Pictures of the Week

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OA block pt.2

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I thought it was some type of strange fusion. Thanks for posting, interesting image.
 
Saw today a X-ray photo of a one year old girl who swallowed a sewing pin.
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New patient. Axial neck pain, slow onset, possibly fall from horseback as a kid. No radiating arm pain or neuro deficit. Noticing some difficulty swallowing and "if I put on finger just here on my throat, it's hard to breath."
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Referral for L4 fracture either malignancy or osteoporosis. Pedicles were already taken, so I had to go really slow to avoid the exiting root. Patient kept mostly awake to make sure I could dock in the vertebral body. Didn't go bad, just more stress getting in.
 
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70m 3 weeks moderate back and right L4 distribution parasthesias with "foot slap" after shoveling snow. Tib ant 2/5. Knee extension/quad weak at 4/5 manually, but unable to rise from single leg squat. Bowel/bladder fine. Biggest disc I've seen with cephalad/caudal migration. Lami/microdisc following day after expedited surgery consult...


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70m 3 weeks moderate back and right L4 distribution parasthesias with "foot slap" after shoveling snow. Tib ant 2/5. Knee extension/quad weak at 4/5 manually, but unable to rise from single leg squat. Bowel/bladder fine. Biggest disc I've seen with cephalad/caudal migration. Lami/microdisc following day after expedited surgery consult...


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whats the rush? damage already done. central canal huge, no cauda equina. his foot will keep slapping. outcome (strength)would be the same with or with surgery.

if the foot slapping gets worse, then yes, surgery. but it wont

if this was pain-free, id just do PT
if there was pain, right L4 TFESI.

dont let the size of the disc scare you.
 
whats the rush? damage already done. central canal huge, no cauda equina. his foot will keep slapping. outcome (strength)would be the same with or with surgery.

if the foot slapping gets worse, then yes, surgery. but it wont

if this was pain-free, id just do PT
if there was pain, right L4 TFESI.

dont let the size of the disc scare you.

Thank you for input. I admit the size of disc played a role, but really the degree of weakness pushed me to surgery consult ASAP. What patient called foot slap I called frank foot drop with inability to clear/dorsiflex on gait and less than anti-gravity Tib ant. You sit on that if its your back? I have a hard time sitting on anything less then 3/5 motor.


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Overdevest et al found two risk factors for poor motor recovery after radic due to disc herniation were 1) severe weakness (authors deemed 3/5 "severe") and 2) size of herniation that took up 25% or more of canal. I'd send that person to spine surgeon to at least allow patient to have the option of surgery.
 
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Thank you for input. I admit the size of disc played a role, but really the degree of weakness pushed me to surgery consult ASAP. What patient called foot slap I called frank foot drop with inability to clear/dorsiflex on gait and less than anti-gravity Tib ant. You sit on that if its your back? I have a hard time sitting on anything less then 3/5 motor.


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yes.

without a doubt.

that disc will resorb, and the motor recovery will be the same with or without surgery.

there is no wrong answer here. if this patient has surgery, that is fine. non-operative treatment is also fine.

if pain leg pain cannot be resolved with non-operative measures, or there is progressive motor loss, then i am all for a discectomy
 
Overdevest et al found two risk factors for poor motor recovery after radic due to disc herniation were 1) severe weakness (authors deemed 3/5 "severe") and 2) size of herniation that took up 25% or more of canal. I'd send that person to spine surgeon to at least allow patient to have the option of surgery.

http://www.ncbi.nlm.nih.gov/pubmed/12131740
 
Another huge disc. Largest cervical hnp I've seen in my short career. 2 weeks of worsening right c6 radic pain, progressive weakness, mild balance deficit, new Hoffmanns on right and brisk reflexes....
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can i ask - do you guys get "approval" from patients before posting? i obviously do not see identifying markers, so it appears HIPAA compliant, but all the same....
 
can i ask - do you guys get "approval" from patients before posting? i obviously do not see identifying markers, so it appears HIPAA compliant, but all the same....

No, deidentified info. No face, no tatoo, no ID of person possible. Otherwise need their consent.
 
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My informed consent document states:

I consent to the taking and publication of any photographs in the course of this operation for documentation or for advancing medical education.

I still anonymize before using.
 
I didn't see where the contrast went under lateral.... went to clo and injected under live again...
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Bored. One of my kyphos from last week. 80+ yr old was stuck in bed or chair. T8 got way worse between CT and procedure date.











Had a good AP showing cross fill, but contrast on software makes it all look the same.
 
From my office to the ER then OR today......

Hey doc is it normal that I can't feel anything in my crotch....

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Do I go CESI or MBB first?

Neither. Cervical SCS obviously with an occipital nerve stim. Follow up with stem cells, ketamine infusion and decompression table with your in house chiropractor. After that, they'll be good as new.
 
Neither. Cervical SCS obviously with an occipital nerve stim. Follow up with stem cells, ketamine infusion and decompression table with your in house chiropractor. After that, they'll be good as new.
Def need to aspirate that
 
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what the CPT for a burr hole? something like 25 RVUs if i remember correctly. cha ching!!!
 
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