Discogenic lbp

[Taus]

Stable weakness I manage. Progressive weakness goes to surgery.

Depends on balance of weakness duration, severity and where (ie functional loss of dominant hand in a worker vs quad in sedentary). Been something I’ve gotten more comfortable with the shades of grey over the years. If you sit on even stable weakness for too long, even mild weakness, it can be game over for nerve recovery. I’ll go 3-6 months max, generally max 3, without surgical consult on stable, mild weakness (>=4/5) , on average, but shorter in certain situations as above. Patients can refuse surgical consult but must clearly understand that the weakness may not recover and I document as such. This is much more challenging to help patients decide when there is minimal pain. Severe radicular pain with compressive pathology, refractory to PT, meds, shots.... that’s easy with or without weakness.... goes to surgeon.


Severe weakness or progressive goes to surgeon now.

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[Ducttape]

If there is neurological deficit as pronounced as weakness, I refer to surgery and depending on the situation typically schedule an epidural. If they need advice on whether to proceed with surgery when they return I tell them they may want to try one or two epidurals (if we haven't already done one) and give it a little time to see what happens before jumping the gun. That way I'm providing access to resources but I'm also providing my own treatment and giving some experienced reasonable medical advice, which is what they came seeking. That's what I would want done for me.

Epidurals “cure” motor weakness?

 

[lobelsteve]

Epidurals “cure” motor weakness?

Weaness can be caused by pain. Your exam canot know the difference.

 

[pmrmd]

Epidurals “cure” motor weakness?

On recheck after injection strength is usually improved, so yes. You improve nerve function if you stop the inflammatory process about the epineurium.

 

[DODOCSS]

On recheck after injection strength is usually improved, so yes. You improve nerve function if you stop the inflammatory process about the epineurium.

wrong

you improve the pain

 

[pmrmd]

wrong

you improve the pain

Wrong. I've seen many people weak with complaint of paresthesia only with improved exam after injection. Pain isn't always part of the equation.

 

[SommeRiver]

Depends on balance of weakness duration, severity and where (ie functional loss of dominant hand in a worker vs quad in sedentary). Been something I’ve gotten more comfortable with the shades of grey over the years. If you sit on even stable weakness for too long, even mild weakness, it can be game over for nerve recovery. I’ll go 3-6 months max, generally max 3, without surgical consult on stable, mild weakness (>=4/5) , on average, but shorter in certain situations as above. Patients can refuse surgical consult but must clearly understand that the weakness may not recover and I document as such. This is much more challenging to help patients decide when there is minimal pain. Severe radicular pain with compressive pathology, refractory to PT, meds, shots.... that’s easy with or without weakness.... goes to surgeon.


Severe weakness or progressive goes to surgeon now.

There are many nuances to managing weakness.

 

[Ducttape]

Doing epidural for patients with pain and weakness I agree with.

Epidural for weakness only I disagree with.

 

[SSdoc33]

Depends on balance of weakness duration, severity and where (ie functional loss of dominant hand in a worker vs quad in sedentary). Been something I’ve gotten more comfortable with the shades of grey over the years. If you sit on even stable weakness for too long, even mild weakness, it can be game over for nerve recovery. I’ll go 3-6 months max, generally max 3, without surgical consult on stable, mild weakness (>=4/5) , on average, but shorter in certain situations as above. Patients can refuse surgical consult but must clearly understand that the weakness may not recover and I document as such. This is much more challenging to help patients decide when there is minimal pain. Severe radicular pain with compressive pathology, refractory to PT, meds, shots.... that’s easy with or without weakness.... goes to surgeon.


Severe weakness or progressive goes to surgeon now.

reference please?

if you have a disc herniation causing motor weakness, do you have any literature supporting surgery for strength recovery? if there is weakness, the damage is done, whether you operate or not. recovery will or wont happen regardless of surgery.

if there is expanding lesion (like a cyst) or progressive myelopathy, then yes, decompressing the nerve will aid in surgical recovery. otherwise, im not sure your bolded statement is accurate.

 

[cbest]

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[jonnylingo]

reference please?

if you have a disc herniation causing motor weakness, do you have any literature supporting surgery for strength recovery? if there is weakness, the damage is done, whether you operate or not. recovery will or wont happen regardless of surgery.

if there is expanding lesion (like a cyst) or progressive myelopathy, then yes, decompressing the nerve will aid in surgical recovery. otherwise, im not sure your bolded statement is accurate.

I wouldn't say the damage is necessarily done. If weakness is acute, it may be conduction block. Peroneal neuropathy, acute radic, wrist drop -- most recover nicely if simply conduction block or demyelination.

 

[Taus]

if any of you personally had a foot drop, let’s say 4-/5 on manual testing of tib ant and the pain from the large compressive L4-5 paracentral hnp was manageable with an NSAID...... how long are you waiting before getting a microdiscectomy?

How about if it was your dominant hand from cervical hnp?

 

[SSdoc33]

if any of you personally had a foot drop, let’s say 4-/5 on manual testing of tib ant and the pain from the large compressive L4-5 paracentral hnp was manageable with an NSAID...... how long are you waiting before getting a microdiscectomy?

How about if it was your dominant hand from cervical hnp?

fair enough.

i think intuitively, we would want to get a surgery and "fix" the problem, but the reality is that your tib ant will come back or wont come back at the same rate whether you have a surgery or not

 

[Timeoutofmind]

if any of you personally had a foot drop, let’s say 4-/5 on manual testing of tib ant and the pain from the large compressive L4-5 paracentral hnp was manageable with an NSAID...... how long are you waiting before getting a microdiscectomy?

How about if it was your dominant hand from cervical hnp?

The spine surgeon I share an office with told me when he was in his spine fellowship, the fellowship director's wife had an acute radic with foot drop. The fellowship director did not want her operated on immediately, but wanted to watch and wait.

I thought that was an interesting antecdote.

 

[Timeoutofmind]

fair enough.

i think intuitively, we would want to get a surgery and "fix" the problem, but the reality is that your tib ant will come back or wont come back at the same rate whether you have a surgery or not

what evidence do you have for that statement?

 

[SSdoc33]

what evidence do you have for that statement?

cbest's article is one piece
https://www.thespinejournalonline.com/article/S1529-9430(13)01377-6/abstract

this is another one:
https://www.sciencedirect.com/science/article/pii/S1529943013015830

 

[Timeoutofmind]

Neat

cbest's article is one piece
https://www.thespinejournalonline.com/article/S1529-9430(13)01377-6/abstract

this is another one:
https://www.sciencedirect.com/science/article/pii/S1529943013015830

Thanks so much!