Contrast patterns using CLO view

[GottaHaveIt]

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Does anyone have any good images of intrathecal contrast patterns in this view? I feel like I have an appreciation of what epidural flow looks like on CLO but I would like to see what intrathecal spread in this view would look like.

 

[NJPAIN]

Does anyone have any good images of intrathecal contrast patterns in this view? I feel like I have an appreciation of what epidural flow looks like on CLO but I would like to see what intrathecal spread in this view would look like.

Give me a day or two and I will post some. A basic rule is that any column of contrast that does not layer along the VLL is most likely not epidural.

 

[Orin]

Give me a day or two and I will post some. A basic rule is that any column of contrast that does not layer along the VLL is most likely not epidural.

It also clears faster.

 

[Ferrismonk]

And make sure you check AP afterwards.

 

[epidural man]

I think it is tricky. Contrast wrapping around may not give just a interlaminar contrast line.

 

[mid|ine]

Look at density. If the density is peripheral, then it should be epidural spread as you have a thin "cylinder" surrounding the inner cylinder. As you take cuts through that thin outer cylinder it should be darker towards the edges and lighter toward the middle.

If it is intrathecal spread in the lumbar area, the inner cylinder will have contrast and the darkest ("densist") area will be toward the middle

 

[lobelsteve]

L2-3 entry this AM. Thoughts?

 

[BobBarker]

Myelogram

 

[Ducttape]

if equivocal - get a lateral while doing the CLO...

 

[lobelsteve]

Myelogram

Hope so. IT dilaudid 0.25mg, 3cc.
Current regimen is oxy 30 4-5 per day, Fent 100 q3d.
Uncontrolled pain.

 

[Ducttape]

how often do you do pumps?

what is underlying condition?

 

[lobelsteve]

how often do you do pumps?

what is underlying condition?

4 patients. 5th today was trial.

 

[Ducttape]

ugh. gynecomastia.

nothing further to say. pump approved by insurance....

 

[lobelsteve]

ugh. gynecomastia.

nothing further to say. pump approved by insurance....

Guessing it's part of treatment..and lack of T.

Lots of boogers in spine and retroperitoneal.
We are here to help. Hopefully soon enough. Hate the nicest guys with the worst disease.

 

[epidural man]

I need to see more of these intrathecal contrast shots. I’m so damn good, I never get to see them. 🙂

pump placers, mind posting pics?

 

[joshmir]

Steve thanks for posting

The A/P is clear, but wasn’t sure if the second pic was a lateral or CLO?

 

[lobelsteve]

Lateral

 

[lobelsteve]

ugh. gynecomastia.

nothing further to say. pump approved by insurance....

13 days post-implant. Pain worsened, now cannot walk. Patient in ER. Onc consulted and calls me. Can they get an MRI? Is it the pump? I said too late in course for hematoma, unlikely infection. New MRI done. Mind you, last MRI done in last 4 months.

So it is not the pump. How high can I titrate quickly to try and stay ahead of the pain? XRT? Poor guy...

 

[SommeRiver]

L5-S1 ILESI wouldn't help? Can you safely get the needle there without penetrating cancer? Depo and ropivacaine? Obviously increase the pump.

I can't think of ever doing that in residency or fellowship and certainly not in PP.

 

[Ronin1]

I would program a bonus of 20% and increase rate by 20%. Make sure he has a PTM. Boluses as desired. Usually helps. Reassess daily with continued titration

 

[Laryngospasm]

Awful case. I have a similar one. Has pt. Considered hospice? Any local in the solution? Could go higher on the local considering he can’t walk anyways.

 

[BobBarker]

You can put bupivicaine in the pump. Turn it up until the pain is manageable. He isn’t able to walk anyways.

 

[lobelsteve]

Good advice. I told onc i will add bupi and titrate for comfort. He has ptm. Thx.

 

[Ferrismonk]

If he's palliative, go as high as needed, but agree with the addition of bupi.