All right, we're going to get started here. Thank you guys for joining us. This is Advancing the Chronic Back Pain Algorithm for those who are joining us. We got a great esteemed panel formed here together, and I'm proud to be kind of leading and moderating this session. We do want it to be somewhat interactive, but we're going to have a Q&A section towards the end of the presentation here. So to start off, I just want to, here's our disclosures, and then subsequently a brief introduction from all the panelists here. And we'll start from all the way from my left, and then we'll go right. Good afternoon, everyone. Dr. Gurtej Singh, board certified, obviously, at PM&R and interventional pain management, trained at Wayne State in Detroit, and then went to Beth Israel in New York City for anesthesia pain fellowship. Since then, joined neurosurgeons here outside of Baltimore, worked with them for about five, six years, and now part of the largest private practice orthopedic group in the country, the Centers for Advanced Orthopedics, where I serve as the director of interventional physiatry and pain management. Honored to be here. Thanks, David, for the invitation. Well, I feel like I need to have a longer introduction now, but my name is Mehul Desai. I'm in private practice in Washington, D.C. I was in academic practice at George Washington University for about six years, now in my own practice in the D.C. area. So really happy to be here. Thanks, everyone, for coming. Jordan Tate. I went to Emory, PM&R program, and then Mayo for interventional pain fellowship, and I've been in private practice in the Atlanta area since 2014, and also very honored to be here. Thank you. Hi, my name is Patrick Buchanan. I did my residency at Kessler Rutgers in New Jersey, and my fellowship at Loma Linda University. So now I'm back in private practice in Camarillo, California, which is between L.A. and Santa Barbara. So, again, thank you for letting me be here, and we should have a great discussion. Yeah, and to conclude, I'm David Lee. I also practice in California. Me and Patrick are the lone people from California. There's some of you guys from the West Coast, but we're happy to be here. I did train out at SUNY Downstate, and for my residency, did an interventional spine fellowship in Arizona. Since been back in California for the past decade, and I practice in a small orthopedic group, I do most of their interventional spine. And a lot of the things that we're going to be discussing here today, a little bit beyond that of your traditional epidurals and facet injections. We're going to start with a case report here really quickly, but I did want to start off introductory by saying that this panel was bred out of the desire to bring attention to a lot of the interventional procedures that have come to market for chronic low back. It's been somewhat of an explosion, and I've been very fortunate through learning a lot of these therapies and doing them and going to society meetings to interact and work with the panel members before you. So you're in a really good group here in terms of their fund of experience, in terms of their expertise in doing these procedures. I would absolutely encourage all of you that if you have a specific procedure that you're interested in that we discussed today, that you approach them separately and of course, you know, pick their brain. So this case report is pretty generic, but we wanted to start it off because to emphasize a couple things. One, this is a patient that all of us ubiquitously probably have in our practice. So this isn't such an esoteric thing. A very common discussion that all of us come about where, you know, we are commonly dealing with whether you're in interventional spine pain or general physiatry patients with low back pain. So this is a 50-year-old male presents with chief complaint low back. Pain level ranges four to eight depending on the activity level. Low back pain insidiously started eight years ago, so atraumatic. Progressively worsened over the past year. Pain refers to the upper buttock, but no true radiculopathic symptoms. No numbness, tingling in the legs. Like a good patient and compliant patient, physiatry's best friend. He's been doing physical therapy for the past two months with modest improvement. And his overall pain level has been relatively unchanged. Other treatments includes TENS, anti-inflammatory medications, Medrol dose pack only with transient relief. So I wanted to start off the panel discussion first and foremost with knowing this kind of case report and keeping in mind novel therapies that are actually making their way into the market right now. What in terms of what you do for a low back pain workup on physical examination? And we'll initially start with Patrick here. Thanks, David. So yeah, so I think us as physiatrists are pretty well equipped to start diagnosing these low back pain syndromes and kind of differentiate this between the pain generators. So as you guys know, there's a lot of different pain generators in that area. So you have your facets right there, especially the L5-S1 facet. So facet loading, to distinguish if this is pain worse with extension versus pain worse with flexion. And then you have your sacroiliac joint right next to there too. So those provocative maneuvers are going to be really important for that. And if you have three out of five positive provocative maneuvers, you have an 85% pre-test probability that the injection into the joint will be positive as well. So I think that's very important to distribute there. And you've got to distinguish between your radiculopathy and spinal stenosis patients too by doing a good neurologic exam as well. So I think that one thing that we want to highlight is obviously first and foremost, even though patients may complain of axial back symptoms, that you rule out any kind of neurological or neurogenic aspect to their pain. A lot of them may say they have low back pain, but because the leg symptoms are intermittent. So it's particularly important that you still do a full neurological examination. And of course, I think this is one of the aspects that obviously a lot of panel member here are passionate about in the sense that when we deal with interventional spine and spinal pain, I think physiatrists in particular are very much equipped to doing the workup and seeing that patient to the appropriate therapy as opposed to other fields of subspecialties that do pain like neurology or anesthesiology. Any additional things you guys would do on workup in particular? When it comes to physical exam, I think some of the things we certainly struggle with is just sort of the insurance authorization process. So it's sort of interesting that you've got a bunch of different tests, right? The Finger Fortin test, the Patrick's Maneuver, Gainesville Maneuver, Thigh Thrust, Distraction Compression, right? I had an interesting conversation with one of our other colleagues earlier this morning. They were kind of complaining that nowadays, even though Finger Fortin test in the data shows such a great correlation to SI joint pathology, a lot of the insurance carriers are not covering that anymore. So just simply doing that may not count. So kind of unfortunately, as you stay up to date with all the things we're also discussing, stay up to date with what the insurance companies are sort of accepting and not accepting in terms of your physical exam findings. I think the other thing to keep in mind is, and tomorrow there's going to be a talk on if you really like to be depressed in the middle of the day, come to the new coding and billing talk that we're going to be giving tomorrow midday. Riveting, you want to cry, a Kleenex will be provided, but it is important. I mean, these days you have to, most insurances want you to document the Laszlot cluster. So if you're not familiar with that, you should familiarize yourself with that. As Dr. Singh said, I prefer calling the Fortin Finger because I don't want Dr. Fortin to get offended by me doing something else to him. But it's important to make sure that, at least got one laugh out of that. It's important to make sure that you're aware of the tests that they're looking for. We talked about the fact that there is the sensitivity, specificity of the Laszlot cluster is pretty good, but there's new data out that suggests it's maybe not as good as we once thought. Based on the paper that Laszlot published, I think it was an 88% sensitivity, 78% specificity. But the problem with that is that there's newer studies that sort of debunk that a little bit. So we have to be thoughtful of what insurance is really requiring us to document. Understanding in the backdrop of the fact that most of the tests we do have terrible sensitivity and specificity, and furthermore have really even worse reliability. So between an expert physical examination person versus someone who hasn't done that many physical exams, there's a huge difference. So despite all that, we have residents and fellows working with us all the time. I tell everyone that most times the patient's going to tell you what's wrong. We use the physical exam and radiographic. We really try not to let people look at MRIs until they've talked to the patient and examined the patient. Because usually the patient tells you what's wrong if you just listen. But we live in a world where we have to document, so keep that in mind. Yeah, and that's a great point. The other thing, aspect, Jordan, you had something to add? Oh, yeah. Please. I was going to jump in about really listening to the patient first, and really starting with that history gathering, and allowing that to dictate what you are maybe adding into your physical exam, what you're looking for. Specifically, if you have sort of a younger male patient, and you might be hearing findings that are more consistent with some sort of anterior column pain, like discogenic pain or tuberogenic pain, for example. Or you're a multi-pares female, and you might be thinking SI joint. We don't always have to do a full comprehensive exam on every patient, although we could, and we maybe should. But you can also let that history guide that exam. And when you're looking at things like discogenic pain or vertebrogenic pain, sustained hip flexion is going to be a helpful additive, as well as when you're looking at potentially, you mentioned up here, multifidus dysfunction. So two tests there are your multifidus liftoff and your pit test. So there's some additive, kind of nuanced new testing that is, in some ways, driven by the opportunity to treat these patients in different ways. Yeah. And we're going to talk about that aspect of actually stimulating the multifidi versus ablating the nerve in just a moment here, when we kind of take a little deeper dive into the actual therapies themselves. But those are two additional provocative maneuvers which have been similar to the last studied in the physiotherapy world extensively. And so there's a high sensitivity specificity for both of those, and they're being utilized more frequently now than ever before to identify candidates for certain therapies. I do think that Jordan makes a good point, Dr. Tate makes a good point, in the sense that you don't necessarily have to do a full-blown workup for everybody. Although it can be good because you may find things that you weren't necessarily looking for kind of right underneath your nose. But listening to the patient and then kind of driving your physical exam, just like you would like electrodiagnostic study when you're looking for a specific type of nerve pathology, can make your time with that patient much more efficient. I know that Dr. Desai said that the imaging isn't everything, but it is part of the picture. And so we're going to kind of discuss that. So when looking for a patient with low back pain and now the patient has failed conservative management and looking at the MRI or CT scan, what would you be looking for, Dr. Desai? I mean, I think the key to looking at any imaging is practice, right? So taking a look at as many images as you possibly can. I don't claim to be by any means a radiologist or an expert in all sorts of imaging modalities, but understanding when to order certain tests, what tests to order for specific pathologies, and then how to interpret those yourself. You alluded to this a little bit, but something that differentiates great physiatric practice is the ability to do all the physical exam maneuvers and the ability to look at your own images, right? So I would advise anyone who's early in their career not to be a technician, but to be a physician, right? To really think about the patient beyond what they're coming in to talk to you about. We had a patient yesterday that had bitemporal wasting. She's had six compression fractures in the last six months. I could look at her as a potential kyphoplasty, or I could look at her as a person and sort of try to figure out why she's having those fractures, why she's lost 25 pounds in the last six months, and at least do sort of my due diligence. From an imaging perspective, I mean, so we do, in 2015, we did 31 million MRIs in this country in one year. That's an MRI every 30 seconds. That number is going to continue to go up, and that's because we rely on MRIs considerably more than we do almost any other imaging modality, and that's driven a lot of sort of questions that come up about MRI conditionality. There's really no device that's MRI compatible. They're only conditional, which means under certain conditions, you can get an MRI with certain devices. But I think looking at MRIs yourself, understanding, familiarizing yourself with the different findings that you might see, and also using consistent terminology and nomenclature is really important, right? So looking at MRIs to look at discs to see if you see intradiscal pathology, internal disc disruption, disc degeneration, annular tears, annular defects, looking at end plates and dictating in your notes very specifically if there are modic changes and what type of modic changes you're seeing, not just saying end plate changes or end plate sclerosis, commenting on Schmorl's nodes, commenting on the multifidi, and really looking at the multifidi and familiarizing yourself with what atrophy may look like, so what is normal, what is slightly atrophied, moderately atrophied, and very much or severely atrophied. And then also understanding the grading criteria that you should use for spondylolisthesis. How do you diagnose and grade spondylolisthesis? A lot of our colleagues get x-rays sort of blindly. We never get obliques. I don't know what the point of getting an oblique in 2022 is. If you really are worried about foraminal pathology, you're always going to get an MRI. So if you're going to get a plain x-ray, which you almost always have to get these days in order to get insurance approval to get an MRI, and it's increasingly going to be that way that you cannot get an MRI without an x-ray. An x-ray costs an insurance payer maybe $40. An MRI costs them, let's say, $600 at a freestanding MRI center, $3,000 at a hospital center. So there are some payers that are even driving where they want those studies to be done. But understanding why to get, for example, standing dynamic radiographs so that you can, under weight-bearing conditions, you can truly ascertain spondylolisthesis. I always tell patients that my job is to keep you away from a knife, right, and keep you away from surgeons. But it's also to identify people who do need surgery and help get them to the right surgeon so they can get better. So I think it behooves us, if we truly want to provide value to both our patients but also to our partners and to payers, that we understand how to do these things ourselves. Yeah, I think that's great. I just had a curiosity from the crowd. How many physiatrists actually read their own MRIs? So about half, it looks like. Yeah, so I think, I mean, that question has come about not just here but also other society meetings, and it's profoundly hit me that, kind of shocked me that, you know, there's not, we're not doing that more frequently. Because I'm sure the panel members will, you know, agree, and you guys as well who are reading your own images, a lot of times I will find things that are over-called or under-called on the MRI, you know. And so, and the advantage that, of course, that I have, and I tell my patients this when I find them, is that I have, like, it's like doing an open book test because we're actually, we know the pathology, we know what we're looking for, we know the person has, like, for instance, a right L5 or DIC, you know, and symptoms suggestive of that. And so we can actually be a little bit more meticulous at looking, is there actually a far lateral disc herniation, is there something going on in the frame in there, you know, as opposed to the radiology who's just kind of blindly looking at leg pain, right. And so they don't know exactly what side or, you know, maybe sometimes they don't even know about that much information. Just to add to that, for the x-rays, I'm always getting a flexion extension x-ray, you know, especially if you're suspecting facets or if they have neurological changes, you know, that's going to really change your management if it's a stable or unstable spinal anesthesis. So for all my patients, I'm getting a Flex-X. Me too. I'll actually, so I'll add to that too, a lot of our surgical colleagues will do that Flex-X actually in a laying recumbent position. So sometimes you'll get standing Flex-X. I guess surgeons have kind of commented that if a patient is in enough pain, they'll guard themselves and not flex and extend enough. So sometimes depending, you know, working in an orthopedic practice, we have our own in-house x-ray. So if you do happen to have that kind of access and you can kind of guide your x-ray text to actually have them do flexion extension with the patient laying on their side, you'll usually be able to actually appreciate a larger mobility than you would in a standing situation. So you may take that patient from potentially not a surgical candidate to a surgical candidate. Just to be difficult, I'm going to disagree with Dr. Singh. Because actually- That's what the panel's for, so this is good. I mean, if you look at the literature, standing x-rays are better than side-lying x-rays, right? In Columbia, Maryland, literature is less important than in Washington, D.C. We like reams and reams of paperwork in D.C., but the pragmatic reason that most orthopods get side-lying x-rays is because they don't have the equipment to do standing x-rays. So it's easier to bill for a side-lying x-ray when you don't have the equipment for a standing x-ray. So we have orthopods that we work with and they get- Most good spine surgeons won't operate on side-lying or x-rays, they'll want standing x-rays because you'll potentiate this bondolilosthesis. And it's almost always L4-5, right? So if you look at an MRI, you'll see facet gapping, you'll see fluid in that L4-5 facet, and they might look like they have a grade one, barely, you get a FlexX and they've got a grade one, grade two suddenly, right? So that is, you know, just to be difficult. Dr. Tate, I just have one question. So two-part question. So do you always get x-rays before MRI? And when typically do you order an MRI then? Because we're talking about trying to be resourceful in terms of when we order the imaging. Yeah. So I work in an outpatient private practice and do not have in-house imaging or x-ray. So it's extra effort to order an x-ray if I'm looking for a neurologic compromise. So I'm generally going directly to an MRI when that's appropriate. I will get FlexX standing dynamic FlexX x-rays or AP pelvis to rule out a concomitant hip pathology if that's suspected or may show something with SI joints potentially. But I'm not always ordering a lumbar x-ray just to get the MRI approved. And I'm not seeing denials either currently. The only thing I will add, and we kind of again alluded to this new idea of a multifidus dysfunction is that you can also look on the axial reconstructions of an MRI, whether they have actual multifidi atrophy. We're gonna discuss that a little bit here shortly, but kind of underneath our noses this entire time, but we don't typically look for it, but if the multifidis are atrophied, it may indicate that there's a possible dysfunction that are leading to some micro instability of the lumbar spine resulting in further deterioration over time. The only other thing I will disagree a little bit with Dr. Desai in the sense that only time I agree with the fact that obliques are probably overutilized in terms of radiographs. I know most non-physiatry specialists and interventional specialists don't use them, but I think it can be critical or helpful if you're looking for a PARS defect. So in that respect, I think if you suspect a younger patient who has extension-based pain, maybe potentially PARS related, then you should probably order an oblique. Of course, the gold standard would be CT scan, but if you have a suspicion and you have X-ray on site, it's not a bad study to take a look at. Sometimes you're not able to catch that on the lateral. We're gonna now kind of take the second half of this discussion into the actual therapies themselves. So we're gonna start off by talking about peripheral nerve stimulation, and Dr. Desai has done quite a bit of this and a lot of research and studies on this, and I'm gonna hand the mic over to him to discuss temporary medial branch nerve stimulation for the treatment of low back pain. Sure, thank you. So I think peripheral nerve stimulation has been around just as long as spinal cord stimulation has been around. So late 1960s was when peripheral nerve and spinal cord stimulation really kind of sort of came onto the market. But historically, what we were doing is using spinal cord simulator leads off-label in the periphery, and it was a pretty invasive, relatively, for lack of better words, sort of, not barbaric, but a pretty big surgery. You often had to expose a nerve, put a lead directly on the nerve, and suture the lead in place. That sort of evolved over time in the early 2000s, mid-2000s. What you had was sort of this hybrid approach for anyone who was around back then. A lot of times we'd put one spinal cord simulator lead in and two peripheral leads in under the skin. We called it peripheral nerve stimulation, but it was probably more like peripheral field or peripheral field nerve stimulation. And then there was sort of, basically CMS got wise to that and decided to cut RVUs for peripheral nerve stimulation and sort of basically went away. And I think there was a lot of interest in peripheral nerve stimulation, and there was a lot of desire to come up with a better opportunity, better option to be able to provide peripheral nerve stimulation. And so two big things happened about five to seven years ago. One, a group of companies came into the market that had better devices that were more suited to the periphery and were more stable when placed peripherally. And also the work RVUs related to peripheral nerve stimulation kind of bounced back, and there was sort of this perfect storm, perfect opportunity to start applying this therapy again. And candidly, in the last five years, three years, particularly the last three years, the use of peripheral nerve stimulation has probably skyrocketed. And much of that is because two reasons. One, we probably had groups of patients that we thought we could use this for, but we didn't have a technology suitable for them. So, for example, modern neuropathies, CRPS, joint pain, like shoulders, knees, things of that nature. And then the other thing was we started to see hints in the data that this therapy was actually not just fun to do or interesting to do, but also efficacious. And in that sort of place, there's a paradigm put forth by one of the companies where there's a 60-day treatment for low back pain. So, for 60 days, a lead was placed typically bilaterally. So Chris Gilmore down in North Carolina and that group really put forth this data initially. And now we have a prospective sort of case series study that's been published with about 74 patients. And now there's a randomized control trial that's going on that the last two studies I've been a part of. And in that paradigm, you basically place one lead on each side along the medial branch and stimulate for 60 days. And typically the patient stimulates sort of a motor stimulation paradigm at 12 hertz for six to 12 hours a day. And after 60 days, the device is removed. And the first study that was published demonstrated not just improvement, but people out to one year. So 12 months after the cessation of therapy still had improvement. So the responder rates of folks who had greater than 30% improvement in pain, but also disability indices showed improvement that was durable out to that 12 months. And now we even have, I think there's a fall paper that's pending that's gonna be looking at 24 months. So the folks that still were reporting data also showed durable relief for that timeframe. What was interesting for our practice is that historically the only option that was available for folks who had axial low back pain felt like it was either you did our radio frequency ablation or spinal cord stimulation when sort of some of the newer data around spinal cord stimulation for non-surgical low back pain became available. And particularly for some of our younger patients who I didn't necessarily want to subject to a lifetime of repeat ablations. Those are the patients we started having conversations with about these therapies. And it's been, and I'm not gonna stand here and say that every single person is better, but it's been really illuminating to see large groups of patients get so much better and have not just better for a short term, but durable relief out to that one year and one year beyond time horizon. And I think what's gonna be interesting to see with this randomized controlled trial is whether the durability and the efficacy is sustained in a more robust trial design, but also starting to look at some of the sort of cost effectiveness literature to see how does this compare to doing other treatments. So for those of us who do a lot of RF, RF is sort of the backbone of many, many, many spine and pain practices. Even now, even though there's a lot of new and exciting therapies like the folks up here are talking about, but is it right for everybody? And most of us see these patients that come back around four or five months, they're starting to creep back into our office being like, oh, it's kind of wearing off. When can I do my next one? And it's not that we shouldn't do that therapy, but it really does offer some of these patients an alternative that may be more durable, but also less invasive and non-destructive. We're actually working on a paper looking at, if you look at most of the literature on RF, that literature is based on five cadavers in Australia. And then from that, there's been some retrospective work to look at the multifidi cross-sectional area after RF, but it wasn't controlled work. It was sort of like MRIs that were maybe done at no particular timeframe after. So we're actually, we prospectively looked at a few patients to see if there is some atrophy of the multifidi. So it'll be interesting to see if we're actually creating injury instead of just sort of, instead of allowing them to possibly heal and even maybe to cure some of these issues. Yeah, that's a great summary. I'm gonna kind of take the reins there. Excellent initial talk about the temporary nerve stimulator. There is another system out there that's a permanent one that does not come with a trial. The idea with this is very similar to what Dr. Desai was alluding to, where we put leads adjacent to the medial branches at L2, and then we stimulate those in 30-minute sessions twice a day. And its stimulation is not as robust and aggressive as those of what we feel on a twitch response motor during an RF, but rather a kind of a bell-shaped contraction, which kind of ramps up and then ramps down. So more of a natural contraction of the multivis. And the idea here is to reestablish that connection, that neural drive to that muscle, which may become inactive over time due to chronic pain symptoms. This idea of what we call arthrogenic inhibition, which has been described in the orthopedic world quite a bit, particularly for knee and shoulder pain symptoms. The main difference here is, obviously this stays in for a longer duration of time. And then now there's three-year data published in Neuromodulation Journal by Dr. Christopher Gilligan, who's up here in Boston, in regards to the durability of the therapy, in terms of also reduction of opioids and increase in function in terms of ODI. So the main difference, of course, between the temporary and the longer duration or implantable version is that the patient is expected to utilize the therapy consistently. And the idea with this is relatively simple. From the physiatry standpoint, we present this because it's very easy for us to understand and grasp, is that the more you stimulate a muscle, and the larger that muscle will get potentially, but more importantly, the more function that you'll have in that area. The idea, of course, is stabilizing the spine by making the motifidae response more robust. And that kind of goes back to what we had initially talked about when you're examining this patient. So there are two provocative maneuvers, the PITT and the MLT test. We're not going to go into those in a lot of detail, but those tests, if there are positive, in terms of examination, would indicate that there is some dysfunction with the actual muscle there. Additionally, if you're looking at the MRI and you see muscle atrophy in the motifidae, that's also a hint in terms of, maybe this type of therapy will be helpful for that particular patient. We're going to kind of move on here onto newer ablative therapies. We talked about radiofrequency ablation, but there is a new ablative therapy, and I'm going to hand over that to Dr. Tate. Sure, yeah, so I was going to talk about basal vertebral nerve ablation. And interosseous BVN ablation has really emerged in the last couple of years with evidence originally showing up in about 2018. And since then has accumulated both a 12 and a 24-month RCT, as well as five-year long-term real-world outcomes data. And there is a documented LCD for BVN therapy. So what is the BVN, right? It's not something that we really learned about, I don't think, when I was going through residency much. But the idea here is that we're treating that elusive discogenic slash vertebrogenic back pain. So we talked about looking at MRIs, and we were all taught to look at the Schmerl's nodes and the Modic changes, but there was always this question of how that correlated clinically, and whether this was something that we felt confident was a source of nonspecific axiolo back pain or not. But what we know now is that if you treat patients who have type one and type two Modic changes seen on MRI with BVN ablation, they do quite well. And so we see that patients who have baseline pain scores in the sevens and eights are getting down to average of 2.6. And this is being carried out to 24 months and appears to be of durable benefit. What we also are seeing in the long-term data is that this is not seeming to be a recurrent condition. Once the BVN has been ablated in these patients, it does not appear as though it needs to be repeated. And in fact, the LCD comments that it is a once in a lifetime treatment between L3 and S1. So as you're looking at patients who have Modic changes on their MRIs, and you're considering other techniques or they have failed other basic interventions, consideration for BVN ablation should be on your radar. That's great. Dr. Desai, do you do BVN in your own practice? Can you just describe for the audience, for those who aren't familiar, exactly how the procedure is kind of done? Sure, I mean, so I trained at a time when there was a lot of excitement about the sinovertebral nerve and ablating the sinovertebral nerve. So for those people who remember IDET, that was a procedure where you put a catheter into the disc. You sort of had to fish that catheter around and it would get caught on annular fissures and all sorts of fun things. And it got a Medicare code, and then people used it on people who didn't have discogenic pain, and then it disappeared. The sinovertebral nerve and the basal vertebral nerve have the same basic sources, right? So you've got a root off the ventral rami that primarily, along with the gray rami communicans, which is a branch of the sympathetic trunk, forms the sinovertebral nerve. And there's a similar kind of root. It goes through the posterior, there's a posterior neuroforamina in the back of the vertebral body in the midpoint, and it goes into the vertebrae, and then it sort of, there's a central portion where it's almost, it's not a ganglion, but it sort of centers in, and then it spreads out through the vertebral body. And there's some thought that the reason that kyphoplasty, vertebroplasty works is because when you put hot cement into a vertebral body, you're basically ablating the basal vertebral nerve. But basically, the way, the technical part of the procedure is you essentially are doing what seems like a kyphoplasty, vertebroplasty, in that you're using a trocar to cannulate the pedicle of the vertebral body at the level where you have inferior motor changes and the level where you have superior motor changes. And you're driving that trocar sort of towards the posterior midline of the vertebral body. Once you get it into the back of the vertebral body, you essentially put a catheter that's somewhat steerable into the vertebral body and get it into the final location. And then you heat up that catheter, typically over, is it 14 minutes right now? And I think there's a modified technique where you can do it for seven to eight minutes, which is analogous to what we used to do when we did IDET and by kyphoplasty, which we're heating up these catheters slowly over time to about, to over 15 to 16 minutes. The idea there is that nearly all unmyelinated fibers are fully ablated at 45 degrees centigrade and almost all unmyelinated fiber, I mean myelinated fibers are ablated at 45 degrees centigrade. But if you burn too hot, you char everything and then you lose efficiency. So burning a little bit lower but slower allows you to kind of really get that ablation fully across that nerve. Great. So we're gonna move on to discussion of some percutaneous fusion therapies. Actually, we will do PERC and we'll talk about a little bit further in terms of inner spinous. I'm gonna turn the mic over to Dr. Buchanan to discuss percutaneous sacroiliac joint fusion. Thanks, David. So yeah, SI joint pain accounts for up to 30% of all low back pain. So it's pretty under diagnosed in our population. And I think we as physiatrists, I think we are able with our physical exam skills to really pinpoint this. We see these patients all the time in our office, right? A lot of patients with lumbar fusions, you get that adjacent segment disease in the SI joint. So that's where I'm immediately going to on my physical exam. And we really haven't had a lot of long-term treatment options for SI joint pain as physiatrists. So you can do your physical therapy, your injections, even the radiofrequency ablations, those last maybe at best six to nine months plus with insurance carriers, a lot of people aren't covering that. So SI joint fusion is kind of one of those tools in our toolbox now we're able to use to get that long-term relief with our patients. So SI joint dysfunction is a mechanical problem, right? It's not a neuropathic problem. So either the joint is hypermobile or hypomobile. So what SI fusion does is kind of stabilizes that joint and gets it back to its pre-disease state where patients can walk better and get back to their life. So lateral fusion. So there's two types of SI joint fusions, lateral fusion going through the muscles, the glutes, the iliac crest into there. And there's also kind of a newer therapy called posterior fusion. And that's kind of been approached more to the interventional pain physician side where you're kind of going in posterior just like you are for a SI joint injection right there. So you are able to avoid a lot of the major structures in that area, as well as the major nerve roots. So the advantages of the lateral fusion, that's done by typically surgeons, orthopedics or spine surgeons. You know, there's really good randomized controlled trials on this. The insight study has great one to two year data showing the efficacy of this versus conserved management. But now we're seeing more data on the posterior approach. So one of the studies, the SECURE study, using a single allograph into the middle third of the joint. They just published a six month data on that showing it non-inferior to the lateral fusion, which is the gold standard. And also with much less severe adverse events. So the insight study quoted about a 13% SAE rate. Some of those were included was an S1 nerve root injury, some superior gluteal hematomas. The SECURE study, which is done by all interventional pain physicians, had about a one to 2% SAE rate. So you're getting pretty much the same efficacy, but being a lot safer for the patients. That's great. And so the actual, I know you're a part of the SECURE study too, right? So Dr. Buchanan has firsthand a fund of actual expertise in terms of the procedure. So the actual allograft is filled with bone mineral and it's placed intra-articular, correct? Yeah, that's correct. So that helps kind of promote the fusion. So what's it's allowing the SI joint to do, right? Like I said, it's either too mobile or not mobile enough. So what the implant allograft is doing is first it's distracting the joint to opening it up. So less grinding. And it's also stabilizing the joint or kind of securing it back to its pre-disease state. So typically you have one to two degrees of mutation, counter-nutation, right? A lot of people, like Dr. Tate was saying, after pregnancy, you have that hypermobile joint, three to four degrees mutation. What the SI fusion doing is stabilizing back to that one to two degrees of mutation to have. And I'll just finish with this because I'm sure that in terms of application for patients, who do you choose to do this fusion on? Is there a selection criteria? Yeah, so typically they have to go through at least two diagnostic intra-articular injections. They have to have at least over 75% pain relief with that. And right now, quite honestly, I'm typically bypassing the RFA. I'll give them the option for radiofrequency ablation, but a lot of the patients want this permanent fix, right? So they don't have to keep ablating every six months or have to keep coming in for procedures, procedures. And they've been doing fantastic so far. Yeah, we didn't even talk about sacroiliac joint RFA on this particular talk, but right now I'm doing kind of a meta-analysis of all the data through our sister organization, CIS. And what we have found is that a lot of the data is all over the place. So patient selection criteria was pretty poor. Some studies were using intra-articular injections. Some were using sacroilateral branches, but most not for a diagnostic criteria. Some use 50%, some use 75%. So it's really a smattering of selection of patients. And then techniques were completely different and varied as well. So some would use L5, some would use S1, S2, S3, S4, some would do all of it. Some would do a strip lesion, some use cooled, some use conventional. So it was just kind of a mess. And the basic conclusion is that the data out there seems to point to a positive effect, but there are some studies that are also against that. And the one thing to keep in mind with sacral RF, of course, for all those who do these interventions is that there is an anterior innervation as well to the sacroiliac joint that is not reachable. So keeping in mind that even the actual procedure itself is somewhat limited. We're going to kind of turn kind of quite a bit. Go ahead, please. So in my experience, there is also the technique of a oblique lateral, right? So you have the true lateral, which Dr. Buchanan mentioned in terms of SI bone, did a lot of those studies. You have these three dowels that go in parallel across, or you have this posterior technique like an intraarticular injection. Well, there's also an oblique lateral approach, and you essentially use a combination of a cannulated and fenestrated screw. So you can pack the screw with DBM, but you also allow it to pass over a guide wire. So in that direction, you can also approach the SI joint for a percutaneous fusion. So just to be comprehensive, you know, there are a couple other options. I mean, the other thing to keep in mind, I keep plugging our billing coding talk here, but reimbursement just changed. So it's going to be an interesting thing. There's Category 1, Category 3 codes, but there's now going to be a Category 1 code. So but it'll be interesting to see how it's valued. So it's nice to have a code, but the devil's always in the details. So for a while, that looked like they were going to lose coverage in terms of Category 1 codes. But there's going to be a separate Category 1 code for posterior fusion versus lateral fusion. So it's going to be interesting to see how that gets valued and how uptake gets up. Now the other thing to keep in mind, too, is we need more trials, right? We need to see the fusion actually occurs. We need to see like outcomes from all of these things. And that's where, you know, it's fun to talk about all these. And I'm just going to make one comment about this. It's fun to talk about these things because they're really fun and exciting and new and interesting. But we have to continue to stay sort of committed to putting out good work because just as exciting as this is, it's vulnerable, right? So payers look at it as like, how do we cut these things? So we have to keep that in mind. Yeah. And not just payers. I think a lot of the motivation for the code changing was because a lot of surgeons were obviously upset because a lot of interventional pain doctors were starting to come into this gray area of what's, you know, not really surgical, what's not really interventional. And really like what we've seen in cardiology, those who are familiar is that that world has kind of changed. You know, interventional cardiologists started doing a lot more procedural-based therapies and techniques and the same thing has happened in the interventional spine world. I'm going to turn kind of tables. Thanks for that, both of you. But we're going to turn the tables and we're going to talk about inner spinous fusion now, which Dr. Singh has quite a bit of experience with. So inner spinous fusion, essentially you're looking at an individual typically in our practice and in most of those of us who practice in this field, you're looking at either typically one level, sometimes two levels where a patient has sort of a combination of spinal stenosis, neurogenic claudication, as well as some form of instability with regard to, you know, flex and extension. These devices, most of them are approved for those with up to a full grade one spondylolisthesis. Anything more, you really should be getting your spinal surgeon involved. It's an interesting, as Dr. Desai said, fun and new, but also super vulnerable area. You know, spine surgeons look at it and say, we already did this. And for those of you who are familiar with the X-stop procedure, they kind of already did. And what did the X-stop procedure demonstrate? It didn't work. Or if it did, it did for a very short period of time. In you know, the actual disease process itself continued to progress, so patients had that initial robust experience of feeling a decrease in their claudicatory symptoms, but then they all came back. Those who were on the younger side tended to be more mobile, and unfortunately that device would eject or displace itself from the inner spinous window. It was not, if I remember correctly, intended as a fusion device, and so some of these newer inner spinous, or what I will also call interlaminar, I think they're two different types of devices in my opinion, do have the ability to pack DBN or demineralized bone matrix so that you can promote a fusion between these spinous processes. Let's go back and talk to the surgeon again. They think that's hogwash, and the reason they say that is that it doesn't really promote a true fixation in all of the different planes of the spine, and they are very concerned with sort of our ability to understand instability, number one, and number two, balance, whether that's sagittal or coronal. And are we putting in devices that are causing kyphotic moments in the part of the spine that should be lordotic? So there's so many of these surgical considerations to think of, and so this is where our sort of two fields are butting heads at this time. When it comes to up-current sort of data, some of the newer companies who have these devices are in the midst of doing these projects, so those are not yet published or can't really share that information with you because they're not out yet. There are a couple different techniques. So you have typically either a posterior approach where you would be making a midline incision, cutting down to the inner spinous ligaments, taking down those ligaments, and then depending on your skill set, doing a laminotomy defect or taking some of the ligamentum flavum, then depending on the type of device, you're either setting that in between the spinous processes or you're able to actually set the device down onto the lamina itself. So you have typically two or three devices that are out there, and we're going to be sensitive not to sort of name names, but about two or three devices that are truly interlaminar and will actually sit down on the lamina, and then about two or three devices that just sit posterior to that between the spinous process. There is a lateral technique. One should be a little cautious because some of their clinical indications are for actually a posterior approach, but they do offer interventionalists a lateral approach. And the question there, again, for those who are familiar with the interspinous spacer, like a Vertiflex, and that's the only one out there, so I'll just say that. Some argue that a lateral approach to interspinous fusion is just a robust interlaminar spacer. So care must be taken in those cases as well. There have been reports of injuries to patients and unintended consequences, we'll say it that way. At the end of the day, what's that? It's in kidney biopsies. Yeah, okay. True, I just didn't want to say it, but thanks. So I think the biggest issue, right, we're physiatrists. What's funny is my dad's a physiatrist as well, so I think he's grossly horrified that I'm sitting up here fusing SI joints in the spine, because that's nothing of what he did. But we're sort of taught to keep people moving, right? But yet, in our space, we are also moving in a way where technology is growing, and the ability to access some of the true pathology is coming into smaller and smaller windows. And so while not on this talk, but what could be something in the future that we discuss is how do we actually fix that patient's pathology? So when you then look at the two forms, right, you have the spinal stenosis component, and you have the mobility component, a lot of surgeons and spine surgeons will tell you that if you go in there, do an adequate laminotomy, or even a hemi-laminectomy, the likelihood that those patients will continue to become hypermobile and require fusion is somewhere in the 10 to 15-ish percent range, and these are studies out of the University of Virginia Department of Neurosurgery. So I think some of these inner spinous interlaminar fusions are a bit overutilized in general, and I don't think we're actually getting to the true pathology, which is to actually decompress that posterior segment. And so if you're looking to truly decompress, there's a posterior interlaminar lumbar decompression. You can call it a PILD. There's another name for it as well. But you could also theoretically use like an endoscope. And so if you're actually trying to treat the pathology of the stenosis, doing a distraction device starts the process, and it may be great as an adjunct. But I would kind of caution everyone, are you really treating the spinal stenosis if you're not actually taking some of that ligament or some of that lamina down? That's a good point. We're not going to be focusing so much here on neurogenic claudication. We're talking about lower back, but that does segue nicely into our last topic, which is spinal cord stimulation. So for most of the people in the room, they probably know that the indications of spinal cord stimulation traditionally have been complex regional pain syndrome and post-laminectomy syndrome. But with the continued use of spinal cord stimulation as well as change into novel waveforms that are offered now through various companies, we're finding that we're able to capture other areas other than just the limb. So this is for the full entire panel, because I know the full entire panel has a huge fund of knowledge in spinal cord stimulation, as well as a kind of love for it. And we all here have probably utilized spinal cord stimulation and seen improvements in low back pain in our own practices. So I'm going to, without just going into too much detail as to the companies, but I'm going to just kind of turn over real quickly the table here and first start with Dr. Singh, because there is some data actually available out there, some pretty robust data now that supports the use of spinal cord stimulation for low back. So when it comes to non-surgical refractory low back pain, the data in a level one RCT out past two years clearly shows that 80% of patients obtain at least 50% pain relief and approximately 50% of the patients received 80% pain relief when using 10 kilohertz stimulation. These are, the leads are placed anatomically, unlike the days of the past, which all my panelists know, where we would stimulate on the table and try and test on the table. You use anatomic landmarks, typically the T9, yes, the T9, T10 window, and you're sort of targeting wide dynamic range neurons. So in terms of, instead of the classic, you know, posterior column, sort of targeting other neural structures and then the RCT to back that support. Great. I'm going to have Dr. Buchanan, we can't go into too much detail because it's not published yet, but he is part of a current study on looking at low back pain treatment with spinal cord stimulation as well. Yeah. So similar to what Dr. Singh was talking about, there is another RCT that's out right now using Burst DR. So not the Burst that was mentioned in the JAMA article this week, that'll be a complete different discussion for tomorrow, I think Dr. Lee has a lot. But Burst DR, and we're getting similar results of that, we've had a 91% responder rate with either NRS or ODI in this, compared to the conservative management arm. So we're getting some really good data so far on this. And then for Dr. Desai and Dr. Teja, just going to ask you guys for your own experiences using spinal cord stimulation for low back. Yeah. I mean, I think overall, we know that electroceuticals work. If you pick the right patient and you have the right target, you do your appropriate clearances and psychological evaluations and rule out really true surgical pathology, you're likely to be met with a good outcome in utilizing dorsal column stimulation. We know that our traditional low frequency stimulation, the evidence is quite paltry that you are likely to be met with a less than 50% overall satisfaction rate with long-term efficacy not really withstanding. But our newer options that are available to us, high frequency stimulation, burst stimulation, something called differential target multiplex, as well as newly available closed loop technologies are all showing superior evidence when compared to traditional tonic stimulation, specifically looking at patients who have either pre-surgical, non-surgical, or post-surgical axial low back pain. Yeah. That's great. And so for those not familiar, of course, it's a big, huge change in probably in the past, gosh, like 10 years. So most of our careers in this room, but dramatically changing in terms of the availability of therapy and waveforms that are out there. And as a result of that, we've seen a huge evolution in neuromodulation. Dr. Desai? Yeah. I mean, I think I was, prior to 2013, it was adequate to show, to have a randomized control trial in the spinal cord stimulation space where the kinds of outcomes that were sort of relatively nominal were what was like sort of the going rate, 50% of people getting about 50% better. That benchmark changed after 2013 with the introduction of 10,000 or 10,000 Hertz. And now all the companies are publishing, that's sort of the basic level you have to meet where it's like 80% of patients get 50% better, which can be really interesting to see the next year or two, because we've got basically four major manufacturers that each have proprietary waveforms. Then you have a fifth company that has some proprietary waveforms, but a much, much smaller IPG. And then two new companies that are going to go commercial in the next three months, possibly as late as the first quarter of next year. One will have closed loop technology, so it's sort of a sensing e-caps type of technology. And the other will have its own kind of sort of relatively novel waveform as well. So the question really becomes, how do you choose, right? So that's its own whole own talk, right? So we could probably talk for hours about, how do you pick the right therapy for your patient? And I would implore everyone to keep that question at the front of mind. Should it necessarily be one device manufacturer for every patient? In my mind, it should be the right therapy, the right capacity, the right capabilities for the right patient. And if you can sort of keep that thought in play, you can pick, hopefully, the best possible device for each of your patients. Because the choices are going to continue to grow, and it's going to be interesting to see how people make decisions with this sort of almost overabundance of data, where you sort of, you know, we're sort of getting into this area where there's death by data. People start throwing papers at you all the time, and you're like, well, how do I decide from everyone's got the same kind of basic outcome? So it's going to be an interesting time. It's an exciting time, I mean, because now we have more choices, and I think it's important to have more choices, because that, but the primary beneficiary of those choices should be the patient, not us, right? So I think that's my take. And that's a great point. We're going to finish off with some final thoughts from the panelists, and Dr. Desai has kind of segued nicely into that. I think that's a great point. One of the things that I do in my own clinic is that when I'm, well, first I should say, let me take a step back. The whole purpose of this panel discussion, and hopefully you guys gain a lot of it, is that there's a lot of choices now, and it's up to us to kind of make sure that we're making the right decisions, but at the same time, including the patient is imperative. So when I see a patient and I do the workup, I include them oftentimes in the decision-making process. I have a conversation with them, like, we can go this way, traditional route of radiofrequency ablation, or hey, look, there's these different devices that we can try to actually restore the multifidi in a non-destructive manner. But some people have different needs or wants or goals, right? Some people are looking for just a year, and then they're okay with getting reablated. Well, who am I to take that away from them? And the success rates of ablation have done good by us historically. But I think it is imperative that we become knowledgeable and then hand that information over to our patients so that we together can make a good decision. Final thoughts, Dr. Buchanan. Yeah, so just two main points. Number one is Dr. Desai was alluding to earlier. We've kind of talked about some very encouraging data for these emerging therapies, but there's still, we need to do more, and I encourage everyone to continue to follow up on these studies as well. Next time a rep comes into your office or you go into the exhibit hall, tell them, show me the data. That's what we base our patient decisions on, evidence-based medicine. And at the end of the day, that's what should be the most important thing. So there's a lot of different companies that are going to be approaching you, all these different techniques, all these different things, but I think data comes to be number one to me in deciding who to partner with. And number two, I think we need to do a better job at communication with our spine surgeons. I think that is another way to get these emergent therapies out is partnering with them. That's what I do with mine as well, talking about the data, talking about the procedures and having a conversation with them too. My final thoughts. Yeah. Thank you. You know, I think it all goes back to stick to your roots, right? We were taught to put our hands on the patients, we were taught to use our ears and listen to them. And I think all of that is extremely important in helping to decide what's going to be best for your patient and how to get them the best outcome for their chronic low back pain. It's a great time to be an interventional pain physician. It's an exciting precipice to see all of these different options and watch our armamentarium grow and all of that, but it can also be overwhelming and confusing. And the other thing I would say that we really kind of drove home is look at your own MRIs, but at the same time, don't treat the MRI, treat the patient. I mean, I see a couple that are residents in the front row here. So as they know, I have so many opinions on literally everything, but I won't share all those with everyone. But I echo the sentiments of the folks that are up here. I think the key here is that, and sort of one of the things I think, and I don't mean to speak for Dr. Lee, but I would say that one of the things that inspires talks like this is that we want to continue to push the envelope of what physiatric practice looks like, right? So we don't want it to, there's so much change occurring in the marketplace. There's so much change occurring in every single practice. No one in this room practices medicine exactly the same way. It's one of the things that makes us really unique, but it also makes it challenging because it's hard to aggregate when everyone's different. But I think it's really important to have conversations like this because it allows all of us to sort of talk about the things that are happening and to figure out what we're interested in so we can explore those as well. So my final thought would be, so many of us are interventionalists. Some of us are becoming almost minimally invasive spine surgeons to some extent. I think as you sort of make your choice in how you're gonna navigate your practice, for those who tend to go more to the advanced intervention, think a little bit more like a surgeon, right? So you have an anterior column, a middle column, a posterior column. And I think Dr. Lee did a fantastic job in helping today guide these different devices and how they fit into those columns. And so you have something that's in the anterior column. What are some of the new techniques? A middle column and a posterior. So these two fields are butting heads, stepping on toes, whatever, however you'd like to describe it. So we do also, as Dr. Buchanan said, work with your colleagues. There are ways that we can help patients without being so openly destructive. Awesome. As promised, we do wanna make this somewhat interactive. So if there's any people who have questions, if there's a mic here and there's also one in the back, please, this would be the time to do that. We wanna thank everybody for also sitting in on this. It's been over an hour. We understand what that does to a person, especially on an afternoon, on a Friday, on Thursday, excuse me. So, thank you. Thank you. Thank you for all that information. Thank you. So, two parts. One is with these newer techniques, if you have noticed or any published side effects on each of the procedures or adverse events other than the spinal cord stimulator, which everybody knows has been going on for a long time. The other thing is a question for Dr. Buchanan. If you have lumbar spine fusion and the stress is on SI joint, when you have SI joint fusion, where is the stress now? Yeah, that's a good question. The SI joint is kind of the shock absorber between the lumbar spine and lower extremities, right? So, that could provide a little more pressure to your hips, to your hip joints, to your glutes, to the piriformis, as well as your lumbar spine as well. So, those forces dissipate that way. Or your other SI joint. Yeah, yeah, that's what I was gonna say. The contralateral SI joint is what I've seen, especially in a lot of the patients who have the large dowels with the lateral. They're coming to me with, now I have contralateral SI joint. And I'm actually not seeing that with the posterior fusion. I haven't done as many as some of my colleagues, but the end of like 12 patients that I've seen, I've been following them out over almost two or three years now. And it's really not seeming to have that same effect. I don't think, we're still maintaining some of the degrees of freedom. It's not fully fusing it as much as those dowels are. And then the other question you asked, or the first question you asked was about side effects or adverse event reporting for specific procedures. One, for example, the interspinous process implant that we talked about is known to potentially cause spinous process fractures. The other, the BVN ablation that I talked about, it's helpful to let your radiology colleagues know because after you do this ablation, it creates a large circular hole in the vertebral body that has been misread as malignancy. So these are just a few that I've thought of. Yeah, I think with any implant, you got misplacement of the actual implant. I think that's obviously the biggest concern. With some of the, I know you weren't kind of too concerned about spinal cord stimulation, but for PNS, I think the biggest one is lead fracture. Obviously migration is still a concern with some systems and then also infection, infection bleeding still, you have to be cognizant about those things. Dr. Desai, probably. Yeah, I think with the BVN procedure, you can sometimes have a transient radiculitis. So sometimes when you put the trocar in, it can irritate, not directly irritate the nerve root at that level, but sometimes you can, depending on how close you get to the medial cortex of the bone, you can sometimes irritate the nerve root. We've seen that for a few patients that, and a lot of, there's a online community that talks about some of the side effects. But I think that generally speaking, I agree with everybody up here, don't do the procedure if you don't want to manage a complication. So that's the biggest challenge we're seeing is that if you don't have a good relationship with the surgeon that's willing to back you up, and you're not gonna go in and talk to that patient, you're just setting yourself up for failure. Because if you're like, I did the procedure, who cares? The complication, go to the ER. The number of neurosurgeons and orthopedic spine surgeons who now despise you has gone up exponentially. And those folks have a really tight community, and they'll tell, they love talking about all the stuff we do wrong. So it is important to have, if you're gonna do these, in my opinion, to A, be able to manage those complications, and B, have those conversations up front so that when that patient invariably, one someone is gonna go to the ER, that you can make a phone call, you show up at the ER, you're talking to your colleague, and that patient gets taken care of, and it doesn't create a big mess. Because especially as we try to, we didn't even really talk about credentialing, trying to get credentials to do these procedures, especially in hospital settings, can be really challenging, you're gonna get blocked. But if you have those kinds of relationships, you can often overcome those situations. We have a question in the back. Yeah, hi, I wanna compliment all the speakers for an excellent job and the dynamics of this discussion. My name's Ron Tolchin, I direct the Spine Center in Miami, and we're comprised, I'm a non-interventional physiatrist, but I have interventional physiatrists working for me, I have anesthesia pain working for me, and I have, we have nine neurosurgeons in our group. So we run a neuroscience institute, and I think we, you brought up some great points, all of you, but we do walk a fine line when we start to get into some neurosurgical procedures. As in your last point about the complications, if you're not willing to manage the complications, and your team is not there to step in during a complication, even if it's intra, even if it's right at the time of your procedure, I think you put yourself in a precarious situation. I think one of the biggest, and we have all these great techniques, and I'm excited about some of our newer techniques, and I encourage our interventional group to really try some of these things, because managing chronic low back pain, axial back pain, is, I think, the hardest thing to do in the spine world. It's much easier to do an epidural and take care of radicular pain, and I think the other hard thing is, for me, the most difficult thing is changing lifestyle. Lifestyle modification, for me, is paramount. I'm an osteopathic physician, and I use some of my OMT techniques. I try to change people's behavior, which, really, you probably would all agree is the hardest thing, to lose weight, to exercise daily, to do core strengthening. That's my focus, but I have my interventional people to help, and certainly, I understand the need for that. Having worked with Dr. Fortin and published with Dr. Fortin in the past, I have a true respect for the sacroiliac joint. As an osteopath, I feel it should always move, but I do agree that we have degenerative aspects of the SI joint, that it's a question, where is the pain coming from, and that's what makes it so complicated to do stimulation of the SI joint, to do radiofrequency of the SI joint, because it's a very complicated area of where the nerves overlap and go to that joint. I don't think we fully understand it. So, I think it's a very complex area. I compliment you for picking this topic. I mean, there's been things like antibiotic, long-term antibiotic treatment for chronic axial back pain and modic end plate changes. Who knows if that works, but no one can tolerate the antibiotics. I don't think we have the answers yet, right, but I think we do have to work together as both interventionalists and non-interventionalists and work closely with our spine surgeons. I know that some of my physiatrists are trained in kyphoplasties, but I have neurosurgeons that do them and don't really want anyone else doing them for various reasons, particularly complications if some of that cement does leak. So, and the mild procedure. I know we didn't get into neuropathic pain for neurogenic claudication, but we have physiatrists doing the mild procedure, and it's very complicated when you have neurosurgeons who do open procedures or minimally invasive procedures. And I have not personally been so impressed by the mild techniques and how they perform. However, it could be that the selection criteria is not right for those patients. So I just bring these points up for us to think about. Again, I compliment you on an excellent job, but I wanted to stimulate the conversation by saying, I think it all boils down to basics also. I mean, I try very hard to change behavior in my patients, and I think that's the root of it. And putting our hands on, you mentioned that, putting our hands on and doing a comprehensive examination is, I think, paramount as well. And putting our hands on in a therapeutic way can be very beneficial as well. So thank you all. Yeah, thank you. So to that extent, right? So kind of to be inspired as a physiatrist among all the devices and techniques we sort of showed today I think potentially multifidi stimulation is where you as a physiatrist are going to sort of feel most stimulated, pun intended, right? You need to be hands on to diagnose the patient well. You need to be able to read your MRI to know if they qualify or not. That's a key point. We look at, I think, everything you order you should own. So you should really look at everything. And then the final point is, thus far, as you look at the data among all of these devices that are out there, even the ones that we didn't talk about today, to see potential where year after year there's actually growth and benefit to the patient, whether it's function or pain improvement, I'm not sure that there's another device out there that can show better something at two years, at three years, and at four years. So in the physiatry, you want to be still a really good physiatrist? I think that's your intervention of choice. Yeah, and we're doing a study on low back pain. And the motivation of patients to actually do exercises you give them, should we be sending everyone to therapy like we do? Or should we be doing cognitive behavioral therapy on a subset of patients who are not ready to go out and do those exercises and just want a quick fix? It's easy to do a procedure. It's much harder to get them to do core the right way most days of the week, right? Would you all agree with that? And so we're looking at pain stages of change in patients and who are actually pre-contemplative patients and who are contemplative patients. Maybe the pre-contemplative, they're not ready to work on their own. We need to maybe do cognitive behavioral therapy first before we say, look, you should go to therapy. You should do this procedure. Maybe they need to change their paradigm in order to get better, right? So I think it's interesting. I think the jury's still out on it. But thank you. Thank you for your comments. Any other questions for the panel members? Just on the shoulder of what he just said, what do you guys do in terms of when you're evaluating a patient, the candidacy of a patient for one of your procedures? Because chronic low back pain and depression coincide, right? And so how do you do a psych screen on these patients? Or have you maybe retrospectively looked at the patients that are failing the procedures or it's not working? And why that might not be if there's like an emotional component that you're not, that is maybe not the full cause of their pain, but certainly is complicating the situation. Yeah. I mean, I think that's a great question. I think that I always joke about this, that 50% of patients in a chronic pain clinic are depressed. It's hard to know which came first, the depression or the pain. 35% of patients who go to chronic, who are seen in a chronic pain clinic have personality disorders. They're either borderline or histrionic. And I always joke that the doctors are all narcissists. It's really hard to get anything done. But I think that some of us have slightly unique settings where patients are coming to us specifically for some sort of expertise and some sort of specific intervention. Somehow I've developed this. Someone put me on their Facebook group that all the hypermobile EDS patients on the East Coast come see me. And they drive like hours. I had a patient that drove all the way from South Carolina to come see me for like an hour. And my job is to tell them there's no real great options out there, right? So I think most of us, when possible, most of us try to use some sort of screening tool. Like we're thinking about using brief pain inventory just because it kind of has elements of different things. In my practice, we use this thing called the central sensitization inventory, which we then grade. And we kind of get an idea of how much of this is sensitization versus sort of, and if they have high sensitization scores, we rarely offer interventions because it's like poking a hornet's nest. So you do something and they're even more flared. Fundamentally, though, whatever tool you use, I always tell our residents and medical students that I can teach anybody to put a needle somewhere. What I really need to teach you is when not to. And we should really do a better job talking people out of procedures sometimes because a lot of people don't need them. There's a lot of people that need them and will benefit from them as well. But there's a significant subgroup that we should sort of pass on. Yeah, that's great. We had this brief conversation, I think, over lunch. Because we all do spinal cord stimulation. As I said, most of the panel members here are very passionate about spinal cord stimulation. That's how a lot of us met before we even started doing a lot of these minimally invasive spine techniques and procedures. But one of the jokes was like, when have you had a patient you sent for a spinal cord stimulator psychiatric clearance that came back as failed? And it's like probably less than 1%. So the hard part here is that we do them because it's a necessity. It's a part of the approval process that you need a psychiatric evaluation for a spinal cord stimulator. But I mean, I always tell residents and fellows that I meet, and I don't have a program, but those who rotate through with me on any given time, is you have to be doing that yourself. So sometimes, and we joke around about it, interventional pain doctors are basically a psychiatrist with a needle. But it's true. And if you are having red flags in your head, I often will have. And sometimes it's like, OK, well, like Dr. Desai pointed out, that's not the patient to do a procedure on. Or if you're going to do a procedure on a patient because they're looking for some kind of answer, definitely don't do something that's going to have a permanent implant involved or something that is more surgically involved. Because there's going to be complications. Not physical, per se, but maybe mental, and cognitive, and psychological complications. So it's all about minimizing those things. So you have to make those calls. And even in the best interest of patients, you send to a psychiatrist, I still listen to my own thoughts and my own intuition when I'm making that decision. I know we're out of time. I just wanted to, not to disagree with you guys, but I feel very passionately about what you're talking about and that a lot of our treatments as interventional chronic pain practice and this Western approach in all of this is very much overlooking the psychiatric component, the mental health component, the lifestyle component. And instead of thinking of it as an either or, or screening for a patient, and then when they get high enough on your depression screen, then that flips a referral. I've instead changed my practice to where, I'm seeing new patients, if they've had chronic pain over six months, I'm using an opt-out strategy. I'm referring everybody to a pain psychology telehealth program that I'm working with, and having them work simultaneously while I'm also offering them other options. And what I've seen is so much more buy-in, so much improved outcomes, and specifically with our implantable devices, instead of just having that one touch point of a psychological clearance or evaluation, but instead looking at that as a long-term strategy. I really think that a lot of our spinal cord stimulation long-term failures are related to behavioral aspects of the patients abandoning the device or giving up or having missed the mark on what their expectations were, that I think that's something that has been horribly overlooked, and I'm so glad you brought that up. Yeah, I totally agree with you, and by the way, I don't do any of these procedures. I just do the basic bread and butter, but I also am a certified yoga teacher, so I offer yoga for a lot of these patients, and so I have this hybrid practice that I'm trying to be able to balance both of those things. And I totally agree with you, it's not an either-or, and a lot of these patients have a lot of fear aversion, they're afraid to move, and so whatever it is that's gonna break that cycle, whether it's interventional or behavioral or psychological, I don't care, just throw whatever you can at them with the least harmful consequences. I mean, a lot of these people need pain education because they're catastrophized, and there's a lot of fear avoidance, right? So we work with a physical therapist really closely that oftentimes will work as a team, even though we're not really, it's like a virtual team, but we'll refer a lot of patients to behavioral health services, because it can be overwhelming, right? So I think that we forget sometimes that that person, I'll use the hypermobility patient as an example, often these patients are like 30, and they were like, fine, and suddenly some illness came along, and now they're catastrophically no longer fine, right? Like their lives have completely changed, often high-achieving people with good jobs, can't really work, can't focus, can't concentrate. I agree wholeheartedly we need more comprehensive strategies for everybody, but especially those people. One of the challenges, I think the virtual environment, that helps a lot, but 50% of counties in this country don't have a psychologist or a licensed social worker, right? So, and it's the counties of greatest needs that don't have that. It's not people who live in D.C., right? Everyone, I live in D.C., it's every election, there's like sobbing on all the trains and all the buses, and then people get their Xanax refills, right? But if you live in like Mississippi or Louisiana, and you can't get to someone, and you have, not that anxiety's not a real problem, I don't wanna diminish that, but if you have family, job, you know, children, all that stuff weighing on you, can't find a psychologist, it's, you can't get out of that hamster wheel, so. Any other questions? I wanna thank everybody. We do have a neuromodulation talk with some of the panelists who are here today, tomorrow, so please check your schedules, and we look forward to seeing you guys again. Thank you.

chronic low back pain

therapies

peripheral nerve stimulation

basal vertebral nerve ablation

percutaneous sacroiliac joint fusion

radiofrequency ablation

long-term relief

discogenic back pain

SI joint dysfunction

facet joint pain

interlaminar fusions

spinal cord stimulation