Pictures of the Week

[pmrmd]

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

Yes clearly connected but still something I haven’t seen ever. You all are like ‘what ev’ but it’s unusual for me. Maybe I have just a boring patient population.

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[SSdoc33]

Yes clearly connected but still something I haven’t seen ever. You all are like ‘what ev’ but it’s unusual for me. Maybe I have just a boring patient population.

its unusual, for sure. stenosis symptoms?

 

[runfastnow]

View attachment 359659View attachment 359660

Impressive - causing radic or neuroclaudication?

 

[MitchLevi]

CSF leak?

 

[pmrmd]

its unusual, for sure. stenosis symptoms?

Axial back responsive to facet blocks. Doesn’t seem to bother him at all. He’s 90 and happy if he wakes up in the morning.

 

[guytakingboards]

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I'd read that out as calcified disc extrusion all day, not just endplate osteophyte.

 

[pmrmd]

I'd read that out as calcified disc extrusion all day, not just endplate osteophyte.

it looks more like an icicle than any extruded disc I’ve ever seen. Just weird.

 

[SSdoc33]

I'd read that out as calcified disc extrusion all day, not just endplate osteophyte.

yeah, you are probably right. id agree with that

 

[MitchLevi]

Highly appropriate. Nothing unusual on these intake forms. This language is perfectly acceptable.

Monthly MS IR 15mg #28, MS ER 15mg #84, Lyrica 200mg #56.

 

[lobelsteve]

Highly appropriate. Nothing unusual on these intake forms. This language is perfectly acceptable.

Monthly MS IR 15mg #28, MS ER 15mg #84, Lyrica 200mg #56.

View attachment 359693

Already has everything they need. RTS.
Return to sender.

 

[MitchLevi]

S

Already has everything they need. RTS.
Return to sender.

SCS referral. Her prescribing MD is a local guy who is now playing pills for shots. He can do her SCS; I'm not getting involved.

 

[SSdoc33]

Dont use intake forms. Adds time and kills trees

 

[MitchLevi]

Dont use intake forms. Adds time and kills trees.

PMH
PSH
SH
FH
MEDS
ALL
ROS

 

[deleted875186]

PMH
PSH
SH
FH
MEDS
ALL
ROS

I believe we can simply skip ROS and FH at this point with E and M guidelines no? Never seen family history relevant, unless history of OUD.

 

[MitchLevi]

I believe we can simply skip ROS and FH at this point with E and M guidelines no? Never seen family history relevant, unless history of OUD.

I'm traditional. I like the same stuff in all NPV.

 

[crunchymedicine]

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.

View attachment 359116

Did you get obturator nerve stimulation on this placement?

 

[cowboydoc]

Did you get obturator nerve stimulation on this placement?

Almost never, but have retracted (moved tip laterally) in those instances.

 

[lobelsteve]

84 y/o developed severe back pain after prone chiropractic adjustment.

 

[callmeanesthesia]

84 y/o developed severe back pain after prone chiropractic adjustment. View attachment 359787

Surprised we don’t see this kind of thing more often.

 

[SSdoc33]

84 y/o developed severe back pain after prone chiropractic adjustment. View attachment 359787

does the story line up? b/c it seems unlikely.

 

[cowboydoc]

does the story line up? b/c it seems unlikely.

I'm SURE she was feeling symptoms of a stroke compression fracture for which she sought chiropractic care.

 

[lobelsteve]

does the story line up? b/c it seems unlikely.

Story in reviewing the chart. Adding her on tomorrow so I can ask for the timeline.

 

[MitchLevi]

84 y/o developed severe back pain after prone chiropractic adjustment. View attachment 359787

Saw this last week. Huge HNP L3-4 with right L3 radic. Saw chiro, got an adjustment and told the chiro he just fractured his back.

Sees us, gets an MRI with an L3 just like that. Some back pain, but his radic is red hot and I did a TFESI at that level Friday.

 

[pmrmd]

84 y/o developed severe back pain after prone chiropractic adjustment. View attachment 359787

Went to chiro for the pain from the fracture. Doubt an adjustment is going to do that.

 

[lobelsteve]

Went to chiro for the pain from the fracture. Doubt an adjustment is going to do that.

Let you know in about an hour. Hoping for some pre adjustment films.

Busy recovering from a long tough morning.

 

[deleted875186]

Let you know in about an hour. Hoping for some pre adjustment films.

Busy recovering from a long tough morning.

That’s some bougy toast. Honestly I should open an avocado toast food truck, people will pay enormous amounts of money for avocado gently spread across some bread.

 

[lobelsteve]

OK. Saw the patient this afternoon and she has not seen a regular doctor in about 20 years. She takes new medication and she’s been treating with a chiropractor on and off for the last 10 years. She does this for leg pain which bothers her when she walks. She’s never had her spine adjusted before the chiropractor usually just plays with her legs. She had no back pain prior to this visit and had a mediate onset of seven out of 10 back pain with the thrust procedure in a prone position. I would offer that as causality. Kypho on Thursday 3:30 PM

 

[MitchLevi]

OK. Saw the patient this afternoon and she has not seen a regular doctor in about 20 years. She takes new medication and she’s been treating with a chiropractor on and off for the last 10 years. She does this for leg pain which bothers her when she walks. She’s never had her spine adjusted before the chiropractor usually just plays with her legs. She had no back pain prior to this visit and had a mediate onset of seven out of 10 back pain with the thrust procedure in a prone position. I would offer that as causality. Kypho on Thursday 3:30 PM

This is what happened to the guy I just saw. To chiro for a nasty HNP. Severe back pain from an adjustment. MRI with L3 fracture.

 

[deleted875186]

This is what happened to the guy I just saw. To chiro for a nasty HNP. Severe back pain from an adjustment. MRI with L3 fracture.

“Ma’am, I believe the chiropractor broke your back …. But I think he fixed the subluxation”

 

[lobelsteve]

This is what happened to the guy I just saw. To chiro for a nasty HNP. Severe back pain from an adjustment. MRI with L3 fracture.

Epidemic in Georgia. Starting Evenity next week.

 

[MitchLevi]

“Ma’am, I believe the chiropractor broke your back …. But I think he fixed the subluxation”

Ever read chiro notes?

Any work comp pt I get that has chiro notes...I read those notes for sure.

They're as ridiculous as they are amazing. Entertaining is putting it mildly.

 

[drrosenrosen]

I have a chiropractor who sends me quite a few patients. The referral relationship is one-way, but he seems to do a decent job and not go outside his sandbox. He did however send me a patient that who developed worsening urinary incontinence and weakness after an adjustment . Pre and post adjustment imaging is essentially unchanged.

Before:

After:

 

[Orin]

I have a chiropractor who sends me quite a few patients. The referral relationship is one-way, but he seems to do a decent job and not go outside his sandbox. He did however send me a patient that who developed worsening urinary incontinence and weakness after an adjustment . Pre and post adjustment imaging is essentially unchanged.

The cauda equina knows what the MRI doesn't show. The horrors it has seen.

 

[MitchLevi]

Peer to peer on an S1 radic later today. Failed PT + HEP, gait dysfxn, sleep dysfxn and declining QoL. Severe leg pain x 5-6 months. SLR+. Full motors. Patellar and ankle reflexes normal.

I just want to say MRI techs should be publically beaten when they perform their job terribly. Look at this leveling.

 

[SSdoc33]

Peer to peer on an S1 radic later today. Failed PT + HEP, gait dysfxn, sleep dysfxn and declining QoL. Severe leg pain x 5-6 months. SLR+. Full motors. Patellar and ankle reflexes normal.

I just want to say MRI techs should be publically beaten when they perform their job terribly. Look at this leveling.

View attachment 359880View attachment 359881View attachment 359882View attachment 359883

make sure to really chew out your "peer". i rarely do them b/c it is a colossal waste of time, but when i do, i make sure that the reviewer knows they are playing for the wrong team and they are a disgrace and an embarrassment to themselves and their profession.

 

[Ducttape]

radicular back pain, failed back syndrome, fusion L5S1 anterior hardware with spacer 2005.

radicular right leg pain, S1 distribution.

SCS trial. pre op, radicular back and right leg pain. otherwise feels fine.

Trial was on Wednesday.

Update on Thursday - doing well. some procedural pain, stim is taking all of leg pain away.

Update on Saturday - patient worried that lead moved. tingling and pain now in the right lower quadrant, fairly intense. doesnt recall twisting. called device rep, who contacted me.

 

[unchockey21]

radicular back pain, failed back syndrome, fusion L5S1 anterior hardware with spacer 2005.

radicular right leg pain, S1 distribution.

SCS trial. pre op, radicular back and right leg pain. otherwise feels fine.

View attachment 359916
View attachment 359917

Trial was on Wednesday.

Update on Thursday - doing well. some procedural pain, stim is taking all of leg pain away.

Update on Saturday - patient worried that lead moved. tingling and pain now in the right lower quadrant, fairly intense. doesnt recall twisting. called device rep, who contacted me.

Are these the x-rays from this week looking for lead migration? Any stenosis on pre-trial thoracic MRI?

 

[lobelsteve]

T8-10 all a little compressed. T9 mostly. Need imaging after the lead migrated to the gutter.

 

[Ducttape]

those were the post procedure leads. the rep turned off the stim and over the next hour, there was no change in his pain. he did note that he felt kind of nauseous.

we sent him to ER.

in ER, T36.2, BP 119/58, P68, R 16, 98% sat.
tender RLQ.
WBC 19.2.

now the surgeon wanted me to keep the stim lead in because maybe it would help with postop pain.....

 

[Orin]

those were the post procedure leads. the rep turned off the stim and over the next hour, there was no change in his pain. he did note that he felt kind of nauseous.

we sent him to ER.

in ER, T36.2, BP 119/58, P68, R 16, 98% sat.
tender RLQ.
WBC 19.2.

now the surgeon wanted me to keep the stim lead in because maybe it would help with postop pain.....

This is appendicitis in an SCS trial? The lead generally wouldn't be expected to do much for abdominal pain at that location, but it does become an infectious risk for seeding. I would get them out while the patient is on IV antibiotics for the GI source.

 

[Ducttape]

yep. appendicitis.

not all "complications" are due to our handiwork.

 

[lobelsteve]

 

[Tboned]

View attachment 360154

What’s the story behind this?

 

[lobelsteve]

What’s the story behind this?

Extravasation vs not. Part of article or text. Not sure if yet published.

 

[pmrmd]

Interesting. Thanks Steve

 

[MitchLevi]

An older aged PCP is prescribing this mess.

MBB on this pt, he passed but in my procedure note I dictated, "emotionally disastrous." He was wildly out of control, and at one point I told him to grow up. I realize how that sounds, but he was completely and inappropriately out of control.

He demanded intubation for an RFA so I sent him out of our practice.

My purpose for posting this is to remind myself and anyone reading that it is okay to let ppl hurt. Saying no is sometimes the best option. I will not be providing care to this pt when he shows up.

 

[lobelsteve]

An older aged PCP is prescribing this mess.

MBB on this pt, he passed but in my procedure note I dictated, "emotionally disastrous." He was wildly out of control, and at one point I told him to grow up. I realize how that sounds, but he was completely and inappropriately out of control.

He demanded intubation for an RFA so I sent him out of our practice.

My purpose for posting this is to remind myself and anyone reading that it is okay to let ppl hurt. Saying no is sometimes the best option. I will not be providing care to this pt when he shows up.

View attachment 360380
View attachment 360381

Something in the Georgia water? You sound like Lobel. Hoping for you to post his review on Healthgrades next week.

 

[SSdoc33]

An older aged PCP is prescribing this mess.

MBB on this pt, he passed but in my procedure note I dictated, "emotionally disastrous." He was wildly out of control, and at one point I told him to grow up. I realize how that sounds, but he was completely and inappropriately out of control.

He demanded intubation for an RFA so I sent him out of our practice.

My purpose for posting this is to remind myself and anyone reading that it is okay to let ppl hurt. Saying no is sometimes the best option. I will not be providing care to this pt when he shows up.

View attachment 360380
View attachment 360381

then why did you stick him at all?

i also have lost patiencw with these histrionic types. a stern voice like you are talking to a child seems to work best. the coddling/supportive approach just feeds the beast

 

[lobelsteve]

then why did you stick him at all?

i also have lost patiencw with these histrionic types. a stern voice like you are talking to a child seems to work best. the coddling/supportive approach just feeds the beast

Act like a baby get treated like a baby.

 

[lobelsteve]

82 yo SCS implant by me 6/21. Last seen post op 1 week later. Since then no contact. Until today. A few falls, became non ambulatory. Care in another hospital system. A few months in hospice. Husband calls. Wound.