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BackTable / VI / Podcast / Transcript #199
Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Obesity Medicine and Interventional Radiology
(2) Getting Patients Past Their “Catching Point”
(3) Bringing Interventional Radiology into Mainstream Pain Management
(4) Building a Pain Management Brand
(5) Caring for Clinic and Non-Clinic Patients
(6) Pain Management Procedures
(7) Cryoneurolysis
(8) Setting Patient Expectations for Cryoneurolysis
(9) Cryoneurolysis Evaluation and Follow Up
(10) Advice for Growing Your Pain Practice
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[Dr. Michael Barraza]:
I'm honored to welcome back Dr. Prologo from Emory University who joined us on the podcast back in 2017. It's actually one of our first ones, I think was number seven, to discuss novel bariatric and paint therapies. Dr. Prologo, thanks for sharing your time and expertise with us today.
[Dr. David Prologo]:
Oh, my gosh. Thank you. for having me and thank you for the amazing evolution in technology and content over the last five years. You guys are stupendous.
[Dr. Michael Barraza]:
Thank you. Thank you for staying busy and trying to keep making this a good resource. So today we're going to be focusing primarily on minimally invasive pain interventions. We're going to talk about some of Dr. Prologo’s leadership activities. We'll talk about the role of IR and multidisciplinary management of pain.
We'll learn about what pain interventions look like in Dr. Prologo’s practice, and then we'll review some of the various interventions that fall under pain management. I want to encourage our listeners to check out the December 2020 issue of techniques in vascular and interventional radiology, which was led and edited by Dr. Prologo, focusing on advanced interventional pain management. It’s something that was very useful to me as I started to expand that part of my practice. I refer to those articles all the time. But David, before we dive into pain interventions, I want to take a minute to talk about another focus of your practice.
Could you tell us a bit about how and why you became trained and certified in obesity medicine and how this fits into your practice as an interventional radiologist?
(1) Obesity Medicine and Interventional Radiology
[Dr. David Prologo]:
Sure, absolutely. That's a little bit of an interesting story. For a long time during my career starting, even in medical school, I had a particular interest in a weight loss and even more specifically the attrition that goes along with all these attempts to lose weight. And so I had always in parallel been pursuing that and found out that there was something as an interventional radiologist that I could become certified in and we all could certified in, through a standard training exercise and then a certification exam. So I had that interest personally for a very long time. And then at the same time, my interventional radiology career became almost exclusively about pain, as you know, and as part of that we were doing a lot of interventional cryoneurolysis procedures.
Now both for the management of cancer related pain and non-neoplastic pain. So a very interesting intersection occurred when it became clear to me that surgically, the vagus nerve was being transected during things like duodenal resections to manage all sorts historically. And so what they realized during that time and what has been published and supported for some time now in animals in humans is that interruption of that nerve pathway resulted in decreased appetite and resulted in attenuated hunger. There's this quote that I love from one of the papers that says interruption of that vagus nerve results in a decreased appetite and interruption of weight gain in all species. So just kind of came together when we said, well, we're putting these cryoablation probes and we're trying to freeze these nerves and understand that mechanism. What if we did that and block the hunger signal from an empty stomach percutaneously, would that help people to diet? And so that's what we did.
And that's how it all ultimately came together, the percutaneous Cryoneurolysis stuff and the obesity medicine stuff. And there's offshoots now from that and metabolic conditions, diabetes, hypertension, we should talk about all that stuff if we have time.
[Dr. Michael Barraza]:
I'd love to hear about some of your more recent developments and some of the data that you've accumulated.
[Dr. David Prologo]:
Well, I'll start here. Certainly what I think is interesting for this audience, and I like to talk about this when I can, because not only is an interesting application in and of itself, but it really illustrates what interventional radiologists can do with their skillset beyond what we're already doing. If we can get beyond the logistics of already having full days.
If we think about the management of hypertension by endovascular ablation of nerves, renal artery nerves, for example. We are wondering if there's some way that we can attenuate that signal with an endovascular catheter across the wall and thereby help patients with refractory hypertension or hypertension in general. But without getting too far into the weeds, the point is that there's a lot of these things like the posterior vagotomy that are supported in a surgical literature.
We don't have to reinvent the wheel and go back to the animals and say, if we interrupt this vagus nerve, will it interrupt weight gain? Will it attenuate hunger? We already know that. So all we have to do is superimpose our existing skillset onto that and make it a percutaneous procedure. So I would say the same thing is probably true for the management of hypertension by ablating these nerves. It's already been shown in animals. It's already been surgically supported by splanchnicectomies, by nephrectomies and now we're trying to endovascularly, and I would suggest potentially percutaneously, target those nerves where they come together at the aortorenal ganglion. Then maybe accomplish all of this again with just a CT guided percutaneous procedure.
So there's a lot of things we can do like that. I think that all the basic clinical work and the human support work through surgery is already there for us. We just need to take it across the finish line.
[Dr. Michael Barraza]:
It's really exciting, this stuff that you're developing. I was telling you earlier we've got some different podcasts now and one of them is a medical innovation podcast. It's kind of hard to choose which one to put you on. But with that in mind, you've got a new book that I’d like to hear about and it's called the Catching Point Transformation. What's the “catching point” and how do we get there?
(2) Getting Patients Past Their “Catching Point”
[Dr. David Prologo]:
Ah, thank you for asking about that. So that's a totally different project, indeed, trying to translate some of these thoughts for the general public. So the “catching point” is this point beyond which the struggle for weight loss is gone. It's a super important thing, at least for all the work that I've been doing. Because again, one of these things that's already known is that the current gold standard for weight loss is diet and exercise programs, right? It doesn't really work very well. And so the attrition rate is really high and the failure rate is really high and the explosion of the prevalence of obesity is obvious.
And so it really doesn't work. And if we ask ourselves why it doesn't work, there's sort of this outside of medicine and it even crosses into medicine, unfortunately, sentiment that it doesn't work because somehow it's the patient's fault. We can talk a little bit more about that sentiment because I think it's important.
But to answer the question, what is the “catching point?” What is really happening during these failures are that things like hunger hormones are spiking. People's metabolisms are slowing. All these survival-based signals are jumping up and fighting this person all the way until they quit right until the great majority of them quit during this diet and exercise attempt.
What the “catching point” though is it represents this point beyond which we don't have a spike in hunger hormones anymore. We don't have a compensatory slow in our basal metabolic rate to offset what the body thinks of starvation. And then it's a little bit easier. It's a lot easier. If you think about many of these people who are lean and who work out and run, they're not having a hard time at all, right? They're not struggling. They're not fighting hunger hormone spikes. They're not fighting compensatory metabolism changes or any of those things. They're loving their life. They'll tell you they can't live without it. So there's a clear separation between people who are engaged in maintenance activities, the same activities, eating kale, and working out, whatever it might be on one side of the catching point where it's enjoyable and stress-free, and even addictive. And then there's a whole population of people on the other side of that catching point for whom the exact same activities, eating kale and working out are miserable and almost undoable. So then the question becomes, how do we get people from where they are now through that catching point to
the other side, where it's easy and that's really where the vagotomy came in.
Can we stop hunger for a while? Get people across that catching point, and make it easier for them? And then they're off on their way. And so many of them did exactly that. And so I'm sorry, that was a long answer, but that’s what the catching point is. And that's what the book is about.
[Dr. Michael Barraza]:
I mean, there's a lot to say you made a whole book out of it. Lots of people have great ideas. Tell me about the process of taking this program and making it into a book.
[Dr. David Prologo]:
So for this audience, I'm going to just give them straight scoop. The program really was integrated into the book because of sort of real-world issues. What I wanted to write about was this sentiment that people are faced with biological challenges and when they can't overcome these biological challenges on their own, they can’t overcome this pathology on their own. We somehow turn it back on them and make it their fault and fat shame and say that they must not really want it. And somehow, we just turn it back on a patient. And that phenomenon has really been my passion for a long time. And that's what I wanted to write about because we don't do that in any other setting.
We don't have anyone come to us with a cardiac disease, even if they got it smoking and drinking and eating steaks, even if that were the case, we still don't tell them to just sort of figure it out on your own. And if you can't, you must not really want it. And we don't do that with cancer. If someone comes back to us with because they can't tolerate their antineoplastic drug because it makes me nauseated, we don't roll our eyes at that person and say that you must not really want to be rid of your cancer. We never do that. We say, okay, let us figure out how we can make the treatment more tenable for you or switch your treatment.
But when it comes to weight loss and a condition of obesity, when people come to us and say I've tried this diet and exercise program, and I can't do it. We just looked down our noses at them and say you must not really want it. So that's what I wanted to write about. And, it turns out that there's a whole process here of how to get a book published. And it has a lot to do with what the publisher thinks they can sell. And that's sometimes there's a little bit of a disconnect between what you want to write and what they think that they can sell. So I had to incorporate a program into the Catching Point Transformation book for our purposes of being able to sell it. But what I think is important that is contained in that book is really not the program. It's really the defining of what's been stopping people so far. And then the ways that we can get around that, like the vagotomy, like fluidity. All these things that are evidence supported. But I had to put a prescriptive trap chapter in there to get it published.
[Dr. Michael Barraza]:
David, is the book available yet and where can we find it?
[Dr. David Prologo]:
It is. And thank you again for asking that question. January 25th was the day that it became available. It's available on Audible. So people listening to this podcast, if you're a listener instead of a reader, it's on Audible. And then it's available all the sort of typical places you might think: Amazon, Barnes and Noble, Target books, Google Play. It's everywhere. It's distributed by Simon and Schuster. So it's easy enough to acquire should someone have the interest.
[Dr. Michael Barraza]:
Congrats, man. That is awesome. Very exciting.
[Dr. David Prologo]:
Thanks for saying that. But I will tell you though, Michael, how it being available is one step short of it being sold. And so I appreciate you having me on here so that I can talk about that and try to get copies into people's hands.
[Dr. Michael Barraza]:
Hey, that's part of it. So the other thing we're talking about is pain interventions which are a vital and growing component of interventional radiology practice. You became one of the principal authorities in the IR community on pain intervention. So for our listeners, Dr. Prologo is the current chair of the SIR Pain Management Clinical Specialty Council. Can you tell us about your experience with the council including the objectives and what you hope to accomplish?
[Dr. David Prologo]:
Absolutely. So largely due to Parag Patel and others, the governance structure of the SIR has been restructured in recent years. It is restructured in such a way now that there's crosstalk between what we used to call service lines and in all the other parts of the society, such as economics, council, education, committee and guidelines, reimbursement. The foundation has done a brilliant job of creating this matrix now so that the clinical specialty councils, of which one is pain management, can take advantage of the full resources of the society and accomplish the sort of action steps that we define early on, such as generating guidelines, acquiring funding for studies, and generating education modules so people can have answers to some of the things you and I were talking about before we came on. So the power of the Clinical Specialty Councils now, thanks to the SIR governance restructuring, is significant. And each of the chairs of each of the specialty councils
now as part of the steering committee.
So we’ve sort of leveled the entire governance structure and now we're so much more effective and we're so much more efficient and we have access to all the resources within the society. So, it’s an honor to be a chair of that Clinical Specialty Council. And I hope that we can use this opportunity to get all of the things to the members that they need.
[Dr. Michael Barraza]:
Okay, good deal. It is an honor and you certainly earned it. You've really built quite a practice in pain intervention. So my next question then is why pain? So why and how did this become such a large focus of your career?
(3) Bringing Interventional Radiology into Mainstream Pain Management
[Dr. David Prologo]:
Wow. What a great question. So, early on, Matt Carlstrom and Damien DePuy and, I can't name them all. So, no disrespect to anyone who I don't name in that long list of people laid the foundation for us. Essentially through the development of the percutaneous ablation of painful osseous metastatic disease or soft tissue neoplasms that are causing pain. And from there, that foundation that they laid really was the idea that we can take our interventional radiology skillset and do something else. That's the door that they opened for us.
We know that we can take a thermal ablation and treat a renal cell carcinoma as percutaneously and as an outpatient and so on. And then what they did was say, well, why don't we use that same skillset to manage pain? And that opened the door to the following thinking, which is there are pain generators in the body that can't be reached unless they're reached surgically, which comes with mortality, complication, cost to the point where those surgeries aren't even done.
And so the pain generators are just left. We can reach those with our advanced imaging guidance and with our interventional radiology skillset. And we can do things we can inject. We can ablate, we can freeze, we can modify these pain generators, and that in combination with the evolution of technology has created a brand new specialty. It's a subspecialty now of interventional radiology now that interventional radiology is officially and formally a specialty, because we can solve all of these problems because we can get there and we can do something.
[Dr. Michael Barraza]:
Right on. Well, you answered my next question. My next question was going to bring up the fact that we are one of many players in this sphere and we're also working with physical medicine and rehab. We're going with ortho, palliative care, physical therapy. They’re often quarterbacking it. And then we aren't the only ones doing their procedures too. I’m not taking about open surgery but for minimally invasive therapies there's pain medicine, general anesthesiology, sports medicine, primary
care docs, et cetera.
My question was going to be where do we fit in in this multiple disciplinary team and what advantages do we have that really warrant us becoming a key contributor? And it sounds like image guidance and being able to get to these places that otherwise would have been only options for surgery is one of our main advantages that correct.
[Dr. David Prologo]:
That's correct. And in our technology and our position in the hospital, we can make sure that we maintain relationships with all the other subspecialties in a non-threatening manner by focusing our initial steps in our initial role, our initial procedures on those things that other people aren't doing. Patient is coming in with, for example, painful osseous metastatic deposit. Combination of interventional radiology, advanced imaging guidance, and our blade of technology, we manage that situation, right? And so when we take the low-hanging fruit where we can help the referrers and help the patient, that's how we get our foot in the door. And that's how we define ourselves and get put on the radar. And some halo business will follow from that.
But we have other advantages. Oftentimes we are stationed in the hospitals. So we've got patients who are coming into the hospital with intractable pain. For example, we can say neoplasm related intractable pain. Now there's a driver for the doctors who are taking care of that patient on the floor for the hospital system, and even now, because of COVID just based on capacity.
So there's three drivers there. There's the person being held accountable for their length of stay on the ground, which it might be a hospitalist, it might be internal medicine or oncology. There's the hospital system in general, which wants to shorten the length of stay. Which is almost always better for the patient as well. And then superimposed on that, and the last three years has been COVID. Well, we need hospital beds. And so those three drivers, and our presence in the hospital came together such that we can offer these patients therapies to decrease their pain today and get them out of the hospital. And that way, if we stick with the cancer example in that way, we're not taking
anyone's business, we're not eating anyone's lunch.
We're just here to help the patient get their pain under control and get out of the hospital. They can have their radiation therapy as an outpatient. We have our imaging guidance, we have our ablative technology, but we also have our position in the hospital that allows us to go through the sequence that I just described, but also build relationships with those referrers which will then bring us halo business that's pain-related in non-pain related.
[Dr. Michael Barraza]:
Right on. That was a great answer to that question.
[Dr. David Prologo]:
And I think you're experiencing that. You're there, and you're getting requests. The ever so familiar requested that any interventional radiologist gets. I just wrote an editorial about this, actually, what will be new seminars in the Interventional Radiology issue on advanced interventional pain will be coming out. And we talk about exactly this, which is oftentimes we get the question. Can you help? I mean what we do and how we do it sometimes is so far ahead of what the general population and the referrers are aware of. They can't even ask for anything specific, which is fine. We want to be a consultative service anyway. So we get that question. Can you help?
There's another driving force, Michael, as if that isn't enough. As you know, there's an opioid crisis now in the world and the opioid crisis is essentially this sort of phenomenon that occurred for various reasons that I won't take up time on this podcast going over. But the point now is that the societies and the legislators have generated guidelines and laws that are driving patients away from opioids. And sometimes that's just what they do: drive them away from opioids. And then you're kind of on your own after that. Right? So there we are, again, just like we're there for the inpatients who need to shorten their length of stay, there we are offering procedural alternatives to opioid therapy. And so you really couldn't line it up any better if your interest was to take care of these patients in pain.
[Dr. Michael Barraza]:
Absolutely. David, I want to hear a little bit about your own practice. I know enough about it to know that it's pretty unique. I mean, you've got a destination element of your practice and where people come from all over to get pain treatments from you. I know that one of my own partners as recently as last week recommended that somebody send a patient to you. And I get the understanding that this happens a lot. So before we get into kind of the details of it, I just want to ask you, how did you build this brand, this name value, and how did you build this element of your practice? You’re the guy for this.
(4) Building a Pain Management Brand
[Dr. David Prologo]:
Yeah, interesting that you would say that because we really have an army of guys and girls and people. We have an army of people across the world who can do all of the things that I can do. And we just want to be able to activate them when a need arises. It really, I guess it's sort of a vantage point question here on the one hand, has Dave Prologo been able to raise a little bit of awareness that I've got this interventional radiology skillset that I can apply to pain. I suppose that might be true. But on the other side of it, it's my greatest professional frustration, to be honest with you, that we have all of these things that we can do for all of these patients. And once a month, I meet somebody that I could have helped 18 months ago. And so even though what you say may be true and the way that that happened really was, through exactly what I've just described to you.
We would take care of these patients as inpatients. We would accidentally run into them and do something. And then what happened from there is essentially a word-of-mouth chain. And now with the internet availability and people's ability to go into Facebook groups and so on, the word kind of spread organically like that. But not anywhere near what we as a specialty / subspecialty, if we're talking about advanced interventional pain, could be doing for the human beings in the world here. We're not even scraping the surface as far as being able to translate and disseminate the message. And what you're doing is so critical for that reason. Because what I've learned over the years is that you honestly could have the so-called cure to cancer in your lab. But if you can't figure out a way to let the people know that you can help them, you'll die with it. And so these kinds of platforms are critical. So I would thank you again for doing this and for having me.
[Dr. Michael Barraza]:
Well, thank you for joining us, David. So these patients that are coming from all over, are they referred to you for a specific thing or do they just come with “we've got pain, we need help?”
[Dr. David Prologo]:
They honestly come with “we've got pain and we need help.” And what we try to do from there is we try to divide those presentations into those that are related to cancer, those are not related to cancer. And then after that, those that are spine related and those are not spine related. So that then gives you four buckets. You can put your patient into one of those buckets and there's a list of procedures there. And so we're trying to organize all of these things that we can do by taking that initial approach with any potential presentation.
But people still get to us. I tell this story at SIR. I hope you don't mind me telling it here. I had a patient who came to my clinic for some interventional radiology reason that I don't even remember the actual reason. But they had this horrific leg pain and they had metastatic breast cancer and they weren't there for that. They were crying and couldn't get past the pain. And the family told me that they had been told that there was nothing that could be done about this. They were just trying to be maxed out on opioids and they couldn't spend time with their family and the opioids weren't working anyway. And we went on and we looked at this at this person's MRI and they had a lytic metastatic deposit right in the posterior elements pressing on exiting L4 nerve root that was keeping them in 10 out of 10 pain.
This was something that we could solve in 45 minutes. Michael, we brought the patient into the hospital and kept them overnight. The next morning we did a CT guided cryoablation of that metastatic deposit and the exiting nerve and brought that patient's pain from a 10 to a 2. The purpose of this story is that this was a patient who was at an academic tertiary care center, getting great care, where I worked being taken care of essentially what would be one of my partners in a different specialty and still I had to find out about them accidentally. And so we've got to pay attention as we're innovating and evolving and expanding our abilities to messaging to our referrers into the patients themselves that we're here. And we can help you.
[Dr. Michael Barraza]:
Right on. Yeah. That's a great point. Very important. There are so many different pain procedures that have varying degrees of difficulty. I’m curious which of these treatments, which patients are you seeing in clinic beforehand? For example, I don’t see spinal. Yes I see patients in clinic versus just get scheduled, but some of the bigger procedures that we do, I like to see them ahead of time.
(5) Caring for Clinic and Non-Clinic Patients
[Dr. David Prologo]:
I see. Almost all of them. So 90% of them I see in clinic and 10% I don't. So let's first talk about the 10% that I don't, and that that's a 100% practice building relationship move. That 10% are those, so our audience here on the BackTable Podcast will understand this. That 10% are the people who want to just tell you what to do. This is what I need done. Can you do this for me? And so, I don't mind absorbing that 10% to keep that relationship for the more complicated cases down the road. The other 90% I see in clinic number one, because the question usually is can you help this patient and not for a specific procedure. But the other reason for word for that is they're coming with the wrong diagnosis. I mean, I think the people who come to me with “pudendal neuralgia,” 50% of them have pudendal neuralgia and the other 50% have some other problem. And sometimes it's things that we can manage sometimes it's not, but you have to work that out in clinic and you have to listen to their story.
And at the risk of being a little bit preachy, I would encourage everybody to take care of these patients, even if it turns out that the solution to their problem is not interventional radiology. Because what happens to these folks is that they are abandoned by doctors who have a list of procedures that they do, or a list of options that they offer. And when that patient doesn't fit into one of those boxes, they just cut them loose. And so what that means for a person who's not connected medically to one of us on the inside is that now they're out in the world trying to figure out how to solve this complicated pain problem, and they just are lost.
And so in addition to all the things that we can do, technically we should take responsibility for these patients once they cross our paths and get them to the right place, because it's very difficult for them to do it themselves. So if it's not us, we can still advocate for them. We can still stay plugged into them and we can still make sure that they get taken care of. I can give an example of that if I'm not going on too long.
We had a patient who came in over Christmas. Two weeks before that had come into the ER with this intractable radiculopathy. Then we were asked actually at that time, during a very busy week, at the end of the year to do a transforaminal L5 injection for this patient. And they made it kind of into our machine and out, and we just did it right. They fell into that 10%. We got asked to do it by a neurosurgeon who's knowledgeable. We did it. And I didn't give that patient a second thought because there were so many other things going on.
Over Christmas then, patient comes back to the hospital with the same pain and the same problem. That particular day I was in the hospital but not on the clinical schedule. So I went to see this patient and I listened to this story about how she was showing up in the ER and getting this sort of very disconnected discussion and treatment and getting an injection or getting some Percosets and then discharged out into the world. And as it turned out, she had a disc herniation that was sitting on that L5 that must've been excruciatingly painful that wasn't responding to injections. And what she really needed was somebody to operate on that. But because nobody was really taking charge of her case and advocating for her, she just kept bouncing in and out of the ER, even with this ungrounded, sort of all this patient is here looking for a medicine or whatever. What she really needed was an advocate. She didn't need an interventional radiology procedure. She needed an advocate to get her into the right place and get the right procedure done. So I would encourage all of us to own that when it comes across our clinic schedule.
[Dr. Michael Barraza]:
Man, that's a great point. A lot of our listeners are trainees. And so I thought it would be worth going through the different procedures that we offer that kind of fall under the pain management umbrella. And so what I try to do is that I made a list and it's not comprehensive. And I should also mention that in interventional radiology, there's something new it seems like every month. And so this will still be obsolete in a few months. I'm gonna just go through a list and you tell me if I'm missing anything glaring.
(6) Pain Management Procedures
[Dr. Michael Barraza]:
I broke it down between the stuff that I'm doing and the stuff that I know of that I'm not doing yet. So in my practice, we're doing spinal ESI or doing median nerve branch block and RFA. We're doing the various types of vertebral augmentation for compression factors, we're doing ablation and sometimes submit to plasty for painful osseous metastasis. We're doing ablations for osteoma, various joint injections. Injecting for pudendal neuralgia, and various other nerve blocks. I'm not doing a lot of them, but I'm thinking of some examples, like my friend for example. He does nerve blocks on parts of the body that I don't even know where to find some of these nerves.
But we'll do celiac blocks, celiac neurolysis, and then I've recently started treating patients for piriformis syndrome and then just started doing pudendal cryoneurolysis. Other procedures I can think of, some of which came from your techniques article, basivertebral nerve ablation, percutaneous disc interventions, percutaneous spinus process augmentation, a percutaneous image guided lumbar decompression, which I hadn't heard about until the techniques issue, sphenopalatine blocks for migraines. So I've been really excited about embolizations for MSK conditions like genicular artery embolization and embolization for adhesive capsulitis. Anything else big that I missed?
[Dr. David Prologo]:
No, I think that you're right. It's always changing and we are always solving problems. Your friend is approaching it exactly the right way. We can oftentimes track back where the source of this pain is. And we can target it for an injection. Or we can take it a step farther and analyze the nerve that we identify as transmitting that pain. And then value it. Can we sacrifice this nerve completely as we can in the case of pudendal neuralgia, for example, or saphenous veins that carry a pretibial sensation and so on. Then of course we have mixed nerves. Like the L4 example I gave you. Can we sacrifice that nerve and a little bit of strength? In that case, it was a no brainer. Of course we can do that because she couldn't walk because of pain anyway. The obturator nerve is another good example of that carrying sensation from the hip. We can sacrifice that in a little bit of motor, but not completely. And then all the way to the other end of the spectrum, where we can purposely sacrifice motor by freezing a nerve and then ultimately get the patient to relief. So I know the question was are there other procedures, but let me expound on that a little bit more.
So, what has happened during the last, I would say five to seven years with the percutaneous cryoneurolysis procedures is the following. Early on, we thought that if we could use imaging guidance, target a nerve and freeze it, we're going to block the signal. For example, Michael, your pudendal neuralgia patients who get damage to that nerve during a traumatic childbirth or while they're bike riding of, so on. That nerve being damaged and irritated in and of itself is sending messages. And we thought early on that if you freeze this, you block the signal. That was the intuitive idea. But what we realize now is that if you do it correctly and expose that nerve to the right cold temperature for the right amount of time, you induce a Wallerian degeneration and that nerve is then followed by axonal regeneration along an intact connective tissue scaffold at a rate of about one to two millimeters per day. Now that's super exciting for a couple of reasons. The first reason is you can manage patient's expectations, right? If you do have to sacrifice motor, you can tell them that this is going to recover over X number of days given that calculation. Also, if you accidentally freeze a nerve…
[Dr. Michael Barraza]:
You've published on this.
[Dr. David Prologo]:
We did. And the reason we did that was because people were accidentally freezing these nerves, right? This wasn't even a deliberate thing. I would get calls, “Oh my gosh. I was doing a tumor in the acetabulum and clipped the femoral nerve. What do I do now?” And so what we realized over the years between basic science research done by us and done by this guy who's in California and our clinical cases, realize that with almost 100% certainty, this nerve is going to regenerate. So we were able to answer people's questions and I love to get those calls because people would call me in an absolute panic about some paralysis that their patient was having post-tumor ablation. So I was able to tell them, don't worry about it. Here's how long it's going to take to recover. You can accelerate that with PT.
But what I wanted to talk about now was that that application does save you in that situation, but it can be even more exciting if we think about the conditions like pudendal neuralgia or otherwise, when the nerve itself is damaged. If the nerve is damaged and you induce that degeneration and regeneration, what you've essentially offered this patient is a percutaneous neuro-regenerative therapy and they're cured, right? So you didn't just temporarily block the signal. Like we thought 10 years. You're inducing an axonal regeneration and a nerve regeneration, so that the patient has a pudendal nerve that wasn't present during that traumatic childbirth. And so they don't have that pain anymore. And you can go beyond there. I give an example of a patient who came to us, had a motorcycle accident like 10 years ago and had this irritated perennial neuropathy. Still had motor but had pain in that distribution. So we blocked, it got better. Came back. We did a radiofrequency ablation. It got better.
(7) Cryoneurolysis
[Dr. David Prologo]:
And so essentially we said, look, why don't we freeze this nerve? The whole thing would degenerate. You're going to have foot drop for six or eight months. And when a nerve regenerates, we think your pain will be gone and that's exactly what happened. And so, that application for percutaneous cryoneurolysis is super exciting and we may be able to help a lot of people with that.
[Dr. Michael Barraza]:
That's awesome. I think I want to start calling it percutaneous neuro-regeneration. That sounds great. I want to keep talking more about cryoneurolysis, but I do want to tell our listeners to check out from that TVIR interventional pain issue article that Dr. Prologo published on that. It was called Interventional Cryoneurolysis an Illustrative Approach. It really breaks it down and goes through a lot of this in detail. But it takes a good global look at this procedure. So David, can you walk me through patient and lesion selection for cryoneurolysis? How do you determine if a specific nerve or pattern of symptoms is likely to respond to this?
[Dr. David Prologo]:
Okay. So great question. So, we’ll go back to our global approach from a couple of minutes ago. First step being, is this a cancer patient or not? And then is this a spine lesion or not? And most of the time you're going to say the second part, is this a spine lesion or not usually the answer to that? It's going to be no. And that's going to leave you with two buckets, which are cancer related lesions outside of the spine, and then non neoplastic conditions outside of the spine. And so once we have the source of the patient's pain, you may have to go back to the internet or back to your medical school book to decide where exactly the nerve is and what is the composition of that nerve that is carrying the pain signal from the generator.
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.
[Dr. Michael Barraza]:
No, not at all. And I think it's really useful breaking it down between neoplastic and non-neoplastic conditions. I was going to ask what other regions you do this for? But I think the answer is probably very different between those two patient groups. And I would expect you could be a bit more aggressive with the neoplastic ones because in those patients if you ask them like, Hey, look, there's a real risk that you're going to have some motor deficits after that. Most of them would just say fine, just get rid of this pain.
[Dr. David Prologo]:
Right. Or they already have a motor deficit because if the nerve that we're talking about, again why I love this audience, because we can just say it the way it is. Right? Most of the time if it's a mixed composition nerve and they're coming to you with intractable pain that's involving that nerve, it's almost certainly already affecting the motor component. Or it is what you said. It's so painful that they're happy to sacrifice the motor component. And if they're going to live long enough to see that nerve regenerate, you can tell them “look with physical therapy this nerve is going to regenerate.” But a lot of the times that's not the case. They might not live long enough to see that regeneration, but they really do care. Again, it's not only the patient's pain, but they want to spend that time they have left interacting with their family. Not gorked on pain meds, right?
[Dr. Michael Barraza]:
Yeah. I told her a patient recently with an advanced endometrial cancer. I was like, “Hey, look, this might make you numb.” And she said, “that sounds awesome.” To her, that sound like a dream, like I don't care.
[Dr. David Prologo]:
Exactly. We have a patient just last week with this slow growing liposarcoma that is finally starting to invade the S1 nerve roots and the question for us was, and this is why you have to see these, I know everybody on the podcast probably says, this is why you have to see these patients and you have to work them up and you have to make sure you're doing the right thing. And if you can, spend time with them. This thing has been grown for years. I mean like eight years growing in the pelvis. But now it's growing into this S1 nerve system. So the question for us was, “Hey, can you ablate this mass?” And it was gonna be a big job. So ablate the mass and there's all kinds of bowel loops all over the place.
And the question really became, why is it bothering them now after all these years? And if you go through the scans, you see it's really that the S1 that's now being affected and that's where the patient was pointing. And so in that case, even though I just said with the neoplastic patients, we don't do this and that case, we blocked that S1 first and we talked to the patient. We said, “Look, if we block this S1 and you get better, then I think we ablate this S1, let the mass go. Cause it's been growing slowly for the last five to seven years or whatever, not bothering you. And so we can take out that S1 and you’re going to get a little bit of weakness on that side.” But he said the same thing to your point.
That reason that I came on this show, because I enjoy your company, number one. But also, I came on because that patient found us, but almost serendipitously once again, right? So we've got to find a way, and maybe this is my job as the clinical specialty council chair, to get this message out to the general public and activate our army all the way across the country in the world to help these patients.
[Dr. Michael Barraza]:
Yeah. I gave grand rounds at a new hospital. We started covering a women's hospital and just kind of what we do. And it amazed me at how little that the audience knew about what we do. And actually the consults started pouring in after that because a lot of people don't know that we offer really anything for pain. So it's important for the patients to know, but the doctors too.
[Dr. David Prologo]:
Right. And even now they don't comprehend them. Go back to this S1 patient. I am always amazed at how that disconnect exists. I guess it's because everyone's so busy and we're so busy and we don't have time to talk to every person in the universe and we don't go straight to the public and so on. There's a lot of reasons for it. But this S1 thing that we just went through liposarcoma complicated approach, we thought it through, we looked at the images, we blocked this one while prepping this patient back for a cryo. And I always love to go read the notes shortly after that. And it'll say something like “IR did block. Patient doing well.” That's sort of grossly oversimplify all the work and the technology that goes into the case. But you're the person to help us get the word out. You're doing the job right now that can help us solve that problem. So thank you.
[Dr. Michael Barraza]:
We're certainly trying. But I think one of the other challenges is that unlike something like, let's say like a ear nose and throat physician, they have a very circumscribed area that they're treating. We are treating the entire body and with extraordinary array of different things that we offer. It's very easy for things to get lost in that. People are used to sending us XYZ, they forget that we also do ABC. There are just so many things out there that we do, and not everyone does the whole array of those procedures. And I think all of that kind of feeds into the lack of understanding about what we may be able to offer.
[Dr. David Prologo]:
And the demand is there. It's an existing demand. I have a startup company that's developing a cryoneurolysis probe. And we talked to investors and we sort of go through that whole process. And what we'd find again and again, is the investors will come back to us with a device that you've developed to solve an existing or to meet an existing demand, which is unusual.
They’re used to seeing people invent devices and then try to find some role for them, some application for them. But the demand for interventional radiology and the management of pain, cryoneurolysis or not, it's already in place. People are already calling and saying, “How do I do this?” You are seeing it. You're seeing that the demand. The problem is there, if we can figure out a way to get to them.
(8) Setting Patient Expectations for Cryoneurolysis
[Dr. Michael Barraza]:
Sure. So I know it's going to vary a lot based on what part of the body you're treating, what the indication is and everything. But I'm curious how you set expectations with the patient. What do you tell them in terms of duration of pain, relief, and degree of pain relief?
[Dr. David Prologo]:
Normally what I will tell them. Patients who have had pain are going to fall into, I think, one of three outcomes. And the first one is it's going to be a home run and you're going to feel better tomorrow and you're going to be on your way. And these are your patients who come in with acute fractures related to neoplasm, right? And you bring them in radiofrequency, ablations. The next day, they're singing your praises and they go home, right? There's home runs like that. Then there's this middle bucket. And I think this is the soft tissue and osseous metastatic disease patients where you might do an ablation and they're going to have procedure related pain. And also what I call kind of this hornet's nest effects, where they've got something that's painful and you put a bunch of needles into it and exacerbated it somehow. And so they're going to have 48 hours of maybe even worsened pain. And then after that, they're going to do better because you've addressed their pain generator and you kind of went to war with it and it is, but it was ugly. But you won and then they're going to do better in the long run.
And then you've got this third group of patients who are going to have a delay. These are the responders, by the way. And this third group of patients are going to have a delayed response. And you see that a lot of times with the cryoneurolysis cases, because the first 28 days following a cryoneurolysis you've got this acute infiltration of inflammatory cells and the induction of that Wallerian degeneration. But until that time, the patient can have exacerbation of their pain. They can have new pain. But even then the Wallerian degeneration and regeneration wins out. And so they end up doing better, but it's at the three month mark or the six month mark. So that's how I divide up. If you respond, this is what I think is going to happen, one of these three things for you.
And then of course there are non-responders. That really comes down to patient selection. I think we can minimize our non-responders by doing logical things. Doing test blocks, understanding our technology and the process that goes along with the pain, understanding central sensitization. I think our non-responders can be minimized.
[Dr. Michael Barraza]:
Totally. I want to ask you just a little bit about a specific area: pudendal nerve cryoneurolysis. I learned from a couple of excellent studies that you published on this procedure that for any listeners out there I'm happy to share. We're trying to put together some of our references that we used when we release these podcasts and that'll be included in there. So I just wanted to ask you, just using this as an example, how do you work a patient up for this procedure and determine if they're a candidate?
[Dr. David Prologo]:
Sure. That’s a good question. Because as I mentioned, a lot of these patients who think they have pudendal neuralgia don't and so the first thing you want to do is talk to them about the distribution of their pain. And there are diagnostic criteria for pudendal neuralgia, the Nantes criteria. We can apply them and we can ask them if they have the right distribution of pain. Did they have an antecedent even? But at the end of the day, it comes down to the block. And again, to sing the praises of interventional radiology and be thankful for our position in life, we have CT guidance, right? So we do an injection in Alcock’s canal and you slide a 22 gauge needle underneath that obturator internus fascia, blow it up like a balloon, get an image of it blown up by your bupivacaine. Because at that point you have shut down the pudendal nerve. And if the patient doesn't get better, they don't have pudendal neuralgia. This is a critical crossroads for a lot of patients. I've had patients come to me for 10 years. This is what they'll tell me “For 10 years, I've had pudendal neuralgia. Can you help me?” And they're just convinced. I mean, I don't know how it happens. Somebody told them and they research it. They're seeking help for pudendal neuralgia. And so I explained to them that, look, maybe you don't have pudendal neuralgia. Let's sort that out first, because if you don't, you can drop this whole pursuit and we can start to think about what exactly you do have, why you would have pain. We can paint the cause into a corner and we can get to a solution. So what I tell the patients is I'm going to get you somewhere now that you've come to me, we're going to do something different. The very first step we take is going to be a critical crossroads for you. Because if you don't respond to this injection, then we're going down a different path and you're never going to talk about pudendal neuralgia again. And this is very unsettling for them, right? And if you do respond to this injection, I'm going to cure you of it. Right. And you can get them really to take this big step. So the injection is absolutely critical and key.
And you can say “I know you’ve had injections in the past, but unless they were done under CT guidance, you have to consider the possibility that that injection didn't go where they wanted it to go. If you had an injection done with landmark guidance, transvaginal guidance, or even fluoroscopic guidance, and you had some equivocal response, you have to consider the fact that they might've missed. With CT, I'm going to have an image that tells me with a hundred percent certainty that I didn't miss. So if you don't respond, then you don't have your pudendal neuralgia and we're going to help you.”
[Dr. Michael Barraza]:
I use that same approach with, with ESI, for example. If I do it ESI, which uses fluoro guidance. We do an ESI twice and it doesn't work, then we're done. It's like we have to find something else. We're barking up the wrong tree.
[Dr. David Prologo]:
Right. We have to move on. I work at an academic center where I can say the following as well. This is another speech that I give the patients. “I'm not getting paid by procedure. I'm a salaried guy. So I don't have any motivation to hook you in and do procedures for the rest of my life. What I want to do is find the one that's going to help you.” So to your point, if you're not responding to that, maybe it's something else. Maybe it's axial pain from facet hypertrophy, right? It could be degenerative disc disease, et cetera. Maybe you need surgery, whatever. It becomes a game for us to solve this problem and get the patient taken care of.
But back to the pudendal patients. So for patients who don't respond, the next step for me is MRN. So we do magnetic resonance neurography in part because we are looking for a target, right? If we see something abnormal on there, that means we can most certainly target it with some image guidance and maybe take care of the patient there. The other reason is we get a look at everything else. And maybe there's pelvic venous congestion syndrome. Many times we pick that up and we go back and talk to the patient again. “Is this worse for you in the evening after you're standing up all day?” “Yes, yes.” And so we make some diagnostic maneuvers that way, by going to MRN. If the MRN comes up negative, then we have to start to consider the patient's symptoms in the setting that we talked about the saphenous nerve example. Where's this pain that didn't respond to a pudendal nerve? How is that possible? There's nothing else on the MRN. What other nerve can be supplying this? If the answer is none, then you've now sort of stumbled onto another big principle for us as interventional radiologists, especially if we're going to target nerves. And that is that if you can't find a sniper one-to-one solution, start to back off and start to look at autonomic targets.
You know this from doing celiac plexus in the abdomen. People who have isolated rectal pain, for example, you are not likely to find a sniper one-to-one solution to that because there's such redundant supply to the rectum. So you back up and you start to think about inferior hypogastric plexus, superior hypogastric plexus as targets for patients that have persistent pain that you haven't found a one-to-one response to.
And so that's the next step after negative MRN, no clear one-to-one response. Start going after the autonomic targets like the superior hypogastric plexus and inferior epigastric plexus and so on. Or look for vascular causes. And so on the pudendal side, when what I call a response and what I tell our trainees and anyone who asks me: if you can do the CT guided injection without sedation, which most of the time you can, then when you talk to the patient afterwards, or specifically the next day, their response should not be ambiguous. A positive response is not subtle. A positive response is, “Oh my God. I've had pain there for 10 years. And yesterday I went out to dinner because my pain was gone. And then at 10 o'clock it came raging back.” Because your bupivacaine wore off. That's a positive response. If they give you a non-ambiguous, non-subtle description to the injection, that's the patient who's going to do great from a cryo.
[Dr. Michael Barraza]:
But obviously, that the immediate response for a cryoneurolysis is different. And when I read your articles to learn how to do this procedure, you had mentioned that for at least for pudendals you were keeping the patients in house for the first night. Are you still doing that?
[Dr. David Prologo]:
No. And the other thing that's different from those early articles is our target. And that's super important. I've done hundreds and hundreds of these now and haven't written them up and we really need to do that. And I apologize to the audience for that, but what we need to know right now before that's done is that the targets, early on, we were trying to go really far distal and we described this distal target. And the reason for that was there was an inferior rectal branch from the pudendal nerve. We didn't want to cause incontinence, right. But as I mentioned a few minutes ago, there's such redundant supply to the rectum and anus that you can smoke both of those inferior rectal nerves and you're not going to cause incontinence and you certainly are not going to cause urinary incontinence. And so we've moved proximal and the proximal portion of the pudendal nerve and the pudendal canal. You can follow the pudendal artery, you can see exactly where it enters into that canal. We go in there and target it, so essentially that's the middle of the pudendal nerve.
And you'll see this antegrade degeneration like we talked about earlier, but there's also retrograde degeneration to the closest cell body. And that's actually where the regeneration will start again. So the target now is put the probe in the ischiorectal fat, don't stab the nerve cause we don't want to cause any mechanical damage, and put it adjacent to the obturator internus muscle where the pudendal nerve and artery come into that canal together. So that's our target. And our time right now is an eight minute, a 100% freeze followed by a three-minute passive thaw. Which is going to segue into another thing. So we'll come back to that. Followed by a three-minute, a hundred percent active thaw. And then a passive thaw.
So that's going to segue into two things. The first one is it's a passive thaw because the mechanism of action here is not an osmotic gradient shift induction. That's what we do to kill cancer. What we're doing here is trying to induce that specific nerve injury that we talked about earlier. It's called a Sunderland 2 injury so that we can induce neurodegeneration. We can manage the patient's expectations that time course and passive haw is the best we can come up with so far with current available technology to induce that Sunderland 2.
That's based on the nerve composition and nerve size. And so those times get longer for bigger nerves and they get shorter for smaller nerves just a little bit. So that's the first thing I wanted to say. The mechanism of injury is different, so no need for an act of thaw. And then that's what our startup is developing. The startup’s called FocusCryo we're developing the device that will take these calculations out of the operator's hand. Because what we need to know is what is the actual in vivo temperature during this ablation and how long is that temperature present? How long has that nerve exposed to that temperature? And then we need that feedback so that you can just put the probe in there and the machine will tell you when it's done instead of us doing this guesswork. But until we have that in your hands, Michael, 8333 for the pudendal nerve.
(9) Cryoneurolysis Evaluation and Follow Up
[Dr. Michael Barraza]:
8333. I've got two of these next week. I'm going to write that down. My last question about this is, and for all cryoneurolysis procedures, when do you evaluate the patient and clinic and follow up? Like when do you bring them back and how frequently?
[Dr. David Prologo]:
We talk to them the next day and then we bring them back in about a month. And the reason for that is we don't want to get too far into the weeds. The third day, fourth day, fifth day, and try to interpret what response that might be, because it could be in any one of those three buckets. But at the one month mark is when we usually see them back in clinic. And over the years, what happened was these patients just weren't coming back. Because the question was when you do a cryo, you're going to have to repeat this, et cetera, et cetera. And until we figured out this neuro-regeneration mechanism, the answer was, I don't know.
And so we'd follow them for a while. But what we realized over the years was these patients aren't coming back because they're better. So we see them at one month and then we cut them loose. And that's what I tell him in the original clinic visit that. That's my hope. That's what I want to do for you. I want to put an end to this pain and saga for you.
[Dr. Michael Barraza]:
All right. Well, look, I think that gives us a fantastic overview of advanced pain interventions for the interventional radiologists. Before we sign off, just a couple more things. I'm curious if you have any advice that you could share for any listeners out there who are interested in growing this element of their practice, or even starting it from scratch.
(10) Advice for Growing Your Pain Practice
[Dr. David Prologo]:
Sure. Absolutely. I have a whole talk actually that I give on exactly this topic. So I'll try to hit the high points. First and foremost, be there for the inpatients. We talked a little bit about that earlier. You’re already there. The inpatients need you. And this is the first place where you can show the referrers what you can do, and the administration, that's number one.
Number two is the 20983, which is the code that we use for soft tissue and osseous ablations. You're already there in the tumor boards and you already have a relationship or you will have an obligatory relationship with the oncologist. And so you just have to let them know we're here for your intractable pain patients. Which brings me to number three. The way you present that to oncology and non-oncology is don't try to figure out what we can do. If you've got a patient who's got pain, send them to us and we'll take care of it. Because like we said before, if it is us great, if it's not us, then we're going to get them to the right place.
But in the so-called real world where people are working, these referrers are busy. And so if they've got a patient that's got a problem and you can you say to them, look, I'll take care of this for you. And they love it. Great, boom. They're onto the next patient. And that way you don't have to try to educate them about every little thing that we can do and then go to the APPs and the= nurse navigator, seek them out, find them, let them know the same exact thing. Look, we're here. Keep us in mind. If Mrs. Smith is on the floor with intractable femoral neuropathy, we may be able to help. Keep us in mind.
And then what I think is the holy grail for our specialty / subspecialty: go to the public, find your media liaison and tell them that you want to go to the public. You want to go on the news. You want to go on the BackTable Podcast. You want to go wherever it may be to tell your story to the public. Because when the public hears about it, they start asking the referrers and then the referrers looking for you. So those are the places where I would start.
Another thing that I say in that talk is that if you have a good outcome, try to capitalize on it because that's what everyone else does everywhere else in the world for everything else. If you have something and it's great, and you own a vacation resort and some influencer stays there and has a great time, you try to capitalize on that, right? And the reason is you have something great and you want more people to know about it. So if you take care of somebody who may be an influencer or maybe a so-called VIP, or even if you just have a great outcome, try to capitalize on that and let people know that you can do these things.
[Dr. Michael Barraza]:
That's fantastic advice. And again, thank you so much for joining us on here. Just want to remind our listeners, check out that TVIR issue. Another thing that you brought up, there's a great article in there about coding for pain interventions, which obviously is important for somebody to start this off.
Guys, be on the lookout for the book The Catching Point Transformation. And I look forward to seeing that seminars issue as well, between seminars and TVIR. You got the high points hit. thanks again for everybody for listening and we'll catch you on the next one.
Podcast Contributors
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.
Cite This Podcast
BackTable, LLC (Producer). (2022, April 11). Ep. 199 – Advanced Minimally Invasive Pain Interventions [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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