Hyaluronidase; anybody have experience for nerve blocks?

[Ligament]

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Title says it all. Pros/cons/costs...

I've never used it but considering for refractory peripheral nerve issues.

Thank you!

 

[Doctodd]

no but i have used PRP with success. Reversed a 3 year duration foot drop with PRP in a patient after lumbar surgery.

 

[lonelobo]

no but i have used PRP with success. Reversed a 3 year duration foot drop with PRP in a patient after lumbar surgery.

Call me skeptical, but think it is highly unlikely your PRP injection reversed a 3 year footdrop

 

[Doctodd]

Call me skeptical, but think it is highly unlikely your PRP injection reversed a 3 year footdrop

Maybe you are just unlucky at thinking

 

[lobelsteve]

Maybe you are just unlucky at thinking

But Todd, at least he is thinking. What magic is in your juice that can reverse a 3 year foot drop?

 

[Doctodd]

Maybe it was the placebo? Not sure, but it happened.....young guy so his protoplasm must have been good. Some improvement after 1 so we did a couple after trial epidurals because he also had radicular pain after lumbar surgery

 

[deleted993114]

no but i have used PRP with success. Reversed a 3 year duration foot drop with PRP in a patient after lumbar surgery.

That is physiologically impossible. You should write that up and report it as a case study- let's see how much traction that gets.

The patient obviously did not have an actual foot drop. After 3 years, God could not reverse a foot drop. How was the foot drop measured? Did he have a gait disturbance? Instead of direct exam, did you have him stand on heels and toes? Was it L5 or S1? Are you saying that he had no strength whatsoever against gravity? Was there atrophy of any musculature? Was the guy walking without a brace (hard to do with a real foot drop)?

 

[Ducttape]

maybe not. but Chuck Norris could....



(FWIW only person Chuck couldn't beat - Bruce Lee)

 

[deleted993114]

maybe not. but Chuck Norris could....



(FWIW only person Chuck couldn't beat - Bruce Lee)

I could buy Chuck Norris fixing it, but no one else.

Let's think about nerve injury for a minute. We have from Seddon:

neurapraxia

axonotmesis

Neurotmesis


Are you suggesting that you either restored the myelin sheath and neuronal conduction by injecting PRP??? As this was going on for three years, we probably had axonotmesis, as it should have resolved with a nerapraxic injury in about six months.

This may be a biblical, religious event, as it is akin to raising Lazarus. Thus I really, really doubt this guy had a foot drop and I really, really, really doubt you fixed him with a PRP injection.


PS- Not being condemning. We do many things that appear to "work", when in fact something else may have contributed to the success.

Personally, I NEVER do steroid injections if there is a defined motor deficit. This implies a greater degree of compression/injury and that chances of a steroid helping is quite low. One would assume the same for those who believe in PRP. I personally do not do PRP, as I did it about 20 years ago and it did not work then, so despite the enthusiasm, I am very reluctant to try it again. We tried it for about a year and gave it "a good try".

With a motor deficit, you have a narrow window in which to reliably restore motor function, and it really depends on how much motor loss a patient would be comfortable with if it perpetuated. I generally consider these patients to be surgical candidates and not injection candidates. A person three years out with a motor deficit has no hope of anything improving that deficit. If we had a mild degree of injury (neurapraxia), we would expect a gradual resolution of function over six months. Pain, on the other hand, has componants of inflammation which would be expected to improve somewhat (even if transiently) with steroids.

 

[MD87]

I second what everyone here has said. Resolution of foot drop with any injection after 3 years goes against everything we know about neural regeneration. If true, that would blow my mind and that patient needs to be studied under a microscope to figure out what is so resilient about his nerves that would permit improvement after 3 years.

My 2 cents regarding injections and motor deficit, in response to the above comment: When patients have motor deficit, I tell them that injections are for pain, not weakness and not objective numbness. As long as they understand that, I am OK with injecting. I tell them that I would like them to speak to a surgeon so that they are fully informed on what surgery would entail, so that they can make an educated decision. Many of them flat out refuse and say they are never having surgery no matter what - that's OK, I just document that they refused surgical consultation. I also tell them that there's a lot of evidence that indicates that weakness from a disc herniation, whether or not surgery takes place, is likely to improve to a degree over the next months to 2 years, but that surgery may expedite that recovery. As far as I know, most of the data says that the only things that improve weakness from radiculopathy are: time and/or surgery... and neither guarantees improvement in strength. There is a fair amount of literature on this, and there is a recent (past 3-4 months, I think) article in PM&R about conservative management of disc herniations and weakness, and the vast majority of the patients did have resolution, or at least significant improvement in their strength, without surgery.

 

[DOctorJay]

I second what everyone here has said. Resolution of foot drop with any injection after 3 years goes against everything we know about neural regeneration. If true, that would blow my mind and that patient needs to be studied under a microscope to figure out what is so resilient about his nerves that would permit improvement after 3 years.

My 2 cents regarding injections and motor deficit, in response to the above comment: When patients have motor deficit, I tell them that injections are for pain, not weakness and not objective numbness. As long as they understand that, I am OK with injecting. I tell them that I would like them to speak to a surgeon so that they are fully informed on what surgery would entail, so that they can make an educated decision. Many of them flat out refuse and say they are never having surgery no matter what - that's OK, I just document that they refused surgical consultation. I also tell them that there's a lot of evidence that indicates that weakness from a disc herniation, whether or not surgery takes place, is likely to improve to a degree over the next months to 2 years, but that surgery may expedite that recovery. As far as I know, most of the data says that the only things that improve weakness from radiculopathy are: time and/or surgery... and neither guarantees improvement in strength. There is a fair amount of literature on this, and there is a recent (past 3-4 months, I think) article in PM&R about conservative management of disc herniations and weakness, and the vast majority of the patients did have resolution, or at least significant improvement in their strength, without surgery.

is this the article you're referring to?

Error - Cookies Turned Off

onlinelibrary.wiley.com

Abstract

Background
The clinical course of motor deficits from lumbosacral radiculopathy appears to improve with or without surgery. Strength measurements have been confined to manual muscle testing (MMT) and have not been extensively followed and quantified in prior studies.
Objective
To determine if motor weakness and patient‐reported outcomes related to lumbosacral radiculopathy improve without surgical intervention over the course of 12 months.
Design
Prospective observational cohort.
Setting
Outpatient academic spine practice.
Participants
Adults with acute radicular weakness due to disk herniation.
Methods
Forty patients with radiculopathy and strength deficit were followed over a 12‐month period. Objective strength and performance tests as well as survey‐based measurements were collected at baseline and then every 3 months. Patients underwent comprehensive pain management and rehabilitation and/or surgical approaches as determined in coordination with the treating specialist. This study was approved by the institutional review board of Colorado.
Main Outcome Measurements
Testing of strength was through MMT, handheld dynamometer, and performance‐based testing. Furthermore, visual analog scale, modified Oswestry Disability Index, and 36‐Item Short Form Health Survey (SF‐36) were used to measure pain and disability outcomes.
Results
Of the 40 patients, 33 (82.5%) did not have surgery; 7 (17.5%) had surgery. Twenty‐four of the 33 patients (60%) did not undergo surgery and were followed for 12 months (Comprehensive Pain Management and Rehabilitation, Complete [CPM&R‐C]), and 9 (22%) did not have surgery and lacked at least one follow‐up evaluation (Comprehensive Pain Management and Rehabilitation, Incomplete [CPM&R‐I]). No statistically significant differences were found on baseline measures of strength deficits and SF‐36 domains between the CPM&R‐C, Surgery, and CPM&R‐I groups. Pain and disability scores in the Surgery group were significantly higher than in the CPM&R‐C at baseline. There were statistically significant improvements in all areas of strength, pain, and function when comparing measurements at the 12‐month follow‐up to baseline in the CPM&R‐C group.
Conclusions
Individuals with motor deficits due to lumbosacral radiculopathy improve over time regardless of treatment choice. Most did not choose surgery, and almost all of these patients regained full strength at 1 year. Strength recovery typically occurred in the first 3 months, but there was ongoing recovery over the course of a year.
Level of Evidence
II

 

[jsaul]

no but i have used PRP with success. Reversed a 3 year duration foot drop with PRP in a patient after lumbar surgery.

man why do you bull**** all the time. You know that is impossible

 

[MD87]

is this the article you're referring to?

Error - Cookies Turned Off

onlinelibrary.wiley.com

Abstract

Background
The clinical course of motor deficits from lumbosacral radiculopathy appears to improve with or without surgery. Strength measurements have been confined to manual muscle testing (MMT) and have not been extensively followed and quantified in prior studies.
Objective
To determine if motor weakness and patient‐reported outcomes related to lumbosacral radiculopathy improve without surgical intervention over the course of 12 months.
Design
Prospective observational cohort.
Setting
Outpatient academic spine practice.
Participants
Adults with acute radicular weakness due to disk herniation.
Methods
Forty patients with radiculopathy and strength deficit were followed over a 12‐month period. Objective strength and performance tests as well as survey‐based measurements were collected at baseline and then every 3 months. Patients underwent comprehensive pain management and rehabilitation and/or surgical approaches as determined in coordination with the treating specialist. This study was approved by the institutional review board of Colorado.
Main Outcome Measurements
Testing of strength was through MMT, handheld dynamometer, and performance‐based testing. Furthermore, visual analog scale, modified Oswestry Disability Index, and 36‐Item Short Form Health Survey (SF‐36) were used to measure pain and disability outcomes.
Results
Of the 40 patients, 33 (82.5%) did not have surgery; 7 (17.5%) had surgery. Twenty‐four of the 33 patients (60%) did not undergo surgery and were followed for 12 months (Comprehensive Pain Management and Rehabilitation, Complete [CPM&R‐C]), and 9 (22%) did not have surgery and lacked at least one follow‐up evaluation (Comprehensive Pain Management and Rehabilitation, Incomplete [CPM&R‐I]). No statistically significant differences were found on baseline measures of strength deficits and SF‐36 domains between the CPM&R‐C, Surgery, and CPM&R‐I groups. Pain and disability scores in the Surgery group were significantly higher than in the CPM&R‐C at baseline. There were statistically significant improvements in all areas of strength, pain, and function when comparing measurements at the 12‐month follow‐up to baseline in the CPM&R‐C group.
Conclusions
Individuals with motor deficits due to lumbosacral radiculopathy improve over time regardless of treatment choice. Most did not choose surgery, and almost all of these patients regained full strength at 1 year. Strength recovery typically occurred in the first 3 months, but there was ongoing recovery over the course of a year.
Level of Evidence
II

yes

 

[Doctodd]

man why do you bull**** all the time. You know that is impossible

Is that you Avennatti?

 

[deleted993114]

is this the article you're referring to?

Error - Cookies Turned Off

onlinelibrary.wiley.com

Abstract

Background
The clinical course of motor deficits from lumbosacral radiculopathy appears to improve with or without surgery. Strength measurements have been confined to manual muscle testing (MMT) and have not been extensively followed and quantified in prior studies.
Objective
To determine if motor weakness and patient‐reported outcomes related to lumbosacral radiculopathy improve without surgical intervention over the course of 12 months.
Design
Prospective observational cohort.
Setting
Outpatient academic spine practice.
Participants
Adults with acute radicular weakness due to disk herniation.
Methods
Forty patients with radiculopathy and strength deficit were followed over a 12‐month period. Objective strength and performance tests as well as survey‐based measurements were collected at baseline and then every 3 months. Patients underwent comprehensive pain management and rehabilitation and/or surgical approaches as determined in coordination with the treating specialist. This study was approved by the institutional review board of Colorado.
Main Outcome Measurements
Testing of strength was through MMT, handheld dynamometer, and performance‐based testing. Furthermore, visual analog scale, modified Oswestry Disability Index, and 36‐Item Short Form Health Survey (SF‐36) were used to measure pain and disability outcomes.
Results
Of the 40 patients, 33 (82.5%) did not have surgery; 7 (17.5%) had surgery. Twenty‐four of the 33 patients (60%) did not undergo surgery and were followed for 12 months (Comprehensive Pain Management and Rehabilitation, Complete [CPM&R‐C]), and 9 (22%) did not have surgery and lacked at least one follow‐up evaluation (Comprehensive Pain Management and Rehabilitation, Incomplete [CPM&R‐I]). No statistically significant differences were found on baseline measures of strength deficits and SF‐36 domains between the CPM&R‐C, Surgery, and CPM&R‐I groups. Pain and disability scores in the Surgery group were significantly higher than in the CPM&R‐C at baseline. There were statistically significant improvements in all areas of strength, pain, and function when comparing measurements at the 12‐month follow‐up to baseline in the CPM&R‐C group.
Conclusions
Individuals with motor deficits due to lumbosacral radiculopathy improve over time regardless of treatment choice. Most did not choose surgery, and almost all of these patients regained full strength at 1 year. Strength recovery typically occurred in the first 3 months, but there was ongoing recovery over the course of a year.
Level of Evidence
II

Yes- that is consistent with what we know about neuropraxia, which tends to resolve over a 6 month period. That is statistically what happens.

1. I agree with above that epidurals are for pain, not motor weakness

2. If someone has a motor deficit (NOT A FOOT DROP!), I emphasize that the chances of it resolving spontaneously in 6 months is good. However, if the deficit persists, the chances of anything (including surgery) is poor. Thus the question to the patient is how they want to "place their bet" and if they could live with their current deficit. If not- surgery.

3. Note the article above (very important) is not about a foot drop, but is a decrease in motor strength, which would be less severe.

 

[deleted993114]

Is that you Avennatti?

Well................... I am sure that you are recounting events as they happened and what you witnessed. However, it is very unlikely that the patient had an actual foot drop for three years and that PRP "fixed it".

It was a simple coincidence. Perhaps the patient was inaccurate in reporting the duration of motor weakness, which was obviously a less extreme motor deficit than a foot drop. That happens all the time with patients, who can often be poor historians.

 

[MD87]

Yes- that is consistent with what we know about neuropraxia, which tends to resolve over a 6 month period. That is statistically what happens.

1. I agree with above that epidurals are for pain, not motor weakness

2. If someone has a motor deficit (NOT A FOOT DROP!), I emphasize that the chances of it resolving spontaneously in 6 months is good. However, if the deficit persists, the chances of anything (including surgery) is poor. Thus the question to the patient is how they want to "place their bet" and if they could live with their current deficit. If not- surgery.

3. Note the article above (very important) is not about a foot drop, but is a decrease in motor strength, which would be less severe.

Agree with all this.

 

[lonelobo]

Is that you Avennatti?

Great comeback DocFraud

 

[Ducttape]

Is that you Avennatti?

fwiw, I think you meant Avenatti with one N.

 

[Doctodd]

I haven’t seen the patient in a while so I pulled his chart after the above discussion. To summarize, the first visit was March 9, 2016. He complained of a right foot drop after a twisting and lifting injury in July 2015. He had significant lumbar degenerative changes which were acute on chronic. Neurosurgeon stated that he may recover in 2 to 3 years. EMG nerve study showed radiculopathy versus plexopathy, but we know how good they can be. I did three total epidural steroid injections dated April, July, and October of 2016. All of them gave short term benefit. PRP epidurals done in 2017. Last time I saw him was December 2017 where he was with mild discomfort and increased strength. We called him today and he said his foot drop is doing great working events lifting heavy equipment with no back pain. He was a Workman’s Comp. patient which we know usually don’t want to get better. Take it for what it’s worth.

Dictated on my phone so excuse any spelling errors

 

[epidural man]

I haven’t seen the patient in a while so I pulled his chart after the above discussion. To summarize, the first visit was March 9, 2016. He complained of a right foot drop after a twisting and lifting injury in July 2015. He had significant lumbar degenerative changes which were acute on chronic. Neurosurgeon stated that he may recover in 2 to 3 years. EMG nerve study showed radiculopathy versus plexopathy, but we know how good they can be. I did three total epidural steroid injections dated April, July, and October of 2016. All of them gave short term benefit. PRP epidurals done in 2017. Last time I saw him was December 2017 where he was with mild discomfort and increased strength. We called him today and he said his foot drop is doing great working events lifting heavy equipment with no back pain. He was a Workman’s Comp. patient which we know usually don’t want to get better. Take it for what it’s worth.

Dictated on my phone so excuse any spelling errors

TFESI with PRP?

 

[epidural man]

Title says it all. Pros/cons/costs...

I've never used it but considering for refractory peripheral nerve issues.

Thank you!

I dont' know anything about it. Can you explain more?

Peripheral nerve injection around the nerve? Does it need to be around the area of injury?

 

[epidural man]

man why do you bull**** all the time. You know that is impossible

Umm...I would be careful saying anything is impossible.

Why would everyone not be open to something cool and interesting and surprising happening?

Doctodd isn't saying anything that surprising. He is saying - this was the situation...I tried this...this happened. He isn't making claims about how or why it even worked.

Let's welcome findings. Let's discuss how it could even be possible. Why would it not be possible?

If PRP is somehow a nidus to get stems cell to do their thing...why couldn't this be something useful to talk about?

".. goes against everything we know about neural regeneration.."

Maybe we don't know enough about neural regeneration.

Have you guys looked recently at the proteins, enzymes, new chemicals that have been discovered and talked about in the last 3 years? Most I've never heard of.

 

[Doctodd]

yes i did tfesi each time.... with corticosteroids first and then prp

 

[Orin]

yes i did tfesi each time.... with corticosteroids first and then prp

Interesting report.

Temporally speaking if the neurosurgeon is correct, the patient recovered approximately within the expected 2 - 3 year window, but attributing it to TFESIs with steroids or PRP is an attractive thought.

Title says it all. Pros/cons/costs...
I've never used it but considering for refractory peripheral nerve issues.

Regarding the OP, I have not done that ever. I would be interested in hearing about how it works out. The animal work has not been done to my knowledge. There have been application of the substrate of hyaluronidase (hyaluronic acid or HA) in animal models with application perineurally in the immediate aftermath of the nerve injury that seems to show benefit, but I'm not sure what injecting the enzyme would do.

If I had to sit and think about it, the enzyme would possibly degrade the HA locally. That could help if the HA is a big component of the scar tissue, but if HA is there to quiet down inflammation/help it resolve, that might be bad. I would have to look up what perineural scarring is made up. I'm not sure if something other than hyaluronidase would be better. I'm not sure if just doing a hyaluronic acid injection would be a better first test.

I'm not ready to sign up for you to do it to me yet, but I like where your head is at.

 

[Ligament]

I dont' know anything about it. Can you explain more?

Peripheral nerve injection around the nerve? Does it need to be around the area of injury?

I'm thinking of doing peripheral nerve hydrodissection with it under sonography.

 

[joshmir]

I'm thinking of doing peripheral nerve hydrodissection with it under sonography.

I have seen this work very well on MR neurogram proven ulnar neuropathy, on myself, by a master of this technique.

And others

Unfortunately that master has passed away.

Good technique to develop. Which nerves/indications are you contemplating?

 

[Ligament]

I have seen this work very well on MR neurogram proven ulnar neuropathy, on myself, by a master of this technique.

And others

Unfortunately that master has passed away.

Good technique to develop. Which nerves/indications are you contemplating?

Any peripheral nerve really, but particularly interested in trying on pudendal nerves.

 

[Orin]

Any peripheral nerve really, but particularly interested in trying on pudendal nerves.

Are you doing a lot of hydrodissection? My anesthesia training scares me to inject too closely near a nerve due to the risk of pressure neuropraxia, but anesthesia training might be a lot of fear mongering?