Cerivcal ESI in pt. with stenosis and spondylotic myelopathy?

[Lodoc]

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Anyone have any thoughts on this?

I had a patient with cervical spondylosis referred to me for cervical ESI. Patient had obvious myelopathy on physical exam - hyperreflexic, Hoffman's, gait disturbance, etc. I ended up referring her to Sx. for decompression.
I didn't really think that an ESI would have helped her symptoms anyway. She had stenosis mainly at C3-C6 region secondary to osteophytes and hypertrophy and broad disc bulges. I deferred on the ESI because I didn't think it was really indicated, but it made me question if I would have done it if she wasn't myelopathic and this was a typical radic. I believe I had enough room to do a C7-T1 ILESI.

I mainly passed for two reasons: 1. Didn't want anything "blamed on the procedure" if something were to go wrong. 2. I am always concerned about cervical ILESIs when there is signficant stenosis directly above the level I'm injecting. Seems to me that even if you inject lower than the level of stenosis, you are still pushing a large volume through a tight space above and that could cause cord contusion/compression?

I'm interested in various opinions on this. It is something I always struggle with in deciding whether to inject or not to inject.

What say you?

 

[Ligament]

You get paid $60 to do this procedure. You did the right thing. 😀

 

[specepic]

Great call. In pts who have significant imaging and exam findings, especially finding which, with a little progression, could affect their ability to walk, stand, poop, etc. - they at least need a surgical opinion. I have had a pt with rather severe Lumbar spinal stenosis who could barely walk due to weakness turn around nicely after an ESI but I had him see the surgeon first and he was deemed a poor candidate due to medical issues.

A case like this illustrates why our procedures should not be done willy nilly and not be done by PAs, CRNAs, and why pain docs should either do their own evals before injection, or really trust the person sending them an injection. Its been said before by others: knowing why and who to inject is just as important as knowing how.

 

[SSdoc33]

i get nervous whenever there is even moderate stenosis in that the volume (only 2-3 mL) may precipitate a myelopathic event. when there is cord signal change or clear myelopathy on exam, a CESI will do nothing for the patient but can make you look like a chump if something bad happens. good call

 

[PMR 4 MSK]

Plus I doubt the surgeon wants steroid sitting in there when he's waiting for everything to heal after he cuts on it.

I would not have injected as presented.

Without myelopathy, I would likely inject, at least 1 level below the stenosis with interlaminar approach.

 

[lobelsteve]

No CESI for severe canal stenosis in neck, and with myelopathic findings on exam- not a chance.

 

[painMD24]

Agree with all that has been said....absolutely no ESI in this setting. I had a similar case just last week where the patient had upper extremity myelopathy and radiculopathy with severe cervical stenosis on MR. Referred to surgeon.

 

[Lodoc]

Thanks everyone for all your input. I really appreciate it.
I guess I should clarify some things: First, I would never do a C-ILESI if I thought there was significant or severe stenosis at that particular level - even if it was a clear radic with no evidence of myelopathy.

But what I sometimes struggle with is whether or not it is safe to do one if you are beneath the level of the stenosis. I have been taught that traditionally you are "ok" as long as you are one to two levels below the level of stenosis. In this particular patient, there was "room enough" below the stenotic level, and the stenosis itself really wasn't that severe by MRI. It was really only that she was myelopathic that made me not do it at all, but I was wondering what I would have done if she was not myelopathic. Does that make sense?

 

[Gauss]

What were your outcomes after ILE with the stenosis you describe at levels above?
I find the duration of benefit to be rather short, so I dither on repeating it