facet joints

[PMR 4 MSK]

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So I see a new pt today - 74 y/o male, Dx - lumbar stenosis, has been to another pain doc, had 2 epidurals w/ 400 mg Depomedrol, both helped about 70%, with some residual a.m. stiffness and back pain, so he apparently decided to try medial branch blocks. L2-3, 3-4, 4-5, 5-1 and S1 MBB blocks done with 1 ml .5% bupiv + 80 mg Depomedrol/level. 1st one side, then a few weeks later the other. Both times the pt felt 50% better (by progress notes, at f/u appt a few weeks later, no report of pain relief immediately post-procedure) so he RF'd one side, apparently same levels. The pt reported 1 day of relief, then recurrence of pain. He then came to me for another opinion before going through RF for the other side.

Here's my questions for anyone who wants to chime in:

1) Would you RF the other side?
2) Would you RF or do MBB on 5 levels at once?
3) Was the Depomedrol beneficial to MBB or did it just cloud the response?
4) Each side MBB = total 400 mg Depomedrol = 800 mg for 2 sides, + 400 mg/LESI = 1600 mg Depomedrol over about 5 months. Any thoughts on this amount of steroid?

 

[lucyz02]

sounds like he got better relief from the initial epidurals- are you sure they were 400mg depo??
It's possible there is another pain generator.... besides the facet joints (MBB).

 

[PMR 4 MSK]

yep - the report said 400 mg Depo both times😱

I also meant to put this under the pain forum, so I'll repost it there, but any replies here are welcome as well.🙂

 

[SSdoc33]

throw out all data from the previous physician. its useless. steroid doses are ridiculous (choice of that particular steroid is ridiculous for that matter), choice of interventions is misguided, response to treatment was poor.

only do the RF with double controlled MBB without steroid and try to follow the ISIS if possible.