In this episode of the BackTable Podcast, host Dr. Jacob Fleming and Dr. Alexa Levey have an in-depth discussion about the current uses and potential future applications of cryoneurolysis in interventional radiology. Dr. Levey is an interventional radiologist at the Memorial Hermann Health System in Houston, TX.

The doctors discuss how cryoneurolysis differs from radiofrequency (RF) ablation, highlighting the increased precision and gentleness to surrounding tissues. Dr. Levey describes the specifics of stellate ganglion procedures and cryoneurolysis techniques. They delve into the importance of research and collaboration in advancing the field, as well as the necessity of being patient-centered. They also address the need for financial discussions in medicine and the prospect for cryoneurolysis as desmoid tumor treatments. Additionally, Dr. Levey shares her journey in building a career as a female in a male-dominated space and emphasizes the importance of physician availability to patients and colleagues.

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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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SHOW NOTES

00:00 - Introduction to RF Ablation and Cryoneurolysis

03:20 - Dr. Alexa Levey’s Journey and Inspiration

07:00 - Building a Pain Practice

14:03 - Advantages of Cryoneurolysis over RF

21:09 - Patient Selection and Planning for Cryoneurolysis

32:02 - Understanding Patient’s Condition and Treatment Options

36:21 - Role of Stellate Ganglion Procedures in PTSD and Anxiety Management

37:48 - Challenges and Impact of Long COVID

41:34 - The Future of Cryoneurolysis in Medical Practice

54:55 - Future of Cryo Treatment in Medical Practice

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RESOURCES

Safety and Effectiveness of Stellate Ganglion Cryoablation in Complex Regional Pain Syndrome:

https://doi.org/10.1016/j.jvir.2023.09.030

Treating phantom limb pain: cryoablation of the posterior tibial nerve:

https://pubmed.ncbi.nlm.nih.gov/35801126/

Stellate Ganglion Block for Psychiatric Disorders: A Systematic Review of the Clinical Research Landscape:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8664306/

The Efficacy of the Stellate Ganglion Block as a Treatment Modality for Posttraumatic Stress Disorder Among Active Duty Combat Veterans: A Pilot Program Evaluation:

https://pubmed.ncbi.nlm.nih.gov/33242072/

Stellate Ganglion Block in the Treatment of Post-traumatic Stress Disorder: A Review of Historical and Recent Literature:

https://pubmed.ncbi.nlm.nih.gov/27739175/

Stellate ganglion block reduces symptoms of Long COVID: A case series:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8653406/

Stellate Ganglion Block Relieves Long COVID-19 Symptoms in 86% of Patients: A Retrospective Cohort Study:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10498998/

In this BackTable MSK episode, host Dr. Jacob Fleming discusses the future of musculoskeletal radiology with Dr. Glade Roper of VIP Specialists in Visalia, California. Dr. Roper is an MSK radiologist who specializes in minimally invasive procedures.

The doctors explore the potential of musculoskeletal interventional radiology in private practice, with emphasis on the role of device companies’ training, marketing, and the role of minimally invasive procedures in a patient’s treatment algorithm. They also cover procedural topics such as endoscopic disc procedures and peripheral nerve stimulation. Dr. Roper highlights both the advantages and challenges of starting an outpatient-based lab (OBL). Throughout the episode, Dr. Roper shares the story of how he decided to pursue MSK radiology and his perspective on balancing his medical practice with his family life.

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CHECK OUT OUR SPONSOR

Stryker Interventional Spine

https://www.strykerivs.com

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/Tnhqyf

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SHOW NOTES

0:00 - Introduction to the Podcast

3:00 - Dr. Roper’s Career Path in MSK Radiology

9:10 - Practicing in the OBL and ASC Settings

18:19 - Clinic Presence and Collaboration with Advanced Practice Providers

22:18 - Practice Marketing and Referral Patterns

32:18 - New Developments in Endoscopic Spine and Neuromodulation Procedures

43:30 - Patient Access to Procedures

52:58 - The Future of MSK Radiology Training Pathways

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RESOURCES

Dr. Glade Roper’s Twitter:

https://twitter.com/darthglader

BackTable VI Ep. 211- Extraspinal Augmentation and the Future of Vertebral Augmentation with Dr. Douglas Beall:

https://www.backtable.com/shows/vi/podcasts/211/extraspinal-augmentation-the-future-of-vertebral-augmentation

Disc-FX:

https://www.elliquence.com/education/patients/disc-fx-overview/

ReActiv8 Neuromodulation:

https://mainstaymedical.com/

In this episode, host Dr. Dana Dunleavy interviews NFL player Taylor Rapp and neurointerventional radiologist Dr. Wayne Olan about the role of the Q collar in safeguarding the brain from impact.

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SHOW NOTES

Taylor Rapp, a native of Washington state, pursued his college education at the University of Washington, where he also played football. He was later drafted by the LA Rams and played for them for a few years. Recently, Taylor made a move to Buffalo, NY, and now plays safety for the Buffalo Bills. He recounts his brain injury and severe concussion in 2021 while he was playing for the LA Rams. Later on, he heard about the Q collar from his agent and subsequently incorporated it into his gear in the following season.

Dr. Olan discusses the origin of the Q collar, which was initially developed in the military to protect and minimize brain movement. He highlights a study from St. Xavier High School in Cincinnati and Cincinnati Children’s Hospital where the role of the Q collar was examined utilizing Diffusion Tensor Imaging (DTI), a type of MRI technique that specifically examines the white matter tract. Within a cohort of 500 athletes, 77% of athletes who wore the Q collage showed no evidence of shear injury whereas 73% of athletes who did not wear the collar showed gray-white matter shearing injury. He further discusses the mechanism by which the Q collar protects the brain from injury. It stabilizes the brain and minimizes movement by decreasing venous return to the brain by 30%, which he compares to wearing a necktie. He makes an important distinction that the Q collar does not occlude venous return, therefore, does not have significant clinical adverse effects.

They end the episode by advocating for the significance of educating younger athletes about the risks of contact sports and enhancing safety across all sports.

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RESOURCES

Neck Collar with Mild Jugular Vein Compression Study:

https://pubmed.ncbi.nlm.nih.gov/28437225/

In this episode, host Dr. Jacob Fleming and Dr. Jason Cox interview musculoskeletal radiologist Dr. Jon Jacobson about the current uses and future role of musculoskeletal (MSK) ultrasound.

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CHECK OUT OUR SPONSOR

Stryker Interventional Spine

https://www.strykerivs.com

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SHOW NOTES

To begin, Dr. Jacobson provides insight into his professional journey, from training at Henry Ford Hospital to his current practice at Lenox Hill in New York City. He reflects on the formative period of his career spent under the mentorship of Dr. Marnix Van Holsbeeck, who played a key role in his training over MSK ultrasound. Dr. Jacobson also discusses his specific areas of interest, in particular, microvascular imaging, especially in the context of assessing blood flow following the treatment of rheumatoid arthritis. He underscores the need for further research and exploration on this topic.

Next, Dr. Jacobson explores the significance of MSK ultrasound education across various specialties, emphasizing the mutual learning that takes place across different specialties. Dr. Jacobson has led an annual MSK ultrasound course in San Diego for nearly two decades. He believes that MSK ultrasound has the potential to be scaled up to a level comparable to MSK imaging with CT and MRI. He emphasizes the important role that a skilled technologist plays in this process. He advocates for investing in training efficient and experienced technologists. This includes designating a lead technologist with expertise who can train other newer technologists.

Dr. Jacobson further addresses ultrasound-guided interventions such as joint, bursa, and tendon sheath injections. The conversation also delves into the different paradigms of interventional radiology, which can sometimes be viewed as the provision of a clinical service versus the performance of order-based procedures.

Finally, Dr. Jacobson elaborates on his collaboration with a nonprofit organization called Imaging the World. Their primary mission centers around ultrasound in Uganda, with a particular emphasis on advancing shoulder ultrasound capabilities in remote and underserved areas, both in terms of diagnosis and treatment. Dr. Jacobson provides training to physical therapists and technologists in ultrasound procedures and ultrasound-guided injections. The next phase of these nonprofit’s efforts is directed towards underserved rural communities in North America.

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RESOURCES

Musculoskeletal Ultrasound Education

https://www.jacobsonmskus.com/

In this episode, host Dr. Jacob Fleming interviews Dr. Dana Dunleavy about spinal tumor ablation and vertebral augmentation. Dana is an interventional radiologist and Director of Windsong Interventional & Vascular Services.

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CHECK OUT OUR SPONSOR

Stryker Interventional Spine

https://www.strykerivs.com

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SHOW NOTES

Dana begins the discussion by reflecting on his upbringing in a small country town. His parents, his mother a midwife and his father a contractor, shaped his early experiences. His exposure to medicine began through his mother, particularly in witnessing childbirths. As he navigated his way through medical school, he contemplated various specialties, including orthopedic surgery, interventional radiology, and neurosurgery. He discovered incredible mentors in radiology and ultimately found his place in the field of interventional radiology. During his residency at Johns Hopkins, he sought externships in interventional spine and had the opportunity to immerse himself in this field for one month.

He underscores the significance of participating in tumor boards and being a valuable contributor to the team in terms of diagnosis and treatment. He also emphasizes the value of calling consults when performing biopsies and the importance of meeting with the patient face-to-face and engaging in a thorough discussion of the treatment plan.

Next, Dana delves deeper into the topics of bone tumor ablation and mechanical augmentation. He notes the importance of having a comprehensive understanding of the patient's anatomy and being well-versed in interventional tools. Cement extravasation is a feared complication of vertebral augmentation, so Dana discusses the role of implants as a means to establish structural support and mitigate the risk of cement leakage. In addition, he talks about his approach in combining ablation with mechanical augmentation so that the augmentation provides a structure after the ablation.

Lastly, he discusses the use of advanced technology such as cone beam CT in trajectory planning. He shares his hybrid approach to performing bone biopsies, utilizing fluoroscopy during access and cone beam CT to ascertain accurate trajectory.

In this episode, Dr. Jacob Fleming interviews Dr. William Morrison, the medical director of Trace Orthopedics. Trace Orthopedics is developing a minimally invasive implantable device for tendon repairs.

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CHECK OUT OUR SPONSOR

Stryker Interventional Spine

https://www.strykerivs.com

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SHOW NOTES

William's passion for radiology traces back to his early love for art. In the initial stages of his career, he conceived the idea of a curved, steerable needle to navigate this L5-S1 space for discographies. After bringing the needle to market, its adoption was hampered by cost factors and the challenge clinicians faced in transitioning from traditional straight needles to the new design. Despite the initial challenges and disappointment with the needle's limited uptake, the product found a valuable application in celiac plexus blocks for pancreatic cancer and has shown to reduce surgical risks and complications compared to the traditional approach.

After taking several years off from his innovation journey, William’s personal experience with a partial rotator cuff tear drove him back into action. At that time, the available treatment options were strictly rehabilitation-focused, severely limiting his activity. He crafted a device in his garage using materials from Home Depot to percutaneously anchor tendons. Taking his prototype to Jefferson, where the idea gained endorsement, he proceeded to obtain a patent and established the Trace Orthopedics company. The implanted device has the ability to withstand greater force compared to commonly used suture anchors and is a minimally invasive procedure that is both efficient and single-step. William's invention has garnered interest from various medical specialties. With FDA approval in sight, the device is expected to hit the market within the next year.

During their last remarks, William addresses the persistent challenge of public awareness regarding the full scope of minimally invasive interventional practices within radiology when discussing potential investments. According to William, radiology currently stands at a critical juncture where the significance of imaging and research in driving product development has never been more crucial.

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RESOURCES

Trace Orthopedics:

https://www.traceorthopedics.com/

In this episode, host Dr. Jason Cox interviews Dr. Marnix van Holsbeeck, who is considered to be one of the godfathers of musculoskeletal ultrasound.

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SHOW NOTES

Dr. Holsbeeck begins by reflecting on his early life in Belgium. Raised in a family of medical professionals, he started his career as a general practitioner at the age of 24, all while pursuing a comprehensive radiology training. His introduction to musculoskeletal ultrasound occurred during his tenure at his father's practice, where he discovered not only his affinity for radiology but also his deep passion for patient interaction. He soon realized that conducting ultrasound was the perfect intersection of both of his passions for radiology and patient care.

He then provides a history of the origins of musculoskeletal ultrasound, dating back to its inception in 1979-1980. He shares his experiences from his time in gastroenterology, where ultrasound was beginning to be utilized for diagnosing gallbladder stones. It was during this time that he became captivated by the ability to correlate a patient's medical history with the findings of the ultrasound.

Dr. Holsbeeck also elaborates on his journey on musculoskeletal ultrasound, recounting the numerous single-contrast arthrograms he conducted in conjunction with ultrasound during his training. As a practicing general practitioner, he recollects performing therapeutic joint injections and he recognized the need for image-guided procedures, specifically ultrasound-guided therapeutic joint injections. This approach offered superior precision and visualization of the joint space, further enhancing patient care.

He also shares the development of the Musculoskeletal Ultrasound program at Henry Ford in Detroit, Michigan, upon his arrival in 1989. He initially began using ultrasound in the Emergency Department with regards to abscess aspiration and drainage. This approach was subsequently integrated into the field of orthopedics. Dr. Holsbeeck highlights the pivotal role of ultrasound in the diagnosis of tendon tears, underscoring its capacity to promptly assess whether surgical intervention is warranted for the patient.

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RESOURCES

Musculoskeletal Ultrasound Society:

https://www.musoc.com/

In this episode, guest host Dr. Jacob Fleming interviews Dr. Dan Nguyen about MSK and neurologic pain interventions, specifically how he evaluates and treats different types of headaches at his practice.

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/em9n8O

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SHOW NOTES

Dr. Nguyen left academia and the East Coast 6 years ago, where he trained in neurointerventional radiology and pain intervention to open his own practice in Oklahoma City after visiting Dr. Beall. He now has a clinic where he sees musculoskeletal and neurologic pain patients. He enjoys the long term relationships he has built with many patients in his practice. He still does a degree of diagnostic work so as not to lose his skills.

Next, Dr. Nguyen discusses how he evaluates and treats headaches as a neurological pain interventionalist. Understanding the neuroanatomy of the face is key. He tries to understand the presentation of the patient’s headaches, whether it is located above the eyebrow, near the ear or at the jaw. He treats cervicogenic headache, trigeminal neuralgia and occipital neuralgia with a diagnostic block, radiofrequency ablation and neuromodulation. He also treats migrainous headaches. After determining whether the pain is musculogenic or neurogenic, he does a trigger point injection or a test injection of the nerve, followed by RFA and neuromodulation.

Dr. Nguyen tells us his approach to trigeminal neuralgia workup. There are three branches, and the Gasserian ganglion (trigeminal ganglion) lies deep to the foramen ovale. To approach it, he usually tries to target the most peripheral nerve branch. For V1, he evaluates the supraorbital, supratrochlear nerves, which you can see with ultrasound. For V2, he evaluates the infraorbital with ultrasound. The foramen rotundundum requires CT guidance to access. For V3 he evaluates the mental and alveolar nerves or the foramen ovale. He does diagnostic blocks, and if this provides relief to the patient they discuss radiofrequency ablation. He advises operators to take the longest path to the nerve to ensure the ablative needle is fully buried under the skin to avoid burns. He also discusses the rare outcome of anesthesia dolorosa which can cause facial numbness and pain after ablation of the Gasserian ganglion. He says that for most of his patients, they accept this potential risk due to the more likely possibility of relief from the excruciating pain they experience with trigeminal neuralgia.

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RESOURCES

Dr. Nguyen Twitter:

@neuroradiology

Narouze: Interventional Management of Head and Face Pain

https://link.springer.com/book/10.1007/978-1-4614-8951-1

American Society of Spine Radiology:

https://assrannualmeeting.org

American Society of Neuroradiology:

https://www.asnr.org/annualmeeting/

In this episode, guest host Dr. Shamit Desai interviews Dr. Keerthi Prasad about his path to starting an IR practice alongside interventional pain specialists.

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/TQUUf1

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SHOW NOTES

This unique collaboration started after Dr. Prasad finished fellowship. He describes the support and investment that his anesthesiologist partners provided in helping him launch IR service lines in their existing practice. On the pain management side, he primarily performs vertebral augmentation, DRG stimulation, and nerve blocks. He has also expanded his services into vein care, since venous disease is often concomitant with PAD, wound care, and pain. Dr. Prasad emphasizes the value of focusing on specific procedures and disease states in order to provide the best and most up to date clinical care possible. This can also set you apart from other competitors and help patients identify you as their vascular specialist.

Dr. Prasad delves into the infrastructure of their centers. Their high volume of patients requires close coordination of all office and medical staff. To retain highly trained medical staff, he recommends investing in their training, minimizing office politics, and granting sufficient autonomy.

Since 2016, the Centers for Pain Control and Vein Care has expanded to multiple locations in northwest Indiana. Dr. Prasad closes the episode by speaking about practice marketing and forming new referral networks. He emphasizes the importance of identifying if there is a true clinical need to perform each procedure and following up with patients and referring doctors.

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RESOURCES

Centers for Pain Control and Vein Care:

https://www.discover-cpc.com/

In this episode, guest host and interventional radiologist Dr. Dana Dunleavy interviews neurointerventional radiologist Dr. Wayne Olan about growing neuroIR and IR through a neurosurgery department. Wayne serves as the Director of Interventional and Endovascular Neurosurgery at George Washington University Medical Center.

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SHOW NOTES

First, Wayne tells us more about his training, journey in academia, and role in building robust neuroIR and IR service lines through his leadership of the neurosurgery department at his institution. Wayne also shares how powerful being involved in interdisciplinary clinics can be in growing the scale, reach, and impact of minimally-invasive image guided interventions. These collaborations include neuroIR/neurosurgery for neuro clinic and IR/ gynecology for fibroid clinic.

Dana and Wayne then discuss how neuroIR and IR has evolved over the years, highlighting watershed moments and key innovations. They discuss sacroiliac joint interventions in detail and how MSK has become one of IR’s newest subspecialties.

Wayne shares his history of playing and coaching lacrosse, and he also tells us about the Q-Collar and his role in serving on the company’s board of medical advisors. The device has been shown to protect the athletes’ brains from concussive and subconcussive impacts by increasing internal jugular vein pressure.

We conclude the episode with some parting wisdom from Wayne regarding career paths, navigating reimbursements and insurance as a neuroIR or IR, and finding joy and purpose at and outside of work.

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RESOURCES

SI-Bone, iFuse TORQ Device:

https://si-bone.com/providers/solutions/trauma/ifuse-torq

SI-Bone, iFuse Triangle Device:

https://si-bone.com/providers/solutions/ifuse

Stryker, Spine Jack Device:

https://www.stryker.com/us/en/interventional-spine/products/spinejack-system.html

Q-Collar Company web-page:

https://q30.com/

Q-Collar Studies / Research Briefing:

https://q30.com/pages/fda-reviewed

Boston University CTE Clinic:

https://www.bu.edu/cte/