TFESI for huge disc extrusions vs surg ref

[schmee90]

Greetings all,

I had an experience last week with a surgical referral I placed and would love any input in the group. Long story short young healthy guy with a huge disc exrtrusion l4-5 with severe stenosis NF narrowing severe pain X6 months with all the classic radic symptoms and severe pain. Failed PT, NSAIDS, gabapentin. Neuro exam in tact other then some reduced sensation to LT but no weakness and sym reflexes... just severe pain. Talked to patient about options for tx including TFESI which included a discussion on risks/benefits including TFESI doesnt always help and rarely can worsen symptoms. His main concern was getting back to work for finacial reasons and wasnt interested in TFESI and wanted a surgical ref which I placed.

Got a Grumpy call from surgeon a week later about why I sent a patient to him without trying and epidural, in a long winded way called me an idiot for not maximizing not surgical treatment before sending him for a surgical opinion. I'm a fairly new attending but anecdotally have seen some patient do ok, and some patients get worse with TFESI targeting large disc extrusions with severe stenosis but do give patients options for surgical referral when talking to them about treatment options even if their exam is intact. My reasonsing being is that yes most lumbar radics to get better but there is data that early surgery achieves more rapid relief for patient (Prolonged conservative care versus early surgery inpatients with sciatica caused by lumbar disc herniation:two year results of a randomised controlled trial-BMJ) and if patient is like hey im young in severe pain and dont want to try and injection and want surgical intervention that is a reaonsbable thing to consider...AKA not all patients with lumbar radic need an ESI before referred to a surgeon.

Am I out of touch, or being a bit gas lighted by this surgeon...would love the groups thoughts on this. TIA. Would also love to see if there is any data anybody has come across on certrain characteristics of disc hernation vs extrusion that do not do well with TFESI and may consider referring to surgeon earlier. I am unaware of this but would love any insights.

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[Agast]

No self respecting surgeon takes the time to call a pain doctor to do an epidural. They send the patient back with a sticky note “order” with “Nerve block at L4-5” scribbled on it.

 

[GlowInTheDark]

Surgical referral is always in my conversation of treatment plans for young patients, huge discs, radic. Not because I think they need it now and time/ESI won’t help, but because I bet good money the pain will return at some point before they die and they’re going to ultimately require surgery to achieve their goal. A fair proportion have already been to the surgeon before meeting me, but for those who haven’t they have an idea of next steps if I’m not getting them to where they want to be.

Surgeon sounds like a ***** not worthy of further referrals. If they don’t think their job includes explaining treatment options/indications/timing and helping patient make an informed decision then I don’t think we will have a good working relationship.

 

[DrSpine]

That surgeon chewing you out is an idiot. Why? Unlikely for you to refer in the future. Take your referrals elsewhere. So much for his business.

That being said, if the patient prefers a permanent surgical solution with discectomy, send him off to the surgeon and explain it if you got the call. Insurance obstacles aside, there are a select few patients that don't even want to try an Epidural, and want to go straight to surgery after failing conservative treatment, despite me telling them otherwise.

The vast majority will try an epidural. As long as NF isn't occluded, you could do the TFESI. Also, if more space can try interlaminar.

 

[DrSpine]

Surgical referral is always in my conversation of treatment plans for young patients, huge discs, radic. Not because I think they need it now and time/ESI won’t help, but because I bet good money the pain will return at some point before they die and they’re going to ultimately require surgery to achieve their goal. A fair proportion have already been to the surgeon before meeting me, but for those who haven’t they have an idea of next steps if I’m not getting them to where they want to be.

Surgeon sounds like a ***** not worthy of further referrals. If they don’t think their job includes explaining treatment options/indications/timing and helping patient make an informed decision then I don’t think we will have a good working relationship.

This. Younger they are, it's likely the problem will come back at some point. I have that discussion as well.

 

[pmrmd]

If no weakness on exam you should proceed with ESI. The injection will not make the condition worse overall. Surgery sure can.

 

[RoloTomassi]

Atypical reaction. Most surgeons would salivate at that. No harm in trying ESI. I usually order both injection and consult.

 

[Agast]

Corollary to above: if the patient is an engineer, spend half the amount of time and effort on your explanation and refer to a surgeon immediately, you will save yourself a major headache.

 

[callmeanesthesia]

Corollary to above: if the patient is an engineer, spend half the amount of time and effort on your explanation and refer to a surgeon immediately, you will save yourself a major headache.

I tell the engineers that there are no OEM parts for their spine,

 

[schmee90]

If no weakness on exam you should proceed with ESI. The injection will not make the condition worse overall. Surgery sure can.

Thanks all for the replies, it's greatly appreciated but wanted to make sure I am not missing anything. While this is anecdotal, some of the huge disc extrusion with bascially just severe stenosis are some of those patient who get acute worsening of their radicular pain with ESIs.

While I agree no permanent damage acute worsening of symptoms is something I have seen a bit more with the large disc extrusion patients...I have no data to back this up, but just mechanically I feel that there is just very little space and even small volume of meds can worsen the situation.

 

[MD87]

Pain for 6 months, if the extrusion hasn’t resolved yet, not likely going to, and the ESI is probably not working. Wouldn’t be wrong to try it, though. I would have had the same conversation with the patient that you did. Only difference is I would have had less restraint and likely in some capacity told the surgeon off - I would never send to that surgeon again.

 

[MD87]

Corollary to above: if the patient is an engineer, spend half the amount of time and effort on your explanation and refer to a surgeon immediately, you will save yourself a major headache.

Most true thing ever said in this forum. If only you had posted this 5 years ago before I developed all my gray hairs from these patients.

 

[Ducttape]

what may have happened - patient went in to see surgeon, for some reason surgeon did not see eye to eye with the patient.

possibly patient did not like hearing about potential risks, or that the surgeon would not be able to get him to the OR in like a week or two, or recovery might take 2-3 months, or could not guarantee results.

patient then asked "well what can i do NOW because i have to go to a wedding/take a cruise/have a dinner date with this hot date".

surgeon in fit of frustration sends you that note.

i would have done what Rolo said - ordered the TFESI, given the referral at the same time, told the patient 'if no immediate surgery, consider an injection", and when the surgeon calls, told him "i knew this would happen, the injection is approved, my office will call him."

 

[SSdoc33]

there is some belief that is there is a big HNP with extrusion, those are the types that resorb/retract better. if the annulus is intact, like with a smaller or focal protrusion, they stay there forever.

there is no right answer here but let the surgeon blow off some steam and just not refer to him if he is a d$ck.

 

[Taus]

Pain for 6 months, if the extrusion hasn’t resolved yet, not likely going to, and the ESI is probably not working. Wouldn’t be wrong to try it, though. I would have had the same conversation with the patient that you did. Only difference is I would have had less restraint and likely in some capacity told the surgeon off - I would never send to that surgeon again.

This.

If it’s been 6 months without improvement in leg pain, it ain’t gonna happen, just kicking the can down the road.

And f that surgeon.

 

[po_boy]

If there was weakness, would you inject? Depends on severity of weakness? Send straight for surgical consult?

I had an attending in fellowship that would order an EMG on every patient with radicular pain and weakness on exam...

 

[DrSpine]

there is some belief that is there is a big HNP with extrusion, those are the types that resorb/retract better. if the annulus is intact, like with a smaller or focal protrusion, they stay there forever.

there is no right answer here but let the surgeon blow off some steam and just not refer to him if he is a d$ck.

My favorite question from patients. "Will the disc heal or get better?" It's the one question that epitomizes this field at times. There's no clear cut answer. My response, "Well...some say no. Some say yes. Anecdotally, I've seen discs improve on MRI after 1-2 years. The bigger the herniation some say they resorb and retract better, some say smaller unlikely."

 

[Ducttape]

there is consensus opinion, however.

In the absence of reliable evidence relating to the natural history of lumbar disc herniation with radiculopathy, it is the workgroup’s opinion that the majority of patients will improve independent of treatment. Disc herniations will often shrink/regress over time. Many, but not all, papers have demonstrated a clinical improvement with decreased size of disc herniations.

look to one of "our" organizations - Spine.

https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf

also suggested that younger age group and lateral herniations and shorter duration were associated with better prognosis. but dont use these factors to determine whether or not to do a transforaminal.


the only Grade A recommendation is for transforaminal injections for short term pain relief - page 34.

even discectomy was Grade B.

 

[NJPAIN]

This.

If it’s been 6 months without improvement in leg pain, it ain’t gonna happen, just kicking the can down the road.

And f that surgeon.

TOTALLY agree with this. Having said that, many surgeons are trained to believe that there is never a justification to go ahead with surgery without failing 1-3 epidural injections. They also are under the impression that surgery will never be authorized without a failure of epidural injections. As far as I am aware, that is not true for most if not all insurers. This completely ignores the palliative nature of ESI. If disc resorption didn’t occur over 3-6 months, I can’t see how steroids will change anything.

We have quite a well respected neurosurgical service. Along with that they are extremely rigid and dogmatic. Primary care admitted relatively young patient 2 weeks after onset of his third recurrence of L4-5 disc extrusion in 3 years. They threw everything at this guy in an attempt to control his radicular pain in the ED and then failed equally with him as an inpatient. It was an ordeal to get him positioned for an ESI and there was no relief. NS repeatedly refused to CONSIDER surgery for intractable pain in the setting of a big recurrent extruded disc. Because of his medication requirements and lack of ability to safely discharge him, NS had him remain in the hospital, unable to ambulate due to pain for 4 additional weeks before they accepted him as a transfer for surgery.

 

[lobelsteve]

TOTALLY agree with this. Having said that, many surgeons are trained to believe that there is never a justification to go ahead with surgery without failing 1-3 epidural injections. They also are under the impression that surgery will never be authorized without a failure of epidural injections. As far as I am aware, that is not true for most if not all insurers. This completely ignores the palliative nature of ESI. If disc resorption didn’t occur over 3-6 months, I can’t see how steroids will change anything.

We have quite a well respected neurosurgical service. Along with that they are extremely rigid and dogmatic. Primary care admitted relatively young patient 2 weeks after onset of his third recurrence of L4-5 disc extrusion in 3 years. They threw everything at this guy in an attempt to control his radicular pain in the ED and then failed equally with him as an inpatient. It was an ordeal to get him positioned for an ESI and there was no relief. NS repeatedly refused to CONSIDER surgery for intractable pain in the setting of a big recurrent extruded disc. Because of his medication requirements and lack of ability to safely discharge him, NS had him remain in the hospital, unable to ambulate due to pain for 4 additional weeks before they accepted him as a transfer for surgery.

I would sue them for pain and suffering. Failure to treat after consult.

 

[specepic]

No self respecting surgeon takes the time to call a pain doctor to do an epidural. They send the patient back with a sticky note “order” with “Nerve block at L4-5” scribbled on it.

facts

 

[MitchLevi]

For huge HNP with nerve compression, I've had pts tell me they didn't even get 6 hrs of benefit from dexamethasone 7.5-15 mg mixed with either lido 2% or bupi 0.5%.

Do the procedure while you refer for surgery. The shot, while unlikely to result in long-lasting relief may buy them a few days while they wait for the surgeon.

I cannot understand why a surgeon wouldn't be all over this. It makes no sense to me. These are great surgical pts. I don't get it.

Edit - One of my partners. Big HNP left L5-S1. He did NOT want surgery. I did a TFESI with dexamethasone 10mg and 2cc lido 2%. Lasted 2 days.

Repeated it 7 days later with dexamethasone 15mg and bupi 0.5% 3cc and it lasted 3 days.

Surgery completely resolved it. He's working. No issues. Back to nml.

He can't operate on me or my family, but his back is great. His wife is smoking hot and I don't understand that, but I don't understand a lot of things.

 

[GoBeers]

For huge HNP with nerve compression, I've had pts tell me they didn't even get 6 hrs of benefit from dexamethasone 7.5-15 mg mixed with either lido 2% or bupi 0.5%.

Do the procedure while you refer for surgery. The shot, while unlikely to result in long-lasting relief may buy them a few days while they wait for the surgeon.

I cannot understand why a surgeon wouldn't be all over this. It makes no sense to me. These are great surgical pts. I don't get it.

Edit - One of my partners. Big HNP left L5-S1. He did NOT want surgery. I did a TFESI with dexamethasone 10mg and 2cc lido 2%. Lasted 2 days.

Repeated it 7 days later with dexamethasone 15mg and bupi 0.5% 3cc and it lasted 3 days.

Surgery completely resolved it. He's working. No issues. Back to nml.

He can't operate on me or my family, but his back is great. His wife is smoking hot and I don't understand that, but I don't understand a lot of things.

No Tfesi with depo?

 

[MitchLevi]

No Tfesi with depo?

I usually don't, especially not in the case of acute HNP.

All ILESI with Depo.

 

[SSdoc33]

For huge HNP with nerve compression, I've had pts tell me they didn't even get 6 hrs of benefit from dexamethasone 7.5-15 mg mixed with either lido 2% or bupi 0.5%.

Do the procedure while you refer for surgery. The shot, while unlikely to result in long-lasting relief may buy them a few days while they wait for the surgeon.

I cannot understand why a surgeon wouldn't be all over this. It makes no sense to me. These are great surgical pts. I don't get it.

Edit - One of my partners. Big HNP left L5-S1. He did NOT want surgery. I did a TFESI with dexamethasone 10mg and 2cc lido 2%. Lasted 2 days.

Repeated it 7 days later with dexamethasone 15mg and bupi 0.5% 3cc and it lasted 3 days.

Surgery completely resolved it. He's working. No issues. Back to nml.

He can't operate on me or my family, but his back is great. His wife is smoking hot and I don't understand that, but I don't understand a lot of things.

You always see a hot woman with an ugly ugly but rarely the other way around. I wonder why that i$ ???

 

[MitchLevi]

You always see a hot woman with an ugly ugly but rarely the other way around. I wonder why that i$ ???

She's a grandslam on EVERY level. Great mother. Super nice. All the good things.

When I did his two shots, he was unbelievable. Completely made a fool of himself in the very ASC he operates within, and embarrassed himself in front of our staff.

He was a complete wimp.

Totally out of proportion.