VERY INTERESTING - DR. FILLER'S OFFICE ON MRN VS. 3T

[HerMajesty]

2009_MRN-DTI_5000_Neurosurg.pdf

above is PDF article about MRN sent to me by Dr. Filler's office

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Hi all,
I had a post in the "case updates" section which led me to send an inquiry to Dr. Filler's office about the MRN I got in May. In the answer back, the staff member of Dr. Filler's office argued at length about the superiority of MRN to 3T, and attached a PDF article on the subject as well. I am going to cut and paste the exchange verbatim below, and have attached the PDF as well to this post. I am NOT taking any stance whatsoever on the benefits of 3T vs. MRN but thought this info would be very informative to anyone trying to make a decision about whether to do 3T or MRN. Of course keeping in mind this is one-sided, and there is I am sure an argument for the 3T as well. Again my disclaimer is I am not in any way well informed on this subject but just want to share what Dr. Filler's office is saying on this matter.

My email inquiry to nervemed (Dr, Filler's office):

Hello, I had an office visit & MRN there in May, I believe the 12th The recommended treatments I elected to get locally in-network. I would like this question called to the attention of Dr. Filler please. I just had an impar ganglion injection, and post-procedure the Dr. showed me a film from the fluoroscopy, which showed the med had trouble infusing past S2, not surprising to me as I have known patholgy there, and past the tip of the coccyx, for which I do not have an explanation. He commented there could be scar tissue in this area and nothing was noted there on MRN. I am at this point wondering if I have scar tissue in the pelvis not noted on MRN and if I should be getting a 3T scan. However it also occurred to me, that maybe the MRN showed scarring at the coccyx and that Dr. Filler did not note it on report because it is a common beneign result of child birth. I am wondering if this can be clarified to me, the MRN looked at and any evidence of something at the tip of the coccyx noted. This would help me make a decision as to whether the MRN gave me sufficiient data, or whether I should be pursuing a 3T scan. Thank you very much.

Response from Dr Filler's staff (plus PDF article was attached):

thank you for your status update regarding your in network treatment planning. We can certainly clarify the soft tissue MR Neurography and indicate scar tissue in all known image views. I will have the Neurography Coordinator go over the image files with Dr. Filler and provide any updates as needed. However, I did want to take the opportunity to clarify a couple of misconceptions taht seeme apparent in your email. The 3T MRI is not a better quality MRI scan for peripheral nerve and soft tissue injury. While it utilizes a larger magnet, it does not provide the same image detail as MR Neurography due to our patented method and formatting process. It is not just a simple mattter of putting raw data into a larger magnet, rather MR Neurography affords nerve imaging details which are actually best viewed by a smaller (1.5) magent that slows down the gradient and provides a higher field of resolution to the actual nerve and soft tissue details. 3T MRI will not be more detailed than MR Neurography and in fact the opposite is more likely to be true in that the components of specialized protocol and 3D formatting will be missing from the 3T scan.

Simply put CT and Fluoroscopy are not the best means for clinical diagnosis or treatment for soft tissue injury or peripheral nerve conditions so it would really not be an accurate statement to say that you are pursuing the treatment options that we recommneded. We do not recommend Fluroscopy injections and while many patients choose to go through with these injections because they are in network, it should be underscored that these are not standard of care injections for soft tissue injury or peripheral nerve issues rather these types of injections are orthopedic based for interventional standards and are simply a less expensive and less accurate means for treatment. It is a shame that many patients do not attempt to apepal for out of network coverage for the Interventional MR treatments provided here in southern California. Almost every patient who does is so pleased post procedure and we have patients from all over the United States who are simply amazed and grateful that they were able to complete the procedure. We get emails saying it was "life changing" or how happy they are to "finally be pain free" and that this was the first intervntional treatment that alleviated the pain symptoms.

Conversely, the Fluoro unit uses x-ray radiation for guidance which means that it must guide according to the bone. Because of the high dosage of radiation, the doctor must leave the room during imaging which negates ‘the putting your finger right on the spot’ method of accuracy, then the doctor has to come back into the room guess or estimate how far away the nerve or muscle is is based upon the x-ray images and inject the general area hoping that he is close to the muscle and that there is some effect. The fact that the fluroscopy unit can not see scar tissue is a red flag as to the clinical efficacy of it use for soft tissue treatment, the accuracy is not even close to real time guidance under Interventional MR. Also with magnetic resonance there isn’t the radiation concern that there is with fluoroscopy. You should consider that these are high dose x-ray emissions to your pelvic region which may result in secondary medical issues later. Additionally, because there isn’t any soft tissue (i.e. muscle) visible through fluoroscopy you will likely be asked to complete a series of injections where there is an inherent risk of the needle being advanced into the wrong area because this is a ‘blind’ injection.

Based on the real time accuracy of magnetic resonance for soft tissue guidance and MR Neurography for detailed imaging, we have built this practice and have set the gold standard for medical care in this field. The fact that patients who have had fluoroscopy guided and CT guided injections come to us years later without relief is a prime indication that they need MRN and IMR to confirm the diagnosis. The bottom line question is to ask the provider is, “if there is no visualization from fluoroscopy injection then how do you even know you have the right spot?” Trying to ask us to provide the answer in an indirect thrid party manner is not a very efficieint or accurate means of targeting the area especially if the equipment being used does not have the same viaul capacity for targeting treatment With x-ray guidance they simply do not know what they are going until they are in there and have advanced the needle. Our method allows us to do this beforehand, keeping things narrowed down to the exact location of pain symptoms.

I hope that this helps and do not want to unnecessarily alarm you but I do believe that patient education is essential and that many patients are simply unaware of the risks of x-ray based injections. Basically, the reason why we have such a long history of success in this field is because our method allows for an approach taking into consideration any nerves, nerve roots, or scar tissue that are seen from the MR Neurography. The Interventional MR uses the same magnetic resonance for guidance which unlike CT or Fluoroscopy is much more accurate, consequently, the neurosurgeon can pinpoint the exact location for the needle and then target the approach to make the least amount of disturbance to the surrounding tissue elements. He never has to leave the room because there isn’t any harmful x-ray hence he can literally talk with the patient, put his finger on the spot, and then using the MRN and IMR images guide the needle. It is the difference between treating a patient blindly and waiting to see what you have once you get there versus knowing exactly where you are going and what you will encounter along the way. And if money was the primary reason for not pursuing Imterventional MR procedures in our center at the very least an appeal for in network benefits from the insurance plan to try to minimize the patient out of pocket concerns could have been completed by our Interventional Patient Coordinator so that the standard of care is not compromised. If there is any further information that I can provide that will help in your research for care, please let me know.

(I also attached the PDF sent along with this)

my response this evening, will let you know reply when I hear something:

Thank you for your prompt response. I would certainly appreciate any clarification Dr. Filler can give me about this issue. If it would help, I can scan and attach the fluoroscopy pictures which show what my Doctor was concerned about. Let me know if that would be helpful.
I have chosen not to battle my insurance for coverage for the care suggested by Dr. Filler, because from my own research I believe my remaining symptoms correlate very well with the S2 tarlov cysts found on the MRN, which I was advised by your office should probably be disregarded. I understand treatment for tarlov cysts is rather experimental and risky; and therefor after getting the necessary consultations on this issue I might choose to decline treatment and live at my current level of function. However as far as the piriformis and obturator internus injections (I have already had these done with steroid, which did not relax the muscles, and so am waiting for approval for botox), and possible impar ganglion injection, recommended in my consult with your office, I consider this to be "trying stuff just in case", and am skeptical that any of it will be curative. therefor I have chosen not to make the investment of time and money for out of town / out of network care. I do appreciate Dr. Filler's expertise but am ultimately responsible to manage my own care and use my own best judgement in managing my resources.
I sought out the MRN believing that it would show definitively whether the pudendal nerves were entrapped in scar tissue; however in my phone consult after the MRN was read, I asked if there was scar tissue entrapment and this was addressed in vague terms by the NP: She seemed to suggest that this was still unknown but might be visualized during perfusion of med into the tissue, if I returned to Dr. Filler for piriformis injections. I brought up the 3T because I have heard patients who got it, received reports which definitively identified scar tissue. This is what I had thought I was getting with the MRN. I am by no means an expert on imaging tests, and in fact am very aware of their limitations as I have been helped most so far in this process by correction of pelvic joint dysfunction, which is rarely visible on any kind of imaging test.
I would certainly like a clarification, of whether my MRN shows scar tissue, rules out scar tissue, or cannot determine whether or not there is scar tissue.
Thank you very much.

[A's Mommy]

Hermajesty,

You just plain out rock. You go get 'em.

So intrigued by their first response too... I'd love to see a debate between Filler and Potter.

I can't comment on Filler directly because I've never had his MRN but I do know that Dr. Potter is highly regarded in her field.

Have any of Dr. Filler's MRN findings correleated with his surgical findings?

[AliPasha1]

Hi,
I think Dr. Filler has answered the question himself.Any 3 Tesla MRI scanner or radiologist won't be able to do that.It has to be a specially patented method and formatting process or as we call it "model tuning "in Electrical Engineering.That has exactly Dr. Potter and her team has done at Hospital for special surgery in New York City for 3 Tesla MRI machines specifically for the Pudendal Nerve or any other smaller nerves.
As far as being 1.5 Tesla be better than 3.0 Tesla seems untrue as regards to Electrical Engineering concepts.
I think Ezer could shed more light on it as far as Electrical Engineering goes,because he used to work on Imaging.In fact he was a VP of a imaging company.
My speciality is DSP and telecommunications Engineering.I almost flucked my electromagnetics class.

Best Regards,
Ali

[ezer]

Hermajesty,
Great thread!

Alipasha,
You are too modest! I am sure you did fine with those Maxwell equations!
Let me first of all say that the MRN is not a gimmick. I read Dr.Filler's original patent and it is totally valid. it is really an interesting invention. It is a standard MRI but the specific burst of signals sent to the coils manage to discriminate and visualize nerves during the post image processing phase.
The 3T MRI has twice the magnetic field. it allows for faster scans ($$$) and also gives a better contrast of the images because of the higher signal to noise ratio (SNR). I know that the 3T MRIs do have some drawbacks as they create sometimes artifacts that have to be dealt with (maybe it is what Dr.Filler is referring to).
I am not familiar with Dr.Potter's technique to show the nerves so before writing something stupid, I should better do a bit of research.

[Griff522]

This is very interesting indeed.

I just talked to the radiologist today that read my 3T MRI and she says the nerve and ligaments are still very tiny and hard to read. She couldn't tell if there was entrapment unless the nerve was damaged or something of the like. I may consider a trip to Dr. Filler. I really want to know what is causing the pain!

[AliPasha1]

Hi Grif,
Please proceed with Dr. Potter's 3 Tesla MRI or Dr. Michael Hibner for the MRI.Dr. Olga Kalinkin MRI report (She does Pudendal Nerve MRI for Dr. Hibner)exactly correlates with Dr. Potter's findings.He does value Dr. Potter's input.
In addition,Dr. Hibner has also stated that the ligaments are very important for Pelvic Stability.The rest is upto you whatever you decide.
Dr. Filler's MRN isn't very accurate.

All the Best,
Ali

[Charlie]

Dr. Filler's MRN isn't very accurate.

I can understand this thread and I think its a very good debate to have. It's a question people are bound to ask. However I think theres a danger that we are saying that Potter and Filler are against each other. I don't think that is the case at all. Yes they will prefer their own technique but I am sure they are both respectful of each others developments.

[ezer]

Griff522
Dr.Filler pointed to me on the screen the normal and suspicious areas from the MRN before surgery. It looks like the MRN correlated quite well with what was found during surgery.
He has turned away people from surgery because the MRN was completely normal.

[HerMajesty]

Griff, there are MRN centers around the country; all are read by Dr. Filler but FYI if you do not live in his area, you can access the MRN someplace geographically closer to you. You do not need to see him to get the imaging test done.

[ezer]

Good point. The list is here.
http://www.neurography.com/locations
Again it is a completely standard 1.5T MRI. The difference is the special stream that is sent to the coils. The raw data is then transfered back to Dr.Filler's office for computer analysis and image processing. Finally Dr.Filler reviews the result.

But I think it is very important to note that the MRN is there to help make a decision whether to have the surgery or not and if yes whether it will be unilateral or bilateral. During the surgery, Dr.FIller checks and decompresses all the known entrapment locations. It is not because a location looks normal on the MRN that Dr.FIller is going to ignore it.