Complicated Case...input please!

[Timeoutofmind]

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In brief:

60yo F

Had left leg pain around 14 months ago. Extensive workup by outside ortho group. Found to have a meniscal tear on the knee, but not thought to be the cause of her symptoms, as well as moderately large focal far left lateral disc herniation at L3-L4 resulting in severe left foraminal narrowing with contact and deformity of the left foraminal nerve at that level. ESIs without relief.

Anyway, she got frustrated with that care and the no relief and just was lost to f/u for a year.

Presented to me recently as a consult with a very severe CRPS type picture in the leg. Pain centered around the knee, extending down to the ankle. Looks really bad. Much allodynia. Of note, she cannot flex the knee more than 10 degrees and ankle ROM poor as well.

I tried antineuropathics, my PT CRPS protocol (desensitization/Graded motor imagery/mirror therapy/left-right flash cards, related techniques. Aggressive ROM at therapy and also aggressive ROM HEP).

No relief. Therapist says making a little progress with desensitization but not with ROM.

LSNB and appeal by me both denied by insurance company.

Anyway, I am confused on the following two points:

1. The foraminal stenosis is really pretty bad and SLR is positive. Do you think surgery is a good idea given the superimposed CRPS type picture? Could reliving the compressive lesion help with some of these neuropathic pain issues, or is this just going to flare everything up?

2. What about a knee manipulation under anesthesia by ortho? Any utility in this context? I guess at PT it is just too painful and tight to get beyond 20 degrees even with active assistance by the therapist. I am worried about permanent loss of limb function if we dont turn a corner soon here.

3. Or would you just ignore both of these and go to stim?

Thanks in advance

 

[willabeast]

In brief:

60yo F

Had left leg pain around 14 months ago. Extensive workup by outside ortho group. Found to have a meniscal tear on the knee, but not thought to be the cause of her symptoms, as well as moderately large focal far left lateral disc herniation at L3-L4 resulting in severe left foraminal narrowing with contact and deformity of the left foraminal nerve at that level. ESIs without relief.

Anyway, she got frustrated with that care and the no relief and just was lost to f/u for a year.

Presented to me recently as a consult with a very severe CRPS type picture in the leg. Pain centered around the knee, extending down to the ankle. Looks really bad. Much allodynia. Of note, she cannot flex the knee more than 10 degrees and ankle ROM poor as well.

I tried antineuropathics, my PT CRPS protocol (desensitization/Graded motor imagery/mirror therapy/left-right flash cards, related techniques. Aggressive ROM at therapy and also aggressive ROM HEP).

No relief. Therapist says making a little progress with desensitization but not with ROM.

LSNB and appeal by me both denied by insurance company.

Anyway, I am confused on the following two points:

1. The foraminal stenosis is really pretty bad and SLR is positive. Do you think surgery is a good idea given the superimposed CRPS type picture? Could reliving the compressive lesion help with some of these neuropathic pain issues, or is this just going to flare everything up?

2. What about a knee manipulation under anesthesia by ortho? Any utility in this context? I guess at PT it is just too painful and tight to get beyond 20 degrees even with active assistance by the therapist. I am worried about permanent loss of limb function if we dont turn a corner soon here.

3. Or would you just ignore both of these and go to sim?

Thanks in advance

If this patient came to me as a referral I would repeat the work up including more /repeat imaging. 90% of referrals to me from neurologists for CRPS eventually turn out not to be CRPS. I hate suggesting RX but if there is no infection and you are convinced it is CRPS oral steroid trial after informed consent might help.

 

[lobelsteve]

Surgeon to operate on disc. Do LSB and eat cost of time. If not better then scs. Too late for steroids.

 

[pastafan]

Memantine trial may be worthwhile. You could get approval for ESI and perform with local to get a sympathetic block or just do LSB at the same time.

 

[Orin]

Agree with the above, but you can also do a simple lumbar plexus block with local into the psoas, do the passive ROM yourself, and assess benefit. The LSB would be ideal, but why waste time?

 

[clubdeac]

Do a left L3/4 TFESI with 0.5% marcaine and steroid if they're denying the LSB. That should give you some helpful information no?

 

[Timeoutofmind]

No one thinks that knee manipulation is a good idea?

 

[DOctorJay]

I would run the knee manipulation by the orthopedist and let them order it if they feel it's appropriate.

 

[SSdoc33]

No one thinks that knee manipulation is a good idea?

No, i dont.

 

[SSdoc33]

do an EMG to confirm the left L3 radiculopathy. if there is that much weakness, it will show up on EMG and confirm the diagnosis.

i have never seen CRPS from a radiculopathy.

also, confirm that a LEFT L3 transforaminal ESI was the actual injection given. dollars to donuts, some yahoo did the wrong level.

 

[Agast]

Repeat the knee MRI if you’re considering sending her back to ortho. I think some insurances are not paying for manipulation under anesthesia any more.

 

[Ferrismonk]

Do a left L3/4 TFESI with 0.5% marcaine and steroid if they're denying the LSB. That should give you some helpful information no?

Agree. Either eat the cost of a diagnostic LSB (maybe further will be approved if significant relief from first one), or do a diagnostic SNRB. If radicular, maybe surgery will benefit her.

 

[cowboydoc]

do an EMG to confirm the left L3 radiculopathy. if there is that much weakness, it will show up on EMG and confirm the diagnosis.

i have never seen CRPS from a radiculopathy.

also, confirm that a LEFT L3 transforaminal ESI was the actual injection given. dollars to donuts, some yahoo did the wrong level.

I haven't had good experiences doing an EMG in the region of allodynia. Otherwise, not a bad idea. Good luck if you heed this advice.

 

[SSdoc33]

I haven't had good experiences doing an EMG in the region of allodynia. Otherwise, not a bad idea. Good luck if you heed this advice.

one needle in the VMO is all you really need....

 

[jesspt]

No one thinks that knee manipulation is a good idea?

I'd bet the surgeon would get 120 degrees on the table and the therapist would get 10 degrees in the outpatient clinic.

 

[lonelobo]

10 degrees of flexion? so he knee is essentially straight, was she able to sit in chair? did you watch her walk?
Is lumbar MRI 14 mo old? did you personally look at it?

 

[Aether2000]

If the foraminal stenosis is so severe that the contrast pattern does not outline the nerve into the lateral epidural space, then I would consider an posterior ipsilateral interlaminar approach just medial to the medial laminar border in the interlaminar window. In this case I would also add some local anesthesia to the steroid in order to assess for immediate effect. CRPS could be present if enough symptoms are present, but disuse atrophy or muscle contractures could also be present. If the epidural had no effect, then 100mg IV propofol and mobilize the knee. I really don't need an orthopedist for that.

 

[Tapspatellas]

In brief:



1. The foraminal stenosis is really pretty bad and SLR is positive. Do you think surgery is a good idea given the superimposed CRPS type picture? Could reliving the compressive lesion help with some of these neuropathic pain issues, or is this just going to flare everything up?

L3 neural tension won’t give positive SLR, would be positive femoral stretch. Consider secondary piriformis pain if you are getting an early positive SLR at low angle, this will stir up when everything in the area hurts.

 

[SeniorWrangler]

Any skin changes, edema, etc? I suspect neuropathic pain with severe guarding and kinesiophobia rather than CRPS, just based on the story.
I am not aware of any evidence that manipulation under anesthesia has any lasting effect, but would be happy to read some.

 

[Green Grass]

A knee MRI in an elderly patient is going to show degenerative changes, just like the xray probably showed too. Pointless to repeat.

EMG seems reasonable, pinpoint the problem. I'd try repeat TFESI, refer to spine surgeon.

 

[painfree23]

would she be able to tolerate emg in the leg?

 

[244913]

A knee MRI in an elderly patient is going to show degenerative changes, just like the xray probably showed too. Pointless to repeat.

EMG seems reasonable, pinpoint the problem. I'd try repeat TFESI, refer to spine surgeon.

If her problem is pain, spine surgery is not the answer

 

[244913]

In brief:

60yo F

Had left leg pain around 14 months ago. Extensive workup by outside ortho group. Found to have a meniscal tear on the knee, but not thought to be the cause of her symptoms, as well as moderately large focal far left lateral disc herniation at L3-L4 resulting in severe left foraminal narrowing with contact and deformity of the left foraminal nerve at that level. ESIs without relief.

Anyway, she got frustrated with that care and the no relief and just was lost to f/u for a year.

Presented to me recently as a consult with a very severe CRPS type picture in the leg. Pain centered around the knee, extending down to the ankle. Looks really bad. Much allodynia. Of note, she cannot flex the knee more than 10 degrees and ankle ROM poor as well.

I tried antineuropathics, my PT CRPS protocol (desensitization/Graded motor imagery/mirror therapy/left-right flash cards, related techniques. Aggressive ROM at therapy and also aggressive ROM HEP).

No relief. Therapist says making a little progress with desensitization but not with ROM.

LSNB and appeal by me both denied by insurance company.

Anyway, I am confused on the following two points:

1. The foraminal stenosis is really pretty bad and SLR is positive. Do you think surgery is a good idea given the superimposed CRPS type picture? Could reliving the compressive lesion help with some of these neuropathic pain issues, or is this just going to flare everything up?

2. What about a knee manipulation under anesthesia by ortho? Any utility in this context? I guess at PT it is just too painful and tight to get beyond 20 degrees even with active assistance by the therapist. I am worried about permanent loss of limb function if we dont turn a corner soon here.

3. Or would you just ignore both of these and go to stim?

Thanks in advance

Strange picture. What's her mental health like? Is she filing for disability? Is this a workman's comp case?

I think injections of any type would be low yield unless for diagnostic purposes

I would think about an inpt admission for 5 day epidural and aggressive ROM mobilization/PT with a pain free leg, see how she does with that

Then stim trial if she is a reasonable person on no opioids, non smoker etc.

- ex 61N

 

[Blitz2006]

do an EMG to confirm the left L3 radiculopathy. if there is that much weakness, it will show up on EMG and confirm the diagnosis.

i have never seen CRPS from a radiculopathy.

also, confirm that a LEFT L3 transforaminal ESI was the actual injection given. dollars to donuts, some yahoo did the wrong level.

This was my thought as well. Can you get CRPS from radiculopathy? I didn't think so...

 

[Orin]

There are multiple case reports of CRPS developing from what were initially radiculopathies.

For example:
Reflex sympathetic dystrophy syndrome secondary to L5 radiculopathy. - PubMed - NCBI
[Reflex sympathetic dystrophy secondary to lumbar disk herniation]. - PubMed - NCBI
Complex Regional Pain Syndrome Caused by Lumbar Herniated Intervertebral Disc Disease. - PubMed - NCBI

 

[Timeoutofmind]

There are multiple case reports of CRPS developing from what were initially radiculopathies.

For example:
Reflex sympathetic dystrophy syndrome secondary to L5 radiculopathy. - PubMed - NCBI
[Reflex sympathetic dystrophy secondary to lumbar disk herniation]. - PubMed - NCBI
Complex Regional Pain Syndrome Caused by Lumbar Herniated Intervertebral Disc Disease. - PubMed - NCBI

Good points and discussion all. Thanks much. Informative.

This is her exam:
Blue and red discoloration
Warm
Hair loss
Diffuse swelling from mid thigh down
Poor range of motion of the ankle and cannot flex the knee more than 20°.
Diffuse dysthesthia but no allodynia
Pain with gentle palpating diffusely

I think this is the crux of basically what I am struggling with. Say I get an EMG and it confirms a radiculopathy as I suspect it would. The point is she also has CRPS on top of it. Her exam findings cannot be explained by radiculopathy alone. And she is totally normal with zero secondary gain stuff. Given this, would a surgical decompression be helpful in resolving things? Or is it not gonna even touch all these CRPS type symptoms? Could it flare her CRPS up? I guess I could always send her for decompression, at least resolve the radicular issues and only have the CRPS to deal with, see how she does, and offer her the stim afterwards...

 

[lobelsteve]

Surgery is only chance for cure. And it is not like things could be worse from a pain standpoint.
If fails to improve from microdiskectomy, then SCS trial at 6 weeks post-op- then Prialt trial if that fails.

 

[SSdoc33]

Good points and discussion all. Thanks much. Informative.

This is her exam:
Blue and red discoloration
Warm
Hair loss
Diffuse swelling from mid thigh down
Poor range of motion of the ankle and cannot flex the knee more than 20°.
Diffuse dysthesthia but no allodynia
Pain with gentle palpating diffusely

I think this is the crux of basically what I am struggling with. Say I get an EMG and it confirms a radiculopathy as I suspect it would. The point is she also has CRPS on top of it. Her exam findings cannot be explained by radiculopathy alone. And she is totally normal with zero secondary gain stuff. Given this, would a surgical decompression be helpful in resolving things? Or is it not gonna even touch all these CRPS type symptoms? Could it flare her CRPS up? I guess I could always send her for decompression, at least resolve the radicular issues and only have the CRPS to deal with, see how she does, and offer her the stim afterwards...

first, you need to treat this as if it were a radiculopathy alone. EMG, then L3 TFESI, then aggressive PT.

if she doesnt respond, then im not sure surgery would be indicated. it really depends on the EMG findings and the response to the appropriate treatment.

if you get nowhere, then go down the CRPS pathway with sympathetic blocks and stim

 

[NOSfan]

Review previous TFESI record/films. If good placement and no benefit, even with expected LA time frame, then disc likely non-contributory.

If you desire EMG, then you don't necessarily need to EMG entire leg. You can just check lumbar paraspinous muscles to confirm presence of radiculopathy.

Regardless, due to chronicity, do not believe that there is a surgical 'fix here' - discectomy or otherwise. Additionally, LSB would not likely provide any durable effects.

Namenda, TPX or even perhaps low dose methadone options, but likely SCS is the best course.

 

[Ducttape]

what I am not understanding is...

I thought the basic tenant of CRPS is that there is nothing else that could be diagnostically appropriate to be the underlying cause of the condition. while dermatologic changes are not common in a radiculopathy, they can occur ( and we all know about skin changes in shingles.)


how are those articles making a presumptive diagnosis of CRPS, when the clinical course and benefit from intervention "fit" better post hoc with untreated lumbar radiculopathy?

 

[Timeoutofmind]

Update:

Saw neurology. Sort of interesting...



ASSESSMENT:
1. Segmental dystonia
2. Left leg pain
3. Difficulty walking

The patient reports onset of symptoms during the Fall of 2016. She started with pain which was evaluated by orthopedics and diagnosed as runner's knee. The pain continue with no improvement after physical therapy and the radiculopathy was suggested. She was seen by orthopedic spine who recommended some injections with no improvement of symptoms.

She sent after the diagnosis of dystonia was suggested. Patient underwent an EMG suggested the diagnosis of dystonia given the involuntary motor unit action potentials seen during the study.

Examination suggest the possibility of a dystonic left lower extremity, most compartments of the left lower extreme are affected and there is no ability to bend the knee. Patient still ambulatory.

Discussed the diagnosis of dystonia with patient. Recommended for her to undergo blood tests and an MRI of the brain. She thinks she has had an assessment of the thoracic spine but discussed with patient that if MRI of the brain is unremarkable imaging of the cervical and thoracic spine may be reasonable.

The possibility of a dopamine responsive dystonia was discussed with patient. Suggested Sinemet 25/100 starting with half a tablet 3 times a day increasing after 2 weeks to one tablet 3 times a day.

Patient will call us, medication could be increased if needed.

Patient appears to understand and agrees with recommendations. Will be happy to see her in about 2-3 months but she will calls in 4 weeks for an update. Sinemet could be increased

PLAN:
Sinemet goal dose 1 tab 3x a day
F/u in 2-3 months

Orders Placed This Encounter
• MRI Brain
• Vitamin B12 Level
• Vitamin B6 Plasma
• Vitamin B1 Whole Blood
• Treponema Pallidum Antibody IgG
• Thyroid Stimulating Hormone Reflex
• Sedimentation Rate Westergren
• Protein Electrophoresis Serum
• Glutamic Acid Decarboxylase AB
• Folate Level
• ANA Screen with AB and IFA Reflex
• Glycohemoglobin
• Lyme IgG & IgM AB Screen
• Metals Panel 1 Blood
• IFE Serum w/IgG,A,M & Kappa/Lambda Free Light Chain
• Copper, Blood
• Ceruloplasmin
• Zinc Blood
• carbidopa-levodopa (SINEMET) 25-100 MG per tablet

 

[drusso]

Update:

Saw neurology. Sort of interesting...



ASSESSMENT:
1. Segmental dystonia
2. Left leg pain
3. Difficulty walking

The patient reports onset of symptoms during the Fall of 2016. She started with pain which was evaluated by orthopedics and diagnosed as runner's knee. The pain continue with no improvement after physical therapy and the radiculopathy was suggested. She was seen by orthopedic spine who recommended some injections with no improvement of symptoms.

She sent after the diagnosis of dystonia was suggested. Patient underwent an EMG suggested the diagnosis of dystonia given the involuntary motor unit action potentials seen during the study.

Examination suggest the possibility of a dystonic left lower extremity, most compartments of the left lower extreme are affected and there is no ability to bend the knee. Patient still ambulatory.

Discussed the diagnosis of dystonia with patient. Recommended for her to undergo blood tests and an MRI of the brain. She thinks she has had an assessment of the thoracic spine but discussed with patient that if MRI of the brain is unremarkable imaging of the cervical and thoracic spine may be reasonable.

The possibility of a dopamine responsive dystonia was discussed with patient. Suggested Sinemet 25/100 starting with half a tablet 3 times a day increasing after 2 weeks to one tablet 3 times a day.

Patient will call us, medication could be increased if needed.

Patient appears to understand and agrees with recommendations. Will be happy to see her in about 2-3 months but she will calls in 4 weeks for an update. Sinemet could be increased

PLAN:
Sinemet goal dose 1 tab 3x a day
F/u in 2-3 months

Orders Placed This Encounter
• MRI Brain
• Vitamin B12 Level
• Vitamin B6 Plasma
• Vitamin B1 Whole Blood
• Treponema Pallidum Antibody IgG
• Thyroid Stimulating Hormone Reflex
• Sedimentation Rate Westergren
• Protein Electrophoresis Serum
• Glutamic Acid Decarboxylase AB
• Folate Level
• ANA Screen with AB and IFA Reflex
• Glycohemoglobin
• Lyme IgG & IgM AB Screen
• Metals Panel 1 Blood
• IFE Serum w/IgG,A,M & Kappa/Lambda Free Light Chain
• Copper, Blood
• Ceruloplasmin
• Zinc Blood
• carbidopa-levodopa (SINEMET) 25-100 MG per tablet

Wow. Pretty far down the DDX when you're ordering immunofixation and plasma ceruloplasmin levels. Could be Wilson's disease...🙂 If the cerulosplamin comes back equivocal, better send her for liver biopsy...

Or, try putting from botox into her thigh and see what happens....

 

[pastafan]

Wish I had that neurologist in my neck of the woods.

 

[lobelsteve]

Wish I had that neurologist in my neck of the woods.

Glad I don't. Spent a million dollars and highly likely no change in plan of care.

 

[willabeast]

Onset and progression of dystonia in complex regional pain syndrome. - PubMed - NCBI
Pain. 2007 Aug;130(3):287-93. Epub 2007 May 17.
Onset and progression of dystonia in complex regional pain syndrome.

 

[Orin]

Yeah, I'm not sure what value that adds except to revenue the "system" as the pre-test probability is low

I hope no incidentalomas are found

Someone should order this workup for all those athletes that develop the yips...

 

[SSdoc33]

Yeah, I'm not sure what value that adds except to revenue the "system" as the pre-test probability is low

I hope no incidentalomas are found

Someone should order this workup for all those athletes that develop the yips...

 

[Orin]

He's really the best example of it...but I still love him cuz how can you not love the round mound?

 

[Bsb2015]

Good points and discussion all. Thanks much. Informative.

This is her exam:
Blue and red discoloration
Warm
Hair loss
Diffuse swelling from mid thigh down
Poor range of motion of the ankle and cannot flex the knee more than 20°.
Diffuse dysthesthia but no allodynia
Pain with gentle palpating diffusely

I think this is the crux of basically what I am struggling with. Say I get an EMG and it confirms a radiculopathy as I suspect it would. The point is she also has CRPS on top of it. Her exam findings cannot be explained by radiculopathy alone. And she is totally normal with zero secondary gain stuff. Given this, would a surgical decompression be helpful in resolving things? Or is it not gonna even touch all these CRPS type symptoms? Could it flare her CRPS up? I guess I could always send her for decompression, at least resolve the radicular issues and only have the CRPS to deal with, see how she does, and offer her the stim afterwards...

What about ketamine infusion? If no access to this, intranasal ketamine?