Interlaminar ESI, TFESI, or MBBs/facet injections

[gaseous_clay]

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I am not asking for advice, but I just want everyone’s opinion. You have a patient presenting with axial, non radiating low back pain with no evidence of myelopathy on exam. Exam is notable for facet loading, but MRI shows a disc bulge (or two) with some questionable stenosis without evidence of facet mediated pathology (hypertrophy, etc.). What do you do? Interlaminar ESI, bilateral TFESI, or MBBs/facet injections. We are already assuming they have failed PT and NSAIDs prior to getting to your doorstep.

 

[NJPAIN]

Age?
Pain provocation sitting vs standing?

 

[DOctorJay]

I'd start with MBBs based on the patient's complaint and facet loading reproducing symptoms.

 

[paindoc007]

PT...

But injection wise, yeah agree Bil MBB

 

[SSdoc33]

> 40, mbbs. < 40, no shots

 

[deleted472101]

MBB:

Dull aching stabbing at times.

increases with sitting long standing long cold damp weather, stiff in morning worse at end of day, can’t sleep on back but can sleep on side until that hurts and then they switch sides.

Chirp/PT helped a little with traction but then came back an hour later

Better with changing position, heat and recliner

Facet loading
Faber + low back
No true radicular Pain or at least no SLR
MMT 5/5
Silt

 

[gaseous_clay]

> 40, mbbs. < 40, no shots

Let’s just say they were <40 yrs and have failed all forms of conservative therapy and are not interested in being on Tylenol or NSAIDs forever. You wouldn’t do any interventional therapy?

 

[gaseous_clay]

Age?
Pain provocation sitting vs standing?

For argument’s sake, <40 and standing.

 

[deleted131481]

They're young, I'd try facet injections before mbb and repeat if 3 mo relief and they were satisfied.

 

[Orin]

These are folks that I consider doing MBBs/IA injections with long acting LA +/- low dose steroids for if they're actively working with a PT that I trust.

I suspect they're hitting a wall with the exercises and are not maximally engaging. The injections are to assist in their ability to work with PT.

Also, trial of duloxetine for chronic MSK pain

 

[SSdoc33]

For argument’s sake, <40 and standing.

without any MVA or trauma, i probably wouldnt inject. i MAY try B 4-5 and 5-1 intra-articular facets with steroids with a low expectation bar, but honestly i probably wouldnt inject

 

[Ferrismonk]

ESI only for radicular pain. I'd stick with facets/MBB.

 

[emd123]

I am not asking for advice, but I just want everyone’s opinion. You have a patient presenting with axial, non radiating low back pain with no evidence of myelopathy on exam. Exam is notable for facet loading, but MRI shows a disc bulge (or two) with some questionable stenosis without evidence of facet mediated pathology (hypertrophy, etc.). What do you do? Interlaminar ESI, bilateral TFESI, or MBBs/facet injections. We are already assuming they have failed PT and NSAIDs prior to getting to your doorstep.

If axial without radicular symptoms, then start with MBB.

You can have facet pain without obvious facet pathology on MRI.
If negative MBB, consider SIJ.

 

[SSdoc33]

algorithms are for suckers, nurses, or insurance companies.

make your own decisions on a case by case basis.

with the current info, a shot is unlikely to help

 

[NOSfan]

Treat the patient secondary to your clinical findings (H/P & Exam & imaging +/- facet arthropathy) do not treat the picture (DDD, stenosis, bulging....etc.). There is a high prevalance of lumbar 'findings' in asymptomatic populations.

Agree with SS........young = FJI

 

[Crybaby]

I often see youngish patients with RA or other autoimmune arthropathy that I will go ahead and inject even with fairly clean mri, works great as long as clinical symptoms are there

 

[SSdoc33]

I often see youngish patients with RA or other autoimmune arthropathy that I will go ahead and inject even with fairly clean mri, works great as long as clinical symptoms are there

sure, if they have a rheumatologic syndrome or a spondyloarthropathy. that is not the above situation

 

[gaseous_clay]

I am not asking for advice, but I just want everyone’s opinion. You have a patient presenting with axial, non radiating low back pain with no evidence of myelopathy on exam. Exam is notable for facet loading, but MRI shows a disc bulge (or two) with some questionable stenosis without evidence of facet mediated pathology (hypertrophy, etc.). What do you do? Interlaminar ESI, bilateral TFESI, or MBBs/facet injections. We are already assuming they have failed PT and NSAIDs prior to getting to your doorstep.

Same scenario as above but now with moderate stenosis seen on MRI but no radicular symptoms, just facet loading. Do you still do nothing, ESI, or facets? Once again, assume the patient has failed PT and does not want pharmacotherapy.

 

[Ducttape]

some insurances will not cover ESI without radicular symptoms.

for medicare patients, check your LCD too

 

[callmeanesthesia]

Same scenario as above but now with moderate stenosis seen on MRI but no radicular symptoms, just facet loading. Do you still do nothing, ESI, or facets? Once again, assume the patient has failed PT and does not want pharmacotherapy.

Stenosis due to what? Presumably not facet hypertrophy given the above scenario states they look ok. If the discs are degenerated enough to cause stenosis then there is some degree of mechanical stress on the facets whether they have begun to show degeneration or not (this may also apply to the original scenario presented above, though that sounded like more mild disc bulges). If there is ligamentum flavum hypertrophy then there is probably hypermobility, which could cause inflammation in the facet joints. If lipomatosis then obesity may be playing a big role in the back pain too.

 

[pmrmd]

I would try z-joints first regardless of age. Even young people get joint pain.

 

[epidural man]

Let’s just say they were <40 yrs and have failed all forms of conservative therapy and are not interested in being on Tylenol or NSAIDs forever. You wouldn’t do any interventional therapy?

I do injections on people younger than 40 every week - and it gives me heart burn. I guess the job they have makes a difference. If they ride in helicopters and Humvee's and carry 75lbs of gear all day long, I think I can justify it a little more.

However, I would say that conservative therapy has not failed...they have failed conservative therapy.

I am 100% confident that with high quality sustained physical therapy, high quality mental health and mind-body medicine class, yoga and daily aerobic exercise and high quality plant based, whole food diet - these patients wouldn't need any interventions.

 

[DrSpine]

Never let a bulge or disc dictate your exam and plan. Always go by symptoms. MRI imaging is to help facilitate your exam findings. Facet Loading pain? Most definitely MBB over TFESI/LESI. I use this for all my "gluteal pain" patients. Gluteal pain is such a murky zone that can be anything. So if positive facet loading that is characteristic of the pain - MBB. If worsened with flexion/radiation down the leg/positive straight leg raise test with negative facet loading? Consider LESI/TFESI.

>40 MBB sure.
<40? Facet Injection at best. Try PT first, if PT failed, here's a Facet Injection to help you out and facilitate that. I try not to get too gung ho with young people.

We're doctors, overall, no algorithms. Use clinical skills, judgement, and thought process. And yes, I try not to jump toward injections, especially with younger people. Big believer in PT, aerobics/yoga, good dieting, etc.

 

[lonelobo]

Never let a bulge or disc dictate your exam and plan. Always go by symptoms. MRI imaging is to help facilitate your exam findings. Facet Loading pain? Most definitely MBB over TFESI/LESI. I use this for all my "gluteal pain" patients. Gluteal pain is such a murky zone that can be anything. So if positive facet loading that is characteristic of the pain - MBB. If worsened with flexion/radiation down the leg/positive straight leg raise test with negative facet loading? Consider LESI/TFESI.

>40 MBB sure.
<40? Facet Injection at best. Try PT first, if PT failed, here's a Facet Injection to help you out and facilitate that. I try not to get too gung ho with young people.

We're doctors, overall, no algorithms. Use clinical skills, judgement, and thought process. And yes, I try not to jump toward injections, especially with younger people. Big believer in PT, aerobics/yoga, good dieting, etc.

You may be , but unfortunately a majority of the patients are not 😕

 

[paindoc007]

Never let a bulge or disc dictate your exam and plan. Always go by symptoms. MRI imaging is to help facilitate your exam findings. Facet Loading pain? Most definitely MBB over TFESI/LESI. I use this for all my "gluteal pain" patients. Gluteal pain is such a murky zone that can be anything. So if positive facet loading that is characteristic of the pain - MBB. If worsened with flexion/radiation down the leg/positive straight leg raise test with negative facet loading? Consider LESI/TFESI.

>40 MBB sure.
<40? Facet Injection at best. Try PT first, if PT failed, here's a Facet Injection to help you out and facilitate that. I try not to get too gung ho with young people.

We're doctors, overall, no algorithms. Use clinical skills, judgement, and thought process. And yes, I try not to jump toward injections, especially with younger people. Big believer in PT, aerobics/yoga, good dieting, etc.

Why bother with imaging if it never matters?
Yes, their symptoms and exam are always the most important, but incorporation of imaging findings into your assessment is impt too

 

[Dr. Ice]

Because the insurance company won’t authorize the treatment you ordered because you didn’t get the mri that they denied...‍♂️That’s why you get the mri..

 

[lobelsteve]

You get imaging to establish concordance between history, exam, and imaging. Without that, you are a drone.

 

[painfree23]

Why facets over medial branches for <40?

 

[SommeRiver]

Why facets over medial branches for <40?

Multifidus atrophy IMO

 

[No_Pain_No_Gain]

I have found that many insurance companies will not cover facet injections or MBBs unless there is documented evidence of facet disease on imaging.

 

[deleted131481]

Multifidus atrophy IMO

I learned in fellowship that repeat RF is less effective over time, so try to hold off on younger patients. Is that the experience here? And if so any idea on time span or totally variable? I haven't been out of training long enough to see enough repeat burns.

 

[nvrsumr]

You get imaging to establish concordance between history, exam, and imaging. Without that, you are a drone.

I disagree. I tell medical students every rotation history is 90% of the equation.

 

[painfree23]

I learned in fellowship that repeat RF is less effective over time, so try to hold off on younger patients. Is that the experience here? And if so any idea on time span or totally variable? I haven't been out of training long enough to see enough repeat burns.

Find it pretty variable but I do burns 1-2 times per year (if needed)

 

[lobelsteve]

I disagree. I tell medical students every rotation history is 90% of the equation.

It is for fields with objective criteria. It takes 3 for us.