Pictures of the Week

IPSIS: Formerly the Spine Intervention Society
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Baron Samedi said:
View attachment 292129

Young guy. Axial extension-based pain with bilateral L5 pseudoarticulations that I suspect are the primary pain generator. I want to inject for diagnostic and therapeutic reasons but unsure where exactly I should target my needle -- thinking the inferolateral corner of each L5 transverse process. Any thoughts?
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When in doubt exam under fluoro to confirm precise tender area facet vs pseudoartic vs si.
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pubic ramus.jpg
 
Total failure.
 

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pmrmd said:
Total failure.
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I've done that twice and I'll never do it again. Both instances were severely painful for the pt, neither worked, and I didn't feel comfortable with the "flip over" part prior to the burn.

On the rare occasions when I burn an SIJ I just carpet bomb them with 7 or 8 needles.

Edit - I went back and looked at Simplicity placement pics and I have no clue if that probe is well placed...I hate the procedure regardless...
 
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SommeRiver said:
I've done that twice and I'll never do it again. Both instances were severely painful for the pt, neither worked, and I didn't feel comfortable with the "flip over" part prior to the burn.

On the rare occasions when I burn an SIJ I just carpet bomb them with 7 or 8 needles.

Edit - I went back and looked at Simplicity placement pics and I have no clue if that probe is well placed...I hate the procedure regardless...
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Did a lot of simplicity in Fellowship and that looks well placed. I assume you burned the L5 DR too? Now I just do the Palisade technique with 7 needles - after reading a few review articles it seems to have much better outcomes. Regarding procedural pain, I would use a 5-7” 22g, curve it a bit, and march it up the same patch, injecting a lot of local as I went. Made it very minimally painful.
 
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callmeanesthesia said:
Did a lot of simplicity in Fellowship and that looks well placed. I assume you burned the L5 DR too? Now I just do the Palisade technique with 7 needles - after reading a few review articles it seems to have much better outcomes. Regarding procedural pain, I would use a 5-7” 22g, curve it a bit, and march it up the same patch, injecting a lot of local as I went. Made it very minimally painful.
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Yeah I went back and reviewed images bc it has been awhile and that looks similar to what's taught. It's still (IMO) not the same as 2-3 needles in a clump around the foramen like the traditional method that I was taught, and the placement of the Simplicity electrodes just doesn't look right to me.

Both times I did it we used IV fentanyl and Versed and a lot of local and barely made it through that procedure. With an N=2 my experience sucks but I hated it and so did the pts. Flipping it over never stayed flipped over and it constantly wanted to flip back.

I do 4 needles and burn, then 4 needles and burn.

I usually do L5 as well, yes.
 
L4.jpg



MBB the week before did not help even in anesthetic phase. Xray the week prior normal. Intermittent radic down left leg controlled on baclofen and tramadol. Since MBB failed I got MRI. H/o prostate CA 5 yrs ago with XRT. My nurse tells me that he smells like a smokestack.
 
hawkeye be damned, i still get MRIs on all my mbbs. yes, they shouldnt get pain relief after an MBB, but you never know. and its good this patien followed up. sometimes they dont

just today, i found a some big tumor in L3 and psoas with just axial pain.
 
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lobelsteve said:
View attachment 293619


MBB the week before did not help even in anesthetic phase. Xray the week prior normal. Intermittent radic down left leg controlled on baclofen and tramadol. Since MBB failed I got MRI. H/o prostate CA 5 yrs ago with XRT. My nurse tells me that he smells like a smokestack.
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Patient sent to me for an RFA. Pain clinic is currently prescribing OxyContin 40mg BID and oxycodone 20mg TID. He's been on that regimen a long time. Disability obviously.

You didn't do that PE...You didn't do it, and we all know you didn't do it, and this is a total fabrication. This isn't the complete PE either...The template goes on further but this is one screen's worth...

You didn't look in his ears. There is no surgical scar on his face - Just a tattoo. Waddell signs are merely a predictor of surgical outcome...

RLE is tender to palpation? Where exactly? In the thigh or the calf? You didn't document it bc you made it up.

This is BS.
 

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^ should be:
All appears WNL to brief visual inspection.
Answers yes/no questions appropriately.


Sent from my iPhone using Tapatalk
 
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Mods - Any reason this thread has disappeared for me? I can't see it unless I search for it.
 
lobelsteve said:
New patient. Traded percs for percs. I hate our field because of the doctors.
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What is that supposed to be? Is there an actual peripheral nerve target in there?
 
Agast said:
What is that supposed to be? Is there an actual peripheral nerve target in there?
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He had a successful trial. When it came time to implant they were unable to get the leads in the epidural space. They placed them in the paraspinal’s subcutaneously and threw the battery on his rib cage.
 
lobelsteve said:
He had a successful trial. When it came time to implant they were unable to get the leads in the epidural space. They placed them in the paraspinal’s subcutaneously and threw the battery on his rib cage.
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Sounds like a case of possible Medicare fraud to be honest.
 
lobelsteve said:
He had a successful trial. When it came time to implant they were unable to get the leads in the epidural space. They placed them in the paraspinal’s subcutaneously and threw the battery on his rib cage.
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That...if accompanied by an op note that describes subcu placement...should be prosecutable IMO. I would find a way to call that physician and talk about it. If they admit to it I'm seriously considering their state board.
 
Lesson in “always review your own images.” This patient came to me today for severe neck pain and headaches, progressive for 6 months. She came in in a wheelchair, could barely transfer to the exam table, crying out in pain and nearly vomiting. Had been to the ER the day before and they gave her a toradol shot and sent her home. She had an MRI c-spine a month ago. For some reason they had grabbed a T2 Sag view of the brain too, but the radiologist made no comment on the brain in the report - just some disc bulges and central and foraminal stenosis. Pulled up the brain images for a quick look given her complaint of dizziness. Exhibit A:
F64104DC-9D2E-4C20-9E04-4C46A5321C94.jpeg

(I’ll give you a hint: there’s not normally a golf ball size cystic lesion in the middle of the cerebellum...)
Talked to the on call neurosurgeon and sent her to the ER. She was very ataxic but surprisingly mild disturbance of finger to nose, rapid alternating movement, or extraocular movement. Did complain of progressively worsening headaches, loss of balance, visual aura (like a kaliedascope around the edge of her vision), numbness of head and arms, and hearing loss.
 
changeofheart2016 said:
proly part of scout images the radiologist didn't bother to look at
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Not a scout image - this was a full T2 sagittal set of images of the brain. Incidentally you could see it in the scout film too. Clearly the radiologist didn’t look at these images at all though - even in the 1x1 inch preview on the viewer website it was obvious. What I really wonder is why these images were taken as part of the c spine.
 
Maybe the MRI techs saw the finding on the scout and then did the full sag T2 as prophylactic measure for the attending radiologist (MRI tech thought, oh the attending is definitely gonna see this, why don't i do an additional t2 so the attending doesn't call the patient back)
 
lol wut? liver looks completely normal

it's just a displaced rib isn't it? thoracotomy hx?
 
MVA. Rollover. Liver lac, spleen lac, Fx ribs. 9th and 10th ribs displaced. Chest tube in for 20 days. T10 Fx as well. Lost a kidney in accident. Non functional but did not need removal. By the time she left ICU she was good enough per trauma team. Lost to follow-up.
 
2020-04-13 09.13.38.jpg


Amazing tattoo work. Posterior laminectomy gone wrong led to a 1" divot once wound healed. Patient cleaned it up and owned the scar. Helps to have the talented tattoo artist help out. Life gives you lemons....this guy.
 
lobelsteve said:
View attachment 303725

Amazing tattoo work. Posterior laminectomy gone wrong led to a 1" divot once wound healed. Patient cleaned it up and owned the scar. Helps to have the talented tattoo artist help out. Life gives you lemons....this guy.
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Now i understand why tattoo parlors were first to open Georgia
 
I hate tattoos almost as much as i hate DJT... but this is pretty cool
 
2 months of low back pain with relatively sudden onset.
 

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www.mayoclinic.org

Bone metastasis-Bone metastasis - Symptoms & causes - Mayo Clinic

Learn about the symptoms and causes of cancer that spreads to the bones. Find out about treatments, including medications, radiation and surgery.
www.mayoclinic.org www.mayoclinic.org

Breast
Lung
Prostate

Above based on statistics.

Kidney cancer
Lymphoma
Multiple myeloma
Thyroid cancer

Above based on rest of common causes.
 
lobelsteve said:
www.mayoclinic.org

Bone metastasis-Bone metastasis - Symptoms & causes - Mayo Clinic

Learn about the symptoms and causes of cancer that spreads to the bones. Find out about treatments, including medications, radiation and surgery.
www.mayoclinic.org www.mayoclinic.org

Breast
Lung
Prostate

Above based on statistics.

Kidney cancer
Lymphoma
Multiple myeloma
Thyroid cancer

Above based on rest of common causes.
Click to expand...

All good guesses.

Stage IV Renal Cell

s/p Osteocool + kypho. Got rid of her back pain at least.
 
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