Energy Therapeutic Technologies – A Primer

Energy Therapeutic Technologies – A Primer

Introduction

Harnessing the power of energy to precisely control and affect tissue in the human body has revolutionized medicine for nearly a century. It all began in 1926 when Cushing and Bovie pioneered electrosurgery, a groundbreaking innovation that dramatically reduced blood loss and enabled safer, more precise surgical procedures, particularly in neurosurgery. 

Since then, the continuous evolution of innovative energy technologies has kept this field at the forefront of improving patient outcomes across a vast array of chronic conditions. This overview takes you through the clinical applications and cutting-edge technologies currently making waves in this ever-advancing realm.

Clinical Applications

Minimally-invasive surgery

Electrosurgical devices have become essential workhorses in the laparoscopic OR, enabling meticulous hemostasis and intricate tissue dissection. However, the real game-changers have been vessel-sealing technologies that harness radiofrequency energy to fuse blood vessels up to 7mm in diameter. These technologies eliminate tedious suture ligation, significantly reducing operating times and blood loss.

Spine 

Energy modalities have proven indispensable in spine procedures for treating the debilitating pain of chronic conditions. Precisely applied radiofrequency (RF) and thermal energy can shrink collagen and denervate problematic nerves like the basivertebral nerve or medial branches. These technologies have also become mainstays for treating herniated discs by damaging nerve fibers, shrinking collagen, and stiffening disc tissue.

Sports Medicine

Controlled plasma radiofrequency (RF) systems have emerged as a revolutionary technology in sports medicine. These systems create an arc in a saline field, providing ionization and controlled energy delivery at lower temperatures. The real breakthrough lies in their ability to shrink the collagen within joint capsules by up to 30% when treated with this controlled energy delivery. These plasma RF systems offer a highly effective solution to improve joint function after injury by precisely shrinking the collagen in the damaged capsule. As a result, athletes can get back in the game faster, with improved joint mechanics and reduced risk of long-term complications.

Endoscopic GI

Energy has been widely employed in endoscopic gastrointestinal (GI) and colorectal procedures to maintain hemostasis. With increased screening for colorectal cancer, there is a growing demand to enhance polypectomy and endoscopic submucosal resection during routine GI procedures. The utilization of energy can facilitate the challenging task of selective tissue removal through the working channel of an endoscope.

Moreover, energy technologies have been used to treat upper GI disorders like Barrett’s esophagus. The principal approach involves controlled energy application to heat and denature tissue, leading to tissue restructuring and remodeling during the healing process.

Urology

For men suffering from benign prostatic hyperplasia (BPH), a range of energy modalities have emerged as highly effective solutions. These modalities precisely heat and shrink the prostate to relieve distressing symptoms.

In this arena, modalities like radiofrequency (RF), cryotherapy (cryo), laser therapy, and steam therapy are successfully deployed. Each of these techniques offers unique advantages and may be tailored to the individual needs of the patient.

Additionally, lithotripsy, a tried-and-true technique for fragmenting stubborn urinary and renal calculi, remains crucial for providing relief for those experiencing urinary obstruction or discomfort.

Interventional Oncology

In the fight against cancer, the ability to deliver controlled thermal ablation via RF, microwave, and cryo energies has emerged as a powerful weapon. These technologies enable targeted tumor ablation across organs like the lung, breast, thyroid, and liver – representing a significant therapeutic advancement that improves and extends lives.

Electrophysiology – Atrial Fibrillation

Erratic electrical signals in the heart often cause atrial fibrillation and abnormal heart rhythms. Targeted ablation procedures, using thermal or cryo energy, create small scars in the heart tissue. These scars block faulty electrical signals and restore normal heart function.

Pulsed-field Ablation (PFA) is an emerging technology in this field. It utilizes non-thermal high-amplitude pulses to disrupt cell walls and cause cell lysis. PFA shows promise in reducing adverse events associated with cardiac ablation, potentially making it a safer option for patients.

Denervation

While targeting nerves with energy to relieve chronic pain is a well-established clinical practice, innovative approaches are taking this concept even further. By denervating sympathetic and parasympathetic nerve bundles, these new frontier therapies are opening the door to treating systemic conditions like hypertension (renal denervation) and rhinitis that have long plagued patients.

Cardiovascular and Peripheral Vascular Applications

In the interventional treatment of vascular disease, technologies like intravascular lithotripsy, using hydro-electrical shocks to fragment calcifications, have emerged as breakthroughs for treating occluded vessels. This innovative approach addresses the challenge of calcified plaque, which can obstruct blood flow and lead to severe complications such as heart attacks or strokes.

Moreover, the precise application of energy is proving effective for remodeling vein structures and valves to redirect flow in chronic venous insufficiency (CVI). This debilitating condition impacts the quality of life for many. CVI occurs when the valves in the veins of the legs weaken or are damaged, causing blood to pool and leading to symptoms like leg swelling, pain, and skin changes. By carefully reshaping the vein structure and improving valve function through energy-based techniques, clinicians can alleviate symptoms and improve the overall circulation in affected individuals, enhancing their quality of life.

Energy Modalities

Radiofrequency and Radiofrequency Ablation (RFA)

Radiofrequency (RF) and Radiofrequency Ablation (RFA) are advanced medical techniques used in various procedures. RF energy operates between 100 kHz and 1 MHz, utilizing ohmic heat to cauterize or denature tissue through coagulation necrosis.

The higher frequency range of RF energy minimizes muscle stimulation and reduces interference with cardiac electrical signals, making it suitable for delicate procedures. In some applications, actively cooled probes are used to extend the ablation size or limit coagulation at the electrode-tissue interface.

RF energy is typically delivered in one of two ways: monopolar or bipolar. In monopolar systems, the return path is through the body to a return electrode pad, providing precise and controlled energy delivery to the targeted tissue.

Microwave Ablation

Microwave technologies operating above 1MHz work via a different mechanism—radiation rather than ohmic heating. This allows for larger ablation diameters that are less impacted by adjacent vasculature or tissue structures. An antenna transmits the microwave energy through an actively cooled cable and system for precision.

Cryoablation

Heading to the opposite temperature extreme, cryoablation harnesses the power of extreme cold (cryotherapy) to freeze and destroy tissue. Multiple freeze/thaw cycles are typically required to fully denature the target. A key advantage is the ability to monitor the ice ball visually using imaging like ultrasound. Traditional systems use compressed argon gas, but liquid nitrogen is an emerging cryogen that reduces cost and complexity.

Laser Ablation

With lasers, precision is unmatched. Laser energy is utilized to precisely target and ablate tissue. Dermatology and ophthalmology are just two specialties benefiting from this approach. However, the effective wavelength can be limited by the absorption spectrum of the target tissue, sometimes requiring adjuvant dyes to improve energy absorption and selectivity.

Pulsed Field Ablation (PFA)

PFA is driving paradigm shifts by using high-amplitude, short electrical pulses to disrupt cell membrane integrity and cause cell lysis—all via a non-thermal mechanism that can be tissue-selective. It shows particular promise in oncology and treating atrial fibrillation, with a key advantage being the avoidance of thermal injury to the esophagus when ablating near the left atrium.

Irreversible Electroporation (IRE): 

Closely related to PFA, IRE uses electrical pulses to create nanopores in cell membranes, inducing lysis. However, unlike thermal ablation, IRE uniquely preserves the surrounding extracellular matrix and vasculature while destroying the target cells. It shows significant potential for treating pancreatic and prostate cancer and soft tissue tumors.

Ultrasound

The dynamics of ultrasound involve converting longitudinal waves into mechanical energy and heat generated by molecular tissue vibration. Typical frequencies range from 1.0 to 3.0 MHz, with faster propagation in denser media like saline versus air. Ultrasound can be delivered focally via a catheter or probe with piezoelectric transducers or externally through HIFU (high-intensity focused ultrasound).

Electrohydraulic Lithotripsy

For fracturing vascular plaques or calculi, electrohydraulic lithotripsy (EHL) employs a high-voltage arc between bipolar electrodes to generate a hydraulic shock wave. This waveform has a compressive phase followed by a tensile tail that produces cavitation – the key mechanism facilitating fragmentation.

Conclusion

While energy-based therapies have been around for decades, they remain at the cutting edge of innovation – continually evolving to improve the treatment of chronic disease with greater precision and selectivity than ever before. The diversity of energy modalities covered here – from radiofrequency and microwave to cryoablation, laser, pulsed-field ablation, irreversible electroporation, ultrasound, and electrohydraulic lithotripsy – represents just the tip of the iceberg. With each modality offering its own unique physical characteristics and clinical advantages, this field is ripe for continued breakthroughs and novel applications.

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