CESI with marked stenosis

[NJPAIN]

Though I am certain this has been discussed previously I would appreciate your opinions. In the past I have not proceeded with CESI when faced with midline sagital canal diameter < 9 mm at ANY level. Recently started feeling overly conservative and would proceed at a level if diam > 9mm but > 7mm at all other levels. Now I am faced with the following MRI report in a healthy 40 yo with neck and RUE symptoms and no symptoms/signs of of myelopathy. Would any of you perform a CESI at C7-T1 or T1-2 on this guy?

"There is straightening of the normal cervical lordosis. Vertebral body
heights are well-maintained. There is mild intervertebral disc space
narrowing at the C4-5, C5-6, and C6-7 levels. The visualized portion of the
brainstem, cerebellum, and brain parenchyma is unremarkable.

C2-C3: There is right-sided uncovertebral hypertrophy causing mild to
moderate right neuro- foraminal narrowing without spinal canal stenosis.

C3-C4: There is a broad-based right paracentral disc herniation, bilateral
uncovertebral hypertrophy, and bilateral facet arthropathy causing severe
right and moderate left neuro- foraminal narrowing. There is minimal spinal
canal stenosis at this level with measured anterior posterior dimension off
of the sagittal sequence of 9 mm.

C4-C5: There is a concentric disc bulge with right broad-based paracentral
disc herniation, bilateral facet arthropathy, and bilateral uncovertebral
hypertrophy causing severe right and moderate to severe left neuroforaminal
narrowing with moderate to severe spinal canal stenosis. The spinal canal
measures 6 mm in anterior-posterior dimension on the sagittal sequence.
There is mild increased T2 signal intensity within the cord at this level
which may be related to edema versus myelomalacia.

C5-C6: There is a concentric disc bulge, bilateral facet arthropathy, and
uncovertebral hypertrophy causing severe bilateral neuroforaminal narrowing
with moderate spinal canal stenosis. Spinal canal measures 7 mm at this
level.

C6-C7: There is a concentric disc bulge with right paracentral broad-based
disc herniation, bilateral facet arthropathy, and uncovertebral hypertrophy
causing severe right and moderate left neuroforaminal narrowing with severe
spinal canal stenosis. The spinal canal measures 5 mm at this level.

C7-T1: There is no significant spinal canal or neuroforaminal stenosis.

The paraspinal soft tissues are unremarkable."

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[Jcm800]

best moved to physician forum

 

[lobelsteve]

Though I am certain this has been discussed previously I would appreciate your opinions. In the past I have not proceeded with CESI when faced with midline sagital canal diameter < 9 mm at ANY level. Recently started feeling overly conservative and would proceed at a level if diam > 9mm but > 7mm at all other levels. Now I am faced with the following MRI report in a healthy 40 yo with neck and RUE symptoms and no symptoms/signs of of myelopathy. Would any of you perform a CESI at C7-T1 or T1-2 on this guy?

"There is straightening of the normal cervical lordosis. Vertebral body
heights are well-maintained. There is mild intervertebral disc space
narrowing at the C4-5, C5-6, and C6-7 levels. The visualized portion of the
brainstem, cerebellum, and brain parenchyma is unremarkable.

C2-C3: There is right-sided uncovertebral hypertrophy causing mild to
moderate right neuro- foraminal narrowing without spinal canal stenosis.

C3-C4: There is a broad-based right paracentral disc herniation, bilateral
uncovertebral hypertrophy, and bilateral facet arthropathy causing severe
right and moderate left neuro- foraminal narrowing. There is minimal spinal
canal stenosis at this level with measured anterior posterior dimension off
of the sagittal sequence of 9 mm.

C4-C5: There is a concentric disc bulge with right broad-based paracentral
disc herniation, bilateral facet arthropathy, and bilateral uncovertebral
hypertrophy causing severe right and moderate to severe left neuroforaminal
narrowing with moderate to severe spinal canal stenosis. The spinal canal
measures 6 mm in anterior-posterior dimension on the sagittal sequence.
There is mild increased T2 signal intensity within the cord at this level
which may be related to edema versus myelomalacia.

C5-C6: There is a concentric disc bulge, bilateral facet arthropathy, and
uncovertebral hypertrophy causing severe bilateral neuroforaminal narrowing
with moderate spinal canal stenosis. Spinal canal measures 7 mm at this
level.

C6-C7: There is a concentric disc bulge with right paracentral broad-based
disc herniation, bilateral facet arthropathy, and uncovertebral hypertrophy
causing severe right and moderate left neuroforaminal narrowing with severe
spinal canal stenosis. The spinal canal measures 5 mm at this level.

C7-T1: There is no significant spinal canal or neuroforaminal stenosis.

The paraspinal soft tissues are unremarkable."

No epidural warranted, urgent decompression for the myelomalacia would be my choice if it were my neck. Because of the other findings I'm asking for C4-7 to be decompressed and fused. I see no role for CESI, PT, or anything other than fixing the anatomy first.
I don't care about symptoms when imaging evidence of cord damage is occurring. One sneeze and you could have a quad.

 

[SSdoc33]

One sneeze and you could have a quad.

that is a bit over-stated. one severe MVA and you are a quad.

its talk like that that allows spine surgeons to be be as callous and pigheaded as they want to be.

yes, i agree that surgery would be the best bet. however, i think this patient cant sleep at night just fine without the fear that he/she will wake up and not be able to move, especially if there are no clinical signs of myelopathy.

 

[jsaul]

that is a bit over-stated. one severe MVA and you are a quad.

its talk like that that allows spine surgeons to be be as callous and pigheaded as they want to be.

yes, i agree that surgery would be the best bet. however, i think this patient cant sleep at night just fine without the fear that he/she will wake up and not be able to move, especially if there are no clinical signs of myelopathy.

in competitive markets overzealous surgeons looking for cases have told numerous patients with findings signicantly less than this case--- " if you do not have surgery you could be paralyzed." They end up getting fused and then continue to have neck pain but the patient spouts off "at least I am not going to be paralyzed and can you refill the norco. the surgeon wont do it anymore."

 

[lobelsteve]

that is a bit over-stated. one severe MVA and you are a quad.

its talk like that that allows spine surgeons to be be as callous and pigheaded as they want to be.

yes, i agree that surgery would be the best bet. however, i think this patient cant sleep at night just fine without the fear that he/she will wake up and not be able to move, especially if there are no clinical signs of myelopathy.

Do you want to meet my patient who had minimal trauma and quaded out?
How about T11-12 HNP from valsalva on toilet? She didn't pin the conus, just the ASA and infarcted her cord?

Sitting on cord signal changes is malpractice. It is dereliction of duty not to get them to a surgeon for evaluation. If the surgeon wants to wait- that's his problem. No ESI on that neck. And " Talk like that allows spine surgeons...." They have a job to do- multilevel fusion is rarely needed in anybody- but it is in this patient at this time. if you want to sit on myelomalacia- I recommended the Quickie GT in blue opal, though the mossy oak aint bad.

http://www.quickie-wheelchairs.com/fs/o/images/products/additional_info/documents/eiqscolors.pdf

You PMR or Gas?

 

[pmrmd]

I didn't read that he is already being referred to surgery. Do you mean attempt a CESI while he is waiting to have surgical evaluation? If his symptoms are severe and the consult is awhile off, I may do one, but if he can get in to the surgeon next week why bother?

 

[lonelobo]

You have the MRI picture by chance? Would be interested in seeing.

Neurosurgeons that I have worked with don't get very excited to operate
with the above MRI findings and no signs of myelopathy

 

[101N]

Do you want to meet my patient who had minimal trauma and quaded out?
How about T11-12 HNP from valsalva on toilet? She didn't pin the conus, just the ASA and infarcted her cord?

Sitting on cord signal changes is malpractice. It is dereliction of duty not to get them to a surgeon for evaluation. If the surgeon wants to wait- that's his problem. No ESI on that neck. And " Talk like that allows spine surgeons...." They have a job to do- multilevel fusion is rarely needed in anybody- but it is in this patient at this time. if you want to sit on myelomalacia- I recommended the Quickie GT in blue opal, though the mossy oak aint bad.

http://www.quickie-wheelchairs.com/fs/o/images/products/additional_info/documents/eiqscolors.pdf

You PMR or Gas?

I'm PM&R and you are overstating both the tempo of progression of CSM and risk of rapid decline if watched. (1) That's not to say that decompression, rather than injection, isn't the best way to treat CSM, it is. A multilevel fusion is one way to treat this, an open door laminoplasty is another.

In the vast majority of cases the natural history of CSM is one of slow, progressive decline. (1)

1. http://www.bmj.com/highwire/filestream/287380/field_highwire_article_pdf/0.pdf

 

[lobelsteve]

I'm PM&R and you are overstating both the tempo of progression of CSM and risk of rapid decline if watched. (1) That's not to say that decompression, rather than injection, isn't the best way to treat CSM, it is. A multilevel fusion is one way to treat this, an open door laminoplasty is another.

In the vast majority of cases the natural history of CSM is one of slow, progressive decline. (1)

1. http://www.bmj.com/highwire/filestream/287380/field_highwire_article_pdf/0.pdf

Lovely historical article. 50 yrs old and a case series predating MRI. Would like # needed to harm for that. If teaching residents or fellows, or for anyone reading- the right answer is that injection is unlikely beneficial and may cause harm. Surgical consult MUST be obtained. I would not advise pt other than trying to keep arms strong. Would not let anyone "touch the neck". I'd consider meds for symptom mgmt.

 

[101N]

Give not that which is holy unto the dogs, neither cast ye your pearls before swine, lest they trample them under their feet, and turn again and rend you.

 

[SSdoc33]

Do you want to meet my patient who had minimal trauma and quaded out?
How about T11-12 HNP from valsalva on toilet? She didn't pin the conus, just the ASA and infarcted her cord?

Sitting on cord signal changes is malpractice. It is dereliction of duty not to get them to a surgeon for evaluation. If the surgeon wants to wait- that's his problem. No ESI on that neck. And " Talk like that allows spine surgeons...." They have a job to do- multilevel fusion is rarely needed in anybody- but it is in this patient at this time. if you want to sit on myelomalacia- I recommended the Quickie GT in blue opal, though the mossy oak aint bad.

http://www.quickie-wheelchairs.com/fs/o/images/products/additional_info/documents/eiqscolors.pdf

You PMR or Gas?

PMR

seen enough quads to know i dont wanna be one.

id also have the surgery if it were my neck.....

but that cord signal change has probably been there for years. why freak somebody out when its not necessary?

and i thought your paint color choice was another one of your car references that i didnt understand until i opened the link

 

[PinchandBurn]

does pt have Hoffman's Positive?

Most surgeons I know wthat are 'conservative' ask this.

I've had a pt w/ ventral cord abuttment. No s/s of myelpathy like decreased DTRs or Hoffman's. I send pt to the neurosurg. He stated would consider CESI prior to surgery.

In a case like that I think it's reasonable to then start at C7/t1 and then inject there. You will get the medicine 'up higher'.

 

[Pain Applicant1]

does pt have Hoffman's Positive?

Most surgeons I know wthat are 'conservative' ask this.

I've had a pt w/ ventral cord abuttment. No s/s of myelpathy like decreased DTRs or Hoffman's. I send pt to the neurosurg. He stated would consider CESI prior to surgery.

In a case like that I think it's reasonable to then start at C7/t1 and then inject there. You will get the medicine 'up higher'.

decreased?

 

[SSdoc33]

In a case like that I think it's reasonable to then start at C7/t1 and then inject there. You will get the medicine 'up higher'.

no, it is NOT reasonable to perform an epidural here. you are setting yourself up for a huge problem, medically and legally

 

[Jcm800]

You have the MRI picture by chance? Would be interested in seeing.

Neurosurgeons that I have worked with don't get very excited to operate
with the above MRI findings and no signs of myelopathy

agree...

there are probably thousands of people walking around with this same picture and no symptoms, and if they do have symptoms, never have any neurological sequalae

 

[Doctodd]

im on Steve's side with this one......send to surgery right away to at least get an opinion, and then let the patient decide if he wants to sit on it. Im not making that decision for him. You could add that symptoms will most likely worsen eventually and to be more aggressive when that happens.

 

[Doctodd]

agree...

there are probably thousands of people walking around with this same picture and no symptoms, and if they do have symptoms, never have any neurological sequalae

this is a very vague statement......got any literature to support it? And i mean cord impingement and myelomalacia in thousands of asymptomatic people, not just HNP's.

 

[NOSfan]

No CESI. The patient needs to go to the to the surgeon as he has critical stenosis and likely cord signal changes.

Clinically also don't forget about Lhermitte's phenomenon, which I suspect with close questioning he has expericend at some point.

 

[Jcm800]

this is a very vague statement......got any literature to support it? And i mean cord impingement and myelomalacia in thousands of asymptomatic people, not just HNP's.

literature to support it? yes. see my post above. it is immortalized on the web forever...

 

[PMR 4 MSK]

In this pt, I would get him/her to a surgeon quickly.

Without myelomalacia, I would go 1-2 levels below the stenosis and inject.

 

[Pain Applicant1]

So, you have no problem injecting a c-spine with MRI findings of severe stenosis? I'm currently sending out to get neurosurg recs prior to injecting just to stay on the conservative side but am still not sure if I should just inject first to try and alleviate symptoms. I spent a lot of time training with ortho spine during residency and as long as no signal changes were noted on MRI, he used to tell patients that there would be no difference if the patient went into the OR today or waited a few months to see how the symptoms progressed.

With myelomalacia, I would definitely send out ASAP due to the unforgiving nature of the CNS.

 

[PinchandBurn]

In this pt, I would get him/her to a surgeon quickly.

Without myelomalacia, I would go 1-2 levels below the stenosis and inject.

ecactly what I'm suggesting.

No quesiton, send to Surgeon.

If he says try conservative stuff...just go lower and get hte medicine up....

 

[SSdoc33]

ecactly what I'm suggesting.

No quesiton, send to Surgeon.

If he says try conservative stuff...just go lower and get hte medicine up....

NO. once again, YOU ARE WRONG. who is calling the shots here, you or the surgeon? if he says "conservative stuff", you still shouldnt do the shot. just becuase he surgeon says so, it makes it the right thing to do? grow a pair, man.

i apologize for being inflammatory, but you keep taking a backseat role, and you will always remain in the backseat.

 

[101N]

NO. once again, YOU ARE WRONG. who is calling the shots here, you or the surgeon? if he says "conservative stuff", you still shouldnt do the shot. just becuase he surgeon says so, it makes it the right thing to do? grow a pair, man.

i apologize for being inflammatory, but you keep taking a backseat role, and you will always remain in the backseat.

This is a case where we should probably deploy a shared decision making model. You inform the patient of the risks, benefits, alternatives of watchful waiting vs decompression and let him decide his course. The literature on CSM is grim ; slow, progressive, irreversible decline in function with conservative care.

Personally I'd refuse the injection unless/until he had seen a surgeon to discuss his surgical options.

 

[PinchandBurn]

🙄

NO. once again, YOU ARE WRONG. who is calling the shots here, you or the surgeon? if he says "conservative stuff", you still shouldnt do the shot. just becuase he surgeon says so, it makes it the right thing to do? grow a pair, man.

i apologize for being inflammatory, but you keep taking a backseat role, and you will always remain in the backseat.

All good.

I think this could be a good discussion, no need for being inflammatory.

Let's take the MRI findings above. Let's say the clinical exam is otherwise normal (ie no myelpathic symptoms). You send the patient to the surgeon first. He does not feel that the patient needs surgery. Pt has tried all the usual neuropathic meds and is in a tremendous amount of pain. He/She would like something done. All r/b/a including paralysis,etc were discussed.

Are you suggesting that going to a level like C7/T1 or T1/2 and slowly letting the medication go in will be a problem? I dont know about you, but I always have my patients keep moving their hands and/or feet while doing cervicals. If there is ANY increased discomfort or resistance, insertion of medication is stopped immediately.

When my attendings as a fellow have reviewed cases and told us about adverse events . MOst of these occur when people RAPIDLY inject medications and cause a 'mass effect'. As long as you dont do that, likely not to happen.

At any rate...this all maybe a moot point. How many surgeons do you know that WOULD NOT operate on a patient like this ? 🙄

They usually operate on patients w/ lot less of issues. I think the opinions will vary. Already, many other 'older' attendings on here stated they would do the case in a manner as described above.

Again, we dont treat MRIs, we treat patients.

Trust me, I dont take a back seat. Dont worry, I've been called worse by patients that just want high dose opioids and I dont cave.

 

[SSdoc33]

🙄


All good.

I think this could be a good discussion, no need for being inflammatory.

Let's take the MRI findings above. Let's say the clinical exam is otherwise normal (ie no myelpathic symptoms). You send the patient to the surgeon first. He does not feel that the patient needs surgery. Pt has tried all the usual neuropathic meds and is in a tremendous amount of pain. He/She would like something done. All r/b/a including paralysis,etc were discussed.

Are you suggesting that going to a level like C7/T1 or T1/2 and slowly letting the medication go in will be a problem? I dont know about you, but I always have my patients keep moving their hands and/or feet while doing cervicals. If there is ANY increased discomfort or resistance, insertion of medication is stopped immediately.

When my attendings as a fellow have reviewed cases and told us about adverse events . MOst of these occur when people RAPIDLY inject medications and cause a 'mass effect'. As long as you dont do that, likely not to happen.

At any rate...this all maybe a moot point. How many surgeons do you know that WOULD NOT operate on a patient like this ? 🙄

They usually operate on patients w/ lot less of issues. I think the opinions will vary. Already, many other 'older' attendings on here stated they would do the case in a manner as described above.

Again, we dont treat MRIs, we treat patients.

Trust me, I dont take a back seat. Dont worry, I've been called worse by patients that just want high dose opioids and I dont cave.

im suggesting that i would not do an epidural because it wouldnt work. plain and simple. with that much compression, you will get maybe a week or 2 of pain relief. just becasue the patient wants to have somethign done is not a legitimate reason to do an injection. it has to be medically indicated. i think you would be unlikely to precipitate a myelopathic event if you go lower, but the possible benefit far exceeds the risk.

this scenario occurs relatively frequently in older patients with multiple medical problems who arent the greatest candidates for surgery. eventually, they usually get some sort of laminoplasty, which is thought to be less invasive. my answer is pretty much always the same: no epidural

 

[NJPAIN]

Thanks for all of your replies and the lively discussion. Would all of you inject if there were no cord changes on MRI and no myelopathic changes? If so would you have a minimum canal diameter that you would feel safe with?

BTW, I won't be seeing this patient again. His attorney informed me that he is going to jail for robbery. Hope he doesn't fall off of the top bunk in his cell.

 

[lobelsteve]

Thanks for all of your replies and the lively discussion. Would all of you inject if there were no cord changes on MRI and no myelopathic changes? If so would you have a minimum canal diameter that you would feel safe with?

BTW, I won't be seeing this patient again. His attorney informed me that he is going to jail for robbery. Hope he doesn't fall off of the top bunk in his cell.

WOuld not inject the criminal with pending court hearing in any situation. Exam and imaging not withstanding.

If canal is 5mmm no chance for me to inject no matter what. If 6mm and single level with no cord signal and adequate room elsewhere, I'd put in 2cc celestone and nothing else. Need to review images before injecting and I do not trust reports from folks who have not examined the patient when I am the one with the needle.

 

[clubdeac]

Steve your saying you would inject at the level that is stenosed 6mm or at an adjacent level that is not stenosed?

WOuld not inject the criminal with pending court hearing in any situation. Exam and imaging not withstanding.

If canal is 5mmm no chance for me to inject no matter what. If 6mm and single level with no cord signal and adequate room elsewhere, I'd put in 2cc celestone and nothing else. Need to review images before injecting and I do not trust reports from folks who have not examined the patient when I am the one with the needle.

 

[lobelsteve]

Steve your saying you would inject at the level that is stenosed 6mm or at an adjacent level that is not stenosed?

I inject at C7-T1 99% and T1-2 1%.
If 2 levels are 6mm, no injection.

 

[101N]

I inject at C7-T1 99% and T1-2 1%.
If 2 levels are 6mm, no injection.

Why?

 

[lobelsteve]

Why?

Because I believe that I cannot make them any better by injection. Gentle PT, home exercise program, meds. I am not a hero. And I do not want to do procedures that I think will not be beneficial.

 

[PMR 4 MSK]

I inject at C7-T1 99% and T1-2 1%.
If 2 levels are 6mm, no injection.

Do you run catheters, and if so, how close? Say you have C4-5 stenosis at 7 mm.

 

[lobelsteve]

Do you run catheters, and if so, how close? Say you have C4-5 stenosis at 7 mm.

I'll thread a cath to 1/2 to 1 level below the stenosis if spread isn't good from C7-T1.

 

[drf]

I'll thread a cath to 1/2 to 1 level below the stenosis if spread isn't good from C7-T1.

I do a lot of catheters for CESI, however I decide before I start, as I open a different tuohy and kit for this versus a single shot.

Do you simply always open a 17-18 g tuohy just in case?

 

[PinchandBurn]

I do a lot of catheters for CESI, however I decide before I start, as I open a different tuohy and kit for this versus a single shot.

Do you simply always open a 17-18 g tuohy just in case?

are the Racz caths you guys using different in size for the cervical vs the lumbar? The standard Touhy is a 17 or 18 G like you mentioned, but not sure if the Racz caths come in different sizes and if it's really that necessary to use a smaller catheter in the cervical space.

I typically use a 20G touhy in the cervical spine (and lumbar) when not threading catheters. But hospital couldnt find a catheter small enough to place through it..

 

[lobelsteve]

I do a lot of catheters for CESI, however I decide before I start, as I open a different tuohy and kit for this versus a single shot.

Do you simply always open a 17-18 g tuohy just in case?

Nope. I use a 25g for all Tfesi and an 18g for all Ilesi.

 

[101N]

C6-C7: There is a concentric disc bulge with right paracentral broad-based
disc herniation, bilateral facet arthropathy, and uncovertebral hypertrophy
causing severe right and moderate left neuroforaminal narrowing with severe
spinal canal stenosis. The spinal canal measures 5 mm at this level.

C7-T1: There is no significant spinal canal or neuroforaminal stenosis.

If you were to perform the typical C7/T1 ILESI on this patient your aliquot would migrate
along the path of least resistance, which in his case is caudad. You won't cause 'critical
stenosis' @ C6/7 because the fluid will flow along the path of least resistance below that
level.

As others have stated, the reason not to inject isn't that it would do harm, but
that it will do no long-term good. Cervical spondylotic myelopathy is a surgical
disease.

 

[PinchandBurn]

Re Hashing this thread a bit.

Say you have a lady in her 40s. She has radic down the right upper extremity. On gabapentin (no help). This started a few months ago. Neg Hoffmans, Reflexes are intct. mild dec in cold / pin prick on the right.

I get a cervical MRI. No increased cord signal. However, read by radiologist (I looked at it too) and it says SEVERE central canal stenosis at C5/6. Also has a severe neruo-foraminal stenosis at c4/5 and I think at c5/6.

Again no bowel or bladder incontin, she is able to move her extremities.

Question is do you send to a neurosurg for eval for 'blessing'. Do you go ahead and do the CESI at c7/t1?

The issue is, I know if I send to a surgeon the response is going to be one of two things:
a) try one CESI, if no relief---> surgery
b) he will tell pt "if you get in a MVA or fall, you could be paralzed cuz your spinal cord is being pinched, almost no fluid is going around it". This is what these guys say to patients even with just mild/mod stenosis without cord signal!!

What would you guys do?

 

[Dr. Ice]

You could try to go in at T1-2.

Re Hashing this thread a bit.

Say you have a lady in her 40s. She has radic down the right upper extremity. On gabapentin (no help). This started a few months ago. Neg Hoffmans, Reflexes are intct. mild dec in cold / pin prick on the right.

I get a cervical MRI. No increased cord signal. However, read by radiologist (I looked at it too) and it says SEVERE central canal stenosis at C5/6. Also has a severe neruo-foraminal stenosis at c4/5 and I think at c5/6.

Again no bowel or bladder incontin, she is able to move her extremities.

Question is do you send to a neurosurg for eval for 'blessing'. Do you go ahead and do the CESI at c7/t1?

you could go T1-2
The issue is, I know if I send to a surgeon the response is going to be one of two things:
a) try one CESI, if no relief---> surgery
b) he will tell pt "if you get in a MVA or fall, you could be paralzed cuz your spinal cord is being pinched, almost no fluid is going around it". This is what these guys say to patients even with just mild/mod stenosis without cord signal!!

What would you guys do?

 

[PinchandBurn]

You could try to go in at T1-2.

sure, I dont see y not at C7/t1 as that space is wide open. The issue is much more cephald from there C5/6 there is SEVERE stenosis.....will there be A) a mass effect from the volume injected that can mk the pt a quad...although i could just inject very slowly B) if medicine goes to areas of least resistance is it even going to get to that c5/6 level...

 

[Gauss]

I used to do CESI with steroid only (1-2mL max volume) for these cases but found duration of effect declined after each one. Usually radic symptoms improved but neck pain persisted. Tried facets, MBB, RFA, but they always came back. So you could do it, but she'll be back, and then keep repeating until...??

 

[PinchandBurn]

I used to do CESI with steroid only (1-2mL max volume) for these cases but found duration of effect declined after each one. Usually radic symptoms improved but neck pain persisted. Tried facets, MBB, RFA, but they always came back. So you could do it, but she'll be back, and then keep repeating until...??

Gauss--

That's wht I was trying to figure out. I think doing a minimal volume C7/t1 CESI to atleast eliminate some radic pain. Then going after the MBB's to address the facets.

But with that sort of 'severe' stenosis is it just more prudent to send to a surgeon? We all know what hte success rate of surgery is, atleast the above option would be less invasive. If it fails then of course surgery is there...........

Perhaps I'm just CYAing, thinking of sending to a surgeon...