quick patient question....RF of DRG for T HNP

[Doctodd]

i say quick cuz i dont want to forget and patient was here today.....she had only 5 days relief each time from T ESI x2 for a T12-L1 central protrusion. NS says nonsurgical surprisingly cuz films show a decent sized protrusion. Any anecdotal results for DRG RF at this level?

thx in advance

T

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[ampaphb]

i say quick cuz i dont want to forget and patient was here today.....she had only 5 days relief each time from T ESI x2 for a T12-L1 central protrusion. NS says nonsurgical surprisingly cuz films show a decent sized protrusion. Any anecdotal results for DRG RF at this level?

thx in advance

T

Predominantly axial or radicular symptoms?

 

[Doctodd]

both

 

[Tenesma]

most surgeons won't go after T12 level unless there is cord compression or horrible radicular pain....

and just because she gets relief for 5 days w/ ESI doesn't mean that surgery will cure the pain

i agree management will change based on pain patter.

 

[ampaphb]

both

I have had anecdotal good responses from some patients with pulsed RF of the DRG where the pain was unilateral and predominantly radicular.

A colleague went out to the guru of pulsed out in Utah, and watched him for a day. He came back amazed at how the guy did "sensory stim". We ask the patient to tell us when they first feel any change in sensation as we ramp up. They ramp up to the point where the sensation is nearly intolerable, and then ask the patient when they STOP feeling something. I have found the threshold to be MUCH lower doing it his way.

For predominantly axial pain, our practice is to first try low volume intradiscal injections of steroid and 4% lidocaine. If it lasts great. If not, we move on to PDD (in our case, Nucleoplasty)

 

[Doctodd]

i first thought nucleoplasty too, but she is a cash patient. Plus i dont feel experienced enough to do it at T12 yet. Moot though cuz of no insurance. She asked about lase, but it is 35K. Intradiscal might work and be cost effective/reasonable.

thx

T

 

[Tenesma]

so is it radicular or axial?

 

[chinochulo]

For predominantly axial pain, our practice is to first try low volume intradiscal injections of steroid and 4% lidocaine. If it lasts great. If not, we move on to PDD (in our case, Nucleoplasty)

Am I missing something here? nucleoplasty for axial LBP?

 

[ampaphb]

Am I missing something here? nucleoplasty for axial LBP?

with an underlying central protrusion as the eitiology? yes.

 

[Tenesma]

there is that guy that injects 50% dextrose into the disc for "prolodiscotherapy" - forget his name but he is in chicago and does a lot of speaking for IDET

I have really stopped doing a lot of intra-discal procedures for axial back pain - for two reasons

1) it can REALLY hurt some patients - and then you have to hold their hand over the phone for the next few weeks until it calms down - not to mention that some of these patients are on narcotics - and you end up feeding them with more narcotics.... and when you hurt a patient like that then odds are they will never trust you with a procedure in the future

2) outcomes: i just haven't seen consistent results --- i was on the intra-discal steroid bandwagon (especially after i had one patient who had miraculous complete pain relief - that still lasts to this day) - but abandoned it after I realized that the % of patients with improvement was ridiculously low - not to mention one case of discitis (ouch)

for axial back pain at the thoraco-lumbar junction when the imaging only reveals a protrusion I tend to stick with
1) no surgery
2) no procedures
3) Physical Therapy
4) TENS unit
5) some muscle relaxants
---

I mean how many of us have seen the woman in her 30-40s who has "burning" pain in her dorsal spine who comes to your office with MRIs from the cervical spine down to the sacrum - and she is convinced that all of her pain is from a protrusion at T8 - I see that frequently and I am sure you guys do to --- does the protrusion imply that that is the pain generator? especially when their canal is usually patent throughout?

I agree with Derby et al. from the moderated ISIS discussion from 2005 about discogenic pain - leave it alone because we just don't have the right procedures to offer

I just wish some surgeons would understand that as well.

 

[ampaphb]

there is that guy that injects 50% dextrose into the disc for "prolodiscotherapy" - forget his name but he is in chicago and does a lot of speaking for IDET

I have really stopped doing a lot of intra-discal procedures for axial back pain - for two reasons

1) it can REALLY hurt some patients - and then you have to hold their hand over the phone for the next few weeks until it calms down - not to mention that some of these patients are on narcotics - and you end up feeding them with more narcotics.... and when you hurt a patient like that then odds are they will never trust you with a procedure in the future

2) outcomes: i just haven't seen consistent results --- i was on the intra-discal steroid bandwagon (especially after i had one patient who had miraculous complete pain relief - that still lasts to this day) - but abandoned it after I realized that the % of patients with improvement was ridiculously low - not to mention one case of discitis (ouch)

for axial back pain at the thoraco-lumbar junction when the imaging only reveals a protrusion I tend to stick with
1) no surgery
2) no procedures
3) Physical Therapy
4) TENS unit
5) some muscle relaxants
---

I mean how many of us have seen the woman in her 30-40s who has "burning" pain in her dorsal spine who comes to your office with MRIs from the cervical spine down to the sacrum - and she is convinced that all of her pain is from a protrusion at T8 - I see that frequently and I am sure you guys do to --- does the protrusion imply that that is the pain generator? especially when their canal is usually patent throughout?

I agree with Derby et al. from the moderated ISIS discussion from 2005 about discogenic pain - leave it alone because we just don't have the right procedures to offer

I just wish some surgeons would understand that as well.

perhaps i need to clarify

I ALWAYS document the pain generator through discography first

I ALWAYS document an intranuclear injection with contrast prior to injecting local anesthetic and steroid

and I ALWAYS add 10mg/cc of Kefsol into my contrast solution to prophylax against discitis

 

[Doctodd]

Tenesma......as i said, it is both.

more on her....her "radicular" pain is about groin level. My thinking is that RF might disconnect her pain generator while she can do all the PT she can.

Agreed with most of what has been said...that is why i brought it up. These are difficult patients, and i dont see the reward to outweigh the risk for intradiscal procedures. The risk seems like it is alot less for RF. Plus i thought extrusions and protrusions didnt respond well to nucleoplasty, hence another point in favor for RF. Bottom line....we need more research.

 

[Tenesma]

i have had a few patients with groin pain attributed to T12 discs -- only to find out that I could give them complete relief with an ilio-psoas tendon injection... so much for necessarily being radicular

ampa

what is your success rate with patients with concordant pain by disco after intra-discal steroid? after nucleoplasty? for axial pain? curious what your experience has been

 

[Tenesma]

to add insult to injury -
Pain Physician. 2006 Apr;9(2):115-21

the first author on this study is a Physician Assistant who got a bogus Doctorate of science from a non-accredited fake university - who practices interventional pain in Lebanon Pennsylvania...

what a bunch of crap - and that manchikanti accepted that paper is even more amazing...

 

[Mister Mxyzptlk]

I mean how many of us have seen the woman in her 30-40s who has "burning" pain in her dorsal spine who comes to your office with MRIs from the cervical spine down to the sacrum

You've seen her too? We need to track this woman down and stop her.

Seriously, I think sometimes pain can propagate along the spine from one initial source. They get one problem and then there are subtle involuntary changes in biomechanics to minimize the pain, which sets up another segment for dysfunction. Sort of like cracking a whip. A more concrete example is the person with leg length discrepancy who develops SI or facet joint pain.

As for nucleoplasty, there is lots of literature on the subject but it is terrible quality and rather unconvincing. It was released on the market to treat radicular (not axial) pain but people do it for axial pain anyway.

 

[Tenesma]

i think anybody who comes for an initial consultation with more than 2 different body parts on MRI will be "trouble" --- either that, or the PCP has ownership in an MRI center

i agree that remote areas may become painful because of biomechanical issues ---

i have yet to see ONE patient who has benefited from surgery for thoracic axial pain in the setting of degenerative changes or discopathy (as opposed to stabilization for neoplasm or traumatic fractur) - in fact, i have quite a few whose lives are worse after the surgery

i have yet to see any literature (except for some odd oxygen-ozone intradiscal literature from italy) to support intra-discal injection of anything - in fact there was a good study in 2004 in SPINE that showed that intradiscal steroid was no better then placebo

 

[ampaphb]

i have yet to see any literature (except for some odd oxygen-ozone intradiscal literature from italy) to support intra-discal injection of anything - in fact there was a good study in 2004 in SPINE that showed that intradiscal steroid was no better then placebo

you are absolutely right - there is no literature support for doing it - but when the alternative is surgery or telling the patient to live with their pain, it does not seem unreasonable to try, in light of the number of patients I have seen who report significant prolonged relief.

 

[Tenesma]

personally i have no problem telling the patients that they may have pain for a long time - i also lay out all the options for them - including procedures.

But I also tell them that there does not appear to be much difference between the outcome of real procedures and placebo... very few of them then elect to have the procedure done

 

[ampaphb]

personally i have no problem telling the patients that they may have pain for a long time - i also lay out all the options for them - including procedures.

But I also tell them that there does not appear to be much difference between the outcome of real procedures and placebo... very few of them then elect to have the procedure done

I am a firm beleiver that it is all in the way you present it - if you tell them it is unlikely to improve your pain, why would they ever agree to a procedure?

On the other hand, we all know that the placebo response rate for interventional procedures is ~35%. If you tell them their choice is a procedure which in general will work 1/3 times, and their alternative is either surgery, or to live with the pain, most of my patients opt in.

Anecdotally, my success rate with intradiscal therapeutic steroid injections is closer to about 50% (with success being defined as >80% pain relief for 3-6 months)

 

[Mister Mxyzptlk]

On the other hand, we all know that the placebo response rate for interventional procedures is ~35%. If you tell them their choice is a procedure which in general will work 1/3 times, and their alternative is either surgery, or to live with the pain, most of my patients opt for.

I thought the goal was to do things that work better than placebo. When did we lower the bar?

 

[SSdoc33]

i dont know if there is any literature out there on this, but i have to believe that injecting steroids directly into the disc will lead to dessication and atrophy. we know that happens in other tissues, so it seems that you'd lose the bouyancy and elasticity of the disc if you inect steroids into it. i can buy injecting AROUND a nerve root, or INTO a joint, but directly into a disc seems like it would have too many adverse consequenses. its akin to directly injecting steroids into an achilles tendon. sure, it might take some of the pain away, but its just not a good idea.

if there is any literature out there on the adverse sequelae of intradiscal steroids (not on efficacy) id be more than happy to hear it.

 

[ampaphb]

I thought the goal was to do things that work better than placebo. When did we lower the bar?

That is, indeed, the goal. In day to day practice, however, my primary mission is to attempt to address appropriate patient's complaints of pain with every reasonable modality available.

 

[Mister Mxyzptlk]

That is, indeed, the goal. In day to day practice, however, my primary mission is to attempt to address appropriate patient's complaints of pain with every reasonable modality available.

And your definition of "reasonable" is "indistinguishable from placebo"? That's what you seem to be saying. You state that the placebo rate for pain procedures is ~35% but you would recommend a procedure with a 1/3 success rate.

Suppose there was an RCT showing that intra-discal steroid injections had a success rate of 33%, and the placebo success rate was 33%.

What would you conclude from that article? That they work?

Would you offer the procedure to your patients anyway because ". . . their choice is a procedure which in general will work 1/3 times, and their alternative is either surgery, or to live with the pain . . ."?

If so, why not just do placebo procedures, which are safer and just as effective?

 

[Tenesma]

gorback

thank you for making my point

i have never heard of anybody getting discitis from placebo...

i agree it is all in how you phrase it - but i also believe in being honest with my patients... something i wish spine surgeons would be when they discuss fusion for axial pain...

I consider myself an interventionalist but I have no problem telling patients that there are no good interventions for "such-and-such" pain - just like there are some Cancers that we can't cure nowadays

you don't see Oncologists treating unresectable lung CA with cisplatin based on the argument that they gotta try/offer something

i do offer them other avenues that can help with axial pain that are not invasive with potential complications (ie: Bracing, TENS, acupuncture, etc...)

i am concerned because you made it clear that you were taking over a bigger role in ISIS and I would like to see a bit more science coming from you...

 

[nvrsumr]

Synopsis of a few studies on intradiscal steroids(the Khot study references the others):

Blinded study 120 pts w/ MRI DDD. + discography. Steroid vs saline
No difference Oswestry or VAS at 1 yr
This study did not show a worsening or betterment of symptoms due to degeneration

Previous studies revealed degeneration after intradiscal steroid in humans and in rabbit discs

Prospective randomized dbl blind study 25 pts steroid vs bupivicaine
No sig diff at 2 weeks

Khot Spine 2004, Simmons Spine 1992, Kato J Neurol Orthop Med Surg 1993, Aoki Spine 1997

 

[chinochulo]

i have never heard of anybody getting discitis from placebo...
i agree it is all in how you phrase it - but i also believe in being honest with my patients... something i wish spine surgeons would be when they discuss fusion for axial pain...
I consider myself an interventionalist but I have no problem telling patients that there are no good interventions for "such-and-such" pain - just like there are some Cancers that we can't cure nowadays
you don't see Oncologists treating unresectable lung CA with cisplatin based on the argument that they gotta try/offer something
i do offer them other avenues that can help with axial pain that are not invasive with potential complications (ie: Bracing, TENS, acupuncture, etc...)

Great post Tenesma--my sentiments are similar

 

[Diamox]

I thought the goal was to do things that work better than placebo. When did we lower the bar?

The bar is not really lower - look at the Pharm industry where a 30% reduction in Blood Pressure is golden and people jump up and down. In our case placebo works too good and the back is much more complex (or we know less about it) then the circulatory system.

D

 

[Tenesma]

diamox - that is a fundamental misunderstanding of what placebo means

anti-hypertensives that reduce BP by 30% are clearly better than placebo - not to mention that a 30% drop is most likely to be statistically significant.

by the way, i don't think anybody would be proud of dropping BP by 100%

 

[Diamox]

diamox - that is a fundamental misunderstanding of what placebo means

anti-hypertensives that reduce BP by 30% are clearly better than placebo - not to mention that a 30% drop is most likely to be statistically significant.

by the way, i don't think anybody would be proud of dropping BP by 100%

Fair enough - it was a bad example.

 

[Tenesma]

it was a good try - because i understand your point...

the issue is that we sometimes fight over things that are really no better than placebo...

the only difference is that some among us are willing to make money off the fact they can still charge for their treatments - even though they should know that placebo is just as effective - saves the system a lot of money but also means a lower salary...