Are Interventional Spine Physicians Capable of Practicing Interventional Orthopedics?

This past month I had an interesting back-and-forth with an interventional spine physician about interventional orthopedics. This dialogue brought up an important issue that I think most interventional spine physicians don’t yet understand. While they have the requisite skills to start training in interventional orthopedics, they don’t have the skills needed to practice the specialty. In fact, they are sorely undertrained. Let me explain.

How the Issue Came Up

I was asked to write a book chapter by a specialty society for interventional spine physicians. This work would have been my seventh or eighth on regenerative orthopedics, but I said yes and got to work. The last several chapters I’ve written have all clustered around the theme that interventional orthopedics (IO) is an emerging specialty. Also, while stem cells and PRP allow IO to have great tools to help patients, the real magic is in rethinking orthopedics as an interventional (i.e., precise injection-based) specialty rather than a surgical one. Much to my surprise, the word came back from on high that my book chapter couldn’t be about interventional orthopedics. I got the distinct sense that the editors felt that it was not in keeping with their messaging that regenerative medicine for interventional spine physicians was more about using PRP and stem cells as just another injectate (i.e., something that is injected). I also got a distinct sense that the editors didn’t know what they didn’t know, hence this blog.

What Is Interventional Spine or Interventional Pain Management (IPM)?

Interventional spine and IPM have changed the world for patients with spinal pain for the better. We have lots of physicians to thank for that specialty, which was birthed in just a few private practices around the country rather than in a university. This all happened because of physicians like Charlie April, Rick Derby, the Saal brothers, Paul Dreyfus, and Lax Manchicanti. When I began residency in the late ’80s, these giants were just starting to learn how precise steroid injections could reduce spine-surgery rates. Millions of patients who didn’t get back or neck surgery since the 1990s onward owe their thanks to these doctors. They then went out and trained crew after crew of physicians through a few different organizations, and I was one of those doctors who eventually learned how to perform these procedures.

My IPM Practice Hits a Wall

I remember way back in 2004 that my practice had hit a wall. While I loved the fact that precisely injecting steroids into the neck and low back of my patients could help them, most of the relief was temporary, and sometimes the pain returned with a vengeance. As I began adding the simplest type of regenerative medicine in the form of prolotherapy injections, I noticed that this often worked better than steroid shots. It was those observations that caused me to get into stem cells in 2005, at a time when nobody else in the U.S. was doing that type of work.

What Is Interventional Orthopedics and Why IPM Doctors Are Sorely Undertrained to Practice in This New Specialty

I’ve noticed of late that a few IPM societies have begun offering regen med courses. The offerings are often a little amusing for me, as it’s clear that they view orthobiologics as just another injectate. Something to be bolted onto their current routine of spinal injections or just added to simple joint injections. Regrettably, these physicians are missing the whole point of IO.

While IO is about precise injections of orthobiologics, it also opens up a whole new world where orthopedic treatments can be rethought from the ground up. This idea is likely invisible to most IPM physicians because they don’t know what they don’t know. Let me explain.

Let’s take the example of a posterior shoulder labral tear. The patient shows up to the IPM physician with shoulder pain. Not having much training in how to correctly perform a shoulder exam (because his or her fellowship focused on spine injections), the IPM physician doesn’t know where to begin. So a cursory shoulder exam is performed and a quick guided PRP shot is delivered into the joint. The patient doesn’t get much better, so an MRI is ordered, which shows a posterior labral tear. This is where our IPM physician hits his or her first roadblock. The course that was given by the specialty society only focused on simple inside-the-joint shoulder injections. How to precisely inject a posterior labrum with ultrasound wasn’t taught, and while the IPM doctor bought an ultrasound machine, he or she doesn’t actually know more than the basics.

Let’s say for argument’s sake that our IPM doctor figures out how to inject the posterior labral tear with some PRP and manages through some miracle to get it close to the tear. The patient reports some improvement but is back the next year with the same problem. The IPM doctor is stumped and refers the patient for surgery.

If this IPM physician knew anything about IO, not only would he or she be an expert on how to get platelets or stem cells to this spot, but even more importantly, the doctor would know that a posterior labral tear is often caused by glenohumeral instability in the posterior direction. The doctor could have checked for that instability using stress ultrasound and if found, could have easily targeted the specific lax ligaments leading to that instability. If the IPM doctor had known how to diagnose and treat what was actually wrong, the patient would never have been referred to the surgeon.

Not Knowing What You Don’t Know

While I tried to explain the example above to the IPM doctors who felt threatened by the idea of IO, it seems to have sailed over their collective heads. I can’t say that I blame them as when I was a practicing IPM physician, it would have also sailed over my head. So the purpose of this post is to say to all IPM doctors, “You’re not qualified to practice IO, but you sure could be with the proper training.” That’s more than the weekend courses being taught by IPM organizations. It requires a staged and structured educational program.

The upshot? IPM doctors, I have a challenge for you. Up your game substantially as you learn how to use these new tools. Your patients will thank you, and, hopefully, a whole new world of how to prevent knee, hip, shoulder, foot/ankle, and hand/wrist surgery will open up for you!

 

 

 

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  1. I agree with you Chris that IPM is far from been IO on several points but I think that it is even worse for those that try to do IO without ever having done a precision guided injection in their life. Those that tell you that their fluoroscope is in the tip of my index finger!
    I personally have discovered many ways to help patient since I expanded my horizon outside the common steroid injection and really think that regenerative medicine is the wave of the future. Even if the majority of everyday physicians when you mention to them the words regenerative medicine, prolotherapy or stem cell therapy think that it is Indian cure.

    However, I was also shock to see at regenerative medicine conferences some of those so called instructors of interventional orthopedics doing risky injections totally blind. What is more sometime even teaching someone who has never held a needle in their hands to do risky procedures blind. We all have to work together and learn from each other. Keeping an open mind and knowing our limitation is important in our profession for it to continue to advance. We need to share our respective strong points and try to learn from one another.

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