Pictures of the Week

IPSIS: Formerly the Spine Intervention Society
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when all you have is a hammer, everything looks like a nail.
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amadeus_lee said:
Want to hear the opinion from the veterans here.

34yo, female with right medial foot pain for 4 years, unclear injury history. MRI of foot/ankle showed mild tibialis posterior tendinopathy, peroneus longus and brevis tenosynovitis and scar remodeling of the anterior talofibular ligament from prior remote trauma. MRI of the L/S reported mild bilateral L5-S1 neural foraminal narrowing, but i am not convinced that is the culprit. See picture.

Physical exam showed:
Right foot:
Mild swelling on medial mid foot
No hair or toenail atrophy
At the rest the right big toe in extension
Very exquisite tenderness to palpation in the medial border of the right foot, at the hindfoot to midfoot
+ Hypersensitivity to touch along right medial foot
Weak right ankle inversion and toe flexion/extension

Tried topical compound cream, gabapentin, lyrica, various NSAIDs, did not have good response.
Did a tarsal tunnel tibial nerve block and tibialis posterior peri tendon steroid injection, had two weeks of good relief, but now pain returned.

I am debating, what to do next, dorsal column vs L5/S1 DRG stimulator? Pro and Cons of each?
Click to expand...
Heads up - the jpeg is labeled w/ what I assume to be pt's name.
 
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amadeus_lee said:
Oops, thank you for pointing it out. Will delete it.
Click to expand...
123123123.jpeg


I went through the last several posts and removed all the attachment links. Pic above now de-identified.
 
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clubdeac said:
Sounds like the ankle is the culprit. Send to foot specialist and if nothing to do from their standpoint offer her an L4 DRG stim. Why you thinking L5/S1 with medial foot pain
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In the past 4 years she was seen by various podiatrist, orthopedist, various causes of PT and different PO med before she come to see me. Thanks for pointing out, L4 is more appropriate.
 
RoloTomassi said:
I would try PNS before implanting something in her spine. Not me personally but podiatrists and foot/ankle around me do StimRouter and other PNS. I'm not too knowledgeable about all the systems.
Click to expand...

I was actually debating between PNS or SCS/DRG. But she does not want anything visible outside. If PNS, would you do saphenous or tibial or both? Where would you put the leads, at ankle or popliteal/adductor canal ?
 
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amadeus_lee said:
I was actually debating between PNS or SCS/DRG. But she does not want anything visible outside. If PNS, would you do saphenous or tibial or both? Where would you put the leads, at ankle or popliteal/adductor canal ?
Click to expand...
How about a diagnosis first. Show us she meets criteria (Budapest) first.
 
lobelsteve said:
How about a diagnosis first. Show us she meets criteria (Budapest) first.
Click to expand...
At my DRG course I tried to get clarity on that (unsuccessfully).

Do you give a LSB first? Strict Budapest? I can tell you 95% of the time this isn’t CRPS. It’s mechanical pain…Clearly, it’s nociceptive pain and I can’t imagine why DRG would help that.
 
MitchLevi said:
At my DRG course I tried to get clarity on that (unsuccessfully).

Do you give a LSB first? Strict Budapest? I can tell you 95% of the time this isn’t CRPS. It’s mechanical pain…Clearly, it’s nociceptive pain and I can’t imagine why DRG would help that.
Click to expand...

Would a LSB predictive of the success of SCS or DRG?

At the beginning of the disease, she might meet the criteria with the sensory, vasomotor, sudor motor and motor changes.

Do you strictly only do SCS for CRPS? What about neuropathic pain and failed back? They are not CRPS and SCS are frequently used for them.
 
amadeus_lee said:
Would a LSB predictive of the success of SCS or DRG?

At the beginning of the disease, she might meet the criteria with the sensory, vasomotor, sudor motor and motor changes.

Do you strictly only do SCS for CRPS? What about neuropathic pain and failed back? They are not CRPS and SCS are frequently used for them.
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The vignette provided described a morbidly obese young lady with foot pain. This isn’t CRPS, and I can’t believe anyone would offer her a DRG stimulator bc it’s wrong IMO. If you choose to do it, have fun with that procedure bc it won’t be easy looking at that adipose tissue, and a pt that big is likely to migrate.

I have several of these pts in my practice and I give them nonopiate meds. I can’t stand seeing them bc I hate repeatedly driving home the fact they’re obese, and I generally hate med management visits bc I don’t get anything out of it.

I would strongly advise against stim. Dude, you’ll regret it.
 
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amadeus_lee said:
I was actually debating between PNS or SCS/DRG. But she does not want anything visible outside. If PNS, would you do saphenous or tibial or both? Where would you put the leads, at ankle or popliteal/adductor canal ?
Click to expand...
Not sure, PNS really not my forte, just throwing it out there. I'd sent to a PNS KOL before doing SCS/DRG for a foot that isn't clear-cut CRPS
 
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T10-S1 fusion. Discitis + osteo at L1-2, with extensive debridement, corpectomy and multilevel decompression. Severe sensorimotor peripheral polyneuropathy. Got one lead in and bailed, but I'm sure I could have dropped a lead at T11-12 and steered it up next to the first lead. Coude needle. Great coverage from one lead. I may try to put two leads in if I implant him. Risk of migration is extremely low in a patient fused to T10, so a one lead trial should be adequate, and it was safe. Good case. Implant will be Abbott Eterna because he's tiny and that battery is small.

1709946700375.png
1709946743685.png


1709946654835.png
 
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MitchLevi said:
T10-S1 fusion. Discitis + osteo at L1-2, with extensive debridement, corpectomy and multilevel decompression. Severe sensorimotor peripheral polyneuropathy. Got one lead in and bailed, but I'm sure I could have dropped a lead at T11-12 and steered it up next to the first lead. Coude needle. Great coverage from one lead. I may try to put two leads in if I implant him. Risk of migration is extremely low in a patient fused to T10, so a one lead trial should be adequate, and it was safe. Good case. Implant will be Abbott Eterna because he's tiny and that battery is small.

View attachment 383757View attachment 383758

View attachment 383756
Click to expand...

The first lead enters at T11-12? Can see the SP but hard to make the laminae. How did you do that? Any technical tricks ?
 
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amadeus_lee said:
The first lead enters at T11-12? Can see the SP but hard to make the laminae. How did you do that? Any technical tricks ?
Click to expand...
Entry at T10-11. It may look like a steep entry into T11-12 but that's just the function of the Coude - Takes a perpendicular approach until it flattens out at the tip of the needle. Difficult to see lamina for sure, but if you have the SP in view, and your disk is reasonably squared off you should know where the lamina is located.
 
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lobelsteve said:
www.linkedin.com

Glade Roper, MD — MSKIR on LinkedIn: #mskir

More #MSKIR in a man in his 70s who presents with intractable bilateral knee pain. he has a history of throat cancer, which makes him not a really good…
www.linkedin.com www.linkedin.com


Love hearing a Radiologist say treat the patient and not the pics.
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I saw that comment too made me chuckle a little. Perhaps this will be used to justify kypho in the future -- normal imaging but let's just treat the patient not the pic. It's the integration if the case as a whole which leads to the decision making and injection are not always the answer lol

Also I noticed this on his page. Is this something pain guys are doing in the US? I haven't seen anyone do this up north so wasn't sure if this is a new thing

www.linkedin.com

Glade Roper, MD — MSKIR on LinkedIn: #mskir #neurogenicclaudication #mri #inspan

Great #MSKIR case! 83-year old man with a history of chronic back pain and #NeurogenicClaudication. Serious pain and numbness in the legs, relieved by…
www.linkedin.com www.linkedin.com
 
Glade is an interesting follow but he is prone to doing some wild stuff and keeps doing it despite people gently trying to steer him out of it in the comments.
 
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wahh?

theres still a lot i need to learn about medicine, i guess.

oddly, in my anesthesia training, noone ever told me that a history of throat cancer by itself was a contraindication to surgery.



and i never considered, in a patient with what he is describing as having neurogenic claudication, doing "therapeutic and diagnostic facet injections in the L5S1 facet joints" would cure neurogenic claudication.....

or that based on that L5S1 facet injection, the next step would be a fusion. (the fusion was an appropriate treatment, however, for the anterolisthesis)
 
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lobelsteve said:
View attachment 383947

Yes I commented. Love him pushing the envelope. Would never let him go near my family. Glade’s a neurosurgeon light.
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In summary: If someone has leg pain, do diagnostic and therapeutic facet joint injections. If the facet joint injections completely resolve the right leg pain, then fuse the patient.

This post is one of the dumbest things I've seen in a while. It's astounding that a physician is so ignorant that they don't know to not broadcast it.
 
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Right T7-8 TFESI...Nice shot. Police officer with congenital stenosis.

Dexamethasone 12mg + 2cc saline.

1710462273195.png
1710462303338.png
 
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What would be good resources to educate yourself about programming aspect of neuromodulation devices?
 
Increase you pulse width to try to increase coverage from side to side. Increase amplitude to increase strength of stim and increase coverage down the leg. Increase frequency to decrease sensation of stim.


Those are the old school basics. Now everyone wants to run their patented program and try to keep the doc clueless.
 
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t11.jpg


T12 burst Fx s/p kypho and fusion. Notice the cord damage. Injury 4 years ago.

t12fx.jpg


L1-2 fail.jpg


SCS trial entered at L1-2. Lead not advancing past L1. No bueno. My trials are local only and this was uncomfortable. But good music, kind doctor, nice patient.

t10-11win.jpg


Decided to come in above the Fx site at T0-T11. With successful placement.
Patient 75% better leg pain during trial.

T8.jpg


Single lead. Trial went over an hour.

Final.jpg


Implant this week. Got an extra lead in there. Felt like I was going in blind as could not see SP with all the hardware.
 
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lobelsteve said:
View attachment 384708

T12 burst Fx s/p kypho and fusion. Notice the cord damage. Injury 4 years ago.

View attachment 384709

View attachment 384705

SCS trial entered at L1-2. Lead not advancing past L1. No bueno. My trials are local only and this was uncomfortable. But good music, kind doctor, nice patient.

View attachment 384707

Decided to come in above the Fx site at T0-T11. With successful placement.
Patient 75% better leg pain during trial.

View attachment 384706

Single lead. Trial went over an hour.

View attachment 384704

Implant this week. Got an extra lead in there. Felt like I was going in blind as could not see SP with all the hardware.
Click to expand...
Nice, how high did you have to go, was there any residual lead left over, or were you able to fit it all in?
 
IMG_6589.jpeg

Was doing a L2-3, L3-4 injection on the left. Started my fluoro high and was going to count down from T12. Saw that rib on the left and worked down. My nurse went too far and I saw L5 and the numbers didn’t add up. Turns out he has an extra rib off left L1! I must have counted 3 times going up and down to figure out what level I was at. Incidence is 1% but I’ve done thousands of injections and never seen it.
 
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camkiss said:
View attachment 385081
Was doing a L2-3, L3-4 injection on the left. Started my fluoro high and was going to count down from T12. Saw that rib on the left and worked down. My nurse went too far and I saw L5 and the numbers didn’t add up. Turns out he has an extra rib off left L1! I must have counted 3 times going up and down to figure out what level I was at. Incidence is 1% but I’ve done thousands of injections and never seen it.
Click to expand...
Better post would be how you bent that needle to do a trans facet right L2-3 infraneural TFESI.
 
camkiss said:
View attachment 385081
Was doing a L2-3, L3-4 injection on the left. Started my fluoro high and was going to count down from T12. Saw that rib on the left and worked down. My nurse went too far and I saw L5 and the numbers didn’t add up. Turns out he has an extra rib off left L1! I must have counted 3 times going up and down to figure out what level I was at. Incidence is 1% but I’ve done thousands of injections and never seen it.
Click to expand...
To be sure (100%), you have to count down from C1. Only matters for SCS.
 
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Stick an 18g through a piece of gauze is what I do if it’s rolling around
 
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camkiss said:
View attachment 385081
Was doing a L2-3, L3-4 injection on the left. Started my fluoro high and was going to count down from T12. Saw that rib on the left and worked down. My nurse went too far and I saw L5 and the numbers didn’t add up. Turns out he has an extra rib off left L1! I must have counted 3 times going up and down to figure out what level I was at. Incidence is 1% but I’ve done thousands of injections and never seen it.
Click to expand...

Incidence of transitional anatomy in the literature is 5-15%. Anecdotally, I think closer to 15%.

I always document in my note whether there is presence of lumbarizarion/sacralization or tiny ribs. Saves you a headache day of the injection. The more you look the more you’ll see it!
 
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Learned something Friday of last week. Patient with a T10-S1 fusion. Scars running up and down his entire back basically. Entered at T11-12, and I my lead pocket dissection is left of midline. Patient wants a right IPG pocket. No problem. My implant took 2 hours because I could NOT tunnel. There was so much scar tissue in the lower back I couldn't get my tunneling device into the most inferior portion of my anchor dissection. That part of the case took longer than it did to place leads. I didn't want to put too much pressure because the moment it pops through there will be a second or so of uncontrolled advancement. Leads were hard to steer too. Couldn't steer to the extent that electrode 1 would stay exactly midline, which is fine though.

I learned - Ipsilateral IPG if the back is covered in scars.

1713183036180.png
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MitchLevi said:
Learned something Friday of last week. Patient with a T10-S1 fusion. Scars running up and down his entire back basically. Entered at T11-12, and I my lead pocket dissection is left of midline. Patient wants a right IPG pocket. No problem. My implant took 2 hours because I could NOT tunnel. There was so much scar tissue in the lower back I couldn't get my tunneling device into the most inferior portion of my anchor dissection. That part of the case took longer than it did to place leads. I didn't want to put too much pressure because the moment it pops through there will be a second or so of uncontrolled advancement. Leads were hard to steer too. Couldn't steer to the extent that electrode 1 would stay exactly midline, which is fine though.

I learned - Ipsilateral IPG if the back is covered in scars.

View attachment 385485View attachment 385486View attachment 385487
Click to expand...
Nice job working around the hardware. This seems like a unique case where this probably wouldn’t have worked anyway, but do you ever use the Tuohy to tunnel? Seems like that might at least push through the scar tissue better.
 
callmeanesthesia said:
Nice job working around the hardware. This seems like a unique case where this probably wouldn’t have worked anyway, but do you ever use the Tuohy to tunnel? Seems like that might at least push through the scar tissue better.
Click to expand...
Not a bad idea.
 
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Don’t worry Steve, it’s just Contrast that leaked out of the tubing and pooled up on the skin
 
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