mr guided ultrasound surgery

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Yoyomama88

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For example, for fibroids, who is the primary physician who performs this procedure? An OBGYN or a radiologist?


I'm interested in neurology and I was wondering whether or not you think a neurologist would be able to perform this procedure for essential tremors if it becomes more widely used? Or would this likely be limited to a neurosurgeon or radiologist?
 
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I honestly have no idea how to answer this. No part of this post makes any sense.
 
Seriously, rather than wasting your time here on Saturday night, go out with your friends and have fun. College is the best time of your life and don't destroy it by thinking about reimbursement of intra-op monitoring (as you mentioned in another post). Even if you do hundreds MR guided US surgery (I even don't know what the heck is this) or whatever imaginary surgery is in your mind, these days won't come back. My 2 cents.
 
For example, for fibroids, who is the primary physician who performs this procedure? An OBGYN or a radiologist?


I'm interested in neurology and I was wondering whether or not you think a neurologist would be able to perform this procedure for essential tremors if it becomes more widely used? Or would like this likely be limited to a neurosurgeon or radiologist?
I second enjoying college and not worrying about future medical school.

In IR, a better name for their 'surgeries' is image-guided percutaneous procedures. The image-guidance can be under fluoroscopy, CT, U/S, and MR (MR in very few settings, only for certain procedures, mostly in large academic centers, mostly experimental).

For surgical/procedural treatment of fibroids, they can be managed either by an OBGYN performing a hysterectomy and, less often, an IR doing a uterine artery embolization. The OBGYN and IR do not work together on procedures -- patients choose one or the other (if they are even presented the choice of uterine artery embolization -- hysterectomies are far more common ).

Neurologists, neurosurgeons, and IR's all have turf in some way or the other in doing image-guided percutaneous procedures in the brain. In places where neurosurgeons want to have these procedures, they often have the trump card over both neurologists and IR's.

I say all this to answer your questions, but, unless you have a close family member that is one of the types of physicians you mentioned, your perspectives will change. Enjoy your time before med school -- play video games, go out with friends, see movies -- these are things you'll miss in med school
 
Surgery is the wrong word, but the procedure that the OP is describing already exists. It uses high-powered sound waves to ablate fibroids, using MR has guidance. So far, I believe that's the only FDA-approved use, but they've also used it to ablate some bone lesions in ongoing trials.

It's hard to say who will control this technology, if it even pans out as practical. The problem is the magnet. It represents such a huge investment, that a practice/hospital really needs to maximize its effectiveness. Radiologists are in a great position to do this, because the tables can be switched out to also do diagnostic scans. But if the volume grows, then who knows?
 
Surgery is the wrong word, but the procedure that the OP is describing already exists. It uses high-powered sound waves to ablate fibroids, using MR has guidance. So far, I believe that's the only FDA-approved use, but they've also used it to ablate some bone lesions in ongoing trials.

It's hard to say who will control this technology, if it even pans out as practical. The problem is the magnet. It represents such a huge investment, that a practice/hospital really needs to maximize its effectiveness. Radiologists are in a great position to do this, because the tables can be switched out to also do diagnostic scans. But if the volume grows, then who knows?

I understand parts of his question, but it seems like he was a little scatterbrained when he made it. Maybe he's an IMG? Either way, neurologists, neurosurgeons, and OB/GYNs will not be doing fibroid embolizations. I've seen OB and IR work together in other procedures, such as internal iliac balloon occlusions for placenta increta (before you guys say it, yes the procedure is of debated benefit).

The MRI question is an interesting one, at least in theory. Neurosurgery currently has a few institutions that are using a functional MRI intra-operatively, which is a very cool idea. I'm not sure how an MRI would provide additional benefit to most current IR procedures. Again, as you mentioned, the cost to benefit is really questionable. A huge benefit to IR procedures is avoiding the cost associated with the OR, which would be partially negated by a procedure MRI.
 
The OP was asking also about ablations for essential tremor, not just about fibroids. That's why neurologists and neurosurgeons were brought up.
 
Rather than be condescending like everyone on this thread, I'll answer your question.

No, radiologists don't do these procedures. I can't tell you if it's neurologists or neurosurgeon, or a combination that do them. Try those forums
 
Rather than be condescending like everyone on this thread, I'll answer your question.

No, radiologists don't do these procedures. I can't tell you if it's neurologists or neurosurgeon, or a combination that do them. Try those forums

Please explain to me how I've been condescending on this thread.

And if you're referencing MR-guided US ablation for essential tremor, like the OP asked about, then no one does those. That's not even experimental at this point.
 
I should have said with the exception of your post.

Either way, it sounds like he's just asking about DBS for tremors, so just guiding him to the appropriate forum, which isn't here
 
I should have said with the exception of your post.

Either way, it sounds like he's just asking about DBS for tremors, so just guiding him to the appropriate forum, which isn't here

Curious as to how mine is condescending as well. I really have no idea what he's asking (and you apparently don't either, given your vague answer). He's entitled the thread with a hodgepodge of imaging-related words, and in his post he discusses a number of specialties and procedures that are rather unrelated. Maybe I just don't know enough about image-guided procedures yet? I answered with what I thought was an acceptable answer. If that's condescending, my freakin' bad, bro.
 
I missed the part of colb's post where he talked about ablation of fibroids with MR guidance. That's pretty cool...
 
I stand corrected. I sat through a lecture on this subject not too long ago during which a number of currently off-label trials were discussed, but this particular use was not mentioned.
 
I did not understand the OP, and I suspect the confusion is that the OP has not done any MS3 and is all confused about the different procedures. So since he got some answers, I wanted to ask additional questions that are confusing. So, I have pretty much decided to apply for radiology and am in the process of setting up 4th year electives. And I want to know a bit more about different procedures in radiology. Something that I could aspire to get a "niche" in after some type of fellowship. So here are the questions:

1) if you do IR fellowship, how likely is it to have an outpatient practice and do uterine, prostate, and veins only? Do you feel that vascular surgeons wouldn't want to take away prostate(once it is fda approved) or gynecologists take away uterine(in other countries those procedures are done by gynecology and urology respectively)?
2) I notice that most programs no longer offer AAA, does it mean that IR in private practice no longer do it or will no longer do it in 5yrs?
3) If you do an IR fellowship does it mean that you will never be specialized in any diagnostic reads, and so u will never be able to do telerads? Alternatively if instead of IR u do something like msk, is it possible to still pick up some of those IR procedures if u decide some day to open a vein and pain clinic?
 
1) if you do IR fellowship, how likely is it to have an outpatient practice and do uterine, prostate, and veins only? Do you feel that vascular surgeons wouldn't want to take away prostate(once it is fda approved) or gynecologists take away uterine(in other countries those procedures are done by gynecology and urology respectively)?
2) I notice that most programs no longer offer AAA, does it mean that IR in private practice no longer do it or will no longer do it in 5yrs?
3) If you do an IR fellowship does it mean that you will never be specialized in any diagnostic reads, and so u will never be able to do telerads? Alternatively if instead of IR u do something like msk, is it possible to still pick up some of those IR procedures if u decide some day to open a vein and pain clinic?

I'm really no further along than you. I'm a 2014 grad, but I'm planning on going into IR, so I hope I can help to answer some of these questions. These are all my take on them from what I've seen/read/talked to people about. Sorry if they're inaccurate.

1. I don't think that doing "only" these procedures is realistic. I've been told by numerous successful IR guys that you need to say, "Yes," more often to get the things you want to do. This means you'll be doing plenty of the "other" IR stuff (drains, lines, PCNs, biliary drains, etc.) to get the things you want to do.
2. I was just talking to a poster on these boards about it. He started working in private practice last year. Apparently companies are willing to train you in doing procedures such as AAA after you go out on your own. While training, you go to one of their centers and it's like having an attending teach you step by step. Then, when on your own, you can ask the reps for help. They're apparently an invaluable resource. I know the private practice world is a huge mystery...It is for me, too.
3. From what I understand, a lot of private practices want you to do reads. Will you be as good as someone that is fellowship trained in something like MSK and sees the tough cases every day? No. Will you be good enough to pick up the basic reads expected of you? Yes. As for the second part of the question, yes I know people that do IR procedures (even endovascular procedures) that are not IR trained. It's about what you're comfortable with, your training background, and what the hospital will allow you to do.
 
I did not understand the OP, and I suspect the confusion is that the OP has not done any MS3 and is all confused about the different procedures. So since he got some answers, I wanted to ask additional questions that are confusing. So, I have pretty much decided to apply for radiology and am in the process of setting up 4th year electives. And I want to know a bit more about different procedures in radiology. Something that I could aspire to get a "niche" in after some type of fellowship. So here are the questions:

1) if you do IR fellowship, how likely is it to have an outpatient practice and do uterine, prostate, and veins only? Do you feel that vascular surgeons wouldn't want to take away prostate(once it is fda approved) or gynecologists take away uterine(in other countries those procedures are done by gynecology and urology respectively)?
2) I notice that most programs no longer offer AAA, does it mean that IR in private practice no longer do it or will no longer do it in 5yrs?
3) If you do an IR fellowship does it mean that you will never be specialized in any diagnostic reads, and so u will never be able to do telerads? Alternatively if instead of IR u do something like msk, is it possible to still pick up some of those IR procedures if u decide some day to open a vein and pain clinic?

It all depends on the location that you work. I live in a big coastal city. Here, if you through a stone, there is high likelihood that it hits a doctor esp a specialist (any field). A few months ago, we were evaluating the referral potential in our area and the number of doctors within 10 miles of our offices is ridiculous. As a result, any doctor is doing a lot of "scut work" to be able to pay for the business overhead. Successful practice here means to do whatever comes by and not your interest in most part. The only exception is academics where you can narrow your practice according to your interest. On the other hand, if you move to the middle of nowhere, there is a high likelihood that you can have the type of practice that you want for most of it. Now back to IR:

1- As you see above, IMO most of your competition will be other IR doctors and not necessarily vascular surgeons.I personally don't think Gynecologists and vascular surgeons will done UAE or prostate. At the same time, I don't think UAE or prostate embolization will be high volume in the future. You may get to do a few between your cases but not most of your time. PAD is something that if you put time and energy you can get more cases.

2- You will be able to learn AAA but there is a huge pressure from vascular surgery. I don't think you have to choose your field based on one procedure.

3- If you do IR in big cities, expect to do a lot of DR and also a lot of bread and butter procedures like biopsies, lines and drains. Your DR work will be a lot of bread and butter radiology like CXR, bone XR, anything CT and anything US. Higher end studies like MSK MRI, Neuro MRI or Body MRI will be read by sub-specialists. Telerad is a different beast. I don't think it is doable if you do IR at the same time.

3b- I am MSK trained and I do about 30-40% of my time procedures. I do pain management and spine procedures including kypho/vertebro. Also I do bread and butter procedures like biopsies, biliary tubes, drains including percut chole, lines and ports. I don't do something like IVC filter or angio, but I have heard some non-IR trained people do. Personally, I think other than ports and lines, anything vascular (excluding vein) should be done only by IR. For non-vascular procedures some body fellowships train you to do most of them like biopsies, drains, biliary tubes, Perc chole, PCNs and tumor ablations. Many MSK and Neuro fellowships train you to do pain management. Vein work like varicose vein is no man's land. It is something like Botox injection or Derm-ablation. The busiest vein clinic in our area belong to a family physician.

Bottom line: There are lots of opportunities in this field. If you do IR, you will be very well trained to do tons of procedures. But even if you are not IR, still you can do lots of procedures.
 
For example, for fibroids, who is the primary physician who performs this procedure? An OBGYN or a radiologist?


I'm interested in neurology and I was wondering whether or not you think a neurologist would be able to perform this procedure for essential tremors if it becomes more widely used? Or would this likely be limited to a neurosurgeon or radiologist?
IMO, this is ultimately going to end up being a turf war between neurosurgery and neuroradiology, which neurosurgery will likely win. It may not even be much of a fight.

Neurology will play a role, but not likely compete to be the ones performing these procedures on patients with movement disorders. IMO, Rad Onc is more likely to pick up this tech than Neurology, b/c it's more similar to something they already do...but that might not even happen b/c it's use is so limited right now (unlike SRS).

Neurologists who treat movement disorders control the patient flow. Once their patients become candidates for more invasive procedures (b/c conservative Tx has failed), they're going to want to send their patients to the consultant with the widest range of therapies to offer. Functional NSGY is the logical choice. They could offer the patient DBS, SRS (in concert with Rad Onc) or open surgery in some cases (becoming less common by the day). There are some who are doing MRgFUS and related procedures already for tumors and likely some of them who are already involved in experimental Tx for movement disorders.

Don't choose Neurology if you really think you want to do this kind of procedure. If you want to do this stuff, NSGY is your best bet. This pretty much goes for any neuro procedure, not just MRgFUS.

If the disease processes are more what you're interested in, Neurology could be a good choice. They work directly with patients over the long-term and do more of the interesting electrophysiology (when it comes to DBS and epilepsy surgery). NSGY simply comes in, does the procedure, and then hands the patient back to Neurology. They're also usually the ones doing the adjustments to the DBS unit's settings once it's in place. NSGY ain't got no time for that...too many skulls and spines to surgerize.
 
appreciate the detailed opinion. So you don't think an interventional neurologist can carve out a piece of this pie, if the technology plays a greater role in functional neurosurgery?

I don't see the point in doing a 7 yr neurosurgery residency to perform non-invasive brain surgery lol.
 
appreciate the detailed opinion. So you don't think an interventional neurologist can carve out a piece of this pie, if the technology plays a greater role in functional neurosurgery?

I don't see the point in doing a 7 yr neurosurgery residency to perform non-invasive brain surgery lol.

Endovascular is the way to go if you're doing NSG (depeding on what you want to do). If you like dealing with aneurysms, NSG is the best way to go. You can provide a truly unbiased opinion to your patient because you can both clip and coil. You can also open the patient up if you absolutely have to during the interventional procedure.
 
Endovascular is the way to go if you're doing NSG (depeding on what you want to do). If you like dealing with aneurysms, NSG is the best way to go. You can provide a truly unbiased opinion to your patient because you can both clip and coil. You can also open the patient up if you absolutely have to during the interventional procedure.

If you like doing procedures and surgeries pertaining to the brain, then neurosurgery is the best bet. It is not, however, the only option. Neurologists are increasingly becoming trained, and trained well, to perform many procedures. Most highly specialized fields have become multi-disciplinary. Take NIR for example - there are radiologists, neurosurgeons, neurologists, and interventional cardiologists (UGH) doing these procedures. As far as MRgFUS use, it will most likely follow a similar pattern. There will be some Type A personality neurologists/movement disorder specialists that will eventually train to perform this procedure - but once again, other fields might have a stronger foothold.
 
appreciate the detailed opinion. So you don't think an interventional neurologist can carve out a piece of this pie, if the technology plays a greater role in functional neurosurgery?

I don't see the point in doing a 7 yr neurosurgery residency to perform non-invasive brain surgery lol.
I think Interventional Neurology is primarily focused on endovascular techniques for aneurysm and stroke right now. If NIR starts doing a lot of MRgFUS, then the neurologists who train under them will pick it up, too. However, as I understand it, it is mainly neurorads who are doing this right now, not the NIR guys.

Either way, the interested neurologist will likely have to find someone who is willing to train him/her in the use of the technique. It might not be that hard (as in the case of cerebral endovascular techniques), but it could be if radiologists learn to be more protective of their turf with this particular technique.

As to your 2nd comment, this is exactly why I chose Radiology over NSGY. Didn't see the point of enduring the residency to do functional (3rd year residents at my institution hate it because the procedures themselves are so straight-forward and simple, it feels like you don't really get to operate = no fun for a "real" surgeon).
If you like doing procedures and surgeries pertaining to the brain, then neurosurgery is the best bet. It is not, however, the only option. Neurologists are increasingly becoming trained, and trained well, to perform many procedures. Most highly specialized fields have become multi-disciplinary. Take NIR for example - there are radiologists, neurosurgeons, neurologists, and interventional cardiologists (UGH) doing these procedures. As far as MRgFUS use, it will most likely follow a similar pattern. There will be some Type A personality neurologists/movement disorder specialists that will eventually train to perform this procedure - but once again, other fields might have a stronger foothold.
First of all, barf...I can't believe interventional cards are getting in on this. F*@! that. Seriously.

Second of all, neurologists usually don't treat brain tumors. Do they diagnose them? Sure...occasionally. But there aren't many out there who are trained as neuro-oncologists (though one of my friends is an exception). Again, as I understand it, tumors are the primary use for MRgFUS right now. That may change in the future, but I just don't see very many neurologists (no matter how well trained in other interventional procedures) treating tumors with this technique. That significantly limits the financial benefit of being trained in this technique. Therefore, the incentive to pick it up is significantly lower and fewer people will do it. It's kinda like saying "I'm gonna get trained in cerebral angio & intervention, but only do carotid stents".

I'm not saying it won't happen, but I just think there won't be as much encroachment by Neurology due to the reasons stated above.
 
I think Interventional Neurology is primarily focused on endovascular techniques for aneurysm and stroke right now. If NIR starts doing a lot of MRgFUS, then the neurologists who train under them will pick it up, too. However, as I understand it, it is mainly neurorads who are doing this right now, not the NIR guys.

Either way, the interested neurologist will likely have to find someone who is willing to train him/her in the use of the technique. It might not be that hard (as in the case of cerebral endovascular techniques), but it could be if radiologists learn to be more protective of their turf with this particular technique.

As to your 2nd comment, this is exactly why I chose Radiology over NSGY. Didn't see the point of enduring the residency to do functional (3rd year residents at my institution hate it because the procedures themselves are so straight-forward and simple, it feels like you don't really get to operate = no fun for a "real" surgeon).

First of all, barf...I can't believe interventional cards are getting in on this. F*@! that. Seriously.

Second of all, neurologists usually don't treat brain tumors. Do they diagnose them? Sure...occasionally. But there aren't many out there who are trained as neuro-oncologists (though one of my friends is an exception). Again, as I understand it, tumors are the primary use for MRgFUS right now. That may change in the future, but I just don't see very many neurologists (no matter how well trained in other interventional procedures) treating tumors with this technique. That significantly limits the financial benefit of being trained in this technique. Therefore, the incentive to pick it up is significantly lower and fewer people will do it. It's kinda like saying "I'm gonna get trained in cerebral angio & intervention, but only do carotid stents".

I'm not saying it won't happen, but I just think there won't be as much encroachment by Neurology due to the reasons stated above.

Absolutely agree with the above. I think the MRgFUS will be either under neuroradiology (in which case, there is a chance NIR guys, including neurologists will get in on it - it'll just become part of their training, along with other endovascular ultrasound catheter techniques, TCD, etc.) OR under NSGY and Rad-Onc, who treat most of the brain tumors. Neuro-oncology (per neurology) does a lot of chemotherapy and procedures are usually limited to intra-thecal administration. NIR does do pre-op embolization for vascular tumors, though.

And about interventional cardiologists - they regard anything "circulatory" as their territory, especially after cardiac cath took a reimbursement hit. So basically, they were like YAY! CAROTIDS! YAY! PVD/PAD! YAY! MIGHT AS WELL DO NEUROINTERVENTION SINCE WE ARE IN THE CAROTIDS! Seriously, SNIS/SVIN/ASITN needs to get together and be like... nope, we need to restrict training only to the neuro-trained individuals.
 
How are diagnostic neuroradiologists performing MRgFUS for brain tumors and not NIR? That's a little counterintuitive.
 
How are diagnostic neuroradiologists performing MRgFUS for brain tumors and not NIR? That's a little counterintuitive.
Ferenc Jolesz is a diagnostic neuroradiologist at Brigham who helped develop the technique along with a radiation oncologist from U of AZ and scientists from GE. You develop the technique, you use it...simple as that.

Historically, Radiology - as a field - hasn't really been concerned with the "interventional" label when it comes to developing new procedures and techniques. These subspecialties of Radiology (IR will be, but is not yet, a distinct specialty) evolved because there arose a sufficient number of these procedures to merit entire subspecialties dedicated to their practice. For example, even though IR has taken over a lot of interventional onc for body tumors, RFA for liver and kidney tumors was initially brought along by body imagers, not IR - as IR was originally VIR with an emphasis on the vascular.
 
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