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50 y/o male s/p MVA rollover 7 mo prior. Imaging is from time of injury. NS cleared as non-operative.
I'm asked to do MBB. Anyone want a second opinion?
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lobelsteve said:


50 y/o male s/p MVA rollover 7 mo prior. Imaging is from time of injury. NS cleared as non-operative.
I'm asked to do MBB. Anyone want a second opinion?
Click to expand...

1) I would make sure there is a CTA that documents vertebral artery integrity.
2) I would get a repeat CT to see how the bony structures have healed. You can be dealing with a remodeled joint at this point.
3) I would get an MRI with STIR to see if there is edema in the area. If edema, pt may respond well to a good old fashioned steroid in the area.

Those are my 2-3 cents.
 
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Another day, another big disk... Bowel/bladder fine. Just some severe S1 parasthesias and mild s1 motor deficit on toe walking. Who sits on this vs see surgeon now?
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Taus said:
Another day, another big disk... Bowel/bladder fine. Just some severe S1 parasthesias and mild s1 motor deficit on toe walking. Who sits on this vs see surgeon now?
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Click to expand...

My plan: Lyrica 75 bid x2d then 150 bid. Zanaflex 4mg 1 to 2 tid for spasm and sedation. Ultram 50mg 2 tid prn. S1 tfesi. I get consult so if progressive deficit or intractable pain despite meds and tfesi they are ready to get fixed.
 
Taus said:
Another day, another big disk... Bowel/bladder fine. Just some severe S1 parasthesias and mild s1 motor deficit on toe walking. Who sits on this vs see surgeon now?
View attachment 205175
View attachment 205176


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Click to expand...

S1 TFESI. with quick f/u. i wouldnt reflexively send to surgeon without progressive neuro deficit. warn about b/b/cauda equina. if you send to a surgeon, the pt will be scared into an operation. may need one, but doesnt need one tomorrow.
 
Ducttape said:
RFA or cryo...
Click to expand...
I've been following the gentleman for a few years for stable thoracic spondylosis. He has done well with Tramadol and home exercises and was last seen in March. His pain was improving at that time. He was admitted to the hospital 2 weeks ago for worsening Mid back pain period they are working on finding the primary but the metis static disease is in the pelvis and long bones as well. He is going to SNF
 
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freddydpt said:
You need a diffusion sequence for a definitive answer...
Click to expand...

Surgery was in 1999 for her astrocytoma, serial scans for 10 years were without change. Stopped in 2009. This study was done last year after having symptoms related to hypokalemia. No clinical change since 2009 from cord standpoint.
 
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Really starting to lean on that rolling walker. Trying to avoid surgery....




But it is cool to see some pseudofacets inside the canal. OPLL
 
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Thoracic facet arthrograms bilaterally. I've never gotten one so clear before.
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20's aged female w chronic RUQ pain that radiates around right chest wall to flank/back as well as colicky symptoms. Exhaustive GI work up neg. GB taken out without change. Ligamentous laxity on exam. Symptoms resolved completely during pregnancy and returned afterwards.

These are all from CT scan. I scrolled down to SI joint and saw some attenuation in the anterior portion of SI joints.

(Not sure if I need to post in a separate thread for discussion or not).
 

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Long term patient for back and axial neck pain, prior back surgery. 68+ years old, takes 2-3 Percocet per day. Saw in May and had new Hoffman's reflex, neck more achy, no weakness, sensory loss, no real change in pain. Saw PCP yesterday and said neck was worse. Decided to get MRI I ordered in May. No known primary lesion. Seeing her back next week. Will get Oncology consulted and may order PET for them Monday.
 
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29yo Axial pain only, unilateral intermittent ant tibia paresthesia
 
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lobelsteve said:


Was working until 2 weeks ago, he said his right hip needs surgery again. Can't wait to see the rebuild.
Click to expand...

Cage, washers +\-, bigger cup, bigger head...joint guy is licking his chops. Did he have a periprosthetic fracture at the greater torch previously?

Might as well revise the other side while they're at it.


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Last edited:
lobelsteve said:


Long term patient for back and axial neck pain, prior back surgery. 68+ years old, takes 2-3 Percocet per day. Saw in May and had new Hoffman's reflex, neck more achy, no weakness, sensory loss, no real change in pain. Saw PCP yesterday and said neck was worse. Decided to get MRI I ordered in May. No known primary lesion. Seeing her back next week. Will get Oncology consulted and may order PET for them Monday.
Click to expand...

Looks noninvasive, completely contained in the vertebral body. Possible met. Possibly a hemangioma. Hard to tell with one T2 image.


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lobelsteve said:
Keyboard on phone wasnt working. that is a STIR image. Radiologist called me on phone and said only other thing was periglottic node or mass. C7 was normal on mri 2011.
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Seeing her back today. T1 on left, parasagittal on right in STIR. Got some schmutz in front of the vertebrae. Who gets her first? ENT for tissue, Oncology?
 
Can I bill for the c tfesi too? I've seen this with lumbar interlam but a first for me on cervical. Pt actually has right c7 radic so couldn't ask for better spread

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Taus said:
I thought my entry and final needle position looks slight right paramedian... you go much more lateral?


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Click to expand...

i typically start more lateral and inferior. its hard to tell from the pic, but if you start midline, you have to worry about the interspinous ligament and the gap in the ligamentum flavum. if you are paracentral, then its not a huge deal
 
SSdoc33 said:
i typically start more lateral and inferior. its hard to tell from the pic, but if you start midline, you have to worry about the interspinous ligament and the gap in the ligamentum flavum. if you are paracentral, then its not a huge deal
Click to expand...

Gotcha and agreed re midline. In lumbar I go perhaps 1-1.5 cm lateral. Cervical I was taught and usually do just a few mm off midline for most capacious epidural space while avoiding true midline. Either way I have a very low threshold to verify depth with a puff of contrast under clo if at vill and no loss.


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Green Grass said:
Winging occurred when in relation to fx, ORIF, and HWR?
Why HWR?
Any symptoms in ipsilateral arm or shoulder?
Any XR of clavicle at fx and now?
Click to expand...

Winging after Fx, but Fx, ORIF, removal of hardware all in last 18 months. Pain in shoulder, not to elbow, pain in chest as well.
EMG done early with "plexus irritation or damage" but I have not looked at it in a while. Surgeon discharged as nothing left to do.
Imaging includes Xray before and after, MRI x2 brachial plexus and C-spine x1. Sending to NS to see if there is something that can be fixed.
 
lobelsteve said:
Winging after Fx, but Fx, ORIF, removal of hardware all in last 18 months. Pain in shoulder, not to elbow, pain in chest as well.
EMG done early with "plexus irritation or damage" but I have not looked at it in a while. Surgeon discharged as nothing left to do.
Imaging includes Xray before and after, MRI x2 brachial plexus and C-spine x1. Sending to NS to see if there is something that can be fixed.
Click to expand...

Any AC separation on initial injury? Why did she need ORIF?


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