Pictures of the Week

[deleted875186]

View attachment 351618

Perhaps transverse process fracture, hard to tell without scanning through images. The conus looks normal to me ….

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[BobBarker]

It might not be normal but is anything there “fixable”?

 

[Orin]

It might not be normal but is anything there “fixable”?

@lobelsteve says

I assume after talking to the great IR gurus, he's all in on spinoplasty for spinous process avulsion fractures (Posterior Vertebral Arch Cement Augmentation (Spinoplasty) to Prevent Fracture of Spinous Processes after Interspinous Spacer Implant)

Then he'll milk the site of service to do some erector spinae plane blocks for the transverse process fracture (Erector spinae plane block for bilateral lumbar transverse process fracture in emergency department: A new indication - PubMed), maybe dropping an SPR lead to treat the acute multifidus strain.

But seriously, what're we looking at?

 

[lobelsteve]

Nothing but a left TP fx.

 

[MitchLevi]

Then he'll milk the site of service to do some erector spinae plane blocks for the transverse process fracture (Erector spinae plane block for bilateral lumbar transverse process fracture in emergency department: A new indication - PubMed), maybe dropping an SPR lead to treat the acute multifidus strain.

SPR multifidi is stupid. It is uncomfortable, skin hates it, MoA makes no sense. I'll never do another. This pt still has wire left inside her bc the 300 micron lead fractured.

 

[lobelsteve]

SPR multifidi is stupid. It is uncomfortable, skin hates it, MoA makes no sense. I'll never do another. This pt still has wire left inside her bc the 300 micron lead fractured.

View attachment 351675

Guest of the week. 😁

 

[swamprat]

Minuteman for adjacent segment disease. 3 months now - very happy, can walk with less pain, sit with less pain. Extremely surprised it helped him as much as it did.

 

[lobelsteve]

Minuteman for adjacent segment disease. 3 months now - very happy, can walk with less pain, sit with less pain. Extremely surprised it helped him as much as it did.

Pain with sitting. Delightful. So how’s that work? MOA?

 

[swamprat]

Pain with sitting. Delightful. So how’s that work? MOA?

Discogenic pain along with LSS w/ neurogenic claudication. This is taking pressure off the disc and tilting the vertebral body forward in a vertiflex type fashion for indirect decompression of the neural structures. But of course you knew that right - such a hater lol

 

[SSdoc33]

Discogenic pain along with LSS w/ neurogenic claudication. This is taking pressure off the disc and tilting the vertebral body forward in a vertiflex type fashion for indirect decompression of the neural structures. But of course you knew that right - such a hater lol

dafuq?

 

[lobelsteve]

Discogenic pain along with LSS w/ neurogenic claudication. This is taking pressure off the disc and tilting the vertebral body forward in a vertiflex type fashion for indirect decompression of the neural structures. But of course you knew that right - such a hater lol

Tilting forward and taking pressure of the disc. Time to go back to middle school physics for you.

 

[MitchLevi]

Discogenic pain along with LSS w/ neurogenic claudication. This is taking pressure off the disc and tilting the vertebral body forward in a vertiflex type fashion for indirect decompression of the neural structures. But of course you knew that right - such a hater lol

The opposite right?

Flexion for LSS sure.

 

[swamprat]

Tilting forward and taking pressure of the disc. Time to go back to middle school physics for you.

Those were 2 separate thoughts - depending on the goal you are trying to achieve - I wrote that in one thought so it sounds like doing both. Discogenic pain or LSS not both no **** it putspressure on the disc if you crank it forward too much. If they have both they can get a laminectomy and fusion.

 

[swamprat]

To change subjects - how do you suppose this happened?

 

[lobelsteve]

To change subjects - how do you suppose this happened?

One more and it is Dx for DISH. Xray would show it better. In Georgia we call that age 65+

 

[swamprat]

One more and it is Dx for DISH. Xray would show it better. In Georgia we call that age 65+

However those are HNP not bridging ostephytes

 

[lobelsteve]

However those are HNP not bridging ostephytes

Show me the xray. Those spurs in that parasagital cut appear to curve up. Sure, some fibrous tissue and/or disc is there and we all see this routinely.

 

[Taus]

However those are HNP not bridging ostephytes

You can say that confidently without CT or X-ray? Not that it matters for this patients care, just an academic point

 

[RoloTomassi]

However those are HNP not bridging ostephytes

Look like not uncommon degenerative disc-osteophyte complexes to me.

 

[swamprat]

Show me the xray. Those spurs in that parasagital cut appear to curve up. Sure, some fibrous tissue and/or disc is there and we all see this routinely.

I don’t think I have X-rays but here is an axial cut

 

[lobelsteve]

Get plain films. Call it DISH, offer NSAIDs if not too old/medically frail. Cat/camel exercises.
Limited options for us to make a difference. Offer MBB. Would not do ESI.

 

[SSdoc33]

yeah, this is DISH. if there id a focal anterior single disc herniation, then MAYBE it would cause some trouble. but i doubt it.

this isnt unusual.

you sure you should be throwing in those inter-spinous spacers?

 

[swamprat]

yeah, this is DISH. if there id a focal anterior single disc herniation, then MAYBE it would cause some trouble. but i doubt it.

this isnt unusual.

you sure you should be throwing in those inter-spinous spacers?

My plan was discogram -> at least 2 level minuteman -> SCS trial for "failed back"

 

[drrosenrosen]

 

[drrosenrosen]

39M, back pain for 9months, no inciting injury, although he notes that 20 years ago he was thrown into a pool and caught his back on the edge of the pool, right around that level. Back pain, radiating right groin and inner thigh pain and tingling. No weakness. Trying an ESI. Could be a candidate for Intracept if radic resolves and axial back pain persists.

 

[lobelsteve]

39M, back pain for 9months, no inciting injury, although he notes that 20 years ago he was thrown into a pool and caught his back on the edge of the pool, right around that level. Back pain, radiating right groin and inner thigh pain and tingling. No weakness. Trying an ESI. Could be a candidate for Intracept if radic resolves and axial back pain persists.

Maybe post some axials. Looks at least moderate stenosis. PT vs HEP, ESI at L3 TFESI vs ILESI at L3-4.

 

[DODOCSS]

F/E films?

 

[Taus]

39M, back pain for 9months, no inciting injury, although he notes that 20 years ago he was thrown into a pool and caught his back on the edge of the pool, right around that level. Back pain, radiating right groin and inner thigh pain and tingling. No weakness. Trying an ESI. Could be a candidate for Intracept if radic resolves and axial back pain persists.

Axials, flex/ex or at least standing xrays?
Legit pathology. Still a last resort, and I’d proceed w PT/esi/etc….. but will prob still end up fused

 

[deleted875186]

View attachment 351830
View attachment 351831

That’s a really crappy disc for a 39 yo. Basovertebral ablation would be worth a try if all axial, certainly better than fused.

 

[MD87]

39M, back pain for 9months, no inciting injury, although he notes that 20 years ago he was thrown into a pool and caught his back on the edge of the pool, right around that level. Back pain, radiating right groin and inner thigh pain and tingling. No weakness. Trying an ESI. Could be a candidate for Intracept if radic resolves and axial back pain persists.

From the website: The Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency (RF) generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae.

Not sure if that means that you could do it at L3 but not L2. Maybe if you say L5 is actually an S1 and they have transitional anatomy you could get away with it.

 

[MitchLevi]

Burning it won't correct the slip.

 

[deleted875186]

Burning it won't correct the slip.

But will correcting the slip correct the pain?

 

[RoloTomassi]

Burn it!

 

[MitchLevi]

But will correcting the slip correct the pain?

Stabilizing that offers the best chance of long term success. All these treatments being mentioned will help for some length of time and should be pursued, but the biggest problem is segmental instability.

 

[fathead88]

Agree with drrosenrosen. ESI first, if radicular pain resolved but axial pain persists would offer Intracept but I’m not 100% sure how you would get paid. Isn’t the payment “$xx for the first two levels” but it’s only approved for L3-S1. Not sure if that will fly. But for example if you had modic changes at 2-4 then you could bill 3 and 4 and do 2 for free.

 

[Orin]

Chiropractor couldn't pop that back in?

 

[SSdoc33]

this will end up being fused. i might try an ESI if there is radicular pain, but the guy will need an L2-3 fusion and he "should" do well with it. not all fusions cause pain -- just the ones that end up in our office

 

[Taus]

But will correcting the slip correct the pain?

So when surgeons do a fusion in a case like this we, as pain docs, question and condemn it?

But when pain docs do a “fusion” it’s totally indicated, a good thing and deserves a group high-five on linked in?

I’m so confused…..

 

[MitchLevi]

So when surgeons do a fusion in a case like this we, as pain docs, question and condemn it?

But when pain docs do a “fusion” it’s totally indicated, a good thing and deserves a group high-five on linked in?

I’m so confused…..

Correct, IF you're a Rolex, Patek or Audemars guy.

Tudor and below LOL...

Pt in this thread needs to ride the ESI for awhile and then get fused.

 

[deleted875186]

So when surgeons do a fusion in a case like this we, as pain docs, question and condemn it?

But when pain docs do a “fusion” it’s totally indicated, a good thing and deserves a group high-five on linked in?

I’m so confused…..

Im not condemning, just saying we know the long term consequence of a fusion.

I meant more along the lines of, does correcting the slip actually correct pain, or is it just removing the diseased disc that does it. If removing the diseased disc is the main thing, theoretically the intercept should also have just as goid an outcome.

 

[Taus]

Im not condemning, just saying we know the long term consequence of a fusion.

I meant more along the lines of, does correcting the slip actually correct pain, or is it just removing the diseased disc that does it. If removing the diseased disc is the main thing, theoretically the intercept should also have just as goid an outcome.

Sorry- I wasn’t specifically directing my reply at you, just a general theme on this thread and pain docs doing fusions in general

 

[RoloTomassi]

Might not be mobile if it's from old injury and only require a lami. Or dare I say Minuteman before surgery on a 39 yo?

 

[callmeanesthesia]

Why has no one mentioned $tem cell$?!

 

[MitchLevi]

We need flex/ex plain films of course, but common things are common and this pt needs to be stabilized at some point.

ESI should go first, and I'd exhaust that avenue before moving on...

Unstable translation, not just a dead disk...Meaning, the pt is actively slipping during flex/ex movements and the pain comes from that instability, and that's the reason so many pts do well after fusing these.

We're not talking spondylosis with 3 level spinal and foraminal stenosis with lateral recess obliteration and 3 level fixed degenerative listhesis. That's a different fusion pt.

No one wants to do surgery on a 39 yo, but I'm not going to stand in the way of that pt receiving what we all know to be a much more definitive solution.

Maybe some of you who do Modic burns have great results but this isn't just a dead disk with endplate edema - The disk collapse lead to the instability and the instability is most likely your culprit.

 

[deleted875186]

We need flex/ex plain films of course, but common things are common and this pt needs to be stabilized at some point.

ESI should go first, and I'd exhaust that avenue before moving on...

Unstable translation, not just a dead disk...Meaning, the pt is actively slipping during flex/ex movements and the pain comes from that instability, and that's the reason so many pts do well after fusing these.

We're not talking spondylosis with 3 level spinal and foraminal stenosis with lateral recess obliteration and 3 level fixed degenerative listhesis. That's a different fusion pt.

No one wants to do surgery on a 39 yo, but I'm not going to stand in the way of that pt receiving what we all know to be a much more definitive solution.

Maybe some of you who do Modic burns have great results but this isn't just a dead disk with endplate edema - The disk collapse lead to the instability and the instability is most likely your culprit.

Sure if there is movement on flex extension and symptoms with flex ion in everyday life, then he needs a fusion. If not and it’s stable, no way to tell if it’s from the disc or from the lithesis, why not try intracept.

 

[MitchLevi]

Sure if there is movement on flex extension and symptoms with flex ion in everyday life, then he needs a fusion. If not and it’s stable, no way to tell if it’s from the disc or from the lithesis, why not try intracept.

Sure. Try it. At best you're buying time on the order of months. From a 30k foot view I can't see the utility of it long term.

 

[SSdoc33]

Sure if there is movement on flex extension and symptoms with flex ion in everyday life, then he needs a fusion. If not and it’s stable, no way to tell if it’s from the disc or from the lithesis, why not try intracept

1. because it will put a hole in their vertebra
2. because it costs a ton of money that the patient MAY need to pay out of pocket
3. because it will get the patient's hopes up
4. because it will delay treatment
5. --and most importantly -- because it won't work

 

[BobBarker]

Hybrid Nalu implant

 

[RoloTomassi]

1. because it will put a hole in their vertebra
2. because it costs a ton of money that the patient MAY need to pay out of pocket
3. because it will get the patient's hopes up
4. because it will delay treatment
5. --and most importantly -- because it won't work

It doesn't really put a hole in there. The trocar/stylet tract heals up quick, like kypho tract.

 

[deleted875186]

1. because it will put a hole in their vertebra
2. because it costs a ton of money that the patient MAY need to pay out of pocket
3. because it will get the patient's hopes up
4. because it will delay treatment
5. --and most importantly -- because it won't work

I would try intracept before getting a fusion. All the above arguments are unfounded, except for it may potentially cost something out of pocket. Delay treatment? What is the risk of delaying a fusion for chronic axial back pain.