, but neurosurgeons who still offer foramniotomies are become few and far between, generally are near retirement.

Finally, if a patient fails both ILESI with depo and TFESI with dex and is otherwise facing a lumbar fusion, I will do an S1 TFESI with depomedrol if severe foraminal stenosis at L4-L5 or L5-S1

The S1 TFESI with depo will spare about 50-60% of patients from a fusion. But it certainly doesn't work for everyone.

Maybe it’s just my practice but I see a lot of severe NF stenosis, secondary to disc osteophyte complex in an elderly population. Unfortunately, I don’t have Vertiflex in my arsenal and my surgeons don’t do foraminotomies.

I’m a bit stumped on things to do for this group!

 

[Ducttape]

You getting paid like Jassal to spout that nonsense?

you know i get paid nothing.

thats the latest year. again, i did have a $64 charge in 2014 because a stim rep screwed me over - i paid wiith my credit card to buy office lunch, he presented, but he picked up the food and kept the receipt and submitted it.

i didnt use that company for 2 years.

 

[Ducttape]

What?

You're doing exactly what you accuse sooooo many people of when you post in this forum.

first, this is data from a randomized study that suggests that the procedure can benefit those with severe neuroforaminal stenosis.

second, as with the patients in the study, my patient had central and neuroforaminal stenosis. central was moderate to severe, neuroforaminal was severe, claudication symptoms, so indicated just for central stenosis.

this is not hypothetical, or conjecture.

 

[Taus]

first, this is data from a randomized study that suggests that the procedure can benefit those with severe neuroforaminal stenosis.

second, as with the patients in the study, my patient had central and neuroforaminal stenosis. central was moderate to severe, neuroforaminal was severe, claudication symptoms, so indicated just for central stenosis.

this is not hypothetical, or conjecture.

That is entirely different from treating radicular pain from foraminal stenosis with mild. Plenty of elderly patients with severe tricompartmental stenosis have neurogenic claudication, but not radicular pain.

 

[Taus]

Maybe it’s just my practice but I see a lot of severe NF stenosis, secondary to disc osteophyte complex in an elderly population. Unfortunately, I don’t have Vertiflex in my arsenal and my surgeons don’t do foraminotomies.

I’m a bit stumped on things to do for this group!

Unfortunately, not everyone and everything will do well with non-operative treatment. If the patient is doing very poorly with their leg pain, despite maximum care, they may just truly need surgery, even if it’s fusion. If they have severe disc height collapse, unilateral asymmetric collapse, listhesis and/or too much of the facet joint needs to be resected to fully decompress the exiting nerve root, as these patients often do, they will need some instrumentation. I also do not see many isolated foraminotomies, outside of very select patients with ideal anatomy for it in this population. The few that I have seen over the years ended up needing to go back for fusion due to recurrent or persistent exiting nerve compression in the foramen.

 

[Ducttape]

as i pointed out, if surgical options do not exist for the patient, a MILD or spacer might be a consideration.

i am not a big fan of spacers, having seen a couple of fractures from them, and having been in group discussions with spine surgeons who look very negatively at them.

 

[Norepi]

Why is it that foraminotomies are falling out of favor? I was not aware of this and have been referring for these patients.

No luck with SCS for these virgin backs in the real world despite FDA approval? Not sure what else to offer these people.

 

[MitchLevi]

first, this is data from a randomized study that suggests that the procedure can benefit those with severe neuroforaminal stenosis.

second, as with the patients in the study, my patient had central and neuroforaminal stenosis. central was moderate to severe, neuroforaminal was severe, claudication symptoms, so indicated just for central stenosis.

this is not hypothetical, or conjecture.

Not the same.

 

[Ducttape]

yes, not the same as doing an unproven procedure, with no studies that show evidence, on a new site.

 

[manowar rules]

I also get a little confused when a patient has severe foraminal stenosis and the surgeon does a central decompression but the foremen remain super tight. Like, did that fix the problem?

 

[RoloTomassi]

I also get a little confused when a patient has severe foraminal stenosis and the surgeon does a central decompression but the foremen remain super tight. Like, did that fix the problem?

Not a good surgeon

 

[swamprat]

I have done endoscopic foraminatomy via tran SAP coridor with bone reamers with excellent results however ultimately I think they need an ALIF or OLIF or XLIF or whatever apprroach for indirect decomopression to restore foraminal height. My one patient was great for 8 months then pain came back sent her to surgeon who did this and she is great now. Anecdotally I have not found MM or posterior spinous clamps to work for this despite the logic that it should