Tips and Techniques for Spinal Ablation

[Sabeen Dhand]
…Can you describe your technique for pathologic fractures? What is going in there? Why are we combining thermal into this procedure?

[Peder Horner]
Yeah so these patients often come with a diagnosis that's been confirmed metastatic disease, but some of these patients do need biopsies to confirm the diagnosis. Sometimes it can be a little confusing on imaging whether or not a fracture is actually pathological. But yeah, I do mine under MAC anesthesia. The patients will get on the table and we'll do a bilateral transpedicular approach.

At my institution, we use the Medtronic OsteoCool, RF ablation device. I've used the Merit STAR ablation setup at other institutions, but the main one we use is the Medtronic device. We do the bilateral transpedicular approach typically is if it's a larger tumor. If it's a single pedicular lesion, well I'll just do a unipedicular approach. After the ablation is done, which is typically 10 to 15 minutes, the probes come out, the kyphoplasty balloons go in, and the rest is like a kyphoplasty procedure. If you have a pedicular lesion, you can ablate that on the way out by changing the parameters of the target temperature, or the ablation time, et cetera.

[Sabeen Dhand]
You mentioned something very interesting yesterday in your talk, and you said that a lot of times you combine ESI or epidural steroid injections after your procedure. How are you doing that? How often are you doing that? And why are you doing that?

[Peder Horner]
That's a good question. Every once in a while, it's not the majority of patients, we do have patients that have radicular pain. It seems like the thoracic compression fractures have more of a radicular component to them compared to the lumbar level. Patients will describe this radiating, sharp pain around the intercostal distribution.

So I talk to them about this before and offer an epidural steroid injection. Typically I do an interlaminar approach because there's often a bilateral component to these. If it's unilateral I'll do a transforaminal approach. Adding these really helps in my experience. I don't have a whole lot of data for this, but it has really helped, at least anecdotally, for my patients to get through that radicular pain. Which is interestingly one of the biggest problems that I've seen, in terms of pain control after the procedure, if you don't do it.

Their central back pain may be gone or 50% better within a week or so, but it's that nagging radicular pain that some of them will have and if you get them an ESI, I've seen that it drastically reduces the incidence of that.

[Sabeen Dhand]
Yeah. I actually really liked that part of your presentation, and I'm gonna incorporate that to my practice. I have had several patients, their pain character changes and I think the pain of the actual fracture was treated, but then there's this lingering other pain, exactly what you're describing.