Cauda Equina in elderly with severe stenosis

[oneforfighting]

Did an SIJ on an 86 yo patient last month who also has severe L3-4, L4-5 CCS. Called me a few days later complaining of saddle anesthesia (can't feel toilet paper when wiping) and new right lower extremity weakness. No b/b incontinence. Instructed pt to go to ED for suspected CES likely due to prone positioning. Pt overwhelmed and wanted me to convey to daughter which I did. Don't think they went. Have not seen since.
Pt coming in tomorrow for scheduled f/u. Assuming Cauda Equina symptoms resolved and pt still with sig back/leg pain --- Who would offer a LESI on this patient? Or would you stand firm and recommend neurosurgery referral?
Patient likely a poor surgical candidate given age, afib on Xarelto, AAA s/p repair, CAD, CKD, etc. Pharmacological options also limited given CKD, age, lives alone.

---

Members don't see this ad.

 

[nopain1234]

I wouldn’t stick a needle anywhere near the severely stenotic regions. Could consider caudal ESI (or maybe L5/S1) but with that much compression I’d even worry about volume compressing the sack further. Would consider getting another MRI to compare to previous. I’d do a thorough PE and determine acuity and weight pros and cons and the poor health of an 86 yo going for a decompression. One option could be to do it under a spinal. But then the question is how well she could recover from a big surgery depending on technique (laminectomy vs laminotomy)

 

[DrSpine]

I've dealt with this before, sort of. They had Cauda Equina/significant stenosis on MRI, but they didn't have saddle anesthesia or any urgent symptoms though. I also told the patient that it was unlikely they would get much relief due to how stenotic they are. My recommendations: 1) Order N/S Referral to CYA. The problem is, even if you do a LESI, it'll probably hurt. Maybe you could squeeze in 1 CC utilizing interlaminar approach if you're lucky (you'll most likely get spinal tap the minute you lose resistance), but I imagine it'll hurt and not provide much relief.

If the patient declines your referral and they are experiencing Cauda Equina Syndrome, then flat out no LESI.

 

[nopain1234]

nm

 

[Asclepius186]

If being prone potentially caused cauda equina symptoms, I don’t think I would do it again with another injection. Consider TPI with steroid or oral steroids if still having some symptoms.

 

[Orin]

MRI and surgery eval make sense.

How soon after your injection did these symptoms start?

mild vs butrans if something must be done, but it's not clear there is a pain indication here. I imagine it's the usual neurogenic claudication pain though?

 

[DrSpine]

just curious what you think the utility of LRFA would provide in this setting? The back and let pain is due to nerve compression

If the patient is not a surgical candidate; absolutely it is extremely fair to try an LMBB x2. If it helps, do RFA. Especially if the symptoms stop at the knee and don't specifically follow an exact radicular path down the foot. Stenosis can manifest itself in many different ways.

 

[nopain1234]

Could consider bilateral TFESI at the suspected level causing the symptoms

 

[oneforfighting]

I wouldn’t stick a needle anywhere near the severely stenotic regions. Could consider caudal ESI (or maybe L5/S1) but with that much compression I’d even worry about volume compressing the sack further. Would consider getting another MRI to compare to previous. I’d do a thorough PE and determine acuity and weight pros and cons and the poor health of an 86 yo going for a decompression. One option could be to do it under a spinal. But then the question is how well she could recover from a big surgery depending on technique (laminectomy vs laminotomy)

She had a CT L spine 2 months ago so not sure how a new MRI would change management? Although surgeon may want for pre-op planning.

 

[nopain1234]

She had a CT L spine 2 months ago so not sure how a new MRI would change management? Although surgeon may want for pre-op planning.

New symptoms right? I’d much rather see an MRI vs CT

 

[oneforfighting]

I've dealt with this before, sort of. They had Cauda Equina/significant stenosis on MRI, but they didn't have saddle anesthesia or any urgent symptoms though. I also told the patient that it was unlikely they would get much relief due to how stenotic they are. My recommendations: 1) Order N/S Referral to CYA. The problem is, even if you do a LESI, it'll probably hurt. Maybe you could squeeze in 1 CC utilizing interlaminar approach if you're lucky (you'll most likely get spinal tap the minute you lose resistance), but I imagine it'll hurt and not provide much relief.

If the patient declines your referral and they are experiencing Cauda Equina Syndrome, then flat out no LESI.

I've done LESI's with my regular 5cc of volume in patients with severe stenosis before. I usually just go at the level below and very slowly. However, they usually don't last and I don't think it will in this case either. And based upon the CES, I'm in the N/S referral camp for CYA purposes.

 

[oneforfighting]

New symptoms right? I’d much rather see an MRI vs CT

They are new symptoms. Sure MRI would be a bit better than CT. But how would it change your management? And would they tolerate lying flat on their back for 30 minutes with that level os stenosis?

 

[oneforfighting]

If being prone potentially caused cauda equina symptoms, I don’t think I would do it again with another injection. Consider TPI with steroid or oral steroids if still having some symptoms.

Yeah, definitely a concern. Maybe put 3-4 pillows underneath the belly?
I'm very much leaning towards spine referral but figured it would be good to pose this question to the community to get everyone's thoughts.

 

[nopain1234]

They are new symptoms. Sure MRI would be a bit better than CT. But how would it change your management? And would they tolerate lying flat on their back for 30 minutes with that level os stenosis?

CES = stat imaging plus surgical evaluation. It could identify worst level etc

 

[oneforfighting]

MRI and surgery eval make sense.

How soon after your injection did these symptoms start?

mild vs butrans if something must be done, but it's not clear there is a pain indication here. I imagine it's the usual neurogenic claudication pain though?

Started same day but pt called in a few days afterwards.
I should clarify that the patient continued to complain of back/leg pains, although left leg pain improved after L SIJ.
CT L-spine was done 2 months ago. How would MRI change your management? And would they tolerate lying flat on their back for 30 minutes with that level of stenosis?
I don't do MILD or spacers but they are certainly options I can give to patient to consider.

 

[oneforfighting]

If the patient is not a surgical candidate; absolutely it is extremely fair to try an LMBB x2. If it helps, do RFA. Especially if the symptoms stop at the knee and don't specifically follow an exact radicular path down the foot. Stenosis can manifest itself in many different ways.

This is usually what I offer to patients who can tolerate lying prone for a while but RFAs take a lot longer than an SIJ...

 

[Orin]

Started same day but pt called in a few days afterwards.
I should clarify that the patient continued to complain of back/leg pains, although left leg pain improved after L SIJ.
CT L-spine was done 2 months ago. How would MRI change your management? And would they tolerate lying flat on their back for 30 minutes with that level of stenosis?
I don't do MILD or spacers but they are certainly options I can give to patient to consider.

MRI would help for defining whether surgery or ESIs or mild make some sense. You'll see LFH on CT but epidural fat is harder to isolate in tight spines. The CT would be sufficient for a ISS discussion. I generally don't refer our for surgical work without a CT myelogram or MRI ordered/completed, although in this case the neurologic deficits could cause me to pull the trigger sooner if they are resolved. If they haven't and it has been a month, I'm not sure it's going to matter at this point.

The time prone isn't as critical as how they're positioned. Obviously for any of these, you'll want some support to create kyphosis, much like you'd want to do for your next SIJ on him.

 

[oneforfighting]

CES = stat imaging plus surgical evaluation. It could identify worst level etc

I guess what I'm getting at is that it wouldn't change my management even if I found out which level is most stenotic. I would recommend ED and/or spine surgery either way if they continue to experience CES. It's when the symptoms are "intermediate" and "intermittent" when it's tricky. Like in this case where there is saddle anesthesia and weakness (possibly pain limited) but no b/b dysfunction. I can't find anything in the literature beyond CES = surgery. Maybe one paper stated elective surgery for those with 'suspected CES'.

 

[bedrock]

next step is clear, refer to spine surgeon, but at a university that is more likely to treat an 86 year old. Also see if their pain department will offer MILD. And the way to expedite the surgical/pain consult is by sending them to the ED.

If both options are denied by tertiary care center, only then do you consider other options

 

[oneforfighting]

MRI would help for defining whether surgery or ESIs or mild make some sense. You'll see LFH on CT but epidural fat is harder to isolate in tight spines. The CT would be sufficient for a ISS discussion. I generally don't refer our for surgical work without a CT myelogram or MRI ordered/completed, although in this case the neurologic deficits could cause me to pull the trigger sooner if they are resolved. If they haven't and it has been a month, I'm not sure it's going to matter at this point.

The time prone isn't as critical as how they're positioned. Obviously for any of these, you'll want some support to create kyphosis, much like you'd want to do for your next SIJ on him.

In reviewing her CT's myself, it's primarily posterior disc protrusion and significant facet hypertrophy at the aforementioned levels that cause stenosis. If there was any lipomatosis, it would likely be a minor contribution. I understand why MR would help with identifying LFH for MILD but if they have ongoing CES then it's surgery c/s...and if not then would you still offer ESI given recent CES symptoms?

I agree that I may have to request pillows for any injections with known mod-severe LSS patients.

 

[oneforfighting]

next step is clear, refer to spine surgeon, but at a university that is more likely to treat an 86 year old. Also see if their pain department will offer MILD. And the way to expedite the surgical/pain consult is by sending them to the ED.

If both options are denied by tertiary care center, only then do you consider other options

Agreed. Broached this with patient over the phone but they were not too interested in surgery. Will of course reiterate in clinic. But what would you do if they decline referral? I'm in the 'don't prescribe narcotics for nonmalignant pain camp'.

 

[callmeanesthesia]

I’d send to surgeon. Their call whether the patient is a surgical candidate. If they send them back for injections then agree with above about pillow under abdomen, maybe try MBB if prominent axial pain.

 

[Orin]

In reviewing her CT's myself, it's primarily posterior disc protrusion and significant facet hypertrophy at the aforementioned levels that cause stenosis. If there was any lipomatosis, it would likely be a minor contribution. I understand why MR would help with identifying LFH for MILD but if they have ongoing CES then it's surgery c/s...and if not then would you still offer ESI given recent CES symptoms?

I agree that I may have to request pillows for any injections with known mod-severe LSS patients.

The struggle I see is surgery may not be offered due to patient factors and/or the patient may decline but still request analgesia. In that scenario, the MRI will help guide your remaining treatment options, but my assumption here is that the surgical team would likely want to have an MRI in addition for surgical planning. The lipomatosis isn't the issue, but an ILESI in the absence of epidural fat is an LP waiting to happen.

If they're done with injections/procedures/surgeries, then you definitely don't need it, but I would document that you thought that out and discussed it with them.

 

[oneforfighting]

The struggle I see is surgery may not be offered due to patient factors and/or the patient may decline but still request analgesia. In that scenario, the MRI will help guide your remaining treatment options, but my assumption here is that the surgical team would likely want to have an MRI in addition for surgical planning. The lipomatosis isn't the issue, but an ILESI in the absence of epidural fat is an LP waiting to happen.

If they're done with injections/procedures/surgeries, then you definitely don't need it, but I would document that you thought that out and discussed it with them.

Gotcha. Point taken on epidural space. There appears to be space at L5-S1 but if I had any doubts then consideration for MR would make sense.
Thank you.

 

[painfree23]

Thoughts on SCS here?

 

[gaspasser127]

Thoughts on SCS here?

I would rather do MILD

 

[bedrock]

Agreed. Broached this with patient over the phone but they were not too interested in surgery. Will of course reiterate in clinic. But what would you do if they decline referral? I'm in the 'don't prescribe narcotics for nonmalignant pain camp'.

Make it clear to the patient that you will not continue to treat them if they will not at least meet with a spine surgeon (and a pain physician that does MILD). If they speak with both docs and decline both procedures and that is documented, at that point you resume care.

I've had this chat with elderly patients before. A significant percentage of the time they will agree to either surgery or MILD.

If the patients refused those two consults then.... you are 1- covered legally if the patient loses further neurologic function on your watch. 2- you are not a lap dog for a patient who lacks your education and experience.

 

[RoloTomassi]

You sure it's from positioning not acute herniation? Never heard of such. Cervical myelopathy from surgical flipping/positioning with ET tube, yes, but not lumbar, awake, for 15 min injection. Would get MRI.

Would not inject again if truly from prone positioning. Why would you risk reoccurrence of CES for a few months relief? Might not be so lucky next time. Must be super sensitive if lying down for 15 min caused that. MILD would be even riskier--prone longer, epidurogram, pressure on LF--but at least it might help longer.

Refer to pain doc experienced in MILD and/or NSG. Communicate with doc what happened and document the convo, for CYA and courtesy. Likely better off academic, because I don't see why PP would take the liability.

 

[nopain1234]

If the patient is not a surgical candidate; absolutely it is extremely fair to try an LMBB x2. If it helps, do RFA. Especially if the symptoms stop at the knee and don't specifically follow an exact radicular path down the foot. Stenosis can manifest itself in many different ways.

I’m all for trying anything to help the patient in a damage control type situation. Just saying with this clinical presentation it sounds related to nerve compression. Neither of us have seen the patient tho so I guess anything is fair game

 

[Greenbayslacker]

Started same day but pt called in a few days afterwards.

Is it possible there was a nerve root injury? No accusations here, just postulating.

 

[Greenbayslacker]

Would not inject again if truly from prone positioning.

Could it be done lateral?

 

[oneforfighting]

Is it possible there was a nerve root injury? No accusations here, just postulating.

Did an SIJ so not from injection

 

[oneforfighting]

You sure it's from positioning not acute herniation? Never heard of such. Cervical myelopathy from surgical flipping/positioning with ET tube, yes, but not lumbar, awake, for 15 min injection. Would get MRI.

Would not inject again if truly from prone positioning. Why would you risk reoccurrence of CES for a few months relief? Might not be so lucky next time. Must be super sensitive if lying down for 15 min caused that. MILD would be even riskier--prone longer, epidurogram, pressure on LF--but at least it might help longer.

Refer to pain doc experienced in MILD and/or NSG. Communicate with doc what happened and document the convo, for CYA and courtesy. Likely better off academic, because I don't see why PP would take the liability.

Positioning is just my guess. I have had patients who have worsened stenosis pain following injections from lying prone. Sometimes it’s the SIJ. Most folks, especially the elderly, just don’t lie on their stomach at home on a regular basis.

 

[Greenbayslacker]

Did an SIJ so not from injection

?? Certainly can get a nerve injury from SI injections...

 

[oneforfighting]

?? Certainly can get a nerve injury from SI injections...

Which nerves and how?

 

[MitchLevi]

?? Certainly can get a nerve injury from SI injections...

Overwhelmingly unlikely.

 

[Centurion38]

You can rarely see spread from SIJ to lumbosacral plexus/sacral foramina/epiradicular sheath especially if using high volume and you rupture the capsule

 

[SSdoc33]

responses in this thread are pretty disappointing

 

[Ducttape]

?? Certainly can get a nerve injury from SI injections...

what exact nerve injury are you causing from a sacroiliac injection? the sciatic nerve is on the other side of the joint, and it is highly unlikely you would be able to traverse the entire joint and puncture the nerve behind the joint.

 

[Centurion38]

AJNR Am J Neuroradiol. 1999 Sep; 20(8): 1429–1434.

PMCID: PMC7657746
PMID: 10512224

Three Pathways between the Sacroiliac Joint and Neural Structures​

 

[Ducttape]

an observational study. and done in 1999 by an author that has already emphasized that he thinks that it spreads, so a little bias...

question - how much contrast was given? does anyone really expect that 1 ml of 0.25% bupivacaine is going to spread all over the place?

this study clearly states that no nerves are in the needle path. i would keep that in mind, and would really want to press on how much contrast is spreading to be concerned, especially since we use such little local anesthetic volume.