Advanced Minimally Invasive Pain Interventions

[Dr. David Prologo]:
For example, we have a patient who comes to us with bilateral pretibial metastatic deposits from melanoma and intractable pain. Had been all the way around the horn from interventional pain to PM and R and all those other subspecialties that you mentioned, still with intractable pain. So we track that back. What nerve is carrying a sensation from that pretibial region? The saphenous nerve. Is it carrying significant is not, can we find it and put a needle there and freeze it? We can. And so right away, that's how you manage this cancer. Oftentimes in the cancer setting though, if we go back to the L4 example, the tumor itself will be in contact with the nerve. And so then you ask yourself, can I get to the tumor and the nerve? Can I get it all with a cryoablation procedure? And if you can, then you do as long as you're willing to sacrifice motor. So I like this audience because we don't have to really maintain the mysterious smoke and mirrors type PR. Because for this audience, I can just say, look, it's a matter of figuring out where the generator is, what's transmitting that pain and can you get there and freeze it? And that's how it works in the cancer arena. In the non-neoplastic arena it gets a little bit complicated, but not too much more. If you consider for illustration, patients who have inguinodynia post-hernia repair, they get to genitofemoral nerve and ilioinguinal nerve entrapped in that mesh, and they've got constant irritation of those nerves. And so we ask ourselves what's the generator? And we know it's that post-operative bed or it's that postoperative mesh hardware that's left in there. Can we get to those nerves? Yes. Do they carry significant motor? No. And so we can freeze them and get the patient some relief.

Now in a non-neoplastic arena, when it's usually less urgent. But in the non-neoplastic arena, we have the time to do the diagnostic injection to make sure what we're going to do is going to help the patient. So you can bring that inguinodynia patient in to ultrasound or CT. You can infiltrate bupivacaine and steroid into that region and give them sort of a dress rehearsal of what it's going to be like post-cryo. You have that luxury. And most of the time we do that in a non-neoplastic arena. But the reasoning is this: If you can get there and you can sacrifice it and it's going to help the patient, then that's what you do. And these things, these inguinodynia and pudendal neuralgia for example, there are many, many more. But these examples are really populations of patients who don't have another option. And without us are left to sort of figure this out on their own or manage it with opioids for the rest of their lives. So there's not an insignificant number of people that we can help with these procedures.