ESI for weakness?

[knoxdoc]

Has anyone tried doing an ESI primarily for radicular weakness? I have a 50 y/o F with a 3 month h/o L L5 radicular symptoms. Her back pain has nearly resolved and no radiating pains now. Her only complaint is ankle weakness. She has 4/5 strength of left ankle DF, invertors, evertors, and EHL. EMG consistent with a subacute L L5 radic (1+ fibs in TA and TP). MRI shows diffuse disc bulge at L4/5 and a small, central HNP at L5/1. No mechanical impingement. Presentation seems out of proportion to MRI findings, but pain is not an issue.

Would anyone try a TFESI in addition to PT?

Any studies on ESI for weakness?

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[PMR 4 MSK]

My anecdotal experience shows that ESI works well on pain for about 70% of those injected, but that weakness and numbness take a lot longer to respond to it. Pain relief is often fast - 2-3 days, but relief of weakness can take much longer.

Since we still haven't proved ESI works for pain D) it would be much harder to prove a link to something that is far less common and likely takes longer between injection and response.

 

[lobelsteve]

Has anyone tried doing an ESI primarily for radicular weakness? I have a 50 y/o F with a 3 month h/o L L5 radicular symptoms. Her back pain has nearly resolved and no radiating pains now. Her only complaint is ankle weakness. She has 4/5 strength of left ankle DF, invertors, evertors, and EHL. EMG consistent with a subacute L L5 radic (1+ fibs in TA and TP). MRI shows diffuse disc bulge at L4/5 and a small, central HNP at L5/1. No mechanical impingement. Presentation seems out of proportion to MRI findings, but pain is not an issue.

Would anyone try a TFESI in addition to PT?

Any studies on ESI for weakness?

I would not. And if reviewing for insurance, I would not pay you.

 

[SSdoc33]

ive seen a bunch of these patients -- clear cut radic but no pain. i cant fathom a reason why an injection would help their weakness. i have typically told this to patients and they decided to forego the injection. if you do it, let us know what happens. id be surprised if all of a sudden, he/she can dorsiflex better

 

[mdvol]

If there is true axonal damage causing the weakness which is what you will see on the needle EMG then an injection of steroid across the nerve root will not cause the axons to re-appear. Given time, there can be sprouting of nerve fibers from one motor unit to innervate other muscle fibers and you will see larger amplitude PSW and also polyphasic motor units.

I see some weakness return really fast (along with pain relief) and wonder if the weakness was just movement limited by pain on exam.

 

[Pain_doc]

I tell the patients the injection is good for radicular pain. I agree with the above, that sometimes "weakness" is more related to effort and does improve after the pain improves. It seems as though your patient has no pain, so unlikely an esi would help.

 

[Tenesma]

don't do ESI for weakness... if there is no pain...

you would be a fool in my book.

 

[knoxdoc]

don't do ESI for weakness... if there is no pain...

you would be a fool in my book.

It would be dumb to inject lidocaine around a nerve root and expect weakness to resolve. Corticosteroids are not anesthetic medications, so why do they work for pain? Is it by reducing inflammation around a nerve root? Can it be that inflammatory changes are affecting the sensory fibers, leading to radicular pain? Who is to say that there is not an inflammatory process contributing to interruption of the motor fibers, even in the presence of known axonal damage?

I am not advocating ESIs for radicular weakness, but I'd like to hear your rationale for avoiding such foolishness.

 

[Tenesma]

because i have proved my own foolishness in the past by attempting this.

i haven't see true neurologic weakness recover with ESIs.... in fact, in patients who have surgical decompression, it takes 2-6 months for the strength to come back.

in patients without pain, i just focus on rehab/rehab/rehab... and let the body heal itself.

 

[knoxdoc]

because i have proved my own foolishness in the past by attempting this.

i haven't see true neurologic weakness recover with ESIs.... in fact, in patients who have surgical decompression, it takes 2-6 months for the strength to come back.

in patients without pain, i just focus on rehab/rehab/rehab... and let the body heal itself.

I'll buy that, anecdotally I have seen the same outcomes. Its just a little weird to have dense L5 weakness and no root compression on MRI. If I saw compression I would send her straight to surgery, but I'm just stuck with trying conservative tx for now. I may consider a CT myelogram if this doesn't get better.

 

[Tenesma]

i missed part about MRI looking underwhelming - i would be perplexed too...

i had one patient with IDENTICAL presentation, but on the low axials there was a mass on the descending nerve root... ended up being lymphoma (also had significant retroperitoneal lymphadenopathy)... gradually w/ lymphoma treatment, the weakness improved.... i would suggest getting a Sacral MRI and follow that nerve root closely.

 

[lobelsteve]

MRI negative with true weakness= CT myelgram and EMG needs to be done by PMR or Neuro and not their tech. Katirji has the best charts to differentiate between all causes of L5 weakness. If possible de-identify and post some pics and EMG report.

 

[PMR 4 MSK]

MRI negative with true weakness= CT myelgram and EMG needs to be done by PMR or Neuro and not their tech. Katirji has the best charts to differentiate between all causes of L5 weakness. If possible de-identify and post some pics and EMG report.

I agree with EMG before ESI in this case. And it has to be done by someone who knows how to do proximal exams and tease out L5 radic from extra-foraminal and distal lesions.

 

[melancholy]

Agree with above. However, to play devil's advocate (and patient would probably still have a pain component in this case), if this was due to an annular defect causing spilling of inflammatory "soup" onto nerve roots, theoretically you can get a motor radiculopathy from this chemical etiology. I seem to recall there has been some prior study that have demonstrated decreased CMAP amplitudes after exposing a nerve root to chemical irritation of some sort. Slap me if my recollection is incorrect.