Q&A: The art and business of cutting-edge musculoskeletal ultrasound

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pavlov_100px.jpgThe Hospital for Special Surgery (HSS) Department of Radiology and Imaging in New York City today opened the Center for Musculoskeletal Ultrasound and Nuclear Medicine. The main reason for the expansion to the new center is an ever increasing referral and patient base in the areas of orthopedics and rheumatology, the Center’s focus. The new facility will allow the hospital to delve deeper into research towards pioneering new clinical treatments as well as education.

Health Imaging News spoke with Helene Pavlov, MD, radiologist-in-chief, HSS, and professor of radiology and orthopedic surgery at the Weill Medical College of Cornell University, about the implications of the new Center and its use of ultrasound technology in particular.

What’s your department’s focus?

The Hospital for Special Surgery and its Department of Radiology and Imaging is completely focused on orthopedic and rheumatologic diseases. This gives us the ability to be at the cutting-edge of imaging musculoskeletal disorders. We work directly with some of the premier orthopedic surgeons and rheumatologists in the world and use imaging to help them optimally diagnose, treat and answer their clinical questions.

One of your core diagnostic tools is ultrasound. How do you make the most of it as a diagnostic tool?

Ultrasound is extremely user dependent and requires experienced personnel and practitioners. The majority of our studies are done by radiologists who are sub-specialized with fellowship training in musculoskeletal ultrasound. We do have technologists who assist and provide preliminary scans, but basically the physicians do the diagnostic examinations as well as perform the interventional examinations. The level of competence and confidence for the referring physicians is excellent. I think that that makes a big difference in building a practice.

What are the benefits of ultrasound-guided treatments?

Ultrasound uses non-ionizing radiation so it is safe for patients of all ages, children included. It is extremely useful when conducting targeted injections and aspirations. We currently do examinations using fluoro or CT guidance but that usually requires the injection of contrast to be able to confirm where the needle is. Contrast is not needed with ultrasound. Ultrasound allows us to do guided aspirations of, for example a ganglion cyst or calcific tendonitis, and go very specifically into the affected area and see that the needle is exactly where you want it to be. The aspirations can be done for patient relief, culture and other lab analysis. We also do therapeutic injections, which are typically done in a doctor’s office where a doctor will probe around and a needle will be placed into a “trigger point” or the area that reproduces the pain. Using ultrasound guidance, the physician knows specifically where the medication is being injected into, for instance, the tendon sheath as opposed to into the tendon proper. It’s very specific and very targeted.

How about ultrasound in relation to MR? Can they be used together?

It’s an alternative method for identifying tears in the rotator cuff, for instance. While most often these examinations are done with MR, ultrasound provides us a corroborative method for diagnosis, and a means of examining the claustrophobic patient. Ultrasound also provides a less expensive method for following a patient post-surgery. There is a fear in some institutions that use of ultrasound in this way could mean a loss of MR patients, but we have found that ultrasound and MR are absolutely corroborative and complementary examinations as opposed to being competitive.

Do you use portable ultrasound systems?

We don’t use portable ultrasound units for diagnostic exams, although we do use it for vascular guidance for some interventional studies. There is a lot of low-end, less expensive equipment out there that is being touted to the lay public as being capable of doing all of the elaborate exams that larger, full-size ultrasound systems can do – but there is a big difference compared with what an experienced user, using high-end equipment can accomplish and the studies are not really the same. All images and imaging are not created equal, although all billing seems to be created equal.  I think a lot of general practitioner offices are using the smaller portable units for early diagnosis of rheumatoid arthritis, but again the difference between the results we get from a high-end machine in experienced hands is really quite significant.

You have an education center at your facility. Describe how you use videotaping of procedures to benefit students. Also you have an observation area that is interactive. How does that work?

The audio/visual setup in the Academic Center for Musculoskeletal Ultrasound at HSS is quite unique. We felt that it was important for students to see exactly what was being displayed on the monitors and what the ultrasound anatomy actually looks like. We felt it was equally important to identify how the transducer was being held and maneuvered to achieve the desired image. It’s that subtlety that makes the difference between a poor, mediocre and an excellent image of diagnostic quality. So the capability for a student to view both the ultrasound image and the transducer in use as it generated, simultaneously on a large screen TV makes it a very unique experience. If someone is trying to demonstrate a specific part of a tendon, a student can see how you have to move the transducer and how you have to manipulate the patient in order to get that image. And this is all while you’re watching real-time. 

I would compare it to Ansel Adams taking pictures of the sky and being able to acquire pictures completely differently than what perhaps you or I would get using an instamatic or even the same camera. Ultrasound is truly an art form and you want it to be as diagnostic as possible.

Is this observational area interactive?

The observer does not have to be in the same room as the patient, though the patient is always notified that there is an observer. They can listen to what the patient is saying and what the doctor is saying. The cameras are actually wireless and remote controlled, which means they can be zoomed in and zoomed out without interrupting the performance of the examination.

What other teaching components do you have at HSS?

We are building a library of basic musculoskeletal ultrasound cases as well as more complex and rare cases, which can be used as a resource so that if somebody needs examples they can refer to past cases. For example, someone might want to see what a normal shoulder looks like, or a normal post-op shoulder, or perhaps a rotator cuff that is not healing well. What do you look for, and how do you image it? That is why we are building the library of musculoskeletal ultrasound cases.

What suggestions do you have for hospitals considering the adoption of some of the more progressive treatments and diagnostic tools you are using?

First, they have to have the appropriate level of expertise. To achieve the required level for HSS, I brought in an expert, Dr. Ronald Adler. Second, the referring physicians needed to be educated on the potential of what ultrasound could do for them and their patients. This would require a change for our referring physicians. In general, our referring physicians were used to doing it one way and do not like to change without good reason. We had to build confidence with the doctors, give them lectures, and do some one-on-one between referring physicians and the radiologist so that a common language and trust could be established. Now we do about 8,000 cases annually and the whole referring pattern has changed. Referring physicians will order either an MR or an ultrasound and will work with us so that the appropriate imaging study is performed with the most efficient, cost-effective patient care being considered. At HSS, we are uniquely positioned with our level of MR and ultrasound expertise being equal; in general, at most facilities the business will go to the stronger modality. Basically, you have to know what you’re doing.