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Food for thought

Discussion in 'Pain Medicine' started by member, Mar 3, 2007.

  1. member

    member Junior Member
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    A middle aged male with 10 week onset of L5 and S1 radiculopathy with 50% response to #1 TFESi, no resoponse to #2 and #3 TFESI showed positive block by local anesthetic in the TFESI but pain returned in 6 hours. Pt does not like surgery. WHat would you do next?? any success in your personal experience if so what %??
     
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  3. ParaVert

    ParaVert Interventional Pain
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    what pathology is seen on MRI?
     
  4. member

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    5 mm disc herniation at L4-5 contacting L5 nerve root and extending superiorly in the ventral epidural space and 4 mm herniation at L3-4 level
     
  5. lobelsteve

    lobelsteve SDN Lifetime Donor
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    What are the findings on exam and mechanism of injury?
    What dos the EMG show?
    What else is being done besides poing him in the back?
     
  6. member

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    He has had PT with no benefit. EMG shows neuropathy in L5 and S1 territory.
     
  7. analgesic

    analgesic Member
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    Member,

    I know your patient does not want to consider surgery but perhaps he would consider something a little less invasive. I don't know if any pain fellows in your area are doing percutaneous endoscopic discectomy (LASE). At our hospital this procedure has been beformed with good functional outcomes(VAS scores and Pain free ROM) that have been preserved up to 5 months from patients I have followed. However, my experience is extremely limited. I haven't followed that many patients but Dr. Tabaa did them in Phoenix and feels that there is good evidence to support there efficacy. I believe Algos has done over 100 of these. Perhaps you could IM him for any further inquiry. I hope this helps.
     
  8. member

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    thanks for the input. I do perc disc using stryker dekompressor but the ins carrier does not recognize that.??
     
  9. ParaVert

    ParaVert Interventional Pain
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    I would also agree with PDD. I would consider doing a CT/discogram first. If he has a big annular tear with the bulge, decompression is less likely to help.

    As far as other technology for disc decompression, Clarus Medical has an APLD auger as well as the LASE. Both are very expensive hardware. You could also consider nucleoplasty, but if the insurance company won't approve Dekompressor they are even less likely to pay for that.

    Anybody out there believe in lumbar distraction (VAXD type stuff)?
     
  10. member

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    his primary complaint is radicular pain and so I think it is the disc herniation that is causing the pain. Let me try the carrier otherwise there is no point in doing discogram.
     
  11. Disciple

    Disciple Senior Member
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    Maybe not with the PDD.

    "5mm herniation extending superiorly in the ventral epidural space".

    Sounds like an extrusion.

    I would look at the films first. "Tooth-paste sign" on Sagittal.
     
  12. lobelsteve

    lobelsteve SDN Lifetime Donor
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    What does that mean? Did they just have NCV and no needle EMG done?
    Was the testing done by qualified personnel?

    Positive sharp waves and fibs on EMG without reinnervation findings would get my vote for surgical intervention. Neuropathy? What the heck does that mean? Axonal? Demyelinating? What studies were done? What were the latencies and amplitudes?

    It's like saying the MRI had a bulged sisc and giving no other info.
    And clinically? DTR's reduced at ankle? Can the patient toe walk, heel walk? SLR? CLR? CLue us in?

    Algos and I were at an Intermedic demo a few months ago in SC. If the device were available in the US, I'd do that.
     
  13. Doctodd

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    Sure i believe in traction...a cheaper way is to have them hang upside down for awhile....seriously, the benefits usually go away as soon as they weightbear.

    I prefer nucleoplasty myself.....easy to do, can use the same needle for a discogram, decent results. Wish there were more studies though.

    Regarding Clarus PLD.....in less than a year period ive seen 2 tips break off inside the disc.

    Lase.....only NS and Ortho spine doing it. Plus if you melt a nerve they wont feel it cuz they are usually done under general. No thanks. Gotta love the NS bills 20-80K while we can only bill 4-5K for a PLD.

    T
     
  14. Disciple

    Disciple Senior Member
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    Hmmm...

    We sometimes do LASE at our facility. Very involved and time consuming. There are papers on it but I'm not convinced it's any better than Nucleoplasty or Dekompressor. Definitely not from a practicality standpoint.

    As for APLD. I thought that had fallen out of favor. Doesn't that method remove too much of the nucleus?
     
  15. jsaul

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    lobelsteve is right. if there are signs of active ongoing denervation then he should condioer decompression. "neuropathy at L5" means nothing
     
  16. Doctodd

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    The tips breaking off made it fall out of favor with me. Thankfully they did not break off inside my patients. One was in the room next door at the ASC i was doing cases at. The other i was assisting as a favor.

    I guess who will get paid for LASE depends on your state...im in Florida.

    Too much nucleus removed for Clarus PLD?.....i hadnt heard that. How much is too much? I dont know the answer to that question. I guess it depends on how long you keep the suction on and/or how much nucleus you see come out. I dont like the huge canister in my procedure room. Space is an issue for me.

    As usual.....Steve is right on.

    T
     

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