Interventional Pain for the Radiologist

[freddydpt]

I'm starting this thread because I wanted a focused forum on those who are entering radiology and plan on practicing pain management. From time to time I will post links to articles with a copy of the abstract. Enjoy!

http://radiographics.rsna.org/content/21/4/927.full

Imaging-guided Injection Techniques with Fluoroscopy and CT for Spinal Pain Management1

1. Richard Silbergleit, MD2,
2. Bharat A. Mehta, MD,
3. William P. Sanders, MD and
4. Sanjay J. Talati, MD3

+ Author Affiliations

1.
1From the Department of Radiology, Henry Ford Hospital, Detroit, Mich (R.S., B.A.M., S.J.T.), and the Department of Diagnostic Radiology, William Beaumont Hospital, 3601 W Thirteen Mile Rd, Royal Oak, MI 48073-6769 (W.P.S.). From the 1999 RSNA scientific assembly. Received November 3, 2000; revision requested December 8 and received December 28; accepted December 29. Address correspondence to R.S. ([email protected]).


Next Section
Abstract

Local spinal pain and radiculopathy are common conditions that debilitate millions of Americans annually. Most cases are successfully treated conservatively with rest or physical therapy. Chiropractic manipulation or, in some cases, surgery may also be performed. Percutaneous injection has been used for spinal pain management for many years, but many of these procedures have historically been performed without imaging guidance. Recently, however, newer minimally invasive, imaging-guided percutaneous techniques have been added to the list of available treatment options for spinal pain. Imaging-guided techniques with fluoroscopy or computed tomography increase the precision of these procedures and help confirm needle placement. Cervical, thoracic, lumbosacral, and sacroiliac pain can be evaluated and treated safely and effectively with injections of local anesthetics or long-acting steroids into facet joints, sacroiliac joints, selective nerve roots, spondylolytic areas, and the epidural space. Because imaging-guided techniques appear to provide better results and reduce complication rates, they are becoming more popular despite controversy regarding their effectiveness. Controversy will continue to surround these imaging-guided techniques until large, double-blinded studies become available. In the meantime, there is an increased demand for these procedures from referring physicians, and it is important to be able to safely perform them with a minimum of patient discomfort.

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[bedrock]

a focused forum on those who are entering radiology and plan on practicing pain management.

Sorry to rain on your parade, but pain interventions will be done less and less by radiologists in the future for the simple fact that these patients need pain MANAGEMENT, i.e. a physician to manage the pain including interventional pain procedures, not just someone who briefly puts a needle in patients without the context of their medical and psychological history.

Patient referrals to radiology for pain procedures are becoming less and less common for those reasons.

(not withstanding the unnecessary radiation exposure from CT guided procedures that could be done with a fraction of the radiation under fluoro)

 

[youngdoc8205]

short answer to can IR practice pain mgmt: sure

long answer:


from what I saw when I was in rads residency, pain procedures were split between IR and anesthesia, where IR did more of the high end things like with CT or MRI guidance, injecting strontium or samarium (experimental), and things like cementoplasty of metastatic fractures in bone other then vertebrae, as well as some of the run of the mill stuff.


for bedrock's benefit: using CT when it's not needed only occurs in PP, and believe you me if anesthetia, pmr or whoever else could get their hands on a CT scanner, they would irradiate the hell out of their patients, just look at PP cards, ortho, and neurosurgery with their own "imaging" sections, the vast majority of unnecessary imaging is ordered by those mooks

I don't think pain tx is the draw to IR though, it seemed most rads I worked with kind of sighed when they had to do these as they are exceptionally boring, at least the ones I participated in, and pale in comparison to say coiling a GI bleeder or TACE of a liver tumor.


The things that others say, i.e. anesthesia, is true to an extent the chronic patients need management, you can either pick them up in practice (not something I would feel comfortable with) or in fellowship,
but to say that anesthetia or PMR training is superior to IR is laughable at best: both also do a 1 year fellowship in interventional pain, whereas an IR who does an additional pain fellowship would have far superior image guidance experience than either of the 2, particularly with non-flouro stuff, and because of that they can spend extra time learning the "management" aspect of it in pain fellowship; though im not sure it takes a hell of a lot of brain cells know about the different medical options, and
to hear the anesthetia/pmr guys say "oh i read my own mri, i never rely on rads reads" is plain ridiculous, rads residents don't even get to mri things until r2-r3 or late in r1, and for these jokers to claim they have a better understanding then neurorads, or even general rads is plain old dangerous

it's like the neurosurgeons we work with to do VP shunts or anterior exposures, they think they are the shiznit, but they couldn't get to do their part if we weren't there, my attendings won't even let the NS attendings assist on the closures b/c they are shockingly cruddy at it,

any IR can do a fellowship in pain via anesthetia (a lot less difficult than matching into radiology residency from what I understand, but I would check with specific programs)

But again doing pain in IR is quite easy in PP,and the docs trained in other specialties are sort of in the same boat, i.e. you all get referrals, and refferers will send to the doc who gets the best results and provides the best service. Though I personally feel if you want to do pain mgmt as an IR, you really should learn the "management" part of it, like the above guy said, having a good interventional and imaging background won't really help you if the optimal tx is medical: why would people only want to refer to you for the intervention and deal with the crap (i.e 120 oxycodone a month) themselves, and if you want to base a career on pain management I personally wouldn't do IR, simply b/c if you want a thriving pain practice you really have to devote your energy to that and can't really focus on other major aspects of IR, PVD, dialsysis care, UFE, oncology, each of those is really a separate knowledge base and you can't be good at all of them if trained in the current paradigml, so if you're endgame is pain, go pmr or anesthetia, as they really are not focusing on that other stuff and can devote their time to pain

but on the flip side the ability to manage pain should really be within the scope of practice of an interventional oncologist, as should ports and lines

Also, in case people wonder why I keep popping up in IR forums and in defense of IR, even though I jumped ship to surgery, here's the disclaimer:
1)
I think IR is a fabulous field, I just missed the OR, and I couldn't stomach 4 years of DR to get to IR;

2) I absolutely despise others coming in and saying "i am better than you for x,y,z reason so suck it"
it takes a lot of hubris for one specialist to go around and say they are better suited to do something than another (IRs are included in this statement) and often these are the people who will put patients at risk doing things they have no business doing

I think such people are cancers to the field of medicine and should be attacked in every possible way, Ithey are in no small way the reason medicine is in the state that it is in this country and I'm certain are driven purely by ego and economics not patient outcomes

I am fortunate to work in a hospital system where turf battles are literaly non-existent b/c of salaried physicians and profit sharing to the point of VS, IR, and cardiology all have an equal share in the heart and vascular center (granted neither one is raking in millions of dollars, but neither are they starving and all are extremely satisfied in their professional lives) and it is just amazing what kind of affect this has on patient care, compared to where I came from where every department would fight for the others' scraps; it really should be the model of care in this country and not the greedy, capitalistic way medicine is practied today

 

[freddydpt]

Management of Chronic Low Back Pain: Rationales, Principles, and Targets of Imaging-guided Spinal Injections1

1. Jan Fritz, MD,
2. Thomas Niemeyer, MD,
3. Stephan Clasen, MD,
4. Jakub Wiskirchen, MD,
5. Gunnar Tepe, MD,
6. Bruno Kastler, MD,
7. Thomas Nägele, MD,
8. Claudius W. König, MD,
9. Claus D. Claussen, MD and
10. Philippe L. Pereira, MD

+ Author Affiliations

1.
1From the Departments of Diagnostic Radiology (J.F., S.C., J.W., G.T., C.W.K., C.D.C., P.L.P.), Orthopedic Surgery (T. Niemeyer), and Neuroradiology (T. Nägele), Eberhard-Karls-University, Hoppe-Seyler-Str 3, Tübingen, Germany; and Department of Radiology, Université de Franche Comté, CHU Minjoz, Besancon, France (B.K.). Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received February 13, 2006; revision requested June 14; final revision received March 23, 2007; accepted March 23. All authors have no financial relationships to disclose.

1. Address correspondence to
J.F., Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287 (e-mail: [email protected]).

Abstract

If low back pain does not improve with conservative management, the cause of the pain must be determined before further therapy is initiated. Information obtained from the patient’s medical history, physical examination, and imaging may suffice to rule out many common causes of chronic pain (eg, fracture, malignancy, visceral or metabolic abnormality, deformity, inflammation, and infection). However, in most cases, the initial clinical and imaging findings have a low predictive value for the identification of specific pain-producing spinal structures. Diagnostic spinal injections performed in conjunction with imaging may be necessary to test the hypothesis that a particular structure is the source of pain. To ensure a valid test result, diagnostic injection procedures should be monitored with fluoroscopy, computed tomography, or magnetic resonance imaging. The use of controlled and comparative injections helps maximize the reliability of the test results. After a symptomatic structure has been identified, therapeutic spinal injections may be administered as an adjunct to conservative management, especially in patients with inoperable conditions. Therapeutic injections also may help hasten the recovery of patients with persistent or recurrent pain after spinal surgery.

© RSNA, 2007

 

[Doctodd]

2) I absolutely despise others coming in and saying "i am better than you for x,y,z reason so suck it"

this is funny....