Pictures of the Week

IPSIS: Formerly the Spine Intervention Society
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Since I know everyone here loves SI joint fusions, here’s someone I saw for a new consult today. At least, I assume that was supposed to be an SI joint fusion. Either that or she got “grazed” like the guy above. Shockingly, her SI joint still hurts...
Axial and coronal CT (again sorry for the rotation. Happens any time I upload a vertical photo from my iPhone. If anyone knows how to fix that I’d appreciate it)
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Young patient presents 2 years of bilateral hand numbness in ulnar distribution and slight loss of dexterity. MRI attached, shows bilateral C6-7 and C7-T1 perineural cysts but otherwise normal. Originally sent to me as a cervical radiculopathy eval but exam findings more consistent with ulnar neuropathy at the elbow, and she has very minimal neck pain. She's failed to respond to elbow bracing and activity modification, EMG/NCS showed borderline slowing across the right elbow only, no other abnormalities.

Has me questioning whether or not these perineural cysts could be symptomatic and, if so, what to do about it? I always assumed these were just incidental findings unless they were massive.
 

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Baron Samedi said:
Young patient presents 2 years of bilateral hand numbness in ulnar distribution and slight loss of dexterity. MRI attached, shows bilateral C6-7 and C7-T1 perineural cysts but otherwise normal. Originally sent to me as a cervical radiculopathy eval but exam findings more consistent with ulnar neuropathy at the elbow, and she has very minimal neck pain. She's failed to respond to elbow bracing and activity modification, EMG/NCS showed borderline slowing across the right elbow only, no other abnormalities.

Has me questioning whether or not these perineural cysts could be symptomatic and, if so, what to do about it? I always assumed these were just incidental findings unless they were massive.
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Is there objective sensory and/or motor deficit or just tingling/numb sensation? Myofascial pain/tension with a TOS-type numbness? That’s usually ulnar aspect of hand/arm too.
 
Baron Samedi said:
Young patient presents 2 years of bilateral hand numbness in ulnar distribution and slight loss of dexterity. MRI attached, shows bilateral C6-7 and C7-T1 perineural cysts but otherwise normal. Originally sent to me as a cervical radiculopathy eval but exam findings more consistent with ulnar neuropathy at the elbow, and she has very minimal neck pain. She's failed to respond to elbow bracing and activity modification, EMG/NCS showed borderline slowing across the right elbow only, no other abnormalities.

Has me questioning whether or not these perineural cysts could be symptomatic and, if so, what to do about it? I always assumed these were just incidental findings unless they were massive.
Click to expand...
Show the EMG details.
 
cowboydoc said:
Show the EMG details.
Click to expand...

Woops, I had misread it. Normal velocities across elbow with just a bit of prolonged distal latency in the right ulnar nerve. Still would have trouble thinking that would cause her degree of symptoms, unless she's just overselling her symptoms. She had also previously used carpal tunnel braces without significant change.

Needle study was normal, full radic screen bilaterally
 

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Baron Samedi said:
Has me questioning whether or not these perineural cysts could be symptomatic and, if so, what to do about it? I always assumed these were just incidental findings unless they were massive.
Click to expand...

You won't fix numbness but they can be symptomatic. There's not a lot of great treatments. I generally look for someone willing to do this. I would not normally do this myself as I don't do CT guidance.

www.ncbi.nlm.nih.gov

Treatment of 213 Patients with Symptomatic Tarlov Cysts by CT-Guided Percutaneous Injection of Fibrin Sealant

This cohort study assesses outcomes in patients who underwent CT-guided aspiration and injection of sacral Tarlov cysts at Johns Hopkins Hospital from 2003–2013. A total of 289 cysts were treated in 213 consecutive patients, with 83% followed ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
geauxg8rs said:
I think you are missing a terminal s
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Intentional.
Ankylosing Spondylitis for past 50 years. Fx from trying to lift 60 lb suitcase full of shotgun shells then falling to ground.
I need Xrays to see if there is a path to fix the Fx. This will not look easy on fluoro.
 
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Insidious onset 6 week ago. No trauma. Current Sx are merely stiffness. Severe lumbar stenosis is why I normally see her. No cancer Hx. Normal physical exam except tender to palpation at the neck. Strength and reflexes normal. Neg Hoffman.

WTF? Probably chronic I guess...Malignancy? Plasmacytoma or myeloma or something?

No CA Sx - Sweats, weight loss, etc...

MRI with/without and CT.
Collar.
Norco TID (chronic Rx I bumped to TID from BID - Stable and functional opiate patient).
 

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post the MRI picks when you can without telling us the dx

cancer is my bet
 
chudat said:
My moneys on myeloma or osteorporosis
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C3 is a funny place for osteoporosis though. I know children break at C2 or C3, but I can't say I can recall an adult C3 fracture from osteoporosis.

Minimal motion at C3 relative to C5-7.

Just an odd place for a fracture like that.
 
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SommeRiver said:
Insidious onset 6 week ago. No trauma. Current Sx are merely stiffness. Severe lumbar stenosis is why I normally see her. No cancer Hx. Normal physical exam except tender to palpation at the neck. Strength and reflexes normal. Neg Hoffman.

WTF? Probably chronic I guess...Malignancy? Plasmacytoma or myeloma or something?

No CA Sx - Sweats, weight loss, etc...

MRI with/without and CT.
Collar.
Norco TID (chronic Rx I bumped to TID from BID - Stable and functional opiate patient).
Click to expand...
That all sounds good for management but while you’re waiting for the MRI, any prior imaging catch that area? Maybe a CT or MRI head, T spine with a scout image, or even an old cervical x ray if you’re lucky?
 
Epiducer /S8. Crap.
 
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Those weren’t crap. They were fun. Biggest thing you could stuff in the epidural space without a lami. Just took out a pair of S8s and a Protege IPG. I placed the S8s in 2007-09. Lady had a battery implanted in 2019 even though she only consented for explant. I took out all of it 2 weeks ago. Had the epiducer in my collection.
 
We use to place a S8 first and then a octrode in fellowship. Justiz didn’t think that two S8’s would fit.
 
Let's all take a moment and thank capitalism and its role in innovation bc that looks like it sucks...
 
It wasn’t bad at all. Access one side at a nice flat angle. Guidewire, ensure nicely posterior. White dilator and then gray. The S8’s were a bit hard to steer but do-able. We would probably still be doing them if they made a MRI compatible S8.
 
BobBarker said:
It wasn’t bad at all. Access one side at a nice flat angle. Guidewire, ensure nicely posterior. White dilator and then gray. The S8’s were a bit hard to steer but do-able. We would probably still be doing them if they made a MRI compatible S8.
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I agree. More fun to use in OR, but stiff as heck and can easily see potential for neural injury. Flipping those suckers face down when they rolled was always a challenge. After 10 years in, they still slid right out.
 
Is that an introducer and the lead?
 
The introducer was a blessing and a curse. If it bumped up on the lamina you messed it up and needed a new one. It was nice to put 2-3 leads through one access. I used the introducer once to exchange a lead like you would a central line over a wire.
The S-8 itself I think appealed to those who wanted to feel like they could put a paddle in without a surgeon. It certainly wasn’t a PENTA. It was a new toy. I recall talk about a paddle that would deploy through a needle and unfold in the epidural space. I guess all of the new wave forms put these toys into CabbagePatch doll status. Last year’s Sears Xmas catalog so to speak- for those old enough to remember paper catalogs.
 
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More pics. Wide introducer. Can put 3 leads through it.
 

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Wow...So one epidural access and thread several leads?

That's cool.
 
BobBarker said:
Doug Beall is going to put a balloon in it and cement it.
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My pt canceled. We called repeatedly last week and she finally answers the phone today. Said she went to the ED for constipation.

Now I'm ordering STAT imaging and she's saying she can't go bc she has no ride and then questions whether it is "necessary."

I told her in the clinic I'm worried about CA, and here we are still with no advanced imaging.
 
Toughest trial in years for me today. Multiple back surgeries. 3 mo ago had medtronic implant without trial and explanted a week later due to csf leak. Has broken hardware at T12.
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Glad you were able to place this lead.

Could you explain what your thought process was to retrial this patient?

Would be interesting to see how they respond. What’s your trial plan for waveforms? Was previously explanted system a paddle or perc?
 
What were the prior surgeries? Can’t really see the anatomy on the photos. Did you enter at a level with intact lamina and navigate through area with laminectomies??
 
No prior trial. Emory U just popped in a Medtronic paddle and ipg without a trial. Complications occurred leading to explant a week later.
She had multiple level discectomy and fusion. Highest hemilami was left L2. Spinous processes clipped and pedicle screws placed iliacs to T9. Several levels had cages placed.
Tough 69 y/o and I beat the heck out of her with no IV, just 6 cc lidocaine. Tried T12-L1 and fIled to find interlaminar space. Just angled up and stretched her skin to enter T11-12. She weighs 110 lbs and I moved her body while advancing 14G through scar. A lot tougher than I am.
 
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Good job. Impressive.

Emory Neurosurgery I bet. They do that all the time.
 
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I don’t understand the surgery. I see a lot of fixated healthy levels. And no fusions other than the hardware.
 
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