Dr. Sabeen Dhand chats with Interventional Radiologist Shankar Rajeswaran from Lurie Children's Hospital in Chicago about a novel minimally invasive treatment of unicameral and aneurysmal bone cysts.

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In this episode, pediatric interventional radiologist Dr. Shankar Rajeswaran joins host Dr. Sabeen Dhand to discuss a novel minimally-invasive treatment for unicameral and aneurysmal bone cysts.

Pediatric interventional radiology is a rapidly growing field, and Dr. Rajeswaran describes how it has evolved in complexity and innovation over the course of his career. Dr. Rajeswaran says that there is a significant challenge that pediatric IRs must overcome-- treating children with IR devices that were originally designed to be used in adults. As a result, he emphasizes the need for creativity and flexibility in this field.

Next, we define and differentiate between unicameral and aneurysmal bone cysts. Both can be benign; however, they carry the risk of causing pain, bone fracture, and growth deformities. Dr. Rajeswaran outlines the current standard of care, which includes monitoring and curettage and bone grafting. Then, he describes a new method of treatment, which involves needle injection of doxycycline to burn the walls of the cyst and bone paste to help generate new bone. This method can be applied to unicameral bone cysts and aneurysmal bone cysts, and it leaves no scarring. He also discusses the recurrence rate for various treatment methods.

Overall, Dr. Rajeswaran encourages anyone interested in pediatric IR to reach out to doctors in the field for shadowing opportunities and guidance.

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RESOURCES

Society for Pediatric Interventional Radiology:

https://www.spir.org/

Lurie Children’s Hospital blog article over novel treatment of bone cysts:

https://www.luriechildrens.org/en/blog/interventional-radiology-cutting-edge-procedure-puts-brooklyn-back-in-the-game/

In this episode, Dr. Jacob Fleming interviews Dr. Majid Khan, a spine interventionalist and expert in neuroimaging, about microwave ablation, a new treatment modality that has garnered significant attention.

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SHOW NOTES

Dr. Khan completed his radiology residency in New York and his fellowship in neuroradiology at John Hopkins. As he progressed in the field, he observed a significant shift in spinal care towards interventional methods and began to study these techniques, which included radiofrequency ablation (RFA) and cryoablation for treating spinal tumors. However, when he treated cases of prostate cancer spine metastases, he realized that RFA was challenging, due to the high bone impedance of osteoblastic lesions. This obstacle piqued his interest in microwave ablation, an alternative technique that employs an electromagnetic wave to induce rapid oscillation of hydrogen atoms in water molecules. This oscillation generates frictional heat, leading to coagulative tumor necrosis. Unlike RFA, microwave ablation significantly reduces bone impedance, making it a promising solution for these cases.

Dr. Khan cautions that special care must be taken when operating in areas near nerves due to the elevated temperatures. To ensure safety, he recommends the use of a probe within the frequency range of 900 MHz to 1.2 GHz and the incorporation of thermocouplers as a safeguard during the ablation process. Furthermore, Dr. Khan delves into the indications for ablation based on the extent of tumor metastasis. In cases of oligometastatic disease, he advises a more aggressive treatment approach by extending the ablation zone beyond the actual tumor size. On the other hand, when dealing with diffusely metastatic disease, the primary goal of treatment shifts towards pain reduction.

The two conclude their discussion with Dr. Khan’s advice for physicians planning to utilize microwave ablation. He advises them to approach their initial 5-10 cases judiciously, in an effort to minimize the risk of complications that may adversely impact their self-confidence. Having adequate self confidence enhances the likelihood of achieving successful outcomes. For those looking for a valuable resource in the field, Dr. Khan has recently published a comprehensive textbook that features contributions from experts in the field.

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RESOURCES

“Assessing long-term locoregional control of spinal osseous metastases after microwave ablation”:

https://pubmed.ncbi.nlm.nih.gov/35963064/

Vertebral Augmentation:

https://shop.thieme.com/Vertebral-Augmentation/9781684200153

Image Guided Interventions of the Spine

https://link.springer.com/book/10.1007/978-3-030-80079-6

Dr. Steven Yevich from MD Anderson Cancer Center talks with us about his approach to Treatment and Management of Painful Extra-spinal Bony Metastases.

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Medtronic OsteoCool

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In this episode, Dr. Steve Yevich joins Dr. Michael Barraza to discuss treatment of extraspinal painful bony metastases. Dr. Yevich tells us about his training in interventional oncology at Gustave Roussy Cancer Campus in Paris, and we discuss how he adjusted to identify the individual needs of the hospital when he came back to the US.

We explain how to go into a case with either curative or palliative intent. Dr. Yevich shares when he would do soft tissue ablation around nerves and the location of the metastases he commonly treats. We emphasize the anatomic considerations to determine if ablation for the extraspinal bony metastases is feasible.

We discuss some of the advanced techniques Dr. Yevich learned in Paris and the two types of cases that may need pre-ablation embolization. We discuss advancements in technologies and devices that have allowed for more creative solutions in IR.

In this episode, Dr. Jacob Fleming interviews Dr. Alok Sharan about low back awake spinal surgery. This innovative approach offers patients a more pleasant surgical experience compared to traditional surgery under general anesthesia. Not only does it provide better patient outcomes, but it also reduces the need for opioid pain medication and allows for improved mobility after the procedure.

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Dr. Sharan began his career in academic medicine at Montefiore, where he gained valuable experience in caring for individuals with severe back problems requiring spine surgery. During his time at Montefiore, Dr. Sharan recognized the changing landscape of healthcare and decided to pursue a healthcare MBA. This unique combination of medical expertise and business knowledge led him to transition to private practice.

Dr. Sharan explains that awake spinal surgery offers several benefits for patients undergoing spine procedures. It enables patients to mobilize and recover from surgery more quickly, leading to faster overall recovery times and decreased risk of delirium. Additionally, patients have the opportunity to return home on the same day as the surgery, promoting a more convenient and comfortable experience. Awake spinal surgery also helps reduce the reliance on narcotics for pain management, with patients typically only needing narcotics for around four days compared to the usual four to six weeks with surgeries performed under general anesthesia. Due to the improvement in patient outcomes and the tremendous cost-efficiency of the procedure, awake spinal surgery is an appealing option for individuals requiring spinal fusions and other procedures.

Dr. Sharan's entrepreneurial drive has led him to create a comprehensive preoperative education program. His patients are provided with virtual reality headsets to simulate and experience the day of surgery and the actual surgical procedure. The aim is to alleviate any fears or anxieties the patients may have prior to undergoing surgery by immersing them in a realistic virtual environment. This approach helps to prepare patients mentally and emotionally, ensuring a smoother and more comfortable surgical experience. Dr. Sharan is now sharing his techniques with surgeons around the world and anticipates this technique being implemented in many fields in the future.

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RESOURCES

Awake Spinal Fusion:

https://awakespinalfusion.com

Doc Social:

https://doc.social

Dr. Sharan’s LinkedIn:

https://www.linkedin.com/in/alok-sharan-6a612610/

Interventional Radiologist Jason Levy and Radiation Oncologist Amir Lavaf discuss the benefits of a Multidisciplinary Approach in the Treatment of Spinal and Bone Metastases.

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In this episode, Dr. Jason Levy and Dr. Amir Lavaf join Dr. Michael Barraza to discuss their multidisciplinary approach to treating spinal metastases. We examine the collaborative efforts between IR and radiation oncologists, and we break down the indications for treating spinal metastases.

We discuss pain control and local control rates, and how doctors are working to improve them. Dr. Levy and Dr. Lavaf tell us why they are able to get better survival numbers when they approach the primary and metastatic disease at the same time. We explain how to work with tumor boards and different groups of doctors to make spinal metastases treatment easier.

We discuss how to reduce risk of delayed skeletal events and radiation failure after spinal metastases treatment. We go over some of the challenges of working with the tumor board, and why it is important to develop relationships with medical oncologists and the importance of continuing systemic therapies.

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RESOURCES

BackTable Podcast Episode 68: RF Ablation Therapy for Bone Metastases

https://www.backtable.com/shows/vi/podcasts/68/rf-ablation-therapy-for-bone-metastases

In this episode, host Dr. Jacob Fleming interviews one of his attendings Dr. Bhavya Shah about the remarkable features of focused ultrasound technology and its applications. They discuss its dynamic nature, allowing for a wide range of applications.

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SHOW NOTES

Dr. Bhavya Shah is a neuroradiologist at UT Southwestern in Dallas, TX and the director of their transcranial-focused ultrasound lab. While in residency at Boston MIT, he studied the radiology applications for nerve regeneration and expanded his scope of practice during his fellowship at Stanford. Dr. Bhavya Shah explains the use of low intensity focused ultrasound (LIFU) and high intensity focused ultrasound (HIFU), particularly in the context of movement disorders including essential tremor and Parkinson’s disease. LIFU is used to identify the appropriate targets in the brain in relation to the disease and may be used to alter how neurons behave. In contrast, high intensity focused ultrasound (HIFU) is utilized to ablate and destroy tissues typically after the localization of the intended treatment area.

Dr. Shah developed a way to identify targets in the brain for treatment with focused ultrasound with the use of four-tract tractography in cadavers. Using this technology, the brain can be thinly sliced into sections which could then be registered off an MRI back to the path using block face photography, allowing the identification of white matter tracts that enter and leave the thalamus. With these tracts identified, neuroradiologists can first stimulate the localized area with LIFU to confirm the location, then ablate using HIFU. The procedure lasts approximately 30-45 minutes as the patient remains awake. Remarkably, patients with essential tremor usually experience benefit immediately following the procedure as patients with Parkinson’s have symptom improvement within days to weeks. After two hours of observation, patients are discharged assuming no side effects. Side effects are uncommon but can include numbness and tingling around the mouth or fingertips as well as muscle weakness.

Beyond its use for movement disorders, the adaptable nature of focused ultrasound technology shows promise for a broad range of applications, particularly for the use of neuropsychiatric conditions. Dr. Shah offers the potential for the use of HIFU as a wearable device that delivers constant stimulation modulated by biofeedback, potentially eliminating the need for MRI for the procedure. Dr. Shah and Dr. Fleming end the discussion with how radiology has evolved over the years and the importance of keeping an open mind working in a multidisciplinary team. They emphasize the gravity of patient engagement and the central goal of medicine and improving the standard of care should always be aimed at benefiting the patient.

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RESOURCES

MRI–Guided Focused Ultrasound Thalamotomy for Essential Tremor:

https://thejns.org/view/journals/j-neurosurg/138/4/article-p1028.xml

Trial of Globus Pallidus Focused Ultrasound Ablation in Parkinson’s Disease:

https://www.nejm.org/doi/10.1056/NEJMoa2202721

Long-term effects of bilateral subthalamic nucleus deep brain stimulation on gait disorders in Parkinson's disease: a clinical-instrumental study

https://pubmed.ncbi.nlm.nih.gov/37208527/

Magnetic Resonance Image Guided Focused Ultrasound Thalamotomy. A Single Center Experience With 160 Procedures:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8894664/

En este episodio de BackTable, las Dras. Gina Landinez y Ana María Fernández Martínez hablan sobre el intervencionismo musculoesquelético y las técnicas para la embolización del hombre rígido.

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SHOW NOTES

La Dra. Fernández Martínez explica su trayectoria en el campo de intervencionismo musculoesquelético y la oportunidad de entrenarse en Japón. Luego entra en detalles técnicos, describiendo cómo obtiene acceso usando su microcatéter para entrar a las articulaciones que quiere tratar. Explica que estas arterias son de un calibre muy pequeño, así que necesita herramientas diferentes para los procedimientos esqueléticos. También, ella describe el efecto que tiene la embolización en las fibras nerviosas y la inflamación para restaurar la vascular normal.

Adicionalmente, las doctoras explican quienes son los pacientes ideales para la embolización de un hombro rígido. Dra. Fernández Martínez distingue síntomas de un hombro rígido, como la limitación de la vida diaria y la movilidad, y hace la distinción entre esta patología y la artritis. Habla también del tiempo ideal para la embolización para optimizar los resultados y la importancia de la rehabilitación con la fisioterapia. Próximo, la doctora explica los beneficios inmediatos y a largo plazo que ve en sus pacientes. Usualmente, se pueden ver los efectos de la embolización tres meses después del procedimiento si el paciente participa en la fisioterapia, y el máximo beneficio ocurre a los seis meses. Repetición del procedimiento es posible también.

Finalmente, las doctoras hablan sobre las complicaciones de la embolización, que incluyen un hematoma en la zona de punción. Dra. Fernandez Martinez termina el episodio alentando a sus colegas radiólogos intervencionistas a explorar la embolización musculoesquelética.

In this episode, host Dr. Michael Barraza interviews Dr. Stephen Hunt about building a pain practice, including his nerve ablation technique, how to obtain referrals, and why it is one of the most rewarding procedures that he does.

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We begin by discussing what caused Dr. Hunt to start building a pain service. He was treating many patients with lung cancer, and he saw so many patients toward the end of their life. What they wanted was to reduce their suffering due to pain. He saw what was being offered for them, which was opioids, but this caused them to be disconnected from their families at such an important time in their life. He knew he could offer nerve blocks and ablation, so he began educating himself. As he learned about different blocks, he adapted them to create his own technique.

Pretty soon, word got out that he was doing this, and he started getting referrals from oncologists. Soon after this, thoracic surgeons and breast surgeons began referring to him for post-thoracotomy and post-mastectomy pain. Next, radiation oncologists referred their patients with radiation necrosis of the ribs, and orthopedic surgeons referred patients to him for pain from musculoskeletal metastases.

For his technique, he often starts with a test block using bupivacaine and triamcinolone, which prolongs the effect of the bupivacaine and provides relief for around two weeks. For the ablation, he does the block in the same way, waits 15 minutes, and then injects ethanol to ablate the nerve. Some tips he has learned for celiac ablation are to ablate the retrocrural splanchnic nerves, because they feed into the celiac, and you will get a better result. Other areas he commonly ablates are intercostal nerves. For these, to avoid devastating paralysis from damage to the spinal cord, he always orients his needle lateral and stays at least two inches away from the spine. He advises those new in pain interventions to remember your anatomy. In radiology, we learn it all, and if you remember these nerves, you will be able to help a lot of people with their pain and decrease their suffering, making an enormous impact on someone’s quality of life.

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RESOURCES

PIGI Lab:

https://www.med.upenn.edu/pigilab/

Twitter:

@PigiLab

@md_rogue

In this episode, host Jacob Fleming interviews interventional radiologist Tony Brown and orthopedic oncologist Daniel Lerman about their multidisciplinary IR/orthopedics practice and innovative techniques for pelvic fixation in metastatic cancer patients.

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Viz.ai

https://www.viz.ai/

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The guests recount their first case together, a “no option” patient in which they collaborated on a tripod fixation of an acetabulum, using a combination of screw placement and cementoplasty. They realized that they were both invested in improving minimally invasive fixation and helping patients with pain management and daily functioning. Their collaboration blossomed into a joint practice of MSK interventional oncology that offers biomechanics knowledge of orthopedic surgery and the precise image guidance of interventional radiology. With the rise of systemic cancer therapies, more patients are living with metastatic bone disease, and this new treatment paradigm could offer them a true joint reconstruction and stable fixation. Overtime, they have streamlined the technique to make their cases more efficient and precise.

Despite their advances, Dr. Brown notes that MSK interventional oncology still has a long way to go. In the community, pelvic fractures usually go untreated. He speaks about the importance of outreach to radiation oncologists and orthopedic surgeons and letting them know about new methods of pelvic fixation. Dr. Brown encourages IRs who are curious about MSK interventions to get in contact with colleagues who are already doing innovative techniques and device companies that offer classes. Additionally, there is a need for innovation in instrumentation. Most pelvic intervention tools have been adopted from spine tools; however pelvic anatomy and pelvic lesions are vastly different. Dr. Lerman highlights the uniqueness of each patient’s disease, tumor, and bone lysis. He believes that there is a need to elucidate why different patients respond to different types of constructs.

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RESOURCES

Institute for Limb Preservation:

https://www.limbpreservationcolorado.com/

Musculoskeletal Tumor Society (MSTS):

http://msts.org/

In this episode, Dr. Jacob Fleming interviews Dr. Olivier Clerk-Lamalice about basivertebral nerve ablation for vertebrogenic back pain, including indications, procedure technique and exciting tech on the horizon in minimally invasive spine interventions.

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Dr. Clerk-Lamalice trained in Canada, first in engineering, and then medicine and diagnostic radiology at the Université de Sherbrooke in Calgary. He then completed a neuroradiology fellowship at Harvard, and a fellowship in interventional pain at The Spine Fracture Institute in Oklahoma City with Dr. Douglas Beall. Furthermore, he obtained his credentials as a fellow of interventional pain practice (FIPP), which is a widely recognized international designation. He now works at a comprehensive outpatient radiology center, where he practices both diagnostic and interventional radiology daily. They offer intrathecal drug administration, spinal cord stimulators, vertebral augmentation, Spine Jack, disc augmentation, nucleolysis, and various nerve blocks and ablations in and out of the spine. Their goal was to create a one stop shop for patients to come for consultation, imaging, expert advice and treatment.

Next, we discuss vertebrogenic back pain and the basivertebral nerve (BVN). The BVN is a nonmyelinated, intraosseous nerve, while most other peripheral nerves are myelinated, meaning they can regenerate. The BVN cannot, so ablation of this nerve is a permanent treatment. It is located within the central portion of the vertebral body midway between the superior and inferior end plates, one third ventral to the posterior wall of the vertebral body. On a sagittal T2 sequence on MRI, there is a triangle at the posterior aspect at the midpoint of the vertebral body called the basivertebral canal, which contains the nerve, artery and vein. The BVN is responsible for vertebrogenic back pain, which is a form of anterior column pain characterized by low back pain worsened by flexion and sitting. It is diagnosed via MRI using the Modic classifications. Modic type 1 (edematous), and type 2 (fibrofatty end plate) changes can be seen in this disease. It can be difficult to distinguish vertebrogenic from discogenic pain due to the fact that the sinuvertebral nerve (SVN), responsible for discogenic pain, crosses paths with the BVN. However, with MRI and an anesthetic discogram, it is possible to determine the etiology and choose the right treatment.

Finally, we discuss the steps of the procedure. Dr. Clerk-Lamalice uses an 8 gauge needle via a transpedicular approach, as is common for other spine procedures. He ensures the probe is positioned in the center of the vertebral body, parallel to the endplates. The nerve is ablated for 15 minutes at 85 C. The procedure takes 45 minutes, which includes an epidural steroid injection to bridge pain control during the periprocedural period. Patients usually go home within one hour after the procedure, and begin to experience the results within a couple days. There have been two trials for BVN ablation, which have made this intervention the most minimally invasive and evidence-based treatment for vertebrogenic pain. These studies indicated 25% of patients had a 50% reduction in pain, while 75% of patients had a 75% reduction of pain. Within that 75%, 30% reported being almost entirely pain free. To date, the study has followed participants to 8 years, and the results show the treatment is durable.

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RESOURCES

Ep 210: Modern Vertebral Augmentation

https://www.backtable.com/shows/vi/podcasts/210/modern-vertebral-augmentation

Ep 94: Spine Interventions

https://www.backtable.com/shows/vi/podcasts/94/innovation-in-spine-interventions