1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice

Marked Cervical Cord Impingement. Epidural or no?

Discussion in 'Pain Medicine' started by watson, Jul 22, 2011.

  1. watson

    watson Junior Member
    10+ Year Member

    Joined:
    Mar 19, 2000
    Messages:
    9
    Likes Received:
    0
    I saw a case with patient having radicular symptoms. MRI was performed with showed large central protrusion with marked cervical impingement on the spinal cord. There was a question on whether to do the CESI or not vs surgery. Any thoughts?

    :shrug:
     
  2. Note: SDN Members do not see this ad.

  3. SSdoc33

    10+ Year Member

    Joined:
    Apr 23, 2007
    Messages:
    5,556
    Likes Received:
    1,200
    Status:
    Attending Physician

    what the radiologist says and what is actually present may be different things. any cord signal changes? myelopathic on exam? my gut says no, but if not myselopathic, no cord signal change, and pictures dont look that bad, it could be considered
     
  4. lobelsteve

    lobelsteve SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    May 30, 2005
    Messages:
    12,525
    Likes Received:
    2,638
    Status:
    Attending Physician
    If canal is <7mm would not do with or without signal changes. Exam dictates 7-9mm canals, and 9+ is a no brainer.
    If multilevel canal stenosis I can do the CESI, but talk the patient out of it until they see the surgeon and if he wants them to have a try of CESI before multilevel ACDF, I'll do one.
     
  5. watson

    watson Junior Member
    10+ Year Member

    Joined:
    Mar 19, 2000
    Messages:
    9
    Likes Received:
    0
    Thanks guys. The radiologist stated was a little less than 9mm. The patients symptoms were of mild radiculopathy. I think seeing a surgeon before doing one would be a good idea.

    :)
     
  6. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician

    I saw a similar case. The patient saw both ortho spine and neurosurgery but surgery was not offered. My partners didn't want to do it, but I said I would.

    He got the CESI, but had no relief from this. His ortho spine doc then ordered a c6 SNRB. I did that under ultrasound, but again had no relief. :(

    I think getting the surgery consult first is a good idea.
     
  7. lobelsteve

    lobelsteve SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    May 30, 2005
    Messages:
    12,525
    Likes Received:
    2,638
    Status:
    Attending Physician
    Ouch, I bit my tongue. Twice.
     
  8. Lodoc

    Lodoc Junior Member
    10+ Year Member

    Joined:
    Oct 26, 2003
    Messages:
    31
    Likes Received:
    0

    Are you saying you don't do it at all or just at the stenotic level? I posed a similar question on another thread. I was taught you could go below the level of significant stenosis, but not at the level. But I've always been concerned about even going lower than the level.
    For example, if C6-7 stenosis is <7mm, but at C7-T1 >8. Would you do it at C7-T1?
     
  9. bedrock

    bedrock Member
    10+ Year Member

    Joined:
    Oct 23, 2005
    Messages:
    4,098
    Likes Received:
    1,025
    Status:
    Attending Physician
    Agree with Steve that if canal less than 7mm anywhere, no CESI, off to surgeon for you.

    Regarding the C7-T1 question, if there is moderate stenosis of 8mm at C7-T1, just do CESI at T1-T2, it's safer and the medication will still get there.
     
  10. Ligament

    Ligament Interventional Pain Management
    Physician Lifetime Donor SDN Advisor Classifieds Approved 10+ Year Member

    Joined:
    Jan 8, 2002
    Messages:
    4,775
    Likes Received:
    1,142
    Status:
    Attending Physician
    Seriously, why would you do a cervical SNRB under u/s? :scared:
     
  11. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician
    Why would you not?

    I can see small vessels, large vessels like the vertebral artery, my needle, the nerve root, the local spread around the nerve root, facial planes, etc

    On fluoro you can see your needle, bone, contrast spread.

    It's a no brainer for me. I guarantee it would be for you if you saw a few done.

    stellate ganglion blocks under Ultrasound are pretty cool also, and so much safer in my opinion - but we will have to wait for the data for that.
     
  12. lobelsteve

    lobelsteve SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    May 30, 2005
    Messages:
    12,525
    Likes Received:
    2,638
    Status:
    Attending Physician
    As the crowd is silent- so it is said, so it is written.

    You got any data to back up the US guided SNRB, or just a C-spine SNRB?
    Many of us abandoned the TFESI route in the neck after the first 22 catastrophic cases of death/quadriplegia were reported. I was privy to the depositions of one of those cases a few years ago. You might want to hear Racz or Kapural lecture of distant vascular uptake patterns and blood flow from the needle site. Veins on the other side of the neck, arteries without evidence of contrast for 4" from the needle tip. Also a note to open up collimation for watching the live fluoro contrast spread.

    Your training goes beyond the current literature and strains credulity from known science.
     
  13. 101N

    101N Membership Revoked
    Removed Account on Hold 5+ Year Member

    Joined:
    Apr 7, 2011
    Messages:
    5,313
    Likes Received:
    1,065
    Status:
    Attending Physician
    Pass.
     
  14. Jcm800

    10+ Year Member

    Joined:
    Jul 13, 2008
    Messages:
    5,597
    Likes Received:
    704
    Status:
    Attending Physician
    At the risk of offending the natives...I wouldhave done it, without much concern...

    No cord signal,no myelopathic signs...what's the big deal with 2 to 3 cc injection...maybe I'm cavalier....
     
  15. 101N

    101N Membership Revoked
    Removed Account on Hold 5+ Year Member

    Joined:
    Apr 7, 2011
    Messages:
    5,313
    Likes Received:
    1,065
    Status:
    Attending Physician
    To me that's not the point. I think a bunch of us could do it safely. But will it change the outcome? Like putting are in a flat tire, needs fixin not air.
     
  16. Jcm800

    10+ Year Member

    Joined:
    Jul 13, 2008
    Messages:
    5,597
    Likes Received:
    704
    Status:
    Attending Physician

    how many patients have severe spinal stenosis and improve without surgery, or one step further, have no symptoms at all...


    therefore, yes, it may change the outcome. If pain is the issue, improving the pain is all that needs to be done...
     
  17. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician
    I am very confused about your post. I explained that I do cervical SNRB under ultrasound. I said nothing about a TFESI. As it is yet unknown what causes the problem with TFESI (is it the particulate steroid as many believe? Or is it vessel damage as Dr Mark Wallace reported about in some of the case reports he has written up - with damage to the vertebral artery?) Either way, I'm not using any steroid (no point in doing steroid for a selective nerve root block - if you don't expect epidural flow) so that isn't a problem. If it is direct damage to the vessel, under ultrasound I can see clearly the vertebral artery and stay far away from that. It is likely that a vessel I can't find on ultrasound will be able to cause death or paralysis if I were to pierce it.

    Without being pedantic, please explicate the reason for calling me gullible. For one thing, of course there is no data that would suggest that doing a cervical SNRB under ultrasound is safer. But it sure as hell aint more dangerous, and there clearly is no data to suggest that.

    By the way, I'm curious to know how you use an ultrasound in your clinic? For example, what did you use one for last week?
     
  18. lobelsteve

    lobelsteve SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    May 30, 2005
    Messages:
    12,525
    Likes Received:
    2,638
    Status:
    Attending Physician
    No such thing as a SNRB:

    Pain Physician. 2008 Nov-Dec;11(6):855-61. Contrast flow selectivity during transforaminal lumbosacral epidural steroid injections. Furman MB, Lee TS, Mehta A, Simon JI, Cano WG.

    You have magic eyes. You can see things in US that the machine lacks the resolution and scanning area to see:
    2010 Pain Practice
    Evidence-based Interventional Pain Medicine according to Clinical Diagnoses
    4. Cervical Radicular Pain
    Jan Van Zundert, MD, PhD, FIPP*†; Marc Huntoon, MD‡; Jacob Patijn, MD, PhD†; Arno Lataster, MSc§; Nagy Mekhail, MD, PhD, FIPP¶; Maarten van Kleef, MD, PhD, FIPP†
    Read the part about vascular anatomy of the C-spine. Racz has a lecture since 2009 abou tall of the neat stuff Netter did't see through his cigar smoke and that an US cannot ever see due to limited scan area and resolution.

    US in my clinic is relegated to the Rheumatologist for now. It is for knees and shoulders. As we play with it more, maybe elbows, maybe CTS. I know you do lots of peripheral nerve blocks in your pain clinic- but I fail to see how regional anesthesia is useful for my outpatients. They didn't teach that in my fellowship.

    There is a 1000 ways to skin this cat, but only 100 of them are the right way. Pain is such a young and diverse field and there have been so many peddlers and charlatans, so much false hope and lies in the research for profit that we need to improve our data before venturing out into less studied territory as part of daily practice.

    So show me your safety, efficacy, and outcome data for US guided SNRB's. WHo even came up with this crap? GE, Philips? 5 years ago US was a tool of the chiropractor as spinal diagnostic US and the tool of the PT for healing. For several years it has become an adjunct to NS for regional anesthesia to augment safety/efficacy. This crossing over into a must use for everything we do is quite strange- as regional anesthesia for chronic pain is a bizarre concept. The need for 100's of crappy articles on using US for every procedure (nurses placing an IV under US is next) escapes me. Help me understand.
     
  19. Tenesma

    Tenesma Senior Member
    10+ Year Member

    Joined:
    Jun 11, 2002
    Messages:
    5,332
    Likes Received:
    127
    Status:
    Attending Physician
    Part of our expertise is knowing when something is appropriate.... Just cause a surgeon says you should do something does not absolve you if something goes wrong....

    It is okay to counsel a patient and explain that the risks do not outweigh the benefits and that an injection is not the solution...

    I tell about 10 consults/month that injection is not appropriate and that they should go back to the surgeon.....

    If I had a whopper disc herniation in my c spine.... I would rather do PT for 2 months.... And if no improvement, then give me acdf...
     
  20. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician
    I'm not sure we are understanding one another here.

    First of all, I completely agree about the no selective comment. In fact, in my notes, I always document "targeted nerve block" rather than selective nerve block because of the fact you point out. However, with ultrasound, I am pretty sure I don't get epidural or central flow, and I can see the medicine flow around the nerve root in question. By the way, I mix contrast with the local so I can confirm with a fluoro shot after injection - and I have never seen epidural flow yet. I always get a great perinuerogram however.

    I also AGREE that there is no data that US is better. However, I promise you, I can see much more than you can on fluoro - but maybe you think YOU have magic eyes with fluoro and DSA. (And the truth is, I can't think of a time I saw vascular uptake on DSA that I didn't already notice on live fluoro.) Has DSA sensitivity ever been proven (correlated to the size of vessel it can pick up?) I am unaware of any comparison to US - as far as which can pick up the smallest vessel.

    By the way, I never claimed that (or if I did...I retract it) we should all be using ultrasound cuz it is so much safer. I do, however, find it strange that i mentioned I used that AND you came with guns ablazing with accusations why I SHOULDN'T be doing it. That to me is a little odd. Also considering the fact that you don't use a lot of ultrasound confirms that. I'm not saying you should use ultrasound, but holy crap - so what if some are.

    For me, it makes a lot of sense for lots of things. If you have ever seen a piriformis under ultrasound - it just works so well and so reliable and satisfying. (I am always so dissappointed in my blobagrams). And that is my crutch - if I were better at fluoro, I probably would never get a blogagram. A genifofemoral injection and ilioinguinal, or lateral femoral cutaneous - all make so much sense with ultrasound.

    And as I mentioned in another post, any time I can cut down on my fluoro time - its a good thing for me. I'm a little paranoid about that - maybe I don't need to be, but I am I.

    Final point - I have no idea what most people do. It sounds like people are using ultrasound (for spinal procedures - like Dx MBB's) just to get more billing. I agree that this is fraud and horrible. I can't imagine using ultrasound for Dx MBB's or many of the things I do. I have tried using it for the suprascapular nerve, but it still makes no sense to me.

    I will say that I love using it for my mid and upper back trigger points. I can see the muscle, the depth of the pleura, my needle, and the medicine spread. Now that may be overkill and it does take longer, but I get the trigger point right every time. :cool:
     
  21. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician
    Not to me...another discussion for another day I suppose.

    Agreed 100%. We all love our name in print I guess.
     
  22. Ligament

    Ligament Interventional Pain Management
    Physician Lifetime Donor SDN Advisor Classifieds Approved 10+ Year Member

    Joined:
    Jan 8, 2002
    Messages:
    4,775
    Likes Received:
    1,142
    Status:
    Attending Physician
    Some regional anethesia techniques are really useful in outpatient clinical practice, TAP blocks for example. U/S has been a wonderful addition to my use of fluoro and CT (on occasion) guided blocks.

    It sounds like the SNRB at C6 with U/S was done as safely as possible. If you are blocking that far out of the neuroforamen, and using contrast to confirm no epidural spread, and not using steroids, I see very little downside to it. I would caution those that do not yet use U/S that you cannot see radicular arteries or microvasculature on U/S, even with power doppler or color doppler, which can lead to a false sense of security.

    Yup, U/S is phenominal for muscle blocks, peripheral nerve blocks, small joint blocks. It really is a game changer.

    RE: DSA...I have seen vascular uptake visible on DSA not visible on regular cine loop.
     
  23. SSdoc33

    10+ Year Member

    Joined:
    Apr 23, 2007
    Messages:
    5,556
    Likes Received:
    1,200
    Status:
    Attending Physician
    i dont know. you keep futzing around in the neck, and you are gonna get in trouble sooner or later.

    u/s is useful for some things. dont get a false sense of security with it, however. a bad outcome is a bad outcome, and the use of u/s will in no way "protect" you
     
  24. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician
    Seriously, I feel like I am speaking in another language.

    I have never even come close to saying I am protected with ultrasound. I never said I felt secure with ultrasound. I never said I couldn't get a bad outcome.

    The question that is begged is wether we should even do SNRB in the neck in the first place. That hasn't even been addressed in the thread.

    The point is - IF - you are going to do it, can ultrasound be used, and I feel like you can see more shtuff with ultrasound over fluoro. I feel more comfortable seeing soft tissue structures and bone, and my needle. For this, I was chastised.

    I think it is great that many of you feel like you can see more with fluoro - good on ya. Good luck with that.
     
  25. SSdoc33

    10+ Year Member

    Joined:
    Apr 23, 2007
    Messages:
    5,556
    Likes Received:
    1,200
    Status:
    Attending Physician
    you are not speaking a different language. you are just making a silly argument.

    you say that you aren't sure that a SNRB should even be done in the neck (actually, what you have described is really a "SNB" or spinal nerve block, but lets not split hairs), but if you do, you are gonna use ultrasound? it is nice that you feel more comfortable with this. however, your approach has not been validated, studied, and time-tested. i think steve was pretty clear on this, and i agree with him. you are performing a procedure with questionable benefit (if any) and using a technique with questionable (if any) literature behind it. such an easy case against you if something goes wrong. good luck with all that.
     
  26. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician

    Please repeat for me what my silly argument is...just so we all are sure you understand what I am arguing.
     
  27. SSdoc33

    10+ Year Member

    Joined:
    Apr 23, 2007
    Messages:
    5,556
    Likes Received:
    1,200
    Status:
    Attending Physician
    sure

    you say that you aren't sure that a SNRB should even be done in the neck (actually, what you have described is really a "SNB" or spinal nerve block, but lets not split hairs), but if you do, you are gonna use ultrasound? it is nice that you feel more comfortable with this. however, your approach has not been validated, studied, and time-tested. i think steve was pretty clear on this, and i agree with him. you are performing a procedure with questionable benefit (if any) and using a technique with questionable (if any) literature behind it. such an easy case against you if something goes wrong. good luck with all that.
     
  28. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician
    So just to clarify....let me try to understand, you think that my whole argument has been in this thread that I'm not sure we should be doing SNRB (SNB), right? That is my argument?
     
  29. SSdoc33

    10+ Year Member

    Joined:
    Apr 23, 2007
    Messages:
    5,556
    Likes Received:
    1,200
    Status:
    Attending Physician
    look, i dont know what your angle is, but that is clearly not what i wrote. are you trying to bait me into something here? what i wrote stands for itself
     
  30. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,842
    Likes Received:
    565
    Status:
    Attending Physician

    No baiting. I just think before trying to argue a point, we should seek clarification. In my experience, wether I am arguing or discussing a point with anyone, half the arguement is not understanding what the other person is trying to say - or missing their point completely. So a good rule for me is to seek clarity before speaking my mind.

    And, in a forum such as this, it is very easy to misunderstand, it is easy to judge, easy to be a douchebag, or to be cruel, or to say things we might not otherwise say if we were actually speaking face to face. I seek clarity so I might ovoid acting like that.

    In addition, there are red hearings all over the place in disucssions like this and it often is difficult to keep an argument on track. For this reason I was seaking clarity.

    A perfect example of this - in an adjacent thread, you said we couldn't even have a reasonable argument because I was somehow claiming that caudals were more effective than TFESI - and I made no such claim (not even close) - yet somehow you thought I did. See? Misunderstanding flying around everywhere.
     
    #29 epidural man, Jul 25, 2011
    Last edited: Jul 25, 2011
  31. lobelsteve

    lobelsteve SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    May 30, 2005
    Messages:
    12,525
    Likes Received:
    2,638
    Status:
    Attending Physician
    Back on topic.

    CESI is fine with canal stenosis and no neurologic findings, or findings without progressive deficit.

    CESI is unlikely to work if multi-level canal stenosis as moderate to severe or single level severe.

    CESI is likely to be a bad idea if cord signal changes unless surgery is scheduled and the surgeon asks for it.
     
  32. voltron

    voltron Member
    10+ Year Member

    Joined:
    Jan 12, 2003
    Messages:
    81
    Likes Received:
    0
    Status:
    Attending Physician
    agree with above. This guys probably getting surgery anyways. If its severe I'll do a thorough neuro including all reflexes, babinski, clonus just to cover my ass and make sure they're ok...and usually go a level below the severe lesion. I also inject very very slowly.
     
  33. ampaphb

    ampaphb Interventional Spine
    10+ Year Member

    Joined:
    May 13, 2007
    Messages:
    4,352
    Likes Received:
    720
    Status:
    Attending Physician
    There is no data to support the safety or efficacy of using US to perform diagnostic or therapeutic cervical transforaminal blocks. If you do one, and something bad happens, your "in my opinion/experience/hands" argument will not be defensible in court.
     
  34. PinchandBurn

    7+ Year Member

    Joined:
    Jul 26, 2010
    Messages:
    1,835
    Likes Received:
    25
    Status:
    Attending Physician

    It's interesting you picked <7mm as the cutt off for doing a cervical ESI. Per ISIS guidelines <10mm is contraindication for cervical discography. It would seem that <10mm shoudl then be teh cutoff for a CESI (interlaminar)...
     
  35. ampaphb

    ampaphb Interventional Spine
    10+ Year Member

    Joined:
    May 13, 2007
    Messages:
    4,352
    Likes Received:
    720
    Status:
    Attending Physician
    Why would you equate the risks and parameters of a cervical disco to those of a CESI?
     
  36. mille125

    7+ Year Member

    Joined:
    Dec 8, 2006
    Messages:
    2,127
    Likes Received:
    8
    Status:
    Attending Physician
    i dont understand this either
     
  37. mille125

    7+ Year Member

    Joined:
    Dec 8, 2006
    Messages:
    2,127
    Likes Received:
    8
    Status:
    Attending Physician



    Out of curiosity for the U/S trigger folks, do you feel that your success for trigger points has improved with u/s. Stated another way, do you feel that some/many of your trigger point injections were unsuccessful. I do not use u/s for trigger but I am curious about what you think. No sarcasm here just a question.

    I do not feel that my trigger points fail. In fact to me it seems that failure rate is less than 1%. Maybe I am wrong but I cannot convince myself to do ultrasound. Yes you see more than in a blind technique but is it necessary. If so, should it be used for things like nurse administered flu shots in the deltoid, etc.
     
  38. powermd

    Physician Lifetime Donor Classifieds Approved 15+ Year Member

    Joined:
    Mar 30, 2003
    Messages:
    2,632
    Likes Received:
    377
    Status:
    Attending Physician
    I do these and they tend to be very successful. The majority of patients come back in two weeks 50-75% improved, or sometimes 100%. A few get no improvement, and guess who they are... the depressed, low SES, fast-food addict, smokers who may or may not pop Norcos q4hrs.

    What I do with the US may make the procedure a lot more effective than a blind TP. I use the US to identify the relevant planes of muscle, then hydrodissect them with a mix of local and steroid. On the US you can watch the tissues spread apart. Typically I will do "scout" injections of 0.5-1 mL local only, withdraw the needle, and ask the patient to provoke their pain. If the pain goes away, I know in which tissue layers the problem lies, and I'll do a larger injection there, now inclusive of steroid. If there's no change, I'll go to a deeper level. I most commonly treat the upper back and neck, and the vast majority of patients have pain that responds to injections at the surface of the cervical trap, or just beneath it. Rarely I have to go deeper, to the rhomboids, subscapular bursa, etc. Supraspinatous tendon sheath, the muscle insertions along the iliac bones, and the insertion of the gluteus maximus on the sacrum are popular too.
     
  39. Mister Mxyzptlk

    10+ Year Member

    Joined:
    May 16, 2006
    Messages:
    4,668
    Likes Received:
    819
    Status:
    Attending Physician
    The main issue is cord protection. One good tap from behind at a stop sign and this guy is potentially quadriplegic. In that sense, getting them feeling better with an ESI gives a false sense of security.

    I always send these out for surgical evaluation even w/o long tract signs or signal changes. If the surgeon feels it can wait then I'll do an ESI.
     
  40. 101N

    101N Membership Revoked
    Removed Account on Hold 5+ Year Member

    Joined:
    Apr 7, 2011
    Messages:
    5,313
    Likes Received:
    1,065
    Status:
    Attending Physician
     
  41. Gauss

    Gauss Damnit Jim!
    10+ Year Member

    Joined:
    Mar 3, 2002
    Messages:
    1,025
    Likes Received:
    97
    Status:
    Attending Physician
    <7mm being severe I assume, what is your moderate range?
     
  42. lobelsteve

    lobelsteve SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    May 30, 2005
    Messages:
    12,525
    Likes Received:
    2,638
    Status:
    Attending Physician
    I've seen 8 mm bony canals with a mm CSF in each side of a small cord. Ive seen 12mm canals with cord impingement.

    I have never seen a 7mm canal without obliterated CSF.
     
  43. lobelsteve

    lobelsteve SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    May 30, 2005
    Messages:
    12,525
    Likes Received:
    2,638
    Status:
    Attending Physician
    At Isis listening to Aprill talk about tfesi complications. Good idea to take a look at Huntoon in Pain 2005. 110-117
     

Share This Page