Diagnostic Imaging
October 2003

SONOGRAPHY

Musculoskeletal ultrasound muscles into MRI territory

With a little patience and persuasion, referring physicians will appreciate and respond to modality's value

Mike is an aging weekend warrior who plays various sports as if he were in the major leagues. Like many athletes, he lives with intermittent low-level chronic pain, considering it an acceptable price for competitive glory. But the pain eventually begins to impinge on his athleticism, and he seeks counsel from Dr. John McShane, a sports medicine physician in the Philadelphia suburbs. Like many professional and amateur athletes, Mike immediately rules out surgery as an option.

The doctor prescribes physical therapy, rest, and medication. The pain persists. Next come the cortisone shots. No relief. Mike is about to join a group of patients who, having discounted surgery, will live with pain for the rest of their lives-except that McShane refuses to let these baby boomers go that route.

McShane wonders if it is possible to get inside the tendons and ligaments and break up the scar tissue, thereby allowing buoyancy back into a crippled tennis swing or a hobbled basketball layup. His search for answers leads him to Dr. Levon Nazarian, who has been steadily gaining a reputation in and around Philadelphia for his work in musculoskeletal ultrasound. McShane describes his small group of patients who do not respond to conservative therapy. He brings Mike to Thomas Jefferson University Hospital where Nazarian directs the proper placement of the needle for an injection. For the first time in years, Mike has no pain.

McShane and Nazarian become a team, using each other's strengths to heal and relieve pain. They also succeed with McShane's idea to use an ultrasound-guided needle to break up calcification and scar tissue. Fast forward four years: McShane and Nazarian have treated over 500 patients and are receiving worldwide media attention.

They presented a study at the 2002 RSNA meeting that documented a 65% success rate for 246 patients treated with ultrasound-guided percutaneous debridement and corticosteroid injection. These patients, who were resistant to conservative management, had a range of pathology that included tendinopathy, tendon tear, muscle tear, bursitis, tenosynovitis, ligamentous injury, and plantar fasciitis. The most commonly affected anatomic areas were the common extensor tendon at the lateral elbow and the patellar tendon. Needle placement was successful in all cases, and all injections were documented in real-time, according to the lead investigator Dr. James Traiforos, a resident in radiology at Thomas Jefferson University Hospital. Average procedure time, including diagnostic ultrasound and treatment, was about one hour.

Nazarian, chief of musculoskeletal ultrasound at Jefferson, believes that the procedure encourages blood vessels to enter the area and enables the body to dissolve scar tissue and lay down new, healthier tissue. After the procedure, stretching and physical therapy encourage this tissue to become more elastic and lengthened, enabling the tendon to function more normally.

"It is simple in concept, and it's helping bring patients along the path of recovery," he said. "Once we see the abnormality on the ultrasound, we can make a diagnosis right away and tell exactly what is wrong. And we can treat the problem immediately."

MAKING MONEY

Nazarian says there is enough room in musculoskeletal imaging for MR and ultrasound to exist side by side. Sometimes an MR scan is negative, while an ultrasound is positive, and the reverse can also occur. But ultrasound has several advantages over MR that enable Nazarian to sell it to referring physicians. First, ultrasound allows a dynamic evaluation of tendons and ligaments. Nazarian often sends videotapes of ultrasound scans to surgeons, because the injury can only be seen in stress.

Second, ultrasound allows radiologists to perform immediate interventions when applicable. Both ultrasound and MR can image a Baker's cyst, for example. But a practitioner like Nazarian can call the referring physician and offer to aspirate the cyst on the spot, giving him an interventional as well as a diagnostic billing. In addition, he has brought a patient into the hospital system who might not otherwise be there.

"Philadelphia is a hub of quality healthcare centers, and I get referrals from all over the city. The next time a musculoskeletal patient needs a chest x-ray, he might think of Jefferson because of his experience," he said.

All the diagnostic ultrasound procedures and most of the interventions are reimbursable. A simple injection has three codes: diagnosis, injection, and guidance of the injection. The more innovative ultrasound-guided debridement is not specifically covered, but it can be billed under a code for percutaneous tenotomy. McShane performs these procedures-the patients are mainly his-with supervision by Nazarian. McShane submits a bill, which invariably gets rejected. He then negotiates a price with the carrier. At some point, probably after the publication of a peer-reviewed article reporting on the use of musculoskeletal interventional ultrasound in the general population, which shows the procedure's efficacy, the duo will petition the government for a separate code.

"We're hoping that since our procedure is less expensive than surgery, insurance companies will welcome it because it saves them money," Nazarian said.

WEANED ON MR

MR has all but cornered the soft-tissue diagnostic market, so building a viable musculoskeletal ultrasound practice was not easy for Nazarian. In fact, the work continues: Thomas Jefferson's public relations department recently embarked on a mass-market promotion of Nazarian and musculoskeletal ultrasound. Dr. Vijay Rao, the radiology department chair, believes Nazarian is doing pioneering work.

"Not only is musculoskeletal ultrasound unique, but it is also cost-effective because it replaces some diagnostic MR procedures," Rao said. "If we educate referring physicians, they can then channel patients to get the right imaging study, MR or ultrasound."

Combing through Medicare databases from 1996 to 2000, Jefferson researchers found that musculoskeletal imaging in general is increasing gradually, while the costs are rising more sharply. They project an overall utilization increase of 3.7% in 2010, compared with a projected 40% rise in cost, mainly driven by the increase in musculoskeletal MR.

"One way to reduce costs would be to replace musculoskeletal MR with ultrasound," Nazarian said.

Such a switch could save Medicare up to $162 million in 2010, according to the study, which was presented at the 2002 RSNA meeting.

Nazarian's work has Rao and others at Thomas Jefferson discussing the creation of a sports medicine imaging center. But you would have been hard-pressed to find evidence of such momentum 10 years ago, when Nazarian knew nothing about musculoskeletal ultrasound. It just happened that a course brochure caught his attention. Inside the pamphlet were many familiar names among the lecturers, including Dr. William D. Middleton of the Mallinckrodt Institute of Radiology.

"Here were these major players in the field endorsing a discipline I essentially didn't know existed," Nazarian said. "It was an eye-opener. I told myself, 'If it's good enough for them, it's good enough for me.'"

He began scanning healthy volunteers to learn about normal tendon appearance and thickness, and slowly he refined his technique. As he met clinical colleagues, he preached about musculoskeletal ultrasound and suggested that they send him patients contraindicated for MR. One by one, podiatrists, orthopedic surgeons, and others did send those patients. Satisfied with the results, they sent more.

"There was one orthopedic surgeon who never gave me feedback. When I asked if he liked what I was giving him, he said, 'The only thing I don't like is that you're not down the hall from me.' That meant a great deal to me because surgeons are demanding," Nazarian said.

But the going was still rough. Older physicians, accustomed to using MR for musculoskeletal evaluation, were reluctant to recommend ultrasound. MR scans bring in more dollars than ultrasound, and some institutions could not afford to lose those funds. But Nazarian believed there was enough musculoskeletal room for both modalities.

"I'm promoting ultrasound for the procedures for which it's as good as or better than MR," he said. "We're not trying to replace musculoskeletal MR with ultrasound. We think the two are complementary."

But converting others to that belief was a daunting task. Nazarian promoted musculoskeletal ultrasound in lectures, papers, grand rounds, and at national meetings. He talked with MR musculoskeletal colleagues who had their own contacts with orthopedists, suggesting that they consider ultrasound for certain indications. Simultaneously, the literature of other disciplines began to fill with studies touting the benefits of musculoskeletal ultrasound. As rheumatologists, orthopedists, podiatrists, sports medicine physicians, and chiropractors sought musculoskeletal ultrasound expertise, all roads in Philadelphia led to Nazarian. Bit by bit, he built up a practice.

Next, he wants to talk directly to patients, informing them that ultrasound is an effective alternative to MR. But all the patients in the world will not matter if other radiologists do not learn musculoskeletal ultrasound. Nazarian currently teaches the art of musculoskeletal ultrasound to more nonradiologists than radiologists. He believes this is a dangerous trend.

"Musculoskeletal ultrasound is here to stay. Whether it's in the hands of radiologists is completely up to them," he said. "Surgeons and sports medicine physicians already scan patients. And why not? Why should they wait three weeks for an MR when they can perform ultrasound in their offices and bill for it?"

PLAY BALL

McShane, who is one of the team physicians for the Philadelphia Phillies, has recruited Nazarian to study baseball pitchers. Pitchers often throw until they hear a "pop," at which time they have a serious injury to address. The two researchers wondered if pitchers show early signs of degeneration. In 2001, they scanned all the Phillies pitchers during spring training, looking specifically for laxity in the ulnar collateral ligament, the main stabilizer in the elbow. They found that the tendon is thicker in the pitching arm compared with the nonpitching arm and that about 35% contained calcifications. In addition, when valgus stress was applied, the pitching arm joint opened up to a greater degree. The study was published in Radiology in April (2003;227:149-154).

"The only way to determine the elasticity of the ligament is by stressing the joint to see how much it gaps under real-time imaging," Nazarian said. "MRI can determine whether the ulnar collateral ligament is torn but cannot see whether the ligament is tight or lax."

The researchers have many questions that, when answered, may affect the multibillion-dollar sports industry. Do asymptomatic pitchers with abnormal-looking ligaments perform worse in the long run than those whose ligaments look pristine? Are these pitchers more likely to have a career-threatening ulnar collateral ligament injury?

"We can only speculate at this point," Nazarian said.

The practical near-term goal is to use these data as a baseline when pitchers are injured. One pitcher, for example, complained of soreness during the season. His ultrasound scan showed slight laxity. When Nazarian reviewed the spring training scans, he saw the same laxity. The pitcher was treated for tendinitis and the condition improved.

Nazarian is convinced that ultrasound has many advantages over MR, including a higher spatial resolution and real-time imaging. But ultrasound's efficacy is operator-dependent, and far fewer practitioners are as proficient in musculoskeletal ultrasound as in MR. Nazarian is trying to reverse that trend while he continues to build his practice. He is head of the musculoskeletal section of the American Institute of Ultrasound in Medicine, whose ultimate goal is to accredit centers doing musculoskeletal ultrasound. He is writing questions dealing with musculoskeletal ultrasound for the American Board of Radiology examination. And he is training practitioners, although many are nonradiologists.

"As my practice expands, I'll need more help. And because of the shortage of personnel, I can only expect so much crossover help from other colleagues before it's necessary to bring in a dedicated musculoskeletal ultrasonographer," he said.