Perineural Scarring Post-Op

[facetguy]

I have a 45 year old patient who underwent fusion at L5-S1 about 6 months ago and is still in agony (worse than pre-surgery). I just got his MRI w/ and w/o today, and there is evidence of perineural/peridural scarring encasing the thecal sac at L5 as well as the L5 and S1 roots.

Is this something that can be improved with minimally invasive techniques, or is he headed for another surgery?

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[PMR 4 MSK]

Please put the images up if you can.

Some would do lysis of adhesions percutaneously.

Surgery is not going to help.

 

[Mister Mxyzptlk]

I have a 45 year old patient who underwent fusion at L5-S1 about 6 months ago and is still in agony (worse than pre-surgery). I just got his MRI w/ and w/o today, and there is evidence of perineural/peridural scarring encasing the thecal sac at L5 as well as the L5 and S1 roots.

Is this something that can be improved with minimally invasive techniques, or is he headed for another surgery?

You didn't describe his symptoms.

If he has SI joint pain due to the fusion (or had it before and was misdiagnosed and now it's exacerbated by the fusion) you have a chance with SI joint injections or RF. He also has a fighting chance if it's facet pain above the fusion.

If this is radicular pain you can play with it if you want, but eventually there will be a stim trial. I don't think ESI's will help and adhesiolysis is a BS procedure engaged in by people who have never seen epidural fibrosis in vivo.

 

[SSdoc33]

really not enough info. did the pt undergo the fusion for axial or radicular pain? is thequality of pain different after the surgery, or the exact same? the perineural scarring is unlikely to cause radicular pain.

no great "minimally invasive" technique to address this, but again, dont have enough info.

id stay away from epidurolysis and stim trial for that matter (especially if pain is radicular)

 

[facetguy]

He had a Grade 2 spondylolisthesis of L5 on S1, which over time and disc degeneration began to create more and more radicular symptoms. He had tried conservative treatments as well as a variety of injections. Pre-surgically, it was the radicular symptoms that bothered him most (he also had some mild intermittent urinary incontinence issues, which his urologist couldn't completely attribute to a mildly enlarged prostate). He did not have SIJ problems. So, he decided to go for the fusion surgery.

Now, after months of unhelpful PT, lots of meds, and a few more injections (some form of epidurals, I think), he continues with not only bilateral radicular symptoms but now also a deep diffuse ache of the hip and thigh area bilaterally. He cannot sit for more than a few minutes and constantly must keep moving. He stands with a slight degree of trunk flexion and has almost zero extension tolerance (immediate foot pain/numbness). He is normally a very active guy and this is driving him crazy.

He sees both the surgeon and pain managment in 2 days. Last visit, the surgeon discussed possibly removing the hardware if no improvement. The most recent MRI then showed the perineural fibrosis and I wondered what options that may open up. I appreciate your insights.

 

[SSdoc33]

He had a Grade 2 spondylolisthesis of L5 on S1, which over time and disc degeneration began to create more and more radicular symptoms. He had tried conservative treatments as well as a variety of injections. Pre-surgically, it was the radicular symptoms that bothered him most (he also had some mild intermittent urinary incontinence issues, which his urologist couldn't completely attribute to a mildly enlarged prostate). He did not have SIJ problems. So, he decided to go for the fusion surgery.

Now, after months of unhelpful PT, lots of meds, and a few more injections (some form of epidurals, I think), he continues with not only bilateral radicular symptoms but now also a deep diffuse ache of the hip and thigh area bilaterally. He cannot sit for more than a few minutes and constantly must keep moving. He stands with a slight degree of trunk flexion and has almost zero extension tolerance (immediate foot pain/numbness). He is normally a very active guy and this is driving him crazy.

He sees both the surgeon and pain managment in 2 days. Last visit, the surgeon discussed possibly removing the hardware if no improvement. The most recent MRI then showed the perineural fibrosis and I wondered what options that may open up. I appreciate your insights.

actually sounds like a reasonable candidate for a fusion. the radicular pain on extension makes me think that there is some degree of instability or an incomplete/immature fusion. dont know what injections he's had but only thing id do is a bilateral L5 TFESI if he hasnt already had one done well.

 

[Mister Mxyzptlk]

the perineural scarring is unlikely to cause radicular pain.

Not on my planet.

 

[lobelsteve]

Perineural fibrosis can cause chronic radicular pain.

Adhesiolysis is 60000x useless unless you are Racz.

I have had success with a Myelotec or Target catheter for burning pain below the knee, but no improvement with thigh or back pain.

This guy sounds like he went with the fusion. If he is normal enough, SCS is all I would offer.
Lyrica, Cybalta, Savella, Pamelor, Keppra, Neurontin. Good luck.

 

[SSdoc33]

the perineural scarring is unlikely to cause radicular pain.

gooo! my bad. hard to get in a legible post in between patients. should have read

"the perineural scarring is unlikely to cause AXIAL pain"

 

[clubdeac]

The surgeon would most likely evaluate this guy by getting flex/ext films to assess for gross segmental instability. He may also get a CT w/coronal and sag reconstruction if there's any question of pseudoarthrosis or hardware failure. Either of these can be treated surgically. Perineural/epidural fibrosis - good luck. I've done a few adhesiolysis procedures with mixed results. Sounds like the more experienced docs on here think its hogwash. I would trust their opinion. If it's still mainly radicular, agree with some bilateral TFESIs and if no luck stim may be your only option.

Although you could just send him to LaserSpine and have them laser it out

 

[Cruiser]

Did he have severe foraminal stenosis bilateral L5-S1 pre surgery? I assume he did given the degree of listhesis and your report of radic pain pre-op. Also in the differential would be inadequate surgical decompression of the L5 nerves, or injury of the nerves intra-op. Surgeons would says, "it don't matter cuz it's fused" but I would disagree with them.

 

[facetguy]

Although you could just send him to LaserSpine and have them laser it out

I just had a patient today ask me about this. Apparently it was just on an episode of "The Doctors" or some such thing.

 

[facetguy]

Did he have severe foraminal stenosis bilateral L5-S1 pre surgery? I assume he did given the degree of listhesis and your report of radic pain pre-op. Also in the differential would be inadequate surgical decompression of the L5 nerves, or injury of the nerves intra-op. Surgeons would says, "it don't matter cuz it's fused" but I would disagree with them.

He did have severe foraminal stenosis pre-op. We'll see what the surgeon says later this week.

 

[painchas]

Radic pain post fusion this far out that is actually radicular should respond well to stim assuming all other w/u neg. Not unusual to see L5 scar with referral to the hips/gluts. These folks will respond well to SCS. We trial perc dual octrodes at T8 x 7 days with follow up paddle via neuro friend after reviewing the pictures. Usually like to see in excess of 75% relief on the trial before moving forward. Put the paddle where I need it. Never seen hardware removal be helpful. Injection of the screws not so great long term.

 

[Tenesma]

1) what kind of fusion was it? was it a PLIF/TLIF? could the interbody spacer have migrated? this is frequently poorly visualized w/ MR -- better w/ CT.

2) did the sacral screws snap? are they loose? -- better seen w/ CT

3) perineural fibrosis can cause axial pain.... at least in my neck of the woods

4) he needs a good pain doctor to re-eval him first - and whoever is doing epidurals on a post-fusion patient without updated imaging is an idiot...

5) oh... and the artifact on MRI can cause you to miss infection - so check an ESR/C-reactive protein

 

[facetguy]

1) what kind of fusion was it? was it a PLIF/TLIF? could the interbody spacer have migrated? this is frequently poorly visualized w/ MR -- better w/ CT.

2) did the sacral screws snap? are they loose? -- better seen w/ CT

3) perineural fibrosis can cause axial pain.... at least in my neck of the woods

4) he needs a good pain doctor to re-eval him first - and whoever is doing epidurals on a post-fusion patient without updated imaging is an idiot...

5) oh... and the artifact on MRI can cause you to miss infection - so check an ESR/C-reactive protein

I'm not sure which specific type of fusion. And to my knowledge, a CT scan has not been done. Infection has been considered and ruled out. Pain Mgmt sees him Friday, shortly after surgical appointment.

 

[facetguy]

Radic pain post fusion this far out that is actually radicular should respond well to stim assuming all other w/u neg. Not unusual to see L5 scar with referral to the hips/gluts. These folks will respond well to SCS. We trial perc dual octrodes at T8 x 7 days with follow up paddle via neuro friend after reviewing the pictures. Usually like to see in excess of 75% relief on the trial before moving forward. Put the paddle where I need it. Never seen hardware removal be helpful. Injection of the screws not so great long term.

When you say injection of the screws, is that what it sounds like? Injecting right along the screws?

And, on the topic of SCS, do you ever advise removal of a surgically placed SCS if the unit fails one month in? Or is it advisable to just leave it there?

 

[specepic]

I just had a patient today ask me about this. Apparently it was just on an episode of "The Doctors" or some such thing.

It does an excellent job removing green peices of paper from billfolds

 

[facetguy]

So, in brief then:

1) Consider a CT scan for better visualization of key structures.

2) Try a TFESI at L5 if not done already.

3) There is no good way to eliminate the perineural scarring.

4) If all fails, SCS trial.

Sound about right?

 

[Tenesma]

pretty much...

 

[stim4u]

add trial of epidural lysis of adhesions prior to #4, if you are skilled at it. I have seen significant improvement with my population.

 

[facetguy]

add trial of epidural lysis of adhesions prior to #4, if you are skilled at it. I have seen significant improvement with my population.

What's the technique for this?

 

[hyperalgesia]

What's the technique for this?

Easy. Just push the long, flimsy, useless catheter cephalad via sacral hiatus. Say things like, "Wow there's lots of scar tissue in here" and "Oh, there we go, now we're talking". Inject contrast, steroid and local. Then, preferably with a large reassuring smile, ask, "NOOOWWW, how do you feel?"

 

[facetguy]

Easy. Just push the long, flimsy, useless catheter cephalad via sacral hiatus. Say things like, "Wow there's lots of scar tissue in here" and "Oh, there we go, now we're talking". Inject contrast, steroid and local. Then, preferably with a large reassuring smile, ask, "NOOOWWW, how do you feel?"

I take it you don't have much confidence in the effectiveness of trying to eliminate the scar tissue?

Is this the general consensus?

 

[Tenesma]

it is useless..

 

[facetguy]

Thanks for the replies.

The patient saw his surgeon today, who essentially said to either give it more time, or he could go back in to remove the hardware and scarring. Surgeon would be willing to do CT scan at 1 year point to assure all solid. Patient opted to wait it out and get an EMG, with 3 month follow-up scheduled.

Later today, the patient saw his pain doc, who agreed with the surgeon. Meds remain Percocet, Lyrica and MS Contin.

 

[Tenesma]

i don't recommending one year post-op --- if there are significant issues after 3-4 months, then CT is warranted in my opinion... a broken screw, a loose screw, a displaced spacer --- those things don't get better w/ time.

 

[SSdoc33]

and EMG will do what, exactly?

 

[Tenesma]

it is a stall technique used by most surgeons so it looks like they are doing something without having to act on the information... if the EMG is normal then they say nothing can be done, if the EMG shows a chronic radic they recommend no surgery....

completely useless testing at this point in time...

 

[The pyramids]

DD : Stenosis (Leaning forward), Scarring or Fusion failure.
for you DD you have to follow step by step for:

In this case time has nothing to do with the issue:

I do agree with this step.

1) Consider a CT scan.
2) X-ray flexion and extension
3) EMG
2) Try a TFESI 2 level L5-S1/L4-L5 we usually use CT scan guided injection.
3) Do not play with perineural scarring( it is not good option)
4) If all fails, SCS trial.
5. Play with Medication , Fentanyl Patch could be good option with breakthrough pain medication.
6. Consider second opinion for surgery.

 

[Tenesma]

1) EMG - why? and what will you do with that data?

2) what is the advantage of CT-guided injection other than to increase risk of mantle-cell lymphoma?

3) what data do you have to support the use of long-acting opioids for mechanical pain associated with neuropathic complaints?

4) what do you mean with TRY a TFESI... you either do it or you dont... you don't TRY... and why a 2 level TFESI? we know he has an L5/S1 spondy that is now reportedly fused - what does l4/L5 have to do with it - other than you can code for that extra level...

5) the fact that extension causes worsening pain/numbness into the legs already suggests a degree of dynamic instability --- what does the x-ray flex/extension add to that equation

your tag line summarizes it all....

 

[The pyramids]

Dear Tenesma :

1- EMG - why? and what will you do with that data?

A: good tool why?
A. If he has Fibs and large sharp waves tell you he has new radiculopthy,
B. Screen other level if there L3_L4 and so on

2) What is the advantage of CT-guided injection other than to increase risk of mantle-cell lymphoma?


A: I am sure you never try that tool but I was trained by intervention radiologist who used it all the time for cases like that. It is better to look at that tool.



3) What data do you have to support the use of long-acting opioids for mechanical pain associated with neuropathic complaints?
A: As I said it is combination of multiple causes it you are not using opoiod in this case !!!!!!!!!! do you use it for Fibromyliga patient??????
4) what do you mean with TRY a TFESI... you either do it or you dont... you don't TRY... and why a 2 level TFESI? we know he has an L5/S1 spondy that is now reportedly fused - what does l4/L5 have to do with it - other than you can code for that extra level...



A: I am sure he has multilevel . Spine did not work as one Neurocell mechanism.

5) the fact that extension causes worsening pain/numbness into the legs already suggests a degree of dynamic instability --- what does the x-ray
flex/extension add to that equation



A: Work up for instability, I think you had question in your board exam about that:
I was working with more than 10 neurosurgeons . They order what I told you blindly for work up

Your tag line summarizes it all....

A: My tag line about America Boss

 

[Tenesma]

1) so are you using the EMG as a screening tool? it doesn't sound like this guy has any specific new weakness, so what are you screening for?

2) just because somebody uses CT guided injections doesn't mean the radiation exposure is worth it.

3) i rarely recommend opioids and primarily for nociceptive pain - never recommend it for fibromyalgia

4) if you are sure he has multi-level why don't you do a 5 level TFESI - that way you can cover the whole lumbar spine

5) why would he have instability - he had his spondy already fused... so now you get a flex/ext films and you see motion --- hmm, he already reported that his symptoms worsen mechanically and w/ extension, you will have to get a CT scan anyway - the flex/ext doesn't really add much to the equation.

6) 10 neurosurgeons ordering things blindly is a sad statement about the practice of clinical medicine.

7) welcome to our forum ...

 

[The pyramids]

Tenesma
Thank you very much.

The pine is a black box.
We have to solve the puzzle by collecting small pieces and put them together.
Order tests, examine your patient and get the conclusion and plan of treatment.
With fusion always look at level above and level below.
Medication goal is to make your patient functional. Screen for functional status and adjust your medication.
I found 2 levels will help more than one level
CT scan guided injection, you inject air instead of contrast, you see the tip of your needle ( 3D) the best for cervical.
I did not mean it as blindly, but I watched how those guys treat their patients and how they think to solve the problem . May be they disagree on order some test but you could get some information if you could read your own films.
Pain management operate by trial as we know .

 

[clubdeac]

Dear Tenesma :

1- EMG - why? and what will you do with that data?

A: good tool why?
A. If he has Fibs and large sharp waves tell you he has new radiculopthy,
B. Screen other level if there L3_L4 and so on

2) What is the advantage of CT-guided injection other than to increase risk of mantle-cell lymphoma?


A: I am sure you never try that tool but I was trained by intervention radiologist who used it all the time for cases like that. It is better to look at that tool.



3) What data do you have to support the use of long-acting opioids for mechanical pain associated with neuropathic complaints?
A: As I said it is combination of multiple causes it you are not using opoiod in this case !!!!!!!!!! do you use it for Fibromyliga patient??????
4) what do you mean with TRY a TFESI... you either do it or you dont... you don't TRY... and why a 2 level TFESI? we know he has an L5/S1 spondy that is now reportedly fused - what does l4/L5 have to do with it - other than you can code for that extra level...



A: I am sure he has multilevel . Spine did not work as one Neurocell mechanism.

5) the fact that extension causes worsening pain/numbness into the legs already suggests a degree of dynamic instability --- what does the x-ray
flex/extension add to that equation



A: Work up for instability, I think you had question in your board exam about that:
I was working with more than 10 neurosurgeons . They order what I told you blindly for work up

Your tag line summarizes it all....

A: My tag line about America Boss

Forget about your w/u (he's gonna get a stim anyway), the more important question, Did you just knock America????

 

[SSdoc33]

DD : Stenosis (Leaning forward), Scarring or Fusion failure.
for you DD you have to follow step by step for:

In this case time has nothing to do with the issue:

I do agree with this step.

1) Consider a CT scan.
2) X-ray flexion and extension
3) EMG
2) Try a TFESI 2 level L5-S1/L4-L5 we usually use CT scan guided injection.
3) Do not play with perineural scarring( it is not good option)
4) If all fails, SCS trial.
5. Play with Medication , Fentanyl Patch could be good option with breakthrough pain medication.
6. Consider second opinion for surgery.

ahhhhh, the ART of medicine. gotta love it.

 

[The pyramids]

Forget about your w/u (he's gonna get a stim anyway), the more important question, Did you just knock America????

Shakespeare - Henry VIII Quotes
Farewell! a long farewell, to all my greatness!
This is the state of man: to-day he puts forth
The tender leaves of hopes; to-morrow blossoms,
And bears his blushing honours thick upon him;
The third day comes a frost, a killing frost,
And when he thinks, good easy man, full surely
His greatness is a-ripening, nips his root,
And then he falls, as I do. I have ventured,
Like little wanton boys that swim on bladders,
This many summers in a sea of glory,
But far beyond my depth.

I found similarity between what Shakespeare said long time and now . I just like it .
</SPAN>ahhhhh, the ART of medicine. gotta love it.

It is just opioion may be wrong may be right .

 

[bedrock]

Definitely not born in America-