Spine & Nerve

Spine & Nerve

By Brian Joves, M.D.Health & Fitness
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Spine & Nerve episodes

  • Case Report: Persistent Spinal Pain Syndrome

    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.


    28 min
  • Journal Club: Landmark Articles for Treating Persistent Spinal Pain Syndrome
    In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss landmark articles regarding the treatment of patients with Persistent Spinal Pain Syndrome (PSPS).
    PSPS is a new term that was recently proposed by an expert international committee to describe patients with chronic, severe pain of spinal origin, refractory to treatments, including at times surgery. Please listen to the Back to Basics episode for a full description and discussion of the pathophysiology.
    Though this is a new term, many studies have looked at the outcomes of interventions such as dorsal column spinal cord stimulation and repeat spine surgery when managing patients who had continued chronic pain after spine surgery. Listen as the doctors dive in and discuss these legendary articles that have transformed the management of patients with PSPS.
     
    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.
    References:
    1. North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005;56(1):98-106.
    2. Alf L Nachemson (1993) Evaluation of results in lumbar spine surgery, Acta Orthopaedica Scandinavica, 64:sup251, 130-133.
    3. Arts MP, Kols NI, Onderwater SM, Peul WC. Clinical outcome of instrumented fusion for the treatment of failed back surgery syndrome: a case series of 100 patients. Acta Neurochir 2012;154(7):1213–1217.
    21 min
  • Back to Basics: Persistent Spinal Pain Syndrome
    In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves go back to Basics with a twist - the doctors discuss Persistent Spinal Pain Syndrome (PSPS).
    PSPS is a new term that was recently proposed by an expert international committee to describe patients with chronic, severe pain of spinal origin, refractory to treatments, including at times surgery. Previously, certain diagnoses were utilized to describe these pathologies including but not limited to Failed Back Surgery Syndrome and Post-laminectomy syndrome.  These terms are not without their limitations: terms such as failed back surgery Syndrome can carry a very negative connotation, and also patients can have the clinical presentation consistent with this diagnosis without having a history of spine surgery (for example a chronic disc herniation can lead to the development of fibrosis around a nerve root ).  
    The aforementioned group of experts published an article in Pain Medicine in April of 2021 proposing the adoption of PSPS with the goal of continuing to optimize the most accurate diagnosis for all appropriate patients, advancement of research in this field, and communication between healthcare providers.  
     
    PSPS is not a single diagnosis, but rather an encompassing term that includes persistent painful disease processes of spinal origin 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 be the site of pathology.  Importantly, spinal surgery may or may not have occurred, and may or many not be the primary contributor to the clinical presentation.  
     
    Listen as the doctors discuss the article regarding this important new nomenclature, as well as review some important pathophysiology for PSPS including epidural fibrosis and adjacent level syndrome.
     
    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.
    References:
    1. Nick Christelis, MD, Brian Simpson, MD, Marc Russo, MD, Michael Stanton-Hicks, MD, Giancarlo Barolat, MD, Simon Thomson, MD, Stephan Schug, MD, Ralf Baron, MD, Eric Buchser, MD, Daniel B Carr, MD, Timothy R Deer, MD, Ivano Dones, MD, Sam Eldabe, MD, Rollin Gallagher, MD, Frank Huygen, MD, David Kloth, MD, Robert Levy, MD, Richard North, MD, Christophe Perruchoud, MD, Erika Petersen, MD, Philippe Rigoard, MD, Konstantin Slavin, MD, Dennis Turk, PhD, Todd Wetzel, MD, John Loeser, MD, Persistent Spinal Pain Syndrome: A Proposal for Failed Back Surgery Syndrome and ICD-11, Pain Medicine, Volume 22, Issue 4, April 2021, Pages 807–818.
    2. Chan CW, Peng P. Failed back surgery syndrome. Pain Med. 2011 Apr;12(4):577-606. doi: 10.1111/j.1526-4637.2011.01089.x. Epub 2011 Apr 4. PMID: 21463472.
    3. Bosscher, H.A. and Heavner, J.E. (2010), Incidence and Severity of Epidural Fibrosis after Back Surgery: An Endoscopic Study. Pain Practice, 10: 18-24.
    24 min
  • The Surgeon's Perspective: Cervical Myelopathy with Dr. Erich Anderer
    In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves is joined by a very special guest to continue the discussion on Degenerative Cervical Myelopathy (DCM).
    Dr. Erich Anderer joins the podcast today to give us the surgeon's perspective on DCM. During his day job as the Chief of Neurosurgery at NYU Langone Hospital- Brooklyn, Dr. Anderer does his best to work with patients to develop a treatment plan that doesn’t require surgery- incorporating yoga, Pilates, or meditation into someone’s care. He has preached this "less is more" philosophy across Instagram, teaching yoga classes, or lecturing at wellness retreats. When not performing surgery on the brain or spine as an assistant professor of neurological surgery, Dr. Anderer is one of the most interesting men in the world - He practices Ashtanga yoga, spends as much time outdoors with his wife and two children as possible, and still has time to: be a founding member of the North Brooklyn Runners; an advisory board member of the Concussion Legacy Foundation; serve on the boards of the NY State Neurosurgical Society, the Japanese Medical Society of America, God’s Love We Deliver, and the North Brooklyn Parks Alliance; and play in a band...
    You can find Dr. Anderer on social platforms under his name: Dr.Erich Anderer.
    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.
    39 min
  • Back to Basics: Degenerative Cervical Myelopathy
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss Degenerative Cervical Myelopathy (DCM).  DCM, previously called cervical spondylotic myelopathy, is defined as neurologic injury to the cervical spinal cord due to various age-related degenerative conditions of the cervical spine resulting in injury to the spinal cord secondary to static compression, and/or dynamic injury due to instability. DCM results in symptoms including loss of hand function / dexterity, imbalance/falls, weakness, numbness, pain, bladder / bowel dysfunction.
    DCM is a common disease process- it is the most common cause of spinal cord injury in the developed world. Natural history studies of DCM show that for patients with significant cervical stenosis, the risk of development of DCM is 8% at 1 year, and up to 23% at 3-4 year follow up. Dr. Karadimas and his colleagues found that between 20-60% of patients with initially mild DCM will have significant clinical deterioration over time; as measured by functional outcome measures including Timed 10 meter walk, and ADL’s score.  This understanding of the typical natural history of DCM highlights the importance of close monitoring of patients with significant cervical stenosis, and prompt surgical referral once DCM is diagnosed.  
     
    Listen as the doctors discuss this important topic including the definition, epidemiology, clinical presentation, diagnosis, and management.  
     
    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.
     
     
    References:
    1. Lebl, Darren R. MD; Bono, Christopher M. MD Update on the Diagnosis and Management of Cervical Spondylotic Myelopathy, Journal of the American Academy of Orthopaedic Surgeons: November 2015 - Volume 23 - Issue 11 - p 648-660.
    2. Nouri A, Cheng JS, Davies B, Kotter M, Schaller K, Tessitore E. Degenerative Cervical Myelopathy: A Brief Review of Past Perspectives, Present Developments, and Future Directions. J Clin Med. 2020;9(2):535.
    39 min
  • Case Report: Lumbar Discogenic Pain
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves present a case of an early 40s female physician who presented with about 1 year of back pain that was progressively impacting her marathon training.
    Listen as the doctors talk through this case presentation, including the history, physical, workup, conservative management and dive into some of the options they are considering as this case (and the science behind Interventional options) progresses.
     
    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.
    References:
    1. Smuck M, Khalil J, Barrette K, Hirsch JA, Kreiner S, Koreckij T, Garfin S, Mekhail N; INTRACEPT Trial Investigators. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Reg Anesth Pain Med. 2021 May 24:rapm-2020-102259. doi: 10.1136/rapm-2020-102259. Epub ahead of print. PMID: 34031220.
    2. https://anchor.fm/spine/episodes/Smoking-is-still-the-new-smoking-how-smoking-can-make-chronic-pain-worse-eb8h1b
    35 min
  • Journal Club: Regenerative Medicine and Discogenic Pain
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves dive deeper into lumbar discogenic pain and discuss a recent publication reviewing the evidence for regenerative therapies in the management of discogenic pain.
    Regenerative medicine and orthobiologic therapy utilizes the body's own healing factors to treat the underlying pathology.
    Listen as the doctors talk through this important topic, and dive into the basic science behind regenerative therapies specifically targeting disc degeneration, as well as the clinical evidence that has been presented.
     
    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.
     
    Intervertebral Disc Degeneration: The Role and Evidence for Non–Stem-Cell-Based Regenerative Therapies
    Saarang Singh, MD CANDIDATE, Ankur A. Patel, DO, and Jaspal R. Singh, MD. Int J Spine Surg. 2021 Apr; 15(Suppl 1): 54–67. Published online 2021 Apr 30. doi: 10.14444/8055
    32 min
  • Back to Basics: Lumbar Discogenic Pain
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves go back to basics and introduce the topic of lumbar discogenic pain.
    Lumbar discogenic pain is defined as a painful disease process due to compromise of the lumbar disc and is very common, with most studies documenting that around 40% of low back pain is predominantly due to discogenic pain.  Disc degeneration is part of the natural degenerative cascade of the spine, but can be more advanced and lead to significant symptoms and impairments.
    Discogenic pain is often characterized by centralized low back pain that tends to be worse with forward flexion (ie bending at the waist) and sitting (especially with vibration like in a car). MR Imaging can show internal disc disruption, annular fissures, and modic changes. Risk factors for disc degeneration and discogenic pain include aging, genetics, obesity, and smoking. Smoking and weight, are modifiable risk factors that should be emphasized and addressed when applicable.  
     
    Though the disc itself can be painful, if the disc puts pressure on other structures (like the nerve roots) it can cause different pain patterns.
    Listen as the doctors talk through this important topic, and dive into the basic science behind disc degeneration, as well as emphasize certain important concepts including but not limited to Modic changes.  
     
    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.
     
     
    References:
    1. Nikolai Bogduk, MD, Charles Aprill, MD, Richard Derby, MD, Lumbar Discogenic Pain: State-of-the-Art Review, Pain Medicine, Volume 14, Issue 6, June 2013, Pages 813–836.
    2. Sertac Kirnaz, MD, et al. Pathomechanism and Biomechanics of Degenerative Disc Disease: Features of Healthy and Degenerated Discs. International Journal of Spine Surgery. 2021.
    33 min
  • Case Report: Lumbar Facet Joint pain
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves present a case of a relatively young patient with lumbar facetogenic pain in the setting of spondylolisthesis with some level of dynamic instability.  
    There is strong evidence for the treatment of lumbar facetogenic pain with lumbar medial branch radiofrequency ablation (RFA), including a recent study published in Pain Medicine in 2020 demonstrating sustained benefit after RFA for over 2 years (Conger et al., Pain Medicine. 2020).  However, when the anatomy is considered including the fact that the medial branch targeted with RFA also innervates the multifidus musculature; one may hypothesize that RFA could potentially negatively impact spinal stability.  This negative impact on spine stability would be of particular concern in a young patient with listhesis and dynamic instability. The available published literature investigating this topic has demonstrated that RFA does not result in a significant negative impact on listhesis or instability.
    As providers considering, ordering, and/or performing these procedures, it is important to be aware of the relevant neuroanatomy and the published research regarding this matter; and importantly to discuss these risks/benefits with the patient.  
     
    Listen as the doctors talk through this case, and discuss some of the recent literature including a study out of Emory University School of Medicine investigating RFA’s impact on spondylolisthesis / spinal stability.
     
    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. Patel T, Watterson C, McKenzie-Brown AM, Spektor B, Egan K, Boorman D. Lumbar Spondylolisthesis Progression: What is the Effect of Lumbar Medial Branch Nerve Radiofrequency Ablation on Lumbar Spondylolisthesis Progression? A Single-Center, Observational Study. J Pain Res. 2021;14:1193-1200.
    2. Conger A, Burnham T, Salazar F, Tate Q, Golish M, Petersen R, Cunningham S, Teramoto M, Kendall R, McCormick ZL. The Effectiveness of Radiofrequency Ablation of Medial Branch Nerves for Chronic Lumbar Facet Joint Syndrome in Patients Selected by Guideline-Concordant Dual Comparative Medial Branch Blocks. Pain Med. 2020 May 1;21(5):902-909.
    20 min
  • Journal Club: Interventions for Lumbar Facetogenic Pain
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves continue the discussion on lumbar facetogenic pain with a journal club.
    Lumbar spondylosis with a primary pain generator of facet joint pain is a common pathology that can have a significant negative impact on a patient’s function and health.  There are multiple Interventional treatment options available to address lumbar facetogenic pain including lumbar medial branch blocks, intraarticular facet joint injections, and lumbar medial branch radiofrequency ablation (RFA).
    There is high quality evidence for the utilization of RFA for axial low back pain due to lumbar facetogenic pain. As with all medical interventions, It is important to continue evaluating patient factors that can alter the expected outcomes.  Listen as the doctors discuss a recent article investigating factors that predict outcome after facet joint treatment.
    The second article reviewed is one of the landmark studies regarding medial branch blocks prior to RFA. Medial branch blocks are a critical tool in the diagnosis of lumbar facetogenic pain, and are the gold standard diagnostic tool prior to consideration of RFA.    
     
    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. Javed S, Chen J, Huh B. Predictors of response to medial branch block, radiofrequency ablation or facet joint injections: a retrospective study. Pain Manag. 2021 Mar;11(2):145-149.
    2. Cohen SP, Moon JY, Brummett CM, White RL, Larkin TM. Medial Branch Blocks or Intra-Articular Injections as a Prognostic Tool Before Lumbar Facet Radiofrequency Denervation: A Multicenter, Case-Control Study. Reg Anesth Pain Med. 2015 Jul-Aug;40(4):376-83.
    26 min

About Spine & Nerve

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We are physicians who practice pain management and physical medicine and rehabilitation, and believe that the main goal of practice is to improve the quality of life of our patients and communities. We will dive deep into the world of modern pain management to help healthcare providers and consumers understand various diagnoses, treatment options, and the changing landscape of pain management.