Far lateral disc protrusion

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NJPAIN

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Thoughts and experiences with the non-operative management of patients with far lateral, extra-foraminal symptomatic disc protrusions?


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No surgical opinion yet. I unfortunately have to see him tomorrow. I don’t normally see inpatients but he is a self-proclaimed VIP. Admitted via ER with a few weeks of worsening low back and LE pain. Radiologist reports a “far lateral extraforaminal disc hernation at L2-3 with surrounding soft tissue edema”. I briefly looked at MRI and must say this “disc” looks VERY far lateral.
Of course he is on Plavix as well as 325 mg ASA but expects that I’m somehow going to cure him by arranging a Saturday morning inpatient ESI so he can be good as new for thanksgiving.


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They admitted him inpatient for radicular pain?? Maybe his name is on something.
 
My thoughts exactly. Actually, his wife’s ex-in-laws have their name on the conference center.


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Give him Medrol dose pack and gabapentin. TFESI but not on Plavix and ASA. I hold Plavix 7d.
 
Why not just stay a bit lateral since its extraforaminal anyway? I do TFESIs on Plavix so that doesn't bother me but if it does you, stay outside the spine. The problem isn't in the canal anyway.
 
pmrmd said:
Why not just stay a bit lateral since its extraforaminal anyway? I do TFESIs on Plavix so that doesn't bother me but if it does you, stay outside the spine. The problem isn't in the canal anyway.
Click to expand...
I think there’s enough data to support doing the tfesi on full AC..... but I still haven’t done it on more than asa. We’re not curing cancer with an esi.
 
Left anterolateral thigh pain and numbness. No weakness. No reflex changes. Positive SLR on the left as well as crossed straight leg raise, Moderate foraminal stenosis at L5-S1 L > R.
upload_2018-11-17_15-41-44.png
 
pmrmd said:
Why not just stay a bit lateral since its extraforaminal anyway? I do TFESIs on Plavix so that doesn't bother me but if it does you, stay outside the spine. The problem isn't in the canal anyway.
Click to expand...

Nope...Not worth it to me. If it goes against ASRA I'm not doing it bc we are talking about an elective procedure that doesn't always work and I'm not doing it.

Besides, let's be real and all agree there is NO SUCH THING as an inpatient TFESI. This is not emergent and this is preferential treatment for a VIP which is an even bigger reason to stick to guidelines...

Also I'm unimpressed with that MRI. The odds I'm heading to hospital for that MRI are 0%. This is a joke...
 
SommeRiver said:
Nope...Not worth it to me. If it goes against ASRA I'm not doing it bc we are talking about an elective procedure that doesn't always work and I'm not doing it.

Besides, let's be real and all agree there is NO SUCH THING as an inpatient TFESI. This is not emergent and this is preferential treatment for a VIP which is an even bigger reason to stick to guidelines...
Click to expand...

I agree. Going against guidelines is VERY difficult to defend. VIP medicine is bad medicine. I told the patient to go home and we can consider moving forward a few week after cardiology gives the ok to interrupt Plavix.


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Seems more likely to be meralgia paresthetica based on the above information. If obese, lose weight and loosen the belt.


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NJPAIN said:
No surgical opinion yet. I unfortunately have to see him tomorrow. I don’t normally see inpatients but he is a self-proclaimed VIP. Admitted via ER with a few weeks of worsening low back and LE pain. Radiologist reports a “far lateral extraforaminal disc hernation at L2-3 with surrounding soft tissue edema”. I briefly looked at MRI and must say this “disc” looks VERY far lateral.
Of course he is on Plavix as well as 325 mg ASA but expects that I’m somehow going to cure him by arranging a Saturday morning inpatient ESI so he can be good as new for thanksgiving.
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Click to expand...

If it merits an inpatient consult it must be an emergency. Better check sphincter tone.
 
VIP medicine on a self-proclaimed VIP is even dodgier. Historically, when I've acquiesced to the demands to a "VIP", I usually regret it. It is harder, in my opinion, to satisfy the needs/wants of these people, many of whom seem to have poor pain tolerance and unrealistic expectations. They flood my phone lines, fill my EMR inbasket with other various demands, and treat me like one of their many assistants/housekeepers.

I tend to be even more conservative with VIPs in general.
 
maybe its the slices or contrast, but i dont see anything on that MRI
 
i have done TF ESI on plavix on several occasions.
 
Convince me is it worth the risk on Plavix. TF, not even IL.
 
SommeRiver said:
Convince me is it worth the risk on Plavix. TF, not even IL.
Click to expand...
Pain Med. 2017 Mar 1;18(3):403-409. doi: 10.1093/pm/pnw108.
The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures.
Endres S1, Shufelt A2, Bogduk N3.
Author information

Abstract
BACKGROUND:
Guidelines have been published that recommend discontinuing anticoagulants in patients undergoing interventional pain procedures. The safety and effectiveness of these guidelines have not been tested.

OBJECTIVES:
The present study was performed to determine if continuing or discontinuing anticoagulants for pain procedures is associated with a detectable risk of complications.

METHODS:
An observational study was conducted in a private practice in which some partners continued anticoagulants while other partners routinely discontinued anticoagulants.

RESULTS:
No complications attributable to anticoagulants were encountered in 4,766 procedures in which anticoagulants were continued. In 2,296 procedures in which anticoagulants were discontinued according to the guidelines, nine patients suffered serious morbidity, including two deaths.

CONCLUSIONS:
Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must be considered when deciding between continuing and discontinuing anticoagulants.



Convince me it is worth the risk to hold the thinner/antiplatelet.
 
Even the guidelines published April 2018 recommend 7 days off of Plavix.
I think perhaps noble but foolish to go against them.


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SommeRiver said:
Convince me is it worth the risk on Plavix. TF, not even IL.
Click to expand...

using a small needle with slow precise movements. Not a big needle and then mucking around with catheter and leaving it in there for a few days. That's not what we are doing and lot of these guidelines were made for epidural catheters.
 
lobelsteve said:
Pain Med. 2017 Mar 1;18(3):403-409. doi: 10.1093/pm/pnw108.
The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures.
Endres S1, Shufelt A2, Bogduk N3.
Author information

Abstract
BACKGROUND:
Guidelines have been published that recommend discontinuing anticoagulants in patients undergoing interventional pain procedures. The safety and effectiveness of these guidelines have not been tested.

OBJECTIVES:
The present study was performed to determine if continuing or discontinuing anticoagulants for pain procedures is associated with a detectable risk of complications.

METHODS:
An observational study was conducted in a private practice in which some partners continued anticoagulants while other partners routinely discontinued anticoagulants.

RESULTS:
No complications attributable to anticoagulants were encountered in 4,766 procedures in which anticoagulants were continued. In 2,296 procedures in which anticoagulants were discontinued according to the guidelines, nine patients suffered serious morbidity, including two deaths.

CONCLUSIONS:
Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must be considered when deciding between continuing and discontinuing anticoagulants.



Convince me it is worth the risk to hold the thinner/antiplatelet.
Click to expand...

really dont like how TPI were lumped into the same category as ESIs. complications still low for just ESIs, but put putting the 4,766 number in there is disingenuous.
 
I don’t think you can generalize adherence to the guidelines though. Big difference between someone who had a blood clot 10 years ago after a transatlantic flight and their PCP has just continued the Coumadin, or someone who has had 6 DVTs and clots every time she comes off her blood thinner, even if she’s bridged. Same with plavix - on it for a small MI years ago, and got that cholesterol and diabetes under control since then, or a VA referral vasculopath who is perfusing his entire brain through half a carotid and has chronic angina from his untreatable multi vessel CAD. More important to have a conversation about risks and benefits with the patient (and document the hell out of that conversation).
 
That study was taken into account by ASRA and yet consensus was to stop Plavix for all epidurals. That study sucks bc it includes lumbar MBB, SIJ, and TPI.
 
When epidurals become life saving interventions I'll be a little more cavalier.
 
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