S desai mr guided focused ultrasound surgery in pain managementt jfim mumbai 2016

MR GUIDED FOCUSED ULTRASOUND SURGERY IN PAIN MANAGEMENT

DR SHRINIVAS B DESAI

DR RITU K KASHIKAR

JASLOK HOSPITAL AND RESEARCH CENTER

MUMBAI

JFIM 15E EDITION NOV 3RD TO 6TH 2016

MRGFUS What is MRgFUS?

ExAblate 2000

Clinical Applications

Clinical Research

Clinical Partners

About InSightec

Uterine Fibroids

MR guidedMR guidedF ocus edF ocus edUltras oundUltras oundS urgeryS urgery

Offeryourpatients c uttingedgetec hnology

… … … .withoutthec uttingOffers cutting edge technology without cutting

MRGFUS •  Breakthrough technology that

combines

A)  High intensity focused ultrasound beam that heats and destroys targeted tissue non invasively

B)  MRI that visualizes patient anatomy and controls treatment by monitoring tissue effect in real time

What is MRgFUS?

ExAblate 2000


Clinical Research

Clinical Partners

About InSightec

Uterine Fibroids

How does Focused Ultrasound work?

Focused ultrasound generates heat, ablating tissue only at the focal point. The effect is similar to a magnifying glass used to focus the sun’s energy on a single point.

1x2mm

10x30mm

WaterBath

FocusedUltrasound

Beam

Tumor

T ransducer

Spot sizes

Perpendiculartobeam

Paralleltobeam

Treatment illustration

What is MRgFUS?

How does MRgFUS work

What is MRgFUS?

ExAblate 2000


Clinical Research

Clinical Partners

About InSightec

Uterine Fibroids

Why is MR guidance and control important?

3D anatomic information for exact tumor targeting

Beam path visualization for safe treatment

Real time MR thermometry to achieve planned outcome

Post treatment contrast imaging for evaluating treatment outcome

C L OS E DL OOP

THE RAPY

C L OS E DL OOP

THE RAPY=

What is MRgFUS?

What is MRgFUS?

ExAblate 2000


Clinical Research

Clinical Partners

About InSightec

Uterine Fibroids

3D anatomic views for planning treatment region

Coronal Axial Sagittal

What is MRgFUS?

What is MRgFUS?

ExAblate 2000


Clinical Research

Clinical Partners

About InSightec

Uterine Fibroids

3D beam path visualization

Surgical Clips Scars BowelSciatic Nerve

Position transducer to avoid complications:

What is MRgFUS?

Real time thermometry

Click once to view

Temperature buildup during 10 second sonication (3 second intervals)

Too cold

Too hot

100.2[C}

57.8[C]

Parameters changed based on thermal feedback

Real time MR thermometry and tissue ablation

MR thermometry demonstrates clear correlation with tissue ablation and sharp edges of sonication

Thermal dose threshold (above 240 minutes at 43° C)

Pathology of same sonication

Temperature map of a sonication

3

1 2 3

1 2

1 2 3

2 Temperature rise at margin

3 Temperature rise in untreated area, 7mm from center

1 Temperature rise at center of sonication spot

PHYSIOLOGY OF THERMAL THERAPY

Coagulated regions seen in macro pathology image

Histology analysis shows a sharp demarcation between treated and non treated regions

0.1 mm

CHRONIC LOW BACKACHE

•  Chronic Low Back pain is defined as pain exceeding 3 months duration

•  Low back pain or lumbago one of the commonest causes of disability and work days lost – major socioecomonic problem

•  Mechanical problems including disc disease and facetal arthopathy account for approx 98 %

•  25 % of pts receiving current standard primary care remain symptomatic

FocusedUltrasoundSymposium2102,WashingtonDC,USA

FACET JOINT ANATOMY

•  Facet joint = Zygoapophysial joint. •  Synovial joint •  Located between the superior

articular process of one vertebra and the inferior articular process of upper vertebra


FACET JOINT ARTHROPATHY

• Richinnerva+onfrommedialandlateralbranchesofdorsalramiandmedialbranchesofposteriorrami.• Degenera+onoftheFacetjointandresultantirrita+onoftheNervePlexus.

FACET JOINT ARTHROPATHY

GRADING OF DEGENERATIVE FACET JOINTS: (Gorbach et al)

0- Normal Facet joint ( 2-4 mm).

1- Narrowing of the joint < 2mm, mild osteophytes, mild hypertrophy of the articular process,

2- Moderate osteophytes, moderate hypertrophy of the articular process or mild subarticular erosions.

3- Large osteophytes, severe hypertrophy of the articular process and severe subarticular erosions.


FACET JOINT PAIN DIAGNOSIS

MBB(NERVEBLOCK)

Inj. Kanacort (40 mg), 0.5% Bupivacaine and 1% Lidocaine in 1:2:2 ratio. If the block reduces the pain by 50% , the test is considered as positive.


LUMBAR FACETAL ARTHROPATHY TREATMENT OPTIONS

INTRA-ARTICULARSTEROIDS THERMALABLATION

WITHMRgFUS

SURGICALORRADIOFREQUENCYABLATION


§  Patient population:

Ø  25 Patients in the age group 40 to 80 yrs ( Mean Age 58.6 yrs)

Ø  19 Male patients and 6 Female patients. §  10 patients underwent diagnostic injection of facet joints with a

combination of local anaesthetic and steroid injection ( Inj. Kanacort (40 mg), 1 % Lidocaine and 0.5% Bupivacaine in 1:2:2 ratio).

§  Remaining patients were included in the study on basis of the MRI features, Numerical rate scale scores(NRS) and Oswestry Disability Index (ODI).


INCLUSION CRITERIA

- Age > 40 years. -  LBP due to facetal arthropathy by

-  Low backache without significant Radiculopathy. -  MRI - Facet joint arthropathy without significant spinal canal or neural

foraminal stenosis. -  Diagnostic facet jt. injection with L.A. & steroid injection causing significant

pain reduction

- Numerical rate score (NRS) > 5. - Oswestry Disability Index(ODI) > 50%.


EXCLUSION CRITERIA

- Spinal canal stenosis

- Lumbar Radiculopathy

- Contraindications for MRI or contrast


Number of patients treated: 25 Average Numerical rate scale (NRS) score before treatment: 9 Average Numerical rate scale (NRS) score after treatment: 4 Facet joints treated: L3-L4, L4-L5, L5-S1. Number of Facet joints treated: 150 Average number of sonications: 20-25 Average duration of treatment: 1- 1.5 hrs.

TREATMENT DETAILS


TECHNICAL PARAMETERS Frequency- 0.95-2.0 MHZ Energy- 500- 700 joules Sonication duration- 20 sec Focal spots- VERTICAL AND HORIZONTAL 25mm flat, 45mm dome shaped gel pads and Waterbags. IMAGING PLANES- AXIAL SAGITTAL


TREATMENT SETUP

• MRI SUITE: GE 1.5 TESLA HDXT with EXBLATE 2000. • POSITION: FEET FIRST , SUPINE. • ANESTHESIA: MILD CONSCIOUS SEDATION (1-2 mg Midazolam and 25-50 microgram Fentanyl).


SONICATION

IMMEDIATE POST TREATMENT EVALUATION

POST TREATMENT SUBSTRACTION IMAGES


NUMERICAL RATE SCALE (NRS)SCORE

JASLOKHOSPITAL,MUMBAI

OSWESTRY DISABILITY INDEX (ODI)

JASLOKHOSPITAL,MUMBAI

BRIEF PAIN INVENTORY(BPI)

JASLOK HOSPITAL, MUMBAI

DISCUSSION Safe and effective procedure and no adverse side effects or complications were encountered.

Can be performed on out patient basis and is done with thermal monitoring. Patient selection is important.

Results comparable to Radiofrequency ablation and other techniques. Larger case study and longer follow-up will help to prove long term efficacy.

JASLOK HOSPITAL, MUMBAI FocusedUltrasoundSymposium2102,WashingtonDC,USA

MRGFUS IN FACETAL ARTHROPATHY

MRI-guided focused ultrasound (MRgFUS) to treat facet joint osteoarthritis low back pain--case series of an innovative new technique. Eighteen patients were treated. There were no major adverse events. At 6/12 we found a reduction in both the NRS (average/worst) pain scores (60.2 %/51.2 %). This was associated with 45.9 % improvement in the ODQ score and 61.9 % reduction in the BPI interference score. We observed an improvement in the EuroQol (EQ-5D) health state score based on UK coefficients of +0.379 (0.317 to 0.696).

Weeks EM, Platt MW, Gedroyc W Eur Radiol. 2012 Dec;22(12):2822-35. doi: 10.1007/s00330-012-2628-6. Epub 2012 Aug 31

MRGFUS VS RHIZOTOMY As a noninvasive form of facet rhizotomy, focused ultrasound may offer benefits including:

•  no needles (anticoagulation thus not an issue)

•  no ionizing radiation

•  can treat several affected facet joints in one session

•  real-time anatomic and thermal monitoring, which reduces the risk for complications

•  shorter recovery time.

NumberofbonemetastasistreatmentsdoneatJaslokhospitalandresearchcentre:9Averagedura+onoftreatment:1-2hoursAveragenumberofsonica+ons:15-25Be[erthanradiotherapy1daytreatment

BONEMETASTASIS

CASES 74 YEAR OLD/ MALE PATIENT K/C/O CA LUNG WITH LEFT ILIAL METASTASIS PAIN IN PELVIC REGION LEFT SIDE SINCE 6 MONTHS NRS PAIN SCORE BEFORE TREATMENT: 7 NUMBER OF SONICATIONS: FIRST SESSION: 26 DURATION : 1.4 HOURS SECOND SESSION: 29 DURATION: 1.5 HOURS NRS PAIN SCORE AFTER TREATMENT: 2

PRETREATMENTPOSTCONTRASTT1WEIGHTEDIMAGE.

POST TREATMENT POST CONTRAST T1 WEIGHTED IMAGE.

JASLOKHOSPITAL,INDIA

PRETREATMENTPOSTCONTRASTT1WEIGHTEDIMAGE

POST TREATMENT POST CONTRAST T1 WEIGHTED IMAGE

NRS SCORE BEFORE MRGFUS

NRS 5 DAYS AFTER MRGFUS

PAIN PALLIATION IN PATIENTS WITH BONE METASTASES USING MAGNETIC RESONANCE-GUIDED FOCUSED ULTRASOUND

A total of six painful metastatic bone lesions in five patients were treated using MRgFUS with the ExAblate Conformal Bone System for pain palliation. The follow-up sessions were at 3 days, 2 weeks, 1, 2, and 3 months, and 1 year after treatment. Efficacy was evaluated by the changes in visual analog scale (VAS) scores.

MRgFUS was demonstrated to be effective palliative treatment within 2 weeks in selected patients with painful bone metastases.

Yonsei Med J. 2015 Mar 1; 56(2): 503–509.

MRGFUS OF OSTEOID OSTEOMA

PRE TREATMENT

POST TREATMENT

MRGFUS IN OSTEOARTHRITIC KNEE PAIN

•  Sonication area -as the bone surface just below the rim osteophyte of medial tibia plateau, which is the insertion site of deep medial collateral ligament

•  The ultrasound beam angled to avoid popliteal neurovascular bundles.

Arrow heads in MRI indicate low intensity curved line at the sonication site. Arrows in X-p indicate osteosclerotic change in accordance with the line in MRI.

MR-GUIDED FOCUSED ULTRASOUND FOR THE NOVEL AND INNOVATIVE MANAGEMENT OF OSTEOARTHRITIC KNEE PAIN

These initial results illustrate the safety and efficacy of the newly developing MRgFUS treatment. Significant increase of PPTs on treated area showed successful denervation effect on the nociceptive nerve terminals. MRgFUS is a promising and innovative procedure for noninvasive pain management of knee

BMC Musculoskelet Disord. 2013; 14: 267A.

PATHOLOGY TOTAL NUMBER

UTERINE FIBROID 1005

ADENOMYOSIS 92

FACETAL ARTHROPATHY

25

BONE METASTASIS

9

OTHER BONE TUMOURS

1

PROSTATE CANCER 7

MRgFUS EXPERIENCE AT JASLOK HOSPITAL AND RESEARCH CENTER,MUMBAI

S desai mr guided focused ultrasound surgery in pain managementt jfim mumbai 2016

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