Severe spinal stenosis with cauda equina crowding

[PAINISGOOD]

Would anyone inject? Patient with bilateral leg weakness.

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[pmrmd]

Not at the level but below. IL works as well as TF in these cases. Really a surgical case or Vertiflex if not a candidate.

 

[SommeRiver]

Bilateral TF one level below to help the pt tread water for as long as possible before surgery.

 

[Ferrismonk]

Urgent surgery referral, no injection. If severe weakness or bladder/bowel incontinence, I sent to ER to see a neurosurgeon immediately. Otherwise, maybe oral steroids to tie over until surgical eval.

 

[MD87]

Severe lumbar stenosis by definition is crowding of the cauda equina. I inject at level below.... not a huge volume though, as can be painful. Crowding of the cauda equina does not equal cauda equina syndrome.

Sorry did not see the bit about weakness. If they have weakness, I would recommend surgical consult if it is new weakness. If it is old weakness/stable, I would still recommend surgical consult, but would be more OK if patient refused and wanted to try the route of injection instead. I have a guy who has pretty dense weakness in his S1 myotome, but still working and says it has been like that for "years." Severe stenosis. I did an injection and he did great. He doesn't care about the weakness and refuses to see a surgeon. I just document.

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[lobelsteve]

Meh. See it everyday. Weakness can be pain limited or neurological. If claudicatory pain offer epidural. Tf or IL below stenosis. If progressive deficit send to surgeon.

 

[paindoc007]

No. Severe stenosis, weakness, and the absence of pain is not an indication for epidural steroid injections. No, no, no.

 

[gdub25]

Inject, do it all the time. I’m with lobelsteve. Sure, there’s a chance it doesn’t help but it might. Patient came to you for help, treat them, if it doesn’t help or only helps for a short time they’ll be happy you tried and have piece of mind going to surgeon knowing they tried all other options before hand.

 

[SommeRiver]

I'd guess I see this and inject it a few times per week.

 

[callmeanesthesia]

Very much depends on the character - if acute/progressive, objective weakness then urgent surgical referral vs send to ER. If chronic stable, and/or subjective, then I’ll try an ESI. Usually a caudal.

 

[PAINISGOOD]

Some more info....patient on prasurgel and 2 MIs two months ago with stent placement....

 

[lobelsteve]

Some more info....patient on prasurgel and 2 MIs two months ago with stent placement....

Unless impending paralysis and loss of B/B no chance at decompression surgery.
TFESI on thinners.

 

[CalH22a]

Would do TFESI or caudal depending on level of stenosis. Would always offer surgeon referral and document if they want to or not. Newer onset neuro deficits I always strongly recommend surgical referral. If they have signs of cauda equina syndrome then ER

 

[SommeRiver]

IMO - Caudal only if a pt is fused to the sacrum.

Otherwise bilateral S1 TFESI for lower lumbar severe stenosis, or if higher level (I usually see this between L2-3 to L4-5) I do one level below.

I think a caudal is a POS injxn. I do them, but incredibly hit or miss for me.

Bilateral S1 is far superior than a caudal in my experience.

 

[paindoc007]

IMO - Caudal only if a pt is fused to the sacrum.

Otherwise bilateral S1 TFESI for lower lumbar severe stenosis, or if higher level (I usually see this between L2-3 to L4-5) I do one level below.

I think a caudal is a POS injxn. I do them, but incredibly hit or miss for me.

Bilateral S1 is far superior than a caudal in my experience.

hm, my experience is the opposite. Hate bil S1 tfesi. Never seem to get the results I want.
Caudals are great and my preference all day.

 

[SommeRiver]

A few older pics. I'm using more ipsilateral obliquity and that's getting me a more medially oriented needle and maybe better pics but results are good enough when I was doing straight AP. I strongly recommend S1 over caudal unless the pt is fused to sacrum and you can't see the S1 foramen (you can still walk it in without seeing it though).

 

[gdub25]

Agree that caudals are the worst. I do maybe 5-6 a year. Only do them when I have to.

 

[lobelsteve]

A few older pics. I'm using more ipsilateral obliquity and that's getting me a more medially oriented needle and maybe better pics but results are good enough when I was doing straight AP. I strongly recommend S1 over caudal unless the pt is fused to sacrum and you can't see the S1 foramen (you can still walk it in without seeing it though).

No lateral means you were never there.

 

[SommeRiver]

No lateral means you were never there.

Haha...

I always save a lateral too...

 

[DrSpine]

I see this everyday or at least weekly. I always do IL a level below typically. Urgent surgery referral is only if bowel/bladder dysfunction, severe sudden weakness (ie footdrop or flaccid paralysis), sudden ED in relation to this pain, etc.

But typically, I see a lot of old patients, and they all have weakness/stiffness and severe stenosis. I doubt 80 year old wants surgery. I explain risk, alternative, and benefit everyday with everyone. Alternatives include 1) Doing nothing and living with it, 2) PT and Oral Meds, 3) Epidural from me, and 4) Surgery.

I never do TFESI with these stenotic patients - I don't feel like it works because IMO Dex doesn't do anything for them, I never get good results with it. I feel like they do better with Depo. Not ballsy enough to do TFESI with Depo as per SIS Guidelines. I've always thought about doing a large study with this. My theory that I postulate is that TFESI with Dex works for more younger people, disc herniation, etc. When its elderly with stenosis, doesn't do poo diddly squat. Washes right in and out. But perhaps I am wrong, who knows, I am always open to new ideas and being wrong.

 

[bedrock]

I see this everyday or at least weekly. I always do IL a level below typically. Urgent surgery referral is only if bowel/bladder dysfunction, severe sudden weakness (ie footdrop or flaccid paralysis), sudden ED in relation to this pain, etc.

But typically, I see a lot of old patients, and they all have weakness/stiffness and severe stenosis. I doubt 80 year old wants surgery. I explain risk, alternative, and benefit everyday with everyone. Alternatives include 1) Doing nothing and living with it, 2) PT and Oral Meds, 3) Epidural from me, and 4) Surgery.

I never do TFESI with these stenotic patients - I don't feel like it works because IMO Dex doesn't do anything for them, I never get good results with it. I feel like they do better with Depo. Not ballsy enough to do TFESI with Depo as per SIS Guidelines. I've always thought about doing a large study with this. My theory that I postulate is that TFESI with Dex works for more younger people, disc herniation, etc. When its elderly with stenosis, doesn't do poo diddly squat. Washes right in and out. But perhaps I am wrong, who knows, I am always open to new ideas and being wrong.

Did the sis guidelines change to now recommend depo for lumbar TFESI?

Agree that while del may work for radiculopathy, it rarely provides sustained relief in stenosis. Two different processes.

 

[DrSpine]

Did the sis guidelines change to now recommend depo for lumbar TFESI?

Agree that while del may work for radiculopathy, it rarely provides sustained relief in stenosis. Two different processes.

To my knowledge, nope. I don't think that'll ever change either. Just Dex for TFESI. I can never risk it. One time, while doing a TFESI, I used Kambin's approach for the infra-neural approach that is safer. I was in a vessel. Yes. A vessel, the very thing this method is supposed to avoid. Everyone's anatomy is different I've realized after that.

 

[bedrock]

To my knowledge, nope. I don't think that'll ever change either. Just Dex for TFESI. I can never risk it. One time, while doing a TFESI, I used Kambin's approach for the infra-neural approach that is safer. I was in a vessel. Yes. A vessel, the very thing this method is supposed to avoid. Everyone's anatomy is different I've realized after that.

I still do bilateral S1 TFESI with depo. All other TFESI with dex. S1 w Depo works particularly well in the ancient lumbar stenosis crowd.

 

[paindoc007]

To my knowledge, nope. I don't think that'll ever change either. Just Dex for TFESI. I can never risk it. One time, while doing a TFESI, I used Kambin's approach for the infra-neural approach that is safer. I was in a vessel. Yes. A vessel, the very thing this method is supposed to avoid. Everyone's anatomy is different I've realized after that.

There is a lot of literature to suggest anatomy is variable and you can find a vessel anywhere. Hence: dex, live fluoro, dsa, etc

 

[callmeanesthesia]

To my knowledge, nope. I don't think that'll ever change either. Just Dex for TFESI. I can never risk it. One time, while doing a TFESI, I used Kambin's approach for the infra-neural approach that is safer. I was in a vessel. Yes. A vessel, the very thing this method is supposed to avoid. Everyone's anatomy is different I've realized after that.

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