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good one...

i was thinking of a different DC character....
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Screenshot 2023-09-08 at 11.06.58 AM.png


Kyphoplasty this T12 or burst fracture?
 
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SpineandWine said:
View attachment 376577

Kyphoplasty this T12 or burst fracture?
Click to expand...
Would want to see a CT scan or at least cuts through the pedicles. 3 columns of Denis?
From what is posted it looks like an easy kypho. Bealle has proven that the horizontal line in the vertebral body in that one axial slice does not push back in the spinal canal when cement is injected anterior to it.
 
Hi, i do not know honestly about this 3 lines of denis (I looked it up, saw the ALL, PLL and afterwards) - not sure how this will change management.
Can you tell me what i should be looking for?
 
45 yo m acute on chronic low back pain with radicular pain to right anterior thigh, posterior calf and lateral ankle. No trauma. +SLR b/l at 20 deg, midline SP tenderness with pain radiating to RLE when pressed, resisted left hip flexion provokes right radicular pain. Neurological intact.
XR showed below.
Ordered MRI of T spine and L spine and lab for bone metabolism.
He went for second opinion and told no need for imaging. Did I over call?
New graduate. Just want to hear what would you do ? Thanks.
IMG_5105.jpg
 
amadeus_lee said:
45 yo m acute on chronic low back pain with radicular pain to right anterior thigh, posterior calf and lateral ankle. No trauma. +SLR b/l at 20 deg, midline SP tenderness with pain radiating to RLE when pressed, resisted left hip flexion provokes right radicular pain. Neurological intact.
XR showed below.
Ordered MRI of T spine and L spine and lab for bone metabolism.
He went for second opinion and told no need for imaging. Did I over call?
New graduate. Just want to hear what would you do ? Thanks.
View attachment 376678
Click to expand...
Don’t think you overcalled
What bone labs you order?
 

Vit D, Ca, Mg, phos, CMP, CBC, TSH, PTH, ESR. On the hindsight, looked at his Chest CT in Jan, the T11 compression fracture was there, with rib sclerotic changes.

Lab showed vit D 16, slightly elevated WBC which might due to the oral steroid he was on. Other labs were not significant.

Otherwise general healthy and active person.
 
besides the T11 compression fracture, im not seeing anything that i would have ordered all of those blood tests.

im not appreciating bone changes from Pagets disease. the rib findings are hard to see, and dedicated rib films might be helpful. i dont appreciate any pagets of the spine itself...
 
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Thoracic fracture is all I see. MRI is what I'd get. I wouldn't have gotten any labs.
 
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I would've just done MRI lumbar but nothing wrong with being more thorough
 
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I would have gotten MRI lumbar for his new symptoms and MRI thoracic for fracture. An otherwise healthy guy without a history of trauma would make me want to get a better look at that fracture to make sure that it is old and benign, which it most likely is.
 
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Thank you all for the input.

On the topic of vertebra fracture. 76 year old female history of ovarian cancer with acute onset left sided low back pain with radiation to the left thigh just to above the knee. She pointed to left SIJ area for pain. It started 13 days ago after she came back from a cruise trip when she walked a lot. It is aggravated with standing and walking and improves with laying down. Neuro exam was normal. SI joint provocative test were positive. X-ray and urgent care showed L3, L4 superior endplate concavity. Mild degenerative changes in the SI joint and pubic symphysis. I ordered lumbar MRI. Despite the MRI findings, I’m considering doing a SI injection instead of lumbar epidural. What would you do?
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Better axials through lower discs and left sided sagittals would help.

But SI, ESI, MBB all reasonable.
 
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If exam consistent with SIJ and without any neuro findings I would start with the SIJ injection. Especially if she has pain with transition movements given the remainder of her story.

If not better move on to ESI.
 
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its reasonable, but those SI images do not look bad at all. and the MRI does look more convincing, particularly in light of the description of the radicular pain down the anterior thigh.

SI dysfunction can give some radicular pain, but that description sounds more like L3 radic...
 
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the dangers of anticoagulation (even when necessary)

acute onset of back pain on someone anticoagulated for multiple DVTs. rapidly progressed within 24 hours to dense paralysis, even after evacuation.

thor hema antiphospho 1.GIF



thor hema antiphospho 2.GIF

thor hema antiphospho 3.GIF
 
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amadeus_lee said:
Thank you all for the input.

On the topic of vertebra fracture. 76 year old female history of ovarian cancer with acute onset left sided low back pain with radiation to the left thigh just to above the knee. She pointed to left SIJ area for pain. It started 13 days ago after she came back from a cruise trip when she walked a lot. It is aggravated with standing and walking and improves with laying down. Neuro exam was normal. SI joint provocative test were positive. X-ray and urgent care showed L3, L4 superior endplate concavity. Mild degenerative changes in the SI joint and pubic symphysis. I ordered lumbar MRI. Despite the MRI findings, I’m considering doing a SI injection instead of lumbar epidural. What would you do?
View attachment 376717
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View attachment 376722
Click to expand...
This clinical picture could also fit with sacral insufficiency fracture
 
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Ducttape said:
the dangers of anticoagulation (even when necessary)

acute onset of back pain on someone anticoagulated for multiple DVTs. rapidly progressed within 24 hours to dense paralysis, even after evacuation.
Click to expand...
Wild. Some questions:

Unprovoked, I assume?
Any concurrent NSAID or SSRI/SNRI use?
Any weird med interactions causing like a CYP 3A4 inhibition or something?
 
yes unprovoked. INR 2.7 on admission.

anticoagulated for triple antiphospholipid syndrome due to lupus.

took him off of anticoagulation postsurgery and put him on prophylactic heparin.... and he then developed an upper extremity DVT.
 
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Baron Samedi said:
Looks subdural. How much volume of contrast is that?
Click to expand...
0.5cc, went down a level.

lobelsteve said:
I am more interested in what the F did he do that needle?
Do not use a mallet for epidurals.
Click to expand...
Lol yes, we did get a new one for the next level. I'm going to go ahead and blame the fellow for the bend but to be honest I can't remember when I took over the epidural.
 
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ragnathor said:
Not intentional. I took over trying to salvage from the fellow. I could have pulled out and aborted sooner.
Click to expand...
So was it subdural?

I'm always amazed at fellows' abilities to place needles in places I couldn't get if I tried. Recently I saw a fellow end up anterior to the vertebral body on an L5-S1 TFESI and my first reaction was "how???"
 
72 year old man with Colon cancer currently on chemotherapy presented with low back pain radiating to the right lower extremity. Radiology reported DJD, facet arthropathy and central canal stenosis. I was going to do an ESI until I review the imaging. Now not sure if I want to do that. Any thoughts? Mets?
IMG_5131.jpg

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Don't get back surgery if you can help it. This dude has collapsed above and below his L3-5 fusion, has a screw in the psoas and thoracolumbar DISH, advanced sensorimotor peripheral polyneuropathy and he's on Coumadin. Sagittal balance is off and he needs a 3 column osteotomy which he's too sick to get. Miserable. If a stimulator fails (I'll probably try it), he will require decompression L1-3 which won't do anything for his L5-S1 disease.

Moral of the story - Exercise, eat right and don't get fat.
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MitchLevi said:
Don't get back surgery if you can help it. This dude has collapsed above and below his L3-5 fusion, has a screw in the psoas and thoracolumbar DISH, advanced sensorimotor peripheral polyneuropathy and he's on Coumadin. Sagittal balance is off and he needs a 3 column osteotomy which he's too sick to get. Miserable. If a stimulator fails (I'll probably try it), he will require decompression L1-3 which won't do anything for his L5-S1 disease.

Moral of the story - Exercise, eat right and don't get fat.
Click to expand...
agree with not recommending spine surgery, but...

not sure if DISH or sensorimotor peripheral polyneuropathy is an effect of having back surgery...


i cant tell why he needs decompression L1-3 based on these images.

are you saying your stimulator will cure the compression at L1-3?
 
MitchLevi said:
Don't get back surgery if you can help it. This dude has collapsed above and below his L3-5 fusion, has a screw in the psoas and thoracolumbar DISH, advanced sensorimotor peripheral polyneuropathy and he's on Coumadin. Sagittal balance is off and he needs a 3 column osteotomy which he's too sick to get. Miserable. If a stimulator fails (I'll probably try it), he will require decompression L1-3 which won't do anything for his L5-S1 disease.

Moral of the story - Exercise, eat right and don't get fat.
View attachment 377003View attachment 377004View attachment 377005
Click to expand...
its strange that he had the supra and infra adjacent degeneration with that much DISH.

Im assuming his leg is giving him trouble? is that a plexopathy or from the stenosis you mentioned?

no good outcome here
 
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amadeus_lee said:
There looks like a soft tissue posterior to the L1-2 level, that is what concerns me.
Click to expand...
im not a radiologist and dont have all the cuts, but it "looks" like DDD to me as well
 
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MitchLevi said:
Don't get back surgery if you can help it. This dude has collapsed above and below his L3-5 fusion, has a screw in the psoas and thoracolumbar DISH, advanced sensorimotor peripheral polyneuropathy and he's on Coumadin. Sagittal balance is off and he needs a 3 column osteotomy which he's too sick to get. Miserable. If a stimulator fails (I'll probably try it), he will require decompression L1-3 which won't do anything for his L5-S1 disease.

Moral of the story - Exercise, eat right and don't get fat.
View attachment 377003View attachment 377004View attachment 377005
Click to expand...
Intracept above and below if significant axial component
 
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Ducttape said:
agree with not recommending spine surgery, but...

not sure if DISH or sensorimotor peripheral polyneuropathy is an effect of having back surgery...


i cant tell why he needs decompression L1-3 based on these images.

are you saying your stimulator will cure the compression at L1-3?
Click to expand...
Severe stenosis L1-3.

My point mentioning DISH and neuropathy is just to say pathology compounds and life gets harder with our without surgery as you age.
 
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L2.jpg


L2 Fx on STIR. Modic changes at L4-5.
No mention of disc pathology at L2-3 or L3-4. No retropulsion per report.

Right paramedian extrusion with superior migration of L2-3 disc is my call.
In T2 images it does not look same as disc or bone. Call in to radiologist.
Thoughts on disc vs bone vs badness?
 
lobelsteve said:
View attachment 377012

L2 Fx on STIR. Modic changes at L4-5.
No mention of disc pathology at L2-3 or L3-4. No retropulsion per report.

Right paramedian extrusion with superior migration of L2-3 disc is my call.
In T2 images it does not look same as disc or bone. Call in to radiologist.
Thoughts on disc vs bone vs badness?
Click to expand...
fracture plus herniation. very difficult to say what is causing the pain. i think you probably just sit on this-- or an ESI for the leg pain
 
SSdoc33 said:
fracture plus herniation. very difficult to say what is causing the pain. i think you probably just sit on this-- or an ESI for the leg pain
Click to expand...
Had series of 3 elsewhere while trying to get into see me. No osteoporosis treatment offered. I would have done things differently.
 
1695842791693.png

"Status post L3-L5 discectomy and anterior fusion with posterior fusion hardware at L3-L5 on the
left. Hardware is intact without evidence for breakage or loosening. 1 cm anterolisthesis L4 on L5."
 
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