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  • Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    The SNRB (selective nerve root block) performed at any level is performed at the specific level of the nerve root compression. Threading a catheter in the spinal canal at any level is challenging and at the cord level is dangerous. There is no real difference between the two levels that you mention in regards to difficulty.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
    exercise453
    Member
    Post count: 53

    Thanks Doc
    A while back I asked you if a cervical epidural, tilted left, would reach the c3-4 level and you wrote no……… “A steroid injection at C7-T1 will not reach the C3-4 level unless the bolus of liquid injected during the ESI or SNRB is very large and most injectionists will not do that for fear of a pressure injury.”

    I have had 2 cervical epidurals in the past. The steroid helped some down low (c7-T1 left herniation) but the C4 irritated root, and possibly C3 root likely never benefited. How would you get those roots medicated.?

    In through the side like a snrb for each or in thru C4 and let the medicine flow up?
    How many levels will a steroid injection reach?
    (of course the pm docs said the neck was a small capsule and the medicine would reach everywhere but I do not think that happened)

    (you may have a typo on the medication page.…..”The maximum dosage is 3000 mg per day”
    The following is from the FDA And Tylenol website and bottle: Warnings Liver warning: This product contains acetaminophen. Severe liver damage may occur if you take more than 4,000mg of acetaminophen. This is from the FDA and Tylenol website and bottle.

    :))))))))))))))))))))))

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    These roots are typically treated by specific selective nerve root blocks. The nerve is injected in the foramen by an approach in the front/side of the neck.

    A selective nerve root block that uses more volume than the foramen can contain will then enter the canal and bathe the central canal and even a level above and below. This would be called a transforaminal epidural steroid injection (TFESI).

    The new FDA findings recommend using tylenol (acetaminophen) at a maximum of 3000mg/day.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
    exercise453
    Member
    Post count: 53

    Dear Doctor,
    One of the questions I have asked is why would someone have an open-midline foraminotomy when they could have the minimally invasive method as you perform it, (other than not knowing better.) Basically you suggested it was just the way a particular surgeon performs the surgery and the result was the important thing. Peyton Manning has easy access to the best doctors and most advanced techniques in the world. Why he had the open-midline, muscle resecting method twice has confused me and continues to do so. My diagnosis is similar to his and the excellent surgeon I saw would use the midline-open procedure. (I do not yet know if he performs the minimally invasive as well) All things being equal I would of course prefer minimally invasive.

    I have come across a case study by the doctor who performed the two foraminotomies on Manning on another major spine website. This patient has a C7-T1 herniation (like mine). The surgical choice was endoscopic foraminotomy/discectomy. So here is Mannings doctor performing the minimally invasive procedure on one patient and the open-midline on Manning). Clearly there is some surgical reason. Why? Why? Why?
    Next another important surgeon comments on the case study and is praising Mannings doctor for performing the muscle sparing, smaller incision procedure. It seems Mannings doctor may have invented the procedure. Yet he does not use it for Manning…twice. WHY???

    The surgeon I saw wrote he would do a foraminotomy and a laminotomy. He writes that there is probably no advantage to try to remove any part of the disc because it is likely quite hard (after 7 years……”I would rather decompress the nerve root posteriorly to an adequate degree to make adequate room for the nerves through the foramen” (He did tell me he would try to remove disc if possible.) He acknowledges the slight subluxation. “At C7-T1 there is a very slight degree of subluxation with C7 slightly forward on T1 and this is slightly more noticeable on his symptomatic left side. The patients C7-T1 level is relatively low set and his sternum is approximately 1 or 2 finger breaths below the C7-T1 disk space”

    Why does Manning have the more invasive proceure???

    Does the laminotopy open the foramen in a different place vs removing ½ the facet as you do???

    Manning did have that herniation for years as I do. Is the open midline approach better for long standing (hardened) discs???

    Is the open midline approach better where there is a (“very slight”)subluxation???

    Would any of this change your approach or would you still do the procedure as you did on the C7-T1 posterior foramintomy video and remove the hardened disc.???

    I do want to ask you to review my scans but I want to resolve every issue first and have decided the surgery is the right thing to do before burdening you with that. Also with degenerative changes at most every level and numerous, directly related injuries it is quite difficult. The injury timeline is important and takes a long time to relay. And I have an insurance issue delaying the SNRB.

    Thank You as always

    exercise453
    Member
    Post count: 53

    Dear Doctor

    I am going to see a new PM doc tomorrow who does SNRB. The left arm pain (C7-T1 herniation) has grown to debilitating in the last few weeks after being second to upper neck pain for years. I am concerned about how much steroid gets on the nerve vs a general cervical epidural. I would pass up the diagnosis right now to quiet it down if the general epidural would get significantly more steroid to the nerve vs the SNRB.

    Would the regular cervical epidural steroid injection performed thru C7-T1 put more, less, or the same amount of steroid on the left C7-T1 nerve root???

    Thanks

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    You have two questions-open vs. “minimally invasive” foraminotomy and SNRB vs. epidural.

    Regarding the first one, you are hung up on the “minimally invasive” term being so superior. You would be wrong. There are times I use the tube retractor which is considered “minimally invasive” and times I do not use it. It depends upon the situation. This is just a retractor and not necessarily superior for retraction. An open procedure may have less retraction than the Metrx tube.

    In fact, I do not use the “minimally invasive” retractors for lumbar fusion as I have devised a technique that requires less tissue retraction and a smaller incision than the two required on either side of the spine for the “minimally invasive”approach with a higher success rate. I call it MISS for “minimal incision spine surgery”.

    As for the cervical spine, the posterior foraminotomy is a good technique but not always the best for nerve root decompression. If there is a spur or “hard disc” compressing the root, the posterior foraminotomy only unroofs the nerve root but does not remove the spur from the front of the foramen. This means the root is still tented but not circumferentially compressed. This is why an ACDF (fusion-see website) is sometimes a better procedure. Peyton Manning is the example here.

    For injection, you would obtain better coverage of the nerve root with a SNRB than you would with an epidural but both should be adequate to cover the root with steroid.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
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