Input for Difficult Case

[docnyc]

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Hi Everyone,

I would like some thoughts on a difficult case I saw today. 82 yo male who underwent L4-S1 fusion 5 years ago for unstable spondy. Was doing well until last yr when he started to develop severe right anterior thigh pain and some weakness. Imaging showed spondy grade 3 above prior fusion site at L2-3. Patinet was taken by surgeon in for revision of his fusion, old hard ware removed is now fused from L2 to Sacrum.

Patient doing fine post op for 3 weeks, right thigh pain has resolved. However he then starts to develop excruciating left lower lumbar pain. Surgeon thought it may be sacroiliac joint irritation, had him sent to for SI joint injection, no relief. Tried L2, L3 TFESI no real relief. Imaging shows screws are intact no displacement. He saw another doc in the community for injection who knows what he is doing. Surgeon was asked me to see him to see if I have any other thoughts. He is a reliable surgeon who does good work and also sends me a lot of referrals (I was on vacation when he sent to other doc).

On exam patient is exquisitely in the left L5 area approximate 3 cm lateral of midline. Wheel chair bound, can stand and pain is actually better when he stands, its worse when he sits or is supine. Rolling over is extremely painful.

No spinal percussion tenderness, some pain with palpation over the left approxiamte L5-S1 facet level, SI joint not really tender. I ask him to point out pain and it is actually more lateral overlying oblique muscles. He can barely tolerate touch to the area as even skin is painful.

Imaging shows no sign of discitis, CT shows intact hardware. CT myelogram shows what is expected, no red flags.

He has tried all meds, no relief. I try a TPI in the area and deliberately flood the area with anesthetic just to see if he is numb if he will get any relief. I inject all tender points generously with lidocaine. No relief.

One consideration is hardware related pain, however he was so thin, I actually was able to palapate his lower pedicle screw and I also injected over that area. No relief either.

Any thoughts?

 

[101N]

Hi Everyone,

I would like some thoughts on a difficult case I saw today. 82 yo male who underwent L4-S1 fusion 5 years ago for unstable spondy. Was doing well until last yr when he started to develop severe right anterior thigh pain and some weakness. Imaging showed spondy grade 3 above prior fusion site at L2-3. Patinet was taken by surgeon in for revision of his fusion, old hard ware removed is now fused from L2 to Sacrum.

Patient doing fine post op for 3 weeks, right thigh pain has resolved. However he then starts to develop excruciating left lower lumbar pain. Surgeon thought it may be sacroiliac joint irritation, had him sent to for SI joint injection, no relief. Tried L2, L3 TFESI no real relief. Imaging shows screws are intact no displacement. He saw another doc in the community for injection who knows what he is doing. Surgeon was asked me to see him to see if I have any other thoughts. He is a reliable surgeon who does good work and also sends me a lot of referrals (I was on vacation when he sent to other doc).

On exam patient is exquisitely in the left L5 area approximate 3 cm lateral of midline. Wheel chair bound, can stand and pain is actually better when he stands, its worse when he sits or is supine. Rolling over is extremely painful.

No spinal percussion tenderness, some pain with palpation over the left approxiamte L5-S1 facet level, SI joint not really tender. I ask him to point out pain and it is actually more lateral overlying oblique muscles. He can barely tolerate touch to the area as even skin is painful.

Imaging shows no sign of discitis, CT shows intact hardware. CT myelogram shows what is expected, no red flags.

He has tried all meds, no relief. I try a TPI in the area and deliberately flood the area with anesthetic just to see if he is numb if he will get any relief. I inject all tender points generously with lidocaine. No relief.

One consideration is hardware related pain, however he was so thin, I actually was able to palapate his lower pedicle screw and I also injected over that area. No relief either.

Any thoughts?

Bone scan. Doesn't make sense.

 

[Ligament]

Agree with bone scan. Could do F18 bone tomogram to get more specific.

Willing to bet his SI joint injection was poorly done. Did you review the injection images? Was there an optimal arthrogram? I'd repeat the SIJ block if you are not absolutely convinced the first one was great.

Seems like your workup is great so far. Best of luck!

 

[hyperalgesia]

I'm sure you would have mentioned erythema or WBCs.

It could be a scar neuroma or some hardware/nerve issue that is referring pain superficially. Wondering if a TENS unit helps or hurts. Even though the field block didn't work I still might try lidoderm patch. But... probably hardware related unfortunately...

 

[pmrmd]

Reminds me of a patient of mine not long ago, an older lady who fell and was worked up in some E.D. somewhere No fractures noted in any of the imaging. The lady is pointing RIGHT THERE at L5. Excruciating pain. Kind of all-over tender and she has Alzheimer's so she can't remember she told me she fell one minute after she told me she fell. So the CT I order shows 90% burst fracture of L1 with retropulsion into the canal. Amazing she can walk let alone keep her panties dry. I guess the point is to look higher.

 

[facets]

Try mbb above the fusion, these facets always go bad. PT done already? Pensaid cream or flextor patch? I have gotten good relief with back pain as a last resort with SCS, St Judes penta lead, awesome coverage of anything below the waist. At 82, he should not be sibjected to another spine surgery and probably should not have had the first one. Not on my momma

 

[caedmon]

How far out again from surgery? If the CT scan is unremarkable, I'm not sure if a bone scan will help or add to the confusion as there is likely still bone turnover ongoing from the procedure.

 

[joshmir]

Please clarify

Did the field block result in numbness over the painful area ?

If so , what you're saying is the pain was unchanged ?


TENS feel good or bad?



Would psoas or ql spasm refer in this way? I doubt it. The allodynia is the weird thing; subq Botox in a field block area works for the allodynia of PHN and crps?

I'd max out antineuropathics , consider ketamine or lidocaine infusions....

He's 82. Shouldn't he be on named anywYs?

 

[joshmir]

Namenda anyways?

 

[SSdoc33]

my advice? you could always find SOMETHING else to inject. dont. no more shots.

 

[101N]

my advice? you could always find SOMETHING else to inject. dont. no more shots.

1+

Reminds me of an old guy with a spondy that I admitted about a week post op L4/5 PLIF. Pain all over. Sed rate up, bone scanned him and got bupka. I was certain it was discitis or CA. Turned out to be a gout flair.

 

[lovebailey2001]

Plz rule out QL spasm, coz superficial Trigger Point below 12th rib may refer pain at Iliac crest, also pain is better on standing and worse by rolling (P.Raj, Int. Pain Manangement)

 

[mille125]

Plz rule out QL spasm, coz superficial Trigger Point below 12th rib may refer pain at Iliac crest, also pain is better on standing and worse by rolling (P.Raj, Int. Pain Manangement)

why not SCS trial

 

[lobelsteve]

why not SCS trial

Back pain without leg pain.

 

[Ligament]

Plz rule out QL spasm, coz superficial Trigger Point below 12th rib may refer pain at Iliac crest, also pain is better on standing and worse by rolling (P.Raj, Int. Pain Manangement)

Yes this happens in the elderly. Called 12th rib syndrome in the literature, there are a couple papers on it over the decades.

 

[101N]

Yes this happens in the elderly. Called 12th rib syndrome in the literature, there are a couple papers on it over the decades.

I'm thinking zebra...

 

[mille125]

Back pain without leg pain.

my bad, i misread (thought is said L5 radiculopathy)...make sure that you have rule out psychological cause the best that you can...what is going on at home?

 

[lovebailey2001]

Yes this happens in the elderly. Called 12th rib syndrome in the literature, there are a couple papers on it over the decades.

No Sir, I was talking abt Quadratus Lumborum Spasm, which has got 4 TrP, 2 superficial & 2 Deep. The first Super Ficial one is 5-6 lateral to L-1 spine, just below 12 rib, which refers pain to the Iliac crest.
The 12th Rib Syndrome usually present with Loin Pain & provoked by stimulation of tip of 12th or 11th rib and their costal cartilage.

 

[Ligament]

No Sir, I was talking abt Quadratus Lumborum Spasm, which has got 4 TrP, 2 superficial & 2 Deep. The first Super Ficial one is 5-6 lateral to L-1 spine, just below 12 rib, which refers pain to the Iliac crest.
The 12th Rib Syndrome usually present with Loin Pain & provoked by stimulation of tip of 12th or 11th rib and their costal cartilage.

I stand corrected 🙂

 

[facets]

Back pain without leg pain.

I have tried SCS as a very last resort with back pain and recieved surprisingly good results with st judes penta lead, 20 electrodes 4 across to get the back fibers that are more lateral, it has been a Godsend in some of my hopeless patients where EVERYTHING else has been tried and failed. One came in, kissed me, and said it was the first time in 35 years that she woke up without back pain😍 On these days, I think it may almost be worth it to be a doctor, almost, with BO in charge I'm still considering moving abroad

 

[lobelsteve]

I have tried SCS as a very last resort with back pain and recieved surprisingly good results with st judes penta lead, 20 electrodes 4 across to get the back fibers that are more lateral, it has been a Godsend in some of my hopeless patients where EVERYTHING else has been tried and failed. One came in, kissed me, and said it was the first time in 35 years that she woke up without back pain😍 On these days, I think it may almost be worth it to be a doctor, almost, with BO in charge I'm still considering moving abroad

Getting stim is not that hard, keeping stim in the axial low back after 4-6 months proves quite difficult. I am aware of Holsheimer's data and the recent poster from Rosenberg in Myrtle Beach. Transverse tripole has been around for several years and the penta is helpful in maintaining the stim in select patients. The Epiducer from St Jude will be a game changer and allow us to put in S8 paddle's and a pair of quads without a lami. It will be 2 years until we really know if it works (I distrust Rosenberg's data implicitly). But now we can try and pull those leads if it doesn't do what the patient needs. Cost containment will always be a big issue for SCS.

I'll be doing my first few Epiducer cases in the next 30 days.

 

[facets]

Getting stim is not that hard, keeping stim in the axial low back after 4-6 months proves quite difficult. I am aware of Holsheimer's data and the recent poster from Rosenberg in Myrtle Beach. Transverse tripole has been around for several years and the penta is helpful in maintaining the stim in select patients. The Epiducer from St Jude will be a game changer and allow us to put in S8 paddle's and a pair of quads without a lami. It will be 2 years until we really know if it works (I distrust Rosenberg's data implicitly). But now we can try and pull those leads if it doesn't do what the patient needs. Cost containment will always be a big issue for SCS.

I'll be doing my first few Epiducer cases in the next 30 days.

Please let us know how these do

 

[101N]

Getting stim is not that hard, keeping stim in the axial low back after 4-6 months proves quite difficult.

It's one thing to capture the back with a paresthesia and another thing to provide pain relief. At the last NANS meeting Richter had a nice little poster
- N of 5 - describing EMG activity in the paraspinals during intra-op testing with the Penta. All 5 of his patients had good paraspinal activity during testing. However, capture is not a guarantee of pain relief.

Now Nevro is claiming that you don't even need a paresthesia with their burst system. We are going to see a lot of mission creep with implants being done
for back pain as a result of all of this speculation.

1. Low back paresthesia coverage with lateral programming of five-column paddle leads. Richter, E et al. NANS, poster, 2010.

 

[hyperalgesia]

I have tried SCS as a very last resort with back pain and recieved surprisingly good results with st judes penta lead, 20 electrodes 4 across to get the back fibers that are more lateral...

Are the leads subcutaneous or epidural? Just curious.
I've replaced subcutaneous arrays before when someone else put them in and they were apparently working. But I've never put them in primarily.

 

[101N]

Are the leads subcutaneous or epidural? Just curious.
I've replaced subcutaneous arrays before when someone else put them in and they were apparently working. But I've never put them in primarily.

The Penta is an epidural paddle.

 

[SSdoc33]

call me crazy, but i dont believe in SCS for back pain, especially failed back surgery backs. if there is good data and a proven method, then maybe until then, do these guys/gals really need another surgery and no MRIs ever again? for a procedure which never seems to give pain relief for more than a coupla months?

 

[docnyc]

Thanks for the input everyone. I apologize for the late reply.

WBC: Normal

Bone Scan: (4 months after surgery)
"Whole body bone scan demonstrates increased activity throughout the lower 4 lumbar vertebrae, particularly in the second and third. This may represent a combination of postsurgical change and trauma. The sacral and sacroiliac regions appear unremarkable."

ESR is elevated (from 2 months ago) 47 (nl in this lab is 0-20)

Trigger point did make area numb in the left lower lumbar paraspinal, however he still had allodynia. And then when I asked to point where it hurts it overlied the area I had just injected.

I did recommend TENS as well on first visit. Not sure if they have followed thru on this rec yet.

Patient had repeat myelogram ordered by second opinion surgeon last week:
"Posterior fusion L2 through transitional S1. Solid interbody fusion L5-S1.

Lucency at hardware/bone interface at S2 which was present to an extent on CT
from 03/27/11 but slightly increased. There is minor similar lucency
involving the pedicle screws of L3.

Mild retrolisthesis L3 on L4.

No central stenosis. Bony neural foraminal narrowing is seen, most prominent
bilaterally at L3-4 with slight retrolisthesis at this level.

There is very limited bridging bone on the left side posterolaterally across
L2-3 but otherwise fused levels appear to have solid bridging bone
posterolaterally."


If ESR is elevated, what is signficance in light of above imaging findings? The patient is currently on oral steroids and his pcp is try himing to taper him off slowly.

Thanks.