Each week we hope to add pictures to this thread for discussion. Please feel free to add pictures from your practice. Images need to be resized to 400 x 400. If you need help with uploading attachments, please send me a private message or e-mail us at painrounds@gmail.com. Thank you.


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During a transforaminal blunt needle block, the first picture depicts the vascular pattern obtained which clearly fills Batsons plexus and the contralateral extraspinal veins. The second picture is one second later. The third is with proper repositioning of the needle and the neurogram obtained in real time injection. Click on the pictures to enlarge.

Lack of knowledge regarding the course of the cervical medial branches can lead to misplaced RF needles and a failed procedure. In the case below, one lesion was created at each cervical lateral articular pillar. Unfortunately, the RF needle missed the medial branches as demonstrated in the right panel. It is important to understand the cervical medial branch anatomy before attempting RF. The anatomy may be viewed in the ISIS Guidelines (http://www.algosresearch.org/Education/ISISGuidelines/AbridgedGuidelines.html) section of this website. Click on the pictures to enlarge.

Selective nerve root blocks are so called due to the limited volume of anesthetic deposited into the neuroforamen with tracking to that single segment of the nerve in the cervical spine, or in the lumbar spine to the level of the disc herniation. Small sequential volumes of contrast are injected with fluoroscopy used in-between injections through a stationary needle. The volume required to achieve the goal of being selective is noted, then the same volume of local anesthetic is applied through the needle. Unfortunately, the physician below simply blasted the area with contrast with one injection thereby obliterating the volume data needed for selectivity of the local anesthetic application. The same volume of local anesthetic injected as seen below would eradicate any selectivity and potentially cause a false positive block due to local anesthetic spread over several nerves.

This unfortunate patient developed an enlarged pump pocket with intrathecal pump freely rotating each day after the fascial stitches ruptured. She came into my practice after this had been occurring for over a year and complained it was increasingly difficult to fill her Codman pump because of the rotation. Also there was a significant edema and fluid collection prior to each refill. For the past year the fluid had been drained (usually 100-150cc) in order to fill the pump. On our evaluation, the patient did indeed have a rotating pump and had 100cc non-colored clear fluid collecting under the skin. Elective surgery was undertaken to fix the pump to the fascia and the picture below was encountered. The catheter had over 30 loops in it due to the repetitive rotations of the pump and a significant amount of clear fluid was drained from around the pump. The catheter was also frayed and slighly split near the metal catheter connector. The Flex tip portion was trimmed, the catheter from the pump was trimmed, and a new catheter connector was used. Interestingly it was not possible to disconnect the Flex tip catheter from the catheter connector even using hemostats (frozen screw threads). It was decided the fluid collection had been a CSF hygroma from continuous leakage from the slight split in the catheter. The pump was sutured to the fascia with size 0 Ethibond stiches, the pump pocket imbricated, and closed. She had no more fluid collections in the future and the pump has remained fixed onto the fascia. Contributed by AlgosDoc (http://67.43.153.76/member.php?find=lastposter&t=198455).

algos,

nice case

did you infer a CSF hygroma since the catheter slit was distal to all the knots...implying the only fluid that could leak would be CSF? or did you test it, e.g for Beta Transferrin or mix it with pentobarbital (intra-operatively)


..we had a similar problem with the medtronic pump, but ours developed in a pump that had been fine for over 2 years, but then developed over the course of 2-3 follow-up visits......curiously, records showed that the pump refill went fine on the first visit...but by the second visit, some fluid had accumulated and the pump was very hypermobile; we were obligated to exclude a CSF hygroma, but I doubted it on clinical grounds...the patient had no neurological signs...e.g. spont intracranial hypotension or subdural hemmorhage..head CT was negative

also, the rate of CSF production (>500cc/day) accumulation of fluid would have been substantially higher than our bedside aspirate (about aobut 30-40cc) and the fluid analysis was negative for beta transferrin.. we were able to successfully refill the pump; notably he reported that his pain relief had deteriorated over the past month

by the third visit the patient's pump had flipped, but we refilled it successfully....he stated that he had increased yawning and GI motility and anxiety over the past few weeks (since the second visit)...not much diaphoresis

we took him to the OR and sure enough the pump and catheter were twisted....but not as tightly as yours...but curiously there were multiple holes in the catheter...this segment was removed and replaced.

I believe that the catheter was punctured during one of the refills...the patient was getting opioids, by default, parenterally rather than intrathecally..however the leaked fluid caused hydrodissection and released the pump and the non-absorbable retaining sutures (prolene)....

the pump then flipped...during the second refill, our 'flipping back' the pump...may have partially twisted the catheter...so that the patient got less parenteral drug (partially sealing off fluid leak into the pocket)...mild withdrawal

hence...even refilling flipped pumps can be hazardous!

I have had a couple of these flipped pumps. They seem to be in obese people, and they report that when they sit on the toilet they can feel the pump flip. I think the rolls of fat turn the pump. Maybe we should put these in the lower abdomen for obese people. Or maybe the buttock - there's lots of room.

Cervical intra-articular facet injections may be useful if there is insufficient clinical grounds (based on medial branch block response) to proceed to radiofrequency neurotomy. Using a caudad beam rotation of about 30 degrees to the cervical spine, one can often visualize the joints directly. Because the volume accommodated by the cervical z-joints is very small (often 0.25-0.5ml), mixing local anesthetics with steroids may exceed this volume for injection and can spill over into the epidural space, causing some nerve root anesthesia. Using small judicious volumes of injectate can also avoid overdistension of the joints. Contributed by AlgosDoc (http://forums.studentdoctor.net/member.php?userid=68824).

nice pictures

Hello Epidural,

I found this fascinating MRI of a degenerated disc and thought you might consider it for picture of the week. :laugh:

No, it is not Siamese twins.

Hello Epidural,

I found this fascinating MRI of a degenerated disc and thought you might consider it for picture of the week. :laugh:

No, it is not Siamese twins.

Lots of porn on the internet, but I do not think this qualifies.

I have had a couple of these flipped pumps. They seem to be in obese people, and they report that when they sit on the toilet they can feel the pump flip. I think the rolls of fat turn the pump. Maybe we should put these in the lower abdomen for obese people. Or maybe the buttock - there's lots of room.


As a potential patient and new home for a pump, and being over wieght since injuring my back, why not in the arm pit? or in the rump? Most large people sleep on their sides, so just keep it in the back??

Is there any doc's out there with these devices implanted? I would love to hear from you.

I have been uploading pictures for a while here: http://www.angelfire.com/planet/painkillah/pain_pictures/index.album?i=10

It started as postings of pictures relevant to discussions on the ISIS forum and I have been adding to it intermittently. I figured the denizens of the SDN forum might find them of use too but I'm too lazy to reformat them to the required size.

http://home.comcast.net/~lobelsteve/Stellate-pellets.jpg

How a fluoro guided stellate can still be done blindly.
The patient has LUE CRPS. Not sure how he survived, but he claims to be not dead. Amazing...

Dr. Idrissi (fellow) and I put down some stereo cable. It was my idea to put three across at the same level. The patient had 722.83 as a prior Dx (L4-5 microdiskectomy) and failed all prior conservastive care before being referred for SCS. Axial>radicular pattern.

http://home.comcast.net/~lobelsteve/tripole.jpg

Just wanted to share a misadventure with kyphoplasty! Suprisingly the patient did well afterward and nothing was sticking out of her back!!! Lesson for the day- Twist and wiggle as you withdraw the kypho needle!!! Paravert--> I told you I would post it! hehe

B

7559 7560



So here's a typical case in the Lone Star State. This is how it's supposed to go. This is a 4 level kyphoplasty (myeloma), done under GA. It took me about 90 minutes of operative time, patient felt great the next day. These pictures are from the case that was done immediately prior to the pics posted above by my partner in crime.

So, here's the deal with the case above. We normally use the PMMA cement from Stryker regardless of whether we do kypho or vertebro, but the Kyphon rep wanted us to try his cement. Turns out, that stuff takes several more minutes to harden. In that case, as we were injecting through the left pedicle trocar, we noted some spread of cement into the posterior 1/3 of the vertebral body. We stopped injecting and waited about 4 minutes before we took the trocar out. As you can see, the cement hardened inside the trocar but did not break off at the pedicle like it is supposed to.

Either way, we told the patient about this immediately after the procedure. She did not complain of any focal tenderness at the site. She continues to deny any soft tissue pain in this area. In fact, she is very satisfied with her results. I suppose if it becomes a problem later, we can excise some of the more superficial cement. Unless it becomes a HUGE bother to her, I don't see any need to dissect down to the pedicle to get it all out.

Just wanted to share a misadventure with kyphoplasty! Suprisingly the patient did well afterward and nothing was sticking out of her back!!! Lesson for the day- Twist and wiggle as you withdraw the kypho needle!!! Paravert--> I told you I would post it! hehe

B


I'm jealous...Looks fun...I want to play with cement!

Here are some really good quality fluoro shots from a Gasserian I did a couple of weeks ago. Here's a tip I picked up to help get good lateral images -- look carefully at the teeth and try to align the shadows. I did it in this pic, and the rest of the anatomy is really clear.

I liked it so much, I made it my avitar.

Paravert, thats some BADASS stuff you are doing! Props!

OK, so here's the follow-up to my case that bbruel posted on my "behalf". So, the patient came to clinic two weeks later pissed off because it felt like someone was stabbing her in the back whenever she lied down. We figured that she had about a 3cm spike of hardened PMMA from the subcutaneous fat, extending through the muscles down to the facet joint. No problem.

So here's what I did. First off, I infiltrated the surrounding tissues with 10cc Lido 1% with epi. Then, we used fluoro to "gunbarrel" the spike (oblique.jpg).

Next, I made a 3cm incision parallel to the spine over the distal tip of the cement and blunt dissected down to lumbodorsal fascia. I used a Bovie, going around the cement spike to create a channel around it. Then I used a long, heavy duty clamp to nip the spike off at the base and pulled the thing out (lateral1.jpg).

The defect going down through the muscles to the facet was just big enough to get my index finger into. There was still about 1cm of PMMA remaining, so I nipped the rest out with a small rongeur. You can see that the PMMA goes all the way through the pedicle and stops just at the posterior wall of the facet (lateral2.jpg).

I irrigated the wound and closed in layers. Here are some pictures of the cement. The first has each piece spaced out (PMMA1.jpg), then put back together as best I could to demonstrate total length (PMMA2.jpg).

I think I'll send this as a letter to the editor to show how easy this is to do. Although this problem is fairly rare, it is the most common complication that patients complain about. Good to know I can easily deal with it if it happens again, or if I see somebody else's.

I think this is an old technique which has some utility in extremely tight neuroforamina. Indicated when a standard transforaminal cannot be placed due to osteophytes. Use a 20ga introducer and a 25ga inner needle. Place a very aggresive curve on the 25ga as with discography such that the 25ga veers medially as it emerges from the introducer needle. Note the tip of the 25ga needle at the 6 o'clock position on the pedicle. This particular patient is 400lbs so image quality is not great. 5" 20ga introducer and 8" 25ga epidural needle.

Nothing exciting, just lumbar discogram with contrast extending into a Schmorl's node on AP and lateral views.

I tried a transforaminal lateral recess block as instructed by algosdoc. This patient has a large right paracentral HNP at L4/5. L5 radic symptoms. Previous right L5/S1 TFESI did not show contrast tracking up to level of pathology. I wanted to wash out the inflammatory soup at the HNP so directed a 8" 20ga epimed BLUNT tip needle to make direct contact with the bulging annulus, and injected steroid and saline. Patient tolerated the procedure roughly the same as the prior TFESI and no complications. A/P, Oblique, and Lateral images. On the lateral image you can see the needle tip being deflected dorsally and caudally by the large annulus bulge which was later outlined by contrast.

You can find a better technical writeup at algosdoc's website:
http://algosresearch.org/Techniques/TFLRB.html

What makes you think that a 20 gauge needle can be pushed by HNP?

What makes you think that a 20 gauge needle can be pushed by HNP?

I'm not quite sure I understand your question but I think there are two possible answers. This is a blunt tipped needle, not a quinke. And technically it would be deflected by a bulging annulus, not nucleus.

I thought I'd try an resurrect this sticky. This is a simple case, but hopefully helpful to those in training and a reminder to the rest of us.

Saw this today - x-ray and MRI of L-Spine with a calcified mass in the right lower lumbar soft tissue. On AP it's clearly to the right of the spine, on lateral it is posterior, but the MRI shows that it is SubQ and not in the muscle.

This most likely represents a calcified granuloma from an old TPI - and the needle likely did not get into the muscle, but remained in the adipose tissue.

Caveat - when doing TPI's and IM injections, make sure your needle is long enough, 1.5" won't do it on many Americans these days.

I thought I'd try an resurrect this sticky. This is a simple case, but hopefully helpful to those in training and a reminder to the rest of us.

Saw this today - x-ray and MRI of L-Spine with a calcified mass in the right lower lumbar soft tissue. On AP it's clearly to the right of the spine, on lateral it is posterior, but the MRI shows that it is SubQ and not in the muscle.

This most likely represents a calcified granuloma from an old TPI - and the needle likely did not get into the muscle, but remained in the adipose tissue.

Caveat - when doing TPI's and IM injections, make sure your needle is long enough, 1.5" won't do it on many Americans these days.

also make sure you dont use corticosteroids.....

OK, so here's the follow-up to my case that bbruel posted on my "behalf". So, the patient came to clinic two weeks later pissed off because it felt like someone was stabbing her in the back whenever she lied down. We figured that she had about a 3cm spike of hardened PMMA from the subcutaneous fat, extending through the muscles down to the facet joint. No problem.

So here's what I did. First off, I infiltrated the surrounding tissues with 10cc Lido 1% with epi. Then, we used fluoro to "gunbarrel" the spike (oblique.jpg).

Next, I made a 3cm incision parallel to the spine over the distal tip of the cement and blunt dissected down to lumbodorsal fascia. I used a Bovie, going around the cement spike to create a channel around it. Then I used a long, heavy duty clamp to nip the spike off at the base and pulled the thing out (lateral1.jpg).

The defect going down through the muscles to the facet was just big enough to get my index finger into. There was still about 1cm of PMMA remaining, so I nipped the rest out with a small rongeur. You can see that the PMMA goes all the way through the pedicle and stops just at the posterior wall of the facet (lateral2.jpg).

I irrigated the wound and closed in layers. Here are some pictures of the cement. The first has each piece spaced out (PMMA1.jpg), then put back together as best I could to demonstrate total length (PMMA2.jpg).

I think I'll send this as a letter to the editor to show how easy this is to do. Although this problem is fairly rare, it is the most common complication that patients complain about. Good to know I can easily deal with it if it happens again, or if I see somebody else's.

I broke off a straw on a V-plasty 2 weeks ago. From pedicle to superficial in the paraspinals. I opened with the 11 blade 2cm, recannulated the cement into the V-plasty needle using a mosquito and my finger to guide it in. Took the needle down to the pedicle and applied sheer force inferolaterally. Broke the straw of PMMA at the pedicle and it came out with the needle. Saved it on my desk to remind me to replace the stylet before removing the needle.

http://home.comcast.net/~lobelsteve/missed.jpg

http://home.comcast.net/~lobelsteve/missed2.jpg

Blind epidurals. This was the first of 2. This one didn't work. The second one was a wet tap requiring blood patch. The patient came to me 2 months after these epidurals and was needle phobic. The MRI was obtained 9 months after the 1st ESI.

(If you don't read MRI well, look behind the spinous process at L4 in the subQ fat) In the sag image, I measured 3.3cm from the placement of the prior ESI to the epidural space. Using US to drain out the fluid this afternoon.

http://home.comcast.net/~lobelsteve/missed.jpg

http://home.comcast.net/~lobelsteve/missed2.jpg

Blind epidurals. This was the first of 2. This one didn't work. The second one was a wet tap requiring blood patch. The patient came to me 2 months after these epidurals and was needle phobic. The MRI was obtained 9 months after the 1st ESI.

(If you don't read MRI well, look behind the spinous process at L4 in the subQ fat) In the sag image, I measured 3.3cm from the placement of the prior ESI to the epidural space. Using US to drain out the fluid this afternoon.

This would be a great case report, great visuals.

59 y/o WF with chronic LBP radiating down left leg postrior thigh and calf as aching, burning, stabbing, 8/10. No weakness, no sensory loss, normal DTR at ankle, not tested at knee because of recent arthroscopic knee surgery. MRI x2 with mild L4-5 spondylosis without foraminal or canal stenosis, no disc HNP, bone island at S2. Seen by NS, OSS, and 2 pain clinics before me. Failed ESI's as TF and IL approaches. Had some relief with SIJ/Piri injection but short lived. Multiple opioids tried, multiple neuropathic agents used.

Still no relief. Bone scan for sacral insuff Fx negative. Labs negative.
Sees 3rd opinion NS in another state. He feels weak pulses in the foot, asks for vascular studies.














http://home.comcast.net/~lobelsteve/iliac.jpg



Left main iliac disease mimics L5/S1 radicular pain.

Vascular surgery consulted. Appt in 2 weeks.

The prevalence of occult peripheral arterial disease among patients referred for orthopedic evaluation of leg pain
Joseph Bernstein
Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA; Veterans Affairs Medical Center, Philadelphia, PA, USA

John L Esterhai

Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA; Veterans Affairs Medical Center, Philadelphia, PA, USA

Mitchell Staska

Veterans Affairs Medical Center, Philadelphia, PA, USA

Sally Reinhardt

Veterans Affairs Medical Center, Philadelphia, PA, USA

Marc E Mitchell

Department of Surgery, University of Mississippi, Jackson, MS, USA memitchell@surgery.umsmed.edu

Abstract

Lower extremity peripheral arterial disease (PAD) and musculoskeletal conditions both produce symptoms of leg pain, and may coexist. This study assesses the prevalence of PAD among patients referred to orthopedic surgery for evaluation of lower extremity pain. Fifty consecutive patients aged 50 years or more who had a chief complaint of leg pain, no history of trauma, and no previous history of PAD were studied prospectively. The presence of known risk factors for PAD and classic claudication symptoms was assessed by telephone interview and medical record review. Individuals were then evaluated by measurement of the ankle–brachial index (ABI) using Doppler and pulse volume recordings (PVR). A patient was deemed to have PAD if the ABI was below 0.9 or if the PVR demonstrated significant abnormalities. Occult PAD was detected in 10 of the 50 patients (20%) on the basis of the non-invasive vascular studies. There were no differences between patients with PAD and those without PAD regarding the presence of risk factors for PAD. None of the patients without PAD had claudication, while only one of the 10 patients with PAD had symptoms of classic claudication. In conclusion, 20% of patients referred by primary care providers to the orthopedic surgery clinic for lower extremity pain were discovered to have occult PAD. The majority of these patients did not have claudication. Orthopedic surgeons and primary care providers must maintain an appropriately high index of suspicion for PAD when evaluating patients with non-traumatic lower extremity pain.

Article out 1 month too late.

Just wanted to share a misadventure with kyphoplasty! Suprisingly the patient did well afterward and nothing was sticking out of her back!!! Lesson for the day- Twist and wiggle as you withdraw the kypho needle!!! Paravert--> I told you I would post it! hehe

B




oh........

Here are some really good quality fluoro shots from a Gasserian I did a couple of weeks ago. Here's a tip I picked up to help get good lateral images -- look carefully at the teeth and try to align the shadows. I did it in this pic, and the rest of the anatomy is really clear.

I liked it so much, I made it my avitar.




man, he has skills.......

just now decided to look through this sticky. LOVE it!!! great learning. post more if ya'll got em.

Picture of a Neurotherm Simplicity probe during sacral RFL.

This came up in a discussion of thoracic RF on the ISIS forum. After reviewing thoracic MB anatomy a while back I decided to place my probe over the pedicle shadow. The thoracic MB runs right across the area.

You have to come in at a steep angle so you can place the probe along the dorsal surface of the lamina. I enter over the pedicle shadow of the level below and target the inferior aspect of the pedicle shadow below the joint. Come in paramedian so you can come across the pedicle perpendicular to the nerve. I suppose it would be better if you were parallel to the nerve but then you'd have to enter from the contralateral side. I am just grateful to get a decent burn in this area and this gives me the best shot at catching the nerve.

For example, if I want to burn at T4 I enter at the pedicle shadow of T5. Then I aim for the pedicle shadow of T4. Sometimes you have to enter even more caudally, between the T5 and T6 pedicle shadows. I fish around for a sensory paresthesia and then do a 90 sec 80C burn.

To my surprise, this has worked very well. Here is a picture of two burns with the MBs drawn in. The circles under the tips of the probes are the pedicles and the yellow lines are the nerve pathways.

This came up in a discussion of thoracic RF on the ISIS forum. After reviewing thoracic MB anatomy a while back I decided to place my probe over the pedicle shadow. The thoracic MB runs right across the area.

You have to come in at a steep angle so you can place the probe along the dorsal surface of the lamina. I enter over the pedicle shadow of the level below and target the inferior aspect of the pedicle shadow below the joint. Come in paramedian so you can come across the pedicle perpendicular to the nerve. I suppose it would be better if you were parallel to the nerve but then you'd have to enter from the contralateral side. I am just grateful to get a decent burn in this area and this gives me the best shot at catching the nerve.

For example, if I want to burn at T4 I enter at the pedicle shadow of T5. Then I aim for the pedicle shadow of T4. Sometimes you have to enter even more caudally, between the T5 and T6 pedicle shadows. I fish around for a sensory paresthesia and then do a 90 sec 80C burn.

To my surprise, this has worked very well. Here is a picture of two burns with the MBs drawn in. The circles under the tips of the probes are the pedicles and the yellow lines are the nerve pathways.

The way I have seen it done is to go to the superolateral border of the transverse process - so transverse process/rib junction. I think because of this study?

Acta Neurochir (Wien) (1995) 136:140-144
W. H. Chua1 and N. Bogduk1

(1) Faculty of Medicine and Health Sciences, The University of Newcastle, New South Wales, Australia


Summary Thoracic percutaneous facet denervation has been employed for the treatment of thoracic zygapophysial joint pain. But the surgical anatomy of this procedure has been assumed to be the same as for lumbar medial branch neurotomy. To establish the anatomical basis for thoracic medial branch neurotomy, an anatomical study was undertaken. Using an X40 dissecting microscope, a total of 84 medial branches from 7 sides of 4 embalmed human adult cadavers were studied.
The medial branches of the thoracic dorsal rami were found to assume a reasonably constant course. Upon leaving the intertransverse space, they typically crossed the superolateral corners of the transverse processes and then passed medially and inferiorly across the posterior surfaces of the transverse processes before ramifying into the multifidus muscles. Exceptions to this pattern occurred at mid-thoracic levels (T5–T8). Although the curved course remained essentially the same, the inflection occurred at a point superior to the superolateral corner of the transverse process.
At no time during the dissection were nerves encountered crossing the junctions between the superior articular processes and transverse processes which have been the target points advocated for thoracic facet denervation. Rather, the results of this study indicate that the superolateral corners of the transverse processes are more accurate target points.

Keywords Thoracic nerves - dorsal rami - facet denervation - zygapophysial joint

I do the same as Gorback but come medial to lateral, caudal to rostral- in an effort to get more of the 10mm tip along the nerve as it wraps into the joint.

I have looked at Chua's work and it is one of the only published anatomical articles on thoracic MBB's. There was some 1990's stuff from Stolker or some name similar to that.

Also Stanton-Hicks 2004 article on Thoracic RF procedures:

History, Physics, and Clinical Proceures

RFA of Thoracic Medial Branch Nerves

Anatomy
Unlike the medial branch nerves in the lumbar region that pass
superiorly and medial close to the pedicle before passing under
the mammilo-accessory ligament and climbing up the articular
pillar superior to arborize on the capsule of the zygapophyseal
joint capsule, the thoracic medial branch nerves follow slightly
different courses between T1-T4, T5-T8, and T9-T10. At T11
and T12 each nerve follows a similar course to that in the
lumbar region (Chua and Bogduk,18 Chua,19 and Stolker and
coworkers20). Between T1 and T2, the medial branch nerves
cross the transverse process at the junction of the pedicle and
transverse process, passing medially and downward toward the
posterior surface of the transverse process. Between T5 and T8,
the medial branch nerve passes slightly superior and may not be
in contact with the transverse process. Between T9 and T10, the
nerve, after crossing the transverse process, may pass down
over the posterior surface of the transverse process.

gorback

what is your feedback on SImplicity (from Neurotherm) - i saw the picture you posted.

i have done the scorched earth technique for SI joints and have been unimpressed w/ results, and suspect this may be more of the same but with a cooler/easier/quicker way of doing it.

my neurotherm rep is hoping that i can start doing these - btw, they are quoting $500-600 per probe

your thoughts?

This was my first one and all I can say so far is that the postop pain is phenomenal. I have confirmed this with others. Bill Rittman at Neurotherm thinks it's due to the large burn, but the probe has a very sharp point and I think at least some of the pain might be mechanical trauma from scraping along the periosteum. I have encouraged him to try making a blunt-tipped probe and see if the postop pain is less.

Some of my colleagues have been enthusiastic. There seems to be a significant divide between those who think SI RF is wonderful and others who can't seem to make it work. The literature so far supports the latter conclusion.

do you think it was a patient-selection issue?

how long did you burn for - at what temperature? neurotherm rep was saying 5-8 minutes... i would prefer 2 minutes......

primarily, because the longer you char tissue the higher the incidence of infection....

now, if there was a delicate way of doing this both posteriorly AND anteriorly then it would be REALLY cool - if you don't puncture the rectum or cause massive pelvic floor dysfunction/laxity :(

This woman clearly has severe scoliosis and DJD. She had severe tenderness to palpation directly over the L5 transverse process batwing deformity/pseudoarticulation as confirmed by fluroscopy. I then proceeded to inject this area with a surprisingly nice arthrogram! I'm sure I'm not the first to ever do this, but I've never seen a published case nor a published arthrogram, so here is one for future reference. Might do a case report on it.

I've been evaluating different needles for TFESIs. Today, I tried out a 29 gauge 3.5" Sprotte tip needle from Pajunk, Germany. Very nicely made needle. It was so flimsy it could not penetrate the skin. Used an 18 gauge to do that. However, once through the skin, it "drove" like a F1 car. It pierced the intertransverse ligament without difficulty, which I was surprised about. I'm on the lookout for 31 gauge spinal needles now!

Any suggestions on non-surgical treatment for the bat-wing deformity. I have a patient with fusion on the left, not right, and mild-moderate facet sclerosis at L4-5 and L5-S1. Symptoms more consistent with sacroiliitis. No response to MBB or to SI injection.

Any suggestions on non-surgical treatment for the bat-wing deformity. I have a patient with fusion on the left, not right, and mild-moderate facet sclerosis at L4-5 and L5-S1. Symptoms more consistent with sacroiliitis. No response to MBB or to SI injection.

Did you see my images two posts above? you could try an injection like that and see if it helps.

I placed the needle in a similar position and contrast tracked all the way back to within 5 mm of the L5 vertebral body. Her articulation extended up on to the ilium as if to extend her SI joint and so I injected that extension as well. She got off the table with a smile on her face. We'll see. Thanks.

http://www.box.net/shared/jzkk9xr1x9

http://www.box.net/shared/aj1tibo80h


Anybody see anything funny here?

Patient has h/o RA (C1-2 is intact)

Saw this today. 59 yo with polio as a child.

His lower C-Spine is actually parallel to the ground.

Pt came to see me for lower back back. Just wants an NSAID. Does his own HEP.

Wish I could load original size, hopefully you can enlarge it.

Did this a few weeks ago. 70-ish lady with old smashed proximal humerus. Never fixed. Now with severe shoulder pain (go figure). Sent to me to inject the shoulder joint under fluoro.

To the left is the humerus. There's a huge osteophyte cupping the inverted humeral head. The dye shows the injection is intra-articular. Pt had near 100% pain relief for the first time in several years.

She came in with a bursa injection. I got an Xray.

You tell me.

http://www.box.net/shared/74s2178gr7

She came in with a bursa injection. I got an Xray.

You tell me.

http://www.box.net/shared/74s2178gr7

left prosthesis has eroded quite far cephalad. osteomyelitis?

Acetabular poly cup has fallen inferiomedially.
Much of the bony changes are old sclerosis from prior Fx.

Needs a new hip or a wheelchair.

http://www.box.net/shared/ihxn8kovhm

http://www.box.net/shared/ihxn8kovhm

http://www.box.net/shared/ihxn8kovhm

http://www.box.net/shared/ihxn8kovhm

how much pain did he/she have?

how much pain did he/she have?

I turned of his facets b/l L4-5 MBB. Rt side 100% relief, left side 50-70% relief.

70 y/o who plays in a masters softball league and needs to be ready for playoffs in 2 weeks. Feels that he can give up horseshoes if he can play in the big game. I think he can have both.

He refuses to say he has pain, only discomfort. :)

24 y/o WF seen for state disability eval. On no meds, only a little pain. Sees DC for all her medical needs. No vaccines, no recent PFT's, EKG, labs.
No follow-up with Ortho, PMR, or Neuro.

Has trouble with prolonged standing, walking, sitting. Weighs 76 pounds.

Links provided as I did not want to resize these.

http://www.box.net/shared/0d9129mqo5
http://www.box.net/shared/6ooajihccn

24 y/o WF seen for state disability eval. On no meds, only a little pain. Sees DC for all her medical needs. No vaccines, no recent PFT's, EKG, labs.
No follow-up with Ortho, PMR, or Neuro.

Has trouble with prolonged standing, walking, sitting. Weighs 76 pounds.

Links provided as I did not want to resize these.

http://www.box.net/shared/0d9129mqo5
http://www.box.net/shared/6ooajihccn

Malpractice on the DC's part.

I thought you took the jpeg and morphed it paintshop!

I've seen 3 of these. One I sent to surgery because she had a contralateral L5 radiculopathy that didn't respond to steroids, one that got good relief with injection of the deformity, and one that I did an ablation on. I bent the RFA needle into an arc and laid the active tip perpendicularly across the L5 transverse process. It took 2 placements to cover the trasnverse process and it did lead to relief. I have ablated the innervation to SI joints with this technique. Its less traumatic then the tools that are sold for SI joints, and I find that going down to the S2 foramen is low enough.

Friend of mine. No pain, a little weak in the right hand, numb in the left leg with proprioceptive diminution. Rough one. Frontal and axial cuts.

http://picasaweb.google.com/lh/photo/eks3zbaEItSAViEWB-9Qxw?authkey=Gv1sRgCIT6gJXzqNT2gQE&feat=directlink


http://picasaweb.google.com/lh/photo/Q6HLPwcv8mZczXyidvWsIQ?authkey=Gv1sRgCIT6gJXzqNT2g QE&feat=directlink

Friend of mine. No pain, a little weak in the right hand, numb in the left leg with proprioceptive diminution. Rough one. Frontal and axial cuts.

http://picasaweb.google.com/lh/photo/eks3zbaEItSAViEWB-9Qxw?authkey=Gv1sRgCIT6gJXzqNT2gQE&feat=directlink


http://picasaweb.google.com/lh/photo/Q6HLPwcv8mZczXyidvWsIQ?authkey=Gv1sRgCIT6gJXzqNT2g QE&feat=directlink

Holy crap!

When is the surgery?

Next few weeks. Cute little cord next to that spinebooger.

I have found this technique to be much easier than fishing around on the transverse process. The yellow lines are the path of the MBs.

Larger picture is available here:

http://www.angelfire.com/planet/painkillah/pain_pictures/index.album/thoracic-rf?i=26

I have found this technique to be much easier than fishing around on the transverse process. The yellow lines are the path of the MBs.

Larger picture is available here:

http://www.angelfire.com/planet/painkillah/pain_pictures/index.album/thoracic-rf?i=26

Same here, but I come medial to lateral, inferior to superior to get as parallel as I can. I still believe Dreyfuss's 97 ISIS article that it's a 50/50 deal.

I have found this technique to be much easier than fishing around on the transverse process. The yellow lines are the path of the MBs.

Larger picture is available here:

http://www.angelfire.com/planet/painkillah/pain_pictures/index.album/thoracic-rf?i=26

Gorback,

Do you have a reference-a pdf is even better :) for the course of the thoracic medial branch at that location? All I really know of are the scatter diagrams in the ISIS guidebook. I had some attendings as a fellow do their thoracic MBBs AP to the pedicle which is obviously super easy and probably less risk of pneumothorax. I currently do MBBs and RFLs at TP but your method is easier if I can convince myself the nerve reliably lives there.

Regards.

Chua & Bogduk
The surgical anatomy of thoracic facet denervation
Acta Neurochirurgica September, 1995

Or you could what I did: send the picture to Bogduk and have him send it back with the nerves marked in yellow. That was far easier and less expensive than paying for the article online, and the Australian government paid for the consult!

thanks!

58 y/o. If you look closely T12 is plana. The bone over the pedicular lines extends in to the paraspinals. T12 is also retropulsed taking up more than half the canal. She walks without a limp.

No aberrant behaviors. No facets to inject, no epidural space to inject. Fracture is old, not amenable to plasty, and she refuses surgery 14.

I'd consider SCS trial if the meds fail. SOL.

58 y/o. If you look closely T12 is plana. The bone over the pedicular lines extends in to the paraspinals. T12 is also retropulsed taking up more than half the canal. She walks without a limp.

No aberrant behaviors. No facets to inject, no epidural space to inject. Fracture is old, not amenable to plasty, and she refuses surgery 14.

I'd consider SCS trial if the meds fail. SOL.

Too Many Surgeries Syndrome.

I think many of these patients are still looking for THE CURE (not the band, lol). They've come to realize they won't get it from surgery, and they come to me hoping to find a chemical or needle cure.

Here's where a pain psychologist is the only real hope for long-term.

Ice cream out of the cone. Leg pain. Works full time as a waitress. Getting a little weak in trying to carry trays. Takes tylenol.

http://www.box.net/shared/albykehadr
http://www.box.net/shared/7lzp5dvras

Nice case for a Friday morning. I accidentally started mixing before putting in my trochar. I got into position quickly and safely, but would rather take my sweet time and dawdle while the cement is mixing. It turned out perfectly as the cement was just hard enough to inject.

http://images5a.snapfish.com/232323232%7Ffp63244%3Enu%3D42%3C%3B%3E76%3B%3E259% 3EWSNRCG%3D325542433334%3Anu0mrj

http://images5a.snapfish.com/232323232%7Ffp63244%3Enu%3D42%3C%3B%3E76%3B%3E259% 3EWSNRCG%3D325542433534%3Anu0mrj

Patient with paddle at T10, getting good leg coverage and some in foot. Has developed CRPS in the foot (sudomotor) and needs to overstim the legs to drive the feet to comfort. Sent to me for ideas. I went above the fusion initially and placed an octrode paramedian over the conus on the left and still got more leg than foot (capture proximal S1/2 roots. So I bailed out and went trans-sacral for a trial. Used the lead blank and the long blue cath to advance a lead through scar. Slow and steady and don't tear the dura. This placement is foot more than leg. No groin. No pelvis.

http://i927.photobucket.com/albums/ad112/lobelsteve/turner-l0002.jpg

Friend of mine. No pain, a little weak in the right hand, numb in the left leg with proprioceptive diminution. Rough one. Frontal and axial cuts.

http://picasaweb.google.com/lh/photo/eks3zbaEItSAViEWB-9Qxw?authkey=Gv1sRgCIT6gJXzqNT2gQE&feat=directlink


http://picasaweb.google.com/lh/photo/Q6HLPwcv8mZczXyidvWsIQ?authkey=Gv1sRgCIT6gJXzqNT2g QE&feat=directlink


Hey Doc I had question regarding these images. On the frontal view there is lesion compressing the cord on the right side yet the patient has left leg numbness. Shouldn't he have more RLE symptoms than left? What was the diagnosis made by the surgeon/radiologist?

Hey Doc I had question regarding these images. On the frontal view there is lesion compressing the cord on the right side yet the patient has left leg numbness. Shouldn't he have more RLE symptoms than left? What was the diagnosis made by the surgeon/radiologist?

This is a friend and not a patient. Here is text from an email he sent me:

It's not really funny. The tumor is huge filling more that 3/4 of the canal at the C3-C4 level. He believes it's a meningioma. He's rather amazed that my only complaint has been my "arthritic" hand symptoms which have not increased since they began 10 months ago. He did show me that my right knee reflex is hyper reactive though surprisingly to him my arm is not. By comparison my left leg is slightly numb compared to the right leg: all the way down into the foot. I've know the left shin has been numb for several years and always assumed it had to do with round house kicks from karate and bone on bone blocks I would use.
Meanwhile, I broke my right foot in judo 4 weeks ago. LOL. It's improving now. But, the neurosurgeon broke my heart when he said I have to stop judo NOW. He was pretty impressed I didn't paralyze myself landing on my neck which I've done several times.
Now I have to find someone who's an expert at intra-canal tumors in the cervical spine. >From what I was told, nobody is an expert because they're very rare in that location. Well, I have the opinion from the one neurosurgeon who is chief of neurosurgery at our local hospital and he wants to go in the old way through the back of the spine, opening a large section and hoping to "pop" the tumor out....... I'm trying to get another opinion from someone at AAA Medical Center, a teaching hospital. When I called their neurosurgery department and said cervical canal tumor she gave me a specific physician's name. He does most of the cervical spine work there, so that's kind of heartening to hear. He does do minimally invasive surgery though (something I should have asked the doctor yesterday) I don't know if he would do it in this particular case. I guess I'll find out.
The doctor yesterday feels my hand muscles are somewhat atrophied but is not sure if that might just be normal appearance for me: I really don't know.
I have caught you up to date. Hopefully you are doing well. BTW, I don't see much difference between 4mg and 8mg of zanaflex.

This is a friend and not a patient. Here is text from an email he sent me:

It's not really funny. The tumor is huge filling more that 3/4 of the canal at the C3-C4 level. He believes it's a meningioma. He's rather amazed that my only complaint has been my "arthritic" hand symptoms which have not increased since they began 10 months ago. He did show me that my right knee reflex is hyper reactive though surprisingly to him my arm is not. By comparison my left leg is slightly numb compared to the right leg: all the way down into the foot. I've know the left shin has been numb for several years and always assumed it had to do with round house kicks from karate and bone on bone blocks I would use.
Meanwhile, I broke my right foot in judo 4 weeks ago. LOL. It's improving now. But, the neurosurgeon broke my heart when he said I have to stop judo NOW. He was pretty impressed I didn't paralyze myself landing on my neck which I've done several times.
Now I have to find someone who's an expert at intra-canal tumors in the cervical spine. >From what I was told, nobody is an expert because they're very rare in that location. Well, I have the opinion from the one neurosurgeon who is chief of neurosurgery at our local hospital and he wants to go in the old way through the back of the spine, opening a large section and hoping to "pop" the tumor out....... I'm trying to get another opinion from someone at AAA Medical Center, a teaching hospital. When I called their neurosurgery department and said cervical canal tumor she gave me a specific physician's name. He does most of the cervical spine work there, so that's kind of heartening to hear. He does do minimally invasive surgery though (something I should have asked the doctor yesterday) I don't know if he would do it in this particular case. I guess I'll find out.
The doctor yesterday feels my hand muscles are somewhat atrophied but is not sure if that might just be normal appearance for me: I really don't know.
I have caught you up to date. Hopefully you are doing well. BTW, I don't see much difference between 4mg and 8mg of zanaflex.

Weird case. Can't believe he was active enough to do Judo. Hyperreflexive RLE makes sense although his arms should definitely have more signs I'm tempted to say the LLE numbness is a red herring due to yrs of fighting..what do you think?

35 y/o male seen for disability. Ejected from vehicle 2 yrs ago with posterior dislocation and femoral head Fx. Subsequent MRSA osteomyelitis of the femur and pelvis (look at the rami). I saw him 2 years later for SSI eval. Wound has healed, he is TTWB on the right using a walker.


http://i927.photobucket.com/albums/ad112/lobelsteve/hip-o-1.jpg

[QUOTE=lobelsteve;9516707]35 y/o male seen for disability. Ejected from vehicle 2 yrs ago with posterior dislocation and femoral head Fx. Subsequent MRSA osteomyelitis of the femur and pelvis (look at the rami). I saw him 2 years later for SSI eval. Wound has healed, he is TTWB on the right using a walker.


girdlestone?

[QUOTE=lobelsteve;9516707]35 y/o male seen for disability. Ejected from vehicle 2 yrs ago with posterior dislocation and femoral head Fx. Subsequent MRSA osteomyelitis of the femur and pelvis (look at the rami). I saw him 2 years later for SSI eval. Wound has healed, he is TTWB on the right using a walker.


girdlestone?

Girdlestone? Huh? I'll google it. Lop off the femoral head and let the bone fuse to the acetabulum. I think he will get SSI and then MC will buy him a new hip.

I'm not certain he'd be able to find an orthopod both skilled enough and willing enough to do THA. Those muscles or going to be too short to keep him in place - he'll dislocate the first day he puts weight on it.

right, so girdlestone may be an option. basically you just take out the hip joint and a new pseudojoint is formed. apparently it works better than one would think. i have actually never even seen one, but thats what i hear. maybe some old school othopod could give their 2 cents. you know, the types that wear bow-ties.

i think you need to be 85, a neurologist, or rhematologist to wear a bow-tie. wonder why that is.....

right, so girdlestone may be an option. basically you just take out the hip joint and a new pseudojoint is formed. apparently it works better than one would think. i have actually never even seen one, but thats what i hear. maybe some old school othopod could give their 2 cents. you know, the types that wear bow-ties.

i think you need to be 85, a neurologist, or rhematologist to wear a bow-tie. wonder why that is.....


Orthopods at Mayo (and I'm sure other large academic institutions) do these. Work best for old, greatest generation types who just want to gimp around and don't complain much. Are any of those kind of patients left??

I think this guy is more fix it or disartic it.

http://i927.photobucket.com/albums/ad112/lobelsteve/hipogram2.jpg

Pretty...

Positive mushroom sign...nice...

I do these under US now, since I don't have fluoro in the office. Same amount of time, no radiation.

I do these under US now, since I don't have fluoro in the office. Same amount of time, no radiation.


honestly, i cant imagine how that can be possible. needle in to needle out, i typically do hips in around 30 seconds. it takes me that long to boot up the U/S machine, let alone the deal with the goo. do you mind sharing about how much better it renumerates (percentage-wise)?

honestly, i cant imagine how that can be possible. needle in to needle out, i typically do hips in around 30 seconds. it takes me that long to boot up the U/S machine, let alone the deal with the goo. do you mind sharing about how much better it renumerates (percentage-wise)?

I guess I take more time under fluoro than you.I'm currently getting about 30% more under US than I did with fluoro, but I don't own the machine.

honestly, i cant imagine how that can be possible. needle in to needle out, i typically do hips in around 30 seconds. it takes me that long to boot up the U/S machine, let alone the deal with the goo. do you mind sharing about how much better it renumerates (percentage-wise)?

30 seconds :eek: what approach are you using?

30 seconds :eek: what approach are you using?

15 sec of live should be plenty. Scout and check every 2-3cm of advancement to guide subcapsular onto the femoral head inferolaterally. 3 seconds of live. Last pic for washout.

30 seconds :eek: what approach are you using?


i am in AP flouro view the whole time. start at intertrochanteric line, follow femoral neck down to the head obliquely. not in a hub-view, but whatever. i hear patients tell me that when they had an MR arthrogram, it takes 10 minutes. i dont know how. somebody tell me if im doing something wrong, but the pics always look good.

40 y/o male with 2/10 LBP with no weakness, sensory loss, b/b issue. Pain controlled with OTC Motrin. Mild paresthesia in posterior thigh not below knee. Doing well with DLS as taught in PT. Injections performed in another state were not helpful. Wondering if surgery would help...

Larger pics when I get home from work. Photobucket not working with work firewall.

40 y/o male with 2/10 LBP with no weakness, sensory loss, b/b issue. Pain controlled with OTC Motrin. Mild paresthesia in posterior thigh not below knee. Doing well with DLS as taught in PT. Injections performed in another state were not helpful. Wondering if surgery would help...

No B/B incontinence?? :eek:

As Paris Hilton says, "that's huge!!!"

What is DLS?

Tell him that surgery will turn his 2/10 pain into 7/10. ;)

http://i927.photobucket.com/albums/ad112/lobelsteve/axialL5-S1_28.jpg

A bigger axial cut.

He is functionally limited by a large extruded disc- he cannot ride his mountain bike or workout with intensity. He is set up for a microdiscectomy in Miami in a few weeks with a respected Neurosurgeon. I'd get the surgery done if this were my MRI and if I could not physically do what I wanted to do.

DLS = dynamic lumbar stabilization exercise program.

Procedure suite (super small pics as photobucket blocked at work.
Just had the room redone.

I'll leave it up to you guys to tell me what's wrong....

http://i927.photobucket.com/albums/ad112/lobelsteve/C10001.jpg


http://i927.photobucket.com/albums/ad112/lobelsteve/C10002.jpg

where's the atlas?

where's the atlas?

Patient complained of neck pain so I took it out. It wasn't doing anything anyways. Or it was a congenital abnormality. 29 y/o computer programmer with left levator area referred pain from neck.

i cant imagine there is any stability there. not a great option to fuse his skull to his neck, but id bet a surgeon would say there is a big risk of catastophic injury. what did a surgeon say?

Congenital deforminty and at 27 yrs old with no issues and only left levator pain, no reason to think instability.

He has sneezed several times since birth and not once did his head pop off or his cord get crushed. Now as far as roller coasters and bungee jumping.....

Congenital deforminty and at 27 yrs old with no issues and only left levator pain, no reason to think instability.

He has sneezed several times since birth and not once did his head pop off or his cord get crushed. Now as far as roller coasters and bungee jumping.....

Dont do a spurlings on this dude!

Borderline canal stenosis? Find the CSF dot...

http://www.box.net/shared/mbq2ax1bqz

http://www.box.net/shared/2vb7py0l2e

http://www.box.net/shared/2vb7py0l2e

Borderline canal stenosis? Find the CSF dot...

http://www.box.net/shared/mbq2ax1bqz

http://www.box.net/shared/2vb7py0l2e

http://www.box.net/shared/2vb7py0l2e

And I know several people who would do an IL ESI @ L4-5 there

.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/woundinfection.jpg


Wound infection post-fusion. Closed after 3 months of packing.

Note that there is purulence, not sloughing, not serosanguinous discharge. I have a patient 2 weeks post SCS with serous discharge over the T-spine wound and the 3-0 Vicryl suture at the top margin of the wound ripped. I probed and did not see my 0 Vicryl suture or the wires/anchors. I put in a 2-0 Vicryl through skin to 5mm on each side and loosely approximated the margins. I then steristripped with benzoin to cinch it together and dressed with a tegaderm. 1 week prophylactic ABX due to the probing of a wound in office.
Appreciate comments and criticism on this, and feel free to say Ewww for the pic above.

Just some good old spine.



http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/e46029bf.jpg

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/94cf8027.jpg


Name that tune.

MM? I feel like a hole puncher

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/94cf8027.jpg


Name that tune.

Hint. RA.

She had surgery this week and I'll post films on follow-up.

Hint. RA.

She had surgery this week and I'll post films on follow-up.

Opps.. AA instability or subluxation causing myelopathy leading to fusion?

Another Lobel patient neck. Missing some vertebral bodies, what else is wrong? Think Mt Sinai.



http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/f6275f7a.jpg

those dentures look out of place

those dentures look out of place

That 20k in implants in the mouth, but the 80k in implants at C7 is 4-5 mm anterior to the vertebral body. Causing dysphagia/dysphonia.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/fb98093f.jpg


Sometimes you gotta just call it as it lies.

Why even accept self-pay patients in pain management? They cannot afford anything except cheap opioids. They won't do anything except fill scripts for cheap opioids. And they have a 90% + risk of abusing and/or diverting.

Whenever I get asked if I will see a self-pay, I have the staff tell the patients not only about the office-wide policy of $300 upfront, but also that my services are expensive including MRI, EMG, PT and injections. If that doesn't deter them enough, they are also informed I don't prescribe opioids.

I get about 1-2/year that agree to all this. Around half have deluded themselves into thinking they can talk me into either giving them opioids or doing everything for free.

Why even accept self-pay patients in pain management? They cannot afford anything except cheap opioids. They won't do anything except fill scripts for cheap opioids. And they have a 90% + risk of abusing and/or diverting.

Whenever I get asked if I will see a self-pay, I have the staff tell the patients not only about the office-wide policy of $300 upfront, but also that my services are expensive including MRI, EMG, PT and injections. If that doesn't deter them enough, they are also informed I don't prescribe opioids.

I get about 1-2/year that agree to all this. Around half have deluded themselves into thinking they can talk me into either giving them opioids or doing everything for free.

Either slipped through the cracks or was one of the deluded...

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/winning.jpg

Winning!!!

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/0a29cbd5.jpg


Guess who is going to get discharged for non-compliance.

CLO view

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-1-1.jpg

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-2-1.jpg



70 y/o female with back pain. Had ESI in another state 3 years ago without improvement. Developed severe back pain and right leg weakness/paresthesias on day 1. Made calls to office and not taken seriously. At 2 weeks post ESI the MRI was obtained. New MRI shows the DDD and resolution of this problem. Not going into her canal and she has only axial pain. Might try MBB if she fails PT.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/ck.jpg

Unsure if this was posted earlier. Sent from Ortho for shoulder pain. Wanted opiates for pain. Got MRI- deltoid torn from bone. Came back in 2 weeks with knee pain. MRI with cellulitis, abscess, no osteo. Gets PICC and 4 weeks of IV ABX. Comes in 4 weeks later with new back pain. MRI as above. Back to ID buddy. Probably needs autoimmune workup or to stat playing the lottery.

Probably needs autoimmune workup or to stat playing the lottery.

Or to stop doing IV drugs...

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-3.jpg


78 y/o male with 10 days of back and buttock pain after lifting a 32" TV. Pain is tolerable but severe. Limited from 3 rounds of golf per week 3 weeks ago to 9 holes this week.
No weakness, sensory loss, B/B incontinence, or saddle anesthesia.

No prior LBP or stenosis symptoms. Impending cauda vs might get better.
Surgeon notified just in case.

My 2c: They don't make us men tough like the prior generations.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-4.jpg


81 y/o female referred for LESI. Axial LBP. Has PM so CT done and shows old Fx with 7mm retropulsion at T12. Pain is aching at LS junction and upper buttocks (Type C). Recent fall and Fx of right humeral head.

I got BS as above because falls and little old ladies mean fresh Fx to me. Expected T12 and the humeral head. Report was as follows:


IMPRESSION
1. Marked increased activity about a lower thoracic vertebra and vertebral rib articulation proximal to this area, most likely traumatic, possibly pathologic with associated metastatic disease with the patient's history.
2. Increased activity right humeral head, most likely traumatic, possibly pathologic.
3. Increased activity right anterior rib, left anterior iliac wing, proximal left femur and right femoral neck. These findings are consistent with metastatic disease.


Now I've got to make a couple phone calls. I'm not cut out for just needle monkeying.

Now I've got to make a couple phone calls. I'm not cut out for just needle monkeying.

The last time I had one like this, the guy was dead before I could get the results to him.

http://i927.photobucket.com/albums/ad112/lobelsteve/file-1.jpg

#86 MSContin 15mg. Tried BID for 4 days. Wants to go back to bid short acting.

We keep a log and require all unfilled Rx's and filled Rx's returned to our office or we do not release the next Rx. If a med does not work, bring it in- no appt needed, and we will replace it with new Rx. (Must be current patient and through due diligence policy first). Hardest part is destroying the old meds before we dump them in the sharps. Using hot water and alcohol gel. Bleach worked Ok but too messy.

I need a coffee bean grinder.

My malpractice recommends we do not take pills from patients, as this can be construed as coertion of the patient - forcing them to bring in pills and give them to you in order to get more pills.

Several sources have discussed disposing of pills. Most municipalities would not want them flushed. Many pharmcacists will accept them back for disposal, but some wont.

http://i927.photobucket.com/albums/ad112/lobelsteve/628688a5.jpg

Wait a sec. You mean you can charge for failed screens? I'm going to add $100 per level for bulged disks.

http://i927.photobucket.com/albums/ad112/lobelsteve/0ea653da.jpg

My closest competition. HPI is the procedure note. I'm just behind the times.

looks like someone needs to work on their templates a bit and become more familiar with their Electronic Mistake Record.

http://i927.photobucket.com/albums/ad112/lobelsteve/0ea653da.jpg

My closest competition. HPI is the procedure note. I'm just behind the times.

After you initially read this, I hope you went directly to this doc's clinic and shot him in the head. WTF?

After you initially read this, I hope you went directly to this doc's clinic and shot him in the head. WTF?

sadly, this isnt all that far below the norm from the procedure notes i read....

After you initially read this, I hope you went directly to this doc's clinic and shot him in the head. WTF?

I dictated my opinion that the prior procedures, though reported effective per the patient, were not within the standards of care. CC to the PCP.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-5.jpg


Anyone want to try a TKR on this?

Anyone want to try a TKR on this?

I asked one of our orthos a couple years ago, how do you decide how many screws to put in a plate?

His answer - I count the number of holes and use that many screws. Sometimes more.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-6.jpg

Yes, T7 is not broken, but T6 is subacute and T8-L5 are all broken.

No, I did not put any of that cement in there. Nor will I at T6.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-6.jpg

Yes, T7 is not broken, but T6 is subacute and T8-L5 are all broken.

No, I did not put any of that cement in there. Nor will I at T6.


she doesnt have compression fractures. she just has ginormous discs. yes, i said "discs"

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-8.jpg

Had 2 kyphoplasties today, back to back. FIlled this one in with 7cc.
Went back and looked at the MRI and wondering if I should have taken a Bx. It might be resolving hematoma from the Fx. I don't see other bony "mets", but it was dark on T1, T2, and STIR. Any thoughts?

Had 2 kyphoplasties today, back to back. FIlled this one in with 7cc.
Went back and looked at the MRI and wondering if I should have taken a Bx. It might be resolving hematoma from the Fx. I don't see other bony "mets", but it was dark on T1, T2, and STIR. Any thoughts?

Yeah, what's up with the picture on the right?

Is that scoliosis giving a false impression of critical stenosis L3?
Is that fluid pocket anterior to L2-3, sub ALL, or just an osetophyte?

http://i927.photobucket.com/albums/ad112/lobelsteve/file-3.jpg


http://i927.photobucket.com/albums/ad112/lobelsteve/file-2.jpg




Do you want to fix problem 1 or problem 2 first?

Any advice on fixing what we can fix? No answers from Rinoo allowed. ;)

https://picasaweb.google.com/lh/photo/VbCy83kYk0E1I9hp1SvQ9Ai-heTkO0Im38AGTGPmKWM?feat=directlink

http://i927.photobucket.com/albums/ad112/lobelsteve/file-4.jpg

There's a bit of a femur in there!

How long is that leg?

There's a bit of a femur in there!

How long is that leg?

A pair of condyles and 2 little bone blebs. No joint- no acetabulum.

The stump is real thin, like a lower leg :D .

It's a long AKA looking stump with the completely wrong shape to it.
Looks great for a custom CF socket.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-21.jpg

You dipped your chocolate into my peanut butter.

Ok, you dipped your carcinoid into my pedicle.

In the next few years, your ability to get MRIs will likely get very restricted. Already, most of the private insurance companies in my area are demanding that you try 2 NSAIDs, 6 weeks of PT, and have an x-ray, and still require a peer-to-peer call to get an MRI authorized.

Cases like this one will slip by until the patient is completely hosed. And we will still get blamed. The widow's attorney will claim delay in diagnosis.

Another day in paradise.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-5-1.jpg


http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/file-6-1.jpg

Where do you find these patients? Are you making the initial discovery of the pathology, or does the local oncology group have you on speed dial and hope you can do something for these kids?

I'm not Dexter, but I'm helping people die with less pain and more dignity.
I bet I'm one of the biggest writer's for Fentora and Actiq now that REMS has gone through.

Most get by with 50-100mcg patches and 4 200-400 fentora a day. I have some that require 6 per day and a little Ativan. I feel like a lose the battle every time when they pass. I have needed 10-20% of folks to get hospice involved.

The more folks I see, I realize the more serious pathology I have missed over the years.

I am probably one of the few that reads the local obituary section of the paper. Those were or should have been my patients.

I feel like a lose the battle every time when they pass.
.

I always feel more like I helped them reach death with dignity and comfort with some compassion mixed in to an inevitable situation. I'd get more satisfaction out of my job if I did more cancer care. Probably less pay, but more satisfaction.

I don't see it as a battle to stay alive, but a struggle to get as much quality out of the limited time left.

It's the oncologists who fight the life/death battle. I fight the QOL battle.

http://farm9.staticflickr.com/8297/7999593131_8c67d5c672_b.jpg

I'd rather see the scoobie. link some video from that GoPro.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/kneearthorgram.jpg

12cc Omni240 and 8cc lido 2%, pre CT scan.

Why a CT arthrogram?

Why a CT arthrogram?

Pacemaker limited MRI and knee trauma. Worried about meniscal tear or ACL. I didn't order it.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/Hips_zps230a4770.jpg

His hips are aching a little more? Ya think?

2 new patient this week.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/Spine2/bigdisk_zps9005c273.jpg

She is losing control of b/b, a little weak in right leg, saddle anesthesia just starting. Surgery 6 hours after visit with me.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/Spine2/bigdisk2_zps889cea85.jpg

35 y/o male self referred for 2 weeks back and leg pain. Local competition saw him, ordered MRI, and was setting him up for L4, L5, S1 TFESI at same visit. He walks OK, cannot get onto toes.

58 y/o male slipped through scheduling and on my schedule as uninsured. LBP and left foot pain as ice cold and getting weak. Started 11/12 while lifting a flat screen TV. Seen in ER 4 times since then and Xrays reported as negative. Given 20 Lortab and 20 Flexeril each visit after getting cocktail of IV Dilaudid and Valium at each visit.

Walk in room and he is lying on the table writhing in pain. Possible mild weakness left foot but really appears limited by pain/effort. Intact sensation and reflexes. Pain limits posture and gait.

I go through my discussion on how have little to offer and that I do not Rx opiates for self pay patients. I told him I'm happy to treat otherwise, but care is expensive. I told him his pain is out of proportion to a herniated disc, but with back and left foot pain I'd order an MRI of his back to see what is going on.

He calls my bluff and gets MRI next day. Cash price for non contrast MRI is $365 for this guy.


















He comes back right after MRI and is using a walker. He can walk without it and uses it improperly. He lifts the rolling walker most steps. His gait is antalgic and as soon as he makes it into the exam room he lays on the table as prior. I pull up the MRI.......


























http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/Spine2/CA_zps67f8d546.jpg


Anyone want to see the ER notes and their Xray?

yes would like to see the xrays at least

yes would like to see the xrays at least

Mild anterior spurring. Nothing else mentioned in report. I'll try and capture the image so you can see the T11 Fx from the cancer that ate his spine. I called Onc who saw him that day and admitted him the following morning. He refused direct admit cause no one was home to take care of his dog. CT whole body next day showed massive lung tumor. No cough, malaise, fatigue, weight loss, sweats. No prostate symptoms either (wasn't sure where primary was once I saw the films). Cord compression in mid T-spine on CT of chest. NS and IR on case, need Bx to begin chemo. May need surgery to spare cord. Not good.

http://i927.photobucket.com/albums/ad112/lobelsteve/Spine/Spine2/file_zps230a7949.jpg

This is the film as best I could adjust it to show the upper lumbar and lower thoracic.

Pancoast tumor

Those images settle question of getting MRI prior to injection.

Elderly patient with Lt occipital pain radiating to vertex.

Paraspinous atrophy leading to anterior column collapse and atraumatic compression fx's.

http://www.ncbi.nlm.nih.gov/pubmed/16517392

Paraspinous atrophy leading to anterior column collapse and atraumatic compression fx's.

http://www.ncbi.nlm.nih.gov/pubmed/16517392

Nice open epidural space. Why the atrophy?

Nice open epidural space. Why the atrophy?

Focal myopathy with trophism for the paraspinals.

Focal myopathy with trophism for the paraspinals.

Or repeated RFs...

In theory, that takes out only the mutifidi not the semispinalis. This spine is virgin.

BTW: show me an axial MRI post RF that shows fatty atrophy of this level. It don't happen.

so, you think this is a focal myopathy? and this has led to anterior coloumn degeneration? i suppose thats possible, but it appears to be a guess on both of your conclusions.

i have seen fatty atrophy like that every now and then. RF does make it look a bit worse, but granted, not as severe as above.

so, you think this is a focal myopathy? and this has led to anterior coloumn degeneration? i suppose thats possible, but it appears to be a guess on both of your conclusions.

i have seen fatty atrophy like that every now and then. RF does make it look a bit worse, but granted, not as severe as above.

Have you ever seen an aggressive posterior decompression leading to instability and compression fractures anteriorly? I have, this case is completely akin to that. This fellow lost his rear stays and broke his mast.

65ish year old fellow sent to to me by NS for Vertebro/Kypho. Wife complains that he walks 'leaning back with his hips jutting forward'. Case didn't make sense, the CF's at that time were acute on STIR but there was no antecedant trauma. So I did a big workup - testosterone(nl), EMG, Muscle Bx, dexa(nl)- focal myopathy. Discussed the case and images with Andy Haig & he agreed.

Depending on terminology, SNs are herniations, extrusions, or invaginations of intervertebral disk material into the vertebral body endplates and were first described in 1927 by Schmorl (6). They are usually observed as chronic, asymptomatic entities in approximately one third of the population, although one study reported a 74% incidence (1). They are generally thought to be of no clinical consequence, probably because their inception is assumed to be remote, and they are mentioned only as incidental findings. Reports in the literature of symptomatic acute SNs caused by trauma are sparse, with diagnosis being based on high clinical suspicion after exclusion of other causes (3, 7).



Those do not look like Fx's to me.

Have you ever seen an aggressive posterior decompression leading to instability and compression fractures anteriorly? I have, this case is completely akin to that. This fellow lost his rear stays and broke his mast.

65ish year old fellow sent to to me by NS for Vertebro/Kypho. Wife complains that he walks 'leaning back with his hips jutting forward'. Case didn't make sense, the CF's at that time were acute on STIR but there was no antecedant trauma. So I did a big workup - testosterone(nl), EMG, Muscle Bx, dexa(nl)- focal myopathy. Discussed the case and images with Andy Haig & he agreed.

i understand the biomechanics. muscle biopsy should be diagnostic.

did you put him in a TLSO?

i understand the biomechanics. muscle biopsy should be diagnostic.

did you put him in a TLSO?

No, would need to be an HTLSO. Wasn't ready for it at that time.