Pictures of the Week

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Congenital deforminty and at 27 yrs old with no issues and only left levator pain, no reason to think instability.

He has sneezed several times since birth and not once did his head pop off or his cord get crushed. Now as far as roller coasters and bungee jumping.....

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Congenital deforminty and at 27 yrs old with no issues and only left levator pain, no reason to think instability.

He has sneezed several times since birth and not once did his head pop off or his cord get crushed. Now as far as roller coasters and bungee jumping.....

Dont do a spurlings on this dude!
 
Borderline canal stenosis? Find the CSF dot...

http://www.box.net/shared/mbq2ax1bqz

http://www.box.net/shared/2vb7py0l2e

2vb7py0l2e
 
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woundinfection.jpg



Wound infection post-fusion. Closed after 3 months of packing.

Note that there is purulence, not sloughing, not serosanguinous discharge. I have a patient 2 weeks post SCS with serous discharge over the T-spine wound and the 3-0 Vicryl suture at the top margin of the wound ripped. I probed and did not see my 0 Vicryl suture or the wires/anchors. I put in a 2-0 Vicryl through skin to 5mm on each side and loosely approximated the margins. I then steristripped with benzoin to cinch it together and dressed with a tegaderm. 1 week prophylactic ABX due to the probing of a wound in office.
Appreciate comments and criticism on this, and feel free to say Ewww for the pic above.
 
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Why even accept self-pay patients in pain management? They cannot afford anything except cheap opioids. They won't do anything except fill scripts for cheap opioids. And they have a 90% + risk of abusing and/or diverting.

Whenever I get asked if I will see a self-pay, I have the staff tell the patients not only about the office-wide policy of $300 upfront, but also that my services are expensive including MRI, EMG, PT and injections. If that doesn't deter them enough, they are also informed I don't prescribe opioids.

I get about 1-2/year that agree to all this. Around half have deluded themselves into thinking they can talk me into either giving them opioids or doing everything for free.
 
Why even accept self-pay patients in pain management? They cannot afford anything except cheap opioids. They won't do anything except fill scripts for cheap opioids. And they have a 90% + risk of abusing and/or diverting.

Whenever I get asked if I will see a self-pay, I have the staff tell the patients not only about the office-wide policy of $300 upfront, but also that my services are expensive including MRI, EMG, PT and injections. If that doesn't deter them enough, they are also informed I don't prescribe opioids.

I get about 1-2/year that agree to all this. Around half have deluded themselves into thinking they can talk me into either giving them opioids or doing everything for free.

Either slipped through the cracks or was one of the deluded...
 
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70 y/o female with back pain. Had ESI in another state 3 years ago without improvement. Developed severe back pain and right leg weakness/paresthesias on day 1. Made calls to office and not taken seriously. At 2 weeks post ESI the MRI was obtained. New MRI shows the DDD and resolution of this problem. Not going into her canal and she has only axial pain. Might try MBB if she fails PT.
 
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Unsure if this was posted earlier. Sent from Ortho for shoulder pain. Wanted opiates for pain. Got MRI- deltoid torn from bone. Came back in 2 weeks with knee pain. MRI with cellulitis, abscess, no osteo. Gets PICC and 4 weeks of IV ABX. Comes in 4 weeks later with new back pain. MRI as above. Back to ID buddy. Probably needs autoimmune workup or to stat playing the lottery.
 
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78 y/o male with 10 days of back and buttock pain after lifting a 32" TV. Pain is tolerable but severe. Limited from 3 rounds of golf per week 3 weeks ago to 9 holes this week.
No weakness, sensory loss, B/B incontinence, or saddle anesthesia.

No prior LBP or stenosis symptoms. Impending cauda vs might get better.
Surgeon notified just in case.

My 2c: They don't make us men tough like the prior generations.
 
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81 y/o female referred for LESI. Axial LBP. Has PM so CT done and shows old Fx with 7mm retropulsion at T12. Pain is aching at LS junction and upper buttocks (Type C). Recent fall and Fx of right humeral head.

I got BS as above because falls and little old ladies mean fresh Fx to me. Expected T12 and the humeral head. Report was as follows:


IMPRESSION
1. Marked increased activity about a lower thoracic vertebra and vertebral rib articulation proximal to this area, most likely traumatic, possibly pathologic with associated metastatic disease with the patient's history.
2. Increased activity right humeral head, most likely traumatic, possibly pathologic.
3. Increased activity right anterior rib, left anterior iliac wing, proximal left femur and right femoral neck. These findings are consistent with metastatic disease.


Now I've got to make a couple phone calls. I'm not cut out for just needle monkeying.
 
Now I've got to make a couple phone calls. I'm not cut out for just needle monkeying.

The last time I had one like this, the guy was dead before I could get the results to him.
 
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#86 MSContin 15mg. Tried BID for 4 days. Wants to go back to bid short acting.

We keep a log and require all unfilled Rx's and filled Rx's returned to our office or we do not release the next Rx. If a med does not work, bring it in- no appt needed, and we will replace it with new Rx. (Must be current patient and through due diligence policy first). Hardest part is destroying the old meds before we dump them in the sharps. Using hot water and alcohol gel. Bleach worked Ok but too messy.

I need a coffee bean grinder.
 
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My malpractice recommends we do not take pills from patients, as this can be construed as coertion of the patient - forcing them to bring in pills and give them to you in order to get more pills.

Several sources have discussed disposing of pills. Most municipalities would not want them flushed. Many pharmcacists will accept them back for disposal, but some wont.
 
looks like someone needs to work on their templates a bit and become more familiar with their Electronic Mistake Record.
 
After you initially read this, I hope you went directly to this doc's clinic and shot him in the head. WTF?

sadly, this isnt all that far below the norm from the procedure notes i read....
 
Anyone want to try a TKR on this?

I asked one of our orthos a couple years ago, how do you decide how many screws to put in a plate?

His answer - I count the number of holes and use that many screws. Sometimes more.
 
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Yes, T7 is not broken, but T6 is subacute and T8-L5 are all broken.

No, I did not put any of that cement in there. Nor will I at T6.


she doesnt have compression fractures. she just has ginormous discs. yes, i said "discs"
 
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Had 2 kyphoplasties today, back to back. FIlled this one in with 7cc.
Went back and looked at the MRI and wondering if I should have taken a Bx. It might be resolving hematoma from the Fx. I don't see other bony "mets", but it was dark on T1, T2, and STIR. Any thoughts?
 
Had 2 kyphoplasties today, back to back. FIlled this one in with 7cc.
Went back and looked at the MRI and wondering if I should have taken a Bx. It might be resolving hematoma from the Fx. I don't see other bony "mets", but it was dark on T1, T2, and STIR. Any thoughts?

Yeah, what's up with the picture on the right?

Is that scoliosis giving a false impression of critical stenosis L3?
Is that fluid pocket anterior to L2-3, sub ALL, or just an osetophyte?
 
There's a bit of a femur in there!

How long is that leg?
 
There's a bit of a femur in there!

How long is that leg?

A pair of condyles and 2 little bone blebs. No joint- no acetabulum.

The stump is real thin, like a lower leg :D .

It's a long AKA looking stump with the completely wrong shape to it.
Looks great for a custom CF socket.
 
In the next few years, your ability to get MRIs will likely get very restricted. Already, most of the private insurance companies in my area are demanding that you try 2 NSAIDs, 6 weeks of PT, and have an x-ray, and still require a peer-to-peer call to get an MRI authorized.

Cases like this one will slip by until the patient is completely hosed. And we will still get blamed. The widow's attorney will claim delay in diagnosis.
 
Where do you find these patients? Are you making the initial discovery of the pathology, or does the local oncology group have you on speed dial and hope you can do something for these kids?
 
I'm not Dexter, but I'm helping people die with less pain and more dignity.
I bet I'm one of the biggest writer's for Fentora and Actiq now that REMS has gone through.

Most get by with 50-100mcg patches and 4 200-400 fentora a day. I have some that require 6 per day and a little Ativan. I feel like a lose the battle every time when they pass. I have needed 10-20% of folks to get hospice involved.

The more folks I see, I realize the more serious pathology I have missed over the years.

I am probably one of the few that reads the local obituary section of the paper. Those were or should have been my patients.
 
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