All right, the lights came alive. We're going to let everybody kind of get settled into a seat here, if we can. And with the lights, we can't really see people and make things out too much, so we were going to do a little question and answer, so we'll still practice raising hands a little bit about different things that are going to happen during the case. My name's Jim Atchison. I'm at the Mayo Clinic in Florida and kind of the moderator, which, once again, I had a topic that I was interested in maybe having some discussion and debate about with experts, so what I went out and did was find some experts to have that discussion so that we can hopefully get a thought process through them and then let you weigh in some at the end with different things. The main focus of the session is to discuss things that we commonly do and maybe in some ways a lot of other pain providers are more commonly doing without possibly the correct indications and what those things mean in a younger patient group. It's starting to filter down further and further into young patients where they're getting a lot of procedures done early in their life, and some of the difficulty with that is I don't believe there's a lot of literature or data to support what's going to happen to them in the future, so they are going to become a different candidate for rehab and the things that we do because we probably don't know what's happening to them after we do it now, so that's part of the interest that I had in the discussion and creating the discussion on this. I'm going to introduce our panel real quickly and kind of talk about the cases a little bit as we move forward, but as we go in order here, so Mehul is third down on the table here, Byron's down on the end, Zach is in the nicely cropped beard at this point as we discussed on the way in, so I knew Zach long before he had a beard, and then Wen-Chin is down on this end, and you see their home institutions, and real quick we'll run through relevant disclosures so you all have a sense of where our backgrounds are with some of the things that we're going to be talking about, but I would consider these people very much to be experts in the discussion of what we want to talk about here. We're going to look at some different cases, and one is meant to be facet-mediated pain and posterior elements, and the cases aren't designed to confuse us, okay? We're not trying to trick somebody into saying this isn't really what's going on, we should be doing something else. More of the discussion is we try to just make simple cases that will then lead to what is it we should be doing with that, not did we make the right diagnosis or not, so we're going to do likely facet-mediated pain, likely discogenic-mediated pain for axial spine problems, and then as we get to the bottom in the axial spine, we get into perhaps even a little more controversial area where we talk about SI joint-mediated pain, and what's happening now with lack of insurance coverage, especially through Medicare, are we pushing people towards having fusions, which probably doesn't have a lot of strong data to support that either, but it's still a controversial area of what are we doing with axial back pain. All right, originally we were going to try to do some of the AVR things, but it got a little bit complicated within the cases, so what I was here to tell everybody is I'm an old person, we're going to do it old style, if you want to raise your hand, we're just going to practice getting a response, but I'd like you to think through these cases with the idea of would I do this, would I not do this, at the end we'll have discussion, would you do something different if you want to do that. My understanding, though, is we don't have mics, we can try to stand up and talk and I'll repeat them, but there's a button at the bottom of the session for you to send in questions, okay, so I have the iPad up here with questions that are coming in, I'll review those, so if you have a question early, write it down so that we can come back to it as we get to things. First case was designed to be very simple. We have a young woman, athlete, having really acute radicular pain, not showing a significant weakness pattern, has all the exam findings that would say it's acute radicular pain, the slides didn't come very well, but we can still see that bottom disc, and the idea was this is an acute radiculopathy in a young person. We're talking in the session today about where age has an impact on what we are going to do. So, for this person, the idea would be likely most of us would think about recommending having an epidural steroid injection. All right, everybody who would agree with that, we're going to say yes, all right? Everybody who would disagree having that done in a person this age, okay? So that's kind of where we're just starting through, making you think about them. Now the polar opposite to this is a young person who comes in, has longstanding pain, even at a young age, changing pain pattern, if you will, moving from neck to low back, now to the arms, now to the legs, different sensation changes that wouldn't follow a specific dermatomal pattern, comes in, moved recently to the area where I practice and wanted to have an epidural steroid injection. Well, the first challenge was we weren't sure whether they were requesting to have it done in the cervical spine or in the lumbar spine. Things were rather widespread, changing in the pain pattern. We went back, got their imaging, not a lot of specific changes, and I know that's not our definitive answer all the time, but in conjunction with the physical exam, which did not really show specifics to that, the challenge was this person had started having epidural steroid injections done at a very young age, with what I would have to say is very little indication based on their imaging now some 20 years later. They continue to get them. We did a session last year about the possibilities and the difficulties with having repetitive steroid injections done over and over again in people and the complications related to that. Then we come finally to the person after having a long visit of what they were recently diagnosed with and things that are changing in their pain pattern, which we probably would treat in a different way than having an epidural steroid injection done. Who wants to inject this person? Well, good. I'm going to have to agree with everybody on that. The next cases aren't going to get quite so simple. Let's start in with the meat where we're going to get the panel involved just to get you thinking a little bit more about the first case. We're talking about what I would say is a younger person, 35 years old. That's because I'm near 70. They're half my age. We're going to consider them very young at this point. Kind of a varying low-level pain pattern, two to six, six at the worst. Most of the time, they were still functional during the day, doing activities. They did work out, but they'd really never had any adequate instruction as to what to do specifically for their back pain in that aspect. They did play golf regularly even without doing any cross-training. That's a word I figured out works a lot in my area in Florida is you have to cross-train to co-play golf now, which they understand a little bit about. At that point, when we saw them at first, they were really not at a level of pain consistently that seemed like it would fit with a procedure, but they did come back two years later. They had gone and gotten an appropriate exercise training program. They were actually doing it. Let's assume we had compliance with what's going on. They still have axial pain, no leg pain. Even on the examination, it really seemed, and once again, I know examinations and imaging is not our final issue, but we're trying to paint a picture of posterior element facet mediated pain so we can have the debate a little bit through here. So 37 years old, pretty significant one-level disc abnormality. I understand that doesn't clarify this is clearly the pain generator at that point, but certainly may be more reliable than seeing a person with multi-level changes, which we'll talk about. And then we are at 37 years old, pain consistently above the level of six. We're going to start to jump in and see what do we think about procedures on this person? What procedure would be indicated most in a young person? Should we be thinking inter-articular versus having some type of ablation done at this time? And also then how does it impact what would be in the literature for treating people in this age group versus this person generally has a 40 to 50-year life expectancy, and they're going to start having procedures done at age 37. So I think that's something we have to consider as rehab docs. Dr. Schneider, I'm going to let you weigh in first. Am I going to recommend a procedure? I think you're trying to lead me into considering a facet procedure. When I think of this case, and I get this a lot, and I think I'm in the minority, so people maybe shouldn't do things like I do. The first thing I think of in this case is it started when he was 27, and he may not have multiple things going on, but presumably this has been an eight-year problem, and that's why he wants it treated, and it's getting worse. But it's hard to convince myself that in a 37-year-old who's had back pain since they were 27 that it's likely he has facet pain. So we don't have a lot of good data on this, but DePalma published a nice study where he looked at all his patients and tried to figure out prevalence of conditions based on age, and in the 20s and even in the 30s, the likelihood, at least from that paper, that he has facet pain is 20% or less. And maybe when we debate a little bit more, I'm going to unpack that, but if you consider that an ablation is effective for someone like this 60 to 80% of the time, and I think it's 20% or less that he has a facet problem, in my head, I'm thinking that if I go down a pathway to treat him for facet pain, I have a less than 20% chance of that working for him. And the only way I would consider doing something like that for him would be if he had full understanding that what we're going to do, I think, is unlikely to help. And if they still wanted to do it, then that's part of shared decision making. I know you say he has pain with extension. Discs can hurt when you have extension, especially a posterior, perfectly midline posterior disc bulge. They can? Oh, yeah. They can, all right. There's no indication for an epidural or something. He has some lateral recess stenosis there, but he has no leg pain. And we also know that epidurals as a treatment for just back pain, whatever that means, are effective at 30% or less, which is probably the same as any placebo treatment effect. So this becomes a challenging case, and then I'll pass the mic over, because essentially what we have here is a patient who has a worsening problem that's following doctor recommendations and is not getting better. And I probably know what's wrong with him. And the humbling thing is, is no matter how much I want to fix him, the truth is probably that I don't have anything to fix him, at least not with a needle, and probably not with a surgery. But that's my thoughts when I hear this case. Dr. Desai. So I think, one, I'm a little disappointed that Dr. Atchison didn't mention my beard. But it's probably because this has been here since birth, and I feel like maybe Dr. McCormick was- It's got gray in it. It's a little harder to see. Yeah. The other thing I was going to say is, as a part of this panel, I think I'm going to take perhaps a position on purpose that is a little bit more controversial, not necessarily because I believe in that position fully, but because it sort of makes it more interesting. I'm also the only, I think, only private practice person up here. So it sort of changes the way sometimes we approach patients. I generally tend to agree with what Dr. Schneider said with regards to sort of trying to ascertain what the patient's pain, where it's coming from, what the etiology of their pain is. Even though I'm in private practice, I tend to see a lot of people that come from quite a distance or sort of get referred in for more of sort of a diagnostic approach. I tend to believe that a patient who's had pain for as many years as this patient probably has multifactorial pain as opposed to a singular source of pain. One of the things that we try, and I don't necessarily think it's completely grounded in a whole lot of evidence, and I would actually go further and say that in our space, if you dig sort of a centimeter deep, the evidence gets pretty, is pretty shallow for the most part, right? We don't have a ton to guide us in these situations. But we do often take, in a patient like this, kind of a diagnostic approach, trying to ascertain, especially if the patient is insistent that they want to seek therapy and treatment, trying to understand whether at least their primary etiology of pain is perhaps discogenic versus facetogenic. In patients like in this age group, as Dr. Schneider said, I would be personally thinking, despite the extension-based pain, that it's more, that the disc is at least playing a part in their pain. Although if your disc starts to degenerate at a young age, theoretically, your facets are going to start having changes as well. So you're not, it's unlikely 10 years in that you're sort of sitting on a pristine primary disc problem or a pristine primarily facet problem. Great. Let's kind of move into some scenarios. We start moving around in the case a little bit, all right? So from a diagnostic standpoint, would you consider an intraarticular facet if you were going to do more of the diagnostic, or would you talk about medial branch blocks in this age group? Yeah. If you're going to move more in the diagnostic, because I do think that's still a question a lot of people would have, where is my pain coming from? So maybe this is, and I think, again, if I was going to play the odds, right? So I think a little bit of this is, I think our job is to play the odds and sort of talk to patients about the likelihood of successes versus the likelihood of failure. Or what, trying to define success before you even get to the likelihood of success or failure. Because a lot of times patients come in, I don't know, I think we probably all have this experience where they're like, I want to be pain free. And I'm like, the best I can give you is 50%, right? And that's, if you don't set those expectations or agree upon expectations up front, you tend to fail no matter what. So in this situation, I would honestly be more inclined to be thinking about the disc, like I said. Now, there's no, we could debate probably for hours about what an appropriate diagnostic is to evaluate the disc, especially as a first step. And I'm sure we could all rabidly disagree with one another about what the first step would, should be. We, I would consider intra-articular injections with just anesthetic, again, based on a risk sort of discussion with the patient. But I would also probably consider what we do a lot in our practice is a retro-discal injection with just anesthetic to see if we can sort of start that conversation about whether this is truly disc or facet. All right. So you're not jumping on the do a medial branch block train. Can we pull the audience? Yeah. I was like waiting for you to say this. Who in the, I think the most common, do we all agree the most common thing this patient would get in the community is a medial branch block? I think that's true if I saw this patient as a second opinion. I would assume this patient has already had a medial branch block. So even though I'm asking this, don't be embarrassed. Put your hands up if that's what you would do, because I would expect half the room to say so. Yeah. Right. That's where you're trying to get us to go in this conversation. Let's add to the, let's add to the discussion on this is I've seen this patient at 32. They had two medial branch blocks, which they reportedly responded to, then got the ablation. And when I got the report in on the medial branch blocks, they did medial branch blocks with steroids. Should we do medial branch blocks with steroids? No. Go ahead, Zach. I'll chime in real quick. So will you go back to the MRI real quick? This is a great discussion. And I think the first thing is maybe just a couple of extra pearls for all of us to chew on. This is an image that is much more consistent with discogenic back pain than it is facetogenic. And the only feature on exam that's sort of leading us towards branch blocks and posterior element pain is pain with extension. And if you look at the studies, that's not actually a validated exam maneuver for predicting facet pain or at least response to medial branch ablation. So as I look at this, I agree, and I think you said the same thing. This person probably has some element of discogenic and facet pain. Why their exam is the way it is, who knows? But people present in all sorts of ways. The other thing is that we have one cut on the sagittal section right here. We have one cut. But without knowing what the rest of the MRI looks like, we don't really know what's going on at that 5.1 level in particular. And I'm guessing there easily could be modic change. And that is something that I won't get too far ahead of ourselves, because I know that's meant to be kind of a piece of the next case. But I wouldn't rule out that this patient doesn't have what we maybe would call vertebrogenic pain on top of other things as well. The patient also has a retrolysthesis at L5-S1. So there's a grade one retrolysthesis. We don't have flexion extension x-rays, but there's grade one. So I would say in our practice, this is a patient that's often received two or three epidurals, even though they don't have any leg symptoms, before they come to us based on this. When somebody is saying, I want to diagnose or treat them, because they have responded to some type of steroid, right? I mean, my feeling is you put steroids in anywhere, something responds sometimes, right? That's the principles of steroids. But those are kind of the dilemmas here with this case. Very much so. I'm going to add one more point. Again, looking at the sagittal view, it's without having more cuts, it's really hard to say, but that looks like it could be essentially a teardrop disc extrusion. So with just the information we have, this feels a lot more like not only maybe discogenic pain, but there could be a little proximal radiculitis or whatnot. And I think that, no, there's no radiating leg pain, classic distal radiculitis. But from that image, if this person's never had an epidural steroid injection, I don't know that it would be unreasonable to start there. So I want to bring back to, or go ahead, were you going to say one more thing? The only last thing I was going to say is there's also a hint of some multifidus atrophy there. It's hard to say, because at L5-S1, you get a tapering of the multifidus anyway. But if we had perhaps a cut above, you would start seeing some multifidus atrophy. So again, I think that goes back to the conversation of multifactorial. So because it's the cassette case, and half the room said they do a medial branch block, I'm going to, in three minutes, try to explain how I think about that. And my thought process is I might undertreat a few people. But the answer or the question would be, this is a diagnostic test. That's what you're asking us. Why not do a diagnostic test? So why wouldn't you just do a medial branch block, and they don't have facet pain? It's going to be negative, and you have your answer. And that's the way it should work in theory. So if the test was perfect, I would argue doing a medial branch block is perfectly reasonable, because you can rule out something that, if otherwise, they had would be treatable. The challenge with that is, and I think that's the logic everyone uses. I think that's why these patients would get a medial branch block. And we have no way of actually quantifying the likelihood that this person has facet pain. But if you assume that, in this age, it's unlikely that they have facet pain, if you say it's 10% or 20%, and you also appreciate that we know the false positive of a medial branch block is about 30%, and that is the reason we're told to do two. But if we all remember, in medical school, they teach us how to calculate the likelihood of what your test actually tells us. We all get in the habit of, I did something, this test result showed up, that's true. And it's not binary. Test results just increase or decrease the likelihood that you think someone has a problem. And in this situation, and I would have a much longer, I'd have a 15-minute conversation with this patient about this. But if you assume their prevalence of this is 10% or 20%, and the test is wrong 30% of the time, even if you do the test twice, if they have two positive medial branch blocks and you plug it into that formula we learned in medical school, the post-test probability of him having facet pain still is less than 50%. So you could have a test times two telling you they have facet pain, and the likelihood that they have facet pain is actually still less than 50%. So that is the danger in doing a medial branch block, because now you've convinced yourself and them that they have a problem that you can fix. And in reality, it is more likely that you're going to do an ablation and they're going to come back to your clinic in four weeks and tell you that their back is not meaningfully or significantly better. So you mentioned 20% in this age group, and we see patients getting it done at age 20. I mean, so the percentage of facet-mediated abnormalities potentially in these younger age groups would be even less than 20%? Yeah, or almost assuredly. There's one paper that would suggest otherwise, and it hasn't been researched that much, John McVicker's new paper. They kind of show that in their practice, people of all ages were equal likely to have facet pain, but that was a very unique patient population. It was like people with unemployment and car accidents. If you just take for granted that it is almost assuredly the most likely cause of facet pain is osteoarthritis, like I tell my residents, I'm like, you're a smart person. If your knee hurt and you went to the doctor, and my residents are in their 20s or 30s, and your orthopedic surgeon looked at you and was like, you have really bad knee OA, you need a knee replacement, you'd laugh your head off. You'd be like, that's not why I have knee pain, right? It's a meniscus problem, or that's the last thing you have is arthritis at this age. And so the younger they are, I'm definitely not going to do a medial branch block. And there's no right number, but the older you get, the more likely, the higher it is on my differential. And once you get into your 50s or 60s, it becomes reasonably probable that that's their problem, and then it makes more sense to try to treat it. Wenqian? So, and the age is very important, but in the meanwhile, why is age relevant? Because with age, your disc degenerate. So there's a statistical model that says 0.025 per year, so that with age, you have a collapsed disc, a higher chance of that. That's where your bad mechanics get altered. That's what, you know, how you started to have degenerative processes of the joint. In this patient, this height has lost more than 75%. We don't know how long he has these heights lost. So in terms of age, you cannot just look at it. You have to see longitudinally how long the disc has lost this height. And then it's an athlete. If there is an athlete, of course, the patient is going to be more active, lose the disc earlier, and then that's where you have a lot in this patient. One of the things is you look at the facet joint. There's no subchondral meridema. So there's not a whole lot to indicate that the facet actually is actively, you know, there's inflammatory processes going on there. But here's the question. There's a chance it's a discogenic pain. There's a chance it's a facetogenic pain. So where are you going to go? You're going to go test on a discogenic pain. How do you do that? You do a provocative discography. That's very, very safe. Or you do a medial branch block and see if that's, of course, there's a risk. And you know, Byron properly pointed out there's a good risk of over-treatment. But how about the other opportunities? If there is a, you know, a lot of time we have just the low back sprain is coming out of the ligaments, and then how are you going to identify the ligaments and so forth with physical therapy. In this case, I think these are probably the three sources of pain you can think about at this patient. But I would say, you look at it, this height is there. And if the facet is having either synovitis or subchondra edema, I would go with the medial branch block. This one, I hesitate because there's no signs of inflammatory processes in the facet joint, even though this height has lost pretty much all of it. So just a couple of other considerations. If we do go down the route of working up the facets, this is a situation where probably this individual has commercial insurance, right? They don't have Medicare, or maybe they do have Medicaid, but let's just say for sake of argument for a minute, you know, a younger person, I missed if they were working or not, but if there is a presumption that there may be some component of facet pain, whether it's arthritis related or otherwise, this is somebody who I would consider doing a facet steroid injection in. And you can get that approved, you know, through commercial carriers. You can't do it in Medicare patients outside of very unique scenarios, right? So either they have a facet joint cyst and you're planning on, you know, rupturing it because there's radiculopathy and maybe you're accessing the cyst so you're billing for that code inter-articular, or there's some medical reason they can't have radiofrequency ablation. But I guess this person's 37, I think, when it was presented. So, you know, that's not super young, but the younger they get, if there is something about their clinical presentation that is highly significant, and I agree with everything that Byron said about what we know about prevalence of facet joint pain, but this is where I think it is reasonable to consider a steroid injection as opposed to following that pathway to radiofrequency ablation. So let's expand the discussion a little bit because we were talking about what I was hoping was fairly localized pain, right? Now, the same person, the pain really is, let's say, diffusely through the lumbar area. Still we won't throw in any kind of a radicular pattern to it from there. But the questions are, if the pain is more widespread, does it change your thoughts about what you would do in terms of doing the diagnostic or any procedure? And then the idea would be, let's say the imaging was actually showing some mild to moderate changes at multiple levels, and the bigger discussion as we move forward is people are getting procedures done at three levels, five levels at times before they've come to see us. What would you think about that or the literature think about that in terms of testing those wider patterns, which are paid for by insurance, as Zach points out, which is probably why they're being done. That this changes really the perspective of this patient in terms of, I think, what they are a candidate for even further. Sure. I'm going to answer your question, but I want to fully make sure that my other point is the problem with my logic is if there's a 10% or 20% chance that they have facet pain, then if I have five of these patients in my clinic, I'm missing someone I could treat if I don't offer them a medial branch block, right? So there is a flaw in how I think about this. I might miss being able to treat someone that I could otherwise help. And so we all like to think that we have good clinical skills. It's hard to research to show that doctors have good diagnostic skills, right, like inner radar reliability of exams and can history predict things. It shows that we aren't as good at it as we think. But to your question, there's probably a scenario if they're 37 or 40 where I would change into thinking I would do a medial branch block because I might not want to deny treatment. And it probably has to do with the things you're mentioning, meaning if they have pretty focal pain that's like paramidline and they don't have any midline pain or any flexion-based pain, if there's clinical things that might make you think they have facet pain versus where you're going with this, it's like more widespread pain, then that's actually going to make me less and less likely to start injecting them. I think most of us probably do bilateral or unilateral L4, L5 blocks to start because just the numbers are that that's usually the problem. And if you're trying to lead us down the path of like what if it's their whole lumbar spine, I'm still going to start with two levels probably. It is so unlikely that someone has four or five symptomatic lumbar facet joints. And if they do, then they probably have an underlying medical condition that needs to be diagnosed like a spondyloarthropathy. They don't need me to stick a needle in them. But I don't know what clinical, to keep the discussion going, like what clinical things would you maybe tip you to doing or not doing facet procedures for this case? I would tend to agree that I think that with the whole panel in the sense of you sort of sometimes have to start somewhere, right? So you have to, you may, and hopefully we all start in a sort of relatively narrow fashion so that we're able to increase our confidence as much as possible. So like you said, the levels that you described would be probably where I would start, especially in the scenario where we had a more limited pain pattern. I think, again, to try to be a little bit more, push the envelope a little bit, if you're talking about a more diffuse patient where I've done some testing to make sure that psychologically things are not, that's not the issue here, that the person truly feels like their back just hurts, but it just hurts in multiple, sort of a bigger territory, that may be an interesting place to think about some form of neuromodulation, right? So there is some data for like medial branch stimulation for like 60 days, and I tried to pull this. I mean, it's really hard to get like the data on the young patients, right? It's because we have lots of aggregate data that's been published, but really when you start looking at younger patients under 40, so I was able to get, you know, what we have that's been published so that we have, in the studies, 11 patients were under 40. And in those 11 patients under 40, 100% had greater than 30% or equal relief at the end of two months, the end of treatment of 60 days, and they had a 10 point or greater reduction in ODI. And at 12 months, which is 14 months after the start of treatment, 64%, or 7 out of 11, still had improvement. So in one of four, sorry, one of three areas, either pain, disability, or pain interference, and there's only one subject under 30, and they had success kind of at all end points. So obviously, that is a very small end. It's really hard to extrapolate from that. But I think that when you start thinking about slightly more diffused pain in the back, but still where you have some confidence that it's coming from the back and not some other source, then I start thinking about these sort of broader treatment options that aren't necessarily about a singular level. And that's also another technology. And again, it depends on the chronicity of this issue, the patient's desire for something that's more perhaps, I hate to say curative, but perhaps along the lines of curative. And that's where you get these things like restorative neuromodulation, where you're stimulating the medial branch blocks kind of perpetually, where there's also some, again, it's more signal. I wouldn't say it's like declarative by any means. But when you start looking at aggregate data, actually, the company that manufactures the device for restorative neuromodulation looked at this, because they were really looking at older patients. But they also published information on patients, 66 patients between 22 and 43. And they actually had better outcomes as time went on. So at six months, only 67% of patients had greater than or equal to 30% improvement. By 24 months, 86% had greater than or equal to 30% improvement, and 71% had greater than or equal to 50% improvement. So I think, obviously, I may not jump into that therapy for these patients, for this patient. But it would depend on what, to some extent, what the patient was seeking as well. let's just finish up, kind of the thought I see a lot in the community is, let's just do more levels. Right? I mean, do three, do four, do five, and have them done over several times, often times before they're coming into at least our academic center to get a different look at things from there. So, the issue I guess I'd hear one comment on or more is, in the trials that actually got radiofrequency lesioning approved, were they doing multiple levels in the trials? My recollection would be there were more single level, maybe two in some cases, and we're going to have to talk about the same thing when we get to basal vertebral nerve ablation discussions about how many levels or what should go on at different levels. Byron? Yeah, I don't, I think the studies that have the best outcomes from radiofrequency were predominantly one or two level, often more unilateral, and occasionally three levels. I don't think there's any good data that shows like everyone was getting three levels or anything like that. When radiofrequency ablation got approved, and this is like, this like predates what would be usual with requiring, you know, some number of clinical trials first, et cetera, right? Radiofrequency ablation has been around since the 70s or earlier even, but like the first described treatment. Sure. The first description of it? Yeah. So, but I mean, if you go back to cervical spine in the Lord study, which everyone will point to is, you know, the probably the best sham controlled trial of spinal radiofrequency ablation. I mean, they treated C3 through C7. Yeah. Well, they did two, three, but it didn't work in that. Okay. But that's cervical spine, but, but, you know, strangely actually, I mean, that's, they actually treated multiple levels. Not that we should be doing that or anyone is doing that at this point, but lumbar spine, you know, approval, so to say, there hasn't been a sham controlled trial that, that in the lumbar spine. So it isn't actually based on clinical trial data where they looked at a certain number of levels. But the best studies of lumbar RFA with great outcomes, I want to say most of them, so McVicker study and Dreyfuss, they mostly were treating, I think, L3, four or five. Is one or two levels and unilateral too, which it was pretty selective. Yeah. The other issue is that, well, certainly if it's a Medicare patient, this is not, you can't treat more than two levels anyway. So that just is what it is. But I, you know, it's going, I don't know if others have different experience, but treating like four levels, ablating or denervating four levels bilaterally, you know, most commercial insurers are also not going to allow that. So I'm not advocating that should be done. That should not be done in this case. But just, you know, there is also a logistical issue with doing that, which wasn't probably the case five years ago or five years ago, more liberal what, you know, insurers were covering than what it is now. I think realistically, it's sort of, if you looked at all comers these days, I don't, I don't know that any of us have access to this kind of data right now, but like, I think the vast majority of people getting radiofrequency ablation, all comers, community, academics, et cetera, are probably getting three levels, either unilateral or bilateral. Like three, I mean, two level, two facet joints, three nerves, right. But typically bilateral, sometimes unilateral. The number of times in our practice, we do a unilateral and they come back a month later and they're like, oh, but now, but the left side hurts now, right. It's pretty common. But just three years ago, we were seeing five levels bilaterally, right. You get, I mean, jokingly in, you know, maybe a hundred miles from where Dr. Atchison is, everyone gets five levels bilaterally. Like you could go into Florida and it's like, let's ablate everything, right. I had a patient one time that had an S1 radiculopathy. We did a right S1 nerve root block. They got a hundred percent relief for three months, came back from Florida, showed me the images, 10, like five levels on each side ablation, right. So there's things that are happening for different motivations. But and the other thing is, I mean, we haven't really talked about this, but it may be interesting. There's a new paper I think that's out that's looking at, is there multifidus atrophy after radiofrequency ablation? So in a patient like this, who's 37, who may have some segmental problems, maybe at L5 S1, and you then ablate, especially if you repeat ablate, do you then end up with some sort of, I'm not saying it's, I don't think we have enough data to declaratively say it does or it does not happen, but there's kind of evidence on both sides that it might be happening. It probably does a little. I think that my answer to your question, and then I want to hear what Zach has to say is, is yes, but no. So the rules are probably overly restrictive right now. There's times I think I should be able to do a medial branch block or an ablation and I can't because the rules are so restrictive. But those rules are in place because, I wish I could give you the actual papers, but I know we surveyed members of Ipsos, which people would say are like the most conservative of the injection people. And that survey was done before the new Medicare rules. And there was still a good chunk of people that were, their most common practice was doing three levels bilateral procedures because that's what was getting paid. And so you could see that like a lot of people were just practicing to the ceiling of what they were allowed to do. And then once the insurance changes came out, started with Medicare and then through most private insurers, I saw another paper that was same thing, just kind of describing practice patterns and in that paper, everyone was doing two levels bilaterally, which is the most you can do now. And so there's restrictions, which stink, but those restrictions and we can all blame insurance companies. And like, I don't think any of us really like dealing with insurance companies, but they put rules in place because you look at the data, we all, most doctors doing this tend to do as much as they're permitted to do. So then they're going to put more guardrails up. So we kind of have ourselves to blame for why I would say yes, but no to your question. We're going to close. Our time is flying by, although we're having a great discussion. We wanted to get into the second case. We're moving on and even in the first case, you guys thought maybe there was a little bit more discogenic property to the patient and even facet mediated, but let's switch to a case and we can even think about the first one still with axial pain. Second one was axial pain. Once again, with mechanics, we were talking about more discogenic from a flexion standpoint, still no radiculopathy or leg problems and things like that, but one of the things that is a requirement to go after treating the disc is the MODIC changes, correct? So I just threw in the slide of what MODIC changes were from one of the original articles, and this isn't necessarily just specific to this patient, but I guess as we move into talking a little bit more from the facet or posterior elements into the anterior part, this person had had some previous epidurals done without response and then had bilateral transforaminals done without response. I would still make the comment as the moderator that it's fascinating to me that they come into our clinic having had five to six procedures done and have still never gotten an exercise program or been to physical therapy to learn what to do to help manage their back better. So I'm going to throw that out that in this case, let's say they had, so we're not in a debate about the PMNR aspect of it, but we're really up to what do we think about in more discogenic pain moving past the posterior elements, and I'm going to let Zach start off with talking about the things that you do to consider basal vertebral nerve ablation or when that fits in, once again, age-wise, and do you have to do posterior element evaluation before you're allowed to do anterior treatment? Zach. Sure. So real quick, let's just rewind to the first slide where you showed a little bit of the demographic information and history exam. So you have to keep going back before this slide, too, to the demographic. There we go. So 31-year-old, so this is now more we expect with discogenic pain, and I guess maybe taking one more step back, I think it's probably helpful to sort of define, we throw around the term discogenic pain, and there's definitely been a bit of an evolution in the past five or so years where we're talking about discovered vertebral pain, and sometimes it's really hard to distinguish what is end plate and what is annular pain. But importantly, you've got a couple different pathways for nociception that are relevant to the anterior column, right? So the end plate is innervated by the basal vertebral nerve, and we'll certainly touch on basal vertebral nerve ablation, Winston indicated considerations of the procedure. And then separately, you've got innervation to the disc annulus, posterior annulus, by the sign of vertebral nerve. So you have really these two distinct pathways of nociception, and we are okay at understanding what might be more end plate dominant versus annular dominant type pain, but we are far from perfect. And there really is no single imaging exam, injection-based test to really understand how much of it is annulus and how much of it is end plate, but I bring that up because this example, the MRI you're showing, type 1 modic changes, this person may have dominant vertebrogenic pain mediated through the basal vertebral nerve. They may have dominant annular pain. They may, I actually don't think this is the correct step in this patient right now, but if they had a basal vertebral nerve ablation, we don't know what the outcome would be just based on what you've shown us. So this modic change, type 1 or 2, is one of a variety of, it's the core imaging biomarker for selecting a patient for potential basal vertebral nerve ablation. But in this young woman, so she's got 4 to 8 out of 10 pain, which would not be uncommon with discogenic type back pain, and we argue in history that pain is worse with standing, excuse me, with flexion. So, all right, it's all fitting, right? The first thing I would do is reboot on the PT conversation. So if I hadn't evaluated her, I want to know exactly what was it that she did in physical therapy and what can we add? Can she see someone that I have a high level of trust in as a physical therapist and is there anything else, additional pearls they might be able to add to the program that she's been following? So I'm not going to just assume that she's had all the PT that's going to help her. Number two is I wouldn't be offering her basal vertebral nerve ablation, even let's say that she's been through PT with someone that I trust and she's struggling and frustrated and I'm assuming it's very much affecting function and she's very unhappy. So we are going to consider a procedure. I would do an intradiscal steroid injection in this case. So there is actually a literature on this and our group at Utah put together a systematic review not too long ago. In the context of type 1, especially type 1, but type 1 or type 2 modic change, intradiscal steroid actually has reasonable effectiveness. So I have started doing intradiscal steroid injections in the past four years. I didn't train doing them, but we introduced them actually because in folks that are appropriate candidates for basal vertebral nerve ablation, which I know we can talk about more, early on when the procedure was first rolled out and still today, those who do it know, somebody might have a 3, 4, 5 month waiting period before the procedure is authorized through commercial payers. So we were looking for something that maybe would help bridge the gap for these folks. So our group started doing intradiscal steroid injections and I will tell you, I'm not sure if others on the panel have the same experience, but these injections can last for six months or a year in these folks with especially type 1, but type 1 or type 2 modic change. The other little, I guess, interesting comment that I'll make is that in these folks with especially type 1 modic, there's some thought that in a subset of them, this could be related to P. acnes infection or other anaerobic bacterial infection, bacteria that can live in the disc, you know, oxygen deprived environment, and that you may actually be treating the smoldering P. acnes infection if you do an intradiscal injection, which I hope, you know, most people are adding steroid to. I would always add ANSEF or something else if allergic. So do you put antibiotics in with the steroids? I do. I'll mix. I typically use Kenalog, mix it with ANSEF and then Rapivacaine because you've got a cartilagin plate and Rapivacaine is the least contra-toxic of the anesthetics. So we get six months of relief. She's now 31 and a half instead of 31. So yep. And if she got six months of relief, this is, she is a candidate in theory, you know, based on what we have, she is at least radiographically a candidate for radiofrequency ablation of the basal vertebral nerve. I don't know that that image you showed was, this was not the case example, correct? So yeah, exactly. I'm not talking about number of levels yet, et cetera, but she's on the younger side. I will say that, you know, similar to what Dr. Desai put together on some of the PNS the two large RCTs that evaluated the SMART trial and the intercept trial that evaluated basal vertebral nerve ablation versus sham and then subsequently basal vertebral nerve ablation versus conventional medical management. They included patients that were as young as 25 or 26 years old. Now to be fair, that was a minority. And I don't know that I couldn't find, I don't think that there are numbers from the trials. They don't tell us how many are, for example, younger than 30 or younger than 40. The mean age in the first one I want to say was 49 and the second one was 46. So these aren't older patients that were included in the trials. I mean, they are, you know, late 40s to early 50s and that's reflected in additional non-controlled trial literature that's come out. But I wouldn't say that this is, the basal vertebral nerve ablation procedure is, you know, something that you absolutely shouldn't be doing in someone who's 31. I think there are, there's going to be a case by case, you know, a process of counseling the patient and trying to understand how bad is their function. How much is this affecting their life, their occupation, all of it. Right. And for the future changes and that's why if you wouldn't mind passing over to Wenchin. I mean, part of the reason we have Wenchin is he's an expert in regenerative medicine and the research going on there. And so the question in my mind was many of these other procedures are a degenerative, an ablative procedure and regenerative medicine theoretically is not an ablative procedure. It's more of a process. Would it change things for the future? Should we start to consider young people more for regenerative medicine earlier as opposed to ablative procedures as opposed to waiting until that first patient with the disc that's almost totally collapsed and degenerated and not probably going to recover very well, things like that. Wenchin. First off, you know, when we talk about, I'm running back to the facet. So how many levels shall we do on the medial branch? How many levels shall we burn? Remember, the medial branch, if you look at the nerve, it is quite a large motor nerve. It goes to the mortificus in the lumbar spine, semispinalis in the cervicals. We are physiatrists here. We send patients to go train and the key purpose of the training is to keep these muscles strong. In the meanwhile, I think we should try to minimize the levels as we burn it. Don't burn too many. If you burn five, definitely your mortificus is going to degenerate quickly, a lot faster, and then becomes, you know, fibrostasis is there's no return. So try to, but regarding this degenerative processes, so I agree with Dr. McCormick where, you know, there's no good treatment, but a anti-inflammatory approach is a good approach moving forward. So what is a disc degeneration? If you think about the pathophysiology of the disc degeneration, there's cell loss, there's matrix loss, and there's loss of the water content. So the cell loss is natural, but with genetic and mechanical issues, you may accelerate in certain levels. That's where you have inflammatory processes and then inflammatory processes accelerate the matrix degradation. It activates the matrix degrading enzymes and downregulate the matrix synthesizing. So that's a, so the cell loss, matrix loss and finally the pain. How do we feel pain? We have a nerve fiber and at the end of a nerve fiber there are a lot of receptors to your pro-inflammatory cytokines that opens up your calcium channel. That causes you have action potentials that's going to go in a higher frequency transmitted to your spinal cord you interpret it as a pain. So the inflammatory processes is directly related to the perception of pain of course and then of course this whole process then when we treat that there has been many therapy that has been tried and I think we should go into the direction first you know controlling inflammatory processes locally and then corticosteroid can be tried somebody tried the TNF alpha antagonist these are all there are studies going on but from the regenerative medicine perspective we're talking about mesenchymal stem cells. We're talking about gene therapy. We're talking about cell product therapy such as the extracellular vesicle therapy. Why do we use those? The first hypothesis of these regenerative products is that they do have a immunomodulatory effect. Essentially they produce anti-inflammatory cytokines and looking for the intended it took one RNA and then they decrease the you know expression of the MMP3, MMP13 and they upregulate your type 2 collagen. They upregulate the SOX9 so that in the sense they are number one anti-inflammatory that's what we are trying to that's what we're hoping for. So if we are accomplishing anti-inflammatory effect so first well the matrix degradation a degradation is going to slow down get halted right so that's the first so this preservation is a first step so anti-inflammatory is targeting on that but then Dr. Atchison asked about how about this regeneration. This regeneration is in the next step so that's a two-part answer of that. For this regeneration you're gonna have to study the disks phenotypes and finding out the most important molecules in the crossroad of the regenerative processes and this can be done this can be done as far as you get the good disk bad disk and sequence them and do the bioinformatics studies and there has been many of that just not ideal so the next step is to find out which would be a good sequence to target on you can start with simple ones such as type 2 collagen and you can start from some of the SOX9 for example so these are potentially genes you can target by what by using gene therapy tools like using a vector viral vector or you can put a gene in a cell and put a cell in this or you can put the gene in the extracellular vesicles nanoparticles and then that will be the future of this so what we are looking at at this point are we gonna be are we on money do we how much do we know we're gonna be successful in vitro studies we have very good results in vivo we have been working on animals for the past two years we tried virus which had viral transduced cells we tried other types of a gene modification of the stem cells and then put into it animal animal study is tough because if you are gonna we don't have an MRI for so that's one of the things we don't have an MRI for animals so so that's a little bit difficult but we do collect the gene PCR and the protein study that that shows actually it does help so how much of that is gonna be a break yeah that's it I see my whole ready to weigh in leaning forward heavily I was gonna go back to something dr. McCormick mentioned which was this concept of sort of disco vertebral pain right so it's very hard probably in clinical practice to distinguish whether the pain is coming from the disc or the vertebrae or vertebral body or in this case the end plates and most at least some of the I'm sure the people up here but some of the folks in the audience remember like I debt and then by bioplasty I think we actually had a debate it a few yeah a few years ago about about bioplasty so one of the questions I guess open questions is that it are there are we ultimately gonna have to treat both the disc and the vertebral body so are we gonna have to do things that can get to the sign of vertebral and the base of vertebral and or are they going to be singular targets like the ventral rami prior like where the where it branches off into the sign of vertebral which then gives you the base of vertebral also right so one of the questions we've asked is that if you've looked at some of the dorsal root ganglion stimulation literature where people are stimulating the L2 dorsal ganglion are they really selective to the L2 dorsal ganglion or are they actually getting some stimulation of the sort of the sign of vertebral base of vertebral complex because they're all sort of originating from that very same area and it could be that they're getting great pain relief because of a sort of a combination of mechanisms as opposed to just dorsal ganglion stimulation while we're commenting on this there's a question came in online from the group the streaming about does anyone use discography to try to sort this out at this time I'll comment no and mainly because that's the shortest answer we've had so far let me explain so there there's good data basically that with provocation discography we're talking about you know provocation discography not just injecting contrast to sky but provocation to try to recreate what's typical back pain and you know following the operational criteria from ipsis ISP etc you while you stretch the annular fibers and you're gonna produce nociception through the sign of vertebral nerve in that in that process you also create end plate deflection and that's going to create nociception to the basal vertebral nerve so some people think well maybe if we do you know very low pressure provocation discography that will select out people who have more annular dominant pain that could be true it's never been tested and frankly because the intradiscal steroid injections in my experience again and based on our systematic review to work decently well I'd rather put some steroid in and do essentially a poor or pseudo diagnostic and therapeutic injection if we're going to put something into the disc and puncture the annulus with a needle yeah I feel like that's a common question or yesterday in another session someone asked about like doing a block before BVN ablation I'll still Matt Smukes line which is just like it's really common for us in medicine to do a treatment based off of imaging or something like not all pain procedures need to have a pain block to select them out and I wanted to just briefly touch it's not my topic so I'll try not to talk too much but on the question about biologics like I am glad there are really smart people trying to figure out what's going to work in a disc and that'd be really cool if we had gene therapy or some formulation of stem cells but your question of like would you consider it for this patient I I wouldn't because there's not a lot of compelling evidence at all in my opinion that the things that are available to us work very well and the reason the data is not compelling and I don't have an answer why I want to say it's to see what other people think the reason it's not compelling is every study that looks at stem cells or PRP the outcomes look really good but they don't demonstrate efficacy because no matter what they choose as the sham the sham does really good too and then everybody goes like oh well maybe the antibiotics had a treatment in the disc or maybe the anesthetic wasn't active like no matter what people choose as a sham the sham does really well too so my answer to this would be like I'm open to put a steroid in a disc or something I can't because of where I'm at but like that's a good option but there's this weird irony that the answer might be like yes stick something in the disc because discs tend to feel better when you put something in them but I don't know if it needs to also be PRP or something because those actually carry confer a risk of discitis and things like that probably because of how it's processed it's not this clean drug it's been handled when you draw the blood and spin it and like there's probably a risk to putting in PRP you'd probably make them feel better but you could probably put something else in there and make them feel better too whether it's steroids or antibiotics or who knows to your point if you look at a lot of the studies that are being designed now that are assessing some sort of intradiscal inject it everyone is basically making a strong effort to not put anything into the disc as the sham group because probably even injecting saline is rehydrating the disc to some extent you know for how long who knows but there may be therapeutic effect of just saline in the disc I think the other thing is you know like I mean we talk about all these products I mean really commercially I think most of us have access to PRP and you could probably go down a rabbit hole of how PR like how good is the PRP that you're getting based on the sort of the centrifuge you have and all sorts of other sort of technological elements and then bone marrow concentrate is probably the best like relatively readily available version of or a stem cell rich product because really there's no such thing as a stem cell product per se like that's because it's not it's actually illegal from the FDA to market stem cells as something that you do for patients except under the auspices of clinical trials I think there's some really exciting things being studied we you know again I'm in the community setting we get patients that come to us and they're like all I want is PRP or all I want is bone marrow they're not willing to entertain any other conversation and I think that in those settings you do have to have a really like honest conversation with them about the likelihood of success right so like if you were to stack these things like intradiscal steroids intradiscal PRP intradiscal BMAC like what is the likelihood of improvement and it's it's it's hard to really quantify in a really honest way because we don't like like you described that sort of the flaws with all the studies that exist so I think it's sort of I try to undersell it as much as possible you're you could always go to talks where people sit up and anecdotally tell you like every one of my patients is great and they're all cured but that's probably not realistic it's probably not honest I think the reality is that some people are gonna improve and if if they understand the risks and they're comfortable with the likelihood of success within reason that you can suggest and it's I think it's reasonable to consider it but in the absence of having that honest conversation I think you're sort of doing each other a disservice we've got about five minutes left we wanted to just touch briefly on a third case with more potential SI joint mediated pain in a in a young woman who's already had a pregnancy and delivery and also kind of non-specific symptoms that would seem to fit in with some of our limited physical exam skills to discern SI joint mediated pain along the way and the the idea once again in this younger age group imaging and the SI joint anybody find usefulness with SI joint imaging in particular to help discern making our decisions not really the the idea of in this area we move into with younger women maybe hypermobility type questions and things along that area also we actually had an online question about that as we were talking about things coming in but heading down the discussion of procedures once again to the joint or part of the issue is the idea of stabilizing this area versus it seems like with lack of approvals now for certain procedures we're almost forcing people to think about SI joint fusions which I think is probably one of the more controversial areas we would be able to talk about and see so Mahul you you kind of brought the case to start with you want to comment for I think if we go back if you don't mind to the first slide of the case I think there's some key factors here right so and I think that these patients probably deserve a lot more thorough assessment than we're often able to give them because they just they have a lot of complexities so in this patient there's there's a key one of the key elements here and I put this here on purpose is this prolonged labor with a grade 2 episiotomy right so this patient had an uncontrolled episiotomy during delivery so that results in a fundamental change in the pelvic floor hypertonicity right so now you've got this pelvic floor that has changed essentially forever you know when we when I first started training there wasn't this conversation about the fourth trimester now there's this concept of a fourth trimester but I feel like I'm you know having not pushed a baby out of me I feel like it's more like a year if not more that that fourth trimester is a much more protracted period of time and these problems that can come from it can can exist for a lot longer so I think that was one key part I think of the next slide I think this this whole idea of I don't do people use the biting scale in their practices anyone so I probably in the last three years have seen maybe I'm and this is gonna sign hyper sound hyperbolic but maybe the most hyper mobile patients of anyone in the country on average I see like six a day maybe more than that on some days people come from all over and I think that it's it's it is a controversial kind of area it's hard to assess these patients they tend to have multifactorial issues but for those patients who are hyper mobile do we have like what is our thought process for these patients because historically we've thought about the joint as the problem but is it really a ligamentous issue right and a lot of the things we do for interventions are either we make an assumption like we did an interticular injection they had good relief it's it's coming from the SI but is it really coming from the joint or is it coming from the ligaments that hold the SI joint together so I think that was sort of the idea behind this case of having so one of the things we've come up with is this idea of like sort of a intrinsic extrinsic SI joint so is it the joint or is it the ligaments or hyper mobile hyper mobile like is it that it doesn't move very well because it's arthritic or it moves too much because it's hyper mobile and I think that kind of changes the way we sort of approach these patients as opposed to sort of this traditional way of being like throwing out one other thought about stability then would be prolo therapy so we published so we had a we used to have a physical therapist like an amazing PT in our practice that helped us come up with this prolo therapy protocol we've probably done about a hundred patients now where we've we do the pubic symphysis the SI the ligaments around the SI joint in the ilial lumbar ligaments and we put them in an SI belt and we do it three times over five five weeks and it's we need to obviously publish it because we published a couple of cases but it sort of does I think as you as you talked about we really can't get RFA for the SI joint covered anymore I don't know if you guys are having different experiences but we cannot get it covered and so now you're seeing this in enormous proliferation in SI fusion and the fundamental question about SI fusion is are you infusing anything and do you even know how to fuse something right so like the average pain doc doesn't actually know the fundamentals of fusion they're stabilizing a joint potentially but they're not fusing a joint so that's inherently a giant open question right so like just putting three screws across the joint doesn't fuse it it actually just stops it from moving around as much as it does before but even the concept of you know are you putting these in osteoporotic people where the screws cavitating are you putting are you stripping the joint of cartilage putting bone graft into it and then fusing across that so you could actually get a fusion construct as most of the studies actually don't do post fusion CT scans so they don't even have imagery to tell you if it fused or not so I think there's a lot of open questions about this area sorry well I think it would be obviously getting that last case in at the last moment but the controversial area once again at 27 back to the point is there osteoarthritis in that age group in any of the other structures probably not so just addressing something like that potentially not a value but doing an ablation versus other things that might proliferate some tissue we don't know prolotherapy has some basis of that we heard yesterday in the regenerative medicine session by Dr. Bowen that he put it in as kind of one of the precursors even to moving into PRP and other areas because it created at the inflammatory process at that point and to see unfortunately we're out of time and the questions we kind of overlap with some of the things we talked about here along the way with that I'm sure the the panel would be happy to stay in chat if there are specific things to do otherwise but I'd like to thank them for all throwing out their thoughts and kind of debating with each other a little bit and hopefully had a good session and thank you for coming

pain management

younger patients

diagnostic advancements

epidural steroid injections

radiofrequency ablation

basal vertebral nerve ablation

neuromodulation

regenerative medicine

sacroiliac joint pain

individualized assessment

conservative management