Tfesi with drg lead?

[Taus]

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I’ve got a patient w drg stim implant for crps. Now has radic with foraminal disc at level of lead. Any concerns with tfesi at same level? Haven’t encountered this before. Thanks.

 

[DOctorJay]

I've wondered about this scenario but haven't seen it clinically yet. I would imagine as long as you don't contact the lead with the TFESI it will be fine. Maybe consider infraneural approach for this one. Would really look closely at imaging to help plan out best approach.

 

[Taus]

I've wondered about this scenario but haven't seen it clinically yet. I would imagine as long as you don't contact the lead with the TFESI it will be fine. Maybe consider infraneural approach for this one. Would really look closely at imaging to help plan out best approach.

Thanks. Not ideal as it’s CT scan. Scs hardware from about 3 years ago not mri compatible. Does look like big foraminal hnp. So infra neural likely to cause discogram. I’d have to stay high n tight to bone to not stick nerve which would likely contact drg lead. What do you think would happen if I poke lead w needle? Worst case scenario? Just damaged lead? Otherwise I’m trying to avoid doing a shot.... Not responding to meds/pt etc. considering far lateral paramedian interlam.... but then I’m thinking about hitting lead loops or going through lig flavum where introducer went. I know prob overthinking this.......

 

[BobBarker]

Interlaminar on that side but one level below?

 

[Taus]

Interlaminar on that side but one level below?

That’s what I’m thinking may be safest. Though hope I reach target.

 

[MD87]

When I was trained, I learned to do DRG by entering from the contralateral side 1 level below. If that's how this one was performed, a far lateral paramedian interlam on the ipsilateral side should not be an issue from the perspective of entering where the introducer went. Alternatively, you could do a TFESI at the level below. My 2 cents, but I have had really good success rate with doing TFESI the level below for massive foraminal herniations when I'm scared of going intradiscal at the level of neural impingement. I just inject 3-4 cc to make sure it reaches that level.

Also - consider reaching out to device rep to see if maybe they can mess around and cover his new radicular pain?

 

[SommeRiver]

One level below.

 

[Orin]

Just do an interlaminar below and thread a catheter?

The leads are visible on fluoro though so why are we stressed?

 

[lobelsteve]

Paramedian interlaminar at level below reaches the level and the two above it.

 

[Taus]

Paramedian interlaminar at level below reaches the level and the two above it.

Reaches level yes.... but reliably reaches pathology of nerve/disc interface with foraminal hnp? It’s not central or lateral recess pathology.

 

[deleted993114]

When I was trained, I learned to do DRG by entering from the contralateral side 1 level below. If that's how this one was performed, a far lateral paramedian interlam on the ipsilateral side should not be an issue from the perspective of entering where the introducer went. Alternatively, you could do a TFESI at the level below. My 2 cents, but I have had really good success rate with doing TFESI the level below for massive foraminal herniations when I'm scared of going intradiscal at the level of neural impingement. I just inject 3-4 cc to make sure it reaches that level.

Also - consider reaching out to device rep to see if maybe they can mess around and cover his new radicular pain?

Use the interlam approach as you have described and simply place an epidural catheter. The good thing about catheters is that they go ventral as well, which is the point of impingement with herniated discs.

I use catheters all the time (particularly for cervical epidurals and lumbar levels at which there is stenosis). You get a really nice epidurogram that extends right out the root.

Regarding the "DRG" lead (I have always called this "root stimulation", which is really what it is)- do you think they had the far lat disc when the lead was placed and they just missed it, or has it clearly developed since then? Additionally, what relief are they getting from the stim for this disc herniation? A far lat catches the segmental nerve above- so is the lead covering the involved segment, or is it one off?

 

[Ducttape]

to Taus: wait... are you using the injection for pain management or do you think that the injection actually "cures" the foraminal hnp?

 

[deleted993114]

to Taus: wait... are you using the injection for pain management or do you think that the injection actually "cures" the foraminal hnp?

Steroid injections don't "cure" anything. It is just buying time for the natural history (in most cases) to run its course.

 

[Taus]

Steroid injections don't "cure" anything. It is just buying time for the natural history (in most cases) to run its course.

This.

Crps here is chronic. Doing this for new hnp.

Thanks all for the input. It’s helpful.

 

[PainMD23]

I've had this scenario. DRG worked well for CRPS knee. Then, new foraminal disc protrusion at the DRG level. Patient developed drop foot. I sent to neurosurgery, who performed discectomy after removing the device.