Caudal ESI and sacral fractures/sacral dura reconstruction

[Papermate44]

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Patient who had an MVC 2 years ago with subsequent severely displaced sacral fracture repair, S1-3 sacral laminectomy and graft reconstruction of lumbosacral dura. Also had left L5 hemilaminectomy and L5 foraminotomy. She presented with significant left-sided L5 radicular pain.

Would you attempt a caudal ESI considering the extensive surgery and dura reconstruction performed in the sacrum?

 

[BobBarker]

No.

 

[Orin]

You can safely do it as the caudal space extends to S4 but I would highly doubt efficacy.

Retrograde catheter ESI?
SCS?

 

[lobelsteve]

You can safely do it as the caudal space extends to S4 but I would highly doubt efficacy.

Retrograde catheter ESI?
SCS?

Catheters and retrograde are things not done any more for non cancer pain.

SCS. Only realistic option.

 

[Laryngospasm]

Scs..

 

[SommeRiver]

Wow...Some people really get it in life. That sucks.

Stim for radicular pain IMO.

 

[Taus]

No. Meds. Stim.

 

[lobelsteve]

OP: Post the post-op CT. Are those S1 screws an inch into the pelvis?

 

[Papermate44]

Thanks for the replies. Forgot to mention she’s 29 years old. I was primarily thinking stim but figured if there were feasible procedures to try first that would kick the can down the road I might start there. I just don’t see the data backing up stims for decades of pain relief. If her stim stops providing pain relief I don’t know where to go to from there. Hopefully the technology will continue to improve though.

 

[Papermate44]

OP: Post the post-op CT. Are those S1 screws an inch into the pelvis?

She had a pelvic ring fix repair too.

 

[BobBarker]

she is going to end up with a pump and a stim, which is unfortunate. But at least she is alive and can walk. I would hope with the young bone there is hope of removing the hardware. One of my friends who is a transplant surgeon had a big Harrington rod construct as a young adult from a mvc injury but has had that removed and does lots of fitness activities and completed a grueling residency and fellowship.

 

[Papermate44]

Totally agree. She was on nothing but OTC medications when I saw her so there is lots of room for improvement. Just hate this trajectory for a young mother. Any other suggestions or creative ideas welcome. Thanks for all the input.

 

[Laryngospasm]

Yeah this is what I call LFS syndrome... Life F... Sucks .. I hate seeing these folks because there is just not much that can be done and they are looking for anything.

 

[Orin]

Catheters and retrograde are things not done any more for non cancer pain.

SCS. Only realistic option.

Then send her to an academic place or someone that does cancer pain

If you can do a catheter for a high cervical, you can do it for this. Retrograde access/threading here is accessing at L3/L4 and pushing it down one/two levels. It's not hard and in some ways easier with the lack of a cord to stress about.

Agree though that SCS is reasonable, but you could also consider taking a flier on PNS if you're trying to avoid instrumenting the spine more, but I would prefer dorsal column if it were me.

 

[lobelsteve]

Then send her to an academic place or someone that does cancer pain

If you can do a catheter for a high cervical, you can do it for this. Retrograde access/threading here is accessing at L3/L4 and pushing it down one/two levels. It's not hard and in some ways easier with the lack of a cord to stress about.

Agree though that SCS is reasonable, but you could also consider taking a flier on PNS if you're trying to avoid instrumenting the spine more, but I would prefer dorsal column if it were me.

No one should be doing catheters for high cervicals. Literature. Bleeds. Injuries.

 

[Ducttape]

she is going to end up with a pump and a stim, which is unfortunate. But at least she is alive and can walk. I would hope with the young bone there is hope of removing the hardware. One of my friends who is a transplant surgeon had a big Harrington rod construct as a young adult from a mvc injury but has had that removed and does lots of fitness activities and completed a grueling residency and fellowship.

don't let her go to pump. and no to caudal.

try the stim by all means, which is what id suggest.


life does suck but she probably needs the usual PT/CBT care, more than most.

 

[Orin]

No one should be doing catheters for high cervicals. Literature. Bleeds. Injuries.

I'm confused. Are you conflating the literature for the stiffer epidurolysis catheters with the ones for epidurals? OR anesthesia puts these in with landmark guidance pre-operatively in the T-spine.

Regardless, sounds like we're all in agreement SCS first if the patient is willing to pursue it.

 

[lobelsteve]

I'm confused. Are you conflating the literature for the stiffer epidurolysis catheters with the ones for epidurals? OR anesthesia puts these in with landmark guidance pre-operatively in the T-spine.

Regardless, sounds like we're all in agreement SCS first if the patient is willing to pursue it.

For chronic pain mgmt procedures. OR anesthesia and OB are different worlds.

 

[Ferrismonk]

I don't think a retrograde epidural would do anything here, but why the hate for retrograde? I had a patient I was thinking of doing a retrograde SCS on that had prior thoracic and lumbar fusions (never actually happened though). Other than procedural difficultly, is there a reason not to?

I also agree no catheter for epidural. Not needed. 0.5mL contrast at C7/T1 easily goes up 2 levels. 5mL will go all the way up.

 

[Laryngospasm]

Could also try ILesi above with depo and larger volume.

 

[bedrock]

Could also try ILesi above with depo and larger volume.

Agree with this. I’ve had success in these situations doing ILESI with depo at level above with the needle tip directly inferiorly.