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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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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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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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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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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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/

In this episode, host Dr. Eric Keller interviews Dr. Sean Tutton about palliative care as an interventionalist, how he became interested in palliative care, and why he believes it is a crucial aspect of patient care in interventional radiology.

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The role of palliative care is to talk with patients about their goals, make them comfortable, optimize medical management, help patients understand their diagnosis, and coordinate care. Though palliative care involvement does not mean a patient is close to death, many palliative care patients will enroll in hospice at some point. Once in hospice, life-prolonging therapies are no longer pursued. Hospice care is a benefit of Medicare. It has support such as home care, and it can be expensive but is covered by the government. Due to this, there are guidelines that need to be adhered to. Frequently, palliative interventional pain procedures such as a celiac plexus block or neurolysis may not be covered so patients may have to come off hospice to get the procedure, then go back on.

Next, we talk about how an IR can start to incorporate these ideals and practices into their daily work. Dr. Tutton emphasizes that you don’t need to do the fellowship. You can start rounding with palliative care, go to their conferences, and establish relationships. Having residents and fellows rotate with palliative care is a great way for future IRs to learn how to practice with a palliative care mindset, and also to educate palliative care on the minimally invasive options that IR can offer to patients such as nerve blocks and ablations. By adopting palliative care ideals as an interventionalist, you can help your patients achieve better pain control, improve their cognition and reduce narcotics use.

Dr. Tutton recommends all IRs understand the medical management of post-op pain for any procedure they perform. He provides a standard medication regimen for a patient having an ablation. He uses Tylenol 1g pre-op and gabapentin 300-600mg 48-72hrs before the procedure and intraoperative steroids and NSAIDs such as Decadron 8-10mg and Toradol 10-30mg. All of these have level 1 data, help reduce narcotic requirements, and help with post-op nausea and pain. He discharges patients on a Medrol dose pack, ibuprofen, Tylenol, and gabapentin for a couple of days. Doing a nerve block can help as well, he frequently does ankle, digital, intercostal, and hypogastric blocks for his MSK and palliative interventions.

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RESOURCES

Ep.199: Advanced Minimally Invasive Pain Interventions with Dr. Prologo

https://www.backtable.com/shows/vi/podcasts/199/advanced-minimally-invasive-pain-interventions

Ep. 68: RF Ablation for Bone Metastases with Dr. Levy and Dr. Bagla

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

Dr. David Wood, interventional radiologist and chief medical officer of Advantage IR, tells us about his experiences with geniculate artery embolization (GAE) practice building in the office-based lab (OBL).

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In this episode, host Dr. Michael Barraza interviews Dr. David Wood, interventional radiologist and chief medical officer of Advantage IR, about building office based labs (OBLs), the untapped potential of the geniculate artery embolization (GAE) market, and how to build patient referrals for new OBLs.

We begin by discussing why Dr. Wood chose to do geniculate artery embolization (GAE) in his OBLs. He says that GAE makes a great procedure for an office setting because it is relatively easy, only requiring a C arm with digital subtraction angiography (DSA). It is also a quick procedure with little side effects and low rates of complications. He says that patients who get GAE are a unique patient population because they know they have arthritis, and have exhausted conservative measures or declined treatment options that they have been offered, which are often quite invasive.

Dr. Wood says his GAE patients are mostly self-referred. He has marketing liaisons for local clinics, but what he has found most effective is TV commercials in English and Spanish, because this reaches the populations that need the most help. His patient population for GAEs consists mostly of self referred patients, as well as referrals from PCPs and occasionally orthopedic or sports medicine providers.

Regarding how Dr. Wood evaluates which patients to treat, he says that he began by using the point of maximal tenderness as described by Sandeep Bagla and required MRI before patient selection. He now uses primarily X-ray and only treats pain rated at least 5 out of 10. He does not do GAE in patients who have had knee surgery or with a history of significant PAD or calcification seen on preoperative X-ray. He generally tells patients they can expect up to a 70% improvement of pain after geniculate artery embolization.

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RESOURCES

BackTable Ep. 27: Geniculate Artery Embolization for OA with Dr. Sandeep Bagla and Dr. Ari Isaacson

https://www.backtable.com/shows/vi/podcasts/27/geniculate-artery-embolization-for-osteoarthritis

BackTable Ep. 85: Genicular Artery Embolization for OA with Dr. Jafar Golzarian

https://www.backtable.com/shows/vi/podcasts/85/genicular-artery-embolization-for-oa

Bagla GAE Publication:

https://pubmed.ncbi.nlm.nih.gov/31837946/

Padia GAE Publication:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8542160/

We talk with interventional radiologist Dr. David Prologo about minimally invasive pain interventions, multidisciplinary pain management, and how he built a successful pain practice.

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In this episode, host Dr. Michael Barraza interviews Dr. David Prologo, director of interventional radiology at Emory about minimally invasive pain interventions, multidisciplinary pain management, and how he created a booming practice that is well known by patients and providers nationally.

Dr. Prologo begins by discussing his training in obesity medicine and how his interests in pain management developed. He discusses his book, The Catching Point, which explores weight loss culture and the fault of society and medical providers in placing the blame on patients and the new options available in IR for weight loss. He says his interest in pain management was similar to his interest in obesity medicine. He was curious about how he could use his tools and skills as an IR to treat obesity and pain with minimally invasive procedures.

Next, they discuss how IR fits into the multidisciplinary team that plays a role in pain management. He explains that the combination of technology and an IRs position in the hospital makes them ideal for the job. He says a key is to maintain relationships with all other specialties by focusing initially on procedures that other specialties don't perform, in order to build rapport. He also notes that the procedures he performs result in rapid pain reduction and greatly decrease length of stay which is a huge incentive for hospitals and other specialties to seek out IR and make referrals.

Finally, the two discuss the types of patients Dr. Prologo treats, and the procedures he does. He divides patient population into neoplastic versus non neoplastic pain, and spine versus non spine pain. He sees 90% of patients in clinic for procedure planning. Dr. Prologo emphasizes the importance of advocating for patients and continuing to see them even if they do not need an IR procedure. He discusses his 8, 3, 3, 3 method for percutaneous cryoneurolysis and discusses the various outcomes he is able to achieve in pain reduction. Dr. Prologo minimizes non responders by doing test blocks, understanding central desensitization, and selecting patients for procedures appropriately.

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RESOURCES

Interventional Cryoneurolysis: An Illustrative Approach: https://pubmed.ncbi.nlm.nih.gov/33308581/

Focused Cryo:

https://gra.org/company/213/Focused_Cryo.html

Nantes criteria for pudendal neuralgia:

https://pubmed.ncbi.nlm.nih.gov/17828787/

The Catching Point

https://www.catchingpoint.com

David Prologo Website:

https://www.drprologo.com/about