Discogenic lbp

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SSdoc33 said:
you should be asking "why", rather than "why not"

casting a spell is also harmless
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What is the problem with trying an ESI if your pt is miserable and has already tried all the normal conservative measures?
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lobelsteve said:
As good as casting a spell....
I believe PSL works as well.
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I got it the first time. I still don't see a problem with it personally. If I am the pt and I'm miserable I would want to try it.
 
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SommeRiver said:
I got it the first time. I still don't see a problem with it personally. If I am the pt and I'm miserable I would want to try it.
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my office will no longer supply me with "eye of newt", so i am officially out of the magic game.

i suppose if there is a clear annular tear and the injury is relatively acute, you could put out the fire with a little cortisone. it is just not a great treatment option.
 
If surgery, stem cells, and scs offer little in the way of relief


get rid of the "If" part of your statement and repeat that phrase at least 1000 times.

then have the patient do it at least 10 fold.
 
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SSdoc33 said:
my office will no longer supply me with "eye of newt", so i am officially out of the magic game.

i suppose if there is a clear annular tear and the injury is relatively acute, you could put out the fire with a little cortisone. it is just not a great treatment option.
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Okay, so you too do it...
 
lobelsteve said:
Who doesn't love the PSL?
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Yeah it's a great time.

Edit - What is a PSL, and why did you bring it up? You talking about the sciatic nerve ligation?
 
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The placebo response is strong, so I'm not above an inexpensive and relatively safe placebo.

A little steroid rush timed with aggressive PT may help.
Stimulation of whatever flavor may help.
Surgery may help.

I can't say any of them make sense, but the only one with face validity is surgery, which is irreversible and carries risks of worsening pain/function in the long term.
 
SommeRiver said:
What is the problem with trying an ESI if your pt is miserable and has already tried all the normal conservative measures?
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I would likely try it - so I am fully admitting I am being a hypocrite here...

But there are several issues with "trying" it.

This patient needs to learn that to master his painful condition - to "manage" this chronic pain problem, it has very little, if anything to do with nociceptive input, and everything to do with the emotional and cognitive arm of pain management.

By agreeing to stick a needle in his back, you are validating (very powerfully I might add) to this patient that he has a serious problem that requires medical intervention. You will validate that he is broken and can or should be repaired with some intervention that the hallowed halls of medicine can provide.

Once this thought process sets, it is extremely difficult to change.

We MAKE sick patients by trying to make them better.
 
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epidural man said:
I would likely try it - so I am fully admitting I am being a hypocrite here...

But there are several issues with "trying" it.

This patient needs to learn that to master his painful condition - to "manage" this chronic pain problem, it has very little, if anything to do with nociceptive input, and everything to do with the emotional and cognitive arm of pain management.

By agreeing to stick a needle in his back, you are validating (very powerfully I might add) to this patient that he has a serious problem that requires medical intervention. You will validate that he is broken and can or should be repaired with some intervention that the hallowed halls of medicine can provide.

Once this thought process sets, it is extremely difficult to change.

We MAKE sick patients by trying to make them better.
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Good post, but I am very upfront with pts about this, and I set low expectations. I tell ppl I have no clue if the shot will help, sometimes it does, but it isn't the cure they're looking for. The epidural may help make PT easier, etc.

Definitely not a curative treatment.
 
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epidural man said:
I would likely try it - so I am fully admitting I am being a hypocrite here...

But there are several issues with "trying" it.

This patient needs to learn that to master his painful condition - to "manage" this chronic pain problem, it has very little, if anything to do with nociceptive input, and everything to do with the emotional and cognitive arm of pain management.

By agreeing to stick a needle in his back, you are validating (very powerfully I might add) to this patient that he has a serious problem that requires medical intervention. You will validate that he is broken and can or should be repaired with some intervention that the hallowed halls of medicine can provide.

Once this thought process sets, it is extremely difficult to change.

We MAKE sick patients by trying to make them better.
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This.

I see patients all day long that are sent to me by clinicians who are not nearly as thoughtful as @epidural man. Trying to help them out of the mindset he describes is an uphill battle.
 
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SommeRiver said:
Good post, but I am very upfront with pts about this, and I set low expectations. I tell ppl I have no clue if the shot will help, sometimes it does, but it isn't the cure they're looking for. The epidural may help make PT easier, etc.

Definitely not a curative treatment.
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I treated a young lady recently with axial low back pain with right-sided dominance, no radicular symptoms, concordant with ONLY MRI finding showing L4-L5 annular tear. Did SIJ injection first, relieved some degree. Provided thorough discussion and expectation management about LTESI in treating discogenic pain. She then consulted another pain physician in the area (she is an attorney) who recommended the same procedure.

I did the procedure 2 months ago. She is doing very well. Pain pretty much all gone.

Not everyone with annular tear is this lucky.

If I was the patient, I would try it with reasonable understanding and expectation.
 
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there is a good chance that this is either steroid or placebo effect.

unfortunately, i personally struggle with this concept: have you set her up for a lifelong pursuit of some medical/surgical intervention to relieve pain that she essentially self-relieved in her own mind? after all, when you do a subsequent injection and it doesnt work, will she then search endlessly until she finds a surgeon willing to operate (ie Laser Spine)? if she were 80 with no reasonable expectation of surgery, then yes.... in her 20s? not so much...
 
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Ducttape said:
there is a good chance that this is either steroid or placebo effect.

unfortunately, i personally struggle with this concept: have you set her up for a lifelong pursuit of some medical/surgical intervention to relieve pain that she essentially self-relieved in her own mind? after all, when you do a subsequent injection and it doesnt work, will she then search endlessly until she finds a surgeon willing to operate (ie Laser Spine)? if she were 80 with no reasonable expectation of surgery, then yes.... in her 20s? not so much...
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I understand your reluctance and I understand your concern but this is why you carefully choose your pts to whom you inject.
 
Ducttape said:
there is a good chance that this is either steroid or placebo effect.

unfortunately, i personally struggle with this concept: have you set her up for a lifelong pursuit of some medical/surgical intervention to relieve pain that she essentially self-relieved in her own mind? after all, when you do a subsequent injection and it doesnt work, will she then search endlessly until she finds a surgeon willing to operate (ie Laser Spine)? if she were 80 with no reasonable expectation of surgery, then yes.... in her 20s? not so much...
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first of all, as a patient myself with discogenic lower back from annular tear, I can tell you this, discogenic LBP from annular tear, if it's symptomatic, it's not SELF-RELIEVING (did I tell you I bought decompression table to be used on myself?)

with respect to your point about searching the "fix", what we can do a as physician is to try to manage their expectation and provide the best to our knowledge and skill within ethical, moral and legal boundary. At the end of day, patients will make up their decision. Hopefully, they will gain good insight to their problem, and trust what you are telling them about risk, benefit, alternative of surgical procedures. You do the best of you can, but you shouldn't hold back something potentially could work, simply because the patient has no insight or unreasonable expectation. It's our job to educate these patients and empower them with insight and manage their expectation.

On the other hand, if I see someone who has poor insight and unreasonable expectation, despite of my thorough discussion, I would hold off doing injections.

I tell my patients I don't offer an injection to a patient until 1) he/she are comfortable with me (I meant, literally, do you feel comfortable for me to stick 6 needles into your spine?), and 2) until I feel comfortable with the patient that I feel they understand their condition and have reasonable expectation.
 
lobelsteve said:
I wouldnt let anyone do that on my mom.
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But do you even like your mom?

699efdde9f73d55279702b3ea34f3e22.jpg
 
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lobelsteve said:
Heresy. Non science.
Tincture of time and theatric placebo.
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So when someone is miserable and sees you every month for 9 months you just keep telling them to take Mobic and do PT? What are you doing for these pts?
 
SommeRiver said:
So when someone is miserable and sees you every month for 9 months you just keep telling them to take Mobic and do PT? What are you doing for these pts?
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Mobic is in a class of drug that kills 10k plus per year with 31% increased risk of MI at end of month of taking, increase CA risk, GI bleed risk.
Self directed exercises, acceptance. There are a lot of pain guys around me happy to inject these folks. They get better, deal with it, or go to someone else. I have 37 slots on my schedule MTRF and 21 slots on Wed AM. New pts get 2 slots as do RFs. SCS trial gets scheduled at 3 to end the day (3-5 per month max).

If a patient disagrees with my care, they can go elsewhere, but I do not need to compromise my ideals and the science to make a patient happy or validate their pain for profit. My team has a list of patients who can come in within 30 min if we get a cx slot. I believe my community appreciates what I am doing because my wRVU is high and folks keep coming to see me.
 
lobelsteve said:
Mobic is in a class of drug that kills 10k plus per year with 31% increased risk of MI at end of month of taking, increase CA risk, GI bleed risk.
Self directed exercises, acceptance. There are a lot of pain guys around me happy to inject these folks. They get better, deal with it, or go to someone else. I have 37 slots on my schedule MTRF and 21 slots on Wed AM. New pts get 2 slots as do RFs. SCS trial gets scheduled at 3 to end the day (3-5 per month max).

If a patient disagrees with my care, they can go elsewhere, but I do not need to compromise my ideals and the science to make a patient happy or validate their pain for profit. My team has a list of patients who can come in within 30 min if we get a cx slot. I believe my community appreciates what I am doing because my wRVU is high and folks keep coming to see me.
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Thank you for the education on Mobic, but what percentage of young adults (bc that is who gets discogenic pain) are having MI, GI bleed, etc within one month of taking it? I don't see that in young adults...at all...If someone comes to see you and they have discogenic pain you don't give NSAIDS, but what about any other meds? Do you give Robaxin or anything? I just don't see how a pt comes to see you and you tell them to do a HEP and if they don't get better too bad and go see another MD if they don't like it.

Also it is total BS to accuse me, or anyone else who offers an ESI for discogenic pain, of being out for profit bc we will try the injxn for someone who's miserable.

Pain physicians talk more BS about their colleagues than any other field in medicine.
 
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SommeRiver said:
Thank you for the education on Mobic, but what percentage of young adults (bc that is who gets discogenic pain) are having MI, GI bleed, etc within one month of taking it? I don't see that in young adults...at all...If someone comes to see you and they have discogenic pain you don't give NSAIDS, but what about any other meds? Do you give Robaxin or anything? I just don't see how a pt comes to see you and you tell them to do a HEP and if they don't get better too bad and go see another MD if they don't like it.

Also it is total BS to accuse me, or anyone else who offers an ESI for discogenic pain, of being out for profit bc we will try the injxn for someone who's miserable.

Pain physicians talk more BS about their colleagues than any other field in medicine.
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I'm happy to talk bad about you if you base care on nonscience. I like SMRs and APAP. NSAIDs are fine if 3 days per week. I don't see a lot of young folks.

Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data
https://www.snopes.com/news/2018/04/24/nsaids-and-heart-attack-or-stroke/
Common painkillers linked to increased heart risks, new study finds

Gave you the popular references which link to the journals.
Start with ACC Circulation J June 2010.

You can do whatever you like in your practice, and if your patient came to me after you gacve them ESI for axial LBP, I would share with them the literature that suggests it is not better than theatrical placebo for profit. I make a joke over you maybe having a boat payment...Then I tell them we have little to offer other than GRC that is experimental, and maybe in the future we can drill holes in the bones and cauterize the nerves inside the bones. I whip out my 10G kypho needle and model and show them why it is better to exercise and deal wit hit then have someone experiment on them. Technology does not currently offer a cure for discogenic LBP.
 
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I see a good bit of young adults with discogenic pain, and if they have an annular tear a TFESI is not unreasonable if that pt has tried conservative measures first, and nothing is helping. I work in a large ortho practice and I bet I see young adults that meet these criteria a several times per week.

I've never seen a young adult have an MI from Mobic, or Duexis, or Aleve. I don't even know anyone who has seen that bc I'm sure I'd have heard about it.

I kills me when I say something about NSAIDs, which for a young and medically healthy adult is perfectly reasonable in limited quantity, the very first thing you do is intimate that you don't prescribe it, but then admit it isn't a big deal in limited quantity when you surely know my initial mentioning Mobic was in such a way that reasonable use was implied!

Edit - Let's be clear too, just like I said earlier, no one is saying anything about CURING anything.
 
drpainfree said:
first of all, as a patient myself with discogenic lower back from annular tear, I can tell you this, discogenic LBP from annular tear, if it's symptomatic, it's not SELF-RELIEVING (did I tell you I bought decompression table to be used on myself?)

with respect to your point about searching the "fix", what we can do a as physician is to try to manage their expectation and provide the best to our knowledge and skill within ethical, moral and legal boundary. At the end of day, patients will make up their decision. Hopefully, they will gain good insight to their problem, and trust what you are telling them about risk, benefit, alternative of surgical procedures. You do the best of you can, but you shouldn't hold back something potentially could work, simply because the patient has no insight or unreasonable expectation. It's our job to educate these patients and empower them with insight and manage their expectation.

On the other hand, if I see someone who has poor insight and unreasonable expectation, despite of my thorough discussion, I would hold off doing injections.

I tell my patients I don't offer an injection to a patient until 1) he/she are comfortable with me (I meant, literally, do you feel comfortable for me to stick 6 needles into your spine?), and 2) until I feel comfortable with the patient that I feel they understand their condition and have reasonable expectation.
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The problem is, that is not what the patient hears. Much like “well, this drug has side effects but we will try for a week”. That ultimately translate s to “I was on percs (thrn oxys) for 20 years and never had a problem!”

You are not responsible for providing a treatment that in your best medical judgement is not beneficial and will be harmful in the future.

In effect, you are advocating for moo shu medicine, because “it might help”. Chiropractic, acupuncture, massage, reflexology are as likely to provide benefit long term as your injection, but the risks of following down an intervention based pathway are much greater in the long run.

And somme, unfortunately you have bought in to the thought that medicine is going to make someone better. There are just some diseases for which there is no good medical treatment without great risk - ie aging, dementia, primary hypertension, end stage renal disease, metastatic cancer especially abdominal, etc. your focus on giving them something goes hand in hand with your thought that pain psychology is never helpful...

What is wrong with telling patients the truth - you have a chronic condition not conducive to any medical interventions?
 
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I tell ppl daily that they have a problem for which there is no cure. I most certainly have seen pts with discogenic pain that have gotten relief from ESI, or I wouldn't do it. The pain psych thing is based off of repeated failures witnessed first hand at the highest level of pain psych exposure in the USA. That plus I don't have any local options for it that haven't exploded in my face.
 
Ducttape said:
What is wrong with telling patients the truth - you have a chronic condition not conducive to any medical interventions?
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I confess that I struggle with this. I will offer patients with discogenic low back pain a "Hail-Mary" ESI but only has a palliative intervention if they've stalled in their PT or rehab. I think it's important to keep these patients engaged because I've seen them end up in the surgeon's office with the story, "Everyone has given up on me..." They're easy pickings for a fusion-happy surgeon.
 
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drusso said:
I confess that I struggle with this. I will offer patients with discogenic low back pain a "Hail-Mary" ESI but only has a palliative intervention if they've stalled in their PT or rehab. I think it's important to keep these patients engaged because I've seen them end up in the surgeon's office with the story, "Everyone has given up on me..." They're easy pickings for a fusion-happy surgeon.
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Pre stim pts for drpain and somme
 
drusso said:
I confess that I struggle with this. I will offer patients with discogenic low back pain a "Hail-Mary" ESI but only has a palliative intervention if they've stalled in their PT or rehab. I think it's important to keep these patients engaged because I've seen them end up in the surgeon's office with the story, "Everyone has given up on me..." They're easy pickings for a fusion-happy surgeon.
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This is exactly what I'm talking about, and God forbid someone undergo spine surgery at 28 yo.
 
Ducttape said:
The problem is, that is not what the patient hears. Much like “well, this drug has side effects but we will try for a week”. That ultimately translate s to “I was on percs (thrn oxys) for 20 years and never had a problem!”

You are not responsible for providing a treatment that in your best medical judgement is not beneficial and will be harmful in the future.

In effect, you are advocating for moo shu medicine, because “it might help”. Chiropractic, acupuncture, massage, reflexology are as likely to provide benefit long term as your injection, but the risks of following down an intervention based pathway are much greater in the long run.

And somme, unfortunately you have bought in to the thought that medicine is going to make someone better. There are just some diseases for which there is no good medical treatment without great risk - ie aging, dementia, primary hypertension, end stage renal disease, metastatic cancer especially abdominal, etc. your focus on giving them something goes hand in hand with your thought that pain psychology is never helpful...

What is wrong with telling patients the truth - you have a chronic condition not conducive to any medical interventions?
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while I agree with you and have always advocated "co-existence with your aging process", however, I do not believe so-called "moo shu" medicine. it's the kinda arrogance we have in western medicine (really, in this country) to think anything outside allopathic medicine is just that. Yes, there are unethical practitioners in these fields, but you just don't know what you don't know.
 
I have been treating a 39 year old patient who's not been receiving objective care. He has severe pain in the morning as soon as he opens his eyes and wakes up. He rolls in bed from supine to left and right, tossing and turning all night long. Tempurpedic mattress. He pushes off his knees to get out of bed and braces against his knees/thighs every time he bends to pick something up. He grabs toilet tissue to blow his nose in the morning by turning/bending sideways because although it hurts as well, bending forwards to 20-30 degrees is incredibly painful. He has an incredibly hard time tying his shoe laces due to severe pain with that flexion. He can't pick up his 3 month old baby. He can't wash dishes or do any lifting at all in front of his body. He lifts things by keeping his spine perfectly upright and bending awkwardly at the knees and hips, grabbing the item close, and standing. He's had pain since he was 20 from basketball, etc, but that was standard pain which clinically presents like facet joint pain which improved with warming up, and really did not limit him at all, just caused some aching 5/10 pain in the morning and the day after significant physical activity like a basketball game. But things changed with no clear inciting event around Jan 2018. He has pain on exam over the lower lumbar facets and pain on extension as well as flexion of course. It is a typically dull and aching, but sometimes stabbing and sharp pain that is axial. He's sick of NSAIDs and Tylenol. He tried other herbal remedies to no avail. MRI shows large protrusions measuring 5mm at L4-5 and 3mm at L5-S1 with nerve root effacement but no radicular symptoms whatsoever in this patient. STIR sequence lights up the endplates and disc at the L4-5 level. He has moderate facet arthropathy L3-S1. He is afraid to sneeze or cough because there is sharp stabbing horrible pain with a sneeze or cough, especially if he's seated or has any rounding of his back at all. The flexion pain is worse than the extension pain. Otherwise he can sit in a chair all day and do his work, with a few adjustments in his chair and get by. It's just at times the pain is so severe, and has gone on for so long he has gone past desperate and kind of given up. He's tried a fair bit of physical therapy on his own including bird dogs, back extensions and other isometric contraction movements for the lumbar spine without significant progress. He's tried yoga but those positions are too painful to get into. Pilates does not hurt but progress is very slow if at all.
I believe it's discogenic pain primarily that's acutely worsened his state, with a background of facet joint pain. He received an interlaminar ESI which only helped for a day or two. He received L4-L5 and L5-S1 mbb injections with 0.5ml of 0.75% bupi which did help 40-50% he thinks, and that lasted about 3 days. SIJ injections were not helpful at all. He used to avidly exercise but no longer does much. Do you guys agree this is discogenic LBP and he's gotta wait it out for 5-10 years and see if it gets better with more of what he's sort of doing (continues to try HEP stuff as tolerated). Should he proceed with the second MBB and RFA and if it doesn't help potentially completely lose hope? He thinks he understands pain management and is probably not a good patient for that reason. I know it doesn't seem that difficult a case at all. But what would you do if you were him? What would you advise him? (And yep, I am the patient.)
 
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This is an interesting question. What's y'alls thoughts on the role of the multifidus' muscle for discogenic pain? I generally say they are probably critical to helping recovery, and so I try to avoid RFAs of those with primarily discogenic pain in lieu of PT/etc. I'm looking forward to what the multifidus motor stim trials show in terms of help for that.
 
Orin said:
This is an interesting question. What's y'alls thoughts on the role of the multifidus' muscle for discogenic pain? I generally say they are probably critical to helping recovery, and so I try to avoid RFAs of those with primarily discogenic pain in lieu of PT/etc. I'm looking forward to what the multifidus motor stim trials show in terms of help for that.
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My fellowship institution was a site for Mainstay. It wasn’t specifically targeted to discogenic, but makes good sense for it. I didn’t see the data but heard second hand that it was quite favorable. Implant is simple, a little like a conventional stim but the leads lay across the medial branch nerves, one on each side (I think it was at the L4 level).
 
Papa Lou said:
I have been treating a 39 year old patient who's not been receiving objective care. He has severe pain in the morning as soon as he opens his eyes and wakes up. He rolls in bed from supine to left and right, tossing and turning all night long. Tempurpedic mattress. He pushes off his knees to get out of bed and braces against his knees/thighs every time he bends to pick something up. He grabs toilet tissue to blow his nose in the morning by turning/bending sideways because although it hurts as well, bending forwards to 20-30 degrees is incredibly painful. He has an incredibly hard time tying his shoe laces due to severe pain with that flexion. He can't pick up his 3 month old baby. He can't wash dishes or do any lifting at all in front of his body. He lifts things by keeping his spine perfectly upright and bending awkwardly at the knees and hips, grabbing the item close, and standing. He's had pain since he was 20 from basketball, etc, but that was standard pain which clinically presents like facet joint pain which improved with warming up, and really did not limit him at all, just caused some aching 5/10 pain in the morning and the day after significant physical activity like a basketball game. But things changed with no clear inciting event around Jan 2018. He has pain on exam over the lower lumbar facets and pain on extension as well as flexion of course. It is a typically dull and aching, but sometimes stabbing and sharp pain that is axial. He's sick of NSAIDs and Tylenol. He tried other herbal remedies to no avail. MRI shows large protrusions measuring 5mm at L4-5 and 3mm at L5-S1 with nerve root effacement but no radicular symptoms whatsoever in this patient. STIR sequence lights up the endplates and disc at the L4-5 level. He has moderate facet arthropathy L3-S1. He is afraid to sneeze or cough because there is sharp stabbing horrible pain with a sneeze or cough, especially if he's seated or has any rounding of his back at all. The flexion pain is worse than the extension pain. Otherwise he can sit in a chair all day and do his work, with a few adjustments in his chair and get by. It's just at times the pain is so severe, and has gone on for so long he has gone past desperate and kind of given up. He's tried a fair bit of physical therapy on his own including bird dogs, back extensions and other isometric contraction movements for the lumbar spine without significant progress. He's tried yoga but those positions are too painful to get into. Pilates does not hurt but progress is very slow if at all.
I believe it's discogenic pain primarily that's acutely worsened his state, with a background of facet joint pain. He received an interlaminar ESI which only helped for a day or two. He received L4-L5 and L5-S1 mbb injections with 0.5ml of 0.75% bupi which did help 40-50% he thinks, and that lasted about 3 days. SIJ injections were not helpful at all. He used to avidly exercise but no longer does much. Do you guys agree this is discogenic LBP and he's gotta wait it out for 5-10 years and see if it gets better with more of what he's sort of doing (continues to try HEP stuff as tolerated). Should he proceed with the second MBB and RFA and if it doesn't help potentially completely lose hope? He thinks he understands pain management and is probably not a good patient for that reason. I know it doesn't seem that difficult a case at all. But what would you do if you were him? What would you advise him? (And yep, I am the patient.)
Click to expand...
Has he (you) been checked for ankylosing spondylitis or any of the other spondyloarthropathies? The morning stiffness and pain is a bit concerning
 
Papa Lou said:
I have been treating a 39 year old patient who's not been receiving objective care. He has severe pain in the morning as soon as he opens his eyes and wakes up. He rolls in bed from supine to left and right, tossing and turning all night long. Tempurpedic mattress. He pushes off his knees to get out of bed and braces against his knees/thighs every time he bends to pick something up. He grabs toilet tissue to blow his nose in the morning by turning/bending sideways because although it hurts as well, bending forwards to 20-30 degrees is incredibly painful. He has an incredibly hard time tying his shoe laces due to severe pain with that flexion. He can't pick up his 3 month old baby. He can't wash dishes or do any lifting at all in front of his body. He lifts things by keeping his spine perfectly upright and bending awkwardly at the knees and hips, grabbing the item close, and standing. He's had pain since he was 20 from basketball, etc, but that was standard pain which clinically presents like facet joint pain which improved with warming up, and really did not limit him at all, just caused some aching 5/10 pain in the morning and the day after significant physical activity like a basketball game. But things changed with no clear inciting event around Jan 2018. He has pain on exam over the lower lumbar facets and pain on extension as well as flexion of course. It is a typically dull and aching, but sometimes stabbing and sharp pain that is axial. He's sick of NSAIDs and Tylenol. He tried other herbal remedies to no avail. MRI shows large protrusions measuring 5mm at L4-5 and 3mm at L5-S1 with nerve root effacement but no radicular symptoms whatsoever in this patient. STIR sequence lights up the endplates and disc at the L4-5 level. He has moderate facet arthropathy L3-S1. He is afraid to sneeze or cough because there is sharp stabbing horrible pain with a sneeze or cough, especially if he's seated or has any rounding of his back at all. The flexion pain is worse than the extension pain. Otherwise he can sit in a chair all day and do his work, with a few adjustments in his chair and get by. It's just at times the pain is so severe, and has gone on for so long he has gone past desperate and kind of given up. He's tried a fair bit of physical therapy on his own including bird dogs, back extensions and other isometric contraction movements for the lumbar spine without significant progress. He's tried yoga but those positions are too painful to get into. Pilates does not hurt but progress is very slow if at all.
I believe it's discogenic pain primarily that's acutely worsened his state, with a background of facet joint pain. He received an interlaminar ESI which only helped for a day or two. He received L4-L5 and L5-S1 mbb injections with 0.5ml of 0.75% bupi which did help 40-50% he thinks, and that lasted about 3 days. SIJ injections were not helpful at all. He used to avidly exercise but no longer does much. Do you guys agree this is discogenic LBP and he's gotta wait it out for 5-10 years and see if it gets better with more of what he's sort of doing (continues to try HEP stuff as tolerated). Should he proceed with the second MBB and RFA and if it doesn't help potentially completely lose hope? He thinks he understands pain management and is probably not a good patient for that reason. I know it doesn't seem that difficult a case at all. But what would you do if you were him? What would you advise him? (And yep, I am the patient.)
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It was reasonable to rule out other pain generators and undergo facet/SIJ injections but this is clearly discogenic pain. Agree you can try to wait another 5-10 years and hope it goes away as your discs stiffen, but if you're losing patience.....

Procedure options
1- caudal ESI with depo actually reaches the central anterior disc unlike any other ESI. However, given your twenty year history, ESI is unlikely to eliminate all your pain, but I have treated a number of patients with caudal esi with depo that obtained sustained 50% relief, and these were patients who failed other ESI. I have treated patients with annular tears who obtained >90% sustained relief. Obviously not everyone responds to this, but low risk option to consider.
2-Intradiscal PRP- cash obviously and no guarantee, but worth considering
3- nevro SCS trial

Medication options
1- You mentioned nsaids and tylenol. Have you not been on tramadol? Definitely worth a try.
2- I'm sure we all agree that traditional opiods are a bad idea for discogenic LBP and a rabbit hole you don't want to go down, but if you fail everything else above, a butrans patch is a reasonable option.
 
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bedrock said:
It was reasonable to rule out other pain generators and undergo facet/SIJ injections but this is clearly discogenic pain. Agree you can try to wait another 5-10 years and hope it goes away as your discs stiffen, but if you're losing patience.....

Procedure options
1- caudal ESI with depo actually reaches the central anterior disc unlike any other ESI. However, given your twenty year history, ESI is unlikely to eliminate all your pain, but I have treated a number of patients with caudal esi with depo that obtained sustained 50% relief, and these were patients who failed other ESI. I have treated patients with annular tears who obtained >90% sustained relief. Obviously not everyone responds to this, but low risk option to consider.
2-Intradiscal PRP- cash obviously and no guarantee, but worth considering
3- nevro SCS trial

Medication options
1- You mentioned nsaids and tylenol. Have you not been on tramadol? Definitely worth a try.
2- I'm sure we all agree that traditional opiods are a bad idea for discogenic LBP and a rabbit hole you don't want to go down, but if you fail everything else above, a butrans patch is a reasonable option.
Click to expand...
Oh the backlash you will get on this forum for procedure option number 2..I can see it already..”snake oil” etc etc
 
technically, all 3 of those do not have clinical evidence to support their routine use. if he, as an educated consumer, wants to find an interventionalist and pay out of pocket for such treatments, that is on the patient, but these are not treatments that we as a specialty should be recommending or advocating without clinical evidence. yes, for the general populace, it is snake oil

back to the thread:
SNRI?

how long ago was the MRI? thnk about a repeat MRI or a SPECT scan?

have you had any imaging for possible instability?

id repeat MBB at least...
 
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Papa Lou said:
I have been treating a 39 year old patient who's not been receiving objective care. He has severe pain in the morning as soon as he opens his eyes and wakes up. He rolls in bed from supine to left and right, tossing and turning all night long. Tempurpedic mattress. He pushes off his knees to get out of bed and braces against his knees/thighs every time he bends to pick something up. He grabs toilet tissue to blow his nose in the morning by turning/bending sideways because although it hurts as well, bending forwards to 20-30 degrees is incredibly painful. He has an incredibly hard time tying his shoe laces due to severe pain with that flexion. He can't pick up his 3 month old baby. He can't wash dishes or do any lifting at all in front of his body. He lifts things by keeping his spine perfectly upright and bending awkwardly at the knees and hips, grabbing the item close, and standing. He's had pain since he was 20 from basketball, etc, but that was standard pain which clinically presents like facet joint pain which improved with warming up, and really did not limit him at all, just caused some aching 5/10 pain in the morning and the day after significant physical activity like a basketball game. But things changed with no clear inciting event around Jan 2018. He has pain on exam over the lower lumbar facets and pain on extension as well as flexion of course. It is a typically dull and aching, but sometimes stabbing and sharp pain that is axial. He's sick of NSAIDs and Tylenol. He tried other herbal remedies to no avail. MRI shows large protrusions measuring 5mm at L4-5 and 3mm at L5-S1 with nerve root effacement but no radicular symptoms whatsoever in this patient. STIR sequence lights up the endplates and disc at the L4-5 level. He has moderate facet arthropathy L3-S1. He is afraid to sneeze or cough because there is sharp stabbing horrible pain with a sneeze or cough, especially if he's seated or has any rounding of his back at all. The flexion pain is worse than the extension pain. Otherwise he can sit in a chair all day and do his work, with a few adjustments in his chair and get by. It's just at times the pain is so severe, and has gone on for so long he has gone past desperate and kind of given up. He's tried a fair bit of physical therapy on his own including bird dogs, back extensions and other isometric contraction movements for the lumbar spine without significant progress. He's tried yoga but those positions are too painful to get into. Pilates does not hurt but progress is very slow if at all.
I believe it's discogenic pain primarily that's acutely worsened his state, with a background of facet joint pain. He received an interlaminar ESI which only helped for a day or two. He received L4-L5 and L5-S1 mbb injections with 0.5ml of 0.75% bupi which did help 40-50% he thinks, and that lasted about 3 days. SIJ injections were not helpful at all. He used to avidly exercise but no longer does much. Do you guys agree this is discogenic LBP and he's gotta wait it out for 5-10 years and see if it gets better with more of what he's sort of doing (continues to try HEP stuff as tolerated). Should he proceed with the second MBB and RFA and if it doesn't help potentially completely lose hope? He thinks he understands pain management and is probably not a good patient for that reason. I know it doesn't seem that difficult a case at all. But what would you do if you were him? What would you advise him? (And yep, I am the patient.)
Click to expand...

You have tried PRN back brace, voltaren gel, TENS? I would trust myself with 15 norco 5's a month too personally. ES Tylenol TID PRN with one half to one tab of norco for the bad breakthrough days.

And I mean this in the most collegial and respectful way possible, because we all have our issues and baggage. I know I do. But have you really introspected about stress, anxiety or depression in your life? We all know the way these things can transform the experience of chronic pain. Maybe take a short weekend in the outdoors away from the family and try and slow down and honestly journal. Your marriage possibly, kids, or work? Are you making constructive changes to work on your relationships if there are issues there? Or working less/modifing your work environment if it is overwhelming? Are you doing things that you genuinely enjoy and taking time to recharge yourself? Do you have a church you are connected to and you could chat with the pastor/priest if needed?

If all that wasnt cutting it, and If I were you, and your pain was this severe and causing this much functional limitation...
HF10 with perm perc leads

See attached

Best wishes
 

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  • Axial pain%2c virgin back%2c SCS study.pdf
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Repeat the MBB IMO, and I forgot to add an ESI sometimes helps in my experience. I don't agree with SCS for discogenic LBP, but I also wouldn't accuse a provider of malpractice for trying it.
 
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good so see there is such a concesus from all of us "experts"

this is disc pain. dont MBB again because RF wont help and could theoretically be harmful at your age. its not the facets

i find it hard to swallow that some here actually advocate to put a stimulator in you

i guess you could get a epidural when you are in agony, but we both know it wont do anything in the long run.

you need to be as active as your body lets you. try to find a cardio exercise that is do-able. swimming, running, etc that you do on a regular basis. you will sleep better and these are actually good core exercises.

agree with timeout's comments as well.

this is a hard diagnosis to treat. no doubt about it. wear a light lead.

i would have a tough time paying 5K for "stem cells" A. because i think it is a bogus treatment and B. because I am cheap
 
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Not sure advocating high impact activity consistently like running is good for any chronic spine condition. This patient will turn his non facet pain into facet pain by doing that
 
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