Pictures of the Week

IPSIS: Formerly the Spine Intervention Society
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SommeRiver said:
I send him for an MRI and here are two pics from that scan. These images basically sum up L3 to the sacrum.
Click to expand...

But choosing wisely says...
Imaging Tests for Back Pain | Choosing Wisely

I would hope the B symptoms weren't there initially, and I'm shocked that wasn't noted on the initial xrays as the posterior elements look to be completely gone.
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Orin said:
But choosing wisely says...
Imaging Tests for Back Pain | Choosing Wisely

I would hope the B symptoms weren't there initially, and I'm shocked that wasn't noted on the initial xrays as the posterior elements look to be completely gone.
Click to expand...

My opinion on this kind of thing is let's pretend there are no B symptoms and you've got a dude with intractable pain for several months...scan that individual with something other than XRAY. Just do it bc there's no reason not to and I don't care what the "guidelines" say about the judicious use of advanced imaging.

I have so many Q about those ED visits too. I never got records bc all this happened so quickly I just needed him seen and worked up.
 
The ER is not really a good place to do long term evaluation and treatment.

I could critique the pain clinic, but unless those symptoms were noted, it was missed.

You should also check and see what role the insurance company played in denying MRI scans. It is a huge current scam is that an insurance company can deny an MRI because you need 6-8 weeks on “physician directed care”, yet it has to be the SAME physician... had a PCP have patient go through PT x3 mo in a 90 yo lady, referred to me, but insurance denied MRI because I hadn’t seen her for over 6 weeks when I ordered the scan..... this occurred last month! When I saw her 5 weeks and 4 days after the initial appt, they still denied.

And then there was the case where I requested an MRI at 6 weeks, and the insurance denied and stated that he had to wait 2 months and thus he was not eligible for an MRI for a year. (No prior MRI).
 
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So I assume this was a minority or non-normative patient and folks assumed they were drug seeking because whatever. I've seen this same pattern play out though in the Christian white lady with a h/o breast cancer, so I don't think it's just a race/socioeconomic/discrimination thing.

They presented with hip pain and got an ultrasound guided bursitis injection for GTB which it turns out 12 months later was really a huge honking cancer metastasis that fills up their L5 - S3. It sucks for everyone.

I can't fault anyone in my case or yours, but we have got to figure out a balance between pulling the trigger on everybody and never getting an MRI.

In this scenario, it sucks, but other than HIV = high risk of cancer, the initial presentation wouldn't have warranted imaging until 3 - 6 months in.
 
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Clubfoot repair as child, RA age 18. Rheumatoid nodule removed x2 and grown back.
Sent for MBB, but SIJ on left makes more sense and is + on exam, facet load neg. MRI spine equivocal, mod facet on L4-5, L5-S1 disc worn out. Nice lady. Sending her to aggressive Podiatry for consideration of triple arthrodesis, nodule excision, hammer toe repair. I'm getting her started on SIJ program and will inject if not tolerating it. On Actemra, MTX, Plaquenil from Rheum.









SvdzIsg.jpg


CSmKFfB.jpg
 
lobelsteve said:
Clubfoot repair as child, RA age 18. Rheumatoid nodule removed x2 and grown back.
Sent for MBB, but SIJ on left makes more sense and is + on exam, facet load neg. MRI spine equivocal, mod facet on L4-5, L5-S1 disc worn out. Nice lady. Sending her to aggressive Podiatry for consideration of triple arthrodesis, nodule excision, hammer toe repair. I'm getting her started on SIJ program and will inject if not tolerating it. On Actemra, MTX, Plaquenil from Rheum.









SvdzIsg.jpg


CSmKFfB.jpg
Click to expand...

rheumatoids do great with MBBs/RFs if the SIJ fails.

id be careful about effing up her feet too much. takes 6 months to heal, and they always still complain
 
lobelsteve said:
Clubfoot repair as child, RA age 18. Rheumatoid nodule removed x2 and grown back.
Sent for MBB, but SIJ on left makes more sense and is + on exam, facet load neg. MRI spine equivocal, mod facet on L4-5, L5-S1 disc worn out. Nice lady. Sending her to aggressive Podiatry for consideration of triple arthrodesis, nodule excision, hammer toe repair. I'm getting her started on SIJ program and will inject if not tolerating it. On Actemra, MTX, Plaquenil from Rheum.
SvdzIsg.jpg


CSmKFfB.jpg
Click to expand...


What's your SIJ program?
 
lobelsteve said:
Clubfoot repair as child, RA age 18. Rheumatoid nodule removed x2 and grown back.
Sent for MBB, but SIJ on left makes more sense and is + on exam, facet load neg. MRI spine equivocal, mod facet on L4-5, L5-S1 disc worn out. Nice lady. Sending her to aggressive Podiatry for consideration of triple arthrodesis, nodule excision, hammer toe repair. I'm getting her started on SIJ program and will inject if not tolerating it. On Actemra, MTX, Plaquenil from Rheum.









SvdzIsg.jpg


CSmKFfB.jpg
Click to expand...

Would she consider BKA? Nothing good will come from an aggressive foot surgery?


Sent from my iPhone using Tapatalk
 
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Ah.... now she is fixed!

Pain free forever.

Cool case, though.
 
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lobelsteve said:
View attachment 237355

I can forgive the straw at L1. But I want a CT to see how the VC dodged that bolus. And I appreciate the left sided venous flow. No, not me.
Click to expand...

Cement ablation of the vessels leads to less pain right? Any individual item is forgivable but overall that looks like an inattentive person performing the technique.
 
drrosenrosen said:
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.


I know I'm a little late but can someone explain this one to me? I don't see any contrast.
Click to expand...
 
5fx.jpeg




50 y/o female with polysubstance abuse. Addiction mgmt has her on 5.7 Zubsolv bid, PCP Xanax 1mg bid. Fell in tub at home. In addition to Fx T11, L1, L2, L4, L5, b/l sacrum, has severe spinal stenosis at L3-4, L4-5 from lipomatosis, facet/lig. No significant bony retropulsion.

What's your move?
 
[QUOTE="

What's your move?[/QUOTE]

Honestly I'd try a lumbar MBB first. Might get away with doing less.
 
lobelsteve said:
View attachment 237965



50 y/o female with polysubstance abuse. Addiction mgmt has her on 5.7 Zubsolv bid, PCP Xanax 1mg bid. Fell in tub at home. In addition to Fx T11, L1, L2, L4, L5, b/l sacrum, has severe spinal stenosis at L3-4, L4-5 from lipomatosis, facet/lig. No significant bony retropulsion.

What's your move?
Click to expand...
Good Lord. What kind of fall rattles your back like that?
 
Some stuff I've recently come across.

B cell lymphoma - initial symptoms were axial then radicular back pain
B cell.jpg
 
Right rib pain x1 year. Radiology missed the lesion on the initial CT Thorax. You can compare the right/left rib's to notice the lesion shape. Heavy smoker. Biopsy showed adenoCA.
rib.jpg
 
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The people in your area must be drinking water from the cooling tower of the nuclear reactor.
 
drusso said:
Looks like mostly Medicare. I would be afraid that I could be all day and still go broke! Is that able to pencil out for you?
Click to expand...

I am straight salary and with the fat SOS you keep telling me about.....
But I am office based and not billed as HOPD. They give me a check and I show up and do my job. No pressure. No risk on my side. Reward is govt employee like comfort.
 
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lobelsteve said:
I am straight salary and with the fat SOS you keep telling me about.....
But I am office based and not billed as HOPD. They give me a check and I show up and do my job. No pressure. No risk on my side. Reward is govt employee like comfort.
Click to expand...

I'm keeping my fingers crossed and praying every night for site neutral payment reform. It will bring all pain doctors into alignment and united. No longer will we be divided into SOS-haves and SOS-have not's. Then, we can advocate with one single voice for fair solutions that will benefit everyone equally.

Alliance for Site Neutral Payment Reform

http://www.siteneutral.org/wp-content/uploads/2018/09/Alliance-letter-on-2019-OPPS-1.pdf

http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI_Medicare Cost Analysis -- FINAL 11_9_17.pdf

• Physicians employed by hospitals perform a higher volume of services in HOPD settings than in physician offices o For some procedures studied, employed physicians were 7 times more likely to perform services in a HOPD setting than independent physicians
 
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drusso said:
I'm keeping my fingers crossed and praying every night for site neutral payment reform. It will bring all pain doctors into alignment and united. No longer will we be divided into SOS-haves and SOS-have not's. Then, we can advocate with one single voice for fair solutions that will benefit everyone equally.

Alliance for Site Neutral Payment Reform

http://www.siteneutral.org/wp-content/uploads/2018/09/Alliance-letter-on-2019-OPPS-1.pdf

http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI_Medicare Cost Analysis -- FINAL 11_9_17.pdf

• Physicians employed by hospitals perform a higher volume of services in HOPD settings than in physician offices o For some procedures studied, employed physicians were 7 times more likely to perform services in a HOPD setting than independent physicians
Click to expand...

Darn, I'm the exception that proves the norm.
 
painfree23 said:
what do you do for your 90+ patients. most of mine are so arthritic that they hurt everywhere -- not good opiate candidates either usually given their age but i do feel bad for them.
Click to expand...

decompression table 3x weekly
 
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