Cervical radiculopathy

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Bsb2015

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I have a young male patient with bothersome right hand paresthesias consistent with radiculopathy, tried gabapentin but had some sexual dysfunction so will not try anything else with that potential side effect (TCA, Cymbalta). NSAID not helpful, doesn't want anything "stronger" than that. Tried a bunch of muscle relaxants per PCP without help. CESi somewhat helpful. PT no help, chiro no help...any reccs on something else to help without affecting his libido?
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Bsb2015 said:
I have a young male patient with bothersome right hand paresthesias consistent with radiculopathy, tried gabapentin but had some sexual dysfunction so will not try anything else with that potential side effect (TCA, Cymbalta). NSAID not helpful, doesn't want anything "stronger" than that. Tried a bunch of muscle relaxants per PCP without help. CESi somewhat helpful. PT no help, chiro no help...any reccs on something else to help without affecting his libido?
Click to expand...

Peripheral nerve or cervical radic? Distribution of pain? Any imaging of the cervical spine? Any EMGs? Any weakness? Reflexes?
 
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Pain can radiate from neck to shoulder, posterior arm and to the dorsum of the hand, digits 3,4,5. EMG (2018) shows C7 radiculopathy without CTS or ulnar neuropathy. Reflexes 2+, slight weakness 4/5
 
one teaspoon ground up turmeric root q day. he can buy a months supply in the spice section of the supermarket for about 8 dollars. tell him in might take a month to work, maybe he will fix himself during that time.
 
Cervical MRI shows moderate to severe neural foraminal stenosis at C6/7 right greater than left. I presented the possibility of surgery, but he wants to avoid it. He's a "young" 56 y.o. very active
 
> “Young male patient”

> 56

:/

At least with the hand paresthesias he can pretend someone else is jerking him off ✊
 
IMO he should be told there are only so many to treat this problem and his options at this point include living with the pain or surgery. Anything else is a waste of time. Your job is to tell him the reasonable ways to treat it. His job is to make a decision. If he doesn’t want surgery, fine. But foraminal stenosis is not going to go away.


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Recommend a surgery consultation if he hasn’t had one. Tell him seeing a surgeon doesn’t commit him to surgery but he needs to know what surgery would entail. Don’t bother messing around with meds for this - you have a very clear radic with concordant symptoms, MRI, and EMG. He could do very well with surgery.
 
I'd try a second CESI and if again no relief send to surgeon
 
there’s some scant literature about NAC and ALA improving EMG finding’s.

And I guess you could say the same about time though so gain of salt

Chiro, lido infusion if you feel like you have to do something. But agree with the above.

Take some reality and call me in the morning
 
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Surgery.

cbd cures everything apparently.

try ALA.

If all else fails, “manage pain”/“live with it” and cognitive therapy...

finally, try switching hands...
 
MD87 said:
IMO he should be told there are only so many to treat this problem and his options at this point include living with the pain or surgery. Anything else is a waste of time. Your job is to tell him the reasonable ways to treat it. His job is to make a decision. If he doesn’t want surgery, fine. But foraminal stenosis is not going to go away.


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Click to expand...
I would tell him one more thing - that the problem might go away with no treatment, and if he wants to wait it out, to return if he gets more weakness, etc.//To date, there have been no high-quality studies that have demonstrated the natural history of cervical radiculopathy. The epidemiologic study by Radhakrishnan, et al. showed that at 4-year follow up, nearly 90 % of patients with cervical radiculopathy were either asymptomatic or only mildly symptomatic [1•]. Other authors have shown similar findings [10]. //https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958381/
 
Bsb2015 said:
I have a young male patient with bothersome right hand paresthesias consistent with radiculopathy, tried gabapentin but had some sexual dysfunction so will not try anything else with that potential side effect (TCA, Cymbalta). NSAID not helpful, doesn't want anything "stronger" than that. Tried a bunch of muscle relaxants per PCP without help. CESi somewhat helpful. PT no help, chiro no help...any reccs on something else to help without affecting his libido?
Click to expand...

How long have symptoms be going on? If less than 3 months, would tell him that there is still a likelihood symptoms could improve markedly


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I have been learning with a radiculopathy medications don't help the numbness anyways? Is this wrong?
 
If more than three months and symptoms not controlled with PT, CESI, etc, it’s time for surgery. I really don’t understand the total aversion to surgery. An ACDF in the hands of a skilled surgeon is tremendously successful and patients recover rapidly. I agree that foraminal stenosis isn’t going away.


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its based on what you/we see. if I remember correctly, you work with neurosurgery office? so you get to see the successes and, statistically speaking, for ACDF there is a preponderance.

those of us who do not work in that situation only see the failures - because those are the ones coming in to "independent" pain clinics.
 
I’m solo; however, I have worked closely with a good ortho spine surgeon. I’ve assisted him on quite a few ACDF and it has really changed my view on the role of surgery. I can’t say the same for PLIF.
I should add that I myself had cervical surgery 15 years ago (posterior foraminotomy) after several ESI and 6 months of a whole lot of pain.


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NJPAIN said:
I’m solo; however, I have worked closely with a good ortho spine surgeon. I’ve assisted him on quite a few ACDF and it has really changed my view on the role of surgery. I can’t say the same for PLIF.
I should add that I myself had cervical surgery 15 years ago (posterior foraminotomy) after several ESI and 6 months of a whole lot of pain.


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Click to expand...
When you assist with your fellow surgeon do you bill an assist fee?
 
NJPAIN said:
I’m solo; however, I have worked closely with a good ortho spine surgeon. I’ve assisted him on quite a few ACDF and it has really changed my view on the role of surgery. I can’t say the same for PLIF.
I should add that I myself had cervical surgery 15 years ago (posterior foraminotomy) after several ESI and 6 months of a whole lot of pain.


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Click to expand...

I worked with a neurosurg group for most of my career. An ACDF and lumbar lamy are God's procedures.................... lumbar fusions not so good. A posterior cervical laminectomy ALWAYS results in posterior axial pain.
 
I’ve never done cervical TFESI either. I will say that (rarely) I get better contrast flow caudally than cephalad when I do the c7/t1 ILESI if they have a bit of stenosis, even if the stenosis isn’t that bad. I will reposition at most 1x, and if I don’t get more cephalad flow the second time, I still inject anyway. I don’t like mucking around in that area. I think in this situation it wouldn’t be unreasonable to try a TFESI.


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MD87 said:
I think in this situation it wouldn’t be unreasonable to try a TFESI.
Click to expand...

I dunno, man. All the risk in the world for 2-3 months of ~50% pain relief. If their pain is mild enough for me to do an ESI, I'm doing ILESI no higher than the C6-7 space. If it's bad enough that I'm thinking an ILESI won't cut it, they probably need surgery. If they have significant central canal stenosis, they're one good fall away from a central cord syndrome and probably need to seriously consider surgery anyways -- alleviating their pain for a short period of time with a high risk procedure might convince them otherwise.
 
Last edited:
Baron Samedi said:
I dunno, man. All the risk in the world for 2-3 months of ~50% pain relief. If their pain is mild enough for me to do an ESI, I'm doing ILESI no higher than the C6-7 space. If it's bad enough that I'm thinking an ILESI won't cut it, they probably need surgery. If they have significant central canal stenosis, they're one good fall away from a central cord syndrome and probably need to seriously consider surgery anyways -- alleviating their pain for a short period of time with a high risk procedure might convince them otherwise.
Click to expand...

Is there a lot of data out there on catastrophic event when dex is used?


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No, most if not all are related to particulate use, I'm not aware of prospective study RCT that is not a single case report, or not anecdotal regarding dexamethasone causing paralysis. Jim talks about this pretty commonly that the number of cervical TFESIs performed are far fewer so these numbers would be blushingly small compared to lumbars with particulates
 
lobelsteve said:
The needle spearing the vert has done in a few. Also, the vert is mobile in the neck and sometimes refuses to get out of the foramen.
Click to expand...

Gotcha. Even with 25g needle? I don’t do these. But good to know.


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www.ncbi.nlm.nih.gov

Vertebral artery anatomical variations as they relate to cervical transforaminal epidural steroid injections - PubMed

CTESI have become a mainstay in the treatment algorithm for painful cervical radiculopathy. Described techniques take extreme care to avoid cannulation of the vertebral artery during this procedure. Unexpected deviation of the artery, or an arterial segment, into the posterior neural foramen...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Vertebral Artery Position in the Setting of Cervical Degenerative Disease: Implications for Selective Cervical Transforaminal Epidural Injections - PMC

Cervical transforaminal epidural injections (C-TfEI) are commonly performed in patients with cervical radiculopathy/pain. C-TfEIs are typically performed without incident but adverse events can occur. Using CT-fluoroscopy-guided C-TfEI, we commonly ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
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