Myelodysplasia

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gasgasgas

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Pt referred to clinic from neurosurgeon for ESI. 90 yo M w virgin back, h/o CLBP MRI L5/S1 DDD, spondylosis L5 radic and concordant symptoms. States he has had an ESI a year ago from neurosurgeon w relief. Has h/o myelodysplasia with plts from 45K-48K. Wants ESI done. I haven't dealt w myelodysplasia since 3rd year of medical school, so I'm not really sure here. What to do?

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the issue is the platelets. i would not do an ESI if platelets <100K UNLESS patient has ITP - might make an exception for ITP.
 
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If you really want to try and you have it available, thromboelastography will tell you if there is a functional hemostasis problem despite the low platelet count.
 
Do a TEG as noted above and if normal consider, but I would consider TFESI with 25 G, due to smaller guage of needle and hopefully less risk of bleeding. If slightly abnormal, give a 6 pk of plts and do within an hr, again with 25 G. I know its putting yourself out there a little. But unlikely will be able to tolerate gabapentin or other neuropathic meds or opioids or NSAIDS (with all the warnings etc and true risk of renal harm at that age). I hope if I ever make it to 90 and have a hot radic someone will do it.
 
Tell the ns to repeat. If he did it a year ago he can do it again. You guys got 20000 of my tax dollars to test and pretreat this lady before performing a 200 dollar procedure of dubious value.

You failed the core competency of systems based practice.
 
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