Spinal stenosis and TFESI case planning?

[lobelsteve]

Can we not discuss different view points on this forum without attacking one another?

No. 2 men enter, 1 man leaves. It is the way it has always been.

---

Members don't see this ad.

 

[Ducttape]

if you are doing an L5 TF and you are not getting sufficient spread to cover S1, then I would argue that your technique is not that great or the patient requires urgent surgery.

 

[Nodolor]

Duh, MBB don't work if someone has severe stenosis, which is why in contrast to some of the posters on this board, I don't proceed to MBB without an MRI or CT scan to rule that out first as well as other pathology. I have posted that MRI perspective several times on this board, so either you are fairly new here or have a bad memory.

Really ?
severe stenosis usually has a l large component of facet arthropathy. if no neurogenic claudification symptoms and axial back pain with provocative maneuvers would most likely do MBB as first choice

 

[SSdoc33]

Really ?
severe stenosis usually has a l large component of facet arthropathy. if no neurogenic claudification symptoms and axial back pain with provocative maneuvers would most likely do MBB as first choice

i find that the MBBs dont work AS well with concurrent severe stenosis, but ill still offer it to them if their legs dont hurt

 

[bedrock]

Really ?
severe stenosis usually has a l large component of facet arthropathy. if no neurogenic claudification symptoms and axial back pain with provocative maneuvers would most likely do MBB as first choice

Yet another worlds greatest pain physician.... that was the point of my main post here, how our field suffers in respect, partially because a patient gets so many different answers for the same problem.

Anyway, severe stenosis is accompanied by neurogenic claudication most of the time. Your argument might hold water for mild-moderate stenosis, but much less commonly for severe.

SSdoc33, pointed out the clear fact which is that in the rare cases of severe stenosis with no neurogenic claudication of any kind, generally the MBB don't work as well because it the facets are not the primary problem.

Certainly reasonable to offer them MBB if they fail/have very brief relief after ESI and are not surgical candidates due to age, etc.
However, I wouldn't start with MBB in a patient with severe stenosis no claudication. I'd still do one ESI and then move on the MBB/RFA.

And as ctts mentioned above, nothing makes you look worse, and annoy the patient, like doing MBB X 2, RFA X 1-2, then finding the patient only had modest relief, but then you do an epidural and they are truly better now. Makes the physician look like a ***** and puts the patient through a lot.

On those 50/50, I'd only start with MBB/RFA if the patient was on blood thinners for a serious reason, so I wanted to defer on ESI.

 

[NJPAIN]

Ok. Let me make certain I’m clear on this because this is a frequent scenario In my practice. Patient with primarily if not exclusively low back pain. Pain of increasing intensity with standing and/or ambulating that essentially resolves when seated. *Low back pain at or above L5. *Minimal or absent buttock or lower extremity pain. Minimal facet column tenderness. Minimal pain provocation with facet loading. MRI shows severe central stenosis in the lower lumbar spine in large part from severe facet arthropathy.

ESI or MBB as first intervention?

 

[deleted875186]

Ok. Let me make certain I’m clear on this because this is a frequent scenario In my practice. Patient with primarily if not exclusively low back pain. Pain of increasing intensity with standing and/or ambulating that essentially resolves when seated. *Low back pain at or above L5. *Minimal or absent buttock or lower extremity pain. Minimal facet column tenderness. Minimal pain provocation with facet loading. MRI shows severe central stenosis in the lower lumbar spine in large part from severe facet arthropathy.

ESI or MBB as first intervention?

ESI first, just my opinion.

I feel as though the patients with true facet syndrome as their primary pain tell me that provocative maneuvers reproduce the pain, where’s canal stenosis typically give some story like above.

 

[NJPAIN]

ESI first, just my opinion.

I feel as though the patients with true facet syndrome as their primary pain tell me that provocative maneuvers reproduce the pain, where’s canal stenosis typically give some story like above.

I think you are probably correct and this likely accounts for majority of my failed MBB. Interestingly it’s my experience that patients with this clinical picture do NOT do well with VERTIFLEX. Interested to hear other’s experience.

 

[RoloTomassi]

I wouldn't start with MBB in a patient with severe stenosis no claudication. I'd still do one ESI and then move on the MBB/RFA.

I do ESI first too when I see severe stenosis with axial pain. If I don't I end up having to do a P2P for the MBB because there's stenosis on the MRI report so I go ahead and get it out of the way, like doing an XR to make sure your MRI is approved. Funny thing is it works a decent percentage of the time. Mechanism? Axial neuropathic pain?

 

[callmeanesthesia]

Ok. Let me make certain I’m clear on this because this is a frequent scenario In my practice. Patient with primarily if not exclusively low back pain. Pain of increasing intensity with standing and/or ambulating that essentially resolves when seated. *Low back pain at or above L5. *Minimal or absent buttock or lower extremity pain. Minimal facet column tenderness. Minimal pain provocation with facet loading. MRI shows severe central stenosis in the lower lumbar spine in large part from severe facet arthropathy.

ESI or MBB as first intervention?

MBB first. Several reasons. Literature shows poor correlation of physical exam (facet loading) or imaging to success with diagnostic MBB. Also I’d say at least 25% of my patients with this pathology (not hard numbers but it feels like it) are on blood thinners. However, I will acknowledge poor performance of MBB/RFA in this population and I warn patients of this. Anecdotally I’m not seeing great success with ESIs for this pain patter either and I believe the literature backs that up. I will offer it to patients especially if they aren’t surgical candidates or would be heading to surgery next, but I likewise warn them studies show questionable outcomes.

 

[Nodolor]

Yet another worlds greatest pain physician.... that was the point of my main post here, how our field suffers in respect, partially because a patient gets so many different answers for the same problem.

Anyway, severe stenosis is accompanied by neurogenic claudication most of the time. Your argument might hold water for mild-moderate stenosis, but much less commonly for severe.

SSdoc33, pointed out the clear fact which is that in the rare cases of severe stenosis with no neurogenic claudication of any kind, generally the MBB don't work as well because it the facets are not the primary problem.

Certainly reasonable to offer them MBB if they fail/have very brief relief after ESI and are not surgical candidates due to age, etc.
However, I wouldn't start with MBB in a patient with severe stenosis no claudication. I'd still do one ESI and then move on the MBB/RFA.

And as ctts mentioned above, nothing makes you look worse, and annoy the patient, like doing MBB X 2, RFA X 1-2, then finding the patient only had modest relief, but then you do an epidural and they are truly better now. Makes the physician look like a ***** and puts the patient through a lot.

On those 50/50, I'd only start with MBB/RFA if the patient was on blood thinners for a serious reason, so I wanted to defer on ESI.

Like like the "world greatest pain physician " comment.
You imply this is a straight forward case example. I see many cases of severe stenosis without neurogenic claudication, so I guess your "rare" population is different than mine.

We all "know" how well an ESI works for axial back pain no matter what the source.
But hey when YOU are the greatest pain physician out there I guess YOUR results just reign supreme

 

[lobelsteve]

Yet another worlds greatest pain physician.... that was the point of my main post here, how our field suffers in respect, partially because a patient gets so many different answers for the same problem.

Anyway, severe stenosis is accompanied by neurogenic claudication most of the time. Your argument might hold water for mild-moderate stenosis, but much less commonly for severe.

i see at least 5 patients a day with severe stenosis (my read, not the mild-mod read as severe by Rads)

SSdoc33, pointed out the clear fact which is that in the rare cases of severe stenosis with no neurogenic claudication of any kind, generally the MBB don't work as well because it the facets are not the primary problem.

Certainly reasonable to offer them MBB if they fail/have very brief relief after ESI and are not surgical candidates due to age, etc.
However, I wouldn't start with MBB in a patient with severe stenosis no claudication. I'd still do one ESI and then move on the MBB/RFA.

so you are treating the images and not the patient?
Sigh

And as ctts mentioned above, nothing makes you look worse, and annoy the patient, like doing MBB X 2, RFA X 1-2, then finding the patient only had modest relief, but then you do an epidural and they are truly better now. Makes the physician look like a ***** and puts the patient through a lot.

Id argue placebo response and nothing more. Because that’s how science works. You know, like anatomy, physiology, pathology.

On those 50/50, I'd only start with MBB/RFA if the patient was on blood thinners for a serious reason, so I wanted to defer on ESI.

 

[Taus]

Ok. Let me make certain I’m clear on this because this is a frequent scenario In my practice. Patient with primarily if not exclusively low back pain. Pain of increasing intensity with standing and/or ambulating that essentially resolves when seated. *Low back pain at or above L5. *Minimal or absent buttock or lower extremity pain. Minimal facet column tenderness. Minimal pain provocation with facet loading. MRI shows severe central stenosis in the lower lumbar spine in large part from severe facet arthropathy.

ESI or MBB as first intervention?

My suspicion with this group has always been that they just can’t walk far enough to get their legs to hurt. I find it really not much works well on this group.

 

[bedrock]

i see at least 5 patients a day with severe stenosis (my read, not the mild-mod read as severe by Rads)


so you are treating the images and not the patient?
Sigh



Id argue placebo response and nothing more. Because that’s how science works. You know, like anatomy, physiology, pathology.

I agree that the reading of spinal stenosis may vary between pain physicians and maybe even a bit between pain physicians. My severe stenosis is generally also read as severe by rads. So virtually no canal at all.

Right, so the patients with stenosis, that I treat with esi and particulate stenosis, who feel better for 4-6 months, do you think those patients reported their pain relief for 6 months just to make me happy?

If so, why didn't they say that after their failed RFA?

Anatomy, physiology, pathology, and pharmacology....

 

[lobelsteve]

I agree that the reading of spinal stenosis may vary between pain physicians and maybe even a bit between pain physicians. My severe stenosis is generally also read as severe by rads. So virtually no canal at all.

Right, so the patients with stenosis, that I treat with esi and particulate stenosis, who feel better for 4-6 months, do you think those patients reported their pain relief for 6 months just to make me happy?

If so, why didn't they say that after their failed RFA?

Anatomy, physiology, pathology, and pharmacology....

You see what you want to see. If you collected better data on your patients, your bias would melt.

 

[deleted875186]

You see what you want to see. If you collected better data on your patients, your bias would melt.

Or you believe in extrapolating results from other studies, without acknowledging the possibility that the studies may not be as generalizable as you think.