Pictures of the Week

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BoardingDoc said:
If you injected steroid + local, did they piss themselves or have a hard time walking after you injected? If not, not intrathecal.
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No. All my ESI are normal saline and dex. It just made me concerned they put that in the chart and there's always patients with ESI with some pain a few days later so didn't want them to blame it on this. The picture are garbage but it felt epidural and tbh it looks ESI to me may have looked more clear if I obliqued more but on PA I see the epidural fat and spread starting to track along the epidural path
 
A lot of outdated info on ESI on thread.
And pics so bad no way of telling.
Made worse by cellphone appearance of vertical striations on picture (I do not believe in picture).

A little local and steroid will not make someone piss themselves.
Wet taps are often dry.
Large wet taps can be asymptomatic. 14g SCS trial with 2 wet taps and no headache for me.

If there was a complication and this was the imaging you had, you would be hurt rather than helped by it.
If this is all you have, do not do ESI. It is not better than blinded. But what do I know.

pubmed.ncbi.nlm.nih.gov

The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data - PubMed

In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
Curious… anyone know why contrast on esi and the barium with PMMA on vert augmentation show up dark on fluoro x-ray, but white on regular x-ray?
 
interjectionreflection said:
Would appreciate thoughts on if this is epidural. I had good LOR felt the pictures looked epidural. I am at a old hospital C arm is down so used the mobile XR which doesnt oblique as much as I would like. The rads dont seem confident its epidural. Patient had great relief and felt like epidural to me but would be happy to learn from others. Dont plan to do these again until I have access to Carm.
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Images are terrible but this looks IT to me. I would recommend collimating significantly to improve image quality. Fortunately if you’re only injecting PF dexa and NS you’re not going to get into trouble except for a potential PDPH. Agree that you would expect to see CSF come out of the hub with an 18g but not always
 
I also think it looks like a myelogram on the AP films. I have done a few myelogram because the rad couldn’t get access when I worked for the hospital. They look like that AP.


Why they could get access? Well, the primary reason was they were using the mobile xray not the c-arm. I think their issues resolved once they started using the pain room.
 
interjectionreflection said:
Would appreciate thoughts on if this is epidural. I had good LOR felt the pictures looked epidural. I am at a old hospital C arm is down so used the mobile XR which doesnt oblique as much as I would like. The rads dont seem confident its epidural. Patient had great relief and felt like epidural to me but would be happy to learn from others. Dont plan to do these again until I have access to Carm.
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Probably epidural. I see nothing ventral. But hard to get worse pictures.
 
interjectionreflection said:
Would appreciate thoughts on if this is epidural. I had good LOR felt the pictures looked epidural. I am at a old hospital C arm is down so used the mobile XR which doesnt oblique as much as I would like. The rads dont seem confident its epidural. Patient had great relief and felt like epidural to me but would be happy to learn from others. Dont plan to do these again until I have access to Carm.
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Very difficult to tell from the pictures. I don’t think it is intrathecal because on a CLO or lateral if the contrast is intrathecal it doesn’t typically sit there like a blob like your picture. The classic intrathecal appearance in a lateral is the train tracks appearance as the contrast gets dispersed through the CSF much easier than it does through the epidural space and the contrast follows gravity to the ventral intrathecal space.
 
Gnarvin said:
Very difficult to tell from the pictures. I don’t think it is intrathecal because on a CLO or lateral if the contrast is intrathecal it doesn’t typically sit there like a blob like your picture. The classic intrathecal appearance in a lateral is the train tracks appearance as the contrast gets dispersed through the CSF much easier than it does through the epidural space and the contrast follows gravity to the ventral intrathecal space.
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Train tracks are at the level of the cord. Lumbar myelogram spreads throughout the cauda equina, which is kind of what the AP pic looks like. Still, with non-ionic contrast, preservative-free NS and dex, then most likely no headache, no problem anyway.

 
callmeanesthesia said:
Train tracks are at the level of the cord. Lumbar myelogram spreads throughout the cauda equina, which is kind of what the AP pic looks like. Still, with non-ionic contrast, preservative-free NS and dex, then most likely no headache, no problem anyway.

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Keep in mind that for a myelogram that they inject a lot more contrast than any of us would inject for an ESI. Perhaps that is a reason that more of the intrathecal space shows to be filled in the article you posted.

I don’t know how to post it, but in the Furman textbook they specifically show an example of the contrast layered all ventrally in a thin layer in the L spine with intrathecal contrast injection. Admittedly that picture doesn’t show any contrast posteriorly so it isn’t quite train tracks, though.
 
Gnarvin said:
Keep in mind that for a myelogram that they inject a lot more contrast than any of us would inject for an ESI. Perhaps that is a reason that more of the intrathecal space shows to be filled in the article you posted.

I don’t know how to post it, but in the Furman textbook they specifically show an example of the contrast layered all ventrally in a thin layer in the L spine with intrathecal contrast injection. Admittedly that picture doesn’t show any contrast posteriorly so it isn’t quite train tracks, though.
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What I’m saying is the train tracks appearance is that you get that from seeing a hollow cylinder of contrast around the cord, where the edges of that cylinder are thicker along the line of sight and therefore darker.
 
interjectionreflection said:
Would appreciate thoughts on if this is epidural. I had good LOR felt the pictures looked epidural. I am at a old hospital C arm is down so used the mobile XR which doesnt oblique as much as I would like. The rads dont seem confident its epidural. Patient had great relief and felt like epidural to me but would be happy to learn from others. Dont plan to do these again until I have access to Carm.
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There is definitely some epidural spread. I can't rule out intrathecal spread.
I apologize but to me it looks like you went ipsilateral oblique on your CLO view. The needle tip and arm both appear to be left of midline.

A few simple points for intrathecal things
- CSF won't leak from a needle unless the CSF pressure is > hub air pressure, so you might need to suck in some cases
- Iodinated contrast is generally hyperbaric. Look to see if it drops with gravity to the ventral side or down/up a level depending on how they are positioned.
- Contrast gets harder to appreciate as it diffuses with CSF whereas it moves much less in epidural fat, so watch for the fuzziness of the borders with a second shot 30-60s after the first.
- Contrast can be both epidural and intrathecal, so the presence of fat lobules meaning epidural and the presence of linear striations meaning intrathecal with nerve roots can both exist. Just inject preservative free/local anesthetic free/particulate free/etc in those cases or inject more contrast to see if you're actually filling both spaces if you don't want to or can't re-access somewhere else.
 
pmrmd said:
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Who is doing what?
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Need more shots but that vertical cleft and retropulsion makes me more likely to consider armed kypho/spinejack if they're neuro-intact, it's subacute, and pedicles are accessible. PLL looks intact but definitely want to talk with surgical team as a good jack can save them doing a fusion/decompression in a 67 yo.
 
Seen on linkedin. What do you make of this spread pattern?
 

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cameroncarter said:
Seen on linkedin. What do you make of this spread pattern?
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Left sided subpedicular flow looks epidural. No contrast being injected currently and none on right side. Catheter is injecting steroid or saline or is empty.
 
What does that mean?

What are "shavings," and do yall check pupils on telehealth? He had her on oxy 30mg TID. I'm sure me and her are about to enjoy one another. This will surely go well for both of us...
 
Bipolar for lumbar rfa due to bladder stim. I didn’t want to chance having an issue, damaging it etc. didn’t have time to look it up, get clearance etc. bipolar or nothing it was. Under local so didn’t want to need 2 separate track local needles per level … therefore used 20g instead of my usual 18 and kept them close together at skin. Was pita adjusting w both hubs close together at skin. Def more difficult w 20g vs usual 18g re making small adjustments of tips on os.

Followed it up with a routine rf w my usual 18 to redeem myself
 

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I’ve done bipolar lumbar due to devices. I used a single set of skin entry sites a little above and lateral to the sacral ala. 2x 18g about a cm apart. Then I do sacral ala, then L5, then L4, bilaterally. I don’t use a tract needle though unless they have poor procedure tolerance. I just numb skin/subq with 1.5”, then add about 0.5mL through the RF cannula as soon as I touch os.
 
Taus said:
Bipolar for lumbar rfa due to bladder stim. I didn’t want to chance having an issue, damaging it etc. didn’t have time to look it up, get clearance etc. bipolar or nothing it was. Under local so didn’t want to need 2 separate track local needles per level … therefore used 20g instead of my usual 18 and kept them close together at skin. Was pita adjusting w both hubs close together at skin. Def more difficult w 20g vs usual 18g re making small adjustments of tips on os.

Followed it up with a routine rf w my usual 18 to redeem myself
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Looks solid for the circumstance!
 
BobBarker said:
Looks good but in the future you just need to put the grounding pad away from the IPG.
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Could you drop some knowledge that we can print and keep in the office? 😆

Cervical RFA - Pacemaker:
Cervical RFA - ICD:
Lumbar RFA - Pacemaker:
Lumbar RFA - ICD:
Cervical / Lumbar RFA - Other (Occipital nerve stimulator, bladder stim etc):
 
I have always just given monopolar rf with the grounding pad away for all of those. Also, I did that for a cervical rf with a patient with inspire. It makes you have pause at first as there is a coiled wire nearly overlying the facet joint but it is pretty far anterior.


The only one I’m not sure about is DBS and cervical rf.
 
I recently did cervical RF with AICD that caused a reaction I think. Patient jumped twice. Never happened before with an AICD. Tolerated fine with magnet in place.
 
You will know if they get shocked. I had a patient get shocked about 30 times in the ICU during my internship. It isn’t a reaction. You can hear the AICD and the patients entire body convulses.
 
I’ve had an AICD discharge on a cervical RF. Never again. I always do bipolar if patient has AICD now. I’ve also seen a pacemaker inhibit while doing cervical RF, even though the grounding pad was on the opposite side. I do bipolar if above the umbilicus.

By the way, does anyone know of research on the lesion morphology with multiple simultaneous bipolar lesions? Everything I can find is just two needles, but I’ve wondered what happens when you have 4 sequential needles, like for a palisade. So you have + - + -, it wouldn’t make much sense for it to just make 2 blobs of ablated tissue since the current wouldn’t really know which probe it’s “paired” with.
 
callmeanesthesia said:
I’ve had an AICD discharge on a cervical RF. Never again. I always do bipolar if patient has AICD now. I’ve also seen a pacemaker inhibit while doing cervical RF, even though the grounding pad was on the opposite side. I do bipolar if above the umbilicus.

By the way, does anyone know of research on the lesion morphology with multiple simultaneous bipolar lesions? Everything I can find is just two needles, but I’ve wondered what happens when you have 4 sequential needles, like for a palisade. So you have + - + -, it wouldn’t make much sense for it to just make 2 blobs of ablated tissue since the current wouldn’t really know which probe it’s “paired” with.
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Not sure about others but Boston machine burns between 1&2 and 3&4. It shows up on the screen that way.
 
callmeanesthesia said:
I’ve had an AICD discharge on a cervical RF. Never again. I always do bipolar if patient has AICD now. I’ve also seen a pacemaker inhibit while doing cervical RF, even though the grounding pad was on the opposite side. I do bipolar if above the umbilicus.

By the way, does anyone know of research on the lesion morphology with multiple simultaneous bipolar lesions? Everything I can find is just two needles, but I’ve wondered what happens when you have 4 sequential needles, like for a palisade. So you have + - + -, it wouldn’t make much sense for it to just make 2 blobs of ablated tissue since the current wouldn’t really know which probe it’s “paired” with.
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I have had the same with a cervical pacemaker. I got a call from a patient’s cardiologist later that day… He was not very happy. Patient was pacer dependent…fortunately he was fine. I had to have the pacer rep on site when I did the contralateral side.

For bipolar… It goes between 1-2 and 3-4. You don’t need a separate burn cycle between 2-3. The cosman article shows there morphology of the bipolar lesions between the two electrodes.
 
I just don't do any ablations higher than L3 if you have a pacemaker, and I won't ablate anyone with an AICD.

Facet CSI or Tx MBB (which is a BS procedure btw).
 
callmeanesthesia said:
I’ve had an AICD discharge on a cervical RF. Never again. I always do bipolar if patient has AICD now. I’ve also seen a pacemaker inhibit while doing cervical RF, even though the grounding pad was on the opposite side. I do bipolar if above the umbilicus.

By the way, does anyone know of research on the lesion morphology with multiple simultaneous bipolar lesions? Everything I can find is just two needles, but I’ve wondered what happens when you have 4 sequential needles, like for a palisade. So you have + - + -, it wouldn’t make much sense for it to just make 2 blobs of ablated tissue since the current wouldn’t really know which probe it’s “paired” with.
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Same. If the AICD discharges, there is no question. The patient seems to come off the table, and you feel the need to go check your scrub bottoms.

I bipolar all AICD pts. for cervical RF. The way the Stryker works sounds similar to how the Colman is described above. Current will flow between lead one and two and current will go between lead three and four creating an hourglass type shape if the distance is fairly far. I don’t think there’s any large studies on this, but some basic burn patterns have been demonstrated. When I demoed machines a few years ago, with the leads about a centimeter apart, the burn between them was not much narrower than the centimeter exposed tip (essentially square)
 
Taus said:
I have had the same with a cervical pacemaker. I got a call from a patient’s cardiologist later that day… He was not very happy. Patient was pacer dependent…fortunately he was fine. I had to have the pacer rep on site when I did the contralateral side.

For bipolar… It goes between 1-2 and 3-4. You don’t need a separate burn cycle between 2-3. The cosman article shows there morphology of the bipolar lesions between the two electrodes.
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Yes, I know that’s what it shows on the screen, and I know the morphology for one pair. What does it look like with 2 pairs next to each other? If you have + - + - how does the electricity know which neutral to flow to? Wouldn’t you get a more complex morphology where there is some flow from the positive in position 3 to both neutrals?
 
I’m not sure. I can see a common scenario on a si rf where you are doing bipolar 1-2 3-4 and you move 1 inferior to next do 2-3 4-1 but you screw up the electrodes and do 2-4 and 3-1. I have never had a bipolar give an error. I bet as long as the machine perceives an appropriate amount of current returning it will not give an error but the lesion will be chaotic.
 
callmeanesthesia said:
Yes, I know that’s what it shows on the screen, and I know the morphology for one pair. What does it look like with 2 pairs next to each other? If you have + - + - how does the electricity know which neutral to flow to? Wouldn’t you get a more complex morphology where there is some flow from the positive in position 3 to both neutrals?
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Interesting. I guess you could potentially create a lesion between 1-2 and 2-3 and almost nothing between 3-4 in the scenario you describe, depending on impedance. I like the description of chaotic morphology. For this reason, I wouldn’t count on this configuration.
 
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