Chapters
MySpine Systematic Workflow
MySpine Systematic Workflow
2016chapterdissectionMedactaNASSnoindexvertebraworkflow
Celiac Plexus Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
Celiac Plexus Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRbiliaryblockceliacchapterdiarrheadilatationepigastricfull videogastricimproveintractablenauseaparasympatheticplexus
Adequate Pre Procedural Imaging | Bone Ablation for Local Tumor Control
Adequate Pre Procedural Imaging | Bone Ablation for Local Tumor Control
2018ablatingactivearinAVIRchapterfull videomedullarymodalitiespreproceduralproximalsclerotictumoruptake
Dealing With Pain | Rapid Resilience for Staff and Patients in IR
Dealing With Pain | Rapid Resilience for Staff and Patients in IR
2018anxietyarinAVIRaxisbreastcarechaptercomfortdrugsfull videopainpainfulparanoidpatientstandardtumorworst
Neuropathic Pain in R Ribs | Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
Neuropathic Pain in R Ribs | Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRchapterfull videointercostalpainpleuralsagittalskinthermalultrasound
Percutaneous Ablation - Cryoablation vs RFA | Bone Ablation for Local Tumor Control
Percutaneous Ablation - Cryoablation vs RFA | Bone Ablation for Local Tumor Control
2018ablationarinAVIRbonechaptercryoablationextremefull videomicrowavepercutaneousradiofrequencyscapulatreattumortumors
Superior Hypogastric Block | Nerve Blocks, Neurolysis, and Rizotomies
Superior Hypogastric Block | Nerve Blocks, Neurolysis, and Rizotomies
2018aorticarinarteryAVIRbasicallybifurcationchaptercontractilefluoroscopicfull videohypogastricinnervateischemianeedlepelvicsplanchnicuterinevertebral
Treating MSK Oligometastatic Disease and mRCC | Bone Ablation for Local Tumor Control
Treating MSK Oligometastatic Disease and mRCC | Bone Ablation for Local Tumor Control
2018ablateablationablativearinAVIRcancercellchaptercomplicationcontrolcostcryoablationfavorablyfull videohistologieslocallookedmedianmetastasesmetastaticmusculoskeletalpatientsrenalsurvivalsystemictreatingtumortumors
Ablation Evidence and Oligometastatic RCC | Bone Ablation for Local Tumor Control
Ablation Evidence and Oligometastatic RCC | Bone Ablation for Local Tumor Control
2018ablatearinAVIRcarcinomacellchapterfull videohistologiesmetastaticpatientsradicalrenalresectionsurgerytumor
Ablation Devices in Neurolysis and Rhizotomies | Nerve Blocks, Neurolysis, and Rizotomies
Ablation Devices in Neurolysis and Rhizotomies | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbasicallychapterconductioncryoablationdorsalfull videonervepulsedthermal
Geniculate Nerve Ablation and Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
Geniculate Nerve Ablation and Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbupivacainechapterfull videoinferiorlateralmedialsuperior
Lumbar Sympathetic Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
Lumbar Sympathetic Block and Neurolysis | Nerve Blocks, Neurolysis, and Rizotomies
2018anteriorarinarteritisAVIRblockchainchapterdefiniteextremityfull videoimprovelumbarpainpatientreflexstentsympatheticvasodilatationvertebral
Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockchapterembolicesophagusfull videopainpatientsrefractorysyndromesuppervasospasmvertebral
Objectives | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
Objectives | Anesthesia, Nursing, and Technologists: Synergy of Three Teams for One Common Goal
2018anesthesiaanesthesiologistsarinAVIRchaptercrisisfull videopatientteam
Aggressive Ablation and Complications | Bone Ablation for Local Tumor Control
Aggressive Ablation and Complications | Bone Ablation for Local Tumor Control
2018ablatingablationarinAVIRchapterfemoralfull videolocalmetastasispatientproberecurrencestudysurgicaltumortumors
Nerve Blocks and Sympathetic Blocks | Nerve Blocks, Neurolysis, and Rizotomies
Nerve Blocks and Sympathetic Blocks | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbupivacainechapterfull videolidocaine
Technical Tips For Maintaining Carotid Flow During Branch Revascularization When Performing Zone 1 TEVARs
Technical Tips For Maintaining Carotid Flow During Branch Revascularization When Performing Zone 1 TEVARs
anastomosisanterioraorticarteriotomyarterybordercarotidcarotid arterycommoncreateddissectiondistalendograftflowhemostasisincisioninnominateleftlooploopsLt Subclavian RetrosmiddlepreferredprostheticproximalproximallyrestoredsecuredshuntstentsubclavianSubclavian stentsuturesystemicallyTAVRtechniquetherapeutictransversetunnelingvesselwish
Multifocal mRCC | Bone Ablation for Local Tumor Control
Multifocal mRCC | Bone Ablation for Local Tumor Control
2018ablationarinAVIRchapterfull videolimitedminimallypatientsresectedsystemictumors
Celiac Plexus Nerve Block - Pancreatic Ca c Intractable Pain and Nausea | Nerve Blocks, Neurolysis, and Rizotomies
Celiac Plexus Nerve Block - Pancreatic Ca c Intractable Pain and Nausea | Nerve Blocks, Neurolysis, and Rizotomies
2018anterioraortaarinAVIRceliacchapterconductioncurvedfull videogaugelidocaineneedlenerveplexusposterior
Resection to Ablation | Bone Ablation for Local Tumor Control
Resection to Ablation | Bone Ablation for Local Tumor Control
2018ablationacetabulararinAVIRchapterfull videometastaticnephrectomypatientrenalresection
Goal of Neurolysis and Nerve Ablation | Nerve Blocks, Neurolysis, and Rizotomies
Goal of Neurolysis and Nerve Ablation | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationalcoholarinAVIRchaptercryoablationfull videoradiofrequency
46 | Chronic L Shoulder/Arm Pain | Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
46 | Chronic L Shoulder/Arm Pain | Stellate Ganglion Block | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockbupivacainecarotidchapteresophagusfull videojugularlidocaineneedlepatientvertebral
Female | 55 | Pancreatic Ca | Celiac Plexus Neurolysis and Cryo | Nerve Blocks, Neurolysis, and Rizotomies
Female | 55 | Pancreatic Ca | Celiac Plexus Neurolysis and Cryo | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationanteriorarinAVIRceliacchaptercontrolcryocryoablationecogepigastricfull videogloveimprovementinvadinglivermetastasesmultipleneedlepainpancreaticpatientsalineultrasound
Block and Neurolysis of Ganglion of Impar | Nerve Blocks, Neurolysis, and Rizotomies
Block and Neurolysis of Ganglion of Impar | Nerve Blocks, Neurolysis, and Rizotomies
2018anteriorarinAVIRbupivacainechapterfull videogaugeinjectneedlesacrum
Dealing With Pain: Communication Pitfalls & Pearls | Rapid Resilience for Staff and Patients in IR
Dealing With Pain: Communication Pitfalls & Pearls | Rapid Resilience for Staff and Patients in IR
2018arinAVIRchaptercomfortcoolfull videomeasurementspainpatientstrippingtinglingvein
IR Treatment Topics | Nerve Blocks, Neurolysis, and Rizotomies
IR Treatment Topics | Nerve Blocks, Neurolysis, and Rizotomies
2018arinautonomicAVIRblockschapterfull videonarcoticnerveneuropainpulsedtalk
Pudendal Nerve Block and Rectal Ca | Nerve Blocks, Neurolysis, and Rizotomies
Pudendal Nerve Block and Rectal Ca | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockbupivacainecervixchapterfull videolidocainemedialnervepatientperinealperineumposteriorpudendalrectalsciatic
Sympathetic NS | Nerve Blocks, Neurolysis, and Rizotomies
Sympathetic NS | Nerve Blocks, Neurolysis, and Rizotomies
2018arinautonomicAVIRchapterfull videosomaticurinary
CPBN Meta Analysis | Nerve Blocks, Neurolysis, and Rizotomies
CPBN Meta Analysis | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRchaptereffectivefull videometapainpatients
Transcript

table before surgery and I think this is

a part is really really important benefit or it increases our workflow considerably. So we'll have all the screws already laid out already chosen. We'll have each vertebra and each guide all laid out. So once we do our dissection which you have

to do anyway from there on putting the screws goes really fast really systematic and our workflow is really significantly increased. Screws go and very easily very accurately and with a lot of

confidence essentially hardly any radiation during each case. These are a

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.

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.

I mean I just thought I'll show you that second clip, how natural it can actually look to cross one's arms but then she opened it up and it's very hard to then not follow along, so that's how you sometimes can save the day

in a fast way. Now dealing with pain and that's something I think that gets to all of us emotionally, I mean we are gonna be poking people and there's certain things of how we feel about

what the patient should be experiencing. We've done several large clinical trials so we had the opportunity to look at the standard of care groups of those where patients could get as many drugs as they wanted and if I were to ask you, just by show of hands,

what do you think hurts the most? Okay angiography? Large core breast biopsy? Tumor embos? Okay well it's kind of like, what I thought too. However if you plot onto this graph

on the X axis is the time zero you wheel a patient into the room and on the Y axis is their self reported pain. We ask them like every end of 15 minutes, by the way we don't say how bad is your pain, we say what is your comfort level on a scale

of zero to 10, no pain at all and worst possible, and zero no anxiety at all, 10 worst possible. And what you find out is, I mean there are these three curves going up over time and the blue line is the tumor embos, the red one is the angio renal and the yellow

is the breast biopsies, there's really no difference. And furthermore when we dug deeper into this data not only is this increase in pain over time, this trend relatively independent of how hard you poke somebody, but also independent of how many drugs they get.

Actually there's a somewhat inverse relationship between the amount of drugs people get and how much pain they experience over time that is sent. And the question is why is that the case? So from nature we are used to always assume the worst

and similar curve applies, although with some differences for anxiety but there's an increase in anxiety over time in the case under standard of care and I think it goes all down, that's one explanation (mumbles), he's a surgeon in (mumbles) uses,

he says, you know, hundreds and thousands of years our ancestors, let's say who walks through the Savannah and one behind hears a little noise and says, oh this could be a tiger, perhaps I should look around and do something about it and the other one says it's just the wind it's not a big deal.

You can see that being a little paranoid over time still probably translates into higher longevity and the ability to create offspring so we are all deriving from the somewhat more paranoid people that particularly, in a setting of ambiguity, we assume it's hurting

or it's bad or it's dangerous to us and it's a protective mechanism of the subconscious. That is going to happen. Furthermore, once there had been one painful stimulus then all subsequent stimuli are going to be interpreted as being painful or even more painful

and there have been studies done where they hook people up to a machine with little flashing lights and the first time they got a little shock and the next time just the little lights were flashing and they experiencing more and more pain with the little lights flashing even though

there weren't any more shocks. So that's what you have to deal with and this is what we all know. If you do a case that's over in 15 minutes it's not that big a deal. It's like you're in hour number one,

where you now are number two or in hour number three. That's when certainly everybody can get really, really stressed out. However, the good news is if right at the beginning you do something, you say to the patient something in words but also in your behavior

that reframes this experience this doesn't happen. And this is kind of the secret sauce, all you need to do is do something at the beginning, at time zero, and then you don't get this blue line on the standard of care where the pain keeps going up

over time, time, time, time. If you do some empathic attention the increase is not as steep but if you do some comforting words at the beginning, these are IR data in interventional radiology, you can go on for ever.

I mean it's just like a very different atmosphere in the room and very similar for anxiety. We've found similar responses in a trial we did with breast biopsies and tumor embolizations under standard of care pain to go up,

getting better if you give some empathic attention but anxiety dropping down very quickly while this patient is still on your table and actually even though the whole thing is called Comfort Talk you're gonna end up to talk much less

because the idea is to get that patient on autopilot as fast as you can, particularly in MRI. You wanna have them in there doing their own thing, having, as we shall say, their own experience while you can start to do all your paperwork

and your reconstructions and whatever you need to do.

and stopping conduction. Just to finish up, a couple of nice cases. This one that we did recently, a guy had pleural plaques and had significant neuropathic lancinating pain

in his rib cage and you can see on the right hand side, we've brought the needle down underneath the ribs, so this is sort of a sagittal view on ultrasound of the rib. You go and target underneath the rib where the intercostal nerve runs. You do your diagnostic block.

We did that and the patient had significant improvement in pain, and then we come in behind that and do thermal ablation, so we're taking the RF probes and we're placing them in multiple intercostal nerves around where the patient's pain is

and you can see that we've marked on his skin the exact areas where he has profound pain. You can't even touch his skin without him having severe pain. And after we finished the thermal ablation, he still had pain, but he could rub his skin,

he could wear a shirt, he could do more things. That was definitely successful.

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.

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.

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.

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.

as well as the chemical. In thermal RFA, the target is to get the nerve to 70 to 90 degrees, which basically then disrupts the axonal continuity.

You get this Wallerian degeneration of the nerve because you disrupt the myelin, and the axon, and the endoneurium. Basically you're doing what the surgeon does by basically stopping that conduction of the nerve. Pulsed RFA is a newer way of addressing this

and this is not entirely well understood. Basically you're doing a non-lethal ablation affecting what's called modulations. You're modulating the nerve by passing an electric current across the nerve. And what that's supposed to do is reset the nerve.

There's actually genetic changes that occur in the dorsal root ganglion based on doing this modulation. I will tell you that if I ask my colleagues on this esteemed panel, how does pulsed RFA work, they would all give me kind of funny looks, I suspect. Because it really isn't totally understood right now.

Cryoablation is similar to thermal RFA where you basically are damaging the nerve

We're doing this in the knee where we do the geniculate nerves. We target the medial and lateral superior geniculate nerves, as well as the inferior medial geniculate nerve.

This is the approach, you can see the probe placed right where the geniculate nerve lives in the lateral position. This is what it looks like when we're placing the probes. We place these sheath needles. We inject some bupivacaine and lidocaine,

and then we form the RFA. This is another patient where we performed the medial and lateral superior geniculate and then the inferior medial geniculate ablation with significant relief of this patient's pain.

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 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.

- [Dr. Vazquez] Honor to be here. And Stephanie, thanks for inviting me. I think I'm one of the few anesthesiologists that are, have been given the chance, opportunity to talk here but I think this is just a sign of the trend that's gonna happen here.

I think we're gonna see more and more anesthesia involvement in these national talks because it's gonna be, it's a very exciting time to be in. We're gonna see more of us. The title of my topic today is IR Anesthesiology, Nursing, and Technologists: Three Teams with One Goal.

You guys can probably guess what that one goal is. And I have no financial disclosures. And the objectives for today are three fold. Gain insight about the future of Non-OR Anesthesia in the IR suite. Learn how the anesthesia team works with the IR team

to enhance patient care and experience. And learn how closer team collaboration enhances patient safety during crisis situations. And you know, we just heard, you know, the previous talk about a crisis that happened and I can only imagine all the commotion

that was going on with the patient that was exsanguinating and all the key team players that were there, you know, weren't highlighted, but kind of like the unsung heroes. But I wanna talk about that.

That we can actually, we're gonna get more of that. And that's where we should get better and focus our attention. And everyone of you is important and vital for patient safety.

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.

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.

- [Audience member] How about children?

- [Elvira] Children, the beauty with children is that they have a very great imagination. I mean they are Batman, they are whatever they want to be and you can get them very quickly into their state. So for a kid, all you may need to do is,

oh what do you like to do? And then when they tell you what they like to do we use a little, how shall we say, ego strengthening piece in it. So for example, we do work a lot with Toronto Hospital for SickKids

and obviously what kids love there to do is play hockey, and so they go and play hockey and all the sounds there is your fans cheering you on and then they're gonna hit a goal and that kind of makes them really proud. What I may also add to that,

I've been thinking about this earlier to include in that is landscape in medicine is really, really shifting and what is happening that nursing and technologists, frontline staff are gonna be determining what is happening with patients.

We see this more and more, I mean doctors don't have really that much to say anymore and at Toronto Hospital for SickKids the nurse is running an absolutely landmark study. She's 11 patients away from 170 and this is gonna be the very first trial

that shows can you actually, if you decrease pre-operative anxiety, and that's kids who have cardiac ablations under general anesthesia, can the pre-intubation anxiety reduction, is that gonna result in better post operative behavior? Because there's a lot of research that you basically

create PTSD in these kids who come, they're in this environment the next time it's gonna be worse and worse. So she follows them up. But the other thing too is there always has been some thought about how much do patients

actually hear? When they are under, so with those kids we're actually also looking at not only a script at the onset but right before extubation. How is that gonna affect how they recover in recovery? What's it gonna do afterwards, what's it gonna do

for the whole safety? So I think particularly in kids, anesthesia is a problem because brain development can be affected depending on the age so we are very much into, hopefully soon, knowing exactly what is happening

in the pediatric population on a broad scale there.

- Thank you. Here are my disclosures. Our preferred method for zone one TAVR has evolved to a carotid/carotid transposition and left subclavian retro-sandwich. The technique begins with a low transverse collar incision. The incision is deepened through the platysma

and subplatysmal flaps are then elevated. The dissection is continued along the anterior border of the sternocleidomastoid entering the carotid sheath anteromedial to the jugular vein. The common carotid artery is exposed

and controlled with a vessel loop. (mumbling) The exposure's repeated for the left common carotid artery and extended as far proximal to the omohyoid muscle as possible. A retropharyngeal plane is created using blunt dissection

along the anterior border of the cervical vertebra. A tunneling clamp is then utilized to preserve the plane with umbilical tape. Additional vessel loops are placed in the distal and mid right common carotid artery and the patient is systemically anticoagulated.

The proximal and distal vessel loops are tightened and a transverse arteriotomy is created between the middle and distal vessel loops. A flexible shunt is inserted and initially secured with the proximal and middle vessel loops. (whistling)

It is then advanced beyond the proximal vessel loop and secured into that position. The left common carotid artery is then clamped proximally and distally, suture ligated, clipped and then transected. (mumbling)

The proximal end is then brought through the retropharyngeal tunnel. - [Surgeon] It's found to have (mumbles). - An end-to-side carotid anastomosis is then created between the proximal and middle vessel loops. If preferred the right carotid arteriotomy

can be made ovoid with scissors or a punch to provide a better shape match with the recipient vessel. The complete anastomosis is back-bled and carefully flushed out the distal right carotid arteriotomy.

Flow is then restored to the left carotid artery, I mean to the right carotid artery or to the left carotid artery by tightening the middle vessel loop and loosening the proximal vessel loop. The shunt can then be removed

and the right common carotid artery safely clamped distal to the transposition. The distal arteriotomy is then closed in standard fashion and flow is restored to the right common carotid artery. This technique avoids a prosthetic graft

and the retropharyngeal space while maintaining flow in at least one carotid system at all times. Once, and here's a view of the vessels, once hemostasis is assured the platysma is reapproximated with a running suture followed by a subcuticular stitch

for an excellent cosmetic result. Our preferred method for left subclavian preservation is the retro-sandwich technique which involves deploying an initial endograft just distal to the left subclavian followed by both proximal aortic extension

and a left subclavian covered stent in parallel fashion. We prefer this configuration because it provides a second source of cerebral blood flow independent of the innominate artery

and maintains ready access to the renovisceral vessels if further aortic intervention is required in the future. Thank you.

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.

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.

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.

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,

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.

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.

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.

And again I'm gonna go later a bit more in what we do in interventional radiology where we do use some script reading but sometimes it's just very important what you say or that there is something you don't say.

So let's look at a situation, at a video that you kind of all know, like you have to put this IV in. And that's no uncommon and she's actually a very, very compassionate nurse but I mean this is replayed.

So you know the big question is, what do you actually believe happens when you say oh it's not going to hurt that much? What the patient hears is hurt, they don't hear that much, or it's just a little pinch and we had, when we did our breast biopsy study,

a very hard time because the team really believe that you have to use all these negative statements so we said okay, you know what, let's just get the data. So we listened to about 160 tapes in IR, what were people saying?

Just naturally what were they saying? And we listened for their statements that included pain or heat or bad or any other undesirable sensations and we were taking pain measurements every 10, 15 minutes and anxiety measurements and what we found

that if you warn for a stimulus with these kind of words they actually are gonna experience more pain than if you didn't say it and the same with the anxiety. If afterwards you sympathize and say oh that wasn't all that bad,

or how bad was that, it doesn't affect subsequent pain experiences but it will get the anxiety up. So what can you then actually say? I'm gonna show you another little video. Oops perhaps not, one moment we'll go back here

and yeah we can show the video now. Again Comfort Talk doesn't make things longer. You noticed what she did the second time? Right, okay she didn't say anything negative. She actually got the needles out of sight a little bit from the sight

and then she used something very tricky. She said well you might, because I always say give the patient the right to their own experience. You actually don't know what they're gonna feel. I never say this is not going to hurt, I mean what do I know, I don't.

So we call this a very permissive approach, we give some options. You might feel a sensation of cool or warmth or a delicious sense of tingling which we call a confusional type of induction because nobody really knows what that is

but now the brain is suddenly thinking, is it gonna be cool is it gonna be warm or is it delicious sense of tingling? (audience laughs) And that is the really very powerful phrase you can use in two settings.

One of the technologists at Boston Medical Center we trained said she had this patient come in with a real attitude, kinda under the whole idea. Oh you're putting that IV in, since how long are you in the business, do you know how to do this, yeah I'm a really hard stick, nobody does that

I don't see how you can do it, well she just put what we always say, put the confidence on and said, oh yeah and she put it in and when she said her thing, you might feel some cool or warmth or delicious tingling she said that patient suddenly went quiet

and was extremely cooperative till everything was completed. The other time this statement is extremely helpful when you are having a procedure. Somebody told me she had a vein stripping done, I mean not stripping but vein ablation,

you know you give a lot of local along the vein all the way up and down and she actually brought one of her colleagues with her because she wanted her colleague to do some Comfort Talk for her. But just in the preparation the doc was telling her the whole time, oh it's gonna hurt

and she said don't say that to me because I'm gonna be just fine. Said no, no, no but it's gonna hurt and she said, no you got this all wrong I will have a delicious sense of tingling. (audience laughs)

And I use that with my dentist too. I kind of just makes it quiet and you can have your own experience and cruise along. When we train the teams, now it's about the book, the key thing is this instant rapport and a lot of it is the matching

and leading to a more relaxed state. You shape the experience by the kind of wording you give but again the whole idea is to help these patients help themselves, to get them on autopilot because that's when they walk out the door, that's how they'll feel

the proudest of themselves. You're not doing it for them and I think sometimes it may interfere with your image as the giving healthcare provider. This is not about you, this is helping them to do their own stuff and what it does

in a very miraculous way that it actually cuts your stress level way down. And again with the self-hypnotic experience, I'm gonna show you in a little moment what it is because I'm gonna walk you through a little script we do. You can even, once you know how to do that,

support a stable physiology, get blood pressure a bit up and down although I always say this should not be your only way of keeping your patient stable.

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.

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.

Alright so now if there's still a bit of disbelief in, oh let's just look a bit how it can normally look,

and how you might be able to change it, there we go.

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.

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.

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