Spinal Stenosis with only axial pain

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Timeoutofmind

Timeoutofmind

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Hello all:

I have a few patients like this.

Severe lumbar spinal stenosis. No claudication at all.

Failed RF.

Would you send someone like this for a decompression if they have failed an ESI?

Say the axial pain is definitely worse with walking versus if it is not, does that make a difference to you on this issue?

Any surgical literature out there regarding decompression outcomes in this patient population?

Thanks in advance.
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I still believe that's facets personally.
 
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Try a diagnostic MBB, even if the MRI doesn't show fluid on T2 in the facet joint. Generally stenosis is caused by ligamentum flavum hypertrophy in conjunction with facet hypertrophy and potential disc protrusion. If it's axial pain only, and we are talking stenosis on an older person, trying a diagnostic MBB wouldn't be a bad idea. Esp if there's some logic when eliciting positive facet loading test.
 
DrSpine said:
Try a diagnostic MBB, even if the MRI doesn't show fluid on T2 in the facet joint. Generally stenosis is caused by ligamentum flavum hypertrophy in conjunction with facet hypertrophy and potential disc protrusion. If it's axial pain only, and we are talking stenosis on an older person, trying a diagnostic MBB wouldn't be a bad idea. Esp if there's some logic when eliciting positive facet loading test.
Click to expand...

so try the Mbb even if the facsts look fine on MRI? How do u justify that to insurance company who may deny it because it looks normal
 
i see this once in a while. doesn't respond to mbb but temporary relief to ESI. if you haven't tried interlaminar or caudal i recommend that. response is better than TFESI. usually not a good candidate for lami due to age. can consider vertiflex/mild
 
No good data supporting any correlation of severity of facet arthropathy on imaging with likelihood of pain so stop letting presence or absence of ugly facets on an MRI dictate whether you think the pain is facetogenic.

In folks with stenosis on imaging but primarily axial pain, I’ll try MBB/RFA. It it works, great. If not, would consider 1-2 ESI. If that doesn’t provide adequate benefit, send for decompression.


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what is your ICD for this if MRI looks fine, but axial loading and positive history for facetogenic pain?
 
but is it really spondylosis if MRI clear, or can you put panniculitis, or enesthesopathy? I'm not saying I disagree, but I'm asking given insurances being tricker now adays
 
I would try caudal lysis of adhesions. Has some evidence > ESI for spinal stenosis.

Epidural Lysis of Adhesions - PMC

As our population ages and the rate of spine surgery continues to rise, the use epidural lysis of adhesions (LOA) has emerged as a popular treatment to treat spinal stenosis and failed back surgery syndrome. There is moderate evidence that ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
cbest said:
No good data supporting any correlation of severity of facet arthropathy on imaging with likelihood of pain so stop letting presence or absence of ugly facets on an MRI dictate whether you think the pain is facetogenic.

In folks with stenosis on imaging but primarily axial pain, I’ll try MBB/RFA. It it works, great. If not, would consider 1-2 ESI. If that doesn’t provide adequate benefit, send for decompression.


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Click to expand...

Agree. Took me awhile to trust the PE over the MRI, but I got there.
 
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afob100 said:
I would try caudal lysis of adhesions. Has some evidence > ESI for spinal stenosis.

Epidural Lysis of Adhesions - PMC

As our population ages and the rate of spine surgery continues to rise, the use epidural lysis of adhesions (LOA) has emerged as a popular treatment to treat spinal stenosis and failed back surgery syndrome. There is moderate evidence that ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...

1576765223053.png
 
Agree w above. Injections are not gong to be helpful since RFA wasn’t already. I see no reason in going through more mbb except to pad your pockets. The needle gets put down.

Also, Surgical decompression for back only pain, without any leg or neurogenic claducation sx? Hmmmm

Not all pain problems can be fixed. Patient needs to be educated on that.
 
Consider CT to id the bony structures, CT better at picking up bony related issues, surgeons rely on these more for their hardware placement/ eval of bony structures. This is all assuming your PE is indicative and additional XR is worth it. Whats the pain diary look like? Also back brace could be an option, TENS etc. Agree with higher MBB levels as well.
 
Ferrismonk said:
Didn't he already say RF was ineffective? What's to be gained by facets/MBB? For that matter, what was the relief with facets/MBB prior to RF?

What is the exam like? SLR? Faber? Provocative maneuvers? We treat patients, not images.
Click to expand...

Good questions
Could have been more clear

Failed back brace and TENS

Facet loading positive
Lower lumbar facets TTP
SIJ TTP BL
Fabers + BL
Who cares about SLR as he has no radicular features? But neg since you asked.

BL L2-5 MBB was no relief with lido at all. (Sorry my mistake never did RF)
BL SIJ wih no relief with lido or steroid
No relief with ESI

I like the idea of MBBs higher up and then give up.

Seems like the consensus is no decompression in absence of claudication, despite the severe stenosis? That was my main question...

What am I really looking for on CT? What could I possibly find that would change management given he already had an MRI?
 
Timeoutofmind said:
Seems like the consensus is no decompression in absence of claudication, despite the severe stenosis? That was my main question...
Click to expand...
I think claudication can present as axial pain. Maybe it's referred from buttocks, idk.
If the pt is an operative candidate and desperate, I would consider sending to surg.
 
send to surgery.

at the very least, if patient hears "no surgical options", that means he will be more amenable at whatever treatment he probably thought useless, like home exercise, CBT, etc.
 
painfree23 said:
so try the Mbb even if the facsts look fine on MRI? How do u justify that to insurance company who may deny it because it looks normal
Click to expand...

painfree23 said:
so try the Mbb even if the facsts look fine on MRI? How do u justify that to insurance company who may deny it because it looks normal
Click to expand...

You should not rely soley on imaging to determine if facets are a pain generator. If it looks like facets, smells like facets, do an MBB trial. If +, it is facet mediated. Simple. There are lots of reasons for facetogenic pain that to not image on MR. This is going to open up your practice to a whole slew of patients you can now treat, it is going to be great! Remember, MRIs do not image pain, they image some tissues.

Just do a trial run; spend a week, if patients have failed conservative measures and their history and physical exam suggest facetogenic pain, do an MBB trial. Just do it over a week. I think you will be astounded at he lack of correlation between imaging and MBB outcomes.
 
Ligament said:
You should not rely soley on imaging to determine if facets are a pain generator. If it looks like facets, smells like facets, do an MBB trial. If +, it is facet mediated. Simple. There are lots of reasons for facetogenic pain that to not image on MR. This is going to open up your practice to a whole slew of patients you can now treat, it is going to be great! Remember, MRIs do not image pain, they image some tissues.

Just do a trial run; spend a week, if patients have failed conservative measures and their history and physical exam suggest facetogenic pain, do an MBB trial. Just do it over a week. I think you will be astounded at he lack of correlation between imaging and MBB outcomes.
Click to expand...
that is very true but it also speaks to the importance of a confirmatory block.

this is only my opinion, but I do find a significant portion (? 30%) will get a placebo type benefit from the first block but get really no relief with the second.
 
Timeoutofmind said:
Good questions
Could have been more clear

Failed back brace and TENS

Facet loading positive
Lower lumbar facets TTP
SIJ TTP BL
Fabers + BL
Who cares about SLR as he has no radicular features? But neg since you asked.

BL L2-5 MBB was no relief with lido at all. (Sorry my mistake never did RF)
BL SIJ wih no relief with lido or steroid
No relief with ESI

I like the idea of MBBs higher up and then give up.

Seems like the consensus is no decompression in absence of claudication, despite the severe stenosis? That was my main question...

What am I really looking for on CT? What could I possibly find that would change management given he already had an MRI?
Click to expand...

1st question- How severe is the stenosis? If mild, or mild-moderate, then less likely to be an issue, if moderate or moderate-severe you have to consider it as a pain generators.

You also have to consider a technique problem. Did you do your MBB with contrast, and readjust if you were off target? Otherwise, your MBB results may not be valid.

Similar question regarding ESI. You said they failed ESI. Did you do TFESI or some other kind that that is less target specific? If they have 2 levels of moderate or moderate-severe stenosis, did you do a TFESI for each level or just one? Finally, you said they had no relief with ESI. Not even for a few days? Because then you have to consider dex effect.

Regarding your main question. If the patient didn't have even brief relief with multi level TFESI with great dye flow, then I wouldn't send them for surgical decompression. If they had no relief after an ILESI, that's a different story.
 
cbest said:
No good data supporting any correlation of severity of facet arthropathy on imaging with likelihood of pain so stop letting presence or absence of ugly facets on an MRI dictate whether you think the pain is facetogenic.

In folks with stenosis on imaging but primarily axial pain, I’ll try MBB/RFA. It it works, great. If not, would consider 1-2 ESI. If that doesn’t provide adequate benefit, send for decompression.


Sent from my iPhone using SDN mobile
Click to expand...

No ethical neurosurgeon will do a decompression for axial pain.

How about intra-articular facet injections with steroids? The Lake article suggests that in the lumbar spine (unlike the cervical spine) there is efficacy of intra-articular facet injections. If the pt has acquired stenosis, then by definition they have facet hypertrophy at that level.

Field stim? Perhaps- I did quite a few of them when I had a VA clinic. Tough to get approval for commercial insurance.

Lateral epidural stim (to address SVN and GRC) would be an option. Needs high freq to avoid radic stim. Conventional dorsal column stim has a very poor track record for axial pain. It is like applying a cast to the ankle for someone with a distal radius fracture and expecting good results. Wrong anatomical target- poor results.
 
Last edited by a moderator:
Timeoutofmind said:
Good questions
Could have been more clear

Failed back brace and TENS

Facet loading positive
Lower lumbar facets TTP
SIJ TTP BL
Fabers + BL
Who cares about SLR as he has no radicular features? But neg since you asked.

BL L2-5 MBB was no relief with lido at all. (Sorry my mistake never did RF)
BL SIJ wih no relief with lido or steroid
No relief with ESI

I like the idea of MBBs higher up and then give up.

Seems like the consensus is no decompression in absence of claudication, despite the severe stenosis? That was my main question...

What am I really looking for on CT? What could I possibly find that would change management given he already had an MRI?
Click to expand...
It sounds like you don’t necessarily have a great diagnosis at this point. When I am in this situation I may consider nuclear medicine scan SPECT/CT to see what lights up.
 
Purely axial. No mobile spondy. No response to mbb or facet/steroid. Not SI joint. Stenosis or not, there is no further indication for procedures, surgical or interventional. Lami /Decompression not gonna fox their axial back pain.

I see patients like this every few months. Sucks. Usually nice old people. Just nothing further great to do. Can try more meds, more rehab, lso, tens, omt/dc manip etc.
 
Last edited:
Baron Samedi said:
What would this potentially tell you that an MRI wouldn't?
Click to expand...
It could help to localize the problematic pathology whether it is a specific facet, SI joint, Baastrup’s etc as it is better at picking up bony turnover than an MRI. I have been surprised that the handful of times I have ordered a SPECT/CT I have had one single facet joint light up. Picked up this nugget from one of my attendings in fellowship a couple of years ago. The attending is an SIS board member.
 
Taus said:
Purely axial. No mobile spondy. No response to mbb or facet/steroid. Not SI joint. Stenosis or not, there is no further indication for procedures, surgical or interventional. Lami /Decompression not gonna fox their axial back pain.

I see patients like this every few months. Sucks. Usually nice old people. Just nothing further great to do. Can try more meds, more rehab, lso, tens, omt/dc manip etc.
Click to expand...

painfree23 said:
wat?
Click to expand...

MBB without contrast is wrong all the time. I trained with dreyfuss. I can't tell you how many people we successfully treated with MBB/RFA, who failed MBB by docs going too fast during their MBB (or RFA). If you don't take the time to confirm you covered the MBB with contrast, you have no idea where your medication travels.

All due respect to everyone else, but if you have haven't tried TFESI, possibly multi level TFESI, then you don't really know if stenosis is a pain generator. Just a really quick ILESI can certaintly help, but it doesn't rule out stenosis as a pain generator if they fail the ILESI.

Just had a patient this week. Saw another pain doc before me. Nice elderly patient. Has axial pain, which radiates to to upper buttock only, no leg pain. Failed MBB, failed ILESI by the other doc.
Just followed up with me on Thursday, having now achieved 100% relief after two level TFESI for her two level moderate lumbar stenosis.
 
Last edited:
bedrock said:
MBB without contrast is wrong all the time. I trained with dreyfuss. I can't tell you how many people we treated with MBB/RFA, who failed MBB by docs going too fast during their MBB. If you don't take the time to confirm you covered the MBB with contrast, you have no idea where your medication travels.

All due respect to everyone else, but if you have haven't tried TFESI, possibly multi level TFESI, then you don't really know if stenosis is a pain generator. Just a really quick ILESI can help, but it doesn't rule out stenosis as a pain generator if they fail the ILESI.

Just had a patient this week. Saw another pain doc before me. Nice elderly patient. Has axial pain, which radiates to to upper buttock only, no leg pain. Failed MBB, failed ILESI by the other doc.
Just followed up with me on Thursday, having now achieved 100% relief after two level TFESI for her two level moderate lumbar stenosis.
Click to expand...

So you did..a two level bilateral tfesi? Four needles? Or was this all unilateral?
 
bedrock said:
MBB without contrast is wrong all the time. I trained with dreyfuss. I can't tell you how many people we successfully treated with MBB/RFA, who failed MBB by docs going too fast during their MBB (or RFA). If you don't take the time to confirm you covered the MBB with contrast, you have no idea where your medication travels.

All due respect to everyone else, but if you have haven't tried TFESI, possibly multi level TFESI, then you don't really know if stenosis is a pain generator. Just a really quick ILESI can certaintly help, but it doesn't rule out stenosis as a pain generator if they fail the ILESI.

Just had a patient this week. Saw another pain doc before me. Nice elderly patient. Has axial pain, which radiates to to upper buttock only, no leg pain. Failed MBB, failed ILESI by the other doc.
Just followed up with me on Thursday, having now achieved 100% relief after two level TFESI for her two level moderate lumbar stenosis.
Click to expand...
Radiates to upper buttock in your case. I consider butt=limb. Would you have done same if pure axial?
 
bedrock said:
MBB without contrast is wrong all the time. I trained with dreyfuss. I can't tell you how many people we successfully treated with MBB/RFA, who failed MBB by docs going too fast during their MBB (or RFA). If you don't take the time to confirm you covered the MBB with contrast, you have no idea where your medication travels.

All due respect to everyone else, but if you have haven't tried TFESI, possibly multi level TFESI, then you don't really know if stenosis is a pain generator. Just a really quick ILESI can certaintly help, but it doesn't rule out stenosis as a pain generator if they fail the ILESI.

Just had a patient this week. Saw another pain doc before me. Nice elderly patient. Has axial pain, which radiates to to upper buttock only, no leg pain. Failed MBB, failed ILESI by the other doc.
Just followed up with me on Thursday, having now achieved 100% relief after two level TFESI for her two level moderate lumbar stenosis.
Click to expand...

Can you explain why a tfesi is necessary to evaluate stenosis as a pain generator ?
 
DODOCSS said:
Underwhelming results w/ lb rfa here

Quit offering
Click to expand...

In my limited experience lateral branch blocks could be quite positive but the RF provided less than ideal results. I don't generally offer lateral branch RFA either but in this case where there continues to be diagnostic uncertainty with some positive SI tests it may be helpful to do the LBB to rule SI in or out. What you do after that...harder to say.
 
Taus said:
Radiates to upper buttock in your case. I consider butt=limb. Would you have done same if pure axial?
Click to expand...
Upper buttock pain did help sway me, though I also see that pain pattern with l5-s1 facets. Her stenosis and bad facets were located l3l4,l4l5, with almost normal l5s1 facets.

soccerpunk600 said:
Can you explain why a tfesi is necessary to evaluate stenosis as a pain generator ?
Click to expand...

Because you often don’t get reliable anterior epidural flow with ILESI.
 
Last edited:
I doubt a surgeon would do just a lami for axial pain with severe spinal stenosis. He's gonna do the whole package.

It really depends on the pt and how desperate they are to *try* to get relief. They have to be educated on the risks but they make the final decision.
 
Do a lami on that pt and you'll end up with a slip.
 
SommeRiver said:
Do a lami on that pt and you'll end up with a slip.
Click to expand...

No.

Decompression without Fusion for Low-Grade Degenerative Spondylolisthesis - PMC

Retrospective series. Assess results of decompression-only surgery for low-grade degenerative spondylolisthesis with consideration of instability. There is no consensus on whether fusion or decompression-only surgery leads to better outcomes for ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

link.springer.com

Decompression with or without concomitant fusion in lumbar stenosis due to degenerative spondylolisthesis: a systematic review - European Spine Journal

Purpose The primary objective of this systematic review is to compare the outcome after decompression with and without concomitant instrumented fusion in patients with lumbar stenosis and degenerative spondylolisthesis. Does adding fusion to simple decompression lead to better results? Methods...
link.springer.com link.springer.com
 
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