Re: Old lumbar injury (Full Version)

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Diane -> Re: Old lumbar injury (March 9, 2006 3:05:00 AM)

How can stones in the circulatory system be good or benign in the long run? What causes them to form in the first place?



Shill -> Re: Old lumbar injury (March 10, 2006 2:02:00 AM)

So, if you follow the left border of the sacrum down, it seems to be missing a chunk, at least on my screen. Is this shrouded completely by gas, or a normal variant in (non) development? Could it be that a cookie cutter shark got him?

OK, I do really want to know why this looks the way it does, all kidding aside.



Alex Brenner PT MPT OCS -> Re: Old lumbar injury (March 12, 2006 9:13:00 PM)

Taken from Urologystone.com:

Phleboliths
Phleboliths, defined as focal calcified venous thrombi, are frequently seen along the normal anatomical course of the lower ureter. They are usually the result of injury to the vein wall commonly from venous hypertension and are composed of concentric calcified strata around a central kernel. Typically, phleboliths are rounded with a central lucency and are seen in the true pelvis often below the distal ureter.

As far as consulting with another physician, I guess you really have to look at your clinical picture. If you suspect kidney stones as a cause of the low back pain a non-contrast CT scan can be done to look for a stone vs. a phlebolith. We have such a good working relationship with our internal medicine and family physicians in the Army that we can simply walk down and poke our heads in their door to get a second opinion. This is what I did with this case and a urinalysis was ordered which came back negative.



chiroortho -> Re: Old lumbar injury (March 13, 2006 2:41:00 AM)

Interesting little tidbit about phleboliths: although you'll universally hear about this 'central lucency', I recall reading a study where they did CT scans on the phleboliths and found no such lucency. So you see it on plain films but not CT.

I just thought that was kind of interesting.



jma -> Re: Old lumbar injury (March 13, 2006 2:54:00 PM)

Hmmm, what is the next course of action for this particular individual?



chiroortho -> Re: Old lumbar injury (March 15, 2006 3:04:00 AM)

[QUOTE]So the question is, what are phleboliths and should we be concerned? As a PT would you refer back to the physician? Is this worth a call to the referring physician?[/QUOTE]Alex I see phleboliths on a significant percentage of the L-spine/pelvic films I review and when they're in the typical pelvic basin position I essentially ignore them. Much of the time I don't even mention them in my rad reports because they're clinically insignificant.

That said, my suggestion to folks that are see them and aren't sure what they are would ALWAYS be to get the MD to over-read and opine. Can't go wrong, and the worst that could happen is that the MD says 'phleboliths - no problemo' but you've shown that you're sharp and cautious. Opacities (or lucencies for that matter) in areas that they shouldn't be should always be correlated clinically and ferreted out if you're not sure. Play it safe. If it was a ureteral stone for example, and you ignored it, you could be in a bit of trouble. Same goes for bladder calculi. So prudence is the better part of valor.

When I was a lowly student - now I've moved up a notch to lowly DC :) - I remember 'seeing' all manner of pathology on just about every film I read (most of which was not really there but when you're a newbie you tend to freak out over every little thing because you just don't have much experience). Just part of the learning process. But don't think for a minute that I don't still scratch my head and wonder from time to time over things like a mach band over the base of the odontoid (normal) or some bowel gas overlying a transverse process (is it a fracture?)

T-spine films are particularly prone to things like this due to summation of vascular shadows. Is it a 'spot' in the lung? Is it a calcified mesenteric node? Or is it just summation (normal). One thing that helps when looking at films is to force ourselves to look at 2D images with a 3D mindset.

Have a great day all.

Greg



Alex Brenner PT MPT OCS -> Re: Old lumbar injury (March 15, 2006 3:17:00 AM)

Thanks Greg. You are correct too about the CT scan not being much more help to differeniate between the phlebolith and kidney stone.



LloydChiro -> Re: Old lumbar injury (June 12, 2006 7:02:00 AM)

Hi Alex,

Thanks for the case study. In the initial post, you mention that it is a two-year old injury, with a presentation of a left flank pain. Then, the radiologist comes back saying there's no fracture in the thoracic/lumbar junction.

Well, there wouldn't be a fracture if it's a two year old injury. But what we are seeing is the sequelae of an old fracture. To me, the T11 on top of the T12 looks angled anteriorly, as if there is a deformity of the T12 vertebral body.

Of course, at the time of the injury, there probably wasn't just a fracture, but also other soft tissue problems as well. The scar tissue in the joints and soft tissue is likely causing some of these problems now.

Thoughts?



Alex Brenner PT MPT OCS -> Re: Old lumbar injury (June 12, 2006 11:38:00 AM)

Hi Todd,
This is very tough to see with the posted images but I can sort of make out the sequelae that you mention. It was not noted by the radiologist so I am unsure of the significance. This is an old case study so it would be difficult to go back and examine this particular patient.



fisiovilaca -> Re: Old lumbar injury (April 1, 2007 2:11:00 PM)

A oblique view is essential to eliminate lumbar facet arthrosis.



jma -> Re: Old lumbar injury (June 3, 2007 8:37:00 AM)

Any more post being posted anytime soon, Alex?



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