S1 postherpetic neuralgia

[Timeoutofmind]

SCS vs DRG

What would you do?

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[DOctorJay]

where's the pain?

entire S1 distribution I'd offer SCS

mainly foot I'd try L5 and S2 DRG

 

[willabeast]

Need more information what interventions have been tried already and how long has the patient had the problem?

 

[Timeoutofmind]

where's the pain?

entire S1 distribution I'd offer SCS

mainly foot I'd try L5 and S2 DRG

Entire S1 distribution

Need more information what interventions have been tried already and how long has the patient had the problem?

Has tried/failed antineuropathics and doesnt want anymore

Going on for a couple years

 

[willabeast]

MRI L/S spine?

 

[Orin]

It is hard to reliably capture S1 alone due to conus movement with SCS, but it can work. I would consider a trial if insurance denies DRG, but DRG makes more sense.

Deploying DRG at the adjacent levels is the teaching point for these cases as that DRG is far too sensitive. DRG hasn't really taken off though in my area as most people are just using some paresthesia free modality in the dorsal columns. The difficulty in placing it and risk profile I think are a turn off.

 

[Timeoutofmind]

MRI L/S spine?

EMG shows S1 radic but there is no way to get S1 sxs out of her MRI...

Also, her symptoms started immediately after her shingles rash down the back of the leg and she had no symptoms prior to this.

SLR neg

Had ESIs without relief

L4-5 demonstrates moderate overall canal stenosis, related to broad
diffuse disc bulge and ventral ridging, with facet degenerative change and
ligamentum flavum hypertrophy. This is slightly progressive from the prior
study, likely due to progressive disc bulging, with further flattening of
the anterior margin of the thecal sac. There is minimal, if any, residual
epidural fat seen and there is encroachment upon bilateral neural
foramina. The nerve roots, especially the left, exit very closely
related to the lateral disc spur margin may be minimally contacted. No
superimposed disc herniation is seen.

L5-S1 demonstrates mild disc bulge. Ventral ridging and ligament flavum
hypertrophy. Again, no significant encroachment upon the neural foramina,
contact of the nerve roots or superimposed disc herniation are
appreciated. The SI joints are unremarkable.


I was just going to jump to stim as I am pretty convinced not radicular

My main question was just SCS vs DRG...

Could always try an LSNB first I guess as I know there is some evidence for stellates with head/neck/upper extremity zoster. They always seem so hit and miss though...

 

[Timeoutofmind]

It is hard to reliably capture S1 alone due to conus movement with SCS, but it can work. I would consider a trial if insurance denies DRG, but DRG makes more sense.

Deploying DRG at the adjacent levels is the teaching point for these cases as that DRG is far too sensitive. DRG hasn't really taken off though in my area as most people are just using some paresthesia free modality in the dorsal columns. The difficulty in placing it and risk profile I think are a turn off.

Interesting comment...
A lot of post lami people have S1 radic pain and SCS seems to cover the dermatome pretty well.

But maybe your right DRG would be better.

Its a tough call

 

[Orin]

Interesting comment...
A lot of post lami people have S1 radic pain and SCS seems to cover the dermatome pretty well.

But maybe your right DRG would be better.

Its a tough call

I'm not saying you can't cover an S1 radic. I'm saying you can't isolate it specifically.

I'm not sure why this is so difficult. If you need to do it, try one and then the other.