Podcast Transcript: Cryoneurolysis Pearls & Pitfalls

[Dr. Jacob Fleming]
There's a lot of room for creativity with it. The interventional radiology mindset is really all about that. I think that's something unique that interventional radiologists can bring to the pain therapies. You're talking about this a moment ago, you can get some raised eyebrows or people getting a little bit defensive of what they consider their turf when we talk about radiologists getting into pain. I think that we come at it from a different angle, and bring some of our problem solving and ways of thinking outside of the box using different tools. Like I said, most interventional pain docs are not using cryo to any significant degree. We've taken that from what's been done within our specialty. I think we can do a lot of really cool stuff with that.

I do want to talk about specifics in terms of, how do you talk to patients about this? Obviously, you just listed off a myriad of different topics or different targets, so many different things, but talk to us a little, in general, about the process of patient selection, how you generally plan your procedures and the discussion in clinic with the patient: what can be expected, talking about risks, and that sort of thing.

[Dr. Alexa Levey]
Sure. That's all these super important topics. Number one, everybody's a candidate. There's always something you could potentially do for someone, and if I can't do it, I know who can. I still have connections with other anesthesiologists, PMNR colleagues, neurology, where I can send the patient somewhere else if there's something that I can't do. Becoming a person who is known for doing pain, if you don't do it all, then you need to know people who can and you need to be able to get them in and be able to network them out because that is your patient. That is the most important thing. You take care of that patient like your mother or your brother, somebody you actually like in your family and treat them like family because there is nothing worse than to be in pain and there's nothing a patient wants more than to be heard and to be understood. Hearing them out and evaluating. There's nothing more than a doctor who wants to. Your patient's in pain and they're terrible, they can't manage it? Let me help you. I will talk to them. If they need something else, I'll discuss it with you and I will get them referred out so they can get their problem fixed. That is the best thing you can do and say to refer and to build your practice. That's the first thing.

My phone is always on for my referrers. All my patients have my email address. I am constantly checking it. If I had a second phone, my patients would have my phone. Being accessible is super important. When I'm evaluating a patient for pain, imagine, is it chronic or is it cancer related? Let's talk about cancer related. I had one that got referred to me over the weekend that I looked at today, a patient who has metastatic cancer of an unknown primary and just has this diffuse nonspecific abdominal pain. Normally what you want to do is read the patient's history, find out if it's acute, if it's chronic, if they have cancer. You want to look at some type of cross-sectional imaging and you want to see first, is there anything on that imaging that looks like it could cause the pain described in the note, some kind of general pain in one area or not? Is there a mass encasing the femoral nerve that's causing pain to shoot down their leg? Do they have a cervical cancer that's invading their obturator or pudendal nerves, something that you could target? Is there something that is in the splanchnic bed that is causing pain, or is there nothing and maybe you just try a splanchnic block to get something general? Look at the notes, number one. Look at cross-sectional imaging, number two, to try to determine some potential targets.

For this particular patient, generalized abdominal pain, it was the most unimpressive CT I've ever seen, retroperitoneal adenopathy, and just diffuse abdominal pain, which she was describing. I looked up a little higher and I realized just inferior to the right where the celiac plexus is coming off at the celiac axis retrocrural is this massive node. Then, I look a little more cranial and there's a lot of dirt in the fat, and I'm like, "Gosh, this node is invading the splanchnic plexus and it's probably contributing to her abdominal pain." What if I planned after I talked to her to treat the splanchnic plexus and then try to treat that little node and cause some regression back from the diaphragm and from the crura and see if that helps a little bit? That's a thought process of things I go through.

Next most importantly, go see the patient, go see the patient yourself. I had people ask me, "This patient has 8 out of 10 pain here. What would you do?" I said, "Where? Can they point to it with one finger? Is it sharp? Is it stabbing? Is it burning? Does it radiate? Does anything make it better? Does anything make it worse? How does it feel when they take pain meds? Does it regress at all? Is there anything that exacerbates it?" You really have to get incredibly granular with pain patients because what you'll find is often you will help pretty much every single patient but not to the degree that they would normally think about it, if that makes sense. You can make a change and impact everybody's pain, who you treat, but it will be in one certain sector of what they categorize as their pain. They'll get less crampy. They'll be able to eat more. They'll still get a crescendo of their pain, but it will be to a five or six versus a 9 out of 10, and it will go away faster. The more granular you can be with your patient interview, the better you will be at helping your patients succeed in getting their pain under control and realize that they are making progress.

That also being said, the first thing I say to patients when I see them, and it's the hardest thing to say to somebody is, "I'm sorry, but there's no way I'm going to be able to make your pain zero. That's not possible. If anybody tells you that, they're lying to you. That's a hard truth to accept that you're always going to have some level of pain, but I am here to help you manage it. I am here to help you get through it. I am here to hopefully reduce it by 50%, if not more. I am here to hopefully get you on a lower dose of opioids so that you can be more active in your life, you can get out, you can drive, you're not sleeping all day, you don't feel constipated, and you don't feel nauseous. If that doesn't work, here's plan B." I think having a very honest and real conversation with the patient is the most important thing. There are no magic wands for pain. It is always going to be multimodal in management. A big part of what I do is therapy, 100%. I would say that my initial clinic visits are usually about 35 to 40 minutes and the follow-ups are much faster. That's actually for any patient I see. That's just the way I am. I like to describe things, everything, and be very thorough so that if anything comes up, they can feel free to ask me. My subsequent visits actually end up being a lot shorter.

With pain too, when you do that, you can actually help patients identify what kind of pain they're having, get those granular things, and then you have something to compare to. Then, you could show them their progress. I can say my complex regional pain syndrome patients I've treated, they actually continued to improve. I think that's just because of learning to accept that this is their new baseline and their new normal, not because I didn't do anything, I usually get them a decent amount of pain relief, but them willing to adapt, being able to do more physical therapy, and learning to do some cognitive restructuring about what their current life is. That's so important. That's how you maintain a practice. That's why I can say I love my pain patients. They're amazing. People are like, "Are you crazy? They're so hard." It's like, no, they just want to be heard. They need little goals, little things to say, "Look, this is what you said before. This is what's happening. That's good. Not to say that your current pain is not important, but look where we have made strides and made improvements."

Those are things I really focus on in the clinic visit. Of course, I talked about that in my physical exam, asking about history, blood thinners, typical procedural things, chronic health issues, and then I plan for a procedure if I have something to target. Usually I have multiple steps after that.

General risk with cryo, gosh, it depends. Is it going to be close to the skin and they can get frostbite? Depending on the pathophysiology of the disease, when I cryo a stellate ganglion for VTAC and for complex regional pain syndrome, they do great. Some get Horner's. When I do it for long COVID, a third of them get Horner's and they get a raging neuritis, which some describe as the worst pain in their life, which goes away after six weeks, very predictably. You have to talk to people about that and tell them how to manage it and guide them through it, have follow-up visits, tramadol for pain, lidoderm patches for the shooting neuritis, anti-inflammatories, bedroll dose pack. You have to be able to handle all those things.

Also, it brings up another really big important point. You should almost, I say almost never because there are situations I do, go straight to cryo. You do a block first. You need to make sure people have success with the block so that they can want to have longer lasting relief and see that it's actually efficacious. Especially, I have people coming to me and asking me questions now about just doing cryo for long COVID. Don't do that. Not a good idea to go straight there. Because of the side effects of having the cryo in that particular pathophysiology, you're not going to have any more patients after your first one.

[Dr. Jacob Fleming]
Really good point there. That was something you mentioned to me earlier I hadn't really thought of before, about the different response between blocks and cryo. Can you expound on that a little bit more? What are the situations in which you see quite a different response?

[Dr. Alexa Levey]
I would say in general, talking about response to treatment. If you have a positive block, you're going to get a positive response to cryo and it will be about the same level, if not a little bit more. It's usually very predictive of how they're going to do.

Now, when we start to change the pathophysiology of what we're doing, remember cryo too, you can't distinguish sensory and motor. For example, if I'm going after a tumor encasing the obturator nerve, I already know that's going to affect adduction, but older lady, she has a walker and within about six months, it's going to regenerate. She's going to be fine. She can still walk without her adductors and that's okay. All those things are what are going through my mind whenever I'm thinking cryo.

Whenever I'm talking about, block versus, again, cryo, sorry, I'm being a little repetitive. Blocks are temporary. You inhibit signaling via two different methods with a local anesthetic and then also with a steroid. There's two different mechanisms by which those actually inhibit neuronal-signaling and can actually regulate pain and nociceptive signaling. Obviously over time that wears off, and the whole idea with cryo is that it lasts a lot longer. I would always do a block before cryo, except in those cases when I have patients who have tumor encasement and I can target it to a nerve, then I'm not necessarily going to always want to put a bunch of steroids around a nerve. I'd probably just go ahead and cryo that area. After we have a nice thorough talk about the consequences of cryo-ing certain nerves.

I did have one patient who was in her 30s who had metastatic cervical cancer and had been in a wheelchair for the last three months and unable to walk, and terrible pain in her legs. I was able to map it out to, I'm already forgetting which nerve it was, but I said, "Okay, I see this, I can map out. This is where your pain is. I see tumor encasement. I can ablate this and I can get you pain relief and numbness and tingling, but you're not going to be able to walk with this leg." "Oh, that's fine. That's fine." So I said, "No, you don't understand. You're going to feel better and you're not going to be able to walk. Are you going to be okay? Within about six months, you can do braces and boots and stuff and the nerve will regenerate unless the tumor grows back and invades it again.” I will say I have had patients who had two years out for the tumor to regrow and cause issues. This is something that's really good and really efficacious for patients. Of course on board. "Yes, doc. Yes, doc." I made sure to record this and have plenty of conversations. Next day, I went and saw her after I ablated her. In tears. "I can't walk. I can't walk. I can't walk." I said, "How's your pain?" "It's gone." Okay. For those things too, I would say, in general, you can go straight to cryo, but just make sure you have a very, very, very real talk with your patients and make sure you document about what's going to happen too.

[Dr. Jacob Fleming]
Absolutely. The expectations are so important. My mentor, Dr. Beal has said, "The patient needs to be able to be a partner in their own care.” I think we can't make all our patients want to cooperate and that kind of thing. I think explaining as best as we can and trying to get on their level of understanding and really letting them know, "Hey-", you said earlier, "-I'm not going to be able to take your pain away 100%. We're going to do our best to mitigate it, and then these are potential things that can happen.” Just letting them know. A lot of times it, when you're going for a mixed nerve and predictably you get a motor deficit afterwards, if the patient knows what to expect, a lot of times they may say, "Hey, I knew to expect this." Other times patients say, "Yes, let's do it," and maybe they're not hearing it to the same extent that you want to, but it's so crucial to have that conversation. Obviously on the medical legal aspect, it's completely indefensible if the patient had no idea, "Hey, I'm not going to be able to walk after this." That's no good.

[Dr. Alexa Levey]
Correct. Then also too, even if it's just a sensory thing, they can have some numbness and tingling, making sure they have that. If you do an ablation for pudendal neuralgia, they're going to have some numbness down there and not have some sensation down there. You have to make yourself very clear about that. Genitofemoral nerve blocks, I do a lot for chronic testicular pain. Haven't gone after ablating those yet because I don't think that's going to be very well tolerated by the patient. Making sure you have, as you said, very very clear expectations and that they are a part of their care.