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Old 07-25-2006, 12:17 PM
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Dr. Aaron Filler is a leading expert in treatment of nerve pain and has revolutionized nerve-pain treatment by inventing several new technologies. One such technology, MR Neurography, enables doctors to use an MRI scanner to examine nerves — previously a difficult-to-impossible tissue to see through MR imaging. Dr. Filler's research in axonal transport is leading to a whole new generation of advanced pain medications. He has developed many new “minimal access” surgery methods that allow him to treat complex nerve problems with small outpatient surgeries. He has also pioneered the use of the Open MRI scanner to do surgeries and other therapies with the ultra-high precision and safety of the magnetic resonance imaging. Dr. Filler and his team were kind enough to address some questions from the ADRSupport community.
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ADRSupport: In what ways is MRN better than any other conventional imaging technology, e.g. CT mylegram, MRIs with contrast, etc.? What nerve conditions are better imaged with MRN?

Dr. Filler: MRN is better for nerve imaging outside of the brain and spinal cord. A CT myelogram will show shadows of the nerve root sheaths but it will not provide a clear picture of distal nerve roots as the MRN does. Very importantly, a CT myelogram is a difficult experience for most people, since it involves dye injection -- and lying down for a day -- and can often cause a terrible headache for 1 –2 days. The MRN avoids all of that since no dye is used. You can see comparison on the nerve med site at http://www.nervemed.com/spinal-repair.html#

CT’s simply do not show soft tissue well enough and routine MRI’s are not specific for nerves, because the nerve signal is the same as muscle and there is no discernable difference. All nerve conditions can be imaged, with the exceptions of diabetic neuropathy, disc herniations or brain tumors.

ADRSupport: How are the different nerves identified and/or differentiated from veins and arteries?

Dr. Filler: It’s easy -- nerves simply look different until they become very small, even then when compared on axial and coronal images they can be identified by position. For example, valves in the veins can often be identified, so they appear nothing like the nerves, in addition to using basic anatomy. For example, looking at the ulnar nerve at the elbow, it looks different than the vessels but there is an obvious pattern on the axial nerve; where it can be easily differentiated from other anatomical structures. It is between the artery and bone in most cases.

ADRSupport: How specific or unambiguous are the image study findings? Can you quantify this with a percentage?

Dr. Filler: The MRN is 100% reliable, for most nerves. However, this can go down to 50% reliability for very small nerves in the groin; e.g., when someone has hernia surgery. Nonetheless, even when surrounded by lymph nodes and other structures, an irritated nerve will show up well enough to be identified most of the time.

ADRSupport: What has your institute learned about more complex pain syndromes, e.g., myofascial regional pain syndrome or TOS?

Dr. Filler: We have been able to accumulate huge amounts of information and provide even more detail for someone who has a specific “spot” of pain. This can be found at nervemed.com. Our diagnoses have become extremely specific, for example, probably no one can find and decompress the long thoracic nerve at the middle scalene muscle, except at the institute for nerve medicine

ADRSupport: What types of nerve problems are not appropriate for MRN imaging?

Dr. Filler: Diabetic neuropathy, other systemic problems, spinal cord and brain problems. We can image cranial nerves outside the brain though.

ADRSupport: How many people with failed back surgeries have been helped with an MRN study? What has been learned about these studies?

Dr. Filler: 100’s of people have been helped. The link above gives a few examples of inadequate decompression of the spine and foramen because they were looking for a simple laminectomy to fix the problem. The MRN helped with the specificity of the problem -- an accurate diagnosis -- and therefore the patient had the exact corrective procedure needed.

ADRSupport: How can MRN identify the actual source of the nerve problem? E.g., how can MRN differentiate between discogenic, nerve root or peripheral nerve problems?

Dr. Filler: This can be a conceptual problem, the MRN only images nerves well, and it does not go to a source of a problem. For example, if you fell down and hurt your leg, you would most likely get an X-ray. If the X-ray identified a broken bone that would most likely be the problem. If the MRN were used to image the lumbar area, we would simply see a lateral disc, distal foraminal entrapment, or an even more distal problem. If the symptoms were persistent and the lumbar study did not indicate any pathology, for example, then another area such as the sciatic notch area would be imaged subsequently. One important additional aspect is that a lumbar MRN can determine whether or not a spinal nerve is irritated. Many lumbar MRI’s show abnormalities that aren’t actually causing symptoms. With MRN, however, the presence of spinal nerve irritation adjacent to a narrowed foramen or bone spur can be verified.

ADRSupport: Are anterior & posterior nerves imaged? Or do MRNs provide the radiologist with a three dimensional view of nerve structures?

Dr. Filler: Yes, the great thing is that the MRN is a three dimensional study, all nerves are imaged in a given volume.

ADRSupport: What kind of success rates with patients have been attained with open MR image guided injections? What types of injections are performed?

Dr. Filler: Please note that that this is an INM practice question. However, I can say that 90% of patients who have injections are extremely satisfied with their injection because they understand the diagnostic value of this type of guidance system. We let them know that the injection should take care of their pain, but it is important to understand by being able to look at the muscles and tendons in the area and not only the boney landmarks, Dr. Filler is able to provide a very detailed picture of what is going on (an accurate assessment). For example, the MRI process occurring simultaneously with the medicinal injection throughout the procedure allows Dr. Filler to see if the area is fibrotic, full of scar tissue, muscle is in spasm, etc. If the patient is not experiencing numbness it may be because the nerve is encased by some scar tissue or wrapped in abnormal vasculature; or perhaps the medicine cannot penetrate the problematic area and the patient continues to experience pain and no numbness.

All types of injections are performed; it depends on the clinical findings.
For back pain patients, Dr. Filler has had great success in treating psoas muscle and iliacus muscle spasm – these are two major sources of back pain that most spinal doctors can’t see or treat because they don’t show up on X-ray fluoroscopy or CT. When a patient needs a discogram, Dr. Filler does “anaesthetic disk injections” rather than “provocative.” Essentially, he believes that if an injection can block the back pain by numbing the disk, then a disk problem is confirmed. Pain from a provocative injection is often confusing to assess.

Injections are also done for sciatica caused by piriformis syndrome and for arm, neck, shoulder, and headache pain from thoracic outlet syndrome. Many patients have groin symptoms that will respond to pudendal blocks or obturator internus muscle injections.

ADRSupport: Can minimal invasive surgery be carried out during the scanning? Are non-metal objects used during surgery if this can be done during the scan?

Dr. Filler: Yes, we can operate in the open MRI scanner in cases that require it, however, we are not quite set up for that at the INM. We used to perform those procedures at another facility but the Open MRI surgical procedures are not carried out at that facility any longer. Keep in mind that the use of the open MRI scanner is usually used in cases where there is a tumor or other pathology of that nature. We use metallic instruments made of titanium. Titanium has no magnetic properties.

ADRSupport: After an MRN diagnosis, how many successful minimal invasive surgeries have been done successfully using this technique since its invention?

Dr. Filler: That is hard to answer; we are getting over or close to 1000.

ADRSupport: What is the success ratio of any interventions done?

Dr. Filler: Success ratio in general for us is about 85% of patients claim to be at least 50% better, meaning they can resume life with a small amount of medicine, about 40% or so get 100% relief. The 100% relief mark depends on a number of things such as time of compression, if the nerves are deformed (nerve damage) etc.

ADRSupport: How many artificial disc patients have been imaged? What have you seen or learned from these studies?

Dr. Filler: We are seeing significant numbers of patients with artificial disk replacement (ADR) who were not helped by their ADR surgery. The ADR causes some image artifacts, but the MRN scans are still very helpful. We have found that surgeons are more likely to place an ADR when they are uncertain of the diagnosis than in the old days of fusion only. In many cases, this is because of patient enthusiasm for the ADR as well as the perception that they are less invasive than a fusion. We have also imaged patients in whom the ADR was placed off center and is causing a nerve impingement.

ADRSupport: Fundamentally, can’t MRN technology help thousands of patients who are cursed with nerve disorders – and are in dire need of a proper diagnosis?

Dr. Filler: YES. Without a doubt, MRN is the way to go, thousands should be done each day! Medicine is slow to take up new things sometimes.

ADRSupport: What are some of the promising diagnostic capabilities you see developing in the next 1 or 2 years?

Dr. Filler: Contrast agents that will make blood vessels “disappear” and bone and joint imaging greatly improved using contrast agents, this will not be MRN, it will be MRJ or something, we are not sure at this time.

ADRSupport: What insurance plans are covering this procedure? E.g., are HMOs more amenable to paying than PPOs? Is this changing?

Dr. Filler: Most insurance plans pay the reasonable at the out of network level. Medicare pays for the MRN as well. HMO’s simply need authorization and sometimes pay better than PPO’s it depends.

ADRSupport: If MRN is a very effective technology for imaging complicated, hard to diagnose conditions, why isn’t it more available? And why aren’t insurance companies more eager to endorse the technology as a money saver?

Dr. Filler: This is a very complex question. The MRN is not an easy study to perform, it is very labor intensive and medicine is unfortunately time-sensitive; more radiology practices need to image 40 routine patients per day rather than 20 difficult MRN patients, for example. There are sites that are willing to put in the effort and deal with the intellectual property issues; the MRN is patented technology like many complex computer programs. These factors can make it difficult to set up; however, we are working very hard on this. We expect us to have several additional sites in the next 24 months.

Part 2. Insurance companies have never been known to have “patient logic”; they are set up with numbers and percentages. They try to serve the largest population; and complex spine and peripheral nerve problems are very, very rare. There are only about 200 – 250,000 spine surgery candidates each year, while there are several million cardiac and diabetic patients, for example, it is all about numbers, really. It would be hard for them right now to change the way they do things, but they do try, believe it or not, and there are some excellent doctors who work with them. We can hope they will adapt and care for more individuals and make the individual care cost effective as well.

ADRSupport: Is there a “laundry list” of conditions that can be diagnosed with MRN – that were previously undiagnosed by conventional imaging? Where can I read about patient success stories?

Dr. Filler: You can find this at Neurography.com, and nervemed.com. Conditions include: undiagnosed back pain, chest wall pain, TOS, shoulder pain, upper arm pain, ulnar nerve – cubital tunnel, carpal tunnel, tarsal tunnel, sciatic nerve entrapment at any level, nerve injury, peroneal nerve compression, pudendal nerve entrapment or neuropathy, and so on. We have some success stories at the INM site.
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
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  #2  
Old 05-12-2010, 11:52 AM
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Harrison Harrison is offline
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Default Update on MRN Locations

Choose from the following centers for immediate scanning appointments:

Pasadena, California
San Francisco, California
New York, New York
Boston, Massachusetts
Oaks-King of Prussia, Pennsylvania
Norristown, Pennsylvania
Vandalia-Dayton, Ohio
Metro DC - Arlington, VA
Coming soon:

St. Petersburg, Florida (live May 2010)
Atlanta, Georgia (live June 2010)
Phoenix, Arizona (live June 2010)

http://www.neurography.com/locations
__________________
"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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distal nerve roots, dr. aaron filler, failed back surgery, long thoracic nerve, mr neurography, mrn, mrn diagnostics, open mri scanner, pudendal nerve entrapment, sciatic nerve entrapmen, spinal nerve irritation, tos, undiagnosed back pain

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