5 Points on Ultrasound for Pain ManagementWritten by Abby Callard | November 23, 2011
Ultrasound technology is an emerging technology for pain management and can be used in both diagnostic and procedural applications. Michael Gofeld, MD, University of Washington assistant professor in the Department of Anesthesiology and Pain Medicine and the Department of Neurological Surgery, discusses the future of ultrasound technology for pain management.
1. Ultrasound results in increased diagnostic specificity. MRI is the most common imaging technologies used in musculoskeletal diagnosis; however it is a static tool, says Dr. Gofeld. Patients have to lie immobile in the scanner, and it produces a "snapshot of this moment," he says. But often, a still picture doesn't tell the whole story. For example, with nerve impingements or entrapments, it's essential to see how the nerves and joints are working in motion.
"Utrasonography makes it live, we can see exactly what is going on," he says. "This is a really sensitive and specific diagnosis at the point of care."
An ultrasound can also give physicians a more detailed diagnosis. MRI cannot pick up superficial layers, small nerve injuries and anatomical structures hidden by surrounding scars and metallic hardware . Ultrasound also allows physicians to see the internal architecture of the nerve. An MRI can show if the nerve is entrapped or enlarged, but it will not give an assessment of the internal structure which can tell physicians if the nerve is damaged beyond repair.
This is important to make treatment decisions. For example, if the nerve is entrapped but the nerve fibers aren't damaged, a simple nerve release and transposition can solve the problem. However, if the nerve fibers are damaged, the nerve has to be grafted or nerve stimulating techniques are considered. This specificity makes Dr. Gofeld predict that the ultrasound will become a "new-wave stethoscope for diagnosis of painful conditions" in the future.
2. Ultrasound can improve procedure quality. Using an ultrasound for procedures can reduce complications and result in higher success rates, Dr. Gofeld says. Ultrasound is especially helpful in procedures such as stellate ganglion blocks, cervical nerve root blocks and joint injections. In joint injection, the ultrasound actually allows the injection to bypass the joint altogether and be injected into the space just outside the joint, which usually serve as "fluid collectors" when the joint is inflamed, he says. Injections in this area are virtually painless, he says, and provide just as much pain relief as an injection directly into the joint itself.
An ultrasound also makes it easier for physicians to locate hard-to-find nerves. For example, entrapment of the lateral cutaneous nerve of the thigh, which causes severe neuropathic pain, cannot be found without an ultrasound. Another promising application is for peripheral nerve stimulation, which Dr. Gofeld has conducted research on. Traditionally, this procedure involved a large incision. Using ultrasound, physicians can transform the procedure into one that is minimally invasive and results in just as much pain relief.
3. The technology repays itself in three to four months. Dr. Gofeld estimates the price range for ultrasound machines to be $5,000-$500,000. The $5,000 machine is essentially a transducer that can be hooked up to any computer and produce low-quality images. A machine of this quality is not very useful for clinical practice, he says. On the other end of the spectrum, the $500,000 machine is what Dr. Gofeld uses for his research. This produces an image of microscopic quality allowing him to create an anatomical structure of the nerves or the spinal cord.
He says the typical price range for machines used in pain management facilities is $20,000-$80,000, and the machine will pay for itself in three to four months with a good volume of cases. The ultrasound equipment is less expensive than fluoroscopy equipment, which is commonly used for these procedures. There is also no radiation exposure with ultrasound, he says.
4. Payors are currently reimbursing procedures with ultrasound. Dr. Gofeld says he has not had problems with reimbursement for ultrasound procedures, but has had the occasional rejection for injections aided with a fluoroscope. He says a simple ultrasound procedure reimburses very well for a physician practice.
"Payors are willing," he says. "We don't have rejections for ultrasound injections"
However, it's important to only use ultrasound when it's medically necessary. For example, a payor might reject a claim for an injection in the finger joint done with ultrasound because the joint is so easy to see, he says.
"The deeper or more complex the injection, the easier it is to explain medical necessity," he says.
5. Medicare might disprove some applications in the future. Dr. Gofeld says whenever a procedure or new technology is a point of revenue for physicians, it can also become a point of abuse. Ultrasound usage is no different. He says the increase in claims of injections with ultrasound will cause Medicare to investigate the applications and eventually to disprove some of them. Dr. Golfed predicts trigger point injections with ultrasound will almost definitely not be reimbursed next year. That change isn't too bad in and of itself, he says, but it can have a snowball effect.
"When they disprove one application, it can cause an avalanche and chain reaction," he says.
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