Spine and Nerve podcast

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.

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.

In this week's episode of the Spine & Nerve podcast Dr. Nicolas Karvelas and Dr. Brian Joves discuss neuromodulation of the vagus nerve as a therapy for chronic pain conditions. The vagus nerve is an incredibly complex and important nerve.  The critical and wide array of effects that the vagus nerve has on the body make it an intriguing target for treatment of a variety of different conditions. Must notably, the vagus nerve is considered to be essential in the body's parasympathetic response... Which in pain medicine is interesting because many chronic pain conditions are believed to have a heightened sympathetic response. Vagus nerve stimulation is FDA approved for treatment of refractory epilepsy and refractory depression.  There is growing animal model and clinical research demonstrating that vagus nerve stimulation also has significant analgesic potential.  There is currently early promising research demonstrating potential effectiveness of vagus nerves stimulation for multiple difficult to treat pain conditions including fibromyalgia, chronic pelvic pain, rheumatoid arthritis, trigeminal allodynia, and refractory headaches.     Listen as the doctors discuss some of the available literature regarding this interesting, important, and emerging therapy. This podcast is for information and educational purposes only, it is not meant to be medical or career advice. If anything discussed may pertain to you, please seek council with your healthcare provider. The views expressed are those of the individuals expressing them, they may not represent the views of Spine & Nerve. References: 1. Chakravarthy K, Chaudhry H, Williams K, Christo PJ. Review of the Uses of Vagal Nerve Stimulation in Chronic Pain Management. Curr Pain Headache Rep. 2015;19(12):54. 2. Johnson RL, Wilson CG. A review of vagus nerve stimulation as a therapeutic intervention. J Inflamm Res. 2018;11:203-213. Published 2018 May 16.

In this week's episode of the Spine & Nerve podcast, Dr. 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.  

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.

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.

Thank you all so much for listening to the Spine & Nerve podcast in 2019. We started this podcast to provide another option for both patients and healthcare practitioners to learn more about musculoskeletal medicine and pain medicine. Drs. Raman Gurai, Nicolas Karvelas and Brian Joves have had a great time educating about various diagnoses and treatment options, diving deep into the medical literature, and sharing their experience treating these challenging pathologies. As the decade comes to an end, we believe that just as the 2000s have gone down in history as the decade of pain... The 2010s will be remembered for two main themes: fighting and reversing the opioid epidemic, and the rise of technology in pain medicine. We have addressed both of these topics at length (please refer to our previous episodes: https://anchor.fm/spine/episodes/When-opiates-fail-your-patients-e3pjl2. https://anchor.fm/spine/episodes/Opiates--opiates--and-more-opiates----We-just-cant-stop-talking-or-educating-on-them-e62be0 https://anchor.fm/spine/episodes/Neuromodulation-an-introduction-e7r6k0 ). We are humbled by the response we have received from you, our listeners. We are so grateful that you have taken the time to listen, engage with us, and share the podcast with your friends, colleagues, and patients. Our most listened to podcast of the year was our introduction to spinal stenosis, and we have chosen to rebroadcast that episode to wrap 2019. Wishing you all a very happy new year and looking forward to continue bringing you value with education and information on all things musculoskeletal, spine, orthobiologic and pain medicine! 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.

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.

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.

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.

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.