ESIs on possible surgical patients?

[Baron Samedi]

Just curious how those more experienced than me would handle this.

Young person comes in subacute pain, imaging shows chronic pars defects with grade I listhesis and nasty looking HNPs at L4-5 and L5-1 Book the patient for an ESI, when they come back for the procedure a couple weeks later now they have mild dorsiflexion weakness that they didn't have before and severe pain. Because of this person's age and occupation, trying to treat somewhat aggressively and am reaching out to ortho colleagues to try and get him in for evaluation sooner.

I did an L5-S1 IlESI with no local anesthetic effect. Now somewhat second guessing myself if I should have just treated with oral meds since he may be going down the fusion road and theres some data regarding ESIs and surgical complications.

What would others have done in this situation?

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[DubVille]

If he didnt have weakness before , I would've tried ESI. If he had true weakness on initial presentation, I'd have a long convo about shots not helping strength (nerve "irritation/pain" vs "damage/neurogenic weakness") and leave shot vs surgery referral up to patient.
How big was epidural fat pad for IL at the listhesis?

 

[Baron Samedi]

 

[Baron Samedi]

It was pretty tight. I was able to get a good epiduragram but not a ton of spread to adjacent levels like I was hoping for.

 

[clubdeac]

Wouldn't be too worried from that MRI. Also that T1 cut does not explain the weakness, no neurocompressive lesion

 

[Timeoutofmind]

Just curious how those more experienced than me would handle this.

Young person comes in subacute pain, imaging shows chronic pars defects with grade I listhesis and nasty looking HNPs at L4-5 and L5-1 Book the patient for an ESI, when they come back for the procedure a couple weeks later now they have mild dorsiflexion weakness that they didn't have before and severe pain. Because of this person's age and occupation, trying to treat somewhat aggressively and am reaching out to ortho colleagues to try and get him in for evaluation sooner.

I did an L5-S1 IlESI with no local anesthetic effect. Now somewhat second guessing myself if I should have just treated with oral meds since he may be going down the fusion road and theres some data regarding ESIs and surgical complications.

What would others have done in this situation?

When presented with weakness:
Would have held off on ESI
Arranged for surgical eval in the next week or two at the latest

If they wanted to hold off on surgery:
Do the ESI
Monitor if the weakness is improving or worsening carefully with q2 week office visits x2 initially and take things from there

 

[Baron Samedi]

Wouldn't be too worried from that MRI. Also that T1 cut does not explain the weakness, no neurocompressive lesion

He has severe foramenal stenosis at both levels and also some displacement of transversing nerve roots. He also looks miserable and can't forward flex more than 5 degrees without severe pain.

 

[SSdoc33]

the 4-5 and 5-1 discs dont look "nasty". there may be severe NF stenosis, though, which we dont see.

i would have done the shots. just b/c a patient might have weakness, it doesnt mean an automatic surgical referral.

i am more concerned with joint injections before a replacement. ESIs pre-surgery are fine, IMHO, as they may obviate the need for surgery (Riew)

 

[Baron Samedi]

Sorry, to clarify...the sagital view was just in response to the question regarding the size of the epidural space at that level, not to really show the lesion. Here's the L5-S1 level. This is also how it looked prior to developing weakness, which happened maybe a week after the MRI.

The arrows are the radiologist's, not mine.

 

[deleted993114]

It was pretty tight. I was able to get a good epiduragram but not a ton of spread to adjacent levels like I was hoping for.

"Tight"?

That scan doesn't look too bad at all.

I would have to see the axial cuts at L4/L5 as well,, but based on that imaging, I don't know any neurosurgeons who would operate on that. Is there something further lateral in the foramen at L4/L5? The "slip" at L4/L5 is almost non-existent. You will need flex/ext films to see if there is movement.

The axial cut above shows moderate, not severe, foraminal stenosis to the left. If the patient has had a significant change in symptoms, despite a recent MRI, you would need repeat imaging to see if something has changed. The degree of weakness (although you have not stated to what degree) is certainly not a foot drop and in need of urgent surgical attention by any means.

If the guy has weakness (to what degree? 4/5?3/5?), dorsiflex is L5, not S1. With a slip at L4/L5, one would expect L4 symptoms if a radic. From the foraminal stenosis at L5/S1, one would expect a left S1 radic, which would affect plantar flexion. L4, of course, would not have changes in either dorsi-flex or plantar flex.

 

[Baron Samedi]

The L4-L5 level where the traversing root L5 root is affected. Sorry for the terrible phone picture quality.

 

[Baron Samedi]

And again just to reiterate -- my decision to send him for a surgical evaluation was based more on the progressive weakness and his vocation. When I originally saw the MRI, I favored conservative management, scheduled him for the ESI and gave some meds. It was only when he presented for the procedure that I saw his weakness was progressing(4/5 to a worse 4/5, not frank foot drop) and became more concerned.

My question isnt really about sending him for the evaluation, but more so whether or not people would have done the ESI knowing that he may get surgery in the next month or so.

I do appreciate the input. I'm literally by myself as a new staff so don't have others to discuss these things with.

 

[callmeanesthesia]

And again just to reiterate -- my decision to send him for a surgical evaluation was based more on the progressive weakness and his vocation. When I originally saw the MRI, I favored conservative management, scheduled him for the ESI and gave some meds. It was only when he presented for the procedure that I saw his weakness was progressing(4/5 to a worse 4/5, not frank foot drop) and became more concerned.

My question isnt really about sending him for the evaluation, but more so whether or not people would have done the ESI knowing that he may get surgery in the next month or so.

I do appreciate the input. I'm literally by myself as a new staff so don't have others to discuss these things with.

I’ve looked through some studies on operative risk after ESI and it doesn’t seem like there is strong evidence of a risk increase like there is for joints. I think I still would have tried the ESI, maybe with dex so it doesn’t hang around though.

 

[Ducttape]

around where I am, standard of care seems to be flex-extend films, then CT myelo to determine degree of dynamic listhesis.

I wouldn't have done the procedure myself, but doubt you would have caused any harm.

fwiw, in the future, if you are on a Microsoft product, use the Snip tool to make a .gif and then upload it onto this forum, easier and better pic.

 

[Ducttape]

for example:

:

 

[geauxg8rs]

for example:

:View attachment 284537

I see this all the time at cirque de soliel

 

[Timeoutofmind]

around where I am, standard of care seems to be flex-extend films, then CT myelo to determine degree of dynamic listhesis.

I wouldn't have done the procedure myself, but doubt you would have caused any harm.

fwiw, in the future, if you are on a Microsoft product, use the Snip tool to make a .gif and then upload it onto this forum, easier and better pic.

Why do u need the CT meylo if you already have the flex/ex? That will clearly show any motion of any real consequence? And a meylo is not a benign study...

None of the surgeons around here do that...

 

[paingamechanger]

I would have done TFESI

 

[Baron Samedi]

I would have done TFESI

At both levels or just one? I chose ILESI because I hoped for spread as I think both levels are symptomatic(he has both L5 and S1 pain) but I considered doing 2 level TF.

 

[SommeRiver]

That MRI isn't very alarming to me.

I'd just do bilateral TFESI bc there's nothing at all with epidural steroid injxns and back surgery.

 

[pmrmd]

Agree the MRI is not overly impressive. I would have injected also. Strength usually improves after ESI.

Now that scoliosis pic is impressive. That spine is almost parallel with the floor.


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[SommeRiver]

Agree the MRI is not overly impressive. I would have injected also. Strength usually improves after ESI.

Now that scoliosis pic is impressive. That spine is almost parallel with the floor.


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Neuromuscular weakness doesn't get better with steroid. Subjective weakness does, but not a true deficit.

 

[paingamechanger]

At both levels or just one? I chose ILESI because I hoped for spread as I think both levels are symptomatic(he has both L5 and S1 pain) but I considered doing 2 level TF.

I usually always do 2 levels

 

[ateria radicularis magna]

Neuromuscular weakness doesn't get better with steroid. Subjective weakness does, but not a true deficit.

True or false

 

[MD87]

I would have injected.
I barely consider weakness a red flag, unless it is functional weakness and the patient is falling or tripping all over the place. I just use it as another piece of my physical exam to diagnose the problem. Now, if we are talking three out of five strength or less, that is different issue, but that is obviously rare in radiculopathy.
The spine surgeons that I work with require two weeks between an injection in surgery. The hip surgeons require three months.


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[pmrmd]

Neuromuscular weakness doesn't get better with steroid. Subjective weakness does, but not a true deficit.

My eyes and hands tell me otherwise. An inflamed root cannot function normally. Improve that and better function returns. How many people have you examined with just buttock pain with EHL weakness that improved two weeks after ESI? They aren't and weren't faking. They didn't even realize they were weak until examined.

 

[SommeRiver]

I understand the urge to make the claim you're making, but legitimate neuromuscular deficit isn't going to occur simply due to an "inflamed root."

What is an inflamed root? Honest Q bc I haven't ever seen one on MRI.

I'm not accusing anyone of faking anything, but "weakness" isn't always real.

How often do you do motor testing on a pt and your knee extension results in 4/5 strength in a pt with a bad radiculitis? You think that's a true deficit or just a severely positive neural tension sign? I say the latter...

 

[pmrmd]

I understand the urge to make the claim you're making, but legitimate neuromuscular deficit isn't going to occur simply due to an "inflamed root."

What is an inflamed root? Honest Q bc I haven't ever seen one on MRI.

I'm not accusing anyone of faking anything, but "weakness" isn't always real.

How often do you do motor testing on a pt and your knee extension results in 4/5 strength in a pt with a bad radiculitis? You think that's a true deficit or just a severely positive neural tension sign? I say the latter...

Wut? HNP —-> radic —> weakness in a myotome. The MR isn’t going to show inflammation but the radicular pain tells you it’s there. MR can show compression without findings and you leave it alone.

Neural tension sign? With strong ADF and PF but weak EHL? No.

 

[pmrmd]

How often do you do motor testing on a pt and your knee extension results in 4/5 strength in a pt with a bad radiculitis? You think that's a true deficit or just a severely positive neural tension sign? I say the latter...

I would say never. If there is an SLR stop before the pain and test then. Even in a position that gives the muscle a disadvantage there will be normal strength.

 

[SommeRiver]

Wut? HNP —-> radic —> weakness in a myotome. The MR isn’t going to show inflammation but the radicular pain tells you it’s there. MR can show compression without findings and you leave it alone.

Neural tension sign? With strong ADF and PF but weak EHL? No.

Considering today is my first day on the job...

I can't say I've ever documented true weakness and resolved it with an ESI.

Subjective weakness all the time...

 

[SommeRiver]

I would say never. If there is an SLR stop before the pain and test then. Even in a position that gives the muscle a disadvantage there will be normal strength.

You would say never? We live and practice in different worlds.

 

[MD87]

Weakness that resolves after the ESI because of the ESI or weakness that resolves after the ESI because a lot of weakness resolves with time anyway? I’m thinking the latter, which there is evidence for. No evidence for the former. Do the study that proves it- it will make our lives easier to get ESI approved through insurance.


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[pmrmd]

Weakness that resolves after the ESI because of the ESI or weakness that resolves after the ESI because a lot of weakness resolves with time anyway? I’m thinking the latter, which there is evidence for. No evidence for the former. Do the study that proves it- it will make our lives easier to get ESI approved through insurance.


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You aren’t considering the time frame at all. You may see someone painful for months with weakness noted by their PCP. Your intervention will help them, at least in the short term. The exam will improve. We don’t need an RCT to prove the sun will rise in the morning. Check your patients a week out then. They will be improved.


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[SommeRiver]

Weakness per PCP?

 

[pmrmd]

You would say never? We live and practice in different worlds.

Since you question what an inflamed radicle is I would say so.


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[pmrmd]

Weakness per PCP?

Jesus man. The PCP may happen to examine their patient you know. How long have you been a doctor?


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[SommeRiver]

I intentionally avoid terms like "inflamed nerve" and "swollen nerve." I'm telling you I can't fix drop foot with an epidural.

 

[SommeRiver]

Jesus man. The PCP may happen to examine their patient you know. How long have you been a doctor?


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...bout 2 weeks...

I do not care what a PCP documents on a PE if we're talking about MSK pathology. You can hurt like crazy and display weakness bc of pain, and that will improve, but if you have drop foot for example you're only means of resolution...in my 2 weeks of experience...is decompression.

 

[BobBarker]

We all know pcp’s do not examine patients.

 

[Baron Samedi]

I guess theoretically if inflammation is causing more compression resulting in a conduction block, an ESI could help improve weakness?

Clinically, I haven't seen that in true weakness like this patient had. More often I see people improve in their own subjective weakness and give more effort in the exam.

 

[SSdoc33]

i would have done a bilateral TFESI.

i dont inject for weakness. only for pain. can an ESI improve weakness? i mean, i guess, possibly. there is no literature of -- that i am aware - that states injecting painless weakness is beneficial.

 

[clubdeac]

Clinically in my experience I have seen ESIs help subjective weakness as well as numbness and tingling. Objective weakness is another matter

 

[SommeRiver]

i would have done a bilateral TFESI.

i dont inject for weakness. only for pain. can an ESI improve weakness? i mean, i guess, possibly. there is no literature of -- that i am aware - that states injecting painless weakness is beneficial.

This is basically what I'm saying.

Acute radic surely causes subjective weakness and that frequently gets better with an ESI but don't try to tell me that a pt with foot drop is reliably treated with an ESI.

Also the PE can be very confusing in these pts, and it is all too common to see 4/5 strength due to neural tension exclusively.

 

[pmrmd]

...bout 2 weeks...

I do not care what a PCP documents on a PE if we're talking about MSK pathology. You can hurt like crazy and display weakness bc of pain, and that will improve, but if you have drop foot for example you're only means of resolution...in my 2 weeks of experience...is decompression.

We aren’t talking foot drop. Foot drop is not 4/5 strength. You will examine patients that may only have pain at the notch. They may have leg pain but aren’t in 9/10 pain. They will be weak when you examine them. After your intervention they will have an improved exam. Get back to me after 15 years and tell me if you notice the same thing or not.


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[pmrmd]

i would have done a bilateral TFESI.

i dont inject for weakness. only for pain. can an ESI improve weakness? i mean, i guess, possibly. there is no literature of -- that i am aware - that states injecting painless weakness is beneficial.

I’m not saying painless weakness improves. Painful weakness does, as the inflammation reduces and conduction improves. Inflammation about the root is how axonal loss develops so it must interfere with conduction at the least before the axon dies.


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[SommeRiver]

Radicular syndrome improves with ESI...I agree with that statement.

Radicular syndrome also improves with time, with or without steroid.

The ONLY reason to give steroid is to treat PAIN, not weakness.

Foot drop is one example of true weakness, and I never said foot drop is a 4/5 PE finding.

 

[pmrmd]

Read the index patient report above. Foot drop was never part of this conversation until you inserted it inappropriately. You will examine people without severe leg pain that are weak. There aren't tension signs present. Your injection will improve them. You may change your mind about some things after you gain a little more experience.

 

[SommeRiver]

Read the index patient report above. Foot drop was never part of this conversation until you inserted it inappropriately. You will examine people without severe leg pain that are weak. There aren't tension signs present. Your injection will improve them. You may change your mind about some things after you gain a little more experience.

True weakness does not get better with an ESI.

Foot drop is ONE EXAMPLE of true weakness.

Radicular syndrome (THE PT IN QUESTION) gets better with ESI and/or time.

Since you have all this experience, maybe you can tell me how many pts you've seen with TRUE WEAKNESS that got better with one of your magical injections...

 

[SSdoc33]

Read the index patient report above. Foot drop was never part of this conversation until you inserted it inappropriately. You will examine people without severe leg pain that are weak. There aren't tension signs present. Your injection will improve them. You may change your mind about some things after you gain a little more experience.

you are not the only guy on this forum who has done a billion shots. tone down the condescension.

 

[pmrmd]

True weakness does not get better with an ESI.

Foot drop is ONE EXAMPLE of true weakness.

Radicular syndrome (THE PT IN QUESTION) gets better with ESI and/or time.

Since you have all this experience, maybe you can tell me how many pts you've seen with TRUE WEAKNESS that got better with one of your magical injections...

There is nothing magical about it. So foot drop is an example of true weakness for you. Good. How about the same condition, perhaps not as severe as to cause foot drop, but only causing mild weakness.

Simple questions: When, in your extensive experience, does pain-inhibition weakness become true weakness and vice versa? Is there no such thing as true weakness to a mild degree or is it only to a severe degree?

The people with sciatic notch pain only or mild leg pain but have 5/5 strength at the ADF and APF but not the EHL? If they have so much pain why can the other muscles be normal?

You ought to have some cogent answers with all your comments.