Pictures of the Week

IPSIS: Formerly the Spine Intervention Society
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Cervical block vertebrae as well.
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It’s Mounjaro for the spine.
 
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clubdeac said:
Young grasshopper
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After how many pts does one become seasoned enough to comment? Of course I'd inject this, and if this lady shows up on time and doesn't cuss out my phone service I'll probably offer her procedural based pain management but look at all that fat.

She won't get better with anything I do.
 
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MitchLevi said:
After how many pts does one become seasoned enough to comment? Of course I'd inject this, and if this lady shows up on time and doesn't cuss out my phone service I'll probably offer her procedural based pain management but look at all that fat.

She won't get better with anything I do.
Click to expand...
She will not. L2-S1 fusion will make her worse.
RFA, ESI will fail. SCS will get her 1 year of relief then fail.
Mounjaro might be best injection for this patient.
 
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lobelsteve said:
She will not. L2-S1 fusion will make her worse.
RFA, ESI will fail. SCS will get her 1 year of relief then fail.
Mounjaro might be best injection for this patient.
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Entire point of my post.

No potential for salvage.

Multilevel disk collapse with pan lumbar stenosis. She's 5'3" and 300 lbs (taxes ought not to pay for your bag of fudge rounds)...

I'll listen to her and give her the 3 min she wants to vent about her shortcomings in life, then I'll offer a few shots and in the end nothing will change and she will not benefit from seeing me.

She called 20 min late today and was en route. Yelled at my call service. I refused to see her.

We rescheduled her and she has one more chance or she's fired.
 
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MitchLevi said:
After how many pts does one become seasoned enough to comment? Of course I'd inject this, and if this lady shows up on time and doesn't cuss out my phone service I'll probably offer her procedural based pain management but look at all that fat.

She won't get better with anything I do.
Click to expand...
Ahhh I misunderstood your post. I thought you were concerned about the degree of stenosis. My eyes went straight to the spine. I didn’t even look at all her back fat. This is where seeing the patient and the entire clinical picture helps
 
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MitchLevi said:
Entire point of my post.

No potential for salvage.

Multilevel disk collapse with pan lumbar stenosis. She's 5'3" and 300 lbs (taxes ought not to pay for your bag of fudge rounds)...

I'll listen to her and give her the 3 min she wants to vent about her shortcomings in life, then I'll offer a few shots and in the end nothing will change and she will not benefit from seeing me.

She called 20 min late today and was en route. Yelled at my call service. I refused to see her.

We rescheduled her and she has one more chance or she's fired.
Click to expand...
i guess you dont see these patients often enough...

this is like 20% of my patient population.

fwiw, she has some degree of scoliosis, so the stenosis is probably not as bad as visualized on the one sagittal.

how you can help make her better -
1. try one epidural. use a 7 inch needle. i have a bunch in stock, if you need them.
2. discuss weight loss
3. refer her to bariatrics. even if she loses 20 pounds with mounjaro, she wont get markedly better.
4. tell her that she can make changes if she chooses to, but it is hard work. she is the one that can make herself better.
 
Ducttape said:
i guess you dont see these patients often enough...

this is like 20% of my patient population.

fwiw, she has some degree of scoliosis, so the stenosis is probably not as bad as visualized on the one sagittal.

how you can help make her better -
1. try one epidural. use a 7 inch needle. i have a bunch in stock, if you need them.
2. discuss weight loss
3. refer her to bariatrics. even if she loses 20 pounds with mounjaro, she wont get markedly better.
4. tell her that she can make changes if she chooses to, but it is hard work. she is the one that can make herself better.
Click to expand...
Scoliosis is minimal despite the way it appears on that saggital view. If she shows up on time I'll see her. I refused to see her Friday bc she was way too late AND was rude to our phone ppl.

I think we all see these ppl frequently enough. It won't go well.

Doesn't mean I won't try.
 
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This one's brutal...That's the best axial I can do.

Hx breast cancer. Severe back and leg pain.

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Going to university cancer center.
 
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Here are two doozies. One patient better with PT and refusing to see the surgeon. Other patient can barely walk and previous doc chalked it up to issue prior to lumbar lami. Fortunately got her in with another surgeon who’s gonna operate
 

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clubdeac said:
Here are two doozies. One patient better with PT and refusing to see the surgeon. Other patient can barely walk and previous doc chalked it up to issue prior to lumbar lami. Fortunately got her in with another surgeon who’s gonna operate
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C2-6 ACDF vs ACDF then Posterior cleanup. For both.
Surgeon: Try an epidural.
Us: Nopes.
 
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hip.jpg


This was a bummer, sent for back pain and referral to try mbb. Had seen surgeon who was hoping RFA would help. Known Cancer, no mets to spine. He mentioned new leg length discrepancy.........
 
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Nails on chalkboard

(Season 1 Jack Ryan and apparently he has the spine of a 55 yo female)
 
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the show was pretty good. at least season 1 was. season 2 meh, season 3 decent. havent watched season 4 yet.

the best thing about putin and the invasion of ukraine is that we now have a legitimate enemy for spy novels and movies. it just wasnt the same when the middle easterners were the bad guys in the 2000s and 2010s
 
Saw this today. 27 yr old man. Does manual labor. Has left L5 radicular pain.
MRI report states they think the cyst arises from the disc.

My first step is clear, a left L4-L5, L5-S1 TFESI. The next step is less clear. I had a mental debate about trying the rupture the cyst with a transforaminal approach and using discogram protocosl (IV abx and double needle) .

Or I could send him straight surgery if he fails the TFESI, I suppose.
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bedrock said:
Saw this today. 27 yr old man. Does manual labor. Has left L5 radicular pain.
MRI report states they think the cyst arises from the disc.

My first step is clear, a left L4-L5, L5-S1 TFESI. The next step is less clear. I had a mental debate about trying the rupture the cyst with a transforaminal approach and using discogram protocosl (IV abx and double needle) .

Or I could send him straight surgery if he fails the TFESI, I suppose.
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Interesting. Not sure that's not a facet cyst. Looks like a small one coming off the right posterior facet. Never seen a disc cyst
 
bedrock said:
Saw this today. 27 yr old man. Does manual labor. Has left L5 radicular pain.
MRI report states they think the cyst arises from the disc.

My first step is clear, a left L4-L5, L5-S1 TFESI. The next step is less clear. I had a mental debate about trying the rupture the cyst with a transforaminal approach and using discogram protocosl (IV abx and double needle) .

Or I could send him straight surgery if he fails the TFESI, I suppose.
View attachment 381214
View attachment 381215
Click to expand...
I’d try the TFESI then send to surgery. Not worth trying to be a hero over, especially for something they can probably deal with permanently through a 1” incision. Have never heard of a disc cyst. Perineal cyst maybe.
 
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im also not sure it is a facet cyst.

would agree with TF and refer to surgery, but wouldnt try to be a cowboy. even if you ruptured it, what are the odds that that will solve the issue?
 
i have seen disc cysts. but they are much smaller.

you could try to aspirate the cyst via a facet approach -- as it is most likely a facet cyst. but, that may not get paid, and you would have to do it on a separate visit from the TFESI.

i like to do a TFESI AND facet aspiration/injection at the same time but that is getting harder and harder to get covered.
 
SSdoc33 said:
i have seen disc cysts. but they are much smaller.

you could try to aspirate the cyst via a facet approach -- as it is most likely a facet cyst. but, that may not get paid, and you would have to do it on a separate visit from the TFESI.

i like to do a TFESI AND facet aspiration/injection at the same time but that is getting harder and harder to get covered.
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I’d do this, too. Would be interested if contrast in facet showed this filling.
 
I vote discal cyst. Rare, but it’s been described. Personally, I would try TFESI and send to surgery over attempted rupture if no relief.
 
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