muscle pain

[Tenesma]

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fair enough ... i would recommend that they both get used to the pain because likely outcome with surgery is poor... would only consider disco if they absolutely could not live w/ the pain, in constant tears, curled up in the corner in pain all day, vomiting non-stop from the pain and have lost >30 lbs because of the anorexia from vomiting all day

 

[hyperalgesia]

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.

Agree with other commenters, forget about interventions in these pts. They are too young with too unclear pictures. Discography is only appropriate if you have a good f/u plan afterward. And you don't because there isn't one. Therapy, TENS, biofeedback, multivitamins, etc. are your best options for both pts.

 

[axm397]

what kind of PT? can try extension based mckenzie spine PT.

 

[lovebailey2001]

Thanx Tenesma and Hyperalgesia! I will advise them for the same. But again, is there any order for the effectiveness of disc relaated procedures!not for these patients, but for some other patients in which they are realy indicated.

 

[clubdeac]

Thanx Tenesma and Hyperalgesia! I will advise them for the same. But again, is there any order for the effectiveness of disc relaated procedures!not for these patients, but for some other patients in which they are realy indicated.

Here's how I was trained:

If midline axial lbp with degenerative changes or tear noted on MRI, smells like disc (sitting intolerance, worse with flexion, pain w/increased intrathoracic pressure etc) and high unlikelihood of facetogenic pain then try conservative measures as recommended previously. If no relief then disco and if 1 positive disc try GRC blocks and RF or biacuplasty (if you got it). Could always do a diagnostic GRC block prior to disco I guess

If patient is older (higher likelihood of facet pain) and has any whiff of possible facet pain, I would first r/o the facets before considering discogram.

That's what I would say......

 

[hyperalgesia]

Thanx Tenesma and Hyperalgesia! I will advise them for the same. But again, is there any order for the effectiveness of disc relaated procedures!not for these patients, but for some other patients in which they are realy indicated.

I have not seen very good relief with therapeutic disc procedures (IDET, biacuplasty, etc) so I can't justify going in and cooking part of the anatomy based on subjecive discogram pain concordance. If the pt is hell bent on getting a fusion for pain relief and other pain generators have been ruled out, then I would consider trying perc disc diagnostics/interventions first. That's as much to postpone/prevent the fusion as it is to treat the pain.

 

[lovebailey2001]

Thanks both of you🙂! I have recently come across to some articles in which they have used intradiscal steroids and in one of the studies they have found them to be beneficial in Modic type 1 disc changes (in more recent one). What is the experience here?

 

[SSdoc33]

Here's how I was trained:

If midline axial lbp with degenerative changes or tear noted on MRI, smells like disc (sitting intolerance, worse with flexion, pain w/increased intrathoracic pressure etc) and high unlikelihood of facetogenic pain then try conservative measures as recommended previously. If no relief then disco and if 1 positive disc try GRC blocks and RF or biacuplasty (if you got it). Could always do a diagnostic GRC block prior to disco I guess

If patient is older (higher likelihood of facet pain) and has any whiff of possible facet pain, I would first r/o the facets before considering discogram.

That's what I would say......

people in medicine always try to make up algorithms. i dont see how you can put people in a box like that. sounds like every patient you see is gonna get a needle in their back, some of them several. might want to try to treat patients individually, rather than checking off boxes in your preprogrammed mind. you are costing us a crapload with this approach.

 

[joshmir]

can also try intradiscal methylene blue for discogenic pain

do you guys first do a discogram to make sure there are no fullthickness tears which extravasate contrast?

 

[clubdeac]

people in medicine always try to make up algorithms. i dont see how you can put people in a box like that. sounds like every patient you see is gonna get a needle in their back, some of them several. might want to try to treat patients individually, rather than checking off boxes in your preprogrammed mind. you are costing us a crapload with this approach.

That's the Slipman model for ya. However, didn't I say try conservative tx first? "If midline axial lbp with degenerative changes or tear noted on MRI, smells like disc (sitting intolerance, worse with flexion, pain w/increased intrathoracic pressure etc) and high unlikelihood of facetogenic pain then try conservative measures as recommended previously."

So you've now exhausted all conservative measures i.e. TENs, PT, trigger points, accupuncture, various adjuvant meds, chiropractic etc, what do you do next. Do you use your interventional skills to try and find and treat "the pain generator" or do you tell them that's too costly, lets try some capsaicin cream and get you on the never ending opioid train. Trust me, I've got no incentive for doing extra procedures, I'm salaried.

 

[Tenesma]

the truth is that most axial back pains do NOT respond very well to interventional procedures (except in proven cases of facet disease)....

so knowing the above, what is the point of finding the pain generator? if you know you don't have much to offer?

well Bogduk feels that at least we owe it to the patient to provide them with a diagnosis...

frequently once i offer disco w/ risks/benefits so that we can confirm the diagnosis with the understanding that i won't recommend any action based on that diagnosis, most patients decline the procedure... in fact most decline discography even if i do offer surgical mgmt in the future because they don't want fusions

 

[clubdeac]

Thanks both of you🙂! I have recently come across to some articles in which they have used intradiscal steroids and in one of the studies they have found them to be beneficial in Modic type 1 disc changes (in more recent one). What is the experience here?

Intradiscal steroids were popular for a brief moment in time years back. They didn't work so most all main stream, reasonable and prudent pain docs in the US have abandoned that practice. I would liken it to injecting intrathecal steroids. No good evidence for efficacy and some evidence for harm (arachnoiditis)

And Tenesma you're probably right when you say that other than facet pain, axial lbp doesn't respond well to interventional procedures. However, I'm pretty fresh out, still have that "I can cure the world" naivete and haven't seen enough failures of my own to throw it all in the IDET basket. I'm gonna give GRC blocks and biacuplasty a fair shake before scrapping all interventional treatment of "discogenic lbp". There's gotta be something we can do for discogenic pain. Remember when they used to inject chymopapain into the discs for this. It was big in the ortho world. Actually was very successful except too many catastrophic complications occurred with subsequent law suits causing it to be abandoned.

 

[lobelsteve]

BRING BACK CHYMO!!! And allergy test prior to procedure.

Other experimental: TNF alpha, Ozone, Derby cocktail.
I'd like to see data on the other RA drugs intradiskal (but done far away from me for safety).

 

[SSdoc33]

That's the Slipman model for ya. However, didn't I say try conservative tx first? "If midline axial lbp with degenerative changes or tear noted on MRI, smells like disc (sitting intolerance, worse with flexion, pain w/increased intrathoracic pressure etc) and high unlikelihood of facetogenic pain then try conservative measures as recommended previously."

So you've now exhausted all conservative measures i.e. TENs, PT, trigger points, accupuncture, various adjuvant meds, chiropractic etc, what do you do next. Do you use your interventional skills to try and find and treat "the pain generator" or do you tell them that's too costly, lets try some capsaicin cream and get you on the never ending opioid train. Trust me, I've got no incentive for doing extra procedures, I'm salaried.

yeah,i hear whatyou are saying, club. but, just because they "fail conservative treatment" does not mean that they are 1.)destined for a life on opioids, or 2.) deserve/need any interventional treatment. im all for an interventional treatment for discogenic pain. however, im gonna wait until one exists before i utilize it.

 

[Tenesma]

i COMPLETELY agree w/ SSdoc33...

a lot of those patients end up with counseling on lifestyle modifications...

i had one patient who was absolutely close to disability due to axial low back pain, had gone thru everything imaginable and was begging for a disco....

i told him that his 2 hour commute in AM and PM is what is killing him...

he somehow convinced his employer to tele-commute, and he no longer has much back pain at all...

opioids are NOT the answer to all ailments that fail interventions...