BackTable / VI / Podcast / Episode #199
Advanced Minimally Invasive Pain Interventions
with Dr. David Prologo
We talk with interventional radiologist Dr. David Prologo about minimally invasive pain interventions, multidisciplinary pain management, and how he built a successful pain practice.
BackTable, LLC (Producer). (2022, April 11). Ep. 199 – Advanced Minimally Invasive Pain Interventions [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. David Prologo
Dr. David Prologo is an interventional radiologist at Emory Healthcare in Atlanta, GA
Dr. Michael Barraza
Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.
In this episode, host Dr. Michael Barraza interviews Dr. David Prologo, director of interventional radiology at Emory about minimally invasive pain interventions, multidisciplinary pain management, and how he created a booming practice that is well known by patients and providers nationally.
Dr. Prologo begins by discussing his training in obesity medicine and how his interests in pain management developed. He discusses his book, The Catching Point, which explores weight loss culture and the fault of society and medical providers in placing the blame on patients and the new options available in IR for weight loss. He says his interest in pain management was similar to his interest in obesity medicine. He was curious about how he could use his tools and skills as an IR to treat obesity and pain with minimally invasive procedures.
Next, they discuss how IR fits into the multidisciplinary team that plays a role in pain management. He explains that the combination of technology and an IRs position in the hospital makes them ideal for the job. He says a key is to maintain relationships with all other specialties by focusing initially on procedures that other specialties don't perform, in order to build rapport. He also notes that the procedures he performs result in rapid pain reduction and greatly decrease length of stay which is a huge incentive for hospitals and other specialties to seek out IR and make referrals.
Finally, the two discuss the types of patients Dr. Prologo treats, and the procedures he does. He divides patient population into neoplastic versus non neoplastic pain, and spine versus non spine pain. He sees 90% of patients in clinic for procedure planning. Dr. Prologo emphasizes the importance of advocating for patients and continuing to see them even if they do not need an IR procedure. He discusses his 8, 3, 3, 3 method for percutaneous cryoneurolysis and discusses the various outcomes he is able to achieve in pain reduction. Dr. Prologo minimizes non responders by doing test blocks, understanding central desensitization, and selecting patients for procedures appropriately.
Interventional Cryoneurolysis: An Illustrative Approach: https://pubmed.ncbi.nlm.nih.gov/33308581/
Nantes criteria for pudendal neuralgia:
The Catching Point
David Prologo Website:
[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.
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