Does this patient have obvious arachnoiditis?

[conerve]

27 y.o male was referred my to pain clinic for continued pain management (opiate therapy) and c/o continued lumbar and lower thoracic (T8-T12) pain. Pain that persist and worsens through the night and has been present and worsening/staying around the same intensity for approx. two years.

The pt. proposes a few challenges towards treatment from a pain management perspective. Pt. is currently on long acting opiate therapy and has been on around the clock opiate therapy for almost a year. Pt presents with no signs of hyperanalgesia, no aberrant behavior, no failed tox screenings, and opiate therapy seems to drastically be improving Pt. quality of life.

Pt. has had four MR of the the thoracic spine, all yielding an interpretation of visible soft tissue masses at T8 & T11. Pt. also has degenerative changes, moderate foramenal stenosis at L5/S1, L4/L5...and the last neurological rad providing interpretation of lumbar MR, noted pt has arachnoiditis, with "empty sac sign"...moderate to severe.

Given the limited treatment options available for arachnoiditis or the adhesive version, I am curious as to what others thoughts are on this Pts. imaging.... any eyes would be appreciated.

---

Members don't see this ad.

 

[lobelsteve]

Normal MRI.

 

[conerve]

Thanks lobelsteve, as for the L spine, the study seemed unremarkable, other than some foramenal stenosis at L5/S1. Pt. was involved in ATV accident, comminuted pubic ramus fracture(s), L&R sacral ala, S1, S2, seven non displaced fractures throughout the pelvis/sacrum. Pt said pain started two years ago, accident was one year ago, and Pt says the original pain has returned and does not feel related to pelvis. Pt is currently unable to work due to the severity of pain. Two of the images I meant to attach, did not go through, illustrating abnormal lesions in the T spine...Pt complains of burning, searing, nocturnal pain that awakes him from sleep, which has persisted for two years.

Would you give this pt an ESI or put a needle near the epidural space? Patient has seen oncologist, hematologist, multiple neuro surgeons..wanting to take a wait and see approach...debating on whether Pt has Tarlov cyst(s) or schwannomas...patient has been to Johns Hopkins, diagnosed with ICD 10 G69.19...which doesn't give us much to off of as far as treatment.

.

 

[clubdeac]

Does he have right T8 and left T11 radicular like pain in the distribution of the presumable schwannomas? If so and you get clearance from neurosurgery you could do intercostals? Would want someone else's blessing first. And agree with Steve, the lumbar spine is normal

 

[101N]

The problem is supratentorial.

 

[lobelsteve]

Not working due to pain or not working due to pain medication. Consult 101N. What is role of opiates when no pathological process ongoing and no functional status.

 

[DrCommonSense]

27 y.o male was referred my to pain clinic for continued pain management (opiate therapy) and c/o continued lumbar and lower thoracic (T8-T12) pain. Pain that persist and worsens through the night and has been present and worsening/staying around the same intensity for approx. two years.

The pt. proposes a few challenges towards treatment from a pain management perspective. Pt. is currently on long acting opiate therapy and has been on around the clock opiate therapy for almost a year. Pt presents with no signs of hyperanalgesia, no aberrant behavior, no failed tox screenings, and opiate therapy seems to drastically be improving Pt. quality of life.

Pt. has had four MR of the the thoracic spine, all yielding an interpretation of visible soft tissue masses at T8 & T11. Pt. also has degenerative changes, moderate foramenal stenosis at L5/S1, L4/L5...and the last neurological rad providing interpretation of lumbar MR, noted pt has arachnoiditis, with "empty sac sign"...moderate to severe.

Given the limited treatment options available for arachnoiditis or the adhesive version, I am curious as to what others thoughts are on this Pts. imaging.... any eyes would be appreciated.

View attachment 228294 View attachment 228295 View attachment 228296 View attachment 228297

Nothing that a little Suboxone and CBT wont cure!

 

[conerve]

Interesting case. Does he have right T8 and left T11 radicular like pain in the distribution of the presumable schwannomas? If so and you get clearance from neurosurgery you could do intercostals? Would want someone else's blessing first. And agree with Steve, the lumbar spine is normal

Yes, pt has radicular pain at T8 & T11, there also appear to be other "schwannoma" like lesions through the T spine. Serial thoracic MRs this year, so them as slow growing, yet getting a bit larger. No clearance from neurosurgery. They want to remove the rib to get to the posterior mass, even for biopsy.

 

[conerve]

The problem is supratentorial.

I would have to disagree, and it's the dismissal of this patient, by numerous specialist, but there's clearly abnormal findings associated to what the Pt. c/o

 

[101N]

You have an otherwise healthy 27y/o with back pain and no clear anatomic cause. Do you start all of those on opioids?

 

[conerve]

You have an otherwise healthy 27y/o with back pain and no clear anatomic cause. Do you start all of those on opioids?

Pt also suffers from poly-inflammatory arthritis, suspect of RA or SLE. Full genetic testing for pharmacodynamics...pt has rare polymorphism to of CYP450/ CYPD6.

Pt was not started on opiates right away. Pt spent a year bouncing from conservative treatments, chiro, acupuncture, PT. Opiates are providing pt quality of life, which was before, absent, diminished, and the Pt had exhausted every other drug, without affect. This problem has been worsening over two years. And there's clearly "anatomic" cause for pain. Given 1.5cm x 1.5cm posterior paraspinal masses along the thoracic spine.

 

[Ducttape]

“Something is rotten in the state”


Marcellus.

 

[101N]

How long you been doing this

 

[lobelsteve]

Pt also suffers from poly-inflammatory arthritis, suspect of RA or SLE. Full genetic testing for pharmacodynamics...pt has rare polymorphism to of CYP450/ CYPD6.

Pt was not started on opiates right away. Pt spent a year bouncing from conservative treatments, chiro, acupuncture, PT. Opiates are providing pt quality of life, which was before, absent, diminished, and the Pt had exhausted every other drug, without affect. This problem has been worsening over two years. And there's clearly "anatomic" cause for pain. Given 1.5cm x 1.5cm posterior paraspinal masses along the thoracic spine.

Please share the QOL of a nonworking male at 27 with no definable pathology, nothing more than incidentalomas and failure of multiple specialists to find what is wrong? How do you justify giving narcs? Failed other treatment is the bar towards chemical coping? I see schwannomas every day . I have seen 2 patients in 14 years with possible pain from schwannomas. Both worked FT. Now you mention genetic tests for pharmacodynamics and inflammatory arthritis? These appear like buzzwords here for "I'm giving opiates, he requires high doses, and there is nothing wrong so we make stuff up. Give me an ESR at 75 or up before I get an eyebrow raised. Until then, it is mushu. The size and location of the high signal intensity areas appear to be a yawn. I'd view a tarlov cyst the same way.

 

[Ducttape]

the entire post feels wrong.

1. First time poster
2. Only thread ever posted on
3. Engrish language no good - well, at least the punctuation isn’t
4. Why are conditions continuously being added? (Ie first discuss arschnoiditis, then cysts, then pelvic fractures, then poly inflammatory arthritis then genomic testing +...... all in setting of opioids tx for no working young male)

 

[DODOCSS]

OP is the patient

 

[244913]

I would have to disagree, and it's the dismissal of this patient, by numerous specialist, but there's clearly abnormal findings associated to what the Pt. c/o

Is the patient you? I'd recommending getting in touch with Forest Tennant's clinic in Covina. I think he's out on bail. Sounds like you have chronic intractable pain.

- ex 61N

 

[101N]

Or folie a duex

 

[conerve]

Or folie a duex

You a sincerely are a horrible Doctor and the reason our medical system is so jacked. The "OP" is not the patient, albeit, a concerned medical student for this patient. It scares me that you're actually treating human beings as you treat the people in this forum. Misinformed, small minded, condescending, "opiate naive" vantage point.

The only person who has guided to a direction in which the Pt. might benefit from is Dr. Tennant in CA for IP. ESR is above 75, RF is high-positive. What's a yawn to you is a Pt.s QOL. Pt just got back from Johns Hopkins, scheduled at the Mayo Clinic for orthopedic oncology investigation, and we're just trying to provide a HUMAN approach towards treating this patients pain whilst they wait for a proper answer..which our medical community has failed to offer.

Shakespearian humor or french asinine comments from "highly educated" individuals without a soul, wanting to help someone or help others help someone, find answers to a vexing problem.

"We are not ourselves When nature, being oppressed, commands the mind To suffer with the body. "

 

[conerve]

Is the patient you? I'd recommending getting in touch with Forest Tennant's clinic in Covina. I think he's out on bail. Sounds like you have chronic intractable pain.

- ex 61N

I'm not sure if this is satire, although, Dr. Tennant's work affects the lives of many I come into contact with my research...and this suggestion is the only one I shall point the Pt. to--Dr. Tennant's intractable pain survival guide. As the Pt. has to deal with cynical, self-gloating, "strong" acumen physicians, against the hippocratic oath of practice.

 

[Biohazard685]

These Russian bots sure are advanced nowadays.

Never thought I would see shills on SDN.

 

[lobelsteve]

I'm not sure if this is satire, although, Dr. Tennant's work affects the lives of many I come into contact with my research...and this suggestion is the only one I shall point the Pt. to--Dr. Tennant's intractable pain survival guide. As the Pt. has to deal with cynical, self-gloating, "strong" acumen physicians, against the hippocratic oath of practice.

If you are a med student, please avoid practicing in Georgia. It will not end well.

 

[101N]

You a sincerely are a horrible Doctor and the reason our medical system is so jacked. The "OP" is not the patient, albeit, a concerned medical student for this patient. It scares me that you're actually treating human beings as you treat the people in this forum. Misinformed, small minded, condescending, "opiate naive" vantage point.

The only person who has guided to a direction in which the Pt. might benefit from is Dr. Tennant in CA for IP. ESR is above 75, RF is high-positive. What's a yawn to you is a Pt.s QOL. Pt just got back from Johns Hopkins, scheduled at the Mayo Clinic for orthopedic oncology investigation, and we're just trying to provide a HUMAN approach towards treating this patients pain whilst they wait for a proper answer..which our medical community has failed to offer.

Shakespearian humor or french asinine comments from "highly educated" individuals without a soul, wanting to help someone or help others help someone, find answers to a vexing problem.

"We are not ourselves When nature, being oppressed, commands the mind To suffer with the body. "

This isn’t a leper in Guinea Albert, it’s a 27yo with back pain seeking opioids amidist an epidemic. Go back to National Pain Report troll you’ve been outed.

 

[Winged Scapula]

Closing as the OP is either clearly a patient or family/friend.