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lobelsteve

lobelsteve

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80% improved with this placement means not likely anterior
 
That's the T6 SCS procedure where you go in at T12-L1 and immediately dive out the same foramen of the level you entered.
 
Strange technique. Don't know how you could end up so far lateral with needle placement in AP unless that's where you're aiming.
 
Yeah but he plays piano for his patients!
 
stsa84 said:
Strange technique. Don't know how you could end up so far lateral with needle placement in AP unless that's where you're aiming.
Click to expand...
That is where he was aiming. It says unilateral paramedian so he accessed both at the same level on the same side. One tuohy ends up being either a little lateral or a little cephalad from the other.

The AP is a little more lateral than I'd typically enter, but we also have no idea how much further he advanced in CLO so it's impossible to know where the final location was. The CLO appears more anterior because of the lateral entry point(the epidural space is V shaped so more lateral entry = deeper LOR).

Either way, both leads are posterior so I fail to see what the issue is.
 
I guess. As long as it gets to the intended location. I do both leads unilateral paramedian, but end up dead midline with both needles, one just inferior to the other. Seems like you'd be fighting to get the lead to start posterior with that lateral of an approach. But yeah, maybe he advanced further in CLO. Maybe just an odd image to have saved.
 
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Baron Samedi said:
That is where he was aiming. It says unilateral paramedian so he accessed both at the same level on the same side. One tuohy ends up being either a little lateral or a little cephalad from the other.

The AP is a little more lateral than I'd typically enter, but we also have no idea how much further he advanced in CLO so it's impossible to know where the final location was. The CLO appears more anterior because of the lateral entry point(the epidural space is V shaped so more lateral entry = deeper LOR).

Either way, both leads are posterior so I fail to see what the issue is.
Click to expand...

I bet his needle isn’t in the space yet on the AP
 
He's just doing procedures and posting random pics of said procedures. This is an easy stim case. Really nothing to post about on LinkedIn.
 
Baron Samedi said:
That is where he was aiming. It says unilateral paramedian so he accessed both at the same level on the same side. One tuohy ends up being either a little lateral or a little cephalad from the other.

The AP is a little more lateral than I'd typically enter, but we also have no idea how much further he advanced in CLO so it's impossible to know where the final location was. The CLO appears more anterior because of the lateral entry point(the epidural space is V shaped so more lateral entry = deeper LOR).

Either way, both leads are posterior so I fail to see what the issue is.
Click to expand...
His final placement may have been posterior but based on CLO, it still seems like he climbed out of the gutter

May also be an odd image he saved
 
1. Angle of entry lateral to medial is poor.
2. Because of 1 his lead goes anterior to contact dura and is in middle of canal on CLO.
3. Lead then courses posteriorly to wind up dorsal to cord.
4. T6-7 placement? Anyone want to grab an MRI and tell me how much CSF is here and how this is the proposed target?
5. Angle of entry into canal is way too steep. This patient has giant interlaminar spaces. Angle of entry appears close to 55 degrees. Would have been easy to go at 30 degrees to allow better safety and avoid the anterior dip before advancing up the canal.
6. Placing both trial leads unilaterally makes no sense. Makes it harder on yourself. Great to do if you cannot get in on the other side. Not a first choice.
7. If targets are back and left leg pain, one lead should be midline or leads should be paramedian approaching the midline.
 
nothing to see here. Maybe Steve could comment further. If that depth view image was lateral then he’s in trouble but it’s a CLO and probably just fine. Maybe the point is that it’s not a nevro case so it won’t work 😉
 
lobelsteve said:
1. Angle of entry lateral to medial is poor.
2. Because of 1 his lead goes anterior to contact dura and is in middle of canal on CLO.
3. Lead then courses posteriorly to wind up dorsal to cord.
4. T6-7 placement? Anyone want to grab an MRI and tell me how much CSF is here and how this is the proposed target?
5. Angle of entry into canal is way too steep. This patient has giant interlaminar spaces. Angle of entry appears close to 55 degrees. Would have been easy to go at 30 degrees to allow better safety and avoid the anterior dip before advancing up the canal.
6. Placing both trial leads unilaterally makes no sense. Makes it harder on yourself. Great to do if you cannot get in on the other side. Not a first choice.
7. If targets are back and left leg pain, one lead should be midline or leads should be paramedian approaching the midline.
Click to expand...
I don’t agree with 2, I don’t understand 4.

And I definitely don’t agree with 6. I do this routinely and I would consider myself experienced and competent. Despite what everyone else says…
 
NVO said:
View attachment 368682
I'm just an applicant applying pain this year. Could someone explain to me what these additional 2 fellowships mean?
Click to expand...
It means he spent time with two prolific and well-known private practice pain physicians. It’s name-dropping and borrowed glory that patients won’t understand. And not accredited.
 
most spine fellowships have only 1 to 3 fellows. not sure that CHIEF FELLOW is that big of a deal.

esp since there appears to be only 1 fellow per year at Johns Hopkins Interventional Spine and Musculoskeletal Fellowship program.

www.hopkinsmedicine.org

Interventional Spine and Musculoskeletal Fellowship Program

Learn to evaluate and manage patients in our spine/musculoskeletal clinic under the guidance of our spine rehabilitation specialists.
www.hopkinsmedicine.org www.hopkinsmedicine.org



the other 2 probably mean that he took a month off to hang out with them or he took a course and they were presenters.
 
Ducttape said:
the other 2 probably mean that he took a month off to hang out with them or he took a course and they were presenters.
Click to expand...
He took a course in how to raise your profile on LinkedIn

I do think it’s funny how these device companies will trot out different pain physicians as their distinguished advisors, with the implication that they’re supposed to be better pain physicians than you are and we should take note. I don’t think that happens in other specialties.
 
lobelsteve said:
1. Angle of entry lateral to medial is poor.
2. Because of 1 his lead goes anterior to contact dura and is in middle of canal on CLO.
3. Lead then courses posteriorly to wind up dorsal to cord.
4. T6-7 placement? Anyone want to grab an MRI and tell me how much CSF is here and how this is the proposed target?
5. Angle of entry into canal is way too steep. This patient has giant interlaminar spaces. Angle of entry appears close to 55 degrees. Would have been easy to go at 30 degrees to allow better safety and avoid the anterior dip before advancing up the canal.
6. Placing both trial leads unilaterally makes no sense. Makes it harder on yourself. Great to do if you cannot get in on the other side. Not a first choice.
7. If targets are back and left leg pain, one lead should be midline or leads should be paramedian approaching the midline.
Click to expand...
darn... here i thought you were going to say "he crossed the streams"...


agree angle is way too steep.


my big question... this is the kind of case that all of us (besides the nuances mentioned by Steve) do every week.

what was so special that he needed to post this on LinkedIn? what am i missing that makes this special?


wait...
maybe the problem is me.... i did a stim yesterday that looked better than this, and i havent posted it yet.... brb
 
In clo view depending on the angle, needle entry too much off midline, will look like that. Nbd to me.
 
There's a lot to criticize here...IMO the technique is very low on the priority list
 
Clearly epidural, can see air in the epidural space, the lateral entry makes the CLO look weird, hopefully he confirmed with a true lateral. I don’t see a need for two leads if there is one sided pain. I would also stagger the two leads to get more contact rather than simply place them side by side a mm from each other. I don’t understand the high placement of the leads.
 
NVO said:
View attachment 368682
I'm just an applicant applying pain this year. Could someone explain to me what these additional 2 fellowships mean?
Click to expand...
Lots of folks will allow you to come visit their practice for a day or more. Silly thing to put in your resume, unless you visit Lobel’s operation.

Kind of like how he’s the “CEO” of his one doc shop.

“Everyone is cooler online.”-Brad Paisley
 
cowboydoc said:
Lots of folks will allow you to come visit their practice for a day or more. Silly thing to put in your resume, unless you visit Lobel’s operation.

Kind of like how he’s the “CEO” of his one doc shop.

“Everyone is cooler online.”-Brad Paisley
Click to expand...
Two doctors, and one of them is Racz. That seems like something bigger to brag about…
 
Ducttape said:
most spine fellowships have only 1 to 3 fellows. not sure that CHIEF FELLOW is that big of a deal.

esp since there appears to be only 1 fellow per year at Johns Hopkins Interventional Spine and Musculoskeletal Fellowship program.

www.hopkinsmedicine.org

Interventional Spine and Musculoskeletal Fellowship Program

Learn to evaluate and manage patients in our spine/musculoskeletal clinic under the guidance of our spine rehabilitation specialists.
www.hopkinsmedicine.org www.hopkinsmedicine.org



the other 2 probably mean that he took a month off to hang out with them or he took a course and they were presenters.
Click to expand...
Chief fellow couldn’t be more of a joke.
When i did fellowship, there were only three of us. We would joke around and self proclaim that ourselves as co chief fellows
 
cowboydoc said:
Lots of folks will allow you to come visit their practice for a day or more. Silly thing to put in your resume, unless you visit Lobel’s operation.

Kind of like how he’s the “CEO” of his one doc shop.

“Everyone is cooler online.”-Brad Paisley
Click to expand...
Awesome, so what I'm hearing is when I finish training maybe I can swing by @lobelsteve's shop for a day and say I completed an additional fellowship :clown:
 
lobelsteve said:
1. Angle of entry lateral to medial is poor.
2. Because of 1 his lead goes anterior to contact dura and is in middle of canal on CLO.
3. Lead then courses posteriorly to wind up dorsal to cord.
4. T6-7 placement? Anyone want to grab an MRI and tell me how much CSF is here and how this is the proposed target?
5. Angle of entry into canal is way too steep. This patient has giant interlaminar spaces. Angle of entry appears close to 55 degrees. Would have been easy to go at 30 degrees to allow better safety and avoid the anterior dip before advancing up the canal.
6. Placing both trial leads unilaterally makes no sense. Makes it harder on yourself. Great to do if you cannot get in on the other side. Not a first choice.
7. If targets are back and left leg pain, one lead should be midline or leads should be paramedian approaching the midline.
Click to expand...
Agree to most points. As far as number six, will need less incision of tissues if enter from same side. You don’t need to retract tissue as laterally.
I’ve seen other docs do this.

I do approach one from both side but don’t see it necessarily as issue. Unless there is another reason?
 
Agast said:
I don’t take the tuohy out until both leads are in, having accidentally pulled one down before
Click to expand...
Ever been threading a tough second lead and found yourself accidentally advancing the first needle? That first 14g Tuohy needle also takes up a lot of space.
 
Last edited:
Here's an implant I just did. It was hard. Entry T11-12 for a T12-L5 FBSS with leg pain bilaterally.

Junctional kyphosis and she's tight, so my approach angle is flat.

Not an easy case, and final lead positions aren't perfect, but I was mud bogging from epidural entry to T8 and she's lucky to get two leads.

The flat entry and I'm sure I'm getting lead pushing on the LF as I steer superiorly. That and maybe some adhesions. Some mild SS too.

Nice lady. Severe leg pain bilaterally.

Also...Large seroma and she's had a lumbar surgical site infxn...Twice? I think twice.

Abbott Eterna.

20230331_170030.jpg

20230331_170117.jpg
 
Last edited:
lobelsteve said:
1. Angle of entry lateral to medial is poor.
2. Because of 1 his lead goes anterior to contact dura and is in middle of canal on CLO.
3. Lead then courses posteriorly to wind up dorsal to cord.
4. T6-7 placement? Anyone want to grab an MRI and tell me how much CSF is here and how this is the proposed target?
5. Angle of entry into canal is way too steep. This patient has giant interlaminar spaces. Angle of entry appears close to 55 degrees. Would have been easy to go at 30 degrees to allow better safety and avoid the anterior dip before advancing up the canal.
6. Placing both trial leads unilaterally makes no sense. Makes it harder on yourself. Great to do if you cannot get in on the other side. Not a first choice.
7. If targets are back and left leg pain, one lead should be midline or leads should be paramedian approaching the midline.
Click to expand...
Agree his angle too steep which caused lead to drop anteriorly upon entry
 
NVO said:
View attachment 368682
I'm just an applicant applying pain this year. Could someone explain to me what these additional 2 fellowships mean?
Click to expand...
The only thing this tells you is his program sucks. I don’t care if it’s John’s Hopkins. Most of the name brands have horrible procedure numbers.
 
Agree Steve, the angle is way too steep however i disagree with the assertion that inserting both leads from the same side is a problem. I trained to enter from each side but switched to the same side half way into my career. It has turned out to be faster and easier. The angle and trajectory of the second lead is easy peasy. Just follow the first lead
 
clubdeac said:
Agree Steve, the angle is way too steep however i disagree with the assertion that inserting both leads from the same side is a problem. I trained to enter from each side but switched to the same side half way into my career. It has turned out to be faster and easier. The angle and trajectory of the second lead is easy peasy. Just follow the first lead
Click to expand...

I’ve had a lot of questions on this over the years. I’ve done it both ways. I find it easier to do paramedian from opposite sides, especially on trials. Sometimes it’s hard to get the lead places on the opposite side when going unilateral. Plus you’re fighting the needle on your second pass, also might accidentally disrupt or advance the first needle.

I do agree with the double barrel unilateral paramedian approach on perms as you make one incision, on the same side as battery placement, and avoid having leads cross midline.
 
TweeterB said:
The only thing this tells you is his program sucks. I don’t care if it’s John’s Hopkins. Most of the name brands have horrible procedure numbers.
Click to expand...
Maybe 3 yrs ago or so we were hiring another pain doctor in our group. I was interviewing candidates and some bigger named institution grads applied.

Definitely surprised at some of the discussions I had.

Edit - Speaking of which...From the last stim case in fellowship to the 1st case you do as an attending will be X months. I didn't do an implant for prob 9-10 months. First trial was probably 7-8 months.

You become an attending and IMO the first 6-9 months are you trying to figure out your schedule, to hell with stim. It's you learning basic day to day logistics.

My first 10 or so implants as an attending consisted of me figuring out how to do them on my own, and I'm better now for it.

To any fellows or residents reading this, if you are interviewing for jobs find out if anyone in the practice can help⁷ you.

My first implant out of fellowship I had one of our spine surgeons who does paddles scrub in with me. That was a ******* idea. Paddles and percs are not similar in any way.

He had no idea what I was doing and it didn't help me at all as far as stim, but he did show me how to Bovie correctly, AND he turned me on to silk sutures (game changer).

Put your anchors down with a silk through one of the anchor eyelets, then get your Ethibond 3-0 and tie it down. It won't move and it's easier, faster and you sound cool bc you're using an assortment of different "surgical stuff."

Silk ties the easiest of all sutures.

Another thing I do...Silk loses integrity over time, but when you pull it through the eyelet bring tissue through the eyelet with it. That tissue is your new suture.
 
Last edited:
MitchLevi said:
Here's an implant I just did. It was hard. Entry T11-12 for a T12-L5 FBSS with leg pain bilaterally.

Junctional kyphosis and she's tight, so my approach angle is flat.

Not an easy case, and final lead positions aren't perfect, but I was mud bogging from epidural entry to T8 and she's lucky to get two leads.

The flat entry and I'm sure I'm getting lead pushing on the LF as I steer superiorly. That and maybe some adhesions. Some mild SS too.

Nice lady. Severe leg pain bilaterally.

Also...Large seroma and she's had a lumbar surgical site infxn...Twice? I think twice.

Abbott Eterna.

View attachment 368706
View attachment 368707
Click to expand...
Great angle of entry. Surely made for easy steering.
 
Aren't you nervous that the patient had 2 surgical site infections already? With the development of that sermons, would you consider empiric antibiotics?
 
Ducttape said:
Aren't you nervous that the patient had 2 surgical site infections already? With the development of that sermons, would you consider empiric antibiotics?
Click to expand...
Hibiclens x 4d BID.
Vanc allergy (I use Vanc powder in every implant but couldn't this time).
Clinda 900 IV.
Thorough irrigation.
Ioban of course.
I'll see her in follow up a few days from now and she's got a short leash for PO clinda or even Bactrim.

Not only the infxn Hx but also she had a large seroma. The seroma and the jxnl kyphosis is why I entered at T11. Otherwise, I would have entered at T12-L1 as she has lamina.

Not an ideal case on any level.

Thin thoracic, obese lumbar and buttock.

These are the cases I'm interested in discussing, not the ones that began this thread.
 
I had one that entered like the LinkedIn case above, but it was because of body habitus. I had the 6” needle pushed down as parallel to her back as I could. The lead dove all the way into the gutter but I was able to get it to come back to midline a level up. Thankfully she didn’t have nerve root irritation and is having good relief. Maybe another pillow under the chest would have helped.
 
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