Pictures of the Week

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She has fairly diffuse degen/stenotic changes and the surgeon wanted to try to isolate it to one level. Researched the injection. Decided I could safely do it. Lido and dex.
 
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Very sick 65 yo M - severe vascular diesease with multiple major vascular stents, etc., multiple ostomies from complications from prostate cancer treatment related fistulas, bilateral chronic (but maybe slightly worsening hip AVN). Severe right axial lumbar and SIJ type pain. SIJ CSI didn't do much for him, MBBs did awesome ... RF 'helped' for 1-2 weeks then back to severe pain. Hallucinates with multiple different pain meds.

Obviously something else could be going on - hip AVN, etc. but scans have been negative of pelvis for other bad stuff.

Any advice/critique on RF placement? Appears to be my "standard" placement that gets good results.
 
runfastnow said:
View attachment 382195

Very sick 65 yo M - severe vascular diesease with multiple major vascular stents, etc., multiple ostomies from complications from prostate cancer treatment related fistulas, bilateral chronic (but maybe slightly worsening hip AVN). Severe right axial lumbar and SIJ type pain. SIJ CSI didn't do much for him, MBBs did awesome ... RF 'helped' for 1-2 weeks then back to severe pain. Hallucinates with multiple different pain meds.

Obviously something else could be going on - hip AVN, etc. but scans have been negative of pelvis for other bad stuff.

Any advice/critique on RF placement? Appears to be my "standard" placement that gets good results.
Click to expand...
placement is ok. maybe start a little more lateral on 2,3, and 4, but it isnt your technique that the problem

RF has a known failure rate and this guy has multiple other pain generators.
 
runfastnow said:
View attachment 382195

Very sick 65 yo M - severe vascular diesease with multiple major vascular stents, etc., multiple ostomies from complications from prostate cancer treatment related fistulas, bilateral chronic (but maybe slightly worsening hip AVN). Severe right axial lumbar and SIJ type pain. SIJ CSI didn't do much for him, MBBs did awesome ... RF 'helped' for 1-2 weeks then back to severe pain. Hallucinates with multiple different pain meds.

Obviously something else could be going on - hip AVN, etc. but scans have been negative of pelvis for other bad stuff.

Any advice/critique on RF placement? Appears to be my "standard" placement that gets good results.
Click to expand...
Tell me more about the L4 fracture....
 
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runfastnow said:
View attachment 382195

Very sick 65 yo M - severe vascular diesease with multiple major vascular stents, etc., multiple ostomies from complications from prostate cancer treatment related fistulas, bilateral chronic (but maybe slightly worsening hip AVN). Severe right axial lumbar and SIJ type pain. SIJ CSI didn't do much for him, MBBs did awesome ... RF 'helped' for 1-2 weeks then back to severe pain. Hallucinates with multiple different pain meds.

Obviously something else could be going on - hip AVN, etc. but scans have been negative of pelvis for other bad stuff.

Any advice/critique on RF placement? Appears to be my "standard" placement that gets good results.
Click to expand...
No offense but those are supremely crappy images. I really try to get true APs and true laterals when doing RFs so I can see where I am. The needles at the MB of 3 and 4 aren’t at the junction I don’t think but it’s so blurry to be totally sure.
 
runfastnow said:
View attachment 382195

Very sick 65 yo M - severe vascular diesease with multiple major vascular stents, etc., multiple ostomies from complications from prostate cancer treatment related fistulas, bilateral chronic (but maybe slightly worsening hip AVN). Severe right axial lumbar and SIJ type pain. SIJ CSI didn't do much for him, MBBs did awesome ... RF 'helped' for 1-2 weeks then back to severe pain. Hallucinates with multiple different pain meds.

Obviously something else could be going on - hip AVN, etc. but scans have been negative of pelvis for other bad stuff.

Any advice/critique on RF placement? Appears to be my "standard" placement that gets good results.
Click to expand...
I think the biggest thing you could do is collimate your images. It's really hard to make out the anatomy in the AP, partly due to degenerative changes and bone density.
 
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AP mostly looks bad because of the caudal tilt I assume was used to place the needles. L5 DR is almost hub view in AP and look how flat it is on the lateral
 
3 level kypho done out of state. I think the other doc got spooked by the uptake in the basivertebral plexus and stopped. Still has edema on MRI. Surgeon sent him over for MBB. Noticed the bad fill on MBB and recommended kypho redo.

Before:
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...sup with that bladder stimulator? Is that what that is? Peripheral nerve?

FYI - Cirrhotic with portal hypertension and cognitive decline. Hallucinosis, sundowning.

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MitchLevi said:
...sup with that bladder stimulator? Is that what that is? Peripheral nerve?

FYI - Cirrhotic with portal hypertension and cognitive decline. Hallucinosis, sundowning.

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Need more pics of the interstim. Looks like it goes through S3 than into the pelvis and then the hip. Screw look a mess up top.
Ammonia level? MELD score?
 
Interesting case: 80 yo woman long standing hx of SI joint pain. Failed PT and SI injections. L spine MRI several years ago shows nonspecific edema around the SI joint. She saw rheum who didn't think much since no meaningful erosions were seen. I did SI RF one month ago at the request of another spine provider in my office. No relief so I MRI her sacrum and L spine and this shows up. Radiologist says consistent with recent RF. I call rads and say this is not at all related to RF and what else could it be. Rads are reevaluating it and will addend MRI report. Any thoughts on what what it could be?

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ED50 said:
Interesting case: 80 yo woman long standing hx of SI joint pain. Failed PT and SI injections. L spine MRI several years ago shows nonspecific edema around the SI joint. She saw rheum who didn't think much since no meaningful erosions were seen. I did SI RF one month ago at the request of another spine provider in my office. No relief so I MRI her sacrum and L spine and this shows up. Radiologist says consistent with recent RF. I call rads and say this is not at all related to RF and what else could it be. Rads are reevaluating it and will addend MRI report. Any thoughts on what what it could be?

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Looks like run of the mill degenerative joint marrow changes, like what you see in knees, facets, endplates
 
the RF didnt work b/c the degenerative changes are at the anterior portion of the joint.

agree that it looks degenerative but not 100% sure
 
Thanks for the replies. The radiologist who read it is on vacation until next week so we'll see what he says. The MRI pics I showed don't really do the degree of edema justice. It's from the top to the bottom of the sacrum mainly on the ilium. Definitely could be just wear and tear, I guess I've never seen it so pronounced but I admittedly don't MRI the sacrum too often. If just wear and tear any suggestions on tx? It's been ongoing and progressive for two years? Eval for osteoporosis/penia and tx?
 
72 year old male with eight months of low back pain, radiate to right LE to just below the right knee. No significant pain with sitting or standing or forward bending. Able to go up and down 3 flights of stairs and ambulate at least 8 blocks. Most of pain is in the night while he lays down to sleep. Pain is severe enough that he has not been able to have a decent sleep for the past 8 months.

Physical examination significant for severe tenderness in interspinal process space on l4-5, l5-S1, resembling the pain he has in the night.

Is the end plate severe degenerative or concern for discitis? Would a MRI with contrast indicated ?

Will you do L5 TFESI or go directly for basivertrbral ablation if infection is ruled out ?
 

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Does not sound like discitis. How does stir look? ESI first, L5 TF is fine but I'd probably do L4 with it. Maybe another at S1 depending on how the lateral recess looks and if pain in that distribution.
 
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Agree. That isn’t discitis and it sounds like an epidural is what you want to do. BVN ablation is for back pain so you wouldn’t do that procedure with that history or exam.
 
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pmrmd said:
Agree. That isn’t discitis and it sounds like an epidural is what you want to do. BVN ablation is for back pain so you wouldn’t do that procedure with that history or exam.
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Pain in the night and increases while laying down is what makes me think other than a radiculopathy.
 
amadeus_lee said:
Pain in the night and increases while laying down is what makes me think other than a radiculopathy.
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Pain from the low back radiating down the leg makes me think radiculopathy….. everything else is non-specific unfortunately… unless there was something pretty clear on exam or imaging to suggest otherwise… I would just squirt some steroids on it. Plenty of people with radic have pain laying down at night, often with foraminal stenosis, mobile mobile spondy that reduces with laying down… but still non-specific
 
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Laying down commonly worsens radic. Can't lean on your shopping cart in bed.
 
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amadeus_lee said:
72 year old male with eight months of low back pain, radiate to right LE to just below the right knee. No significant pain with sitting or standing or forward bending. Able to go up and down 3 flights of stairs and ambulate at least 8 blocks. Most of pain is in the night while he lays down to sleep. Pain is severe enough that he has not been able to have a decent sleep for the past 8 months.

Physical examination significant for severe tenderness in interspinal process space on l4-5, l5-S1, resembling the pain he has in the night.

Is the end plate severe degenerative or concern for discitis? Would a MRI with contrast indicated ?

Will you do L5 TFESI or go directly for basivertrbral ablation if infection is ruled out ?
Click to expand...

Unlikely to be discitis. Check an ESR/CRP, WBC.
If WNL then proceed to an epidural.
Why are you considering an L5 TFESI? That will skip the bottom half of the L5-S1 disc. If labs are clean, I’d recommend an S1 TFESI. If the patient gets good but brief relief then do a caudal with depo medrol.
 
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pmrmd said:
Like what?
Let pain lying down is radicular pain.
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It happens only in the night and no pain with walking or stairs makes me think otherwise. But sure, if there is foraminal stenosis/lateral recess narrowing, laying down can increase the pain. Unfortunately, the MRI from outside did not have the cut through the neuroforamen.
 
bedrock said:
Unlikely to be discitis. Check an ESR/CRP, WBC.
If WNL then proceed to an epidural.
Why are you considering an L5 TFESI? That will skip the bottom half of the L5-S1 disc. If labs are clean, I’d recommend an S1 TFESI. If the patient gets good but brief relief then do a caudal with depo medrol.
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I was hopeful that with 2ml of injection, the med can spread up and down. I always thought the sacral epidural space is larger? How many cc you usually inject for S1 transforaminal ?
 
4cc at S1 with a superomedially positioned needle will cover L5-S1 and commonly L4-5 as well. Angle your needle superiorly.

I'd inject L5-S1 by the way. If you put 3-4cc at L5-S1 you'll douse that entire level.

Dex 10mg, 2cc saline, 0.5cc lido 2%

You won't get a dead leg with that mixture.
 
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i dont think he is in at L5. who knows about L4 - cant see contrast.

at least he got SI.

10 min to get in 1 location correctly whereas the rest of us would take 4 min to hit all 3 targets.....

kudos to him.
 
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Def lateral at 5.

I was lateral at 4 and 5 this AM bc nasty foramen. Got there eventually. Ugly saved images.

It happens.
 
lobelsteve said:
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So here he brags about taking only 10 minutes to put in 2 TFESI and 1 SIJ. Sounds like a winner. Hope his payment is denied.
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he's bragging about ****ty blobograms outside the foramen? Essentially sham procedure. someone needs to call him out on LinkedIn or wherever this is posted. Steve do it!
 
its like a paperclip. if you bend it enough times, it will break.

depending on the story, id be tempted to put the pt in a TLSO and just walk away
 
Need flex/ext films. If the patient isn't moving this doesn't matter.
 
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amadeus_lee said:
Want to hear the opinion from the veterans here.

34yo, female with right medial foot pain for 4 years, unclear injury history. MRI of foot/ankle showed mild tibialis posterior tendinopathy, peroneus longus and brevis tenosynovitis and scar remodeling of the anterior talofibular ligament from prior remote trauma. MRI of the L/S reported mild bilateral L5-S1 neural foraminal narrowing, but i am not convinced that is the culprit. See picture.

Physical exam showed:
Right foot:
Mild swelling on medial mid foot
No hair or toenail atrophy
At the rest the right big toe in extension
Very exquisite tenderness to palpation in the medial border of the right foot, at the hindfoot to midfoot
+ Hypersensitivity to touch along right medial foot
Weak right ankle inversion and toe flexion/extension

Tried topical compound cream, gabapentin, lyrica, various NSAIDs, did not have good response.
Did a tarsal tunnel tibial nerve block and tibialis posterior peri tendon steroid injection, had two weeks of good relief, but now pain returned.

I am debating, what to do next, dorsal column vs L5/S1 DRG stimulator? Pro and Cons of eac
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Sounds like the ankle is the culprit. Send to foot specialist and if nothing to do from their standpoint offer her an L4 DRG stim. Why you thinking L5/S1 with medial foot pain
 
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I would try PNS before implanting something in her spine. Not me personally but podiatrists and foot/ankle around me do StimRouter and other PNS. I'm not too knowledgeable about all the systems.
 
amadeus_lee said:
Want to hear the opinion from the veterans here.

34yo, female with right medial foot pain for 4 years, unclear injury history. MRI of foot/ankle showed mild tibialis posterior tendinopathy, peroneus longus and brevis tenosynovitis and scar remodeling of the anterior talofibular ligament from prior remote trauma. MRI of the L/S reported mild bilateral L5-S1 neural foraminal narrowing, but i am not convinced that is the culprit. See picture.

Physical exam showed:
Right foot:
Mild swelling on medial mid foot
No hair or toenail atrophy
At the rest the right big toe in extension
Very exquisite tenderness to palpation in the medial border of the right foot, at the hindfoot to midfoot
+ Hypersensitivity to touch along right medial foot
Weak right ankle inversion and toe flexion/extension

Tried topical compound cream, gabapentin, lyrica, various NSAIDs, did not have good response.
Did a tarsal tunnel tibial nerve block and tibialis posterior peri tendon steroid injection, had two weeks of good relief, but now pain returned.

I am debating, what to do next, dorsal column vs L5/S1 DRG stimulator? Pro and Cons of each?
Click to expand...
Biscuit poisoning. Spine normal. MSK pain right foot. Not CRPS sounding though I can tell you are making the argument so you can stim her.
When distance from skin to multifidus is greater than multifidus to foramen, put down the needles.
 
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