Percutaneous radiofrequency ablation is palliative, and acts to minimize the spread of local tumor burden. Spinal ablation expert Dr. Peder Horner discusses spinal ablation techniques, how to manage extraosseous tumor spread, and when and why epidural steroid injections are helpful.
The BackTable Brief
Dr. Peder Horner prefers using the Medtronic OsteoCool device for spinal ablation procedures; consider a bilateral approach for large tumors and a unipedicular approach for pedicular lesions.
For cases of extraosseous tumor spread, consider working with radiation oncology, as thermal injury may be avoidable with alternative treatments such as XRT.
For spinal ablation cases requiring a bilateral approach, an interlaminar epidural steroid injection (ESI) can be performed in order to minimize post-procedural radicular pain.
When using a unilateral approach, a transforaminal ESI is best, says Dr. Horner.
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Spinal Ablation Techniques with Dr. Horner
For spinal ablations, Dr. Horner typically uses a bilateral transpedicular approach with the Medtronic OsteoCool device under general anesthesia. For larger tumors the bilateral approach is preferred, however, for single pedicular lesions he will use a unipedicular approach.
…Can you describe your technique for pathologic fractures? What is going in there? Why are we combining thermal into this procedure?
Yeah so these patients often come with a diagnosis that's been confirmed metastatic disease, but some of these patients do need biopsies to confirm the diagnosis. Sometimes it can be a little confusing on imaging whether or not a fracture is actually pathological. But yeah, I do mine under MAC anesthesia. The patients will get on the table and we'll do a bilateral transpedicular approach.
At my institution, we use the Medtronic OsteoCool, RF ablation device. I've used the Merit STAR ablation setup at other institutions, but the main one we use is the Medtronic device. We do the bilateral transpedicular approach typically is if it's a larger tumor. If it's a single pedicular lesion, well I'll just do a unipedicular approach. After the ablation is done, which is typically 10 to 15 minutes, the probes come out, the kyphoplasty balloons go in, and the rest is like a kyphoplasty procedure. If you have a pedicular lesion, you can ablate that on the way out by changing the parameters of the target temperature, or the ablation time, et cetera.
Minimizing Complications when Treating Extraosseous Tumor Spread
Complete ablation of extraosseous tumor involvement may be difficult while avoiding thermal injury to surrounding structures. Dr. Horner has not experienced thermal injury complications by involving radiation oncology in the treatment plan. Radiation oncologists can offer XRT to completely treat the extraosseous lesion.
… I guess we always get scared about thermal injury, you mentioned it. Especially if you're going on the pedicle. Have you ever seen thermal injury to the exiting nerve roots, or anything like that?
Not that I know of. Now if you do have an extraosseous component, sometimes those can be difficult to actually ablate completely. Those are the ones where you can combine therapy with your rad onc. If there's extra osseous component, paravertebral or wherever, they can often hit that with some XRT and treat the patient completely.
Do epidural steroid injections help post-procedural radicular pain?
Following spinal therapies, Dr. Horner will occasionally perform an ESI to minimize radicular pain. He has noticed thoracic compression fractures are more likely to be associated with radicular pain compared to the lumbar level. The interlaminar technique is preferred following bilateral approaches, whereas a transforaminal technique is used for unilateral approaches.
You mentioned something very interesting yesterday in your talk, and you said that a lot of times you combine ESI or epidural steroid injections after your procedure. How are you doing that? How often are you doing that? And why are you doing that?
That's a good question. Every once in a while, it's not the majority of patients, we do have patients that have radicular pain. It seems like the thoracic compression fractures have more of a radicular component to them compared to the lumbar level. Patients will describe this radiating, sharp pain around the intercostal distribution.
So I talk to them about this before and offer an epidural steroid injection. Typically I do an interlaminar approach because there's often a bilateral component to these. If it's unilateral I'll do a transforaminal approach. Adding these really helps in my experience. I don't have a whole lot of data for this, but it has really helped, at least anecdotally, for my patients to get through that radicular pain. Which is interestingly one of the biggest problems that I've seen, in terms of pain control after the procedure, if you don't do it.
Their central back pain may be gone or 50% better within a week or so, but it's that nagging radicular pain that some of them will have and if you get them an ESI, I've seen that it drastically reduces the incidence of that.
Yeah. I actually really liked that part of your presentation, and I'm gonna incorporate that to my practice. I have had several patients, their pain character changes and I think the pain of the actual fracture was treated, but then there's this lingering other pain, exactly what you're describing.
Dr. Peder Horner is a practicing interventional radiologist with Diversified Radiology in Colorado.
Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in California.
Cite this podcast:
BackTable, LLC (Producer). (2018, October 11). Ep 34 – Spinal Ablation Therapies with Dr. Peder Horner [Audio podcast]. Retrieved from http://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.