From the Guidelines
For multilevel foraminal narrowing, you should refer to a spine specialist, specifically a neurosurgeon or orthopedic spine surgeon, as they have the expertise to evaluate the severity of the condition and determine the most appropriate treatment approach. These specialists can assess the need for surgical intervention, which may be necessary in cases of progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate medical therapy, as suggested by the 2015 IDSA clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults 1. When evaluating the need for referral, consider the following key points:
- The presence of progressive neurological deficits, such as weakness, numbness, or bladder/bowel dysfunction, which may necessitate urgent surgical evaluation.
- The severity of symptoms and the impact on quality of life, which can guide the decision for conservative management versus surgical intervention.
- The importance of early specialist consultation to prevent chronic nerve compression, which can lead to permanent nerve damage if left untreated. In terms of treatment, conservative management may include physical therapy, anti-inflammatory medications, and possibly epidural steroid injections, while surgical intervention may involve decompression and stabilization procedures to alleviate nerve compression and improve symptoms. Pain management specialists can also play a role in non-surgical pain control options. Ultimately, the decision for referral to a spine specialist should be based on the individual patient's clinical presentation and the potential for improvement with specialist care.
From the Research
Multilevel Foraminal Narrowing Referral Options
- For patients with multilevel foraminal narrowing, referral to a pain management specialist or an interventional pain physician may be considered for procedures such as transforaminal epidural steroid injections 2.
- A spine surgeon or an orthopedic surgeon may also be referred to for surgical evaluation and management of multilevel foraminal narrowing 3.
- Additionally, a physical medicine and rehabilitation (PM&R) physician or a physiatrist may be referred to for non-surgical management and rehabilitation of patients with multilevel foraminal narrowing 4.
Treatment Options
- Transforaminal epidural steroid injections have been shown to be effective in treating radicular pain due to disc herniation, with Level I evidence supporting its use 2.
- Gabapentinoids such as pregabalin and gabapentin may be used to relieve remnant pain after transforaminal epidural steroid injection, with studies suggesting equal effectiveness between the two medications 5, 6.
- Multimodal care, including non-pharmacological therapies, education, and lifestyle changes, may be recommended for patients with lumbar spinal stenosis causing neurogenic claudication 4.
Safety and Efficacy
- Transforaminal epidural steroid injections are generally safe, but may be associated with major neurologic complications related to cord infarct 2.
- Gabapentinoids may have a significant effect on pain scores at 3 months, but may also be associated with higher adverse events 6.
- Epidural steroidal injections are not recommended for patients with lumbar spinal stenosis causing neurogenic claudication, due to high-quality evidence showing no long-term benefits 4.