Did bilateral L3/L4 tfesi on a lady above level of fusion. Has significant scoliosis to the right, along with massive facet and degenerative disc at L3L4 causing severe stenosis. She got 100% relief for day of and day after of her right sided symptoms but then pain worsened. Mostly muscles spasms and tightness in buttock and hip region. Also maybe some new occasional pain at very specific location of medial knee although states that pain has reduced. No pain in between hip and specific area of knee. No new weakness or sensory changes. Was really hard to get into foramen...literally couldn't get into top of foramen because of huge facet encroaching into foramen so had to settle for near middle. Injection with decent epidural flow but maybe more tracing of nerve root than I would have liked. Didn't see "train track" sign. No severe pain during injection just pressure in area of back at into hip with contrast and meds. States she is having bowel frequency. No incontinence or retention but also history of abdominal issues and reported some "incontinence" after her L4/L5 fusion. Hoping I didn't intraneural. Started on baclofen and medrol dose pak. Patient hasn't started medrol dose pak but has been taking baclofen with benefit in regard to spasms and tightness. Almost 3 weeks since injection. Brought her in to discuss just a few days ago and for physical exam which is essentially unchanged. Going to see surgeon for follow up in 2-3 weeks. Any other recs or concerns?
Persistent Pain Post TFESI
- Thread starter Dansk2011
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Now retired 
but every time a spine patient said they were worse after an injection a fresh MRI would show a new corresponding lesion (oftentimes a disc) that had nothing to do with my injection with the sole exception of an iatrogenic infection I caused once. My suggestion is get a new MRI.
but every time a spine patient said they were worse after an injection a fresh MRI would show a new corresponding lesion (oftentimes a disc) that had nothing to do with my injection with the sole exception of an iatrogenic infection I caused once. My suggestion is get a new MRI.She just had an mri about a month ago just prior to the injections. I assume it would be hard to make anything out because of artifact from fusion at L4/L5 as was the case with the most recent one. But definitely thought about it. I'm inclined to believe it's nerve root irritation given how much stenosis she had at that level.Now retired
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Probably facet arthropathy
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ESR/CRP/CBC, MRI with and without.
CYA for hematoma/infection.
CYA for hematoma/infection.
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Chances are it's an iatrogenic radiculitis. If above workup negative, consider L3-4 ILESI
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What? Repeat MRI?
This happens regularly. Do nothing, as there’s no indication for anything other than watchful waiting. You elected to continue the injection despite resistance into a severely stenotic adjacent level. It’s neuritis vs facet capsule and should be ignored.
This happens regularly. Do nothing, as there’s no indication for anything other than watchful waiting. You elected to continue the injection despite resistance into a severely stenotic adjacent level. It’s neuritis vs facet capsule and should be ignored.
I actually had no resistance with the injection. Just reported pressure in the area of her initial/original pain but wasn't overtly uncomfortable for her. Which I attributed to the degree of stenosis at that level. The bowel frequency situation is confusing to me but she also has had bowel issues before apparently which I have documented in my previous note. No weakness no sensory changes. Just increased pain and some new occasional pain at the medial knee which seemed to be better with baclofen. I plan to touch base with her again after the weekend and see how she is doing. If not better will strongly consider further workup.
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I can’t say for sure without images but it sounds like I would have gone TF at L4-5 and with an extra cc of injectate tagged the joint at 3-4 because you know there has to be pain there.
I give away too many freebies maybe.
I give away too many freebies maybe.
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I would not repeat an MRI and get a bunch of labs for mostly muscle spasms and questionable bowel issues. Increased bowel frequency without new incontinence or retention doesn’t mean much to me. Plus, this sounds like my patients who are questionable historians to begin with.
If you’re confident it’s not an infection do a mdp. Especially if it’s a nerve irritation post injection
She had labs on Thursday just before I saw her ordered by pcp. No elevated white count. There was no crp or esr ordered. I ordered a medrol dose pak on Thursday. When I spoke to her on Friday she had not picked it up yet.
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Nothing wrong with injecting that level, and whether you have resistance during the injection portion or the pt reports pressure is not a big deal IMO. Ignore this. It means nothing dude.
Spending thousands of insurance dollars at this point makes no sense IMO. Pain is subjective, and bowel frequency could mean anything.
Update. Spoke to her thus morning. Pain has nearly completely resolved with MDP and baclofen. No bowel issues. Urgency has resolved. Still no weakness or sensory changes. No other issues. Says she's doing much better. Much appreciated for all the input. Great to have varying opinions/perspectives to think over.
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I love all these confident answers. The real answer is you gotta look at the clinical picture and make your best gestalt. I’ve had several of these that I’ve attributed to neuritis and they got better on their own and then I’ve had several that I ordered an updated MRI even though the last one was only a few months old and low and behold they had a new large disc protrusion.
So it’s hard to know sometimes although purely from a % standpoint, most will be neuritis. That’s why a good initial exam and pain description are so important. Compare the f/u exam and pain description closely to the original
So it’s hard to know sometimes although purely from a % standpoint, most will be neuritis. That’s why a good initial exam and pain description are so important. Compare the f/u exam and pain description closely to the original
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Another thought would be on the relative value of dex TFESI in a situation like this. No way in hell will this give relief for over 4 months.
I can understand that some feel it has to be tried, however IPSIS instructors have said and I agree that with a really right foramen, the risk of injury is greater than chance of significant sustained improvement. Safer in these rare cases to inject as the nerve exits the foramen, but not in the foramen.
I can understand that some feel it has to be tried, however IPSIS instructors have said and I agree that with a really right foramen, the risk of injury is greater than chance of significant sustained improvement. Safer in these rare cases to inject as the nerve exits the foramen, but not in the foramen.
