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Introduction | Interventional Pain Management
Introduction | Interventional Pain Management
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Role of Interventional Procedures in Pain Management | Interventional Pain Management
Role of Interventional Procedures in Pain Management | Interventional Pain Management
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Categorisation of Pain | Interventional Pain Management
Categorisation of Pain | Interventional Pain Management
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Case: Radiofrequency Ablation and Cementoplasty of Spinal Metastasis | Interventional Pain Management
Case: Radiofrequency Ablation and Cementoplasty of Spinal Metastasis | Interventional Pain Management
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Case: Cryoablation of Rib Metastasis | Interventional Pain Management
Case: Cryoablation of Rib Metastasis | Interventional Pain Management
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Case: Pudendal Nerve Cryoablation | Interventional Pain Management
Case: Pudendal Nerve Cryoablation | Interventional Pain Management
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Case: Necrotic Vaginal Mass Nerve Cryoablation | Interventional Pain Management
Case: Necrotic Vaginal Mass Nerve Cryoablation | Interventional Pain Management
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Case: Non-cancer Back Pain (Follow-up of Case 1) | Interventional Pain Management
Case: Non-cancer Back Pain (Follow-up of Case 1) | Interventional Pain Management
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Case: Cryoablation in Inguinodynia | Interventional Pain Management
Case: Cryoablation in Inguinodynia | Interventional Pain Management
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Objective Outcomes in Interventional Pain Management | Interventional Pain Management
Objective Outcomes in Interventional Pain Management | Interventional Pain Management
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Questions | Interventional Pain Management
Questions | Interventional Pain Management
2018ablationablationsAVIRchapterepiduralfull videointernetinterventionalkyphoplastypalliationpatientspracticingreimbursementuniquevertebroplasty

- Our next speaker is Dr. David Prologo. Dr. Prologo completed his medical training at Ohio State University, he then completed his diagnostic radiology residency at University Hospitals Case Medical Center and his vascular interventional fellowship at Case Western Reserve School of Medicine in Cleveland, Ohio.

He is currently an assistant professor with Emory University Atlanta Georgia, where he also serves as a director of interventional radiology. Please help me welcome Dr. David Prologo to the podium. (applauding) - [David] Thanks.

- [Woman] Hi. (murmuring) - Hello. Good afternoon, I'm Dave Prologo, thank you all for being here this afternoon and thank you for inviting me to talk.

This is one of the best talks of the meeting to be honest with you, at least definitely the most fun, so, the topic here is gonna be interventional radiology, palliation, and pain management. And I've been giving this talk for a while,

and I would put up a procedure and talk about the indications and then throw up a review article and some data, then shortly after, I'd look out into the group and like half the people are zoning out or on their phones, and so I wanted to do it a little bit differently, and then after that

I'd walk out and people would say, well, what do you actually do with these patients? And so I tried to change the talk so that I can answer the question up front. How do we actually manage these pain patients in interventional radiology and why?

These are my disclosures, most of them are research related. And so the opening slide really is here to illustrate the following point. Pain specialists are usually anesthesia trained and there's a fellowship in anesthesia called anesthesia interventional pain management,

and those are the folks who historically have done these procedures. We include these here to demonstrate that on their flagship journal, which is Interventional Pain Management, there's images, right? There's radiology on the front of all of these

and it sort of illustrates how they are moving towards us by trying to learn how to use image guidance for their procedures. On the other hand, we all in this room understand the skill set and routinely use image guidance for other reasons,

and so we're meeting in the middle here, applying our interventional radiology skillset to pain syndromes that we've learned about, or, trying to address the pain syndromes that we know using image guidance. Superimposed on all of this

is a blade of technology that we use for cancer, and I'll show you what I mean by that.

So why do it? I'm sure that everybody here is super busy and a lot of late nights and a million cases to do as it is, so why do we even wanna dip our toe here at all?

The primary reason is really the opioid crisis that the world is in, that our nation is in, that we see on TV every day, and that the CDC has recently declared the need for interventional procedures, the need for innovation on the interventional procedure side to address

these pain conditions in lieu of opioids. Let me go into what I mean. So that's what this one is, so sorry for the sports reference, but this is supposed to represent a scene here, and this guy's running through it. So really we have an opportunity right before us that

we can address through innovation and through clinical practice. So that's one reason to do it, that it's right here in front of us and perhaps we're called to do it. We're all sort of curious, we didn't find our way into these professions without having some sort

of curiosity and professional satisfaction from helping the patients. And then finally, we have an opportunity to put some good back into the world. Helping these patients in pain can be extremely rewarding.

So once we're past the why, this is really the how.

And so each one of these can be a talk in and of itself, and the purpose of this slide is to show that when a patient presents with pain, either in the hospital we get a consultation. Routinely they'll say to us, we have a patient on the floor with pain, no kidding,

and then we have to go up and sort it out. Or, a patient will walk into our clinic and say, I've got pain. And so from there, we hope to put them into one of these four boxes, and that is, is this a cancer related pain?

And is it a spine related pain? And then those combinations, so, cancer in the spine, cancer outside of the spine, spine pain that's not cancer related, which is exceedingly common you can imagine, and then pain outside of the spine that's not cancer related.

So as soon as we sort out those things, we have choices inside each box for how we can treat.

And to illustrate that, we'll use some real world examples instead of long descriptions, and hopefully that will be better. So this is a patient who walked into our clinic

and said Dr. so-and-so sent me here because I have back pain. And so the first question in our attempt to put him into one of these boxes was, do you have a diagnosis of cancer, is this cancer-related? Oh yeah, I have cancer and I think it's in my back.

So now, we've got a cancer-related legion that's in the spine, the only image we had was an abnormal bone scan. So we put this patient, I'm gonna skip this one. We put this patient into the CT scanner because they couldn't get an MRI,

demonstrated this lytic lesion, which was a primary lung cancer that has metastasized to L5. This is what it looks like on the sagittal. And once we have this patient... So I can go back. So once we have the patient into this box,

then we can limit our available procedures and it's not so overwhelming and/or confusing. And in this case, it's spinal ablation and cementoplasty in the spine and this is done in the IR suite. And I'm sure most everyone has done or is familiar

with kyphoplasties and vertebroplasties and probably even this procedure, which has evolved recently. It's the same approach, it's a percutaneous coaxial approach. We use the same needles that we use

for kyphoplasty of vertebroplasty, we go down the pedicle, we do a particular approach for this particular vendor. This is what it looks like in the lateral. Once we have our coaxial needle though, instead of pulling out the inner stylet

and putting a balloon, we put in a radiofrequency ablation probe, and the radiofrequency ablation probe creates a zone of heat that kills the cancer. We can't see it, but we know the epicenter is here and we know that if we reach the appropriate temperatures on the readout mechanism, that it'll be

two centimeters by three centimeters. So this does two important things. The first one is it kills cancer, right, because the source of pain for this patient is cancer cells that are in contact with the bone. And that hurts, as the cancer eats away your bone,

you can imagine. And then the second one is when a bone gets weakened by the cancer eating it away, you end up with a fracture. And when those patients move, those fracture fragments move on each other and that hurts. So by having this coaxial approach

and the ability to move things in and out, we can kill that cancer, and address the biological portion. We can follow this with cement and address the mechanical portion or glue those fragments together so that they move together when a patient moves together. And we've had great outcomes subjectively at our center,

meaning that we see these patients the next day, or we see them that night and they feel better and it's bearing itself out in the literature as well.

Same patient came back to clinic, no more cane, and this is true, I'm not making this story up. No more cane, says his back pain is gone,

but he forgot to tell me that he's got rib pain. Since we did such a great job on his back, is there anything we can do about that rib? So back to the same thing. We know he's got a diagnosis of cancer, so he's probably gonna fall in one of these boxes,

not that a patient with a diagnosis of cancer can't have osteoarthritis, but most likely the pain that they're presenting with is gonna be in one of these boxes. There were no more lesions in the spine, but PET, he certainly had this huge area

of abnormal radiopharmaceutical activity and he was pointing there saying, this hurts. So that makes it pretty easy, we'd drop him into this box, which is a cancer-related pain that's not in the spine. And so what options do we have in this box? These, ablative techniques, meaning cryoablation,

microwave ablation, radiofrequency ablation, nerve ablations, which are the same modalities but targeted at the nerves that are carrying the pain, I'll show you what I mean about that, and then catheter techniques. Sometimes if we have a huge vascular mass,

we can embolize the vessels and de-bulk the mass. So let me go back. So cancer pain, not in the spine, these are our options. For this particular patient... Skip that. For this particular patient, we chose to use cryoablation

at the epicenter of the mass. This is the mass eating away at the rib, eating away at the adjacent soft tissues. The mechanism of relief here is death of the cancer cells that are in contact with the soft tissue. So it's important that we...

If we just ablated here, and then attempt to de-bulk this, the patient wouldn't do well. But if we continue to ablate and let the ablation zone engulf the entire tumor, then the patient leaves the CT table feeling better than they did the day before.

Another example of the same box, this is a patient who was on the floor in intractable pain with a pelvic mass. Can't have radiation, can't have surgery, on a PCA, not leaving the hospital. Is there anything we can do?

That's the consult, right? And so, not to be brutally repetitive, but we go through this process every time, this is cancer, it is a pelvic mass, it is causing her pain, it's not in the spine, what can we do here?

One of these three things. In this particular case though, directly ablating this is not really a feasible option. It's just too big and there are too many critical structures to ablate the entire thing like we did with the rib met. So we have to pick something else.

It's not particularly vascular, so this is where the nerve ablations come in. We do a lot of these cases at Emory, and the way that this works is we bring the patient in to CT, we drop our cryoablation probes into the region of the nerves that are carrying this pain.

So a patient with a pelvic mass has painful signals going to their brain out this way, out the pudendal nerves, so we cryoablate the pudendal nerves, we create a saddle anesthesia, and the patients are eternally grateful.

Same sort of example.

Patient on the floor, this was a necrotic vaginal mass actually. No options, PCA, no radiation, to interventional radiology for cryoablation of the exiting nerves and relief of her pain.

Same patient from the beginning, no lie.

Back pain gone, cane gone, rib pain gone, this guy is dancing a jig. But he mentions to us that, I still have this kind of ache. Is there anything you can do about that? And so we said sure, we said sure. But we think that you no longer have cancer related pain.

There are no new mets in the spine, this is not outside of the spine, and so we're gonna work you up as if it's a non cancer-related spine issue. And this is definitely something that we could run a whole course on, if not an entire day

covering the conditions that cause non cancer-related back pain because there are so many, facet hypertrophy, spinal stenosis, disc disease, and on and on. But globally speaking, if it's not a cancer in the spine, this is how we go about it.

We ask the patient, what is your pain? If it's band-like low back pain that's one thing and that's gonna drop us down here. Oftentimes we end up with just midline epidurals. If it's leg pain that's related to a disc herniation or other, then we go down the radicular pathway

and we end up with either disc decompression or transforaminal nerve blocks. Another group of procedures that we do quite a number of. And in this particular guy, we did, this is not actually him, I gave this talk this morning and somebody pointed out

that there was no cement at L5 and called me out that I had made this whole story up. This was just a good image that I had of an epidural, I swear I didn't make this story up. And this is contrast in the epidural space of a patient who didn't have a diagnosis of cancer,

but this is what it looks like.

So continuing on, trying to keep with our same triage of the patients who come in, our same workup, this is another real life situation that we're seeing a lot of, patients who have inguinodynia, they have pain in the inguinal region,

sometimes after an interventional radiology procedure because we hit the nerves during the access, but more commonly during our post hernia repair. So a hernia repair with mesh oftentimes will damage or include accidentally genitofemoral ilioinguinal nerves.

And these patients for the last 40 years or so haven't really had good options. The surgeons don't wanna take the mesh out, and so they get opioids. And this is included in this talk to sort of bring home the point that we can use

what we have to address problems that otherwise are gonna be opioid recipients. So this is not cancer, this is not in the spine, this is a peripheral legion in a patient who had mesh. This is another big topic, but if we're asking what's in this box, what's in this box

are all of these things. Sympathetic nerve blocks, sympathetic nerve neurolysis, and all of the peripheral nerves. So using CT or using fluoroscopy, I'm sure you're all familiar with hip injections and SI injections and fluoro, we can take it a step farther in CT

and do genitofemoral, illioinguinal, illiophyogastric, all these nerve that are otherwise not easily accessible in the fluoroscopy suite. So for this particular patient, we imaged him. This the normal side, this is the femoral artery inferior epigastric, this is what it's supposed to

look like, this is normal fat over here. Over here, this is the mesh and in deep to the mesh, you can see all this shmutz, which is fibrous tissue and inflammatory tissue entrapping the nerves and accounting for his pain. So these are real life human beings

who have a real problem in pain and no one has an option for them, so they just give them opioids and this is something that we can get to with image guidance. And this is just a cadaveric analock here to show you that this is where these nerves live between these two vessels.

Take this patient to CT, do a diagnostic injection, we can't just start cryoing everything, we have to do a bupivacaine injection first to make sure that if we do cryo that the patient's gonna feel better. So this is the dress rehearsal here.

This is a different patient obviously, we're on the other side, but this is what the cryo looks like. We took a cryoablation probe right in from the side, put some fluid around the femoral nerve here, create an ablation zone that engulfs the nerves,

engulfs the fibrous tissue, engulfs the mesh, and cuts off the signal of those nerves to the brain through freezing.

So big picture. Cancer in the spine is radiofrequency ablation like kyphoplasty but with radiofrequency ablation instead

and followed by stabilizing cement. Peripheral cancer legions, we usually ablate them, but we can also ablate the nerves that carry the pain signal or even de-bulk them using a embolization technique. The pain that people have outside of the spine

that's not cancer related is usually amenable to some advanced imaging guidance access to the sympathetic nervous system or actual peripheral nerves. And then finally the algorithm we talked about for patients who have non cancer-related spine pain,

which is probably the most common complaint of all. So is it worth it? And after you do this for a while, you definitely start to ask yourself this because your partners are just doing some Y-90s and then going out fishing and so you wonder

if I'm getting all these calls from all these pain patients, is it worth it? So that's what this is supposed to represent, you gotta kiss a lot of frogs before you get to this inguinodynia guy who's real thankful and sending you a fruit basket.

They're not all like that. And that's the subjective part of it. Is it worth it to deal with a lot of secondary gain issues and difficult patients to get to the good ones? And for now, it is, for me at least. And then objectively is it worth it?

So it's not just what do I think is in my opinion, but what are the objective outcomes? We know what we study radio embolization or some of the other things that all of you do, that the variables we're looking at are disease control, overall survival, stuff that we understand.

But that's not here, here the outcome variables are different, and when you talk about VAS, you're talking about visual analog score, that's a really murky thing because if I ask you what your 10 to nine is, that might be 10 to one for somebody over here, so it's hard to kind of

equalize those things. And so we look to the literature for this. The literature defines a significant decrease in pain on average as three points on a VAS. So 10 to seven, seven to four, and so on. But this is tough, this is tough to stick by.

So we use these other two things. This one is patient global impression of change. It's a seven point question. You simple ask them to mark one of the following and it says compared to prior to the procedure, my pain is unchanged, in the middle,

or slightly worse, very much worse, and I forget what the last one is. And on the other side, slightly better, very much better, and so on. And so that's another way to sort of evaluate if what you're doing is worth it,

if you can look back at the hundred patients you did in 2017 and get yourself an average here of how many people said that they were improved compared to how many people report objective improvement, you can start to see whether or not you're doing any good and is it worth it.

Lastly, time travel, I call it time travel, it's just, both of these can also be murky and so I have found that to simplify these, you can just ask them, if you could go back in time again, would you do this procedure again. To try and dispel with all these other things

and the fact that it's subjective interpretation of pain and so on and so on. And so this is actually very helpful. In some of the procedures we've done, we've gotten the answer 80% of people said that if they could go back in time,

they would do this procedure again. Not to get to far off the topic, but you try to correlate that with this then, and sometimes it goes and sometimes you'll see a patient who says they have 11 out of 10 pain, but they would definitely do it again.

So, it's a lot of ongoing analysis of what you're doing. But in the end, it is definitely rewarding to be able to take someone's pain away, especially when no one else can in the interventional suite or in the CT suite.

And I think that is all I have. Are there any questions about all that?

Hopefully that wasn't too fast. I have to run out (laughs). So, that's a good question. The question was how's the pay, right? Do we have trouble with reimbursement? And so it varies.

An epidural RVU, if we're gonna compare RVUs, an epidural is like a pick line, but a spinal ablation is like a tips, so, and then the third option really are some of these CT guided nerve ablations you end up fighting with the insurance company because they're on the leading edge.

And most of those end up being reimbursed at a decent rate, so for the most part it is still... I'm in an academic center, so I'm not too involved in that, but still fairly lucrative. If it wasn't, I'm sure I would know, they would call me.

That's another great question. Do we follow the patients in clinic? So a lot of these patients travel to us to have these things done, and so we don't follow them. And to be honest with you, we really don't. We should, but we don't.

And it's just sort of a resource thing. We see these patients in clinic and we have such a high volume, and we do the cases, and one good thing about this patient population is they will definitely call you if anything is wrong. (laughing)

So you can get away with that, with not following, but we should, we should. Yes sir. Oh boy, that's an interesting question. So they're both usually approved. The kyphoplasty reimbursement is much higher

than the vertebroplasty reimbursement and there is definitely as school of thought that that fact drives us to perform kyphoplasty instead of vertebroplasty and I'll sort of just leave that out there like that. So I think they're both approved, which you'll find

that kyphoplasty at this point in time is much more lucrative than vertebroplasty. You mean... Oh, oh, oh, yes (laughs). Not self referrals like hey, do you wanna come and see me for your pain, but, after I do their Y-90 or something

or mess up their groin, but no, no, I know what you mean. Yeah, we get a lot of people because we're practicing in a very unique time, all of us, and that's the world wide web and people will find you and they will come with the most unique pain syndrome

that they've been trying to get treated for 40 years and if you can treat them, that's great. And you'll love it. And then sometimes, we have some, you know if I had some more time, we have some interesting stories. But yes, they will find you on the internet for sure.

Yes, ma'am. (laughs) So this is Leslie, she's my friend (laughs). And this is how we talk all day in the interventional radiology suite. And she called me yesterday and I go

hello, are you here? And my wife is like, what's that, what is that? And I told her, we talk all day like this, it's so fun! She's like you're such a nerd. (laughs) But yes I do, thank you for asking.

Alright well thank you for having me, I really appreciate it. (applauding)

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