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I would do Intracept first, see how she is overall if axial pain is better and only has to deal with leg symptoms. If leg symptoms are bad enough then mild.
 
Cement augmented pedicle screw placement. Usually a scoliosis/deformity surgeon is more comfortable with this. The patient really needs to lose weight. Lots of adipose and visceral fat which is accentuating the lordosis.
Brace, PT, weight loss
Dexa scan, increase bone density with ca/vit D, teriparatide

Do they not want to do it because old, OP, or overweight? The age won't change the weight could and so could the OP. They can also do bone stimulator after surgery
 
soccrwz said:
Cement augmented pedicle screw placement. Usually a scoliosis/deformity surgeon is more comfortable with this. The patient really needs to lose weight. Lots of adipose and visceral fat which is accentuating the lordosis.
Brace, PT, weight loss
Dexa scan, increase bone density with ca/vit D, teriparatide

Do they not want to do it because old, OP, or overweight? The age won't change the weight could and so could the OP. They can also do bone stimulator after surgery
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Yes own the bone @lobelsteve !!! Just like you taught all of us. Then when no longer osteoporotic send to surgery for the only treatment that’ll really work. That is unless you want to pay off your boat with a procedure
 
RoloTomassi said:
I would do Intracept first, see how she is overall if axial pain is better and only has to deal with leg symptoms. If leg symptoms are bad enough then mild.
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Have you done Intracept in patients with documented osteoporosis?
 
BobBarker said:
Yes, I would never call that a grade 2.
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With all that spurring I believe it is a mild grade 1.
But I do not do MILD or spacers.
I can refer out for MILD but no one by me with heavy experience.
Not sure who does spacers in my area.
Punting to another surgeon. If he says no then I will send for SCS trial or do it myself. Tramadillio time.
 
there is fluid in those facets. there is microinstability. MILD could worsen it. and if the symptoms do get worse after MILD, even if imaging changes, you will be to blame.

no additional interventions on this patient IMHO
 
she is old. As they get more and more dementia they forget about the pain. I wouldn’t worry about making her worse.
 
clubdeac said:
This is not what is being taught at the ASIPP or AAPMR conferences. Have been told several times that osteoporosis is a relative contraindication
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From website:

Safety and effectiveness in patients with conditions that are associated with poor bone quality such as osteoporosis have not been established.

CONTRAINDICATIONS
Use of the Intracept Intraosseous Nerve Ablation System is contraindicated in:

Patients with severe cardiac or pulmonary compromise
Patients with active implantable pulse generators (e.g. pacemakers, defibrillators)
Patients where the targeted ablation zone is < 10 mm away from a sensitive structure not intended to be ablated, including the vertebral foramen (spinal canal)
Patients with active systemic infection or local infection in the area to be treated
Patients who are pregnant
Skeletally immature patients (generally ≤ 18 years of age)
 
RoloTomassi said:
From website:

Safety and effectiveness in patients with conditions that are associated with poor bone quality such as osteoporosis have not been established.

CONTRAINDICATIONS
Use of the Intracept Intraosseous Nerve Ablation System is contraindicated in:

Patients with severe cardiac or pulmonary compromise
Patients with active implantable pulse generators (e.g. pacemakers, defibrillators)
Patients where the targeted ablation zone is < 10 mm away from a sensitive structure not intended to be ablated, including the vertebral foramen (spinal canal)
Patients with active systemic infection or local infection in the area to be treated
Patients who are pregnant
Skeletally immature patients (generally ≤ 18 years of age)
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Need to check the LCD as well. T score <-2.5 listed under exclusion criteria in some. I have done cases with osteopenia, I am much more restrictive with bending lifting precautions and duration post op. There was also that one case series published where fracture rate was I believe about 10% with OP.
 
Taus said:
Need to check the LCD as well. T score <-2.5 listed under exclusion criteria in some. I have done cases with osteopenia, I am much more restrictive with bending lifting precautions and duration post op. There was also that one case series published where fracture rate was I believe about 10% with OP.
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Good call on the LCD.

I would take that published data with a grain of salt. I heard it was mostly one provider's patients and his technique likely had an effect.

n=75.

There were 8 patients with a new low energy VCFs at an incident vertebral level and one patient who developed sacral insufficiency fractures at a non-incident level. The average age in this fracture group was older at 78 and the fractures occurred at interval average of 69 days following the ablation procedure. The bone density T-score in this group averaged −3.0. Four fractures were at L2, and 1 fracture was at L5. Of the other 4 fractures, 2 were at levels adjacent to prior fusion surgery (Figure 2), 1 was at a level adjacent to a prior kyphoplasty, and the remaining level was at an untreated sacral S2 level in a patient with severe osteoporosis.

Takeaway for me: if T score -3, maybe don't do L2 or a level adjacent to fusion or kypho
 
Last edited:
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 swore I just saw this case on LinkedIn about a Stryker Omnicurve access, cementing the body/disc/body below, but forgot who did it. Regardless, Butrans/bone health/MILD/BVNA/PNS vs SCS
 
RoloTomassi said:
Pretty sure Beall and only Beall would do that
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Well…. I’d like to think he would at least make sure he was actually treating a compression fracture….
 

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What is the recovery for minuteman? Have an 89 year old male. Cardiac stents obese etc. Riding 4-wheeler 2 months ago. Failed obvious treatments. Good candidate? Would be referring out.

5-1 grade 2 lithesis
 
Orin said:
I swore I just saw this case on LinkedIn about a Stryker Omnicurve access, cementing the body/disc/body below, but forgot who did it. Regardless, Butrans/bone health/MILD/BVNA/PNS vs SCS
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I saw a patient a little bit ago who had this done to them by an IR doc doing vertebroplasty. The doc then refused to follow up with the patient and pcp sent them to me.
 

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PMROralBoards said:
I saw a patient a little bit ago who had this done to them by an IR doc doing vertebroplasty. The doc then refused to follow up with the patient and pcp sent them to me.
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Review this thread from the beginning. It could be worse- on the other side of the VB into the canal.
 
Taus said:
If contained and stays localized… Yes… But still scary re what can embolize in a vessel during the case.
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Even if a small amount vent into the epidural vein, it is not a bid deal, unless it is still liquid, not polymerised. I saw a lung CT with a lot of embodies, but an idiot surgeon missed intravascular injection completely, that is why you do injection on the lateral veiw live, and do not do more than 2 levels at a time
 
mygalperin said:
Even if a small amount vent into the epidural vein, it is not a bid deal, unless it is still liquid, not polymerised. I saw a lung CT with a lot of embodies, but an idiot surgeon missed intravascular injection completely, that is why you do injection on the lateral veiw live, and do not do more than 2 levels at a time
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If pt becomes symptomatic order very scan right a way
 
1753048045184.png


This is my first time seeing this. Patient moved from other side of state and said they got a 'facet spacer' which didn't work. It looks like this CAVUX FFS-LX | Providence

Is anyone doing these? It looks... not helpful.
 
bubaghanush said:
View attachment 406857

This is my first time seeing this. Patient moved from other side of state and said they got a 'facet spacer' which didn't work. It looks like this CAVUX FFS-LX | Providence

Is anyone doing these? It looks... not helpful.
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Surgentec ion screws. Should theoretically work but I haven’t done any. I do like their tilink-p for si joint fusion which is similar.
 
pmrmd said:
Looks like the Surgentec IA dowels to fuse the joint.

Doesn’t work.
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What's The proposed mechanism behind these anyways? Is it just a fuse the joint an isolated facet disease? To me it looks no similar than a facet screw which was abandoned by surgeons long ago.
 
interjectionreflection said:
What's The proposed mechanism behind these anyways? Is it just a fuse the joint an isolated facet disease? To me it looks no similar than a facet screw which was abandoned by surgeons long ago.
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Can consider it for mild instability with primarily facet mediated pain, revision of interspinous spacer failure, adjacent level arthritis in patient who wants a “fix”. I would probably only be offering it to elderly patients who aren’t great surgical candidates and don’t want injections after at least one diagnostic mbb.
 
...and an absolutely massive pannus covering the thighs to the knees.

As usual, it seems I am the first physician to completely focus all of our visit on the weight. Never been told he needs to see bariatrics, but has been told he needs to "lose a few pounds." We are sooooooo far past that bro.



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