Spinal stenosis and TFESI case planning?

[CarabinerSD]

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I have a young guy with low back pain radiating down the left leg in L5 dermatome with mild L5 EHL weakness (on going for several months).

Report & images attached:
L4-5: left paracentral & left foraminal herniated disc measures 15mm in vertical dimension with sequestration, severe spinal stenosis, narrowing of left neural foramen, facet hypertrophy.
L5-S1: 8mm central herniated disc causing severe spinal stenosis.

Previous pain doc tried to do a Left L4-5, L5-S1 TFESI but his contrast flow was suboptimal (don't think it made into epidural space).
He is already on medication but still having left sided radiating pain with L5 weakness.
Discussed surgery but he has a couple of summer trips coming up so holding off on surgery for now. I'd like to do another TFESI to give him some pain relief in the mean time.

What do you guys think?

1) repeat Left L4-5, L5-S1 TFESI (given poor contrast flow from prior pain doc's images)
2) Left L5-S1, S1 TFESI

 

[afob100]

L4-5 looks too stenotic. I would probably do left L5-S1 ILESI

 

[spondy14]

Left L5 TFESI, surgical consult

 

[deleted875186]

L5-S1 interlaminar ESI. I think TFESI versus ILESI is bulls**t.

Patient will either get better with any type of epidural injection or will need surgery. ILESI is less painful, and frequently easier to get access.

 

[painfree23]

L5-S1 interlaminar ESI. I think TFESI versus ILESI is bulls**t.

Patient will either get better with any type of epidural injection or will need surgery. ILESI is less painful, and frequently easier to get access.

I don’t think it’s bs. U can’t control exactly where the med goes when u inject and if there is major stenosis in one area the steroid may not get there. I think it’s reasonable to offer the opposite of what u did before referring for surgery.

 

[Agast]

I would try a caudal ESI or interlaminar ESI. If I hear a colleague has already just done the TFESI I would not assume my TFESI is magically better. I think that's arrogant, why make the same mistakes twice on the patient's dime. At this point I would try something different that could work for the patient, otherwise he's going to think all pain doctors are worthless.

 

[CarabinerSD]

I would try a caudal ESI or interlaminar ESI. If I hear a colleague has already just done the TFESI I would not assume my TFESI is magically better. I think that's arrogant, why make the same mistakes twice on the patient's dime. At this point I would try something different that could work for the patient, otherwise he's going to think all pain doctors are worthless.

Agast, appreciate the feedback. I did not mean to imply my TFESI will be better. However, looking at the previous interventionalist's needle position and fluoro images, it's akin to a lumbar trigger point injection. Hence I didn't want to write off a repeat TFESI because the previous person did a trigger point injection instead. I think Caudal or ILESI is a fair consideration.

 

[bedrock]

I have a young guy with low back pain radiating down the left leg in L5 dermatome with mild L5 EHL weakness (on going for several months).

Report & images attached:
L4-5: left paracentral & left foraminal herniated disc measures 15mm in vertical dimension with sequestration, severe spinal stenosis, narrowing of left neural foramen, facet hypertrophy.
L5-S1: 8mm central herniated disc causing severe spinal stenosis.

Previous pain doc tried to do a Left L4-5, L5-S1 TFESI but his contrast flow was suboptimal (don't think it made into epidural space).
He is already on medication but still having left sided radiating pain with L5 weakness.
Discussed surgery but he has a couple of summer trips coming up so holding off on surgery for now. I'd like to do another TFESI to give him some pain relief in the mean time.

What do you guys think?

1) repeat Left L4-5, L5-S1 TFESI (given poor contrast flow from prior pain doc's images)
2) Left L5-S1, S1 TFESI

Left L5 TFESI, surgical consult

L5-S1 interlaminar ESI. I think TFESI versus ILESI is bulls**t.

Patient will either get better with any type of epidural injection or will need surgery. ILESI is less painful, and frequently easier to get access.

I would try a caudal ESI or interlaminar ESI. If I hear a colleague has already just done the TFESI I would not assume my TFESI is magically better. I think that's arrogant, why make the same mistakes twice on the patient's dime. At this point I would try something different that could work for the patient, otherwise he's going to think all pain doctors are worthless.

Really really sad that this many pain physicians can't agree on anything.

This is clear cut. Left L5-S1, S1 TFESI, with prompt f/u and surgical referral if pain and or weakness doesn't improve.

Everyone on this board knows I am a huge proponent of particulate steroid, but this is fairly acute lumbar radiculopathy, the patient has two major discs and the pathology is anterior. The best way to ensure accurate anterior epidural spread to the disc/nerve interface is with a two level lumbar TFESI with dex. The patient has two large discs, so you inject just inferior to both.

Now if the patient obtains good but brief pain relief from a properly performed TFESI (and his weakness resolves), then yes it is time for a left ILESI or caudal with depo.
If weakness persists after a proper TFESI, then time for him to have surgery.

I would agree with Agast in general, if the OP only had the procedure report of the other pain physician that it looks bad to assume all pain physicians are incompetent.
However, if the OP has the procedure images and they look terrible, then its fine to repeat an ESI and do it correctly this time around. He can tell the patient that he is going one level lower at each site, which is technically a "different epidural" and it would be the correct procedure for this patient anyway.

 

[lobelsteve]

I wouldn’t fault anyone for transforaminal at L5 or S1. I wouldn’t fault anyone for going interlaminar at L4-5 or L5-S1. I think of Caudal as a last resort still poor because you’re putting the medicine really far away from where it’s needed. I’m disgusted that no one on the forum looked at the MRI images and didn’t come and tell there is absolutely zero spinal stenosis.

 

[painfree23]

I wouldn’t fault anyone for transforaminal at L5 or S1. I wouldn’t fault anyone for going interlaminar at L4-5 or L5-S1. I think of Caudal as a last resort still poor because you’re putting the medicine really far away from where it’s needed. I’m disgusted that no one on the forum looked at the MRI images and didn’t come and tell there is absolutely zero spinal stenosis.

There is a hair of it , not absolutely 0 !

 

[deleted875186]

I wouldn’t fault anyone for transforaminal at L5 or S1. I wouldn’t fault anyone for going interlaminar at L4-5 or L5-S1. I think of Caudal as a last resort still poor because you’re putting the medicine really far away from where it’s needed. I’m disgusted that no one on the forum looked at the MRI images and didn’t come and tell there is absolutely zero spinal stenosis.

Lol, I assumed they just posted axials at the level of the foramin as they were asking if you would do a TFESI at that level.

 

[Laryngospasm]

Definitely no severe or even moderate on those images.. to the OP is there a missing axial slice that shows severe? Looks like the L4 disc might be doing that caudal to the foramen.

 

[cbest]

L5-S1 ILESI or L4-5 infraneural TFESI. There’s zero perineural fat to safely do an L5-S1 TFESI. The L4 nerve root is riding high in the foramen so supraneural TFESI at L4-5 not a great option there. Agree with @lobelsteve there’s no central canal stenosis that’s playing a role here. Highly recommend the SIS videos by Dr. Tim Maus discussing epidural planning. So great at utilizing imaging to plan ESI with both safety and efficacy in mind!

 

[lobelsteve]

Relooked at the pics from my computer and the phone. ZERO SPINAL STENOSIS. Capacious spinal canal. Left recess stenosis due to disk protrusion, severe foraminal stenosis L5-S1.

 

[Taus]

Agreed.

Relooked at the pics from my computer and the phone. ZERO SPINAL STENOSIS. Capacious spinal canal. Left recess stenosis due to disk protrusion, severe foraminal stenosis L5-S1.

Agreed. I’d bet the L45 extrusion into lateral recess is main issue.

weakness only slight and EHL so ok to inject again but if ongoing for several months already and not improving with time alone will likely require surgery no matter what you do. Personally I’d probably do paramedian L5-s1 interlam here but nothing wrong w L5 and tfesi. Really tomato tomahto. McKenzie PT.

also if that report called just vague “severe stenosis” without specifying central, lateral recess, foraminal, I’d question if it was some dbag looking to do a vertiflex, mild or some other nonsense in a case like this….

 

[chudat]

? No stenosis where? Maybe not severe but where are you guys calling ZERO central canal stenosis? Anterior thecal sac gone

 

[Taus]

? No stenosis where? Maybe not severe but where are you guys calling ZERO central canal stenosis? Anterior thecal sac gone

Look at the axial cuts. I guess you can call mild central at L5S1.

 

[chudat]

Lol i am looking at the axials.
Show me a normal lumabr mri and compare that to the ones above. Wheres the anterior epidural space? It didnt just magically disappear

 

[Taus]

Lol i am looking at the axials.
Show me a normal lumabr mri and compare that to the ones above. Wheres the anterior epidural space? It didnt just magically disappear

We’ll have to agree to disagree here. There is a little central narrowing but the pathology is in the lateral recess and foramen

 

[chudat]

Not trying to pick a fight, but agree to disagree??

Anterior epidural space, gone. Anterior convex thecal sac, effaced, and is now more concave.

How is there no stenosis? Obviously the disease is more lateral abutting the s1 but to say there is ZERO central stenosis would be a gross misrepresentation of the Mri.

 

[Taus]

Not trying to pick a fight, but agree to disagree??

Anterior epidural space, gone. Anterior convex thecal sac, effaced, and is now more concave.

How is there no stenosis? Obviously the disease is more lateral abutting the s1 but to say there is ZERO central stenosis would be a gross misrepresentation of the Mri.

I said theres mild central in post above…

 

[lobelsteve]

I do not agree. anterior thecal sac effacement is not stenosis. Look at all that CSF- You guys are way off.

 

[pmrmd]

I’m always late to the party. Severe left L4-5 left lateral recess stenosis. Left L5S1 TF and call it a day. I would use depo here though. That thing is chronic and 1 day of dex ain’t gonna cut it, regardless of what the garbage literature says.

 

[pmrmd]

I would try a caudal ESI or interlaminar ESI. If I hear a colleague has already just done the TFESI I would not assume my TFESI is magically better. I think that's arrogant, why make the same mistakes twice on the patient's dime. At this point I would try something different that could work for the patient, otherwise he's going to think all pain doctors are worthless.

Disagree. It totally depends on the placement, injectate, and condition. TF with dex fails all the time for LSS. Repeat with depo and the same injection works well.

 

[chudat]

I do not agree. anterior thecal sac effacement is not stenosis. Look at all that CSF- You guys are way off.

I do not agree. anterior thecal sac effacement is not stenosis. Look at all that CSF- You guys are way off.

I completely disagree this on all fronts.

Effacement of the anterior csf space is stenosis, at least mild.

Clinical validity of two different grading systems for lumbar central canal stenosis: Schizas and Lee classification systems - PMC

To assess the learnability of two magnetic resonance imaging (MRI) grading systems for lumbar central canal stenosis based on inter-observer agreement and test-retest reliability of doctors with no prior knowledge of the two systems. Two clinical ...

www.ncbi.nlm.nih.gov

This is what neuroradiology fellows at my instituions use.

The Lee system [1] is a 4-grade classification system based on the degree of separation of the cauda equina on T2-weighted axial MRI. Grade 0, no LCCS, refers to no obliteration of the anterior CSF space (Fig 4A and 4B). Grade 1, mild LCCS, refers to mild obliteration of the anterior CSF space and all cauda equina clearly separated from each other (Fig 4C and 4D). Grade 2, moderate LCCS, refers to moderate obliteration of the anterior CSF space and some cauda equina aggregation where it is impossible to identify each other visually (Fig 5A and 5B). Grade 3, severe LCCS, refers to severe obliteration of the anterior CSF space, marked compression of the dural sac, and the entire cauda equina appearing as one bundle (Fig 6A and 6B).

lccs=lumbar central canal stenosis.

 

[Taus]

Disagree. It totally depends on the placement, injectate, and condition. TF with dex fails all the time for LSS. Repeat with depo and the same injection works well.

Agreed but an interlam w depo would accomplish the same IMO.

 

[lobelsteve]

I completely disagree this on all fronts.

Effacement of the anterior csf space is stenosis, at least mild.

Clinical validity of two different grading systems for lumbar central canal stenosis: Schizas and Lee classification systems - PMC

To assess the learnability of two magnetic resonance imaging (MRI) grading systems for lumbar central canal stenosis based on inter-observer agreement and test-retest reliability of doctors with no prior knowledge of the two systems. Two clinical ...

www.ncbi.nlm.nih.gov

This is what neuroradiology fellows at my instituions use.

The Lee system [1] is a 4-grade classification system based on the degree of separation of the cauda equina on T2-weighted axial MRI. Grade 0, no LCCS, refers to no obliteration of the anterior CSF space (Fig 4A and 4B). Grade 1, mild LCCS, refers to mild obliteration of the anterior CSF space and all cauda equina clearly separated from each other (Fig 4C and 4D). Grade 2, moderate LCCS, refers to moderate obliteration of the anterior CSF space and some cauda equina aggregation where it is impossible to identify each other visually (Fig 5A and 5B). Grade 3, severe LCCS, refers to severe obliteration of the anterior CSF space, marked compression of the dural sac, and the entire cauda equina appearing as one bundle (Fig 6A and 6B).

lccs=lumbar central canal stenosis.

Might be good for business, but there is clear separation of all nerve roots and so much csf in the canal that there is no compression of anything. Also, your example pics show no stenosis in images A B C. There is epidural lipomatosis and there is a decent bit of stenosis in the C and D images. Moderate.

 

[lobelsteve]

You

Disagree. It totally depends on the placement, injectate, and condition. TF with dex fails all the time for LSS. Repeat with depo and the same injection works well.

Your experience is not that of everyone elses.

 

[pmrmd]

Your experience is not that of everyone elses.

The literature around the world says Depo works better than dex. Only in this country, where they call a 50% reduction of pain a success, is dex equivalent.

 

[chudat]

Might be good for business, but there is clear separation of all nerve roots and so much csf in the canal that there is no compression of anything. Also, your example pics show no stenosis in images A B C. There is epidural lipomatosis and there is a decent bit of stenosis in the C and D images. Moderate.

Lol good for business. No stenosis in a b c but decent stenosis in c and d?? Obviously you typoed or didnt even bother to read the paper. Either way, you can say whatever you want since youre not officiating a report for other physicians.

We can certainly argue whether or not there is any effacement of the anterior csf space based on the above quality images.

but to say that EVEN if there IS effacement of the anterior thecal sac is still not considered ANY stenosis is obviously wrong and no radiologist would or should agree with you.

 

[lobelsteve]

Lol good for business.

We can certainly argue whether or not there is any effacement of the anterior csf space based on the above quality images.

but to say that EVEN if there IS effacement of the anterior thecal sac is still not considered ANY stenosis is not accurate and no radiologist would or should agree with you.

Call it what you want. If doing an esi for anything other than the left leg radic you would be a shmoo. And bu calling that image stenosis, and by Rays saying severe stenosis- you open the patient up for spacers, decompression, etc. all of it wrong.

 

[chudat]

Call it what you want. If doing an esi for anything other than the left leg radic you would be a shmoo. And bu calling that image stenosis, and by Rays saying severe stenosis- you open the patient up for spacers, decompression, etc. all of it wrong.

Lol nobodys is saying that.
I'm simply saying your understanding or nomenclature of canal stenosis is not accurate.

 

[MD87]

Can someone explain why you would do a caudal here? I like caudals in some situations... I just don't understand why you would do one here... if you want to use particulate, do an ILESI. There is plenty of room at L5/S1 do safely do the injection.
I would want to see sagittal cuts, but based on the story, if there is enough room, I would do an L5 TFESI. S1 is likely not playing a role here if the pain is in an L5 dermatome. The literature that I've read indicates that pain patterns are fairly worthless, EXCEPT S1 is pretty much always in the posterior leg... if pain is in the lateral leg I wouldn't want to waste medication along the S1 nerve root... but I wouldn't be offended by someone who did it.

 

[ctts]

In regards to the question of stenosis, as related to the diagnosis, in general, whether or not there is any stenosis is not as important as whether or not there is any nerve impingement. Based on the images available, in regards to the nerves, I agree that the main issue appears to be L5 nerve impingement at the left L4-5 lateral recess. I would like to see more sagittal images to evaluate the degree of left L5-S1 foraminal stenosis (I usually find the T2 sagittals to be more helpful than the T1 sagittals). The nerves within the thecal sac otherwise do not appear to be impinged, so there is no clinically significant central stenosis. I also agree that S1 probably is not the issue, based on symptoms, exam, and MRI images show L5-S1 disc herniation contacting the S1 nerves, possibly displacing, but not impinging. On the images available, I do not see much posterior epidural space at L4-5 or L5-S1, so I would probably lean towards doing left L5-S1 TF ESI rather than an interlaminar ESI. Is the back pain worse, or leg pain worse, or equal? If primarily leg pain, then the left L5-S1 TF ESI alone should suffice. If back and leg pain are equal, or back pain worse than leg pain, then I think adding left L4-5 TF ESI in addition would be reasonable to better address L4-5 discogenic pain. (besides the obvious disc extrusion, there is some degree of high intensity zone suggesting annular fissure/tear). Left L4-5 TF ESI could also be considered if you have technical difficulty with needle placement for left L5-S1 TF ESI. This is just my opinion, but lots of great suggestions above too.

Really really sad that this many pain physicians can't agree on anything.

This is clear cut.

I hope you are being sarcastic? I would expect different opinions on this. Not sure that anything in pain is every really clear cut.

 

[fathead88]

I just want to say I peruse this forum exactly for threads like this. Very enlightening to hear so many different opinions. Thank you all for contributing.

 

[NJPAIN]

In regards to the question of stenosis, as related to the diagnosis, in general, whether or not there is any stenosis is not as important as whether or not there is any nerve impingement. Based on the images available, in regards to the nerves, I agree that the main issue appears to be L5 nerve impingement at the left L4-5 lateral recess. I would like to see more sagittal images to evaluate the degree of left L5-S1 foraminal stenosis (I usually find the T2 sagittals to be more helpful than the T1 sagittals). The nerves within the thecal sac otherwise do not appear to be impinged, so there is no clinically significant central stenosis. I also agree that S1 probably is not the issue, based on symptoms, exam, and MRI images show L5-S1 disc herniation contacting the S1 nerves, possibly displacing, but not impinging. On the images available, I do not see much posterior epidural space at L4-5 or L5-S1, so I would probably lean towards doing left L5-S1 TF ESI rather than an interlaminar ESI. Is the back pain worse, or leg pain worse, or equal? If primarily leg pain, then the left L5-S1 TF ESI alone should suffice. If back and leg pain are equal, or back pain worse than leg pain, then I think adding left L4-5 TF ESI in addition would be reasonable to better address L4-5 discogenic pain. (besides the obvious disc extrusion, there is some degree of high intensity zone suggesting annular fissure/tear). Left L4-5 TF ESI could also be considered if you have technical difficulty with needle placement for left L5-S1 TF ESI. This is just my opinion, but lots of great suggestions above too.



I hope you are being sarcastic? I would expect different opinions on this. Not sure that anything in pain is every really clear cut.

I believe that the T1 sagittals are actually superior for assessing the presence of epidural fat in the foramen just as they are useful for assessing for the presence of epidural fat in the posterior epidural space in the cervical spine. If there is a radiologist among us please feel free to correct me.

 

[bedrock]

I believe that the T1 sagittals are actually superior for assessing the presence of epidural fat in the foramen just as they are useful for assessing for the presence of epidural fat in the posterior epidural space in the cervical spine. If there is a radiologist among us please feel free to correct me.

agree with this

 

[bedrock]

I hope you are being sarcastic? I would expect different opinions on this. Not sure that anything in pain is every really clear cut.

Yes, it is clear cut. That is why there are more likes on my post than for any other post on this thread. Sometimes a pain patient really is clear cut, just like a medicare patient with L4-L5, L5-S1 facet degeneration and axial pain worse with standing/walking and relieved with sitting, who has failed conservative care. They get bilateral L3-L5 MBB/RFA. Can you argue that this is not the standard of care?

This young patient has two large disc herniations. It is reasonable to treat both of them. Doing a supraneural TFESI with dex at the level below each herniation is the standard of care for an acute radiculopathy.
If this case was presented at a national academic meeting, and we took a survey, the majority (not all) of university pain professors, would agree with that interventional approach.

 

[MD87]

I believe that the T1 sagittals are actually superior for assessing the presence of epidural fat in the foramen just as they are useful for assessing for the presence of epidural fat in the posterior epidural space in the cervical spine. If there is a radiologist among us please feel free to correct me.

My thought would be that it doesn't really matter... The main reason T1 is helpful for posterior epidural fat is that it makes the CSF dark so you can see what is epidural vs. CSF... in the foramen everything bright should be fat (unless they have a facet joint cyst or something unusual). Both T1 and T2 should be good.

 

[chudat]

My thought would be that it doesn't really matter... The main reason T1 is helpful for posterior epidural fat is that it makes the CSF dark so you can see what is epidural vs. CSF... in the foramen everything bright should be fat (unless they have a facet joint cyst or something unusual). Both T1 and T2 should be good.

I agree with you.

even for synovial cysts, most of these are NOT purely cysts...meaning that they aren't all fluid but rather a combination of fluid and/or proteinaceous debris. This means that they aren't completely suppressed and can actually be T1 hyperintense.

 

[RoloTomassi]

Sounds like L5 compression in lateral recess from the L4-5 disc is what you are really trying to target. L5-S1 disc protrusion is mostly central, doesn't impinge the S1 to much. I would try L5-S1 TF, especially if your partner was off target. Reasonable to add on S1 TF for cephalad flow to L5 or L4-5 TF for caudal flow to L5, to hedge your bet that the medicine will get there since L5-S1 is so stenotic in the foramen and you might not get good medial flow.

Plan B: far lateral L4-5 IL. Start medial, aim out lateral with endpoint just medial to the facet. Needle tip will be just posterior to the nerve at the level of the disc. This approach will actually get the needle tip closest to disc/nerve interface at the lateral recess, as with TF approach, the needle tip will probably be fairly lateral given the foraminal stenosis. Several studies show far lateral aka modified paramedian/parasagittal IL gets you same or more ventral flow than TF. Plus you can use particulate, which I think anecdotally is superior. Also, doesn't matter if you can't see epidural fat if you are comfortable with your IL technique. It's a potential space that is there.

 

[deleted875186]

Sounds like L5 compression in lateral recess from the L4-5 disc is what you are really trying to target. L5-S1 disc protrusion is mostly central, doesn't impinge the S1 to much. I would try L5-S1 TF, especially if your partner was off target. Reasonable to add on S1 TF for cephalad flow to L5 or L4-5 TF for caudal flow to L5, to hedge your bet that the medicine will get there since L5-S1 is so stenotic in the foramen and you might not get good medial flow.

Plan B: far lateral L4-5 IL. Start medial, aim out lateral with endpoint just medial to the facet. Needle tip will be just posterior to the nerve at the level of the disc. This approach will actually get the needle tip closest to disc/nerve interface at the lateral recess, as with TF approach, the needle tip will probably be fairly lateral given the foraminal stenosis. Several studies show far lateral aka modified paramedian/parasagittal IL gets you same or more ventral flow than TF. Plus you can use particulate, which I think anecdotally is superior. Also, doesn't matter if you can't see epidural fat if you are comfortable with your IL technique. It's a potential space that is there.

I have always thought this but never heard anyone say this or confirm it, epidural space is a potential space, why do I need to look at the MRI and see if patient has some epidural fat. I’m usually just looking to see if there is ligament there for instance if patient had an old L4-5 hemilami at that level but couldn’t remember which level and the flavin is gone.

 

[Taus]

I have always thought this but never heard anyone say this or confirm it, epidural space is a potential space, why do I need to look at the MRI and see if patient has some epidural fat. I’m usually just looking to see if there is ligament there for instance if patient had an old L4-5 hemilami at that level but couldn’t remember which level and the flavin is gone.

I don’t look for it in lumbar at all unless I need to inject at the level of severe stenosis (ie above a fusion). Unlike c spine and scs trials, where I check and confirm epidural fat on t1 every time.

 

[ctts]

I believe that the T1 sagittals are actually superior for assessing the presence of epidural fat in the foramen just as they are useful for assessing for the presence of epidural fat in the posterior epidural space in the cervical spine. If there is a radiologist among us please feel free to correct me.

I agree with this statement as well. However, once the epidural fat in the foramen is completely or mostly effaced, I find it easier to assess the degree of neural impingement in the neural foramen on the T2 sagittals than on the T1 sagittals.

Yes, it is clear cut. That is why there are more likes on my post than for any other post on this thread.

SMH

Sometimes a pain patient really is clear cut, just like a medicare patient with L4-L5, L5-S1 facet degeneration and axial pain worse with standing/walking and relieved with sitting, who has failed conservative care. They get bilateral L3-L5 MBB/RFA. Can you argue that this is not the standard of care?

I agree that this is standard of care, but I do not agree that this is always the right care for every patient in this category. I have seen plenty of these patients with severe spinal stenosis which was initially ignored because they did not have any axial pain, who were treated with two rounds of facet blocks and RFA and upset that after undergoing three procedures over the course of several months, they did not have any relief. So then they finally have an ESI and have good relief. Of course, if one starts with ESI, and they did not have relief,, and later had relief with facet blocks and RFA, they would be faulted for wasting an ESI in the first place, perhaps more at fault because this is not considered standard of care. On the other hand, one wasted procedure versus 3 wasted procedures...

This young patient has two large disc herniations. It is reasonable to treat both of them. Doing a supraneural TFESI with dex at the level below each herniation is the standard of care for an acute radiculopathy.
If this case was presented at a national academic meeting, and we took a survey, the majority (not all) of university pain professors, would agree with that interventional approach.

I agree with the L5-S1 TF ESI, but just curious to know, why are you saying it is clear cut that one should do the S1 TF ESI in addition? I wouldn't fault someone for doing the S1 TF ESI, but I am not sure that it is clearly indicated either? Pain pattern and weakness of EHL is more L5 than S1, although granted there can be some variation. There is L5-S1 disc herniation, but I do not see S1 nerve impingement.

 

[Ducttape]

I would argue that the data for a parasagittal L5 S1 ILESI and L5 TF suggest similar in efficacy.

given spread of medication, hard for me to justify 2 level TF but then again I am a minimalist.

caudal is too low.

and he probably isn't going to get surgery unless he goes to Laser Spine - its probably been going on too long and he is apparently too young.

 

[Nodolor]

I would argue that the data for a parasagittal L5 S1 ILESI and L5 TF suggest similar in efficacy.

given spread of medication, hard for me to justify 2 level TF but then again I am a minimalist.

caudal is too low.

and he probably isn't going to get surgery unless he goes to Laser Spine - its probably been going on too long and he is apparently too young.

Guess it wont happen either as they shutdown a couple years ago

 

[Laryngospasm]

Laser spine was sued into oblivion weren’t they?

 

[lobelsteve]

Laser spine was sued into oblivion weren’t they?

Yes and no.

https://www.bonati.com/

Trail of controversy follows doctor to Las Vegas

Dr. Alfred Bonati, a 76-year-old orthopedic surgeon from Florida who has patented his minimally invasive surgical techniques used in back procedures, has opened a second facility in Las Vegas.

www.reviewjournal.com

 

[bedrock]

I agree with this statement as well. However, once the epidural fat in the foramen is completely or mostly effaced, I find it easier to assess the degree of neural impingement in the neural foramen on the T2 sagittals than on the T1 sagittals.



SMH



I agree that this is standard of care, but I do not agree that this is always the right care for every patient in this category. I have seen plenty of these patients with severe spinal stenosis which was initially ignored because they did not have any axial pain, who were treated with two rounds of facet blocks and RFA and upset that after undergoing three procedures over the course of several months, they did not have any relief. So then they finally have an ESI and have good relief. Of course, if one starts with ESI, and they did not have relief,, and later had relief with facet blocks and RFA, they would be faulted for wasting an ESI in the first place, perhaps more at fault because this is not considered standard of care. On the other hand, one wasted procedure versus 3 wasted procedures...



I agree with the L5-S1 TF ESI, but just curious to know, why are you saying it is clear cut that one should do the S1 TF ESI in addition? I wouldn't fault someone for doing the S1 TF ESI, but I am not sure that it is clearly indicated either? Pain pattern and weakness of EHL is more L5 than S1, although granted there can be some variation. There is L5-S1 disc herniation, but I do not see S1 nerve impingement.

I understand you're the worlds greatest pain physician but you also contradicted yourself here.

Duh, MBB don't work if someone has severe stenosis, which is why in contrast to some of the posters on this board, I don't proceed to MBB without an MRI or CT scan to rule that out first as well as other pathology. I have posted that MRI perspective several times on this board, so either you are fairly new here or have a bad memory.

You reference wasted procedures but you first had to nitpick with my decision to add S1 to the L5 TFESI. It only takes a couple mins to add S1 to an L5-S1 TFESI, when the patient is already there for an epidural anyway. This patient has two huge disks, sure L4-L5 is worse, but L5-S1 disc is quite large and certainly a potential source of pain. If you only do an L5-S1 TFESI, and the patient fails to improve sufficiently, then you have to consider another TFESI that includes S1, then you certainly have a wasted procedure, which contradicts your other paragraph.

 

[ctts]

I understand you're the worlds greatest pain physician

Not sure how you came to that conclusion, but I am sorry if I wrote anything to suggest that.

but you also contradicted yourself here.

Duh, MBB don't work if someone has severe stenosis, which is why in contrast to some of the posters on this board, I don't proceed to MBB without an MRI or CT scan to rule that out first as well as other pathology. I have posted that MRI perspective several times on this board, so either you are fairly new here or have a bad memory.

It was just an example. I think the opposite scenario is also possible, that some patients have severe stenosis, and yet their facet arthropathy is more symptomatic. I did not say anything about MRI...my statement was based on an assumption that MRI or CT was already done prior to any procedures, so I was not implying anything about doing MBB without MRI or CT.

You reference wasted procedures but you first had to nitpick with my decision to add S1 to the L5 TFESI. It only takes a couple mins to add S1 to an L5-S1 TFESI, when the patient is already there for an epidural anyway. This patient has two huge disks, sure L4-L5 is worse, but L5-S1 disc is quite large and certainly a potential source of pain. If you only do an L5-S1 TFESI, and the patient fails to improve sufficiently, then you have to consider another TFESI that includes S1, then you certainly have a wasted procedure, which contradicts your other paragraph.

Sorry for nitpicking your decision to add S1. I do appreciate your explanation and I think it is fine to justify doing the S1 for that reason. In regards to the wasted procedure comment...I think the main point is that we all try to avoid wasted procedures and consider that in our rationale.

Again, if you felt that I was attacking your or insulting you, I apologize, but I did honestly have a hard time with your "clear cut" statement as I took it to mean that you were implying your way is the only way, and anyone else who has a different suggesiton or plan is wrong (myself, spondy14, dipriMAN, Agast, Ducttape). Can we not discuss different view points on this forum without attacking one another?