Pictures of the Week

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lobelsteve said:
I feel like a lose the battle every time when they pass.
.
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I always feel more like I helped them reach death with dignity and comfort with some compassion mixed in to an inevitable situation. I'd get more satisfaction out of my job if I did more cancer care. Probably less pay, but more satisfaction.

I don't see it as a battle to stay alive, but a struggle to get as much quality out of the limited time left.

It's the oncologists who fight the life/death battle. I fight the QOL battle.
 
7999593131_8c67d5c672_b.jpg
 
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2 new patient this week.

bigdisk_zps9005c273.jpg


She is losing control of b/b, a little weak in right leg, saddle anesthesia just starting. Surgery 6 hours after visit with me.

bigdisk2_zps889cea85.jpg


35 y/o male self referred for 2 weeks back and leg pain. Local competition saw him, ordered MRI, and was setting him up for L4, L5, S1 TFESI at same visit. He walks OK, cannot get onto toes.
 
58 y/o male slipped through scheduling and on my schedule as uninsured. LBP and left foot pain as ice cold and getting weak. Started 11/12 while lifting a flat screen TV. Seen in ER 4 times since then and Xrays reported as negative. Given 20 Lortab and 20 Flexeril each visit after getting cocktail of IV Dilaudid and Valium at each visit.

Walk in room and he is lying on the table writhing in pain. Possible mild weakness left foot but really appears limited by pain/effort. Intact sensation and reflexes. Pain limits posture and gait.

I go through my discussion on how have little to offer and that I do not Rx opiates for self pay patients. I told him I'm happy to treat otherwise, but care is expensive. I told him his pain is out of proportion to a herniated disc, but with back and left foot pain I'd order an MRI of his back to see what is going on.

He calls my bluff and gets MRI next day. Cash price for non contrast MRI is $365 for this guy.


















He comes back right after MRI and is using a walker. He can walk without it and uses it improperly. He lifts the rolling walker most steps. His gait is antalgic and as soon as he makes it into the exam room he lays on the table as prior. I pull up the MRI.......


























CA_zps67f8d546.jpg



Anyone want to see the ER notes and their Xray?
 
DOctorJay said:
yes would like to see the xrays at least
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Mild anterior spurring. Nothing else mentioned in report. I'll try and capture the image so you can see the T11 Fx from the cancer that ate his spine. I called Onc who saw him that day and admitted him the following morning. He refused direct admit cause no one was home to take care of his dog. CT whole body next day showed massive lung tumor. No cough, malaise, fatigue, weight loss, sweats. No prostate symptoms either (wasn't sure where primary was once I saw the films). Cord compression in mid T-spine on CT of chest. NS and IR on case, need Bx to begin chemo. May need surgery to spare cord. Not good.
 
Elderly patient with Lt occipital pain radiating to vertex.
 

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In theory, that takes out only the mutifidi not the semispinalis. This spine is virgin.

BTW: show me an axial MRI post RF that shows fatty atrophy of this level. It don't happen.
 
so, you think this is a focal myopathy? and this has led to anterior coloumn degeneration? i suppose thats possible, but it appears to be a guess on both of your conclusions.

i have seen fatty atrophy like that every now and then. RF does make it look a bit worse, but granted, not as severe as above.
 
SSdoc33 said:
so, you think this is a focal myopathy? and this has led to anterior coloumn degeneration? i suppose thats possible, but it appears to be a guess on both of your conclusions.

i have seen fatty atrophy like that every now and then. RF does make it look a bit worse, but granted, not as severe as above.
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Have you ever seen an aggressive posterior decompression leading to instability and compression fractures anteriorly? I have, this case is completely akin to that. This fellow lost his rear stays and broke his mast.

65ish year old fellow sent to to me by NS for Vertebro/Kypho. Wife complains that he walks 'leaning back with his hips jutting forward'. Case didn't make sense, the CF's at that time were acute on STIR but there was no antecedant trauma. So I did a big workup - testosterone(nl), EMG, Muscle Bx, dexa(nl)- focal myopathy. Discussed the case and images with Andy Haig & he agreed.
 
Depending on terminology, SNs are herniations, extrusions, or invaginations of intervertebral disk material into the vertebral body endplates and were first described in 1927 by Schmorl (6). They are usually observed as chronic, asymptomatic entities in approximately one third of the population, although one study reported a 74% incidence (1). They are generally thought to be of no clinical consequence, probably because their inception is assumed to be remote, and they are mentioned only as incidental findings. Reports in the literature of symptomatic acute SNs caused by trauma are sparse, with diagnosis being based on high clinical suspicion after exclusion of other causes (3, 7).



Those do not look like Fx's to me.
 
101N said:
Have you ever seen an aggressive posterior decompression leading to instability and compression fractures anteriorly? I have, this case is completely akin to that. This fellow lost his rear stays and broke his mast.

65ish year old fellow sent to to me by NS for Vertebro/Kypho. Wife complains that he walks 'leaning back with his hips jutting forward'. Case didn't make sense, the CF's at that time were acute on STIR but there was no antecedant trauma. So I did a big workup - testosterone(nl), EMG, Muscle Bx, dexa(nl)- focal myopathy. Discussed the case and images with Andy Haig & he agreed.
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i understand the biomechanics. muscle biopsy should be diagnostic.

did you put him in a TLSO?
 
Vascular CESI sdn.jpg

C7-1 ESI. Pretty cool vascular pic. Im sure venous but the contrast sure didnt stick around.....
 
Last edited:
It's been a long time since anyone posted. Prostate CA with possibly some mets. Hemoglobin 6. Getting transfused. Now palliative. Has had maximum treatment from Oncology and Rad-Onc. On 125mcg fentanyl, Percocet 10mg tid prn, Actiq 200 bid prn (uses 2-3 per week).
 

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my guess would be that he had an ACL repair using wire, probably prior to 1992, instead of ACL reconstruction.

tibial plateau fractures are usually much more extensive in terms of hardware.
 
On the right side the artificial hip joint socket has eroded into the pelvis
Wonder what the symptoms are in this patient
 
L4-l5 disc is bulging and compressing the nerve root? Any bladder or bowel symptoms?
 
If you stimulate the root there you will find that it causes capital extensor and strap muscle contractions in
many if not most patients. Conventional wisdom says it's only sensory.

BTW: it's safer and easier if you have them take the upper plate out prior to the injection.
 
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