Pictures of the Week

[callmeanesthesia]

Aren’t intra-articular facets considered all sham all the time now? Mbb for all according to all payors

I believe if documented association with facet cyst causing radiculopathy you can still do it.

---

Members don't see this ad.

 

[bedrock]

Aren’t intra-articular facets considered all sham all the time now? Mbb for all according to all payors

They all allow facet cyst aspiration, but yes many don’t allow for IA facet injections.

Although Cigna, UHC, my state WC, allow IA facet injections. That’s 35% of my patients.

 

[MitchLevi]

Trial just now. Went great. Should do well. FBSS with radic. Nice guy.

Heading back upstairs to dictate before heading to the gym (bc I train daily for war).

Found this in the stairwell, and instead of being annoyed about its presence in my clinic I'm furious I wasn't invited to the party.

 

[RoloTomassi]

Careful could be that super potent fentanyl

 

[Agast]

It belongs to whomever you just pee tested and they couldn’t wait until they got back home

 

[MD87]

do you have this?

No. I think it is in one of the “community lectures”/case discussions. But I don’t know which one, you’d have to search for it.

Essentially you measure the angle of the opening of the joint using axial MRI or CT. Often with SAP hypertrophy, as it grows medially over the IAP, this will result in an opening that that requires contralateral oblique. With the patient on the table, you oblique to that predetermined angle. If the angle is contralateral, You will see a very faint lucency that looks like a joint. First time I did it my tech looked at me like I was crazy cuz it’s very faint. Then you place the needle and voila.

 

[lobelsteve]

Trial just now. Went great. Should do well. FBSS with radic. Nice guy.

Heading back upstairs to dictate before heading to the gym (bc I train daily for war).

Found this in the stairwell, and instead of being annoyed about its presence in my clinic I'm furious I wasn't invited to the party.

View attachment 378649
View attachment 378650

Clear bag. White powder. Ain’t the joint guy. Probably the guy with the needles.

 

[MitchLevi]

...Glad this dude left our practice. Not a great team guy. Lazy. Weird. Dishonest.

Please don't ablate like this.

 

[manowar rules]

...Glad this dude left our practice. Not a great team guy. Lazy. Weird. Dishonest.

Please don't ablate like this.

View attachment 378822

View attachment 378823

Not to mention the extra RF needles you were paying for

 

[RoloTomassi]

I've seen worse when people bring discs with fluoro images

 

[Taus]

I've seen worse when people bring discs with fluoro images

This is pretty much the norm of what I see when people bring in outside records. I suspect more pain docs do it this way then we’d like to think.

 

[MitchLevi]

Who knows what tilt does to those needles, but those are ugly.

 

[interjectionreflection]

Who knows what tilt does to those needles, but those are ugly.

Did he just put all 6 down in ap? I've seen some people do this and try to rationalize it by claiming less fluoro time just seems like a way to run an injection mill tbh

 

[Dr. Ice]

...Glad this dude left our practice. Not a great team guy. Lazy. Weird. Dishonest.

Please don't ablate like this.

View attachment 378822

View attachment 378823

Wtf is this ****

Unbelievable

 

[BobBarker]

I have seen pretty similar. You can place them all in AP but you have to start much lower.

 

[MD87]

I saw a nice lady the other day. Auto case, but completely legit. She has textbook left C6 ridiculopathy due to 5/6 disc. I went through her notes. She had bilateral C4/5 TFESI. Told me she was prone and each needle took about 15 seconds. Never had bilateral symptoms.

 

[SC Tian]

Are you still able to do L5 kypho using the unipedicular approach?

 

[BobBarker]

Sure. There are some cool pics in my post hx.

 

[RoloTomassi]

Are you still able to do L5 kypho using the unipedicular approach?

Yes. Short wide pedicles, you can oblique a good 45-50 degrees, cross midline even with a straight cannula

 

[SC Tian]

Yes. Short wide pedicles, you can oblique a good 45-50 degrees, cross midline even with a straight cannula

Thanks, do you feel like there is significant room to pass the trochar in this picture?

 

[BobBarker]

 

[RoloTomassi]

Thanks, do you feel like there is significant room to pass the trochar in this picture?

I'd get CT and use a curved kit

 

[MitchLevi]

Who wants to bet the PA's physical exam isn't accurate?

 

[bedrock]

I’m sure the PA missed a few things…..

 

[Taus]

Who wants to bet the PA's physical exam isn't accurate?

View attachment 378900
View attachment 378902

I’ll raise you…. Who wants to bet the average pain doc still does esi x3 then mbb/rfa?

 

[MitchLevi]

I don't think the subacromial CSI worked

 

[MitchLevi]

I’ll raise you…. Who wants to bet the average pain doc still does esi x3 then mbb/rfa?

Disagree.

 

[geauxg8rs]

I’ll raise you…. Who wants to bet the average pain doc still does esi x3 then mbb/rfa?

And then si joint

 

[clubdeac]

Who wants to bet the PA's physical exam isn't accurate?

View attachment 378900
View attachment 378902

That looks terrible. What’s the back story on this one? Age? Sex

 

[lobelsteve]

Same old stenosis in the lumbar spine, but T10-11 ( I see you), not same as it ever was. MRI T-spine tomorrow. Not my patient, so no clinical yet.

 

[RoloTomassi]

View attachment 378945

View attachment 378946

Same old stenosis in the lumbar spine, but T10-11 ( I see you), not same as it ever was. MRI T-spine tomorrow. Not my patient, so no clinical yet.

I bet that was missed for a while

 

[BobBarker]

Hard to think of a physiologic response that would create a LF that is doing that.

“Body, why are you doing that??”

 

[cowboydoc]

I bet that was missed for a while

Needed to do MILD and intracept before ever looking into reason for hyperreflexia!

 

[MitchLevi]

...couple 'phytes causing dysphagia. Stiff neck. Occipital pain.

 

[amadeus_lee]

View attachment 378945

View attachment 378946

Same old stenosis in the lumbar spine, but T10-11 ( I see you), not same as it ever was. MRI T-spine tomorrow. Not my patient, so no clinical yet.

How does the axial cut look like ?

 

[lobelsteve]

How does the axial cut look like ?

L spine MRI. Axial cuts not above T12. MR Tspine done. Patient turfed to NS before seeing me.

 

[lobelsteve]

Another linkedin hero. He knew he was not epidural. But he did not know he was IT.

 

[BobBarker]

Probably a very nice anesthetic for the hip reduction though.

 

[geauxg8rs]

Probably a very nice anesthetic for the hip reduction though.

Can bill as myelogram

 

[lobelsteve]

Linkedin: Where u go to ego.

 

[BobBarker]

Yea that is crazy. And his daughter is defending him in the comments.

 

[Ducttape]

id be pissed if i had to get 47 injections at one time...

 

[MitchLevi]

I've had PRP twice - R shoulder and L hip flexor. It wasn't awful, but it def gets your attention.

What's it like getting 47 shots of fat?

 

[RoloTomassi]

To be fair it's only about 6 needles, just injecting in 1 cc increments

 

[MitchLevi]

 

[geauxg8rs]

I’m changing my name to intelliFat

 

[bedrock]

This is for Steve and his focus on multiple x ray views !

 

[lobelsteve]

Certainly not the worst I have seen. But somehow this person was seen by PCP in office and referral snuck in. Nurse calling now to let him know I would never/ever Rx a controlled substance, but happy to eval.
Combo of opiates, BZD, amphetamine based stimulants.

 

[lobelsteve]

Start with a couple epidermals, then catterize them nerves.
Anyone want to see this patient, pretty sure I cannot help.

 

[callmeanesthesia]

View attachment 379265View attachment 379266

Start with a couple epidermals, then catterize them nerves.
Anyone want to see this patient, pretty sure I cannot help.

What happened there?