Pictures of the Week

looks like an avulsed greater trochanter fracture...

Ducttape said:

looks like an avulsed greater trochanter fracture...

Click to expand...

it does? little too inferior for that.

take a few minutes if you time. its worth it

Ducttape said:

looks like an avulsed greater trochanter fracture...

Click to expand...

I agree that the GT doesn't looked quite right to me. I'm wondering if it's an osteochondroma originating from the GT that broke off.

Had to put in a triangle for insurance reasons. Ran out of room for the third screw so had to free hand it between the alar line and the initial screw.

BobBarker said:

Had to put in a triangle for insurance reasons. Ran out of room for the third screw so had to free hand it between the alar line and the initial screw.

View attachment 385646

Click to expand...

How are your outcomes with these? What type of patient is your ideal candidate?

I have only been using SI bone this year. So everyone has done fine post op, but generally too early to tell.

BobBarker said:

I have only been using SI bone this year. So everyone has done fine post op, but generally too early to tell.

Click to expand...

What about your SI fusions as a whole?

Overall, they have done well. But have around 5 where the pain is coming back around 3 years and they aren’t fused on ct.

BobBarker said:

Overall, they have done well. But have around 5 where the pain is coming back around 3 years and they aren’t fused on ct.

Click to expand...

Does it seem to be a particular kit/approach? Posterior Painteq style kits seem like they would be more likely to pseudoarthrose

Yes, it has been my cornerloc and Omnia’s. Haven’t noticed as much with the Vyrsa Pro’s.

Why do lateral when you can just do posterolateral?

pmrmd said:

Why do lateral when you can just do posterolateral?

Click to expand...

I know some insurances only approve SI Bone in particular, but given the choice, posterolateral seems much less invasive and less vascular than lateral. But I have no actual experience.

pmrmd said:

Why do lateral when you can just do posterolateral?

Click to expand...

This patient insurance required a triangular implant be used.


But in general, I prefer lateral. It is easier on the head math lining up the fluoro.

lobelsteve said:

View attachment 385781

Takes vit D. Refuses OP meds. Xray worse than last year

Click to expand...

she is fakin it. freeloaders

lobelsteve said:

View attachment 385781

Takes vit D. Refuses OP meds. Xray worse than last year

Click to expand...

Hope aortic calcification prevents worsening kyphosis.

cowboydoc said:

Hope aortic calcification prevents worsening kyphosis.

Click to expand...

I was so impressed by that spine that I didnt even see the aorta. Didnt know the aorta could kink like that.....

cowboydoc said:

Hope aortic calcification prevents worsening kyphosis.

Click to expand...

I think her aorta has more calcium than her bones do

What yall think about this?

70ish tiny Caucasian woman with rip roaring shoulder, scapular and arm/hand neuropathic pain which began 2-3 days after ACDF done for severe contralateral arm radic. The right arm symptoms resolved completely with the surgery.

PMH/PSH: C6-7 ACDF 02/28/2024, L5-S1 TLIF + decompression 1/20/2021. Chronic tobacco abuse, anxiety, chronic low back and neck pain, endometriosis s/p repeated laparoscopies with LoA, hyperlipidemia, migraines, CVA, septoplasty, thyroid biopsy, oral surgery, C-section, extensive list of surgical interventions and procedures.

C6-7 ACDF 02/28/2024 - Awoke and within 2-3 days has severe left scapular pain, shoulder and left arm pain with poor ROM. Neuropathic pain in the hand behaving similarly to CRPS but without Budapest.

First visit: Left SSNB under US guidance. See her back in 2W. No benefit.

Stellate ganglion 04/23/2024 (procedure 0645 today, phone calls 1600 today). Talked her down from the ledge basically.

What’s the idea behind this pain? Positioning on the table? Brachial plex doesn’t make sense. CRPS weird timeline.

CESI if when I see her in 2W the stellate is deemed a failure.

lobelsteve said:

Doing a lot of procedures with no diagnosis.

Click to expand...

Any ideas?

MitchLevi said:

Any ideas?

Click to expand...

Weakness? C5 palsy?

mdo1738 said:

I think her aorta has more calcium than her bones do

Click to expand...

Take a bow

MitchLevi said:

What yall think about this?

70ish tiny Caucasian woman with rip roaring shoulder, scapular and arm/hand neuropathic pain which began 2-3 days after ACDF done for severe contralateral arm radic. The right arm symptoms resolved completely with the surgery.

PMH/PSH: C6-7 ACDF 02/28/2024, L5-S1 TLIF + decompression 1/20/2021. Chronic tobacco abuse, anxiety, chronic low back and neck pain, endometriosis s/p repeated laparoscopies with LoA, hyperlipidemia, migraines, CVA, septoplasty, thyroid biopsy, oral surgery, C-section, extensive list of surgical interventions and procedures.

C6-7 ACDF 02/28/2024 - Awoke and within 2-3 days has severe left scapular pain, shoulder and left arm pain with poor ROM. Neuropathic pain in the hand behaving similarly to CRPS but without Budapest.

First visit: Left SSNB under US guidance. See her back in 2W. No benefit.

Stellate ganglion 04/23/2024 (procedure 0645 today, phone calls 1600 today). Talked her down from the ledge basically.

What’s the idea behind this pain? Positioning on the table? Brachial plex doesn’t make sense. CRPS weird timeline.

CESI if when I see her in 2W the stellate is deemed a failure.


View attachment 385831View attachment 385832View attachment 385833

Click to expand...

MRI? CT? EMG? Flexion/extension X-ray? What workup has been done so far? Dermatomal distribution in the arm? Abnormal reflexes? Has anybody checked the hardware to make sure it’s not displaced? Bit hard to tell much from the X-rays you posted.

MRI plexus? Parsonage-Turner?

RoloTomassi said:

Weakness? C5 palsy?

Click to expand...

C5 palsy should be first on the differential. need a post-op MRI to make sure there is no structural lesion. C5 palsy more common in big decompressions for myelopathy, but it can be seen in just a simple ACDF. they typically get better on their own.

if you do any shot, it should be a CESI or (gasp) a C5 TFESI. but you'd need an MRI first.

EMG after 3 weeks would also confirm it, show severity, and give a clue on prognosis if you have a good EMGer

Normal CT 03/2024 - No hardware malpositioning or extruded bone graft.

Traction neuritis or C5 palsy seems reasonable, but she is miserably painful in the inferomedial and lateral border of the scapula, as well as the supralateral and supramedial border of the scapula, left neck and deltoid and upper thoracic paraspinals. She has no motor deficits though the exam is unreliable due to effort. No atrophy or changes in tone. We are 8 weeks out from surgery.

EMG seems like a great idea.

We could MRI the neck and plexus, but she doesn't look like a plexopathy to me. Just super sensitive to touch and constant pain.

My main Q is how fast do yall see CRPS after spine surgery? This began around 2-3 days post op.

I would definitely do MRI cervical. Surgeon seems surprisingly hands off for this early postop

RoloTomassi said:

I would definitely do MRI cervical. Surgeon seems surprisingly hands off for this early postop

Click to expand...

He's involved, but just doesn't really know what to do given the weird timeline and her clinical presentation.

lobelsteve said:

View attachment 385892

Pain free. On Prolia.

Click to expand...

I got a 80ish yo 30mm isthmic spondy who works in a warehouse moving boxes for his son in law.

Thanks, Rocky the service dog

MitchLevi said:

Normal CT 03/2024 - No hardware malpositioning or extruded bone graft.

Traction neuritis or C5 palsy seems reasonable, but she is miserably painful in the inferomedial and lateral border of the scapula, as well as the supralateral and supramedial border of the scapula, left neck and deltoid and upper thoracic paraspinals. She has no motor deficits though the exam is unreliable due to effort. No atrophy or changes in tone. We are 8 weeks out from surgery.

EMG seems like a great idea.

We could MRI the neck and plexus, but she doesn't look like a plexopathy to me. Just super sensitive to touch and constant pain.

My main Q is how fast do yall see CRPS after spine surgery? This began around 2-3 days post op.

Click to expand...

Sounds like the surgeon dinged C7 during the surgery. CRPS wouldn’t show up this early but may later. I’d do a diagnostic and hopefully therapeutic C7 TFESI or lateral paramedian CESI

given location of symptoms and location of surgery, it seems like dorsal scapular nerve injury (C5) would be my guess.

not sure theres anything that can be done...

Ducttape said:

given location of symptoms and location of surgery, it seems like dorsal scapular nerve injury (C5) would be my guess.

not sure theres anything that can be done...

Click to expand...

inferomedial and lateral border of the scapula, as well as the supralateral and supramedial border of the scapula, left neck and deltoid and upper thoracic paraspinals

This sounds like every C7 I’ve ever seen. Only thing that corresponds to C5 is deltoid but everything else around the scapula and thoracic parasponals points to C7

clubdeac said:

inferomedial and lateral border of the scapula, as well as the supralateral and supramedial border of the scapula, left neck and deltoid and upper thoracic paraspinals

This sounds like every C7 I’ve ever seen. Only thing that corresponds to C5 is deltoid but everything else around the scapula and thoracic parasponals points to C7

Click to expand...

Never had one go down to the hand?

Tboned said:

Never had one go down to the hand?

Click to expand...

Yeah that’s a classic textbook C7 but C7 often goes around the scapula and thoracic paraspinals as well, far more often than C5 for sure

Dorsal scapular nerve (DSN) neuropathy has been a rarely thought of differential diagnosis for mid scapular, upper to mid back and costovertebral pain

Click to expand...

Ducttape said:

Dorsal scapular nerve neuropathy: a narrative review of the literature

The purpose of this paper is to elucidate this little known cause of upper back pain through a narrative review of the literature and to discuss the possible role of the dorsal scapular nerve (DSN) in the etiopathology of other similar diagnoses in this ...

www.ncbi.nlm.nih.gov

Click to expand...

I agree that’s a good one to keep in the differential but far less common than a C7 radic. But maybe some traction neuropathy occurred during surgery. Who knows

clubdeac said:

I agree that’s a good one to keep in the differential but far less common than a C7 radic. But maybe some traction neuropathy occurred during surgery. Who knows

Click to expand...

Traction is my best guess. The velocity of this is insane, which makes me question everything.

lobelsteve said:

View attachment 385987View attachment 385988View attachment 385989


T12 looked like I was filling into the T11-12 disc and waited 3 minutes before putting in more cement. I am adequate. Not ready for linkedin.

Click to expand...

Yeah need to work on your transdiscal approach Spinejack preceded by BVNA cryoablation

lobelsteve said:

View attachment 385987View attachment 385988View attachment 385989


T12 looked like I was filling into the T11-12 disc and waited 3 minutes before putting in more cement. I am adequate. Not ready for linkedin.

Click to expand...

I bet you don’t even have pointy shoes

lobelsteve said:

View attachment 385892

Pain free. On Prolia.

Click to expand...

Impressive! Always surprised by what some are able to compensate for compared to our patients with nothing on imaging.