BackTable Bone & Sports

We’ve had many discussions about the technical aspects of vertebroplasty and kyphoplasty on BackTable MSK. However, in this episode, we take a deeper look into the history of these procedures, exploring early research controversies and the challenges that threatened their existence. Our host, Dr. Jacob Fleming, is joined in the BackTable Studio by interventional neuroradiologist Dr. Joshua Hirsch, who was in San Diego for the ASSR 2025 meeting. Dr. Hirsch is the Chief of the Interventional Spine Service at Massachusetts General Hospital.

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This podcast is supported by:

Medtronic MVP

https://www.medtronic.com/en-us/healthcare-professionals/products/spinal-orthopedic.html#aq=%40pagetype%3D%22product-model%22&cq=%40products_category%3D%22Spinal%20and%20orthopedic%22%20OR%20%40ontology_isa%3D%22Spinal%20and%20orthopedic%22

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SYNPOSIS

Dr. Hirsch begins by outlining the historical origins of radiologists using cement injection and how this practice evolved into vertebroplasty. He then highlights early research on the procedure, focusing on key 2009 NEJM papers that sparked both scientific and public controversy, leading to setbacks in research and disparities in access to life-changing care. Since that time, newer studies have demonstrated the clear benefits of spinal augmentation for patients with vertebral insufficiency fractures, including Dr. Hirsch’s own research showing a mortality benefit compared to nonsurgical treatment. Overall, the doctors discuss how far this field has advanced and the exciting developments currently in progress.

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TIMESTAMPS

00:00 - Introduction

03:09 - Historical Origins of Vertebroplasty

07:08 - Development and Evolution of Vertebroplasty

10:21 - Controversy Over 2009 Randomized Control Trials

16:35 - Disparities in Access to Vertebroplasty

21:01 - Dr. Hirsch’s Research on Mortality Benefit of Vertebroplasty

32:31 - Opportunities for Patient Education

35:29 - Vertebroplasty vs. Kyphoplasty

37:34 - Challenges in Research Interpretations and Insurance Coverage

42:26 - Future Directions in Vertebral Augmentation

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RESOURCES

Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects (Jensen et al, 1997):

https://pmc.ncbi.nlm.nih.gov/articles/PMC8337380/

Simplicity of randomized, controlled trials of percutaneous vertebroplasty (Hirsch et al, 2003):

https://pubmed.ncbi.nlm.nih.gov/16880881/

INvestigational Vertebroplasty Efficacy and Safety Trial (INVEST): a randomized controlled trial of percutaneous vertebroplasty (Gray et al, 2007):

https://pubmed.ncbi.nlm.nih.gov/18096050/

A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures (Buchbinder et al, 2009):

https://pubmed.ncbi.nlm.nih.gov/19657121/

A Randomized Trial of Balloon Kyphoplasty and Nonsurgical Management for Treating Acute Vertebral Compression Fractures (FREE) (Meirhaeghe et al, 2013):

https://pmc.ncbi.nlm.nih.gov/articles/PMC3678891/

A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures (Kallmes et al, 2009):

https://www.nejm.org/doi/full/10.1056/NEJMoa0900563

A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis (Friedly et al, 2014):

https://www.nejm.org/doi/full/10.1056/NEJMoa1313265

Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial (Clark et al, 2016):

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31341-1/abstract

Number Needed to Treat with Vertebral Augmentation to Save a Life (Hirsch et al, 2020):

https://pmc.ncbi.nlm.nih.gov/articles/PMC6975314/

Major Medical Outcomes With Spinal Augmentation vs Conservative Therapy (McCullough et al, 2013):

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1710123

Harvey L. Neiman Policy Institute:

https://www.neimanhpi.org/

Dr. John Smirniotopoulos, an interventional radiologist at Georgetown/MedStar Washington Hospital Center, discusses the intricacies of genicular nerve ablation (GNA) for pain management in patients with osteoarthritis and post-surgical knee pain. He delves into the history and evolution of GNA, outlines the neurovascular anatomy, and explains his specific rationale for targeting various nerves for ablation.

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SYNPOSIS

Dr. Smirniotopoulos also compares GNA with other procedures such as corticosteroid injections, hyaluronic acid injections, and genicular artery embolization (GAE). He emphasizes the importance of managing patient expectations, the role of physical therapy, and explores different modalities of GNA, including the use of cryoablation versus radiofrequency technology. The episode offers a comprehensive overview of expert insights for evaluating knee pain and performing effective GNA.

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TIMESTAMPS

00:00 - Introduction

03:13 - Understanding Genicular Nerve Anatomy

12:06 - Tailoring GNA Treatment to Each Patient

22:39 - Comparing Ablation Devices and Methods

28:06 - GNA in Surgical and Post-Traumatic Patients

33:19 - Patient-Centered Decision Making

38:50 - Evaluating Functional Outcomes

43:39 - Comparing Treatment Modalities

49:34 - Post-Procedure Counseling and Expectations

58:40 - Future Directions in GNA Research

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RESOURCES

Safety and efficacy comparison of three- vs four-needle technique in the management of moderate to severe osteoarthritis of the knee using cooled radiofrequency ablation (Wong, et al 2021):

https://pubmed.ncbi.nlm.nih.gov/32968824/

Musculoskeletal embolization is generating significant excitement in the field of chronic pain management. In this episode, Dr. Jacob Fleming hosts a discussion with Dr. Yuji Okuno from Japan, a pioneer in both basic science and clinical practice within the field of musculoskeletal embolization.

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This podcast is supported by:

Medtronic MVP

https://www.medtronic.com/mvp

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SYNPOSIS

The conversation delves into Dr. Okuno's groundbreaking work using embolization to treat chronic pain from conditions such as frozen shoulder, knee osteoarthritis, plantar fasciitis, and various sports injuries. Dr. Okuno discusses the development of new temporary embolic agents and compares different approaches to embolization treatments, including the innovative use of antibiotics as embolic material. The doctors also cover the intriguing concept of differential recanalization, where abnormal inflammatory vessels are less likely to recanalize than normal vessels after embolic treatment. Identifying hypervascularity through MRI, ultrasound, or angiogram is a crucial step before attempting embolization.

Overall, Dr. Okuno offers valuable insights into his clinical practice and the potential for groundbreaking advancements in musculoskeletal care worldwide.

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TIMESTAMPS

00:00 - Introduction

01:54 - Origins of Embolization for Pain

04:15 - Basic Science Research Discoveries and Clinical Trials

09:02 - Temporary Embolic Materials

15:28 - Techniques for Embolization

17:33 - Plantar Fasciitis Treatment

24:04 - Future of Embolization in Sports Injuries

28:11 - Diagnostic Imaging in Embolization

36:10 - Global Expansion and Collaborations

Vertebral augmentation for degenerative disc disease has traditionally been performed using cement injections. However, new biomaterials are emerging that may offer more precise targeting of the vertebral discs, potentially leading to higher patient satisfaction. In this episode of Backtable MSK, Dr. Olivier Clerk-Lamalice discusses significant advances in the treatment of degenerative disc disease, with a particular focus on disc augmentation using intradiscal hydrogel. This episode marks the third and final installment in our series on degenerative disc disease with Dr. Clerk-Lamalice.

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This podcast is supported by:

Medtronic Interventional

https://www.medtronic.com/interventional

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SYNPOSIS

Dr. Clerk-Lamalice begins by exploring the history of hydrogel use for degenerative disc disease, highlighting the different iterations of this biomaterial. As an experienced practitioner in this field, he shares valuable tips on injection volume and technique. His work is especially meaningful to him because the procedure provides significant pain relief for patients. The doctors also delve into patient selection criteria and ongoing clinical trials aimed at obtaining FDA approval in North America. Additionally, the episode offers a preview of the upcoming GRIBOI conference, which will focus on the use of injectable osteoarticular biomaterials in bone augmentation.

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TIMESTAMPS

00:00 - Introduction

02:28 - History and Current Use of Intradiscal Hydrogel

07:19 - Technical Insights for Injection

12:51 - Clinical Outcomes and Patient Satisfaction

15:33 - Ongoing FDA Clinical Trials

16:38 - Future Research and GRIBOI Conference Details

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RESOURCES

BackTable MSK Ep. 67- Introduction to the Treatment of Discogenic Back Pain:

https://www.backtable.com/shows/msk/podcasts/67/introduction-to-treatment-of-discogenic-back-pain

BackTable MSK Ep. 68- BackTable Basics: Lumbar Access and Discography

https://www.backtable.com/shows/msk/podcasts/68/backtable-basics-lumbar-disc-access-discography

GRIBOI Conference:

https://www.griboi.org/annualconference

Hydrogel Augmentation of the Lumbar Intervertebral Disc: An Early Feasibility Study of a Treatment for Discogenic Low Back Pain (Beal et al, 2024):

https://www.jvir.org/article/S1051-0443(23)00694-2/fulltext

The lumbar discogram is a cornerstone of musculoskeletal (MSK) radiology, as it enables interventionalists to pinpoint the exact level of discogenic back pain. In this episode of Backtable MSK, the Dr. Olivier Clerk-Lamalice and host Dr. Jacob Fleming explore the techniques and applications of the discogram, a procedure highly valued for its effectiveness in both diagnosis and pain management.

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This podcast is supported by:

Medtronic Interventional

https://www.medtronic.com/interventional

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SYNPOSIS

They discuss the fluoroscopically guided approach, focusing on techniques like Kambin’s triangle and the far-lateral approach. The doctors also cover their preferred contrast agents and injection methods, along with concurrent therapeutic injections.

The conversation delves into the varied disc anatomies that require different approaches, including adjustments in needle angulation. They also emphasize the importance of prophylactic antibiotics, potential challenges, and the evolving landscape of therapeutic options, including intradiscal platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC).

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TIMESTAMPS

00:00 - Introduction

01:17 - Overview of Lumbar Discogram Technique

04:56 - Contrast Injection and Pain Response

07:40 - Therapeutic Injections

10:00 - Discography Under CT Guidance

12:43 - Strategies for Challenging Cases

17:52 - Protocol for Infection Prevention

20:15 - Post-Discogram Treatment Options

21:30 - Emerging Therapies

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RESOURCES

BackTable MSK Ep. 68- Introduction to the Treatment of Discogenic Back Pain:

https://www.backtable.com/shows/msk/podcasts/67/introduction-to-treatment-of-discogenic-back-pain

BackTable MSK Ep. 62- Exploring Intradiscal PRP for Back Pain Relief with Dr. Guilherme Ferreira Dos Santos:

https://www.backtable.com/shows/msk/podcasts/62/exploring-intradiscal-prp-for-back-pain-relief

Degenerative disc disease, a major cause of low back pain, is the most common musculoskeletal issue worldwide, affecting an estimated 15-30% of the population. In this episode of BackTable MSK, interventional radiologists Dr. Olivier Clerk-Lamalice and Dr. Jacob Fleming cover symptomatic degenerative disc disease, focusing on its diagnosis and treatment with anesthetic injections. This is the first episode in a two-part series on discogenic back pain.

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Get $100 off of your GRIBOI Conference registration using this link:

www.eventbrite.com/e/1027273521757/?discount=BackDoorGRIBOIPromoCode

Visit the GRIBOI website for special hotel rates, available until March 11, 2025:

https://www.griboi.org/annualconference

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This podcast is supported by:

Medtronic Interventional

https://www.medtronic.com/interventional

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SYNPOSIS

Dr. Clerk-Lamalice begins by explaining the pathophysiology of disc degeneration, which can lead to painful annular tears and loss of disc height. The doctors also reflect on the history of discography, from provocative discograms to the more recent anesthetic and CT discograms. They review the modified Dallas Discogram Classification for annular tears, the vacuum disc phenomenon, and the importance of dynamic imaging to assess treatment candidacy. Dr. Clerk-Lamalice emphasizes the need to correlate imaging with physical examination to better identify the symptomatic disc level.

The episode also discusses the challenges of managing multi-level disc degeneration and underscores the importance of early-stage intervention.

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TIMESTAMPS

00:00 - Introduction

02:44 - Pathophysiology of Disc Degeneration

06:49 - Evolution of Discography

12:55 - Classification of Annular Tears

09:01 - Diagnostic Tools and Techniques

14:00 - CT Discogram and Annular Tear Classification

17:12 - Dynamic Aspects and Instability

22:20 - Identifying Symptomatic Disc Level

28:25 - Treatment Approaches and Patient Selection

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RESOURCES

BackTable MSK Ep. 13- Basivertebral Nerve Ablation with Dr. Olivier Clerk-Lamalice:

https://www.backtable.com/shows/msk/podcasts/13/basivertebral-nerve-ablation

Modified Dallas Discogram Classification System:

https://pubmed.ncbi.nlm.nih.gov/2954226/

Many physicians are perfectly positioned to recognize areas of clinical need, so why are so few of them involved in medical innovation? In this episode of BackTable MSK, Dr. Kieran Murphy discusses the ideal circumstances and critical characteristics of physician innovators. Dr. Murphy is an interventional neuroradiologist, a professor at the University of Toronto, and a medical device innovator who has made significant contributions to the field, including the development of the Murphy needle for vertebral augmentation.

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This podcast is supported by an educational grant from:

Medtronic

https://www.medtronic.com/

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SYNPOSIS

Dr. Murphy talks about his recent book, “The Essence of Invention: Medicine and the Joy of Creativity,” which chronicles key innovations in interventional radiology. The book focuses specifically on the characteristics and circumstances of the innovators themselves. Dr. Murphy became interested in this topic after noticing patterns of innovation that clustered around certain institutions and leaders.

He shares his insights on innovation, including the idea that innovation peaks during fellowship, the importance of uninterrupted reflective time for creativity, and how building long-term relationships can be essential for generating ideas and gaining support. He also discusses his work on ozone therapy, the development of the Murphy needle, and the significance of securing small-scale funding through patient donations for research.

Additionally, Dr. Murphy touches on his upcoming books and explores the essential fusion of medicine and the liberal arts.

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TIMESTAMPS

00:00 - Introduction to the Podcast

02:05 - The Role of Creativity in Interventional Radiology

09:52 - Inspiration Behind The Book

14:51 - Environments for Inventors to Flourish

25:18 - Use of Honey in Biopsies

31:32 - Advice for Physician Innovators

45:02 - Balancing Career and Family

51:23 - Upcoming Book

56:31 - Innovations in Radiation Protection

59:45 - The Future of Medical Education

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RESOURCES

The Essence of Invention: Medicine and the Joy of Creativity:

https://www.amazon.com/Essence-Invention-Medicine-Joy-Creativity/dp/1459754034

Robot-assisted technology has revolutionized surgical fields such as general surgery and urology—could interventional radiology be the next frontier? In this episode of the BackTable podcast, host Dr. Jacob Fleming explores the transformative potential of robotic-assisted percutaneous biopsies and ablations with experts Dr. Govindarajan “Raj” Narayanan from the Miami Cancer Institute and Dr. Sean Tutton from UC San Diego.

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This podcast is supported by:

Quantum Surgical

https://www.quantumsurgical.com/

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SYNPOSIS

Dr. Narayanan begins by sharing his initial interest in robotic applications for tumor ablations, aiming to maximize efficiency in his practice. Dr. Tutton then highlights the advantages of robotics for probe placement, especially in challenging cases. The two doctors discuss the logistics of the robotic system, including setup, imaging, and access choices. They also reflect on the learning curve associated with robotics and how it gradually enhances procedural efficiency while reducing mental fatigue. This improvement allows them to take on more complex cases with confidence. Overall, both experts agree that robotics has the potential to democratize minimally invasive procedures, offering new opportunities for skill development and advancement within the field of interventional radiology.

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TIMESTAMPS

00:00 - Introduction to the Podcast

03:30 - Developing an Interest in Robotics

10:44 - Integration of Robotics in the Procedural Suite

13:27 - Logistics of Robot System

18:38 - Planning for Percutaneous Access

22:39 - Future Implications of Robotics on Training Programs

35:51 - Efficiency and Volume Management with Robotics

40:39 - Learning Curves for Robotic Procedures

48:09 - Conclusion and Final Thoughts

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RESOURCES

Quantum Surgical Epione Robot:

https://www.quantumsurgical.com/epione/

ACCLAIM Trial:

https://www.sio-central.org/ACCLAIM-Trial

What evidence is currently available regarding the use of genicular artery embolization (GAE) for treating knee osteoarthritis? Principal investigator Dr. Mark Little discusses the GENESIS 2 trial, a large randomized controlled study aimed at assessing the outcomes of embolizing abnormal genicular arteries to reduce pain in patients with mild to moderate knee osteoarthritis.

Dr. Little explains the trial’s design, methodology, and the significance of key data points such as the Knee Injury and Osteoarthritis Outcome Score (KOOS), cost-effectiveness, and quality of life measures. He also covers the materials and techniques used in both the GENESIS 1 and 2 trials, the neuropsychological tests integrated into the study, and potential geographic and anatomical challenges encountered during GAE. Dr. Little highlights the importance of high-quality research and data to support the procedure's efficacy and safety.

TIMESTAMPS

00:00 - Overview of GENESIS 2 Trial

04:42 - Embolic Materials and Techniques

09:10 - Challenges in Patient Anatomy & Comorbidities

12:40 - Final Thoughts

CHECK OUT THE FULL EPISODE

Exploring GAE: Clinical Insights & Outcomes with Dr. Mark Little

https://www.backtable.com/shows/msk/podcasts/50/exploring-gae-clinical-insights-outcomes

For patients suffering from intractable pain due to knee osteoarthritis, genicular artery embolization (GAE) offers a minimally invasive treatment with potential long-term benefits. Dr. Mark Little, an interventional radiologist at Royal Berkshire NHS Foundation Trust, joins us to provide an introduction to GAE. He shares his experience with the procedure and compares it to other treatments, such as steroid injections and surgery. Dr. Little also discusses the disease process of osteoarthritis and explains how GAE targets abnormal blood vessels to reduce inflammation and alleviate pain.

TIMESTAMPS

00:00 - Introduction 

03:38 - Understanding Knee Osteoarthritis

06:57 - Patient Selection for GAE

08:57 - Challenges and Opportunities in GAE

12:18 - Safety and Procedure Details

CHECK OUT THE FULL EPISODE

Exploring GAE: Clinical Insights & Outcomes with Dr. Mark Little

https://www.backtable.com/shows/msk/podcasts/50/exploring-gae-clinical-insights-outcomes