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FSQT said:
This is interesting. I had this same thing happen to me a few months ago, and I still can't explain it. I also use a mid SIJ for my initial approach (get an arthrogram with it maybe 1/3 of the time).

Any thoughts on best approach for SIJ? I have a younger patient population, so I figure many of them are more extra articular pain. I target mid SIJ. If I get an arthrogram, I inject half of injectate, pull back to interosseous ligament and posterior sacroiliac ligament, and inject the other half. If I don't get an arthrogram, I simply inject the ligament with half of the injectate, withdraw the needle, and hit the intra-articular joint using the traditional approach at the inferior pole.

Maybe this approach is needlessly over-complex, but I worry the conventional approach doesn't target the pain generator adequately extra-articular SIJ pain.
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Textbook says bottom third, but I agree with you that a younger population is more likely to have a ligamentous etiology that tends to respond better to an extra synovial injection. In my younger patients, I take about 6cc of meds total. Inferior approach. Inject 3 into the true joint, then withdraw, advance cranial and try to get into the mid portion if possible. If not, inject the rest as close as you can get to being in the syndesmotic joint which bathes most of the lateral branches that matter here.
 
interjectionreflection said:
Very basic question but did this epidural today, they had it done a few times before by different doc's. This is my first time doing it. is it normal to later in the ventral space with interlam? Previous ones also layered this way. Wondering if anyone sees this or if I missed something? longer this in the lateral with the anterior spread? View attachment 412438View attachment 412439
Click to expand...
The CLO views are the most useful in this as you can see thick ligament and clean retention in the space. The other learning point I hammer home is that since the cord ends at L1/L2, at this level you're just mixing contrast with CSF. You should see the contrast start to mix if you get a second or third shot after some time. You'll also see it pool in a gravity dependent manner as most contrast is hyperbaric, so the dorsal part will get faint. In the cervicothoracic spine it can sit on the cord and confuse you, but a little head up/down will get you to see it traveling.
 
Acute onset LBP as intermittent in March 2025.
Occasional radiculopathy down left leg with buckling. MRI ordered by me looked normal but for spondy and L3-4 facet fluid.
Saw me, went elsewhere for MBB/RF.
No better.

1st pic from 12/9/25
2nd pic from 3/21/25

Screenshot 2025-12-09 141308.png




Screenshot 2025-12-09 141400.png
 
clubdeac said:
What am I looking at? Mets
Click to expand...
L5 sclerotic lesion is new. Not seen in early films (or not mentioned)- but definitely more impressive now. CT done for diff reason in March neg for lesion.
 
But should haw seen it on the MRI I believe, You can see it there on the original xray but Not the L4 lesion/modic/Schmorl
 
DoYouEvenLiftBro said:
But should haw seen it on the MRI I believe, You can see it there on the original xray but Not the L4 lesion/modic/Schmorl
Click to expand...
It was absolutely not there on MRI at all. But I think I see it on old films now more pronounced on newer films. Radiologist did not see it on the old films or MRI or CT. MRI repeat next week. Prostate until proven otherwise.
 
lobelsteve said:
It was absolutely not there on MRI at all. But I think I see it on old films now more pronounced on newer films. Radiologist did not see it on the old films or MRI or CT. MRI repeat next week. Prostate until proven otherwise.
Click to expand...
Interesting case, what’s his age
 
Ducttape said:
are you talking about the anterior superior lesion that is present on both films?

View attachment 412657
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Yes, but more pronounced now. Also not present on CT or MRI, so we see it because we know it is there, but it was not there.
1. It is a new lesion
or
2. It is artifact seen on plain film both times and the new MRI will be negative.

I'm just along for the ride.
 
is it a sclerotic lesion or something on the ilium? may just be a shadow. i think you would have seen it on the MRI/CT. i think this is nothing.
 
First injection w us, 40s female left lower back + sij maneuvers, occ radic
We only had mri from NSGY

I see mr bertolotti there
What success have yall had w it if it is her pain generator, IA rfa any relief with spr?
 
DoYouEvenLiftBro said:
First injection w us, 40s female left lower back + sij maneuvers, occ radic
We only had mri from NSGY

I see mr bertolotti there
What success have yall had w it if it is her pain generator, IA rfa any relief with spr?
Click to expand...
If SIJ IA and MBB/RF do not help, add bipolar RF along back of Bertolotti with next RF.
 
there is no canal there
 
The pt is unaware of the two bottom leads and is using the single dorsal column lead regularly. He is 100% with it and normal. Says no one ever told him there are more leads.

IMG_9472.jpeg
IMG_9473.jpeg
 
MitchLevi said:
The pt is unaware of the two bottom leads and is using the single dorsal column lead regularly. He is 100% with it and normal. Says no one ever told him there are more leads.
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Fair enough, until he needs an MRI. I assume there's an adapter under there if that's an SCS battery?
 
I think it is, but this guy never consented to new leads and said they swapped his IPG in 2018 and was told they initially installed the wrong battery. Original implant 2007.
 
MitchLevi said:
I think it is, but this guy never consented to new leads and said they swapped his IPG in 2018 and was told they initially installed the wrong battery. Original implant 2007.
Click to expand...
Sounds like they are coming up for a replacement so nice time to fix that mess perhaps. It is a very atypical placement for sure. It's very rare I see an IPG so close to midline that low and the thoracic lead looks like it doesn't access the epidural space until rather high up if at all.
 
Orin said:
Sounds like they are coming up for a replacement so nice time to fix that mess perhaps. It is a very atypical placement for sure. It's very rare I see an IPG so close to midline that low and the thoracic lead looks like it doesn't access the epidural space until rather high up if at all.
Click to expand...
Thoracic lead is perfect. Those bottom two leads we have no answer for what they are and why they’re there, and this guy knows nothing about it.
 
4 contacts, is that some weird off shoot of like a Stimwave PNS?
 
DoYouEvenLiftBro said:
4 contacts, is that some weird off shoot of like a Stimwave PNS?
Click to expand...
When I was in fellowship we would do tripole leads. 1 octrode in the canal and a pair of quads over the paraspinals or SIJ as PNS.
Routinely.
 
lobelsteve said:
When I was in fellowship we would do tripole leads. 1 octrode in the canal and a pair of quads over the paraspinals or SIJ as PNS.
Routinely.
Click to expand...
That must be what this is, but I’ve never heard of that personally. These bottom two are maybe what you’re describing and they’re just migrated. This was placed in 2007.
 
MitchLevi said:
That must be what this is, but I’ve never heard of that personally. These bottom two are maybe what you’re describing and they’re just migrated. This was placed in 2007.
Click to expand...
Yep. Back in the days of “field stim”. Saw it as a resident with Falco around 2010
 
MitchLevi said:
Thoracic lead is perfect. Those bottom two leads we have no answer for what they are and why they’re there, and this guy knows nothing about it.
Click to expand...
the answer is money. It was placed in 2007 when per contact was the payout. You made bank for as many contacts you could scatter around the back
 
Yes, I have heard about this. My partner’s dad is an older doc and he said they would place one lead in the epidural space and two other ones wherever. Heck, I have heard some strange stories from patients. I wouldn’t put it past some of our colleagues from that time period taping the extra leads onto the back for the trial.
 
BobBarker said:
Yes, I have heard about this. My partner’s dad is an older doc and he said they would place one lead in the epidural space and two other ones wherever. Heck, I have heard some strange stories from patients. I wouldn’t put it past some of our colleagues from that time period taping the extra leads onto the back for the trial.
Click to expand...
If you used some u/s gel, it may do something. Was there a j-code for lube back then?
 
No, but that has probably been done. US guidance used to pay a large amount of money in that time frame also.
 
this probably wasnt taking place in 2007, but waaay back in the day, i am aware of at least 1 spine surgeon - when doing lamis - would toss in leads both epidurally and a lead in the subcutaneous tissue for later use.

is the thoracic epidural lead a 4 contact lead or higher? if it is a 4, like the other 2...
 
Care Plan:

Injection note-Per standard prolotherapy protocol I injected the ankle joint with 5 cc of D25, followed by 10 cc of
30 gamma ozone. I then injected a mixture of D15 and 1% lidocaine into the ATFL, the fibulocalcaneal ligament,
the calcaneocuboid ligament, and the sinus tarsus. I also injected 5 cc of 30 gamma ozone into the sinus tarsus and
the ATFL.I also injected a mixture of D15 and 1% lidocaine into the navicular and the medial cuneiform attachment sites.
Prior to any injections I cleansed the entire area with a mixture of ethanol and Hibiclens
Follow-up in 1 month.
He is instructed to watch for any signs of infection and to call me immediately if there are any complications.



Part of a file being reviewed.
 
lobelsteve said:
Care Plan:

Injection note-Per standard prolotherapy protocol I injected the ankle joint with 5 cc of D25, followed by 10 cc of
30 gamma ozone. I then injected a mixture of D15 and 1% lidocaine into the ATFL, the fibulocalcaneal ligament,
the calcaneocuboid ligament, and the sinus tarsus. I also injected 5 cc of 30 gamma ozone into the sinus tarsus and
the ATFL.I also injected a mixture of D15 and 1% lidocaine into the navicular and the medial cuneiform attachment sites.
Prior to any injections I cleansed the entire area with a mixture of ethanol and Hibiclens
Follow-up in 1 month.
He is instructed to watch for any signs of infection and to call me immediately if there are any complications.



Part of a file being reviewed.
Click to expand...
Was there harm done? What’s the complaint other than chicanery
 
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