Spine & Nerve

In this episode of The Spine & Nerve Podcast, Dr. Dr. Jason Kung and Dr. Brian Joves have a reflective and forward-looking discussion as we transition from 2023 into 2024, sharing our podcast's journey, personal insights, biggest happenings in pain medicine, and anticipations for the new year. 1. Podcast Journey and Global Reach: Transitioning through 2023: The evolution of our podcast through the year. Spotify Wrapped Insights: A deep dive into our audience demographics, celebrating a significant international listenership with a special shoutout to our friends in New Zealand, India, Spain, Brazil, and Hungary. 2. Engaging Medical Discussions: Spotlight Episode - Spinal Stenosis: Discussion on why our spinal stenosis episode resonated with so many listeners and the importance of addressing prevalent health issues. Medical Innovations and Literature: A look back at the year's significant advancements in radiofrequency ablation and the evolving landscape of pain management. 3. Personal Reflections and Resolutions: Embracing Challenges: The team's participation in a Spartan Race, symbolizing our dedication to personal growth and community engagement. 4. Community Impact and Listener Engagement: Top 10 Recognition: Celebrating being in the top 10 of listeners' favorite podcasts and what it means to us. Listener Interaction: Encouraging feedback, stories, and engagement from our global audience. 5. Looking Forward to 2024: Medical Community and Conferences: Anticipation for upcoming medical conferences, new technologies, and the continuing battle against the opioid crisis. Optimism for the Future: Our commitment to staying informed, optimistic, and ready to tackle the challenges and opportunities the new year brings. Closing Thoughts: A heartfelt thank you to all our listeners for their continued support and engagement. We look forward to another year of learning, growth, and community. Contact Information: We Encourage listeners to stay connected through our social media channels (LinkedIn, YouTube, Twitter (X), and Facebook are the easiest), website, and Spotify Podcast page for feedback, questions, and community stories. Disclaimer: Reminder that the information provided is for educational purposes and is not intended as medical advice. Always consult with a healthcare professional.

In this episode of the Spine & Nerve podcast, Dr. Jason Kung and Dr. Brian Joves delve into a comprehensive discussion surrounding anticoagulation guidelines and their implications in interventional pain procedures.

With over a hundred thousand downloads and over 1,000 YouTube subscribers, we would like to express our sincere gratitude to all the listeners for your engagement and support. Please continue to share and subscribe to help more people discover the podcast.

Today's episode focuses on the safety of epidural steroid injections and the critical role of anticoagulation management.Understanding the rationale behind a patient's anticoagulation therapy is vital for interventional pain physicians. This approach empowers clinicians to make informed decisions about whether to continue or withhold anticoagulation medications prior to procedures. There is a delicate balance between patient-specific risks and the benefits of these interventions.

One of the things that must be known and emphasized is the remarkable safety profile of epidural steroid injections. Approximately nine million epidural steroid injections are administered annually, resulting in an adverse event rate of about one in 780,000. This reassuring statistic is attributed to the collaborative efforts of medical societies and the implementation of strict anticoagulation guidelines. The hosts emphasize the role of fluoroscopic guidance, non-particulate steroids, and avoidance of deep sedation in enhancing the safety of these procedures.

The episode further delves into the nuances of assessing bleeding risks in patients undergoing interventional pain procedures. As always, we must underscore the importance of a comprehensive physical examination, with a specific focus on identifying signs of easy bruising and mucosal bleeding. The hosts discuss the relevance of specific medications, including aspirin and NSAIDs, and their implications for procedural safety.

The hosts engage in an insightful exploration of the guidelines for managing anticoagulation medications pre- and post-procedure. They stress the need for pain physicians to consider the anatomical location of the intervention and evaluate the potential risks versus benefits.

The doctors conclude the episode by highlighting the crucial role of shared decision-making and patient education. By fostering collaboration between patients and physicians, the hosts emphasize the creation of a safe and informed healthcare environment.In this thought-provoking episode, the doctors try to help you navigate the complexities of anticoagulation management in interventional pain procedures, and offer some insights for practitioners seeking to provide the highest level of care to their patients.

References:

Anesthesia Quality Institute Closed Claims Database Review 2011 through 2021 for Epidural Steroid Complications. Naeem Haider. Pain Physician 26 (3), E251, 2023

Stephen Endres, MD and others, The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures, Pain Medicine, Volume 18, Issue 3, March 2017, Pages 403–409, https://doi.org/10.1093/pm/pnw108

Narouze S, Benzon HT, Provenzano D, et alInterventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of PainRegional Anesthesia & Pain Medicine 2018; 43:225-262.

The ASRA App: https://www.asra.com/the-asra-family/asra-app

In this episode, we have a special guest, Dr. Nikhil Verma, who shares his inspiring journey from undergrad to establishing his own medical practice. Dr. Verma opens up about the challenges he faced, the pivotal moments that shaped his career, and the lessons he learned along the way. Join us as we delve into his story of perseverance, passion, and the pursuit of personalized medicine. Episode Highlights: Dr. Verma recounts his early struggles and the uncertainties he faced during his pursuit of medical school. Despite not getting accepted initially, he used the time to reflect and explore different options, eventually finding his way to St. George's University. The importance of resilience and perseverance shines through as he shares how he overcame setbacks and stayed motivated. Dr. Verma's interest in rehabilitation medicine and sports medicine grew during his residency. He shares how his personal experience with a sports-related injury shaped his perspective and ignited his passion for helping others through physical therapy and non-surgical interventions. Dr. Verma discusses the decision to open his own medical practice, highlighting the challenges and rewards of being an independent practitioner. From finding the ideal location to setting up the practice and acquiring necessary equipment, he shares the steps involved in laying the groundwork for his venture. Dr. Verma emphasizes the importance of tailoring treatments to individual patients, providing temporary relief while considering long-term solutions. He highlights advanced procedures and technologies that enable more targeted and effective interventions, showcasing the potential impact of personalized medicine.

Dr. Verma encourages med students and early residents to stay open-minded and embrace change. He shares the significance of finding passion and purpose in one's work, reminding listeners that it's okay to evolve and pursue new interests within the medical field.

Dr. Nikhil Verma's story is a testament to the power of determination, adaptability, and following one's true calling. His journey from facing initial rejections to establishing a successful practice showcases the importance of resilience and finding personal fulfillment in the medical profession. Join us in thanking Dr. Verma for sharing his insights and experiences. Tune in to the full episode to hear his story in his own words.

You can find Dr. Verma on all your favorite social platforms, as well as our hosts.

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

In this week's episode of the Spine & Nerve podcast, we have a return guest! Dr. Hunter Vincent returns to the show to chat with Dr. Brian Joves about health coaches and how they can help your patients to be more successful in their journey with and through chronic pain.

In this episode we'll discuss:

What is a health coach?

Where does this fit into the treatment and provider paradigm?

How can ancillary team members like health coaches help your patients and your team to be more successful?

Dr. Vincent is the CEO of Pogo Health. He is a double board certified physician who received his residency training from UC Davis in Physical Medicine & Rehabilitation (PM&R) with a subspecialty certification in Pain Medicine from UCLA. Prior to starting his medical training, he received a Bachelor's of Science in Exercise Biology. He has spent the last decade actively involved in healthcare initiatives focused on maximizing patient engagement in their own health journey. He has worked with various healthcare teams in the fields of clinical obesity, chronic pain, and neurological disorders. 

Pogo Health is a virtual platform Virtual that utilizes a team approach to treating chronic pain. Their interdisciplinary opioid-free approach integrates the pain physician, pain therapist and specialized health coach to create a completely virtual and customized treatment program. The Pogo Health multi-modal approach utilizes evidence based techniques to provide long term physical and mental health benefits to combat chronic pain.

Learn more at https://pogo-health.com/

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

In this week's episode of the Spine & Nerve Podcast we would like to introduce you all to the newest member of the Spine & Nerve family... Dr. Jason Kung.  Jason Kung, MD, is a board-eligible anesthesiologist and interventional pain physician who joined Spine & Nerve last year. Listen in as Brian Joves, MD gets to know Dr. Kung better and explore his journey into medicine and to discovering his passion for pain medicine.

He  graduated from the University of San Francisco in California with a  bachelor's degree in biology. He then went to Boston University School  of Medicine in Massachusetts for his medical degree.

Dr. Kung  completed his residency in Anesthesiology and fellowship in  Interventional Pain at Harvard Medical School, Massachusetts General  Hospital in 2020.

Dr. Kung specializes in several interventional  procedures, including spinal cord stimulation, epidural injections,  radiofrequency ablations, implantable devices, and ultrasound-guided  nerve/joint injections. He strives to provide  compassionate evidence-based care to all his patients.

He is certified as an instructor in  medical simulation. Dr. Kung has completed research and published in the  areas of bone healing and the effects of natural sources of vitamin D.

During  his free time, he enjoys playing guitar, surfing/snowboarding, and  exploring California with his wife and dog. 

This podcast is for information and educational purposes only, it is not  meant to be medical or career advice. If anything discussed may pertain  to you, please seek council with your healthcare provider. The views  expressed are those of the individuals expressing them, they may not  represent the views of Spine & Nerve.

In this week's episode of the Spine & Nerve podcast Drs. Nicolas Karvelas and Brian Joves discuss a clinical case regarding a patient with Persistent Spinal Pain Syndrome (PSPS).  To review, PSPS is not a single diagnosis, but rather an encompassing term that includes persistent painful disease with spinal origin. This disease can be linked to the predisposition of the human spine to develop painful pathology over time. The distribution of the symptoms in PSPS can be axial and/or radicular, and although commonly involves the lumbosacral spine, the cervical, and thoracic spine can also be the site of pathology. Importantly, spinal surgery may or may not have occurred, and may or may not be the primary contributor. 

Listen as the doctors talk through this clinical scenario of a gentleman in his 50s with PSPS and discuss treatment options including neuromodulation, specifically in this case Differential Target Multiplexed spinal cord stimulation (DTM SCS). DTM SCS targets not only neurons, but also glial cells (all forms of SCS most likely impact glial cells to some degree, however DTM SCS specifically works to optimize the neuromodulation of glial cells). Glial cells include oligodendrocytes, microglia, and astrocytes in the central nervous system; as well as Schwann cells and satellite glial cells in the periphery. All of these cells play critical roles in essential functions which include, but are not limited to regulation of fluid and ion homeostasis, protection of neurons, and creation and maintenance of blood-brain barrier. When glial cells are pathologically, chronically, and abnormally activated they play a critical role in the development and maintenance of chronic pain disease processes. In the setting of abnormal glial cell activity, the most common clinical manifestations for patients include pain sensitivity, fatigue, cognitive disruption, sleep disorders, and mood disorders. For a deeper dive specifically into glial cells, please see our prior conversation (https://anchor.fm/spine/episodes/Glial-cells--glial-cells--glial-cells----The-pain-cascade--modulation--and-chronic-pain-e5fb38) including a discussion with Dr. Ricardo Vallejo (https://anchor.fm/spine/episodes/More-glial-cells---Dr--Ricardo-Vallejo--science-that-matters--and-thinking-beyond-the-neuron-eb4m4i). And please listen to the conversation with Dr. Michael Fishman for a deeper dive on this study (https://anchor.fm/spine/episodes/Profound-Data-with-Dr--Michael-Fishman-elmp3f). 

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, the may not represent the views of Spine & Nerve. 

References:

1. Fishman M, Cordner H, Justiz R, Provenzano D, Merrell C, Shah B, Naranjo J, Kim P, Calodney A, Carlson J, Bundschu R, Sanapati M, Mangal V, Vallejo R. Twelve-Month results from multicenter, open-label, randomized controlled clinical trial comparing differential target multiplexed spinal cord stimulation and traditional spinal cord stimulation in subjects with chronic intractable back pain and leg pain. Pain Pract. 2021 Aug 7. 

2. Vallejo R, Kelley CA, Gupta A, Smith WJ, Vallejo A, Cedeño DL. Modulation of neuroglial interactions using differential target multiplexed spinal cord stimulation in an animal model of neuropathic pain. Mol Pain. 2020 Jan-Dec;16:1744806920918057. doi: 10.1177/1744806920918057. PMID: 32290778; PMCID: PMC7160773.

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves review lumbar radiculopathy.  Lumbar radiculopathy is a common diagnosis in which there is irritation or compression of one or more nerve roots in the lumbar spine. Because these nerves travel to the hips, buttocks, legs and feet, an injury in the lumbar spine can cause symptoms in these areas such as pain, weakness, numbness, and tingling..

Lumbar radiculopathy is typically due to a structural abnormality: specifically disc herniation and/or impingement due to spondylosis. Disc herniation (a rupture in the fibrous outer wall of a lumbar disc allowing the soft nucleus of the disc to bulge outward, which can press against a nerve root) is one of the most common causes of lumbar radiculopathy. Because of how common this pathology is, it is important to understand the usual natural history of radiculopathy due to disc herniation. Acute disc herniations typically improves significantly by 6-12 weeks with conservative treatment, making patient education a key component of helping them through this painful condition.

That being said, the differential diagnosis for lumbar radiculopathy is very broad, and as always it is important to consider and rule out more concerning etiologies.

Listen as the doctors discuss the definition of lumbar radiculopathy, the differential diagnosis, as well as a more detailed discussion of the natural history of radiculopathy and conclude with a look at the pathophysiology of lumbar radiculopathy.

References:
1. Gupta A, Upadhyaya S, Yeung CM, et al. Does Size Matter? An Analysis of the Effect of Lumbar Disc Herniation Size on the Success of Nonoperative Treatment. Global Spine Journal. 2020;10(7):881-887.

2. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA. 2006;296(20):2441–2450.

3. Gugliotta M, da Costa BR, Dabis E, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open 2016;6:e012938.

4. Lin JH, Chiang YH, Chen CC. Lumbar radiculopathy and its neurobiological basis. World J Anesthesiol 2014; 3(2): 162-173.

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas expand on their recent discussion of pain chronification.  The doctors discuss a fairly common scenario in which a patient with very chronic pain develops a relatively new pain condition.  In this setting, the new onset pain process can be significantly amplified and difficult to treat.

Previously, the doctors summarized processes including central and peripheral sensitization, which contribute significantly to the severity and refractory nature of chronic pain conditions.  Listen as the doctors review chronification of pain in the context of a patient case example and discuss treatment approaches, particularly optimizing medication management.

Chronic pain disease processes are very challenging to diagnose and treat, especially when multiple body parts are involved.  However, there are a growing number of tools available to make a positive impact for our patients, and with a carefully crafted treatment plan, progress can be made. Although optimizing patients' health, function, and safety may be a long and winding road, this goal is achievable!

This podcast is for information and educational purposes only, it is not meant to be medical advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve.

References:
1. Borsook D, Youssef AM, Simons L, Elman I, Eccleston C. When pain gets stuck: the evolution of pain chronification and treatment resistance. Pain. 2018;159(12):2421-2436.

2. Ossipov MH, Morimura K, Porreca F. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care. 2014 Jun;8(2):143-51.

3. Morlion B, Coluzzi F, Aldington D, Kocot-Kepska M, Pergolizzi J, Mangas AC, Ahlbeck K, Kalso E. Pain chronification: what should a non-pain medicine specialist know? Curr Med Res Opin. 2018 Jul;34(7):1169-1178.

4. A Comprehensive Review of the Celiac Plexus Block for the Management of Chronic Abdominal Pain. Current Pain and Headache Reports. 2020.

5. Khanna IK, Pillarisetti S. Buprenorphine - an attractive opioid with underutilized potential in treatment of chronic pain. J Pain Res. 2015 Dec 4;8:859-70.

In this week's episode of the Spine & Nerve podcast  Dr. Nicolas Karvelas and Dr. Brian Joves review a common cause of low back pain, sacroiliac joint (SI) pain. The SI joint is a large complex joint that involves the iliac bone and sacrum. The SI joint is a critical component of the connection between the spine and lower limbs, and one of the primary functions of the SI joint is stability.

Chronic SI joint pain is a relatively common cause of low back pain with epidemiologic studies demonstrating that SI joint pain significantly contributes to 10-38% of cases of chronic low back pain. Risk factors for SI joint pain include: leg length discrepancy, gait abnormality, scoliosis, spinal fusion, hip pathology, pregnancy, high force/velocity injury, seronegative HLA-B27 spondyloarthropathies, repetitive shear stress injuries in athletes.

The common clinical presentation for SI joint pain includes aching pain below the belt line, with radiating/referred pain to gluteal/buttock region, groin, posterior leg, and less commonly thigh. This pain is often worsened with prolonged sitting, sleeping positions, movement.

Physical exam results supportive of a diagnosis of SI joint pain include at least 3 positive tests, with at least one of these tests being thigh thrust or compression test. The 5 recommended provocative maneuvers include: 1) Distraction test 2) thigh thrust test 3) FABERE 4) Compression test 5) Gaenslen's maneuver.

A recent expert opinion article titled A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain, works to clarify the approach to diagnosis and treatment of SI joint pain. This review article highlights the importance of optimizing the diagnosis as soon as possible to guide treatment, and image guided injection remains the gold standard for the diagnosis of SI joint pain.

Listen as the doctors review SI joint pain, and discuss the algorithm presented in the recent expert opinion review article.

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, the may not represent the views of Spine & Nerve.

References:

1. Falowski S, Sayed D, Pope J, Patterson D, Fishman M, Gupta M, Mehta P. A Review

and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain. J Pain Res.

2020;13:3337-3348.

2. Wallace P, Bezjian Wallace L, Tamura S, et al. Effectiveness of Ultrasound-Guided

Platelet-Rich Plasma Injections in Relieving Sacroiliac Joint Dysfunction. American

Journal of Physical Medicine & Rehabilitation. 2020 Aug;99(8):689-693.

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss how pain medicine has been affected by COVID-19.  This pandemic has caused so much devastation for our patients, including some who directly experienced COVID-19 infection and those who have had to weigh seeking medical care against risking infection.  It has also impacted our practice as we work to create a safe environment for patients and accommodate their needs.

More and more research is emerging on a persistent syndrome following acute COVID-19 infection.  Although we don't understand its entire clinical picture, it appears most patients with post-COVID-19 syndrome (over 50%) have significant fatigue, and a significant percentage of patients (about 20%) have persistent pain.  We can anticipate this syndrome presenting a growing challenge to the broader medical community, given both the vast number of COVID-19 patients worldwide and the historical difficulty of treating similar post-viral syndromes.

Multiple risk factors associated with acute COVID-19 infection could increase the chance of developing a post-infectious syndrome. For instance, the virus enters cells through the ACE-2 receptor which is present throughout the body, making it possible to spread beyond the respiratory system to the vasculature, neural, and muscle tissues.  At the individual and community level, many patients are experiencing isolation, barriers to health care, and worsening of mental health conditions which can exacerbate symptoms such as chronic pain.

Listen as the doctors discuss the evidence behind the emerging entity of post-COVID-19 syndrome, as well as the challenges and necessity of delivering multi-disciplinary treatment in this COVID-19 era.

As always, we greatly appreciate the effort of all involved in the management of this challenging pandemic, and our thoughts and prayers are with all who have been affected.

This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, the may not represent the views of Spine & Nerve.

References:

1. Kemp HI, Corner E, Colvin LA. Chronic pain after COVID-19: implications for rehabilitation. Br J Anaesth. 2020;125(4):436-440.

2. Characteristics, Symptom Management, and Outcomes of 101 Patients With COVID-19 Referred for Hospital Palliative Care. Journal of Pain and Symptom Management. 2020.

3. Persistent Symptoms in Patients After Acute COVID-19. JAMA. August 2020.