Morbidly obese 59 yo patient s/p lumbar 4-5 and L5-S1 discectomy followed by two failed PLIF. Never fused. Was off of opioids prior to SCS trial. Had successful trial and was implanted with thoracic paddle lead by experienced neurosurgeon. Complaining of burning sensation and intermittent intense spasm in area of implant (paddle) since surgery. Surgeon prescribes hydromorphone and valium. Unsuccessfully trys: Neurontin, pregabalin, duloxetine, Lidoderm and compounded cream. Then, off course, sends back to me to deal with the hydromophone and valium. Any ideas??
Pain after laminotomy lead
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He is an addict and did the surgery to get back on the good stuff.
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NJ,
My estimates are that this happens about 5-10% of the time with lami/paddle leads. I attribute it to the facet joints - muscle spasm (?micro-movement/'new' instability vs patient positioning during surgery?) --> Robaxin + Anti-inflammatory. If it does not resolve after 6-8 weeks post-surgery, I'll go back with FJI.
My estimates are that this happens about 5-10% of the time with lami/paddle leads. I attribute it to the facet joints - muscle spasm (?micro-movement/'new' instability vs patient positioning during surgery?) --> Robaxin + Anti-inflammatory. If it does not resolve after 6-8 weeks post-surgery, I'll go back with FJI.
Interesting. It is already more than 6 months post surgery. Although, a thoracic facet joint injection on this guy (big, big) will not be alot of fun. If it comes to that I will need to resort to the Lobel posterior approach to the pedicle shadow technique for MBB. Refresh my memory on that Steve - please.
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6 mo post op pain and nothing on xray?. Wean opiate and bzd before poking. He was there before. I wouldnt stick a needle in his facet. Post films before anything else. Ap and lat. How about inject posterior to paddle under fluoro in area of lami.
I have got him down to 4mg diluadid (from 24mg) per day and 6mg valium (from 30mg) per day. Will be off shortly. Xrays pending. I had already requested approval for injecting posterior to paddle but insurance is denying as they consider it to be a "trigger point" injection and not requiring fluoro. A work in progress. Another case of surgeon breaks it but won't take ownership of it.
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Do trigger point under fluoro for his safety. You dont want to poke the wires. Dont bill fluoro.
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I would do both facet and TPI. I used to send all my SCS for surgical implant and I would see this in about 3-5% of patients.
Recommend bilateral intra-articular facet injections, and on your way out of the facets I would also inject the paraspinals for a free TPI.
Recommend bilateral intra-articular facet injections, and on your way out of the facets I would also inject the paraspinals for a free TPI.
D
deleted472101
Was dilaudid PO the surgeons go to? That's pretty crazy.
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Had a patient with delayed epidural hematoma after a paddle implant. Pain at lead site for months. Started have motor symptoms and needed explant and decompression of hematoma. Reported by st Jude per protocol. Would have surgeon get CT just in case. My pt had undiagnosed coagulopathy. If CT fine, do recs above.
Anything to shut patient up and make him happy. Surprised he didn't give him Fentanyl oralets. Why not, when the next step was turf to pain doc?
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just one point in clarification - did surgeon do the trial, or did you?
if you did, then you do bear some responsibility for this mess.....
if you did, then you do bear some responsibility for this mess.....
I did the trial. Opted against implanting myself because he is huge, I am not an SCS implant speed demon and I was concerned about infection give that thick layer of fat and prolonged open time. Regardless, I never would have left him on dilaudid and Valium for 6 months
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IA facets and tpi at same time makes no sense, nondx, nontherapeutic.
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Non-therapeutic?
Can someone explain why facetogenic pain would develop after SCS implant?
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6 mo. Little hope for cure. 1st figure out where pain is coming from. Mbb for facet. But no reason this would happen. Anchor and strain relief loop popping up through deep suture makes more sense. Seen it, fixed it. Dx local in area, with fluoro so you dont hit wires. Then if good, open site and reclose with tight spaced 0 vicryl deep.
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No randomized level one evidence for IA facets post lami, just like everything else in pain other than cervical/lumbar MBB/RF.
So why not? Low risk procedure.
Exactly. I have several patients that reported 50% or more relief for 3 months afterwards.
Low-risk procedure, and it could help get this patient off opioids.
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I think this is a good question, sounds like interventionists trying to cure what probably can't be cured by a needle
Not one to defend a needle for everything approach. However the only alternatives are pharmacological and suck it up. I'm not willing to continue opioids so suck it up is looking good for me but not for him.
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There may be a chance of facetogenic pain after a laminectomy, but unusual in my opinion after a laminotomy
-ML
No mechanism for it. No extension overload, no whiplash, no acutely increased instability. Doesn't make sense to me is all.
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