BackTable MSK BackTable

In this episode, Dr. Aron Chary provides an in-depth look into endovascular and minimally invasive treatments for pain management, specifically focusing on cryoneurolysis. He shares his experience of implementing the technology for both benign and malignant conditions in an independent private practice setting.

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CHECK OUT OUR SPONSOR

Boston Scientific Visual ICE Cryoablation System
https://www.bostonscientific.com/en-US/products/cryoablation/visual-ice.html

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SYNPOSIS

The discussion covers various aspects, including collaboration with Boston Scientific for the VISUAL ICE cryoablation system, Dr. Chary’s personal journey from academics at Emory to private practice in Memphis, the effectiveness of cryoneurolysis in different areas such as genicular nerve and palliative care, and the operational dynamics between hospital and outpatient settings. The doctors delve into the procedural specifics, patient response, and outcomes with cryoneurolysis, including Dr. Chary’s efforts to navigate insurance and reimbursement challenges.

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TIMESTAMPS

00:00 - Introduction
07:04 - Evolution of Pain Intervention Techniques
11:08 - Building a Pain Intervention Service
16:16 - Versatility of Cryoablation in Pain Management
23:54 - Expectations and the Future of Pain Management Research
31:41 - Cryoneurolysis Insights and Patient Management
42:10 - Techniques in Celiac Cryoneurolysis
52:33 - Pain Management in the Outpatient Setting

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RESOURCES

Percutaneous CT-Guided Cryoablation of the Celiac Plexus: A Retrospective Cohort Comparison with Ethanol:
https://www.jvir.org/article/S1051-0443(20)30349-3/abstract

BT VI Episode 199 - Advanced Minimally Invasive Pain Interventions with Dr. David Prologo:
https://www.backtable.com/shows/vi/podcasts/199/advanced-minimally-invasive-pain-interventions

BT VI Episode 433 - Kyphoplasty Evolution: Steering Toward Targeted Therapy with Dr. David Prologo:
https://www.backtable.com/shows/vi/podcasts/433/kyphoplasty-evolution-steering-toward-targeted-therapy

Boston Scientific, VISUAL ICE:
https://www.bostonscientific.com/en-US/products/cryoablation/visual-ice.html

In this episode, Dr. Blake Parsons talks through the role of spinal cord stimulation in treating vascular issues and diabetic neuropathy. He also discusses the growing presence of vascular specialists in clinics, the transition from procedural work to clinical involvement, and the significance of building a strong patient-doctor relationship.

The doctors highlight the effectiveness of Nevro 10 kHz therapy in providing long-term pain relief and sensory improvements for patients struggling with painful diabetic neuropathy, even after conventional treatments fail. Additionally, they touch upon reimbursement updates, the rise of outpatient care, and the future of spinal cord stimulation - emphasizing its potential beyond just pain relief to include improvements in patients’ overall quality of life, reducing risks related to diabetic foot wounds, and incidental falls. The need for a multidisciplinary approach in treating vascular and neuropathic conditions is also discussed, along with the role of interventional radiologists in managing these complex cases.

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CHECK OUT OUR SPONSOR

Nevro HFX Spinal Cord Stimulator
https://www.hfxforpdn.com

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SHOW NOTES

00:00 - Introduction
06:00 - Demystifying Spinal Cord Stimulation for Pain Management
17:11 - Optimizing Patient Care: Trials, Techniques, and Insurance
26:03 - Leveraging Telehealth and Support Teams for Patient Success
30:22 - Challenges and Solutions in Managing Peripheral Neuropathy
35:19 - Collaboration and Referral Dynamics in Vascular and Interventional Radiology
39:19 - Exploring the Future of Neuropathy Treatment and Quality of Life Improvements
43:46 - Addressing the Challenges of Permanent Implant Procedures
48:46 - Role of Technology and AI in Patient Management
56:31 - Concluding Thoughts on Neuropathy Treatment and Practice Dynamics

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RESOURCES

Nevro 10 kHz Therapy:
https://nevro.com/English/en/providers/HFX-Advanced-Therapies/default.aspx

Effect of High-frequency (10-kHz) Spinal Cord Stimulation in Patients With Painful Diabetic Neuropathy: A Randomized Clinical Trial (JAMA Neurology RCT 2021):
https://pubmed.ncbi.nlm.nih.gov/33818600/

Long-term efficacy of high-frequency (10 kHz) spinal cord stimulation for the treatment of painful diabetic neuropathy: 24-Month results of a randomized controlled trial (SENZA-PDN RCT 2023):
https://pubmed.ncbi.nlm.nih.gov/37536514/

Electrical spinal-cord stimulation for painful diabetic peripheral neuropathy (Lancet RCT 1996):
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(96)02467-1/abstract

In this episode of the BackTable MSK Podcast, Dr. Dana Dunleavy interviews Dr. David Prologo about his perspective on current advancements in MSK interventions, including steerable spine needles, thermocouples for radiofrequency ablation, and the growing importance of advocacy and longitudinal follow up for patients with chronic pain. Dr. Prologo is an interventional radiologist at Emory University.

Dr. Prologo starts by describing the evolution of interventional radiology’s role in MSK interventions. He explains that establishing solid referral networks is crucial to building this service line, and he gives examples of how new interventionalists can highlight their skills to others. Then, he describes a new steerable needle that allows operators to safely enter the vertebral body with a transpedicular approach and subsequently navigate directly to the location of interest. This device is especially useful when lesions are located in tricky areas where the trajectory of a straight needle would have difficulty reaching. He also discusses different devices for bone tumor ablation and his preferred methods for targeting lesions that are located at varying locations in the spine. For lesions below T5, he uses fluoroscopy for better visualization of the axial plane. For lumbar lesions, he emphasizes the importance of correlating and cross-checking vertebral levels with pre-procedural MRI.

Dr. Prologo also discusses lessons learned from his extensive experience in spine interventions, especially from prior complications. He explains how thermocouple monitoring can give real time feedback on internal temperature during radiofrequency ablation, the necessity of understanding the ablation zone, and the importance of longitudinal follow up. He cites specific cases of patients struggling with chronic pain and how he advocated for each case.

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CHECK OUT OUR SPONSOR

Merit Spine
https://www.merit.com/merit-spine/

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SHOW NOTES

00:00 - Introduction
02:09 - Dr. Prologo’s Career and Leadership Roles
09:52 - Interventional Radiology’s Role in MSK Interventions
13:37 - A Primer for Steerable Vertebral Needles
21:40 - Increasing Standardization and Accessibility of Bone Tumor Ablation
26:37 - Advanced Pain Management in Interventional Radiology’ Book
30:24 - Thermocouples in Radiofrequency Ablation
35:45 - Prior Complications and Importance of Longitudinal Care
44:24 - SIR EDGE 2024
52:31 - Accessing Targets for Basivertebral Nerve Ablation
1:01:17 - The Role of Advocacy in Patient Care

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RESOURCES

Osseoflex Steerable Needle:
https://www.merit.com/product/osseoflex-sn-steerable-needle/

STAR Tumor Ablation System:
https://www.merit.com/product/star-tumor-ablation-system/

Osteocool OsteoCool Radiofrequency Ablation System:
https://www.medtronic.com/us-en/healthcare-professionals/products/spinal-orthopaedic/tumor-management/osteocool-ablation-system-rf.html

OptaBlate Bone Tumor Ablation System:
https://providers.strykerivs.com/products/optablate

‘Advanced Pain Management in Interventional Radiology’ by J. David Prologo and Charles E. Ray Jr:
https://shop.thieme.com/Advanced-Pain-Management-in-Interventional-Radiology/9781684201402

Ablation zones and weight-bearing bones: points of caution for the palliative interventionalist:
https://pubmed.ncbi.nlm.nih.gov/24745905/

SIR EDGE 2024:
https://www.sirweb.org/learning-center/meetings/sir-edge/

‘The Catching Point Transformation’ by J. David Prologo:
https://www.catchingpoint.com/

On this episode of the BackTable MSK podcast, co-hosts Dr. Chris Beck and Dr. Aaron Fritts review the basics of bone lesion biopsy, including patient selection, imaging modalities, and procedural steps.

They begin with summarizing indications for bone lesions, which are most common in the setting of metastatic disease. Patients usually get referred for biopsy when a bone lesion is caught on CT imaging of the chest, abdomen, and pelvis. The doctors emphasize that imaging multiple areas is needed to find the most easily accessible lesion, which is sometimes located within a solid organ, rather than within bone. While PET imaging can be useful for confirmation of sclerotic bone lesions, patients usually cannot receive PET scans without an established cancer diagnosis.

Dr. Beck highlights the fact that lytic lesions with soft tissue components are technically easier to access than sclerotic lesions and result in higher yield. He occasionally uses a soft tissue biopsy needle for these lesions. For sclerotic lesions, he prefers the OnControl or Stryker bone biopsy coaxial systems. With the coaxial system, it can be hard to adjust the biopsy tract after you have already started drilling, but he recommends obtaining multiple cores at different angles of approach. He also advises listeners to choose the shortest needle possible, since this makes it easier to control and image the needle within the lesion.The doctors also discuss biopsy of tricky locations. Sternal lesions carry the risk of lung injury and pneumothorax, so when faced with these, Dr. Beck picks an oblique tract that has a longer trajectory. For lesions located in proximal extremities, he secures the limb to minimize movement.

Next, disc biopsies are discussed. Patients usually present with discitis osteomyelitis from prior back surgery, IV drug use, or idiopathic causes. It is important to distinguish between infection of the disc space versus chronic degenerative disc disease, which can be identified by comparison with prior imaging and lab workup. For the lumbar spine disc biopsy, fluoroscopy is Dr. Beck’s preferred imaging modality, and he reviews imaging landmarks. Dr. Fritts usually biopsies both bone and disc.

Finally, they discuss post-procedural complications to watch for, such as chest x-rays in checking for lung injury and neurological exams to assess for new deficits.

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CHECK OUT OUR SPONSOR

Stryker Interventional Spine
https://www.strykerivs.com

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SHOW NOTES

00:00 - Introduction
03:12 - Referrals and Imaging Techniques for Bone Lesion Biopsy
07:09 - Procedural Steps of Bone Lesion Biopsy
12:32 - Choosing Biopsy Tools
23:22 - Approach to Tricky Biopsy Locations
28:19 - Workup and Indications for Disc Biopsy
32:08 - Fluoroscopy vs. CT for Disc Biopsy
40:15 - Handling Biopsy Samples
48:03 - Post-Procedure Care and Complications

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RESOURCES

Arrow OnControl Powered Bone Biopsy System:
https://irc.teleflex.com/oncontrolsystem/

Stryker Bone Biopsy Coaxial System:
https://www.stryker.com/us/en/interventional-spine/products/bone-biopsy.html

BD Trek Powered Bone Biopsy System:
https://www.bd.com/en-us/products-and-solutions/products/product-families/bd-trek-powered-bone-biopsy-system

Jamshidi Evolve Bone Marrow Needle:
https://www.bd.com/en-us/products-and-solutions/products/product-families/jamshidi-evolve-bone-marrow-needle

BD Illinois Sternal/Iliac Bone Marrow Aspiration Needles:
https://www.bd.com/en-ca/products-and-solutions/products/product-families/illinois-sternal-iliac-bone-marrow-aspiration-needles

BD Mission Disposable Core Biopsy Instrument:
https://www.bd.com/en-us/products-and-solutions/products/product-families/mission-disposable-core-biopsy-instrument

Disc Biopsy Visualization Website:
https://www.pediatricir.com/disc-aspiration-for-discitis.html

In this episode of the Back Table MSK Podcast, guest host and interventional radiologist Dr. Dana Dunleavy speaks with Dr. Majid Khan about building an academic interventional spine program and the need for nonvascular spine intervention fellowships. Dr. Khan is neuroradiologist and Director of Non-Vascular Spine Intervention at Johns Hopkins University.

Dr. Khan discusses his experience in spine interventions, and he believes that it has evolved into a subspecialty that now requires its own fellowship. He proposes a curriculum that involves integration of clinical care and learning from physical medicine and rehabilitation, pain management, radiology specialists. Then, Dr. Khan describes how he built his current department Johns Hopkins. This process required advocating for clinic time, negotiating for split time between interventional and diagnostic work, reaching out to referring specialists, and following up with patients.

Throughout the episode, Dr. Majid also shares his perspectives on defining success in clinical and academic medicine, various ablation modalities, and the potential of neuromodulation in oncology.

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CHECK OUT OUR SPONSOR

Stryker Interventional Spine
https://www.strykerivs.com

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SHOW NOTES

00:00 - Introduction
02:35 - Dr. Khan’s Journey and Training
07:37 - The Need for Nonvascular Spine Intervention Fellowships
09:27 - Importance of Clinical Preparation
15:17 - Multidisciplinary Training
21:10 - The Process of Building a Spine Interventional Practice
27:42 - Defining Success in Academic Medicine
33:43 - Various Ablation Modalities
41:27 - Devices for Mechanical Augmentation
50:18 - Basivertebral Nerve Ablation for Chronic Back Pain
52:25 - The Potential of Neuromodulation in Oncology
55:43 - Establishing an Evidence Base for Spine Interventions

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The BackTable MSK Podcast is a resource for practicing Musculoskeletal Specialists, covering tools, techniques, and expert guidance on medical and interventional care for musculoskeletal conditions.

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In this BackTable MSK episode, Dr. Jacob Fleming speaks with Dr. Joshua Hirsch about the current state of spinal interventional radiology. Dr. Hirsch is an interventional neuroradiologist at Massachusetts General Hospital.

Dr. Hirsch discusses the past and future of spinal interventional radiology. He describes his experience in automated percutaneous lumbar discectomy as well as chemonucleolysis with DiscoGel. He also mentions the previous use of chymopapain and the future use of biologics and weight bearing imaging in the spine. Overall, Dr. Hirsch emphasizes the importance of utilizing precise imaging, understanding different safety profiles of each treatment, and breaking down boundaries between specialties.

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CHECK OUT OUR SPONSOR

Stryker Interventional Spine
https://www.strykerivs.com

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SHOW NOTES

00:00 - Introduction
03:05 - Discussion on Intradiscal Therapies
05:11 - The Evolution of Percutaneous Discal Treatments
10:39 - The Role of Chemonucleolysis and Lessons from Chymopapain
14:55 - Deciding on a Percutaneous Approach
18:00 - The Emergence of the Spine Interventionalist
21:29 - Utility of Weight Bearing Imaging
24:15 - ESNR Spine Interventional Neuroradiology Hands-On Course

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RESOURCES

Efficacy of an ethyl alcohol gel in symptomatic disc herniation (DiscoGel):
https://pubmed.ncbi.nlm.nih.gov/30527290/

Responsible, Safe, and Effective Use of Biologics in the Management of Low Back Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines:
https://www.painphysicianjournal.com/current/pdf?article=NjEwMQ%3D%3D&journal=118

European Society of Neuroradiology (ESNR) Spine Interventional Neuroradiology Hands On Course (April 18-20, 2024:
https://www.esnr.org/event-details/6903