Pictures of the Week

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That’s probably the worst stenosis I’ve come across on my 21 years. Apparently he was stiff pre-op and people blamed the statin for a long while.
 
pmrmd said:
He had C3-6 lami/fusion already. Referred for left arm pain. No one seemingly able to differentiate neck pain from a painful cuff tear.
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so his only symptoms prior to surgery were some stiffness? dang
 
Orin said:
Can you share the T1 and/or FS/STIR sequences for the above slices if you have them?

While I agree it looks like lipomatosis and nerve root crowding, I'm confused by the thickened appearing ventral dura vs PLL.
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There is no FS/STIR. Here is a sagittal T1 FSE and Axial PD FSE. The axial cut from the PD is not aligned through the disc though, so look bit different from the T2 slices.
 
Baron Samedi said:
72F diabetic (A1c 7ish), BMI 48, quite poor baseline functional status, uses wheelchair but does ambulate short distances around the house. She was having radicular pain so did a rather difficult ILESI at L5-S1 10 days ago. She reported she was feeling better but then yesterday began having sudden onset weakness in both legs, peripheral edema, and worsening incontinence. I refer her to the ED and overnight she got scanned.

Hasn't been read yet. Malignancy vs osteomyelitis vs fracture?


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Just as a follow-up on this case: colleague of mind saw her in rehab yesterday and apparently she's doing quite well, all things considered! She is going to have to do some radiation but is getting some strength back.
 
Given a motorized scooter for disequilibrium and weakness. Never had a cervical MRI. DTR 3+. Gait dysfxn blamed on a reaction to cipro. He is 330 pounds at 5’10” and smokes 2 PPD.

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MitchLevi said:
Given a motorized scooter for disequilibrium and weakness. Never had a cervical MRI. DTR 3+. Gait dysfxn blamed on a reaction to cipro. He is 330 pounds at 5’10” and smokes 2 PPD.

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Gnarly. I don’t think anyone around me would operate on him unless he was floridly myelopathic, like losing function of his limbs.
 
bmi of 47.

bariatric candidate.

he could probably fit in an open MRI though at 330 pounds.

try getting an MRI for those 60+ bmi patients. they need to go to a vet rad department that can do large animal MRIs.
 
Sig123 said:
Referral: "Low Back Pain"

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Isn't more like mid back pain?
PCP hears back pain and refers to specialist.
Hopefully did not require PT ahead of time.
Would be nice to hear about where the infection started or possibly what cancer they now have and if any red flags (fever/night sweats/cachexia/malaise/)? Does not yet look bad enough to cause conus syndrome.

ESR>100?
 
81 year old male with a right L5 radiculopathy 2/2 neuroforaminal/lateral recess stenosis.

I performed 2 epidurals, one transforaminal and one interlaminar - both provided relief but short lived.

Elected to perform an endoscopic transforaminal decompression - specifically a foraminotomy and discectomy. POD #1 with complete resolution of radic. Here are a few pics -

Pic #1 - Exiting L5 nerve is to the right off screen, at 12 oclock we have the SAP and at 9 oclock we have the start of the pedicle. Straight ahead is the disc herniation.

Pic #2 - Started decompression - now able to pass a probe into the epidural space

Pic #3 - Almost the end of the decompression, you can see the large defect in the disc space - there was also an ostophyte that i shaved down at the 9 oclock position.
 

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swamprat said:
81 year old male with a right L5 radiculopathy 2/2 neuroforaminal/lateral recess stenosis.

I performed 2 epidurals, one transforaminal and one interlaminar - both provided relief but short lived.

Elected to perform an endoscopic transforaminal decompression - specifically a foraminotomy and discectomy. POD #1 with complete resolution of radic. Here are a few pics -

Pic #1 - Exiting L5 nerve is to the right off screen, at 12 oclock we have the SAP and at 9 oclock we have the start of the pedicle. Straight ahead is the disc herniation.

Pic #2 - Started decompression - now able to pass a probe into the epidural space

Pic #3 - Almost the end of the decompression, you can see the large defect in the disc space - there was also an ostophyte that i shaved down at the 9 oclock position.
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1: I have no idea WTF I'm looking at.
2: Where / how exactly are you learning to do this?
 
BoardingDoc said:
1: I have no idea WTF I'm looking at.
2: Where / how exactly are you learning to do this?
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1. This may help, the red circle is what the view is - so I am caudal to the exiting nerve which is at 3 oclock and off screen. Straight ahead is the spinal canal but as you see there is a disc herniation in front center image. The top (12 oclock) is the ascending facet joint which I had already reamed - in the first picture I posted it is taking up about 45% of the view.

2. I self taught over 4-5 years - started off with just perc discs on contained herniations, then went to endoscopic rhizotomies and then slowly to transforaminal cases and then interlaminar. When I learned it through various industry sponsored labs I became obsessed - kind of like a video game I thought it was so cool so I did A LOT of reading on my own - watched you tube videos etc. At the end my goal was to become proficient but do no harm so the first few cases I did I took my time, I had a clinical specialist to help me and if I felt uncomfortably I aborted it. As you know, learn one, do one, teach one - now I teach labs. There is a fellowship for pain docs now too but I aint going back to training at this point.
 
pmrmd said:
What books or sources do you recommend?
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Atlas of Full-Endoscopic Spine Surgery: 9781684200238: Medicine & Health Science Books @ Amazon.com

Atlas of Full-Endoscopic Spine Surgery: 9781684200238: Medicine & Health Science Books @ Amazon.com
www.amazon.com

This is a great start - I also recommend watching RIWO spine videos on youtube - german surgeons that do this stuff - I've reviewed the videos multiple times - they talk all about the approach, targeting, go through trouble shooting etc.
 
swamprat said:

Atlas of Full-Endoscopic Spine Surgery: 9781684200238: Medicine & Health Science Books @ Amazon.com

Atlas of Full-Endoscopic Spine Surgery: 9781684200238: Medicine & Health Science Books @ Amazon.com
www.amazon.com

This is a great start - I also recommend watching RIWO spine videos on youtube - german surgeons that do this stuff - I've reviewed the videos multiple times - they talk all about the approach, targeting, go through trouble shooting etc.
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Ive also been interested but short of a fellowship wasnt sure how to get experience. How did you explain the the patients the first few cases you did and how do you disclose they may be the first one youve done? What do you say when you abort? How long does the typical case take are you doing endoscopic laminectomies?
 
What about the equipment and the facility?

Is some ASC going to buy this stuff on a whim? If they already have it getting the privileges seems difficult…”yeah I want to start doing this but we need to have YouTube playing on the TV in the OR.”

You’re in a unique spot man. Kudos.
 
interjectionreflection said:
Ive also been interested but short of a fellowship wasnt sure how to get experience. How did you explain the the patients the first few cases you did and how do you disclose they may be the first one youve done? What do you say when you abort? How long does the typical case take are you doing endoscopic laminectomies?
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Well I def did not tell patients it was my first case - but again that is up to you and your call. When I abort a case I told the patient it was more difficult than anticipated we tried our best but unfortunately they will need a bigger surgery that I do not do and will refer you to one of my neurosurgical colleagues.

As far as endoscopic laminotomies - they are actually not that difficult - but def not a beginner level case due to the risk obvious of using a high speed burr. These cases take time though and from a financial standpoint you may not find it worth your time depends how much you enjoy or like doing them.

pmrmd said:
What about the equipment and the facility?

Is some ASC going to buy this stuff on a whim? If they already have it getting the privileges seems difficult…”yeah I want to start doing this but we need to have YouTube playing on the TV in the OR.”

You’re in a unique spot man. Kudos.
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HAHAH thanks.

Soo - the equipment is expensive most facilities outside of a hospital rent them per case.

It actually was difficult initially to get privileges to do them. I went to multiple different ASCs, used some patient testimonials one time of prior cases I did - had certificates of completion of courses (I know stupid weekend course but nonetheless). Eventually I had enough cases under my belt that it became a non-issue and I would just show my procedure log. Now I also am an instructor so I have no issues at this point.
 
Heres the other case I did that day - LSS with NC - not a MILD candidate as she had significant facet overgrowth. I performed a left sided interlaminar endoscopic decompression of the posterior elements. This required using a high speed diamond drill to shave down the caudal portion of the cranial lamina as well as the medial portion of the facet and removal of ligamentum flavum. Here is a pic of the case I marked up -
 

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swamprat said:
Heres the other case I did that day - LSS with NC - not a MILD candidate as she had significant facet overgrowth. I performed a left sided interlaminar endoscopic decompression of the posterior elements. This required using a high speed diamond drill to shave down the caudal portion of the cranial lamina as well as the medial portion of the facet and removal of ligamentum flavum. Here is a pic of the case I marked up -
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Bad ass
 
swamprat said:
Heres the other case I did that day - LSS with NC - not a MILD candidate as she had significant facet overgrowth. I performed a left sided interlaminar endoscopic decompression of the posterior elements. This required using a high speed diamond drill to shave down the caudal portion of the cranial lamina as well as the medial portion of the facet and removal of ligamentum flavum. Here is a pic of the case I marked up -
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Pretty dope!

Have you ever had a Dural tear? Has there ever been a time you had to convert to an open procedure?

How wide of a laminectomy can you get with this approach? Also do you have any pre and post-op MRIs to see degree of on a decompression?
 
interjectionreflection said:
Pretty dope!

Have you ever had a Dural tear? Has there ever been a time you had to convert to an open procedure?

How wide of a laminectomy can you get with this approach? Also do you have any pre and post-op MRIs to see degree of on a decompression?
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Can't tell if your being facetious haha but no I don't open.

Knock on wood no dural tears - however if you do have one small ones do not need to be repaired and larger ones you can use fibrin grafts u can pop down the scope. If there is extruded nerve rootlets then yeah - has to be opened and I do have neurosurgical colleagues I can call.

You can get a pretty wide laminectomy if needed - and take out bone en block but most of the time for cases I would do (I wouldn't do multilevel) you just need to take off enough lamina to get all the ligament out - kind of like MILD. You can def do more bony work with lateral recess stenosis - as long as you preserve like 50% facet joint you should not cause instability. I have used this technique for lateral recess stenosis with good results.
 
swamprat said:
Can't tell if your being facetious haha but no I don't open.

Knock on wood no dural tears - however if you do have one small ones do not need to be repaired and larger ones you can use fibrin grafts u can pop down the scope. If there is extruded nerve rootlets then yeah - has to be opened and I do have neurosurgical colleagues I can call.

You can get a pretty wide laminectomy if needed - and take out bone en block but most of the time for cases I would do (I wouldn't do multilevel) you just need to take off enough lamina to get all the ligament out - kind of like MILD. You can def do more bony work with lateral recess stenosis - as long as you preserve like 50% facet joint you should not cause instability. I have used this technique for lateral recess stenosis with good results.
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Sorry didn't mean to come across that way. I wasn't being facetious. I'm actually very interested in this. I want to learn it but always thought about how to handle these situations. It makes a lot more sense and feasibility if you have a surgeon available for assistance. I'm actually seeing a lot more of these endoscopic cases on LinkedIn. A lot of the surgeons are also starting to lean towards endoscopy. How many cases do you think someone would need to become proficient?
 
its cool that you do this but for me it gets too close to being a spine surgeon.

this may be the future of pain management, if it is not stuffed out by spine surgery.


in a way, it seems more apropos than dead baby dust...
 
Ducttape said:
its cool that you do this but for me it gets too close to being a spine surgeon.

this may be the future of pain management, if it is not stuffed out by spine surgery.


in a way, it seems more apropos than dead baby dust...
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Yeah ur right- then again TAVR is very cardiac surgery-esque too. Spine surgeons don't want to do it in the US due to poor pay and steep learning curve. Its not for everyone thats for sure and one needs to master everything else we do before diving in but this is how innovation occurs. Keeps things interesting - the true "practice" of medicine.
 
interjectionreflection said:
Sorry didn't mean to come across that way. I wasn't being facetious. I'm actually very interested in this. I want to learn it but always thought about how to handle these situations. It makes a lot more sense and feasibility if you have a surgeon available for assistance. I'm actually seeing a lot more of these endoscopic cases on LinkedIn. A lot of the surgeons are also starting to lean towards endoscopy. How many cases do you think someone would need to become proficient?
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Very variable and hard to say - also a big difference in case betwee transforaminal vs interlaminar. Just like anything else goes you hit a point u feel super confident then get smacked down by a hard case and question whether u even know what u r doing. I red start doing endo rhizo you really can’t mess anyone up there and get super comfortable holding the scope , adjusting the pump pressure, using the tools etc. cadaver labs are helpful but they don’t bleed and one of my early fears was a “red out” and how to deal with it.
 
I used to do these procedures. The problem is OR time, turnover, upfront cost, and low reimbursement. Your time is better spent elsewhere given the risk reward at this time. Which is sad because they are good procedures.
 
soccrwz said:
I used to do these procedures. The problem is OR time, turnover, upfront cost, and low reimbursement. Your time is better spent elsewhere given the risk reward at this time. Which is sad because they are good procedures.
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100% - but I guess not everything in life is about money- although a lot is - when ur making > 800K doing pain just on ur W2 is way different than when your grinding just to make 400. First world problems I know but F it.
 
lobelsteve said:
View attachment 405607

Stenosis symptoms, back and leg.
Failed ESI 3 ways and MBB.
Surgeon refuses as osteoporosis and 83 yrs old.

Next step?
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i had this exact case a couple months ago. surgeon tried a non-instrumented fusion with wha tthe patient called "stem cells". i suspect it was BMAC. surgery failed, new and increased spondy, more pain, instability on flex/ext with pseudoarthrosis. needs to get hardware with anterior approach and is scheduled next week.

if active and wants to keep moving, then im sure you can find a surgeon to do it, just make sure that hardware is used.

if no surgery, then it is really just PT
 
Low demand patient. Very fluffy. Listhesis with stenosis. Apparently still asking for help. Options are do nothing or something. If you choose something then you have minuteman vs mild.
 
Grade 2 slip per Radiology. Removing tissue or adding a chunk k of metal?

Meh.

I don’t think anything will help. And I am not that aggressive in the elderly/infirm.
 
Grade 2 not candidate for MILD.

Grade 1 or less then consider MILD.


negative aspects - only 50-60% improvement in pain or neurogenic symptoms.
positive aspects - can be done under local and very short "recovery" period. can be offered when surgery is not available for patients.
 
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