MD Exclusive Interview: Dr Nidhi Bhatnagar,Importance of Musculoskeletal Ultrasound in Radiology
Medical Dialogues Team, interviewed Dr Nidhi Bhatnagar, Consultant Radiologist, Sanjeevan Hospital, Delhi and the Organising Secretary of MUSoc 2015; on the modality of musculoskeletal ultrasound and its importance in Diagnostics today especially in the case of rising emergencies. Â Read Further
MDT: Kindly explain the modality of musculoskeletal ultrasound.
DR NB:Simply put, Musculoskeletal ultrasound is an ultrasound of bones and joints. Same ultrasound machines, same probes, only different frequency that allows  ultrasonologists to evaluate  bones and joints .
MDT:How old is the technology/ methodology of Musculoskeletal Ultrasound?
DR NB: In Europe and USA , it has been a well established diagnostic modality  now for quite a few decades now. One of the earliest  main textbook on  Musculoskeletal Ultrasound was written by Dr. Marnix Vanholsbeeck and had its second edition come out way back in  1991 .One can reasonably assume that this technology was in place since late  80’s. It’s a pity that MSUS  has not been able to take roots in  India and not till very recently has been  a rarely used modality with only a few Radiologists with accredited degrees in it.
MDT:Â Why do you think, that such an important modality has not been able to penetrate the Indian Medical systems?
DR NB: There were important reasons for that. Partly  it was due to lack of promotional activities  by the equipment manufacturers, and partly because of lack of awareness amongst Indian Specialists. These issues however should not be of great concern today since  we have broken through these barriers. Musculoskeletal USG certainly has come of age not as  a competitive modality  but as a complimentary one to  already existing  cross -sectional modalities  such as  MRI and CT Scans for evaluation of bones and joints. Rontgen introduced the world to the diagnostic applications  of X-rays almost a century ago and the symbiotic relationship that it shared with all the latest technologies is just an example of how there can never be a 100 % win- win for any one modality in clinical practice today.
MDT:Â How is the Modality of Musculoskeletal Ultrasound Useful?
DR NB: An illustrative example will perhaps help me answer this question better. Say for example  a 6 year old little girl has a fall , living in one of the remote parts of our country . Clinical examination indicates the mandatory evaluation with Xray which turns out to be "normal". In children bones are very soft and do not break easily like in adults. But they bend and crack which may not be caught on an  Xray. CT scans are harmful to a growing skeleton and for MRI children need sedation. This child can continue to suffer or be given a treatment without a conclusive diagnosis at hand. This is where a dedicated ultrasound of the affected part steps in and can be accurate in 97-98 % cases.
Musculoskeletal Ultrasound addresses two major issues in diagnostics today, cost-effectiveness and Ease of  Availability. For example, you take the city of Delhi where there may be approximately 26-27, maybe 30 centres, with  MRI machines, but when we talk of ultrasound, I know that it are nearly  1526 registered ultrasound Centres . The figures for MRI centres fall even further as we move to tier-2, tier-3 cities. If an  Ultrasonologist is equipped  and has the necessary know-how, he can easily perform a Musculoskeletal Ultrasound especially in the cases of accidents to enable emergency care, which incidentally comes  at  much less a  cost than an MRI.
MDT: How is it better than an MRI or CT?
DR NB: There is absolutely no way anyone should assume that it is better than  MRI, just as it should not be presumed that MRI is better than Ultrasound ! This is an  alternate modality in most  cases where patient has diseases of bones and joints  or also where there is no MRI or MRI can’t be used. Say for example in a case of knee joint replacement with prosthesis. Now MRI is generally not prosthesis friendly and circumstances do arise where we need to have an idea if something worrisome is going on in the joint after the procedure. Just the other day we had an obese lady with  a replaced knee joint, running fever, mild swelling and redness of the affected joint. We performed a dedicated scan and were able to reassure all  concerned  that there was no fluid, infection or any  cause for worry.There are also other circumstances in which MRI cannot be performed and USG comes as a  saviour. eg in a  pregnant lady, or in patients with  pacemakers or when the implants ,  cardiac stents are there ; or with little babies,since  you will need to sedate the patient . You cannot go in with a watch, mobile, or any other metallic foreign body from head to toe. Sometimes there are cochlear implants in the ear,and MRI becomes a bane more than a boon . CAT scans today have been restricted to absolute necessity  ALARA is the slogan which means " as low as reasonably achievable'...in short keep the radiation to the minimum.
MDT: According to you, what are the biggest hurdles in the use of this modality in the Indian system?
DR NB: The first hurdle when it comes to  MSUS  is the lack of information, knowledge and faith on the part of referring physicians. Physicians, orthopedicians, rheumatologists, Pain management consultants, Sports medicine and rehabilitative consultants must realize the power of this modality specially in cases  of emergencies where point of care attention and FAST technique of scanning  gives a very comprehensive perspective to the injuries in the patient. It’s not necessary that every injury warrants an MRI. There are other modalities too which are just as effective , as well as less taxing to the patient.
Secondly, we as radiologists have to put faith in this modality and make an effort to learn it. Even now there are only  a handful of  radiologists, who are practicing this modality in the country. Due to absence of credible teaching programs, a self styled teaching  developed which doesn't help in the long run. Its finally up to the radiologists of the country to familiarize themselves with the technique, the right protocols, the advantages, the shortcomings and the use of this modality, and bring it into main stream practice.
MDT:How difficult is this technology?
DR NB: It is as difficult or as easy as any other modality, I mean for a radiologist I don’t think it should be very difficult. It is like that his/her eyes are already familiar with the grey scale images ,  its just that he needs to know what a cartilage looks like or what an articular  surface  or synovial membrane looks like. With the right kind of  training and dedicated practice, we can actually create an army  of radiologists who will give accurate results to the referring physicians  who  in turn  will be able to build a faith into this modality.
MDT: What efforts are you making for popularizing this technique?
DR NB: MUS ( Muskuloskeletal Ultrasound Society, India ) is  hosting an International event “MUSoc 2015’ dedicated to Musculoskeletal ultrasound training and teaching protocols from 8-11th Oct 2015 at VIVANTA by Taj, Dwarka, New Delhi, India. This  is 25th Annual meeting of MUSoc ,USA, an International Society including MANY Specialists from  Detroit Medical Centre with twenty  world authorities like Drs.Tony Bouffard, Marnix Vanholsbeeck, Carlo Martinolli, Dr. Harcke, Doohi lee, and many more as Faculty. This conference has gained major International credits from The Royal college of Radiologists, European Society of skeletal Radiology, UCAM, Spain, Henry Ford , Detroit, American  college of Physicians, and National  ones from DMC, MCI, National Board of Examinations.
Moreover, during the MUSOC conference, we shall also launch a teaching program for radiologists, due to start in june next year, where again we shall call international stalwarts to provide training and teaching to Radiologists on the techniques of musculoskeletal ultrasound. This will be a certified course at both National and International levels. We welcome radiologists from  India and abroad to come and  participate at this  teaching program to  empower themselves with this very useful modality.
MDT:What message you would want to give to the GP’s?
DR NB: Today ultrasound is flourishing as "The  modality"  in  evaluating  almost every organ  of the body and  giving  credible diagnosis. Our aims and objectives as doctors are  to arrive at  a diagnosis and then provide treatment  to the patient as quickly as we can. Ultrasound in bones and joints is a reality today and it's  efficacious use  in diagnosing most of the diseases of musculoskeletal system  is no more a myth. Judicious use with a practical knowledge of where it works and where it dosn't can help enormously in faith building and patient management. Keep yourself updated with the CME, PROGRAMS, written materials, orientation programs,  Don’t jump to investigations  , without assessing the need for it first,  even if it is an Ultrasound.
MUSOC 2015 is being organised in Delhi this year from 8th-11th October. For further details you can check out the linkÂ
http://www.musoc2015.in
MDT: Kindly explain the modality of musculoskeletal ultrasound.
DR NB:Simply put, Musculoskeletal ultrasound is an ultrasound of bones and joints. Same ultrasound machines, same probes, only different frequency that allows  ultrasonologists to evaluate  bones and joints .
MDT:How old is the technology/ methodology of Musculoskeletal Ultrasound?
DR NB: In Europe and USA , it has been a well established diagnostic modality  now for quite a few decades now. One of the earliest  main textbook on  Musculoskeletal Ultrasound was written by Dr. Marnix Vanholsbeeck and had its second edition come out way back in  1991 .One can reasonably assume that this technology was in place since late  80’s. It’s a pity that MSUS  has not been able to take roots in  India and not till very recently has been  a rarely used modality with only a few Radiologists with accredited degrees in it.
MDT:Â Why do you think, that such an important modality has not been able to penetrate the Indian Medical systems?
DR NB: There were important reasons for that. Partly  it was due to lack of promotional activities  by the equipment manufacturers, and partly because of lack of awareness amongst Indian Specialists. These issues however should not be of great concern today since  we have broken through these barriers. Musculoskeletal USG certainly has come of age not as  a competitive modality  but as a complimentary one to  already existing  cross -sectional modalities  such as  MRI and CT Scans for evaluation of bones and joints. Rontgen introduced the world to the diagnostic applications  of X-rays almost a century ago and the symbiotic relationship that it shared with all the latest technologies is just an example of how there can never be a 100 % win- win for any one modality in clinical practice today.
MDT:Â How is the Modality of Musculoskeletal Ultrasound Useful?
DR NB: An illustrative example will perhaps help me answer this question better. Say for example  a 6 year old little girl has a fall , living in one of the remote parts of our country . Clinical examination indicates the mandatory evaluation with Xray which turns out to be "normal". In children bones are very soft and do not break easily like in adults. But they bend and crack which may not be caught on an  Xray. CT scans are harmful to a growing skeleton and for MRI children need sedation. This child can continue to suffer or be given a treatment without a conclusive diagnosis at hand. This is where a dedicated ultrasound of the affected part steps in and can be accurate in 97-98 % cases.
Musculoskeletal Ultrasound addresses two major issues in diagnostics today, cost-effectiveness and Ease of  Availability. For example, you take the city of Delhi where there may be approximately 26-27, maybe 30 centres, with  MRI machines, but when we talk of ultrasound, I know that it are nearly  1526 registered ultrasound Centres . The figures for MRI centres fall even further as we move to tier-2, tier-3 cities. If an  Ultrasonologist is equipped  and has the necessary know-how, he can easily perform a Musculoskeletal Ultrasound especially in the cases of accidents to enable emergency care, which incidentally comes  at  much less a  cost than an MRI.
MDT: How is it better than an MRI or CT?
DR NB: There is absolutely no way anyone should assume that it is better than  MRI, just as it should not be presumed that MRI is better than Ultrasound ! This is an  alternate modality in most  cases where patient has diseases of bones and joints  or also where there is no MRI or MRI can’t be used. Say for example in a case of knee joint replacement with prosthesis. Now MRI is generally not prosthesis friendly and circumstances do arise where we need to have an idea if something worrisome is going on in the joint after the procedure. Just the other day we had an obese lady with  a replaced knee joint, running fever, mild swelling and redness of the affected joint. We performed a dedicated scan and were able to reassure all  concerned  that there was no fluid, infection or any  cause for worry.There are also other circumstances in which MRI cannot be performed and USG comes as a  saviour. eg in a  pregnant lady, or in patients with  pacemakers or when the implants ,  cardiac stents are there ; or with little babies,since  you will need to sedate the patient . You cannot go in with a watch, mobile, or any other metallic foreign body from head to toe. Sometimes there are cochlear implants in the ear,and MRI becomes a bane more than a boon . CAT scans today have been restricted to absolute necessity  ALARA is the slogan which means " as low as reasonably achievable'...in short keep the radiation to the minimum.
MDT: According to you, what are the biggest hurdles in the use of this modality in the Indian system?
DR NB: The first hurdle when it comes to  MSUS  is the lack of information, knowledge and faith on the part of referring physicians. Physicians, orthopedicians, rheumatologists, Pain management consultants, Sports medicine and rehabilitative consultants must realize the power of this modality specially in cases  of emergencies where point of care attention and FAST technique of scanning  gives a very comprehensive perspective to the injuries in the patient. It’s not necessary that every injury warrants an MRI. There are other modalities too which are just as effective , as well as less taxing to the patient.
Secondly, we as radiologists have to put faith in this modality and make an effort to learn it. Even now there are only  a handful of  radiologists, who are practicing this modality in the country. Due to absence of credible teaching programs, a self styled teaching  developed which doesn't help in the long run. Its finally up to the radiologists of the country to familiarize themselves with the technique, the right protocols, the advantages, the shortcomings and the use of this modality, and bring it into main stream practice.
MDT:How difficult is this technology?
DR NB: It is as difficult or as easy as any other modality, I mean for a radiologist I don’t think it should be very difficult. It is like that his/her eyes are already familiar with the grey scale images ,  its just that he needs to know what a cartilage looks like or what an articular  surface  or synovial membrane looks like. With the right kind of  training and dedicated practice, we can actually create an army  of radiologists who will give accurate results to the referring physicians  who  in turn  will be able to build a faith into this modality.
MDT: What efforts are you making for popularizing this technique?
DR NB: MUS ( Muskuloskeletal Ultrasound Society, India ) is  hosting an International event “MUSoc 2015’ dedicated to Musculoskeletal ultrasound training and teaching protocols from 8-11th Oct 2015 at VIVANTA by Taj, Dwarka, New Delhi, India. This  is 25th Annual meeting of MUSoc ,USA, an International Society including MANY Specialists from  Detroit Medical Centre with twenty  world authorities like Drs.Tony Bouffard, Marnix Vanholsbeeck, Carlo Martinolli, Dr. Harcke, Doohi lee, and many more as Faculty. This conference has gained major International credits from The Royal college of Radiologists, European Society of skeletal Radiology, UCAM, Spain, Henry Ford , Detroit, American  college of Physicians, and National  ones from DMC, MCI, National Board of Examinations.
Moreover, during the MUSOC conference, we shall also launch a teaching program for radiologists, due to start in june next year, where again we shall call international stalwarts to provide training and teaching to Radiologists on the techniques of musculoskeletal ultrasound. This will be a certified course at both National and International levels. We welcome radiologists from  India and abroad to come and  participate at this  teaching program to  empower themselves with this very useful modality.
MDT:What message you would want to give to the GP’s?
DR NB: Today ultrasound is flourishing as "The  modality"  in  evaluating  almost every organ  of the body and  giving  credible diagnosis. Our aims and objectives as doctors are  to arrive at  a diagnosis and then provide treatment  to the patient as quickly as we can. Ultrasound in bones and joints is a reality today and it's  efficacious use  in diagnosing most of the diseases of musculoskeletal system  is no more a myth. Judicious use with a practical knowledge of where it works and where it dosn't can help enormously in faith building and patient management. Keep yourself updated with the CME, PROGRAMS, written materials, orientation programs,  Don’t jump to investigations  , without assessing the need for it first,  even if it is an Ultrasound.
MUSOC 2015 is being organised in Delhi this year from 8th-11th October. For further details you can check out the linkÂ
http://www.musoc2015.in
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