Lateral Canal Stenosis: Treatment options

[lovebailey2001]

Hi! I have a patient, 45 y/ F, with lat. canal stenosis at L 4-5 level, with radiculopathy in L-4 distribution. I gave TFESI at L4-5 level and pt.'s pain was decreased to less than 50%, so I repeated TFESI after 15 days, but after 5-6 days of second intervention patient says her pain has increased and reached up to the previous level! O/E there are no red flag s/s suggesting any complicaion, pain is essentialy in the same distribution.

what are the other options left? repeat intervention? surgery??

---

Members don't see this ad.

 

[Aether2000]

Foraminotomy surgical would be the best option assuming your neurogram demonstrated ingress proximally along the exiting spinal nerve with your second injection. If the neurogram demonstrated inadequate ingress of contrast, then use of a blunt needle transforaminal or eccentric interlaminar approach may be useful.

 

[hyperalgesia]

This is unilateral pain? Could try an L4 pulsed RF as a last resort prior to considering foraminotomy.

 

[Aether2000]

Hmmmm....non-reimbursable procedure, that pulsed RF. Yes, I have seen it work in some of my patients, but am not enamored with instituting free procedures every 2-3 months. Perhaps someday we will get paid for it. In the past I would do an endoscopic foraminoplasty but the reimbursement for that went to zero also. Sigh....

 

[lovebailey2001]

Thank you both! Algos, I remember that you described a technique of Lat. recess block in some thread of SDN! can you please give the link again! shouldn't it be tried before surgery!

 

[Aether2000]

Fluoro angled 35-45 deg from the coronal plane, 16ga angiocath though the skin aiming at the neuroforamen. Sharp needle out, replaced by coude tip 20ga blunt needle that is subsequently advanced through the angiocath into the neuroforamen. Suggest mid neuroforamen after contacting the SAP. Maximum ingress is usually the medial pedicular line....
Cheers

 

[Tenesma]

if 2 good TFESIs don't make much progress, and conservative modalities have improved - then off to surgery

 

[lovebailey2001]

Fluoro angled 35-45 deg from the coronal plane, 16ga angiocath though the skin aiming at the neuroforamen. Sharp needle out, replaced by coude tip 20ga blunt needle that is subsequently advanced through the angiocath into the neuroforamen. Suggest mid neuroforamen after contacting the SAP. Maximum ingress is usually the medial pedicular line....
Cheers

Thanx! I'll try that.

 

[SleepIsGood]

Fluoro angled 35-45 deg from the coronal plane, 16ga angiocath though the skin aiming at the neuroforamen. Sharp needle out, replaced by coude tip 20ga blunt needle that is subsequently advanced through the angiocath into the neuroforamen. Suggest mid neuroforamen after contacting the SAP. Maximum ingress is usually the medial pedicular line....
Cheers

Wow. That's pretty nice.

 

[Aether2000]

Thanks sleep! The patients sometimes feels a pop when traversing the muscle fascia but otherwise no problemo and less fear of pithing the nerve. Sometimes I add an extra 5-10 deg curve to that which is already provided...

 

[Ligament]

Here is Algos' writeup from his website which he is too modest to promote;
http://algosresearch.org/Techniques/TFLRB.html

Here is my attempt at doing this procedure as a fellow:
http://forums.studentdoctor.net/showpost.php?p=5298563&postcount=24

I'm a fan of this procedure Algos, thank you. Wish the needles were not so damn expensive!

 

[lovebailey2001]

Here is Algos' writeup from his website which he is too modest to promote;
http://algosresearch.org/Techniques/TFLRB.html

Here is my attempt at doing this procedure as a fellow:
http://forums.studentdoctor.net/showpost.php?p=5298563&postcount=24

I'm a fan of this procedure Algos, thank you. Wish the needles were not so damn expensive!

Thank you Ligament and Algos!

One more dumb question- if the disc is contained, some attempt to decompress as by Dekompressor, can it be useful or not?

 

[Aether2000]

If you can find a way to get paid for a perc decompresison of a disc with concordant radiculopathy, go for it. That is the indication for the procedure. The insurers on the other hand believe there are no indications for any 62287 code (the only one that is applicable for the procedure) and increasingly believe all pain procedures have no indications.

 

[lovebailey2001]

If you can find a way to get paid for a perc decompresison of a disc with concordant radiculopathy, go for it. That is the indication for the procedure. The insurers on the other hand believe there are no indications for any 62287 code (the only one that is applicable for the procedure) and increasingly believe all pain procedures have no indications.

fortunately that's not a problem at my place! Thank you! I am going to try that coz I also believe that perc discectomy will address the pathology itself.

 

[mid|ine]

In the past I would do an endoscopic foraminoplasty but the reimbursement for that went to zero also. Sigh....

Its not just billed as a foraminoplasty? I am always intrigued by the endoscopic procedures but have never had the training.