Tethered cord

[deleted185747]

New patient today:
25 y/o M with 1 year of gradually increasing low back pain. Non radiating. Increased with standing, LS flexion, working as a chef. Exam normal with the exception of very decreased LS flexion ROM aggravated by CS flexion. NTTP. Neg facet loading. Some hair at low back. MRI shows clean discs but a low conus at L2/3 and fatty film terminale "consider tethered cord" per radiology read. Ultram no help, norco helped in the past. Subjective weakness all ext. No nuro deficit.

I started him on gabapentin 100mg po TID and planning on LESI L4/5. If LESI no help then surgical consultation.

What would you do?

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[101N]

Surgery consult. But, regardless of outcome, no narcs.

 

[lobelsteve]

WTF are you treating with an LESI? The clean discs or the long cord?

25 y old and norco helps with no pathology on mri that works in high risk field for substance abuse.

And it is axial back pain at that. If you had a complication I'd grab the pitchfork and torches.

 

[emd123]

Surgery consult. But, regardless of outcome, no narcs.

Agree. Do nothing and send immediately to a conservative neurosurgeon. If no Neuro symptoms "consider tethered cord" is likely an asymptomatic red herring. If comes back with "no surgery indicated" then treat like any other 25 yr old with low back pain, with first priority to avoid starting a life-ruining course opioids, which you know damn well will likely last the remaining 60 years of this patients life expectancy or shorter if an addiction develops (if it hasn't already). First: Do no harm. Applies as much now as it did 2000 yrs ago in Hippocrates' time.

The most important, beneficial, and life saving thing I can do as a Pain doctor is to not start opiates. Probably needs nothing more than pt, a prn NSAID and tincture of time. In fact, that's probably over-treatment itself.

 

[Agast]

New patient today:
25 y/o M with 1 year of gradually increasing low back pain. Non radiating. Increased with standing, LS flexion, working as a chef.

I have nothing helpful to add that hasn't already been said, except that I've heard and read that people who work in kitchens tend to enjoy recreational drug use.

 

[olafa]

if cord is tethered he would have new onset neuro deficits. You did not mention if there is h/o spina bifida to go along w that.

 

[deleted185747]

Thanks for your input. I cancelled the LESI and sent him to a spine surgeon.

 

[PainDrain]

WTF are you treating with an LESI? The clean discs or the long cord?

25 y old and norco helps with no pathology on mri that works in high risk field for substance abuse.

And it is axial back pain at that. If you had a complication I'd grab the pitchfork and torches.

Couldn't agree more. This screams bogus narc seeking, disability seeking or both. Chef's are notorious for substance abuse.

To give him the benefit of the doubt think about what he does for 8-12 hours a day. He stands on hard floors in lousy shoes, in a hot kitchen, shuffling around. It's likely he has a ton of myofascial pain from supporting his torso for prolonged periods without rest. Tell him to wear sensible shoes, start yoga, PT, possible TENs unit while working. That's as wild as I would get with this guy.

 

[Stim4me]

100mg gabapentin is weak... Start 300mg qhs or pamelor 25mg qhs. Sacroilitis? Facet syndrome? If failed 6 weeks of conservative measures, offer diagnostic mb block or si injection if you determine it medically reasonable.

 

[lobelsteve]

Skip it. Pump and STIM, if fails fusion.
Has no good history, nothing on imaging or exam. No narcs, no pokes. Cardio and DLS.

 

[Stim4me]

100mg gabapentin is weak... Start 300mg qhs or pamelor 25mg qhs. Sacroilitis? Facet syndrome? If failed 6 weeks of conservative measures, offer diagnostic mb block or si injection if you determine it medically reasonable.

Skip it. Pump and STIM, if fails fusion.
Has no good history, nothing on imaging or exam. No narcs, no pokes. Cardio and DLS.

you've offered essentially nothing, strong work... Pat yourself on the back, the day is done, another one saved...

 

[lobelsteve]

100mg gabapentin is weak... Start 300mg qhs or pamelor 25mg qhs. Sacroilitis? Facet syndrome? If failed 6 weeks of conservative measures, offer diagnostic mb block or si injection if you determine it medically reasonable.

you've offered essentially nothing, strong work... Pat yourself on the back, the day is done, another one saved...

You have offered profit, expensive care, and the notion that there is something that needs treatment. I offer he can fix this by lifestyle change and exercises.

 

[Ducttape]

"You've offered essentially nothing, strong work... Pat yourself on the back, the day is done, another one saved..."

This is probably what is best for the patient but of course it does not pay the bills... Regardless of SOS.

 

[101N]

100mg gabapentin is weak... Start 300mg qhs or pamelor 25mg qhs. Sacroilitis? Facet syndrome? If failed 6 weeks of conservative measures, offer diagnostic mb block or si injection if you determine it medically reasonable.

you've offered essentially nothing, strong work... Pat yourself on the back, the day is done, another one saved...

MBB in a 25y/o Jeebus! Did you train with Zimmerman?

 

[Stim4me]

MBB in a 25y/o Jeebus! Did you train with Zimmerman?

The goon squad at work... Read .
Gabapentin 300mg, pamelor, possible si vs mb block if indicated. Patient reports chronic pain, has no other options from what we are being told. Since we don't order pet scans, yes a diagnostic mb block for chronic axial lbp is reasonable.... I have had facet joint pain since my thirties. These patients are not coming to you because that have nothing else to do. If a patient is willing to obtain injection for pain relief(without opioids) then take them seriously... Get off your high horse, back pain is real (facetogenic, discogenic)

 

[Ducttape]

But his exam and complaints do not seem consistent with facet arthropathy.

I do admit, especially if one does an rFA, it is a revenue generator compared to encouraging the patient to do work hardening, alterations in job mechanics, CBT, etc.

 

[Stim4me]

But his exam and complaints do not seem consistent with facet arthropathy.

I do admit, especially if one does an rFA, it is a revenue generator compared to encouraging the patient to do work hardening, alterations in job mechanics, CBT, etc.

That's fine, I agree with the conservative care. But we are chronic pain doctors and a good percentage of our patients have failed the aforementioned therapies. So you continue another round? Over and over? You need an intervention or at least a diagnostic block, test, to facilitate active rehabilitation....plus how great are your exam skills In ruling out facet syndrome, si, discogenic pain.

 

[powermd]

FGS this guy probably just has postural muscle aching from his job and lifestyle. And he's 25. My threshold is high in this group before declaring that he's "failed" any treatment that requires active participation.

Put 5 cc bupi in each erector spinae and repeat his exam. His pretest probability for anything but myofacial pain is very low.

 

[Ducttape]

his "failure" with a certain self-motivated treatment is not a indication of your (or my) failure or an incorrect diagnosis. similar to smoking cessation, it might take 7 attempts to "make it stick".

i might be willing to consider - after at least a full course of PT, at least 2 UDS screens, continuity of care for several months - to consider things such as SI injections, tpis, MBB if the exam were appropriate...

or maybe Cymbalta... or maybe low dose Nucynta ER... (if the alternative were SSD)

 

[SSdoc33]

you are not gonna give this guy an RF, so why the MBB?

for "closure", like a discogram?

c'mon.