Interesting case

[Timeoutofmind]

What would you do????

34yo F

BL buttock type pain radiating to lateral thighs stopping at the knees. No neuropathic descriptors.

Has failed SIJ, MBB, ESI with different provider. Saw a surgeon who did not recommend surgery.

Exam pos for BL SIJ TTP and + Fabers. Groin pain with hip ER BL. Low back somewhat diffusely TTP.

H/o large thoracolumbar scoliosis correction procedure with Harrington rods/hooks as a pre-teen
Rads read is Osteitis condensans ilii and hips normal

MRI report low back

FINDINGS: There is a levoscoliosis of the lumbar spine with a rotatory
component. There are rods in the thoracic spine extending to the
thoracolumbar junction on prior x-ray. This results in some metal artifact
on the current exam. Lumbar vertebral body heights appear maintained. There
is minimal narrowing of the L3-4 and L5-S1 discs. There is a hemangioma at
L2 and L3. The conus is obscured by metal artifact.

T12-L1 and L1-2: There is no disc protrusion. No central or neural
foraminal stenosis is seen. Metal artifact somewhat obscures the central
canal.

L2-3: There is no disc protrusion, or central or neural foraminal stenosis.

L3-4: There is no disc protrusion or central or neural foraminal stenosis.
Minimal right facet degenerative change is present.

L4-5: There is no disc protrusion or central or neural foraminal stenosis.
Mild facet degenerative change is present.

L5-S1: There is a small midline annular fissure, without disc protrusion or
central or neural foraminal stenosis. Mild facet degenerative change is
present.


IMPRESSION: Scoliosis, with mild facet degenerative change, as above. There
is a small midline annular fissure at L5-S1.


I did cymbalta, mobic, PT (because she was tight everywhere with poor flexibility and inactive). Seems like she will fail this stuff though as she has done PT in the past.

---

Members don't see this ad.

 

[lobelsteve]

Start her with self-directed exercises for the sacroiliac joint and Steve's magic cream. I would like to see floral pictures from the last sacroiliac joint injection as it may have been in what may not have been in but I repeat the sacroiliac joint injection * 1 to get the anesthetic response. Where to go from there is a toss-up

 

[NOSfan]

SPECT/CT and check ANA & ESR.

 

[Timeoutofmind]

SPECT/CT and check ANA & ESR.

SPECT/CT in order to localize the pain source?

Why do you suspect autoimmune or rheum disease?

 

[NOSfan]

SPECT/CT in order to localize the pain source?

Yes. Understand previous attempts at localization with MBB, but history and exam seems factogenic.

Why do you suspect autoimmune or rheum disease?

Young female with 'ratty' spine and SIJ's.....need to r/o AI processes.

Cheers

 

[Timeoutofmind]

Yes. Understand previous attempts at localization with MBB, but history and exam seems factogenic.

Thnx

I guess my thought process is that who cares if the facets light up? MBB was already negative. I am not going to repeat or RF so it will not change my management right?

 

[NOSfan]

Thnx

I guess my thought process is that who cares if the facets light up? MBB was already negative. I am not going to repeat or RF so it will not change my management right?

If SPECT/CT positive, then:

#1 Gives you a more definitive diagnosis, which has been elusive
#2 Would do FJI as MBB may have been false negative

 

[Orin]

Sounds like an L5/S1 intra-articular or if you have money and time to play, do a MBNB with an RF needle to see if you can get sensory capture that mimics the pain pattern.

She looks to have some oddness at the superiolateral aspects of her sacral ala making me wonder if there is a compartmentalized pseudarthrosis up there that is bothering her. You might see something on a coronal or axial MRI slice.

Also, is that really an a break/developmental thing on the lamina on the left S1?

This though sounds like a great pump case if anyone still does them

 

[TIVAndy]

i smell intrathecal pump if no other treatable rheum diagnosis is made.

 

[cbest]

Any chance this could be some sort of pelvic floor pain?


Sent from my iPhone using Tapatalk

 

[SSdoc33]

dont fry a young woman's abdomen with a CT

 

[lonelobo]

Sounds like an L5/S1 intra-articular or if you have money and time to play, do a MBNB with an RF needle to see if you can get sensory capture that mimics the pain pattern.

She looks to have some oddness at the superiolateral aspects of her sacral ala making me wonder if there is a compartmentalized pseudarthrosis up there that is bothering her. You might see something on a coronal or axial MRI slice.

Also, is that really an a break/developmental thing on the lamina on the left S1?

This though sounds like a great pump case if anyone still does them

Is there such a thing?( Baclofen pumps notwithstanding)

 

[NOSfan]

dont fry a young woman's abdomen with a CT

CT spine = 6 mSv
X-ray spine = 1.5 mSv

Wonder how many plain x-rays she has had?

 

[NOSfan]

i smell intrathecal pump if no other treatable rheum diagnosis is made.

 

[SSdoc33]

CT spine = 6 mSv
X-ray spine = 1.5 mSv

Wonder how many plain x-rays she has had?

do you have a reference for that?


Dangers of CT Scans and X-Rays - Consumer Reports

"Radiation risk 101. CT scans can expose you to asmuch radiation as 200 chest X-rays. CT emits a powerful dose of radiation, in some cases equivalent to about 200 chest X-rays, or the amount most people would be exposed to from natural sources over seven years."

 

[NOSfan]

do you have a reference for that?

Patient Safety - Radiation Dose in X-Ray and CT Exams

 

[Orin]

Is there such a thing?( Baclofen pumps notwithstanding)

Good for the patient or for the provider?

Baclofen is a slam dunk because you can easily and objectively measure the pathology.
Pain is harder because you can't.

Pumps are still all we have in our armamentarium that work well for nociceptive and mixed pain states. They're just challenging to place, manage, provide emergency coverage for, you don't get paid like a stim, and the well is generally poisoned by the train wrecks.

Still, it helps to have options if you're trying to help someone.

 

[SSdoc33]

Patient Safety - Radiation Dose in X-Ray and CT Exams

how is a chest Xray 0.1 mSV, but a "spine" Xray is 1.5?

can somebody who knows a lot about this give me some info? i hate all these units, conversions, etc.

i was under the impression that a CT scan is a buttload of radiation

 

[lonelobo]

Good for the patient or for the provider?

Baclofen is a slam dunk because you can easily and objectively measure the pathology.
Pain is harder because you can't.

Pumps are still all we have in our armamentarium that work well for nociceptive and mixed pain states. They're just challenging to place, manage, provide emergency coverage for, you don't get paid like a stim, and the well is generally poisoned by the train wrecks.

Still, it helps to have options if you're trying to help someone.

Granted I have only been practicing for 15yrs, but in my personal experience I have not see good results with patients I have encountered who have had pumps placed for chronic pain,
Either multiple issues with pumps or they ended up on high doses of oral narcotics as well.
I saw this back 10 to 12 years ago and they were still reimbursed well at that time.

 

[NOSfan]

how is a chest Xray 0.1 mSV, but a "spine" Xray is 1.5?

J Spinal Disord Tech. 2008 Aug;21(6):409-12. doi: 10.1097/BSD.0b013e3181568656.
The radiation exposure associated with cervical and lumbar spine radiographs.

OBJECTIVE:
To calculate the effective radiation doses of routine anteroposterior (AP) and lateral radiographs of the cervical and lumbar spines.

SUMMARY OF BACKGROUND DATA:
Although plain radiographs are generally used as the initial imaging modality for the evaluation of patients with spinal complaints, the radiation that patients receive during these studies has not been well quantified. The effective radiation dose represents a functional measure of exposure that takes into account the amount of radiation delivered and the radiosensitivity of the exposed organs. Consequently, the effective dose is important to consider from a radiation safety perspective.

METHODS:
The imaging practices of our radiology department were reviewed and the effective radiation doses for AP and lateral radiographs of the cervical and lumbar spines were calculated using the following variables: emitted radiation dose, source-to-object distance [SOD], film area, and patient tissue dimensions. Values were obtained from both direct measurements and an examination of the established protocols employed at our institution.

RESULTS:
The effective doses for AP and lateral cervical radiographs were 0.12 and 0.02 mSv, respectively, whereas the corresponding values for AP and lateral lumbar films were much larger (2.20 and 1.50 mSv, respectively). For comparative purposes, a typical chest x-ray results in a radiation dose between 0.06 and 0.25 mSv.

CONCLUSIONS:
In this investigation, cervical spine films gave rise to radiation doses that are similar to those of chest x-rays. However, lumbar spine radiographs generated effective radiation doses that were approximately an order of magnitude greater than these other studies. In both the cervical and lumbar regions, AP views resulted in significantly greater radiation exposure than corresponding lateral images. The effective radiation doses reported here may prove to be valuable for assessing the relative risks and benefits of spine radiographs to establish appropriate guidelines for their use.

 

[Orin]

Granted I have only been practicing for 15yrs, but in my personal experience I have not see good results with patients I have encountered who have had pumps placed for chronic pain,
Either multiple issues with pumps or they ended up on high doses of oral narcotics as well.
I saw this back 10 to 12 years ago and they were still reimbursed well at that time.

Yeah, the old reimbursement paradigm drove high drug doses and weird combo-therapies. The newer paradigm of low dose opioid monotherapy without systemic opioids is a lot easier to manage.

 

[lobelsteve]

Good for the patient or for the provider?

Baclofen is a slam dunk because you can easily and objectively measure the pathology.
Pain is harder because you can't.

Pumps are still all we have in our armamentarium that work well for nociceptive and mixed pain states. They're just challenging to place, manage, provide emergency coverage for, you don't get paid like a stim, and the well is generally poisoned by the train wrecks.

Still, it helps to have options if you're trying to help someone.

Define this further: I have rarely seen a pump work well. Baclofen excluded.

 

[Orin]

Define this further: I have rarely seen a pump work well. Baclofen excluded.

For me, working well is >50% pain relief, better functional status, and on a safe and sustainable regimen.

Efficacy, Safety, and Feasibility of the Morphine Microdose Method in Community-Based Clinics. - PubMed - NCBI

It's not that pain pumps don't work, they're just different. We've all seen the dramatic failures of therapies but there seems to be an added penalty when it's a pain pump. I think most providers just don't use them well since it's a lot more work for less money, and when they did use them, people just weren't following the recommended guidelines. If you save it for "salvage" as the last step after everything has been done, if you have no experience with implanting/managing them, if you just wing it and do dumb stuff, then the therapy will always suck, but it's not because it doesn't work.

 

[DODOCSS]

34yo no malignancy
IT pump, ridiculous

repeat SI/MBB

 

[Ducttape]

Tell me how this “salvage therapy” is any different from putting someone on chronic opioid therapy and throwing the proverbial keys out the window.

(Unless you are only using Ziconotide....)

 

[TIVAndy]

i'm one of very few pain specialist who implants and manages IT pumps in our area. that being said, i've inherited a lot of pump patients dumped from other practitioners. some are crazy people with psych issues, some are people who are grossly mismanaged. i don't have extensive experience like many practitioners here but i do take joy in trouble shooting some of the IT pump issues. there's one question that i like to ask to all my pump patients(De novo or inherited) is "has the pump made a difference in your life and would you make the same decision again?" often i hear them say it absolutely made a difference and they were able to function again (work, reduction in pain.. etc)
i think it's a powerful tool we can offer, if it is managed carefully (starting from patient selection)

 

[drusso]

Tell me how this “salvage therapy” is any different from putting someone on chronic opioid therapy and throwing the proverbial keys out the window.

(Unless you are only using Ziconotide....)

Intrathecal Therapy for Chronic Pain: A Review of Morphine and Ziconotide as Firstline Options
Intrathecal Therapy for Chronic Pain: A Review of Morphine and Ziconotide as Firstline Options | Pain Medicine | Oxford Academic
Published:

22 August 2018

Abstract
Objectives
To evaluate the evidence for morphine and ziconotide as firstline intrathecal (IT) analgesia agents for patients with chronic pain.

Methods
Medline was searched (through July 2017) for “ziconotide” or “morphine” AND “intrathecal” AND “chronic pain,” with results limited to studies in human populations.

Results
The literature supports the use of morphine (based primarily on noncontrolled, prospective, and retrospective studies) and ziconotide (based on randomized controlled trials and prospective observational studies) as first-choice IT therapies. The 2016 Polyanalgesic Consensus Conference (PACC) guidelines recommended both morphine and ziconotide as firstline IT monotherapy for localized and diffuse chronic pain of cancer-related and non–cancer-related etiologies; however, one consensus point emphasized ziconotide use, unless contraindicated, as firstline IT therapy in patients with chronic non–cancer-related pain. Initial IT therapy choice should take into consideration individual patient characteristics (e.g., pain location, response to previous therapies, comorbid medical conditions, psychiatric history). Trialing is recommended to assess medication efficacy and tolerability. For both morphine and ziconotide, the PACC guidelines recommend conservative initial dosing strategies. Due to its narrow therapeutic window, ziconotide requires careful dose titration. Ziconotide is contraindicated in patients with a history of psychosis. IT morphine administration may be associated with serious side effects (e.g., respiratory depression, catheter tip granuloma), require dose increases, and cause dependence over time.

Conclusion
Based on the available evidence, morphine and ziconotide are recommended as firstline IT monotherapy for cancer-related and non–cancer-related pain. The choice of first-in-pump therapy should take into consideration patient characteristics and the advantages and disadvantages of each medication.

 

[Orin]

34yo no malignancy
IT pump, ridiculous

repeat SI/MBB

Tell me how this “salvage therapy” is any different from putting someone on chronic opioid therapy and throwing the proverbial keys out the window.

(Unless you are only using Ziconotide....)

I don't disagree with y'all, but I think we have to remember our guidelines and algorithms don't leave a lot of wriggle room.

For the first, I'm not sure if you don't like cancer patients or IT pumps. Either way, the therapy works for both. It is obviously less risk for you, but I assume you're a selfless physician focused on the best for the patient regardless of your stress levels.

For the second, salvage therapy is dumb. The big thing in pumps vs oral meds is that you are the keys, and if you stop, there isn't anyone else. Be a Doctor and not a provider. Do the right thing and not the easy thing. Set your limits and step up to the "mic" as they say. This is your only place to have control.

Drugs are not the magic here. This isn't a baclofen vs ziconotide vs morphine. This is you as a Doctor saying, beyond this dose your benefit is from systemic euphoria/anxiolysis/etc with significant risk for apnea/death/addiction, and I can't do that. The nice thing about a pump is that there normally isn't another option, and if you do it right, they've bought what you are selling.

 

[DODOCSS]

I don't disagree with y'all, but I think we have to remember our guidelines and algorithms don't leave a lot of wriggle room.

For the first, I'm not sure if you don't like cancer patients or IT pumps. Either way, the therapy works for both. It is obviously less risk for you, but I assume you're a selfless physician focused on the best for the patient regardless of your stress levels.

For the second, salvage therapy is dumb. The big thing in pumps vs oral meds is that you are the keys, and if you stop, there isn't anyone else. Be a Doctor and not a provider. Do the right thing and not the easy thing. Set your limits and step up to the "mic" as they say. This is your only place to have control.

Drugs are not the magic here. This isn't a baclofen vs ziconotide vs morphine. This is you as a Doctor saying, beyond this dose your benefit is from systemic euphoria/anxiolysis/etc with significant risk for apnea/death/addiction, and I can't do that. The nice thing about a pump is that there normally isn't another option, and if you do it right, they've bought what you are selling.

34yo....come on man

 

[Orin]

34yo....come on man

What's your cutoff here? Would you rather she be on 100 OME?

 

[DODOCSS]

What's your cutoff here? Would you rather she be on 100 OME?

500 MED or 0 will have same VAS in 5 years, then weaned and same VAS.

repeat blocks, if no benefit... sometimes less is more... bup or nucyn if anything

 

[Orin]

Sure, do less and see if they suffer. If they don't, then it's fine.

The problem is we often don't see how poorly they're doing and assume it's good enough. You have options, but you have to try some of this "ridiculous" stuff" when your usual stuff doesn't work. If you're so scared of therapy because it's too hard, you won't. Let me know and I am happy to help if I can, but patient's shouldn't suffer because we won't/can't do what we as interventional pain physicians trained so long to do. The patient doesn't know better, but you need to.

There's no magical number here with 100/500/1000 due to the significant variability in opioid sensitivity and even BBB transport of opioids. Here's a nice paper about why some people are just super responders to ITDD.

Super analgesia of intrathecal morphine may be related to ABCB1 (MDR1) gene polymorphism. - PubMed - NCBI

I understand why you want to do less, but lets not hide behind our fears. We're better than that.

 

[DODOCSS]

Sure, do less and see if they suffer. If they don't, then it's fine.

The problem is we often don't see how poorly they're doing and assume it's good enough. You have options, but you have to try some of this "ridiculous" stuff" when your usual stuff doesn't work. If you're so scared of therapy because it's too hard, you won't. Let me know and I am happy to help if I can, but patient's shouldn't suffer because we won't/can't do what we as interventional pain physicians trained so long to do. The patient doesn't know better, but you need to.

There's no magical number here with 100/500/1000 due to the significant variability in opioid sensitivity and even BBB transport of opioids. Here's a nice paper about why some people are just super responders to ITDD.

Super analgesia of intrathecal morphine may be related to ABCB1 (MDR1) gene polymorphism. - PubMed - NCBI

I understand why you want to do less, but lets not hide behind our fears. We're better than that.

There's no magical number here with 100/500/1000 due to the significant variability in opioid sensitivity and even BBB transport of opioids. Here's a nice paper about why some people are just super responders to ITDD.

agree to an extent..although being an artist, exposes one in this day and age

 

[Orin]

Right.

Risk/Benefit, both for the patient and the provider.

Cancer doesn't make that magically easier.

 

[Ducttape]

What's your cutoff here? Would you rather she be on 100 OME?

Therein lies the problem. You can only think in terms of what opioid to give a noncancer patient.

The problem IS the opioid. One has to get out of the 2000s mindset that the answer is opioids.

You know the long term risks. For cancer pain, palliative care, eh okay. Not so for a 34 year old with decades of life left.

Put her down that path and indubitably in 5, maybe 20 years, she will be at one of our offices complaining how she can’t get off the narcs and no one is willing to prescribe the high doses she is on... if she is alive.


And drusso, what is your point of posting a position paper from the supporters of IT pumps? It’s like posting an op ed by hospital admin about whether to use SOS differential...

 

[Orin]

The problem IS the opioid. One has to get out of the 2000s mindset that the answer is opioids.

You know the long term risks.

The problem I am hearing is fear of a drug class. Again, it's not that opioids don't work for pain. They're just not worth the risk, and I would argue in anyone.

Intrathecally at low doses you're cutting down significantly on the risk of abuse, addiction, hyperalgesia, respiratory depression, etc. There's a big difference between 50 mg orally and 0.17 mg intrathecally.

Regardless, I'm a fan of ziconotide. I'm a fan of bupivacaine. I'm a fan of clonidine. The pump is just a platform to deliver medications to the cord.

 

[Ducttape]

The problem I am hearing is fear of a drug class. Again, it's not that opioids don't work for pain. They're just not worth the risk, and I would argue in anyone.

Intrathecally at low doses you're cutting down significantly on the risk of abuse, addiction, hyperalgesia, respiratory depression, etc. There's a big difference between 50 mg orally and 0.17 mg intrathecally.

Regardless, I'm a fan of ziconotide. I'm a fan of bupivacaine. I'm a fan of clonidine. The pump is just a platform to deliver medications to the cord.

I don't think cherry picking and saying "well 0.17 mg IT is great for pain, and it doesn't cause side effects at such a low dose" is a claim you can substantiate.

in light of giving the medication directly supraspinally rather than through the GI system, liver etc. - the modulation of immunosuppression is thought to be a direct spinal effect than a nonspinal (ie systemic) effect.

show me human evidence that giving opioid IT rather than orally clinically significantly reduces the incidence of hyperalgesia, tolerance, respiratory depression. OIC or nausea I agree, but those are not the primary reasons I wouldn't prescribe opioids at all to a 34 year old. (now in the rat model there may be some preliminary evidence that there is less immunosuppression with IT than with oral dosage for acute dosage, not chronic long term usage.)

just bypassing an organ system to directly go to the spine doesn't make the therapy safer, if the mechanism of side effect is at the spinal level. fentanyl is fentanyl, whether you are giving it IV, transdermally, IT, buccal mucosa.

it would be preferable to use buprenorphine in these situations of concern for hyperalgesia, addiction, respiratory depression, if you have to use a drug of an opioid. but I argue that it narrow sighted and got us in to this supposed epidemic because doctors were shortsighted in to not recognizing that opioids are not the right choice.

fwiw, they don't work for chronic pain. we are still waiting for any significant study to show that chronic opioids produce significant improvement in functional status

 

[drusso]

And drusso, what is your point of posting a position paper from the supporters of IT pumps? It’s like posting an op ed by hospital admin about whether to use SOS differential...

I don't manage pumps anymore. It's a solution in search of a problem. But, that doesn't mean I wouldn't if something came along...And, I posted the PACC article because I knew it would irritate you and that is one of the few pleasures I have left...

 

[Victorinox]

Granted I have only been practicing for 15yrs, but in my personal experience I have not see good results with patients I have encountered who have had pumps placed for chronic pain,
Either multiple issues with pumps or they ended up on high doses of oral narcotics as well.
I saw this back 10 to 12 years ago and they were still reimbursed well at that time.

This is an excellent point, I'm in fellowship at the moment and I'm starting to see a theme with intrathecal pump patients - despite large intrathecal doses, they all seem to also be on equally large oral doses, which makes me wonder if it's worth taking on the medicolegal liability of a pump, if you're going end up supplemting with large doses of oral opioids anyway (this goes for both cancer and non-cancer pain)

 

[Ducttape]

I don't manage pumps anymore. It's a solution in search of a problem. But, that doesn't mean I wouldn't if something came along...And, I posted the PACC article because I knew it would irritate you and that is one of the few pleasures I have left...

that's exactly what my wife stated was one of her last remaining pleasures in life!

 

[Orin]

I don't think cherry picking and saying "well 0.17 mg IT is great for pain, and it doesn't cause side effects at such a low dose" is a claim you can substantiate.

in light of giving the medication directly supraspinally rather than through the GI system, liver etc. - the modulation of immunosuppression is thought to be a direct spinal effect than a nonspinal (ie systemic) effect.

show me human evidence that giving opioid IT rather than orally clinically significantly reduces the incidence of hyperalgesia, tolerance, respiratory depression. OIC or nausea I agree, but those are not the primary reasons I wouldn't prescribe opioids at all to a 34 year old. (now in the rat model there may be some preliminary evidence that there is less immunosuppression with IT than with oral dosage for acute dosage, not chronic long term usage.)

There aren't great studies on opioid IT/orally in humans chronically for non-cancer pain.

The best I have is probably this one from 2009, which was cited for the Canadian reccs (Intrathecal Drug Delivery Systems for Noncancer Pain: A Health Technology Assessment), where they show equivalence to superiority over 3 years vs systemic opoids and a residential rehab program.
Multidimensional Outcomes Analysis of Intrathecal, Oral Opioid, and Behavioral-Functional Restoration Therapy for Failed Back Surgery Syndrome: A R... - PubMed - NCBI

This isn't rocket science though. Opioids intrathecally are more potent analgesics than systemic opioids. If your goal was just to get everyone with axial back pain on the lowest effective dosage of opioids, then if you could use 0.17 mg intrathecally instead of 50 mg orally, using the arbitrary 1:300 conversion, you'd be meeting your goal.

You're correct the side effect profile is generally better, except for effects mediated spinally such as some hormonal effects, itching, urinary retention, etc. The immunosuppression effects is generally described to be a direct effect of opioids on immune cells as it can be recapitulated ex vivo/in vitro, but there may be in addition a neurogenic immunomodulation effect, but that has not been shown to be increased by intrathecal opioids. Still, it would stand to reason, if you've got less in your system the effect should be less right, but you could be right.

The pump is just a platform. It works for Baclofen/spasticity. It'll work well for localized pain. If you don't like morphine, use clonidine, ziconotide, bupivacaine, etc. If you don't know what you're doing, phone a friend.

I do prefer bupe for diffuse pain.

I do see value in being able to deliver drugs to the cord in a targeted manner.

This is like arguing about how you don't like using a hammer. A hammer's is a tool. Learn to use it better. I suspect there's a reason this is covered by insurance as compared to magic cells or platelets.

 

[Ducttape]

Your article is a retrospective non blinded study that failed to show any real clinical benefit of IT or opioid tx, in a set of circumstances most likely to show significant bias. If that’s the best one can do, it is very hard to argue that IT treatment for nonmalignant pain is of any value, given inherent risks of the trial and the treatment. Note that complication rate was not part of the study at all. At least it did look 4 years back...

Call it a hammer if you like. But it is almost impossible to justify using Mjolner on a thumbtack - if the root drug is still an opioid - for nonmalignant non palliative care.

 

[Orin]

And therein lies the conundrum, how bad does it hurt doctor? It is a thumbtack or is this the patient's Ragnarok?

So we'll agree to disagree, and hopefully SI injections or MBNB will fix the OP's patient's pain.