Interventional musculoskeletal radiologist Dr. Douglas Beall is a pioneer in MSK and spine intervention. Through continued innovation, he has expanded the boundaries of minimally invasive MSK/spine therapies, offering an expansive variety of procedures that are too numerous for us to list. He is also actively involved in the development and optimization of AI initiatives for patient-specific diagnosis of spinal disease to guide therapy. Dr. Beall has published several textbooks, including a new comprehensive guide to vertebral augmentation. Through publications, his fellowship program, visiting professor program, and social media initiatives, he shares his passion for intervention and education of the next generation of forward-thinking interventionalists.
We’ve provided the highlight reel below, but you can listen to the full podcast here.
The BackTable Brief
Dr. Beall’s new textbook, “Vertebral Augmentation: The Comprehensive Guide to Vertebroplasty, Kyphoplasty and Implant Augmentation”, offers a deep dive into treating vertebral compression fractures (VCFs) and more. From diagnosis through follow-up, from clinical to technical, from basic to advanced, this book covers all facets of managing VCFs.
To further promote innovation in treating spine disease, Dr. Beall has created a fellowship program as well as a visiting professor program. Using Twitter and LinkedIn, he connects with other experts, and shares his unique procedures and techniques with interventionalists around the world.
Dr. Beall emphasizes the ease of adopting procedures such as spinous process augmentation and basivertebral nerve ablation, and addresses elements of these procedures in his discussion. He also shares promising details of a potential AI application for patient-specific treatment of spinal disease to guide optimal therapy.
Image Courtesy of Douglas Beall MD
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Educating the Next Generation of IRs in Spine Intervention
Dr. Beall recently published a new textbook titled “Vertebral Augmentation: The Comprehensive Guide to Vertebroplasty, Kyphoplasty and Implant Augmentation.” It answers practical questions that interventionalists may have about procedural steps, technique, endpoints, and rationale. Many of the pearls included in his all-encompassing guide are based on the invaluable, career-long observations of leading experts in spine intervention. Dr. Beall also leads a fellowship training program, which was inspired by the textbook and social media interest in spine innovation.
I want to ask you about your new book. It's titled Vertebral Augmentation: The Comprehensive Guide to Vertebroplasty, Kyphoplasty and Implant Augmentation. It was published in March, and our listeners can find it on Amazon and Theme.com. How did you put this together and how is this different from standard textbooks on the topic?
I put it together by doing years of education. We teach people vertebral augmentation techniques, and I've done it for a long time...For teaching curriculum, you have the approaches, and you have vertebroplasty, balloons, implants. You have the usual, typical stuff. You have the prevalence, but what you don't have is questions like how much cement should I put in the vertebral body? I see the patient back. They still have pain. Now what? When should I really choose kyphoplasty versus a vertebroplasty, or does it matter? I try to reduce the height and re-establish, but does that really matter? When should we treat people? Why should we brace people? What data is there behind that, and so forth… The answers to all of these questions, I comprised little Power Points, and I put them in a big file. For every question somebody had, I would shoot them a Power Point like with here's the answer and here's the evidence behind it. By doing that time and time again, there's a grouping of about 25 or 30 questions that are common focuses that are the typical ones that people always ask about. For years, I would just keep up with the literature and every time I found something interesting, ground-breaking or earth-shattering, I would absolutely add it, and I would maintain the evidence and maintain the story in that Power Point… I essentially took those Power Points and made them into a book. This is the real how-to. Hopefully, the Vertebral Augmentation Comprehensive Guide, will answer every question that you have. It even has a chapter of the Masters of Vertebral Augmentation. I put stuff in here that has not been published. For example, thoracic pain after fixing mid-thoracic fractures. A guy named Fergus McKiernan described it originally as postural fatigue syndrome, and I want to credit him for that, but he never published it. He never wrote about it. We have a whole chapter in there about postural fatigue syndrome… It's not an exhaustive resource. It's a book that, if you're really interested in upping your game and doing the best possible augmentation, being the best at it, this is your book. It'll tell you exactly how to do that. It'll give you tips and tricks, most of which are in the literature, some of which is not.
It's got stuff on RF ablation and dorsal root ganglion stimulation. It's deeply comprehensive.
I made the decision to resurrect a fellowship training program and to start posting these things [on social media]. I've been pleasantly surprised. They've been very well-received. I get the occasional blowback from spine surgeons and some of the other people that say we shouldn't be doing it. One of the other reasons to investigate, to be all in, for research and Level 1 data is because you can respond to that by saying, "You shouldn't really rely on your non-randomized, non-placebo control study of your own opinion, because we've got data that says that what we're doing here in this particular case is not only better than the traditional thing. It's a lot better.” For example, fusion for disabled discogenic back pain. A good to excellent surgical outcome is 33% reduction in pain, which is crazy.
Social Media and Spine Innovation
Twitter and LinkedIn have proven effective platforms for facilitating discussions on innovation in MSK/spine intervention. Dr. Beall escalated his social media activity upon establishing a visiting professor program for interventionalists to observe his procedures.
I’m tweeting out section by section in the Masters Guide. I sent an email out to about 100 of my colleagues that are experts in vertebral augmentation and I said, "Give me your fastball. I want your best tip, trick. I want your best thing that you do that you may not have told anybody about that you do that you really rely on, your go-to. I don't care what it is. Give me three or four paragraphs. Give me two or three images... I really would like to see people's best tips and tricks, similar to a Worldwide Curbside.” What we came back with was unbelievable. I got things from all over the world, and I'm tweeting it out right now. My Twitter handle is @dougbeall. I gave a talk last year in France where vertebroplasty was invented. The talk was about the Masters of Vertebral Augmentation, what they did. Stefano Marcia wrote a whole section about treating Magerl A3.3 fractures with SpineJack. There's cementation tips. There's tips on treating recurrent fractures after vertebral augmentation. There's tips on how to allow pedicle screw placement after vertebral augmentation. It's just filled with all kinds of stuff.
I went through your Twitter cases and your website to look at all these different, unique procedures that you're offering.
The reason I started tweeting and sending these out on LinkedIn is I've had a visiting professor program. I had people come through here. They're like, "Man, what are you doing? I've never seen anything like this." They said, "You need to advertise this stuff." I've never advertised. Whenever there was a phone book, I wasn't even in the phone book. That resonated with me. There's a lot of stuff we do that's pretty arcane and unusual, so I started tweeting it out and putting it on LinkedIn. A lot of those, I did so because I wanted people to see what we do. I wanted to show people what was happening. I was always a little bit skeptical. You do things, and you do things for the right reason, but it's always, for me, difficult to have people look over my shoulder, because a lot of what we do, they don't understand… A colleague of mine told me, "You need to be sharing what you do. You're going to step off a curb one time and get hit by a bus, and then none of us will really ever know." I said, "Okay."
Tips for Interventional Spine Procedures
Introducing new procedures such as spinous process augmentation and basivertebral nerve ablation can be intimidating. However, Dr. Beall emphasizes that they are easy to learn, and shares the basics of each procedure.
Doug, what advice do you have for interventionalists out there who are looking to learn procedures like spinous process augmentation or the basivertebral nerve ablation?
The first thing I'd like them to know is that it's not that hard. It's really easy to do these things. Spinous process augmentation is done in concert with putting in interspinous decompression spacers. Subsidence of the implant into the spinous process will cause symptom recurrence, so I learned this technique from a guy named Luigi Manfré. His Italian practice is in Sicily. First time I saw it, I thought, "That looks like something that would really work," because early on doing X-stops, interspinous decompression spacers that were done open, I had a problem with subsidence. I would say we have a problem with subsidence. I'd get very little uptake on this, but later, we knew that to be the case. Luigi did a paper of 688 patients, 256 people did not have spinous process augmentation. The rest did, and used symptom recurrence. That's it, just symptom recurrence as the only method of measurement. He found symptom recurrence in 11.3% of the ones that did not have spinous process augmentation and less than 1% in the ones that did.
Yeah, and this came out this last year. Once it came out, you take one look at the paper and you're like, "Yeah, of course. Duh," as my daughter says with an eye roll. It should make sense. For spinous process augmentation, I developed a kit because we don't really have anything formal made for it. We just cobble things together. I used to use a 14-gauge Bonopty and some verticum 2 cement. Now we actually have a kit that we made through a company called IZIO with a 13-gauge needle that has a ruler lock on it and some plastic 1cc syringes that are easy to control. You don't need that much cement. You need it to be cheap, and you need it to be effective. This is something that's very easy to learn, super easy. It's right up there with basivertebral nerve ablation. Compared with stable discogenic back pain treated with fusion, it's about 50/50, 50% of the people improve and 50% don't improve or get worse. It takes 12 weeks to recover from. You're not yourself again for a year. As I mentioned, the pain reduction is less than optimal. What I didn't mention is about one in five patients will have additional surgery within four years. That's based on the Vermola data. Compare that with basivertebral nerve ablation, which has about a 70% to 75% response rate. On the average, they reduce their pain about 75% and it appears to be durable or permanent. You do that, similar to a vertebral augmentation technique. It's not even an incision big enough, you get a suture or staple. It's no comparison for efficacy, no comparison for durability and level of invasiveness. Anybody that does augmentation can do basivertebral nerve ablation. It's just a matter of targeting and bone. It's really simple. The difference between RF ablation in-bone and outside of the bone is it appears that the nerve doesn't grow back, which is a good thing.
Current Spine Innovations and the Future
It’s difficult to keep track of the sheer volume of innovative techniques Dr. Beall shares on social media, which includes both newer procedures (e.g. percutaneous spinous process augmentation, stem cell disc augmentation) and modifications of established therapies (e.g. SpineJack for discitis). He’s currently helping develop an AI system that analyzes spine MRI to guide therapy and treatment prioritization.
For example, the L2-3 with old discitis. Why would you put a SpineJack in somebody's disc? [People will say] that's just crazy. That's off-label. You shouldn't be doing it, that kind of stuff. Tell that to her. She can walk for the first time in six months, and she's good. I've probably done that for people with degen scoli that are back of the rack cases, that are 85 years old, severe degenerative scoliosis, bad coexisting spinal stenosis. I put a pump in them and they're starting to lose the ability to walk because of nerve recompression. No spinal deformity surgeon worth his weight in salt will touch her because she's too high-risk. What are we supposed to do with that? Just let her be put in a wheelchair? Maybe. Maybe that's the right thing, but I don't think so… Things that have come out in the literature include things like SpineJack. I started working on that in Europe about ten years ago. That's revolution. In 36 years of vertebral augmentation, it's the only thing that's been better than the predicate, and it's been better in three different areas. There's numerous successes that we can point to, concurrent and in the past… Some of the things we're doing, like basivertebral nerve ablation to turn off the pain nerve to the disc and stem cell augmentation of the intervertebral disc has pain improvements from 70% to 85% as well as Westry improvements that are about the same as that, probably a little bit better in terms of stem cell augmentation of the disc. It's far less invasive and far less expensive. This is the reason to be involved in the investigation of it, because you can do crazy cases. Crazy cases are where the new ideas come from.
What are a few things that you're doing beyond SpineJack and these crazy vertebral augmentations?
What are you excited about that we'll begin to see more of in the coming years?
I saw this thing on a conference call that was really something that I had been waiting to see for quite some time--AI software that could read lumbar spine MRIs and create a report automatically. It could detect fractures, disc herniation, spinal stenosis, changes, measure disc height, and do so and create a report automatically and stratify the level of importance and do it in about four seconds.
Wow. That's faster than me.
My goal is to take AI and make a see-and-treat machine out of it. We have an algorithm that combines what we do, the procedures that we do, and to make them condition-specific, digestible, hierarchical that places them so. If you have spinal stenosis, here are the things that you can do for it, one, two, three, four in the level of least invasive to most invasive, possibly less definitive to most definitive and do so in a way that combines it with the diagnosis of the condition in a very accurate, objective, and literature-informed way. You have something that diagnoses what's wrong with you and tells you based on the best available information what to do about it and tells you the order to do it in. That's one of the things that we're working on now. I have to say that we are not more than five years out from having this.
Dr. Douglas Beall is the Chief of Radiology Services at Clinical Radiology of Oklahoma.
Host Dr. Michael Barraza is a practicing interventional radiologist with Radiology Associates in Baton Rouge, LA.
Cite this podcast:
BackTable, LLC (Producer). (2020, November 9). Ep. 94 – Innovation in Spine Interventions [Audio podcast]. Retrieved from https://www.backtable.com/podcasts
The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.