Pictures of the Week

[lobelsteve]

40 yo M with stone cold normal imaging. He even has cervical lordosis, which in my day to day experience I never see.

On this regimen for yrs. Goes to prison for a yr, withdraws in prison, gets out Feb 2nd and MVC Feb 3rd.

Deaf. Communication through a laptop computer with a person on the other end using sign language.

PCP writing this BS.

120mg oxy per day for "scoliosis," which doesn't exist.

PT + baclofen from me.

View attachment 350705

Definition of drug dealing. 180 dose units of same drug in different dose forms. No bueno.

---

Members don't see this ad.

 

[lobelsteve]

Worst T-score I have seen.

 

[The JockDoc]

31F with 3 years of insidious midline cervical and upper thoracic spine pain. 1 year of PT, NSAIDs, chiropractic, massage all unhelpful. Inflammatory labs negative. I got the c-spine MRI. Initial read was atypical lipid poor hemangioma versus vertebral metastasis. Thoracic spine MRI was normal. Oncological work-up - labs, bone scan, CT chest abdomen pelvis, and mammogram all negative.

Referred to neurosurg who was also unsure, presented her case to tumor board. Deemed it most likely an atypical hemangioma, rec against bone biopsy or corpectomy, but continue surveillance with serial MRIs.

Not sure what I’ll do next to help her. If hemangioma is causing pain there's no good treatment for that anyhow. Thoughts?

Time for PRP/stim/BMAC? /s

 

[unchockey21]

31F with 3 years of insidious midline cervical and upper thoracic spine pain. 1 year of PT, NSAIDs, chiropractic, massage all unhelpful. Inflammatory labs negative. I got the c-spine MRI. Initial read was atypical lipid poor hemangioma versus vertebral metastasis. Thoracic spine MRI was normal. Oncological work-up - labs, bone scan, CT chest abdomen pelvis, and mammogram all negative.

Referred to neurosurg who was also unsure, presented her case to tumor board. Deemed it most likely an atypical hemangioma, rec against bone biopsy or corpectomy, but continue surveillance with serial MRIs.

Not sure what I’ll do next to help her. If hemangioma is causing pain there's good no treatment for that anyhow. Thoughts?

Time for PRP/stim/BMAC? /s

What’s her exam?

 

[RoloTomassi]

Start with MBB. Might be red herring

 

[lobelsteve]

31F with 3 years of insidious midline cervical and upper thoracic spine pain. 1 year of PT, NSAIDs, chiropractic, massage all unhelpful. Inflammatory labs negative. I got the c-spine MRI. Initial read was atypical lipid poor hemangioma versus vertebral metastasis. Thoracic spine MRI was normal. Oncological work-up - labs, bone scan, CT chest abdomen pelvis, and mammogram all negative.

Referred to neurosurg who was also unsure, presented her case to tumor board. Deemed it most likely an atypical hemangioma, rec against bone biopsy or corpectomy, but continue surveillance with serial MRIs.

Not sure what I’ll do next to help her. If hemangioma is causing pain there's good no treatment for that anyhow. Thoughts?

Time for PRP/stim/BMAC? /s

I see those white bones all the time. Atypical hemangioma. Move on. MBB reasonable. Doug Bealle would kypho this. And there is literature to suggest kyphoplasty for painful hemangiomas as helpful. I would not.

 

[The JockDoc]

What’s her exam?

Aside from some mid-lower spinous process tenderness, pretty normal including rom, spurlings, upper limb neuro, shoulder exam. Pain is worst when she runs.

 

[The JockDoc]

I see those white bones all the time. Atypical hemangioma. Move on. MBB reasonable. Doug Bealle would kypho this. And there is literature to suggest kyphoplasty for painful hemangiomas as helpful. I would not.

I was thinking MBB - why not. Kypho makes me nervous.

 

[Taus]

Young patient. No trauma. Not much spondylosis. Why would it be the facets? Granted, pretty benign intervention and limited options…

 

[RoloTomassi]

Young patient. No trauma. Not much spondylosis. Why would it be the facets? Granted, pretty benign intervention and limited options…

I've seen a fair number of young, healthy, benign MRI patients with atraumatic facet pain responsive to RFA. Not sure why they get it though. Definitely more common if sports, MVA, scoli involved.

 

[MitchLevi]

Don't need facet OA to hurt.

 

[chudat]

Bone scan/PET was neg right? Why would METs still be high on differential?

 

[The JockDoc]

Bone scan/PET was neg right? Why would METs still be high on differential?

No longer high on my differential. Neurosurg/tumor board more CYA at this point. Which is fine b/c I also wanted to CYA myself with their input.

 

[BobBarker]

The first vertebroplasty was done for an atypical hemangioma. I think it was at c1 or c2 and done through the mouth.

 

[drrosenrosen]

73F axial neck pain with radiation to R arm, C6 distribution. No weakness, tingling, decreased biceps brach reflexes. She has adjacent segment disease with bilateral neuroforaminal stenosis at C5-6 - easy peasy. Except, she's got this fluid collection right at the nuchal ligament at C5-6. Dark on T1. Radiologist reads it as bursitis vs hematoma. There is a palpable mass from the skin, which is exquisitely tender. Pain has been present since a fall six weeks ago - she's in a c collar, reports that any movement, flexion extension rotation, causes severe pain. She wants me to aspirate it. I agree that might help the pain, but I never like poking sterile fluid collections.

I'm considering that the hematoma is a red herring, and just doing a CESI for the NF stenosis with concordant pain, turning up her gabapentin. If that doesn't work, might consider doing something with it. Ideas?

 

[Ducttape]

Severe neck pain.

multiple medical problems.

CAD, with LVAD.
admitted some months ago with E. coli bacteremia probably due to submandibular gland infection.

during hospital stay for 4 weeks of IV antibiotics, noted some increasing neck pain. thought it was due to being in the uncomfortable hospital bed. posterior neck pain. no radiation.

discharged on home ertapenem, but neck pain got worse, so he was referred and seen by me.

of note, CT soft tissue neck a week before i saw him was read as mild to moderated degenerative changes especially C67 and C7T1, and moderate spinal stenosis. no acute fracture. no submandibular abscess seen that was seen on CT 2 weeks previously.

Bone scan 3 weeks before presentation was negative for infection. gallium scan 5 days before presentation showed uptake in right ribs at T11.


on presentation - patient in wheelchair. unable to walk. any movement of cervical spine in any direction causes excruciating pain. weak subjectively all extremities 4/5, but seems primarily due to pain from movement of cervical spine. no foot drop. reflexes biceps, brachiradialis, knee, patellar all 3/3 and equal. no clonus. babinski negative.

1 week before i saw the patient:

bone scan 1 week before:

 

[Ducttape]

these are images 3 weeks after i saw patient. they were ordered the day i saw the patient, but because of his cardiac issues, they were not done for 3 weeks.

 

[Taus]

these are images 3 weeks after i saw patient. they were ordered the day i saw the patient, but because of his cardiac issues, they were not done for 3 weeks.

View attachment 351140View attachment 351141

Ugh. No beuno. Who ate his c56 endplates? This won’t end well.

Had a similar case in L spine recently. Pcp referred for “esi eval”. Started a couple months prior while in icu for sepsis from uti. Debilitating axial lbp. Had mri in hospital that read as most likely advanced ddd Ls1/end plate changes, could not rule out infection….. repeat scan without contrast due to renal failure. Was highly suspicious. Got ct to eval endplates further. Labs were not helpful as recent major infection, other then to trend them. Hardest part is coordinating proper treatment with ID, IR, spine surgery…. Near impossible as outpatient in a timely fashion. Sent to ED for inpatient workup/tx after calling ED


Well It was either that or just jump to bvn rf…

 

[lobelsteve]

these are images 3 weeks after i saw patient. they were ordered the day i saw the patient, but because of his cardiac issues, they were not done for 3 weeks.

View attachment 351140View attachment 351141

Mushy C6 syndrome.

 

[lobelsteve]

Boring case report:

57 y/o male with HNP L5-S1, paramedian and right leg pain to little toe.
Home exercise program, Lyrica, Robaxin.

Nothing exciting. People frequently ask for pics of common procedures.

 

[unchockey21]

Boring case report:

57 y/o male with HNP L5-S1, paramedian and right leg pain to little toe.
Home exercise program, Lyrica, Robaxin.

View attachment 351175View attachment 351176
View attachment 351177
View attachment 351178

Nothing exciting. People frequently ask for pics of common procedures.

I expect to see this presented on your new instagram with a little more pizazz.

 

[lobelsteve]

I expect to see this presented on your new instagram with a little more pizazz.

It will be reserved for cool stuff, comedy, and medical misadventures only.

 

[deleted875186]

Boring case report:

57 y/o male with HNP L5-S1, paramedian and right leg pain to little toe.
Home exercise program, Lyrica, Robaxin.

View attachment 351175View attachment 351176
View attachment 351177
View attachment 351178

Nothing exciting. People frequently ask for pics of common procedures.

How much contrast do you typically do?

 

[lobelsteve]

How much contrast do you typically do?

2-5cc. Depends on what I do and do not see.

 

[lobelsteve]

CT pending. No trauma.

 

[Taus]

Ugh. No beuno. Who ate his c56 endplates? This won’t end well.

Had a similar case in L spine recently. Pcp referred for “esi eval”. Started a couple months prior while in icu for sepsis from uti. Debilitating axial lbp. Had mri in hospital that read as most likely advanced ddd Ls1/end plate changes, could not rule out infection….. repeat scan without contrast due to renal failure. Was highly suspicious. Got ct to eval endplates further. Labs were not helpful as recent major infection, other then to trend them. Hardest part is coordinating proper treatment with ID, IR, spine surgery…. Near impossible as outpatient in a timely fashion. Sent to ED for inpatient workup/tx after calling ED


Well It was either that or just jump to bvn rf…

Pics of my case… hospital later got contrast study as renal labs were good enough at that time. Non-con T2, stir, then CT, then post contrast

 

[lobelsteve]

Pics of my case… hospital later got contrast study as renal labs were good enough at that time. Non-con T2, stir, then CT, then post contrast

BVN RFA should take care of it.

 

[lobelsteve]

Left leg weakness and sciatica. Chronic. In AFO. Lofstrand. Sent for S1 tfesi as effective in past. Did not bring in imaging. Did procedure. Better x 3 days. At follow up drops off MRI. Of leg.

 

[RoloTomassi]

Wow you ordered it or old study?

 

[lobelsteve]

Wow you ordered it or old study?

Old study

 

[Baron Samedi]

View attachment 351193

CT pending. No trauma.

Rheumatoid arthritis?

 

[lobelsteve]

Rheumatoid arthritis?

Nope. CT with old type 2 dens Fx.

 

[lobelsteve]

Myelogram shows T2-3 stenosis. Going in for T1-3 fusion. Because.

 

[SSdoc33]

i like the cervical disc arthoplasties. thats a nice touch

 

[MitchLevi]

Poor guy. One life to live. You get one turn at this thing. No do-overs. Awful.

Hips got did too. Someone should have been the adult in the room and contained this long ago.

 

[lobelsteve]

I tried.

 

[RoloTomassi]

How are the above not legit? Some scolis need T3-ilium. Cervical ADRs good choice if indicated to at least theoretically lessen adjacent segment disease but unfortunately it happened anyway, and if myelopathic there's no option. Hips affected by rigid spine. Bad genetics.

 

[MitchLevi]

How are the above not legit? Some scolis need T3-ilium. Cervical ADRs good choice if indicated to at least theoretically lessen adjacent segment disease but unfortunately it happened anyway, and if myelopathic there's no option. Hips affected by rigid spine. Bad genetics.

IMO, you don't need to treat someone bc they have pain, especially if the treatment is that pic...

Genetics are no doubt to blame, but how many times have you seen absurd fusions done with zero conservative care previously?

I see it...A LOT.

Edit - The chair of my pain fellowship was a past president of one or two pain societies. One of the more well-known men in the field. He gave me sage wisdom one day when he told me "the role of a pain physician in many cases is simply containment."

He was dead on with that.

Let people hurt.

I debated him about opiates one day bc I thought I was real smart and he was old fashioned...He politely reduced me to ashes. Haha. Gently and carefully slit my throat in the nicest way possible.

 

[RoloTomassi]

IMO, you don't need to treat someone bc they have pain, especially if the treatment is that pic...

Genetics are no doubt to blame, but how many times have you seen absurd fusions done with zero conservative care previously?

I see it...A LOT.

Plenty. Just saying there's probably more context to that story. Deformity surgeons aren't the most money hungry in my opinion. Not the most valuable cases.

 

[Ducttape]

wow, steve, i didnt know Wolverine was your patient.

 

[deleted875186]

View attachment 351488

Myelogram shows T2-3 stenosis. Going in for T1-3 fusion. Because.

Some scoliosis repairs are legit. No way to know unless you saw some preop imaging. But I agree this was probably too invasive, probably one of those patients who takes the word of a single surgeon as the end all, thats how he ended up with two cervical disc replacements and hips and a spine fusion, and yet still in the pain clinic ….

 

[RoloTomassi]

IMO, you don't need to treat someone bc they have pain, especially if the treatment is that pic...

Genetics are no doubt to blame, but how many times have you seen absurd fusions done with zero conservative care previously?

I see it...A LOT.

Edit - The chair of my pain fellowship was a past president of one or two pain societies. One of the more well-known men in the field. He gave me sage wisdom one day when he told me "the role of a pain physician in many cases is simply containment."

He was dead on with that.

Let people hurt.

I debated him about opiates one day bc I thought I was real smart and he was old fashioned...He politely reduced me to ashes. Haha. Gently and carefully slit my throat in the nicest way possible.

Sounds like a smart guy, what was his stance on opioids?

 

[deleted875186]

View attachment 351488

Myelogram shows T2-3 stenosis. Going in for T1-3 fusion. Because.

Im always unsure what to tell patients about an overly aggressive surgical consult. I tell them professionally and politely that I think the surgery is too invasive and they should have a second surgical opinion, but part of me thinks I should give a stronger opinion.

 

[MitchLevi]

Im always unsure what to tell patients about an overly aggressive surgical consult. I tell them professionally and politely that I think the surgery is too invasive and they should have a second surgical opinion, but part of me thinks I should give a stronger opinion.

I give strong opinions even when the pt is being seen by one of the surgeons in my group.

Rolo - Basically, there's a role for opiates. Some ppl will benefit from them, just be careful. He is overwhelmingly nuanced though...Name is Sean Mackey.

Younger pain doctors won't know him, bc younger pain doctors only know doctors sponsored by Abbott or Nevro or Boston...Vertos...

At one time, society presidents were well-known...From what I've heard at least.

 

[callmeanesthesia]

I give strong opinions even when the pt is being seen by one of the surgeons in my group.

Rolo - Basically, there's a role for opiates. Some ppl will benefit from them, just be careful. He is overwhelmingly nuanced though...Name is Sean Mackey.

Younger pain doctors won't know him, bc younger pain doctors only know doctors sponsored by Abbott or Nevro or Boston...Vertos...

At one time, society presidents were well-known...From what I've heard at least.

I know him by reputation. Smart guy. I send complex (especially when bio-psycho-social interactions) patients to the Stanford pain program for an eval when they are willing to make the trek.

 

[SSdoc33]

I give strong opinions even when the pt is being seen by one of the surgeons in my group.

Rolo - Basically, there's a role for opiates. Some ppl will benefit from them, just be careful. He is overwhelmingly nuanced though...Name is Sean Mackey.

Younger pain doctors won't know him, bc younger pain doctors only know doctors sponsored by Abbott or Nevro or Boston...Vertos...

At one time, society presidents were well-known...From what I've heard at least.

you don't really do anything half-assed, do you?

 

[MitchLevi]

you don't really do anything half-assed, do you?

...prob my unfortunate downfall, but I've a theory about this - If you have dynamic eyebrow movement you can say anything and get away scot-free.

This requires verbal communication in a face-to-face setting.

Email or text or dictation...No eyebrows. Be careful.

 

[lobelsteve]

 

[lobelsteve]

View attachment 351618

L1, read as normal.
Fell down the stairs.

 

[Orin]

L1, read as normal.
Fell down the stairs.

That cord looks froggy in there.

Is that an avulsion/bruise though at the spinous process with a fracture of the left TP?