This is the technique under CT guidance. This was an actual patient who had chronic pain in the left shoulder with arm pain. This diagnostic block is to determine whether there is a sympathetic component.
You bring your needle down, avoiding the carotid and sometimes you do have to pass through the jugular vein, but that's okay because you're using a small needle. And then as we're getting closer to the spine at the T1 level you also have to avoid the vertebral artery. So we bring the needle down and we basically dock the needle
just lateral to the esophagus at the junction between the rib head and the T1 vertebral body and that's exactly where the stellate ganglion lives. We inject a little contrast to make sure that we're not intervascular, and then the lidocaine and bupivacaine mixture.
Patients often get immediate relief on the table. This patient did well with this block. We've had several patients that have undergone this block for hot flashes and have had improvement in their symptoms. We've had some failures, but this is one that is not often offered and can really help
in some of these complex pain patients.
So what I thought is perhaps to just look a little bit
around and think a little bit of what happens when you are in a situation let's say, where you do feel comfortable, where things kind of go their usual ways and what do you do then, what are your coping mechanisms in that?
So I'm just watching something very interesting, there is three ladies in the third row and one of them took her arm up and the next one did exactly the same and you're looking at me somewhat astonished and scared. (audience laughs)
But this is something people to tend to do when they're in rapport. We do this very, very intuitively and you may perhaps even look a little bit around of how you're sitting there, the two ladies there who have their arms just like perfectly folded
in the right way, I mean one of them is completely not watching what her neighbor does because she's doing her iPhone but both of them are having their hands exactly in the same way. So you know while you're sitting there it's kinda of like a little spooky thing
of what we do when we feel safe and comfortable we do tend to match the body positions of others. So now, okay you gotta work now. So I would like now every second person of you to get up, if you don't have a partner look behind you, every second person gets up and you're gonna be
playing yourself and the person who remains sitting is going to be your patient in the waiting room. Okay, it's work time, yeah yeah work time. Little stretch time, so find yourself a patient victim and the idea is that your patient has been waiting patiently for getting their PICC line
and you had all these emergencies come in and they've already been in the waiting room for over an hour and now you got this neuro case being wheeled in and you're gonna explain now this is gonna take at least another hour, you can't even say how long it's gonna take,
and your patient is allowed to misbehave. So let's go, see how this works. Just keep talking to them, I mean you do, you've got that lingo down all the time. (audience chatters) Alright, and now just kind of freeze in
the body position you have. How much matching is going on right now? (audience chatters) So number one, your patient is kind of sitting and you are, many of you, standing. So you're right on top of them
and there's actually some research that shows that if you sit down, people think you spent more time with them. So, if now you all sit down and this may feel a little unnatural, match whatever your patient's doing. If they do that, you can do that a little bit.
If they do that, you can be a little copying it. The whole thing they tell you in medical school about this open positive section and never raise your voice, does not work. You do want to match, that is like the big secret. So you match a little bit in the beginning.
Now the idea is not that both of you are screaming at the end, but you just follow it a little bit. Oh really, you have to wait long and then you go and go down. If on the other hand your patient is deeply depressed, oh I can't do that, and then you say, ah and then
take your breath up. Okay I'll give you two minutes to continue your conversation with your unwilling patient. So also if your patient has their legs crossed you cross them, if they don't have the legs crossed you uncross yours.
Just do what they do and then the patients you can try to stay nasty but see what happens in trying to stay nasty or unhelpful if the other person matches you.
So is there any cellular or biologic basis for this understanding? Well over the last couple of decades really, there's been a lot of scientific study into tumors on a genomic basis.
And we find that tumors really have a lot of heterogeneity. So this clump of cells that are multicolored here represent the tumor and really, we see that the metastases that develop from this to the brain, liver, and lungs, and spread from different parts of that tumor.
And each of these parts of the tumor may develop different mutations. And even the tumors that spread, like that green metastasis to the liver, then may develop further mutations that allow it to spread further.
And so if we find patients who have a limited amount of metastatic spread, potentially those patients have a single mutation as a more homogeneous tumor. In which case, we could potentially have a therapeutic window in which we can
prevent them from having spread elsewhere. So if we take this example, patient who has a colon cancer and the colon cancer had spread to the liver, those metastases then develop further mutations that spread to the lung and the bone and then the bone metastasis further spreads to the brain,
we could potentially, if we find a patient who only has a liver metastasis and a bone metastasis, if we actually treat those areas focally potentially we can limit their metastatic progression, improve survival.
We're gonna talk about image guided blocks for pain syndromes. The goals of these blocks are often to reduce narcotic requirements, manage acute pain crises, and what we've learned is that the autonomic nervous system contributes significantly to many pain syndromes.
We'll talk about some neuro blocks, neurolysis, and nerve ablations. When we talk about neurolysis and nerve ablations, what we're trying to do rather than a block which is just a temporary fix and control of pain, we now wanna try to make it at least semi-permanent
to give that patient some time to allow them to ramp down their narcotics, maybe have an improved quality of life. The agents that we use for neurolysis are alcohol and phenol, but more recently, we're starting to use both thermal ablation,
pulsed RF ablation, and cryoablation.
So what about if patients have more than just one renal cell carcinoma metastasis? What if they have multiple. So in this study from my institution,
the urology team looked at patients who had all of their tumors resected as opposed to patients who had any of their tumors resected compared to those who had none of them resected. And there was a survival benefit for each of those patients. And these authors wrote a really nice statement
I like in this scenario. And they said limited data exists on the outcomes of these types of patients, and we believe this may result in an unnecessary therapeutic anilism, whereby patients who have multiple lesions
are excluded from an aggressive approach. They're just put onto systemic therapy or comfort care. And why is the literature limited in this case? It's due to the morbidity of surgical resection. So really ablation in these minimally invasive IR techniques provide an opportunity to help this patient population.
So what are the focal therapies we could use?
Well surgery's been used for years, and there's certainly clinical evidence for this in a number of scenarios. Pts who have colorectal metastases to the liver. They undergo a partial liver resection and they live longer. They are long-term survivors from that.
Same thing with resection of lung metastases, even adrenal metastases. Radiation therapy is certainly used for this in certain areas, particularly of the spine. Embolization is certainly used as a local regional therapy
for metastatic disease, particularly into the liver, and currently it's being used in patients who have more than oligometastasis, several metastases. Focus ultrasound is being used, it's really in the experimental stage now for actually developing local control,
not just in the uterine fibroid here or benign tumor, but in bone metastases.
The superior hypograstric block is becoming kind of more commonly seen. In those practices that are doing it, a lot of uterine artery embolization, this is a really nice way to improve patients'
crampy abdominal pain or crampy pelvic pain that's related to uterine ischemia after uterine artery embolization. There have been authors that have proposed that to do UAE as an outpatient procedure, that we should couple the UAE procedure with this block.
It's good for pelvic pain, both uterine contractile pain, but also for cervical, vaginal pain, rectal, as well as bladder related pain. For those cancer patients, this is also a good block to consider. These are all palliative interventions
that are very simple to perform and can really improve patients' quality of life. Again, getting back to this really busy slide, if you target this lower hypogastric region, you're basically picking up the splanchnic nerves that innervate the large intestine,
the small intestine, the ovaries, the scrotum, the urinary bladder, and the perineum. On the right hand side, you can see the fluoroscopic guided way to do this, which is basically just to target the disc space between L5 and S1.
The other way that people do it is that during their uterine artery embolization, they'll take a catheter and put it up and over the bifurcation so that you basically then outline where the bifurcation is and then you just stick your needle right there in the V of your aortic bifurcation.
You take the needle just underneath the aortic bifurcation and dock it up against the vertebral body, pull your needle back, do your block, and you have a significant improvement in the patient's pain.
Now, to become resilient and manage stress if you're in IR this is not something you can do by taking a 20 minute meditation break for yourself and typically by the time you're done with your day, your weekend,
you're coming home and there's a life too so just focusing on yourself and working really hard on meditation may not do the trick because there are other people around you who very much determine how your day goes. And we've published just last year in the JVIR
where we looked, well what happens if a patient walks in the door and they have this really negative affect. I'm getting more and more intrigued by the whole issue of mood contagion and if you look at that the people who come in like that, they actually
have more adverse events, they get about three times the amount of drugs and if you just look at anxious people it's those persons who come in and they look at you with these big, fearful eyes and they tell you I'm gonna die today,
how is that going to affect you? They are gonna experience more pain and above all, their procedures are gonna take much, much longer. The good news though is, what we've found out in this IR room with the multiple players
where there is one person feeding off the stress of the other it is enough to actually just relax one person and with that you can break this cycle. Yeah and then we have relatives that may make some pertinent remarks there
and there was actually a pretty cute study done by a NICU team where they randomized and had a simulated relative say something as kind as, oh if I would have known that you're doing here like third world medicine I would have brought my relative somewhere else.
Just something that pushes all your buttons and they found out that this whole team suddenly couldn't work as well anymore. Now it's not that easy to change what other people do but, you know, you're within this whole setup,
you may be the manager of your division or you have a manager whom you have to report to and there's a lot of other things that goes through your head. I mean this morning you heard about MACRA is in full swing, payment big time depends on it
and the satisfaction ratings and yes, you do wanna retain your staff because you need to have happy staff otherwise your patient's not gonna be happy either.
The stellate ganglion is one of the higher blocks and it's actually probably one of the more difficult blocks. Many of the pain specialists will do these blind which I think is kind of amazing,
considering you have the vertebral artery, you have the carotid artery, you have the esophagus in the vicinity, and so this is a block that I think should definitely be done under image guidance. There have been papers showing that when done under CT guidance, that there's a much greater accuracy
and success with this block. The stellate ganglion block is used to treat complex regional pain syndromes in the upper extremities, like reflex sympathetic dystrophy, hyperhidrosis. So if you have patients who have heavy sweating in the hands, you can use this block to address that.
It's also been used for refractory angina, which I thought was interesting. Phantom limb pain in patients that have had amputations of their upper extremity. Herpes zoster, as well as pain in the head and neck. This block also is used in Raynaud's syndrome
in a scleroderma, it's used in vasospasm syndromes, in patients that are post traumatic or have experienced frost bite, or have embolic syndromes in the upper extremity. And again, intractable angina is one that I actually learned when I was reading about this talk.
One of the indications that is not well known is the use of the stellate ganglion block for hot flashes in the setting of breast cancer. Many of these patients are on tamoxifen and other types of agents that can cause intense hot flashes and a stellate ganglion block can actually
improve those symptoms.
So let's just talk briefly about the evidence and I'll use metastatic renal cell carcinoma as a model case. Different tumor histologies will have different evidence and different studies to support them. So in this case of a patient who has a right renal mass
and develop this renal metastasis and we ablate that with the ice ball you can see very well. So does this oligometastatic state even occur in renal cell carcinoma met, patients? Well, it does. Most patients actually present
with limited metastatic disease. More than half the patients, when they present with metastases, have just a single site of disease, and that proportion actually increases as patients age. So the patients who are the most elderly,
the most frail, the least suited to surgery, actually are the most likely to have a single site of disease to treat. Is there a survival benefit from surgery if we extrapolate those data? Well, if patients have a wide or radical surgical resection
as opposed to a marginal, they're just pinning that metastasis, those patients do better who have a wide radical surgery. And if patients at the end of their surgery actually are free of disease, they don't have other sites of metastasis,
if we can actually treat all of their disease, they live longer.
So when we're doing this technique, what do we need before we get started? We need adequate preprocedural imaging. So if we're seeing this tumor that's in a bit of a scary location in the proximal femur,
sometimes if we treat that too aggressively that can fracture, but this looks like it's isolated into the medullary cavity. But these patients have multiple imaging modalities and these help. So if we have functional imaging, in this case a PET scan,
we can see it's actually a bilobe lesion that actually is a little bit higher than we might just suspect from the CT alone. And so when we're ablating we make sure to cover that entire territory when we're in this indication
of trying to locally control that disease. Likewise, if we have a patient like this who has sclerotic metastases, prostate or breast cancer, they've been treated. It's a little bit hard to know which of these are actually active disease.
Have they already been treated? Because they'll look like this for the rest of their life. And we do a PET scan and we actually see there's really only one tumor that has FDG uptake or choline uptake and is actually active disease, and so we actually target that tumor.
When we're treating these tumors for local tumor control we're really aggressive in ablating them. So we have a rib metastasis here, and we won't just put one probe in it and call it a day. We have to make sure that we have adequate cold temperatures surrounding the entire tumor with margin
to make sure that we can provide a long-lasting effect for these patients, rather than this case in which patient has a spinal metastasis, we put one probe in part of it and leave a little corner of tumor
when our goal is local tumor control that's not really adequate. And local recurrence really matters so in this study this is one example study of a patient who had surgical replacement of renal cell carcinoma, bone metastases.
And in this study they show that threefold higher hazard ratio of death in patients who develop local tumor recurrence at the site of the resection. So if we can, extrapolating that surgical data to ablation we wanna make sure we get that local control.
Unfortunately as we treat aggressively we are more at risk for developing complications. In this large metastasis that's in the supra-acetabulum here we try to be very cautious that we don't actually have that ice ball encroach upon the femoral head,
as opposed to this equally large metastasis in the supra-acetabulum where we actually have the ice that if you extrapolate those into that femoral head and then several months later the patient develops femoral head collapse and fracture, and their pain recurs.
So we've looked at our experience in treating musculoskeletal limited metastatic disease for complete remission, and we looked at 52 metastases in 40 patients. A quarter of them were renal cell in this case. Had about two years followup,
and 87% were able to achieve local tumor control. And these patients live a long time. The median survival of these patients was almost four years with two years survival of 84% with acceptable complication rate. We looked at specifically in renal cell carcinoma,
treating those in multiple different sites. And you know, most of these patients did have locations in bone and soft tissue. So if we used those data to say is there evidence to support this? Well, in these 82 tumors the recurrence
resurvival was very high in 94%, and the patient's overall survival 83% were still alive two years later. In our local tumor control about 88% with an acceptable complication rate. So it is possible to treat these patients
and continue to have them live a long time without systemic therapy. Others have certainly looked at this. This is a group in Detroit that's looked at the same thing, renal cell carcinoma metastasis ablation, and they found the same thing,
median survival over two years in this group. And they actually did a little bit of a cost analysis and said what's the estimated cost even if we have to ablate these people twice and their cost per life year gained was $26,000, which is very reasonable
and compares favorably to systemic therapy, these patients who are put on systemic therapy, the cost is 30 to 45,000 in their study. I've seen estimates over $60,000 for a year. So it's certainly reasonable to do that. This is a busy chart that just shows
that there's a lot of evidence for treating musculoskeletal tumors for local tumor control for a variety of histologies from lung cancer to renal cell cancer to a mixed populations, and breast cancer, whether it's in the spine or other areas in the bone,
a variety of ablation modalities, cryoablation versus heat and the local tumor control rates are reasonable, 70 to 98% depending on the patient population we're looking at. And these data have been compelling enough that the National Cancer Care Network's guidelines
had been revised for patients with stage four renal cell carcinoma. Now that if they are not surgical candidates, ablative techniques in these metastases should be considered.
But I'm really gonna focus on percutaneous ablation because it's particularly well suited to this application, minimally invasive for these potentially frail and elderly patients,
as well as high kill rate with tumors of many different histologies. So when we're choosing, this is the technique, so how do we do it? If we were facing a metastasis in the scapula like this, we can treat it with heat,
radiofrequency, or microwave ablation, or we can treat it with cryoablation, extreme cold temperatures, extreme cold or extreme heat, they'll both kill the tumor. How do we decide? Well, if we compare cryoablation versus microwave ablation
or radiofrequency ablation, ease of use, the heat-based therapies are certainly easier to use. They're generally faster, so the procedure duration is quite a bit shorter, but the energy transmission into bone is better with cryoablation.
It'll go through the cortex, whereas heat is limited in that regard. The predictability of the ablation zone, the cryoablation. As you can see in that scapular picture, we can actually see the edge of the ablation with several different modalities, CTMR and ultrasound.
Our ability to monitor that ablation then and prevent it from escaping into adjacent collateral structures. And then the ablation zone size, we can usually treat a larger area with cryoablation, and patient tolerance, their pain scores are generally less
after a cryoablation than a heat-based therapy. So in general, most of us who are treating for local tumor control would use cryoablation. These factors are a little less true these days where there are newer bipolar radiofrequency devices that are designed specifically for bone
so have better ability to control tumors within these sites.
And it's a big case where, or a big example where the technologist can add a lot of value and help out a lot. So just a case example that kind of ties together. This was a 53 year old male. He's doing pretty good, except he kinda had
some progressive right hip pain for a few months, but was still walking and able to kind of do most things. Was diagnosed with myeloma. And this was his CT scan, kind of a coronal projection. You can see this large lytic destructive lesion
over his right acetabulum. With extensive kind of bony dehiscence and thinning of the cortex throughout. And so this was the plan to stabilize this. And help his pain from kind of a combined augmented screw, cement and screw approach.
These were the needle paths, and the screw paths that we used on pre-procedural imaging. You can kind of see representations of these here. So again it gives you a good idea of where these screws are gonna go, and in the case of the bottom right image
through a narrow corridor, this really allows us to achieve that. Using this live kind of overlay needle guidance. Several of these screws were placed. Again, up on the I guess top left, you can see this narrow ramus corridor,
that this kind of allows us to find. So again, just kind of more examples of how this case progressed. Registration is a key part again. This was the segmentation that I showed you earlier. And then kind of used this in real time
as we filled this entire area with cement. Again, given the bony destruction, at least the kind of posterior aspect of it was extremely difficult to see. Just under fluoroscopy, and I think without this nice contouring of our target lesion,
in cases that we've had, you know, previously, we would have stopped a lot earlier, thinking that we'd filled it. Whereas here we have kind of that confidence that there's a little bit more to go, a little bit more to fill.
So you can kinda see it, as this goes on, we are able to fill most of the target volume. And this was kind of the completion, you can kinda see that these are screws, and then the cement area here, kind of reforming almost the acetabulum roof.
So he did well, so this was all done percutaneously. He basically had three Band-aids from his three different screw entry sites. And was weight bearing within two hours. Afterwards, he underwent radiation therapy. He was on systemic therapy.
He's starting a Zometa for his kind of overall bone health, and he really doesn't have any specific right hip pain. And the biggest thing for him was that he was able to kind of move on to his systemic therapy and radiation therapy almost immediately afterwards. So a really good outcome, and one that I think that
without a lot of these advanced imaging techniques, we either wouldn't have been able to accomplish or probably would not have been able to provide as much structural reinforcement as we were.
However, in 1995 Drs. Welchselbaum and Hellman
wrote an opinion paper called Oligometastases and then rewrote on this subject in 2011 about the concept of oligometastasis, and they really described this as a distinct state in which tumors have an intermediate metastatic potential. So these patients have a limited number
and site of metastases, and these are variably defined in the literature, but usually people will say up to five metastases. And in these patients it makes sense to do focal therapy rather than systemic therapy. These patients do not have all of the changes
that are required to have distant metastatic spread.
This is a super busy diagram, but basically this looks at both the somatic nerves and the autonomic system. I don't think we have a laser, unfortunately. Basically the autonomic system innervates the liver, the gallbladder, the stomach, and the upper epigastrium,
but also innervates the large and small intestine. And then as we move down from top to bottom into the lower sympathetic chain, there's innervation of the kidneys, of the uterus, ovaries, scrotum, the urinary bladder, and the perineum. So, in thinking about it that way,
we then can understand where we're gonna target our blocks based on where the pain syndrome is.
Just finishing up, neurolysis and nerve ablation. We talked a little bit about this, but the goal is to permanently disrupt the axons and the myelin sheath. You can do it chemically with alcohol or phenol. But more and more people now are offering
radiofrequency ablation or cryoablation as a more precise way of performing these ablations. Radiofrequency ablation probably has the most data after alcohol and phenol. It's inexpensive and it has a long track record. Cryoablation is now being reported in the literature.
It's easy to see on CT as my colleagues have demonstrated. It's good in soft tissue tumors, but we still have very early data. Some people are actually looking at MR-guided focus ultrasound, very sexy, very expensive technology, very niche.
I don't really see that becoming a major player. I think it's really gonna be RFA and cryoablation,
So now we move from a potential case like this
where the patient has a large renal mass and a metastasis into their left femur, and that patient underwent a surgical resection here, replacement of that, a big operation for a patient with metastatic disease, now we take a similar kind of patient
with a left renal cell carcinoma and has two metastases, one in a rib and a small one in the acetabular region. And they undergo the nephrectomy and then ablation of these two areas. That may be the new model.
This particular patient had significant improvement, did have some diarrhea, but demonstrated significant improvement after that block. This is an actual patient that we treated several years ago. 55 year old woman, she was very cathectic. She was in the end stages of her life
and she had pancreatic cancer. She had an abdominal wall met that was actually invading into her liver and she had severe epigastric pain and constipation. Her ECOG status was poor and she was on a lot of narcotic medications.
She had one of these metastases resected and her pain had come back immediately. You can see just anterior to the liver, there's this soft tissue mass that's invading into the liver. She has multiple liver metastases and her pancreatic cancer
is invading into her celiac plexus. So using a combination of what Nick has talked about and these nerve blocks, as an interventionalist, we can offer multiple things to these patients to improve their outcomes. I'm a huge fan of ultrasound, so I use ultrasound
to guide my needles as often as possible. I'm using a glove because I'm gonna end up doing cryoablation in the near field of that metastasis that I showed you. On the image on the right hand side, you can see the cryoprobe going down
into the shadowing cryoablation defect. It's treating that lesion, but just above that, you can see a horizontal white line, which is actually a needle that I'm injecting saline to keep the skin safe as we're doing the cryoablation. By using the glove with the saline in it,
I can actually use that as a standoff pad to sort of see that skin and make sure that the cryo energy and that ablation zone is not coming up into the skin. Just a nice technique with ultrasound, very simple. And then, at the same time, while I'm doing the cryoablation just lateral to that,
I'm taking an ultrasound guided approach and dropping a needle down in front of the aorta and doing that celiac plexus block and neurolysis at the same time. So the patient gets the ablation for pain control and they get the neurolysis for pain control
and had significant improvement in their pain. You can see there the cryo defect. We delivered the alcohol to perform the neurolysis and the patient had significant improvement for a while. Ultimately, her pain recurred, but she then ended up going to hospice and passing.
We definitely offered her improved pain control and quality of life for at least a short period.
We've talked a little bit or touched on some of the traditional blocks, Demetrius has kind of run through some of those, so I won't be covering those. But the concept is that basically you put your needle
in the space, you inject a little contrast to make sure you're in a safe position and then you give a combination of lidocaine and a longer acting agent like bupivacaine with a steroid and then that's the block. Once you've done that and diagnosed that that's actually
addressed the problem and is addressing the pain, you can then move on to the neurolysis and ablation where you're sort of more permanently blocking that. We started incorporating some of the more complex sympathetic blocks into our practice which really, many of the pain specialists out there
shy away from because they're much more heavily reliant on imaging and that's where we shine, and that's where you all come in to help us to use the guidance techniques that William talked about to sort of get us to some of these more difficult places to reach.
The celiac plexus block is one that is much better known and I think you probably have all experienced this in your practices, but the celiac plexus block and neurolysis is for the treatment of intractable epigastric pain, most often in pancreatic cancer,
but it can also be in patients who have liver masses or have biliary dilatation and have biliary tubes placed and are having pain related to their biliary tree. But it's also used for intractable nausea and vomiting. If you have somebody who has profound nausea and vomiting and is not responding to normal medications,
a celiac plexus block and neurolysis can improve that. The permanent block blocks the sympathetics and allows the parasympathetic system to start working unopposed, so it actually can improve gastric emptying, which is why we think it improves the nausea and vomiting.
It can improve GI motility, so it can actually improve patients' appetite. The only sort of danger to this block and neurolysis is that it can cause diarrhea by having that parasympathetic system working in overdrive without the sympathetics to balance,
that you can actually develop diarrhea.
Alright, so you know in conclusion,
if you have a happy patient you're going to have a happy staff and the key ingredient really is this rapid rapport piece, to reframe the experience, avoid these negative suggestions and you can use a bit of this hypnotic language and it doesn't need to take extra time.
Thank you. (audience applauds)
This is where the celiac plexus lives, so it's around the celiac artery, usually just slightly above, but is actually a mantle of nerve tissue that is from the celiac down to the SMA. You can see on the image on the right,
we've approached from the posterior paraspinous approach and we're using a curved needle where we basically dock the base needle which is a 22 gauge needle adjacent to the aorta and then we take a 25 gauge needle that's curved and bring it anterior to the aorta and that's where we can eject the contrast.
You can see the contrast now layering just anterior to the aorta, hopefully not in the aorta. But the beauty is, you're using a 25 gauge needle, so you really can't do much harm. Once you've injected the contrast, the lidocaine and bupivacaine, you can then either move directly
to giving the neurolytic which is absolute alcohol, usually about 15 to 20 CCs, or you can use phenol, which is more commonly used in Europe. This basically denatures the myelin, destroys the myelin sheath, and stops the conduction of those nerve fibers.
- Like to thank Dr. Veith and the committee for asking me to speak. I have no conflicts related to this presentation. Labial and vulvar varicosities occur in up to 10% of pregnant women, with the worst symptoms being manifested in the second half of the pregnancy.
Symptoms include genital pressure and fullness, pruritus, and a sensation of prolapse. These generally worsen with standing. Management is usually conservative. Between compression hose, cooling packs, and exercise, most women can make it through to the end of the pregnancy.
When should we do more than just reassure these women? An ultrasound should be performed when there's an early presentation, meaning in the first trimester, as this can be an unmasking of a venous malformation. If there are unilateral varicosities,
an ultrasound should be performed to make sure that these aren't due to iliac vein thrombosis. If there's superficial thrombosis or phlebitis, you may need to rule out deep venous extension with an ultrasound. When should we intervene?
You may need to intervene to release trapped blood in phlebitis, or to give low molecular weight heparin for comfort. When should a local phlebectomy or sclerotherapy be performed? Should sclerotherapy be performed during pregnancy?
We know very little. Occasionally, this is performed in a patient who is unknowingly pregnant, and there have been no clear complications from this in the literature. The effectiveness of sclero may also
be diminished in pregnancy, due to hormones and increased venous volume. Both polidocanol and sodium tetradecyl sulfate say that there is no support for use during pregnancies, and they advise against it. So what should you do?
This following case is a 24 year old G2P1, who was referred to me at 24 weeks for disabling vaginal and pelvic discomfort. She couldn't go to work, she couldn't take care of her toddler, she had some left leg complaints, but it was mostly genital discomfort and fullness,
and her OB said that he was going to do a pre-term C-section because he was worried about the risk of hemorrhage with the delivery. So this is her laying supine pre-op, and this is her left leg with varicosities visible in the anterior and posterior aspects.
Her ultrasound showed open iliac veins and large refluxing varicosities in the left vulvar area. She had no venous malformation or clot, and she had reflux in the saphenofemoral junction and down the GSV. I performed a phlebectomy on her,
and started with an ultrasound mapping of her superficial veins and perforators in the labial region. I made small incision with dissection and tie ligation of all the varicosities and perforators, and this was done under local anesthesia
with minimal sedation in the operating room. This resulted in vastly improved comfort, and her anxiety, and her OB's anxiety were both decreased, and she went on to a successful delivery. So this diagram shows the usual location of the labial perforators.
Here she is pre-op, and then here she is a week post-op. Well, what about postpartum varicosities? These can be associated with pelvic congestion, and the complaints can often be split into local, meaning surface complaints, versus pelvic complaints.
And this leads into a debate between a top down treatment approach, where you go in and do a venogram and internal coiling, versus a bottom up approach, where you start with local therapy, such as phlebectomy or sclero.
Pelvic symptoms include aching and pressure in the pelvis. These are usually worse with menstruation, and dyspareunia is most pronounced after intercourse, approximately an hour to several hours later. Surface complaints include vulvar itching, tenderness, recurrent thrombophlebitis, or bleeding.
Dyspareunia is present during or at initiation of sexual intercourse. I refer to this as the Gibson Algorithm, as Kathy Gibson and I have talked about this problem a lot, and this is how we both feel that these problems should be addressed.
If you have an asymptomatic or minimally symptomatic patient who's referred for varicosities that are seen incidentally, such as during a laparoscopy, those I don't treat. If you have a symptomatic patient who has pelvic symptoms, then these people get a venogram with coils and sclerotherapy as appropriate.
If they are not pregnant, and have no pelvic symptoms, these patients get sclero. If they are pregnant, and have no pelvic symptoms, they get a phlebectomy. In conclusion, vulvar varicosities are a common problem, and usually conservative management is adequate.
With extreme symptoms, phlebectomy has been successful. Pregnancy-related varicosities typically resolve post-delivery, and these can then be treated with local sclerotherapy if they persist. Central imaging and treatment is successful for primarily pelvic complaints or persistent symptoms.
Lumbar sympathetic block and neurolysis is another block that's not often used and actually can solve a lot of difficult problems.
In the lower extremities, if you have non-reconstructible vascular disease, patient can't have a bypass or a stent. If you have vasospasm, again if you have frostbite, if you have some of these more rare entities like Buerger's disease or these arteritis syndromes,
you can use this block to improve pain control. Phantom limb pain if you've had an amputation, peripheral neuropathies. But also this can be good for patients that have pain related to their kidneys, ureters, or genitalia. If you have somebody who has a terrible kidney stone
and they're not being controlled well with their narcotics, you can actually do this block and temporarily improve their pain. The lumbar sympathetic chain is just there, lateral and anterior to the vertebral body, just behind the aorta and the IBC.
It runs on both sides of the vertebral body all the way down into the pelvis. A block at three levels followed by injection of alcohol effects this neurolysis. We basically disrupt the sympathetic chain and you get reflex vasodilatation
in the lower extremity that you've treated. In this particular patient who has rest pain and can't have a bypass, we do this block and lo and behold, you get this reflex vasodilatation. It's a little bit subtle based on my poor photography, but there was definite hyperemia,
definite improved blood flow. This has been shown to reduce the incidence of amputations. It gets people out of rest pain and can be a nice bridge if you're waiting for your stent or other procedure. Just a nice simple way to help a patient and improve their quality of life and pain control.
That's basically what I just said, so let's skip that slide.
The pudendal nerve block is also sort of a deeper block that can help in perineal pain. It's the block that's used actually by the obstetricians in child delivery if you're not having an epidural. They do an internal block through the cervix and vagina
and basically block the pudendal nerve there just medial to the acetabulum and the ischium. We can do this block under CT guidance and you can see I've done the block here on the right hand image from a posterior approach, avoiding the sciatic nerve, obviously,
and injecting a little bit of contrast and then the bupivacaine and the lidocaine and you can get a nice deep block. This is an actual case of a patient who had profound rectal cancer invading the perineum and actually passing through the skin, unfortunately.
The patient was in extreme pain, couldn't get out of bed, just absolutely miserable. And by doing the block and then neurolysis where we actually inject alcohol, you can actually improve this patient's pain syndrome and that in fact is what happened.
Some other less often understood or offered blocks are the ganglion of impar block
which is just anterior to the sacrum, kind of at the junction of the sacrum and coccyx. The ganglion of impar, again, sympathetic chain innervates the rectum, the perineum, and is very useful in patients who have coccydynia, patients that have a coccyx fracture
or have coccydynia, which is actually much more common than you might expect, than you might think. Very simple to do, you can either do it under fluoroscopy laterally, but I think that with our imaging capabilities, we can do this in a very elegant manner,
so you can go just across the sacrum or through the sacro-coccygeal ligament. You can see that I've brought an 18 gauge needle down through the bone and through that needle, I pass a 22 gauge needle. Obviously you have to watch out
for the important structures anterior, so I had to come right up to the rectum, but I couldn't pass the needle through the rectum, that would be a bad day. I inject a little bit of contrast, inject some bupivacaine and lidocaine,
and the patient gets relief of their pain.
These have been looked at and there's meta analysis of over a thousand patients that shows that this is a highly effective way to control pain if offered early. The later you offer this, these blocks,
the less effective they are. But 70 to 90% of patients experienced either partial or complete pain relief at some time prior to their death.
Moving on to percutaneous decompression techniques for the discs, we can have decompression and we can have regeneration techniques for the discs. Specifically for the decompression techniques we can have thermal techniques using laser, continuous or pulsed radiofrequency and plasma energy ablation.
We can have mechanical decompression using a wide variety of devices and we can have chemical decompression by means of Discogel or ozone intradiscal injections. All these techniques, what they are actually based on is that fact that a intervertebral disc is a closed hydro-ablic space and when you are removing a small
part from the nucleus, you are actually causing a significant decrease in the intradiscal disc and this disc pressure actually is what makes the herniation move inwards. And we have these techniques from back in the 1940s. The indications for these kind of treatments
in the intervertebral discs include patients who are capable of providing consent with a symptomatic small to medium-sized herniation and when we are speaking about the size of the herniation, if you have a theoretical line between the facet joints, all herniations which do not cross this line,
they can be percutaneously treated. And when we are speaking about symptomatic cases, symptoms should be consistent with the segmental level where the herniation is located on the MR imaging. For example, if you have a left L4-L5 foraminal herniation, you are expecting the patient
to report a left L4 root neuralgia. Absolute contraindications include sphincter dysfunction, extreme sciatica and progressive neurologic deficit. And actually all these are indications for surgery. Additional absolute contraindications include sequestration or the presence
of asymptomatic herniation, local or systemic infection, spondylosthesis and stenosis of the vertebral canal, anticoagulants, coagulation disorders and the patient refusing to provide informed consent. Most of these techniques are performed under fluoroscopy so we (mumbles) projection with 45-degrees angulation
of the fluoroscopy beam and as far as the lumbar spine is concerned, we perform a direct posterior lateral (mumbles) in the disc. In the final position, we need to have the needle in the anterior third of the disc in the lateral projection towards the midline in the AP projection and you can see
how important the technologist is because we need to have good visualization of what we are doing. Once you are there, you have access to the disc and you can insert any kind of product that you are familiar with, starting from thermal, going to mechanical or chemical decompression.
The magic number for all these techniques concerning success rate is around 80%. The complication rate is very low, between 0.5%. What we do know so far from the literature is that there are no studies of evidence of superiority of one technique over the other.
As we've already said, complications are really rare. Spondylodiscitis is the most fearsome one with a percentage of 0.24% per patient.
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