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For other articles and previous issues click here. April 18, 2005 Back
Support — Interventional Radiologists Are Expanding Their
Role in Helping Patients With Back Pain One big challenge is getting word to colleagues and patients that radiologists have a place treating some back pain cases. More than 65 million Americans suffer from back pain every year. It vies with the common cold as the leading reason why people seek medical care. When people see their physicians because of back pain, they want to know what is causing it and expect their doctor to order diagnostic tests. Unfortunately, even with x-ray, MRI, or CT scans, a diagnosis for back pain is not simple. “There are so many different layers and so many different pain generators that most experts say 80% of the time, ‘We can’t tell you where the pain is coming from,’” says Joseph Ruane, DO. Ruane is medical director of musculoskeletal health at the McConnell Health Center in Columbus, Ohio, and frequently works with back pain patients. In 2001, clinicians at the University of Washington in Seattle published research known as the LAIDBack (Longitudinal Assessment of Imaging and Disability of the Back) Study that found little correlation between lower back pain and MRI findings. The study randomly selected 148 patients of varying ages from clinics at a Veterans Administration hospital, none of whom had reported experiencing back pain. MRI images were obtained through each of the five lumbar disc levels. Although the patients reported no discomfort, 123 subjects (83%) had moderate to severe desiccation or drying out of one or more discs, 95 (64%) had one or more bulging discs, and 48 (32%) had at least one disc protrusion, all of which can cause pain. The researchers hoped to show what a bad back looks like on MRI. What they found instead: “You’re not doing anyone a favor to look at an MRI and say that’s why you hurt,” Ruane says. What may appear to be the cause “is highly prevalent in patients with no pain.” Hold the MRI That’s why Ruane told a group attending the seminar “Doc, My Back Hurts” at the 30th Annual Meeting of the Society of Interventional Radiology (SIR) in New Orleans April 5 that unless red flags are present, patients with acute back pain do not need to be sent for x-rays or MRIs in the first four weeks. There are other items on the list that “all practitioners who care for back pain should be aware of,” Ruane says. Those flags include a history of trauma, such as a significant fall or accident. Patients over the age of 50—especially males and those with accompanying fever, chills, weight loss, or night sweats—should be tested because the symptoms could signal cancer as the pain’s cause. Patients with a history of intravenous drug use should also be tested because they can get serious spine infections. In the absence of red flags, patients can be managed for four to six weeks with rest, physical therapy, and pain medications. “In some countries,” Ruane adds, “if patients clear a red-flag phone triage, doctors will tell their patients to use heat, ice, and Aleve, and, ‘Don’t bother me for four to six weeks.’” If, however, after six weeks the pain persists or gets worse, further diagnosis and treatment is necessary, Ruane says. “If the patient is still experiencing pain, it’s appropriate to consider a specialist.” Several specialties treat back pain—orthopedists, neurosurgeons, physiatrists, anesthesiologists, neurologists—and each has different training and skills. Interventional radiologists and interventional neuroradiologists have been added to that list more frequently in recent years. Interventional Involvement “Not only do we understand the imaging—the x-rays, CAT scans, and MRI,” says J. Kevin McGraw, MD, codirector of vascular and interventional radiology at Riverside Methodist Hospital in Columbus and cochair of the SIR conference on back pain, “but we also can perform image-guided procedures that target the source of the pain.” L. Mark Dean, MD, a colleague of McGraw’s at Riverside and fellow panelist, agrees: “Interventional radiologists are some of best-suited physicians to do pain procedures because we have an excellent knowledge of the adjacent muscles, fascia [connective tissue], and blood vessels.” Also, he says, “we are used to image procedures and image guidance such as CAT scan, MRI, and angiography.” Joshua A. Hirsch, MD, director of interventional neuroradiology and chief of minimally invasive spine surgery at Massachusetts General Hospital in Boston, adds, “Interventional radiologists are perfectly positioned to perform these pain-relieving procedures for the back because imaging guidance is our expertise, and performing these procedures in that fashion has made them safer and more effective over the years.” McGraw says his practice began treating back pain roughly 10 years ago when it started doing vertebroplasty, a minimally invasive procedure for treating compression fractures in the spine. Using fluoroscopic guidance, the interventional radiologist passes a large gauge needle into the vertebral body. Iodinated contrast is injected to confirm proper needle placement, followed by the injection of liquid medical-grade cement. Injecting the cement takes approximately 10 minutes. Once injected, the cement hardens in 10 to 20 minutes. Vertebroplasty Spinal fractures are most often the result of osteoporosis. Nearly 700,000 spinal or vertebral fractures are caused by osteoporosis each year. Before treatment, most patients are in agony and can’t function routinely. Conservative measures such as bed rest and painkillers are often ineffective and can have negative impacts on older adults, says Hirsch, who cochaired the SIR conference on back pain. McGraw believes that as technology advances and the public demands more minimally invasive procedures, interventional radiologists will find themselves treating more and more patients with back pain. “Everyone seeks a way to avoid surgery,” McGraw says. “If we can do the techniques with image guidance and accomplish the same results as with open surgery and have quicker recovery and no hospitalization, everyone is going to go for that.” Hirsch says interventional radiologists and neuroradiologists are not limited to any one procedure. “We can offer the full range of percutaneous services,” he says. Other Interventions • Kyphoplasty. Sometimes called balloon-assisted vertebroplasty, and as the name suggests, kyphoplasty utilizes a balloon in conjunction with the vertebroplasty. In this procedure, a small incision is made on each side of the affected vertebra. Through a hollow tube called a canula, a small instrument with an inflatable balloon at the tip is inserted. Once it is placed inside the vertebra, the balloon is filled with air to increase the space inside the collapsed bone. After the balloon is deflated, a cementlike substance is injected in the bone in a fashion similar to vertebroplasty. • Percutaneous discectomy. This procedure treats patients suffering sciatica or leg pain caused by a herniated or “slipped” disc. The radiologist performs the decompression percutaneously through a needle. Patients can benefit from percutaneous disc decompression if their pain originates from a contained herniated disc, a bulging disc where there is no rupture in the outer wall, Hirsch says. • Disc nucleoplasty. Introduced in 2000, disc nucleoplasty uses a unique plasma technology called Coblation. According to Hirsch, the procedure removes tissue from the center of the disc to relieve back and leg pain symptoms, including sciatica and pain caused by a central bulge of the disc. During the procedure, the Disc Nucleoplasty SpineWand is introduced through a needle and placed into the center of the disc where a series of channels are created to remove tissue from the nucleus. Removing tissue from the nucleus acts to decompress the disc and relieve the pressure exerted by the disc on the nearby nerve root. As pressure is relieved, pain is reduced. • Intradiscal electrothermal therapy (IDET). This procedure offers an alternative to major surgical fusion for treating degeneration, or wearing out, of the lumber intervertebral discs. Hirsch explains that IDET uses a probe inserted into the disc to heat the tissues within the affected disc. Heating the inside of the disc to 85° Centigrade causes the tissues to shrink. It also cauterizes the small nerve fibers in the periphery of the disc. IDET is performed as an outpatient procedure. The procedure uses only local anesthesia and some mild sedation. Studies show that roughly 60% to 80% of patients find improvement in the months following an IDET procedure. • Epidural steroid injections. These epidural injections are administered in a hospital/outpatient medical facility to treat low back pain. According to Hirsch, the patient receives medication intravenously for relaxation. Numbing medication is injected into the skin area where the injection will be placed. The physician works under fluoroscopy to direct the needle into the epidural space at the appropriate spinal level (cervical, thoracic, lumbar). After the procedure, the patient is moved to the recovery area and monitored for approximately one hour. • Nerve blocks. These injections can relieve pain and/or determine whether a specific nerve root is the pain source. Hirsch says nerve blocks are injections of anesthetic, steroid, and/or opioid medication. Anesthetic medications numb the nerves; steroids are potent anti-inflammatory drugs that reduce swelling; and opioids are powerful drugs that fight pain. In some cases, nerve blocks can provide extended periods of pain relief. While minimally invasive, the procedures are not necessarily done in lieu of surgery. Sometimes they are performed in conjunction with surgery. “They’re often done to aid in diagnosis and preoperatively localize for surgery,” Hirsch says. There are different types of nerve blocks including cervical, thoracic, and lumbosacral medial branch blocks that target the medical branch nerves; facet joint blocks; and selective nerve root blocks. Facet joints are the small-paired joints on the back of the spine that provide spinal stability and guide motion in the back. Selective nerve root blocks are performed to reduce inflammation and pain and determine whether a specific nerve root is the pain source. IR Growth Market “I think that down the road, interventional radiologists will be able to do spinal fusions just through needles instead of having open surgery,” McGraw says. “And then we’ll also have ways to do disc replacements just with needles and imaging guidance.” One of the big challenges interventional radiologists and interventional neuroradiologists face is convincing referring physicians that radiologists are the right specialists to see when their patients suffer from back pain. “Many interventional radiologists have been expanding their practice and are becoming more clinically oriented,” Dean says. “For many physicians, that’s somewhat of a new phenomenon. These physicians may be used to having their radiologist sit in a dark room and not talk to anybody. We are providing good diagnostic and clinical evaluations like other physicians.” McGraw believes colleague awareness is more of a regional issue. “What we’re finding, at least in our market,” he says, “is that most primary care physicians and physical medicine docs know about us so they send patients to us to do what we possibly can before that patient goes to surgery.” Still, McGraw, says it’s all in the marketing—making the public aware. “This is something we’ve been working pretty strongly over the last five to six years.” — Beth W. Orenstein is a freelance medical writer in Northampton, Pa. She is a frequent contributor to Radiology Today.
Back and neck pain is a serious problem among interventional radiologists, says Neal Naito, MD, MPH, occupational medicine physician at the National Naval Medical Center in Bethesda, Md. It’s a problem for two reasons, he says: As the public demands more minimally invasive treatments, interventional radiologists are working longer hours. “The number of procedures they can do has increased exponentially as people want to avoid surgery,” Naito says. Also, interventional radiologists must generally wear heavy lead aprons while performing those procedures to protect themselves from radiation. Sometimes, too, they must contort their bodies to be able to properly operate on a patient. “Their work environment can place an extraordinary strain on their back and neck,” says Naito, who discussed the problem at the seminar on back pain at the Society of Interventional Radiology’s (SIR) annual meeting in New Orleans earlier this month. No large-scale study of the incidence of musculoskeletal injuries among interventional radiologists has been done, although the specialty is interested in doing one. “Anecdotally,” Naito says, “it seems significant.” Improvements have been made in the design of workstations and exam tables, Naito says. “The problem is that radiation safety hasn’t kept pace with the specialty. The lead apron as the standard personal protective equipment for interventional radiologists has not changed over many decades.” Alternative strategies to lighten the load are available—such as clear lead shields that can be raised and lowered from the ceiling. “But still the standard is that you have to wear the leaded apron,” Naito says. Back problems can be treated, Naito says, but unless the physician changes his work environment, “then like anything else it will just keep coming back.” J. Kevin McGraw, MD, codirector of vascular and interventional radiology at Riverside Methodist Hospital in Columbus, Ohio, and cochair of the SIR conference, knows firsthand what Naito is talking about. In the beginning of March, a month before the seminar, he underwent surgery to remove a disc in his neck that was pressing on a nerve. “It was occupational,” McGraw says, “the result of my wearing lead all day long.” — BWO |
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