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Taninokuchi Tomassoni M, Braccischi L, Russo M, Adduci F, Calautti D, Girolami M, Vita F, Ruffilli A, Manzetti M, Ponti F, Matcuk GR, Mosconi C, Cirillo L, Miceli M, Spinnato P. Image-Guided Minimally Invasive Treatment Options for Degenerative Lumbar Spine Disease: A Practical Overview of Current Possibilities. Diagnostics (Basel) 2024; 14:1147. [PMID: 38893672 PMCID: PMC11171713 DOI: 10.3390/diagnostics14111147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden.
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Affiliation(s)
- Makoto Taninokuchi Tomassoni
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Radiology Department, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi, 40138 Bologna, Italy
| | - Lorenzo Braccischi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Radiology Department, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi, 40138 Bologna, Italy
| | - Mattia Russo
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Francesco Adduci
- Neuroradiology, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Davide Calautti
- Neuroradiology, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Marco Girolami
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Fabio Vita
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Alberto Ruffilli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Marco Manzetti
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Federico Ponti
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - George R. Matcuk
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Cristina Mosconi
- Radiology Department, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi, 40138 Bologna, Italy
| | - Luigi Cirillo
- Neuroradiology, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Gofeld M, Tiennot T, Miller E, Rebhun N, Mobley S, Leblang S, Aginsky R, Hananel A, Aubry JF. Fluoroscopy-guided high-intensity focused ultrasound ablation of the lumbar medial branch nerves: dose escalation study and comparison with radiofrequency ablation in a porcine model. Reg Anesth Pain Med 2024:rapm-2024-105417. [PMID: 38508592 DOI: 10.1136/rapm-2024-105417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Radiofrequency ablation (RFA) is a common method for alleviating chronic back pain by targeting and ablating of facet joint sensory nerves. High-intensity focused ultrasound (HIFU) is an emerging, non-invasive, image-guided technology capable of providing thermal tissue ablation. While HIFU shows promise as a potentially superior option for ablating sensory nerves, its efficacy needs validation and comparison with existing methods. METHODS Nine adult pigs underwent fluoroscopy-guided HIFU ablation of eight lumbar medial branch nerves, with varying acoustic energy levels: 1000 (N=3), 1500 (N=3), or 2000 (N=3) joules (J). An additional three animals underwent standard RFA (two 90 s long lesions at 80°C) of the same eight nerves. Following 2 days of neurobehavioral observation, all 12 animals were sacrificed. The targeted tissue was excised and subjected to macropathology and micropathology, with a primary focus on the medial branch nerves. RESULTS The percentage of ablated nerves with HIFU was 71%, 86%, and 96% for 1000 J, 1500 J, and 2000 J, respectively. In contrast, RFA achieved a 50% ablation rate. No significant adverse events occurred during the procedure or follow-up period. CONCLUSIONS These findings suggest that HIFU may be more effective than RFA in inducing thermal necrosis of the nerve.
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Affiliation(s)
| | | | | | | | | | - Suzanne Leblang
- Focused Ultrasound Foundation, Charlottesville, Virginia, USA
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Xu R, Treeby BE, Martin E. Safety Review of Therapeutic Ultrasound for Spinal Cord Neuromodulation and Blood-Spinal Cord Barrier Opening. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:317-331. [PMID: 38182491 DOI: 10.1016/j.ultrasmedbio.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 01/07/2024]
Abstract
New focused ultrasound spinal cord applications have emerged, particularly those improving therapeutic agent delivery to the spinal cord via blood-spinal cord barrier opening and the neuromodulation of spinal cord tracts. One hurdle in the development of these applications is safety. It may be possible to use safety trends from seminal and subsequent works in focused ultrasound to guide the development of safety guidelines for spinal cord applications. We collated data from decades of pre-clinical studies and illustrate a clear relationship between damage, time-averaged spatial peak intensity and exposure duration. This relationship suggests a thermal mechanism underlies ultrasound-induced spinal cord damage. We developed minimum and mean thresholds for damage from these pre-clinical studies. When these thresholds were plotted against the parameters used in recent pre-clinical ultrasonic spinal cord neuromodulation studies, the majority of the neuromodulation studies were near or above the minimum threshold. This suggests that a thermal neuromodulatory effect may exist for ultrasonic spinal cord neuromodulation, and that the thermal dose must be carefully controlled to avoid damage to the spinal cord. By contrast, the intensity-exposure duration threshold had no predictive value when applied to blood-spinal cord barrier opening studies that employed injected contrast agents. Most blood-spinal cord barrier opening studies observed slight to severe damage, except for small animal studies that employed an active feedback control method to limit pressures based on measured bubble oscillation behavior. The development of new focused ultrasound spinal cord applications perhaps reflects the recent success in the development of focused ultrasound brain applications, and recent work has begun on the translation of these technologies from brain to spinal cord. However, a great deal of work remains to be done, particularly with respect to developing and accepting safety standards for these applications.
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Affiliation(s)
- Rui Xu
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - Bradley E Treeby
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Eleanor Martin
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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Bao SC, Li F, Xiao Y, Niu L, Zheng H. Peripheral focused ultrasound stimulation and its applications: From therapeutics to human-computer interaction. Front Neurosci 2023; 17:1115946. [PMID: 37123351 PMCID: PMC10140332 DOI: 10.3389/fnins.2023.1115946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/24/2023] [Indexed: 05/02/2023] Open
Abstract
Peripheral focused ultrasound stimulation (pFUS) has gained increasing attention in the past few decades, because it can be delivered to peripheral nerves, neural endings, or sub-organs. With different stimulation parameters, ultrasound stimulation could induce different modulation effects. Depending on the transmission medium, pFUS can be classified as body-coupled US stimulation, commonly used for therapeutics or neuromodulation, or as an air-coupled contactless US haptic system, which provides sensory inputs and allows distinct human-computer interaction paradigms. Despite growing interest in pFUS, the underlying working mechanisms remain only partially understood, and many applications are still in their infancy. This review focused on existing applications, working mechanisms, the latest progress, and future directions of pFUS. In terms of therapeutics, large-sample randomized clinical trials in humans are needed to translate these state of art techniques into treatments for specific diseases. The airborne US for human-computer interaction is still in its preliminary stage, but further efforts in task-oriented US applications might provide a promising interaction tool soon.
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Affiliation(s)
- Shi-Chun Bao
- National Innovation Center for Advanced Medical Devices, Shenzhen, China
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Fei Li
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Yang Xiao
- National Innovation Center for Advanced Medical Devices, Shenzhen, China
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lili Niu
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hairong Zheng
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- *Correspondence: Hairong Zheng,
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Perez J, Gofeld M, Leblang S, Hananel A, Aginsky R, Chen J, Aubry JF, Shir Y. Fluoroscopy-Guided High-Intensity Focused Ultrasound Neurotomy of the Lumbar Zygapophyseal Joints: A Clinical Pilot Study. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:67-75. [PMID: 34534337 PMCID: PMC8723143 DOI: 10.1093/pm/pnab275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 08/25/2021] [Accepted: 09/13/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the safety and feasibility of a fluoroscopy-guided, high-intensity focused ultrasound system for zygapophyseal joint denervation as a treatment for chronic low back pain. METHODS The clinical pilot study was performed on 10 participants diagnosed with lumbar zygapophyseal joint syndrome. Each participant had a documented positive response to a diagnostic block or a previous, clinically beneficial radiofrequency ablation. For a descriptive study, the primary outcome was the safety question. All device- or procedure-related adverse events were collected. Secondary outcome variables included the average numeric rating scale for pain, the Roland-Morris Disability Questionnaire, the Brief Pain Inventory, the Patient Global Impression of Change, the morphine equivalent dose, and the finding of the neurological examination. RESULTS All participants tolerated the procedure well with no significant device- or procedure-related adverse events; there was one episode of transient pain during the procedure. The average numeric rating scale score for pain decreased from 6.2 at baseline to 2.1 (n = 10) after 1 month, 4.9 (n = 9) after 3 months, 3.0 (n = 8) after 6 months, and 3.0 (n = 6) after 12 months. The ratio of participants who were considered a treatment success was 90% at 1 month, 50% at 3 months, 60% at 6 months, and 40% at 12 months. CONCLUSIONS The first clinical pilot study using a noninvasive, fluoroscopy-guided, high-intensity focused ultrasound lumbar zygapophyseal neurotomy resulted in no significant device- or procedure-related adverse events and achieved clinical success comparable with that of routine radiofrequency ablation.
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Affiliation(s)
| | | | - Suzanne Leblang
- Focused Ultrasound Foundation, Charlottesville, Virginia, USA
| | | | | | - Johnny Chen
- Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Jean-Francois Aubry
- Physics for Medicine Paris, Inserm, ESPCI Paris, CNRS, PSL Research University, Paris, France
| | - Yoram Shir
- McGill University, Montreal, Quebec, Canada
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Bucknor MD, Baal JD, McGill KC, Infosino A, Link TM. Musculoskeletal Applications of Magnetic Resonance-Guided Focused Ultrasound. Semin Musculoskelet Radiol 2021; 25:725-734. [DOI: 10.1055/s-0041-1735472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AbstractMagnetic resonance-guided focused ultrasound (MRgFUS) is a novel noninvasive therapy that uses focused sound energy to thermally ablate focal pathology within the body. In the United States, MRgFUS is approved by the Food and Drug Administration for the treatment of uterine fibroids, palliation of painful bone metastases, and thalamotomy for the treatment of essential tremor. However, it has also demonstrated utility for the treatment of a wide range of additional musculoskeletal (MSK) conditions that currently are treated as off-label indications. Advantages of the technology include the lack of ionizing radiation, the completely noninvasive technique, and the precise targeting that offer unprecedented control of the delivery of the thermal dose, as well as real-time monitoring capability with MR thermometry. In this review, we describe the most common MSK applications of MRgFUS: palliation of bone metastases, treatment of osteoid osteomas, desmoid tumors, facet arthropathy, and other developing indications.
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Affiliation(s)
- Matthew D. Bucknor
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Joe D. Baal
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Kevin C. McGill
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Andrew Infosino
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | - Thomas M. Link
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
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Böning G, Hartwig T, Freyhardt P, de Bucourt M, Teichgräber U, Streitparth F. MR-guided lumbar facet radiofrequency denervation for treatment of patients with chronic low back pain in an open 1.0 Tesla MRI system. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1056. [PMID: 34422968 PMCID: PMC8339805 DOI: 10.21037/atm-21-633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/29/2021] [Indexed: 01/20/2023]
Abstract
Background To evaluate the feasibility, safety and efficacy of magnetic resonance imaging (MRI)-guided lumbar facet joint radiofrequency denervation (FRD) in patients with chronic low back pain. Methods The study consisted of two parts. First, a preclinical analysis using an ex vivo animal model was performed to define optimal technical parameters for ablation. Then, 17 patients with chronic lumbar facet joint pain syndrome were prospectively included and underwent MRI-guided FRD in an open 1.0-Tesla MRI. We analyzed technical feasibility and complications as well as clinical outcome in terms of subjective pain assessed on a numerical visual analogue scale (VAS) before and after 1 week/6 months after FRD. Clinical assessment was complemented by measurement of paravertebral muscle volume and fat content before the intervention and at 6-month follow-up. Results All interventions were technically successful without major complications. Initial VAS scores (median: 8, IQR: 1, range: 6-9, CI: 7.14-8.04) decreased significantly both after one week (median: 4, IQR: 5, range: 0-7, CI: 1.9-4.69, P=0.003) and after 6 months (median: 1, IQR: 6, range: 0-7, CI: 1.06-4.23, P<0.001). Mean multifidus muscle volume increased significantly in the patient population (from 366.8±130.8 cm3 before to 435.4±146.7 cm3 after FRD, P=0.031). Conclusions This proof of principle study shows MRI-guided FRD in an open 1.0-Tesla MRI system to be a potential therapy option for patients with chronic low back pain.
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Affiliation(s)
- Georg Böning
- Department of Radiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Tony Hartwig
- Department of Musculoskeletal Surgery, Vivantes Hospital Spandau, Berlin, Germany
| | - Patrick Freyhardt
- Faculty of Health, School of Medicine, University Witten/Herdecke, Witten, Germany
| | - Maximilian de Bucourt
- Department of Radiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulf Teichgräber
- Department of Radiology, Friedrich-Schiller-University, Jena, Germany
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Zhang W, Trivedi H, Adams M, Losey AD, Diederich CJ, Ozhinsky E, Rieke V, Bucknor MD. Anatomic thermochromic tissue-mimicking phantom of the lumbar spine for pre-clinical evaluation of MR-guided focused ultrasound (MRgFUS) ablation of the facet joint. Int J Hyperthermia 2021; 38:130-135. [PMID: 33541151 DOI: 10.1080/02656736.2021.1880650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To develop a thermochromic tissue-mimicking phantom (TTMP) with an embedded 3D-printed bone mimic of the lumbar spine to evaluate MRgFUS ablation of the facet joint and medial branch nerve. MATERIALS AND METHODS Multiple 3D-printed materials were selected and characterized by measurements of speed of sound and linear acoustic attenuation coefficient using a through-transmission technique. A 3D model of the lumbar spine was segmented from a de-identified CT scan, and 3D printed. The 3D-printed spine was embedded within a TTMP with thermochromic ink color change setpoint at 60 °C. Multiple high energy sonications were targeted to the facet joints and medial branch nerve anatomical location using an ExAblate MRgFUS system connected to a 3T MR scanner. The phantom was dissected to assess sonication targets and the surrounding structures for color change as compared to the expected region of ablation on MR-thermometry. RESULTS The measured sound attenuation coefficient and speed of sound of gypsum was 240 Np/m-MHz and 2471 m/s, which is the closest to published values for cortical bone. Following sonication, dissection of the TTMP revealed good concordance between the regions of color change within the phantom and expected areas of ablation on MR-thermometry. No heat deposition was observed in critical areas, including the spinal canal and nerve roots from either color change or MRI. CONCLUSION Ablated regions in the TTMP correlated well with expected ablations based on MR-thermometry. These findings demonstrate the utility of an anatomic spine phantom in evaluating MRgFUS sonication for facet joint and medial branch nerve ablations.
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Affiliation(s)
| | - Hari Trivedi
- Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, GA, USA
| | - Matthew Adams
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Aaron D Losey
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Chris J Diederich
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Eugene Ozhinsky
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Viola Rieke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Matthew D Bucknor
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
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di Biase L, Falato E, Caminiti ML, Pecoraro PM, Narducci F, Di Lazzaro V. Focused Ultrasound (FUS) for Chronic Pain Management: Approved and Potential Applications. Neurol Res Int 2021; 2021:8438498. [PMID: 34258062 PMCID: PMC8261174 DOI: 10.1155/2021/8438498] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/19/2021] [Indexed: 02/08/2023] Open
Abstract
Chronic pain is one of the leading causes of disability and disease burden worldwide, accounting for a prevalence between 6.9% and 10% in the general population. Pharmacotherapy alone results ineffective in about 70-60% of patients in terms of a satisfactory degree of pain relief. Focused ultrasound is a promising tool for chronic pain management, being approved for thalamotomy in chronic neuropathic pain and for bone metastases-related pain treatment. FUS is a noninvasive technique for neuromodulation and for tissue ablation that can be applied to several tissues. Transcranial FUS (tFUS) can lead to opposite biological effects, depending on stimulation parameters: from reversible neural activity facilitation or suppression (low-intensity, low-frequency ultrasound, LILFUS) to irreversible tissue ablation (high-intensity focused ultrasounds, HIFU). HIFU is approved for thalamotomy in neuropathic pain at the central nervous system level and for the treatment of facet joint osteoarthritis at the peripheral level. Potential applications include HIFU at the spinal cord level for selected cases of refractory chronic neuropathic pain, knee osteoarthritis, sacroiliac joint disease, intervertebral disc nucleolysis, phantom limb, and ablation of peripheral nerves. FUS at nonablative dosage, LILFUS, has potential reversible and tissue-selective effects. FUS applications at nonablative doses currently are at a research stage. The main potential applications include targeted drug and gene delivery through the Blood-Brain Barrier, assessment of pain thresholds and study of pain, and reversible peripheral nerve conduction block. The aim of the present review is to describe the approved and potential applications of the focused ultrasound technology in the field of chronic pain management.
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Affiliation(s)
- Lazzaro di Biase
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
- Brain Innovations Lab, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Emma Falato
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Maria Letizia Caminiti
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Pasquale Maria Pecoraro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Flavia Narducci
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
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10
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Hwang BY, Mampre D, Ahmed AK, Suk I, Anderson WS, Manbachi A, Theodore N. Ultrasound in Traumatic Spinal Cord Injury: A Wide-Open Field. Neurosurgery 2021; 89:372-382. [PMID: 34098572 DOI: 10.1093/neuros/nyab177] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/19/2021] [Indexed: 02/02/2023] Open
Abstract
Traumatic spinal cord injury (SCI) is a common and devastating condition. In the absence of effective validated therapies, there is an urgent need for novel methods to achieve injury stabilization, regeneration, and functional restoration in SCI patients. Ultrasound is a versatile platform technology that can provide a foundation for viable diagnostic and therapeutic interventions in SCI. In particular, real-time perfusion and inflammatory biomarker monitoring, focal pharmaceutical delivery, and neuromodulation are capabilities that can be harnessed to advance our knowledge of SCI pathophysiology and to develop novel management and treatment options. Our review suggests that studies that evaluate the benefits and risks of ultrasound in SCI are severely lacking and our understanding of the technology's potential impact remains poorly understood. Although the complex anatomy and physiology of the spine and the spinal cord remain significant challenges, continued technological advances will help the field overcome the current barriers and bring ultrasound to the forefront of SCI research and development.
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Affiliation(s)
- Brian Y Hwang
- Division of Functional Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Mampre
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ian Suk
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William S Anderson
- Division of Functional Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amir Manbachi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Pérez-Neri I, González-Aguilar A, Sandoval H, Pineda C, Ríos C. Therapeutic Potential of Ultrasound Neuromodulation in Decreasing Neuropathic Pain: Clinical and Experimental Evidence. Curr Neuropharmacol 2021; 19:334-348. [PMID: 32691714 PMCID: PMC8033967 DOI: 10.2174/1570159x18666200720175253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/23/2020] [Accepted: 07/07/2020] [Indexed: 01/01/2023] Open
Abstract
Background For more than seven decades, ultrasound has been used as an imaging and diagnostic tool. Today, new technologies, such as focused ultrasound (FUS) neuromodulation, have revealed some innovative, potential applications. However, those applications have been barely studied to deal with neuropathic pain (NP), a cluster of chronic pain syndromes with a restricted response to conventional pharmaceuticals. Objective To analyze the therapeutic potential of low-intensity (LIFUS) and high-intensity (HIFUS) FUS for managing NP. Methods We performed a narrative review, including clinical and experimental ultrasound neuromodulation studies published in three main database repositories. Discussion Evidence shows that FUS may influence several mechanisms relevant for neuropathic pain management such as modulation of ion channels, glutamatergic neurotransmission, cerebral blood flow, inflammation and neurotoxicity, neuronal morphology and survival, nerve regeneration, and remyelination. Some experimental models have shown that LIFUS may reduce allodynia after peripheral nerve damage. At the same time, a few clinical studies support its beneficial effect on reducing pain in nerve compression syndromes. In turn, Thalamic HIFUS ablation can reduce NP from several etiologies with minor side-effects, but some neurological sequelae might be permanent. HIFUS is also useful in lowering non-neuropathic pain in several disorders. Conclusion Although an emerging set of studies brings new evidence on the therapeutic potential of both LIFUS and HIFUS for managing NP with minor side-effects, we need more controlled clinical trials to conclude about its safety and efficacy.
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Affiliation(s)
- Iván Pérez-Neri
- Department of Neurochemistry, National Institute of Neurology and Neurosurgery, Insurgentes Sur 3877, La Fama, Tlalpan, Mexico City, 14269, Mexico
| | - Alberto González-Aguilar
- Neuro-oncology Unit, Instituto Nacional de Neurología y Neurocirugia Manuel Velasco Suarez, Insurgentes Sur 3877, La Fama, Tlalpan, Mexico City, 14269, Mexico
| | - Hugo Sandoval
- Sociomedical Research Unit, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Calzada México-Xochimilco 289, Col, Arenal de Guadalupe, Alcaldia Tlalpan, C.P. 14389, Mexico City, Mexico
| | - Carlos Pineda
- Division of Musculoskeletal and Rheumatic Disorders, Instituto Nacional de Rehabilitacion Luis Guillermo Ibarra Ibarra, Calzada Mexico-Xochimilco 289, Col, Arenal de Guadalupe, Alcaldia Tlalpan, C.P.14389, Mexico City, Mexico
| | - Camilo Ríos
- Department of Neurochemistry, National Institute of Neurology and Neurosurgery, Insurgentes Sur 3877, La Fama, Tlalpan, Mexico City, 14269, Mexico
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12
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Aginsky R, LeBlang S, Hananel A, Chen J, Gofeld M, Perez J, Shir Y, Aubry JF. Tolerability and Feasibility of X-ray Guided Non-Invasive Ablation of the Medial Branch Nerve with Focused Ultrasound: Preliminary Proof of Concept in a Pre-clinical Model. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:640-650. [PMID: 33261908 DOI: 10.1016/j.ultrasmedbio.2020.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/02/2020] [Accepted: 10/28/2020] [Indexed: 06/12/2023]
Abstract
Four to six million patients a year in the United States suffer from chronic pain caused by facet joint degeneration. Thermal ablation of the affected facet joint's sensory nerve using radiofrequency electrodes is the therapeutic standard of care. High-intensity focused ultrasound (HIFU) is a novel technology enabling image-guided non-invasive thermal ablation of tissue. Six pigs underwent fluoroscopy-guided HIFU of the medial branch nerve and were followed up for 1 wk (two pigs), 1 mo (two pigs) and 3 mo (two pigs). At the end of each follow-up period, the animals were sacrificed, and targeted tissue was excised and evaluated with computed tomography scans as well as by macro- and micropathology. No significant adverse events were recorded during the procedure or follow-up period. All targets were successfully ablated. X-Ray-guided HIFU is a feasible and promising alternative to radiofrequency ablation of the lumbar facet joint sensory nerve.
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Affiliation(s)
| | - Suzanne LeBlang
- Focused Ultrasound Foundation, Charlottesville, Virginia, USA.
| | | | | | | | | | | | - Jean-Francois Aubry
- Physics for Medicine Paris, Inserm, ESPCI Paris, CNRS, PSL Research University, Paris France
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13
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Chen J, LeBlang S, Hananel A, Aginsky R, Perez J, Gofeld M, Shir Y, Aubry JF. An incoherent HIFU transducer for treatment of the medial branch nerve: Numerical study and in vivo validation. Int J Hyperthermia 2020; 37:1219-1228. [PMID: 33106054 DOI: 10.1080/02656736.2020.1828628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Chronic back pain due to facet related degenerative changes affects 4-6 million patients a year in the United States. Patients refractory to conservative therapy may warrant targeted injections of steroids into the joint or percutaneous medial branch nerve denervation with radiofrequency ablation. We numerically tested a novel noninvasive high intensity focused ultrasound transducer to optimize nerve ablation near a bone-soft tissue interface. METHODS A transducer with 4 elements operating in an incoherent mode was modeled numerically and tested pre-clinically under fluoroscopic guidance. After 6 lumbar medial branch nerve ablations were performed in 2 pigs, they were followed clinically for 1 week and then sacrificed for pathological evaluation. RESULTS Simulations show that the acoustic spot size in water at 6 dB was 14mm axial x 1.6mm lateral and 52mm axial x 1.6mm lateral for coherent and incoherent modes, respectively. We measured the size of N = 6 lesions induced in vivo in a pig model and compared them to the size of the simulated thermal dose. The best match between the simulated and measured lesion size was found with a maximum absorption coefficient in the cortical bone adjusted to 30 dB/cm/MHz. This absorption was used to simulate clinical scenarios in humans to generate lesions with no potential side effects at 1000 and 1500 J. CONCLUSION The elongated spot obtained with the incoherent mode facilitates the targeting during fluoroscopic-guided medial branch nerve ablation.
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Affiliation(s)
- J Chen
- FUSMobile, Alpharetta, GA, USA
| | - S LeBlang
- Focused Ultrasound Foundation, Charlottesville, VA, USA
| | | | | | - J Perez
- McGill University, Montreal, Canada
| | - M Gofeld
- Silver Medical Group, North York, Canada
| | - Y Shir
- McGill University, Montreal, Canada
| | - J F Aubry
- Physics for Medicine Paris, Inserm, ESPCI Paris, CNRS, PSL Research University, Paris, France
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14
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Haffey PR, Bansal N, Kaye E, Ottestad E, Aiyer R, Noori S, Gulati A. The Regenerative Potential of Therapeutic Ultrasound on Neural Tissue: A Pragmatic Review. PAIN MEDICINE 2020; 21:1494-1506. [DOI: 10.1093/pm/pnaa090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Objectives
Low-intensity ultrasound (LIU)/low-intensity pulsed ultrasound (LIPUS) may influence nerve tissue regeneration and axonal changes in the context of carpal tunnel syndrome (CTS) and in the animal model. The purpose of this pragmatic review is to understand the current knowledge for the effects of low-intensity therapeutic ultrasound in the animal and human model and determine the future directions of this novel field.
Design
Pragmatic review.
Methods
We performed a literature search of available material using OVID, EmBase, and PubMed for LIU/LIPUS, all of which were preclinical trials, case reports, and case series using animal models. For CTS, a literature search was performed on PubMed (1954 to 2019), CENTRAL (the Cochrane Library, 1970 to 2018), Web of Science (1954 to 2019), and SCOPUS (1954 to 2019) to retrieve randomized controlled trials.
Results
Eight articles were discussed showing the potential effects of LIU on nerve regeneration in the animal model. Each of these trials demonstrated evidence of nerve regeneration in the animal model using LIPUS or LIU. Seven randomized controlled trials were reviewed for ultrasound effects for the treatment of carpal tunnel syndrome, each showing clinical efficacy comparable to other treatment modalities.
Conclusions
LIU/LIPUS is a promising and noninvasive means of facilitating nerve regeneration in the animal model and in the treatment of carpal tunnel syndrome. Although many of the trials included in this review are preclinical, each demonstrates promising outcomes that could eventually be extrapolated into human studies.
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Affiliation(s)
- Paul Ryan Haffey
- Memorial-Sloan Kettering Cancer Center, New York-Presbyterian Hospital, Weill-Cornell Medicine, New York, New York, USA
| | - Nitin Bansal
- Memorial-Sloan Kettering Cancer Center, New York-Presbyterian Hospital, Weill-Cornell Medicine, New York, New York, USA
| | - Elena Kaye
- Memorial-Sloan Kettering Cancer Center, New York-Presbyterian Hospital, Weill-Cornell Medicine, New York, New York, USA
| | - Einar Ottestad
- Memorial-Sloan Kettering Cancer Center, New York-Presbyterian Hospital, Weill-Cornell Medicine, New York, New York, USA
| | - Rohit Aiyer
- Memorial-Sloan Kettering Cancer Center, New York-Presbyterian Hospital, Weill-Cornell Medicine, New York, New York, USA
| | - Selaiman Noori
- Memorial-Sloan Kettering Cancer Center, New York-Presbyterian Hospital, Weill-Cornell Medicine, New York, New York, USA
| | - Amitabh Gulati
- Memorial-Sloan Kettering Cancer Center, New York-Presbyterian Hospital, Weill-Cornell Medicine, New York, New York, USA
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15
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Collard MD, Xi Y, Patel AA, Scott KM, Jones S, Chhabra A. Initial experience of CT-guided pulsed radiofrequency ablation of the pudendal nerve for chronic recalcitrant pelvic pain. Clin Radiol 2019; 74:897.e17-897.e23. [PMID: 31447049 DOI: 10.1016/j.crad.2019.06.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 06/28/2019] [Indexed: 11/27/2022]
Abstract
AIM To evaluate initial experience with computed tomography (CT)-guided pulsed radiofrequency ablation (pRFA) of the pudendal nerve in cases of recalcitrant neuropathic pelvic pain. Endpoints include technical feasibility, safety, and efficacy of therapy. MATERIALS AND METHODS Ten patients who underwent pRFA ablation for neuropathic pudendal nerve pain during the trial period were followed for response to treatment for 6 months. Each patient was treated with pRFA under CT-guidance with concurrent perineural injection of anaesthetic and/or corticosteroid. Pain scores were then measured using a numeric rating scale at fixed intervals up to 6 months. RESULTS All procedures were considered technically successful with no immediate complications. pRFA demonstrated improved duration of pain improvement compared to the most recent perineural injection (p=0.0195), but not compared to the initial injection (p=0.64). Reported pain scores were lower with pRFA than with both the first and most recent injection but this did not reach statistical significance (p=0.1094 and p=0.7539, respectively). CONCLUSION Overall, pRFA of the pudendal nerve using CT-guidance can be a safe and effective therapy. This technique provides direct visualisation of the nerve to maximise safety and efficacy while offering a novel form of therapy for patients with chronic, recalcitrant pelvic pain.
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Affiliation(s)
- M D Collard
- Radiology Department, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - Y Xi
- Radiology Department, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - A A Patel
- Radiology Department, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - K M Scott
- Physical Medicine and Rehabilitation Department, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - S Jones
- Anesthesia and Pain Management Department, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - A Chhabra
- Radiology Department, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA; Orthopedic Surgery Department, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA.
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16
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Facet joint syndrome: from diagnosis to interventional management. Insights Imaging 2018; 9:773-789. [PMID: 30090998 PMCID: PMC6206372 DOI: 10.1007/s13244-018-0638-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 05/06/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022] Open
Abstract
Abstract Low back pain (LBP) is the most common pain syndrome, and is an enormous burden and cost generator for society. Lumbar facet joints (FJ) constitute a common source of pain, accounting for 15–45% of LBP. Facet joint degenerative osteoarthritis is the most frequent form of facet joint pain. History and physical examination may suggest but not confirm facet joint syndrome. Although imaging (radiographs, MRI, CT, SPECT) for back pain syndrome is very commonly performed, there are no effective correlations between clinical symptoms and degenerative spinal changes. Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain. These patients may benefit from specific interventions to eliminate facet joint pain such as neurolysis, by radiofrequency or cryoablation. The purpose of this review is to describe the anatomy, epidemiology, clinical presentation, and radiologic findings of facet joint syndrome. Specific interventional facet joint management will also be described in detail. Teaching points • Lumbar facet joints constitute a common source of pain accounting of 15–45%. • Facet arthrosis is the most frequent form of facet pathology. • There are no effective correlations between clinical symptoms, physical examination and degenerative spinal changes. • Diagnostic positive facet joint block can indicate facet joints as the source of pain. • After selection processing, patients may benefit from facet joint neurolysis, notably by radiofrequency or cryoablation.
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17
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Kaye EA, Maybody M, Monette S, Solomon SB, Gulati A. Ablation of the sacroiliac joint using MR-guided high intensity focused ultrasound: a preliminary experiment in a swine model. J Ther Ultrasound 2017; 5:17. [PMID: 28652915 PMCID: PMC5483839 DOI: 10.1186/s40349-017-0095-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/14/2017] [Indexed: 01/06/2023] Open
Abstract
Background Dysfunction of the Sacroiliac Joint (SIJ) is one of the key sources of low back pain. For prolonged pain relief, some patients undergo fluoroscopic guided radio-frequency (RF) ablation of SIJ, during which a number of RF probes are inserted to create thermal lesions that disrupt the posterior sacral nerve supply. This procedure is minimally invasive, laborious, time-consuming and costly. To study if High Intensity Focused Ultrasound (HIFU) ablation is a feasible alternative approach to SIJ pain treatment, we performed experiments using HIFU to ablate SIJ in the swine model. Methods Three female Yorkshire swine (36, 35.2 and 34 kg) underwent bilateral Magnetic Resonance guided HIFU (MRgHIFU) ablation of the SIJs. Treatment assessment was performed using contrast-enhanced imaging, histopathology and evaluation of pain and changes in ambulation and gait. Results Contiguous lesions along the right and left SIJs were achieved in all animals. In one out of three animals, excessive heating of the muscle and skin tissue in the near-field resulted in unwanted muscle necrosis. No changes in animal behavior, ambulation or gait were detected. Conclusions The initial experiments with MRgHIFU ablation of SIJs in sub-acute swine model show promise for this ablation modality as a non invasive and more precise alternative to the currently used fluoroscopically - guided RF ablations and injections.
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Affiliation(s)
- Elena A Kaye
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Majid Maybody
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Sebastien Monette
- Tri-Institutional Laboratory of Comparative Pathology, Memorial Sloan Kettering Cancer Center, The Rockefeller University, Weill Cornell Medical College, 1275 York Ave, New York, NY 10065 USA
| | - Stephen B Solomon
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Amitabh Gulati
- Department of Anesthesiology-Critical Care, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
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18
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Mazumder D, Vasu RM, Roy D, Kanhirodan R. A remote temperature sensor for an ultrasound hyperthermia system using the acoustic signal derived from the heating signals. Int J Hyperthermia 2017; 34:122-131. [PMID: 28540819 DOI: 10.1080/02656736.2017.1324178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We demonstrate a non-invasive technique, based on the modal frequency shift of a region insonified by a dual-beam ultrasound (US) transducer (region of interest, ROI), to remotely assess the temperature of the region in a tissue-mimicking object. The application is in ultrasound hyperthermia systems for controlled maintenance of tumour temperature during chemotherapy. Towards this, we have characterised the variation of the storage modulus with the temperature of two tissue-mimicking visco-elastic materials. Due to this variation in tissue storage modulus (and viscosity), we have observed a shift in the resonant modes of the ROI, vibrated remotely with a dual-beam focussed ultrasound transducer. A modal analysis of the vibrating ROI is done to identify the modes captured by the detector. A variation in this modal frequency with temperature is computed and matches reasonably well with the experimental measurements. Through this, we demonstrate that an ultrasound hyperthermia system can have a remote temperature sensor without using an additional imaging modality.
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Affiliation(s)
- Dibbyan Mazumder
- a Department of Instrumentation & Applied Physics , Indian Institute of Science , Bangalore , India
| | - Ram Mohan Vasu
- a Department of Instrumentation & Applied Physics , Indian Institute of Science , Bangalore , India
| | - Debasish Roy
- b Computational Mechanics Lab, Civil Engineering , Indian Institute of Science , Bangalore , India
| | - Rajan Kanhirodan
- c Department of Physics , Indian Institute of Science , Bangalore , India
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