muscle pain

[powermd]

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Since entering PP I've been seeing an absurd number of young people with very chronic axial muscle pain on opioids. Most have a history of some kind of trauma, but many do not. Some have been in our practice for a while, getting an ESI here, some facet blocks there, which usually work very temporarily (but usually only after the steroids kick in). Opioids just take the edge off, of course. Most don't appear to be "seekers", just poor self-managers.. they smoke, many don't work, all expect you to solve their problem with one shot, or one pill etc.

I counsel these people on the "partially opioid sensitive" nature of muscle pain, and tolerance is going to have to be managed very carefully for them to have continued benefit. I try to put these patients in PT targeted to the muscle groups that bother them. Once guy came back from PT saying they told him they have no treatment for muscle pain in the mid back. WTF??

I don't have enough experience in practice yet (with true continuity of care), so what has been your experience with these guys? I'm going to venture a guess that you're going to reiterate that PT is still the key, but 9/10 patients that you push down this path aren't going to succeed with it because of who they are, psychopathology, etc. For the motivated patient with chronic axial muscle pain for more than a year or two, do they ever get better with PT? I can fool the patients with the PT mantra most of the time, but am I fooling myself?

 

[lobelsteve]

I'll make the drive out there. I only need 90 Lortab per month to lay on the couch, smoke, and watch 3 Springers per day.

 

[drusso]

I'll make the drive out there. I only need 90 Lortab per month to lay on the couch, smoke, and watch 3 Springers per day.

3 Springer's per day??? Are you crazy???

I never prescribe more than 2 Springer's per day and then I check a level. You're ballsy, Lobelsteve.

But to answer Power's question: I avoid RX'ing opioids for these patients. I've had some luck with Botox, but it's expensive. I do trigger points injections, but try not to go overboard. The best thing is find a *GOOD* Rolfing type PT and get them to "work them over." If it's axial thoracic spine, believe it or not, I've had some luck with manipulation. In general, I recommend deep tissue massage, *aerobic reconditioning,* biofeedback, +/- TPI's or Botox, +/- tizanidine.

Don't bring the RX pad into the exam room, keep making these kinds of recommendations, and watch these patient's disappear from your practice...😀

 

[Mister Mxyzptlk]

I once received some gift certificates for massage therapy. I went and got a deep tissue massage. I couldn't move afterward. The masseuse told me to drink a lot of water to wash out the toxins that were released. I usually associate any therapy that refers to eliminating "toxins" with quackery, so I asked him to name 3 toxins. He said, "You know, the toxins".

Well I figured it out on my own. The deep tissue massage releases myoglobin and you have to drink a lot of water to keep your kidneys from shutting down.

I gave the remaining gift certificates to people I don't like.

I question the use of deep tissue massage for muscle pain, especially for trigger points. They find a "knot" and try to grind it out manually. These are damaged tissues and I don't see how squashing them like a lump in a bowl of oatmeal would help.

The only massage I recommend for my patients is the "Swedish" massage with lubricant on the skin and smooth glides with the heels of the hands along the axis of the muscles to stretch them.

 

[drusso]

I question the use of deep tissue massage for muscle pain, especially for trigger points. They find a "knot" and try to grind it out manually. These are damaged tissues and I don't see how squashing them like a lump in a bowl of oatmeal would help.

I've always attributed the analgesic effects to the physiology of counter-irritation. If you thought that it hurt before, wait until now...

 

[lobelsteve]

I've always attributed the analgesic effects to the physiology of counter-irritation. If you thought that it hurt before, wait until now...

I routinely kick patients in the shins to help alleviate chronic low back pain.

 

[SSdoc33]

I once received some gift certificates for massage therapy. I went and got a deep tissue massage. I couldn't move afterward. The masseuse told me to drink a lot of water to wash out the toxins that were released. I usually associate any therapy that refers to eliminating "toxins" with quackery, so I asked him to name 3 toxins. He said, "You know, the toxins".

Well I figured it out on my own. The deep tissue massage releases myoglobin and you have to drink a lot of water to keep your kidneys from shutting down.

I gave the remaining gift certificates to people I don't like.

I question the use of deep tissue massage for muscle pain, especially for trigger points. They find a "knot" and try to grind it out manually. These are damaged tissues and I don't see how squashing them like a lump in a bowl of oatmeal would help.

The only massage I recommend for my patients is the "Swedish" massage with lubricant on the skin and smooth glides with the heels of the hands along the axis of the muscles to stretch them.

i dont like these deep massages, either. they hurt like #$@#%@#. my wife loves them. i can squeeze on her traps as hard as i can, and she thinks its the best thing since sliced bread. i dont know how or why, but some people respond well to this.

btw, true story, a colleague of mine was really into massage therapy and heard about a decent place. referred a patient there. lets just say it wasnt exactly the type of medical massage that most docs would recommend. he was mortified when he heard about it.

 

[drusso]

I routinely kick patients in the shins to help alleviate chronic low back pain.

It works!

 

[lobelsteve]

It works!

It's called the Paterson technique.

 

[mille125]

Since entering PP I've been seeing an absurd number of young people with very chronic axial muscle pain on opioids. Most have a history of some kind of trauma, but many do not. Some have been in our practice for a while, getting an ESI here, some facet blocks there, which usually work very temporarily (but usually only after the steroids kick in). Opioids just take the edge off, of course. Most don't appear to be "seekers", just poor self-managers.. they smoke, many don't work, all expect you to solve their problem with one shot, or one pill etc.

I counsel these people on the "partially opioid sensitive" nature of muscle pain, and tolerance is going to have to be managed very carefully for them to have continued benefit. I try to put these patients in PT targeted to the muscle groups that bother them. Once guy came back from PT saying they told him they have no treatment for muscle pain in the mid back. WTF??

I don't have enough experience in practice yet (with true continuity of care), so what has been your experience with these guys? I'm going to venture a guess that you're going to reiterate that PT is still the key, but 9/10 patients that you push down this path aren't going to succeed with it because of who they are, psychopathology, etc. For the motivated patient with chronic axial muscle pain for more than a year or two, do they ever get better with PT? I can fool the patients with the PT mantra most of the time, but am I fooling myself?

Fairly common patient to see. Consider the following (in no apparent order)

1) Physical therapy +/- aquatic therapy
2) Tizanidine/baclofen/klonopin
3) Botox/Trigger point injection
4) TENS/Muscle stim
5) Connective tissue panel specifically ruling out Hashimotos, RA, SLE, Sjogrens
6) Weaning of opioids (works best after suggesting above)
7) Psychological counselling (for the patient)
8) Topical compounds



Good luck..........

 

[PMR 4 MSK]

young + muscle pain + chornic = no opioids. No evidence for their use, plenty of evidence for high risk of abuse.

You are describing "chemical copers." They want a pill for each symptom they feel. If they've had a bad day, they want an antidepressant or, more commonly, a valium or xanax. If a muscle is tight, they want a "muscle relaxer" - amazing how often Soma is the only that works for them.

They may not realize it, but they are just looking for chemical comfort. It's the wrong way to go.

If PT doesn't work, give 'em John Sarno's book. It'll keep 'em occupied for a few months.

 

[Tenesma]

Sarno's book reference made me smile....

I agree 100% w/ Mille's recs...

but the reality is that we have NOTHING to offer those patients, because we don't truly understand the underlying problem....

my rec for all those patients: off narcotics....

however, i am not dismissive because i do an extensive work-up to rule out anything nutty going on anatomically or rheumatologically...

what kills me are the PCPs who think it is a good idea to manage a 19yo w/ back pain w/ vicodin....... that's the equivalent of me putting a 19yo on daily prednisone for achy joints (with normal rheum w/u)... just plain crazy

 

[Axehandler]

Sadly that PMD usually knows it is the wrong choice but gets 10 minutes a patient and wants that guy in and out quick.

 

[clubdeac]

Young people with chronic axial muscle pain? How do you know it's muscle pain. Do they have trigger points in their paraspinals/quadratus lumborum? Are you sure it's not diskogenic lbp/IDD? US studies indicate IDD is the cause of lbp in 40% of the population - usually all younger. Just wondering how you're diagnosing the muscle as your pain generator?

 

[PMR 4 MSK]

Young people with chronic axial muscle pain? How do you know it's muscle pain. Do they have trigger points in their paraspinals/quadratus lumborum? Are you sure it's not diskogenic lbp/IDD? US studies indicate IDD is the cause of lbp in 40% of the population - usually all younger. Just wondering how you're diagnosing the muscle as your pain generator?

Many years of clinical practice.

 

[Tenesma]

i agree that it is likely to be discogenic if you look at the statistics and if you listen to bogduk a lot...

however treatment of discogenic pain is just as poor in younger patients.

 

[Jcm800]

I think (and i expect to get flack for this statement) that discogenic pain probably will end up being "proved" as nonesense, as much as i wished it was real and soemthing that we could do something about. I am just not sure it is as real of a phenomenum as we would like it to be...

dont get me wrong, i do disc procedures, so it would be nice if it turned out to be a treatable condition, but the more i practice, the more i feel this is kind over used, murky diagnosis....

please dont hurt me...

 

[lobelsteve]

I think (and i expect to get flack for this statement) that discogenic pain probably will end up being "proved" as nonesense, as much as i wished it was real and soemthing that we could do something about. I am just not sure it is as real of a phenomenum as we would like it to be...

dont get me wrong, i do disc procedures, so it would be nice if it turned out to be a treatable condition, but the more i practice, the more i feel this is kind over used, murky diagnosis....

please dont hurt me...

Discs do hurt. It's a very real diagnosis. We just have nothing useful and consistent to treat discs with. Look at the long history and tradition of procedures and devices used to treat disc pain. Glorious failures all of them.

 

[SSdoc33]

I think (and i expect to get flack for this statement) that discogenic pain probably will end up being "proved" as nonesense, as much as i wished it was real and soemthing that we could do something about. I am just not sure it is as real of a phenomenum as we would like it to be...

dont get me wrong, i do disc procedures, so it would be nice if it turned out to be a treatable condition, but the more i practice, the more i feel this is kind over used, murky diagnosis....

please dont hurt me...

ive heard this sentiment before. ive also heard, by a well published, well known guy "i dont believe in the SI joint".

we may not be able -- correct that -- we arent able to treat discogenic pain all that way, but its gotta be real.

 

[Mister Mxyzptlk]

I don't see anywhere near 40% discogenic axial back pain in my practice. I'd say the % is single digits.

 

[powermd]

Young people with chronic axial muscle pain? How do you know it's muscle pain. Do they have trigger points in their paraspinals/quadratus lumborum? Are you sure it's not diskogenic lbp/IDD? US studies indicate IDD is the cause of lbp in 40% of the population - usually all younger. Just wondering how you're diagnosing the muscle as your pain generator?

I press gently on the muscle, the patient says "ow".

729.1

 

[SSdoc33]

I don't see anywhere near 40% discogenic axial back pain in my practice. I'd say the % is single digits.

interesting. mine is closer to 40%. correction: i THINK it is closer to 40%. who really knows.

 

[clubdeac]

Yeah, I trained under a guy who made is living treating discogenic lbp. He trained under Slipman. We'd do 2-4 bilateral S1 TFESIs for presumable discogenic lbp (at L4/5 or L5/S1) - to get the med to the anterior epidural space and "bathe the disc". If no better, the patient got a disco. If 1 or 2 contiguous positive levels we'd send to surgeon for fusion or try biacuplasty. He did not believe in chronic myofascial pain.

Another guy I trained under would press on the paraspinals (facet joint line) and diagnose facet pain and set everyone up for mbbs and RFA. Not sure how he knew it was tender facet joints or tender paraspinals that were causing the pain.

I find that a lot of these patients have so much windup and allodynia that no matter where you press, they jump off the table. Who knows? I'll probably just keep stickin 'em until I find the answer

 

[powermd]

Yeah, I trained under a guy who made is living treating discogenic lbp. He trained under Slipman. We'd do 2-4 bilateral S1 TFESIs for presumable discogenic lbp (at L4/5 or L5/S1) - to get the med to the anterior epidural space and "bathe the disc". If no better, the patient got a disco. If 1 or 2 contiguous positive levels we'd send to surgeon for fusion or try biacuplasty. He did not believe in chronic myofascial pain.

Another guy I trained under would press on the paraspinals (facet joint line) and diagnose facet pain and set everyone up for mbbs and RFA. Not sure how he knew it was tender facet joints or tender paraspinals that were causing the pain.

I find that a lot of these patients have so much windup and allodynia that no matter where you press, they jump off the table. Who knows? I'll probably just keep stickin 'em until I find the answer

This is my little algorithim for sorting out a few causes of low back pain:
Low back pain on extension - likely facets - do targeted MBB.
Low back pain on palpation of muscles - muscle pain. PT, relafen, tizanidine.
Equivocal - do exam under fluoro, palpate hard directly over facets, do MBB on painful facets - muscle pain vs facets.
Pain on flexion with non-tender paraspinals and no pain on extension discogenic vs mechanical back vs pt is FOS. Look to chronicity - if acute, and patient is younger likely mechanical, if chronic, regardless of age, possibly discogenic.

Do insurers actually pay for biacuplasty?

 

[Jcm800]

I don't see anywhere near 40% discogenic axial back pain in my practice. I'd say the % is single digits.

this is what i see, maybe 5-10% at most. I think the more discogenic pain you see is, if you "want" to see more.

Im not saying it isnt real, well i a may be saying that, im not sure. But what I am saying is that IMHO it is grossly over diagnosed...

When i first got into practice, i would aggressively chase this diagnosis in non-responders, only to find that i was probably over diagnosing it. I do sometimes see some with axial pain, sitting intolerance, and annular tears, but i dont disco them unless the surgeon asks now. Since i have limited treating options, and if the patient is not considering surgery, then no point in doing the discogram, unless the patient insists, which is an extreme rarity for me...

I could probably do 10 discograms a week if i wanted to, but instead i do 1, the one referred by the surgeon for surgical planning...

 

[Ligament]

I do very few discos nowadays, BUT I do see the utility in them. Making a diagnosis, even when treatment options are limited or poor, can be of value to the patient. It can help end the never ending quest for a cause and end further expensive workups...I think this was talked about at a recent meeting...

 

[Jcm800]

"When i first got into practice, i would aggressively chase this diagnosis in non-responders, only to find that i was probably over diagnosing it. I do sometimes see some with axial pain, sitting intolerance, and annular tears, but i dont disco them unless the surgeon asks now. Since i have limited treating options, and if the patient is not considering surgery, then no point in doing the discogram, unless the patient insists, which is an extreme rarity for me..." quote


ironically, today i got a new referral for almost slam dunk discogenic pain, hahah

 

[Jcm800]

I do very few discos nowadays, BUT I do see the utility in them. Making a diagnosis, even when treatment options are limited or poor, can be of value to the patient. It can help end the never ending quest for a cause and end further expensive workups...I think this was talked about at a recent meeting...

agreed. in those cases ill do them...

 

[clubdeac]

"Do insurers actually pay for biacuplasty?" -

Not sure. I've started out at the VA spa so I wouldn't have to mess with insurers cockblocking my endeavors. I just do whatever I think is right for the patient - ELOA, biacuplasty, pulsed RF etc.

"I do sometimes see some with axial pain, sitting intolerance, and annular tears, but i dont disco them unless the surgeon asks now. Since i have limited treating options, and if the patient is not considering surgery, then no point in doing the discogram, unless the patient insists, which is an extreme rarity for me"

I definitely don't require an annular tear on MR to presumably diagnose disc pain though. I think an article in Pain Physician last year showed that the abnormalities on MR that correlated highest with positive discs on discography were decreased signal intensity and not annular tears as one would expect. I guess your point was how do we treat it anyway once its diagnosed. So take that for what it's worth I guess.

 

[SSdoc33]

"Do insurers actually pay for biacuplasty?" -

Not sure. I've started out at the VA spa so I wouldn't have to mess with insurers cockblocking my endeavors. I just do whatever I think is right for the patient - ELOA, biacuplasty, pulsed RF etc.

"I do sometimes see some with axial pain, sitting intolerance, and annular tears, but i dont disco them unless the surgeon asks now. Since i have limited treating options, and if the patient is not considering surgery, then no point in doing the discogram, unless the patient insists, which is an extreme rarity for me"

I definitely don't require an annular tear on MR to presumably diagnose disc pain though. I think an article in Pain Physician last year showed that the abnormalities on MR that correlated highest with positive discs on discography were decreased signal intensity and not annular tears as one would expect. I guess your point was how do we treat it anyway once its diagnosed. So take that for what it's worth I guess.

so, you find that pulsed RF is a good way to spend our (taxpayer's) money?

 

[powermd]

so, you find that pulsed RF is a good way to spend our (taxpayer's) money?

I've been really curious to try pulsed RF for those challenging trigger point scar/neuroma patients since reading this article:

Pain Med. 2009 Sep;10(6):1140-3. Epub 2009 Jul 6.
A case series of pulsed radiofrequency treatment of myofascial trigger points and scar neuromas.
Tamimi MA, McCeney MH, Krutsch J.

Colorado Spine and Pain, Littleton, Colorado, USA.
INTRODUCTION: Pulsed radiofrequency (PRF) current applied to nerve tissue to treat intractable pain has recently been proposed as a less neurodestructive alternative to continuous radiofrequency lesioning. Clinical reports using PRF have shown promise in the treatment of a variety of focal, neuropathic conditions. To date, scant data exist on the use of PRF to treat myofascial and neuromatous pain. METHODS: All cases in which PRF was used to treat myofascial (trigger point) and neuromatous pain within our practice were evaluated retrospectively for technique, efficacy, and complications. Trigger points were defined as localized, extremely tender areas in skeletal muscle that contained palpable, taut bands of muscle. RESULTS: Nine patients were treated over an 18-month period. All patients had longstanding myofascial or neuromatous pain that was refractory to previous medical management, physical therapy, and trigger point injections. Eight out of nine patients experienced 75-100% reduction in their pain following PRF treatment at initial evaluation 4 weeks following treatment. Six out of nine (67%) patients experienced 6 months to greater than 1 year of pain relief. One patient experienced no better relief in terms of degree of pain reduction or duration of benefit when compared with previous trigger point injections. No complications were noted. DISCUSSION: Our review suggests that PRF could be a minimally invasive, less neurodestructive treatment modality for these painful conditions and that further systematic evaluation of this treatment approach is warranted.

 

[nvrsumr]

Retrospective chart review of 9 patients. Nice. Can you say dry needling for TPs .... the PTs do that out here.

 

[powermd]

Retrospective chart review of 9 patients. Nice. Can you say dry needling for TPs .... the PTs do that out here.

Haven't had much luck with this for scar neuromas, have your local PTs?

 

[clubdeac]

so, you find that pulsed RF is a good way to spend our (taxpayer's) money?

Yeah, I've only been at the VA a few months but trust me, if you've seen what I've seen in such a short time, pulsed RF is the least of our worries when it comes to wasteful spending. It's absolutely asinine and if it's any harbinger of what's to come with Obamacare, we're royally screwed!

I actually haven't done a lot of pulsed RF but I have a terminal cancer patient with spine mets infiltrating the neuroforamen and encasing the DRG causing chronic radic pain. Rad onc have done all they can and he might not live long enough for a stim. He's had good but temporary relief from TFESIs. I thought he'd be a good candidate for pulsed RF of the DRG. Any thoughts?

 

[nvrsumr]

Ive had luck with peripheral stim for scar neuroma. Small N though. The study included both TPs and scar. My sarcasm wasnt directed toward you. Just at the crappy article and PTs sticking needles in patients.

 

[facetguy]

...and PTs sticking needles in patients.

 

[powermd]

Ive had luck with peripheral stim for scar neuroma. Small N though. The study included both TPs and scar. My sarcasm wasnt directed toward you. Just at the crappy article and PTs sticking needles in patients.

any issues with the lead eroding through the skin?

 

[nvrsumr]

No. Really worked well.

 

[Tenesma]

i believe as our treatment options go up, so does the % of our population with that diagnosis...

my spine surgeons don't believe in facet pain, unless there is a degen spondy that they can fuse...

my spine surgeons don't believe in discogenic pain, unless there is a straight-forward single or two levels they can fuse in a "normal" (ie non-psych, non-smoker, good insurance, non-narcotic, non-obese patient) patient - otherwise their diagnosis is "global spondylosis"...

 

[lovebailey2001]

Since entering PP I've been seeing an absurd number of young people with very chronic axial muscle pain on opioids. Most have a history of some kind of trauma, but many do not. Some have been in our practice for a while, getting an ESI here, some facet blocks there, which usually work very temporarily (but usually only after the steroids kick in). Opioids just take the edge off, of course. Most don't appear to be "seekers", just poor self-managers.. they smoke, many don't work, all expect you to solve their problem with one shot, or one pill etc.

I counsel these people on the "partially opioid sensitive" nature of muscle pain, and tolerance is going to have to be managed very carefully for them to have continued benefit. I try to put these patients in PT targeted to the muscle groups that bother them. Once guy came back from PT saying they told him they have no treatment for muscle pain in the mid back. WTF??

I don't have enough experience in practice yet (with true continuity of care), so what has been your experience with these guys? I'm going to venture a guess that you're going to reiterate that PT is still the key, but 9/10 patients that you push down this path aren't going to succeed with it because of who they are, psychopathology, etc. For the motivated patient with chronic axial muscle pain for more than a year or two, do they ever get better with PT? I can fool the patients with the PT mantra most of the time, but am I fooling myself?

I too saw a young pt./22 yr/M with LBP in a band like fasion at L3-5 distribution/ No neuro s/s/ no redicular s/s, pain decrease on extension, No TPs in paraspinals or Q. lumborum since last 2 yrs.He states that he has to sleep putting a pillow under his low back to keep it extended.I put him on NSAIDs/ Baclofen/ contrast bath and PT, but releived only for 6-8 hrs after meds.

Thinking of Discogenic pain, any thoughts!

 

[lobelsteve]

I too saw a young pt./22 yr/M with LBP in a band like fasion at L3-5 distribution/ No neuro s/s/ no redicular s/s, pain decrease on extension, No TPs in paraspinals or Q. lumborum since last 2 yrs.He states that he has to sleep putting a pillow under his low back to keep it extended.I put him on NSAIDs/ Baclofen/ contrast bath and PT, but releived only for 6-8 hrs after meds.

Thinking of Discogenic pain, any thoughts!

Make theeds tid, add ppi for NSAID.
Stress importance of dls. No procedure needed.

 

[lovebailey2001]

Make theeds tid, add ppi for NSAID.
Stress importance of dls. No procedure needed.

Thanx for the input! I forgot to mention the ppi, though I gave it as well. I'll work for stress m/g also.

 

[TX PAIN DOC]

I too saw a young pt./22 yr/M with LBP in a band like fasion at L3-5 distribution/ No neuro s/s/ no redicular s/s, pain decrease on extension, No TPs in paraspinals or Q. lumborum since last 2 yrs.He states that he has to sleep putting a pillow under his low back to keep it extended.I put him on NSAIDs/ Baclofen/ contrast bath and PT, but releived only for 6-8 hrs after meds.

Thinking of Discogenic pain, any thoughts!

Is this patient an athlete or played athletics when younger? Young people tend to overtrain and develop spondylolysis that can persist. It's sometimes hard to pick up on oblique x-rays and require CT. Usually extension makes it worse not better, but it can mimic discogenic pain. It may progress to spondylolisthesis.

 

[hyperalgesia]

I too saw a young pt./22 yr/M with LBP in a band like fasion at L3-5 distribution/ No neuro s/s/ no redicular s/s, pain decrease on extension, No TPs in paraspinals or Q. lumborum since last 2 yrs.He states that he has to sleep putting a pillow under his low back to keep it extended.I put him on NSAIDs/ Baclofen/ contrast bath and PT, but releived only for 6-8 hrs after meds.

Thinking of Discogenic pain, any thoughts!

Not to sound jaded here, but any secondary gain issues?
Could look for annular tear with MRI...
Might also be ligament enthesopathy.

 

[lovebailey2001]

Is this patient an athlete or played athletics when younger? Young people tend to overtrain and develop spondylolysis that can persist. It's sometimes hard to pick up on oblique x-rays and require CT. Usually extension makes it worse not better, but it can mimic discogenic pain. It may progress to spondylolisthesis.

Pt. is of lower socionomic staus, working on tailor's shop, thin n lean with no athletic training. and yes, this is what he is claiming- extension makes it better! on x-ray joint spaces are maintained, no osteophytes, no deg changes, mild loss of lumber lordosis, m/b postural!

 

[lovebailey2001]

Not to sound jaded here, but any secondary gain issues?
Could look for annular tear with MRI...
Might also be ligament enthesopathy.

No apparent sec gain issues.

I hv ordered for a MR for disc condition. hope to get some clue abt lig. enthesopathy also on MR.

 

[lovebailey2001]

Dear All! I have two cases I wan to discuss-

1. the same 22 yr/ with band fashion pain in low back, came out having little disc bulges L3-4 n 4-5 and marrow edema at lower left L3 body in MRI. have tried one mth conservative care including TPIs, again relieved wit meds for 6-7 hrs.

2. 26 yrs/F, with lower dorsal and lumber midline axial pain, no radicular s/s, no neuro s/s,normal psycho-social profile, no secondary gain issues, sitting intolerance present,on MRI peripheral annular tear of L3-4 disk with disc dessication of L3-4, L5-S1 present. failed PT and conservative care since last one year.

should I go for discography in these patients and If they are positive which intra discal therapy will be most appropriate in these patients.

 

[Tenesma]

how do you know normal psychosocial and no secondary gains?

 

[SSdoc33]

Dear All! I have two cases I wan to discuss-

1. the same 22 yr/ with band fashion pain in low back, came out having little disc bulges L3-4 n 4-5 and marrow edema at lower left L3 body in MRI. have tried one mth conservative care including TPIs, again relieved wit meds for 6-7 hrs.

2. 26 yrs/F, with lower dorsal and lumber midline axial pain, no radicular s/s, no neuro s/s,normal psycho-social profile, no secondary gain issues, sitting intolerance present,on MRI peripheral annular tear of L3-4 disk with disc dessication of L3-4, L5-S1 present. failed PT and conservative care since last one year.

should I go for discography in these patients and If they are positive which intra discal therapy will be most appropriate in these patients.

respectfully, if you have to ask these questions, you shouldnt go any where near invasive therapies. get them some good PT. if that "didnt work" get them some more. if that doesnt work, get them some more.

 

[lovebailey2001]

how do you know normal psychosocial and no secondary gains?

they were examined by a clinical psychologist.