Spine & Nerve

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss a how a needle may go down in history for changing the course of the 2019 World Series!

This needle was brought into the national spot light during the World Series between the Washington Nationals and Houston Astros, when one of the starting pitchers for the Nationals (Max Scherzer) developed severe neck pain and muscle spasms and was unable to use his arm. Max Scherzer is known for his fierce competitive nature, and he was determined to return to help his team.  He underwent a cervical epidural steroid injection and aggressive treatment on his neck by the whole rehabilitation team, and was able to return to pitch in the deciding game 7 of the World Series and pitched 5 innings with 2 earned runs.  The Nationals went on to win in historic fashion bringing home their first World Series title.

The doctors will dive deeper into this specific image guided therapeutic injection, the cervical epidural steroid injection.  The cervical epidural steroid injection is a fluoroscopy (Xray) guided therapeutic injection that is performed to deliver anti-inflammatory pain medication (steroid medication) to a specific location in the cervical spine (epidural space) in order to treat certain neck pathologies (most commonly cervical radiculopathy or radiculitis).  For patients who have moderate to severe neck pain, due to certain processes including cervical radiculopathy/radiculitis,  that is not improving and not responding to lifestyle modifications, activity modifications, physical therapy, medications, and other conservative measures, it is reasonable to consider an epidural steroid injection.

Referenced in the discussion are the most recent systematic reviews, that show at least level 2 evidence that cervical epidural steroid injections improve pain and function for neck and upper extremity pain due to certain processes including but not limited to cervical radiculopathy/radiculitis (Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review. Manchikanti et al. Pain Physician. 2015.) Prior to consideration of surgery (assuming no red flag signs/symptoms requiring more urgent/emergent surgical intervention), cervical epidural steroid injections should be considered to improve function, pain, and ultimately overall health long term.  

 

Cervical epidural steroid injections will most likely not result in you or your patients winning championships, but they are an important and effective treatment option when considering treatment for cervical pathology, especially when dealing with cervical radiculopathy or radiculitis.  

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.

In this week's episode of the Spine & Nerve podcast Dr. Gurai and Dr. Joves give us a quick introduction into neuromodulation.

Some of you may be asking what neuromodulation is... It is defined by the International Neuromodulation Society as "technology that acts directly upon nerves. It is the alteration—or modulation—of nerve activity by delivering electrical or pharmaceutical agents directly to a target area."

Best known as a treatment for chronic pain (and the reason we are passionate about it), neuromodulation also includes deep brain stimulation (DBS) treatment for Parkinson's disease, sacral nerve stimulation for pelvic disorders and incontinence, spinal cord stimulation for ischemic disorders (angina, peripheral vascular disease), and targeting other parts of the nerve for focal nerve disorders such as ilioinguinal neuralgia after hernia repair or pain after total joint replacements.

Neuromodulation works by stimulating nerves to produce a response. When we think of this in the pain management world, we usually explain to patients that we send signals to nerves that change the signaling cascades at the level of stimulation. This changes painful signals to less painful signals, therefore changing the patient's pain experience.

Listen in as the docs walk us through this field from a 50,000 for view. Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people. Disclosure!!! Dr. Brian Joves is a speaker and researcher for companies that produce devices in this space; please see his LinkedIn profile for full details.

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.

In this week's episode of the Spine & Nerve podcast Drs Nicolas Karvelas and Brian Joves give us an introduction to traumatic brain injuries (TBI) have been on my mind this weekend. TBI is defined as "a disruption of brain function due to an external force or blow to the head."

Patients who experience a TBI can present with decreased level of consciousness, memory loss before or after injury, alteration of mental status, neurologic deficits, and/or intracranial lesions. The etiology of TBI from CDC data are from falls (35.2%), unknown/other (21%), motor vehicle/traffic (17.3%), struck by/against an object (16.5%), and assaults (10%).

This conversation focuses a little more on mild TBI and concussion, and steers away from moderate and severe TBI - which is a subspecialty and fellowship of its own. Mild TBI is the result of the forceful motion of the head or impact causing a brief change in mental status; loss of consciousness for less than 30 minutes; as a patient who had a Glasgow Coma Scale (GCS) score of 13 or greater; or post traumatic amnesia less than 24 hours.

Listen in as the docs give an overview of TBI. Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people.

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.

In this week's episode of the Spine & Nerve podcast Dr. Brian Joves and Dr. Nicolas Karvelas are talking opiates again. They discuss the steps to take to ensure we are doing what we can to optimize the safety of not only the patient but also the healthcare provider when dealing with opioid medications.  

In situations where chronic opioid use is indicated, there are certain steps that can be taken to optimize safety for all involved.  Some key points to take away from today's discussion include:

-Review CURES (Prescription Drug Monitoring Program) data before any Rx of opioids

-Obtain baseline UDS, and monitor at least annual random UDS moving forward; and most importantly interpret and utilize the results in treatment decisions

-Perform screening tools for risk of aberrancy, and significant psychiatric comorbidities (ORT, PHQ-9, GAD-7) prior to prescribing and then repeat at appropriate intervals

-Work to find lowest effective dose, with goal of less than 50 OME as a general guideline

-Thoroughly evaluate benefits and harms of continued therapy with patients every 3 months or more frequently (including evaluation of not just improvement in pain score, but also functional improvement)

4 A’s

-Minimize/avoid use of centrally active sedative medications in patients on opioid medications, especially in regards to Benzodiazepine meds

-Rx of Naloxone and provision of education regarding administration of Naloxone for any patient on 90 OME, or for any patient concurrently Rx’d a Benzodiazepine and an opioid medication, or for patient at high risk (hx of overdose, or hx of substance use disorder) (as per California law: AB 2760)

Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people.

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.

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves are introducing electrodiagnostic evaluations.

An electrodiagnostic evaluation is a combination of nerve conduction studies and electromyography, or in simple terms a way to look at the health of nerves. The nerve conduction study uses electrodes and an electrical impulse to send a signal through a nerve and pick it up at a different point along that nerve. Electromyography is a small needle (usually 28g) that goes into muscles and listens to the way the muscle and nerves communicate.

This study is performed by mainly two specialties- neurologists and physiatrists. It is considered by many to be an extension of they physical examination, and part of the normal workup for pathologies just like imaging (MR or XR) is.

Electrodiagnostic evaluations can help assess many pathologies, but the must common are things like carpal tunnel syndrome, peripheral neuropathy, and radiculopathy (nerve root injury originating at they level of the spine). These studies are also integral in the evaluation of more rare processes like muscular dystrophy, ALS, and other neuromuscular diseases; but the docs stick to the more common pathologies in this discussion.

Listen in for some key takeaways including:

- the study is uncomfortable, but overall well tolerated

- Generally, In less than an hour we can have some very useful and objective data

- This tool is a very helpful and useful part of a full workup for the patient

Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people.

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.

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves nerd out about chronic pain pathways, specifically the changes that take place in the signaling over time. Chronic, persistent pain changes the physiologic signaling in the body. This means that it is not purely a nociceptive process.

Along the pathway, we have the classic components of transmission, transduction, modulation, and perception that are each involved in the signaling cascade of our nociceptive nervous system. Each one of these components can have signaling errors that can lead to chronic pain.

Today, we specifically discuss the modulation component and wind up. Wind up is the process by which the signaling in the body changes, so that when the pain signal comes into the central nervous system- it is stronger and lasts longer. The nerves fire more frequently and with greater strength. The longer this lasts in the body, the more wind up occurs. Eventually, the nerves can keep firing these signals without any ongoing stimulus- meaning that over time, even though the anatomy has "healed", the pain signals will still be firing continually. And thus, chronic pain.

The docs will also dive deep into glial cells- how they become a part of the modulation of these painful signals and ways that we may be able to intervene into this cascade.

Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people.

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.

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves chat about "non specific" lies back pain.

Back pain has been well documented as the most common reason people present to a healthcare professional with some studies quoting an incidence as high as 30%. It is also one of the largest causes of disability, morbidity, and lost production in the United States.

But as shocking as those stats can be, maybe even more shocking are studies that quote anywhere between 90 and 99% of acute low back pain as "non specific"!

What is that and how can something that has such a huge personal and societal impact really be called "non-specific"!?! Listen as the doctors dive deeper into this topic. They will discuss their takes on this, from the perspective of double board certified specialists that focus on back pain, and share some practical tips for patients and primary care practitioners to help this large population.

Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people.

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.

In this week's episode of the Spine & Nerve podcast, Dr. Raman Gurai and Dr. Brian Joves introduce the field of regenerative medicine.

Regenerative medicine at its core is a theory that we can influence the body's natural healing abilities to help with pain. The field has been developing over the past few decades, but really made it into the mainstream lexicon when professional athletes began utilizing it in the mid 2000s. Since that time, science and the medical literature have continued to evolve in helping us understand which patients are appropriate for which intervention.

Just like all forms of musculoskeletal medicine, we tend to take a conservative to more invasive approach with regenerative medicine interventions. Some of the techniques that are currently used to help patients with pain and injuries in joints, tendons, ligaments, muscles, etc include:

-Low level laser therapy, also called photobiomodulation (currently recommended by the American College of Physicians and American College of Rheumatology)

-prolotherapy, also called proliferate therapy

-platelet rich plasma therapy (PRP)

-amniotic fluid therapy

-adipose tissue or fat derived stem cell therapy

-bone marrow aspirate concentrate (BMAC)

Listen as the doctors dive deeper into this topic and give some practical considerations as we continue to evolve this burgeoning field.

Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people.

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.

Last week, Andrew Luck shocked the NFL world by announcing his retirement. In his retirement speech, he stated "I've been in this cycle of injury, pain, rehab, injury, pain, rehab, and it's been unceasing, unrelenting... The only way I see out of it is to no longer play football."

This is probably one of the most high profile retirements in the history of the NFL and adds to the growing list of players retiring in or before their "primes". The NFL has dealt with a lot of fall out over chronic traumatic encephalopathy (CTE) since Dr. Bennet Omalu published a case report of the disease in an NFL player (Mike Webster) in 2005. Since then, there have been numerous players that have reconsidered football as a long term career.

Listen in as Dr. Raman Gurai and Dr. Brian Joves discuss this and what may be coming down the road for the NFL. This is a discussion between two long time sport fans, who happen to be physical medicine and rehabilitation physicians. The doctors do not know the details of the NFL policies or standards, specific players' injuries and are simply talking it through from an informed fan's perspective.

Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people.

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.

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves continue the discussion on complex regional pain syndrome. As we discussed last episode, CRPS is essentially nerves not behaving themselves in the peripheral and Central nervous systems, and is one of the models for centralized pain.

Because CRPS is so variable in its clinical presentation and the way that our affects patients, the treatment plans and algorithms have to be tailored specifically to each individual case. Dr. Karvelas and Dr. Joves dive into treatment options and the medical literature for CRPS, taking things from conservative to more invasive.

Because CRPS can be a devastating disease process (especially in the chronic phases), most of the medical literature recommends early and more aggressive treatment. The best data for CRPS states that patients tend to do better in the long run if the symptoms are better controlled in the first 12 months. For this reason, the timeline for trying interventions can be accelerated in certain instances.

Listen as the docs walk through some of the treatments including:

Therapy focusing on contrast bags and contrasting textures

Medications

Infusions including ketamine and bisphosphonates

Injections to block the sympathetic chain ganglia

Neuromodulation including minimally invasive surgeries such as spinal cord stimulation and dorsal root ganglion stimulation

Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Please leave us a comment or review- these help us to improve and provide value to more people.

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.