Vertebral augmentation and spinal ablation interventions are minimally invasive treatment options for spinal compression fractures and spinal metastases. In episode 34 of the BackTable podcast, Dr. Peder Horner and Dr. Sabeen Dhand discuss spinal therapies and ways to integrate these procedures into your practice.
The BackTable Brief
Training courses offered through companies like Merit and Medtronic may be beneficial to attend for those looking to add spinal ablation and vertebral augmentation to their skillset.
Offering spinal ablation and vertebral augmentation as therapeutic options during tumor board meetings may lead to improved relations with oncology and radiation oncology.
Thorough follow up with referring physicians is a great way to continue receiving referrals; Dr. Horner sends a copy of the procedure notes, a letter and procedure images to all referring physicians.
Dr. Horner estimates 5-10% of the vertebral augmentation procedures performed in his practice are for malignancy with the majority performed for osteolytic lesions.
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Adding Spinal Ablation and Vertebral Augmentation to Your Armamentarium
For those looking to add spinal ablation and vertebral augmentation techniques to their armamentarium, Dr. Horner and Dr. Dhand recommend attending training courses. Merit and Medtronic both offer courses to help develop and refine these techniques. Despite familiarity and comfort with both procedures, Dr. Dhand found value in attending a Medtronic course where he was able to try a variety of different techniques at the mobile cadaver lab.
… For someone who's never done one of these procedures before, and isn’t doing it in their practice, are there training courses? Are there things that they can do to get exposure?
The Medtronic folks do have some courses, and I think Dr. Doug Beall in Oklahoma is one of their proctors, he does tons of vertebral augmentations in an OBL setting. I think his course, I've heard, is really good.
I haven't done that. I was really confident with the vertebral augmentation part of the procedure, and really just had a long discussion with our local rep, who I trust, and we went through the pre-procedural planning on the first case, and went from there.
These devices are actually built, not to be fool-proof, but they're pretty darn safe. Not to say you couldn't hurt someone, but I think the way the systems are setup, that you've got a lot of room for error. Which you could actually end up under-treating also, and that's something you don't want to do either.
True. True. I don't have any disclosures either, and I've used both systems. I started off with the Merit STAR and I've recently started with OsteoCool. Medtronic had a ton of courses, and they're really great because it was a cadaver lab. It was a mobile cadaver lab on a bus.
I was able to try so many techniques, whether it was paravertebral, paraperdicular, trying a high thoracic lesion, trying a cervical lesion, and even sacroplasty. I was already comfortable with the procedure by that time, but I learned so much. So I think these courses, whether it's from Merit or from Medtronic, if it's a cadaver lab, I think it's one of the best things you can do, especially for vertebral augmentation.
Exactly. I completely agree, and I just encourage everybody out there, if you're not offering this, and if you're interested, I think it's a wonderful tool to expand your practice, and also really help out some people who can be really miserable.
How do I increase the number of spinal ablation and vertebral augmentation procedures in my practice?
To increase the volume of spinal ablation and vertebral augmentation cases in your practice consider attending tumor boards; offering alternative treatment options for spinal metastases may improve relations with oncology and radiation oncology leading to future referrals. Dr. Horner also suggests sending follow up procedure notes to referring physicians. Doing so may lead to additional referrals down the road.
For those guys who are listening and don't have this as part of their practice, what advice or top two things you would say they should start doing in order to incorporate this?
Well, I would say number one, definitely go to your tumor boards. I'm going to do three. So Tumor Boards, obviously I think that's the low hanging fruit, but you do have to know some data. I mean, you're talking to oncologists and rad oncs, right? So they're going to want to see your data. Because a lot of what we do is, let's be honest, some is with poor data. The more you can bring to the table, the studies that we've got, basically the effectiveness studies and the safety profiles, I think the better off you're going to be. And don't be afraid to repeatedly raise your hand, because the first time you raise your hand, you may not get a referral. It may take two or three times or more.
Second thing is, my big thing that I really harp on is the lunch room and the doctors lounge. Not everybody has it anymore, especially at the academic centers. I think they've gone away, just because of the cost and I don't know, maybe they don't want to seem exclusive, or whatever.
And then, number three, clinical practice, really. Pre-op, H&P with a follow-up letter to the referring doc. And then send them a follow-up letter after with your report, because typically I'm the one ordering the ablation procedure, so the report only gets sent back to me. So I have my assistant send a copy of every procedure report and a little letter, and some images from the procedure.
What type of patient population are you typically treating?
The majority of vertebral augmentations performed by Dr. Horner are for the treatment of osteoporotic compression fractures. He estimates around 5-10% of his cases are performed for malignant tumors with the majority of cases being for osteolytic compression fractures.
… That's a good question. I think probably most practices, most of our vertebral augmentations and osteoporotic compression fractures are in elderly patients. And then, I would say at this point, maybe 5 to 10% of ours are malignant. Typically, osteolytic compression fractures, but sometimes they can be blastic, particularly from prostate. Most of our vertebral augmentations and small tumors has been the osteolytic colorectal cancer, breast cancer, even some osteolytic prostate cancer.
Good. Yeah, you know, 5 to 10% is quite a bit. In my practice, we do maybe 2 to 5 vertebral augmentations a month, but I would say 1% or so of those are pathologic.
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.