Pictures of the Week

IPSIS: Formerly the Spine Intervention Society
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SommeRiver said:
Pt sent to me for LBP. Jan this year had cement augmentation for a fracture. An interesting picture...
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You don't clear your cannulae with cement?
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SommeRiver said:
Like Joe Dirt says, "It'll buff out..."
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In all seriousness, I'm told those straws are easy to remove as they'll snap off with a perc incision and force. The stuff in the disc space though seems like it'll be a problem.
 
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der8mc.jpg
 
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The Night King resides in this man's canal?
 
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6/1: 70 y/o female leans forward and POP. Falls to ground with severe axial LBP. Xray with L2 compression deformity. MRI 6/7.

L2.jpg




Pain non-radiating, midline to right of midline. T1 and T2 sag above.
H/o non-small cell Dx 9/18, no known mets, on CTX. Denies XRT.
Wt 111
H/o osteoporosis, DEXA ordered by PCP today.

What is going on here? Asking but this does not make sense.
What are your next steps?
 
lobelsteve said:
6/1: 70 y/o female leans forward and POP. Falls to ground with severe axial LBP. Xray with L2 compression deformity. MRI 6/7.

View attachment 268451



Pain non-radiating, midline to right of midline. T1 and T2 sag above.
H/o non-small cell Dx 9/18, no known mets, on CTX. Denies XRT.
Wt 111
H/o osteoporosis, DEXA ordered by PCP today.

What is going on here? Asking but this does not make sense.
What are your next steps?
Click to expand...
MRI with contrast.

Review of the Imaging Features of Benign Osteoporotic and Malignant Vertebral Compression Fractures

SUMMARY: Vertebral compression fractures are very common, especially in the elderly. Benign osteoporotic and malignant vertebral compression fractures have extremely different management and prognostic implications. Although there is an overlap in appearances, characteristic imaging features can...
www.ajnr.org www.ajnr.org
 
ESR/CRP/blood cultures

Cancer or infection until proven to be just weak bones
 
Old fracture with acute back strain.
 
iliac 19.JPG


Multiple lumbar surgeries. SCS placed 2 years ago. In June had worse leg pain on right after returning from Cozumel cruise. Xray showed mild migration and programming took care of it. August returns to office for worse back and leg pain. Trip to gulf coast beaches and walking led to a fall. CT ordered. We are no longer in Lspine land. Mammo 2/19 normal, nonsmoker and clear cxr this year. Colonoscopy normal 2 years prior. Bone scan today shows no other lesion.
CT shows 3-4cm mass where ovaries used to be, possible enlarged node. Bx iliac crest in lesion with CT Tuesday and oncology later next week. Thoughts?
 
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lobelsteve said:
View attachment 278276

Multiple lumbar surgeries. SCS placed 2 years ago. In June had worse leg pain on right after returning from Cozumel cruise. Xray showed mild migration and programming took care of it. August returns to office for worse back and leg pain. Trip to gulf coast beaches and walking led to a fall. CT ordered. We are no longer in Lspine land. Mammo 2/19 normal, nonsmoker and clear cxr this year. Colonoscopy normal 2 years prior. Bone scan today shows no other lesion.
CT shows 3-4cm mass where ovaries used to be, possible enlarged node. Bx iliac crest in lesion with CT Tuesday and oncology later next week. Thoughts?
Click to expand...
Keep us posted. I hope things work out for her but certainly something to learn from this case
 
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Not my case, thank God. The story is during a revision, a new fellow cut the lead instead of the anchor and it retracted up into the epidural space. Rather than getting it out, they put in two new leads and closed up.

Curious what others would have done -- left a free lead in the epidural space or call in neurosurgery to bail out?
 
Baron Samedi said:
View attachment 280186

Not my case, thank God. The story is during a revision, a new fellow cut the lead instead of the anchor and it retracted up into the epidural space. Rather than getting it out, they put in two new leads and closed up.

Curious what others would have done -- left a free lead in the epidural space or call in neurosurgery to bail out?
Click to expand...

Good Q. I'd probably have surgery retrieve it, but you can leave leads in without issue. I worry about it moving since it isn't anchored though.
 
SommeRiver said:
Good Q. I'd probably have surgery retrieve it, but you can leave leads in without issue. I worry about it moving since it isn't anchored though.
Click to expand...

My biggest concern was that since the proximal end was crudely cut it might be irritating and be a trigger for a hematoma. As far as I know, the patient has done well.
 
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Baron Samedi said:
My biggest concern was that since the proximal end was crudely cut it might be irritating and be a trigger for a hematoma. As far as I know, the patient has done well.
Click to expand...

Consult neurosurgery if you can't cut down to grab it at the time it occurs. The reason is that it can continue migrating significantly and suddenly you're looking at an electrode array in the brain.
 
Orin said:
Consult neurosurgery if you can't cut down to grab it at the time it occurs. The reason is that it can continue migrating significantly and suddenly you're looking at an electrode array in the brain.
Click to expand...

Would you call NSGY while you're still open or have the patient come back for a second procedure?
 
Baron Samedi said:
View attachment 280186

Not my case, thank God. The story is during a revision, a new fellow cut the lead instead of the anchor and it retracted up into the epidural space. Rather than getting it out, they put in two new leads and closed up.

Curious what others would have done -- left a free lead in the epidural space or call in neurosurgery to bail out?
Click to expand...

I don’t think the end of the lead is in the epidural space looking at the X-ray. . I would cut down and get it.
 
Baron Samedi said:
Would you call NSGY while you're still open or have the patient come back for a second procedure?
Click to expand...

When is a matter of logistics. Calling them while you're open is great if there is an orthopedic or neurosurgical person operating next door. I have often asked if there is someone in an adjacent OR who could be of help when I'm scrubbing in and know it'll be a tough case. I leave my ego at home as I am often humbled in the clinical setting.

I would definitely get a lateral image and consider cutting down to go get it until you hit the spinous process, or trying to at least throw a deep anchoring loop to try to trap any extra spinal segment to prevent it from travelling in further. I postulate that the reason leads migrate in is because of the negative pressure in the epidural space in spontaneously breathing patients, so you could also try things like use suction or flood the space with saline from above to try and get it to flow out, but this is all conjecture.

I have heard of this happening back in the day with the Stimwave epidural leads due to their lack of an IPG anchor with their initial anchors. There are also some reports with conventional systems where the lead has been poorly anchored and poorly connected to an IPG, leading it to migrate up and into the brain.
 
dcr8t3.jpg

rvcyn7.jpg


This is one I revised. Lead was intact and I just pulled it back to the correct position and replaced the anchor. The original ancho either broke or was never clicked close.
 
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-6.3, not -6.8
 

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Nonunion.
 

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No...Late 20s male. Trauma. History of opiate use prior to surgery and coming to see me next week. He's getting a new rod in like 3 weeks and I'm going to manage him until then. Probably give him oxycodone and intramedullary CBD infusion.
 
SommeRiver said:
No...Late 20s male. Trauma. History of opiate use prior to surgery and coming to see me next week. He's getting a new rod in like 3 weeks and I'm going to manage him until then. Probably give him oxycodone and intramedullary CBD infusion.
Click to expand...

No narcs. Get him a nicer walker. Was trauma DUI?
 
Don't THINK it is a DUI but in not positive. If it is a DUI unlikely opiate Rx from me. He's received a few Rx from other pain docs as it has turned out, and my nurse told him I'm not giving him Duragesic (he asked her over the phone). She told him I don't Rx that ever...I agreed to see him bc one of our trauma guys is gonna put a new rod in there soon. I'm sure I know how this will go, and neither of is will benefit but I don't think it is unreasonable to at least see him. I get maybe one or two of these crazy trauma pts pending some form of revision surgery per year, so no biggie. No one really expects too much out of me in these situations.
 
I placed ethibond anchor stitches first, then access needles placed through the free suture ends, then Medtronic Injex anchors, then sewed them down with the already present suture.
 
1572706968744.jpeg

accessed same side, same level
This is after anchoring. I made a lead loop and tunneled same as always.

she had a scs in place that worked well but went for another surgery and the guy who did the unilateral skip fusion pulled it out. I think he had more planned surgically and bailed out intraop.
 
I think it's an S1 on S2 spondyloptosis. No surgery. Happened 40 yrs ago believe it or not. I see the pt Friday. She is apparently completely intact.
 
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