Pictures of the Week

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7 years of back pain. Worse in last 3 months. Xray negative. Started getting weaker in thighs. No B/B.

schwanny.jpg
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Taus said:
T1-2 tfesi. foraminal hnp. Min relief with interlam. Mapped path/angle carefully on mri to avoid ptx…. Love my new c arm…. Oec 9900
Click to expand...
So..they will get 2 weeks of relief with dex?
 
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Never seen a sacral fx quite like this one. Two weeks out.
43 F. CT negative for cancer, mets, etc. Starting osteoporosis work up. Multiple surgeons don't have any answers or don't want to touch her.
Does anyone have any suggestions for interventions that might help? Trying to get her to get that giant poop out is project #1 since she hasn't gone in 6-7 days.

1715948213094.png
 
runfastnow said:
Never seen a sacral fx quite like this one. Two weeks out.
43 F. CT negative for cancer, mets, etc. Starting osteoporosis work up. Multiple surgeons don't have any answers or don't want to touch her.
Does anyone have any suggestions for interventions that might help? Trying to get her to get that giant poop out is project #1 since she hasn't gone in 6-7 days.

View attachment 386907
Click to expand...
i also wouldnt touch this.
 
this might be a rare indication for long term opioids. sacral fractures can take a year to get better.

butrans patch for a year.

suggest Relistor or Movantik for the constipation if that is due to OIC. SQ if you feel the need to initiate faster...
 
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im gonna use this pic as much as possible. its perfect for whenever doctodd starts trolling
 
I would ask orthopedic trauma surgeons to take a look. S3 fracture looks like it could use a reduction and percutaneous screws from caudal to cranial one on each side.
 
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runfastnow said:
Never seen a sacral fx quite like this one. Two weeks out.
43 F. CT negative for cancer, mets, etc. Starting osteoporosis work up. Multiple surgeons don't have any answers or don't want to touch her.
Does anyone have any suggestions for interventions that might help? Trying to get her to get that giant poop out is project #1 since she hasn't gone in 6-7 days.
Click to expand...
Sacroplasty but reduction/fixation would be better with the displacement. Trauma surgeons are the ones that see this more than your usual ortho folks, so sending it to a level 1 trauma center may make sense.

www.mdpi.com

Sacroplasty for Sacral Insufficiency Fractures: Narrative Literature Review on Patient Selection, Technical Approaches, and Outcomes

Sacral insufficiency fractures commonly affect elderly women with osteoporosis and can cause debilitating lower back pain. First line management is often with conservative measures such as early mobilization, multimodal pain management, and osteoporosis management. If non-operative management...
www.mdpi.com www.mdpi.com
1716211609116.png

She might be a candidate for something like approach D there but may be better for IR
 
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lobelsteve said:
Friends with drusso:

View attachment 387290
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He practices in Florida. Medicare is often the best payor in Florida and California.

This is why I don’t live in Florida or California, though I’m sure a high volume efficient office based procedural practice could still do well in those states similar to callmeanesthesia
 
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Looks like that would be lateral to 6' on the pedicle, don't see how that would puncture dura
 
BobBarker said:
Patient stating severe positional headache 30 minutes after this beautiful TFESI with a 23g?
What am I missing here?

View attachment 387335
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More views. More likely they’re having a headache and looked up positional headache after epidural.
 
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lobelsteve said:
More views. More likely they’re having a headache and looked up positional headache after epidural.
Click to expand...
Everything is a post dural. If they call their PCP, they will say is is pdph. Even if they had an si joint
 
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Well, she had been to ED and got some medication and a head ct. negative. Ortho got a MRI l spine. No change from previous. But she pretty clearly had symptomatically what appeared to be a PDPH. Blood patch resolved it by discharge from clinic one hour later.
 
Nothing intrathecal about that picture. But who knows if the needle moved a bit at some point. Was it a young patient?
 
One of my colleagues at my previous job developed a spontaneous spinal headache. I saw him, he was miserable. Had a huge work up cause he had nothing done. Blood patch relieved his symptoms immediately. Strange things happen
 
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lobelsteve said:
More views. More likely they’re having a headache and looked up positional headache after epidural.
Click to expand...
I agree I really can’t comment too much on that picture. It’s in an oblique view, not AP to see needle tip position to pedicle and the remainder of the medial contrast. Mixed flow happens… lateral dural sleeves happen.
 
One view is available. I think it has to have been a sleeve I passed through. So tagged it front and back to have symptoms within 30 minutes.
 
Pocket pain. We've all had a few pts with IPG pain, and it usually gets better over time as the battery settles and the pocket forms. I don't rush the pocket creation, and I take an extra few minutes because it seems to yield better results when the pocket is nice and relaxed during recovery.

This lady was implanted a few months ago. Pocket pain is severe, and she has cramping at the IPG. Stimulator is functioning well and she's actually doing pretty good other than the IPG site. The battery looks to have rotated medially, but they move all the time and I can't see why that would matter.

How long do yall usually let an IPG sit until you move it? We're at 2 months now.

No signs of infection. No warmth, redness, fullness, etc.

She has insulin-dependent diabetes, and I gave her clinda 300mg TID (I realize that's probably an overkill) and baclofen 10mg TID. Zanaflex failed. She does not take opiates.

The lateral images didn't come down inferiorly enough, but I didn't feel like getting more images. If not better in 4W I will reimage her and make sure we got lower on the pelvis.

Nevro. This is another reason I prefer Abbott Eterna.

1717244029764.png
1717244149437.png
 
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MitchLevi said:
Pocket pain. We've all had a few pts with IPG pain, and it usually gets better over time as the battery settles and the pocket forms. I don't rush the pocket creation, and I take an extra few minutes because it seems to yield better results when the pocket is nice and relaxed during recovery.

This lady was implanted a few months ago. Pocket pain is severe, and she has cramping at the IPG. Stimulator is functioning well and she's actually doing pretty good other than the IPG site. The battery looks to have rotated medially, but they move all the time and I can't see why that would matter.

How long do yall usually let an IPG sit until you move it? We're at 2 months now.

No signs of infection. No warmth, redness, fullness, etc.

She has insulin-dependent diabetes, and I gave her clinda 300mg TID (I realize that's probably an overkill) and baclofen 10mg TID. Zanaflex failed. She does not take opiates.

The lateral images didn't come down inferiorly enough, but I didn't feel like getting more images. If not better in 4W I will reimage her and make sure we got lower on the pelvis.

Nevro. This is another reason I prefer Abbott Eterna.

View attachment 387451View attachment 387452
Click to expand...
Revise it. Move it 3" laterally. Too close to spine for my liking.
 
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