Pictures of the Week

[deleted875186]

Sending out 14 consult notes to her current prescribers?

I don’t send out consult notes to all the providers, just the PCP. All the providers writing scripts are required to check the PMP, so they are aware of all the poly pharmacy.

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[MitchLevi]

Those pain MDs are part of the same group. I recognize a few of the names.

Either way, not getting in my clinic.

 

[lobelsteve]

Pretty pars.

 

[lobelsteve]

A little tight, in the entire L-spine.

 

[cowboydoc]

A little tight, in the entire L-spine.

View attachment 354479

How many vertiflexes do you have on hand??

 

[lobelsteve]

How many vertiflexes do you have on hand??

Happily none

 

[SSdoc33]

A little tight, in the entire L-spine.

View attachment 354479

grow a pair and walk it off. people just arent tough enough these days....

 

[lobelsteve]

grow a pair and walk it off. people just arent tough enough these days....

Counselling regarding not walking outdoors on uneven surfaces. Has recumbent and treadmill at home.

 

[SSdoc33]

Counselling regarding not walking outdoors on uneven surfaces. Has recumbent and treadmill at home.

thats a L1-S1 fusion or nothing at all

 

[lobelsteve]

thats a L1-S1 fusion or nothing at all

Nothing it all. 2 epidurals over a year. Ultram replaced Celebrex at age 89. A sprinkle of Robaxin.

 

[MitchLevi]

Nothing it all. 2 epidurals over a year. Ultram replaced Celebrex at age 89. A sprinkle of Robaxin.

Private insurance I take it?

I can't get Robaxin for Medicare pts usually. My fav muscle relaxer too, especially for geriatric pts.

 

[callmeanesthesia]

Private insurance I take it?

I can't get Robaxin for Medicare pts usually. My fav muscle relaxer too, especially for geriatric pts.

https://costplusdrugs.com/medications/Methocarbamol-500mg-Tablet/

 

[Orin]

Happily none

They should have surgery, but it'll also meet criteria for a mild. Do they not want a definitive surgery?

 

[lobelsteve]

They should have surgery, but it'll also meet criteria for a mild. Do they not want a definitive surgery?

Doing well enough currently. Refuses surgery. You going to MILD 5 levels?

 

[Orin]

Doing well enough currently. Refuses surgery. You going to MILD 5 levels?

Are they symptomatic at all 5 levels? If they're doing fine with Celebrex/tramadol/robaxin and epidurals, no need to get heroic. If they're high risk for meds and deconditioning though, I'd go with a few levels now and rest in 3 months. It's a lot of fluoro and case time.

 

[MitchLevi]

S1 TF with dex - 10ish days of benefit.
Caudal with Depo - Performed 10/2020. Follows back up today.

 

[lobelsteve]

So worn out I would not be concerned with F/E stability.
T12 compression deformity. Check BD or make sure OP is assessed.

 

[Baron Samedi]

Probably really poor sagittal balance. Likely multiple compression deformities throughout the T-spine leading to excessive kyphosis, in combination with the listhesis leading to far anterior center of gravity. Is patient ambulatory?

 

[MitchLevi]

Probably really poor sagittal balance. Likely multiple compression deformities throughout the T-spine leading to excessive kyphosis, in combination with the listhesis leading to far anterior center of gravity. Is patient ambulatory?

Works in a warehouse. He's been nearly pain free since that caudal 10/2020.

I'm going to just repeat the caudal.

 

[MD87]

I would have probably done the same thing you did (maybe done the reverse - caudal first, then TFESI), but if someone gets more than 3-4 months relief after anything we do (especially > 1 year) I have a hard time giving myself (or the type of steroid) the credit for it. Maybe I’m jaded.

 

[lobelsteve]

New one. Chinese hamster ovary cell derived.

 

[SSdoc33]

that's racist

 

[lobelsteve]

that's racist

And anti hamster, and female.

 

[Ducttape]

apparently used in production.

may be related to galactose. here is a very technically dense article.

Chinese hamster ovary cells can produce galactose-α-1,3-galactose antigens on proteins

www.ncbi.nlm.nih.gov

how did she ever get that diagnosis, how did they find out about that allergy? is she allergic to some vaccine or drug that uses it?

 

[MitchLevi]

I've been injecting this hip for 2 yrs. Fracture pre-existing his injections. Not sure if I've ever posted this. He's late 90s...98 maybe?

Fell (again) last weekend. Shows up yesterday and I did a GTB CSI. His limb is high riding (wasn't as bad as it is now). I will no longer be injecting his "joint."

Yes, the "hip CSI" reliably helped him the 3-4 times I did it. No integrity in the joint obviously.

Contrast patterns were funny each time, but I'm no longer comfortable with it.

 

[SSdoc33]

I've been injecting this hip for 2 yrs. Fracture pre-existing his injections. Not sure if I've ever posted this. He's late 90s...98 maybe?

Fell (again) last weekend. Shows up yesterday and I did a GTB CSI. His limb is high riding (wasn't as bad as it is now). I will no longer be injecting his "joint."

Yes, the "hip CSI" reliably helped him the 3-4 times I did it. No integrity in the joint obviously.

Contrast patterns were funny each time, but I'm no longer comfortable with it.

View attachment 354875

pretty good joint space for a 98 y/o!!!

 

[lobelsteve]

apparently used in production.

may be related to galactose. here is a very technically dense article.

Chinese hamster ovary cells can produce galactose-α-1,3-galactose antigens on proteins

www.ncbi.nlm.nih.gov

how did she ever get that diagnosis, how did they find out about that allergy? is she allergic to some vaccine or drug that uses it?

Been on Prolia for 3 years. Not sure why this pops up in ehr.

 

[lobelsteve]

pretty good joint space for a 98 y/o!!!

The joint doesn’t take any pressure when there’s no bone holding it up

 

[MitchLevi]

I was always uncomfortable with it but no one will fix it and he's utterly miserable.

 

[cowboydoc]

pretty good joint space for a 98 y/o!!!

But the glut tendons are tough as a $2 steak.

 

[Crybaby]

This is the neck of someone referred to me for cesi. Unfused posterior elements? I found a few case reports of it.
I usually enter at 7/1- I almost canceled case but ended up entering at T2/3. Instead of LOR, I used contrast injected with incremental advancement. Out of curiosity, what would you all have done. I did review MRI- it really wasn’t obvious.

 

[RoloTomassi]

Assuming MRI looks normal in terms of LF, epidural fat, I wouldn't have treated any different, still gone 7/1. Not uncommon to see at L5, still do ESIs there.

 

[lobelsteve]

Bifid spinous process with incomplete fusion. Touch lamina a cm lateral to SP. walk off superiorly and medially. No biggie. CLO eliminates the problem.

 

[Crybaby]

Thanks for the input, the incomplete looking lamina is what really got me nervous. Thought it was interesting enough to share. Wish my pictures were a bit clearer.

 

[SSdoc33]

i think the lamina are still there. i wouldnt have changed anything on my approach

 

[Baron Samedi]

Thanks for the input, the incomplete looking lamina is what really got me nervous. Thought it was interesting enough to share. Wish my pictures were a bit clearer.

T1 sagittal is your friend, assess for presence of epidural fat. If you are a dinosaur like me and use LOR just be aware that you might not get a great loss and check a bit of contrast earlier.

 

[Baron Samedi]

Ortho PA referral: "Persistent pain due to osteoarthritis, history of ACL repair. Failed response to steroids and viscosupplementation. Please perform PRP injections."

 

[lobelsteve]

Ortho PA referral: "Persistent pain due to osteoarthritis, history of ACL repair. Failed response to steroids and viscosupplementation. Please perform PRP injections."

What did the report say?

 

[Baron Samedi]

What did the report say?

Interval complete tear of ACL graft compared to prior. No mention of it whatsoever in referral or PA note(who had ordered the MRI). Patient had no idea his graft was torn.

Mechanical symptoms -- buckling, locking, painful crepitus. Positive anterior drawer, Lachmann.

Sent patient back to ortho clinic with request, "please have patient see physician."

 

[MitchLevi]

...just the messenger...

She said he offered her ozone treatments. Dr. Lobel, do you deny this accusation!?!?

 

[lobelsteve]

...just the messenger...

She said he offered her ozone treatments. Dr. Lobel, do you deny this accusation!?!?

View attachment 355416

No to anything for the disc. Rarely GRC.
Send ROI to office.
Ok to PM me.

 

[MitchLevi]

No to anything for the disc. Rarely GRC.
Send ROI to office.
Ok to PM me.

Just surprised to see your name on my intake forms. She saw you prob 15 yrs ago.

 

[lobelsteve]

A little help here. I was unimpressed with imaging report from Rads. I cannot find a pedicle and that facet does not look right.

 

[geauxg8rs]

Just do L1 it looks easier

 

[SSdoc33]

A little help here. I was unimpressed with imaging report from Rads. I cannot find a pedicle and that facet does not look right.

View attachment 356458

more saggital slices, please. i dont like the look of the vertebral body, either. this needs contrast enhanced MRI at the least. was pt referred for a kypho

 

[lobelsteve]

more saggital slices, please. i dont like the look of the vertebral body, either. this needs contrast enhanced MRI at the least. was pt referred for a kypho

No acute fx. Just ugly arthropathy. Will try and add pics. Nothing lit up on STIR.

 

[lobelsteve]

A lotta porosis

 

[BobBarker]

 

[MitchLevi]

View attachment 356502
View attachment 356503

For real?

 

[lobelsteve]

View attachment 356502
View attachment 356503

Cant tell what is going on besides kypho. Blurry pics. Deets.