"Diagnostic block with bilateral L5 root block"

[painquestions8989]

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Have a young, healthy patient from overseas who had the above procedure done in another country and wants to have it repeated. Is this a bilateral TFESI, or LMBB? Imaging attached. Symptoms include leg weakness and burning pain in the feet.

 

[callmeanesthesia]

Sounds like a bilateral L5-S1 transforaminal injection with local anesthetic only.

 

[paindoc503]

is the purpose of YOUR injection diagnostic or therapeutic?
I wouldnt do a diagnostic block just because the patient wants one. There has to be a diagnostic question.

 

[lobelsteve]

Normal mri. No injections. More history.

 

[MitchLevi]

Sounds like a bilateral L5-S1 transformational injection with local anesthetic only.

Anytime someone writes transformational I LOL. Happens on our EMR at times, where nurses write that on intake forms, etc.

 

[callmeanesthesia]

Anytime someone writes transformational I LOL. Happens on our EMR at times, where nurses write that on intake forms, etc.

Autocorrect. Fixed it.

 

[mdo1738]

Anytime someone writes transformational I LOL. Happens on our EMR at times, where nurses write that on intake forms, etc.

Back in fellowship, we got an inpatient consult for “transfemoral ESI”. Almost as good as another patient we got consulted on for inpatient management of his “intrafecal pump”.

 

[MitchLevi]

Back in fellowship, we got an inpatient consult for “transfemoral ESI”. Almost as good as another patient we got consulted on for inpatient management of his “intrafecal pump”.

No BS. Fellowship, I’m on call for acute pain. I’m at a restaurant around 730-8PM at a Nevro dinner. Not far from the hospital. Get paged on I believe a thoracic epidural s/p MVC. Can we come in and place it. I think that’s what it is…The pt is a woman they caught PUTTING FECES IN HER CENTRAL LINE!

We did not do it.

My attending was at the dinner and I’m talking to him off to the side and he goes, “This lady is f@$&ing crazy…”

 

[GoBeers]

that's a clean MRI. any EMG to suggest radic otherwise?

 

[painquestions8989]

that's a clean MRI. any EMG to suggest radic otherwise?

EMG/NCS normal.

 

[SSdoc33]

no injections, FFS.

 

[DOctorJay]

Is the axial cut you provided at L4-5? Is there more foraminal narrowing at L5-S1? Can you share that image?

Otherwise agree nothing to inject here.

 

[Orin]

Tell me about the tarlov cyst there...

 

[mygalperin]

Check for diabetes first

 

[Laryngospasm]

Half the learning curve with pain is learning when NOT to inject. So much mental illness in pain. So much searching for secondary gain, PI settlements, opioids, disability, workers comp settlements. Once you inject theses folks or give them pain medicine they are your problem now, and they are a special kind of problem that just keeps giving ..

 

[Ferdog27]

What’s that cyst on the bottom? MRI otherwise looks better than mine.

 

[painquestions8989]

What’s that cyst on the bottom? MRI otherwise looks better than mine.

Do you treat Tarlov cysts?

 

[mygalperin]

No

 

[MitchLevi]

I have always said Tarlov cysts do not cause pain, but I have a pt who I am pretty certain is symptomatic from one right now. Saw her maybe 2W ago. Has bony remodeling at S2 and S3. Pain is focal right in the glute. No radicular pain. Bone is STIR- BTW.

 

[lobelsteve]

I have always said Tarlov cysts do not cause pain, but I have a pt who I am pretty certain is symptomatic from one right now. Saw her maybe 2W ago. Has bony remodeling at S2 and S3. Pain is focal right in the glute. No radicular pain. Bone is STIR- BTW.

Mechanical back pain from Tarlov cyst.
Grand Canyon Syndrome. Eroding the bony table. I have one patient with moderate pain, but incontinence. No one here to fix it either.

 

[SSdoc33]

if it scallops out the sacrum, yeah, it can cause pain. some neurosurgeons will mess around with them. outcomes all over the map

 

[Ferdog27]

Do you treat Tarlov cysts?

If they’re pressing on a nerve root, why wouldn’t they be a pain generator?

 

[MitchLevi]

If they’re pressing on a nerve root, why wouldn’t they be a pain generator?

Simple nerve root contact is irrelevant without an inflammatory component.

 

[Ferdog27]

Simple nerve root contact is irrelevant without an inflammatory component.

Well yes….and symptomatic.

 

[MitchLevi]

Well yes….and symptomatic.

Okay, go on…What would you do about it.

 

[Ferdog27]

Okay, go on…What would you do about it.

I’d try a caudal. Or repeat what she had done. Minimal risk….possible reward….why not?

 

[MitchLevi]

I’d try a caudal. Or repeat what she had done. Minimal risk….possible reward….why not?

Sure, try it, but you haven't explained why it hurts. You're saying a Tarlov cyst is compressing a nerve root causing neurogenic edema?

 

[painquestions8989]

Or repeat what she had done.

Would you do B/L TFESI at L5-S1 or B/L LMBB?

 

[paindoc503]

Would you do B/L TFESI at L5-S1 or B/L LMBB?

it depends on her symptoms.
the only symptoms you told us was leg weakness and burning of the feet
no one on this forum (I hope) would do an MBB for those symptoms alone

 

[MitchLevi]

This is anxiety most likely. Definitely no MBB/RFA for burning in the feet, and an ESI for that complaint cannot happen with a clean MRI.

A Tarlov cyst does not cause burning in the feet.

Give 100-300mg gabadeen BID vs QHS, and that's it.

 

[Ferdog27]

Sure, try it, but you haven't explained why it hurts. You're saying a Tarlov cyst is compressing a nerve root causing neurogenic edema?

True but I’m not hands on examining the patient and doing a thorough history. I’m just going by what you’re saying. If you think she’s crazy, then definitely don’t touch her.

 

[Ducttape]

part of your evaluation is supposed to be a physical examination and a thorough history, even if it is rudimentary.

unless you do not plan on billing for the appointment.


if a male physician, you really need to have a female chaperone in the room with you when doing the initial physical examination.

one can argue that even a female physician should have a chaperone...