ESIs on possible surgical patients?

[pmrmd]

Advertisement - Members don't see this ad

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

I don't feel like I was condescending at all. The guy has been practicing for a couple days. He doesn't believe in an inflammed nerve root because he can't see it on an MRI. He thinks all weakness is subjective even though other muscles in the same part of the limb will have normal strength. Then he argues about it.

 

[Baron S]

If there is one thing I am learning about this forum, it's that literally any topic can become an argument.

 

[lobelsteve]

Weakness.
Feigned.
cogwheel.
neurogenic.
pain limited.
effort limited.
Falcons related.

 

[SommeRiver]

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.

I haven't ever injected a patient for painless weakness, and I doubt I ever will. If you have no pain I'm not injecting you, and if your painless weakness doesn't resolve over time I will send you to the surgeon.

Once I hit 6 months of experience I'll get back to you about it...

 

[SommeRiver]

I don't feel like I was condescending at all. The guy has been practicing for a couple days. He doesn't believe in an inflammed nerve root because he can't see it on an MRI. He thinks all weakness is subjective even though other muscles in the same part of the limb will have normal strength. Then he argues about it.

Two weeks and two days to be exact. I've seen over 300 pts so far...

I'm very much aware of the pathophysiology of the radicular syndrome. I will inject that, and yes, chemical irritation is a major component of it, at least as equally important as the compression itself.

Isolated weakness without pain isn't an indication for steroid.

The overwhelming majority of the time the weakness is subjective and improves with time.

I refuse to inject painless weakness bc it doesn't work, and the single best example of that is foot drop.

Once I see maybe 1000 pts my mind will change.

 

[pmrmd]

Two weeks and two days to be exact. I've seen over 300 pts so far...

I'm very much aware of the pathophysiology of the radicular syndrome. I will inject that, and yes, chemical irritation is a major component of it, at least as equally important as the compression itself.

Isolated weakness without pain isn't an indication for steroid.

The overwhelming majority of the time the weakness is subjective and improves with time.

I refuse to inject painless weakness bc it doesn't work, and the single best example of that is foot drop.

Once I see maybe 1000 pts my mind will change.

Who is injecting painless weakness? Certainly not me. ssdoc mentioned that idea out of no where. I never have and never would either since it makes zero sense. The topic of the discussion is why people are weak when painful.


Sent from my iPhone using Tapatalk

 

[SSdoc33]

Who is injecting painless weakness? Certainly not me. ssdoc mentioned that idea out of no where. I never have and never would either since it makes zero sense. The topic of the discussion is why people are weak when painful.


Sent from my iPhone using Tapatalk

you mentioned that a patient's strength usually improves after an ESI. that is where the lines were blurred. it is true, however, that you never mentioned painless weakness.

the question is whether the ESI can improve or hasten the improvement of strength. i suppose it could, but the shot shouldnt be given solely for this reason.

 

[painfree23]

View attachment 284532Sorry, 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.

This doesn't look that bad at all. The image is probably what 70% of my injection patients look like. This is a good example of the scan not always picking everything up and the need for a physical exam.

 

[Ducttape]

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...

apparently, its not the just the range of motion that they are looking at but the vascular flow around the nerve itself due to dynamic component.

 

[SommeRiver]

Who is injecting painless weakness? Certainly not me. ssdoc mentioned that idea out of no where. I never have and never would either since it makes zero sense. The topic of the discussion is why people are weak when painful.


Sent from my iPhone using Tapatalk

I've been in practice a few years now, and I said 2 weeks bc of your "wut" comment.

Someone with acute radic will present with weakness commonly, but the overwhelming majority of the time it resolves on its own bc it isn't real. You yourself mentioned the timeline.

That is why I don't consider that true weakness. It is a transient process that resolves with time.

I am very aware that an acute radic involves chemical neuritis, but it is short lived and if it doesn't hurt you shouldn't inject it.

Send them to PT and give them oral steroids.

I make it a point to never tell a patient anything about "inflammation" bc that is a buzz word in 2019. Physical therapists and chiropractors use that word all the time. Since you're so experienced and smart, I'm sure you know that.

Again I'll say to you, the overwhelming majority of the time the radic pt's weakness isn't real.

Painless weakness is an example of true weakness, which I mentioned a few times as an example of what I consider true weaknes assuming it doesn't resolve. Foot drop being the most common example.

 

[SSdoc33]

apparently, its not the just the range of motion that they are looking at but the vascular flow around the nerve itself due to dynamic component.

sounds like a bit a surgeon-rationalizing BS to me....

 

[paindoc007]

sounds like a bit a surgeon-rationalizing BS to me....

I was thinking the same thing. Literally never heard of that before

 

[pmrmd]

I've been in practice a few years now, and I said 2 weeks bc of your "wut" comment.

Someone with acute radic will present with weakness commonly, but the overwhelming majority of the time it resolves on its own bc it isn't real. You yourself mentioned the timeline.

That is why I don't consider that true weakness. It is a transient process that resolves with time.

I am very aware that an acute radic involves chemical neuritis, but it is short lived and if it doesn't hurt you shouldn't inject it.

Send them to PT and give them oral steroids.

I make it a point to never tell a patient anything about "inflammation" bc that is a buzz word in 2019. Physical therapists and chiropractors use that word all the time. Since you're so experienced and smart, I'm sure you know that.

Again I'll say to you, the overwhelming majority of the time the radic pt's weakness isn't real.

Painless weakness is an example of true weakness, which I mentioned a few times as an example of what I consider true weaknes assuming it doesn't resolve. Foot drop being the most common example.

I asked a simple question in an earlier post. Answer it.


Sent from my iPhone using Tapatalk

 

[Baron S]

In my mind, painless weakness is ALS until proven otherwise.

The last EMG I did was a guy coming in for a supposed S1 radiculopathy based on plantarflexion painless weakness and a small broad-based disc bulge at L5-S1. First, I thought, "huh, that's interesting" followed by "oh ****" once I put a needle in his leg and saw myotonic discharges and abnormal spontaneous activity. Thankfully, he ended up only having Myotonic Dystrophy and not ALS.

 

[Timeoutofmind]

I was thinking the same thing. Literally never heard of that before

apparently, its not the just the range of motion that they are looking at but the vascular flow around the nerve itself due to dynamic component.

so what?
is dynamic nerve root vascular flow compromise a surgical indication?

 

[Ducttape]

If there is one thing I am learning about this forum, it's that literally any topic can become an argument.

no it cant!

 

[Ducttape]

so what?
is dynamic nerve root vascular flow compromise a surgical indication?

yes.... not me saying this...

 

[painfree23]

In my mind, painless weakness is ALS until proven otherwise.

The last EMG I did was a guy coming in for a supposed S1 radiculopathy based on plantarflexion painless weakness and a small broad-based disc bulge at L5-S1. First, I thought, "huh, that's interesting" followed by "oh ****" once I put a needle in his leg and saw myotonic discharges and abnormal spontaneous activity. Thankfully, he ended up only having Myotonic Dystrophy and not ALS.

So, do you tell the patients that? do you diagnose ALS in your clinic routinely? What do you suggest for us non-neurologist who may see weakness on exam?

 

[SSdoc33]

So, do you tell the patients that? do you diagnose ALS in your clinic routinely? What do you suggest for us non-neurologist who may see weakness on exam?

become a physiatrist

 

[SSdoc33]

ive made the presumptive diagnosis of ALS. done it may 5-10 times in my career. usually a patient comes in for a routine EMG, and everything lights up. if you think a patient may have ALS, or if they have weakness on exam that may or may not match the imaging, then an EMG/NCS is the next step. lots of times is an idiopathic brachial or lumbosacral plexopathy. ALS is diagnosed once everything else is ruled out. thats the job of neurology. let them order every test under the sun (and start treating the ALS) once you make sure it isnt spinal in nature.

 

[Baron S]

So, do you tell the patients that? do you diagnose ALS in your clinic routinely? What do you suggest for us non-neurologist who may see weakness on exam?

Absolutely not. ALS also isn't a diagnosis you make by yourself -- that person is getting a 2nd and 3rd opinion and every test imaginable. The formal diagnosis should come from someone with a lot more expertise than me. When I see someone with painless weakness, I say, "it's not normal for your muscle to be this weak. There are a lot of things that can cause it, some minor and some more serious. It is really important that we send you for some additional tests to help determine the cause."

When I see painless weakness on exam, my job is to prove to myself that it's not ALS. If you see these symptoms, I agree with SSdoc33 that EMG/NCS is the next appropriate thing to do.

 

[SommeRiver]

I asked a simple question in an earlier post. Answer it.


Sent from my iPhone using Tapatalk

What question is that?

The one where you fix weakness with an epidural? I believe I asked you that.

Give the acute radic PO steroids and physical therapy and watch that same weakness you're talking about go away completely, because it does go away completely the majority of the time bc it isn't true weakness.

IT IS PAIN THE OVERWHELMING MAJORITY OF THE TIME...

 

[pmrmd]

What question is that?

This one:

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?

You can also try to define "true" weakness while you're at it.

FYI: Oral steroids for radic was shown to be ineffective years ago.

 

[Aether2000]

 

[SommeRiver]

This one:


You can also try to define "true" weakness while you're at it.

FYI: Oral steroids for radic was shown to be ineffective years ago.

"Wut" - I use PO steroids all the time for acute radiculitis and it helps. Doesn't last as long as an ESI but clearly helps.

True weakness is an external hemipelvectomy and test knee extension...Maybe your magic flute can fix that weakness.

 

[No Pain All gain]

I would inject the patient ASAP. Same day or within 5 days is our pledge to our referral sources. If needs surgery, we expedite referral to NSG next door and get them done in ASC downstairs if no improvement in weakness despite resolution/improvement of pain.

I would argue that it is hard to adequately regain strength (subjective or objective) if in radicular pain. I had it myself - big HNP and terrible pain w foot drop. 15 months and 5 ESIs now pain-free with no incision and 5/5.


Sent from my iPhone using Tapatalk

 

[Baron S]

Wish I was so lucky! C7'd myself and now with permanent deficits even with surgery. Could have been worse.

 

[pmrmd]

"Wut" - I use PO steroids all the time for acute radiculitis and it helps. Doesn't last as long as an ESI but clearly helps.

True weakness is an external hemipelvectomy and test knee extension...Maybe your magic flute can fix that weakness.

You are giving a steroid load for no good reason, especially since you don't know what an inflammed root is because you haven't seen one on an MRI. But you keep on being you, which is immature and illogical. Why would anyone expect anything better from you?

Why can't you answer the simple question?