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Spine & Nerve podcast Profile

Spine & Nerve podcast

English, Fitness / Keep-fit, 1 season, 118 episodes, 2 days, 6 hours, 37 minutes
About
We are physicians who practice pain management and physical medicine and rehabilitation, and believe that the main goal of our 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. This podcast is meant for educational and entertainment purposes only, and is not medical advice.
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Journal club: Innovations and insights in Neuromodulation

Episode Summary:Join Dr. Jason Kung and Dr. Brian Joves for an in-depth discussion on the latest in neuromodulation. This episode covers a range of topics from the North American Neuromodulation Society 2024 Annual Meeting highlights to a journal club traversing the topics of spinal cord stimulation, closed-loop technology, and the impact of paraspinal muscle atrophy on vertebral endplates. With a blend of expert insights and a review of recent studies, this episode offers a comprehensive look into the advancements and challenges within the field of neuromodulation. Key Points Discussed: North American Neuromodulation Society Meeting Recap: Dr. Kung shares his experiences and key takeaways from the event, highlighting the growing interest in SI joint fusion and the lack of major announcements in neuromodulation waveforms. MRI Compatibility in Neuromodulation Devices: The hosts delve into the importance of MRI compatibility, discussing the implications for patient care and device selection. The Evoke Study and Closed-Loop Stimulation: An in-depth review of the 36-month data from the Evoke trial, which compares closed-loop spinal cord stimulation to traditional open-loop systems. The study's findings on pain relief and the potential for closed-loop technology to revolutionize patient outcomes are explored. Paraspinal Muscle Atrophy and Spinal Health: A discussion on a recent study examining the association between paraspinal muscle atrophy and vertebral endplate degeneration, underscoring the importance of physical therapy and core strength in pain management. Notable Quotes:" The development of the space is not just about this waveform versus that waveform, but understanding that there are many factors that play into patient success." - Dr. Brian Joves "With ECAPs, we're moving towards a two-way feedback system in spinal cord stimulation, akin to how a pacemaker works." - Dr. Jason Kung Closing Thoughts:The episode wraps up with reflections on the potential of neuromodulation technologies and the importance of continued innovation to improve patient care. The hosts also express interest in seeing how closed-loop stimulation and other advancements will perform in real-world settings. Connect with Us: Find Dr. Jason Kung or Dr. Brian Joves on LinkedIn Connect with the podcast on YouTube, IG and Facebook @ SpineNerve Be sure to share, like and subscribe! Upcoming Episodes:Stay tuned for future discussions on groundbreaking studies in pain management and neuromodulation, along with guest appearances from leaders in the field. References: Mullins CF, Harris S, Pang D. A retrospective review of elevated lead impedances in impedance-dependent magnetic resonance-conditional spinal cord stimulation devices. Pain Pract. 2024; 24: 270–277. https://doi.org/10.1111/papr.13301. Mekhail NA, Levy RM, Deer TR, et al ECAP-controlled closed-loop versus open-loop SCS for the treatment of chronic pain: 36-month results of the EVOKE blinded randomized clinical trial Regional Anesthesia & Pain Medicine Published Online First: 27 August 2023. doi: 10.1136/rapm-2023-104751 Schönnagel, Lukas et al. Understanding the Interplay Between Paraspinal Muscle Atrophy and Lumbar Endplate Degeneration: A 3-Year Longitudinal Study. Spine 48(23):p 1627-1634, December 1, 2023. | DOI: 10.1097/BRS.0000000000004826 Pritzlaff et al. A Review of the Factors and Outcomes of Institutional Interdisciplinary Neuromodulation Committees: A Multicenter Experience. Neuromodulation. February 06, 2024 Disclaimer: Reminder that the information provided is for educational purposes and is not intended as medical advice. Always consult with a healthcare professional.
2/26/202436 minutes, 23 seconds
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A Year in Review: Global Insights, Spinal Health, and Looking Ahead to 2024

In this episode of The Spine & Nerve Podcast, Dr. Dr. Jason Kung and Dr. Brian Joves have a reflective and forward-looking discussion as we transition from 2023 into 2024, sharing our podcast's journey, personal insights, biggest happenings in pain medicine, and anticipations for the new year. 1. Podcast Journey and Global Reach: Transitioning through 2023: The evolution of our podcast through the year. Spotify Wrapped Insights: A deep dive into our audience demographics, celebrating a significant international listenership with a special shoutout to our friends in New Zealand, India, Spain, Brazil, and Hungary. 2. Engaging Medical Discussions: Spotlight Episode - Spinal Stenosis: Discussion on why our spinal stenosis episode resonated with so many listeners and the importance of addressing prevalent health issues. Medical Innovations and Literature: A look back at the year's significant advancements in radiofrequency ablation and the evolving landscape of pain management. 3. Personal Reflections and Resolutions: Embracing Challenges: The team's participation in a Spartan Race, symbolizing our dedication to personal growth and community engagement. 4. Community Impact and Listener Engagement: Top 10 Recognition: Celebrating being in the top 10 of listeners' favorite podcasts and what it means to us. Listener Interaction: Encouraging feedback, stories, and engagement from our global audience. 5. Looking Forward to 2024: Medical Community and Conferences: Anticipation for upcoming medical conferences, new technologies, and the continuing battle against the opioid crisis. Optimism for the Future: Our commitment to staying informed, optimistic, and ready to tackle the challenges and opportunities the new year brings. Closing Thoughts: A heartfelt thank you to all our listeners for their continued support and engagement. We look forward to another year of learning, growth, and community. Contact Information: We Encourage listeners to stay connected through our social media channels (LinkedIn, YouTube, Twitter (X), and Facebook are the easiest), website, and Spotify Podcast page for feedback, questions, and community stories. Disclaimer: Reminder that the information provided is for educational purposes and is not intended as medical advice. Always consult with a healthcare professional.
1/8/202432 minutes, 47 seconds
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Managing and Treating Chronic Pain is about Education with Dr. Andrea Furlan

In this episode of the Spine & Nerve Podcast, Dr. Brian Joves has the distinct pleasure to welcome Dr. Andrea Furlan to the show. Dr. Furlan is a pain specialist in Toronto Canada. She is a physiatrist (specialist in Physical Medicine & Rehabilitation). She holds a medical degree from the University of Sao Paulo and a Ph.D. degree from the University of Toronto. She has 30 years of experience helping people with chronic pain to get better quality of life. In this insightful conversation, Dr. Furlan shares her vast experience in managing chronic pain, addressing key aspects of pain management that are crucial for medical providers to understand. Key Takeaways: 1. The Complexity of Chronic Pain: Chronic pain is a multifaceted condition with complex neurobiological and psychosocial components. Understanding the diverse factors contributing to chronic pain is essential for medical providers to provide effective care. 2. The Role of Empathy and Communication: Dr. Furlan emphasizes the importance of empathy and active listening when interacting with patients in pain. Effective communication skills are crucial for building trust and facilitating patient-doctor relationships. 3. Educating Patients: Educating patients about their condition and treatment options is a fundamental aspect of pain management. Medical providers should learn how to explain complex medical concepts in simple terms to ensure patient comprehension. 4. The Value of Multidisciplinary Approaches: Chronic pain often requires a multidisciplinary approach, involving various healthcare professionals such as physiatrists, psychologists, and physical therapists. 5. The Impact of Lifestyle Modifications: Lifestyle modifications, including diet, exercise, sleep, and stress management, play a significant role in pain management. 6. Emotions and Pain Perception: Emotions can influence pain perception, making it essential for medical students to consider the emotional well-being of patients. 7. Patient Support and Online Communities: Dr. Furlan discusses the value of patient support groups and online communities, where individuals with chronic pain can share their experiences and learn from one another. Medical providers can explore these resources to better understand patient perspectives. 8. Dr. Furlan's Book - A Resource for providers: Dr. Furlan's book, which outlines eight steps for managing chronic pain, is recommended for medical providers looking to deepen their knowledge of pain management. The book provides practical insights and strategies for patient care. Medical providers should embrace the holistic approach to chronic pain management, considering both the physical and emotional aspects of the condition. Dr. Furlan's expertise and insights shared in this episode offer valuable lessons for aspiring healthcare professionals in the field of pain medicine. 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. You can find Dr. Furlan at: https://www.youtube.com/ @DrAndreaFurlan  https://www.doctorandreafurlan.com/ X  @adfurlan  IG @dr.andrea.furlan
10/11/202340 minutes, 25 seconds
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Growing a strong and healthy thrower with Dr. Robert Bowers

In this episode of the Spine & Nerve Show, Dr. Robert Bowers joins Dr. Brian Joves to discuss the progression of young athletes in throwing sports, such as baseball. He emphasizes the importance of allowing children to play multiple sports and avoid specializing too early. Dr. Bowers also highlights the risks associated with overuse injuries and the need for rest periods. He discusses the role of mechanics and training programs in preventing injuries and increasing velocity. Dr. Bowers also touches on the use of biologics, such as PRP, in the treatment of injuries in young athletes.​ About The Guest: Dr. Robert Bowers is a sports medicine physician at Emory in Atlanta, Georgia. He specializes in the treatment of throwing athletes and has a particular interest in baseball injuries. Dr. Bowers has extensive experience working with athletes at all levels, including professional baseball players and college athletes. He is passionate about helping athletes optimize their performance and prevent injuries.​ Key Takeaways: - Young athletes should play multiple sports to develop athleticism and motor skills. - Rest periods are crucial for preventing overuse injuries in young athletes.- Proper mechanics and training programs can help prevent injuries and increase velocity. - Weighted ball programs can increase velocity but also carry an increased risk of injury. - Biologics, such as PRP, can be used to treat certain injuries in young athletes.​ Quotes: "If these kids can take three months of throwing off, four months, even better, that should be good to allow their arm to rest."- "The harder you throw, the more at risk your arm is." "Velocity gets kids noticed, but it also increases injury risk." "Weighted ball programs increase velocity but also increase injury risk." "The way to deal with increased intensity is to decrease volume."
8/31/20231 hour, 3 seconds
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To Anticoagulate or not to Anticoagulate with Interventional Spine Procedures

In this episode of the Spine & Nerve podcast, Dr. Jason Kung and Dr. Brian Joves delve into a comprehensive discussion surrounding anticoagulation guidelines and their implications in interventional pain procedures. With over a hundred thousand downloads and over 1,000 YouTube subscribers, we would like to express our sincere gratitude to all the listeners for your engagement and support. Please continue to share and subscribe to help more people discover the podcast. Today's episode focuses on the safety of epidural steroid injections and the critical role of anticoagulation management.Understanding the rationale behind a patient's anticoagulation therapy is vital for interventional pain physicians. This approach empowers clinicians to make informed decisions about whether to continue or withhold anticoagulation medications prior to procedures. There is a delicate balance between patient-specific risks and the benefits of these interventions. One of the things that must be known and emphasized is the remarkable safety profile of epidural steroid injections. Approximately nine million epidural steroid injections are administered annually, resulting in an adverse event rate of about one in 780,000. This reassuring statistic is attributed to the collaborative efforts of medical societies and the implementation of strict anticoagulation guidelines. The hosts emphasize the role of fluoroscopic guidance, non-particulate steroids, and avoidance of deep sedation in enhancing the safety of these procedures. The episode further delves into the nuances of assessing bleeding risks in patients undergoing interventional pain procedures. As always, we must underscore the importance of a comprehensive physical examination, with a specific focus on identifying signs of easy bruising and mucosal bleeding. The hosts discuss the relevance of specific medications, including aspirin and NSAIDs, and their implications for procedural safety. The hosts engage in an insightful exploration of the guidelines for managing anticoagulation medications pre- and post-procedure. They stress the need for pain physicians to consider the anatomical location of the intervention and evaluate the potential risks versus benefits. The doctors conclude the episode by highlighting the crucial role of shared decision-making and patient education. By fostering collaboration between patients and physicians, the hosts emphasize the creation of a safe and informed healthcare environment.In this thought-provoking episode, the doctors try to help you navigate the complexities of anticoagulation management in interventional pain procedures, and offer some insights for practitioners seeking to provide the highest level of care to their patients. References: Anesthesia Quality Institute Closed Claims Database Review 2011 through 2021 for Epidural Steroid Complications. Naeem Haider. Pain Physician 26 (3), E251, 2023 Stephen Endres, MD and others, The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures, Pain Medicine, Volume 18, Issue 3, March 2017, Pages 403–409, https://doi.org/10.1093/pm/pnw108 Narouze S, Benzon HT, Provenzano D, et alInterventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of PainRegional Anesthesia & Pain Medicine 2018; 43:225-262. The ASRA App: https://www.asra.com/the-asra-family/asra-app
8/11/202327 minutes, 36 seconds
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Going it alone with Dr. Nikhil Verma

In this episode, we have a special guest, Dr. Nikhil Verma, who shares his inspiring journey from undergrad to establishing his own medical practice. Dr. Verma opens up about the challenges he faced, the pivotal moments that shaped his career, and the lessons he learned along the way. Join us as we delve into his story of perseverance, passion, and the pursuit of personalized medicine. Episode Highlights: Dr. Verma recounts his early struggles and the uncertainties he faced during his pursuit of medical school. Despite not getting accepted initially, he used the time to reflect and explore different options, eventually finding his way to St. George's University. The importance of resilience and perseverance shines through as he shares how he overcame setbacks and stayed motivated. Dr. Verma's interest in rehabilitation medicine and sports medicine grew during his residency. He shares how his personal experience with a sports-related injury shaped his perspective and ignited his passion for helping others through physical therapy and non-surgical interventions. Dr. Verma discusses the decision to open his own medical practice, highlighting the challenges and rewards of being an independent practitioner. From finding the ideal location to setting up the practice and acquiring necessary equipment, he shares the steps involved in laying the groundwork for his venture. Dr. Verma emphasizes the importance of tailoring treatments to individual patients, providing temporary relief while considering long-term solutions. He highlights advanced procedures and technologies that enable more targeted and effective interventions, showcasing the potential impact of personalized medicine. Dr. Verma encourages med students and early residents to stay open-minded and embrace change. He shares the significance of finding passion and purpose in one's work, reminding listeners that it's okay to evolve and pursue new interests within the medical field. Dr. Nikhil Verma's story is a testament to the power of determination, adaptability, and following one's true calling. His journey from facing initial rejections to establishing a successful practice showcases the importance of resilience and finding personal fulfillment in the medical profession. Join us in thanking Dr. Verma for sharing his insights and experiences. Tune in to the full episode to hear his story in his own words. You can find Dr. Verma on all your favorite social platforms, as well as our hosts. 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.
7/20/202338 minutes, 58 seconds
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Find yourself a health coach with Dr. Hunter Vincent

In this week's episode of the Spine & Nerve podcast, we have a return guest! Dr. Hunter Vincent returns to the show to chat with Dr. Brian Joves about health coaches and how they can help your patients to be more successful in their journey with and through chronic pain. In this episode we'll discuss: What is a health coach? Where does this fit into the treatment and provider paradigm? How can ancillary team members like health coaches help your patients and your team to be more successful? Dr. Vincent is the CEO of Pogo Health. He is a double board certified physician who received his residency training from UC Davis in Physical Medicine & Rehabilitation (PM&R) with a subspecialty certification in Pain Medicine from UCLA. Prior to starting his medical training, he received a Bachelor's of Science in Exercise Biology. He has spent the last decade actively involved in healthcare initiatives focused on maximizing patient engagement in their own health journey. He has worked with various healthcare teams in the fields of clinical obesity, chronic pain, and neurological disorders.  Pogo Health is a virtual platform Virtual that utilizes a team approach to treating chronic pain. Their interdisciplinary opioid-free approach integrates the pain physician, pain therapist and specialized health coach to create a completely virtual and customized treatment program. The Pogo Health multi-modal approach utilizes evidence based techniques to provide long term physical and mental health benefits to combat chronic pain. Learn more at https://pogo-health.com/ 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.
6/1/202325 minutes, 23 seconds
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IPGs, Artificial Intelligence and Cochrane! An SCS Update with Dr. Jason Kung and Dr. Brian Joves

In this week's episode of the Spine & Nerve podcast, Dr. Jason Kung and Dr. Brian Joves try to digest all the recent happenings in the world of neuromodulation. They address: Internal Pulse Generators Artificial Intelligence The Cochran Study Listen as the doctors get excited, frustrated, and try to bring a silver lining to the whirlwind of headlines that have been discussing neuromodulation so far this year! There were many references in this episode, but most importantly here is the Cochran review on SCS for low back pain: Traeger AC, Gilbert SE, Harris IA, Maher CG. Spinal cord stimulation for low back pain. Cochrane Database Syst Rev. 2023 Mar 7;3(3):CD014789. doi: 10.1002/14651858.CD014789.pub2. PMID: 36878313; PMCID: PMC9990744. Here is the Hara study: Hara S, Andresen H, Solheim O, Carlsen SM, Sundstrøm T, Lønne G, Lønne VV, Taraldsen K, Tronvik EA, Øie LR, Gulati AM, Sagberg LM, Jakola AS, Solberg TK, Nygaard ØP, Salvesen ØO, Gulati S. Effect of Spinal Cord Burst Stimulation vs Placebo Stimulation on Disability in Patients With Chronic Radicular Pain After Lumbar Spine Surgery: A Randomized Clinical Trial. JAMA. 2022 Oct 18;328(15):1506-1514. doi: 10.1001/jama.2022.18231. PMID: 36255427; PMCID: PMC9579901. 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.
5/18/202332 minutes, 54 seconds
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Allow us to Introduce Dr. Jason Kung

In this week's episode of the Spine & Nerve Podcast we would like to introduce you all to the newest member of the Spine & Nerve family... Dr. Jason Kung.  Jason Kung, MD, is a board-eligible anesthesiologist and interventional pain physician who joined Spine & Nerve last year. Listen in as Brian Joves, MD gets to know Dr. Kung better and explore his journey into medicine and to discovering his passion for pain medicine. He  graduated from the University of San Francisco in California with a  bachelor's degree in biology. He then went to Boston University School  of Medicine in Massachusetts for his medical degree. Dr. Kung  completed his residency in Anesthesiology and fellowship in  Interventional Pain at Harvard Medical School, Massachusetts General  Hospital in 2020. Dr. Kung specializes in several interventional  procedures, including spinal cord stimulation, epidural injections,  radiofrequency ablations, implantable devices, and ultrasound-guided  nerve/joint injections. He strives to provide  compassionate evidence-based care to all his patients. He is certified as an instructor in  medical simulation. Dr. Kung has completed research and published in the  areas of bone healing and the effects of natural sources of vitamin D. During  his free time, he enjoys playing guitar, surfing/snowboarding, and  exploring California with his wife and dog.  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.
3/9/202332 minutes, 15 seconds
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Spinal stenosis

In this week's episode we take a deep dive into lumbar spinal stenosis, discussing the underlying disease process as well as treatment options in the medical literature. The studies referenced in this podcast are given at the end of the podcast. This is meant for education and entertainment only, this is not to be interpreted as medical advice. If you feel that something discussed may be relevant to you, please discuss with your medical provider. The views and opinions discussed in this podcast are those of the individuals who express them, and are not the views and opinions of Spine & Nerve Diagnostic Center.
1/13/202322 minutes, 44 seconds
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Movement as Medicine with Evan Hauger, DPT

In this week's episode of The Spine & Nerve Podcast, Evan Hauger, DPT joins Brian Joves, MD to discuss movement as medicine. Dr. Evan Hauger Evan specializes in  sports physical therapy, strength, and conditioning. He knows the ins  & outs of injury from years of personal experience. Growing up, he  was a multi-sport athlete and went on to play baseball at Shasta College. Through multiple personal injuries related to his athletic career, Evan realized that he had a passion for improving the way people  move and enhancing their performance in sport and life. Also a  StrongFirst Certified Level 1 instructor, Evan earned his Doctorate in  Physical Therapy from Sacramento State University and has worked with  athletes of all calibers, including MLB, NFL, NBA, UFC, and Olympians.  He has also spent time with some of the best minds in sports physical  therapy in Boston, MA, been a medical team leader for the USA Track and  Field National Championships, assisted with NFL combine training at Exos  in Phoenix, AZ, and been the performance coach for a group of Olympic athletes. 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.
9/15/202232 minutes, 54 seconds
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Trauma Informed Care with Krystyna Holland, DPT

In this week's episode of the Spine & Nerve podcast, Dr. Julie Hastings connects with Dr. Krystyna Holland, PT, DPT to learn about trauma informed care. Trauma informed care has many definitions, including some fantastic work done by the Substance Abuse and Mental Health Services Administration. One definition is a consistent and intentional effort to reduce our propensity for harm. Another describes it as an approach in the human service field that assumes that an individual is more likely than not to have a history of trauma. Listen in as Drs. Hastings and Holland discuss this very important topic and share some tips on how to better show up for our patients. Krystyna Holland, DPT (she/her)  is a physical therapist in Denver, Colorado specializing in the provision of trauma informed pelvic floor care to individuals across the gender identity spectrum. In addition to helping folks feel confident in their ability to live without leaking and have pleasurable sex, Krystyna aims to change the fundamental patient provider relationship from one that centers the provider as a problem solver to one that focuses on collaboration between the patient and the provider. She is a well-known Instagram educator (@krystyna.holland) and an instructor of trauma-informed care webinars.  She owns a small private practice called Inclusive Care and lives in Denver, CO. https://instagram.com/krystyna.holland https://www.inclusivecarellc.com/
7/12/202227 minutes, 43 seconds
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Infectious Spondylodiscitis

In this week's episode of the Spine & Nerve podcast, Drs. Nicolas Karvelas and Brian Joves discuss infectious spondylodiscitis, a relatively rare inflammatory process involving an intervertebral disc and the adjacent vertebral bodies. Spondylodiscitis has a prevalence of about 4-24 per million, and has been increasing as patients have more risk factors (advanced age, immunocompromised states such as HIV infection, intravenous drug users, healthcare-associated infections, expansion of spinal surgery indications) and improved diagnostic modalities. Patients generally present with pain and tenderness in the region, about 50% present with high fever, and about 1/4 with neurologic compromise. The symptoms can be fairly non-specific, so patients with risk factors must be evaluated with a high degree of suspicion. Infection is the most common cause of spondylodiscitis, which is often spontaneous and hematogenous in origin and most commonly affects the lumbar spine, followed by thoracic, cervical, and sacral. The infectious pathogens can be pyogenic (bacterial), granulomatous (tuberculosis, fungal), or parasitic, though many noninfectious processes affecting the spine such as pseudarthrosis in ankylosing spondylitis, amyloidosis, destructive spondyloarthropathy of hemodialysis, Modic changes type 1, neuropathic arthropathy, calcium pyrophosphate dehydrate (CPPD) spondyloarthropathy and gout can mimic infectious discitis/ osteomyelitis. To determine whether a particular patient’s spinal process is due to an infectious versus non-infectious cause and to determine the pathogencan be challenging. Clinical findings and laboratory studies including erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) can be helpful in the diagnosis due to their high sensitivity; however, their specificity is low. Magnetic resonance imaging and biopsy have become the standard when working up this process, particularly in cases where the origin of the pathogen is unknown. Listen as the doctors give a high-level overview of this disease process, and walk us through the challenging diagnostic process of a disease that may have an insidious onset, with subtle and misleading clinical features and briefly discuss management requiring a multidisciplinary approach involving radiologists, infectious diseases specialists, spine surgeons and rehabilitation personnel. 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. 1. Salaffi, F., Ceccarelli, L., Carotti, M. et al. Differentiation between infectious spondylodiscitis versus inflammatory or degenerative spinal changes: How can magnetic resonance imaging help the clinician?. Radiol med 126, 843–859 (2021).  2. Mavrogenis AF, Megaloikonomos PD, Igoumenou VG, et al. Spondylodiscitis revisited. EFORT Open Rev. 2017;2(11):447-461. Published 2017 Nov 15. doi:10.1302/2058-5241.2.160062
6/20/202240 minutes, 18 seconds
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Journal Club: Interventional Options to Treat Persistent Pelvic Pain Syndrome

In this week's episode of the Spine & Nerve podcast, Drs. Julie Hastings, Nicolas Karvelas, and Brian Joves present a journal club on interventional management of patients with persistent pelvic pain syndrome. Three different interventions are covered in the articles presented, showing a range on invasiveness and diversity of targets to help moderate the pain symptoms. Listen as the doctors dive in and discuss these articles and discuss ways these articles might help patients living with persistent pelvic pain syndrome and the physicians caring for them. 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. Hong DG, Hwang SM, Park JM. Efficacy of ganglion impar block on vulvodynia: Case series and results of mid- and long-term follow-up. Medicine (Baltimore). 2021;100(30):e26799. 2. Agarwal-Kozlowski K, Lorke DE, Habermann CR, Am Esch JS, Beck H. CT-guided blocks and neuroablation of the ganglion impar (Walther) in perineal pain: anatomy, technique, safety, and efficacy. Clin J Pain. 2009 Sep;25(7):570-6. 3. Istek A, Gungor Ugurlucan F, Yasa C, Gokyildiz S, Yalcin O. Randomized trial of long-term effects of percutaneous tibial nerve stimulation on chronic pelvic pain. Arch Gynecol Obstet 2014;290(2):291–8 4. Hunter CW, Yang A. Dorsal Root Ganglion Stimulation for Chronic Pelvic Pain: A Case Series and Technical Report on a Novel Lead Configuration. Neuromodulation. 2019 Jan;22(1):87-95. doi: 10.1111/ner.12801. Epub 2018 Aug 1. PMID: 30067887.
5/16/202227 minutes, 15 seconds
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Allow us to Re-Introduce Dr. Raman Gurai - A Journey Through a Distant Land to Achieve Your Goals

In this week's episode of the Spine & Nerve podcast, Dr. Joves welcomes Dr. Raman Gurai back to the show. Dr. Gurai walks us through his journey in medicine and how he took the road less traveled to achieve his goals and dreams! Dr. Gurai's Bio: Dr. Raman Gurai is a board certified Physical Medicine and Rehabilitation physician with a special interest in Interventional Spine. He was born and raised in northern California and his interest in medicine started in college where he majored in Molecular and Cell Biology with an emphasis in Neuroscience at the University of California at Berkeley in Berkeley, California. From there he headed to Grenada (West Indies) for his medical degree, and thereafter he completed his residency at the UCLA/VA Physical Medicine and Rehabilitation training program. He stayed on for an extra year to complete his current specialty, Interventional Spine. His medical interests include diagnosing and healing ailments of the spine with a multitude of modalities including EMG/NCS nerve testing and spine procedures including facet injections, epidurals, medial branch blocks, radiofrequency ablations, sacroiliac joint injections, and spinal cord stimulation among other cutting edge techniques. Dr. Gurai’s personal approach to medicine is to treat each individual as if they were a family member.  It is with this approach that he hopes to restore the quality of life and function each person deserves. 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.
3/4/202248 minutes, 6 seconds
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Pelvic Physical Therapy with Dr. Julie Hastings and Dr. Shereen Sairafi

In this week's episode of the Spine & Nerve podcast, Dr. Julie Hastings sits down with Shereen Sairafi, PT, DPT, WCS to discuss all things pelvic physical therapy related.  Pelvic floor physical therapists play an integral role in helping patients who have urinary, bowel, or sexual dysfunction, as well as pelvic pain.  Dr. Shereen Sairafi graduated from Boston University in 2013 with a  doctorate of physical therapy. Since that time she has been working in  the pelvic health field and advocating for broader access for patients  with pelvic floor dysfunction. Most recently she founded the pelvic  health physical therapy program at Denver’s public health, safety-net  hospital. Her clinical interests include rehabbing and preventing  obstetric anal sphincter injuries, assisting patients in returning to  all functional activities (including sex) pain free, and caring for  gender diverse patients. In her free time she enjoys running, playing tennis, reading, crafting, and perfecting her tahdig recipe. Some of the big questions that they address in this episode: Who is an appropriate patient for pelvic PT? How to pitch the idea or prepare a patient for pelvic PT? How does pelvic floor dysfunction overlap with other musculoskeletal pathologies? To find a PT: https://aptapelvichealth.org/ptlocator/ https://pelvicguru.com/directory/ Return to run guidelines: https://www.researchgate.net/publication/335928424_Returning_to_running_postnatal_-_guidelines_for_medical_health_and_fitness_professionals_managing_this_population 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.  
2/24/202232 minutes, 24 seconds
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Back to Basics: Persistent Pelvic Pain with Drs. Julie Hastings and Brian Joves

 In this week's episode of the Spine & Nerve podcast, Dr. Julie Hastings and Dr. Brian Joves go back to basics and give us an overview of persistent pelvic pain. Persistent pelvic pain is defined as non malignant pain that is present for more than six months. It may or may not be associated with a woman's cycle or related to intercourse. Studies have shown that approximately 24% of female bodied individuals will experience significant pelvic pain. Persistent pelvic pain tends to have a multifactorial presentation and it can be hard to differentiate the primary source of pain. Pelvic pain is associated with other chronic overlapping pain conditions which contributes to the challenges of diagnosis, treatment and management. The differential diagnosis is vast and etiologies of persistent pelvic pain include sources from many body systems including but not limited to: Gynecologic Urologic Gastrointestinal Musculoskeletal Psychologic The severity and consistency of pain increases with multisystem presentation requiring a multi-specialty combined effort to evaluate and treat these patients effectively.   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.
2/7/202229 minutes, 15 seconds
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100: Allow us to Introduce Dr. Julie Hastings - Be Willing to Learn, Grow, and Ask for Help

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves celebrate the 100th episode and welcome Dr. Julie Hastings to the show! We are so appreciative of the support, and love to hear the feedback from all of you. We never imagined that we would make 100 episodes of the podcast, let alone reach as many listeners as we have. Thank you for subscribing, sharing the podcast and contributing to our continued success in our desire to educate others. Listen in as Dr. Joves and Dr. Hastings discuss her unconventional path to medicine, her passion for women’s health, and why she went back to fellowship for further education and training after years of practicing medicine. They will also preview the upcoming series that Dr. Hastings will host which will take the podcast into pathologies, diagnoses and discussions we have never had before! Please see Dr. Hasting’s bio below for more specific background information. You can reach her at [email protected] to thank her for contributing and sharing her story. And don’t forget to submit your questions and comments, either to one of our social media accounts or on the Spotify app! Dr. Julie Hastings Bio: Dr. Julie Hastings is a board-certified Physical Medicine and Rehabilitation physician with a special interest in Interventional Spine. Dr. Hastings completed a North American Spine Society (NASS) recognized fellowship in Interventional Spine and Musculoskeletal Medicine at Desert Spine and Sports Physicians in Phoenix, Arizona. Prior to this Dr. Hastings was faculty at University of Arizona and Creighton Medical School where she focused on pelvic pain and pelvic floor dysfunction.  She completed residency training in Physical Medicine and Rehabilitation at the University of Colorado and earned her medical degree from Mount Sinai in New York City, and her Bachelor of Arts degree in Community Studies from UC Santa Cruz. Dr. Hastings strives to provide patients with the care she would want for her own family including an accurate diagnosis and treatment plan customized to each patient’s specific goals.  Whether your pain is keeping you from athletic endeavors, work, or simply enjoying time with your family, Dr. Hastings aims to get you back to those activities empowered with knowledge about your own body and skills to manage your pain. Dr. Hastings has presented research nationally on interdisciplinary chronic pain care, opioids and suicide, pelvic pain and joint hypermobility, and healthcare quality improvement, as well as co-authored a textbook chapter on nonsurgical pain management. She believes strongly in education and mentorship and works with medical students and residents around the country as a mentor. Outside of medicine Dr. Hastings enjoys spending time outdoors, fitness, cooking, and spending time with friends and family.
12/7/202149 minutes, 52 seconds
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Post Acute Sequelae of SARS CoV2/ Long COVID with Dr. Monica Verduzco-Gutierrez

In this week's episode of the Spine & Nerve podcast Dr. Brian Joves is joined by a very special guest, Dr. Monica Verduzco-Gutierrez, to discuss Long COVID, otherwise known as Post Acute Sequalae of SARS CoV2 (PASC). Long COVID is defined as a condition in which a patient continues with symptoms of COVID-19 more than 2 months after being infected by the virus. Longitudinal studies quote anywhere from a 15-80% prevalence of long COVID. Although every patient presents with a different compilation of symptoms, the most common symptoms of Long COVID are fatigue, impaired respiratory function, “brain fog”, headache, attention disorder, hair loss and pain. Though the risk factors for developing Long COVID are not fully known, studies suggest anosmia and ageusia, GI symptoms, and more severe acute infection may contribute to long term symptoms. There are many proposed mechanisms for these symptoms including inflammation, peripheral organ dysfunction, and virus shedding from the gut emphasizing the gut-brain connection that still needs to be researched further. Listen as Dr. Gutierrez educates on her experience in helping these patients and provides us with practical considerations when patient's present to the clinic. Most importantly, Dr. Gutierrez recommends one simple way to optimize outcomes for patient's suffering from Long COVID, and all patients for that matter. 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 counsel with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve. References: Herrera, JE, Niehaus, WN, Whiteson, J, et al. Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS-CoV-2 infection (PASC) patients. PM&R. 2021; 13( 9): 1027- 1043. https://doi.org/10.1002/pmrj.12684 You can find Dr. Monica Verduzco-Gutierrez: twitter.com/MVGutierrezM instagram.com/monicavgutierrez https://www.linkedin.com/in/monica-verduzco-gutierrez-m-d-74aab370/
11/19/202143 minutes, 55 seconds
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Post Herpetic Neuralgia: a review and journal club

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss Post Herpetic Neuralgia (PHN), the most common complication of Herpes Zoster (also known as Shingles, which is caused by reactivation of the Varicella Zoster Virus). PHN is defined by pain that is typically burning or electrical, and may be associated with allodynia or hyperesthesia in a dermatomal distribution. Pain from PHN is typically sustained for at least 90 days after the rash. PHN is caused by nerve injury due to the inflammatory response induced by viral replication within the nerve. Epidemiologic studies have found that PHN occurs in about 20% of patients who have Herpes Zoster. With the relatively recent development of the preventative vaccine Shingrix (which has been found to be 97% effective in preventing Herpes Zoster) it is anticipated that the total prevalence of Herpes Zoster and PHN will decrease. However, research has repeatedly demonstrated that immunocompromised patients are at a significantly increased risk for Herpes Zoster and PHN (20-100 times increased risk of development of PHN). As of today, the Advisory Committee on Immunization Practices has not cleared immunocompromised patients to receive the Shingrex (or Zostavax) vaccine; therefore for multiple reasons PHN will most likely continue to be a prevalent diagnosis. Treatment options for PHN include physical modalities (TENS, desensitization), topical medications (including Lidocaine 5% patch, and Capsaicin), oral medications (including Gabapentin, Pregabalin, Tricyclic Antidepressants), and procedures. Listen as the doctors review Herpes Zoster, PHN, and a recent research article evaluating the effect of the Erector Spinae Plane Block in regards to prevention of PHN once Herpes Zoster has already developed. 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 counsel 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. Zeng-Mao Lin, MD, Hai-Feng Wang, MD, Feng Zhang, MD, Jia-Hui Ma, MD, PhD, Ni Yan, RN, and Xiu-Fen Liu, MD. The Effect of Erector Spinae Plane Blockade on Prevention of Postherpetic Neuralgia in Elderly Patients: A Randomized Double-blind Placebo-controlled Trial. 2021;24;E1109-E1118. 2. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103–108.
11/12/202126 minutes, 1 second
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Back (to Basic Physiology to Look) to the Future: Selective Voltage Gated Sodium Channel Modulators

In this week's episode of the Spine & Nerve podcast Drs. Nicolas Karvelas and Brian Joves take a look back at basic physiology to try to look into the future. An area of research that has really piqued the interest of Dr. Karvelas in recent years has been the discussion/possibility of selective voltage gated sodium channel (NaV) modulators. NaV are transmembrane proteins that are an integral part of the initiation and propagation of action potentials in neurons and other electrically excitable cells. We have seen that small changes in NaV function are biologically relevant because there are several human diseases that are the result of mutations in these channels. This has led to research into selective NaV modulators as a potential target as we continue to search for treatment options with significant analgesic potential and decreased risk of side effects / adverse effects. The medical / research community continues to work to optimize medication options to treat painful disease processes. From an analgesic medication perspective, although there are a variety of different medications available including: topical medications, acetaminophen, non-steroidal anti-inflammatory drugs, gabapentin, pregabalin, serotonin norepinephrine reuptake inhibitors, tricyclic anti-depressant medications, non-selective sodium channel blockers, NMDA receptor modulations (Memantine, Ketamine), alpha-2 agonists, glial cell modulators (Low Dose Naltrexone), Buprenorphine, full mu opioids. These Medications are not without their limitations for multiple reasons including but not limited to side effects, risks, and contraindications depending on patient’s age and/or comorbidities. To the best of our knowledge there are 10 different NaV subtypes; and specifically NaV 1.3, 1.7, 1.8, 1.9 have been demonstrated to play a critical role in pain signaling. NaV 1.8 is a sensory neuron specific channel with preferential expression in the dorsal root ganglion and trigeminal ganglion neurons, and it is highly expressed on nociceptors. Similar to the other NaV subtypes that have been identified to play essential roles in pain, mutations in NaV 1.8 have been demonstrated to lead to significant alterations in the nervous system / pain pathways; specifically gain of function NaV 1.8 mutations clinically manifest as painful small fiber peripheral polyneuropathy. NaV 1.8 modulation is being aggressively researched with the goal of positive impact on painful diseases. VX-150 is a oral pro-drug that is a highly selective inhibitor of NaV1.8, and a recent study by Dr. Hijma and colleagues was published evaluating the analgesic potential and safety of VX-150. Listen as the doctors discuss this exciting and important area of research. The discussion includes a detailed review of the fore-mentioned recent research 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, they may not represent the views of Spine & Nerve. References: 1. Hijma HJ, Siebenga PS, de Kam ML, Groeneveld GJ. A Phase 1, Randomized, Double-Blind, Placebo-Controlled, Crossover Study to Evaluate the Pharmacodynamic Effects of VX-150, a Highly Selective NaV1.8 Inhibitor, in Healthy Male Adults. Pain Med. 2021 Aug 6;22(8):1814-1826.
10/20/202130 minutes, 55 seconds
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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.
9/27/202127 minutes, 23 seconds
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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.
9/14/202120 minutes, 28 seconds
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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.
8/16/202123 minutes, 28 seconds
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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.
8/6/202138 minutes, 4 seconds
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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.
7/12/202138 minutes, 47 seconds
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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
6/25/202134 minutes, 59 seconds
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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
6/18/202131 minutes, 19 seconds
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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.
5/28/202132 minutes, 24 seconds
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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.
5/7/202119 minutes, 4 seconds
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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.
4/29/202125 minutes, 57 seconds
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Back to Basics: Lumbar Facet Joint Pain / Lumbar Spondylosis

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves introduce the topic of pain coming from the lumbar facet joints - specifically when it is related to the general aging and degeneration of the spine (also known as spondylosis). Lumbar facetogenic pain is defined as pain originating from any structure integral to both the function and configuration of the lumbar facet joints including the fibrous capsule, synovial membrane, hyaline cartilage surfaces, and bony articulations.  This disease process is common and estimated to account for about 15% of chronic low back pain.   The facet joints are part of the 3-joint complex of the spine which includes the intervertebral disc and the paired facet joints.  The primary function of the facet joints is a protective role, limiting the movement of the spine in specific planes.  Facet joint pathology is typically due to chronic repetitive strain and low grade trauma that accumulates over time and ultimately leads to chronic inflammation of the joint complex as well as peripheral and central sensitization of the involved nerves (which we have discussed in detail in prior talks - see https://anchor.fm/spine/episodes/Back-to-basics-the-Chronification-of-Pain-eon8fq).   As with many chronic pain disease processes, the accurate diagnosis of this condition involves a detailed history, careful exam, diagnostic imaging, as well as the utilization of diagnostic image guided procedures.     Listen as the doctors discuss the definition, epidemiology, pathophysiology, anatomy, clinical presentation, diagnosis, as well as a brief introduction to the approach to treatment for lumbar facetogenic pain associated with lumbar spondylosis. 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. Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007 Mar;106(3):591-614. 2. Cohen SP, Bhaskar A, Bhatia A, et alConsensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working groupRegional Anesthesia & Pain Medicine Published Online First: 03 April 2020.
4/14/202131 minutes, 56 seconds
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Case Report: Acute on Chronic Lumbar Radiculopathy

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves wrap up the series on lumbar radiculopathy with a case presentation.   This is a case of a young man who presented with a severe acute on chronic lumbar radiculopathy after the holidays. As he was already managed by our office, he presented very acutely (about 1-2 weeks into his flare). Important concepts that are emphasized with this case are: natural history of lumbar radiculopathy, electrodiagnostic evaluation for lumbar radiculopathy, and a stepwise approach to diagnostic workup and management of a debilitating case of lumbar radiculopathy. Listen in as the docs walk us through this case and their management choices. 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. McCormick Z, Cushman D, Caldwell M, Marshall B, Ghannad L, Eng C, Patel J, Makovitch S, Chu SK, Babu AN, Walega DR, Marciniak C, Press J, Kennedy DJ, Plastaras C. Does Electrodiagnostic Confirmation of Radiculopathy Predict Pain Reduction after Transforaminal Epidural Steroid Injection? A Multicenter Study. J Nat Sci. 2015 Aug;1(8):e140.
4/6/202122 minutes, 19 seconds
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Journal Club: Lumbar Radiculopathy: A Review of Lumbar Tranforaminal Epidurals Steroid Injection

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves review a recent meta-analysis of transforaminal epidural steroid injections. This continues off of their conversation about lumbar radiculopathy.   Epidural injections to treat pain have been around for over a hundred years. It is one of the most common procedures done to help patients with back and leg pain, both acute and chronic. This meta-analysis from 2021 evaluates the safety of these procedures and looks at the evidence for their use in treating different pathologies of the lumbar spine. Listen as the doctors discuss transforaminal epidural steroid injections to treat disease processes such as lumbar radiculopathy, lumbar stenosis, lumbar discogenic pain and lumbar post laminectomy syndrome, as well as their personal experience treating these patients. 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: Helm Ii S, Harmon PC, Noe C, Calodney AK, Abd-Elsayed A, Knezevic NN, Racz GB. Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy and Safety. Pain Physician. 2021 Jan;24(S1):S209-S232. PMID: 33492919.
3/21/202124 minutes, 31 seconds
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Back to Basics: (Acute) Lumbar Radiculopathy

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves review lumbar radiculopathy.  Lumbar radiculopathy is a common diagnosis in which there is irritation or compression of one or more nerve roots in the lumbar spine. Because these nerves travel to the hips, buttocks, legs and feet, an injury in the lumbar spine can cause symptoms in these areas such as pain, weakness, numbness, and tingling.. Lumbar radiculopathy is typically due to a structural abnormality: specifically disc herniation and/or impingement due to spondylosis. Disc herniation (a rupture in the fibrous outer wall of a lumbar disc allowing the soft nucleus of the disc to bulge outward, which can press against a nerve root) is one of the most common causes of lumbar radiculopathy. Because of how common this pathology is, it is important to understand the usual natural history of radiculopathy due to disc herniation. Acute disc herniations typically improves significantly by 6-12 weeks with conservative treatment, making patient education a key component of helping them through this painful condition. That being said, the differential diagnosis for lumbar radiculopathy is very broad, and as always it is important to consider and rule out more concerning etiologies. Listen as the doctors discuss the definition of lumbar radiculopathy, the differential diagnosis, as well as a more detailed discussion of the natural history of radiculopathy and conclude with a look at the pathophysiology of lumbar radiculopathy. References: 1. Gupta A, Upadhyaya S, Yeung CM, et al. Does Size Matter? An Analysis of the Effect of Lumbar Disc Herniation Size on the Success of Nonoperative Treatment. Global Spine Journal. 2020;10(7):881-887. 2. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA. 2006;296(20):2441–2450. 3. Gugliotta M, da Costa BR, Dabis E, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open 2016;6:e012938. 4. Lin JH, Chiang YH, Chen CC. Lumbar radiculopathy and its neurobiological basis. World J Anesthesiol 2014; 3(2): 162-173.
3/15/202124 minutes, 21 seconds
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Case Report: Myofascial pain syndrome

In this week's episode of the Spine & Nerve podcast Drs. Nicolas Karvelas and Brian Joves conclude the discussion regarding Myofascial Pain Syndromes through a case presentation. The doctors present a common clinical scenario where myofascial pain is causing significant negative impact on a patient's function, quality of life, and health. In the prior background and journal club episodes, the pathophysiology of myofascial pain was discussed in detail (see https://anchor.fm/spine/episodes/Back-to-Basics-Myofascial-Pain-Syndrome-eq461q and https://anchor.fm/spine/episodes/Journal-Club-Neuroinflammation-in-Myofascial-Pain-Disorders-eqlc5l). This episode’s discussion brings things a little more clinical than the prior two. The doctors present a clinical picture of a young woman with chronic neck pain. Listen as they walk through the process of identifying pathology and initiating a treatment protocol that focuses on physical modalities, topical ointments and trigger point 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, the may not represent the views of Spine & Nerve. References: 1. Ting et al. Review of Trigger Point Therapy for the Treatment of Myofascial Pain Syndromes. J Anesthesiol & Pain. 2020;1 (3):22-29.
3/1/202129 minutes, 52 seconds
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Journal Club: Neuroinflammation in Myofascial Pain Disorders

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves expand on the recent discussion of myofascial pain and discuss a recently published article that explored neuroinflammation.   In the prior discussion, it was highlighted how prone chronic myofascial pain processes are to the development of central and peripheral sensitization.  This contributes to the debilitating nature and treatment resistance commonly seen in patients with myofascial pain syndromes.   Myofascial pain may not be the primary underlying process for many patients living with chronic pain, but it is very common for many to have a strong component of myofascial pain. For example, fibromyalgia has been demonstrated to have a strong central sensitization mechanism in regards to pathophysiology, however it has been demonstrated through the research that myofascial pain is a significant and important feature of fibromyalgia.   Listen as the doctors discuss the findings of this interesting recent journal article investigating the objective evidence of neuroinflammation in fibromyalgia patients, and explore the implications of the article's results for the approach to chronic pain disease processes with strong myofascial pain components.     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. Seo S, Jung YH, Lee D, Lee WJ, Jang JH, et al. (2021) Abnormal neuroinflammation in fibromyalgia and CRPS using [11C]-(R)-PK11195 PET. PLOS ONE 16(2): e0246152. 2. Younger J, Noor N,McCue R, Mackey S. Low‐dose naltrexone for the treatment of fibromyalgia: findings of a small, randomized, double‐blind, placebo‐controlled, counterbalanced, crossover trial assessing daily pain. Arthritis & Rheumatism 65 (2), 529-538, 2013
2/20/202118 minutes, 43 seconds
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Back to Basics: Myofascial Pain Syndrome

In this week's episode of the Spine & Nerve Podcast, Drs. Nicolas Karvelas and Brian Joves discuss a very underappreciated component of the chronic pain picture- myofascial pain syndrome. Myofascial pain is pain of the muscle and associated connective tissue. It typically presents as regional pain with associated tension, decreased range of motion, and presence of trigger points. This prevalent condition affects about 85% of patients in chronic pain clinics and will affect an estimated 85% of the general population at some point in their lives. Persistent myofascial nociceptive input appears particularly effective at inducing central sensitization. Notably, a 2012 article in The Pain Practitioner suggests that active trigger points are associated with elevated levels of biochemicals that contribute to sensitization. Constant myofascial pain input can result in decreased activation threshold of excitatory CNS nociceptive neurons, apoptosis of inhibitory nociceptive neurons, and an abnormal stress response. Over time, this may lead to muscle disuse, weakness, and dysfunction. Listen as the doctors explore the pathophysiology of myofascial pain and its connection to central and peripheral sensitization. For an in-depth explanation of peripheral and central sensitization, check out our recent episode on pain chronification (https://anchor.fm/spine/episodes/Back-to-basics-the-Chronification-of-Pain-eon8fq). 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. 1. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. VI and VII Baltimore: Williams & Wilkins; 1999. 2. Shah et al. New Frontiers in the Pathophysiology of Myofascial Pain. The Pain Practitioner. 2012.
2/10/202126 minutes, 56 seconds
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Case Report: The Chronification of Pain - Low back pain in setting of chronic pancreatitis treated with long term opioids

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas expand on their recent discussion of pain chronification.  The doctors discuss a fairly common scenario in which a patient with very chronic pain develops a relatively new pain condition.  In this setting, the new onset pain process can be significantly amplified and difficult to treat. Previously, the doctors summarized processes including central and peripheral sensitization, which contribute significantly to the severity and refractory nature of chronic pain conditions.  Listen as the doctors review chronification of pain in the context of a patient case example and discuss treatment approaches, particularly optimizing medication management. Chronic pain disease processes are very challenging to diagnose and treat, especially when multiple body parts are involved.  However, there are a growing number of tools available to make a positive impact for our patients, and with a carefully crafted treatment plan, progress can be made. Although optimizing patients' health, function, and safety may be a long and winding road, this goal is achievable! 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. Borsook D, Youssef AM, Simons L, Elman I, Eccleston C. When pain gets stuck: the evolution of pain chronification and treatment resistance. Pain. 2018;159(12):2421-2436. 2. Ossipov MH, Morimura K, Porreca F. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care. 2014 Jun;8(2):143-51. 3. Morlion B, Coluzzi F, Aldington D, Kocot-Kepska M, Pergolizzi J, Mangas AC, Ahlbeck K, Kalso E. Pain chronification: what should a non-pain medicine specialist know? Curr Med Res Opin. 2018 Jul;34(7):1169-1178. 4. A Comprehensive Review of the Celiac Plexus Block for the Management of Chronic Abdominal Pain. Current Pain and Headache Reports. 2020. 5. Khanna IK, Pillarisetti S. Buprenorphine - an attractive opioid with underutilized potential in treatment of chronic pain. J Pain Res. 2015 Dec 4;8:859-70.
2/3/202129 minutes, 22 seconds
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Journal Club - PNS for axial low back pain, impact on pain chronification

In this week's episode of the Spine & Nerve Podcast, Drs. Nicolas Karvelas and Brian Joves build on last week's episode on pain chronification and discuss a promising therapy for chronic axial low back pain: Peripheral Nerve Stimulation (PNS). PNS is an implanted device (in our discussion, a temporary implant for 60 days) that uses therapeutic electrical stimulation to target specific peripheral nerves, such as the medial branch of the dorsal ramus.  PNS has been shown to be effective for the treatment of chronic low back pain and is believed to have a positive impact on the processes of peripheral and central sensitization, which play a major role in pain chronification. Be sure to check out last week's episode on pain chronification for a deeper dive into this important topic (https://anchor.fm/spine/episodes/Back-to-basics-the-Chronification-of-Pain-eon8fq) and our interview with Dr. Ricardo Vallejo discussing the important interaction of glial cells in this process (https://anchor.fm/spine/episodes/More-glial-cells---Dr--Ricardo-Vallejo--science-that-matters--and-thinking-beyond-the-neuron-eb4m4i) PNS is an exciting treatment option for patients with chronic axial low back pain, including patients who continue to have symptoms despite radiofrequency ablation treatment. In this episode the doctors discuss an article published by Dr. Deer and his colleagues demonstrating that PNS, utilized for 6-12 hours per day for 60 days, resulted in significant improvement in pain and function in a group of patients with recurrent axial low back pain after radiofrequency ablation. Listen as the doctors discuss the specifics of PNS as a treatment option for chronic axial low back pain, including theories about its mechanism of action. 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) Deer et al.  Percutaneous PNS of the Medial Branch Nerves for the Treatment of Chronic Axial Back Pain in Patients following Radiofrequency Ablation. Poster abstract. NANS 2021. 2) Tiffany Lin, MD, Akshat Gargya, MD, Harmandeep Singh, MD, Eellan Sivanesan, MD, Amitabh Gulati, MD, Mechanism of Peripheral Nerve Stimulation in Chronic Pain, Pain Medicine, Volume 21, Issue Supplement_1, August 2020, Pages S6–S12. 3) 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. 4) Moore et al. Spinal cord stimulation. BJA Education, 16 (8): 258–263 (2016).
1/23/202124 minutes, 23 seconds
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Back to basics: the Chronification of Pain

 In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves go back to the basics to discuss a fundamental topic: pain chronification. Pain chronification is defined as the process of acute pain progressing into chronic pain. Acute pain is a normal, predicted physiological response to adverse stimuli (chemical, thermal, mechanical) and has a clear protective function. Chronic pain, however, is pain without apparent biological value (not immediately protective) that has persisted beyond the normal tissue healing time (usually about 3 months).  The Change Pain Chronic Advisory Board provides the following definition of pain chronification: “Pain chronification described the process of transient pain progressing to persistent pain; pain processing changes as a result of an imbalance between pain amplification and pain inhibition; genetic, environmental, and biopsychosocial factors determine the risk, degree, and time-course of chronification.” Listen as the doctors go over important definitions, and discuss critical aspects of chronification of pain including peripheral and central sensitization. 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. Borsook D, Youssef AM, Simons L, Elman I, Eccleston C. When pain gets stuck: the evolution of pain chronification and treatment resistance. Pain. 2018;159(12):2421-2436.  2. Ossipov MH, Morimura K, Porreca F. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care. 2014 Jun;8(2):143-51. 3. Morlion B, Coluzzi F, Aldington D, Kocot-Kepska M, Pergolizzi J, Mangas AC, Ahlbeck K, Kalso E. Pain chronification: what should a non-pain medicine specialist know? Curr Med Res Opin. 2018 Jul;34(7):1169-1178. 4. International Association for the Study of Pain
1/12/202131 minutes, 55 seconds
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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.
12/18/202024 minutes, 17 seconds
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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.
12/10/202022 minutes, 30 seconds
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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.
11/23/202017 minutes, 2 seconds
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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.
11/15/202020 minutes, 15 seconds
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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.
11/8/202026 minutes, 1 second
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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.
10/29/202029 minutes, 25 seconds
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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.
10/24/202024 minutes, 28 seconds
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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.
10/16/202031 minutes, 36 seconds
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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.
10/9/202024 minutes, 30 seconds
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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.
9/30/202032 minutes, 36 seconds
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Interlude: Are NFL injuries on the rise and is the shortened preseason to blame?

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/
9/25/202017 minutes, 20 seconds
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NSAIDs: the first step of the ladder requires considerations when diving deeper

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.
9/17/202039 minutes, 12 seconds
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One Bad Apple Spoils the Bin: Chronic pain's impact on overall health

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.
9/10/202023 minutes, 11 seconds
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Minimally Invasive options for chronic low back pain; a recent webinar presented by Dr. Joves

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.
9/2/202037 minutes, 5 seconds
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Journal Club: Lumbar Spinal Stenosis and the Impact on Mobility, Function, and Quality of Life

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.
8/28/202031 minutes, 18 seconds
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Not your every day headache: Post dural puncture headache, managing complications

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.
8/21/202025 minutes, 34 seconds
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Journal club: Interventional management of cancer associated pain

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.
8/14/202024 minutes, 44 seconds
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Vagus baby, Vagus: Neuromodulation of the vagus nerve in pain medicine

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.
8/6/202026 minutes, 57 seconds
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How to prepare for a pain medicine rotation? What we actually expect from a resident or student

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
8/1/202024 minutes, 27 seconds
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Buprenorphine and the challenging transition, a discussion and review of literature

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.
7/27/202027 minutes, 2 seconds
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The Dr. Karvelas story: A journey through sport to find a passion for interventional pain medicine

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.
7/17/202031 minutes, 12 seconds
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The journey to pain medicine. A discussion with Dr. Hunter Vincent from The Orthohealing Center

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.
7/9/202036 minutes, 44 seconds
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2 pain docs and bone mineral density; the effect of epidural steroid injections

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.
7/2/202022 minutes, 21 seconds
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To repeat or not to repeat? A discussion on epidural steroid injections.

In this episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss the age old question... whether or not to pursue a repeat epidural steroid injection (ESI) for the possibility of cumulative effect.   Historically there was a time when it was fairly common practice to order a pre-determined series of ESIs.  Over time, based on analysis of the research performed, and based on clinical experience, taking a more nuanced approach has proven to be the recommendation of most pain societies. Listen as the doctors discuss some of the available literature, as well as their clinical experience regarding this high yield / practical 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. Lee JH, Lee SH. Can repeat injection provide clinical benefit in patients with cervical disc herniation and stenosis when the first epidural injection results only in partial response?. Medicine (Baltimore). 2016;95(29):e4131. 2. Lee JH, Lee SH. Can Repeat Injection Provide Clinical Benefit in Patients with Lumbosacral Diseases When First Epidural Injection Results Only in Partial Response?. Pain Physician. 2016;19(2):E283-E290. 3. N. K. Arden, C. Price, I. Reading, J. Stubbing, J. Hazelgrove, C. Dunne, M. Michel, P. Rogers, C. Cooper, on behalf of the WEST Study Group, A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study, Rheumatology, Volume 44, Issue 11, November 2005, Pages 1399–1406. 4. Naveen S. Murthy, MD, Jennifer R. Geske, MS, Randy A. Shelerud, MD, John T. Wald, MD, Felix E. Diehn, MD, Kent R. Thielen, MD, Timothy J. Kaufmann, MD, Jonathan M. Morris, MD, Vance T. Lehman, MD, Kimberly K. Amrami, MD, Rickey E. Carter, PhD, Timothy P. Maus, MD, The Effectiveness of Repeat Lumbar Transforaminal Epidural Steroid Injections, Pain Medicine, Volume 15, Issue 10, October 2014, Pages 1686–1694
6/29/202016 minutes, 20 seconds
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A Pain Medicine Legend joins us to discuss the past, present, and future of our field

In this week's very special episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves had the opportunity to speak with another one of the leaders and legends in the field of pain medicine and pain research, Dr. Timothy Deer. Dr. Deer is one of the most recognizable names and faces in pain medicine. Amongst his many accolades, Dr. Deer is the President and CEO of The Center for Pain Relief, Inc., and Clinical Professor of Anesthesiology at West Virginia University. He is co-founder and chairman of the American Society of Pain and Neuroscience, President Emeritus of the West Virginia Society of Interventional Pain Physicians (WVSIPP) and past President of the International Neuromodulation Society (INS). Dr. Deer is a former member of the board of directors of American Society of Interventional Pain Physicians (ASIPP) and has served as faculty, moderator and presenter on many important subjects at national and international meetings, and has authored or been involved in much of the clinical research that has pushed pain medicine forward over the past couple decades. Some of the topics that the doctors dive into: - How the past has shaped what we currently see as modern pain medicine? - How does technology impact patient outcomes? - Where is pain medicine headed in the future? 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.
6/19/202032 minutes, 43 seconds
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Journal club: Platelet Rich Plasma and the Spine

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss a couple recent articles involving the use of platelet rich plasma to treat spine pathology. Listen as the docs summarize and discuss this orthobiologics and the cutting edge use in the spine. Please see References section below for the articles discussed in today's podcast. 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: Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain. Bise et Al. European Radiology. Feb 2020. Treatment of symptomatic degenerative intervertebral discs with autologous platelet-rich plasma: follow-up at 5–9 years. Cheng et al. Regenerative Medicine. Aug 2019.
6/12/202024 minutes, 14 seconds
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Is the treatment making you worse? A review of Opioid Induced Hyperalgesia

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss opioid induced hyperalgesia (OIH)- a topic that is fairly controversial in the pain medicine world. OIH is a medical process defined by worsening of pain with the use of opioids; typically patients will have evidence of central and peripheral sensitization including hyperesthesia and/or allodynia, and the pain can become more widespread/diffuse.  The doctors will discuss the theories behind the pathophysiology of OIH, including but definitely not limited to increased NMDA receptor activity. Lastly the doctors will address potential treatment options available to providers to help manage this very difficult to treat condition.   Listen as the doctors explore this interesting, and to some degree controversial topic.  Regardless of one’s final opinion on OIH, the potential impact of opioids of the nervous system (including the possibility of sensitization) is an important concept to be aware of and consider for any provider utilizing opioids to treat their patients.   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.
5/29/202025 minutes, 39 seconds
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Journal Club: gluteal/buttock pain

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss several articles regarding both the diagnosis as well as the treatment of gluteal region musculoskeletal disorders.   Topics discussed include the physical exam for sacroiliac joint dysfunction; as well as advanced treatment options for the relatively more rare chronic refractory coccydynia, and the relatively more common greater trochanter region pain syndrome.  Listen as the doctors summarize and discuss these articles addressing a very common chief complaint of buttock/gluteal region pain.     Please see References section below for the articles discussed in today's podcast. 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. Sencan S, Edipoglu IS, Ulku Demir FG, Yolcu G, Gunduz OH. Are steroids required in the treatment of ganglion impar blockade in chronic coccydynia? a prospective double-blinded clinical trial. Korean J Pain. 2019;32(4):301‐306. doi:10.3344/kjp.2019.32.4.301 2. Baker, C. L., & Mahoney, J. R. (2020). Ultrasound-Guided Percutaneous Tenotomy for Gluteal Tendinopathy. Orthopaedic Journal of Sports Medicine. 3. Byron J Schneider, MD, Reza Ehsanian, MD, PhD, Renee Rosati, DO, Lisa Huynh, MD, Josh Levin, MD, David J Kennedy, MD, Validity of Physical Exam Maneuvers in the Diagnosis of Sacroiliac Joint Pathology, Pain Medicine, Volume 21, Issue 2, February 2020, Pages 255–260.
5/11/202030 minutes, 7 seconds
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Journal club: 5/1/20. Treatments at various stages of chronic knee pain.

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss a few recent articles regarding treatment options for chronic refractory knee pain.   Listen in as the docs discuss treatment of knee pain due to osteoarthritis prior to knee arthroplasty, as well as treatment options in the setting of persistent symptoms after knee arthroplasty. They summarize articles exploring platelet rich plasma injections, hyaluronic acid injections, genicular nerve radiofrequency ablation, and peripheral nerve stimulation.       Please see References section below for the articles discussed in today's podcast.   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. Belk, J. W., Kraeutler, M. J., Houck, D. A., Goodrich, J. A., Dragoo, J. L., & McCarty, E. C. (2020). Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials. The American Journal of Sports Medicine. 2. Tate, Q., Conger, A., Burnham, T., Cushman, D.M., Kendall, R., Schneider, B., & McCormick, Z.L. (2019). The Effectiveness and Safety of Genicular Nerve Radiofrequency Ablation for the Treatment of Recalcitrant Knee Pain Due to Osteoarthritis: a Comprehensive Literature Review. Current Physical Medicine and Rehabilitation Reports, 7, 404 - 413.
5/1/202027 minutes, 45 seconds
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Journal Club: 4/24/2020. Pharmacological management of chronic pain

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas begin a new journal club format to discuss multiple articles that have a similar theme. The goal of this series on the podcast is to summarize recent research, and provide a discussion of some key points in regards to potential impact on clinical care. In this week's podcast the doctors summarize and discuss three recent articles regarding medications for treatment of chronic pain. Please see References section below for the articles discussed in today's podcast. References: 1. Alberti P, et al. Topiramate prevents Oxaliplatin-related axonal hyperexcitability and oxaliplatin induced peripheral neurotoxicity. Neuropharmacology. 2020. 2. Karin Bruun-Plesner, MD, Morten Rune Blichfeldt-Eckhardt, MD, PhD, Henrik Bjarke Vaegter, MSc, PhD, Joergen T Lauridsen, MSc, PhD, Kirstine Amris, MD, MedScD, Palle Toft, MD, PhD, MedScD. Low-Dose Naltrexone for the Treatment of Fibromyalgia: Investigation of Dose–Response Relationships. Pain Medicine. 2020. 3. Lynn Webster, MD, Jeffrey Gudin, MD, Robert B Raffa, PhD, Jay Kuchera, MD, Richard Rauck, MD, Jeffrey Fudin, PharmD, Jeremy Adler, DMSc, PA-C, Theresa Mallick-Searle, NP. Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion. Pain Medicine. 2020. 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.
4/24/202028 minutes, 33 seconds
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INTERLUDE: COVID and sport, where do we go from here?

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves take a look at the possibility of sport making a return during the COVID-19 pandemic. Listen in as the docs discuss this and what may be coming down the road for the sport world. This is a discussion between two long time sport fans, who happen to be physical medicine and rehabilitation physicians. The doctors are not epidemiologists, virologists, policy makers, or owners of sport franchises; they 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.
4/21/202014 minutes, 41 seconds
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Maintaining your health through the pandemic: guidance and science.

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss some of the recent guidance coming from state and federal organizations to decrease some of the secondary effects of the COVID 19 pandemic. The stress and anxiety for our patients, front line healthcare providers and essential workers, and the general public can cause significant significant secondary problems to our overall health and health system. Listen in as the doctors discuss some tactics, and some of the science behind the tactics, to optimize your physical and mental health during these hard times. The strategies that have been recommended by the California department of health and surgeon general include: - Supportive relationships - Exercise - Sleep - Nutrition - Mental health support - Mindfulness We have discussed many of these and their relationship with patients in chronic pain in prior episodes. You can look there for a deeper dive. https://covid19.ca.gov/manage-stress-for-health/#top 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.
4/8/202025 minutes, 52 seconds
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When the nerve root falls far from the disc; a case and literature review.

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas present a case report and do a quick review of lumbar disc herniations. Dr. Karvelas presents a case in which a more cephalad lumbar disc herniation can effect nerve roots more than 1 level caudal to the level of disc herniation.  For example typically we would expect a L3-4 disc herniation to impact the L4 or L3 nerve root, but there are cases where the more caudal nerve roots (for example L5) can be impacted.   The docs start by taking a step back and review the anatomy of the lumbar disc, and some important information regarding lumbar disc herniations including definitions and risk factors.     It is well researched and documented that the most common lumbar disc herniation is a posterolateral disc herniation that would effect the traversing nerve root exiting one level caudal to level of herniation.  However, when a patient's symptoms and neurologic exam do not fit with this classic picture it is important to keep an open mind to the differential diagnosis including but not limited to the possibility of more caudal nerve roots being involved.     Listen as the doctors not only present there own recent case in clinic, but also review the case reports in the literature documenting clinical instances where a lumbar disc herniation has resulted in a more rare clinical presentation for a patient.  This discussion reinforces an important principle in medicine that we always want to emphasize: in medicine it is important that we work as hard as we can to determine the most likely cause of the problem, but then importantly keep our mind open to/and think critically through other possibilities.       References: 1. Mekhail N, Costandi S, et al.The Impact of Tobacco Smoking on Spinal Cord Stimulation Effectiveness in Complex Regional Pain Syndrome Patients. Neuromodulation. 2020; 23: 133-139.    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.  
3/17/202023 minutes, 26 seconds
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Smoking is still the "new smoking": how smoking can make chronic pain worse

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss the impact that smoking tobacco can have on the chronic pain disease processes. Smoking tobacco can contribute to the development / worsening / persistence of chronic pain processes, and additionally tobacco use can also decrease the probability that a treatment will work for patients.     It is well researched and documented that smoking has a negative impact on our health including but not limited to cardiovascular disease, lung disease, cancer risk; but there is also growing evidence that smoking tobacco can contribute to and worsen common chronic pain disease processes including chronic low back pain.  Just as we have blood vessels supplying our heart and lungs which smoking can compromise, there are blood vessels supplying our spine and smoking tobacco can have a negative impact on this blood supply and ultimately the spine.   Smoking tobacco has been shown through research to contribute to inappropriate inflammation, immune system abnormalities, autonomic nervous system dysfunction, ischemic states (compromised blood supply to important systems throughout the body).  This has a significant negative effect on chronic pain processes and the treatments we have available to us. Complex Regional Pain Syndrome (CRPS) was discussed in a prior episode (https://anchor.fm/spine/episodes/What-exactly-is-complex-regional-pain-syndrome--Part-1-e52ql0 ) and is one of the correlates used for chronic pain. It has been shown that smoking tobacco and CRPS cause similar pathologic processes in the body, and this may help explain why patients with CRPS who smoke tobacco do not respond as well to one of our most powerful treatment options available for CRPS, spinal cord stimulation.   Listen in as the doctors explore the recent research, and apply the results to the overall approach to a chronic pain patient who also utilizes smoking tobacco.   References: 1. Mekhail N, Costandi S, et al.The Impact of Tobacco Smoking on Spinal Cord Stimulation Effectiveness in Complex Regional Pain Syndrome Patients. Neuromodulation. 2020; 23: 133-139.   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.
3/9/202016 minutes, 3 seconds
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More glial cells!! Dr. Ricardo Vallejo, science that matters, and thinking beyond the neuron.

This week's episode of the Spine & Nerve podcast is a very special episode. Dr. Nicolas Karvelas and Dr. Brian Joves had the opportunity to speak with one of the leaders in the field of pain medicine and pain research, Dr. Ricardo Vallejo. Dr. Vallejo is the co-founder and director of research at Millennium Pain Center in Bloomington, Illinois, and founder and lead investigator of Stimgenics, LLC. They have pioneered a novel spinal cord stimulation (SCS) waveform known as Differential Target Multiplexed (DTM) Spinal Cord Stimulation. Stimgenics’ preclinical research on the neuronal-glial mechanism of action has been recognized at various medical society meetings, receiving six “best of” awards for their research, three of which were specific to research investigating the DTM mechanism of action. NANS awarded the “Best Basic Science Research Award” to Stimgenics at their annual meeting in both 2018 and 2019. In this discussion, the docs dive deep into: - glial cells and their role in chronic pain. - What exactly is DTM? - How is the basic science translating into clinical outcomes? - What do we, as a field/specialty, have to do to continue to progress and change things for our patients? There were many studies referenced in this discussion, here is a short list of the most relevant literature: 1. Fishman M, Cordner H, Justiz R, et al. Randomized Controlled Clinical Trial to Study the Effects of SGX-SCS in Treating Intractable Chronic Low Back Pain: 3 Month Results. North American Neuromodulation Society (NANS); 2020; Las Vegas, Nevada. 2. Calodney AK, Kim PS, Slezak J, et al. Prospective study evaluating differential-target- multiplexed SCS for chronic intractable back pain with or without leg pain. Neuromodulation: Technology at the Neural Interface. 2019;22(3):e40-e295. 3. Fishman M, Calodney A, Kim P, et al. Prospective, multicenter trial to evaluate Multiplexed SCS for differential targets in subjects with chronic intractable back pain with or without leg pain. North American Neuromodulation Society (NANS); 2019; Las Vegas, NV. 4. Cedeno DL, Cass CL, Kelley CA, et al. Pre-clinical comparison of differential-target multiplexed scstm with low and high rate SCS. Neuromodulation: Technology at the Neural Interface. 2019;22(3):e40-e295. 5. Vallejo R, Kelley C, Smith W, Tilley D, Cedeno D. Cell-specific targeting in neural tissue using Differential Target Multiplexed (DTM) SCS. American Society of Regional Anesthesiology and Pain Medicine (ASRA); 2019; New Orleans, LA. 6. Vallejo R, Kelley CA, Smith WJ, Tilley DM, Cedeno D. Targeting specific cell populations in neural tissue with DTM-SCS. North American Neuormodulation Society (NANS); 2020; Las Vegas, NV. 7. Vallejo R, Smith W, Kelley C, Tilley D, Cedeno D. Neuron-glial inflammasome enhanced reversal by DTM-SCS relative to high rat and low rate SCS in a neuropathic pain model. American Society of Regional Anesthesiology and Pain Medicine (ASRA); 2019; New Orleans, LA. 8. Cedeno D, Smith WJ, Kelley CA, Tilley DM, Sanapati S, Vallejo R. DTM-SCS enhances reversal of neuron-glial inflammasome relative to high rate and low rate. North American Neuromodulation Society (NANS); 2020; Las Vegas, NV. 9. Vallejo R, Tilley D, Kelley C, Smith W, Cedeno D. Proteomics of Differential Target Muliplexed- SCS applied to an animal model of neuropathic pain. American Society of Regional Anesthesiologists and Pain Medicine (ASRA); 2019; New Orleans, LA. 10. Vallejo R, Kelley CA, Smith WJ, Tilley DM, Cedeno D. Proteomics of differential target multiplexed-SCS applied to an animal model of neuropathic pain. North American Neuromodulation Society 2020; Las Vegas, NV. 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.
3/2/202049 minutes, 9 seconds
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Just keep swinging? Golf and back pain

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves warmer weather, spring training and the forthcoming golf season by discussing how to keep up with your golf game, even when living with back pain. Golf is one is the most popular pastimes in the world for weekend warriors, but studies have shown that anywhere from 25-65% of golfers will experience a back injury related to their golf game. Many of these are of the muscle strain variety. But just like any low back injury, we have to work through a differential diagnosis that includes the various anatomical structures in the lumbar spine. The low back injury and golf correlation has become very well known at the professional level, where players like Tiger Woods and Jason Day worked through very public injuries. In these world class athletes, we have seen significant increases in the torque and loading forces across the spine as the athletes have evolved more powerful swings. This has seemingly led to higher rates of injury, and given more concern to the amateur athlete trying to replicate the Tiger Woods drive or the Rory McElroy fairway wood. Listen in as the docs discuss the biomechanics behind these injuries, what to do if you tweak your back, and how to continue playing the sport you love for decades and decades. 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.
2/24/202028 minutes, 49 seconds
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Overcoming Objections: Addressing common patient concerns with minimally invasive procedures

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss a few of the common questions patients have when discussing some of the advanced, minimally invasive options to test their pain. The three main questions that the doctors discuss are: Do we have to do something more invasive? What if I'm scared of something implanted in my body? Is this going to fix me? Listen in as the docs discuss these common questions and help educate patients about the amazing treatment options available to treat chronic pain. 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.
2/17/202023 minutes, 50 seconds
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Let's dive deeper into buprenorphine!

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas dive deeper in buprenorphine. The doctors have given an introduction to this medicine in the past (https://anchor.fm/spine/episodes/An-introduction-to-buprenorphine-e3fe2m) . This discussion dives deeper not only into the clinical utility, but also discuss some options for transitioning patients from a full my agonist to buprenorphine. Listen in as the docs dive deep! In this discussion, a Z Dogg MD podcast is referenced: https://zdoggmd.com/podcasting/buprenorphine/ 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.
2/10/202031 minutes, 49 seconds
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Interlude: peripheral nerve stimulation for chronic shoulder pain, a review of current literature

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss a recent study that evaluated peripheral nerve stimulation for the treatment of chronic shoulder pain. Case Series: Axillary Peripheral Nerve Stimulation for Chronic Shoulder Pain: A Retrospective Case Series John Taylor Mansfield DO Mehul J. Desai MD, MPH Neuromodulation: Technology at the Neural InterfaceEarly View . First published: 13 January 2020 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.
2/3/202020 minutes, 27 seconds
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Digesting the North American Neuromodulation Society (NANS) 2020 annual meeting

In this week's episode of the Spine & Nerve podcast, Dr. Brian Joves and Dr. Nicolas Karvelas discuss the awesome and stimulating several days of the most recent NANS conference.  The doctors share their major takeaways from the conference.  The field of neurostimulation has advanced significantly over the years and we are at a point where we can really start to fine tune the exact form of neurostimulation for a specific patient and pathology.  The progress that has been made in regards to neurostimulation therapy has significantly increased the breadth of conditions that can be treated by neurostimulation / indications for neurostimulation.  This progress is accompanied by more and more literature demonstrating the efficacy and safety of neurostimulation, and most importantly we are seeing better and better outcomes for patients.     One of the major new neurostimulation therapies is a form of spinal cord stimulation that targets Glial cells which we know play an important / critical role in the development and perpetuation of chronic pain states.  This form of spinal cord stimulation is Differential Target Multiplexed (DTM) spinal cord stimulation.  This therapy is backed by years of well done basic science research evaluating how neurostimulation can positively impact glial cell activity in the chronic pain state and consequently have a significant positive impact on an individuals symptoms, function, and health.  The preliminary data is very good for this therapy, and we will continue to analyze the research as more information / results become available.     The NANS conference is always an excellent opportunity for learning and interacting with experts in the field; listen as the doctors discuss this experience and some of the exciting new research being done.   References: 1. Fishman M, Cordner H, Justiz R et al. Randomized Controlled Clinical Trial to Study the Effects of DTM-SCS in Treating Intractable Chronic Low Back Pain: 3 Month Results. Presentation at NANS 2020, Las Vegas, Nevada. 2. Cedeno D.L., Cass C.L., Kelley C.A., et al. Pre-clinical comparison of differential-target multiplexed scstm with low and high rate SCS. Neuromodulation 2019 22:3 (E185-) 3. Cedeno D.L., Kelley C.A., Cass C.L., et al. Pre-clinical Comparison of Differential-Target Multiplexed SCS with Low and High Rate SCS. Presentation at ASRA 2018. San Antonio, Texas.    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.
1/31/202022 minutes, 51 seconds
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It's halfway through January, do you know where your resolution is? A discussion on goal setting.

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss goal setting... After all, It's half way through January. How's your new years resolution going? Dr. Joves had asked every patient he's seen this year about their resolutions or goals for the new year, and has been shocked by the responses. Every single person has stated that they don't believe in resolutions. Thankfully, a couple patients said things like "just trying to continue improving" or "getting better each day", but the overwhelming response (read over 99%) was a lack of goals. Listen is as the docs discuss this trickling finding and focus in on the way they try to help patients. the conversation with patients is a similar one that we've discussed before... Let’s start with small steps each day/week/month and start to right the ship. We hope you enjoy this conversation. Look for the top three goal/ resolution making tips from reach of the docs and some actionable advise you can start using today! 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.
1/20/202022 minutes, 35 seconds
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You down with E...S...P!?!? The erector spinae plane block...

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss the erector spinae plane block. This is a science heavy chat about a procedure that first made its way into the chronic pain literature in 2016, which is brand new by medical standards! Listen in as the docs give an introduction to this cutting edge procedure and tag about ways that it may be used in clinical practice. In this discussion, the following papers are discussed: 1. Kot P, Rodriguez P, Granell M, et al. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019;72(3):209–220. 2. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41:621–7.  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.
1/14/202020 minutes, 57 seconds
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There is a fracture, now what? A review of the guidelines for vertebral compression fractures.

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss vertebral compression fractures with an emphasis on osteoporotic compression fractures.   Compression fractures, as the name suggests, are when the bones of the spine fracture and break because the force placed on the spine overcomes the internal strength of the bones. In a young healthy individual this can be seen in trauma, but as three population ages we are seeing this occur not in noon traumatic circumstances- we tend to refer to those as osteoporotic fractures. Osteoporotic vertebral compression fractures are a common medical problem with an estimated prevalence of around 30% in the elderly population over 65 years old.  The consequences of a compression fracture is not limited to significant back pain which can be very debilitating, but there is also increased risk of adjacent spinal fractures in the setting of the vertebral deformity and altered biomechanics, and increased mortality both in the short and long term.  As the population over age 65 continues to grow, the medical community will continue to work to optimize the guidelines for diagnosis and treatment of this medical problem.     Work remains to be done to optimize guidelines, but currently from a diagnostic standpoint, the American College of Radiology does recommend Xrays, DEXA scan, MRI and/or CT for diagnosis.  Once the diagnosis is made the treatment depends on multiple factors including the acuity of the injury.  For severely symptomatic acute compression fractures Vertebroplasty and Kyphoplasty are strong considerations and are on the clinical guideline recommendations for the American College of Radiology and the National Institute for Health and Care Excellence Guidelines.  Especially as the pathology becomes more chronic, stronger consideration may be given to targeting the medial branches of the affected facet joints as a therapeutic target.  Treating the medial branches will positively modulate the pain from the joints affected by the altered biomechanics of the compromised vertebral body.  One of the major benefits of consideration of treating the facet joints themselves to manage the pain associated with vertebral compression fracture (especially more subacute to chronic fractures) is that we can achieve good pain relief with significantly lower risk to the patient. Listen in as the doctors discuss this recent literature and practical ways to approach this challenging issue. 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.
12/23/201924 minutes, 12 seconds
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Interlude: injections in the news- stellate ganglion block for PTSD

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves discuss a recent study that looks at treating post traumatic stress disorder with an Interventional technique called a stellate ganglion block. A stellate ganglion block is a procedure that is most commonly used in chronic neuropathic pain processes such as complex regional pain syndrome. The stellate ganglion is the sympathetic chain the lives in the cervicothoracic region and is responsible for the sympathetically mediated processes (think fight or flight responses) in this region. This procedure blocks the stellate ganglion (as the name suggests) and therefore blocks the signals from transmitting. Multiple case reports have been published over the past decade, however just last month (November 2019), a randomized controlled double blind study was published in JAMA psychiatry with impressive results. Listen in as the doctors discuss this recent literature and practical ways to approach this challenging issue. Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms. JAMA Psychiatry, November 2019. Kristine L. Rae Olmsted, et Al. http://dx.doi.org/10.1001/jamapsychiatry.2019.3474 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.
12/17/201918 minutes, 36 seconds
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What came first: chronic pain or impaired sleep? A conversation on sleep disturbance

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves talk impaired sleep and try to answer the age old question: what came first, impaired sleep or chronic pain? Sleep is an important and unique component of the human condition that is vital for many components in the body. Studies have shown that patients living with chronic pain (both neuropathic, widespread and nociceptive, focal) experience significantly impaired sleep- duration and quality. Listen in as the doctors discuss some recent literature and practical ways to approach this challenging issue. 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.
12/9/201924 minutes, 2 seconds
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Neuromodulation: Peripheral nerve stimulation

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves conclude our introduction to neuromodulation series by discussing peripheral nerve stimulation. Peripheral nerve stimulation utilizes similar technology as is used in other realms of neuromodulation, with the main difference being the targeted structures. Peripheral nerve and peripheral field stimulation, as the names suggest, focus on sending signals to a specific nerve in the peripheral nervous system (ilioinguinal, lumbar medial branch, cluneal, etc) or in the vicinity of a focal chronic pain. Listen in as the doctors discuss this exciting option for patients. They discuss some of the recent literature studying these devices, a couple of which are listed below. Percutaneous Peripheral Nerve Stimulation (PNS) for the Treatment of Chronic Low Back Pain Provides Sustained Relief Christopher A. Gilmore MD et Al. Neuromodulation: Technology at the Neural InterfaceVolume 22, Issue 5 . 03 October 2018 Prospective, Multicenter, Randomized, Double‐Blinded, Partial Crossover Study to Assess the Safety and Efficacy of the Novel Neuromodulation System in the Treatment of Patients With Chronic Pain of Peripheral Nerve Origin Timothy Deer MD , et Al. Neuromodulation: Technology at the Neural InterfaceVolume 19, Issue 1. 22 January 2016 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. 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.
12/5/201926 minutes, 49 seconds
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Neuromodulation: Riding the WAVE of technology to provide stimulating relief

In this week's episode of the Spine & Nerve podcast, Dr. Nicolas Karvelas and Dr. Brian Joves dive a little deeper into the world of neuromodulation therapy with a focus on wave forms and the various wave forms available. Neuromodulation is a powerful and exciting treatment option for difficult to treat chronic pain conditions.  Some common conditions that neuromodulation is commonly utilized to treat include post laminectomy syndrome (or failed back surgery syndrome) and complex regional pain syndrome; but there are many other applications of this therapy.     Advances in neuromodulation technology give the ability to individualize a patient's therapy depending of the specific patient and the specific disease process we are treating.  One of the largest advancements has been the progression of the internal pulse generators to provide different wave forms.  A waveform has different components that can be modulated to have the desired therapeutic effect for patients, these different components include the amplitude, the frequency, and the pulse width.  Different wave forms available currently include the following:   1. Traditional spinal cord stimulation (tonic stimulation): -low frequency (20-120 Hz) -patients tend to feel the individual pulses   2. High frequency stimulation: -high frequency (500-10,000 Hz) -paresthesia free -benefits include but are not limited to potential improved ability to target traditionally difficult to address areas of pain including low back pain   3. Burst stimulation: -groups of high frequency pulsed stimulatory phases separated by pulse free phases, followed by a passive recharge phase -based upon available research, this wave form is most similar to the natural occurring neuronal firing in our central nervous system, which potentially would lower risk of decreasing response to the treatment over time -less energy demand   Ultimately, neuromodulation is a powerful treatment option (that has evolved significantly over the recent years and continues to advance); that is an effective treatment option for difficult to treat chronic refractory pain conditions. 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. 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.
11/18/201926 minutes, 33 seconds
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Neuromodulation: Burning nerves may actually help your pain; Radio frequency ablation may be the way

In this week's episode of the Spine & Nerve podcast, Dr. Gurai and Dr. Joves continue our discussion of neuromodulation by diving deeper into radio frequency ablation. Radio frequency ablation is a procedure that uses needles to target an anatomical structure (usually in our case nerves) and a probe delivers energy (usually thermal energy) to change the way those nerves are able to serve the pain signals. Now, radio frequency ablation is not always looked upon as a component of the neuromodulation realm, but if we look back to the definition we have previously presented- "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." Radio frequency ablation definitely falls within this realm. Listen is as the docs dive deeper into radio frequency and the various pathologies that can be treated. 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.
11/11/201916 minutes, 54 seconds
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INTERLUDE: How a needle may have changed baseball history- Max Scherzer's neck and the World Series

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.
11/6/201917 minutes, 35 seconds
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Neuromodulation: an introduction.

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.
10/22/201924 minutes, 6 seconds
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Why am I thinking twice after hitting my head? An intro to mild traumatic brain injury/ concussion

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.
10/15/201922 minutes, 12 seconds
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Opiates, opiates, and more opiates... We just can't stop talking or educating on them

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.
10/11/201924 minutes, 13 seconds
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Small investment, big rewards- why the electrodiagnostic evaluation should be a part of your workup

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.
10/1/201925 minutes, 23 seconds
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Glial cells, glial cells, glial cells... The pain cascade, modulation, and chronic pain.

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.
9/24/201923 minutes, 35 seconds
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"Non specific" low back pain: a practical conversation for the front lines (primary care)

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.
9/16/201929 minutes
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Regenerative medicine: hype or the future?

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.
9/9/201923 minutes, 20 seconds
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INTERLUDE: Are growing fears of injury (both acute and chronic) putting the NFL in trouble?

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.
9/5/201916 minutes, 43 seconds
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Complex regional pain syndrome part deux

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.
9/3/201940 minutes, 27 seconds
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What exactly is complex regional pain syndrome? Part 1

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss complex regional pain syndrome, better known as CRPS. This topic and diagnosis is one that is very poorly understood by the general public, and many within the medical and healthcare communities. CRPS is essentially nerves not behaving themselves in the peripheral and Central nervous systems, and is one of the models for centralized pain. CRPS is variable in its clinical presentation, but typically is characterized by severe pain and impaired function out of proportion to the original injury. Listen as the doctors dive deeper into this topic and give some practical tips for people living with or treating chronic pain. 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.
8/26/201939 minutes, 58 seconds
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The hip bone's connected to the... Acetabulum 🤷🏽‍♂️

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss one of the most common musculoskeletal pain complaints, especially in an older demographic-the hip joint. Listen as the doctors dive deeper into this topic and give some practical tips for people living with or treating chronic pain. 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.
8/23/201926 minutes, 36 seconds
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Is it really all in their heads? The mind-body connection when living with chronic pain.

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss the behavioral health aspects of chronic pain. It is very well documented that chronic pain has very significant psychologic connections. The International Association for the Study of Pain define pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"; which is derived from a 1964 definition and was first published in 1979. Listen as the doctors dive deeper into this topic and give some practical tips for people living with or treating chronic pain. 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.
8/12/201930 minutes, 32 seconds
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Narcissistic nerves - what exactly is peripheral neuropathy and why you should care

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss peripheral neuropathy. Neuropathic pain is defined as a process that affects the somatosensory nervous system. When the nerves that are affected lie outside of the central nervous system (brain and spinal cord), it is considered peripheral neuropathy. Painful peripheral neuropathy has been identified in up to 3% of the general population, but provides a much greater challenge in patients with diabetes where as many as 25-50% of patients experience symptoms. Numbness, burning, and weakness are characteristic of peripheral neuropathy, and these symptoms can have devastating consequences on a person's quality of life and daily function. Listen in as we dive deeper... 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.
7/29/201932 minutes, 36 seconds
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Can something called MILD change patients' lives?

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss a procedure called minimally invasive lumbar decompression or MILD. What exactly is MILD? Well, it's a way to create more space in the spine with utilizing small entry ports- which means no large incisions, less recovery time after the procedure and decreased risk for the patient. Listen as the docs discuss the two main studies that brought the MILD procedure back into relevance (and coverage by CMS - Centers for Medicaid and Medicare Services) References: Benyamin RM, Staats PS.MiDAS ENCORE: Randomized Controlled Study Design and Protocol.Pain Physician. 2015 Jul-Aug;18(4):307-16. Mekhail, Nagy, et al. (2012), Functional and Patient-Reported Outcomes in Symptomatic Lumbar Spinal Stenosis Following Percutaneous Decompression. Pain Practice, 12(6): 417-425. 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.
7/23/201918 minutes, 16 seconds
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What is CBD and why is everyone talking about it?

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss CBD and it's utility in modern pain management. The doctors discuss a very brief introduction of the 2018 Farm Bill and how it has changed and opened an entire industry. They dive into some of the research that has been done, discuss how they are seeing it used in practice, and future considerations for research. 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, the may not represent the views of Spine & Nerve.
7/11/201927 minutes, 41 seconds
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The Shoulder

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss shoulder pain. Shoulder pain is the third must common musculoskeletal complaint that brings patients to seek medical care. The shoulder is a complex arrangement of joints, tendons, and muscles... Each of which can be injured and contribute to pain. 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, the may not represent the views of Spine & Nerve.
7/2/201928 minutes, 59 seconds
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An underappreciated cause of low back pain, the sacroiliac joint

In this week's episode, Drs. Gurai and Joves discuss one of the under appreciated pain generators for low back pain- the sacroiliac joint (SI joint). The sacroiliac joint is the place where the spine meets the pelvis. It is, as the name suggests, a joint between the sacrum (lowest portion of the spine) and the ilium (one of the bones of the pelvis). Medical studies attribute between 10 and 40 percent of back pain to the SI joint. The most common patients affected are pregnant women and patients with ankylosing spondylitis, though many patients present with pain from trauma, cummulative injuries, and acquired stress such as with prior lumbar fusion. The SI joint is a complex structure with many possible pain generators- the bones, the joint (which is interesting because it has two components; an anterior diarthrodal joint with a complex capsule and a posterior syndesmosis with extracapsular ligaments and muscles involved), the ligaments (at least 11 different ones involved in stabilization), and of course the muscles. SI joint pain generally is aching pain in the low back and buttock. It can radiate further down the leg or anteriorly towards the groin as well. The most consistent sign for SI mediated pain is pointing to the posterior superior iliac spine as the maximal point of tenderness, but there are multiple physical examination maneuvers a provider can utilize to provoke this pain. Diagnostic injection is still considered the gold standard for diagnosis of true SI joint pathology. Once the appropriate diagnosis, we work through the normal treatment algorithms for pain diagnoses including conservative measures such as education, therapy and physical modalities such as bracing and low level laser therapy, and medications. If these conservative treatments are not able to control the pain and improve the patient's quality of life, we move on to invasive procedures. Steroid injections into the joint are the standard of care and work very well for many patients. If steroid injections are either ineffective or don't last long enough, other needle based options such as radiofrequency ablation and platelet rich plasma injections are great options for more prolonged pain relief. For patients that do not get the improvement that we're hoping, there are great surgical options to fuse the SI joint and prevent movement, which in turn should decrease the pain. 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, the may not represent the views of Spine & Nerve.
6/17/201924 minutes, 17 seconds
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Interlude: Hot Topic- Achilles ruptures and calf strains in sport

In this special episode, Dr. Karvelas and Dr. Joves discuss something near and dear to their hearts, the injury the Kevin Durant sustained in the NBA finals. This is a discussion between two long time Warriors fans, who happen to be physical medicine and rehabilitation physicians. The doctors do not know the details of the injury 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. 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, the may not represent the views of Spine & Nerve.
6/13/201915 minutes, 4 seconds
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Diet + Exercise = Pain management?

In this week's episode of the Spine & Nerve podcast, Dr. Karvelas and Dr. Joves discuss nutrition, exercise, and pain management. This is a topic that we don't spend enough time on with patients, despite the growing evidence that it can make a significant difference. In the episode, Dr. Andrew Weil's website was mentioned - https://www.drweil.com/diet-nutrition/anti-inflammatory-diet-pyramid/ amongst many other great online resources (Mayo clinic, well vegan, etc). 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, the may not represent the views of Spine & Nerve.
5/28/201926 minutes, 7 seconds
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A LIVE recording of Dr. Karvelas lecturing about non-opioid management of chronic pain

We have a special treat this week! This is a recording of a lecture Dr. Karvelas gave discussing chronic pain and non-opioid treatment options. He did a fantastic job of describing chronic pain management in 2019 and ways that we can help patients live there best lives. There are some portions of the recording where the audio quality isn't perfect- thank you for your patience at these portions, it was the best our audio team could do with the recording. 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, the may not represent the views of Spine & Nerve.
5/20/201951 minutes, 4 seconds
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Tech neck? Is that really a thing?

Have you heard of text neck or tech neck?? Tech neck is a real thing! Join Dr. Karvelas and Dr. Joves as they explore this topic. Generally speaking, tech neck is the pain in your neck and upper back (periscapular region) muscles. It is caused (or at least exacerbated) by spending a significant amount of time looking down at a tablet or cell phone, improper positioning at a computer workstation (or any workstation for that matter). Imagine your head as a bowling ball- if it stays directly on top of your body (chin parallel to floor, ears over shoulders over hips, otherwise known as correct posture) there is very little pressure on the muscles to hold the bowling ball up. Listen in as we dive deeper! 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, the may not represent the views of Spine & Nerve.
5/13/201925 minutes, 45 seconds
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An introduction to buprenorphine

In this week's episode, Dr. Karvelas and Dr. Joves discuss buprenorphine... What it is, what it isn't, and some ways that it is being utilized to help patients with chronic pain. 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.
5/6/201927 minutes, 8 seconds
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When opiates fail your patients...

Opioids and the opioid epidemic are everywhere in today's news media. Dr. Karvelas and Dr. Joves discuss a sensitive subject today- how to determine when opioids are failing our patients. 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.
4/29/201924 minutes, 46 seconds
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What exactly is fibromyalgia?

Dr. Karvelas and Dr. Joves give an introduction to fibromyalgia. What is it? How has this diagnosis changed within the medical community over the past couple decades? What are the main ways to manage and treat the disease? This podcast is meant for education and entertainment only. This is not medical advice. If you would like further information on any of the topics discussed, please seek council with you healthcare provider. The views expressed are those of the individuals expressing them and may not represent the views of Spine & Nerve.
4/22/201927 minutes, 15 seconds
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An introduction to joint pain

Pain in a joint (knee, hip, shoulder, etc) is a common presentation to health care providers. There are many reasons for a patient presenting with pain, and each joint presents a number of different structures that can be pain generators. Drs Gurai and Joves walk us through the basics of evaluating and treating painful joints. In this episode, we discuss the difference between an acute injury and chronic pain, the early steps in workup and treatment, as well as some of the newer regenerative medicine procedures that are able to help many patients. This podcast is meant for education and entertainment only, it is not medical advice. If you think anything discussed may pertain to you, please consult with your healthcare provider. The views expressed are those of the individuals expressing them, and may not represent the views of Spine & Nerve.
4/19/201930 minutes, 31 seconds
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Treatment options and algorithms for patients living with pain

Dr. Karvelas and Dr. Joves discuss the various treatment options for patients living with pain. For patients and healthcare providers alike, once an appropriate diagnosis is made, the hard work begins. This is when we have to figure out the next steps towards getting back to function, quality of life, and the activities that make our patients happy. We believe that having a consistent and systematic approach to treatment options is the best way to maximize the efficiency of this journey, and we walk you through our treatment algorithms during this episode. As always, this is meant for education and entertainment purposes only. This is not medical advice. Please seek a healthcare provider to further discuss any topics that are discussed. The views expressed are those of the individuals, and may not reflect the views of Spine & Nerve Diagnostic Center.
4/16/201920 minutes, 15 seconds
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Naloxone

In this episode, we discuss Naloxone and the recently implemented laws in California that now require the prescription of naloxone to certain populations of patients. This episode, and all episodes of this podcast, is meant for education and entertainment purposes only. The views expressed are opinions and not meant to be a formal medical opinion or legal interpretation. Please speak to your healthcare provider for more information.
4/10/201914 minutes, 2 seconds
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Introduction

Intro to the Spine & Nerve podcast, with your hosts Dr. Nicolas Karvelas and Dr. Brian Joves
4/5/20193 minutes, 8 seconds