Spinal Stenosis with only axial pain

[SommeRiver]

---

Members don't see this ad.

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

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

To what exactly is the "no" directed?

 

[lobelsteve]

To what exactly is the "no" directed?

no fusion is needed

 

[SommeRiver]

If you're talking about the OP patient I agree, but I was referring to Bedrock's patient with severe stenosis and facet disease.

 

[SommeRiver]

I'll say this though...In our group, if a patient has advanced spinal stenosis and facet disease they're most likely getting offered a fusion and a decompression bc the majority of these pts have foraminal stenosis as well.

 

[deleted993114]

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.

How in the world could one use a transforaminal epidural to "confirm" a diagnosis of stenosis?

Selective diagnostic nerve root blocks, even with radicular pain, have been shown to have little value in confirming a diagnosis. Spinal stenosis is NOT radicular in nature and the distribution of pain is NEVER segmental, unless it is lateral recess stenosis and not central stenosis. Further, most of the impingement is dorsal and central in stenosis, rather than ventral/lateral.

I would offer that your success with the transforaminals is anectdotal and is in contrast to what one would expect from the patho/phys of spinal stenosis.

 

[deleted993114]

I'll say this though...In our group, if a patient has advanced spinal stenosis and facet disease they're most likely getting offered a fusion and a decompression bc the majority of these pts have foraminal stenosis as well.

............................ that would be in contrast to the NASS guidelines (back when they published them). Unless you can demonstrate a spondylolisthesis, fusing the patient upfront at the time of a decompression is excessive. I don't know of a single ethical neurosurgeon who would advocate that. If your surgeons are routinely creating an iatrogenic spondylolothesis with a routine decompression, perhaps they need to return to training. If, in a patient with a third herniated disc at the same level (and two previous disc surgeries), a fusion is also indicated in the absence of a slip.

Fusing people routinely with a decompression is outrageous. Unfortunately, with higher densities of spine surgeons, the fusion rates per capita go up. Check out the annual "fusion map" that SPINE shows every year. If your area is "black", you know your guys are way too aggressive. Sadly, these "black" areas tend to correspond very closely to the number of spine surgeons in the area.

 

[SommeRiver]

............................ that would be in contrast to the NASS guidelines (back when they published them). Unless you can demonstrate a spondylolisthesis, fusing the patient upfront at the time of a decompression is excessive. I don't know of a single ethical neurosurgeon who would advocate that. If your surgeons are routinely creating an iatrogenic spondylolothesis with a routine decompression, perhaps they need to return to training. If, in a patient with a third herniated disc at the same level (and two previous disc surgeries), a fusion is also indicated in the absence of a slip.

Fusing people routinely with a decompression is outrageous. Unfortunately, with higher densities of spine surgeons, the fusion rates per capita go up. Check out the annual "fusion map" that SPINE shows every year. If your area is "black", you know your guys are way too aggressive. Sadly, these "black" areas tend to correspond very closely to the number of spine surgeons in the area.

My point is that severe spinal stenosis and severe facet arthropathy are so commonly seen in conjunction with foraminal stenosis, and when you have all 3 you get fused more often than not.

Debulking the facet is a part of foraminal decompression correct? That would inherently increase the risk of listhesis and instability. That's why I specifically said that about foraminal stenosis.

Where I work in rural GA, my avg pt is probably 65-75 yo with facet disease and spinal, lateral recess, and foraminal stenosis. Obviously I'm not saying every single one, but that's what I mostly see day in and day out, and that's why so many pts are fused.

...but I am not saying my practice fuses every decompression of course.

I'd be interested to know what percentage of pts with severe spinal stenosis and severe facet disease do not have significant foraminal stenosis bc that is my experience.

 

[deleted993114]

My point is that severe spinal stenosis and severe facet arthropathy are so commonly seen in conjunction with foraminal stenosis, and when you have all 3 you get fused more often than not.

Debulking the facet is a part of foraminal decompression correct? That would inherently increase the risk of listhesis and instability. That's why I specifically said that about foraminal stenosis.

Where I work in rural GA, my avg pt is probably 65-75 yo with facet disease and spinal, lateral recess, and foraminal stenosis. Obviously I'm not saying every single one, but that's what I mostly see day in and day out, and that's why so many pts are fused.

...but I am not saying my practice fuses every decompression of course.

I'd be interested to know what percentage of pts with severe spinal stenosis and severe facet disease do not have significant foraminal stenosis bc that is my experience.

I understand what you are saying. Obviously, nearly 100% of patients with severe stenosis will have foraminal stenosis. However, in the absence of discreet radicular symptoms, the average neurosurgeon will not fuse these patients and will only do a segmental lateral foraminotomy in addition to a decompression. Fusing these patients initially is considered excessive.

No knock on you whatsoever- you are just treating the patients others have operated on- I certainly was not criticizing you at all. However, keep in mind that your state has a fusion incidence that is well above norms for the rest of the country. Fusion rates are also higher among ortho spine, as opposed to neurosurgeons. Most neurosurgeons will simply decompress these patients. Even with a grade I iatrogenic slip, most do not require fusions.

I understand when you say that not every decompression gets fused. Again, you are just treating what comes across your doorstep and you certainly can't control that. Further, you have to deal with the local spine surgeons you are dealt to deal with. Some are more aggressive than others.

 

[SSdoc33]

if you have severe central stenosis, you typically have radicular pain along with it.

operating AT ALL on a patient with only axial symptoms and stenosis should not be done. if you fuse or if you don't is a moot point. no operation should be offered.

in a patient with central (and also likely lateral recess/foraminal stenosis, you really should just be seeing laminectomies without fusions. if there is a big spondy or pars defect, then its lami + fusion.

somme, your surgeons seem to be overly agre$$ive.

FWIW, TFESIs do seem to work better on stenosis patients, and this is borne out in the literature as far as pain relief. diagnostically, the TFESI seems to be a lot harder to quantify......

 

[paindoc007]

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.



Because you often don’t get reliable anterior epidural flow with ILESI.

When treating lumbar stenosis, I always start with TFESI. If I get good relief, diagnosis is settled.

If sustained relief, then great. If only a few weeks of relief then I do a different type of epidural with depo hoping for 3 months or more of relief from that procedure.

Central stenosis is a combo of disc, facet, and flavum pathology. Why steroid in the anterior epidural space is gold standard diagnostic inj doesn’t make much sense to me...