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Interventional Radiology Procedures May Help 3 Common Pain Problems

ReachMD Healthcare Image
04/28/2023
practicalpainmanagement.com

Whether in primary care or specialty pain management, physicians hear pain-related complaints every day, multiple times a day.

  • low back pain affects nearly 40% of US adults¹

  • osteoarthritis-related knee pain affects about 25% or 1 in 4 adults²

  • benign prostatic hypertrophy (BPH) affects 50% of men ages 51 to 60 and 90% of those age 80 and older.³ Urinary symptoms can cause discomfort and pain if not treated.

While all three conditions have established treatments that provide varying results, interventional radiologists are now recommending approaches that may be able to produce better outcomes, including less pain and briefer recovery periods. Interventional radiology approaches may also serve as a bridge before more invasive treatments are needed.²

That was the message from experts speaking at the 2023 Society of Interventional Radiology Annual Scientific Meeting, taking place in Phoenix this March. They gave a conference preview in late February.

Interventional Radiology for Pain Management is Growing

Interventional radiologists are board-certified physicians who use imaging guidance, including x-ray, CT, and ultrasound, to perform minimally invasive procedures. The goal is to deliver targeted treatments with a quicker recovery than other approaches.⁴˒⁵

Some general practitioners, internists, and pain specialists may not be aware of this specialty, or the advantage of collaboration or referral, said Douglas Beall, MD, chief of radiology services at Clinical Radiology of Oklahoma, Edmond, who presented research on a minimally invasive treatment that injects allograft disc tissue into the spine for chronic back pain relief.

In a report published in 2020 in the American Journal of Roentgenology, researchers talked about the role of interventional radiology (IR) in pain management, including how reducing pain via various IR approaches could potentially prevent people with chronic pain from becoming dependent on opioid use.⁶

Here, additional highlights of what IR can do for chronic pain, based on the annual meeting preview talks.

Disc Pain: Viable Allograft Supplementation

Viable disc allograft supplementation involves injecting specialized cells and fluid into a patient’s damaged disc. The cells from the fluid trigger those in the damaged disc to regenerate with healthy tissue, according to Dr. Beall.

The approach can help when conservative care does not provide the desired long-term outcome, he said.

Dr. Beall presented results from his 3-year extension study of the VAST trial (Viable Allograft Supplemented Disc Regeneration in the Treatment of Patients with Low Back Pain).⁷* The findings added to his previous report of results at 12 months.

For the 3-year extension, 50 individuals at 9 sites participated. Of these, 46 received allograft treatment and 4 received saline. Pain levels were measured using the VAS Analog Scale and functionality was evaluated using the Oswestry Disability Index (ODI).

At the 24-month mark, allograft-treated patients had a 41% improvement in pain scores, compared to 22% improvement for the saline group. Saline effectiveness waned sharply at the 2-year mark, Dr. Beall said. While 54% of those in the saline group needed retreatment at the 24-month mark, 39% of those in the initial allograft group did.

At the 36-month mark, 60% of those receiving the allograft treatment reported greater than 50% improvement in pain; 70% reported more than a 20-point improvement in ODI scores. No persistent adverse events were reported.

The clinical benefits of the allograft group remained at 3 years post-treatment. Dr. Beall sees this as a ‘’durable, nonsurgical treatment for patients with chronically painful degenerated lumbar discs.”

*The VAST trial is sponsored by Vivex Biologics, which makes the treatment, VIA disc.

Knee Pain: Genicular Nerve Radiofrequency Ablation

Adults age 50 and older can obtain significant pain relief with genicular nerve radiofrequency ablation, according to a study co-authored by Kaitlin Carrato, MD, chief resident in interventional radiology at MedStar Georgetown University Hospital, Washington, DC.⁸

Image guidance helps physicians to place probe needles next to the nerves of the knee that can send pain signals to the brain. The probes generate radio waves, with the creation of a ball of heat to dull or destroy these pain nerve endings. Muscles and balance are not affected, wrote Dr. Carrato and team in their paper.

In their study, Dr. Carrato and colleagues evaluated pain reduction for 36 patients, using VAS and the WOMAC (Western Ontario McMaster Universities Osteoarthritis) pain scale. Prior to treatment, patients had a mean VAS baseline of 8.58 and mean WOMAC of 66.6. All those treated experienced a statically significant reduction in pain, with the mean VAS reduced to 5.02 and the mean WOMAC reduced to 41.

Older adults (50 years and up), compared to those under age 50, had the greatest reduction in pain and increase in function.

No differences in benefits were found among different genders, patients with different BMIs, or those with a history of knee surgery or fibromyalgia. The average follow up was 75.5 days.

An additional benefit that patients reported, beyond the pain relief, noted Dr. Carrato, was that they left treatment “with Band-Aids, not stitches.”

BPH: Prostate Artery Embolization

An interventional radiology technique can also provide long-term effectiveness for urinary symptoms such as urgency, frequency, and straining to urinate, which can cause discomfort and pain if not treated. These symptoms all commonly occur with an enlarged prostate, or BPH, according to Shivank Bhatia, MD, chair of interventional radiology at the University of Miami Miller School of Medicine.

Dr. Bhatia reported results on prostate artery embolization (PAE) in 1,000 patients, followed for up to 72 months, who had lower urinary tract symptoms (LUTS) or retention due to BPH.⁹ The treatment involved injections of tiny particles into the arteries feeding the prostate gland, reducing its blood supply and shrinking it. The particles are acrylic polymer coated with gelatin, designed to stick to the blood vessels. They are in place permanently to block blood flow long-term to the prostate gland. According to Dr. Bhatia, the particles do not move through the bloodstream to the brain; they stay in place.

Participants underwent the treatment from January 2014 to September 2022. Researchers evaluated pre- and post-procedure IPSS (International Prostate Symptom Score) and quality of life (QoL). Pre-treatment, the prostate volume on average was 107 grams; it was 70.9 grams at 6 to 12 months.

Pre-procedure, the average IPPS score was 23, termed severe. In less than 3 months, the mean was a score of 6. “Mild” symptoms persisted throughout the 6-year study, a finding similar to what is found after more invasive options, the researchers reported.

QoL scores went from 5 (mostly dissatisfied) to 1 (mostly satisfied) within 24 months.

“This is an outpatient procedure, very safe,” Dr. Bhatia said. “They won’t even see where I went in,” he said of the procedure. Recovery is 3 to 5 days. Of note, Dr. Bhatia shared thatthere was no impact on sexual function and no incidence of leakage after the procedure.

This procedure can also be “a bridge between medication and surgical options,” noted Dr. Bhatia.

Practical Takeaways

According to Dr. Beall, ‘’interventional radiologists are entering pain management. Previously, pain management was limited to simple procedures, pain-blocking devices, and medications.” Several new, minimally invasive corrective procedures have evolved for pain conditions, and these are well-suited for interventional radiologists to perform, he said.

Pain specialists in his region often refer to him, he said, as they become aware of the potential of interventional radiology treatments.

John Smirniotopoulos, MD, MS, principal investigator of the knee study and assistant professor of radiology at MedStar Georgetown University Hospital and Georgetown University School of Medicine, added that physicians should be aware of these alternative procedures to surgery for appropriate patients. “For those who don’t want surgery yet, aren’t surgical candidates yet, or have had surgery but still have pain,” he said, interventional radiology techniques could be an option.

*Disclosures: Dr. Beall is a consultant for Vivex Biologics and principal investigator in its ongoing trials. He is also a member of the Vivex scientific advisory board.

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