Injection vs surgery for weakness

[Dr. Ice]

What’s the consensus on upper extremity weakness? Multilevel cervical stenosis with no upper extremity pain only weakness. Weakness has plateaued. Surgery would likely require multiple fusion. Weakness on dominant side. Hasn’t had EMG yet but I think it’s clearly radicular. Has anyone had success with cervical esi? I believe I’ve tried it in the past with varying success.

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[willabeast]

If you look at the rationale for ESI doing an ESI for only weakness and no pain does not make sense. I could go on but the short answer is no for CESI on this patient.

 

[TheLoneWolf]

No pain= no injection. Send to PT and surgery.

 

[Taus]

For me, it would depend on age, activity levels, comorbidities, degree of weakness

Only times I can really say I’ve seen improvement in strength from esi was in acute radic with extruded or sequestered fragment, a lot of edema/hemorrhage surrounding disc on MRI. Granted these had associated pain.

Also, unless it clearly started with associated radicular pain that has since subsided, I would get EMG.

Nothing good typically comes from painless weakness…

 

[MD87]

If you are certain it is ridicular, I typically follow this protocol, which is somewhat evidence-based and also reasonable from a legal standpoint, I think -

1. If improving, monitor.
2. If worsening, send to surgeon.
3. If stable but debilitating and it has been 2-2.5 months, send to surgeon and make the surgeon have the discussion with the patient that surgery may or may not improve weakness. On average, the more caudal myotomes (hand intrinsic stuff) tend to do worse even with surgery.

If I were the patient, I probably wouldn’t get surgery but it’s a difficult decision.

I have never injected these patients. Hard to imagine how it could help, and always the risk of them saying they are worse after. I don’t think it’s worth it.

 

[Baron Samedi]

Painless weakness = ALS until proven otherwise.

 

[sloh]

If you are certain it is ridicular, I typically follow this protocol, which is somewhat evidence-based and also reasonable from a legal standpoint, I think -

1. If improving, monitor.
2. If worsening, send to surgeon.
3. If stable but debilitating and it has been 2-2.5 months, send to surgeon and make the surgeon have the discussion with the patient that surgery may or may not improve weakness. On average, the more caudal myotomes (hand intrinsic stuff) tend to do worse even with surgery.

If I were the patient, I probably wouldn’t get surgery but it’s a difficult decision.

I have never injected these patients. Hard to imagine how it could help, and always the risk of them saying they are worse after. I don’t think it’s worth it.

You wouldn’t get surgery for significant weakness that isn’t improving or worsening?

 

[Dr. Ice]

Painless weakness = ALS until proven otherwise.

Interesting, it’s all unilateral though, patient is beyond the age demographic of ALS. Severe R>L multilevel stenosis. It smells radicular all the way. Agree EMG in likely necessary however

 

[Dr. Ice]

Weakness is stable

 

[JBM16BYU]

Interesting, it’s all unilateral though, patient is beyond the age demographic of ALS. Severe R>L multilevel stenosis. It smells radicular all the way. Agree EMG in likely necessary however

ALS is an interesting neuromuscular disease. Yes it presents as painless weakness, but how it presents is incredibly variable. I’ve seen patients from mid-20s to 80s at first onset. For some, it’s asymmetric in multiple areas of the body. Others, bulbar symptoms only before any limb involvement. Still others present as painless weakness in a single limb, mimicking a radiculopathy… If it were me, I would definitely order an EMG to differentiate between cervical radiculopathy versus motor neuron disease, looking for abnormal spontaneous activity (fasciculations, positive sharp waves, and fibrillation potentials) and chronic neurogenic changes in the motor unit potentials. Need to check a fair number of muscles in the affected limb and, if leaning towards a motor neuron disease electrodiagnostic picture, a few muscles will need to be checked elsewhere (lumbosacral, thoracic, and cranial segments). If at all suspecting this diagnosis, consider referring to neuromuscular specialist for the EMG.

 

[Dr. Ice]

So let’s say neuromuscular disease has been ruled out. I sent to surgeon and they recommend multilevel fusion and then the patient is no better…

What are the chances that a surgeon would not cut in this case?

Patient is active, 74 years old, stable HTN is only other medical issue.

I’m asking because this is a very close friend’s father.

Taus, he’s also seeing one of your guys next month…

 

[RoloTomassi]

Will ESI help? Chances are slim but nonzero. If it were my neck, facing a fusion, I'd try. In good hands + good protoplasm, I think it's a relatively benign procedure.

 

[Taus]

So let’s say neuromuscular disease has been ruled out. I sent to surgeon and they recommend multilevel fusion and then the patient is no better…

What are the chances that a surgeon would not cut in this case?

Patient is active, 74 years old, stable HTN is only other medical issue.

I’m asking because this is a very close friend’s father.

Taus, he’s also seeing one of your guys next month…

We both know that even in the best of hands, depending on degree and duration of weakness, fair chance no major improvement is seen after adequate decompression, but gives the best chance if not improving with time and PT. Fair chance suboptimal outcome no matter what is done.

Im generally more aggressive in recs for active healthy patient with dominant hand weakness

 

[PinchandBurn]

What’s the consensus on upper extremity weakness? Multilevel cervical stenosis with no upper extremity pain only weakness. Weakness has plateaued. Surgery would likely require multiple fusion. Weakness on dominant side. Hasn’t had EMG yet but I think it’s clearly radicular. Has anyone had success with cervical esi? I believe I’ve tried it in the past with varying success.

The textbook answer is surgery. Additionally I have seen patients do very well after surgery.


However , if it were me. I would want an esi. Why? 10 years ago. Patient had legit foot drop. Sent to surgeon. Surgeon didn't operate as patient had medicaid. I gave medrol dosepak. Weakness and foot drop went away....

 

[Dr. Ice]

Thanks all..interesting case. This guy is likely looking at a 4 level fusion based on anatomy and I’m doubtful he will do it. He’s apparently also getting some slow improvement with PT

 

[Taus]

The textbook answer is surgery. Additionally I have seen patients do very well after surgery.


However , if it were me. I would want an esi. Why? 10 years ago. Patient had legit foot drop. Sent to surgeon. Surgeon didn't operate as patient had medicaid. I gave medrol dosepak. Weakness and foot drop went away....

Yeah, it happens. But its still rolling the dice. I would have them empirically on PO steroids as well. Depends how open to living with the consequences patient is if it doesn’t work out in their favor. Most done like risk permanent weakness. I think, however these typically declare them self by the time they get MRI, get on PO steroid, have consult, pending surgery for 1-3 weeks out.

 

[Taus]

Thanks all..interesting case. This guy is likely looking at a 4 level fusion based on anatomy and I’m doubtful he will do it. He’s apparently also getting some slow improvement with PT

Ugh. That sucks re needing 4 level. If no pain and slowly improving, I would encourage to stay the course, but also get the consultation to be fully armed with all the information and have things teed up in case needed.

 

[Doctodd]

Need more info on MRI. Yes weakness and atrophy from an extrusion or HNP happens and sometimes resolves after the acute incident resolves. I’ve had success with epidural PRP after surgery for foot drop and arm weakness after everything else failed, even more than a year out.

 

[PinchandBurn]

Need more info on MRI. Yes weakness and atrophy from an extrusion or HNP happens and sometimes resolves after the acute incident resolves. I’ve had success with epidural PRP after surgery for foot drop and arm weakness after everything else failed, even more than a year out.

How are u doing this?

Abn?

Cash obviously?

 

[Dr. Ice]

I recommended he consider further PT and monitor progress. He had an EMG and somehow the neurologist diagnosed with “C3 bruising.” 🙈 How an isolated C3 lesion can be identified on EMG is beyond me, but apparently the neurologist is board certified in EMG. Maybe I just don’t have the credentials to understand it. Hopefully the spine surgeon recommends another EMG. Agree with Taus, monitor progress but have a new patient consult under the belt in case needing surgical intervention.

I advised against injection but seems like people are saying there has been some positive benefit from CS injectable and oral….

 

[Baron Samedi]

Post the EMG report

 

[Dr. Ice]

Post the EMG report

Don’t have access to it. Whatever I can gather I’ll post on here

 

[MD87]

You wouldn’t get surgery for significant weakness that isn’t improving or worsening?

Worsening, yes.
Not improving? Unsure. Surgery is no guarantee to actually result in improvement. Literature for observation versus surgery doesn’t indicate surgery is a home run

 

[bedrock]

If you look at the rationale for ESI doing an ESI for only weakness and no pain does not make sense. I could go on but the short answer is no for CESI on this patient.

I recommended he consider further PT and monitor progress. He had an EMG and somehow the neurologist diagnosed with “C3 bruising.” 🙈 How an isolated C3 lesion can be identified on EMG is beyond me, but apparently the neurologist is board certified in EMG. Maybe I just don’t have the credentials to understand it. Hopefully the spine surgeon recommends another EMG. Agree with Taus, monitor progress but have a new patient consult under the belt in case needing surgical intervention.

I advised against injection but seems like people are saying there has been some positive benefit from CS injectable and oral….

I’m not understanding why people here won’t just try a single unilateral CESI for his unilateral weakness? Is the patient on blood thinners?
In this vague situation the CESI may provide some diagnostic and therapeutic information. And I’ve certainly seen it improve strength in situations like these.

If I was you, I’d simultaneously proceed to a unilateral CESI, and order a repeat EMG (but from a university physician this time, as the previous EMG is total crap). You can’t diagnose “C3 bruising” on EMG.

After both things you might have an improved patient and you’ll have better information to make the more challenging decision regarding surgery.

 

[JBM16BYU]

Agree with former posts on repeat EMG.

 

[Dr. Ice]

Not on blood thinners. I believe I have some prior success with this entity with injections but has never been a home run. That being said, might be worth the try

 

[GoBeers]

How does steroids help weakness from severe impingement? I'd send to surgeon

 

[bedrock]

Not on blood thinners. I believe I have some prior success with this entity with injections but has never been a home run. That being said, might be worth the try

I've definitely had multiple patients with painless weakness (though often but not always accompanied by some numbness in the hands) that improve significantly after CESI. Though it does help if you direct the medication to the foramina, so it goes where it is needed.

 

[Dr. Ice]

Looking back, apparently this topic was discussed on here in 2011. There were also no real answers at that time either lol

 

[MitchLevi]

If you can inject the pt tomorrow or the next few days, do it. It should take place simultaneously with a referral IMO.

Not gonna hurt the pt to try it.

Stable weakness. Not progressing.

Highly unlikely it will do anything, but so what? I'd want to try it if I'm the pt.

Document UE radic and try the shot IMO.

Just make sure they see a surgeon in the next 2-4 weeks and they show up with a new EMG too.

 

[clubdeac]

surprised so many people on here advocate CSI for painless weakness. Is this recommended in any major society published guidelines? Any actual data on this? I really think it's an exercise in futility and would definitely put you at an increased legal risk should anything go wrong. I'd just send to surgeon and let him make the call. if he doesn't want to operate and says try a shot then do it. At least it'll be on him should legal get involved.

 

[MitchLevi]

Not sure legal risk should be a part of this discussion TBH. I think this entire case is much ado about nothing, at least from a spine perspective.

We've all injected pts with stenosis who have single extremity weakness. It isn't the worst idea in the world, and that's whether they're painful or not.

Certainly defensible in the court of law.

Probably won't work, but isn't necessarily wrong. I'd want to try it in a similar situation.

 

[MD87]

Is anyone injecting patients with APB weakness instead of telling them “live with it or get CTS surgery?”

I get that spine surgery is a bigger ordeal than CTS surgery but still. Can’t wrap my mind around how this could help anyone, even if ESI is a safe procedure.

 

[bedrock]

Is anyone injecting patients with APB weakness instead of telling them “live with it or get CTS surgery?”

I get that spine surgery is a bigger ordeal than CTS surgery but still. Can’t wrap my mind around how this could help anyone, even if ESI is a safe procedure.

There are plenty of elderly patients with only weakness as symptom of PTS. Most get surgery, but I know a surgeon who will inject them first if weakness is mild.

I’m surprised that you’ve never had a patient with painless weakness that has improved at least 50% after ESI?
I’ve seen this multiple times particularly in elderly patients for whom surgeons are trying to avoid surgery due to anesthesia risk.

 

[lobelsteve]

I would never inject painless weakness. This would be a clear loser if there were complications. Can anyone find the articles or guidelines showing this works? Not on my mom.

 

[Ducttape]

i could not find any articles on pubmed, if thats what you were getting at...

 

[Baron Samedi]

We are Pain Management not Weakness Management.

 

[SSdoc33]

if this is a radiculopathy and not myelopathy (unclear from the description and lack of MRI results) then the weakness often gets better on its own.

how do you know if its the shot?

i probably wouldnt offer a CESI, and definitely not if there was concomitant severe central stenosis.

the issue here is that b/c there is multilevel NF stenosis, the surgeon doesnt know where to go and would just decompress and fuse everything. a good electromyographer can give you the exact level and nerve involved. might be able to get away with a simple, 1 level unilateral foraminotomy or laminoforaminotomy

 

[Baron Samedi]

if this is a radiculopathy and not myelopathy (unclear from the description and lack of MRI results) then the weakness often gets better on its own.

how do you know if its the shot?

i probably wouldnt offer a CESI, and definitely not if there was concomitant central stenosis.

the issue here is that b/c there is multilevel NF stenosis, the surgeon doesnt know where to go and would just decompress and fuse everything. a good electromyographer can give you the exact level and nerve involved. might be able to get away with a simple unilateral foraminotomy or laminoforaminotomy

It sounds like pt has whole limb involvement, not myotomal. They either have multilevel chronic radiculopathy (unlikely) or something else entirely (more likely).

The only way someone is calling a C3 radic is based on cervical paraspinal muscle abnormal spontaneous activity -- which is even more concerning for something bad (read: ALS) in the context of the presenting symptoms.

Really curious to see that full report.

 

[SSdoc33]

It sounds like pt has whole limb involvement, not myotomal. They either have multilevel chronic radiculopathy (unlikely) or something else entirely (more likely).

The only way someone is calling a C3 radic is based on cervical paraspinal muscle abnormal spontaneous activity -- which is even more concerning for something bad (read: ALS) in the context of the presenting symptoms.

Really curious to see that full report.

yeah.

need the particulars of the EMG report, MRI, physical exam.

i think it is a single level radic from the description given

 

[ghost800]

Hey guys for my practice if I have a patient with new onset or progressive upper extremity weakness (painless or otherwise), I would first refer to neurosurgery for evaluation before proceeding with CESI, and manage any pain with appropriate medications. That being said, I’ll often times have the patient referred back from them for a trial of CESI. Sometimes the weakness will improve significantly with the injection thereby postponing or avoiding an ACDF altogether.

 

[nynydoc]

Hey guys for my practice if I have a patient with new onset or progressive upper extremity weakness (painless or otherwise), I would first refer to neurosurgery for evaluation before proceeding with CESI, and manage any pain with appropriate medications. That being said, I’ll often times have the patient referred back from them for a trial of CESI. Sometimes the weakness will improve significantly with the injection thereby postponing or avoiding an ACDF altogether.

Agreed. Medicolegally, I will send to surgery and maybe get EMG to evaluate for active denervation. More often than not, a surgeon will say to try CESI first but if I have documented active fibs prior to CESI and the patient makes an informed decision forward to avoid surgery, I feel that I did my due diligence to work the patient up.

The flip side is doing a CESI with documented weakness which gives enough ammo for a lawsuit for not working the patient up and referring to surgery.

 

[Taus]

Agreed. Medicolegally, I will send to surgery and maybe get EMG to evaluate for active denervation. More often than not, a surgeon will say to try CESI first but if I have documented active fibs prior to CESI and the patient makes an informed decision forward to avoid surgery, I feel that I did my due diligence to work the patient up.

The flip side is doing a CESI with documented weakness which gives enough ammo for a lawsuit for not working the patient up and referring to surgery.

Not sure what difference fibs vs no fibs makes here other than the pattern confirming the pathology is spinal in origin. Radic with motor deficit + fibs on emg vs same clinical picture but no fibs gets treated differently? Please explain.

 

[Dr. Ice]

Sorry, patient lives in Delaware. I basically just did a curb side consult over the phone prior to him meeting with a surgeon. I don’t have EMG. He is claiming one day of pain and then pain was gone and he was left with weakness. Weakness involves predominantly triceps. He was apparently ruled out for ALS and parsonage turner but person doing EMG seems fishy.

Exact clinical presentation aside, if he is ruled out for other neurological issues and working dx is spinal in origin, the question I raised is how many would just try one ESI prior to consideration of surgery vs continued time and PT.

 

[MitchLevi]

View attachment 376230
Sorry, patient lives in Delaware. I basically just did a curb side consult over the phone prior to him meeting with a surgeon. I don’t have EMG. He is claiming one day of pain and then pain was gone and he was left with weakness. Weakness involves predominantly triceps. He was apparently ruled out for ALS and parsonage turner but person doing EMG seems fishy.

Exact clinical presentation aside, if he is ruled out for other neurological issues and working dx is spinal in origin, the question I rai how many would just try one ESI prior to consideration of surgery vs continued time and PT.

Sheesh...Tight canal. Not sure I'd do it unless the surgeon saw the pt 1st.

That's a tight canal and liquid is non compressible.

Which arm is weak? Right triceps is good. Is it left?

 

[SSdoc33]

View attachment 376230
Sorry, patient lives in Delaware. I basically just did a curb side consult over the phone prior to him meeting with a surgeon. I don’t have EMG. He is claiming one day of pain and then pain was gone and he was left with weakness. Weakness involves predominantly triceps. He was apparently ruled out for ALS and parsonage turner but person doing EMG seems fishy.

Exact clinical presentation aside, if he is ruled out for other neurological issues and working dx is spinal in origin, the question I raised is how many would just try one ESI prior to consideration of surgery vs continued time and PT.

He has myeloradiculopathy. Surgery, no shots.

Emg findings dont change the plan. Fibs and psw can stay positive for years. Only reason to repeat EMG is to r/o parsonage turner, which shouldnt be that hard.

 

[Ducttape]

even if you did an injection, it is highly unlikely that the medication is going to seep its way up to C45, let alone C34.

surgery.

if spine says no surgery - not sure how many surgeons would be excited for essentially 3 level fusion, then you could try a C7T1 esi.

the steroid effect will make him all better.................

 

[Dr. Ice]

even if you did an injection, it is highly unlikely that the medication is going to seep its way up to C45, let alone C34.

surgery.

if spine says no surgery - not sure how many surgeons would be excited for essentially 3 level fusion, then you could try a C7T1 esi.

the steroid effect will make him all better.................

I was thinking it might be more like a 4 level fusion..yeah agree. Told him to get more than 1 surgical opinion. Unfortunately looking like not a favorable outcome regardless. I guess surgery would be more “preventative” in this case. Spondylitic myelopathy + fall or trauma = no bueno

 

[SSdoc33]

I was thinking it might be more like a 4 level fusion..yeah agree. Told him to get more than 1 surgical opinion. Unfortunately looking like not a favorable outcome regardless. I guess surgery would be more “preventative” in this case. Spondylitic myelopathy + fall or trauma = no bueno

right. the surgery would be to stabilize and halt progression. lots of surgeons opt to a posterior laminoplasty in this situation.

 

[TIVAndy]

View attachment 376230
Sorry, patient lives in Delaware. I basically just did a curb side consult over the phone prior to him meeting with a surgeon. I don’t have EMG. He is claiming one day of pain and then pain was gone and he was left with weakness. Weakness involves predominantly triceps. He was apparently ruled out for ALS and parsonage turner but person doing EMG seems fishy.

Exact clinical presentation aside, if he is ruled out for other neurological issues and working dx is spinal in origin, the question I raised is how many would just try one ESI prior to consideration of surgery vs continued time and PT.

might want to edit this photo to cut out the bottom -
hipaa violation