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Facet capsule. Less likely okada via pars defect. Need obliques to say for sure.
Pictures of the Week
- Thread starter Epidural
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What a joke. Who referred that patient for that?! PCP?
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Got STIR? Report mentions consult IR for kypho? If no and yes, then that seems usual in some places.
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You win some, you lose some I guess.
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Story time! (It’s a long one, but lots of pictures) showing evolution of discitis.
Patient with history of chronic back pain, prior improvement with injections, and Hx of lung cancer and pacemaker presented to my partner as well as to ER several times with new severe (debilitating) back pain. CT scan shows significant degenerative changes, “severe multilevel lumbar spondylosis with erosive endplate changes at L2-3.”
Prior CT for lung cancer screening done 3/21
CT angio obtained in the ER 5/10/21 for “radiating chest pain and diffuse abdominal pain”
New CT lumbar obtained by my partner 6/14/21. Radiologist notes significant degenerative changes, “severe multilevel lumbar spondylosis with erosive endplate changes at L2-3.”
He then obtains a bone scan on 6/22 due to severity of the patient’s pain. The bone scan is read as moderate to severe osteoarthritis changes particularly at L2-3, with compression not excluded. Also gave him oxycodone at this point which did not touch the pain.
At this point. My partner asks me to see him for possible kyphoplasty. I review the imaging and agree to see the patient but also ask him to order WBC, ESR, and CRP as it doesn’t look quite right for a compression fracture. Patient sees me next day, still hasn’t had labs done. We discuss possible kypho - the guy is absolutely miserable from the back pain but denies any infectious symptoms. Prior WBC from one of his ER trips was normal. I tell him I need those labs first and we need a blood thinner clearance from his cardiologist.
Yesterday, labs come back. WBC 12.8, ESR 35, CRP 73.
I called him and told him he needed to go the the ER for new imaging, spine surgeon consultation, and likely biopsy and IV antibiotics. He fought it because they hadn’t helped him before but ultimately agreed.
CT scan in the ER reads discitis with surrounding cellulitis. Had CT-guided biopsy the next day.
Patient with history of chronic back pain, prior improvement with injections, and Hx of lung cancer and pacemaker presented to my partner as well as to ER several times with new severe (debilitating) back pain. CT scan shows significant degenerative changes, “severe multilevel lumbar spondylosis with erosive endplate changes at L2-3.”
Prior CT for lung cancer screening done 3/21
CT angio obtained in the ER 5/10/21 for “radiating chest pain and diffuse abdominal pain”
New CT lumbar obtained by my partner 6/14/21. Radiologist notes significant degenerative changes, “severe multilevel lumbar spondylosis with erosive endplate changes at L2-3.”
He then obtains a bone scan on 6/22 due to severity of the patient’s pain. The bone scan is read as moderate to severe osteoarthritis changes particularly at L2-3, with compression not excluded. Also gave him oxycodone at this point which did not touch the pain.
At this point. My partner asks me to see him for possible kyphoplasty. I review the imaging and agree to see the patient but also ask him to order WBC, ESR, and CRP as it doesn’t look quite right for a compression fracture. Patient sees me next day, still hasn’t had labs done. We discuss possible kypho - the guy is absolutely miserable from the back pain but denies any infectious symptoms. Prior WBC from one of his ER trips was normal. I tell him I need those labs first and we need a blood thinner clearance from his cardiologist.
Yesterday, labs come back. WBC 12.8, ESR 35, CRP 73.
I called him and told him he needed to go the the ER for new imaging, spine surgeon consultation, and likely biopsy and IV antibiotics. He fought it because they hadn’t helped him before but ultimately agreed.
CT scan in the ER reads discitis with surrounding cellulitis. Had CT-guided biopsy the next day.
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Looks like an inadvertent mistake. Should have done L2 and L3. L3 still fractured.
Agreed. Counting can be hard in osteopenic bones with huge disc spaces. It may have been completely not indicated, but that MRI series alone does not provide enough to make the decision.
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Radiologist read that as osteoarthritis at L2-L3 on the bone window???
Sweet baby jesus. Mustve been chiropractor radiologist.
How is everyones local radiologists? Some horror stories in here.
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Agree would need STIR and patient history to know if really indicated but “counting is hard” is not an excuse here - you can pretty clearly see the nice rectangular shape of the vertebral body on the procedure images. I always put spinal needles down to the pedicles and count and check AP/lateral before proceeding, both to verify the target and approach, and to check for new fractures.
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Well, they did note prominent erosive changes, but no mention of discitis being in the differential, even as a “cannot exclude” or “clinical correlation recommended.” If my family ever needs radiology I’ll be asking a friend to over-read it.
Local rads horrible. Pushed to read as many studies as possible and never look at clinical notes.
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PA PCP referred to IR for fx, and me. IR got to her first. First consult I've seen from them.
His HPI: " She describes the pain is eight out of 10 with prolonged standing. Pain is relieved with sitting..."
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Bisphosphonate-induced atypical hip fracture. Referred from Ortho partner for repeat hip injection after 4 months of relief from last one. Patient had not had recent formal x-ray of hips - she was referred to my partner by her chiropractor who had already gotten x rays of the lumbar which also showed moderate-severe hip OA. Prior hip injection and the lumbar x rays were not low enough to see it. This was my first shot getting the fluoro lined up (Sorry for sideway pic, and the needle isn’t in the patient, just a marker held above)
Canceled injection, sent patient for formal x ray, and texted my partner. She’s having her hip replaced on Monday. Partner said this is quite rare but seen with certain bisphosphonates. It’s a chronic process that has likely been evolving for months at least. The beaked appearance is highly characteristic.
Canceled injection, sent patient for formal x ray, and texted my partner. She’s having her hip replaced on Monday. Partner said this is quite rare but seen with certain bisphosphonates. It’s a chronic process that has likely been evolving for months at least. The beaked appearance is highly characteristic.
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Here is a nice review.
Bisphosphonates and atypical subtrochanteric fractures of the femur
Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related ...
www.ncbi.nlm.nih.gov
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Occipital stim trial
Nice job. These seem so innocuous. About 15 years ago at a major NYC teaching hospital they did an “uneventful” trial. At the end patient unresponsive. CT scan revealed leads were intracranial.
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This is what happens when your back orders all come in at the same time
such a beta move
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Degenerative correct?
TKR approx 9 months ago with C diff requiring hospital admission for large volume potassium infusion, ABx, IVF and severe febrile diarrhea.
Pain in a T8-10 referral pattern + thoracolumbar pain R > L.
No current fevers or anything worrisome on that end, just pain.
TKR approx 9 months ago with C diff requiring hospital admission for large volume potassium infusion, ABx, IVF and severe febrile diarrhea.
Pain in a T8-10 referral pattern + thoracolumbar pain R > L.
No current fevers or anything worrisome on that end, just pain.
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Hey, it was a part epidural.
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ha yup. Glad I was in asc as I had dsa available for re-injection of contrast after repositioning.
D
deleted875186
I suppose that why you need live while injecting contrast
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deleted875186
Just for discussion, why not abort the procedure. Aren’t there people who say the paralysis from TFESI could be from spasm and or trauma from the needle to a radicular artery, rather than particulate steroid? Why not just remove needle completely and come back another day and not risk it?
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I
i thought about it…. In the moment I reasoned that what’s done is done in terms of artery stick and if I retract needle back a little and get pure root flow/epidural on dsa I’d just inject the dex. I wasn’t about to advance needle or significantly reposition needle elsewhere in foramen.
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Have you ever seen that with interlaminar?
are there ANY case reports of a cord infarct with dex in the L-spine? seems like the vasospasm theory mainly applies to the C-spine and vertebral arteries. i would not have aborted the procedure -- just repositioned
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:::::Pain Physician:::::
www.painphysicianjournal.com
Spinal cord injury complicating a thoracolumbar selective nerve root block in a deformed spine: neurological and functional outcome - Spinal Cord
A case report of a female patient who sustained injury to the thoracic spinal cord as a direct result of thoracolumbar selective nerve root block. To raise the awareness that selective nerve root infiltration, a very common procedure in a pre-existing deformity, may cause injury to the spinal...
www.nature.com
Here's two, I think there are more though
The first paper: No images of needle positioning. Conus infarct with L4 TFESI though is concerning for a vessel/needle interaction irrespective of drug.:::::Pain Physician:::::
www.painphysicianjournal.com
Spinal cord injury complicating a thoracolumbar selective nerve root block in a deformed spine: neurological and functional outcome - Spinal Cord
A case report of a female patient who sustained injury to the thoracic spinal cord as a direct result of thoracolumbar selective nerve root block. To raise the awareness that selective nerve root infiltration, a very common procedure in a pre-existing deformity, may cause injury to the spinal...
Here's two, I think there are more though
That second paper: "left side T12 root with 80 mg of dexamethasone and 10 ml of 1% lignocaine". That's hopefully a typo or they actually injected depomedrol/kenolog and way too much local.
:::::Pain Physician:::::
www.painphysicianjournal.com
Spinal cord injury complicating a thoracolumbar selective nerve root block in a deformed spine: neurological and functional outcome - Spinal Cord
A case report of a female patient who sustained injury to the thoracic spinal cord as a direct result of thoracolumbar selective nerve root block. To raise the awareness that selective nerve root infiltration, a very common procedure in a pre-existing deformity, may cause injury to the spinal...
Here's two, I think there are more though
thats right. i remember that L4 report. good call. very strange case
D
deleted875186
Also, T12 TFESI for a compression fracture with back pain … wtf
D
deleted875186
Evicore would have a field day with this.
This is why they exist
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sorry, did not save totally.
LSB for presumed CRPS. contrast pattern "funky"... sorry poor quality image.
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Hey guys, new fellow here. Got this referral from ortho, young male with cerebral palsy, basically non verbal, had girdlestone procedure for intractable right hip pain (dysplasia, chronic dislocation/subluxation), 12 months out now. Pain is worse than before, can't lie down flat, parents having difficulty with basic hygiene, sleeping in his chair, getting pressure sores as a result. Any movement of the right hip causes severe pain. Any thoughts on an attempt at hip denervation? Will present case at rounds this week so will get some ideas there too.
Some images below, CT and one xray 1 year post procedure, one xray prior to surgery. Thanks!
Some images below, CT and one xray 1 year post procedure, one xray prior to surgery. Thanks!
Less excited about hip blocks, but can trial. Why not ITB for spasticity contributions with trickled in analgesics after baclofen dose is locked in?
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Great idea Orin. We decided to trial lumbar plexus block +- neurolysis if good response but I will look more into ITB as well. It doesn't seem like my unit has much experience with this but we could always refer.
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deleted875186
There is a technique in the textbook that I’ve never seen anyone do before …. Intrathecal neurolysis with alcohol
Seriously, never seen that before? Making me feel old..er.
I am assuming you mean lumbar sympathetic plexus and not the true lumbar plexus?
I have never seen that either.
Considered it. Read about it. Opted to avoid it. There's a resurgence of interest in some of this older stuff, but I think we have better tools.
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Yes you are correct, lumbar sympathetic plexus block!
Did it as a fellow. We had an older British attending who would do it for chest wall pain in CA. He used a technique her called "painting the ceiling (hypobaric ETOH) and carpeting the floor (hyperbaric phenol). Look at chart and determine the levels of the spinal cord that the needed thoracic nerve roots exit and do a thoracic LP at that level. Lateral position - inject ETOH with the affected side UP. If there is pain on the DEPENDENT side then inject phenol. Hold position for 20 minutes. Pretty scary stuff. I tried it once early in my career. Put patient on his side. Lots of difficulty doing LP. Meanwhile, he starts coughing up tons of bright red blood and I abort the mission.
Absolutely a win
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deleted875186
Did this attending have patients that this worked? Any neurological deficits?
In experienced hands it works well. It’s really an art you have to learn from someone because I have never found a good step by step description in a text. Docs in the UK did a lot more of that stuff than anyone did here. The guys here that really knew the art of neurolysis are either dead (Richard Patt) or retired (Subash Jain). I have a buddy here in NJ who trained with and worked alongside Subash Jain at MSK in NY. He on occasion gets asked by the palliative care team at a major NJ hospital to come in and do intrathecal neurolysis. I’ll bet Allen Burton the CMO at Abbott also has quite a bit of neurolysis experience from his days at MD Anderson. Regarding deficits, you need to be doing these on people in whom you don’t care if a deficit develops.
I remember several board questions about this
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Hard to tell without AP, psoas?
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