interventional pain management from a diagnostic imaging point of view

Interventional Pain Interventional Pain Management from a Management from a

Diagnostic Imaging Point of Diagnostic Imaging Point of ViewView

Arthur S. Watanabe, MD, FIPPArthur S. Watanabe, MD, FIPPFriday, Sept 13, 2013Friday, Sept 13, 2013

Washington Assn of Nurse AnesthetistsWashington Assn of Nurse Anesthetists

Spinal Diagnostics, PLLCSpinal Diagnostics, PLLC 22

Art Watanabe, M.D., Pharm.D.Art Watanabe, M.D., Pharm.D.

•Medical Director Medical Director Open MRI DiagnosticsOpen MRI DiagnosticsSpinal Diagnostics, Spinal Diagnostics, PLLCPLLC

Clinical Assistant Clinical Assistant Professor of RadiologyProfessor of RadiologyUniversity of University of WashingtonWashington

Spokane, WashingtonSpokane, Washingtonwww.openmridiagnostics.comwww.openmridiagnostics.com


DisclaimerDisclaimer• Medical Director, Spinal Diagnostics and Medical Director, Spinal Diagnostics and

Open MRIOpen MRI

• Assistant Clinical Professor, Radiology, Assistant Clinical Professor, Radiology, University of Washington School of MedicineUniversity of Washington School of Medicine

• Board CertifiedBoard Certified– ABRABR– ABIPPABIPP

• Member: ASIPP, ISIS, ASSR, ASNR, NASSMember: ASIPP, ISIS, ASSR, ASNR, NASS

• Past Board Member, ASIPPPast Board Member, ASIPP

• President, Washington Society of President, Washington Society of Interventional Pain PhysiciansInterventional Pain Physicians

• Proctor for Advanced Neuromodulation Proctor for Advanced Neuromodulation Systems, Boston ScientificSystems, Boston Scientific

Lecture Objectives:Lecture Objectives:

• Description of Description of various aspects of various aspects of imaging of the imaging of the spine spine

• RadiographyRadiography• Myelography Myelography • Computed Computed

TomographyTomography• SPECT ScansSPECT Scans

Imaging for Interventional Pain PhysiciansImaging for Interventional Pain Physicians

ModalitModalityy

PhysicPhysicss

TargetTarget SpatiaSpatiall

ContrasContrastt

XrayXray XrayXray BoneBone ++++ ++

CTCT XrayXray Bone, Bone, STST

++++++++ ++++++

Nucl Nucl MedMed

PhotonPhotonss

PhysiologPhysiologyy

++ ++++++++

MRIMRI RF RF WavesWaves

ST, ST, Bone Bone MxMx

++++++ ++++++++

Imaging for Interventional Pain Imaging for Interventional Pain PhysiciansPhysicians

ModalityModality IndicationIndication InformationInformation

XrayXray Localization, R/O Localization, R/O Fx, MetsFx, Mets

Bony anatomyBony anatomy

CTCT Fx,Bony Fx,Bony anatomy, anatomy, StenosisStenosis

Bony & ST Bony & ST anatomyanatomy

Nucl MedNucl Med Fx, Fx, inflammation, inflammation,

arthrosisarthrosis

Active osseous Active osseous processprocess

MRIMRI DDD, Stenosis, DDD, Stenosis, Fx, arthrosisFx, arthrosis

ST & Mx ST & Mx anatomyanatomy

RadiographyRadiography


Radiography Physics – X-rayRadiography Physics – X-ray

• Conversion electron Conversion electron K.E. K.E. E.M.R. E.M.R.

• Electrons boiled off Electrons boiled off x-ray tube hit x-ray tube hit Tungsten anode Tungsten anode X- X-ray ray

• X-rays generated by X-rays generated by 2 processes:2 processes:– General radiationGeneral radiation– Characteristic Characteristic

radiationradiation

Lumbar Radiography Lumbar Radiography AdvantagesAdvantages

• High spatial resolutionHigh spatial resolution

• Good bone contrast resolutionGood bone contrast resolution

• Wide availabilityWide availability

• Fast, easy imagingFast, easy imaging

• Non-claustrophobicNon-claustrophobic

• InexpensiveInexpensive

Lumbar Radiography Lumbar Radiography WeaknessesWeaknesses

• Poor-fair soft tissue contrast Poor-fair soft tissue contrast resolutionresolution

• Only four densitiesOnly four densities– Fat, water, air, boneFat, water, air, bone

• Radiation doseRadiation dose

• Variation in techniques by facilityVariation in techniques by facility

Open MRI DiagnosticsOpen MRI Diagnostics 1111

Lumbar Facet with Lumbar Facet with GadoliniumGadolinium


Vertebral Cement Vertebral Cement AugmentationAugmentation

MyelographyMyelography

1414

MyelographyMyelography• Radio-opaque contrast is injected into the Radio-opaque contrast is injected into the

thecal sac to assss its contents, e.g. spinal thecal sac to assss its contents, e.g. spinal cord, nerve roots.cord, nerve roots.

• Approx 350,000 myelograms/year in U.S.Approx 350,000 myelograms/year in U.S.• 19131913 – Luckett incidentally – Luckett incidentally

noted vetricular system was noted vetricular system was visualized on a post- visualized on a post- traumatic skull x-ray. traumatic skull x-ray.

• 19181918 – Walter Dandy, MD – Walter Dandy, MD Johns Hopkins neurosurgeon Johns Hopkins neurosurgeon air myelography air myelography and air encephalography. and air encephalography.

Lumbar Myelography Lumbar Myelography StrengthsStrengths

• Problem solving toolProblem solving tool– Nerve rootsNerve roots– Intradural lesionsIntradural lesions– ArachnoiditisArachnoiditis

• Alternative for patients unable to Alternative for patients unable to have MRIhave MRI

Myelography WeaknessesMyelography Weaknesses

• Intradural imagingIntradural imaging

• Invasive with attendant risksInvasive with attendant risks

• RadiationRadiation

• Variation in techniques by facilityVariation in techniques by facility

• Variation in readings by radiologistsVariation in readings by radiologists

Myelography TechniqueMyelography Technique

• Fluoroscopic guidanceFluoroscopic guidance

• 25 or 26 G 3 ½ in 25 or 26 G 3 ½ in Quincke tipQuincke tip

• L2/3 interlaminar L2/3 interlaminar spacespace

• Bevel medial or lateralBevel medial or lateral

• Check lateral fluoroCheck lateral fluoro

• 12-15 cc nonionic 12-15 cc nonionic iodinated contrast iodinated contrast 240M240M

Lumbar Myelography Lumbar Myelography ComplicationsComplications

• Spinal headacheSpinal headache

• PneumocephalusPneumocephalus

• Nerve root damageNerve root damage

• Contrast reactionContrast reaction

• Infection, hematomaInfection, hematoma

Computed TomographyComputed Tomography

2020

CT Scan - EvolutionCT Scan - Evolution• CT one of the greatest CT one of the greatest

radiology innovations since radiology innovations since the discover of X-rays.the discover of X-rays.

• X-sectional imaging provided X-sectional imaging provided diagnostic information diagnostic information improved visualization of improved visualization of disease.disease.

• Godfrey HounsfieldGodfrey Hounsfield, British , British electronics engineer with electronics engineer with EMI Company, builds a CT EMI Company, builds a CT scanner between 1969 and scanner between 1969 and 1972.1972.

• Allan CormackAllan Cormack, South African , South African nuclear physicist, in 1963 nuclear physicist, in 1963 described the mathematical described the mathematical basis for constructing a CT basis for constructing a CT scanner. scanner.

Spiral CT Imaging Spiral CT Imaging

– Volume ScanningVolume Scanning– Patient table translates thru scan gantry while Patient table translates thru scan gantry while

x-ray tube rotates 360x-ray tube rotates 360º continuously. º continuously. – X-ray produces a spiral path thru the body X-ray produces a spiral path thru the body

resulting in a data volume acquisition of three resulting in a data volume acquisition of three dimensional picture elements, i.e. voxels.dimensional picture elements, i.e. voxels.

CT Lumbar Spine: CT Lumbar Spine: StrengthsStrengths• High spatial resolnHigh spatial resoln

• Good bone Good bone contrast resolncontrast resoln

• Wide availabilityWide availability

• Fast, easy imagingFast, easy imaging

• Non-claustrophobicNon-claustrophobic

• Multiplanar, 3D Multiplanar, 3D reformationsreformations

CT Spine: WeaknessesCT Spine: Weaknesses

• Fair soft tissue Fair soft tissue contrast resolutioncontrast resolution

• Radiation doseRadiation dose

• Variation in Variation in techniques by techniques by facilityfacility

• Variation in Variation in readings by readings by radiologistsradiologists

CT Scan - Image ProcessingCT Scan - Image Processing

• Axial cross-sectional images Axial cross-sectional images – stored in digital form stored in digital form – processed immediately.processed immediately.

• CT measurement of geometrical CT measurement of geometrical parameters parameters – E.g., distance, area, angle, volume E.g., distance, area, angle, volume

and density.and density.

• Geometrical parameters Geometrical parameters – more accurately defined with CT more accurately defined with CT

than in conventional radiography than in conventional radiography – superimposition and distortion not superimposition and distortion not

presentpresent

Magnetic Resonance Magnetic Resonance ImagingImaging

MRI Scan - EvolutionMRI Scan - Evolution

• 19721972 Damadian files patent for a NMR body Damadian files patent for a NMR body scanner entitled scanner entitled Apparatus and Method for Apparatus and Method for Detecting Cancer in TissueDetecting Cancer in Tissue..

• 19741974 Damadian receives U.S. Patent #3,789,832. Damadian receives U.S. Patent #3,789,832.

• 19771977 Dr. Damadian develops Dr. Damadian develops the first MRI scanner of the the first MRI scanner of the human body human body – Indomitable Indomitable – installed in the Smithsonian Institution.installed in the Smithsonian Institution.

MRI Scan - EvolutionMRI Scan - Evolution

• 1977 the Indomitable produced the first human 1977 the Indomitable produced the first human MRI image.MRI image.


MRI SequencesMRI Sequences

• What is fat doing?What is fat doing?

• What is CSF doing?What is CSF doing?


MRI SequencesMRI Sequences

• T1T1– Fat BrightFat Bright– H2O DarkH2O Dark

• C T2C T2– Fat DarkFat Dark– H2O BrightH2O Bright

• FSE T2FSE T2– Fat, H2O brightFat, H2O bright

• STIRSTIR– Only H2O brightOnly H2O bright

Imaging the Spectrum of Imaging the Spectrum of Facet Joint Pathology Facet Joint Pathology

Normal Facet JointsNormal Facet Joints

• Joint SpaceJoint Space

• Joint MarginsJoint Margins

• Articular cartilageArticular cartilage

• Periarticular soft Periarticular soft tissuestissues

Advanced Facet DiseaseAdvanced Facet Disease

• Articular cartilage Articular cartilage lossloss

• Subchondral bony Subchondral bony eburnationeburnation

• Marginal hypertrophic Marginal hypertrophic changes, spurringchanges, spurring

• EffusionEffusion

• Atrophy of multifidi Atrophy of multifidi and erector spnae and erector spnae musclesmuscles

Advanced Facet DiseaseAdvanced Facet Disease

• Absence of cartilageAbsence of cartilage

• Bone on BoneBone on Bone

• Marginal Marginal hypertrophic hypertrophic changeschanges

• Deconditioning of Deconditioning of multifidi and erector multifidi and erector spinae m.spinae m.

Unilateral Facet DiseaseUnilateral Facet Disease

• Left side normalLeft side normal

• Right sideRight side– Articular cartilage Articular cartilage

lossloss– Joint effusionJoint effusion

Facet SynovitisFacet Synovitis

• Prominent effusionProminent effusion

• Note: medial Note: medial ligamentum flavum ligamentum flavum hypertrophyhypertrophy

• Paraspinous Paraspinous muscles muscles preserveredpreservered

Paravertebral Soft TissueParavertebral Soft Tissue

• Gadolinium contrast Gadolinium contrast enhancementenhancement– Periarticular soft Periarticular soft

tissuetissue– Medullary bone Medullary bone

marrowmarrow

• High clinical High clinical correlation with correlation with pain generatorpain generator

Unilateral Facet Unilateral Facet inflammationinflammation

• Articular cartilageArticular cartilage

• Gadolinium Gadolinium contrast contrast enhancementenhancement– Medullary bone Medullary bone

marrowmarrow– Periarticular soft Periarticular soft

tissuestissues

Facet Marrow EdemaFacet Marrow Edema

• Medullary bone Medullary bone marrow edemamarrow edema

• Indicator of Indicator of inflammationinflammation

• High clinical High clinical correlation with correlation with pain generatorpain generator

The positive predictive value The positive predictive value of isotope lumbar SPECT of isotope lumbar SPECT scans to RF rhizhtomy scans to RF rhizhtomy

responseresponse

Unpublished StudyUnpublished Study

Study Design and MRStudy Design and MR

• Retrospective chart review studyRetrospective chart review study– Initial assessment with diagnosis of lumbosacral arthrosisInitial assessment with diagnosis of lumbosacral arthrosis– Lumbar SPECT scanLumbar SPECT scan– Facet block: (Facet block: (0.4 cc 0.5% Marcaine, 0.4 cc Depo)0.4 cc 0.5% Marcaine, 0.4 cc Depo)– MBB block: (MBB block: (ea branch 0.4 cc 0.5% Marcaine)ea branch 0.4 cc 0.5% Marcaine)– RF Rhizhotomy RF Rhizhotomy (85 Degrees 105 sec) x 3(85 Degrees 105 sec) x 3– Follow upFollow up

• MethodsMethods– Total: 57 patientsTotal: 57 patients– Age: Range: 32 – 80 yrs, Mean: 67 yrsAge: Range: 32 – 80 yrs, Mean: 67 yrs– Sex: M 30 F 27Sex: M 30 F 27

Preliminary Results: SPECTPreliminary Results: SPECT

Preliminary Results: Clinical Preliminary Results: Clinical ExamExam

Preliminary ConclusionPreliminary Conclusion

• Concordant positive lumbar spine bone Concordant positive lumbar spine bone scans are predictive of good clinical scans are predictive of good clinical response to RF rhizhotomy.response to RF rhizhotomy.

• Clinical diagnosis of facet pain Clinical diagnosis of facet pain generator just as sensitive as lumbar generator just as sensitive as lumbar spect scansspect scans

• Lumbar spect scans while predictive Lumbar spect scans while predictive may be unnecesary imaging and costs.may be unnecesary imaging and costs.

ANYBODY MISS THIS ANYBODY MISS THIS GUY?GUY? • 'Government's view 'Government's view

of the economy of the economy could be summed could be summed up in a few short up in a few short phrases: If it phrases: If it moves, tax it. If it moves, tax it. If it keeps moving, keeps moving, regulate it. And if it regulate it. And if it stops moving, stops moving, subsidize it'subsidize it' - - Ronald ReaganRonald Reagan


Spinal Imaging: CaveatsSpinal Imaging: Caveats

• High tech High tech physical examphysical exam

• It’s just an imageIt’s just an image• Doesn’t tell you Doesn’t tell you

where the pain is where the pain is coming fromcoming from

• Lots of false Lots of false positives and positives and false negativesfalse negatives

The truth about imagingThe truth about imaging

• The pictures lieThe pictures lie

• The pictures The pictures rarely tell you rarely tell you what the pain what the pain generator isgenerator is

• Over reliance on Over reliance on imaging = false imaging = false sense of securitysense of security


Which is the more important Which is the more important imaging modality here?imaging modality here?



Only the needle knows…Only the needle knows…

In summary, my take home In summary, my take home messagesmessages• Imaging are just pictures Imaging are just pictures

• Images don’t necessarily tell you what Images don’t necessarily tell you what is the pain generatoris the pain generator

• The patient’s finger may be more The patient’s finger may be more useful and cost effective and accurate useful and cost effective and accurate than any x-ray, CT, MRI or bone scanthan any x-ray, CT, MRI or bone scan

• Get comfortable looking at the images Get comfortable looking at the images you orderyou order


Let me leave you with one Let me leave you with one important thought at the very important thought at the very end…end…


Obama-CareObama-Care

•““We have to We have to pass the bill so pass the bill so that you can that you can find out what’s find out what’s in it.”in it.”– N. Pelosi, N. Pelosi,

3/9/20103/9/2010

"all animals are equal, but some animals are more equal than others."


Obamacare:Obamacare:How could they possibly do How could they possibly do

this?this?


Answer:Answer:

• ““In my many years I have come to a conclusion In my many years I have come to a conclusion that one useless man is a shame, two is a law that one useless man is a shame, two is a law firm and three or more is a congress.”firm and three or more is a congress.” -- -- John John AdamsAdams


so …so …

• ““Remember, Remember, politicians and politicians and diapers need diapers need to be changed to be changed frequently and frequently and for the same for the same reason.”reason.”

Robin Robin Williams, Williams, Man of the Man of the YearYear


Arthur Watanabe, M.D.Arthur Watanabe, M.D.Spinal Diagnostics, PLLCSpinal Diagnostics, PLLC

Spokane, WASpokane, WA

•Thanks Thanks for for listeninglistening!!

interventional pain management from a diagnostic imaging point of view

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