Cesi

[onechance]

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Any role of ESI with only motor weakness, very very mild tingling which pt is not worried about? kind of odd situation.........

 

[lobelsteve]

Any role of ESI with only motor weakness, very very mild tingling which pt is not worried about? kind of odd situation.........

No.

ESI for pain, not neurologic findings. Surgical indication present.
If concordant imaging, make referral.

In interim, can try PT with traction.
If progressive deficit, needs surgery sooner.
If acute, can do PT while waiting to see if it heals vs needs surgery.

 

[onechance]

Thank you,
He was seen by a surgeon at PCP's request (deemed to be a non surgical candidate) , and was referred to us by the surgeon for an ESI. This was the reason I was doubting my self.

 

[lobelsteve]

Thank you,
He was seen by a surgeon at PCP's request (deemed to be a non surgical candidate) , and was referred to us by the surgeon for an ESI. This was the reason I was doubting my self.

Then the surgeon does not believe the patient is weak or the patient got worse.
What does the MRI look like?

If unimpressive and weakness that is not effort or pain limited, you need an EMG and a myelogram. If positive, you need surgery.

 

[bedrock]

Thank you,
He was seen by a surgeon at PCP's request (deemed to be a non surgical candidate) , and was referred to us by the surgeon for an ESI. This was the reason I was doubting my self.

Hot potato. Nobody wants to touch him in case he gets worse..........

This guy needs a good neuro/MSK exam to look for focal weakness and MSK problems.

I've diagnosed people with painless rotator cuff tears, bicep tears, and painless CTS, that the NS missed, in several similar situations.

Rare neurologic syndromes also can start this way. If a good history and exam aren't revealing, then time for an EMG +/- neurology consult.

No way in hell would I do a cervical ESI on a patient with an unremarkable MRI and "weakness". You're just asking for trouble and could be crucified in court if there is a complication.

 

[Louisville04]

No.

ESI for pain, not neurologic findings. Surgical indication present.
If concordant imaging, make referral.

In interim, can try PT with traction.
If progressive deficit, needs surgery sooner.
If acute, can do PT while waiting to see if it heals vs needs surgery.

If the pain is mainly axial but MRI has some protrusions on MRI, would you still do an ESI?

If mild weakness is noted (4/5) which corresponds to a disc herniation on MRI, wouldn't it be difficult to determine if it an acute or chronic deficit (patient may not realize a mild EHL weakness).

Don't most large herniations get resorbed so could you try conservative measures with mild weakness?

 

[Louisville04]

No way in hell would I do a cervical ESI on a patient with an unremarkable MRI and "weakness". You're just asking for trouble and could be crucified in court if there is a complication.

If a PCP refers a patient for an epidural based on MRI findings (does not specify level, says see MRI), do you do an H&P and decide if it is appropriate or do the procedure and refer back to the PCP?

If a neurosurgeon/spine surgeon, neurologist, or other specialist refers for a specific procedure, do you evaluate the patient first and decide or since they are a specialist, do the procedure? I am thinking it might ruffle a specialist's feathers if you don't do what he/she wants.

 

[Ducttape]

i will usually contact the specialist and ask specifically how much they really want the procedure, and the reasons they want it.

the ones i work with are, for the most part, very reasonable about what they want and can be "convinced" if it is not a good idea.

 

[lobelsteve]

If the pain is mainly axial but MRI has some protrusions on MRI, would you still do an ESI?

If mild weakness is noted (4/5) which corresponds to a disc herniation on MRI, wouldn't it be difficult to determine if it an acute or chronic deficit (patient may not realize a mild EHL weakness).

Don't most large herniations get resorbed so could you try conservative measures with mild weakness?

I do ESI for radicular pain or claudication pain from stenosis.
I do not do ESI for DDD with axial pain.
I do not do ESI for what's on the MRI unless it matches the above pain pattern and is concordant with some type of history.
I do not do a series of injections.
I do not have a boat payment.

 

[PMR 4 MSK]

I do ESI for radicular pain or claudication pain from stenosis.
I do not do ESI for DDD with axial pain.
I do not do ESI for what's on the MRI unless it matches the above pain pattern and is concordant with some type of history.
I do not do a series of injections.
I do not have a boat payment.

You paid your yacht off already? Wow, that was quick!

 

[ampaphb]

I do ESI for radicular pain or claudication pain from stenosis.
I do not do ESI for DDD with axial pain

What if they have axial pain and a midline protrusion?

 

[specepic]

Any role of ESI with only motor weakness, very very mild tingling which pt is not worried about? kind of odd situation.........

Depends. How bad is weakness? If 4-/5 or worse then neuro w/u, emg and likely surg consult. If weakness no too bad but present, counsel pt on options: time, inj, surg eval.

If I was the pt I would try an injection before surgery.

Semms strange to rec surgery w/o trying the inj first assuming there is no emergent signs on exam.

no guarentees either way

I have inj pt's with weakness w/o much pain and had them do well. May be that disc hitting the motor rather than sensory fasc.

I do inj's sometimes for atypical applications when the alternatives either don't exist or carry sign morbid/mortality. i.e. discogenic pain. I follow several 30 and 40 somethings who get their 2-3 ESI per year and find it really helps paired with meds/HEP.

I never do SO3

 

[SSdoc33]

Depends. How bad is weakness? If 4-/5 or worse then neuro w/u, emg and likely surg consult. If weakness no too bad but present, counsel pt on options: time, inj, surg eval.

If I was the pt I would try an injection before surgery.

Semms strange to rec surgery w/o trying the inj first assuming there is no emergent signs on exam.

no guarentees either way

I have inj pt's with weakness w/o much pain and had them do well. May be that disc hitting the motor rather than sensory fasc.

I do inj's sometimes for atypical applications when the alternatives either don't exist or carry sign morbid/mortality. i.e. discogenic pain. I follow several 30 and 40 somethings who get their 2-3 ESI per year and find it really helps paired with meds/HEP.

I never do SO3

so how is a shot gonna help the weakness again?

no shot if no pain.

no shot for axial pain with a midline protrusion

 

[lobelsteve]

What if they have axial pain and a midline protrusion?

If it would make you happy, I'd inject you, but not patients.

Unless a real compelling reason like need to get to a wedding or complete PT. But I doubt I've done this more than 2 in 5 years.

 

[onechance]

Reg his MRI, he does have moderate stenosis at C5-6 level, same side, on exam wrist flexion/extension weak, 4+/5. OTW pretty normal.

 

[lobelsteve]

Reg his MRI, he does have moderate stenosis at C5-6 level, same side, on exam wrist flexion/extension weak, 4+/5. OTW pretty normal.

Not enough there to make sense.

EMG + myelogram.

 

[PMR 4 MSK]

Not enough there to make sense.

EMG + myelogram.

Doesn't myelogram only have about a 2-3% chance of finding something the MRI missed? But it carries high risk of PDPH and a small risk of meningitis or arachnoiditis?

 

[specepic]

so how is a shot gonna help the weakness again?

no shot if no pain.

no shot for axial pain with a midline protrusion

Why does a shot help pain? Both are nerve dysfunctions. I typically see strength improve after eSI, you don't?

I find it humorous folks here are so fast to rec surg but poo poo idea of inj x 1

I would agree that painless weakness expandsdiff dx but if you ultimtely decide its a radic, inject 'em

 

[SSdoc33]

Why does a shot help pain? Both are nerve dysfunctions. I typically see strength improve after eSI, you don't?

I find it humorous folks here are so fast to rec surg but poo poo idea of inj x 1

I would agree that painless weakness expandsdiff dx but if you ultimtely decide its a radic, inject 'em

both are nerve dysfunctions? i guess. but true weakness is due to axon loss. i dont see how a steroid is gonna make an axon grow. if the weaness realted to pain-inhibition, then the weakness will improve with a shot. if there is no pain, then THERE IS NO REASON FOR A SHOT.

im not arguing for surgery. i just see no role for a shot. the choice is not necessary "injection vs. surgery". that is a false choice.

 

[specepic]

both are nerve dysfunctions? i guess. but true weakness is due to axon loss. i dont see how a steroid is gonna make an axon grow. if the weaness realted to pain-inhibition, then the weakness will improve with a shot. if there is no pain, then THERE IS NO REASON FOR A SHOT.

im not arguing for surgery. i just see no role for a shot. the choice is not necessary "injection vs. surgery". that is a false choice.

2/5 or 3/5 weakness, prob need surgery sooner rather than later assuming MRI makes sense. "4+/5", I would try inject vs. PT with traction vs. living with it.

I try to keep in mind there is a lot we do not understand about the human body, esp the nervous system. We would like to think our dogma is spot on, but we treat pts, not pictures/labs/etc.

 

[SSdoc33]

2/5 or 3/5 weakness, prob need surgery sooner rather than later assuming MRI makes sense. "4+/5", I would try inject vs. PT with traction vs. living with it.

I try to keep in mind there is a lot we do not understand about the human body, esp the nervous system. We would like to think our dogma is spot on, but we treat pts, not pictures/labs/etc.

would you give a patient a colonoscopy for painless weakness? because that makes as much sense as a cortisone shot does. sure we dont understand everything, but there has to be some reasonable rationale to perform the injection. i heave yet to hear this rationale.

your example of muscle testing is a construct that you have created in your mind, and really not with any validity. surgery only makes sense if there is significant neural impingement. if there is painless weakness, it doesnt mean that the patient needs surgery and it doesnt mean that the patient necessarily needs a shot.

 

[specepic]

would you give a patient a colonoscopy for painless weakness? because that makes as much sense as a cortisone shot does. sure we dont understand everything, but there has to be some reasonable rationale to perform the injection. i heave yet to hear this rationale.

your example of muscle testing is a construct that you have created in your mind, and really not with any validity. surgery only makes sense if there is significant neural impingement. if there is painless weakness, it doesnt mean that the patient needs surgery and it doesnt mean that the patient necessarily needs a shot.

I'm withdrawing from a conversation that was interesting at first, and is now non-collegial. Colonscopy?? 😕

Yes, I would consider an ESI for a radic primarily presenting as mild weakness as an option, as the ESI may address inflammation which may in turn help return the nerve to normal function, hence improve strength. I have seen this exact approach work quite well and it makes perfect sense on my planet

Come to think of it, people get steroids all the time for various acute and acute on chronic peripheral nerve disorders which may or may not be painful.

 

[bedrock]

This guy needs a good neuro/MSK exam to look for focal weakness and MSK problems.

I've diagnosed people with painless rotator cuff tears, bicep tears, and painless CTS, that the NS missed, in several similar situations.

Rare neurologic syndromes also can start this way. If a good history and exam aren't revealing, then time for an EMG +/- neurology consult.

I'm saying it again. I'd look for other MSK reasons for weakness and do a careful neuro exam to be certain there is focal weakness.

This is definitely one of the times to do an EMG, (which people were arguing about on another thread).

If have true neurologic weakness, you should see active denervation on EMG. If they don't, then it's MSK/psych/early systemic neurologic disease, so no epidural for you.....

 

[PMR 4 MSK]

I'm withdrawing from a conversation that was interesting at first, and is now non-collegial. Colonscopy?? 😕

Yes, I would consider an ESI for a radic primarily presenting as mild weakness as an option, as the ESI may address inflammation which may in turn help return the nerve to normal function, hence improve strength. I have seen this exact approach work quite well and it makes perfect sense on my planet

Come to think of it, people get steroids all the time for various acute and acute on chronic peripheral nerve disorders which may or may not be painful.

Having done ESIs for weakness several times, I don't believe they help in a measurable sense. I have not seen anyone show appreciable strength return.

 

[SSdoc33]

I'm withdrawing from a conversation that was interesting at first, and is now non-collegial. Colonscopy?? 😕

Yes, I would consider an ESI for a radic primarily presenting as mild weakness as an option, as the ESI may address inflammation which may in turn help return the nerve to normal function, hence improve strength. I have seen this exact approach work quite well and it makes perfect sense on my planet

Come to think of it, people get steroids all the time for various acute and acute on chronic peripheral nerve disorders which may or may not be painful.

sorry that my comment doenst rise to your level of decorum. i was trying to say that the shot made no sense medically -- the same was a colonoscopy would make no sense medically. seems like im not alone in believing this way.

 

[Ducttape]

not to nitpick (but i am... 😉 )
gastroenterologists recommend colonoscopies just for getting older - i.e. they recommend standard screening at age 50, and every 10 years thereafter.