What would you do?

[NorthernDoc]

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61 y.o female with chronic L5 radiculopathy.Symptoms mostly at night.discrete sensory and motor deficits. MRI demonstrates a small sequestrated left herniated disc at l4-l5 , in slight contact with L5 nerve root. EMG demonstrates chronic L5 radiculopathy changes . failed ILESI, and left L5 foraminal . Repeated the L5 TFESI with no success. Sent her to a surgeon who turned her down for surgery.

What would be your next step?

would you look for another pain generator? would you try an S-I injection? had a few patients, typical L5 raditing topography, no response to epidurals, did an S-I, pain was gone . Would any of you attempt facet blocks or mbbs? she does complains of low back pain as well....

tried lyrica, tramadol....did not tolerate ....not so keen on getting on the opiate track just yet....

would appreciate any insight

 

[lobelsteve]

61 y.o female with chronic L5 radiculopathy.Symptoms mostly at night.discrete sensory and motor deficits. MRI demonstrates a small sequestrated left herniated disc at l4-l5 , in slight contact with L5 nerve root. EMG demonstrates chronic L5 radiculopathy changes . failed ILESI, and left L5 foraminal . Repeated the L5 TFESI with no success. Sent her to a surgeon who turned her down for surgery.

What would be your next step?

would you look for another pain generator? would you try an S-I injection? had a few patients, typical L5 raditing topography, no response to epidurals, did an S-I, pain was gone . Would any of you attempt facet blocks or mbbs? she does complains of low back pain as well....

tried lyrica, tramadol....did not tolerate ....not so keen on getting on the opiate track just yet....

would appreciate any insight

Imaging, exam, and EMG concordant for left L5 radic.

1. Find a new surgeon.
2. S1 TFESI would have been my 2nd choice ESI
3. Pulse the DRG
4. SCS

3 vs 4 is the fun part of the debate here, I'd ask my more aggressive surgeon to fix it- they've got nothing to lose because if it doesn't help, we are there to pick up the pieces. Surgery is definitely indicated.

We can pick apart the EMG- who did it? what muscles tested? what findings?

 

[mille125]

Imaging, exam, and EMG concordant for left L5 radic.

1. Find a new surgeon.
2. S1 TFESI would have been my 2nd choice ESI
3. Pulse the DRG
4. SCS

3 vs 4 is the fun part of the debate here, I'd ask my more aggressive surgeon to fix it- they've got nothing to lose because if it doesn't help, we are there to pick up the pieces. Surgery is definitely indicated.

We can pick apart the EMG- who did it? what muscles tested? what findings?

I would choose from 1, 2, and 4. Surgery is indicated. Why exactly did the surgeon refuse?

 

[SSdoc33]

the devil is in the details here. how "small" is the sequestered disc. do you look at it on the MRI and say "wow, that needs to come out", or is it tiny.

i have said this before, but if you dont personally know the quality of the electromyographer, then EMG finding are meaningless. for example, i would say that most people would have changes consistent with a chronic radiculopathy on EMG. this is a very soft-call, usually based on non-specific changes. if there is legitimate axonal damage that has happened within the last few years, it will be a clear on EMG. "chronic radiculopathy" can be a very misleading term

not sure why you are injecting the SI joint if you believe this to be a L5 radiculopathy. also, if the patient was pain-free after an SI joint injection, than you definitely dont need a surgeon

 

[Tenesma]

i would talk to the surgeon first and try to understand why he wasn't interested in micro-discectomy...