L1 fx/coccyx fx..bowel issues?

[Dr. Ice]

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49 year old otherwise healthy asian woman involved in work related trauma at a wearhouse with a fall onto the backside. Developed minimal superior end plate compression dx and slight distal coccyx fracture. Injury sustained in march. Patient complains of significant lumbosacral pain and difficulty with sitting and transitional movements,

Also complains of constant pressure sensation in pelvic area like feeling the need to defecate and sharp discomfort prompting trips to the bathroom but no bowel movements.

MRI reveals healed L1 fracture, no instability, minimal facet dz lower lumbar. No disc herniation.

X-ray of coccyx with small nondisplaed distal coccyx fx.

She is very sensitive to palpation lower lumbar paraspinals and coccyx. Neuro intact.

Doesn’t seem crazy. Hard working Asian immigrant woman, tearful, came in with her whole family.

Can’t figure out the constant pressure sensation and need to defecate.

I ordered a pelvic mri and intra articular facets for her seemingly mechanical lower back pain.

Thoughts?

 

[RoloTomassi]

I'd try GIB

 

[SSdoc33]

Same. But ditch the facets

 

[willabeast]

GI consult?

 

[Dr. Ice]

It’s comp. I told her to seek out GI through private insurance.

Of course I thought of GIB, but the bowel stuff didn’t make sense. Ordered pelvic MRI cause who knows, and at least it will likely get covered by comp as part of constellation of symptoms

Pain is also pretty significant in lower lumbar region, mild facet disease so hence the facets. I know upper lumbar comp fx pain can be referred to lower lumbar as well but the L1 fx is pretty minimal and I don’t do kypho (yet). The neurosurgeons that do it tell me it’s “near impossible” to get approved where Im at. Btw, patient was already seen by neurosurgeon who does kypho but didn’t want to do it in this patient…

 

[painisfear]

Is it possible she had “stunning” of the cauda equina with the injury?

 

[MitchLevi]

Sacrococcygeal CSI with simultaneous ganglion impar block. That is overall top 3 most effective injections I do.

Depo 40-80mg with 2cc ropivacaine 0.5%.

Entire procedure takes 90 seconds with a 1.5" 25g needle.

 

[SSdoc33]

agree that for some reason ganglion impar blocks seem to be home runs in the right patients. patient LOVE them. have a nuch of patients who come twice/year. may fly across country just for the shot. i never advertise it, but these patients find me somehow

wouldnt be surprised if this patient is just really stopped up/constipated from opioids or muscle relaxants, and has trouble pooping b/c it hurts at the coccyx when she tries

 

[Dr. Ice]

agree that for some reason ganglion impar blocks seem to be home runs in the right patients. patient LOVE them. have a nuch of patients who come twice/year. may fly across country just for the shot. i never advertise it, but these patients find me somehow

wouldnt be surprised if this patient is just really stopped up/constipated from opioids or muscle relaxants, and has trouble pooping b/c it hurts at the coccyx when she tries

Patient on no opioids. I checked the database. She can’t tolerate meds. Anyone have any good pics for ganglion impar block?

 

[Taus]

Patient on no opioids. I checked the database. She can’t tolerate meds. Anyone have any good pics for ganglion impar block?

If you’ve ever injected a sacro-coccygeal articulation it’s the same procedure, just going fully through the joint space. I’ll get some off pacs Monday.

Place 22 or 25g needle through the most open looking distal sacral-coccygeal articulation under lateral. Once get ~1-2mm ventral to it (caution is bowel) inject dye under live, see contrast flow along ventral sacral border. With 5cc injectate, inject ~3ml depo/0.25% marcaine here (over impar). Retract needle into joint, inject some more, retract it just dorsal to joint, inject some more.

Then send them over the bridge for me to fix their PMMA deficiency. Seriously….if still lights up on stir, I’d be happy to do the kypho, can do a telehealth consult then have them come to my office for the procedure, telehealth follow up with xray locally beforehand. I’ve done PA comp cases, not sure if NJ auth will differ. PM me and I’ll expedite in within a couple days for this or any other patient who needs kypho. I do 2-3 kypho/week

 

[RoloTomassi]

Patient on no opioids. I checked the database. She can’t tolerate meds. Anyone have any good pics for ganglion impar block?

Here's a couple, injection into SC joint then advance through capsule to GIB.

Remember there's probably bowel not far from needle tip so it should be a very controlled, LOR-like advancement just past the joint, which can require some force to get through.

 

[oneforfighting]

I know you mentioned the L1 fx is healed but agree with making sure it doesn’t still light up on STIR. If it does then kypho. Radiology read is often deficient on these so you have to look yourself. Treat fracture first always as it often has varied pain referral patterns.

Also, there may be instability of the coccyx which you can rule out with dynamic plain films. If MR pelvis negative for sacral insufficiency fracture, could also consider pelvic PT in addition to ganglion impar block.

 

[Dr. Ice]

Thanks guys! Appreciate the input

 

[clubdeac]

Never thought twice about particulate in GIB until I heard a case report presented at a conference I was at in March of an embolic event causing complete paraplegia. Is nothing safe anymore?! Now I guess I’m using dex for GIB too

 

[MitchLevi]

Never thought twice about particulate in GIB until I heard a case report presented at a conference I was at in March of an embolic event causing complete paraplegia. Is nothing safe anymore?! Now I guess I’m using dex for GIB too

Haha. How do you get to para from there??? Terrible.

 

[clubdeac]

Haha. How do you get to para from there??? Terrible.

No freaking idea. Steroid apparently went vascular up to the cord and infarct. Idk

 

[Agast]

She needs colonoscopy with her private insurance. Hardworking Asian female immigrant complaining of severe pain means cancer.

 

[Taus]

If you’ve ever injected a sacro-coccygeal articulation it’s the same procedure, just going fully through the joint space. I’ll get some off pacs Monday.

Place 22 or 25g needle through the most open looking distal sacral-coccygeal articulation under lateral. Once get ~1-2mm ventral to it (caution is bowel) inject dye under live, see contrast flow along ventral sacral border. With 5cc injectate, inject ~3ml depo/0.25% marcaine here (over impar). Retract needle into joint, inject some more, retract it just dorsal to joint, inject some more.

Then send them over the bridge for me to fix their PMMA deficiency. Seriously….if still lights up on stir, I’d be happy to do the kypho, can do a telehealth consult then have them come to my office for the procedure, telehealth follow up with xray locally beforehand. I’ve done PA comp cases, not sure if NJ auth will differ. PM me and I’ll expedite in within a couple days for this or any other patient who needs kypho. I do 2-3 kypho/week

Attached. Needle tip a bit more ventral than I’d like but had firm resistance to injection til this point.

 

[Dr. Ice]

Thank you!