Slides
Transcript
Well, Andrew, thank you for that introduction. I’m not really sure I should be the keynote speaker, nor do I really recognize the person you’re talking about. But it’s been like a 22-year journey really through this, and it’s been really interesting. And wow – it’s just been a terrific experience. I feel very fortunate.
So I’m going to tell you how we happened to kind of organically get into this. It was organically grown really. What happened was, in 2002, we had the neurosurgeons and the orthopedic surgeons asked us if we could get into pain management. Now, that’s usually a field that anesthesia actually gets into, but they were having a hard time getting into anesthesia. So, they said, could you do injections?
Well, you know, we did all kinds of work in the spine – biopsies, lumbar punctures, myelograms, the whole thing. So, we said, “Well, sure. We know the anatomy. We know the pathology. We can do all of this.” So, Dave Enterline and I went to a couple of meetings. We learned what kind of injectables you had to do. And so, we said, “Yeah, we can do this.” We learned all the injectables.
The interesting thing was that we didn’t really ask anything about credentialing. And so, this is where we started kind of coloring outside the box a little bit.
So anyway, we initiated a pain management service. And then the question was, well, are we going to do this under fluoroscopy like most people do, or are we going to do this under something else? At the very same time, in 2002, CT fluoroscopy came online, and you know what? We said, “We’re not going to do this like everybody else. We’re actually going to do this with CT guidance, and we’ll get a diagnostic study ahead of time so that we’ll really understand what’s going on with the patient.” And we felt like this would enhance our precision and our accuracy. So, that was in 2002.
So, we became 22-gauge sharpshooters, really. And we were doing interventions from the base of the skull all the way down to the sacral-coccygeal junction. So, we learned how to do interlaminar injections, C1-2 facet injections. And, because we got a diagnostic study ahead of time, we could change the therapy that needed to be done to actually address the patient’s problem.
So, the patient would come in. We would see them. We’d hear what was going on. We’d look at their imaging, and, in combination with the imaging and the patient’s story, we understood what kind of treatment they needed.
So, this was a patient – actually a football player right here – who actually was having terrible pain, all of a sudden had a pop. They thought he needed an epidural and actually had something called a Bertolotti syndrome. And he had actually popped this kind of pseudo joint that he had there, and that was the cause of his pain. So, in 2006, I saw him. Really, before that, we were doing post-lumbar puncture blood patches because we were already operating, doing things in the spine.
I saw my real first spinal CSF leak patient in 2006, and she was a 37-year-old female who actually had severe, searing chest and back pain and was taken to the ED and ruled out for MI and PE. This happened when she just bent down to tie her kid’s shoes. So, you can see on the imaging study that she has an obvious spinal CSF leak. She got admitted to another hospital, and they put her to bed, realizing she had a leak. They did all kinds of things. They did three blood patches, and she just wasn’t getting better. So, after 42 days, she actually was sent over to Duke, and we knew we had to look for a leak. They hadn’t done any myelogram. So, we started with a myelogram – traditional myelogram. Take the patient to fluoroscopy, put the needle in, get them on a gurney, and take them to CT.
Okay, so there’s a delay there. And so, we got her supine on the CT scanner table, just like everybody would do. And we could see that she had an obvious leak. I thought, wow, there’s kind of a gap there. Maybe that’s where the leak is located. And I said to my neurosurgical friend, “You know, I think this is where it is.” And he said, “That is a terrible place to operate. You have to go through the manubrium. It’s terrible. See if you can define it better.”
And so, what I did is – okay, what am I going to do? So, I put the contrast in under CT guidance, I hung the patient on off the table, and then put her back on and scanned her prone. And darn, if the leak wasn’t coming from the upper thoracic spine because the contrast did not fill the cervical spine before it filled the space – the ventral collection.
So, I could see that she had leaks coming out along the nerve root sleeves, and I said, “Well, how about if we just take care of this right now?” And we did five targeted patches. And she got up off the table without a headache after 42 days. And I said, “Wow, I mean, this is a big deal. I just cured this patient.” I was pretty – I mean, I was pretty excited. In retrospect, I went back years later, looked at this case, and it was probably that little tiny disc that actually had precipitated this leak. But she never had to be treated again. So, I just thought leaks could be a really big problem.
So, over the next couple of years, it got super busy because we were doing pain management and taking care of CSF leak patients. I was fortunate enough in 2007 to get Jeff Taylor, who was a PA, and he came on board first. Then we started getting some schedulers and support staff.
Peter came on in 2009. I actually recruited him as a medical student into the Duke Radiology program. Then he stayed in and did neuroradiology. That was such a coup to actually have him come. And we wanted to collaborate, so he was willing to come on board and get into whatever the magic I was trying to do. And I was really grateful for somebody to collaborate with.
So, we wanted some neurologists or headache specialists to help us out. So we planned a dinner, took these guys out to dinner, told them what we were doing, and they had zero interest in what we were doing. And so we said, “We’re on our own.”
So, initiation of primary care on neuroradiology – there you go. We had to take care of all these patients ourselves. We did have a group of people in Chapel Hill, not far from us, who actually would help us with patients and stuff when we saw them.
So, how do you manage an interventional neuroradiology outpatient pain headache service? Well, what you do is you actually have a cell phone, you have everybody’s contact information, and we had a headache form that we actually developed with the Carolina headache guys. So, whenever anybody would come in to see us, we would listen to the patients, get all their information, and so we were just taking care of the patients and then doing the studies and then going from there.
And then following up, right? I mean, then we had to call them the next day and the several days after and kept in touch with them. You know, probably not all of you would do this, but everybody had my cell phone number, and they text me and email, and they could get a hold of me however they wanted. And why do you have to do that? Well, when you’re in a space where you’ve never been before, you need to know how to take care of the patients, and you have to listen to them and know what you have to do. And so that’s how we managed it. We got a busier and busier service, and so now there are this many of us. We have another nurse practitioner as well taking care of patients with this problem, and we have a lot more support staff now as well, which has been fantastic. So, we have a couple of schedulers and now three nurses.
And why – how and why would a neuroradiologist want to do this, right? Because most of the time, why would you want to implement care? We all do internships when you go into radiology. So, you’re going to do it in either general medicine, surgery, or family practice. So, I went into – from out of medical school, I went into internal medicine, planning to do internal medicine, and actually was going to do interventional cardiology. Three months on the CCU, MICU, a couple of months – I mean, that’s where I was going.
But you know what? I was writing orders, you know, for patients to go down to radiology and take all the rides, and then they were giving me the answers to the problems. And I wanted to be the person who actually was figuring out the answers. So at the end of my internship year, I went down to radiology and asked them if I could actually transfer into radiology, and they said yes.
Some physicians go into radiology because they want to avoid patient care. I did not do that. I was not avoiding patient care. I wanted to actually go into radiology so I could get the answers to the problems. You know, radiologists are superior diagnosticians with all the different imaging studies that are available. We’re interventionalists. We do biopsies and all kinds of things along the spine.
And Duke is a unique environment in that – you know, even after we’ve been delivering pain management for 10 years, we got grandfathered in. After 10 years, and they just said, you know, you’ve been doing it for 10 years, you have credentials. So, it is unique in that way. And then you’re only limited by your own imagination and personality and self-confidence. And one thing is, you have to own the problem. If you get into this space, you have to own the problem and don’t screw it up. Really important.
So originally, we had one CT floor unit. We were running all of our patients through that, and then it got so busy that we had to have another outpatient scanner.
So, we do all the pain management outpatient, and all the other patients are done on an inpatient scanner. Then there’s been evolution of techniques that I’ve been grateful to be able to participate in. Let’s just talk about LP and pressure measurements first. So, you know, we were doing all of our lumbar punctures with 22-gauge spinal needles – that’s what everybody used – and we would patch those holes at the end.
And then, in April of 2010, there was the Deepwater Horizon Gulf oil spill, right? And I’m listening to NPR on the way into work, and there’s a big oil reservoir, and they were getting pressures out of this reservoir with a small tube. And I said, well heck, if they can do that, I should be able to get pressures with a smaller needle. So, I called Duke Physics, and they said, yeah, absolutely, you can do this. And so, we started using 25-gauge needles.
That is tough with a 25-gauge needle to inject through that and to get pressures. Fortunately, I met Connie Deline right about that time, and she introduced me to the Gertie Marks needle, which was fantastic. Which is bored out like a 22-gauge needle, and so you can get the same kind of pressures, but it’s much easier to introduce. Yes, you have to do it with an introducer, but you have a much lower chance of having a post-lumbar puncture headache, and you don’t contaminate your epidural space when you do it.
So, then we started doing all of our lumbar punctures under CT-guidance. Obviously, you know, those traditional monitors that you use in order to get pressures – forget it. There is a digital monitor that you can use that will get pressures quickly, within seconds. And so, we figured that out as well.
I’ve been a part of figuring out how to detect leaks. Let me just talk about the treatment of leaks and fibrin glue. So, we had so much repeat business in 2011, we said, we have to do something else. So that’s when we started using fibrin glue. It’s more adherent to the dura than blood, and it has a tighter matrix, and it’s absorbed slower. One of the things we had to do is make it up ourselves, so it would not clot as fast. So, we had to put calcium chloride, and we made it up ourselves so that the glue would set up in two minutes as opposed to two seconds, which was what was commercially available at the time.
And sometimes, really, a percutaneous injection is the only thing that’s available. This was a young guy who was T-boned in a motor vehicle accident. He was a passenger. He had an obvious spinal cord injury. He was in his electric chair, and he was doing great. He had such a great attitude, until he couldn’t sit up anymore without losing vision because he was getting occipital ischemia. He was getting ischemia in the occipital poles. So, we figured out where the leak was, and we injected fibrin glue there, and he resolved his symptoms, which was fantastic. So sometimes, really, all you have – you know, we wanted to turf this to neurosurgery, right? They were having no part of it. They said that it was too dangerous.
And then surgery – we worked with one of our orthopedic surgeons, and he actually – we wanted to try and figure out an extra-dural approach to doing the surgeries and shaving down the disc. And he figured this out for us with this collagen wrap. And then he would tuck it underneath the dura and then wrap it around and sew it to the back of the dura. And so, we – he helped us work with that. So, this is a real collaborative thing. You have to work with people who are willing to help you with your problem.
I think we have to think about cerebrospinal fluid as a continuum between high and low. And we see the extremes of this – high and low – but there’s a real balance. Between this because sometimes high-pressure patients actually blow out and present as low, and then sometimes the low-pressure patients actually, after you treat them, become high. So, you really have to realize that you’re working within a continuum.
And then, because of the low pressure turning into high, we had to learn how to prescribe medications that would actually treat rebound high pressure that happens after this. And so, we had to learn how to prescribe this. So, we’re now prescribing medications, and we also had to learn that sometimes you have to monitor sodium and potassium.
Then there’s getting the attention of radiologists and physicians. So, the first lecture we gave was in 2009. And then after that, we have been giving so many lectures. And we’ll listen to anyone who is willing to listen.
The Spinal CSF Leak Foundation started in 2014. And then there was Andrea Buchanan, who actually wrote her book and has been running that until recently.
Andrew wanted me to talk about women in radiology. I was 18 women in a class of 220. I didn’t see myself as a woman but as a person in medicine, and each of us brings something unique to this. I endeavored to be at least as smart, if not smarter, than my counterparts, but always with humility and avoiding being intimidating.
And you have to earn your respect from everyone that you are in touch with – your support staff, your colleagues, referring physicians, patients – everyone. So, it takes a collaborative effort, as we know, and in the center of that is the patient. And I have been so gratified and appreciative to be able to participate in this realm and to participate with patients in terms of participating in their health and well-being and letting me be a part of their healthcare journey. So, with that, thank you. Thanks so much.