Spine & Nerve

Spine & Nerve

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

  • Say Kroe ILL EE I -tis: a review of sacroiliac joint pain, diagnosis and treatment

    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.

    25 min
  • COVID and pain medicine: not just telemedicine and delayed procedures

    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.

    23 min
  • Klay Thompson has us in our feelings- a discussion on achilles tendon injuries
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves return to their Bay Area roots and mourn with Dub Nation after a devastating injury to Klay Thompson (shooting guard for the Golden State Warriors).  Klay Thompson sustained a season ending right Achilles’ tendon tear. Thompson suffered the injury during a workout... after a year of rehabbing from an ACL injury to his left knee that occurred during the 2019 NBA Finals.  If anyone can fight their way back through 2 consecutive grueling rehab processes and return to the level of play we expect from a player of Klay Thompson’s magnitude, it is Klay, but even for him this will be an incredible physical and mental challenge.
     
    Tendon injuries are very prevalent with epidemiologic studies finding it to be the 2nd most common musculoskeletal condition to result in pursuit of medical care (behind spine pain). The pathophysiology of acute and chronic tendon injury does differ, with acute tendon injuries have a stronger proportion of extrinsic factors, while chronic tendon injury is driven more by a variety of intrinsic factors as well.  Inherent characteristics of tendons, including but not limited to relatively low metabolic rate and poor vascularization serve to optimize the tendon’s ability to perform their valuable function in the body, but also contribute to the poor healing potential of tendons.  
     
    Listen as the doctors discuss the basics of tendon anatomy and function, the pathophysiology of tendon injury, as well as the evidence behind some of the treatment options (including platelet rich plasma).  
    Lastly, the doctors explain and emphasize their respect and love for Klay Thompson and how he approached the game of basketball.  Whether it is in basketball, medicine, or life, it is always special to witness someone give it their all for what they love, and Klay Thompson always left it all on the floor.  Rest up, and heal up Klay, and we will see you soon for another championship run with the Warriors.
     
    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. MacLean S, Khan WS, Malik AA, Snow M, Anand S. Tendon Regeneration and Repair with Stem Cells. Stem Cells International. 2012. Article ID 316281.
    2. Sharma, P, Maffulli, N. Tendon Injury and Tendinopathy: Healing and Repair. The Journal of Bone and Joint Surgery. 2005; 87:187-202.
    3. Keene David J, Alsousou Joseph, Harrison Paul, Hulley Philippa, Wagland Susan, Parsons Scott R et al. Platelet rich plasma injection for acute Achilles tendon rupture: PATH-2 randomised, placebo controlled, superiority trial BMJ 2019; 367 :l6132.
    4. Fitzpatrick J, Bulsara M, Zheng MH. The Effectiveness of Platelet-Rich Plasma in the Treatment of Tendinopathy: A Meta-analysis of Randomized Controlled Clinical Trials. The American Journal of Sports Medicine. 2017;45(1):226-233.
    18 min
  • To Taper or not to Taper, that is not the question: how to taper very much is
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves highlight a patient centered approach to tapering opioids. Treatment of the chronic pain disease process is challenging, but optimizing patient buy in and creating an active participant in the treatment plan can be very powerful.  
     
    In many clinical scenarios the goal of tapering / minimizing opioids is medically appropriate to optimize patient safety and health, as well as improve the patient’s function and pain severity.  The tapering of opioids can be very difficult and challenging for the patient and the healthcare provider for a multitude of reasons.
     
    With an intensive regimented opioid reduction program (although indicated in some scenarios, especially when significant aberrancy is identified) there is some level of concern for potential negative clinical outcomes.  These include, but are not limited to, relatively high rate of relapse to utilization of opioids (up to 30%), as well as concern for increased risk for suicide after the taper (Hazard Ratios as high as 6.77 for patients on long term opioids).  The importance of these statements is absolutely not to suggest that opioids should typically be continued for chronic non-cancer pain, but rather to emphasize that the method utilized to achieve the taper is critical.  
     
    Listen as the doctors discuss this difficult medical challenge, including a recent study by Dr. Ziadni and colleagues that demonstrates that a patient centered approach to the opioid taper leads to stable and significant opioid reduction with overall improvement in pain as well.  
    As stated this emphasizes an overall broader and important concept that the active participation of the patient in the treatment plan can result in improved and more sustainable health benefits.      
     
    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. Ziadni, Maisaa; Chen, Abby L.; Krishnamurthy, Parthasarathy; Flood, Pamela; Stieg, Richard L; Darnall, Beth D. Patient-centered prescription opioid tapering in community outpatients with chronic pain: 2- to 3-year follow-up in a subset of patients, PAIN Reports: September/October 2020 - Volume 5 - Issue 5 - p e851.
    2. Huffman KL, Rush TE, Fan Y, Sweis GW, Vij B, Covington EC, Scheman J, Matthews M. Sustained improvements in pain, mood, function and opioid use post interdisciplinary pain rehabilitation in patients weaned from high and low dose chronic opioid therapy. PAIN 2017;18:308–18.
    3. Oliva E, Bowe T, Manhapra A, Kertesz S, Hah JM, Henderson P, Robinson A, Paik M, Sandbrink F, Gordon AJ, Trafton JA. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ 2020;368:m283.
    21 min
  • Pink Past October - Treating breast cancer survivors with post mastectomy pain syndrome
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves want to stay pink past October- they are continuing breast cancer awareness month and discussing one of the overlapping diagnoses: Post-Mastectomy Pain Syndrome (PMPS).  
     
    Breast cancer is the most frequently diagnosed life threatening cancer in women.  There are many different approaches to the treatment of breast cancer, and surgical resection often plays an important role in the management. One potential complication after surgical resection is chronic pain, specifically referred to as PMPS.  The definition of PMPS according to the International Association for the Study of Pain (IASP) is: persistent pain soon after mastectomy/lumpectomy affecting the anterior thorax, axilla, and/or medial arm; typically described as burning, stabbing, pulling sensation.
     
    PMPS is a growing concern, and epidemiologic studies demonstrate that it can affect 20-68% of breast cancers after surgical intervention.  Risk factors for development of PMPS include: younger age (35 years old or younger), type of surgery (total mastectomy and axillary lymph node dissection having increased risk), prior history of chronic pain.
     
    The treatment of PMPS, similar to other chronic neuropathic disease processes, is challenging.  As always it is important to think about the treatment algorithm:
    -lifestyle modifications (including diet, exercise, weight optimization (especially considering BMI can be a risk factor for PMPS))
    -physical therapy (including desensitization techniques)
    -medications (including topical medications, and potentially compounded topical meds)
    -procedures (including the Erector Spinae Block)
    -minimally invasive surgical techniques (including Peripheral Nerve Stimulation and Dorsal Column Spinal Cord Stimulation)
    -and stay vigilant for monitoring for recurrence / progression of the cancer itself
    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.
    Neuropathic pain podcast episode: https://anchor.fm/spine/episodes/Narcissistic-nerves---what-exactly-is-peripheral-neuropathy-and-why-you-should-care-e4njhf
    References:
    1. Gong, Youwei MM; Tan, Qixing MD; Qin, Qinghong MD; Wei, Changyuan PhD. Prevalence of postmastectomy pain syndrome and associated risk factors, Medicine: May 15, 2020 - Volume 99 - Issue 20.
    2. Mainkar, O., Sollo, C.A., Chen, G., Legler, A. and Gulati, A. (2020), Pilot Study in Temporary Peripheral Nerve Stimulation in Oncologic Pain. Neuromodulation: Technology at the Neural Interface, 23: 819-826.
    27 min
  • Profound Data with Dr. Michael Fishman
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss the recent DTM (Differential Targeted Multiplex) Spinal Cord Stimulation Randomized Controlled Trial with Dr. Michael Fishman. Dr. Fishman was one of the clinical investigators in this ground breaking study and joins our podcast to discuss the 12 month data and what it means for the future of neuromodulation and pain medicine.
    The DTM clinical trial was birthed out of basic science research done by Dr. Ricardo Vallejo and his team at Stimgenics- research that we have had the opportunity to explore in depth previously. Please listen to the episode with Dr. Vallejo (https://anchor.fm/spine/episodes/More-glial-cells---Dr--Ricardo-Vallejo--science-that-matters--and-thinking-beyond-the-neuron-eb4m4i) for more details prior to exploring the clinical data.
    The big take aways from this podcast (and the study):
    1.  Profound and superior relief of low back pain at the primary end point (3 months) that was durable through 12 months
    2. Real world data with patients recruited into the study that are a part of all of our practices (insurance based, long standing pain, etc.)
    3. Science and pre- clinical research that leads and directs clinical trial and outcomes
    Reference:
    1. Fishman M, Cordner H, et al. DTM™ SCS RCT 12-month Data Results. Presented at a Medtronic webinar, jointly supported by the North American Neuromodulation Society (NANS), World Institute of Pain(WIP), and the American Society for Pain and Neuroscience (ASPN). October 19, 2020. Webinar available on society websites.
    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.
    DISCLOSURE: Dr. Fishman and Dr. Joves are paid lecturers/educators for Medtronic
    Dr. Fishman's bio:
    Dr. Michael Fishman, MD is a double board-certified Anesthesiologist and Pain Medicine specialist. He graduated from Jefferson Medical College and went on to train in Anesthesiology at Yale University and in Pain Medicine at Stanford University.
    Dr. Fishman has a particular interest in the use of spinal cord stimulation, peripheral nerve stimulation, and dorsal root ganglion (DRG) stimulation in the treatment of neuropathic pain. Dr. Fishman is actively involved with neuromodulation research and is on the cutting edge of new treatments for pain. He is actively involved in the North American Neuromodulation Society, where he serves as director of the Residents and Fellows Section and as course director for pre-conference workshops. In this capacity, he is at the helm of the largest neuromodulation training course in the world.
    30 min
  • Food is Medicine - diet and chronic pain
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss the relationship between diet and chronic pain.  
    Chronic pain including chronic spinal pain is incredibly common and difficult to treat. There are many aspects to a thorough and complete treatment plan including physical modalities, medications, procedures, and surgeries, but one often overlooked component of the treatment plan is diet. What a patient eats has the potential to have a sustained and powerful impact on symptoms and overall health.  
     
    Listen as the doctors discuss the details of a recent study investigating the impact of diet quality (measured by the Healthy Eating Index-2015) on chronic spine pain.  In addition the doctors will share their thoughts regarding some possible beneficial approaches to diet.  
    The main focal points that the doctors discuss include:
    1) a diet with a low glycemic index (minimize processed carbohydrates)
    2) high fiber diet (their is evidence this decreases inflammation and improves joint pain)
    3) increase intake of fruits and vegetables intake (they are rich in polyphenols and data in fibromyalgia patients showing a positive impact on chronic pain disease processes)
    4) optimization of omega 6 to omega 3 ratio (ideally towards a 1:1 ratio- higher levels of omega 3 are associated with decreased inflammation and decreased pain)
    5) ensuring deficiencies are identified and treated including Magnesium and Vitamin D
     
    References:
    1. Zick, Suzanna Mariaa; Murphy, Susan Lynnb; Colacino, Justinc Association of chronic spinal pain with diet quality, PAIN Reports: September/October 2020 - Volume 5 - Issue 5.
    2. Sibille KT, King C, Garrett TJ, et al. Omega-6: Omega-3 PUFA Ratio, Pain, Functioning, and Distress in Adults With Knee Pain. Clin J Pain. 2018;34(2):182-189.
    3. Gandhi R, Perruccio AV, Rizek R, Dessouki O, Evans HM, Mahomed NN. Obesity-related adipokines predict patient-reported shoulder pain. Obes Facts. 2013;6(6):536-41.
    4. Costa de Miranda R, Paiva ES, Suter Correia Cadena SM, Brandt AP, Vilela RM. Polyphenol-Rich Foods Alleviate Pain and Ameliorate Quality of Life in Fibromyalgic Women. Int J Vitam Nutr Res. 2017 Mar;87(1-2):66-74.
    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.
    25 min
  • The journey to sport medicine with Kevin Mullins, M.D.
    In this week's episode of the Spine & Nerve podcast, we sit down with Dr. Kevin Mullins. Dr. Mullins joins the podcast to discuss the journey of becoming a sports medicine physician, specifically focusing on what drove Dr. Mullins into this area of expertise and his tips to the next generation of physicians
    Listen in as the doctors discuss:
    - Why physical medicine and rehabilitation as a primary specialty?
    - How did Dr. Mullins decide to sub-specialize and which fellowship to peruse?
    - What advice does Dr. Mullins give to medical students and residents trying to find their way towards a fulfilling career?
    Dr. Mullins's bio:
    Dr. Kevin Mullins is a Sports Medicine Physician at the University is California, Davis. He is originally from Central California where he graduated as a salutatorian while playing varsity basketball at Buchanan High School. He then matriculated into the University of California, Davis, completing his Bachelor of Science in Exercise Biology with Dean’s List Honors in 2011, as well as a minor in African-American Studies. He remained at UC Davis for his medical degree and was awarded the Sacramento Newspaper 30 Under 30 Award for his community engagement as Chapter President of the Student National Medical Association and Co-Director for the Imani Healthcare Clinic. Upon graduation in 2015, Dr. Mullins was selected as Medical Student of the Year by the Departments of Neurology and Physical Medicine & Rehabilitation. Dr. Mullins remained at UC Davis for his PGY-1 internship year, where he completed a combined medical/surgical training program.
    Dr. Mullins continued residency in Physical Medicine & Rehabilitation at UC Davis, where he achieved the honors of being named Electrodiagnostic Resident of the Year as a PGY-2, and later served as a PGY-4 Chief Resident until graduation in 2019. He covered the California International Marathon event for 4 years, leading as a team captain in his final year of the race. Dr. Mullins then completed his Sports Medicine Fellowship at Stanford University, where he worked as a team physician providing sideline coverage for several NCAA Division 1 teams. He also provided care for local junior college (CCCAA) and Division 2 athletes. Dr. Mullins has also gained experience working with professional level athletes from a wide variety of sports.
    Dr. Mullins is a published author in an academic journal and has given several poster presentations at national conferences including ACSM and AMSSM, as well as at training events including the Annual Team Physician Course. Dr. Mullins has presented for multiple grand rounds, journal clubs, residency lectures and workshops. He is involved in mentoring high school students and educating medical students, and led in the teaching of a weekly Orthopaedic lecture series on the Stanford University undergraduate campus. His clinical interests include motion analysis development, virtual care and ultrasound guided procedures.
    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.
    32 min
  • Case report: Beyond the WHO analgesic ladder - what other options are there for cancer related pain?
    In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves present a clinical case of a patient with advanced metastatic prostate cancer who presented with severe refractory cancer associated pain.  The patient’s cancer associated pain is due to multiple factors including bone pain secondary to metastases to bone, as well as neuropathic pain in setting of chemotherapy induced peripheral neuropathy.  These cases can be very challenging in regard to the development of a treatment regimen that is adequately controlling the patient’s symptoms without significant side effects.  
     
    Cancer associated pain is common with epidemiologic studies finding that around 70-90% of patients with advanced cancer reporting significant pain that impacts their daily function and quality of life.  The World Health Organization analgesic ladder and the European Association for Palliative Care Guidelines have provided guidance for management of this pain that is helpful and important to reference.  
    It is also important to be aware of the multitude of the treatment options available for these difficult cases.  Listen as the doctors discuss some of the treatment options available for advanced cancer associated pain including the utilization of corticosteroids (including the potential adverse effects to be vigilant for), as well as utilization of neuromodulation options.  
     
     
    References:
    1. The Role of Corticosteroids in the Treatment of Pain in Cancer Patients. Curr Pain Headache Rep. 2012.
    2. Yakovlev AE, Resch BE. Spinal cord stimulation for cancer‐related low back pain. American Journal of Hospice and Palliative Medicine 2011;29(2):93‐7.
    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.
    25 min
  • Dr. Raman Gurai presents a webinar on chronic pain and interventional options to help patients.
    In this week's episode of the Spine & Nerve Podcast, we present a recent webinar that Dr. Raman Gurai gave on the treatment options for patients living with chronic low back pain. 
    In this webinar, Dr. Gurai walks through the definition of pain and chronic pain, and presents his approach to helping patients.  He dives deep into three specific procedures that fill the large treatment gap between steroid injections and open surgical intervention. 
    The three main procedures that Dr. Gurai will explore: 
    -Orthobiologic/ Regenerative Medicine
    -Neuromodulation
    -Intrathecal Drug Delivery     
    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.
    33 min

About Spine & Nerve

From the publisher's feed

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.