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I am wondering what your go to procedure is first for mod/severe LSS at one level (ie. L3/4). Symptoms of low back pain radiating into BLEs. Bilat TFESIs at L4/5?
thanks
thanks
Lumbar spinal stenosis treatment
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X-stop in the office would really worry me. It's really not a procedure. It's an operation. The dissection is not minimal...I can't imagine doing one without a bovie. Infection risk is real. Although fracturing bone is not intentional, if you do enough of them you may run across a spinous process that inadvertantly fractures with the distraction...
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X-stop dificulty could make it office based.
The infecion control process QA/QC does not exist in the office setting.
There is no insurance in the world that would pay for this in the office setting.
There is no reason to ever perform open spine surgery in the office.
This would include SCS implants, X-stop, pump placements.
If an 11 blade does more than poke- it goes to the ASC/hospital.
The infecion control process QA/QC does not exist in the office setting.
There is no insurance in the world that would pay for this in the office setting.
There is no reason to ever perform open spine surgery in the office.
This would include SCS implants, X-stop, pump placements.
If an 11 blade does more than poke- it goes to the ASC/hospital.
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I think we all know pain docs who are doing things that they shouldnt...
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Probably with the success reported as $$$ and not outcomes.
I've done some for patients with radiculopathy who need more than a simple decompression and are unlikely to tolerate a fusion. Results have been mixed. I've wondered about neurogenic claudication but have yet to pull the trigger. Anyone else?
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I would be SHOCKED if a pain doc is actually doing Xstop. Not because it's hard, Kyphon and the FDA have limited training and availability of the Xstop to surgeons. That being said, if there are pain guys doing this out there, I've got a bone to pick with my Kyphon rep relative to him BSing me on this issue. If it were available to me, I'd do it for sure. No it doesn't work great, but what in the interventional spine world is a slam dunk for anything?
Office based Xstop? The cost of the device is in excess of 4 grand. There is no way you could do this ouside an ASC or hospital without losing your shirt on the cost of the device. Besides, agree with above comment on dissection. You need to use a cobb / osteotome to get the muscle off the spinous processes down to lamina to expose the interspinous ligament. Occasionally medial facetectomy is needed to get the darn thing in the right place. Cant imagine doing that in an exam room.
Kyphon is working on a "percutaneous" X-stop that will be put in using a curved stylette and a crimping device almost like the Sextant percutaneous fusion device. That will be available to us non-surgeons, but is at least 1 year away from the market per my rep.
"Surgical realm?" Bite your tongue. Unless you'd rather just do shots and scripts...
Office based Xstop? The cost of the device is in excess of 4 grand. There is no way you could do this ouside an ASC or hospital without losing your shirt on the cost of the device. Besides, agree with above comment on dissection. You need to use a cobb / osteotome to get the muscle off the spinous processes down to lamina to expose the interspinous ligament. Occasionally medial facetectomy is needed to get the darn thing in the right place. Cant imagine doing that in an exam room.
Kyphon is working on a "percutaneous" X-stop that will be put in using a curved stylette and a crimping device almost like the Sextant percutaneous fusion device. That will be available to us non-surgeons, but is at least 1 year away from the market per my rep.
"Surgical realm?" Bite your tongue. Unless you'd rather just do shots and scripts...
I heard the same thing about the percutaneous Xstop. I was told there are a couple pain guys affliated with a surgical group in Fl doing them. Were trained by the surgeons. The pain guy in town got trained by his surgeon buddy to do them(all second hand info).
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Calcitonin makes sense for compression fracture related pain, but not for LSS.
Shoot us some abstracts...
If memory serves me correctly, I think a study was done at the Cleveland Clinic years ago which showed no difference between patients receiving calcitonin and placebo.
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Clin Rheumatol. 2009 Feb 14. [Epub ahead of print]
An open study of pamidronate in the treatment of refractory degenerative lumbar spinal stenosis.
Feld J, Rosner I, Avshovich N, Boulman N, Slobodin G, Rozenbaum M.
Rheumatology Department, Bnai Zion Medical Center, Ruth and Bruce Rappaport Faculty of Medicine, Technion, P.O. Box 4940, Haifa, 31048, Israel.
Degenerative lumbar spinal stenosis, manifesting as chronic low back pain and neurogenic claudication, is an increasing chronic problem in an aging population, with limited effective conservative treatment options. Based on previous reports on the utility of subcutaneous calcitonin and two anectodal cases, we launched an open therapeutic trial of IV monthly pamidronate infusions, over a course of 3-6 months in this condition. Of 24 patients, 75% reported pain improvement, with the mean VAS score improved by 40%; while composite functional improvement in walking time, activities of daily living, and sense of well being was reported by 66%, with a mean improvement of 50%. The results of this pilot trial suggest the usefulness of this modality and warrant examination in a controlled clinical trial.
Spine. 2004 Nov 1;29(21):2343-9.
Effectiveness of salmon calcitonin nasal spray in the treatment of lumbar canal stenosis: a double-blind, randomized, placebo-controlled, parallel group trial.
Podichetty VK, Segal AM, Lieber M, Mazanec DJ.
Spine Research & Education, Spine Institute, The Cleveland Clinic Florida, Weston, FL 33331, USA. [email protected]
STUDY DESIGN: Double-blind, randomized, placebo-controlled study to assess the effectiveness of calcitonin nasal spray on symptoms and function in patients with lumbar canal stenosis. OBJECTIVE: To compare effectiveness of calcitonin administered by nasal spray with placebo in patients with clinically symptomatic lumbar canal stenosis.
SUMMARY OF BACKGROUND DATA: Lumbar canal stenosis is the most common reason for spine surgery in individuals over 65 years of age. Nonoperative approaches have been not well studied and limited primarily to physical therapy exercises. Several small trials in the past have suggested that subcutaneous and intramuscular calcitonin is an effective nonsurgical option in treating the symptoms of spinal stenosis patients. Only three trials were randomized and placebo-controlled.
METHODS: Fifty-five patients with clinical lumbar canal stenosis (pseudoclaudication), confirmatory MR imaging, and pain intensity index (VAS) of > or =6 were randomized to either placebo or intranasal calcitonin daily for 6 weeks, followed by an open label 6-week extension, during which all patients received active drug. Outcome parameters performed at baseline, 6 weeks, and 12 weeks, included pain intensity index, walking time and distance to pain, SF-36, and Oswestry disability index.
RESULTS: Thirty-six patients received calcitonin, and 19 placebo. Eight (14.54%) calcitonin and 4 (7.27%) placebo patients withdrew from the study. The mean baseline pain score for calcitonin group was 7.8 and 7.5 for placebo. Comparisons at week 6 showed no statistically significant difference in the change in pain intensity (VAS) between calcitonin group (-2.9) and placebo (-2.4) (P = 0.4382) from baseline. There was no significant difference in walking time to pain (calcitonin -10.0 seconds; placebo +32.2 seconds; P = 0.5136). Walking distance to pain showed a mean improvement of +91.4 ft in the calcitonin group and +254.7 ft in the placebo group (P = 0.4948). No significant difference was observed in the SF-36 score between the treatment groups. Using a threshold of at least 50% reduction in pain from baseline to 6 weeks, 12 of 29 (41.37%) of calcitonin patients were considered responders versus 7 of 18 (38.88%) of placebo patients (P = 0.4238)
CONCLUSIONS: In this first ever largest randomized placebo-controlled parallel group trial of nasal calcitonin in spinal stenosis, nasal calcitonin was not superior to placebo in treating the symptoms of spinal stenosis at 6 weeks. Based on this study, nasal calcitonin does not appear to have a role in nonoperative treatment of lumbar canal stenosis.
Eur Spine J. 2007 Feb;16(2):207-12. Epub 2006 Jul 25.
Randomised placebo-controlled trial on the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis.
Tafazal SI, Ng L, Sell P.
Department of Orthopaedics, University Hospitals of Leicester, Leicestershire, UK. [email protected]
This is a double blind randomised controlled trial to assess the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis. The trial compared the outcome of salmon calcitonin nasal spray to placebo nasal spray in patients with MRI confirmed lumbar spinal stenosis. Lumbar spinal stenosis is one of the commonest conditions encountered by spine surgeons. It more frequently affects elderly patients and lumbar decompression has been used to treat the condition with variable success. Non operative measures have been investigated, but their success ranges from 15% to 43% in patients followed up for 1-5 years (Simotas in Clin Orthop 1(384):153-161, 2001). Salmon calcitonin injections have been investigated in previous trials and may have a treatment effect. Nasal salmon calcitonin has become available and if effective would have advantages over injections. Forty patients with symptoms of neurogenic claudication and MRI proven lumbar spinal stenosis were randomly assigned either nasal salmon calcitonin or placebo nasal spray to use for 4 weeks. This was followed by a 'washout' period of 6 weeks, and subsequent treatment with 6 weeks of nasal salmon calcitonin. Standard spine outcome measures including Oswestry disability index (ODI), low back outcome score, visual analogue score and shuttle walking test were administered at baseline, 4, 10 and 16 weeks. Twenty patients received nasal salmon calcitonin and twenty patients received placebo nasal spray. At 4 weeks post treatment there was no statistically significant difference in the outcome measures between the two groups. The change in ODI was a mean 1.3 points for the calcitonin group and 0.6 points for the placebo group (P = 0.51), the mean change in visual analogue score for leg pain was 10 mm in the calcitonin group and 0 mm in the placebo group (P = 0.51). There was no significant difference in walking distance between the two groups, with a mean improvement in walking distance of 21 m in the calcitonin group and 8 m in the placebo group (P = 0.78). At the end of the trial the ODI had improved by a mean of 3.7 points in the calcitonin group and 3.8 points in the placebo group (P = 0.44). This randomised placebo controlled trial has not shown any treatment effect in patients with lumbar spinal stenosis treated with nasal salmon calcitonin.
Calcif Tissue Int. 1992 May;50(5):400-3.
Calcitonin treatment in lumbar spinal stenosis: a randomized, placebo-controlled, double-blind, cross-over study with one-year follow-up.
Eskola A, Pohjolainen T, Alaranta H, Soini J, Tallroth K, Slätis P.
Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland.
A randomized, placebo-controlled, double-blind, crossover study in 40 lumbar spinal stenosis patients with a 1-year follow-up showed that calcitonin had beneficial effects on the patients' symptoms without producing any notable side effects. Calcitonin had a clear analgesic effect. The mean of walking distance increased, but the crossover trend was not as good as the analgesic effect. Side effects such as erythema and nausea were usually mild and transient. Calcitonin therapy can be used as a conservative treatment in selected cases of lumbar spinal stenosis. When rest pain was mild or the walking distance was under 200-300 m because of neurogenic claudication, the effect of calcitonin seemed to be poor.
An open study of pamidronate in the treatment of refractory degenerative lumbar spinal stenosis.
Feld J, Rosner I, Avshovich N, Boulman N, Slobodin G, Rozenbaum M.
Rheumatology Department, Bnai Zion Medical Center, Ruth and Bruce Rappaport Faculty of Medicine, Technion, P.O. Box 4940, Haifa, 31048, Israel.
Degenerative lumbar spinal stenosis, manifesting as chronic low back pain and neurogenic claudication, is an increasing chronic problem in an aging population, with limited effective conservative treatment options. Based on previous reports on the utility of subcutaneous calcitonin and two anectodal cases, we launched an open therapeutic trial of IV monthly pamidronate infusions, over a course of 3-6 months in this condition. Of 24 patients, 75% reported pain improvement, with the mean VAS score improved by 40%; while composite functional improvement in walking time, activities of daily living, and sense of well being was reported by 66%, with a mean improvement of 50%. The results of this pilot trial suggest the usefulness of this modality and warrant examination in a controlled clinical trial.
Spine. 2004 Nov 1;29(21):2343-9.
Effectiveness of salmon calcitonin nasal spray in the treatment of lumbar canal stenosis: a double-blind, randomized, placebo-controlled, parallel group trial.
Podichetty VK, Segal AM, Lieber M, Mazanec DJ.
Spine Research & Education, Spine Institute, The Cleveland Clinic Florida, Weston, FL 33331, USA. [email protected]
STUDY DESIGN: Double-blind, randomized, placebo-controlled study to assess the effectiveness of calcitonin nasal spray on symptoms and function in patients with lumbar canal stenosis. OBJECTIVE: To compare effectiveness of calcitonin administered by nasal spray with placebo in patients with clinically symptomatic lumbar canal stenosis.
SUMMARY OF BACKGROUND DATA: Lumbar canal stenosis is the most common reason for spine surgery in individuals over 65 years of age. Nonoperative approaches have been not well studied and limited primarily to physical therapy exercises. Several small trials in the past have suggested that subcutaneous and intramuscular calcitonin is an effective nonsurgical option in treating the symptoms of spinal stenosis patients. Only three trials were randomized and placebo-controlled.
METHODS: Fifty-five patients with clinical lumbar canal stenosis (pseudoclaudication), confirmatory MR imaging, and pain intensity index (VAS) of > or =6 were randomized to either placebo or intranasal calcitonin daily for 6 weeks, followed by an open label 6-week extension, during which all patients received active drug. Outcome parameters performed at baseline, 6 weeks, and 12 weeks, included pain intensity index, walking time and distance to pain, SF-36, and Oswestry disability index.
RESULTS: Thirty-six patients received calcitonin, and 19 placebo. Eight (14.54%) calcitonin and 4 (7.27%) placebo patients withdrew from the study. The mean baseline pain score for calcitonin group was 7.8 and 7.5 for placebo. Comparisons at week 6 showed no statistically significant difference in the change in pain intensity (VAS) between calcitonin group (-2.9) and placebo (-2.4) (P = 0.4382) from baseline. There was no significant difference in walking time to pain (calcitonin -10.0 seconds; placebo +32.2 seconds; P = 0.5136). Walking distance to pain showed a mean improvement of +91.4 ft in the calcitonin group and +254.7 ft in the placebo group (P = 0.4948). No significant difference was observed in the SF-36 score between the treatment groups. Using a threshold of at least 50% reduction in pain from baseline to 6 weeks, 12 of 29 (41.37%) of calcitonin patients were considered responders versus 7 of 18 (38.88%) of placebo patients (P = 0.4238)
CONCLUSIONS: In this first ever largest randomized placebo-controlled parallel group trial of nasal calcitonin in spinal stenosis, nasal calcitonin was not superior to placebo in treating the symptoms of spinal stenosis at 6 weeks. Based on this study, nasal calcitonin does not appear to have a role in nonoperative treatment of lumbar canal stenosis.
Eur Spine J. 2007 Feb;16(2):207-12. Epub 2006 Jul 25.
Randomised placebo-controlled trial on the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis.
Tafazal SI, Ng L, Sell P.
Department of Orthopaedics, University Hospitals of Leicester, Leicestershire, UK. [email protected]
This is a double blind randomised controlled trial to assess the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis. The trial compared the outcome of salmon calcitonin nasal spray to placebo nasal spray in patients with MRI confirmed lumbar spinal stenosis. Lumbar spinal stenosis is one of the commonest conditions encountered by spine surgeons. It more frequently affects elderly patients and lumbar decompression has been used to treat the condition with variable success. Non operative measures have been investigated, but their success ranges from 15% to 43% in patients followed up for 1-5 years (Simotas in Clin Orthop 1(384):153-161, 2001). Salmon calcitonin injections have been investigated in previous trials and may have a treatment effect. Nasal salmon calcitonin has become available and if effective would have advantages over injections. Forty patients with symptoms of neurogenic claudication and MRI proven lumbar spinal stenosis were randomly assigned either nasal salmon calcitonin or placebo nasal spray to use for 4 weeks. This was followed by a 'washout' period of 6 weeks, and subsequent treatment with 6 weeks of nasal salmon calcitonin. Standard spine outcome measures including Oswestry disability index (ODI), low back outcome score, visual analogue score and shuttle walking test were administered at baseline, 4, 10 and 16 weeks. Twenty patients received nasal salmon calcitonin and twenty patients received placebo nasal spray. At 4 weeks post treatment there was no statistically significant difference in the outcome measures between the two groups. The change in ODI was a mean 1.3 points for the calcitonin group and 0.6 points for the placebo group (P = 0.51), the mean change in visual analogue score for leg pain was 10 mm in the calcitonin group and 0 mm in the placebo group (P = 0.51). There was no significant difference in walking distance between the two groups, with a mean improvement in walking distance of 21 m in the calcitonin group and 8 m in the placebo group (P = 0.78). At the end of the trial the ODI had improved by a mean of 3.7 points in the calcitonin group and 3.8 points in the placebo group (P = 0.44). This randomised placebo controlled trial has not shown any treatment effect in patients with lumbar spinal stenosis treated with nasal salmon calcitonin.
Calcif Tissue Int. 1992 May;50(5):400-3.
Calcitonin treatment in lumbar spinal stenosis: a randomized, placebo-controlled, double-blind, cross-over study with one-year follow-up.
Eskola A, Pohjolainen T, Alaranta H, Soini J, Tallroth K, Slätis P.
Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland.
A randomized, placebo-controlled, double-blind, crossover study in 40 lumbar spinal stenosis patients with a 1-year follow-up showed that calcitonin had beneficial effects on the patients' symptoms without producing any notable side effects. Calcitonin had a clear analgesic effect. The mean of walking distance increased, but the crossover trend was not as good as the analgesic effect. Side effects such as erythema and nausea were usually mild and transient. Calcitonin therapy can be used as a conservative treatment in selected cases of lumbar spinal stenosis. When rest pain was mild or the walking distance was under 200-300 m because of neurogenic claudication, the effect of calcitonin seemed to be poor.
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Just realized I totally forgot about this thread. Thanks for the good articles Peterman. Guess I won't be using it for my LSS patients
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Saw a N of 2 during fellowship, one displaced, the other wasn't efficacious.
A pain doc I know in Florida has done quite a few x-stops n>60. He was trained by Kyphon and had to be supervised by a spine surgeon for a while. I think, since the time he was trained, Medtronic has gotten quite a bit more cautious about training different specialties. I think the x-stop works well for very carefully selected patients. Once of the criteria is that the pt MUST have 100% pain relief upon sitting. In my humble opinion, x-stop could be done by a properly trained pain specialist. Although it does involve a deeper incision than we are used to, I would still call it less "invasive" than something like a kyphoplasty. And if spine surgeons don't embrace the technique, assuming it is effective, other specialties will.
For those of you that have found success with ESI's for patients with spinal stenosis, what cocktail are you using? and do you inject at the level of the stenosis?
What PT program do you prescribe following the injection?
Had a patient who one ESI and excellent relief for one year. The physician used 10 ml of Normal Saline and some steroid in his cocktail
What PT program do you prescribe following the injection?
Had a patient who one ESI and excellent relief for one year. The physician used 10 ml of Normal Saline and some steroid in his cocktail
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I see the best results with ILESI at the level of stenosis with 80mg kenalog and 1cc 0.25% marcaine. If it's very severe stenosis I'll go one level below. Williams flexion exercise program and daily stationary cycling
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A strong proportion of people with lumbar spinal stenosis do have a directional preference to flexion, so in these cases lumbopelvic exercises should be biased to coincide. Whitman et al, 2006 recommends a walking program, manual Rx (i.e. T/S extension mobs, gentle PA's L/S), and exercise (i.e. DKTC, SKTC, PPT, hip flexor stretches, hamstring/abominal strengthening, T/S self extension mobs, seated pelvic tilts anterior and posterior, quadruped cat/camel). I've found that instructing on gentle lumbopelvic ROM (i.e. Supine Hooklying/sitting/standing pelvic tilts, quadruped cat camel type exercises each direction gently and as tolerated) plus gentle T/S extension ROM/mobs and gentle hip flexor stretching (i.e. In Thomas position) may be best versus flexion biased exercises only. Seems to me that once a person finishes with a series of flexion biased exercises (i.e. Williams flexion) and then go to stand they have even more difficulty tolerating and getting into extension. Maybe we need to incorporate L/S extension but gently and in a controlled fashion.
So:
Walking program (with appropriate A.D. If indicated)
Specific manual Rx
Specific exercise
so.... i guess you think PT actually helps for stenosis. that makes one of us.
never met a diagnosis that the PTs didnt think they could help with....
? really ?
bilateral TFESI 1 level below location of central stenosis. for ex: severe L4-5 central stenosis gets a bilateral L5 TFESI.
agree with smaller volumes. dont put 10 mL in.
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It is very difficult to treat, but it is reasonable to give PT a shot in these patients in my opinion. I have seen far too many instances of poor outcomes after fusions including many who are far worse than pre fusion. People and surgeons often seem to have difficulty comprehending that lumbar fusion surgery for LSS is not indicated to relieve pain IN THE BACK.
I see potential for better outcomes thru PT in these folks but we need less "lets try some PT, but if that doesn't work we'll have to do surgery." Great idea, let's push them into getting surgery if "the PT" "doesn't work" as if chronic LBP is curable and spinal fusion is curative.
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No one will argue re surgery for stenosis with only axial pain and no instability. Different story for neurogenic claudication.
so, you realize that stenosis doesnt cause back pain, right?
i agree that the "if PT doesnt work then we do surgery" mantra is wrong. however, you have to be more specific with your diagnosis. sometimes, surgery IS warranted, and it shouldnt be a fusion (like a 50 year old with severe central stenosis and no spondy).
you can get stenosis from an acute disc or stenosis from aging. treatment is very different.
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I understand that "stenosis" in and of itself, meaning narrowing foraminaly or centrally, shouldn't cause axial LBP in isolation and that there can be varying causes of stenosis (i.e. Facet hypertrophy, spondylolisthesis, disc herniation, DDD, etc). However, I have seen patient's that have had (? Prophylactic) fusions with manageable LBP and no peripheral effects (i.e. Spondylolysis, spondylolisthesis) each had seen me significantly after and were far worse off. I've probably seen hundreds of failed spinal fusions for stenosis. Personally I do not cringe when I see partial discectomy, laminectomy, facetectomy. But, spinal fusions are a different story and are just done far too often, and when it's not even indicated, whether stenosis or otherwise.
I still think a PT trial is warranted in the vast majority of cases, ESPECIALLY if a spinal surgeon is on board or consult pending. If nothing else, me and my colleagues can scare the crap out of the patients so at least they are more thoughtful before going under the knife.
I also feel the idea of "if it doesn't 'work' we'll try something else" idea needs to stop altogether, not necessarily just regarding surgery. Once again as if chronic LBP (in all forms) is curable versus manageable.
I still think a PT trial is warranted in the vast majority of cases, ESPECIALLY if a spinal surgeon is on board or consult pending. If nothing else, me and my colleagues can scare the crap out of the patients so at least they are more thoughtful before going under the knife.
I also feel the idea of "if it doesn't 'work' we'll try something else" idea needs to stop altogether, not necessarily just regarding surgery. Once again as if chronic LBP (in all forms) is curable versus manageable.
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How about walking on an inclined treadmill as an exercise for claudication? Instability from spondylolisthesis bias to extension lumbopelvic stability exercises, spondylolysis bias to flexion gentle stability exercises with LIPUS to speed fracture healing.
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PT for spinal stenosis? Sure, you can try, but I'm not going to expect miracles with a spinal canal that gradually degenerated to the width of a stirring straw over 25 years. A bone saw will have a whole lot more utility.
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If you have seen hundreds of failed fusions for stenosis, its time to write the Medical Board. Except I don't know any surgeons here offering fusion for axial back pain.
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Then you dont know any surgeons
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Could not agree with Dr. Lobel any more strongly. Spinal fusion for axial low back pain is a runaway train and I haven't seen its momentum slow down at all over the last 5-10 years.
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Here is an outlier database in excel format. I would peruse it before you go so far as contacting your state board: http://cbsnews.com/html/cbsnews/spreadsheet/spinal-fusion-data.xls
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This is medicare data only, right?
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Love it. Not good on phone as too hard to sort. Cant wait to stratify my state.
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Right.
Lots of different opinions on injection approach to spinal stenosis...
If symptoms are bilateral, then I typically do bilateral transforaminal at the level of stenosis. I may try interlaminar, esecially if less than adequate relief with transforaminal. If interlaminar, I would not go at the level due to increased risk of dural puncture, and would generally prefer to go above rather than below, but either is probably ok.
If symptoms are unilateral, but not localized to a single dermatome, I would do unilateral TF ESI at the level of stenosis, or sometimes a two level TF ESI, with one at the level and one below. If localized to a single dermatome corrresponding to the the nerve root traversing the lateral recess (e.g. L5 radicular pattern in L4-5 central stenosis), then I may start with unilateral TF ESI one level below the level of stenosis.
I guess it depends on the situation, but that has been my general approach lately.
SSdoc33... I agree that spinal stenosis should not cause axial pain in theory, but I think it is possible that sometimes it does. I have seen some patients with severe spinal stenosis, only axial pain, fail facet injections, but get good relief with ESI. Some patients only complain of pain in the back, and no pain in the legs, but on further questioning, they may admit to feeling of fatigue or tiredness in the legs when walking, and they may also respond to ESI.
If symptoms are bilateral, then I typically do bilateral transforaminal at the level of stenosis. I may try interlaminar, esecially if less than adequate relief with transforaminal. If interlaminar, I would not go at the level due to increased risk of dural puncture, and would generally prefer to go above rather than below, but either is probably ok.
If symptoms are unilateral, but not localized to a single dermatome, I would do unilateral TF ESI at the level of stenosis, or sometimes a two level TF ESI, with one at the level and one below. If localized to a single dermatome corrresponding to the the nerve root traversing the lateral recess (e.g. L5 radicular pattern in L4-5 central stenosis), then I may start with unilateral TF ESI one level below the level of stenosis.
I guess it depends on the situation, but that has been my general approach lately.
SSdoc33... I agree that spinal stenosis should not cause axial pain in theory, but I think it is possible that sometimes it does. I have seen some patients with severe spinal stenosis, only axial pain, fail facet injections, but get good relief with ESI. Some patients only complain of pain in the back, and no pain in the legs, but on further questioning, they may admit to feeling of fatigue or tiredness in the legs when walking, and they may also respond to ESI.
