Quality of Interventional Courses

[drusso]

PASSOR vs ISIS vs others. Any experiences and/or thoughts re: quality, hands-on work, and philosophy.

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[Aether2000]

ISIS workshops are a graduated series of increasingly technical and risk laden techniques that are taught using standardized protocols. The groups are small (usually 4-6 per cadaver), the quality is excellent of the physician instructors, and the experience is very concentrated in techniques of one type or regional area of anatomy (eg. Level I is lumbar injections). The physician must be proficient in one level in order to advance to the next. In all, there are approximately 7 levels and ISIS does teach a workshop on pumps and stim implants. If you do things the ISIS way (Practice Guidelines) you will have the most optimal chance of having a procedure actually work. ISIS courses fill up quickly and one may have to wait for up to 6-9 months to get into the course of choice (upper level).
PASSOR has techniques divided into 3 levels and offers similar experience relative to ISIS minus the intensity of techniques. (for example, ISIS offers a single cadaver course on RF of the spine that includes SI, medial branch, thoracic, splanchnic, etc. while PASSOR offers the more bread and butter cervical and lumbar medial branch. The PASSOR RF is included in Phase III which includes other injection techniques. PASSOR has some of the finest instructors I have ever met. PASSOR is the physiatry equivalent of ISIS and their injection techniques and stratification levels were initially based on many of the ISIS techniques.
ASIPP offers a series of cadaver courses that are rather packed with many physicians per cadaver. They have developed their own practice guidelines independent of other organizations. The techniques they teach range from basic to intermediately advanced and they also have loosely defined the workshops into stratifications. Part of the emphasis in the ASIPP organization is politically motivated.
SPPM offers 3 cadaver workshops each year with some of the workshops being 4 day cadaver workshops. The SPPM experience is comprehensive with a billing/coding/legal/lecture session either preceding or following the cadaver course. The non-cadaver sessions run from 7a to nearly 10p at night with injection workshops and RF workshops being provided outside the cadaver sessions. This year for the first time, selective endoscopic discectomy is being taught with a combination cadaver sessions and didactic sessions for only the most advanced practitioners. The cadaver courses are constantly being updated with non-reimbursed techniques being dropped.
ASRA offers a small cadaver course and I believe the American Academy of Pain Medicine also offers cadaver courses. There are a few commercial cadaver courses (for profit), such as IPI, but I do not know the quality of such.
For a listing of courses coming up, see the conference listings on this website

 

[lobelsteve]

Fellowship training in an accredited program should be your only consideration in learning these peocedures. Unless you are a Ortho spine surgeon or Neurosurgeon, you cannot become an implanter by taking a weekend course.

Think about how you will defend yourself in court when you have a complication from a simple CESI. What ground do you have to stand on.

Just go get the training- it is only 1 year.

 

[Aether2000]

If fellowship training were of consistent quality or would guarantee the appropriate implanting skills be acquired through sufficient numbers of implants, then I would agree. However, with fellowship training all over the map with respect to what is taught and how many implants are performed by the resident vs the attending, I would strongly disagree with a carte blanche statement that fellowship training would yield adequate skills. As an instructor for ISIS, ASIPP, Codman, PASSOR, and SPPM, I will assure you fellowship training in pump and stim implants is inconsistent to the point that a weekend course may actually give more training than an entire one year fellowship training program. How do I know? I train those who have received inadequate training or the absence of training in fellowship programs. So it would be prudent not to throw away a year of your professional life in mediocre fellowship training programs. When interviewing for fellowship programs, don't ask the instructors or program directors about pumps and stims. Ask the CURRENT fellows how many pumps and stims they have been involved with the surgical implantation (not simply the lead placement or catheter trials), what percent of the implants had the fellow performing the majority of the case including the crucial areas such as lead anchoring and pocket development, and whether the surgeons (neuro, ortho, or general) are involved with the implant procedure. If the fellows projected over a year are involved with less than 15 pumps and less than 15 stims, and if the fellow does less than 10 as the primary operator, or if surgeons are routinely involved with the implants (eg surgeons do the pocket or surgeons do the lead implants), forget those programs and find a useful pain program. If the fellowship does not teach the resident to physically do the programming of these devices then you will be poorly educated on matriculation from such program. Pain fellowships are not fungible, and may not offer the needed elements of educational experience to develop even the basal skills necessary for placement of implantable devices. Caveat emptor!

 

[drrinoo]

ISIS workshops are a graduated series of increasingly technical and risk laden techniques that are taught using standardized protocols. The groups are small (usually 4-6 per cadaver), the quality is excellent of the physician instructors, and the experience is very concentrated in techniques of one type or regional area of anatomy (eg. Level I is lumbar injections). The physician must be proficient in one level in order to advance to the next. In all, there are approximately 7 levels and ISIS does teach a workshop on pumps and stim implants. If you do things the ISIS way (Practice Guidelines) you will have the most optimal chance of having a procedure actually work. ISIS courses fill up quickly and one may have to wait for up to 6-9 months to get into the course of choice (upper level).
PASSOR has techniques divided into 3 levels and offers similar experience relative to ISIS minus the intensity of techniques. (for example, ISIS offers a single cadaver course on RF of the spine that includes SI, medial branch, thoracic, splanchnic, etc. while PASSOR offers the more bread and butter cervical and lumbar medial branch. The PASSOR RF is included in Phase III which includes other injection techniques. PASSOR has some of the finest instructors I have ever met. PASSOR is the physiatry equivalent of ISIS and their injection techniques and stratification levels were initially based on many of the ISIS techniques.
ASIPP offers a series of cadaver courses that are rather packed with many physicians per cadaver. They have developed their own practice guidelines independent of other organizations. The techniques they teach range from basic to intermediately advanced and they also have loosely defined the workshops into stratifications. Part of the emphasis in the ASIPP organization is politically motivated.
SPPM offers 3 cadaver workshops each year with some of the workshops being 4 day cadaver workshops. The SPPM experience is comprehensive with a billing/coding/legal/lecture session either preceding or following the cadaver course. The non-cadaver sessions run from 7a to nearly 10p at night with injection workshops and RF workshops being provided outside the cadaver sessions. This year for the first time, selective endoscopic discectomy is being taught with a combination cadaver sessions and didactic sessions for only the most advanced practitioners. The cadaver courses are constantly being updated with non-reimbursed techniques being dropped.
ASRA offers a small cadaver course and I believe the American Academy of Pain Medicine also offers cadaver courses. There are a few commercial cadaver courses (for profit), such as IPI, but I do not know the quality of such.
For a listing of courses coming up, see the conference listings on this website

algos, you have made a nice summary of cadaver workshops and their relative pros/cons...

I, however, take issue with your strong support of ISIS being the way to go....

ISIS represented a very important contribution to our understanding of spinal pain disorders back when it was created in the early 1990s....it took control of this middle ground in spine care. This middle ground, between conservative care and spine surgery, was at the time controlled by the non-fluoro kings and queens who worshipped the blind ESI.

They were able to integrate an advanced understanding of spinal anatomy, spinal pathophysiology (phospholipase A2, metalloproteinases, annular tears, etc..), and imaging into developing a body of procedures that believed in site specific delivery of various medications....and as of late they began incorporating evidence....


Unfortunately, over time, they have deteriorated into a very narrow minded and extremely opinionated group of individuals who have clung to an anatomic/structural view of spine pain...who have not realized how much pain neurobiology has advanced in the preceding 10-15 years.

If you look at other pain conditions, such as headache, chronic pelvic, chronic neuropathic pain, chronic abdominal pain, fibromyalgia...both clinicians and scientists have held hands and have significantly advanced their understanding of these respective disorders...and their clinical journal and clinical papers demonstrate a healthy respect for how little we know in these other pain disciplines...

Unfortunately, spine specialists have dominated the spine literature and this has been dominated by an anatomic and structural approach to spine disorders...fortunately, more and more papers are beginning to look at spinal pain as a visceral/neuropathic pain condition...

The anatomic/structural hemming and hawing...have failed to help the vast majority of spinal pain syndromes...as far as I am concerned, site specific spinal injections simply serve to deliver the minimal effective dose of drug/neurolytic in the hopes of minimizing side effects, reducing oral/parenteral medication use, and facilitating compliance with functional restoration

Spinal injections are not a crystal ball into elucidating the inner workings of spine pain...at best they are a first approximation and in their current form, may be obsolete in 10-15 years

I wish ISIS would realise that Descartes views on pain became obsolete a long time ago...pain is not a simple circuit relay to the brain that can be interrupted at its point of origin.

ISIS has promulgated and supported some concepts that have a lot to be desired and are probably wrong: comparative local anesthetic blocks, 'transforaminal' safe zone, internal disc disruption as a discrete nociceptive entity, diagnostic validity of selective spinal injections,for example....they have also avoided discussions of catheter techniques...additionally they state their techniques are the only way to go...

Regional anesthesia, as a field, has advanced and has recognized that there are many ways to reach the same endpoint...Raj's classic infraclavicular block or the classic Labat sciatic nerve block or the Winnie ISB now have several variations of each, these have been published over the past 10 -15 years..anesthesiologists have embraced these new changes...e.g., Boezaart's approach to the ISB, parasacral approach to the sciatic nerve, the coracoid approach to the infraclavicular

Regional anesthesiologists acknowledge that there are no standard approaches to doing these blocks and have adopted new methods over time....if ISIS demands that everything be done their way...they fail to understand how there could be several permutations of techniques to reach the same endpoints: pain relief and safety.

You all should keep an open mind in our new specialty (interventional pain) and especially with the diverse specialty representation, there should be discussions about innovation rather than criticisms about wrong versus right..

 

[Aether2000]

My understanding of ISIS is that it is not exclusionary to other methods, but rather is chipping away at one part of interventional pain medicine,attempting to define the science behind certain approaches. The ISIS Guidelines represent an enormous effort to that effect, but do not presuppose theirs is the only acceptable or correct method. The use of the guidelines (with which I obviously disagree with in part) reflects the desire of the individual to first learn these approaches that will optimize the potential outcomes, especially in the neophyte injectionist. It is interesting at the upper end of ISIS techniques how the science is not yet developed and there is far more disagreement than agreement in these techniques. The SPPM course have started using ISIS Guidelines as the approach to be taught initially, but not exclusively.
Many of the major pain medicine organizations do not give proper emphasis to non-injection techniques for pain control or to the very real issues in pain that cannot be solved by needles. I am working on ISIS to expand these horizons....

 

[drrinoo]

algos,

point well taken...the neophyte injectionist should have some introductory didactic structure...and anatomy/physiology/imaging with guidelines based on these concepts is important...


...but when practitioners become dogmatic in their views and believe they understand spinal pain based on their selective readings of the literature and conversations with colleagues...it is hard to stomach...especially if they demand all practitioners practice their way

I have had a number of epiphanies at times (having been faculty only for 3 years) with the realization that the plethora of pain practitioners have only helped a minority of patients, that pain and pain management are vastly complex-we will never understand it within our lifetimes, and that oversimplification of a complex entity should only be used for instructional purposes....injections in my view, if they are safe, play a complementary role to any other intervention....what I call...'Reducing the afferent nociceptive burden...RANB'...whether RANB occurs secondary to placebo or not...doesn't matter, as long as your intervention is safe.

pain is a subjective experience and assessment depends on the patient's report (barring any miraculous advancement in functional neuroimaging or identification of a CSF/ serum biomarker)....the use of EBM to study pain interventions is too premature and the use of VAS/outcomes not sensitive enough to determine if a patient has done well....

as a digression, apply Evidence Based 'Medicine' to other sociological problems where the outcomes are completely subjective:

evidence based real estate....how do you prove that house A is better than house B...and how do you present this information to a potential house buyer to make an informed decision

evidence based politics....how do you prove that law A is better than law B or that allocation of monies for project A is better than project B....

evidence based plumbing...how do you prove that the use of a jackhammer is needed to investigate every case of a slab leak...isn't this intervention too expensive?

evidence based beer drinking....a randomized placebo controlled double blind trial demonstrates that St. Pauli Girl beer is more satisfactory than Rolling Rock....it was a tough study to perform, because the ethics committee had to ensure that minors were not allowed to drink beer, that participants would not drive a vehicle, that enrollees were adequately informed about the consequences of drinking such as cirrhosis...in a letter to the editor, one researcher commented that the trial investigators did not control for patients being drunk and not being able to communicate their preferences...in fact, there were several dropouts from the study because they were passed out and could not finish the exit interview

evidence based techniques, when applied to a complicated sociological problem (pain), are not informative....unless you simplify the model you are using....ie., spine pain is an anatomic entity...in this scenario, it is hard for me to accept, in an unselected sample of patients with back pain, to have exclusively SI pain, facet pain, disc pain, epidural pain...and if they don't fall into these categories...then there are non-specific factors..

let us be honest with ourselves...patients are not dumb...we as pain/spine physicians are....


it is fortunate that ISIS is now using the term guidelines...but historically (correct me if I am wrong) they used the term standards....the use of the term standards implies that physicians know it all...this is not a rhetorical semantic debate...because deviation from guidelines versus deviation from standards are mean two completely different things..

for instance, if the consensus conference on IT granulomas came out and said that the standard practice for managing this condition is surgery...then any deviation from this practice would constitute malpractice...but they didn't...rather they presented a balanced review of the literature and provided guidelines for managing this condition, surgically and non-surgically...

remember malpractice lawyers are always on fact finding missions and any signs of impropriety can build a case that the practitioner is incompetent on many levels...so if you perform a lumbar transforaminal with a low posterolateral approach (akin to the discogram approach) which is not the method ISIS advocates (they advocate the 'safe triangle' approach)

if a group of physicians mandates that we have figured out a certain pathological condition (e.g., spine pain), the rest of society will believe us...it is better to admit that we don't know, rather than saving face and pretending that we have it all figured out.

 

[drdatta]

The back and forth between drrinoo and algos make fascinating reading. Algos's defense of ISIS probably reflects that he has an axe to grind with that particular society---maybe it is because he is an instructor for multiple courses given by ISIS.

ISIS again focuses only on the spine. To give a brief history, ISIS was called the International Spinal Injection Society, where the only aspect was spinal injections. The society is now called the International Spinal "INTERVENTION" society. Again the focus is the spine, and to "the hammer everything looks like a nail"

ISIS toutes its evidence based approach, but it forgets that the "spine" is only one of the ways the body perceives pain, and to be really relevant to the science of Pain Management, they need to have a holistic and all encompassing approach-- Perhaps it is time for them to consider a change in name again from International Spinal Intervention Society to International Society of Interventional Pain Physicians.

Finally, a disclosure. I am a member of ISIS for several years and have attended mostly all their courses. I have learnt a lot from the courses, but have been at the same time alienated by the "myopic" vision of ISIS.

algos,

point well taken...the neophyte injectionist should have some introductory didactic structure...and anatomy/physiology/imaging with guidelines based on these concepts is important...


...but when practitioners become dogmatic in their views and believe they understand spinal pain based on their selective readings of the literature and conversations with colleagues...it is hard to stomach...especially if they demand all practitioners practice their way

I have had a number of epiphanies at times (having been faculty only for 3 years) with the realization that the plethora of pain practitioners have only helped a minority of patients, that pain and pain management are vastly complex-we will never understand it within our lifetimes, and that oversimplification of a complex entity should only be used for instructional purposes....injections in my view, if they are safe, play a complementary role to any other intervention....what I call...'Reducing the afferent nociceptive burden...RANB'...whether RANB occurs secondary to placebo or not...doesn't matter, as long as your intervention is safe.

pain is a subjective experience and assessment depends on the patient's report (barring any miraculous advancement in functional neuroimaging or identification of a CSF/ serum biomarker)....the use of EBM to study pain interventions is too premature and the use of VAS/outcomes not sensitive enough to determine if a patient has done well....

as a digression, apply Evidence Based 'Medicine' to other sociological problems where the outcomes are completely subjective:

evidence based real estate....how do you prove that house A is better than house B...and how do you present this information to a potential house buyer to make an informed decision

evidence based politics....how do you prove that law A is better than law B or that allocation of monies for project A is better than project B....

evidence based plumbing...how do you prove that the use of a jackhammer is needed to investigate every case of a slab leak...isn't this intervention too expensive?

evidence based beer drinking....a randomized placebo controlled double blind trial demonstrates that St. Pauli Girl beer is more satisfactory than Rolling Rock....it was a tough study to perform, because the ethics committee had to ensure that minors were not allowed to drink beer, that participants would not drive a vehicle, that enrollees were adequately informed about the consequences of drinking such as cirrhosis...in a letter to the editor, one researcher commented that the trial investigators did not control for patients being drunk and not being able to communicate their preferences...in fact, there were several dropouts from the study because they were passed out and could not finish the exit interview

evidence based techniques, when applied to a complicated sociological problem (pain), are not informative....unless you simplify the model you are using....ie., spine pain is an anatomic entity...in this scenario, it is hard for me to accept, in an unselected sample of patients with back pain, to have exclusively SI pain, facet pain, disc pain, epidural pain...and if they don't fall into these categories...then there are non-specific factors..

let us be honest with ourselves...patients are not dumb...we as pain/spine physicians are....


it is fortunate that ISIS is now using the term guidelines...but historically (correct me if I am wrong) they used the term standards....the use of the term standards implies that physicians know it all...this is not a rhetorical semantic debate...because deviation from guidelines versus deviation from standards are mean two completely different things..

for instance, if the consensus conference on IT granulomas came out and said that the standard practice for managing this condition is surgery...then any deviation from this practice would constitute malpractice...but they didn't...rather they presented a balanced review of the literature and provided guidelines for managing this condition, surgically and non-surgically...

remember malpractice lawyers are always on fact finding missions and any signs of impropriety can build a case that the practitioner is incompetent on many levels...so if you perform a lumbar transforaminal with a low posterolateral approach (akin to the discogram approach) which is not the method ISIS advocates (they advocate the 'safe triangle' approach)

if a group of physicians mandates that we have figured out a certain pathological condition (e.g., spine pain), the rest of society will believe us...it is better to admit that we don't know, rather than saving face and pretending that we have it all figured out.

 

[Aether2000]

I am indeed an active instructor for ISIS, PASSOR, SPPM, and less active teaching in other organizations. The critiques of ISIS are valid, but in the global view of pain medicine, there is not a singular organization that reflects what I do on a daily basis, and therefore it is often necessary to have feet in several arenas at the same time. I do not view the approaches from each organization as exclusionary, but rather complementary. SPPM tries to do everything, offering an expansive overview of pain plus HIPPA, office management, coding, and cadaver courses, but does not provide the focused intense of training of ISIS or to a slightly less degree, PASSOR. AAPM does little in the way of cadaver workshops, but is an excellent overall organization for pain. ASIPP is politically motivated with their own PAC and does much for the reimbursement side of pain medicine. Their journal has improved markedly over the past 2 years yet lacks listing with the NLM indexing system. WIP is more of an international organization with a focus on certifying aptitude in pain management. But as you can see in the conference listings at www.algosresearch.org there are many many other worthy organizations with a different viewpoint of pain. The international intradiscal therapy society, spine arthroplasty society, american back society, american neuromodulation society, and NASS (heavily dominated by surgeons) all have their spin on pain, but all have valuable research to contribute to the field. Even the APS and their psychologists/rat doctors offer profound insights as to basic science, the molecular basis of pain, and psychology of pain. So in effect, it is valuable to have membership in several organizations that are predominately pain medicine, as we do not have a single voice in pain medicine, nor do we have a unitary approach. Waxing eclectic while extracting the best attributes and information out of each organization is a useful way to approach the manifold societies with often contradictory approaches to pain.