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Don't want to ream across and spine jack it?
What's the primary worry? Mobile bust fracture?
See earlier pics in this thread on a different patient. Fx not as bad as this and went through the canal in the end- now requiring more surgery.
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Curious what CT looks like
Fx and the modic below look unusual. More evaluation needed.
Why not trial OsteoPearl on this? No worries about canal leakage and keep them in an LSO.
I would worry about the mechanical effect of the bone pellets pushing acutely but that's a reasonable consideration if surgery says no.
Inflating the balloon makes me nervous when the bone is burst.
Parasagittal STIR from a patient who had SIJ RFA about 4 months ago. She did have pain relief but pain is starting to return in that area (chronic multifocal pain, underlying rheum vs fibro, in addition to spinal degenerative changes, so a little hard to tell how successful it was). Looks very well demarcated, not like an infection. It looks like an almost perfect lesion strip. My technique is to drop 4 needles in parallel about 1 cm apart from the sacral ala down, burn bipolar, then move the top needle to the bottom of the row and burn again.
What do you all think of this?
No, I should have been more clear - I did the RF as described. Palisade technique. Row of conventional 18g RF needles 1 cm apart.
Your palisades/bipolar technique though would make a lesion in that orientation but my concern is the kinetics of healing should have reduced it somewhat as it looks like solid fluid/inflammatory signal extending into the posterior cortical bone.
MRI for in vivo Analysis of Ablation Zones Formed by Cooled Radiofrequency Neurotomy to Treat Chronic Joint Pain Across Multiple Axial Spine Sites - PMC
Radiofrequency (RF) ablation is the targeted damage of neural tissues to disrupt pain transmission in sensory nerves using thermal energy generated in situ by an RF probe. The present study aims to evaluate the utility of magnetic resonance imaging ...
pmc.ncbi.nlm.nih.gov
We don't have much literature out there about it, but the first reference shows a cooled RF lesion on MRI at a week. The second reference is from hepatic RFA where they expect the inflammatory signal to resolve at 1 month. As this isn't exactly liver which regenerates quickly or bone where ablations may be noted for years, perhaps the imaging/time frame is as expected for the connective tissue in that region, but I don't know. Blood work or bone scan might help you understand if that is infection or sacroiliitis rather than RF, but I might just check blood work and top her off with a steroid injection.
Pain overall better but started to return.
So why are we getting this MRI? What is the clinical picture?
Treat the patient and not the imaging.
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SI pain specifically was better. Continued to have lumbar pain.
Very helpful, thank you! The lesion images they show look similar.Your palisades/bipolar technique though would make a lesion in that orientation but my concern is the kinetics of healing should have reduced it somewhat as it looks like solid fluid/inflammatory signal extending into the posterior cortical bone.
MRI for in vivo Analysis of Ablation Zones Formed by Cooled Radiofrequency Neurotomy to Treat Chronic Joint Pain Across Multiple Axial Spine Sites - PMC
Radiofrequency (RF) ablation is the targeted damage of neural tissues to disrupt pain transmission in sensory nerves using thermal energy generated in situ by an RF probe. The present study aims to evaluate the utility of magnetic resonance imaging ...
We don't have much literature out there about it, but the first reference shows a cooled RF lesion on MRI at a week. The second reference is from hepatic RFA where they expect the inflammatory signal to resolve at 1 month. As this isn't exactly liver which regenerates quickly or bone where ablations may be noted for years, perhaps the imaging/time frame is as expected for the connective tissue in that region, but I don't know. Blood work or bone scan might help you understand if that is infection or sacroiliitis rather than RF, but I might just check blood work and top her off with a steroid injection.
Jfc. (You had me for a second. Had to read it a few times).
Let’s see, that’s 40x100x20 = almost 80,000 OME per day. better up it by 25%, plus a little to make it a nice round number.
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Catheter is probably nonfunctional or he's dead. Do a catheter access port study and see. Those are granuloma doses if they're accurate.
Also, is that a Prometra/Flowonix device?
I wish. Clinical presentation -- altered mental status, aspiration pneumonia, walked into a doorframe and dislocated his shoulder without realizing it. Currently in ICU on pressors, propofol, fentanyl drip.
Hmm, how much fentanyl is he riding. Did you stop the pump?
Thankfully I am not directly involved. Not sure on numbers. Pump was swapped to baclofen only to avoid withdrawal.
Tease
tolerance is an amazing phenomenon.
the highest dose i have ever heard of was 10 mg hydromorphone daily. it was prescreening - patient from somewhere out western US that was looking to move to the area and needed new pain doc to "take over".
i wonder how much fentanyl drip is he on.
the highest dose i have ever heard of was 10 mg hydromorphone daily. it was prescreening - patient from somewhere out western US that was looking to move to the area and needed new pain doc to "take over".
i wonder how much fentanyl drip is he on.
That really makes it hard for me to believe this is due to the pump delivering medication intrathecally as I've seen patients wearing that transdermally.
Obviously if those pump doses/units are correct they are heroic for pain or spasticity. But the units/doses just seem unrealistic as unless the pump was being refilled nearly daily, it would have be delivering powdered slurry. Baclofen's max solubility in water is like ~4000 mcg/mL.
My worry would be that intrathecal baclofen withdrawal at that dosing could look a lot like sepsis with hyperthermia, seizures, etc, but realistically speaking, the primary problem is likely secondary in a patient who happens to have a crazy pump delivering somewhere intramuscular/epidural, or someone wrote the concentrations down wrong as the daily dose
Great thoughts. Just to clarify, the pt is still intubated on propofol so we have no idea if the fentanyl is sufficient.
They did get an EEG to r/o seizures due to baclofen withdrawal as well.
The concentrations are, tragically, accurate. It is well documented through pharmacy records and clinic notes over several years.
The pump has a 40mL reservoir and was getting refilled q3 weeks, I believe.
Care to share who the lunatic is who did this to the patient?
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Assuming their propofol/fentanyl gtt dosing is in their normal ranges, it's really unlikely this is in the CSF, but it's a simple thing to aspirate from the side port of the pump with a 25g pencil point spinal needle and check. If the intrathecal dosing was 40 mg/day for hydromorphone and 4 mg/day for baclofen, you'd expect significant resistance to propofol/fentanyl sedation and expect more what you see in palliative cancer cases where you're breaking out the volatile anesthetics and ketamine.
I agree with @lobelsteve that this is far outside normal for intrathecal therapy, but without knowing the whole story and what has been tried, hard to judge the sanity of the clinicians involved.
It might get a bit more...official...to say the least so I'll refrain from publicly naming anyone.
Posts make it sound like we will witness a fatality from door frame injury.
Autopsy goes to coroner and toxicology will point to overdose.
Experts will be called on plasma levels.
Defensing this will be problematic, and I would love to see their depositions.
Surely someone that medicalized has had a CT spine or chest at some point, where you could see the catheter. Also there are really only so many receptors to occupy so there must be a limit beyond which adding more drug doesn’t result in any additional clinical effect.
Plot thickens. Guy was also taking oral hydromorphone 4mg tablets 14/day, receiving ketamine infusions 500-700mg at a time every couple months, and was prescribed ketamine vials, fill needles, and syringes to self administer orally at home.
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Wooow. Check his LFTs?
Dude’s going to be impossible to sedate when he starts to wake up. Either that or they’ll just keep him on propofol until his urine turns green.
Broken record but that oral hydromorphone usage on top of those pump doses reeks of a non-functional catheter. Ketamine SL I've seen in rare cases. IV home usage though sounds like a recipe for problems. DEA will love this one.
Oddly enough, radiologists looking at CTs of the C/A/P aren't looking for the catheter continuity, but even then, it can look contiguous but be clogged with precipitated drug/etc
Oddly enough, radiologists looking at CTs of the C/A/P aren't looking for the catheter continuity, but even then, it can look contiguous but be clogged with precipitated drug/etc
he's intubated. probably propofol infusion.
? paralytic, beta blocker for heartrate, antihypertensive, etc.
even if the catheter were nonfunctional, the medication is going somewhere. he is getting 39.5 mg dilaudid SQ.
yes that is only 488 MED.
it seems the psych literature and palliative care literature talk about 1.25 mg/kg/day, or 10-50 mg orally and the pain literature up to one study using up to 21 mg/kg/day.
? paralytic, beta blocker for heartrate, antihypertensive, etc.
even if the catheter were nonfunctional, the medication is going somewhere. he is getting 39.5 mg dilaudid SQ.
yes that is only 488 MED.
apparently, only 20% of oral ketamine gets by first pass metabolism.
it seems the psych literature and palliative care literature talk about 1.25 mg/kg/day, or 10-50 mg orally and the pain literature up to one study using up to 21 mg/kg/day.
Agreed, which is why 4-8 mg oral hydromorphone and that fentanyl infusion would still kick in, while the baclofen was doing diddly so the propofol won't care.
20% is still greater than zero for ketamine, but I normally use the higher concentration stuff undiluted and asked patients to hold it under their tongue to improve the bioavailability/onset. They seemed to have less of some of the side effects too, but I don't have formal data to support that.
Routes of Administration (ROA) - ASKP
Ketamine must be absorbed into the bloodstream and circulate to the brain in order to yield a therapeutic effect. There are many ways ketamine can be
askp.org
That’s gonna be an amazing case report for someone if you’re right
Saw new NS:
Assessment/Plan
1. Compression fracture of lumbar spine
Ms. X has symptoms of low back pain along with left L5 radiculopathy and pain in her right upper glute which is tender to the touch. I independently interpreted the MRI of her lumbar spine today which demonstrates multilevel degenerative changes and a 80% compression fracture of L4. She does have a lumbarized sacrum and I am calling the lowest segment L5-6. At L3-4 there is a disc bulge along with her previous right hemilaminectomy with facet arthropathy and moderate bilateral neuroforaminal narrowing. At L4-5 her right hemilaminectomy defect is seen along with a disc bulge retropulsion of the L4 vertebral body with severe bilateral neuroforaminal narrowing. At L5-6 her previous laminectomy defect is seen on the right with severe bilateral neuroforaminal narrowing. I independently interpreted the flexion-extension x-rays of her lumbar spine today which demonstrate her compression fracture at L4 and from L3-5 there is a 13 degree kyphosis. Her bone density was most recent DEXA scan. I am not recommending surgery at this time as she needs further workup. I will order a CT of her lumbar spine to evaluate her bony anatomy for surgical planning. I will also discuss her case with my partners to come up with the best surgical option for her. Additionally, we will order an MRI of her right hip/glute to evaluate for anything that would be going on in terms of a tendon or ligament tear that may be contributing to the tenderness that she is having in her upper right glute. I will see her back in the office after she obtains these tests. Ms. X has verbalized agreement and understanding and all of her questions have been answered to her satisfaction. Thank you for allowing me to participate in her care.
Ordered:
CT Spine Lumbar w/o Contrast
MRI Hip w/o Contrast Right
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PHI
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Curtis there's no mention of the Modic changes. They look a little of to me wood be interested to hear their thoughts
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I edited post above to show the sarcasm, otherwise we would think you were nuts.
Sorry was typing on my phone and the keyboard is too small for my fingers lol. Just saying the Modic changes look wonky and was wondering if he mentioned anything about it.
Are you looking at the imaging where L4 has had kypho but the back half of the vertebral body is in her spinal canal?
1: The MRI report Steve posted is not related to the MRI image posted here. It's related to the x-ray posted on the previous page about the L4 kypho disaster, and presumably what the guy wrote about the MRI before he caused said disaster. The MRI image here is a separate case that Steve considered doing which was a similar fracture to disaster case.
2: As Steve mentioned, the bigger issue in the MRI image (not from the other written report) is that L3 is gonna be a kypho disaster like the earlier picture. (I think you could maybe put a lag screw across the two pieces first and then kypho it, but I'd leave that to NSGY)
3: The "modic changes" on this MRI are just from what looks like a prior fusion of L4 and L5. There's no disc in between and there's some posterior artifact on that slice so I'm assuming L4 and L5 are fused and we simply can't see the hardware in that sagittal slice.
Modic changes only in posterior endplate.
As read by Radiologist.
I have not seen this before, and wondering if anyone else has anything to add.
Non suspicious neck pain without significant history.
