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Axial back pain, chronic. 60 y/o female. HLA B27 neg. PMH: DM, HTN. No h/o CA. No prior back surgery.
DISH variant? Getting CT ordered. Any idea what is going on here?

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Axial back pain, chronic. 60 y/o female. HLA B27 neg. PMH: DM, HTN. No h/o CA. No prior back surgery.
DISH variant? Getting CT ordered. Any idea what is going on here?

the AP looks like AS, but there are no bridging syndesmophytes on lateral. i think it is just OA, or call it DISH if you like. do an MBB
 
the AP looks like AS, but there are no bridging syndesmophytes on lateral. i think it is just OA, or call it DISH if you like. do an MBB
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Here is the oblique. Will get CT before trying MBB, really to see if this getting into canal and if I have viable targets to acquire.
 
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I would like to see C-spine/hand films as well. I assume you'll be checking labs for Ca/Phos/PTH?
 
Really pretty contrast spread on a CESI (contralateral oblique approach, nice posterior epidural spread but saw some little wisps going anterior so I grabbed an AP too - you can see it highlighting the nerve roots, especially on the left).
 

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I'll be draining this thing in a few days. Looking fwd to it too. Left THR with 12 months of nonradiating, mechanical iliopsoas pain. Fluid pocket is 5cm x 2cm. Should help this guy significantly.
 

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...shocked no one liked my unhappy dens...
 
Now I understand the need to do adjacent level TFESI same visit. Patient also was injected at S1 same side.
 

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im only seeing blobogram. sorry...

Exactly, that is the image I saw on my patient's old records. Contrast everywhere but epidural. This is the nonsense that my competition gets away with.

Do 2 adjacent levels and perhaps some medication will be epidural.
 
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Referral for new patient. Dropped off mri ahead of visit. Had scs trial elsewhere. MRI when they could not get wires in. Asked me to retrial. No thanks.
 
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Referral for new patient. Dropped off mri ahead of visit. Had scs trial elsewhere. MRI when they could not get wires in. Asked me to retrial. No thanks.

And that’s why all my patients get thoracic MRIs before the trial. A surgeon would never cut without imaging and we would never inject without imaging. Never made sense why that all went out the window when it came to stim.
 
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Random one but I get EMG referrals. This was a weird case because the patient was referred twice within 3 weeks. First referral for new onset LUE painless weakness followed by second for new onset LLE painless weakness. I sent him to the ER. Passed away 9 months later. Metastatic renal cell.

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Done by Neurosurgeon at Emory. I recommended against it. Patient no better.
One lead supraorbital, 1 lead through foramen ovale and an inch into brain.
Gasserian RF trajectory with a 14G Tuohy and leaving a wire is more than I imagine reasonable.
Offered SCS over C2 in the canal for her primary V2 right sided pain.
 
Done by Neurosurgeon at Emory. I recommended against it. Patient no better.
One lead supraorbital, 1 lead through foramen ovale and an inch into brain.
Gasserian RF trajectory with a 14G Tuohy and leaving a wire is more than I imagine reasonable.
Offered SCS over C2 in the canal for her primary V2 right sided pain.

Did the pain pattern change as that seems like overkill for V2? I'm sure they already offered to drop Nevro percs at C1/C2 for HF10 to the nucleus caudalis to fix all things above the neck.
 
Did the pain pattern change as that seems like overkill for V2? I'm sure they already offered to drop Nevro percs at C1/C2 for HF10 to the nucleus caudalis to fix all things above the neck.

elavil to start, 250k later, elavil +/- butrans
 
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Dont forget, a publication in some neurosurgeon journal documenting 80% reduction of pain until lost to follow up...
 
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42 yo M with just under 3 weeks of severe right leg pain. Driving home one day from work (desk job) and right leg started hurting, then couldn't get out of his car. No medical history. Gainfully employed. Wants to get back to work but does not tolerate even minimal ROM of the leg or weight bearing.

IM Toradol, Medrol dose pack, gabapentin, home exercise regimen, follow up in 3 weeks. Will MRI if no better.

I kept thinking I saw fracture but I'm not so sure. That L4-5 disk has seen better days.
 

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42 yo M with just under 3 weeks of severe right leg pain. Driving home one day from work (desk job) and right leg started hurting, then couldn't get out of his car. No medical history. Gainfully employed. Wants to get back to work but does not tolerate even minimal ROM of the leg or weight bearing.

IM Toradol, Medrol dose pack, gabapentin, home exercise regimen, follow up in 3 weeks. Will MRI if no better.

I kept thinking I saw fracture but I'm not so sure. That L4-5 disk has seen better days.

MRI now. Cant get out of car is red flag enough for me.
 
42 yo M with just under 3 weeks of severe right leg pain. Driving home one day from work (desk job) and right leg started hurting, then couldn't get out of his car. No medical history. Gainfully employed. Wants to get back to work but does not tolerate even minimal ROM of the leg or weight bearing.

IM Toradol, Medrol dose pack, gabapentin, home exercise regimen, follow up in 3 weeks. Will MRI if no better.

I kept thinking I saw fracture but I'm not so sure. That L4-5 disk has seen better days.
The posterior inferior L4 body looks... weird. I’d agree with MRI now too. Definitely enough on physical exam to justify to insurance. Reflexes normal and bowel/bladder normal I assume?
 
The posterior inferior L4 body looks... weird. I’d agree with MRI now too. Definitely enough on physical exam to justify to insurance. Reflexes normal and bowel/bladder normal I assume?

Posterior L4 is what I was talking about as looking possibly like fracture, but probably just shadow and bony overlay. The getting out of the car thing was exclusively pain related and not neuromuscular. Reflexes are 2+. No bowel or bladder issues.
 
42 yo M with just under 3 weeks of severe right leg pain. Driving home one day from work (desk job) and right leg started hurting, then couldn't get out of his car. No medical history. Gainfully employed. Wants to get back to work but does not tolerate even minimal ROM of the leg or weight bearing.

IM Toradol, Medrol dose pack, gabapentin, home exercise regimen, follow up in 3 weeks. Will MRI if no better.

I kept thinking I saw fracture but I'm not so sure. That L4-5 disk has seen better days.

ALIF time
 
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