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BackTable / MSK / Podcast / Transcript #63
Podcast Transcript: Bone Tumor Ablation: Techniques & Inisghts
with Dr. Glade Roper
Spine metastases are often painful and can impair a patient's ability to lie flat for radiation therapy. However, radiofrequency ablation (RFA) can address the bulk of the tumor and provide significant pain relief, enabling the patient to undergo radiation therapy. In this episode of BackTable MSK, musculoskeletal radiologist Dr. Glade Roper discusses his experience with spinal tumor RFA, his role on a multidisciplinary oncology team, and key considerations when planning for ablation. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Practice Building for Outpatient Spine & Bone Tumor Ablation
(2) Patient Evaluation: Imaging, Physical Exam & Red Flags
(3) Integrating Pain Pumps with Ablation for Management of Bone Metastasis Pain
(4) Counseling Patients & Families on Pain Management Options
(5) Targeting the Pain Source: Planning Probe & Cement Placement
(6) Optimizing Burn Point: RFA Physics & Cooling Systems
(7) Avoiding Nerve Injury: Pedicle Burns & Posterior Cortex Considerations
This podcast is supported by an educational grant from Medtronic.
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[Dr. Jacob Fleming]
This is your host, Jacob Fleming, and today, my friend and fellow interventional musculoskeletal radiologist, there are dozens of us, is Glade Roper from California. Welcome back to the show, Glade.
[Dr. Glade Roper]
Thanks for having me. It's fun to be back.
[Dr. Jacob Fleming]
Yes, this is number two. I think we've got it dialed in this time, so we'll just jump in. We have two topics for today. First, we're going to talk about bone tumor ablation, just generally about practice building. Let's jump right in. Tell us a little bit about your current practice as far as spine and bone tumor ablation.
(1) Practice Building for Outpatient Spine & Bone Tumor Ablation
[Dr. Glade Roper]
Sure. As you know, we've got our own outpatient IR center. I've got a hospital where I do some cases, and we've got an ASC where I do some cases. The main place where we try to do these is in the outpatient center because it is so much easier to do it when you control the staff, when you control the schedule, and it just works a lot better. As far as practice building, essentially what I do is I look at all the MRIs of the lumbar spine that are done on patients when they come across both at our imaging center and at the hospital.
I'll look through, and I'll look for any bone tumors. If I see a bone tumor, I will call the referring doc and say, "Hey, by the way, your patient has this in their lumbar spine. Would you like me to do something about that?" That's basically the same approach that I use for kyphoplastys for compression fractures. It works pretty well to the point where now I'm starting to get referrals from the oncologists who say, "Hey, this patient has some bone pain. Let's send him over." I think this is an important practice-building point to keep in mind. Your oncologists want the patients to be able to sit still to get their chemotherapy.
Your standard radiation oncologist, 75% of their business is painful bone mets. If you come in and say, "Hey, I'm going to be taking over the treatment of painful bone mets," you're going to have a lot of radiation oncologists who are not happy with you. You need to couch it in a different way than, "I'm going to help take care of these painful bone mets." What you need to point out is, "I'm going to make it so they can hold still on your table to get their radiation treatment." Because if they can't hold still on the table for their radiation treatment, that's a problem. The other thing is making sure that you're letting them know, "This is not something to replace what you're doing. This is something to augment the effectiveness of what you're doing."
[Dr. Jacob Fleming]
Complementary rather than exclusionary.
[Dr. Glade Roper]
Exactly. That is something that you need to make sure that you are talking with your friendly neighborhood radiation oncologist about from the get-go. If you're going to be doing bone tumor ablation, you need to get your radiation oncologists on board because, otherwise, it's going to be a really ugly turf battle.
[Dr. Jacob Fleming]
How did that process go for you? Did you reach out to individuals?
[Dr. Glade Roper]
Oh, yes. I went, and I presented to the radiation oncologists. I went and brought the radiation oncologists in, and we brought them lunch and said, "Hey, listen, this is a service that we offer. It helps to get the patients pain-free a lot quicker than whatever it is that you're doing, which means that they're going to be able to hold still for your treatment." I'm not claiming that I'm killing the entire tumor. I'm just making it so that they can get themselves taken care of. The way I explain it to the patients is, "In your house, if you've got a weight-bearing wall and one of the beams is full of termites, I'm going to go in and rip out that beam and put in some cement to hold it up, but you still need to fumigate the house." That's where your standard medical oncologist comes in. I explained to the radiation oncologist, "I'm just going to get the one beam. You've still got to blast the whole wall to make sure that it gets taken care of."
[Dr. Jacob Fleming]
Right. That's a great metaphor. I really like that. I think I'm going to steal that one.
[Dr. Glade Roper]
It's not patented. The other thing that I think is important is the trials out there all support radiofrequency ablation of bone mets as giving quicker pain relief than radiation therapy. It lasts a long time after you do that. The OPuS One trial is the big one that came out. It's 200 and something patients who they did radiofrequency ablation on. It is a very good trial. It shows that at three days after the treatment, patients are doing significantly better as far as pain and quality of life. In general, it takes radiation therapy a month to get there.
It is undisputably something that works better as far as taking care of the patient right then and there if they've got things going on. Now, in the spine, there's a couple of things to keep in mind. If it is a patient who has neurologic symptoms from this tumor, that is not my patient. They need the radiation therapist, and they need the surgeon to decompress them because I'm not going to do them any favors by going in and trying to burn them if they've got neurologic symptoms.
[Dr. Jacob Fleming]
Sure. You're talking about myelopathy related to cord compression predominantly.
[Dr. Glade Roper]
Right. You're going to check anal wink reflex. If they're incontinent of stool because their cord is compressed, that's not going to be something that I'm going to fix for them. That's something that they need a surgeon and radiation oncologist. Leg weakness, iffy, but those big cord compression things, that's a red flag. Somebody else is going to be dealing with
that issue.
(2) Patient Evaluation: Imaging, Physical Exam & Red Flags
[Dr. Jacob Fleming]
Sure. When you are, as you mentioned earlier, reading the actual studies and seeing what's going on, you take obviously a diagnostic radiologist's eye to that. Have you dabbled with anything like the SINS score, or tell us about just generally what is your process for assessing these tumors on the imaging?
[Dr. Glade Roper]
Is it replacing the marrow signal on T1? That's the big thing that I'm looking for. Is there a fracture line? That's the other thing I'm looking for. Is it pooching into the spinal canal? Sometimes it's okay for it to be pooching out a little bit into the spinal canal. I can still burn it and get a good result. If it is going up the pedicles, that tends to be something that requires a little bit more finesse to take care of. As in, you've got to burn the pedicle on your way out in order to treat that. Those are the big ones that I'm looking for is, does it look like they are actually getting a fracture? A fracture is always going to hurt, and that's something that I know that I'm going to get a good result treating. If it's a painful bony met, that's the question because there's a lot of people who've got mets all over the place that aren't painful.
[Dr. Jacob Fleming]
Exactly. That was my next question is when you have a patient who has multifocal metastases and there's not a pathologic fracture, what's your process for narrowing down?
[Dr. Glade Roper]
Physical exam.
[Dr. Jacob Fleming]
What?
[Dr. Glade Roper]
I know. Who does that anymore? Gross.
[Dr. Jacob Fleming]
As a radiologist, I can't even spell physical exam.
[Dr. Glade Roper]
No. Physical exam is the key to it. You push on their back and find the spot that hurts is the quick and easy way to do it. I've gotten pretty good at that, and my PAs have gotten pretty good at that. We've worked with the PAs very closely on this. Painful bony metastases, especially if they've got an associated pathologic fracture. Here's another plug that I'll put in. I've told my PAs, and I tell myself, "If you are using the words radiofrequency ablation of bone tumor, the next words out of your mouth need to be what? Pain pump."
[Dr. Jacob Fleming]
Great plug.
[Dr. Glade Roper]
Because if you have a patient who has painful bone mets, they're not going to be well controlled on their pain. I tell my PAs, and I follow this rule myself. If I am using the words OsteoCool radiofrequency ablation, the next words that I'm going to say are pain pump.
(3) Integrating Pain Pumps with Ablation for Management of Bone Metastasis Pain
[Dr. Jacob Fleming]
Tell us about how has that process gone. I think this is a great thing to keep in mind, and one of the great things to be able to offer is not, "Oh, I do bone tumor. ablation. Oh, I do kyphoplasty," being able to offer more of a full-spectrum service for the cancer patient with pain. You've added on intrathecal drug delivery to your practice in the recent, last couple years or so. Generally, tell us about what was your process adding that on when you had already started doing, obviously, kyphoplasty and bone tumor ablation? What was your strategy there?
[Dr. Glade Roper]
The strategy was basically to look at all the people who were coming in, and they were in horrendous pain, and we would ablate their bone mets, the worst ones, but they'd still have pain. I said, "There's got to be something else we can do." Then, ding, somebody mentioned pain pump. I believe it was your boss on the BackTable Podcast.
[Dr. Jacob Fleming]
Ex-boss. No, I'm just kidding.
[Dr. Glade Roper]
Your ex-boss mentioned pain pumps.
[Dr. Jacob Fleming]
Yes, exactly.
[Dr. Glade Roper]
He said, "Wait a minute, can I get trained to do that?" I went to the reps who-- I was using Medtronic equipment to do the radiofrequency ablation and the kyphoplasty. They are basically the only game in town as far as pumps are concerned. I said, "Can I get trained to put in pumps?" They said, "Yes, you can. We would love to have you get trained to put in pumps." I got trained in how to do it. It's not rocket surgery, as they say. It's all the skills that we've already got as radiologists of putting things in the right spot under X-ray guidance with a little bit of surgical skill thrown in, but it's the same skills that you use for putting in a port, a tunnel and make a pocket.
[Dr. Jacob Fleming]
Slightly bigger port. Yes, I feel like it's something that gets a bad rap, for some reason, as being something that's really arcane and esoteric. As the boss likes to say, pumps are not complicated. Pumps are complex. They have lots of different parts, and you have to understand how they work. The fundamental thing is it's, you can figure it out.
[Dr. Glade Roper]
Right.
[Dr. Jacob Fleming]
We have guidelines for these, the PACC analgesic guidelines, that help you figure out the process for going through and managing this. What I found is that, in my training, when I got to have a lot of experience with pumps, was that it's the type of thing that once you start doing it, you just can't imagine not having it.
[Dr. Glade Roper]
Oh, yes.
[Dr. Jacob Fleming]
I think it's unfortunate that they've become a little bit less popular over time, with interventional pain trainees coming out. I have spoken to a few in my cohort who were not, let's say, as passionate as me, to put it lightly. I have to brag, and also I think this is just a funny story. We were at the Seattle Science Foundation course a few months ago and the presenter said, "Show of hands, who does pumps?" You and I raised our hand, and our friend Tyler Phillips raised it, and Dr. Beal just laughed. He said, "Okay, what are your specialties?" "Radiology." "Radiology." "Family medicine."
[Dr. Glade Roper]
His next question was, "What's wrong with you guys?"
[Dr. Jacob Fleming]
"What's wrong with you?" Yes, exactly. The three of us who do, we love it. It's one of those things that it can be a little intimidating at first, but you break it down piece by piece, you find good mentors, and you figure it out because that's what the physician who has a patient in need does. I've seen so much positive come back from these patients who, some of them, it's just absolutely life-changing. I think this is not to go too far off track, but I can't avoid any opportunity to put my support out there for pumps and for people to really consider adding it to their practice.
This is really one of the perfect patients, the patient with bony mets and especially diffuse pain. Tell us about when you see them in consultation for the first time, like you said, if the words out of your mouth are RFA, the next words are going to be pain pump. That can be a little-- It can come across in different ways to different patients when you start talking about a pain pump.
[Dr. Glade Roper]
Sure.
(4) Counseling Patients & Families on Pain Management Options
[Dr. Jacob Fleming]
How have you talked about that process of, we're going to start with this, and then we'll have other things in our back pocket to use?
[Dr. Glade Roper]
What I do is I say something along the lines of, "You've got this bone metastasis. We're going to go in, we're going to burn it, and then we're going to cement it." I give them my spiel about termites and fumigation. Then I say something along the lines of, "Now, one of the most important things that we know is if you've got bone mets, you're likely to have more, and it's likely to be difficult with your pain." I'll ask them, "How is your pain control right now?" If they're saying, "Oh, my pain is great," then I'll say, "Then something that we may want to look at later on is a pain pump because then you don't have to go to the pharmacy to get your medications. You never are at risk of overdose. You never are at risk of getting loopy or constipated from the drugs that you're taking."
I explain that at the get-go, so when the time comes it's, they're at a point where they're willing to do it, then they've already had that spiel. There's a lot of Kübler-Ross going on with a lot of these patients of being in denial and not quite being at a place where they are ready to pull the trigger on anything because they are saying, "Oh, I've got to live for the next several years." You're thinking, "That's going to be tricky."
[Dr. Jacob Fleming]
I will have to jump in there and say that one of the amazing things about modern oncology is it's made it so some of these patients are living for years.
[Dr. Glade Roper]
Absolutely.
[Dr. Jacob Fleming]
For me, it's about maximizing the quality of life. The point is well taken that you're meeting these patients at the very vulnerable point in their lives, oftentimes an inflection point in their disease state. It is a lot to take in, and so I like to have strategy of introducing the idea early on so that you go through Step 1, or whatever step you're going to call it, bone tumor ablation, and then revisit that topic later if it is necessary.
[Dr. Glade Roper]
Yes, because we bring them back for follow-up in a couple of weeks, and they're usually doing a lot better as far as their pain is concerned from that met. A lot of them, frankly, are really excited about this possibility. This is especially the case if the patient is there with their adult children who are caring for them because the adult children really like the idea of having somebody else managing the pain medication so that mom isn't going to overdose.
[Dr. Jacob Fleming]
There are so many benefits to the pump, and you have to be able to walk through what does this mean for them. I've generally found that that's the case, too, because it's a family process that they go through. The patient is facing it, but also, as you said, oftentimes the adult children who are caregivers. Getting buy-in from all of them is so important. They're looking for help.
[Dr. Glade Roper]
Absolutely. These are patients who, as you say, they're in a very vulnerable time in their lives. You want to make sure that you're not coming across as mercenary, I guess, is one of the things to say here. You have to say it because it's a procedure that you're doing that you're getting paid to do. There could be a perception that you're just doing this to try and make some money off of this patient. I think there's enough data out there about the effectiveness of pumps and enough other patients who have gotten really good results from these pumps that that is not the case.
You're not doing this for yourself, is the bottom line. You're doing this because you can make their life better by putting a pump in them. For whatever time they've got left, whether it's a year or six years or whatever time they've got left, if they can spend that time not being loopy, not being constipated, that is time well spent. Whatever effort and difficulty you've had to go through to get them to that point is absolutely worth it. Just to get personal here, my grandmother died of colon cancer when I was just three or four. I remember my dad talking to me about times when he would hear her sobbing to my grandpa, "Why can't I just die?" because the pain was so bad. People living in pain are not living. They have a horrendous time of it. Whatever we can do to control that pain, I think, is absolutely worth it.
[Dr. Jacob Fleming]
That was fantastic. Thank you for sharing that, Glade. What a powerful example. Something that happens very frequently for a lot of these patients living with cancer that is painful for whatever reason, it's chronic opioids, as you said, oral opioids, living with loopiness, not really being engaged with the time left they have. You really spelled out so many of the benefits there. I think that anyone who's listening who doesn't yet see the benefit of the pumps should go back and re-listen and come back. You've really well outlined how this is a complementary approach to the bone tumor ablation.
I want to draw back to that, to the bone tumor ablation. We'll talk a little bit about some of the specifics. We've talked some great pearls about practice building, how to approach collaboration with other specialties. Now let's talk just technical details. As you said, you pretty much do these in the office-based setting, is that correct?
(5) Targeting the Pain Source: Planning Probe & Cement Placement
[Dr. Glade Roper]
Yes. I'm doing them under fluoroscopy. 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. How about cases of cortical breakthrough? For example, I was reading a study today with anterior cortical breakthrough, and so that bone interface is gone on that part. Is that still ablating the anterior portion of the tumor? Is that something that is important to the process?
(6) Optimizing Burn Point: RFA Physics & Cooling Systems
[Dr. Glade Roper]
At that point, if it's gone through the bone in that area, there probably is not much nerve tissue left to be bringing pain back. You just want to find the interface between the tumor and the bone and burn there. Now, a key point with that is when you're cementing, you want to put the cement in good bone first and then over into whatever tumor you're going into. That's the ideal. It obviously doesn't happen that way all the time because if the vertebral body is gone, then where's the good bone to put cement into? It's not there. The ideal is if you've got a vertebral body and the left side of it is eaten up, and the right side is normal, put your cement in the right side first and then cement over into the left side.
[Dr. Jacob Fleming]
That's a great point. How do you approach that? Most of these cases, or all these cases, perhaps, are bipedicular access, I'm assuming?
[Dr. Glade Roper]
Yes. All these cases are bipedicular 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 is 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 peeding 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.
[Dr. Jacob Fleming]
Yes, that's the process. That's how you have to do it. Before I forget, 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?
(7) Avoiding Nerve Injury: Pedicle Burns & Posterior Cortex Considerations
[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
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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