Pictures of the Week

[lobelsteve]

so what'd u do for her? lol

Like I said I walked out of the room and she kept talking. I never went back. The nurses helped her out of the office and our parking lot is not that big but you couldn't find her car. She may have gotten an exercise program but she got no medications no referrals and she's not going to get a follow-up visit.

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[pmrmd]

Neurologically normal.

 

[SSdoc33]

View attachment 225248 View attachment 225249

Neurologically normal.

wow. so weird. the body is amazing.

cant be completely normal, or why the MRI? neck pain?

what do they do, shunt that thing? is that just a big syrinx?

 

[pmrmd]

MRI for neck pain. Neurologically normal below, which I can't believe. Its a huge syrinx the NS doesn't want to touch.

 

[lobelsteve]

MRI for neck pain. Neurologically normal below, which I can't believe. Its a huge syrinx the NS doesn't want to touch.

Can't blame them. No neuro deficit. Pain from those disks at C2-3, C3-4, C4-5. ESI?

 

[pmrmd]

She did well with facet blocks with dex last year. She came back for that as well as med management after rheum had enough but doesn’t feel like stopping the Soma, Restoril, and Ativan she takes with her Norco TID so I might not see her again.

 

[lobelsteve]

Cervical SCS troubleshooting.

Here is AP/Lat of trial done today. Leads would not advance any higher. MRI clean. Bumped the lead, rolled it, softened stylet, etc. Could not get further up. Patient is 37 y/o. BMI is 17. Dx: CRPS, left arm after clavicle Fx s/p ORIF.

I'm sure the trial will work well, but I wish I could get up higher for her. Thoughts?

 

[Orin]

Cervical SCS troubleshooting.

Here is AP/Lat of trial done today. Leads would not advance any higher. MRI clean. Bumped the lead, rolled it, softened stylet, etc. Could not get further up. Patient is 37 y/o. BMI is 17. Dx: CRPS, left arm after clavicle Fx s/p ORIF.

I'm sure the trial will work well, but I wish I could get up higher for her. Thoughts?

In the lateral it almost looks like your inferior lead is slipping out of the epidural space through an incomplete ligament.

How do you feel about hydrodissection with PFNS? Saved me a few on "clean MRI" cases. The leads float a bit and are harder to drive perfectly but it can temporarily help you get through a scarred down area. A styletted catheter like the Arrow Flextip would be ideal, but normally I just go through the entry needles with 5 - 10 mL as it's annoying to open another kit.

Was the patient awake or asleep? I would consider pulling the needles out of the space and having her take some deep breaths or valsalva/release and or flex/extend/rotate to see whether the leads can be moved with a slight change in the epidural space geometry/volume.

 

[Biohazard685]

In the lateral it almost looks like your inferior lead is slipping out of the epidural space through an incomplete ligament.

How do you feel about hydrodissection with PFNS? Saved me a few on "clean MRI" cases. The leads float a bit and are harder to drive perfectly but it can temporarily help you get through a scarred down area. A styletted catheter like the Arrow Flextip would be ideal, but normally I just go through the entry needles with 5 - 10 mL as it's annoying to open another kit.

Was the patient awake or asleep? I would consider pulling the needles out of the space and having her take some deep breaths or valsalva/release and or flex/extend/rotate to see whether the leads can be moved with a slight change in the epidural space geometry/volume.

Does hydrodissection interfere with table top testing?

 

[Orin]

Does hydrodissection interfere with table top testing?

It's similar to what happens if you use LOR with saline. Impedances are a little different, but not ridiculously weird. It does get absorbed rather quickly so if you're struggling long enough to get placement/mapping perfect and retract the lead to the obstruction, that volume will have disappeared in ~10 minutes. The one time I've had that happen, it opened right back up with more volume.

 

[lobelsteve]

80 y/o fall at home. 8/10 pain. Failed brace, opiates, Miacalcin. Got Prolia last week. Stayed late yesterday to do this under local in office. Hitting her with the hammer was the best part.

Out of wheelchair, out of pain when leaving office.
Nice to get a win every now and then.

 

[lobelsteve]

Fx and fix in 2006. Seeing me today to see what can be done? Anyone use CLR in the spine?

 

[cowboydoc]

Fx and fix in 2006. Seeing me today to see what can be done? Anyone use CLR in the spine?

Double xstop didn't help iatrogenic stenosis or did they precede the fx?

 

[lobelsteve]

Double xstop didn't help iatrogenic stenosis or did they precede the fx?

Same surgery. All done at once.

 

[Orin]

Same surgery. All done at once.

I haven't done the xstop/vertiflex stuff but what was the thought process there?

 

[lobelsteve]

I haven't done the xstop/vertiflex stuff but what was the thought process there?

Put as much cement in the epidural space and to the left of the bone, then fuse posteriorly for the iatrogenic stenosis? You do know that this patient had no idea what the surgeon did.

 

[Orin]

Put as much cement in the epidural space and to the left of the bone, then fuse posteriorly for the iatrogenic stenosis? You do know that this patient had no idea what the surgeon did.

Okay, so for a second I thought you did both of those. It is a pretty nice looking cement leak, but I would've figured a surgeon would've decompressed at the same time?

 

[Tapspatellas]

Fx and fix in 2006. Seeing me today to see what can be done? Anyone use CLR in the spine?

Fluoro must have broken mid vert and they just guesstimated the amount of cement, or if they just didn’t want to waste that last 8mL of cement when it already looked fine. Wonder if the x stops were the first procedure of the day, or after they gave her the stenosis from the vert.

 

[cowboydoc]

It's a shame they had to lose all that revenue with a -50 modifier for the x-stops.

 

[lobelsteve]

Dysplasia, datplasia. Everywhere a plasia.

 

[BobBarker]

 

[lobelsteve]

Little tight at L3-4.

 

[painfree23]

View attachment 230517

Little tight at L3-4.

ouchhhh that makes me hurt

 

[Tapspatellas]

View attachment 230517

Little tight at L3-4.

That ligament is begging for some MILD relief

 

[lobelsteve]

75 yo female on high dose opiate therapy at 90 meq. Hobbies include killing snakes off her land in the mountains with her .38. Loads are something called snakeshot. Dx M96.1 neck and back.

 

[lobelsteve]

Where's Waldo? I mean L2. You think you see it?

 

[lobelsteve]

In these views, Fx's are dark. L3, whole bone, L1 a good bit of fresh. L2, nope nothing left. Someone is an inch shorter today.

 

[lobelsteve]

Clean up in aisle 4. Adeno with unknown primary location. Elderly. Foot drop on right. Treating with Oncology. Any role for kypho/MBB/ESI as symptom management. Using AFO for L4 weakness. XRT?

 

[SSdoc33]

ESI for pain only, not weakness. radiation to that area could also help with pain if that is the primary complaint

 

[lobelsteve]

ESI for pain only, not weakness. radiation to that area could also help with pain if that is the primary complaint

Mechanism for ESI on compressive/infiltrative lesion in/on nerve?

 

[SSdoc33]

Mechanism for ESI on compressive/infiltrative lesion in/on nerve?

not sure what your question is. too many slashes.

i think you have to assume that the cancer is a mass lesion pressing on the nerve itself, rather than growing within the nerve. if so, it is just like a disc herniation, and the mechanism of action for pain relief would be the same. if it just foot drop without weakness, then there is no role for an ESI

 

[Orin]

If the mets are extending from the vertebral body, I'm told that kypho with RF ablation may cut off the feeder vessels and help with regression of the epidural/foraminal masses. I don't see a ton of wedging/compression so I don't think this is a height loss causing neuroforaminal compression, so you got to treat the cancer I would think.

If the symptomatic ones are too diffuse or you can't get there safely, send them to a good radiation oncologist, as you can come back with ESIs, SCS, or pump for a radiation induced neuritis, but you aren't going to fix a growing cancer lesion's compression with a steroid injection.

If they are a semi-reasonable surgical candidate and you know a good surgeon for a minimally invasive XLIF, that might open up, debulk as they would for a disc, and rod over to stabilize that level. The MIS approach should be a 2 - 3 day hospital stay and isn't horribly tough for recovery, but depends on the patient/chemo/etc. It'll be tricky at that level though.

If they're not hurting, and it's just the leg weakness, you may have a role for those functional electrical stimulation with a thigh/calf cuff to help the nerve fire from the periphery and get them away from the AFO.

Or just send them to an academic place where they have spinal metastases boards to discuss combined approaches for treatment/palliation/etc

 

[lobelsteve]

Myelopathy s/p decompression, CRPS in right hand. PM, CABG, 87 y/o. Gabapentin.
No good options?

 

[lobelsteve]

Right elbow replaced as well. Bony growth about implant limiting elbow ROM.

 

[Orin]

View attachment 231917

Myelopathy s/p decompression, CRPS in right hand. PM, CABG, 87 y/o. Gabapentin.
No good options?

Peripheral stim aimed at the brachial plexus in the supraclavicular region or at the right stellate ganglion?

 

[lobelsteve]

Peripheral stim aimed at the brachial plexus in the supraclavicular region or at the right stellate ganglion?

Fixed it for you.

 

[lobelsteve]

Conus longus longus

 

[drrosenrosen]

This is that vascular uptake on CESI that I posted in the physician's board. Aborted procedure after repeated vascular uptake on replacing the needle from square 1.

 

[lobelsteve]

This is that vascular uptake on CESI that I posted in the physician's board. Aborted procedure after repeated vascular uptake on replacing the needle from square 1.

Seen similar vascular uptake on a lecture from Gabor Racz years ago. Good catch.

 

[lobelsteve]

T1-2 ESI with 25g quincke.
Lateral view with contrast in ligament.

T1-2 lateral with vascular uptake.

T1-2 AP with vascular uptake.

T1-2 after correcting for vascular uptake.

 

[lobelsteve]

2 weeks ago had cardiac cath x2. They said follow up in a month.
Texted to my Cardiologist. He saw her today. I have never seen this before....

 

[SSdoc33]

2 weeks ago had cardiac cath x2. They said follow up in a month.
Texted to my Cardiologist. He saw her today. I have never seen this before....

i suppose that could be a resolving hematoma, but id worry about an infection

 

[Ducttape]

Most likely a pseudoaneurysm...

 

[lobelsteve]

47 y/o male. Urinary retention (visible on MRI), ED. VAS 3/10. No weakness. No sensory loss.
Got consult from his PCP and reviewed MRI ahead of time. Called off consult until he sees surgeon this week.

 

[SSdoc33]

View attachment 234558

47 y/o male. Urinary retention (visible on MRI), ED. VAS 3/10. No weakness. No sensory loss.
Got consult from his PCP and reviewed MRI ahead of time. Called off consult until he sees surgeon this week.

i bet if you saw him in clinic his EHL would be weak. id be tempted to admit this guy if i were the ED doc. at least needs to be seen in the hospital by the surgeon

 

[pmrmd]

Ankle plantar flexors and knee flexors likely weak with normal EHL. I’d have surgeon see that day not next week sometime.


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[lobelsteve]

T10-11 HNP with cord flattening, no signal change. 25g spinal needle. No LOR. Touch lamina, turn superior, advance under lateral.

 

[BobBarker]

 

[drrosenrosen]

Nice shootin, Tex!

 

[SommeRiver]

HIV+ 60 yo male with severe BLE radicular pain for 5 months. Fell off a ladder in his garage and had immediate severe back and BLE pain. No prior episodes of pain or really any medical issues other than well controlled HIV.

After falling off the ladder he presented to the ED who did an XRAY, ruled out fracture, gave toradol, and sent home with tramadol. Presented to the ED again a few days later, and this went on for a few weeks.

Referred to a local pain clinic who did basically nothing for him for 4 months. No imaging. No Rx. Some of these details I don't remember, but basically they did nothing for like 4 months. Definitely no scans or even gabapentin.

I open the door to the exam room and find a pleasant gentleman who can't sit still and is pouring sweat, plus he appears somewhat cachectic and generally feeble. I can't do an exam bc he is in severe pain, but I don't feel like he is histrionic or emotionally labile. He feels legit to me.

I send him for an MRI and here are two pics from that scan. These images basically sum up L3 to the sacrum.

I bring him in to tell him he may have cancer and direct him to the ED for a workup.

I haven't seen or heard from him since then, and this was 4 months ago.

Moral of the story - Get a damn MRI on a diaphoretic and cachectic male with HIV and severe pain.