Pictures of the Week

[BoardingDoc]

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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.

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.

 

[Orin]

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

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.

 

[lobelsteve]

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

 

[clubdeac]

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

View attachment 412570



View attachment 412571

What am I looking at? Mets

 

[BobBarker]

Yea… not seeing anything.

 

[lobelsteve]

What am I looking at? Mets

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.

 

[DoYouEvenLiftBro]

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

 

[lobelsteve]

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

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.

 

[DoYouEvenLiftBro]

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.

Interesting case, what’s his age

 

[lobelsteve]

Interesting case, what’s his age

67

 

[Ducttape]

are you talking about the anterior superior lesion that is present on both films?

 

[lobelsteve]

are you talking about the anterior superior lesion that is present on both films?

View attachment 412657

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.

 

[geauxg8rs]

67

⁶🤷⁷
Sorry had to have it one time on sdn. Now i accept your lifetime ban

 

[SSdoc33]

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.

 

[Ducttape]

6 7!

6 7!

 

[DoYouEvenLiftBro]

 

[DoYouEvenLiftBro]

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?

 

[lobelsteve]

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?

If SIJ IA and MBB/RF do not help, add bipolar RF along back of Bertolotti with next RF.

 

[MitchLevi]

 

[clubdeac]

View attachment 413161

Tumor?

 

[MitchLevi]

Tumor?

Just "wore out."

 

[SSdoc33]

there is no canal there

 

[MitchLevi]

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.

 

[Orin]

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.

Fair enough, until he needs an MRI. I assume there's an adapter under there if that's an SCS battery?

 

[MitchLevi]

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.

 

[Orin]

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.

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.

 

[MitchLevi]

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.

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.

 

[DoYouEvenLiftBro]

4 contacts, is that some weird off shoot of like a Stimwave PNS?

 

[lobelsteve]

4 contacts, is that some weird off shoot of like a Stimwave PNS?

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.

 

[MitchLevi]

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.

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.

 

[Taus]

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.

Yep. Back in the days of “field stim”. Saw it as a resident with Falco around 2010

 

[geauxg8rs]

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.

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

 

[BobBarker]

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.

 

[cowboydoc]

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.

If you used some u/s gel, it may do something. Was there a j-code for lube back then?

 

[BobBarker]

No, but that has probably been done. US guidance used to pay a large amount of money in that time frame also.

 

[Ducttape]

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...

 

[MitchLevi]

T8-9 lead is an octrode

 

[lobelsteve]

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.

 

[BobBarker]

I don’t think there is anyway all that volume could fit anywhere in a foot.

 

[clubdeac]

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.

Was there harm done? What’s the complaint other than chicanery

 

[lobelsteve]

Was there harm done? What’s the complaint other than chicanery

Above is just stupidity. Case is for DEA. Ongoing so cannot comment on the Rx.

 

[pmrmd]

Why DEA?

 

[mdo1738]

Why DEA?

Guessing that someone who was claiming to perform insane procedures was also prescribing insane regimens. “I’ll give you 500 percocets if you let me inject some gamma ozone in your foot lol”.

 

[lobelsteve]

Genic blocks did not work.

 

[cowboydoc]

View attachment 413613View attachment 413614

Genic blocks did not work.

sooo close.

 

[Orin]

Genic blocks did not work.

I don't get it but I haven't done one with fluoro in so long. What am I looking at here?

Because the knee looks too good to do the procedure? They're too proximal on the superior target? No lateral? The needles are too thick? Did a CRNA do them?

 

[pinstriped1992]

I don't get it but I haven't done one with fluoro in so long. What am I looking at here?

Because the knee looks too good to do the procedure? They're too proximal on the superior target? No lateral? The needles are too thick? Did a CRNA do them?

Superior needles are far too north to be near the genicular nerves and off os.

 

[BoardingDoc]

View attachment 413613View attachment 413614

Genic blocks did not work.

Pro tip: It helps when you block the nerve instead of random anatomy.

 

[BoardingDoc]

Jokes aside, has anyone else read this paper?

https://rapm.bmj.com/content/44/10/950

It shows different targets than classically taught (to be clear, the pic above is terrible by classical or this paper's standards)

Curious what people think

 

[callmeanesthesia]

Jokes aside, has anyone else read this paper?

https://rapm.bmj.com/content/44/10/950

It shows different targets than classically taught (to be clear, the pic above is terrible by classical or this paper's standards)

Curious what people think

Tried it for a while (6 months or so?) back when it was published and had an immediate drop in success rate and increase in procedural pain. Went back to conventional targets. Caveat that I do maybe 1 genicular RF every few months, but I was doing more at that time.