Pictures of the Week

[MitchLevi]

Sent to me for a "stim trial."

COPD (1 PPD smoker), CAD/CHF, sleep apnea, cancer Hx, other Dx in his PMH.

"I've had over 30 surgeries." Lumbar surgery x 5. Multi joint replacements.

SCS implant with multiple revisions (at least 3). Initial implant op note reveals 3 levels of attempted paddle placement.

After all this BS - He has ITB/GTB pain.

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[lobelsteve]

Sent to me for a "stim trial."

COPD (1 PPD smoker), CAD/CHF, sleep apnea, cancer Hx, other Dx in his PMH.

"I've had over 30 surgeries." Lumbar surgery x 5. Multi joint replacements.

SCS implant with multiple revisions (at least 3). Initial implant op note reveals 3 levels of attempted paddle placement.

After all this BS - He has ITB/GTB pain.

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Run a pair of Nevro wires to cover T9-10, T-11. Replace IPG and plug in new wires.

 

[MitchLevi]

Run a pair of Nevro wires to cover T9-10, T-11. Replace IPG and plug in new wires.

I'm not doing it. I'll send him to you if you want him. He's medically complicated and continues to smoke. His previous SCS never worked. His pain is lateral hips at the greater trochanter.

 

[lobelsteve]

I'm not doing it. I'll send him to you if you want him. He's medically complicated and continues to smoke. His previous SCS never worked. His pain is lateral hips at the greater trochanter.

No thanks. I would explant the IPG for rvu, inject the GTBs and get him to do some stretches and triple cream.

 

[Ducttape]

patient states "i had a box put in (in different state) and it never did nothing." but she does acknowledge that yes, her belly kind of tingles occasionally when she turns it on.

edit: for failed back, s/p lami L2-S1 and fusion L5S1

 

[pmrmd]

patient states "i had a box put in (in different state) and it never did nothing." but she does acknowledge that yes, her belly kind of tingles occasionally when she turns it on.
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edit: for failed back, s/p lami L2-S1 and fusion L5S1

The paddle looks dorsal and I see a spinous process just below the middle electrode line. Other than it being a level or two more cephalad than optimal what else is there?

 

[lobelsteve]

Basic T12 kypho. 75 y/o 6' 130lb man. DEXA -1.8 No trauma. Has myelodysplastic syndrome. Platelets at 50k.
Posting to get opinions on cement volume. SIS review in last 10 years and I reviewed that volumes 2cc to 4.5cc were all that was needed to fix a Fx. Bealle and others now espousing high volume. I put in 8cc yesterday, no leakage. I would usually see some extravasation over 6cc unless at L4 or L5. Thoughts?

 

[pmrmd]

I fill until I can’t. I get to 5-6-7cc in most cases. With extravasation I’ll move the cannula, wait a bit, and try to place more.

 

[BobBarker]

I’m not as fixated on volume as Doug. He is basically ok with cement running out everywhere but the spinal canal.

 

[Ducttape]

The paddle looks dorsal and I see a spinous process just below the middle electrode line. Other than it being a level or two more cephalad than optimal what else is there?

the lead is at T6. entered at T9.

would have been a good lead for intercostal neuralgia, but not for failed back with S1 distribution leg symptoms.

during trial, i got 100% coverage with this:

we are going to leave the paddle in place, and will replace the battery. it seems like the pain doc kinda misjudged her body habitus.

 

[pmrmd]

The lead is T6-8. Should be a level lower for back and leg agree.

 

[MitchLevi]

Any of you dudes doing 214's and billing for TENS and an ice pack? Is this real life?

 

[SSdoc33]

Any of you dudes doing 214's and billing for TENS and an ice pack? Is this real life?

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ice packs are 0.06 RVUs

the other 2 CPTs are .18

let them have at it.


but no, im not throwing icepacks at the patients and then billing for it

 

[pmrmd]

Any of you dudes doing 214's and billing for TENS and an ice pack? Is this real life?

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Rarely I might see a patient that opts for therapy modalities instead of an injection. We would do ultrasound and traction instead of the other modalities but the bill would look similar I guess. I don’t know RVUs for anything since that isn’t my world.

 

[MitchLevi]

ice packs are 0.06 RVUs

the other 2 CPTs are .18

let them have at it.


but no, im not throwing icepacks at the patients and then billing for it

So, if I buy 3 TENS devices I can have 3 pts hang out for let's say 30 min. That's 0.54 per 30 min, and over the course an 8 hr day like 5-8 additional RVUs.

...or 30ish per week.

...or 120ish per month.

...or 1400ish per year.

We have plenty of clinic space for this.

If I use snake oil charm techniques, they'd get ice packs after the TENS just bc...Small numbers pt to pt, not so small on monthly time scales.

 

[cowboydoc]

So, if I buy 3 TENS devices I can have 3 pts hang out for let's say 30 min. That's 0.54 per 30 min, and over the course an 8 hr day like 5-8 additional RVUs.

...or 30ish per week.

...or 120ish per month.

...or 1400ish per year.

We have plenty of clinic space for this.

If I use snake oil charm techniques, they'd get ice packs after the TENS just bc...Small numbers pt to pt, not so small on monthly time scales.

 

[lobelsteve]

L3 acute Fx with STIR lighting up.

Go to fix it. Usual left pedicle approach. Can feel bone soft as butter, but cannot angle to get into VB without breaching medial border of pedicle. Have no visualization of inferior endplate on lateral, can make it out in AP. Toughest kypho in 10 years. Wound up bailing on left side and did right sided parapedicular approach. Weird.

AP. needle on skin overlying right L4

Initial approach from left L3 pedicle.

Final right sided entry in AP:

Not the final AP, but last one I got a pic of. Looks like this with 2cc more cement. Same fill pattern, just darker.

WTH.

 

[RoloTomassi]

Have you used curved kit? I think that would've allowed you to get in on the left and cross midline, and from the right you can redirect to change flow

 

[manowar rules]

Interesting fracture. That right pedicle is just gone, maybe a new lateral lithesis. Probably got it as good as possible coming from the right side. I would have tried a left parapedicular with a curved needle, but I may have just had the same issues as you

 

[cowboydoc]

 

[lobelsteve]

Big vein, and I think a little bilateral. Yours looks good, but Doug would want MORE CEMENT.
On Prolia or Tymlos?

 

[RoloTomassi]

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Did you abort, wait to clot then resume, or redirect and resume?

 

[cowboydoc]

Did you abort, wait to clot then resume, or redirect and resume?

That was not my circus. This was done before she came to me.

She is on calcitonin and alendronate.

 

[lobelsteve]

That was not my circus. This was done before she came to me.

She is on calcitonin and alendronate.

Let her know about the cancer risk for calcitonin and that if on bishos w fx it is time for better meds?


Own that bone.

 

[cowboydoc]

She came to me like this, but you have gotten me to “own the bone,” as you have preached for years. I now know our endo specialists.

 

[lobelsteve]

Trial done by nearby pain doc (great group) in December. Lots of clearances and delays. Finally got around to it.

70cm leads. Patient under 100 lbs. Left flank pocket in location with most amount of tissue. Entered at T1-2. 3 blankets under chest to get angles adequate for safer entry. Combined LOR to air and lateral view to watch lead come into posterior epidural space and advance posteriorly. Just over an hour skin to skin. Tunneling 50cm is not fun. These cases stress me out 10x more than lumbar. For no good reason. Cord is cord and you can see where it lives on Xray.

 

[Darkside_]

Trial done by nearby pain doc (great group) in December. Lots of clearances and delays. Finally got around to it.

70cm leads. Patient under 100 lbs. Left flank pocket in location with most amount of tissue. Entered at T1-2. 3 blankets under chest to get angles adequate for safer entry. Combined LOR to air and lateral view to watch lead come into posterior epidural space and advance posteriorly. Just over an hour skin to skin. Tunneling 50cm is not fun. These cases stress me out 10x more than lumbar. For no good reason. Cord is cord and you can see where it lives on Xray.

Any reason to not do regular low thoracic entry for cervical implants? Increased risk of migration?

 

[lobelsteve]

Any reason to not do regular low thoracic entry for cervical implants? Increased risk of migration?

I believe migration risk is markedly increased as anchor is now a foot away from target.

 

[swamprat]

Trial done by nearby pain doc (great group) in December. Lots of clearances and delays. Finally got around to it.

70cm leads. Patient under 100 lbs. Left flank pocket in location with most amount of tissue. Entered at T1-2. 3 blankets under chest to get angles adequate for safer entry. Combined LOR to air and lateral view to watch lead come into posterior epidural space and advance posteriorly. Just over an hour skin to skin. Tunneling 50cm is not fun. These cases stress me out 10x more than lumbar. For no good reason. Cord is cord and you can see where it lives on Xray.

Looks great. Excellent job! Cervical SCS is def way tougher than thoracic/ lumbar. I rarely can get 2 leads in. Patient positioning is key and u did great with this - I agree anchoring up high is better if u can do it. Hopefully patient has great pain relief for a long time

 

[Taus]

One of my better C1-2 arthrograms. Little to no joint space

 

[MitchLevi]

Two pts in one week. Both sent to me for "back pain" and "sciatica." One had been receiving knee CSI/visco/Zilretta for a LOOOONG time for knee and thigh pain.

 

[Taus]

Two pts in one week. Both sent to me for "back pain" and "sciatica." One had been receiving knee CSI/visco/Zilretta for a LOOOONG time for knee and thigh pain.

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Two pts in one week. Both sent to me for "back pain" and "sciatica." One had been receiving knee CSI/visco/Zilretta for a LOOOONG time for knee and thigh pain.

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Ugh. Those are absolutely horrendous hips. At least they did not get a back surgery before they figured it out… Seen a few of these over the years sent to me for EMG after lami didn’t help. I did that fancy thing called a physical exam…

 

[runfastnow]

Two pts in one week. Both sent to me for "back pain" and "sciatica." One had been receiving knee CSI/visco/Zilretta for a LOOOONG time for knee and thigh pain.

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Ideal case for regenerative medicine.

 

[SSdoc33]

Ideal case for regenerative medicine.

really? huh. i didnt know that prp or stem cells could actually rebuild a femoral head and smooth out an acetabulum

THR

IA steroids = anything else you inject for a fraction of the cost

 

[cowboydoc]

really? huh. i didnt know that prp or stem cells could actually rebuild a femoral head and smooth out an acetabulum

THR

IA steroids = anything else you inject for a fraction of the cost

Pretty sure they just missed the magenta button with their comment.

IA steroid very well could have contributed to this situation.

 

[MitchLevi]

I aspirated 20cc of bloody fluid from one of those hips. Didn't inject steroid though. MRI pending and she sees one of our total joint guys next week. The other I did inject steroid just to help them tread water until they see an outside joint guy. Shot didn't help her of course. I figured it probably wouldn't.

 

[cowboydoc]

I aspirated 20cc of bloody fluid from one of those hips. Didn't inject steroid though. MRI pending and she sees one of our total joint guys next week. The other I did inject steroid just to help them tread water until they see an outside joint guy. Shot didn't help her of course. I figured it probably wouldn't.

MRI for what?

Most joint guys don’t want to replace a joint within 90 days of steroid injection.

 

[MitchLevi]

MRI for what?

Most joint guys don’t want to replace a joint within 90 days of steroid injection.

We do totals 4w after CSI, and we always get MRI before replacement.

 

[Ducttape]

meh. those are normal findings in my office...


edit: meant to put in magenta

 

[SSdoc33]

maybe this is rapidly progressing hip Oa. maybe not.

ive seen femoral heads completely disappear 2-3 months after a steroid injection. buti've seem them also collapse as a part of the natural disease progression

 

[SSdoc33]

We do totals 4w after CSI, and we always get MRI before replacement.

what is the reason the orthopods give you to get an MRI before every replacement? if the answer isnt "we own the MRI machine", then they are lying to you

 

[Orin]

I aspirated 20cc of bloody fluid from one of those hips. Didn't inject steroid though. MRI pending and she sees one of our total joint guys next week. The other I did inject steroid just to help them tread water until they see an outside joint guy. Shot didn't help her of course. I figured it probably wouldn't.

Why not hip articular branch RFAs to buy time?

 

[MitchLevi]

maybe this is rapidly progressing hip Oa. maybe not.

ive seen femoral heads completely disappear 2-3 months after a steroid injection. buti've seem them also collapse as a part of the natural disease progression

One of these two hips has never received a CSI, the other received one 4 months ago and the joint looked identical at that time.

I shouldn't say we "always get an MRI before every hip replacement." If you've got femoral head collapse and you're concerned about AVN you do.

Typical end stage OA without complications doesn't need an MRI.

I don't do hip RFA, but if I did I wouldn't do it in this case.

 

[lobelsteve]

One of these two hips has never received a CSI, the other received one 4 months ago and the joint looked identical at that time.

I shouldn't say we "always get an MRI before every hip replacement." If you've got femoral head collapse and you're concerned about AVN you do.

Typical end stage OA without complications doesn't need an MRI.

I don't do hip RFA, but if I did I wouldn't do it in this case.

Burn the hip to get them enough time to get THA. My hip guy is great. But picky. Strict BMI, A1C. No scratches on the leg. 3 mo min after injection.

 

[callmeanesthesia]

Tagging on to the above discussion, I have a patient with 2 bad hips, severe COPD, oxygen dependent, pulmonologist told him not a surgical candidate. I’ve been doing steroid injections q3-4 months for him as a palliative measure. Tried to find someone to do cooled RF for him but couldn’t find anyone within 3 hours away who did it for the hips. Even called the company and got some names of practices and called them but they only did knees. I’m private practice, office-based. So I did it myself with bipolar RF (I was very upfront with him about the fact that I’d never done it before and was basically making up the technique as I went along because I couldn’t find published techniques for bipolar ablation; only cooled)
Palpated and marked the femoral artery, came in quite a bit lateral to that with 2 needles. Pics below. I did 2 burns at each site, moving the needles over for the second (not pictured). Just had his follow up this week and was rating his pain 5/10 instead of his usual 9/10 that it’s been every other time I’ve seen him. Seems to be getting a bit of dementia though, thought processes were very scattered, so hard to tell for sure. Has been 6 months since his last steroid injection though so I’m going to call it a win.
I’d welcome feedback on the placement and technique.

 

[MitchLevi]

Burn the hip to get them enough time to get THA. My hip guy is great. But picky. Strict BMI, A1C. No scratches on the leg. 3 mo min after injection.

Tagging on to the above discussion, I have a patient with 2 bad hips, severe COPD, oxygen dependent, pulmonologist told him not a surgical candidate. I’ve been doing steroid injections q3-4 months for him as a palliative measure. Tried to find someone to do cooled RF for him but couldn’t find anyone within 3 hours away who did it for the hips. Even called the company and got some names of practices and called them but they only did knees. I’m private practice, office-based. So I did it myself with bipolar RF (I was very upfront with him about the fact that I’d never done it before and was basically making up the technique as I went along because I couldn’t find published techniques for bipolar ablation; only cooled)
Palpated and marked the femoral artery, came in quite a bit lateral to that with 2 needles. Pics below. I did 2 burns at each site, moving the needles over for the second (not pictured). Just had his follow up this week and was rating his pain 5/10 instead of his usual 9/10 that it’s been every other time I’ve seen him. Seems to be getting a bit of dementia though, thought processes were very scattered, so hard to tell for sure. Has been 6 months since his last steroid injection though so I’m going to call it a win.
I’d welcome feedback on the placement and technique.
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Excellent job.

 

[cowboydoc]

Tagging on to the above discussion, I have a patient with 2 bad hips, severe COPD, oxygen dependent, pulmonologist told him not a surgical candidate. I’ve been doing steroid injections q3-4 months for him as a palliative measure. Tried to find someone to do cooled RF for him but couldn’t find anyone within 3 hours away who did it for the hips. Even called the company and got some names of practices and called them but they only did knees. I’m private practice, office-based. So I did it myself with bipolar RF (I was very upfront with him about the fact that I’d never done it before and was basically making up the technique as I went along because I couldn’t find published techniques for bipolar ablation; only cooled)
Palpated and marked the femoral artery, came in quite a bit lateral to that with 2 needles. Pics below. I did 2 burns at each site, moving the needles over for the second (not pictured). Just had his follow up this week and was rating his pain 5/10 instead of his usual 9/10 that it’s been every other time I’ve seen him. Seems to be getting a bit of dementia though, thought processes were very scattered, so hard to tell for sure. Has been 6 months since his last steroid injection though so I’m going to call it a win.
I’d welcome feedback on the placement and technique.
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Pretty solid. I like your femoral branch placement better on the left than right, both reasonable. I come in a bit more caudal to cephalad in a similar plane in the lateral to medial, which should let you get a bit more medial for your obturator branch. (see below)

I came up with this after training on the coolief technique, but never having it in practice. I usually palpate or use u/s to ID the artery prior. Come in out of plane using AP view, and walk along the ramus. You should see a tear drop like structure called the "incisura" that is your target. It's partially visualized on your left sided images. After discussing with my hip/knee colleagues, it seems this is the medial border of the acetabulum and not something they've really thought about and didn't know the name.

 

[lobelsteve]

Tagging on to the above discussion, I have a patient with 2 bad hips, severe COPD, oxygen dependent, pulmonologist told him not a surgical candidate. I’ve been doing steroid injections q3-4 months for him as a palliative measure. Tried to find someone to do cooled RF for him but couldn’t find anyone within 3 hours away who did it for the hips. Even called the company and got some names of practices and called them but they only did knees. I’m private practice, office-based. So I did it myself with bipolar RF (I was very upfront with him about the fact that I’d never done it before and was basically making up the technique as I went along because I couldn’t find published techniques for bipolar ablation; only cooled)
Palpated and marked the femoral artery, came in quite a bit lateral to that with 2 needles. Pics below. I did 2 burns at each site, moving the needles over for the second (not pictured). Just had his follow up this week and was rating his pain 5/10 instead of his usual 9/10 that it’s been every other time I’ve seen him. Seems to be getting a bit of dementia though, thought processes were very scattered, so hard to tell for sure. Has been 6 months since his last steroid injection though so I’m going to call it a win.
I’d welcome feedback on the placement and technique.
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Right hip possibly too medial to incisura. Tough to tell without seeing how much rotation.

 

[pmrmd]

 

[SSdoc33]

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endplate osteophyte. its connected, just not on the axial slice