Hey everyone, thanks for joining us here for a combined community session again appreciate all of you who have registered and, you know, we would have been much happier to meet in person in Nashville, but again appreciate you guys taking the time to join us. So I'm going to advance here. So my name is Aaron Yang and I'm located in Nashville. I'm currently here at Vanderbilt University Medical Center, and we have some great speakers who are going to be speaking tonight. And again, just to mention, we have three community sessions that we're combining, which is the neuromodulation community pain medicine community in the spine community. I have no financial disclosures I'll be monitoring moderating some of these sessions throughout tonight. And so, we will be starting first with the pain community sessions, followed by the spine medicine community sessions, and then the neuromodulation community session. So I'm going to hand it off to Dr. Sarno, and she is at Brigham and Women's, and she's going to be speaking and also moderating the pain community session so let me stop sharing here and I'll let her take over. Thank you, Dr. Yang. Good evening, everyone. I'm Danielle Sarno. I'm the Director of Interventional Pain for the Department of Neurosurgery at Brigham and Women's and faculty at Spaulding. We're excited to be here today to talk about integration of mindfulness and pain psychology into chronic pain management. Our first speaker, Dr. Zach Isaac, is the Division Chief for Spine Care and Pain Management for the Department of PM&R at Spaulding, and an assistant professor at Harvard Medical School. He performs interventional spine care at Spaulding, Rehabilitation, and Brigham and Women's hospitals, and he also happens to be the pain consultant for the New England Patriots. He's published over 35 peer-reviewed articles, numerous book chapters, and has lectured at the national and international level. Dr. Isaac will be discussing chronic pain and rationale for cognitive therapies. Then you'll hear from Dr. Jennifer Kurz, who is an assistant professor at Harvard Medical School and Spaulding. For the past 12 years, Dr. Kurz has been dedicated to comprehensive clinical care with a focus on interventional spine and chronic pain management at MGH Neurosurgery and Mass General Brigham at Foxborough. She delivers integrative pain care within a very busy clinical practice, and spearheaded a new virtual program called FINER, which you'll hear about this evening. Dr. Kurz practices medical acupuncture, yoga, and meditation, and will be discussing how to incorporate pain psychology and integrative care into current pain practice. Then I'll be discussing implementation of the virtual FINER program. And to conclude our session, Dr. Kurz will return for a guided meditation. If you have any questions, feel free to add them to the chat, and we'll make sure to answer them after our talks. Now, I'd like to welcome Dr. Isaac. Thank you, Danielle, for that warm introduction. I appreciate it. Been looking forward to speaking to all of you today about chronic pain and rationale for cognitive therapies. Let me try to share this screen and get my talk up. All right. Well, I'm going to talk to you about chronic pain and rationale for cognitive therapies. And I'm trained as an interventionalist. I believe in trying to find that peripheral nociceptor and trying to find that biomechanical diagnosis or inflammatory diagnosis that's yielding the nidus for the chronic pain. But I want to flip it upside and talk about that cognitive rationale that we really need to emphasize as well. Because as you all have experienced, diagnosis can be nebulous at times. I have nothing specific to disclose in relation to conflicts of interest. So just to start off, I'd like to do an audience poll question. And just a quick survey of the audience. The most cost-effective treatment for chronic back pain is A, integrative medicine, chiropractic, acupuncture, massage. B, cognitive behavioral therapy, mindfulness-based stress reduction. C, nutrition and weight loss. D, physical therapy and exercise-oriented therapies. E, medications, or F, injections. And I don't know the answer to this. I'm just trying to get a sense of what our audience's belief systems are. Is there a, how long does a survey usually take? Here we go. So of these cognitive behavioral therapy, nutrition and weight loss, physical therapy came out the most common responses. And that's really interesting. No one responded injections or medications, which is really interesting because those tend to be the forefront things that patients are looking for. That's really fascinating. Thank you all for sharing. All right. Not knowing the answer to this is one of the reasons that chronic pain winds up being one of the most expensive chronic conditions in the United States with more than $640 billion a year that we expend either with diagnostic imaging or medications or procedures or surgeries, or even just cost of lost wage hours. Eclipsing a lot of other very expensive conditions like diabetes, Alzheimer's and heart disease. So part of this is the nebulousness of diagnosis. We will see very commonly that patients bat back and forth from provider to provider getting a lot of different questions. So just to get another sense of this common scenario that I see, here's another audience poll question that I want to get a sense of. A, piriformis syndrome is something I see in my practice hardly ever, not sure it's a thing. B, less than 5% of the time. C, five to 10% of my patients. Or D, more than 10% of my patients. I'll give everybody a little chance to respond and I'm just curious to see what people think about this. 25% of us said, I'm hardly even sure it's a thing. 63% of us said less than 5% of the time. Five to 10% said 13% of the time. I mean, 13% of people said five to 10% of the time and 0% said more than 10% of my patients. So, I mean, I'm sure that I've been told by patients that they have piriformis syndrome way more than 10% of the time, which is always an interesting phenomenon. So this ambiguity of diagnosis is part of the challenge in trying to treat patients. And very often I feel like we're blind men encountering aspects of the elephant. And depending on our aspect of our understanding, we're either thinking the elephant's a wall or a trunk or a snake. And similarly, depending on whether we believe in myofascial pain as a primary generator or a secondary phenomenon related to other deeper nociceptive structures or some providers that don't have an anatomical basis for their rationale and how they construct pain and approach it in a more syndromic way. But this simultaneous divide between thinking about it as a problem of a peripheral nociceptor that then generates pain and then you're descending inhibition from above and the cognitive and the mood from above is this back and forth debate, right? Is it the pain driving the depression and the cognitive dysfunction or is the cognitive dysfunction driving the pain? You would think if there was a predominance to one variable then you would just focus on that one variable. But our reality unfortunately is far more complex. But it's clear that pain and depression have a bidirectionality. Some of the most common conditions associated with depression are back pain and migraine headaches. And if you have more than two different pain complaints you're six times more likely to be depressed. So these patients who come in saying, I can't decide whether it's my neck or my back that I want you to focus on, you need to ring some bells that there's more than just our musculoskeletal system talking. And some of the somatic complaints very associated with depression are abdominal pain, headaches, back pain, chest pain, and facial pain. And when patients have more difficulty with their ADLs, more chronicity to their pain and more pain sites, it predicts the severity of the depression associated with it. And, but over the long term, if there's improvement in pain, there's an associated improvement in depression symptoms almost back to normal. So depending on how you want to look at it, if the patient's coming in with a chief complaint of chronic pain to a chronic pain clinic of varying sorts, whether it's a pain clinic or inpatient program or a psych clinic or an orthopedic clinic or a dental facial pain clinic or a gynecological clinic or a primary clinic with a chief complaint of pain, if you then pose the question, how often are these patients depressed? Well, it depends on the venue. If it's a pain clinic, it's typically about 50% plus. If it's in an orthopedic or rheumatology clinic, similarly about 50%. If it's a facial pain clinic, the mean is about 85%. If it's in a gynecologic clinic, it's about 20%. And in primary clinics, primary care clinics, it's about 30%. And if we flip the question the other way, patients presenting with depression, if you then study them and ask them how often are they in chronic pain when they come in with a primary complaint of depression into various psychiatric clinics, about 65% of them have chronic pain. So this relationship is quite profound. And there's this concept of this diathesis model that this propensity towards developing one creates a propensity towards creating the other. Very often depression is a sequela of chronic pain. And so people with a predisposition or a diathesis towards one can, the superimposed stress of chronic pain are more likely to go on to develop clinical depression. And so we wanna understand some of the psychological factors that go on when patients have chronic pain. So there's this concept of yellow flags or psychological risk factors. And a lot of this stem from attitudes and beliefs about back pain. So, and we feed into this when we see a patient and very often they'll start telling us everything they've been told by providers before them. I only had two bulging discs before, now I have three. And I'm just worried next 10 years, am I gonna have four? And we all know that the degree of disc degeneration doesn't seem to predict clearly who's gonna have pain. But this is the story that's been constructed and perpetuated by our anatomy focused perspectives. Very often we say, if it hurts, don't do it. So we sometimes prescribe a disproportionate rest and downtime. Compensation loss is a big psychological factor that drives pain, fear and instability financially will definitely stress a human. And then just emotional context and family context. Very often we'll see a couple come in and the guy's there and he's saying, I have pain but I'm kind of okay, it just doesn't bug me that much. But the spouse will be next to him saying, you better get this shot. I'm sick of hearing you complain. I don't wanna hear it anymore. So there is a dynamic with family interactions also that drive treatment sometimes and also the propagation of pain. A lot's been studied looking at the neuroscience of chronic pain. And we hear about how sensation, and we've read and studied extensively about how sensations arise from the nociceptor, ascend through the spinal cord and then relay through the thalamus to the sensory motor cortices. And there it's mapped in that wonderful homunculus that we learn in medical school with disproportionate representation of the sensitive body regions and less representation of the not so sensitive. But then it becomes so much more complex because of the emotional valence associated with the amygdala and the threat detection and the fear and catastrophization with the overall threat and stress level in humans. And then the role of the prefrontal cortex in modulating it as well by assigning it a unpleasant valence or a pleasant valence when we have these sensations or stomping down pain by saying, you're gonna be fine. It's just the tack. It's gonna hurt for a little while, but you're gonna heal or perpetually catastrophizing and adding additional fear-related worries and perseverations as we deal with the pain. And how pain ultimately is constructed in our brain is ever so complex. And I see this every day when I see my patients. And just recently, I had this patient in her 70s that I've treated in the past with back pain. And as I go to image her lumbar spine with her worsening refractory back pain, I see very recent thoracic fractures. And this is surprising. And this is probably her newest structure because nothing is really wrong in her low back. And yet when I look at studies, it looks like a solid 43% of patients with lower thoracic new vertebral fractures present with lumbar pain, this type C pain pattern with lumbosacral pain with hip girdle radiation. So how pain is ultimately constructed and all the biomechanical forces related to the relationship with pain and the high incidence of asymptomatic findings creates such a muddy water as we try so laboriously to define peripheral nociceptors. So if we flipped it upside down and say, what can we do to try to deal with the cognitive factors, the catastrophizations, we do see a lot of results. And when we look at treatments like mindfulness-based stress reductions for pain, even just four weeks of a abbreviated MBSR program when compared to a stress reduction reading show improvements in pain, improvements in functional MRI in terms of frontal lobe hemodynamic activity. When we look at perioperative patients undergoing spine surgery, getting preoperative mindfulness-based stress reduction, even at 30 days right after their spine surgery, they had better back pain scores than the non-MBSR group. When we look at patients with chronic low back pain of seven years duration and compare CBT versus MBSR and standard care, the patients who underwent eight sessions of CBT or MBSR had, when we look at 30% reduction in pain bothersomeness as success, 60% of patients that get MBSR or CBT feel successfully reduced by 30% as opposed to standard care where it's a little less than half. So as we commonly treat patients with their nociceptors, we talk of inflammation and we're trying to stamp down inflammation, whether it's around a disc herniation or an inflamed facet joint capsule or an inflamed facet joint, or think of hemotic end plate changes and this concept of vertebrogenic pain, these kind of bony edema can happen. But edema can be generalized throughout the whole, I mean, inflammation can be generally present throughout the whole body as elevated CRP as is associated with autoimmune conditions and obesity. And then of course, in the central nervous system, interleukins and cytokines are very involved and in the nervous system, glial cell activation and neurotransmitters are robustly involved in the construction of pain. So when we talk about inflammation, we need to really broaden our concept of what really falls into this bucket. And this distinction between mind and body is very blurred, because in this interesting study, looking at the cytokines in our nasal passages after we have a rhinovirus infection, people who practice cognitive reappraisal, and that could be just experiencing the cold symptoms and having a positive relationship with it, saying, it's just a cold, I'm gonna feel better eventually, it's a temporary thing. Or you just say, I'm gonna power through it, suck it up, buttercup kind of attitude. These patients actually had changes in their interleukins and cytokines in their nasal passages compared to patients who did not practice cognitive reappraisal strategies. So this distinction between mind and body becomes ever so blurry as we understand the mechanisms of our body more and more. So I think there is a strong rationale that we need to work on an overall approach to treating the whole human. And as we focus on these structures that can drive pain, we want to be working on cognition, we want to work on movement, we wanna work on nutrition, and also the whole human sense of connection and purpose, because we've certainly seen patients with a lot of all of these parameters when they're done right, they can present with a significant arthritic burden with very little complaints. So optimizing patients towards whole body wellness I think should be part of our goal as physiatrists. And thank you for your time and attention. And I'm gonna hand it over to Dr. Kurz to take over. Thank you. Thank you so much, Dr. Isaac. Thank you all for having me today. And I especially wanna thank my colleagues, Dr. Sarno and Dr. Isaac, for working tirelessly with me on a mission to try to bring integrative care and pain psychology directly into current pain care practice. And just to comment on the term integrative, it does not mean doing away with interventions and conventional care, which we all need and really help our patients. I love doing injections just like everyone. But there is a more powerful way to combine the alternative complementary psychology and lifestyle approaches with current treatment to make not only our patients happy, but ourselves as well. I have no disclosures. And I'll begin my talk by briefly outlining the cost and impact of chronic pain, which Dr. Isaac has done lovely as well, the demand for integrative care, and then touch on some of the basics of what this actually entails. And these are from the most evidence-based integrative care strategies, CBT, ACT, yoga, mindfulness, MBSR, and meditation. And finally, I wanna call everyone here to action that even if you take one or two thoughts, one or two psychology approaches into your current practice, you can make a world of difference for your patients and try to help transform this culture of chronic pain that we have to work in. As we know, America is in a pain crisis. This is now a decade old statistics from the IOM showing one out of three Americans suffer from chronic pain. 10.6 million adults have high-impact chronic pain. And those are the patients that keep going from doctor to doctor to doctor. They have worse health, muse more health care, and have more disability. How many patients do you have lined up for months on end trying to see you, demanding care, sending you the epic messages, waiting for pills, procedures, surgeries? There's no one on the right side for lifestyle change, the basic root of medicine. And this is from a PCORI, Patient-Centered Outcome Research Institute meeting showing fewer than a third of patients showing fusions skyrocketing up 660%, lumbar MRI imaging up 300 plus percent, epidural steroid injections, facet injections up 250%. But what's going down? It's the self-reported functioning or self-management. And sadly, 72% is the multidisciplinary pain treatment centers are on the decline. And we know as providers that chronic pain is best managed with these types of programs. And if all of these procedures and surgeries and the industry was really improving our culture here, why are we still in the opioid epidemic, which is still on the rise and worse than ever with COVID? 88,000 deaths in the past year, which is 26.8% increase since the prior year. And understandably so with COVID and all of the isolation. Work disability attributed to musculoskeletal pain and back pain. Of course, the number one cause of disability, back pain, increased in the past decade and I'm sure is on the rise as well. And healthcare costs are really at an unsustainable rate with 4 trillion estimated of our US GDP spent on healthcare and 560 to 635 billion, this is again an old decade old statistic, cost in pain care, which exceeds the cost of heart disease, cancer and diabetes combined. I asked a CARF specialist because I was so curious, how many truly CARF accredited interdisciplinary pain rehab programs exist? And she came back with this answer, only four inpatient interdisciplinary programs and only 52 outpatient programs. As Dr. Shatman, a well-known pain psychologist stated, there is only one interdisciplinary pain program per 670,000 chronic pain patients. So clearly there's a problem here with supply. And then we ask ourselves, are procedures really the best way to treat certain chronic pain patients? From this pain medicine systemic review published in 2019, looking at 25 trials, 2000 patients, there was little evidence for specific efficacy beyond sham, 87% was sham results for invasive procedures and chronic pain. A moderate amount of evidence did not support the use of invasive procedures compared to sham for chronic back or chronic knee pain. And then we will ask ourselves, well, how do we diagnose the chronic pain patient who's not gonna do well with our procedures, pills or surgery? How do we predict who develops chronic disabling low back pain? And this was a great study published in JAMA of 20 studies, 10,842 participants showing it's not what you think. It's actually not work environment, it's not pain intensity, prior pain or even radiculopathy that determines this. The most helpful predictors for chronic disabling low back pain include those yellow flags, maladaptive pain coping, non-organic signs, those Waddell signs, functional impairment, general health status and psychiatric comorbidities. So let's take our MRIs. I know we love looking at MRIs and it's almost a necessity to have the MRI. But what would you say on this picture on the left? Oh, this patient's probably okay. He just has a few annular tears, a little disc degeneration. But clearly the one on the right is not doing well with advanced multi-level degenerative disc disease and stenosis. But what if I told you the young man on the left can't even bend down to tie his shoes and he feels like he absolutely can't work ever again. He's age 30. And the guy on the right, well into his 70s, has just finished and won the age group for his marathon. And he's doing pretty well. So we can't determine who is going to do well, what the functional status is and what the overall outcome will be just from pictures. And we probably know the study by now, it's from 2015, looking at a review of all of the imaging findings for 3,110 asymptomatic individuals. And just look at the numbers. By age 30, more than half of us have disc degeneration, disc height loss, disc bulges, protrusions. Clearly this is a factor of age and does not predict who develops chronic back pain. We really need to ask ourselves, does the healthcare system contribute to the chronic pain epidemic? We order redundant testing, excessive MRIs after we've already ruled out the red flags. And then that leads to specialty care, more referrals, patients seeing numerous physicians for the same pain complaint. And of course that doesn't help pain, it just causes confusion, different opinions, conflicting care, and a tremendous amount of stress, anxiety, and more pain. And then we repeat failed therapies and the underlying unsustainable health care costs keep rising. There is a demand for something new, some integrative or alternative options here. And this comes from patients as well as guidelines. Yoga, meditation, acupuncture, CBT, MBSR, and mindfulness are all recommended in guidelines by CDC, NIH, the American College of Physicians, and the VA. In fact, in 2016, CARA mandated the VA to include complementary and integrative health approaches for the management of pain, as well as substance use and mental illness. This was under the Obama administration. Another probably lesser known fact, because it was overshadowed by the beginning of the pandemic, but in January 2020, Medicare began to cover acupuncture for chronic low back pain. And this was as a response to the opioid epidemic and all the mass evidence for acupuncture. So what do we do when we have our patient in the clinic, and we know as good physicians, of course, chronic pain involves the brain. It's actually in the very definition of pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in such terms. So we know it's about the altered circuitry between the deep primitive brain, that stress brain, amygdala, stress response part, and the higher brain, the prefrontal cortex, the anterior cingulate cortex, all those higher parts of our brain that allow us to process pain and put it in its proper context. And now there's a tremendous amount of research from all the fMRI studies, which reveal that the afferent pain pathway is clearly altered and directly influenced by these five concepts. Emotion, memory of pain, think about all the trauma, all the PTSD, attention to pain, and attention is what meditation tries to target. Can we cultivate a focus of attention on something positive? Empathy, as human beings, we always need to connect, and placebo effect, which is hugely inherent in everything we do in healthcare, particularly pain management. So how do we target the brain? We actually have good evidence-based strategies already, and I would like to touch upon the two most common, CBT and ACT therapy. I believe we can all incorporate this directly into clinical care. We don't have to be pain psychologists, because honestly, there aren't enough pain psychologists, and it's hard to find them. At least for me, it has been. CBT is basically, in a nutshell, this idea that feelings, behavior, and thoughts are deeply intertwined, and we can't dissociate them. They all influence and interrelate to each other, and it's connected to core beliefs, which can be really hard to change, but they're tied to culture and conditioned environmental responses. The goal for pain management in CBT is to change maladaptive beliefs. It starts with identifying those thoughts, those automatic negative thoughts, and the behaviors that result from this, that cause chronic pain and further that vicious cycle. It also works on problem-solving in these complex psychosocial conditions that affect patients, to set behavioral goals, to monitor and challenge those maladaptive thoughts and beliefs that keep coming back, and in the end, to self-manage. With CBT, control is given back to the patient. They are no longer passive victims of our treatment. That patient who tells you, you tell me, doc, you fix me. No, we actually tell patients they are in charge of their own pain, and they need to be active players, too. This is taken from the Benson-Henry, which is the MindBody Institute at Harvard and MGH, from the SMART program manual, which I attended that program, and it's actually interesting that you can label the distortions, the thoughts that are constantly coming into our every human mind all the time, but they're just distortions. For instance, all or nothing, fortune-telling, how much do we do this? Always planning and thinking, mind-reading. The mental filter is when we just remember the bad and forget the good, labeling, we're always labeling, we always do this in medicine, and sometimes it's our labels that give patients this identification with their pain that never helps them. Approval-seeking, comparing, shooting and canting, the fallacy of fairness, and of course that term we all love, catastrophizing, which is a combination of fortune-telling and all or nothing, thinking the worst. It involves rumination, loops over and over again, the same negative thought loops, magnification and helplessness, and we know catastrophizing, which comes with its own scale, is associated with poor outcome. On the right-hand column, on a good note, we can actually cultivate the adaptive, better perspectives, and those include acceptance, compassion for self and others, and compassion inherently means suffering with and trying to alleviate suffering in others. Knowledge and discipline are always important, it takes practice, just like practicing the muscle exercises, we need to practice the brain exercises. Forgiveness, focusing on healing rather than blame, and I think of the post-trauma, some of the workers' comp situations, maybe if we, instead of trying to blame, we just focus on getting better. Power, positive influence, we actually have more power than we think. Patience, this too will pass, which is related to mindfulness, and on and on. Let's take an example, let's say a patient comes to your practice saying, ugh, I have degenerative disc disease, at L3 to 5, I can't get better, I'm only going to get worse with age. Well, what if we tell patients, remember that study I showed you, or I can talk about, that showed, no, it doesn't mean you're going to have chronic pain. These are just imaging findings, and there are many people with the same findings without pain. And I've thought of these kind of maladaptive to adaptive CBT approach thoughts throughout my practice, for example, all treatments have failed, doc, you're missing something, order me another MRI, what is wrong, I've seen everyone, what, you're missing the diagnosis, we can change it to, I'm glad more serious conditions have been ruled out, you don't need surgery, that's wonderful. Alright, injured myself doing this exercise, I can never lift again, I can't do physical therapy, it hurts, and I have a patient calling PT physical torture. No, balanced exercise rarely is physically harmful, and movement and activity can make you stronger. You might start to feel good from exercise if you just stick with it. Ugh, this is just going to mask the pain, like what are you giving me, steroids, that's just going to mask the pain. Actually, recommended treatments can help you cope with pain, so maybe you can function better. And finally, I can't do anything in pain. I can only be in bed, I can't get out of bed. Actually, I'm capable of doing more than I think, I can still function with pain. So you see how we start to try to turn around those maladaptive ideas from the get-go. But it's not easy. We often fail, and again and again, it's really hard to change maladaptive thoughts. So this is a third wave psychological approach that I think answers that major problem, how do we actually change negative thoughts? Well, this was founded in 1982 by Stephen Hayes and others, and it actually works with thoughts in a different way. It does not try to change thoughts. It helps people be with pain and just be aware of their thoughts, with two goals, to allow unwanted, uncomfortable experiences, which are often out of personal control, and facilitate commitment and action towards living a valued life, which means a life worth meaning, you know, whatever matters most to you. And sometimes you can start your counseling with that very question, what matters most to you? There are actually six tools within ACT, and it can take many weeks to go through all of these tools, but I find that even if you capture one of these concepts and just start to plant those seeds early, you can really change the trajectory of your patient's outcome. The six tools in general are diffusion, which I will get into a little more, present moment awareness, the mindfulness, just staying present in the moment, values, which is, again, what is most meaningful to you? Can we live towards our values? And using committed actions, such as SMART goals. The self as context. This is sort of more into transcendental mindfulness meditation, where you can actually dissociate from the thinking mind and understand that you're bigger than that. You're actually the observer mind, is what we try to get in touch with. And finally, the concept acceptance itself. And I know what you're going to say. Patients resist this term. They don't want to accept pain. They're like, are you telling me to give up, just surrender, give in? No. Acceptance is the opposite. It's actually, it takes tremendous effort and courage, and it's about psychological flexibility. So I want to get into diffusion, which is a good early little tool you can all use. But in order to understand diffusion, we need to understand fusion. According to ACT, there are five categories of fusion in pain, including number one, future fear. This is probably the number one, that anxiety, the worrying, the fear, it's something worse. It's not going to get better. Past trauma. This is associated deeply with depression, PTSD, and addiction. The rigid rules, the giving reasons. This might be the category of the kind of OCD patient who has the long list of failed treatments in every single response. You know, why they can't do something, why they can't participate. And then finally, the sense of self. Unfortunately, our chronic pain patients are often fused with terribly negative, defacing ideas of themselves. I am a chronic pain patient. I am weak. So we want to diffuse from those thoughts with this concept of deliteralizing, defusing from the internal language, the constant talking mind that doesn't help us. Deliteralizing undermines the negative effect of your own internal language. For instance, you can simply put in front of a negative thought, I'm having the thought that, or I'm noticing I'm having the thought that. And we'll practice this in the meditation. You can kick the butts. For instance, if you have a patient who says, I'd really love to go on that trip, but I'm in pain. I had to cancel it. Instead you change it to, I really wanted to go on that lifelong trip I've planned, and I'm in pain. See what that one word switch can do. You can also label thoughts, name it to tame it. Am I really doing a mental filter? Am I predicting? Am I catastrophizing, judging, criticizing? You just put a label on what you're doing to yourself to make you suffer needlessly. And another way to deliteralize is to just sing the phrase. I know we loop all the time. We all do this, the same thought over and over. What if you sing it in different voices? Or write it down in big bubble letters and kind of just repeat it over and over until it loses its meaning, its significance for you. And we can do this in physical therapy. And I hope all of you have good therapists who have some kind of background training or interest in psychology, because just one or two sentences, one or two phrases within the PT session, they're all part of the same team, consistent messaging can really help the outcome. For instance, when the patient resists the exercise, you can say, well, before we do this exercise, what is your mind telling you? What is that protector telling you right now? And then just keep with it and notice what your mind is doing as you do the exercise. Well maybe thoughts are changing now. Maybe different sensations come up, different worries, different random thoughts come up. And notice how you're doing it. You can do it anyway. What are thoughts? And this is the idea of metaphors. There are many metaphors in ACT. We'll think of them as just leaves on a stream. Let them float down that stream or clouds floating by. And finally, I love this one, spam messages. We all get inundated with the spam. You don't have to click. You don't need every thought. You don't have to get attached to every thought. So instead of focusing only on the pain itself, the pain intensity, the VAS score, the disability scores, what if we actually just turn up the willingness dial? We turn down the pain dial and turn up the willingness dial. This brings us to mindfulness, which is a really important inherent concept. And as Jon Kabat-Zinn defined it, it's the awareness that emerges through paying attention on purpose in the present moment and non-judgmentally. It's just living right now, right here, the only time we actually do live. And the evidence for mindfulness has skyrocketed over the years. The MBSR, Mindfulness-Based Stress Reduction Clinic, was actually founded by Jon Kabat-Zinn in 1979 as a training vehicle for the relief of suffering. He was treating chronic pain. And it's still widely used today, very well-studied, can really help patients. Moving on, I mean, this is another way we can actually implement and practice these concepts. Yoga is meditation in action. Yoga actually is defined as a union or to yoke the mind with the body. I know we have thoughts about it, expectations about yoga, but it actually has deep ancient roots in the wisdom cultures of India, the Buddhism, Hinduism cultures. We know it today in the westernized form of asanas or postures, and it's widely used and available in a multitude of styles with positive effects on stress, pain, mood, physical fitness, and quality of life. Yoga increases awareness of the physical body, negative thoughts, emotions, and behaviors. And this came from the NIH Center for Complementary and Integrative Health. Yoga is actually the most commonly used complementary health approach in our country. And according to this study, 14.3% of US adults practice yoga in 2017. The most common conditions we use it for are back pain, stress, arthritis, all the conditions we treat. And meditation itself surpassed chiropractic care to become the second most commonly used approach. So patients know about these things. We know that there's extensive evidence for it. And there's even an entire textbook, the principles and practices of yoga and health care that go over all of the conditions for which there are yoga trials and positive outcomes. According to the AHRQ, for chronical back pain, they recommend mindfulness-based stress reduction, yoga, acupuncture, and MDR. And for fibromyalgia, CBT, tai chi, qigong, acupuncture, MDR. And this is all from all of the Cochrane reviews and databases. We also know, as Dr. Isaac mentioned, mind-body interventions are cost-effective. In fact, MBSR and yoga were high value, with yoga having the least cost per quality-adjusted life year. And this interesting cost-effectiveness ratio estimated that the additional cost of covering MBSR, yoga, and tai chi to be only $0.23 per member per month, 5% of the cost of NSAIDs and pain meds. And this is just showing my friend and colleague, Rick Frank, who's an adaptive yoga PT instructor at Spalding. He gives a class to really impaired patients who are in wheelchairs, amputees, neurodegenerative, paralysis, stroke. They love yoga. They really connect with their bodies again with yoga. And for those who insist they can't do yoga, what are you talking about? You're crazy. Yes, even if you're mobility impaired, there's chair yoga, there's adaptive yoga, there's gentle yoga, restorative yoga. And age is not a factor. This is Jean, age 100. And she started yoga at age 67 and states, it really changed my life, it helped me cure aches and pains. I used to have trouble from a slipped disc, but doing yoga really helped me cope with it. And finally, this leads to the concept of meditation, which is underlying all of the wellness and health programs we see today and is actually the purpose, the original purpose of yoga. The postures are to prepare the mind and body for stillness, for connecting with the mind. And in this definition, it's just simply focusing one's awareness on one thing. It could be the breath, it could be a word or phrase, a mantra, sensations. And with a conscious surrender of the everyday wandering monkey mind thoughts that keep coming back and causing stress. It's based on the practice of intentional self-regulation and it separates the sensation of pain from thoughts about pain. We know from this is evidence-based that it helps redirect attention, it helps decrease reactivity to negative stimuli, enhance body awareness, and it activates the relaxation response. This is a visual of how meditation affects the brain. You can see the activity increased in the prefrontal cortex, the anterior cingulate cortex, which processes pain rationally. And then what's decreased is activity in the thalamus, the hippocampus, and of course that amygdala. This is a landmark study from Sarah Lazar, which showed actual structural changes in the brain after only eight weeks of meditation, and this was in novice participants who had never meditated, but they meditated for 20 minutes a day for eight weeks, and there were physical changes in the brain. And I don't have time, of course, to go over all the reviews and meta-analyses, but this is one I want to mention. Meditation and mindfulness had moderate evidence for improved anxiety, depression, and pain at eight weeks, with of course less of the toxicity of medication. Just a mention on the relaxation response coined. The term was coined in 1975 by Herb Benson, who is the founder of the current MGH Harvard MindBody program. This is our body's own ability to affect our physiology. We can affect our heart rate, our blood pressure, our respiratory rate, our muscle contractions, and even cerebral blood flow by eliciting the relaxation response. And the two steps necessary, according to Herb Benson, was the repetition of a word, sound, prayer, thought, phrase, or muscular activity, and the passive return to repetition when other thoughts inevitably intrude. I bring this up because it was well studied in this really great study by Stahl, published in PLOS One 2015, showing decreased healthcare utilization. Look at what happened over, and they looked at 4.2 years of studying the relaxation response, which is part of the SMART program, 4,452 patients versus the control group of 13,149 patients, and clinical encounters decreased almost 42%, imaging decreased 50%, labs decreased 43.5%, and procedures decreased by 21%. And there's further evidence, of course, for mind-body interventions in the world of chronic pain, and Dr. Isaac mentioned Churkin's study, which is a great one, showing functional improvement with MBSR or CBT. I won't go through all of this today, but I want to conclude by saying, yes, we as pain management providers, and especially in the realm of physiatry, I think have an integral role to play to help deliver this kind of care. But how can we do this? According to the Delphi study by Louise Sharp, who looked at what are the gold standard ways to deliver non-pharmacological, non-interventional pain management, where in the cases, which is often the case, we don't have access to interdisciplinary MDR programs. We really just need three things. This is from a consensus panel of 42 experts in chronic pain. Number one, pain education. How many of us actually spend the time to try to educate patients on, yes, the brain is involved, yes, your thoughts and beliefs matter. Number two, physical activity engagement. This is exactly what physiatrists and physical therapists and all of our team members try to do. Engage in movement, engage in activity, and we can use yoga, we can use tai chi, doesn't have to always be another PT prescription. And finally, cognitive approaches. And I tried to touch on a few of the basics today, so hopefully you get a little few nuts and bolts of CBT, ACT, and mindfulness. And yes, we can offer it all virtually. That's the one silver lining during the pandemic, is that we have Zoom, we have this ability to engage. This is from my live class with patients, and I've been doing this with the FINDR program over the past two years. Patients love it. So I want to conclude by saying there should be a call to action. I want to inspire all of you to help collaborate. And please reach out to me, I'll give you my email. We all have this capability to offer integrative pain care, which is hugely demanded, and there's strong evidence for it. We can implement directly into our clinical counseling, a little bit of CBT or some ACT ideas, mindfulness, yoga, promote healthy lifestyle, and virtual deliveries feasible and possible. My next colleague, Dr. Sarno, is kind enough to share with you our program. And we all can impact healthcare utilization and the culture of chronic pain to help our patients really overcome their disability, their terrible moods, and dysfunction. It will help not only patients, but ourselves as providers. So what will you do during your next chronic pain encounter? Are you going to just order another MRI or send them to a surgeon, or is there something else you can do? Thank you very much for your time and attention, and I'll leave it to Dr. Sarno to describe FINDR. Thank you so much, Dr. Kurz. So what is FINDR? Led by Dr. Kurz, FINDR has been this truly incredible collaboration between physiatrists, pain psychologists, physical therapists, and integrative therapy specialists who are dedicated to the mission of improving access to interdisciplinary care to help people better self-manage their chronic pain. And how does it work? So FINDR is an eight-week program with twice-weekly group Zoom sessions. One of the weekly sessions is a free, open-to-the-community event. We have usually it's one to two hours educational workshop related to either pain neuroscience, lifestyle medicine, pain psychological principles, and integrative therapy workshops. And then we have this second weekly session, which is specifically for the FINDR participants, the people who have actually registered for the program. And this is an opportunity for those participants to engage and practice those concepts that were learned in the larger community session. We really try to provide a supportive group environment. I wanted to share some examples of the free community sessions that we offer. We typically started out with Dr. Isaac's great talk of Explain My Pain, How Pain Works and What We Can Do About It. And we're currently in our third eight-week FINDR program. So we have a variety of lectures, but I'll just show some examples. We typically dive pretty deep into nutrition and mindful eating. We cover other lifestyle medicine topics, exercise, stress management, sleep hygiene. And we also include Empowered Relief, which is an evidence-based comprehensive pain workshop that is from Stanford University. And one of our senior physical therapists who's part of FINDR is certified. This has been very well received by patients. And it's actually been found in a recent study to be similar to an eight-session CBT with similar outcomes. You heard Dr. Kurz speak about ACT, and you could hear her passion. And so she discusses this and also empowers patients to do their own homework. And so we usually take some information from these larger community sessions. So for example, for ACT, we have a values exercise helping patients identify their personal values and asking the question, am I living fully by my values or acting inconsistently with my values, for example. And then we also have integrative medicine workshop samplers. So even this coming Friday, we have yoga and meditation for pain. So a live workshop that Dr. Kurz showed, having that live workshop on Zoom. And then a PhD pain psychologist will then discuss yoga and mindfulness for chronic pain. Another week, we'll have a workshop about tai chi and also hands-on acupressure. And then we get into our Tuesday smaller group sessions, as I was mentioning, that supportive small group session. And I wanted to show you how we break it down. This is a typical breakdown where we have the first 10 minutes. We're gathering. We're allowing people to engage and share. Some people want to share their thoughts regarding the topic of the week. We have some prompts and questions. Usually about 20 to 25 participants are in this smaller group. And then we break it into a smaller group breakout session. So four to six people per group. These are facilitated breakout sessions with the physiatrist, Dr. Kurz and myself, and Dr. Isaac at times, and physical therapist, as well as a pain psychology intern or student. And then we come back together. And that's when a physical therapist, we have about five or six actually dedicated physical therapists who are committed to the Finer mission and join us. And they have a rotation. They have a whole schedule of PT topics and also exercise that we do as a group together. So we do some posture exercises. And that's really well-received. We have a link. They actually send out a link to the participants with home exercises, specifically from Finer as well. And they keep adding to it each week. And then for about five to 10 minutes, we have closing thoughts. And Dr. Kurz will typically end the session with a beautiful group meditation, which you'll get to experience tonight as well. And early in the program, we encourage participants to identify a SMART goal, something very personal to themselves. Most of you are familiar with this, but for those who are not, we want them to find something specific and measurable, achievable, realistic, anchored within a timeframe. So for example, one patient said that she would like to meditate for 10 minutes a day for five days a week by the end of our Finer eight-week program. And so we help each other stay accountable and encourage each other. But what are our main goals? Like, why are we even doing this? You know, like all of us here tonight, we're always looking for ways to improve our patient's physical function, reduce pain interference, reduce pain catastrophizing, help our patients improve lifestyle, and empower patients to self-manage their pain, ideally. And ultimately, we'd like to reduce health care utilization and reduce opioid use for chronic pain. And in our current stage, we're in this pilot observational trial period where we're assessing the feasibility of Finer. And at this point, we can say with the group facilitators and the participants that this truly is feasible. We've received multiple comments. I have pages of comments. But I just wanted to share and highlight a few that were particularly meaningful about the pain has become the background. I'm living my life, and the pain is present, but I'm not focusing on that anymore. I think it was my focus of attention, and now it's there, but now I have things I can do. Or another patient mentioning about having more tools in the toolbox or not feeling as alone, also feeling empowered. I went walking around my neighborhood. I felt OK. I was like, maybe I can do this every day. It was a little scary at first, but then I thought, yeah, I can do it. And this is something that a participant might share in a small group and get a lot of feedback and encouragement from the others as well, other participants. And then just this past week, a patient, a Finer participant, was very proud of the fact that actually during our PT exercises as a group, she said, for the first time, I could stand up with less pain. She noted that she was getting stronger from the PT exercises. But how do we also know if this is statistically significant difference? We really want to study this more formally and have optimal study design. So we would like to have a control group, make sure it's randomized. Currently, we do have REDCap survey with the outcome measures looking at physical function and pain interference. So we have our PROMIS-29 pain catastrophizing scale. We're also looking at fear avoidance and trying to minimize that as well. Ideally, we would give the survey not just pre and post, as we're currently doing, but three months and six months post-Finer looking for long-term effects. And then ideally, obtain funding. And right now, this mission is driven and sustained by volunteers. We have physical therapists, as I mentioned, pain psychologists, the speakers who just dedicate their time. And we really value time. So ideally, we would actually pay for their time and also offer compensation for survey completion. So we all understand survey burden, and we hope to minimize that. And then ideally, having a platform to host the videos. So we can actually, everyone wants the recording. So we did start recording the Friday community sessions, but have a place to host all the videos, all the handouts with resources, all the homework activities. That would be ideal. So some of our next steps. And prior to the program, Dr. Kurz or I meet with the participant and just assess if they meet inclusion criteria, such as having chronic spine pain greater than six months. They've had multiple physician evaluations, and we want to make sure there's also appropriate imaging and workup within the past three years, plain radiographs, MRIs, just making sure nothing's being missed. And also just persistent pain despite conventional care, medications, procedures that we typically offer for chronic pain. We also want to make sure that we're not including patients with red flags, anyone needing urgent workup, of course, and patients scheduled for surgery or severe mental health disorders. Also, patients who are not compliant with non-opioid options or don't seem to show readiness for change when it comes to opioid use. And then for now, our materials are in English. Ideally, one of our main goals is to improve access to interdisciplinary care, remove the financial barriers. So we don't know what that looks like yet, but ideally we would have possibly translation services, interpreter services, having materials in different languages. So more to come on that. In addition to assessing for inclusion criteria, we also just want to get a sense and give a heads up to the participant that these are group Zoom virtual meetings. So we assess comfort with that. And also we express how confidential this is and HIPAA compliant. We also want to make sure there are waivers for movement-based therapies and consent. And also just confirming if patients are committed. There are many patients who are very interested. And so in that small group, as I mentioned, 20 to 25 people, there's not, there's many more patients who are interested. So if people are not committed, we'd like to make sure we get to include the people who truly want to be there and get the most out of it. And I wanted to share how we can make this sustainable. And for you as well, if you have any interest in having small group sessions with your patients and discussing lifestyle medicine, or these pain psychological principles, or just an opportunity for community and support, after our first FINER eight-week program, we learned about being able to bill for an established code 99213 with our virtual GT modifier. And that's a way that you can incorporate that as well. Some final thoughts that I just wanted to share how FINER has been a journey for us as well as our patients. We're all learning together. And what we're learning is that we also need to keep striving towards our goals of helping patients understand their pain, provide resources, community, and support, so they feel empowered to succeed. And then I finally wanted to share that implementing a virtual chronic pain group program is feasible. We invite you to take these concepts and implement them into your own practice. Thank you so much for your time. This time we're happy to answer questions. And then Dr. Kurz will be here to guide us in a meditation if there are no questions. And I don't see any questions currently. We can give it a few moments. Okay. And feel free to stretch, take a break if you need. I know we're running close to the end, but I'm good. I can do this in less than 10 minutes. For those of you who are novice meditators, this can be a good new experience for you. So I encourage you to get into a comfortable posture. You could be sitting, you could be lying down, but you want to be awake. You don't want to just fall asleep. I'm going to use my good old chakra bowl, singing bowl, to help call us to attention. So for the next few minutes, I invite you all to feel comfortable, maybe close the eyes and make sure your feet are planted firmly on the floor, hands resting perhaps on the thighs. Hopefully you have an upright posture, but relaxed and not too tight. And begin to just tap into the breath. Just noticing how the breath moves through the body. Noticing the sound your breath makes. Perhaps the movements in the belly, the diaphragm. And I want you to imagine that you're wearing a special pair of hearing aids, but unlike most hearing aids that hear the outside world, these are special ones that allow you to tune in to your inner world, to hear your thoughts. And just notice what comes up. Notice the flow of thoughts, maybe the emotions that come up, maybe boredom, maybe planning, maybe listing, maybe worrying, maybe tired. And notice if suddenly your mind just switches topics randomly. And maybe you get caught on another line of thought or another random thought. Sometimes they stop altogether. But if you keep listening, there's a pretty good chance that thoughts are going to ramp right up again. And this is what our mind does. It thinks and thinks and thinks. So there's a part of you that does all the thinking, but then there's another part that has to listen to it all. And this is called the observer perspective. It allows you to gain some distance from your thoughts. And understand that they're just thoughts, they're not you. Sometimes thoughts become too close, too personal, as if you're observing life from your thoughts instead of at your thoughts. And I know some of you are suffering from pain, so I want you to just tune in to one thought about your pain. It doesn't have to be the most challenging one, it could just be a simple one like, Ugh, I have degenerative disc disease, I'm never getting better. Or maybe it's all my joints ache all the time, I'm falling apart. Just take the time, identify one thought, and now simply notice if any emotions come along with that thought. Maybe it's anger and frustration, depression, sadness, maybe it's fear. And notice if there's any physical sensations that are now occurring in your body right now as you think about this. Maybe your muscles are tensing, maybe there's some gripping or resisting. And just continue to allow these thoughts for the next few seconds. There's no need to judge them. Just become curious, like you're looking on it from the outside in. And now I'd like you to add a little phrase to that initial thought. So if it was, I have degenerative disc disease, I'm never getting better. Just add, I'm having the thought that I have degenerative disc disease, I'm never getting better. Or I'm noticing I'm having the thought that I have degenerative disc disease, I'm never getting better. Notice what that does. And notice if anything changes, any new emotions, new sensations. And you can repeat this any time. As you're noticing your thoughts, know that there's a part of your mind that does all the talking each and every moment, trying to decipher, trying to figure it out, trying to associate it. Like a manic person who never stops talking, or that annoying neighbor who just won't stop talking. And sometimes it's fast, sometimes it's slow. Mostly it's the same thoughts over and over again. If your mind is like my mind and every human on this planet, we have very little control over what our mind broadcasts. What we do have is an ability to simply notice thoughts. And as we become more attuned to this and noticing, aware of the thoughts, we have this amazing magic moment of freedom to respond differently, to not react. So you can notice thoughts for what they are and not what they say they are. They're just thoughts. And you can choose to act on these thoughts or not act on these thoughts, depending whether they're letting you live your best life, giving you what matters most. Thank you for your practice today. I'll just end with one more. Okay. Great, thank you, Jennifer, leading us through that. I think there's a question in the chat. If anyone wants to share free resources they use, or not a question, but more of a comment, I think we can maybe put it in the chat box. But he also suggested one of them on YouTube. Yeah, I think everyone knows about Adrienne on YouTube. I think all the patients know about her, too. It's a good one. And I'm hoping eventually we'll have the finer platform. We do have a general MGH Brigham finer website, but I still dream of a bigger platform where we can all share and all use the resources and the education and videos. That would be great. Well, thank you, guys, again, for leading that great community session. We're going to move on to the next planned session. Hopefully take a quick break afterwards. Again, we had a nice little good meditation that Jennifer led for us. So I'm going to go ahead and share my screen. So let me just go through this here. Sorry, started from the beginning. So this is the outline for our spine medicine community session. And we're going to go through three topics. The first one is going to be continuation versus continuation of anti-coagulation, anti-platelet agents prior to spine procedures. And we'll have two speakers for that. Dr. Eric Shaw is going to talk about the AZER guidelines and Dr. Zach McCormick is going to discuss the SIS guidelines. And we're going to follow that up by Dr. David Lee, who's going to talk about gadolinium-based contrast media and if it's safe and alternative for spine procedures. And then we're going to close our session with Dr. Desai, who's going to talk about safety of implantable therapies and radiofrequency ablation for patients with already implanted devices. And hopefully we'll have a little bit of time for Q&A. I encourage you guys, if you have any questions, feel free to put it in the chat box and I'll try to come back to it at the end of all these sessions instead of just answering as we go. So again, just use the chat box and I'll try to monitor that and try to circle back. Before we go on to have Dr. McCormick present the SIS guidelines, hopefully we can get this poll question up and we'd just like to hear a general idea of where our audience stands. So take a look at this and make your answer choice. I'll give you about 20 seconds for you guys to put in your response. Pretty good in terms of time. I'm sure everyone had enough time to click on that button. Can we see the results? So, okay. It looks like the ASRA guidelines are the most popular, followed by some combination and SIS. So what I'm going to do is stop my screen sharing and let Dr. Zach McCormick come and see if he can bring up those percentages of those who are following the SIS guidelines. Take it away, Zach. Thanks, Aaron. Definitely appreciate the invitation and let me pull my slides up really quick. All right. Well, first off, I do appreciate the invitation, the opportunity to join the community session and I have to apologize to everyone for the massive frame shift from that relaxing meditation to talking about hemorrhaging and infarction. So as Dr. Yang alluded to, I'll see if I can maybe change some minds or at least get you to think about, think carefully about how you're making decisions when it comes to discontinuing or continuing anticoagulation in the context of interventional pain procedures. So these are my disclosures. They're not relevant to what I'm going to speak about tonight. So, you know, you can see here, this is sort of a short list of risk mitigation strategies that there's really no debate, right? This is all standard stuff when it comes to interventional spine or pain procedures. We don't use particulate steroids in a cervical transforaminal. We don't use particulate steroids for a first lumbar transforaminal injection. You know, we always use fluoroscopic guidance. We use minimal sedation and, you know, only when necessary. These are things that, you know, sort of well accepted standard practice. The whole, the thought paradigm on what to do with anticoagulation and antiplatelet agents. This is why we're having this session, because it has changed. It's changed over the past 10 years, over the past five, and nuances of it continue to change and are still being written about. And when I talk about sort of the SIS clinical guidelines, what I'm really going to talk about is recommendations. And a lot of these are found in the fact finders that are available on the website. There isn't a true clinical practice guideline that SIS has put out specifically on what to do in these situations, making this decision with stopping versus continuing anticoagulants. But, you know, this is, this is the big, this is the big question is, you know, what's more dangerous? The epidural hematoma or a serious thrombotic event like a myocardial infarction, DBT with a PE or stroke? So these are, I'm sure Dr. Shaw is going to show these. This is, many of you are familiar with table one from the ASRA guidelines, and this is from the 2015 edition. And this effort was meant to stratify risk of bleeding with a given procedure and risk of possible serious hemorrhagic complications or complications related to bleeding. So over on one side, you know, nobody really debates spinal cord stimulation, anything, you know, high risk procedures that involve accessing the central canal, you know, clearly risk of epidural hematoma is high. There's really no debate. And, you know, ASRA made this point and published in 2015 that anticoagulants need to be discontinued. Then, you know, on this, on the opposite side, lower risk procedures, these are things where if someone were to have a bleed, it really shouldn't result in any kind of meaningful complication, anything that would, you know, cause significant long-term sequelae, neurologic damage, et cetera. And you can see what's listed here. To ASRA's credit, these guidelines were updated a couple of years later. The 2017 edition shows that sacroiliac joint injections, sacroilateral branch blocks, and then thoracic and lumbar medial branch blocks and RF were moved from that intermediate risk category to low risk. Essentially saying, you know, go ahead and continue anticoagulants, anticoagulant agents. It's better to do that than to stop them because risk of bleeding is low. And if one were to bleed, it's all going to be extra axial. Where there's still ongoing debate is some of these intermediate risk category procedures. So in particular, transplant injections and cervical medial branch blocks and RF. So I'll focus a bit on these. So to return to the anatomy just briefly, before we get into the literature, this is, you know, everyone here is, I'm sure, familiar with sort of cross-section of a lumbar segmental level. We're, you know, we've got the central canal here. We have neural foramen, facets, disc, et cetera. And just think about if you're accessing the central canal, whether it be an interlaminar epidural injection, maybe it's placement of spinal cord stimulation leads, and there were to be a bleed, that bleed is going to be contained in the bony confines of the canal. So, you know, if it grows and it does not tampon out itself or stop itself, it's going to compress the neural elements in the central canal. No, no question about it. You know, alternatively, what about a transforaminal injection or what about medial branch block? If a bleed were to happen out here or were to happen here at the medial, at the site of a medial branch block, theoretically, just thinking through the anatomy, a hematoma is going to form outside of the spinal canal. So maybe it compresses a nerve root. You know, maybe it's simply tamponades within the muscle tissue. Just logically, fairly unlikely, though, that that bleed would really spread in the epidural space within the spinal canal. So that's the theory. What does the data actually say? So this was a review that we did about four years ago, a group from the Spinal Injection Society, and looked at, you know, in the entirety of the literature, everything that was published, where authors reported on either continuing or discontinuing anticoagulation. And then, you know, what ended up happening? Did people have bleeds? Did they not have bleeds? What did we see? And we excluded studies that didn't really comment on technique where we couldn't tell if SIS technique was followed, if, you know, appropriate elements of injection technique were actually used. Obviously, if someone, you know, is way off and is way off the standard of care for a given injection, how they're guiding their needle, anything could happen. But if proper technique is followed, what does happen? So what we found were in 2017, at least, there were nine total cases of epidural hematomas that resulted in significant neurologic injury, either quadriparesis or paraplegia. And these all involved interlaminar access, some in which anticoagulation was continued, some in which it was actually stopped, and a bleeding event recurred regardless. So interlaminar access being the important factor here. We also found zero reported events with regard to these injection types. Transferral injections at any level and radiofrequency neurotomy. It doesn't mean that it's not possible. It's just never been reported, at least as of 2017. So if we move on now to thinking about thrombotic complications, it's important to talk about two distinct studies. One is from Steve Andres. And this was actually updated data. So they published initial cohort data, and they expanded it. And that's what I'm showing here. So this is a prospective cohort of over 12,000 patients. And this group either continued or discontinued anticoagulation for their patients. And you can see here, I've highlighted, it was for a number of injections, but this is for the transferraminal injections and then also for cervical medial branch RFA. Just because that's, again, going back to the slides I showed earlier, these are kind of areas of debate and, you know, what really should we be doing? What's the right call? So they continued anticoagulation for a lot of patients who underwent lumbar transferraminal injections, not so many for cervical medial branch RFA. So we're a little limited in the data as far as what we can extrapolate from this with regard to cervical RF. But certainly for lumbar transforaminals, large numbers of patients who had lumbar transforaminals in the presence of therapeutic anticoagulation. And nobody in this cohort of over 12,000 had a single bleeding application that was significant enough to create any kind of permanent sequelae. Alternatively, there were nine serious thromboembolic events and two of those were fatal. So one fatal MI and then one fatal stroke. And this is the second study that's good to know about. And this one's actually only published in abstract form, but it's soon, my understanding is that the authors, Bernstein, and this comes from Mike Furman's group, they're hopefully soon gonna be publishing the full article and we'll have access to all the nitty gritty details, but even larger cohort. So this is over 63,000 patients. And interestingly, in this very large cohort, they also reported not a single epidural hematoma or a substantial bleeding complication that led to neurologic compromise or long-term deficits. As far as clotting or thrombotic complications, there were six in the group of about 1,100 that were taking either warfarin alone or warfarin in combination with an antiplatelet agent. And then in the group that there were three thrombotic complications in patients who were only taking an antiplatelet agent and had those stopped. So if we put this, we start to put this data side-by-side from these two large cohorts, which is really kind of the best data that we have right now. You can see the prevalence of serious bleeding when anticoagulation is continued is zero. And you see, this is for lumbar transforaminal injections, very narrow confidence intervals, 95% confidence intervals because we have large numbers to work with. And alternatively, you see there's about a half percent chance that someone will have a serious thrombotic event if their anticoagulation is stopped for the window that's necessary for an interventional pain procedure. And those confidence intervals are also fairly narrow, again, because we have large numbers to work with. What about, hang on one second. What about cervical media branch RFA? So I alluded to the fact that numbers are small, it doesn't change that zero incidence rate of serious bleeding complications. It was zero, but you see very wide confidence intervals because the numbers are small. That said, it also doesn't change the rate of thrombotic complications. So, you know, again, about a half percent chance that somebody is gonna have a serious thrombotic event if you take them off during anticoagulation. So ultimately, I'm not sure we have a clear answer as far as cervical media branch neurotomy or branch blocks. The evidence seems to be pointing us towards the direction that it's safer to continue anticoagulation, but we're gonna ultimately need more data to make that statement with additional confidence. And then for lumbar transforaminal injections, I showed you the data. It seems pretty clear from what we have that it is safer to continue anticoagulants during a lumbar transforaminal injection as opposed to stopping them. We have enough data to really say that confidently, and that's an evidence-based decision that you're making. The one last point I'll make is that all of this does have to be put in the context of each individual patient. So for example, a patient with non-diabular AFib, you can calculate a CHA2DS2-VASc score. And if you input various factors into these calculators, which you can find them online for free, the annual stroke incidence for someone with very low risk profile is 0.3%, whereas the maximum score puts them at 17, over 17%. So you've got like a 50-fold difference in thrombotic risk from one patient to the next. Both of these patients might be taking Warfarin for stroke prophylaxis, but obviously discontinuing for one patient is gonna have a much different risk of potentially allowing for a stroke to happen as opposed to the next patient. So the other piece of what SIS puts forth is keeping in mind each individual patient, assessing the actual risk of bleed versus thrombotic complication on a case-by-case basis. So there's those two key points, and that's what I have, and I'll turn it over to Dr. Shaw. So thanks everyone for your attention. Well, we all know Zach is wrong. I'm just kidding. So Zach, good to see you, buddy. Unfortunately, he's probably right. Hold on, let me get this working here. Bam, okay. This one, share, bada boom, okay. So, all right, so we're gonna just go, there are my disclosures, hold on. So this is the AZA guidelines from 2018. So I have to say that when I heard about this at SIS just a couple of months ago, it kind of won me over, but these are the AZA guidelines. And I would say that the AZA guidelines are the most important guidelines but these are the AZA guidelines. And I would say they're largely in agreement other than the cervical RFA, the transforaminal, and certainly I think we can all agree for a dorsal column stimulation trial, it would not be indicated. Okay, so here are my disclosures. Some of them, I guess, are relevant for this. Okay, so these are published in April, 2018, talking about aspirin, heparin products, SSRIs actually can cause blood thinning factor 10. High, medium, low risk procedures, we're talking about the evidence, and enhanced safety as well as legal ramifications if you proceed. So we're gonna breeze through some of this quickly. Okay, here's the time for the anti-inflammatories that they recommended to hold based on the half-life. And so you see there ibuprofen, nicofinac, just a couple of days, oxaprin, I don't really know who uses them, peroxicam, maybe it's 10 days, nandutone is almost a week, naproxen, four days, meloxicam, and up the line. Okay, so aspirin standalone, right? If there's concomitant SSRI use, it can actually prolong bleeding time pretty substantially, actually. Primary prophylaxis, you may wanna talk about it. If it's a low risk procedure, it may be okay, even for like dorsal column stimulation, if it's primary prophylaxis, you may wanna have a discussion with the patient, shared risk-taking, have a discussion with the cardiologist or neurologist whoever's prescribing it for primary prophylaxis and have a discussion about that. So there's definitely, with aspirin, especially if you stop it, there's a hypercoagulable state for a couple of days, and certainly for the low and medium risk procedures, you don't have to hold it for the whole week beforehand. Okay, so here's the P2Y12 inhibitors down the line. So you're getting there, and so it's five days at the minimum, right, for these drugs. So you really wanna be aware, in my experience, Plavix makes people bleed pretty significantly, so that's always what I'm very aware of, okay. Coumadin, so for neuroaxial procedures, you wanna be less than 1.4. In our center, we do a lot of LPs for inpatients for back to the screening trials, and maybe on Coumadin or heparin for DVT prophylaxis, so we usually hold the heparin for 24 to 36 hours before the procedure and start it eight to 12 hours later. So we do this a lot, okay. The Coumadin, again, wanna be at least below 1.4. It obviously has a pretty long half-life. It's reversible in vitamin K. IV heparin, very short discontinuation. Low molecular weight heparin is a little bit longer, and fondoparano for those with HIT, a lot longer, okay. Here's the drug half-lives for these drugs, so not inconsequential, but going back to the evidence that Zach talked about and referenced, it's kind of hard to get away from the reality of the fact that these drugs have these half-lives and these are the objective pharmacokinetics in front of the dynamics of the drugs, but if there's no observable risk, it may not be worth taking the patient off to their thrombotic risk. So the general low-risk procedures that you don't need to really kind of consider are peripheral nerve blocks, joints, trigger points, piriformis, SI joint, and the medial branch blocks, the lumbar spine, RF lumbar, peripheral nerve stimulator trial or implant, or pocket revision with a pump or a spinal cord stimulator, IPG. So those are low-risk procedures. Intermediate, interlinear ESI, transferral ESI, cervical MBB or RFA, intradiscal procedure or sympathetic plaque, and trigeminal sphenopalatine ganglion block. So I don't know who's doing Gessering ganglion block. Show of hands, please. Not anymore. I haven't done a Gessering ganglion block in a while, but I think with reference to what Zach was talking about, I probably would continue anticoagulation unless I was doing a Gessering ganglion or sympathetic blockade on the right side, probably. Okay. High-risk, again, the implantable devices or a vertebral augmentation or percutaneous decompression laminotomy, like a mild procedure, and the epiduroscopy and epidural decompression. So, you know, I think even Zach might agree, if you get a little bit more frisky with the ligamentum flavum, I said frisky, you probably would want to hold it because that's going to dramatically increase your bleeding risk. It's going to be disrupting those veins a lot more. But, you know, there's obviously some things that weren't studied, and I would just encourage everybody to look at the data that Zach presented specifically for the procedures that he talked about were low risk and not extend that safety profile to perhaps higher risk procedures discussed here. All right. And this is just infection risk and prep, but we don't really need to go into that. So, yep. And so then the Azargarland is going to talk about antiseptic technique and proper ventilation and preoperative, interoperative, and postoperative risk management for patients. And then obviously you want to be careful because there was a recent article when I originally gave this presentation, I was in Reuters in 2019, or maybe 18, about all these neuromodulation devices that had to be explanted at very high rates, and they weren't working for people. And so we really want to make sure that everything we can do from a patient-centric, thoughtful way to kind of reduce risk by looking at all the evidence. All right. That's it pretty much. Okay. So. All right, Eric, thanks for speaking out on that. I mean, basically a lot of overlap with what Zach was saying, but I do think the evidence of Zach and the guys that he worked with presented SIS. It's pretty compelling. And so I would say for me personally, I've sort of shifted over to SIS guidelines for the procedures specifically, but for dorsal column stimulation and some higher risk stuff, I'm still holding anti-coagulation. Great, thanks. And again, I think it'd be great to see more published evidences that abstract Zach discussed. And again, I think we can all look back at our practice patterns too, and think about how we did things five years ago or 10 years ago in training, and how we would hold for even SI joint injections. I remember doing that and contacting the cardiologists and every cardiologist had different recommendation and what their thoughts were. And so I think that a lot of that also delayed patient care to some extent, waiting to hear back and changing that and restarting on patients. And so hopefully more of this data will get published. Just to clarify really quick, the SIS position is definitely in agreement with discontinuing anti-coagulants for the high risk procedures. So just remind anyone to think otherwise. It's really just those extra axial procedures where it seems like, hey, the data really would argue that it's safer to actually continue anti-coagulation. Do you know when SIS is gonna be coming out with any guidelines specific to this data or? Yeah, so it's kind of, it's evolving process, but the fact finders are probably the closest thing to a quote unquote guideline. There isn't gonna be a third edition of the guidelines, but there's gonna be a technical manual and safety practices paired together. But there is a series of fact finders that address these various procedures that we're talking about and present updated evidence. And there has been some conversation about a dual guideline with ASRA and SIS participating together. We'll see, I hope it happens. I think, so I think if that can be, if you have any ownership and leadership in that, Zach, anything to make it more clear cut. For the rest of us, right? To say like, listen, this is what it is. And all these experts came together, looked at all the data and said, bam. And this is a well thought out reasoned article. I think that would be hugely helpful for the pain community, so. Yeah, no, I very much agree. Well, thank you both for that. I wanna move on and before Dr. Lee talks, I wanna share this real quick. And we're also gonna put up our second poll question and we're going to discuss gadolinium based contrast. And so if you guys could answer this question and give it about 20 seconds before we show the results. And just as a reminder, if you have any questions, just put in the chat box and we'll try to get to some of those at the end of the spine community session. So if we could share the results. I'm going to stop screen sharing. Okay, I guess I don't know if anyone can access that from the APM and our side with the poll. All right, well we'll just move on. All right, David, I'll have you share your screen and we'll just assume that people are going to do either or so. Thanks again for joining us, David and speaking on this. I appreciate that, Aaron. So I just wanted to take this time to thank everybody for staying on. We're technically more than halfway through now, the combined neuromodulation pain and spine community session here. So thank you guys for all hanging in there. I'm going to be kind of switching gears here, going from anticoagulation. We're going to be talking about use of gadolin-based contrast agents and whether they're considered to be a safe alternative for spine procedures, board-certified PM&R in pain medicine and practice out of Southern California. These are my disclosures, none of which are applicable to the discussion that we're going to be having here tonight. I'm going to start with a quote that I took from colleague Dr. Timothy Mouse, who most of you guys may already know. Contrast media, however, are drugs. Potential adverse events associated with their administration must be part of the knowledge base of an interventional pain physician who used them. And I think this is quite important. A lot of times contrast media is not often a sexy topic nor discussed. It's often kind of put in the back burner with focus on different types of anesthetics or corticosteroids, which we certainly have addressed not only in discussions, but also publications. And even pharmacological pain management often gets a lot of highlights and discussion, but contrast, not so much. But it is a medication, and if you're going to be utilizing it, you need to be aware of it. So these are my learning objectives. We're going to be mainly focusing on the use of GBCAs within the neuroaxial space, specifically unintentional intrathecal administration of GBCAs. But we will cover at the very end just some brief publications and reviews of case series on actual intrathecal procedures. So the role of gadolin-based contrast agents, we all know. It's observed flow direction patterns while we're doing these interventional procedures, and essentially to avoid any unwanted intrathecal administration or intravascular injection of subsequent agents that we're injecting into the space. For patients who have known allergies to iodinated non-ionic contrast agents, this is often kind of turned towards as an alternative. So before we get into the data and the adverse events, kind of a little background in biochemistry. So for gadolin-based contrast agents, free gadolinium ion is toxic, and therefore it must be bound to chelating agents, and there's two essential ways to do that. If you look at the upper right-hand portion of this slide, you'll see that you can either have it in a linear form or a macrocyclic form. Transmetallation, which has been studied predominantly in intravenous gadolinium use, is where in vivo there's a dechelation process where endogenous cations, copper, calcium, iron, zinc being some of them, essentially compete and displace the gadolinium ion from the chelating agent, and that's what's thought to give these adverse effects. One point that we're going to kind of reiterate later on in the presentation is that risk of toxicity is unique to the structural class of the specific GBCA that you're utilizing, the thermodynamics and kinetic stability, so volume recommendations cannot be necessarily applied universally. This is a table that's taken from Dr. Provenzano's recent publication. It's showing the nine gadolinium products which are presently FDA-approved for use in MRI. Interestingly enough, what I found was that there was even one that did not even talk about the serious nervous system-related complications, and really only one, gadodiamide, which presented information regarding intrathecal injection. Presently, use of agents in the interaxial space, GBCAs in the interaxial space, excuse me, is still off-label, so that's the first and most important part of this. Previously, we were using them with the assumption that it was quite safe, but more recently, numerous case reports have presented themselves with a lot of adverse effects, which we're going to be kind of diving into here presently. First, for gadolinium use in interventional procedures, one of the largest case series to date was recently published by Safriel in 2019. This was in 127 outpatient procedures of 92 patients, and this included a pretty good spectrum of interventional procedures, discograms, epidurals, both IL and TF, nerve blocks, facet injections. He used gadodiamide in a dosage range of 0.2 mL all the way to 15.83 mL. It's a huge range, but he used, obviously, 15.83 mL volumes for the discograms. On review of these patients, there were no complications, so the authors concluded that gadolinium was a safe alternative. However, if we look at case reports and case series of unintentional intrathecal injection of gadolinium, you can see on this slide that there's been numerous adverse events. So they range from everything from seizure, impaired consciousness, pain, spasms in the lower extremities, respiratory distress, and then in the one case report and paper presented by Dr. Provenzano approximately two years ago, the patient actually passed away. And so in 2018, and Dr. McCormick was just alluding to these fact finders, they did publish in Pain Medicine 2018 recommendations, and these recommendations still, I would say, hold pretty firm. They're pretty reasonable recommendations, as general as they are. Use lowest volumes of GBCAs, not to exceed 3 mL. Abort procedure if intrathecal uptake is suspected. If vascular uptake is noted, utilize a different approach or reposition the needle if there's going to be a low amount of gadolinium used. And alternatively, avoid using any contrast. You can do techniques such as anesthetic test dosing, digital subtraction using different types of imaging, as well as repetitive negative aspiration. Fast forward now to this year. The multi-specialty, multi-society-led best practice manuscript was published, and there they identified four potential concerns regarding GBCA use within the neuraxial space. The first was nephrogenic systemic fibrosis. The second, gadolinium deposition or retention in the brain. These two, you'll see, didn't have as much concerns as the latter two, which is encephalon in hypersensitivity reactions. So the first, nephrogenic systemic fibrosis, or NSF. As you can see by this slide, what the advisory group determined was that relative risk was low. So even in patients with chronic kidney disease of stage 3 to 5, you can hypothetically use GBCAs with minimal risk of nephrogenic systemic fibrosis. Kind of important for a lot of our patients that we treat, those with mild renal failure are not at risk for developing NSF, and patients with moderate renal impairment are at very low risk. In regards to gadolinium deposition and retention of the brain, the group found there was no definitive clinical consequences of GABA retention to be proven in the literature search that they conducted. Still, they warned of patients getting multiple different types of procedures using GBCAs that you obviously use the least amount, and also consider if introduction of GBCAs is absolutely necessary. So kind of the more main concerning points with using GBCAs is, one, of course, neurotoxicity. And so there's multiple proposed mechanisms of gadolinium toxicity, which are listed here. Many peer-reviewed published articles, pain textbooks have suggested gadolinium in the past as a safe alternative to using traditional iodinated-based contrast mediums, but really without considering what the potential side effects are. This group found that due to some of the risks, inherent risks with certain types of procedures, specifically introducing GBCAs into the intrathecal space, they suggested that using interlaminar epidural access was not recommended, that they focus on the molar concentration for the specific gadolinium preparation that you're utilizing, and that obviously there's a shared decision-making process between you and the patient when you're making these decisions. Last one was hypersensitivity reactions. And obviously most of us already know this, but the risk of a hypersensitivity reaction to a GBCA is typically the highest in patients with previous history of hypersensitivity reactions to contrast agents in general. Other possible increased hypersensitivity reaction risk factors were asthma, atopy, severe cardiovascular disease, female gender, and having drug allergies. Interestingly enough, seafood allergies, which we often ask our patients, did not have any apparent increased risk factor. The group noted that it is important, and I think most of all of us have had this experience, to ensure that the patient actually has had a hypersensitivity reaction to contrast. A lot of times patients will state that they have some kind of reaction to a contrast medium, but in fact it may have been due to something else that was injected, either something from the actual steroid or the anesthetic that was utilized. So for patients who have a history of a mild hypersensitivity reaction, and this goes to the poll question that Dr. Yang had posted just a second ago, you can actually pretreat them and do so quite successfully. For patients with moderate to severe HR, the advisory group suggested referral to an allergist prior to utilizing GBCA. One of the most important things that they emphasized, and this was done throughout the paper that was published, was that there is no ideal GBCA. This is a slide from Lasser et al., and again showing different options for pretreatment for both utilizing prednisone as well as diphenhydramine. So I'm going to kind of finish up here with just a focus on GBCA use within the actual intrathecal procedures. As early as 1999, there was a feasibility study where they took patients who had, 11 adult patients who had intrathecal administration of GBCAs. No acute neurological changes or seizure activity was noted. At that point, the authors concluded that relative use of GBCAs in intrathecal procedures was safe. In a prospective safe and safety and feasibility study of 100 patients, this was done in 2019 utilizing GATOVIS, there were only a handful of serious adverse events. One included anaphylaxis. There was non-serious events which included headaches as well as severe nausea. All the adverse reactions resolved within four weeks, and therefore the authors concluded that IT injections of 0.5 milliliters of catbutrol was safe. This paper published by Patel is a systemic review and meta-analysis paper. It actually looked at 53 articles which met their selection criteria, which totaled 1,036 patients. You can see from this slide that from these studies, they used different types of gadolinium-based products. Adverse events were approximately 13 percent. Serious adverse events were found in 10 patients, and one was an actual fatality. The interesting thing and one of the most important points from this paper to take away is that there was a strong statistical significant association between the severity of adverse events and the concentration dose of GBCA administered into the intrathecal space. Authors again concluded overall intrathecal administration of GBCAs was safe, but there were serious neurotoxic effects at doses greater than 1.0 millimole. And lastly, there was a recent paper published by colleague Jonathan Hagedorn. What they were doing is they conducted a study to distinguish the use of GBCAs to assess intrathecal drug delivery systems in iodinated contrast allergic patients. There were 11 published cases of gadolinium-induced neurotoxicity due to IT injections, and what they kind of looked at actually was to try to figure out what was a safe dose to use, and what they came up with based upon this small but poignant review was 0.5 milliliters of 0.5 mole per liter gadolinium contrast. So again, it's important to look at the type of GBCA that you're going to be utilizing within the intrathecal space, particularly if you're intending to inject it directly. And in order to get to that particular concentration, the gadolinium-based contrast agent can be mixed with either CSF or normal saline to the appropriate volume. Last slide kind of concludes and kind of wraps up everything we just discussed here. So first and foremost, the most important part of this thing is to not take the use of GBCAs at face value. We want to look at the actual literature and make sure that we're not assuming that it's as safe as we have in the past. This, at the very least, highlights the documented adverse events. Make sure that you're making a shared decision-making process with your patients and that they understand what potentially could happen. As long as you do that, at least the patient goes in with the knowledge of what the risks are. And then, of course, consider alternatives. So different imaging modalities, CT scan, digital subtraction, pretreatment for HR, attention to molar concentrations and how it applies to the volume that you're utilizing, and then, when possible, avoiding GBCAs completely. So that's about it for me. Great. Thank you so much for that great talk, David. Again, another topic that I think a lot of us who are in training use GAD a lot and don't even think about the different types of gadolinium-based contrasts there are out there. So we're going to go on to our last speaker for the Spine Medicine Community Session, and I'm going to introduce Dr. Desai, who's going to be talking about safety of implantable therapies and radiofrequency ablation. So let's see. I don't know if Dr. Desai is on with us. There he is. All right, Nehal, why don't you take it away? All right. Do you know if my talk's already on? If not, I can share my screen. I think you might have to share your screen, Nehal. No worries. So thank you so much for having me, and I appreciate everyone sticking with us and being here for this, and I appreciate the invitation. And also, you know, I'm excited for those people who made it to this, but also those who will watch this at some other point down the road. Hopefully this is sharing now. And so I was asked to talk about the safety of implantable therapies and radiofrequency ablation in patients with implanted devices, but I sort of added on magnetic resonance imaging as well, because I think these are the things that we deal with in everyday practice. In everyday practice, we're going to deal with patients who come in who need an MRI. We're going to deal with patients who have other devices and may have medical needs that are beyond what we're treating them for. So I just thought that was sort of relevant at this point. These are my disclosures, none of which are relevant to today's conversation. So getting right into it, and I think in the interest of time, I'm going to make sure I keep my time short here, but from a comorbidities perspective, there's a concomitant presence of cardiovascular disease, osteoarthritis, a variety of orthopedic disease states, and chronic pain of spinal origin. We know that these disease states exist together, and oftentimes our patients have multiple comorbidities that we're treating or are at least aware of at the same time. Just for a frame of reference, there's about 138,000 cardiac pacemakers in the Medicare population implanted in 2000, and the prevalence of this was about 504.4 in 100,000, which is up from 325.4 in 1990. All of this to say that a fair number of patients of Medicare age have pacemakers. ICDs, about 100,000 are implanted annually, and so again, when you start thinking about aggregate numbers, if 100,000 are implanted annually, they start to add up, and we all have patients in our practices that have ICDs. When it comes to radiofrequency ablation, again, about 113 per 100,000 Medicare enrollees in 2016 get an ablation, so again, a fairly common procedure amongst chronic pain or pain in spine procedures. It's probably the third or fourth most common procedure that we do, so again, something we're going to encounter all the time. Then when it comes to MRI, back in 2012, there were 32 million MRIs performed in the United States alone, and about 30 million in the EU. That's about, in the United States, about an MRI every second of the day, so again, a ubiquitous process. These things are going to come up, and we need to be aware of them and aware of some of the guidelines that exist. When I was doing some work on this and looking it up and educating myself about this as well, I found a couple of different things, and Dr. McCormick previously alluded or talked about fact finders from SIS. And so there's some information out there to guide us. So when it comes to spinal cord stimulation in the setting of permanent pacemakers and defibrillators, there's this myth out there or this thought out there that spinal cord stimulation is an absolute contraindication in the setting of prior permanent pacemaker implantation or ICD implantation. That's just not true. As long as you're closely monitoring the patient, working in close collaboration with other providers and physicians and safely performing the procedure, it can be done. So it's safe in patients who have bipolar cardiac pacemakers and defibrillators. Some of the things that were highlighted, some of the key points that were highlighted in the fact finder were educating the patient on the theoretical risks and hazards of SCS in the setting of preexisting pacemakers or ICDs, particularly when there's a unipolar lead. That's typically not something we see in permanent pacemakers, but rather in trial pacemakers. So typically permanent pacemakers have a bipolar lead, so it tends to be safer because the current is traveling a much shorter direction, a distance, pardon me. We wanna ensure that there's follow-up with a cardiologist or electrophysiologist and whether obtaining approval or engaging in collaborative decision-making, it's important to at least have a conversation with these folks to keep them in the loop. Honestly, most times untoward activities are unlikely to happen or complications are unlikely to occur, but it's always a little bit difficult to go talk to someone after a complications occurred as opposed to talking to them ahead of time and making sure you've filled them in. It's also important to identify the device manufacturer and why it was implanted, because there may be some things that tell us more about whether or not we should proceed with spinal cord stimulation in this setting. Coordinating the trial and implant with the device manufacturer to have onsite support during and after the SES procedure to ensure functionality of the cardiac device is important. And then any changes in the SES settings really should be made in stimulation and frequency parameters that are tested at the time of implantation. So if you start to work outside of those parameters, it's also important to reevaluate the cardiac device. So these are just some general guidelines to consider. When it comes to radiofrequency ablation in the setting of spinal cord stimulation, there's a really nice paper that was published, I believe in 2019, I think primarily out of Baylor and Mayo that talked and kind of collated the guidelines that exist from an industry perspective. So if you really look at industry guidelines or industry recommendations on the use of radiofrequency ablation in patients with spinal cord stimulation, sort of nearly every manufacturer, every major manufacturer of spinal cord stimulator devices talks about the fact that safety has not been established in radiofrequency ablation in the setting of spinal cord stimulation. And when you look at these guidelines here, those manufactured by Abbott and Medtronic have some very specific guidelines about putting the spinal cord stimulation into surgery mode and making sure that things such as avoiding direct contact between the ablation device and the implanted system is sort of monitored and avoided. And so there's some specific guidelines, but for those of us who have done radiofrequency ablation for many years and have also implanted spinal cord stimulators for many years, this is a procedure we have done at the same time. In my opinion, certainly it's something you have to be very cautious about and things such as where the grounding pad is located and where the radiofrequency ablation is being conducted are very important. We know that even when we go back towards permanent pacemakers and defibrillators, there have been studies, and there was a study that was a prospective double-blinded randomized controlled trial looking at, or pilot study looking at interference in patients between an ICD and a spinal cord stimulator when this was implanted for systemic heart failure. And really there were no issues with that. So similarly, when it comes to radiofrequency ablation, we believe that while these guidelines exist, these guidelines exist because several reasons. One, liability, and two, because it hasn't really been tested all that effectively, certainly not tested through the myriad of different radiofrequency parameters that might be applied in the setting of the myriad of spinal cord stimulator parameters that might be applied. So generally speaking, using common sense, being careful about where the grounding pad is placed and where the radiofrequency ablation is being conducted is going to be a good starting point in terms of whether or not to do the procedure in a patient who has a spinal cord stimulator, specifically radiofrequency ablation in the setting of a patient who has a spinal cord stimulator. And then I sort of wanted to sort of wrap up by talking about MRI. We know that the patients we see are likely to need MRIs, whether it's for spinal conditions or for conditions in the periphery. We published a paper back in 2013-14 that talked about the fact that nearly 70% of patients are going to need an MRI within 10 years for non-spine-related conditions, and then for those patients who have chronic pain or chronic painful conditions. And then when it comes to spine indications, it's nearly 90% of patients will need an MRI within five years. So being aware and being cognizant of the specific parameters under which spinal cord stimulation, and I also included the data on peripheral nerve stimulation and this was a paper that was also published fairly recently in 2020 in neuromodulation that really collated this data. Being aware of these specific guidelines is really important. The interesting thing about this, and I'm going to just scroll through here pretty quickly, this goes through the various manufacturers from a spinal cord stimulation perspective. This next slide talks about peripheral, sorry, intrathecal drug delivery. One thing to highlight here is that there have been some cases with the Fluonix device where, because the magnetic field can affect the pump and specifically the inlet and outlet valves, there's been a abrupt release of all the contents of the pump into the CSF in a certain amount of cases, which has resulted in death or can result in adverse events. So things to keep in mind, probably with the Fluonix pump, the pump has to be emptied prior to an MRI. The Medtronic pump typically turns off during an MRI and turns back on within 20 to 30 minutes, oh, sorry, 20 to 90 minutes. But typically in our case, we have a representative from the company monitor that device. And then the last slide here, and I think of particular interest and sort of segues into the next talk during the neuromodulation section is how magnetic resonance imaging affects peripheral nerve stimulation. Really, we don't have as much data, not nearly as many clearances as we do in the spinal cord stimulation space, but being aware of the manufacturer guidelines is probably very important, especially if you're doing a lot of these procedures. Fundamentally and ultimately, it's going to be up to us to advocate on behalf of our patients with radiologists and radiology centers, because despite the fact that a lot of different companies now have some level of MRI conditionality, and remember the difference is nothing is really MRI compliant or compatible that is not a human tissue. So these are conditional and there's certain specific conditions. Despite the fact that this conditionality has been achieved by most of the manufacturers, we find, at least in our area, that most radiology centers and radiologists are very unwilling to do MRIs for these patients despite that factor. So it's going to be important and incumbent on all of us to continue to advocate on behalf of our patients to get them appropriate imaging when warranted. So with that, I think I'll pass it back to Dr. Yang and see if there are any questions for our section. Thanks, Mehul. I didn't see any questions come through the chat box. I know the last section we're going to hand off to is neuromodulation, and again, appreciate everyone for, you know, sort of getting through these past couple hours as we head into the last hour. So again, if you want to just take a quick break, you can. I think, you know, a lot of us are off camera, so maybe you can be a little mobile while we try to finish up on time because I don't want to go too far over our planned time. So Mehul and Eric, do you guys want to just go ahead and maybe introduce the speakers for neuromodulation, and you guys can take it over from there? Sure. I think I can introduce everyone if that's okay, just as I think I'm the accolade chair of the neuromodulation. Community. So, you know, I think I'm really excited to introduce this group of folks. I think I really appreciate them stepping up and being available for this talk. Dr. Shaw, who is in Atlanta, is going to moderate, but I want to introduce Dr. Garan and Dr. Adankar. Dr. Garan is in Ohio, and she's a physiatrist who I've gotten to know a little bit through some of the work she does, and we're really excited to have her here to talk about peripheral nerve stimulation for axial low back pain. And Dr. Adankar is at Yale in New Haven, I believe, and he's going to take on spinal cord stimulation in the setting of axial low back pain. The way this session is structured is, I'm not 100% sure, but I think both speakers may have a couple of slides that they're going to go through, but really we're going to focus in on some cases and get their take on the cases and get audience feedback about what they would do in the setting of these very specific conditions. I want a good, clean fight. No rabid punches. Go. All right, Dr. Shaw, it's on you. Go for it. Okay, so I guess I'll let Cat go first. Dr. Garan is talking about peripheral nerve stimulator for low back pain. Okay, do you want to pull up those slides for me, please? And I made this real nice and sweet. I mean, obviously people on here, you know, kind of self-selected into watching this, but I just wanted to put a couple of examples out there because it is a different option. Go ahead and go to the next slide. So first off, and I probably don't have to say to anybody, what are you watching? But peripheral nerve stimulation, especially for low back pain is not a TENS unit. I do have to explain that to insurance companies quite a bit, but the peripheral nerve stimulation for low back pain research is emerging. It is, you know, there is older research that uses some of the older spinal cord stim leads that didn't work out quite as well. And then there's newer research, which is much better using leads that were specifically made for peripheral nerve stimulation. And that's kind of more of what I'm going to focus on when I'm talking about these as we go through the cases. There are permanent implants as well as temporary implants new on the horizon with everything going on now. So again, just kind of keeping those in mind. Go ahead to the next slide. And this is just one example of the stim placement right on the medial branch of the dorsal ramus in the multifidus muscle. It is, you know, again, just one example of where these can be placed to help out with that axial low back pain. And go ahead on the next one. And again, just an ultrasound image of this. One nice thing about peripheral placement is that you can use ultrasound with this. You don't have to necessarily always have fluoro even though it is helpful to confirm your placement with fluoro. And so it does kind of save some people a little bit there as well. And then there's obviously this other image to kind of, again, verifying the placement of the lead. Go ahead and go to the next one. And then just kind of leading into what we're going to talk about as far as the cases, I'm just going to put this out there. This was a study done recently on patient preference. So they were given the option. They were all chronic axial low back pain patients. And they were given a survey on, you know, just listing out and describing the procedures for a peripheral nerve stimulator for their back pain, RFA for their back pain, or a permanent implant. And on initial and even final choice, most people prefer that peripheral nerve stimulator over the other options. And so, you know, kind of keeping into, you know, yes, we have to have our own expertise. We have to let patients understand the risks and benefits and what may be better for them, not just what they read on the internet. But at the same time, understanding that their preference and what they choose is going to go into how they benefit from that treatment. If they feel like it's what they wanted, it's what they are choosing to go through, they're going to do better in the long run just because they think they will. Go ahead to the next slide. And then I just put in at the end of these, and you can go to the end of the slides here, just a bunch of the newer research, different studies on the new PNS devices for axial low back pain. So short and sweet before we get into the cases. All right, so I'm going to go ahead and share my screen. All right, so thank you very much for the invitation. I'm very excited to just go over these slides and argue for spinal cord stimulation. So just a little bit background, you know, axial back pain is basically part of a continuum and defined by NAS as pain that comes from the lowest rib all the way to the gluteal fold. And sometimes you have a somatic referral also into the thigh. Now under that, we have a subset of patients who have what was previously known as field back surgery syndrome now renamed as post-laminectomy pain syndrome. And then there are those who have basically fragile or non-surgical refractory back pain. In most cases, the pain is not as severe as axial low back pain. In most cases of axial back pain, as we all know, trying to identify pathology can remain elusive. And so a lot of our efforts, you know, we direct that towards rehab, pain modification, and then some treatment options as well. And recently, you know, there's been a lot of data showing the role of the multifidus and transversus abdominus muscle in axial low back pain. And part of it is thought to be a result of atrophy of these muscles related to both peripheral and central mechanisms. And so in terms of treatment options, we usually need to think about what are the underlying reasons for why patients develop axial back pain in terms of a mechanistic standpoint. In the last 20 years, you know, there's also been recognition that beyond just the actual nociceptive sources of pain, that there's also a lot of neuroplastic changes that go in the CNS, including changes in the gray matter, and then functional organization of the neural cortex. And so when we are talking about, you know, SCS versus PNS, I think that putting this in this context help us try to decide which modality to choose. And the data shows that it's really a complex interceptor even for axial back pain between both central and peripheral pain mechanisms. So why should someone choose SCS over PNS? Well, I mean, the data speaks for itself. There's been more than 50 years of research published to support spinal cord stimulation, including both dorsal column and dorsal horn. And since Shili put in the first device several years ago, now we have a lot of data supporting the safety and efficacy of SCS. The cool thing about SCS over PNS is that, you know, the technology is really developing at a fast pace. Almost every year, there's something new that comes out in terms of programming, waveforms, even the neural targets are evolving every day. Lead placement continues to evolve. So I think in this space, there's really a lot of innovation in part because of so much competition between all the different, you know, companies that are producing spinal cord stimulating devices. And what I do like about SCS is that it comes in so many different flavors, different permutations, different programming platforms. And interestingly, you know, it really does target beyond just the peripheral mechanisms. There is at least some data to support that SCS can also target the central pathways as well. So in my review of the literature, really, I came across, I mean, there have been a lot of studies, but for PNS, really, there's really three studies that stand out to me. And really, you're only targeting one target, you know, and as we all know, I mean, there's so many multifocal etiologies, even for axial back pain. And the mechanism really doesn't vary much, you know, in PNS, whereas in SCS, I mean, tons and tons of studies, more than five RCTs, several prospective studies. You know, more recently, a new target has emerged, which is the glial cells, you know, have been shown to have a very key role to play, even in axial back pain, and SCS can help us target that. We cannot do that with PNS. And again, as I alluded to before, SCS gives you so many options, several different flavors from traditional, you know, low-frequency paresthesia-based stimulation. There's closed-loop SCS with the above compound action potential. There's even micro-dosing and, you know, varying the dosage for SCS. Both for PNS and SCS, one of the big issues that we all deal with is inpatient habituation, and, you know, there's evolving ways to try to overcome that with spinal cord stimulation. I don't know so much for PNS. And then there's burst, there's 10 kilohertz. More recently, in my own practice, I've been using a lot of DTM, which is a differential target multivex SCS, and I'm getting some pretty good results, saving for axial back pain, and then also just sort of a little bit side branch, but don't start with gandula stimulation as well. So I think, you know, from my perspective, there's really no contest in terms of trying to decide for axial back pain SCS over PNS. All right, you guys want to present some cases real quick? Dr. Graham, do you want to present your cases? I think they have them to pull up from the slides. I can share the slides too. Do you have them to share? There we go. Here we go. First case I will go on this one. 44-year-old female. Prior history of L5 S1. Tried all of the things. This is her MRI. Looking at those. I will not influence anyone yet. Looking at those. I think there is a poll. Looking at these would you go with first? If not, can we go back to the prior slide? Looking at these. From my point of view, there are a lot of studies on L5 S1. Countering what you just said. PNS is emerging. There are fewer studies on it. There are a ton of studies on SES. One of the reasons you have so many different types of SES, is because there are a lot of studies on L5 S1. In my opinion on this, I would say PNS. However, she needs to lose some weight. For sure. We can all see there. She needs to go through some of those mindful activities . She needs to go back to physical therapy. These are so atrophied. It is no wonder she has pain. That all being said, the fact that she has only right-sided back pain, and we can see that MRI wise is not terrible. Other than what I just talked about. I think the idea of putting in a peripheral stimulator, targeting specifically that right side, and being able to put it into that muscle, stimulate that muscle, help bring down the pain, as well as trying to get her more active during that time, is going to get her better benefit than implanting something long-term. Additionally, she is young. That is another reason why I would choose a PNS over SCS. Long-term, she may need an MRI going down the road. We just talked about that. She may need different things going forward. Again, PNS is outside the general space. It is going to be away from things if needed. If she didn't need an MRI, we can remove it more safely than SCS. I will let you go and see what your opinion is. I would say that I agree with you for all the points you raised about doing mindfulness-based interventions. I would not recommend doing that. I would not jump straight to trialing her with an SCS. With that said, a lot of the data for axial back pain supports the post-laminectomy syndrome. For somebody like her who has had that, if anything, compared to non-surgical axial back pain, I would not recommend doing that. I would support that. Patients do better with spinal cord stimulation. I will be a little bit reserved . I will offer that as a last resort. If she is exhausted and nothing seems to help, we will do a trial and see how she responds. I agree with everything you said. Her muscles look horrible. I will try to stick a device in here . I think we are in agreement on some things. She has sarcopenia of obesity, which we see a lot of. As a moderator, I would say PNS for her. It could potentially allow remodeling . It could allow pain relief for the temporary PNS device . She would not necessarily need a psych screen . It might facilitate her being able to participate in physical therapy and work on actively engaging some of those muscles. PNS is probably the right initial choice for her. Intelligent minds can disagree. Do you want to go first on the next case? Case 2 , 43-year-old male with central axial lower back pain and previously tried all these injections, for certain injections, medium or large blocks, macrophages, and some medications, multiple courses of physical therapy, and then some regenerative options. So next slide. And this is the MRI. Surgical view, and then axial here. Multiple pliers. Do you have another slide after that? Hold on. Which they would choose. Oh, there we go. Yeah. Did we get to see the full results? Oh, 50-50. Yeah. All right. So I guess, yeah, so it seems split down the middle. I think, I mean, one could make the case that, you know, with all the trauma that sort of instigated this patient's central pain, that perhaps there is a component of, you know, central mechanism that is contributing to the pain. And perhaps, you know, SES could have a role. But again, just like the first case, I mean, looking at sort of even the sectional section, this patient does have some obesity. We want to kind of work on a lot of all of the good stuff we talked about before. I kind of jumped to interventions with pretty much what I do in my practice. I know that it's a push really to use SES, be a move beyond using acid salvage therapy and kind of offer it as initial therapy. But I found that sometimes kind of prepping the patient that, you know, this is not kind of going to take away from you actually putting in the hard work. And now also I do talk to my patients about the fact that, you know, the whole concept of nociplasticity, now that's emerging in pain, that sometimes, you know, it's not just a matter of the nociceptive like aspect of pain itself and what is like nerve related or actual inflammatory related, but, you know, there's all these psychosocial stuff that we just don't fully understand, depression or lack of sleep, poor eating habits, all of that. And I do know that even though this is a thing of deciding between PNS and SES, I think we also be remiss not to talk about all of the other aspects of pain as well. So I would kind of, you know, go by all of that with my patient and then perhaps may consider SES if that fails. PNS may play a role here, but, you know, I think that just because we are prompted that this is sort of a central axial back pain, I'm thinking, you know, how much of this is like, how much glial cells are playing a role here and all of that. PNS is not going to help me be able to address some of that. You know, I think PNS is great, but we just don't have, it doesn't target anything else. And so I think I'll probably choose SES over PNS for this particular case if I was going to do neuromodulation. I mean, I would say PNS first. I'm not opposed to the SES. I agree that I do think that there's probably some centralization there that's causing it. However, you know, he at least has much better, you know, musculature than the first one. He's still young, 43. The fact that he's pushing a baby stroller, you know, with mechanism injury, I wonder too, you know, like you're talking, like, does he have some component of PTSD with this? A, you know, is that his kid? And does he need to have, you know, a lot more mobile? You know, a lot of components with this that, you know, we need to attack from outside. The benefit of PNS, you know, a lot of the newer studies have shown that not only is it, you know, purely facetogenic pain, but also kind of that nondescript central axial low back pain that it's approved for, you know, have been really helpful. And so, you know, yes, he's got some other, you know, very small changes on MRI, you know, plus or minus, are they helping? But the one thing that definitely leads me to PNS, and this kind of goes back to the patient preference component of it is, you know, especially with some of the newer, you know, temporary PNS systems is that he's willing to look at some of the regenerative components. You know, he's clearly into some of the more, you know, cutting edge or, you know, maybe a little bit different of a risk taker, you know, depending on where you stand on regenerative things for the spine. And so, you know, he's probably one of those who seems like multiple trials of PT going towards a regenerative, maybe he's a little, you know, OCD about this pain. And once, you know, needs to get some cognitive therapy to help disassociate from that, but also have, you know, a newer cutting edge device that can help his pain, but also kind of take him a step back from focusing on it so much. And then, you know, if he gets great relief from it, fantastic. If not, and you know, he see, you know, the more peripheral components are easing up, he's, you know, doing the therapies and continuing everything, but he still has that central component, then maybe going down the SCS route. But I think that the PNS would be a much better option for him, at least to start with. All right. Last case here is a 72 year old male with central axial low back pain. Prior history, multiple spine surgeries, most recently L2 to S1 posterior inner body fusion. Previously tried epidural injections, SI injections, articular facelift injections, on medications, multiple courses of PT. Go ahead and go to the next one. So here's his MRIs. I'm taking a look at those. And then the next one I believe is the axial. So looking, he's got this, you know, adjacent level, L2-3 disease that you can see pretty well here. So, you know, I think the next one is the pole, which would we choose for him? I'll go first on this because obviously most people are leaning towards the SDS component of it. And I'm not against that for sure. Can we go back to his MRI slides? My question was for him, and again, this is, you know, we're limited on how much information we have on this case. Obviously he's had a ton of surgery and still has pain. However, the question is, does he truly have axial back pain that, you know, we're trying to debate right now? Or is his L2-3 pain truly a little bit more, you know, ridiculous? Is he actually, is he having, you know, some of the groin pain and everything else that would prove that maybe SDS is a better option? Or is that really not as big of a deal as it looks on the MRI? Like we talked about, you know, earlier, MRIs aren't, you know, components of just because your MRI looks this way doesn't mean you're in pain this way. And truly his pain is because he just had major surgery and, you know, he's 72 and isn't healing as well, and his muscles aren't as strong as they were 30 years ago. And so, you know, he's had this multiple surgery. So part of that is, you know, the mentality of it all, how much of this is, I'm a chronic back pain patient versus how much of it is truly, I have pain because of this issue of my L2-3, and I just am having trouble saying, is it truly, purely back? Or do I have some of the ridiculous components of it that I'm just not explaining as well? Because I think getting deeper into his true symptoms is going to give you a better answer on SDS versus PNS. I, you know, first glance at it, SDS does seem like a better option, but if he's truly just having pain from his prior surgery, and it isn't truly more axial, SDS, you know, maybe harder to place, maybe, you know, he's on a blood thinner, he is 72, you know, you've got other medical issues that you have to think about, versus PNS, you don't have to stop those, you know, anticoagulants. And if it's purely just pain from the prior surgery, we can bring that down in a shorter time and get him moving. And again, if we get some of the back pain down, but then he realizes, oh, yeah, I'm having this, you know, hip pain, I'm having this other wraparound pain, and it is truly related, you haven't ruled out SDS at that point. Yeah, so I think that for this particular case, as opposed to the other two, I think it's probably easier for me to make a case for SDS, because the other ones was pushing it a little bit. You know, this patient is really a classic patient that comes in and gets the SDS done, in part because, you know, while he does have post-laminotomy back syndrome, he's older, he's an older patient, and even though this case wants us to believe that this patient is coming in purely actually about pain, I mean, practically most of these patients, when we do see them, they do have a component of either radicular pain or pain going elsewhere. So this patient is probably likely going to benefit better from the SDS than the PNS. So I would probably choose PNS. I mean, so I would probably choose SDS first in this particular case, even much stronger than the other two cases to address his pain. Yeah, I mean, I think this one is a lot more of a slam dunk for SDS. You know, you just got to talk to the patient and make sure that, you know, most likely the symptoms he's having, you're just not projecting that we are thinking that he's having, and if he's not actually having those, and we just are projecting them onto him, you know, can we treat it with PNS instead? That's kind of where I think PNS has its role in here, but I agree. I think for this one, most likely SDS is going to be the answer for him. All right, I'm going to step in. Judge is ruling SDS. How many cases do we have total? I think that's it. That was it? Okay, very good. So any questions that anybody has from the audience? The 10 participants that are left in the audience that are not speakers? I guess the other speakers can have questions too. Anybody at all? So I'd say both excellently done. In my practice, I use both and have good success with both. I think there's a case for both. Conceptually, I just want to kind of echo what both our excellent speakers said tonight. You know, the idea of at least with one of the PNS devices is that it's temporary, doesn't require a surgical implant, and can provide long-lasting benefit through some of the data that's been published. Spinal cord stimulation, of course, for more refractory cases that have a more neuropathic kind of component to it, such as Charles was mentioning after surgery, whether it be anterior or posterior. Right, so I think you have to carefully think about your patients. You have to think about the risk factors they have, like in the 72-year-old gentleman that was on antiplatelet therapy, and it may be more medically complicated. You know, there is possibly a risk of thromboembolic events, as Dr. McCormick talked about a couple of presentations ago. Now, that's 0.5% in the two-week period. Not huge, but not zero, right? So, I think we have to balance, for always, all of these countervailing forces and concerns for our patients. I will say, even with the fully implantable SCS, I'm sorry, peripheral nerve systems, they're still greatly lower risk for implantation. So, you know, if a patient can get by with something that's less invasive and lower risk, maybe that would be worth it, even if the pain relief is not as substantial. Now, I think for patients that have more neuropathic pain, whether it be failed back or neuropathic low back pain, or a failed PNS, and that's a good case for permanent SCS, right? I think we all agree lifestyle modification, exercise program, mindfulness, stress reduction are huge components. We're fortunate enough at our center, at Shepherd in Atlanta, to have a psychologist in our pain clinic working specifically with our patients. And I send the majority of our patients to her for work on all these things. You know, as we all know, not all patients understand how their stress and mindfulness actually impact their pain. But when they do get it, then it's very helpful for them. So I will say to both of you, thank you so much for your presentations tonight. Nice to meet you, Dr. Buran and Charles, good to see you again. And I hope to see everybody more later. I wish everybody a good evening. I'll wrap it up with Dr. Yang. Give it back to him. Thanks, Eric. Really appreciate everyone for being on here live and really just joining us through all these great talks. Again, it will be available. And I also know a lot of people who are asking about that, who could not make it tonight. So I really hope that the next community session will be in person somewhere. So again, thank you for all the great speakers. Thank you for listening in tonight. And hope you all have a great Friday and weekend. Thanks, all.

chronic pain management

mindfulness

cognitive factors

psychological factors

integrative care

cognitive-behavioral therapy

acceptance and commitment therapy

yoga

meditation

mind-body interventions

gadolin-based contrast agents

intrathecal space

safety concerns

peripheral nerve stimulation

spinal cord stimulation