First week on pain, have some questions.

[solomonliu]

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Hi all,
I'm an CA2 just starting my pain rotation. I had some questions regarding the management of some patients. Clinic is sometimes too fast paced to ask questions and was hoping some of you could help clarify some basic concepts on management.

Patient had R neck pain with radicular symptoms down R T1-2 distrubtion; however recent MRI showed "Mild degenerative changes of the cervical spine most pronounced at levels C4-C5 and C5-C6 with small posterior disc osteophyte complexes causing mild-moderate spinal canal narrowing." The attending wanted to do epidural steroid injection at T1-2, where the symptoms were distributed, rather than any cervical level. Question: when deciding what at what level to do a particular procedure, do you go with imaging or H/P?

Attending mentioned it was important to distinguish central canal stenosis and foraminal stenosis, but I'm not sure why. Why is this distinction important?

When are the differences between DRG stim and spinal cord stim? What type of patient would be a good candidate for a "stim trial?"

When do you a nerve block and when do you steroid injection? Are steroid injections for radicular pain that start somewhere in the spine, while a nerve block is isolate to a peripheral nerve (but do not involve the spine)?

Thank you for answering any of these presumably dumb questions.

 

[SSdoc33]

Hi all,
I'm an intern just starting my pain rotation. I had some questions regarding the management of some patients. Clinic is sometimes too fast paced to ask questions and was hoping some of you could help clarify some basic concepts on management.

Patient had R neck pain with radicular symptoms down R T1-2 distrubtion; however recent MRI showed "Mild degenerative changes of the cervical spine most pronounced at levels C4-C5 and C5-C6 with small posterior disc osteophyte complexes causing mild-moderate spinal canal narrowing." The attending wanted to do epidural steroid injection at T1-2, where the symptoms were distributed, rather than any cervical level. Question: when deciding what at what level to do a particular procedure, do you go with imaging or H/P?

Attending mentioned it was important to distinguish central canal stenosis and foraminal stenosis, but I'm not sure why. Why is this distinction important?

When are the differences between DRG stim and spinal cord stim? What type of patient would be a good candidate for a "stim trial?"

When do you a nerve block and when do you steroid injection? Are steroid injections for radicular pain that start somewhere in the spine, while a nerve block is isolate to a peripheral nerve (but do not involve the spine)?

Thank you for answering any of these presumably dumb questions.

The questions are not dumb. It's good you are inquisitive. Takes an entire residency and then a fellowship to answer them, though

 

[Doctodd]

First is look at the MRI yourself and correlate with radiology report. Go with patient history and exam slightly more than imaging....but need to consider both. Sometimes MRI misses things based on the slices, quality of machine, radiologist error, etc.

That being said, a T1-2 ESI is going to spread to multiple levels. An epidural with corticosteroid is a shotgun treatment depending on the amount injected.

 

[paindoc007]

Hi all,
I'm an intern just starting my pain rotation. I had some questions regarding the management of some patients. Clinic is sometimes too fast paced to ask questions and was hoping some of you could help clarify some basic concepts on management.

Patient had R neck pain with radicular symptoms down R T1-2 distrubtion; however recent MRI showed "Mild degenerative changes of the cervical spine most pronounced at levels C4-C5 and C5-C6 with small posterior disc osteophyte complexes causing mild-moderate spinal canal narrowing." The attending wanted to do epidural steroid injection at T1-2, where the symptoms were distributed, rather than any cervical level. Question: when deciding what at what level to do a particular procedure, do you go with imaging or H/P?

Attending mentioned it was important to distinguish central canal stenosis and foraminal stenosis, but I'm not sure why. Why is this distinction important?

When are the differences between DRG stim and spinal cord stim? What type of patient would be a good candidate for a "stim trial?"

When do you a nerve block and when do you steroid injection? Are steroid injections for radicular pain that start somewhere in the spine, while a nerve block is isolate to a peripheral nerve (but do not involve the spine)?

Thank you for answering any of these presumably dumb questions.

A combination of clinical history/exam plus imaging makes your assessment on which injection and where is most appropriate for a patient. So not just one or the other.

Central stenosis and foraminal stenosis are often treated differently is why it’s impt to distriguish

DRG= dorsal root ganglion. Isolated to a specific root distribution.

SCS is typically indicated for neuropathic pain processes than has failed conservative tx.

“Nerve block” is a pretty broad term. Depends what you’re referring to. For instance, medial branch block is a spine nerve block, for diagnostic treatment of spondylosis, which can lead to rfa

Hope that helps.

 

[geauxg8rs]

Definitely go with history/exam >>>> imaging studies. When presenting say the patient has a pain picture
Of an L4 radiculopathy by
Exam
And is supported by
Mri findings
Of...

Much better
Than saying patient has a herniated
Disc at L4-5
And is confirmed
With his pain distribution of...

 

[promethius]

I just want to second what everyone has said so far. In medicine, you treat the patient and not the image. If you notice at the end of most radiology reports, the radiologist will hedge by saying clinical correlation needed. Having said that, imaging should support your clinical decision making, but given different impressions, I would always go with clinical over radiological for treatment.

Central stenosis is narrowing at the level of the spinal cord, whereas foraminal stenosis is narrowing at the opening where the nerve root comes out of the spinal column. As Doctodd alluded to, you can treat central stenosis with an interlaminar epidural steroid injection because the injectant will usually spread up 3-4 levels from the level of injection and will cover all the foramens bilaterally at those levels. You can treat foraminal stenosis with a transforaminal epidural steroid injection because just as its name implies, the injection happens across the opening where the nerve root comes out of the spinal column. Using the analogy to guns, interlaminar epidural steroid injection is similar to a shotgun approach whereas transforaminal epidural steroid injection is similar to a sniper approach.

Traditional spinal cord stimulators are usually used and indicated more for patients with radicular pain, as they "cover up" the pain with a tingling sensation when the stimulator is turned on. You can use them for axial pain too, but they usually do not work as well. Some pain physicians use the spinal cord stimulator leads off-label for peripheral nerve stimulation by placing them under the skin over where the peripheral nerves are causing pain. Peripheral nerve stimulation tends to work better than spinal cord stimulation for axial pain, but peripheral nerve stimulation is not FDA approved and so is not usually covered by insurance.

 

[Ducttape]

you can get a lot of information and "help" from sources that you do not think of. I know it is nerveracking asking attendings questions, particularly for fear of appearing stupid. this is your first rotation through pain.


don't forget to ask the senior resident or the pain fellow some of these questions. they will have a lot more time and probably more interest in answering some of these questions without the fear of looking unknowledgable.

do some reading on the basics.

on your first rotation through, spend a lot of time focusing on how to examine a patient, and going over PT findings.

 

[Aether2000]

The history is the most valuable in determining specific levels. The physical exam may be misleading due to a multitude of factors such as sensory dermatomal overlap and the presence of furcal nerves, weakness secondary to disuse rather than overt neural signal interruption, reflexes blunted by past knee or ankle surgery or hypothyroidism or idiopathic, etc. There are many eponyms for maneuvers or "diagnostic" physical exam tests that may be of very limited usefulness or have low specificity/sensitivities. There is no reliable physical sign of nerve stretch irritation in the upper extremities that has significant sensitivity and specificity.

The MRI can be a treasure trove of information but only if you examine it yourself. Radiologists typically give a systematic review level by level or may give the Cliff note version of a report by employing laconic descriptions that are so generalized as to be meaningless. Yet the MRI is more valuable in telling you where not to inject than where to inject. The cervical spine is largely relegated to medial branch blocks or RF, interlaminar epidural steroid injections, and to a lesser degree, intra-articular facet injections. Rarely performed is the transforaminal ESI, cervical discogram or percutaneous cervical disc decompression. Interlaminar injections with 3-4ml volume will usually spread from T1 to C2 or 3 given the very small volume of the cervical epidural space, although some use up to 12 ml total in their cervical epidural steroid injections. Certainly do not place an interlaminar needle at the level of significant central canal spinal stenosis (no epidural fat seen posterior to the cord on MRI), even if it is the target level of the pathology.

Spinal cord stimulation is still referred to by some (especially insurers) by the archaic term "dorsal column stimulator", first used clinically in 1967. DRG stimulation is a relatively new concept promulgated in the last 5 years, primarily used for radicular pain by placing the lead on or near the dorsal root ganglia in the neuroforamina of the involved exiting nerve

Best wishes in your journey in medicine