multifidus exam

[epidural man]

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When one is twitching a medial branch, is there any way to discern that you are just twitching multifidus, and NOT the other erector spinae muscles (twitching the intermedius or lateral branch)?

What about on physical exam? How does one identify that multifidus might have some atrophy/weakness?

 

[drusso]

When one is twitching a medial branch, is there any way to discern that you are just twitching multifidus, and NOT the other erector spinae muscles (twitching the intermedius or lateral branch)?

What about on physical exam? How does one identify that multifidus might have some atrophy/weakness?

Stick an EMG needle in under the US and see where you are and what it does.

 

[epidural man]

Stick an EMG needle in under the US and see where you are and what it does.

Well, I don't have an EMG - I do have a stim needles though.

So under ultrasound, is there an obvioius distinction between the multifidus and longissimus?

 

[MitchLevi]

Well, I don't have an EMG - I do have a stim needles though.

So under ultrasound, is there an obvioius distinction between the multifidus and longissimus?

Yes, if you're good at US that is...I wouldn't bet my life on being able to cleanly distinguish between the two.

I guess you hug the SP and stim. Watch the multifidi twitch, trace probe laterally and twitch should stop.

What is the reason for the Q by the way?

MRI shows atrophy. I'll mention it in my notes occasionally but I don't think there's anything you can do about it other than PT.

 

[NJPAIN]

Yes, if you're good at US that is...I wouldn't bet my life on being able to cleanly distinguish between the two.

I guess you hug the SP and stim. Watch the multifidi twitch, trace probe laterally and twitch should stop.

What is the reason for the Q by the way?

MRI shows atrophy. I'll mention it in my notes occasionally but I don't think there's anything you can do about it other than PT.

Reactiv8

 

[lobelsteve]

When one is twitching a medial branch, is there any way to discern that you are just twitching multifidus, and NOT the other erector spinae muscles (twitching the intermedius or lateral branch)?

What about on physical exam? How does one identify that multifidus might have some atrophy/weakness?

What are you doing?

 

[TIVAndy]

Reactiv8

this is like the laziest device for the patient.. if you wanna train your multifidus.. please work out.

 

[epidural man]

What are you doing?

Well, I'm curious about Sprint SPR and low back pain. I'd like to do a series of about 10 or 20 patients and see if it works. I have done one, and it dislodged but while it was in, but he really liked it.

I am uncomfortable using Reactiv8 without a way to trial. I am thinking maybe SPRINT leads could be a good trial system for Reactiv8 -

But I am skeptical. I'd like to make sure placement is ideal so at least that isn't the question (about efficacy).

Also, Reactiv8 says you determine multifidus dysfunction by physiological testing. I have no idea how to do that. I assume you PM&R guys can help me with that.

Finally, I was just curious if you could tell a difference in twitch with RF needle placements (if you happen to be on the lateral or intermediate branch).

 

[epidural man]

There are youtube videos about raising arms and legs and stuff with palpation. Does that really isolate only the multifidus with NO erector spinae activation?

 

[MitchLevi]

I do SPRINT multifidus stim.

n = 1

She's getting 25% relief and her skin despises the dressings.

 

[RoloTomassi]

this is like the laziest device for the patient.. if you wanna train your multifidus.. please work out.

Haha Reactiv8 and Sprint are pretty much like those ab stimulators on infomercials that give you a six pack while watching TV

 

[cowboydoc]

When one is twitching a medial branch, is there any way to discern that you are just twitching multifidus, and NOT the other erector spinae muscles (twitching the intermedius or lateral branch)?

What about on physical exam? How does one identify that multifidus might have some atrophy/weakness?

The majority of people can't volitionally fire their multifidi. It isn't that hard to palpate on exam whether they are firing, but a bit tricky to explain here. EMG would be best, but I'd ask a local PT to show you. Prone lying, gentle lumbar flexion, instruct to bring PSIS to contralateral L3 TP while palpating deep to medial aspect of erector musculature is the best I can find you here.

 

[lobelsteve]

Well, I'm curious about Sprint SPR and low back pain. I'd like to do a series of about 10 or 20 patients and see if it works. I have done one, and it dislodged but while it was in, but he really liked it.

I am uncomfortable using Reactiv8 without a way to trial. I am thinking maybe SPRINT leads could be a good trial system for Reactiv8 -

But I am skeptical. I'd like to make sure placement is ideal so at least that isn't the question (about efficacy).

Also, Reactiv8 says you determine multifidus dysfunction by physiological testing. I have no idea how to do that. I assume you PM&R guys can help me with that.

Finally, I was just curious if you could tell a difference in twitch with RF needle placements (if you happen to be on the lateral or intermediate branch).

I do not like the idea of experimenting on patients in a case series without IRB approval.
We have been doing PNS for 30+ years and while easy and profitable, I am sure those of us who were there at the beginning can tell you about our successes we can count on one hand vs the complications and failures. Our field needs less me too.

 

[drusso]

I do not like the idea of experimenting on patients in a case series without IRB approval.
We have been doing PNS for 30+ years and while easy and profitable, I am sure those of us who were there at the beginning can tell you about our successes we can count on one hand vs the complications and failures. Our field needs less me too.

It's not an experiment if you know what kind of results you're going to get.

 

[lobelsteve]

It's not an experiment if you know what kind of results you're going to get.

Results were better when L8680 was over $400 per electrode. (Numbers made up- been too long since I was seeing this stuff)

 

[crunchymedicine]

I do not like the idea of experimenting on patients in a case series without IRB approval.
We have been doing PNS for 30+ years and while easy and profitable, I am sure those of us who were there at the beginning can tell you about our successes we can count on one hand vs the complications and failures. Our field needs less me too.

What type of complications?

 

[lobelsteve]

Infection. Skin erosion. Abscess. Periorbital cellulitis. Hematoma.

 

[cowboydoc]

Periorbital cellulitis.

Where were you putting these leads?

 

[nvrsumr]

had a couple bilateral supra and infra orbital lead placements as a fellow.

 

[lobelsteve]

Where were you putting these leads?

Guy in Dallas Tx used to or still does a ton of cash based PNS. Patients came to him from all over the country to get his magic done. I personally explanted 3 of his complications. Also have an Emory NS who is an arrogant SOB who puts wires everywhere. Including gasserian. Patient infected with meningitis in under a month. Good feeling when she came back to my office and told me it was ok for me to say "I told you so". I was just glad she didn't die.

Here is my pre-op before removing 2 occipital, 2 orbital, connectors, and IPG. IPG was placed on her right shoulder blade.

 

[epidural man]

I do not like the idea of experimenting on patients in a case series without IRB approval.
We have been doing PNS for 30+ years and while easy and profitable, I am sure those of us who were there at the beginning can tell you about our successes we can count on one hand vs the complications and failures. Our field needs less me too.

Although I see your point, I see it differently.

 

[epidural man]

The majority of people can't volitionally fire their multifidi. It isn't that hard to palpate on exam whether they are firing, but a bit tricky to explain here. EMG would be best, but I'd ask a local PT to show you. Prone lying, gentle lumbar flexion, instruct to bring PSIS to contralateral L3 TP while palpating deep to medial aspect of erector musculature is the best I can find you here.

Does this isolate the multifidus and not the erector spinae complex?

 

[Orin]

Infection. Skin erosion. Abscess. Periorbital cellulitis. Hematoma.

I agree, but this just is very unlikely to happen with SPR for sure. The newer hardware is FDA approved for this for a reason.

The old systems worked great until they broke, and most patients begged you to fix it despite the sepsis, but that might just be the CNS infection talking.

 

[cowboydoc]

Does this isolate the multifidus and not the erector spinae complex?

Not inherently, but you may be able to coach with some tactile feedback to relax the erector spinae while trying to activate the multifidi.

 

[epidural man]

Not inherently, but you may be able to coach with some tactile feedback to relax the erector spinae while trying to activate the multifidi.

I’ll work with my PT and get this figured out. Thanks.

 

[MitchLevi]

I’ll work with my PT and get this figured out. Thanks.

I do not believe it possible to selectively activate the multifidus, but I can guarantee your fav PT will say any number of things to the contrary.

I know mine tell my pts to "ask Dr XXX about your piriformis" on a daily basis.

Severe atrophy after back surgery is probably irreversible considering it is very, very common some of these pts have had their medial branches sacrificed by the surgeon.

Look at pts with back surgery Hx and their EMG findings.

I do not believe multifidus stim works for LBP either.

 

[epidural man]

I do not believe it possible to selectively activate the multifidus, but I can guarantee your fav PT will say any number of things to the contrary.

I know mine tell my pts to "ask Dr XXX about your piriformis" on a daily basis.

Severe atrophy after back surgery is probably irreversible considering it is very, very common some of these pts have had their medial branches sacrificed by the surgeon.

Look at pts with back surgery Hx and their EMG findings.

I do not believe multifidus stim works for LBP either.

Why don’t you think it works? Is that a hypothesis or by experience?

 

[bedrock]

Why don’t you think it works? Is that a hypothesis or by experience?

You can selectively activate your multifidus. I have SIJ issues and learned from a great PT in Med school. I can’t teach it but I can do it.

A good PT should be able to teach a normal patient how to do it.

 

[MitchLevi]

You can selectively activate your multifidus. I have SIJ issues and learned from a great PT in Med school. I can’t teach it but I can do it.

A good PT should be able to teach a normal patient how to do it.

How do you know?

 

[MitchLevi]

Why don’t you think it works? Is that a hypothesis or by experience?

Admittedly, my n = 1 and explanted early with a lead fracture during explant. Pt claimed 25% relief and improved standing tolerance but her standing and walking improvements were identical to what was documented before the procedure.

Placing those leads for that indication takes 2 min per lead. In fact, if i wanted to be cool and pick up chicks at a pain conference I bet I could do a lead in under 60 sec. It is absurdly easy, to the extent that when the pt is leaving the procedure room you think, "No freaking way this works...No way something that easy will overcome 75 yrs of gravity."

The mechanism of action as to why it would work doesn't make sense to me.

...and I'll die on this hill - Selective activation of the multifidi while keeping everything else quiet is impossible.

I can't wrap my head around anyone being able to selectively put their medial branch nerves to use on command, while simultaneously keeping the lateral branches quiet. The movements that activate these muscles have overlap with one another.

 

[cowboydoc]

Admittedly, my n = 1 and explanted early with a lead fracture during explant. Pt claimed 25% relief and improved standing tolerance but her standing and walking improvements were identical to what was documented before the procedure.

Placing those leads for that indication takes 2 min per lead. In fact, if i wanted to be cool and pick up chicks at a pain conference I bet I could do a lead in under 60 sec. It is absurdly easy, to the extent that when the pt is leaving the procedure room you think, "No freaking way this works...No way something that easy will overcome 75 yrs of gravity."

The mechanism of action as to why it would work doesn't make sense to me.

...and I'll die on this hill - Selective activation of the multifidi while keeping everything else quiet is impossible.

I can't wrap my head around anyone being able to selectively put their medial branch nerves to use on command, while simultaneously keeping the lateral branches quiet. The movements that activate these muscles have overlap with one another.

To be clear, I'm in agreement with you. A good PT will spend a lot of time teaching someone to activate their multifidi. Coactivation is a given. The issue for many is full activation of the erector with minimal to no activation of multifidi.

You describe atrophy of the multifidi in surgical patients, but look at your non-surgical patients. Distal atrophy is really common in virgin spines, too.

 

[MitchLevi]

To be clear, I'm in agreement with you. A good PT will spend a lot of time teaching someone to activate their multifidi. Coactivation is a given. The issue for many is full activation of the erector with minimal to no activation of multifidi.

You describe atrophy of the multifidi in surgical patients, but look at your non-surgical patients. Distal atrophy is really common in virgin spines, too.

Degenerative spines break down internally and externally. I just spoke to an attorney pt of mine 3 sec ago where I explained that very thing.

I'm not telling you anything you don't already know.

 

[crunchymedicine]

Guy in Dallas Tx used to or still does a ton of cash based PNS. Patients came to him from all over the country to get his magic done. I personally explanted 3 of his complications. Also have an Emory NS who is an arrogant SOB who puts wires everywhere. Including gasserian. Patient infected with meningitis in under a month. Good feeling when she came back to my office and told me it was ok for me to say "I told you so". I was just glad she didn't die.

Here is my pre-op before removing 2 occipital, 2 orbital, connectors, and IPG. IPG was placed on her right shoulder blade.

Is the infection rate higher in PNS than SCS?

 

[lobelsteve]

Is the infection rate higher in PNS than SCS?

I don’t know. I think it is, but clearly not as serious dependent on location.

 

[Agast]

Just got a transfer of care request from a 34 year old. Review of records shows the plan was diagnostic lumbar facet joint blocks (performed) to Reactiv8 (unsure if done.) Doctor documented atrophy of multifidus. Very curious to hear from the patient how that conversation went.