Interlaminar ESI Injectate Question

[SSdoc33]

lot of people advocating ESIs for back pain

severe stenosis: maybe. moderate? no.

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[bedrock]

lot of people advocating ESIs for back pain

severe stenosis: maybe. moderate? no.

Why?

What other magic treatment can you offer for moderate stenosis?

 

[MitchLevi]

Why?

What other magic treatment can you offer for moderate stenosis?

Magic MILD

 

[bedrock]

Magic MILD

Lol.

 

[Ferrismonk]

It seems to me that evidence-based medicine and established guidelines don't seem to matter much in this thread.

 

[deleted875186]

lot of people advocating ESIs for back pain

severe stenosis: maybe. moderate? no.

I do LESI for moderate or severe central canal stenosis if clear neurogenic claudication symptoms, seem to get good results as noted above, many months of pain relief from depomedrol.

 

[SSdoc33]

I do LESI for moderate or severe central canal stenosis if clear neurogenic claudication symptoms, seem to get good results as noted above, many months of pain relief from depomedrol.

yeah, with LEG pain. thats not the issue

 

[SSdoc33]

what did Greenspan call it? Irrational exurberance?

your shots dont work as well as you think they do, so we should at least try to give them for the appropriate indications?

what do you do for moderate stenosis with back pain that doesnt respond to mbb or therapy? more therapy or weight loss. we dont have interventional treatments that help everyone

 

[deleted875186]

yeah, with LEG pain. thats not the issue

Sure, radiation into the thighs, I do it for cramping pain in the low back with walking with a history consistent with claudication, are people not doing a LESI for cramping pain in the back while walking?

 

[Ferrismonk]

I only do a LESI/TFESI for radicular symptoms. Never axial back.

SS with neurogenic claudication in the legs is fine.

 

[SSdoc33]

Sure, radiation into the thighs, I do it for cramping pain in the low back with walking with a history consistent with claudication, are people not doing a LESI for cramping pain in the back while walking?

thats not claudication.

that back pain with walking. claudication is leg pain with walking

you can call it "cramping", i guess...

 

[deleted875186]

thats not claudication.

that back pain with walking. claudication is leg pain with walking

you can call it "cramping", i guess...

Would be interested to hear other peoples experience.

I would have to agree with bedrock. Back pain while walking, mod-severe canal stenosis, if it’s not neurogenic claudication then what is it. Facet interventions seem to always fail in this group, occasionally I’ll find SOJ dysfunction, but otherwise LESI typically offers many months of pain relief in my experience.

 

[GoBeers]

Would be interested to hear other peoples experience.

I would have to agree with bedrock. Back pain while walking, mod-severe canal stenosis, if it’s not neurogenic claudication then what is it. Facet interventions seem to always fail in this group, occasionally I’ll find SOJ dysfunction, but otherwise LESI typically offers many months of pain relief in my experience.

Hmm... I see the reverse results. Part of spinal stenosis pathophysiology is the ongoing development of facet hypertrophy. so there has to be some level of clinically significant facet arthropathy going on. So for me, people with spinal stenosis with back pain have responded well to MBB/RFA thankfully.

 

[jsaul]

I want to know one thing
For all you depomedrol useers

My question to all you is...

Where do you buy the med????
I can barely find it

 

[MitchLevi]

Hmm... I see the reverse results. Part of spinal stenosis pathophysiology is the ongoing development of facet hypertrophy. so there has to be some level of clinically significant facet arthropathy going on. So for me, people with spinal stenosis with back pain have responded well to MBB/RFA thankfully.

Yeah...All of us know this.

I also have pts who fail MBB/RFA despite significant facet disease and well-performed RFA.

Doing an ILESI will occasionally salvage that pt and prevent the surgery referral.

Those of you saying no ILESI in this scenario wouldn't want your mother treated this way.

 

[lobelsteve]

Yeah...All of us know this.

I also have pts who fail MBB/RFA despite significant facet disease and well-performed RFA.

Doing an ILESI will occasionally salvage that pt and prevent the surgery referral.

Those of you saying no ILESI in this scenario wouldn't want your mother treated this way.

No esi for axial back pain. I wouldn’t want my mom having the risk of the procedure based on those symptoms. And having or not having an epidural does not equate to sending for surgery.

 

[GoBeers]

Yeah...All of us know this.

I also have pts who fail MBB/RFA despite significant facet disease and well-performed RFA.

Doing an ILESI will occasionally salvage that pt and prevent the surgery referral.

Those of you saying no ILESI in this scenario wouldn't want your mother treated this way.

it was a response to dipriman's interest in other people's experience. he said mbb's don't work for his patients; fortunately mine do.

 

[RoloTomassi]

Would be interested to hear other peoples experience.

I would have to agree with bedrock. Back pain while walking, mod-severe canal stenosis, if it’s not neurogenic claudication then what is it. Facet interventions seem to always fail in this group, occasionally I’ll find SOJ dysfunction, but otherwise LESI typically offers many months of pain relief in my experience.

If they have Modic changes, Intracept. If they don't, it might be discogenic, especially if listhesis present. Month long response to ESI and pain with walking do not mean it's not vertebrogenic/discogenic pain.

Or maybe your RFA lesions aren't big enough.

 

[RoloTomassi]

Curious...ESI for LBP with mod stenosis peeps: y'all confident enough that it's the stenosis you're treating to do Vertiflex/mild (assuming you think those are legitimate treatments)?

 

[MitchLevi]

No esi for axial back pain. I wouldn’t want my mom having the risk of the procedure based on those symptoms. And having or not having an epidural does not equate to sending for surgery.

Given the risk of an ILESI is on par with that of a heart transplant, I understand your hesitancy.

If an IL yields 2-4 months of less pain it definitely equates to no referral, at least not right now. Meanwhile you can do more PT, optimize meds, etc.

 

[runfastnow]

Anecdotally (n=11) I have been impressed with MILD. Very selective with population though.

I counsel my patients extensively about what the procedure can/can't do and that the best evidence is for functional improvement not necessarily pain relief. So far I've had 10/11 be moderately to very happy with it and the one remaining still have 10-15 minutes improved standing time.

It isn't some magic wand, but when I have a patient with single level mod/severe central stenosis with huge LF failed ILESI and appropriate PT or too sick for surgery (I am in the heart of the Diabetes Belt) ... I'll offer it to them and almost all are happy to try it before surgery. People who demand 100% relief I give them realistic expectations or guide them away from it.

It seems to be helping people so I'll keep it up. *shrug*

 

[MitchLevi]

Curious...ESI for LBP with mod stenosis peeps: y'all confident enough that it's the stenosis you're treating to do Vertiflex/mild (assuming you think those are legitimate treatments)?

I'm more in the severe crowd, but I've injected moderate if the pt has failed MBB/RFA.

I've done 2 MILD cases, and as of last week both got surgery anyways, and neither MRI was changed in any way despite my pulling out large amounts of LF. That procedure will not remove the ligament that has adhered to the dura.

I will not be doing any more MILD any time soon.

Vertiflex is not in my inventory.

 

[AGDOC09]

If a patient has axial-ish low back pain and severe central canal stenosis with failed MBB I think an ILESI is reasonable. Mainly bc I think patients often fail to recognize some of the subtler symptoms of radiculopathy or it can be overshadowed by their severe low back pain. Often if you take the time to talk to them longer it’ll come out that yes they have leg cramping, sensory deficits or some subtle dermatomal pain.

All that being said, I think we also tend to completely miss good old fashioned hip OA in patients with axial back pain. See it missed alllllllll the time. Even weight bearing X-rays dramatically underestimate it and if only the backside of the joint is arthritic they won’t have any groin pain. Good hip exam and a CT are your friends in this group

 

[callmeanesthesia]

I’m thinking a lot of the attitudes on this must have to do with how good your local surgeons are. If they’ll do a 3 level fusion on anything with a pulse then of course you’d do anything, even MILD, Vertiflex, or Minuteman, to keep patients away. If I have someone with severe one-level stenosis who only gets 2 months relief from an epidural, I send them to the surgeon to have a conversation and see if they’re a laminectomy candidate. Even if the patient would require a more invasive surgery, I still send them for a consult so they have their options on the table, because I know the surgeon won’t operate unless he really feels benefit>risk for the patient.

 

[pmrmd]

I don’t think it’s typical to have axial pain respond well to ESI if they have moderate stenosis. There have been a few.

The only absolutely true statement is that there are no absolutes in medicine.

 

[lobelsteve]

Given the risk of an ILESI is on par with that of a heart transplant, I understand your hesitancy.

If an IL yields 2-4 months of less pain it definitely equates to no referral, at least not right now. Meanwhile you can do more PT, optimize meds, etc.

You mean your PA can do that.

 

[MitchLevi]

You mean your PA can do that.

A PA surely can send someone for PT...Yes.

You can argue against the role of the APP all you want, but the entire healthcare system requires their existence. We do not have enough doctors to see every pt, and not every pt needs a doctor.