Pictures of the Week

[PMR 4 MSK]

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.

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[lobelsteve]

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

You tell me.

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

 

[PMR 4 MSK]

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?

 

[lobelsteve]

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

Needs a new hip or a wheelchair.

 

[lobelsteve]

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

 

[dc2md]

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

how much pain did he/she have?

 

[lobelsteve]

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.

 

[lobelsteve]

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

 

[drusso]

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.

 

[mdvol]

I thought you took the jpeg and morphed it paintshop!

 

[onewithpain]

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.

 

[lobelsteve]

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/phot...authkey=Gv1sRgCIT6gJXzqNT2gQE&feat=directlink


http://picasaweb.google.com/lh/phot...authkey=Gv1sRgCIT6gJXzqNT2gQE&feat=directlink

 

[PMR 4 MSK]

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/phot...authkey=Gv1sRgCIT6gJXzqNT2gQE&feat=directlink


http://picasaweb.google.com/lh/phot...authkey=Gv1sRgCIT6gJXzqNT2gQE&feat=directlink

Holy crap!

When is the surgery?

 

[lobelsteve]

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

 

[Mister Mxyzptlk]

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

 

[lobelsteve]

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.

 

[nvrsumr]

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.

 

[Mister Mxyzptlk]

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!

 

[nvrsumr]

thanks!

 

[lobelsteve]

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.

 

[PMR 4 MSK]

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.

 

[lobelsteve]

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

 

[lobelsteve]

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.

 

[lobelsteve]

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.

[/IMG]

 

[nleeds24]

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/phot...authkey=Gv1sRgCIT6gJXzqNT2gQE&feat=directlink


http://picasaweb.google.com/lh/phot...authkey=Gv1sRgCIT6gJXzqNT2gQE&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?

 

[lobelsteve]

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.

 

[nleeds24]

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?

 

[lobelsteve]

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.

 

[SSdoc33]

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?

 

[lobelsteve]

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.

 

[PMR 4 MSK]

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.

 

[SSdoc33]

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.....

 

[drusso]

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??

 

[lobelsteve]

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

 

[lobelsteve]

 

[drusso]

Positive mushroom sign...nice...

 

[PMR 4 MSK]

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

 

[SSdoc33]

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)?

 

[PMR 4 MSK]

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.

 

[dc2md]

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 what approach are you using?

 

[lobelsteve]

30 seconds 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.

 

[SSdoc33]

30 seconds 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.

 

[lobelsteve]

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.

 

[dc2md]

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??

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

What is DLS?

 

[PMR 4 MSK]

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

 

[lobelsteve]

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.

 

[lobelsteve]

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

 

[SSdoc33]

where's the atlas?

 

[lobelsteve]

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.

 

[SSdoc33]

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?