What would you do?

[epidural man]

I'm curious how you all would treat the patient I saw today.

33 y/o, in 2007, fell off a Humvee with all his gear on. After this he had bad back pain for some time, but it got better and for the next 4 years or so, had on and off back pain. In Jan this year, he was doing somy heavy dead lifting, felt something in his back ("it wasn't a pop"), and had pretty bad back pain, and unlike before, this pain has persisted. Pain is worse on the right. All axial, but occasional radiation to the groin. Also after activity will sometimes radiate down the legs, but not the same leg each time and doesn't sound like any particular pattern. Pain worse with bending and twisting. Relieved with rest and also movement. Heat and TENS helps. Chiro has been not very helpful. PT hasn't helped. Elavil doesn't help him sleep and doesn't seem to help with the pain. About the time he had the accident, he started going through a divorce and recently started seeing mental health because of some serious life stressors related to that (kid custody issues). He doesn't smoke. ODI = 55%. PCL-M = 25. PHQ-9 = 9.

Exam shows paraspinal tenderness lower back.

MRI shows disc dessication at L4/5 and L5/S1 with some loss of height but still >50%. He has a prominent HIZ at both levels. L5/S1 has a mild right subarticular herniation, but no foraminal or central canal narrowing. No modic changes.

Besides the continued core strengthening (a goal of doing a plank for 2 minutes is what I told him), mental health for biofeedback, CBT and guided imagery, yoga, Chiro, possibly accupuncture, recommendation for aerobic excersize, and possible other pharm options you would definitely offer, would you offer him interventions? If so, what?

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[lobelsteve]

Re-do his exercise regimen.

Nothing over 225 on the rack or Smith.
No situps or crunches.
Lower abs only- can do these on incline bench or dip stand.
Start the DLS program and if not better in 4 weeks then single shot Right S1 TFESI and keep up the exercise program.

 

[Doctodd]

225lb is still 2 big plates on each side, so i would probably start lower than that and go up based on painfree activity for 48hours after the exercise. If it hurts at all, go back down 50lbs and start over. Treat him like a MLB player. But u didnt mention what his workouts were like now....only in January. How much is he currently lifting if anything?

 

[epidural man]

Re-do his exercise regimen.

Nothing over 225 on the rack or Smith.
No situps or crunches.
Lower abs only- can do these on incline bench or dip stand.
Start the DLS program and if not better in 4 weeks then single shot Right S1 TFESI and keep up the exercise program.

What do you mean re-do his exercise regimen? you mean just have him do the things you suggest? Or are you saying don't have him do aerobic excersize and no planks? just confused a bit on your wording.

Is DLS dynamic lumbar stabilization? Is that better than Mckenzie exersizes? Better than Yoga or tai-chi? I know there is good data on yoga. How about for DLS?

 

[epidural man]

225lb is still 2 big plates on each side, so i would probably start lower than that and go up based on painfree activity for 48hours after the exercise. If it hurts at all, go back down 50lbs and start over. Treat him like a MLB player. But u didnt mention what his workouts were like now....only in January. How much is he currently lifting if anything?

He has stopped lifting because of pain.

 

[SSdoc33]

discogenic pain is the holy grail of back pain. nobody has a great way to treat it..... yet. good core HEP, whichever flavor of the month you like. avoid squats and dead lifts as these put THE most pressure on the discs. you can try fiddling around with injects, but we all know thats not gonna work in the long term. short term to cool things off? maybe

steve, you still poking around with those GRC blocks? getting anywhere with them?

 

[101N]

discogenic pain is the holy grail of back pain. nobody has a great way to treat it.....

1+

This illness tends to favor the ready mind.

 

[epidural man]

GRC blocks? getting anywhere with them?

GRC blocks...define please.

 

[lobelsteve]

If he is a power lifter, 225 is nothing for squats.

No planks. OK for arms just not concentration curls, Shoulder presses with Smith machine only.

No upper abs, only lower abs.

DLS is a mix of flexion and extension exercises. See my website for my handout, I cross out all extension stuff if there is canal stenosis.

GRC is gray rami comm block. Search the forums and we have lots posted as far as literature. I do 1-2 a month and burn the same. twice placebo for 50% VAS reduction but still nagging pain persists. Would love to try and GRC block L4,3,and 2.

For active folks (runners, gym rats, competitive sports) I leave off procedures unless there is a stumbling block.

 

[101N]

GRC blocks...define please.

Gray Ramus Communicans: waste of time and money.

 

[ghost dog]

I'm curious how you all would treat the patient I saw today.

33 y/o, in 2007, fell off a Humvee with all his gear on. After this he had bad back pain for some time, but it got better and for the next 4 years or so, had on and off back pain. In Jan this year, he was doing somy heavy dead lifting, felt something in his back ("it wasn't a pop"), and had pretty bad back pain, and unlike before, this pain has persisted. Pain is worse on the right. All axial, but occasional radiation to the groin. Also after activity will sometimes radiate down the legs, but not the same leg each time and doesn't sound like any particular pattern. Pain worse with bending and twisting. Relieved with rest and also movement. Heat and TENS helps. Chiro has been not very helpful. PT hasn't helped. Elavil doesn't help him sleep and doesn't seem to help with the pain. About the time he had the accident, he started going through a divorce and recently started seeing mental health because of some serious life stressors related to that (kid custody issues). He doesn't smoke. ODI = 55%. PCL-M = 25. PHQ-9 = 9.

Exam shows paraspinal tenderness lower back.

MRI shows disc dessication at L4/5 and L5/S1 with some loss of height but still >50%. He has a prominent HIZ at both levels. L5/S1 has a mild right subarticular herniation, but no foraminal or central canal narrowing. No modic changes.

Besides the continued core strengthening (a goal of doing a plank for 2 minutes is what I told him), mental health for biofeedback, CBT and guided imagery, yoga, Chiro, possibly accupuncture, recommendation for aerobic excersize, and possible other pharm options you would definitely offer, would you offer him interventions? If so, what?

Possible myofascial component LBP ?

Trial of Botox?

 

[SSdoc33]

If he is a power lifter, 225 is nothing for squats.

No planks. OK for arms just not concentration curls, Shoulder presses with Smith machine only.

No upper abs, only lower abs.

DLS is a mix of flexion and extension exercises. See my website for my handout, I cross out all extension stuff if there is canal stenosis.

GRC is gray rami comm block. Search the forums and we have lots posted as far as literature. I do 1-2 a month and burn the same. twice placebo for 50% VAS reduction but still nagging pain persists. Would love to try and GRC block L4,3,and 2.

For active folks (runners, gym rats, competitive sports) I leave off procedures unless there is a stumbling block.

why no planks?

 

[drf]

i did a GRC block today for an old L3 vert fx. Lady had gone through a bunch of interventions at a previous clinic (don't know what) and wasn't terribly optimistic. 0.5 cc bilaterally and she said the pain was gone and to prove it started doing full forward flexion and touching her toes.

Guess I'll try the burn next.

 

[PMR 4 MSK]

HIZ is annular tear +/- small HNP, acutee inflammation. I do ESIs on these when more conservative things (meds and PT) have failed. Some get better with it.

 

[epidural man]

Gray Ramus Communicans: waste of time and money.

I don't think so, pretty fair evidence for it.

We do a fair amount of L2 SNRBS as well.

We have had mixed results with both.

pRF if either of them have a favorable pain diary.

There isn't a med out there with an NNT <6 (so an 18% chance my BEST medicine will work). We have a better than 18% success rate with bilateral L2s and rammus communicans. Sluijtar says to pulse the sympathetic chain above and bellow the level of the problematic disc. I haven't ever tried that.

This guy has at least a 94% chance of having a positive discography. (See attached article).

I"m not sure why anyone would say no planks. If he can do a 2 minute plank, he has adequate core strength. If not, he needs to continue to work on his core.

 

[PinchandBurn]

Have any of you guys tried to do a 2 min plank?

I know guys at the gym that are very fit that can't do that. Especially if you are trying to do a set of 10 or so 2 min planks...

 

[pmrmd]

What's the patient's exam? Beyond tenderness. What makes it worse, flexion or extension, lateral bend? Worse on the same side of motion with lateral bend or opposite?

 

[SSdoc33]

I don't think so, pretty fair evidence for it.

We do a fair amount of L2 SNRBS as well.

We have had mixed results with both.

pRF if either of them have a favorable pain diary.

There isn't a med out there with an NNT <6 (so an 18% chance my BEST medicine will work). We have a better than 18% success rate with bilateral L2s and rammus communicans. Sluijtar says to pulse the sympathetic chain above and bellow the level of the problematic disc. I haven't ever tried that.

This guy has at least a 94% chance of having a positive discography. (See attached article).

I"m not sure why anyone would say no planks. If he can do a 2 minute plank, he has adequate core strength. If not, he needs to continue to work on his core.

oy.

no such thing as a "SNRB".

if you are touting how great your results are with discogenic pain, pulsed RF, and caudals under ultrasound, im having trouble taking you seriously here.

 

[lobelsteve]

Gray Ramus Communicans: waste of time and money.

Maybe you should revisit this modality. Helping a fair number of patients return to work/exercise regimen.

Patient selection? Technique?

 

[epidural man]

oy.

no such thing as a "SNRB".

if you are touting how great your results are with discogenic pain, pulsed RF, and caudals under ultrasound, im having trouble taking you seriously here.

SSdoc33, you don't take me seriously regardless. But I really wish you would, because that would mean a lot to me.

For one, I don't think you read what I write.

I said we have had MIXED results.

Are you this much trouble in real life? Someone reading your post would think - "holy crap, epidural man thinks that caudals under ultrasound work better than caudals under fluoro." When did I say that? A caudal, if it is going to work for whatever reason or for whatever pathology, is going to work no matter how you get the needle tip in there - blind, ultrasound, CT, fluoro, vodoo, dart across the room. The question is confirmation of needle in caudal space - and that is a different arguement altogether.

Seriously, why do you think I ever said I have such phenomenal results with disc pain?

In fact, where have I ever said that my apparently guillable, antiquated, or non-evidence based techniques were better than any of yours, or other posters that have jumped all over my case?

 

[epidural man]

oy.

no such thing as a "SNRB".

if you are touting how great your results are with discogenic pain, pulsed RF, and caudals under ultrasound, im having trouble taking you seriously here.

Oh by the way, I agree with the SNRB. Again, you don't read my posts. I agreeded with that a while ago - I call them targeted nerve blocks on my documentation. Even less SNRB at the L2 level - it is really hard to get a good neurogram without central flow.
Contrast there just loves the epidural space.

 

[epidural man]

What's the patient's exam? Beyond tenderness. What makes it worse, flexion or extension, lateral bend? Worse on the same side of motion with lateral bend or opposite?

Just curious, what would you do with this information?

Let's say he has worse pain with facet loading maneuvers on the right?

Or pain with flexion?

What if he had pain with just extension and lateral bending?

 

[epidural man]

Have any of you guys tried to do a 2 min plank?

I know guys at the gym that are very fit that can't do that. Especially if you are trying to do a set of 10 or so 2 min planks...

It's not easy - you have to work up to it. But you could do it if you did planks for a while. It is hard to do at the end of your workout - a lot easier at the beginning.

By the way, I didn't come up with that. Stuart Mcgill did. He has an impressive list of articles, books, etc on the topic of back pain and body mechanics. I like his stuff and his style and theory. He seems to have some good data to back it up too.

 

[SSdoc33]

epidural, to answer your question, im not as big a PITA in real life.... but its close.

i actually dont really think there is ANY clinical use for caudals, so it doesnt matter if you are doing u/s or fluoro.

i think there are just a good slice of the patients out there where you have to say "i cant help you". L2 "SNRBs", pulsed RF, u/s for spine injections, etc, just seems to be a little silly. no, you didnt say you have great results, but if you are doing all this witchcraft, i think its legit that i give you a little crap about it.

 

[SSdoc33]

good call on mcgill, btw. thats a whole slice of spine care that most interventionalists should know more about

 

[pmrmd]

Just curious, what would you do with this information?

Let's say he has worse pain with facet loading maneuvers on the right?

Or pain with flexion?

What if he had pain with just extension and lateral bending?

I treat people based on what has to move during that motion pattern. When there is a pain produced with flexion, and we are talking purely axial pain, I block the facet capsules and they will bend 90 degrees reproducibly. If he had pain on the same side as lateral bend, its facet--hit the joint and get your relief. If pain is on the opposite on lateral bend, I tend to look at annular cause. The pattern I see is extension pain and pain on the opposite side of motion seems to relieve after annular block and pain with flexion and pain on same side of motion resolves with facet capsule block. But sometimes extension is 5-1 joint also. Its just a pattern that seems to hold true.

 

[ghost dog]

I treat people based on what has to move during that motion pattern. When there is a pain produced with flexion, and we are talking purely axial pain, I block the facet capsules and they will bend 90 degrees reproducibly. If he had pain on the same side as lateral bend, its facet--hit the joint and get your relief. If pain is on the opposite on lateral bend, I tend to look at annular cause. The pattern I see is extension pain and pain on the opposite side of motion seems to relieve after annular block and pain with flexion and pain on same side of motion resolves with facet capsule block. But sometimes extension is 5-1 joint also. Its just a pattern that seems to hold true.

I feel stupid for asking this, but I was taught that all things being equal:

1. Axial / discogenic back pain is worsened with flexion.

2. facetogenic pain is worsened with extension. Lumbar paraspinal tenderness can be helpful
in identifying facet pathology.

With the caveat, that there are no hard and fast physical identifiers when it comes to diagnosing back pain generators and that DX fluoro guided injections rule the roost.

Yes? or am I missing the boat?

 

[pmrmd]

I feel stupid for asking this, but I was taught that all things being equal:

1. Axial / discogenic back pain is worsened with flexion.

2. facetogenic pain is worsened with extension. Lumbar paraspinal tenderness can be helpful
in identifying facet pathology.

With the caveat, that there are no hard and fast physical identifiers when it comes to diagnosing back pain generators and that DX fluoro guided injections rule the roost.

Yes? or am I missing the boat?

Extension pain being facet pain was tossed long ago as you know. Someone mentioned McGill, who made a good point once in a lecture I attended that the disk isn't a shock absorber, the bone is. If the nucleus isn't innervated, why does loading it matter? All I know is I deposit a bit of bupi on the capsule and they bend fine. All I was asking for from the OP was the exam anyway. It seemed the importance was on the MRI findings instead of the person. Do you guys find MRIs helpful for axial pain? Honestly I don't really.

 

[SSdoc33]

interesting how your are calling pain with flexion secondary to a facet joint capusle, and not discogenic.

 

[epidural man]

epidural, to answer your question, im not as big a PITA in real life.... but its close.

i actually dont really think there is ANY clinical use for caudals, so it doesnt matter if you are doing u/s or fluoro.

i think there are just a good slice of the patients out there where you have to say "i cant help you". L2 "SNRBs", pulsed RF, u/s for spine injections, etc, just seems to be a little silly. no, you didnt say you have great results, but if you are doing all this witchcraft, i think its legit that i give you a little crap about it.

If someone calls caudal epidurals witchcraft, they either

1. Can't read, or
2. Can read but don't like to
3. Or are ******ed (...not calling you ******ed ssdoc33).

See 1rst attached review which references a lot of great articles. Of special note is the part about indications...or when you should do a caudal. Also of note, there are two 3 references to comparisons of caudal to TFESI. 2 of them show that TFESI and caudals are equal. One of the studies showed TFESI>caudal.

Also, for those who like and can read, I have attached two articles on pulsed RF - one on L2 DRG pulsing, and just a quick review of pulsed RF which is a good read. (SSdoc33, I would think you would love doing L2 DRG pulsing since you love putting needles near the spine in that approach)

Finally, I tell patients that I don't have interventions for them all the time. I RARELY tell them I have nothing for them. I always can do something - wether that be getting them started on Yoga, helping them quit smoking, encouraging a mental health visit, deep sedation, etc. I feel like I can always do something.

 

[epidural man]

I treat people based on what has to move during that motion pattern. When there is a pain produced with flexion, and we are talking purely axial pain, I block the facet capsules and they will bend 90 degrees reproducibly. If he had pain on the same side as lateral bend, its facet--hit the joint and get your relief. If pain is on the opposite on lateral bend, I tend to look at annular cause. The pattern I see is extension pain and pain on the opposite side of motion seems to relieve after annular block and pain with flexion and pain on same side of motion resolves with facet capsule block. But sometimes extension is 5-1 joint also. Its just a pattern that seems to hold true.

I think that sounds resonable and may be true. I sure wish you would study it and write it up and publish.

I feel stupid for asking this, but I was taught that all things being equal:

1. Axial / discogenic back pain is worsened with flexion.

2. facetogenic pain is worsened with extension. Lumbar paraspinal tenderness can be helpful
in identifying facet pathology.

With the caveat, that there are no hard and fast physical identifiers when it comes to diagnosing back pain generators and that DX fluoro guided injections rule the roost.

Yes? or am I missing the boat?

You are not missing the boat. We were all taught provacative maneuvers for different pain syndromes. Unfortunately, the best available evidence for all it says that none of it matters or makes a difference.

Even though I know it doesn't make a difference, I still do the maneuvers and will document them...I guess cuz I feel like I should. Someday I'll be brave enough to just follow evidenced bassed physical exam/provacotive maneuvers.

Do you guys find MRIs helpful for axial pain? Honestly I don't really.

You should read the first article I posted in this thread about MRI and discography. HIZ has a 95% specificty to postitive discography. That is WAY better than any history or exam finding. Couple that with an MRI grade IV, and some modic changes...I think you've got solid evidence for discogenic pain.

MRI and facets is less certain - the only thing that has come remotely close to predicting facet pain relieved with injection is fluid in the joints - and that isn't that great. Fused SPECT/CT is the best for predicting facet pain relieved with injection - and again, that is much better than any exam of history finding - but who the crap does that?

 

[powermd]

Maybe I haven't read enough yet on the history of discography (because I hardly ever do it), but how did we come to doing the procedure the way it's currently done? Why don't we just inject 1-2 mL lidocaine into a disc, then have the patient get up and try to provoke their pain (as with MBBs)? It would seem to me this would be a much better predictor of true discogenic pain than inflating 3 disks without local and trying to get the often sedated patient to distinguish between "usual oww" and "different owww".

 

[pmrmd]

I think that sounds resonable and may be true. I sure wish you would study it and write it up and publish.



You are not missing the boat. We were all taught provacative maneuvers for different pain syndromes. Unfortunately, the best available evidence for all it says that none of it matters or makes a difference.

Even though I know it doesn't make a difference, I still do the maneuvers and will document them...I guess cuz I feel like I should. Someday I'll be brave enough to just follow evidenced bassed physical exam/provacotive maneuvers.



You should read the first article I posted in this thread about MRI and discography. HIZ has a 95% specificty to postitive discography. That is WAY better than any history or exam finding. Couple that with an MRI grade IV, and some modic changes...I think you've got solid evidence for discogenic pain.

MRI and facets is less certain - the only thing that has come remotely close to predicting facet pain relieved with injection is fluid in the joints - and that isn't that great. Fused SPECT/CT is the best for predicting facet pain relieved with injection - and again, that is much better than any exam of history finding - but who the crap does that?

I tried to publish something a while back but it got rejected--no precedent. Oh well. I'm not saying anything more than its a pattern I see. And since I have no one to answer to I can experiment sometimes.

 

[epidural man]

I tried to publish something a while back but it got rejected--no precedent. Oh well. I'm not saying anything more than its a pattern I see. And since I have no one to answer to I can experiment sometimes.

Stupid journals

 

[epidural man]

Maybe I haven't read enough yet on the history of discography (because I hardly ever do it), but how did we come to doing the procedure the way it's currently done? Why don't we just inject 1-2 mL lidocaine into a disc, then have the patient get up and try to provoke their pain (as with MBBs)? It would seem to me this would be a much better predictor of true discogenic pain than inflating 3 disks without local and trying to get the often sedated patient to distinguish between "usual oww" and "different owww".

It's called functional discography. And I thought it always was a brilliant idea - given the fact that like you mention, everything else we do in pain is with local anesthetic to see if we block the pain - and make the diagnosis.

You actually place a catheter, inflate a small balloon to anchore it in place (in each level you want to interrogate - I think you actually do provocative discography before that, but after the catheter is in place, you get them up, have them do painful maneuvers, then inject the local, then see if you take away the painful maneuver.

I think the problem is you use 4% lidocaine - and local anesthetic is poison to chondrocytes or whatever cytes live in the disc.

but like i said, i love the idea. I have never been brave enough to try it however.

Anybody else ever try it?

 

[powermd]

I have read about this, but it sounds extraordinarily complicated when simply injecting a single disc with local might do.

It's called functional discography. And I thought it always was a brilliant idea - given the fact that like you mention, everything else we do in pain is with local anesthetic to see if we block the pain - and make the diagnosis.

You actually place a catheter, inflate a small balloon to anchore it in place (in each level you want to interrogate - I think you actually do provocative discography before that, but after the catheter is in place, you get them up, have them do painful maneuvers, then inject the local, then see if you take away the painful maneuver.

I think the problem is you use 4% lidocaine - and local anesthetic is poison to chondrocytes or whatever cytes live in the disc.

but like i said, i love the idea. I have never been brave enough to try it however.

Anybody else ever try it?

 

[epidural man]

I have read about this, but it sounds extraordinarily complicated when simply injecting a single disc with local might do.

Yeah maybe, the problem is maybe they don't have a lot of pain lying there prone. It may be you need to get them up to move around. And if testing 2 discs, that would be problematic.

 

[Ligament]

I did a couple cases in fellowship.

 

[joshmir]

PMRMD

Can you please post your write-up here, the one you sent for publication?

I will also PM you with my email address if you prefer

I like your approach and would love to read it

 

[mille125]

I do not have this patient in front of me and I am not looking at the MRI's myself but this really sounds like facet mediated pain to me. I would consider medial branch blocks with eventual RF if he responds.

 

[epidural man]

I did a couple cases in fellowship.

How did it work out?

Why hasn't it caught on more? Like I said, it seems to make clinical sense to me.

 

[deleted185747]

Multiple people have suggested that his pain is from the facet(s). Given the fact that he is in his early 30's (leaving out all the rest of the information and the HIZ on MRI which also point to the disc as the pain generator), I believe that facet is unlikely because of his young age, although an injury at a very young age could set him up for arthritis at an earlier age.

When do arthritic changes begin in the facets in a 'normal' person versus someone who has been in the military, jumping out of planes and off trucks wearing body armor?

 

[lobelsteve]

Multiple people have suggested that his pain is from the facet(s). Given the fact that he is in his early 30's (leaving out all the rest of the information and the HIZ on MRI which also point to the disc as the pain generator), I believe that facet is unlikely because of his young age, although an injury at a very young age could set him up for arthritis at an earlier age.

When do arthritic changes begin in the facets in a 'normal' person versus someone who has been in the military, jumping out of planes and off trucks wearing body armor?

When the MBB according to strict ISIS guidelines says so.

 

[mille125]

Multiple people have suggested that his pain is from the facet(s). Given the fact that he is in his early 30's (leaving out all the rest of the information and the HIZ on MRI which also point to the disc as the pain generator), I believe that facet is unlikely because of his young age, although an injury at a very young age could set him up for arthritis at an earlier age.

When do arthritic changes begin in the facets in a 'normal' person versus someone who has been in the military, jumping out of planes and off trucks wearing body armor?

remember he is not a "normal" person...he has put his spine through hell....

 

[mille125]

When the MBB according to strict ISIS guidelines says so.

It is a guideline. It is not the holy grail. Some exceptions exist.

 

[epidural man]

I do not have this patient in front of me and I am not looking at the MRI's myself but this really sounds like facet mediated pain to me. I would consider medial branch blocks with eventual RF if he responds.

Regardless of how strong my suspicion is for discogenic pain, I always try to rule out posterior elements first.

I think that is what I scheduled for this gentlemen - Dx MBB's.

We will see how it goes.

 

[mille125]

Regardless of how strong my suspicion is for discogenic pain, I always try to rule out posterior elements first.

I think that is what I scheduled for this gentlemen - Dx MBB's.

We will see how it goes.

let us know............