Where does cryoneurolysis fit in contemporary pain management? In this episode of Backtable MSK, host Jacob Fleming is joined by Dr. Alexa Levey to discuss the role of cryoneurolysis in various pain presentations, covering indications, anatomical targets, and techniques in different clinical scenarios.

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SYNPOSIS

This episode offers practical guidance on how to take a detailed patient history, how to use cryoneurolysis for pain management, and the significance of multidisciplinary collaboration. The conversation also highlights the importance of setting proper patient expectations, understanding different types of pain, and the need for standardizing cryoneurolysis procedures through structured research and education.
Dr. Levey also shares her recent career move to Yale, her passion for research, and the challenges she faced returning to academia from private practice.

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TIMESTAMPS

00:00 - Introduction
03:49 - Discussion of Dr. Levey’s Recent Research Paper
09:35 - The Fine Details of Pain and Pain Management
18:42 - Patient Quality of Life Assessment in Regards to Pain Management
28:28 - Game Plan for Managing Neuritis
37:19 - Collaboration Between Different Specialists
40:16 - Offering Patient Education and Support
42:31 - Final Reflections and Gratitude

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RESOURCES

Dr. Alexa Levey
https://medicine.yale.edu/profile/alexa-levey/

Common Cryoneurolysis Targets in Pain Management: Indications, Critical Anatomy, and Potential Complications
https://pubmed.ncbi.nlm.nih.gov/40376212/

Paging all neuroradiologists and spine specialists interested in enhancing their vertebral nerve ablation practice. In this special ESNR edition of Backtable MSK, host Jacob Fleming welcomes neuroradiologist Dr. Luigi Manfre to discuss the intricacies of vertebral nerve ablation, focusing on patient selection, technical approaches, and emerging practice trends.

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SYNPOSIS

The physicians discuss the importance of careful diagnosis using MRI, SPECT scanning, and nerve block tests to improve treatment efficacy. Dr. Manfre emphasizes the need for strict patient selection to mitigate failures and highlights the variability in vertebral innervation between patients that can affect outcomes. The conversation also explores the nuances of conducting procedures under CT guidance and addresses challenges in treating different spinal levels, including L5 and S1. BONUS: Details on the ESNR Hands-On Spine Course held in Catania, Italy from October 16th-18th, 2025.

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TIMESTAMPS

00:00 - Introduction
02:43 - Upcoming Hands-On Spine Course
08:40 - The Rundown: Basivertebral Nerve Ablation
15:18 - Understanding Modic Changes and Their Implications
26:03 - Unique Innervation and Corresponding Challenges in Ablation
38:13 - Technical Approaches and Difficulties in BVNA
51:16 - Patient Selection and Procedure Efficacy for Ablative Procedures
01:00:29 - Conclusion and ESNR Course Information

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RESOURCES

Dr. Luigi Manfre
https://www.linkedin.com/in/luigi-manfre-20b61284/?originalSubdomain=it

European Society of Neuroradiology (ESNR)
https://www.esnr.org/

Musculoskeletal (MSK) embolization is emerging as a transformative, minimally-invasive option for various chronic pain conditions. In this week’s episode of Backtable MSK, host Dr. Jacob Fleming talks with Dr. Ahmed Farag, an interventional radiologist with expertise in MSK embolization. The conversation covers practice building, tools, and techniques.

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SYNPOSIS

Dr. Farag shares insights from his journey beginning with a career in engineering to now a career in medicine and private practice. He emphasizes how good patient outcomes, networking, and continuous learning all work synergistically as a marketing tool. He also touches upon the challenges and triumphs in practice management and the future prospects of outpatient musculoskeletal interventional radiology. This episode provides valuable advice for both veteran practitioners and trainees looking to carve their own paths in this evolving field.

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TIMESTAMPS

00:00 - Introduction
10:53 - Developing a Referral Network in Private Practice
15:54 - Discussing the Variety of MSK Embolization Procedures
19:39 - Sampling Products and Techniques for MSK Embolization
24:52 - Optimizing Relationships with Hospitals
28:05 - Advice for New IR Practitioners
33:39 - Keeping Up to Date: Training and Conferences
37:10 - Future Directions of Outpatient MSK IR
40:52 - Conclusion and Final Thoughts

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RESOURCES

Dr. Ahmed Farag
https://www.flvascular.com/about

Intradiscal ozone offers a minimally invasive approach to disc pain that can reduce inflammation and restore function. How well does it work and where does it fit in the lumbar radiculopathy treatment algorithm? In this episode of the Backtable MSK Podcast, host Jacob Fleming speaks with Dr. Alexis Kelekis about the contemporary role of intradiscal ozone and emerging innovations in interventional spine treatment.
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SYNPOSIS
Dr. Kelekis, a prominent figure in radiology and interventional pain management, shares insights from the 2025 GRIBOI meeting held in Banff, AB, Canada. Topics discussed include the development and possibility of bone augmentation polymers, intradiscal ozone therapy, and various interventional treatments for degenerative disc disease and vertebral fractures. Dr. Kelekis also touches on the need for specialized training in interventional radiology and the future of personalized medicine in pain management.
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TIMESTAMPS
00:00 - Introduction
06:40 - Ozone Treatment: Mechanism and Efficacy
13:23 - Challenges and Innovations in Spine Treatments
20:09 - Treatment Algorithm in Patients with Lower Extremity Radiculopathy
24:00 - Future Directions in Interventional Spine Treatments
30:28 - Closing Remarks
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RESOURCES
SpinaFx:
https://spinafx.com/
GRIBOI:
https://www.griboi.org/

What sets apart those who are good from those who are great? This episode of Backtable MSK features a profound discussion on leadership and legacy with Dana Dunleavy, MD, Wayne Olan, MD, and David Tilton. Dr. Olan, Director of Minimally Invasive Neurosurgery at George Washington University Medical Center, and David Tilton, a former Navy SEAL and current business and racing professional, share their unique experiences and insights surrounding perseverance in success.
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SYNPOSIS
The doctors discuss the importance of mentorship, collaboration, and cultivating a culture of growth and accountability. The conversation highlights how nurturing leaders can impact both professional and personal development, emphasizing that the best measure of success lies within the success of those you lead.
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TIMESTAMPS
00:00 - Introduction
10:50 - Learning from Those Around You
16:56 - The Value of Continuous Learning and Avoiding Complacency
31:43 - The Importance of Teamwork and Mentorship
50:07 - The Role of Failure in Success
52:45 - Closing Remarks: Support and Courage

Who is the ultimate candidate for GAE, which technical approach is best, and how do you set your patients up for success? Tune into this week’s episode of BackTable to hear from interventional radiologists Dr. Osman Ahmed (University of Chicago Medicine) and Dr. Siddharth Padia (UCLA Health) as they discuss everything from patient selection to follow-up care, covering pre-procedure imaging, access, embolics, technical challenges, clinical data, and the future of genicular artery embolization.

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This podcast is supported by:

Guerbet

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SYNPOSIS

Dr. Ahmed and Dr. Padia debate their approaches to patient selection criteria, the use of MRI and cone beam CT, permanent vs. resorbable embolic materials, how many arteries to embolize, and the relevance of pain metrics post GAE. They also delve into follow-up considerations and the potential for GAE as a long term treatment.

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TIMESTAMPS

00:00 Introduction

01:08 MRI for Patient Selection in GAE

08:53 Access Techniques: Femoral vs. Pedal

17:07 Cone Beam CT in GAE Procedures

27:20 Embolization Strategies

39:30 Challenges and Complications in Embolization

44:50 Follow-Up and Pain Metrics in Clinical Practice and Research

01:06:30 Repeat GAE Procedures: When and Why?

01:11:13 Post-Total Knee Replacement and GAE

01:21:01 Advice for IRs Looking to do GAE

01:24:32 Conclusion and Final Thoughts

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RESOURCES

GENESIS Trial: https://pubmed.ncbi.nlm.nih.gov/33474601/

Landers et al Trial: https://pubmed.ncbi.nlm.nih.gov/37051829/

Attention radiologists: Were you trained to look for Tarlov cysts when reading spine MRI? In this episode of Backtable MSK, interventional neuroradiologist Dr. Kieran Murphy joins the studio to discuss the serious issue of chronic pain related to Tarlov cysts, a condition often overlooked in both diagnosis and treatment. Tarlov cysts, also known as perineural cysts, are fluid-filled sacs that form due to the dilation of the subarachnoid space around spinal nerve roots, most commonly at the base of the spine.

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SYNPOSIS

Dr. Murphy highlights the high risk of depression and suicide among patients, who are often misdiagnosed and overprescribed ineffective pain medications. He explains how to identify and treat Tarlov cysts through aspiration and fibrin sealing, addresses the historical dismissal of their significance, and underscores the need for a better understanding of CSF leaks. Additionally, Dr. Murphy emphasizes the importance of institutional responsibility in occupational radiation safety for interventionalists, advocating for improved lead protection and antioxidant use to mitigate radiation damage. The episode concludes with a humbling reminder of the implicit biases present in medical practice and the ongoing need for more inclusive and attentive patient care.

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TIMESTAMPS

00:00 - Introduction

01:24 - Challenges in Diagnosing and Treating Tarlov Cysts

04:05 - Patient Experiences and Misdiagnoses

06:06 - Cyst Aspiration Techniques

15:12 - Improved Diagnosis of CSF Abnormalities

22:10 - Allergic Reactions to Fibrin

25:30 - Implicit Bias in Medicine

34:50 - Radiation Safety in Radiology

43:47 - Final Thoughts and Reflections

You asked, and we delivered – here’s a comprehensive episode on Basivertebral Nerve Ablation (BVNA) for vertebrogenic lumbar pain! In this episode of Backtable MSK, our host Dr. Christopher Beck is joined by Dr. Asad Baig, Director of Interventional Spine at Columbia University, to discuss BVNA patient selection and procedural techniques.

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SYNPOSIS

Dr. Baig begins by sharing his journey from residency to his current role, including his initial exposure to spine procedures and the mentors who guided him. He offers examples of his workup for back pain, covering detailed patient history and key MRI findings. Dr. Baig emphasizes the importance of understanding risks and alternatives, as well as how to effectively counsel patients on these topics. Additionally, he walks through the BVNA procedure and shares his technical pearls.

The episode concludes with Dr. Baig highlighting valuable resources for those interested in starting BVNA procedures and recognizing the supporting role of industry partners.

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TIMESTAMPS

00:00 - Introduction

10:14 - Patient Selection for BVNA

14:45 - Imaging Findings

19:38 - Consent Process and Risks

22:18 - Procedural Technique

28:32 - Sedation and Pain Management

34:03 - Post-Procedure Care and Follow-Up

37:09 - Challenges and Troubleshooting

40:34 - Resources and Mentorship

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/