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OsteoCool Bone Tumor Ablation Techniques for Cancer Pain Relief
Faith Taylor • Updated Jun 25, 2025 • 32 hits
Many patients with painful bone metastases require targeted tumor ablations to achieve lasting symptom relief and preserve spinal stability. Determining where and how to perform an ablation can be a complicated process – particularly when the lesions in question have pedicle or fracture line involvement.
Musculoskeletal radiologist Dr. Glade Roper provides a detailed walkthrough of his approach to ablation and cementing based on tumor location, fracture anatomy and pedicular proximity. He also shares his techniques for improving precision using cooled radiofrequency ablation systems and outlines key strategies to avoid nerve injury during treatment.
This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable MSK Brief
• Fracture lines in the vertebral body should be filled with cement to restore structural support and improve symptoms of pain.
• Ablation should target the tumor-bone interface, where nerve invasion, acidosis, and fracture instability are key contributors to pain.
• Pedicle involvement requires targeted ablation to avoid leaving untreated sources of pain.
• Cooled RFA systems prevent probe surface charring and reduce the risk of impedance rise during ablation.
• When performing pedicle burns with the OsteoCool device, the retract mode setting should be used rather than the standard cooled device setting.
• Simultaneous bilateral pedicle burns should be avoided due to potential crosstalk between probes, which can result in unintended heating of intervening tissue.
• Safe posterior ablation requires relatively delicate trocar placement beyond the vertebral wall and attention to thecal sac proximity to avoid nerve injury.
Table of Contents
(1) Targeting Bone Tumor Pain Sources: Fracture Stabilization & Interface Ablation
(2) Using OsteoCool to Improve Bone Tumor Ablation Safety & Precision
(3) Avoiding Nerve Injury During Pedicle & Posterior Cortex Ablation
Targeting Bone Tumor Pain Sources: Fracture Stabilization & Interface Ablation
Bone tumor ablation planning begins with a detailed review of imaging to identify the tumor's position within the vertebral body and any associated fracture lines. Dr. Roper recommends aligning probe placement to fully cover the affected area, adjusting trajectory based on tumor location. Cement augmentation is tailored to fracture anatomy, with priority given to filling fracture lines that improve structural stability and reduce pain. To further address the patient’s symptoms, pedicles are examined closely. When a tumor extends into a pedicle, Dr. Roper recommends performing a targeted burn to avoid leaving an untreated source of pain.
Patient pain does not originate from the tumor center, but rather from the tumor-bone interface, where several pain-generating mechanisms converge. These include direct invasion of nerves within the bone, local acidosis that sensitizes nerve endings, and the presence of pathologic fractures. To address these mechanisms, Dr. Roper strongly recommends ablating the bone-tumor interface. Each of these factors contributes to the overall pain profile and informs procedural targeting for both ablation and cement augmentation.
[Dr. Glade Roper]
Basically, what I'll do is we'll work up the patient, we'll look at their imaging, make sure that we know where in the vertebral body the tumor is because we're going to try to make sure that we cover that part of the vertebral body with our ablation. If it's off to the left side, then we're going to cheat to the left. That kind of thing. We make sure that we know where the fracture line is because filling the fracture line is the key with these cases. If the fracture line is at the top of the vertebral body, we want to make sure that we're getting cement into that fracture line so that we can actually treat their pain.
We want to take a look at the pedicles and make sure that we know if we're going to have to burn the pedicles on the way out because if the pedicle is involved, and you don't treat it, you may leave them with persistent bone pain, and that's no bueno. One thing to keep in mind is that the pain-generating part is not the center of the tumor, it's the interface between the tumor and the bone. You want to make sure that whatever you're doing, you're burning the bone tumor interface because that's where the evil humors are being released that are causing pain.
I'm using the term evil humors tongue-in-cheek, but there's a couple of things that happen. One is there are nerves inside the bone that get directly invaded by the tumor. One is the tumor creates an acidic environment, which tends to sensitize the nerves in that area, and it causes it to be more painful, and then you get the pathologic fractures. Those are all reasons why bone tumors hurt.
[Dr. Jacob Fleming]
Absolutely. It's a really important point because, especially when I was back in diagnostic radiology residency, there was this notion that floated around. It's like, oh yes, this patient's got bone mets, but they don't have a pathologic fracture, so they probably don't have pain. It's just nonsense. As you said, there's multiple different pain generators there. As you said, the edge of the bone tumor interface is really important.
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Using OsteoCool to Improve Bone Tumor Ablation Safety & Precision
Radiofrequency ablation devices generate heat by oscillating charged particles between electrical poles. As polarity shifts, the rapid directional change of these particles generates kinetic energy, which in turn heats the surrounding tissue. While heat is the mechanism of action in radiofrequency ablation, too much of it can cause overheating of the probe, charring, and unintended damage to nearby tissue.
Cooling systems like the OsteoCool use internal water circulation to actively cool the probe to prevent overheating, minimize the risk of adjacent heat damage and maintain control of the ablation zone. The cooling not only prevents damage directly to the probe but prolongs time before a charcoal layer can build up on the outside of the probe and impede targeting and ablation, improving both safety and accuracy.
[Dr. Glade Roper]
All these cases are perpendicular access. The reason being that shapes the burn to be roughly the shape of the vertebral body. There's some crosstalk between the RFA probes. Now, this is something that I caught onto a little while back and finally understood, but I've asked people, "Do you know how radiofrequency ablation works?" They say, "Yes. It heats up the tissue." I said, "Yes, but how does it work?" "I don't know. It gets hot?" "No, that's not how it happens." I asked them, "What do you know about electricity?" They say, "You plug it into the wall, and it turns on."
You have a positive charge and a negative charge. Anything that is positively charged will go toward the negative pole. Anything that is negatively charged will go toward the positive pole. If you generate a charge between those two things, you're going to move charged particles between them. Then, if you switch the polarity, they'll make a quick U-turn and move back. Then you switch the polarity again, they make a quick U-turn and move back. It's those charged particles moving back and forth at the frequency, which is the same frequency as a radio wave, that generates the heat.
It's the moving particles, the kinetic energy, and it generates heat. It's not the probe getting hot, it's the probe inducing heat in the area around it by causing charged particles to vibrate. Now, the device that I use, OsteoCool, people say, "What's the cool part of it?" What they do is they pump water down through the probe to carry away the heat from the surface of the probe. The reason that's important is because if it gets too hot, you will form charcoal around the probe. Charcoal is a really good insulator, so you can't get an electric field past it. The reason why you have the cooled RFA systems is to increase the size of the burn because it takes away some of the heat right around the probe and keeps it from charring.
[Dr. Jacob Fleming]
That's a really great point. I think anyone who's spent a little time in the operating room, whether at intern year or med school or beyond that, you can just think about a Bovie, which is a radio frequency ablation device, basically. When that starts to get some char on there, it really stops working. That's why you have the scratch pad and do that kind of stuff. These cooled radio frequencies, it's like a scratch pad without the need for it, keeps that char from forming so you get a better ablation zone and that you don't run into those issues with impedance. We call it “pede-ing” out, where the generator, well, the impedance, you just see it climb, and you're like, "No, it's going to go out." I haven't run into that issue using these devices.
[Dr. Glade Roper]
No. Using the cool devices, I have rare as hen's teeth for it to impede out. It just sits and chugs for a while, and you tell your dad jokes, and off you go.
Avoiding Nerve Injury During Pedicle & Posterior Cortex Ablation
To minimize the risk of nerve injury during ablation when performing pedicle burns, a retract mode is used on the radiofrequency ablation device.. This mode follows manufacturer tables that correlate burn time with ablation size. Dr. Roper recommends avoiding simultaneous bilateral pedicle burns due to crosstalk between probes, which can result in unintended heating of intervening tissue.
Probe placement should also account for the posterior extent of the burn. The tip of the trocar marks the posterior boundary, and should be placed just beyond the posterior wall of the vertebral body. This positioning helps avoid thermal spread to the posterior cortex, which contains pain-sensitive nerves. Even when the cortex is intact, heating this region can lead to neuropraxia due to the proximity of dependent nerves within the thecal sac. Dr. Roper emphasizes that accurate AP and lateral fluoroscopic views are critical for safe probe placement and strongly advises confirming that the tip is beyond the posterior wall to reduce the risk of nerve damage.
[Dr. Jacob Fleming]
Can you tell a little bit about the technicality of the pedicle burn? Are you doing a full-length burn as the same duration or no?
[Dr. Glade Roper]
No. There's actually a different setting on the device. You have the cool device setting, and then you've actually got retract mode. When you put it into retract mode, it just does a radio frequency burn. They actually have a table telling you how long you burn in order to make a burn of a certain size. When you are dealing with a pedicle, number one, you do not want to burn both pedicles at the same time. Because, remember, there's crosstalk between those two RFA probes.
[Dr. Jacob Fleming]
Oh, that's a good point.
[Dr. Glade Roper]
There's stuff in between the pedicles that you do not want to heat up.
[Dr. Jacob Fleming]
Duh. Don't cross the streams, bro.
[Dr. Glade Roper]
No, don't cross the streams. It's like Ghostbusters. You want to make sure that you are only doing one at a time if you're doing this retract mode. Let's see. I think that's all for the pre-procedure planning. It's pretty straightforward. If you know how to get into a vertebral body, you basically know what you're supposed to do. There is one point. The device that you use, the needle that you use to put in, they have a particular trocar that goes down through the cannula. The tip of that trocar marks the posterior aspect of the burn. When you put the trocars in, you want to make sure that that tip is just beyond the posterior wall of the vertebral body, and you know that that's as far back as the burn is going to go.
[Dr. Jacob Fleming]
The cortex, as we know, technically.
[Dr. Glade Roper]
That's easier to see on one of the images that I'll show you here later, is where that is. Yes, the cortex has a lot of nerves in it, and you can paradoxically increase their pain by burning the nerves of their posterior cortex.
[Dr. Jacob Fleming]
That's a good pearl to know. A cortex, it's a good insulator sometimes. Then, you don't always have that, and so you can think of, usually the epidural space and the thecal space, if that posterior cortex is intact, you have a nice insulation effect against the heat spreading out too much.
[Dr. Glade Roper]
You'd like to think that.
[Dr. Jacob Fleming]
You'd like to think, but it can happen, as we've talked about. Tell us about-- I was thinking towards the obvious example of the posterior cortex being partly eaten away by the tumor. You told me about a situation where, even with a normal cortex, you can have some issues happen. Pearls on that.
[Dr. Glade Roper]
Pearls on that are the thecal sac, if you think about it, the nerves are going to follow gravity inside the thecal sac. They fall down, and they are resting right against the back of the vertebral body when you have the patient prone. If you heat up that posterior aspect, you can get a neuropraxia from heating up those nerves. That is a very unpleasant thing to try to explain to a patient.
[Dr. Jacob Fleming]
That's good to know. Something that probably should be part of the informed consent process, just about things to be aware of.
[Dr. Glade Roper]
Absolutely. It should be. You always talk about bleeding and infection, but in this case, you also say, "There's a lot of nerves running by there that we don't want to hit, which is why we're going to use X-ray to make sure that our needle is going into the right spot. Despite our best efforts, sometimes those nerves are going to be injured while we're doing this. I will do everything I can to keep that from happening." If they do get injured with heat, they'll probably get better, but it's going to take a while. It's going to take several months.
[Dr. Jacob Fleming]
That's a great point. I think really good to add in because worst possible thing for a patient to wake up and say, "I've got this new sensation that wasn't there before," or lack of sensation for that matter.
[Dr. Glade Roper]
New leg weakness or a new leg foot drop.
[Dr. Jacob Fleming]
Yes, new leg weakness. Motor is really, I think, the thing that surprises a lot of patients. Great point there to talk about. Would you say, in terms of increasing the safety profile, there's things to watch out for when you're burning in regards to this specific issue?
[Dr. Glade Roper]
The main thing is your initial placement. Just make sure that you've got a really good lateral so you know exactly where the tip of that needle is. You don't want to be getting some skiwampus lateral view that doesn't actually show you where things are in space. You want a really good lateral. You want to make sure that the tip of that needle is beyond the posterior wall of the vertebral body. If that is the case, it's highly unlikely you're going to do anything that's going to hurt the patient. That's kyphoplasty 101. Make sure you've got a good AP and lateral.
[Dr. Jacob Fleming]
Yes, absolutely. You can't say enough about the importance of a good lateral. Sometimes it's easy to say, "Those ribs are kind of cattywampus," whatever. Then you clean it up and wow, okay, that looks totally different. Really, really important there.
Podcast Contributors
Dr. Glade Roper
Dr. Glade Roper is an MSK radiologist specializing in imaging and interventions with VIP Specialists in Visalia, California.
Dr. Jacob Fleming
Dr. Jacob Fleming is a diagnostic radiology resident and future MSK interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2024, December 17). Ep. 63 – Bone Tumor Ablation: Techniques & Inisghts [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com 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.
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