Claudicatory axial pain from stenosis

[Taus]

Any tips or tricks on these patients?
Elderly patients with central/lateral recess stenosis, almost all axial pain with standing and walking relieved immediately on flexing or sitting. Little to no leg symptoms. No facet or sij tenderness or provocative maneuvers (and/or neg blocks). No instability. Not responding to PT and activity modifications, short-term response only to variety of ESI. Sedated or poor response on stronger medications. Don’t want to have to use a walker at all times. Not surgical candidates.

Wtf do you do? I see this frequently. Cross my fingers they respond well for a few months to interlam w depo… I’ve been tempted to offer referral to colleagues who do interspinous spacers. Experience with this scenario and spacers or other recs?

---

Members don't see this ad.

 

[manowar rules]

I get some relief doing interlaminars with these. I used to do interspinous spacers - I found them effective for radicular pain, less so with axial.

I also see this claudicatory axial pain commonly, but not sure of the pathophysiology. Painful congestion of the epidural veins?

 

[lobelsteve]

Any tips or tricks on these patients?
Elderly patients with central/lateral recess stenosis, almost all axial pain with standing and walking relieved immediately on flexing or sitting. Little to no leg symptoms. No facet or sij tenderness or provocative maneuvers (and/or neg blocks). No instability. Not responding to PT and activity modifications, short-term response only to variety of ESI. Sedated or poor response on stronger medications. Don’t want to have to use a walker at all times. Not surgical candidates.

Wtf do you do? I see this frequently. Cross my fingers they respond well for a few months to interlam w depo… I’ve been tempted to offer referral to colleagues who do interspinous spacers. Experience with this scenario and spacers or other recs?

Give them a walker.

 

[Ronin1]

if Ligament is a factor. MILD

 

[Ducttape]

Any tips or tricks on these patients?
Elderly patients with central/lateral recess stenosis, almost all axial pain with standing and walking relieved immediately on flexing or sitting. Little to no leg symptoms. No facet or sij tenderness or provocative maneuvers (and/or neg blocks). No instability. Not responding to PT and activity modifications, short-term response only to variety of ESI. Sedated or poor response on stronger medications. Don’t want to have to use a walker at all times. Not surgical candidates.

Wtf do you do? I see this frequently. Cross my fingers they respond well for a few months to interlam w depo… I’ve been tempted to offer referral to colleagues who do interspinous spacers. Experience with this scenario and spacers or other recs?

if no surgical options, and ligamentous hypertrophy without spondylolisthesis, then MILD. these patients probably wont have the spinous process integrity for spacers.

 

[SSdoc33]

this is a tough population. i have trouble recommending MILD in these cases. probably try both MBBs and ESIs and if no real benefit, then no more shots.

 

[Taus]

this is a tough population. i have trouble recommending MILD in these cases. probably try both MBBs and ESIs and if no real benefit, then no more shots.

Exactly. Mbb neg. Not responding to esi. Other conservative measures failed. Surgical outcomes not great/mixed, mine won’t do it for this indication.

RW or bust it seems…

I have a few of these in their 70s, healthy, not accepting to just use a walker and limit activity for the rest of their life. That’s an easier sell on my elderly frail patients. Was tempted to send out for spacer as they just do so well in a little bit of flexion

 

[SpineandWine]

Exactly. Mbb neg. Not responding to esi. Other conservative measures failed. Surgical outcomes not great/mixed, mine won’t do it for this indication.

RW or bust it seems…

I have a few of these in their 70s, healthy, not accepting to just use a walker and limit activity for the rest of their life. That’s an easier sell on my elderly frail patients. Was tempted to send out for spacer as they just do so well in a little bit of flexion

Laminectomy - while it’s axial, it’s failed conservative care and may be worth while having surgeon try it
Not very invasive, doesn’t require bone density as with spacers.

 

[swamprat]

Coflex if one or 2 levels

 

[Taus]

Laminectomy - while it’s axial, it’s failed conservative care and may be worth while having surgeon try it
Not very invasive, doesn’t require bone density as with spacers.

My surgical partners generally won’t do it…

 

[bedrock]

My surgical partners generally won’t do it…

Refer out for MILD if primarily central stenosis.

If mostly lateral recess stenosis, then join the dark side and do bilateral S1 TFESI with depo……

 

[Taus]

Refer out for MILD if primarily central stenosis.

If mostly lateral recess stenosis, then join the dark side and do bilateral S1 TFESI with depo……

Mild for axial component of lss? I’m not opposed referring for it if the odds of success are halfway decent.

Thanks everyone for the opinions.

 

[sdnuser001]

I see this all the time and get solid results with bilateral tfesi at level of worst stenosis

 

[PinchandBurn]

Mild for axial component of lss? I’m not opposed referring for it if the odds of success are halfway decent.

Thanks everyone for the opinions.

Better than lami.

They can always get the lami if mild doesn't help.

Little downside.

 

[lobelsteve]

Better than lami.

They can always get the lami if mild doesn't help.

Little downside.

Fix it right the first time.

 

[Taus]

Fix it right the first time.

Steve, do you see decompression consistently help this subset of primary or isolated axial pain stenosis patients (with all other etiologies ruled out? I don’t have much sample size to work off, literature I have seen seems mixed.

For more typical stenosis with neurogenic claudication to limb….. 100% agree. I see no reason to f around with spacers, mild etc when lami (especially ) indicated unless truly too elderly/frail/ill for it.

 

[lobelsteve]

I do not see a lot of LBP only stenosis. Most of my patients report buttock to upper posterior thigh pain. My N is too low to be useful.
But if back and buttock pain and stenosis, they get flexion exercises, muscle relaxer, and 1 ESI a level below stenosis. If that fails the surgeons get to take a look.

 

[PinchandBurn]

Fix it right the first time.

I dont think this is accurate.

how many thousands of patients do we all see where "fixing" it doesnt work or worsens.

all day long

a MILD especially if it's a older patient may give the patient a chance at a better QOL. It's not perfect but they can always get more done.

Ultimately, even with full Lami, you know they will be back...

 

[lobelsteve]

I dont think this is accurate.

how many thousands of patients do we all see where "fixing" it doesnt work or worsens.

all day long

a MILD especially if it's a older patient may give the patient a chance at a better QOL. It's not perfect but they can always get more done.

Ultimately, even with full Lami, you know they will be back...

My 740 had minimally invasive lami for this 4/24. All better.

 

[Ducttape]

I have all of these patients see a surgeon who is appropriately conservative.

I might try an esi but generally they have risk factors (ie anticoagulation for CAD).

This surgeon knows all about mild, and also appropriate with regards to surgical risk.

If no surgery offered, then the patient be offered mild. Or if surgeon tells patient risk of surgery is so high, consider mild first...

 

[SSdoc33]

Fix it right the first time.

its axial pain

laminectomy is not indicated

 

[Tboned]

I see this all the time and get solid results with bilateral tfesi at level of worst stenosis

What steroid are you using?

 

[lobelsteve]

its axial pain

laminectomy is not indicated

Then I offer to send them to someone willing to experiment with procedures that are of unproven benefit for their symptoms.

 

[SSdoc33]

Then I offer to send them to someone willing to experiment with procedures that are of unproven benefit for their symptoms.

sounds like a glowing endorsement:

"well, i dont think anything will help, but go see this other guy who does weird stuff that i dont do b/c it is nonsense"

 

[lobelsteve]

sounds like a glowing endorsement:

"well, i dont think anything will help, but go see this other guy who does weird stuff that i dont do b/c it is nonsense"

I say that a lot. If I don't think it works, get a 2nd opinion. I don't need to experiment on people at this stage of my career. I am confident in my abilities and no when to say no.

The needle does not fix all.

 

[Taus]

sounds like a glowing endorsement:

"well, i dont think anything will help, but go see this other guy who does weird stuff that i dont do b/c it is nonsense"

Pretty much sums up why I haven’t referred and asked on here

 

[sdnuser001]

What steroid are you using?

15 mg dex

 

[lobelsteve]

15 mg dex

Way too much