In this episode, host Dr. Jacob Fleming interviews Dr. Edward Yoon, interventional MSK radiologist and Chief of IR at the Hospital for Special Surgery. The doctors discuss novel intradiscal therapies to treat anterior column pain, as well as where the field of spine interventions is heading.

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SHOW NOTES

Dr. Yoon outlines his path to his current specialty area. His interest in orthopedics and minimally invasive techniques led him to pursue fellowships in MSK radiology and spine intervention. He highlights how MSK IR is emerging as a cousin to orthopedic surgery, in the same way that VIR is related to vascular surgery. With nine different specialties practicing interventional pain and spine procedures, Dr. Yoon believes that IRs can differentiate themselves by taking ownership of follow up care and complications management. He emphasizes the importance of building a practice instead of waiting for patients to be referred to you. He also highlights the need to collaborate with colleagues in different specialties (orthopedics, PMR, pain management) to educate them about novel IR techniques and patient populations that could benefit from these.

Next, the doctors discuss the leading cause of low axial chronic back pain: stable discogenic pain. Though there has not been a proven treatment to halt degenerative disc disease, there are a few therapies that could help patients with painful symptoms. Dr. Yoon describes his use of anesthetic discogram as a diagnostic and therapeutic tool for discogenic back pain. His injectant is a mix of lidocaine and dexamethasone, and he observes if the patient experiences pain relief. Due to literature that links discograms with accelerated disc degeneration, discograms are less commonly performed today. However, Dr. Yoon believes that many younger patients already have degenerated discs when they present for evaluation and every interventional procedure poses some risk that can reasonably be evaluated in collaboration with the patient. Alongside imaging, he evaluates patient symptoms, the most common being midline back pain that gets worse with flexion or axial loading. Dr. Yoon also offers tips for reading spine MRIs, which include adopting a systematic approach, noting important incidental findings, and correlating findings with patient symptoms.

Finally, Dr. Yoon highlights some exciting therapies that are currently under investigation. The VIA Disc procedure involves an allographic injection of ground up nucleus pulposus into the disc. From the VAST Trial, there is data showing that treatment responders experience pain reduction and improved functioning. Autologous injection options include platelet rich plasma (PRP) and bone marrow aspirate concentrate (BMAC). Spinal modic changes could be treated with basivertebral nerve ablation (BVNA), which is a good option that is low-risk and does not preclude the possibility of future interventions. All of these therapies come with the caveat of unreliable insurance coverage, since many private payers are hesitant about approving them. The disconnect between evidence-based therapies, patient needs, and insurance coverage needs to be addressed if these therapies are to become mainstream.

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RESOURCES

VAST Clinical Trial:

https://pubmed.ncbi.nlm.nih.gov/34554689/

VIA Disc NP:

https://gotviadisc.com/

Owestry Disability Index (ODI):

https://www.aaos.org/quality/research-resources/patient-reported-outcome-measures/spine/

SMART Trial:

https://pubmed.ncbi.nlm.nih.gov/32451777/

INTRACEPT Trial:

https://www.nassopenaccess.org/article/S2666-5484(21)00041-X/fulltext