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.

In this week's episode of the Spine & Nerve podcast, we’re changing things up again and Dr. Brian Joves sits down with Dr. Nicolas Karvelas to get personal on how he progressed from a high school basketball star to a leading pain medicine physician.

Listen in as the doctors discuss:

- How did Dr. Karvelas sleeping with a basketball evolve into a passion for health?

- Why physical medicine and rehabilitation as a primary specialty?

- How did Dr. Karvelas decide to sub-specialize and which fellowship to peruse?

Follow our practice on Facebook at Spine & Nerve Diagnostic Center. Send a message to Dr. Karvelas on LinkedIn. 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 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. Brian Joves sits down with Dr. Hunter Vincent of The Orthohealing Center in Los Angeles. Dr. Vincent joins the podcast to discuss the journey of becoming a pain medicine physician, specifically focusing on what drove Dr. Vincent into this area of expertise.

Listen in as the doctors discuss:

- Why physical medicine and rehabilitation as a primary specialty?

- How did Dr. Vincent decide to sub-specialize and which fellowship to peruse?

- How does Dr. Vincent feel these choices influenced his job opportunities and career path?

Dr. Vincent's bio:

Dr. Hunter Vincent is a graduate of the UC Davis physical medicine and rehabilitation residency program as well as a the UCLA pain fellowship. He is currently practicing at The Orthohealing Center in Los Angeles, CA. He has been actively involved in research in the area of orthobiologics, publishing several peer reviewed manuscripts, coauthoring several textbook chapters on the use of orthobiologics for sports and spine care, and presenting his research at internationally recognized orthopedic conferences. In addition, Dr. Vincent has been the moderator for the TOBI conference which focuses on innovative treatments for musculoskeletal pathology.

He can be found on Instagram (DrHunterVincent) and LinkedIn.

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 discuss the impact of epidural steroid injections on bone mineral density / risk of osteoporosis / fracture risk.  

there is conflicting research/data regarding epidural steroid injections and the impact on bone mineral density and fracture risk.  We know that steroids have the potential to have an impact on osteoblast and osteoclast activity, and consequently bone mineral density; however, the exact steroid, the exact dose, the method of delivery, and the patient's response (including possible increase in function/activity/weight bearing exercise) all need to be taken into careful consideration.  

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

 

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.

References:

1. Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag. 2015;5(2):129-146.

2. Carreon L, Ong K, Lau E, Kurtz S, Glassman S. Risk of osteoporotic fracture after steroid injections in Medicare patients. The American Journal of Orthopedics. 2017.

3. Mandel S, Schilling J, Peterson E, Rao DS, Sanders W. A retrospective analysis of vertebral body fractures following epidural steroid injections. J Bone Joint Surg Am. 2013;95(11):961-964.