Spine & Nerve

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss the recent string of major injuries affecting NFL players, and what role the variations on training camp and a lack of a preseason may play.

This is a discussion between two long time sports fans, who happen to be physical medicine and rehabilitation physicians. The doctors do not know the details of individual injuries or NFL protocol and oversight, and are simply talking it through from a medical perspective. This is not meant to be medical advice, a medical opinion, or to have any opinion on the circumstances of the injury.

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, the may not represent the views of Spine & Nerve.

References:

1.  Dai, B., Sorensen, C.J., Derrick, T.R., & Gillette, J.C. (2012). The effects of postseason break on knee biomechanics and lower extremity EMG in a stop-jump task: implications for ACL injury. Journal of applied biomechanics, 28 6, 708-17 .

2. Gossman WG, Varacallo M. Achilles Tendon Rupture. StatPearls. 2018.

3. https://www.playsmartplaysafe.com/newsroom/reports/injury-data/

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss one of the most commonly utilized medications, non-steroidal anti-inflammatory drugs (NSAIDs).  

NSAIDs are medications with anti-inflammatory, analgesic, and anti-pyretic properties.  The mechanism of action of NSAIDs is predominantly through inhibition of cylo-oxygenase, but there are multiple other pathways by which NSAIDs exert their therapeutic effect including but not limited to modulation of neutrophil function and cell membrane function.  It is important to understand that there are multiple different classes of NSAIDs, and each NSAID has its own unique properties resulting in differences in regards to safety and efficacy.  

 

Listen as the doctors discuss important topics including:

-drug-drug interactions concerning NSAIDs including NSAIDs interaction with aspirin and SSRI medications.  

-research including the PRECISION trial addressing the question of whether or not Celecoxib (a selective COX-2 inhibitor) has increased cardiovascular risk relative to relatively non-selective NSAIDs.

-optimal utilization of NSAIDs in the setting of acute musculoskeletal injuries.

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. Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. N Engl J Med;  2016.

2. Pharmacology of Nonsteroidal Antiinflammatory Drugs and Opioids. Pharmacology in Interventional Radiology; 2010.

3. New insights into the use of currently available non-steroidal anti-inflammatory drugs. Journal of Pain Research; 2014.

4. Cardiovascular outcomes in high risk patients with osteoarthritis treated with ibuprofen, naproxen or lumiracoxib. Ann Rheum Dis;  2007.

5. Efficacy and safety of oral NSAIDs and analgesics in the management of osteoarthritis: Evidence from real-life setting trials and surveys. Seminars in Arthritis and Rheumatism; 2016.

6. COX-2 inhibition impairs mechanical stimulation of early tendon healing in rats by reducing the response to microdamage. Journal of Applied Physiology; 2015.

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss chronic pain as a disease process. Chronic pain has significant negative impacts on overall health including but not limited to: increased risk of hypertension, increased risk of cognitive decline, negative impact on sleep, and compromise of the immune system.  The key concept is that chronic pain is a disease process, and that this disease process is not solely defined by the experience of pain and consequent limitations. Chronic pain leads to significant consequences in regards to overall health as well.  

 

Chronic pain is very prevalent in our world, with research demonstrating that 20-50% of the world's adult population is affected by chronic pain.  High impact chronic pain (defined as pain on most/every day for 3 months or longer with greater than or equal to 1 associated activity limitation) is estimated to have on overall prevalence of 4.8% in the United States.  Chronic pain is strongly associated with increased risk of disability; however, as stated it is not just the painful symptoms and disability that we need to keep in mind when we are working to optimize treatment for these patients.  

 

Listen as the doctors discuss the research that has been done demonstrating chronic pain's impact on multiple important health conditions, including cardiovascular risk, and cerebral gray matter volume / dementia risk.  It becomes critical not only to educate our patients about this information, but also that we as providers keep this in mind as we work to optimize the symptoms, function, and health of patients with chronic pain.

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. Brain gray matter abnormalities in osteoarthritis pain: a cross-sectional evaluation. Pain. 2020.

2. Prevalence and Profile of High-Impact Chronic Pain in the United States. The Journal of Pain. 2019.

3. Association Between Persistent Pain and Memory Decline and Dementia in a Longitudinal Cohort of Elders. JAMA Intern med. 2017.

4. Long-Term Consequences of Chronic Pain: Mounting Evidence for Pain as a Neurological Disease and Parallels with Other Chronic Disease State. Pain Medicine. 2011.

In this week's episode of the Spine & Nerve podcast we present a recent webinar that Dr. Joves gave on the treatment options for patients living with chronic low back pain. In this webinar, Dr. Joves walks through his overall approach and 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. Joves will explore:

Radio frequency ablation

Indirect spinal decompression

Neuromodulation  

 

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 Dr. Nicolas Karvelas and Dr. Brian Joves revisit lumbar stenosis with neurogenic claudication with a journal club of some recent literature. The studies will look at epidemiology, treatment options, and data regarding its impact on mobility / exercise.  

 

Lumbar stenosis is defined as any type of narrowing of the spinal canal, nerve root canals, or intervertebral foramina; it may be local, segmental, or generalized, it may be caused by bone or soft tissue and the narrowing may involve the bony canal alone, the dural sac, or both.  Lumbar stenosis is a common disease process, and depending on the criteria employed for diagnosis the prevalence in the general adult population ranges from 11-39% (this range also highlights the need for optimization / standardization of the diagnostic criteria for this disease).  The classical clinical presentation of lumbar stenosis with neurogenic claudication is lower limb symptoms (including deep muscular pain, cramping, altered strength/sensation) with or without low back pain, that is very much accentuated by standing and walking, and alleviated by sitting down or lumbar flexion (shopping cart sign).  

 

Treatment options include: lifestyle modifications (diet, exercise, weight optimization), activity modifications, physical therapy, lumbosacral orthosis, medications (caution in this typically elderly population with potential fall risk), epidural steroid injections, minimally invasive surgical intervention (including Minimally Invasive Lumbar Decompression (MILD), and Interspinous Process Decompression), and decompression with or without hardware.  Interspinous Process Decompression is a supported by multiple studies including 5 year clinical outcome data demonstrating efficacy for pain and function.  In this podcast discussion the doctors also highlight the cost effectiveness of Interspinous Process Decompression relative to other approaches to treatment.  

 

Listen as the doctors discuss this important and highly prevalent disease process, including a review of recent studies that highlight some important aspects of this disease process including the fact that based upon the best available evidence only about 4% of patients with lumbar stenosis with neurogenic claudication are able to meet the recommended level of physical activity per week.  

 

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. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. European Spine Journal. 2020.

2. Objective measurement of free-living physical activity (performance) in

lumbar spinal stenosis: are physical activity guidelines being met?. The Spine Journal. 2017.

3. Cost-effectiveness and Safety of Interspinous Process Decompression (Superion). Pain Medicine. 2019.

4. The MIST Guidelines: The Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment. Pain Practice. 2018.

5. Five-year durability of stand-alone interspinous process decompression for lumbar spinal stenosis. Clinical Interventions in Aging. 2017.

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss one the potential complications of procedures treating the spine- post dural puncture headaches(PDPHA). Listen in as the docs discuss the typical clinical presentation and the management of PDPHA.  

 

PDPHA is defined as a headache that occurs within 5 days of intended or accidental dural compromise. It is caused by leakage of cerebrospinal fluid (CSF), and is usually accompanied by neck stiffness and/or subjective hearing changes. The symptoms usually remit spontaneously within 2 weeks or after autologous epidural blood patch.  

 

The important aspects of the patient history / clinical presentation include but are not limited to:

-history of dural puncture

-postural component of headache (headache improves/resolves with lying flat, and worsens with sitting/standing)

-location of headache is bi-frontal and/or occipital

-onset of headache usually is within first 24-48 hours after dural puncture

 

Treatment of PDPHA depends on the severity / persistence of symptoms, and includes consideration of conservative management with bed rest, Acetaminophen, NSAIDs, caffeine; and the gold standard of treatment for severe or refractory PDPHA is autologous epidural blood patch.

 

Listen as the doctors discuss the definition, differential diagnosis, epidemiology, clinical presentation, pathophysiology (including normal CSF physiology), treatment (including the research behind autologous epidural blood patch), for post dural puncture headache.  

 

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. Candido. Post-dural puncture headache:pathophysiology, prevention and treatment. Best Practice & Research Clinical Anaesthesiology. 2003.

2. Schievink et al. Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension. JAMA. 2006.

3. Neal JM. Update on postdural puncture headache. Techniques in Regional Anaesthesia and Pain Management 1998; 2: 202–210.

4. Vandam LD & Dripps RD. Long-term follow-up of patients who received 10,098 spinal anesthetics III. Syndrome of decreased intracranial pressure (headache and ocular and auditory difficulties). Journal of the American Medical Association 1956; 161: 586–591.

5. Battal et al. Cerebrospinal fluid flow imaging by using phase-contrast MR technique. Br J Radiol. 2011.

6. Abouleish E, Vega S, Blendinger I & Tio TO. Long-term follow-up of epidural blood patch. Anaesthesia and Analgesia 1975; 54: 459–463.

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves present journal club- therapies for cancer associated pain. They will present recent articles on established treatment modalities like intrathecal drug delivery for advanced cancer pain, as well as more emerging including peripheral nerve stimulation.

 

Significant pain impacting function and quality of life is a common problem in patients with cancer.  Systematic reviews demonstrate that around 50% of patients with advanced cancer have moderate to severe pain.  Additional studies show that around 50% of cancer patients with pain report adequate pain control as their highest priority in regards to management of their disease process. Cancer associated pain is often refractory to oral opioids and/or patients experience significant side effects with the oral regimen.  

 

Listen as the doctors discuss the established and emerging treatment options for significant cancer associated pain including recent studies published on the topic.  

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. Sindt, J.E., Odell, D.W., Dalley, A.P. and Brogan, S.E. (2020), Initiation of Intrathecal Drug Delivery Dramatically Reduces Systemic Opioid Use in Patients With Advanced Cancer. Neuromodulation: Technology at the Neural Interface. April 2020.

 

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. February 2020.

 

3. Dorsal root ganglion stimulation for chemotherapy-induced peripheral neuropathy: a case report. The Journal of Pain. 2017.

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss neuromodulation of the vagus nerve as a therapy for chronic pain conditions.

The vagus nerve is an incredibly complex and important nerve.  The critical and wide array of effects that the vagus nerve has on the body make it an intriguing target for treatment of a variety of different conditions. Must notably, the vagus nerve is considered to be essential in the body's parasympathetic response... Which in pain medicine is interesting because many chronic pain conditions are believed to have a heightened sympathetic response.

Vagus nerve stimulation is FDA approved for treatment of refractory epilepsy and refractory depression.  There is growing animal model and clinical research demonstrating that vagus nerve stimulation also has significant analgesic potential.  There is currently early promising research demonstrating potential effectiveness of vagus nerves stimulation for multiple difficult to treat pain conditions including fibromyalgia, chronic pelvic pain, rheumatoid arthritis, trigeminal allodynia, and refractory headaches.  

 

Listen as the doctors discuss some of the available literature regarding this interesting, important, and emerging therapy.

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. Chakravarthy K, Chaudhry H, Williams K, Christo PJ. Review of the Uses of Vagal Nerve Stimulation in Chronic Pain Management. Curr Pain Headache Rep. 2015;19(12):54.

2. Johnson RL, Wilson CG. A review of vagus nerve stimulation as a therapeutic intervention. J Inflamm Res. 2018;11:203-213. Published 2018 May 16.

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss preparing for an interventional pain medicine rotation.

This discussion is most relevant for PGY-2 and PGY-3 residents looking to go in to a pain medicine fellowship, but is easily relatable to all levels of training.

Some of the discussion points:

- The bare minimum the docs expect from rotators

- Recommended resources for students and residents

- Three key components to impressing on your rotation

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.

Resource recommendations:

‪ISIS Practice Guidelines for Spinal Diagnostic and Treatment Procedures: 2nd Edition.‬ Nikolai Bogduk.

Atlas of Image-Guided Spinal Procedures. Michael Furman.

Danne Miller board review series

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves review some key concepts regarding one of their favorite topics: buprenorphine.  

 

Our goal as healthcare providers is to optimize diagnosis and treatment so that medications are minimized or not needed. When it is medically appropriate and indicated to utilize long term medications acting on the opioid receptor, buprenorphine has superior safety and similar efficacy relative to full mu opioid medications.  Benefits of Buprenorphine include but are not limited to decreased risk of respiratory depression and death, decreased risk of hyperalgesia and tolerance, decreased risk of immunosuppression, decreased risk of hormone alteration, decreased risk of constipation, decreased risk of worsening depression.  

 

The doctors also discuss the challenging clinical scenario of transitioning a patient from Methadone to Buprenorphine. Methadone has unique pharmacology and characteristics relative to other opioids; it has a long and variable half-life, and is disproportionately associated with opioid related deaths.  The transition from Methadone to Buprenorphine is one that needs to be performed in a thoughtful and meticulous manner.  

 

Listen as the doctors discuss some of the available literature, as well as their clinical experience regarding this challenging and important topic.

 

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. Lintzeris N, Monds LA, Rivas C, et al. Transferring Patients From Methadone to Buprenorphine: The Feasibility and Evaluation of Practice Guidelines. J Addict Med. 2018;12(3):234-240.

2. Buprenorphine buccal film for chronic pain management Martin Hale, Joseph Gimbel, and Richard Rauck Pain Management 2020 10:4, 213-223.

3. FREDHEIM, O.M.S., MOKSNES, K., BORCHGREVINK, P.C., KAASA, S. and DALE, O. (2008), Clinical pharmacology of methadone for pain. Acta Anaesthesiologica Scandinavica, 52: 879-889.

4. Chinazo O. Cunningham, Angela Giovanniello, Xuan Li, Hillary V. Kunins, Robert J. Roose, Nancy L. Sohler, A comparison of buprenorphine induction strategies: Patient-centered home-based inductions versus standard-of-care office-based inductions, Journal of Substance Abuse Treatment, Volume 40, Issue 4, 2011, Pages 349-356, ISSN 0740-5472.