Good morning, or good afternoon, everyone. Thank you for joining us for the research spotlight in pain and spine medicine. I am Alexios Karanopoulos, I am the chief of PM&R at Brown University in an academic affiliated medical system, and I'm on the evidence committee, and we are very delighted this year to have had so many abstracts submitted, and high quality scientific abstracts, clinical abstracts, and today we are going to have presentations which are prerecorded from the four best that we found within the field of pain and spine medicine. So each presenter has a lot of time, they're all the same. There is a chat box, a Q&A, where you can present questions to each of the presenters which will be done at the end of the session, and we really would like to make this an iterative process, really get to know a little bit about the research, the focus, and of course introducing all of the speakers, and we're hoping that sessions like this really promote academic activity among our young physiatrists and collaborative spirit. So in order to move forward, I'd like to introduce the first presenter, Dr. Kevin Barrett, or Buzz Barrett, received his medical degree at BU School of Medicine. He won a travel grant from the National Eye Institute for research in diabetic retinopathy. He graduated from the Stanford PM&R program where he was the chief resident. He was awarded an Excellence Award during residency. He's a recent graduate of the PM&R Interventional Spine Fellowship as well, and his current research interests include the use of technology for optimizing patient care, management of facet joint-mediated pain, and vertebrogenic block pain. He recently joined the Department of Neurosurgery at the University of San Francisco in California and assistant professor to begin the next phase of his career. So we welcome Dr. Barrett. All right, perfect. Hey everyone, I'm Buzz Barrett. I'm coming to you from University of California, San Francisco, and I am very happy and excited to talk to you about this study today, basal vertebral nerve ablation for the treatment of chronic low back pain. These are the 12-month results I'm presenting today from the Intercept trial. I don't have any personal disclosures, but there was funding for the study by Relieve and MedSystems who make the device for the procedure. So chronic low back pain is a really big issue in the spine world. It ends up affecting about 10 to 30% of the U.S. population, and it can really be a challenge to deal with for spine providers. The causes can be varied, they can be complex, and oftentimes the available treatments that we have have low effect sizes. One of the relatively newer clinical concepts is this idea of vertebrogenic low back pain. That is pain emanating from the vertebral endplates themselves, and these are innervated by the basal vertebral nerve. So modic changes, as most of us know, have long been associated with disc degeneration and chronic low back pain. And the density of endplate nociceptors actually increases with disc degeneration. And it's actually higher at the endplate than the disc itself. And the first image here is just showing increase in density in areas where there is disc degeneration. So these nociceptors end up tracing back to the basal vertebral nerve, and that's highlighted in red on the image on the right side of the screen, which obviously begs the question, can this nerve potentially be a target for a therapeutic radiofrequency ablation? So there was a previous double blind sham control trial of 225 patients, which demonstrated the efficacy of intraosseous RF ablation of the basal vertebral nerve to treat chronic low back pain in a specific subgroup of patients with modic type 1 or type 2 changes in the vertebral endplates. So based on these results, this randomized control trial was designed to help patients with modic type 1 or type 2 changes in the vertebral endplates to compare the effectiveness of this procedure to standard care in patients with modic type 1 or type 2 changes and chronic low back pain. So this is the data that we're presenting today, and this is called the Intercept Trial. So it's a prospective parallel open label randomized control trial, 140 patients that were recruited across 20 sites in the U.S. Study participants need to have six months of non-responsive low back pain, modic type 1 or type 2 changes, minimum ODI of 30 and VAS of 4. They were randomized one-to-one to undergo basal vertebral nerve ablation or standard care. And the image on the screen here is showing an example of the basal vertebral nerve ablation procedure. So it's a unilateral transpedicular delivery system. So the RF electrodes actually advanced through the pedicle under fluoroscopic guidance into the vertebral body where the basal vertebral nerve lies. And then at that point, there's a 15-minute thermal ablation performed at 85 degrees Celsius. The main endpoints that we were looking at was between arm comparison of the least squared means change in ODI from baseline. We also looked at VAS scores, SF36 and EQ5D5L. The original intent was to compare standard care and ablation over a two-year period. But there was an independent data management committee recommendation that enrollment actually be halted early and that standard care R&D offered early crossover given robust statistical significance, statistical superiority of basal vertebral nerve ablation over standard care at a pre-planned three-month interim analysis. And I do want to highlight this because this is really extremely rare in the back pain literature. So the data I'm presenting here is the entire randomized control trial cohort at the three-month primary endpoint and at six months, and also the 12-month results of the entire basal vertebral nerve ablation arm and the results of the crossover group. So to get into some of the data, first, we'll look at the primary endpoint, which is the first data table on here, which is the difference in least squared means change in ODI at three months. And you can see here there's a 20.3 point difference in change in ODI from baseline favoring ablation over standard care. And this was continued at six months. Similarly, there was a 2.52 and 3.27 point VAS difference between the groups at three and six months, respectively. If we turn our attention over to the figure on the right, the bar graph over there, we're looking at categorical data here. Blue represents the basal vertebral nerve ablation arm, and orange is the standard care arm. And we're looking at responder rates here. So we define responder rate as a greater than 15-point improvement in ODI, greater than two-centimeter improvement in VAS. And there's a combined responder rate as well, which is greater than 15-point ODI improvement and greater than two-centimeter VAS improvement. And you can see at both three and six months, much higher responder rate for basal vertebral nerve ablation than standard care. So importantly, let's take a look at some of the longitudinal data. So on the left side of the screen, we have longitudinal data for ODI, Oswestry Disability Index, which is the top graph, and then right below it for the visual analog scale, so their pain scores. And you can see here, there's a fairly statistically significant and importantly, clinically meaningful change and improvement in ODI and VAS after basal vertebral nerve ablation, which is the lighter blue line here in this graph. Standard care arm pretty much just sort of stays at its baseline level. It's represented in the darker blue lines. But the dotted lines represent the original standard care arm after they crossed over. And you can see a similar decrement in both ODI and VAS, basically bringing them down to the original ablation arm after they also underwent ablation, which really helps to reinforce the reproducibility of this treatment. And importantly, you can also see over time, we go out to 12 months in the original basal vertebral nerve ablation arm, and they're still having a similar decrement in ODI and VAS. Finally, we'll take a look at this graph on the right. We separated patients out by percentage of pain improvement at 12 months after basal vertebral nerve ablation. And you can see here, unfortunately, about a quarter of patients didn't have much improvement. But that being said, 65% of patients had greater than 50% improvement in their pain after 45% had a greater than 75% improvement in pain, and 30% actually had complete relief of their pain. So in patients that this procedure helped, it really seemed to help to a large extent. So to summarize, patients treated with basal vertebral nerve ablation exhibited statistically significant and clinically meaningful improvements in ODI and VAS compared to standard care at three and six months, which really demonstrates the effectiveness of this procedure. And these results are durable up to 12 months so far. These results are also reproducible. This was performed at 20 clinical sites with different providers doing the procedure. So basal vertebral nerve ablation is an effective procedure for some patients with chronic low back pain. And I do want to highlight these are carefully selected patients with refractory chronic low back pain of suspected vertebrogenic origin with MRI evidence of MODIC type 1 or type 2 changes. So these results are not generalizable to the greater back pain population. But it does seem to be an effective procedure for patients with suspected vertebrogenic low back pain. Thank you. Excellent presentation. Thank you so much. It's really exciting that we now have new targets for chronic low back pain, which is a burgeoning spine physiatrist, interventional physiatrist, who we find can be very challenging to deal with this cohort of chronic unrelenting back pain. All right. So going on to the next the next presenter, this is Bo Sperry, who is an undergrad or excuse me, a first year medical student at the David Geffen Medical School of UCLA. He was a research assistant and outcomes analyst under Dr. Zachary McCormick at the University of Utah School of Medicine's Division of PM&R. And he's interested in interventional spine techniques, neuromodulation, and brain injury medicine. So we are especially excited to have somebody so early off in his career join our esteemed group. And we're looking forward to hearing some of his research interests. Bo Sperry, Mr. Sperry, please go ahead. Hi, everyone. My name is Bo Sperry, and I'm a medical student at the David Geffen School of Medicine at UCLA. And I'd like to thank AAPM&R and you all for your time. And I'm happy to be here, albeit virtually, to discuss this really interesting and promising case report. And before I begin, I'd just like to say that I have no conflicts of interest or other disclosures. And I would like to thank my colleagues at the University of Utah, notably Colt Chaney, Erin Conger, Hank Shipman, and Zachary McCormick for their help and guidance on this project. So I'll begin with some background. Phantom limb pain and residual limb pain are common causes of discomfort in amputees. And we see a substantial quality of life reduction in many persons undergoing amputation because of both phantom and residual limb pain. Despite the prevalence and the severity of phantom limb pain, treatments to address PLP phantom limb pain are not standardized. Surgical neuroma resection, opioids, tricyclic antidepressants, NSAIDs, Botox therapy, mirror therapy, and other modalities have all been tried but have shown mixed results. And to begin with the case presentation, our patient is a 61-year-old female with a history of right below knee amputation, strick of 2000, so about 20 years prior to presentation in clinic. And the below knee amputation was secondary to a sciatic nerve sheath sarcoma. The patient reported debilitating episodes of phantom limb pain lasting from 24 to 36 hours, approximately twice monthly. And this phantom limb pain was refractory to physical therapy, SSRIs, TCAs, gabapentinoids, opioids, and TMS and TENS. And if you look at figure one, we can see on this MRI neurogram, axial T2-weighted neurogram, about a 2.2 by 3.4 centimeter mass, contiguous with the sciatic nerve arc and distal to the sciatic notch. And given the size and kind of the starkness of the image, we offered the patient the option to proceed with a prognostic nerve block of the sciatic nerve. And the patient opted to do so. And 3 milliliters of lidocaine and 2 ml of Kenalog at 48 milligrams per milliliter administered at the neuroma site resulted in, very promisingly, over 5 hours of 80% phantom limb pain relief, followed by 10 days of reduced PLP incidence after the block. And given that encouraging finding, the patient opted to continue to radiofrequency ablation. And so you will be able to see in figure two, the three sequential images of the core radiofrequency ablation that was undertaken. Neuroma location and localization was undertaken using both ultrasound and dual fluoroscopic guidance. The neuroma's location in the infrapiriformis foramen was relatively difficult to access. And so using the multidimensionality of both ultrasound and fluoroscopy facilitated locating it and localizing it. After sensory stimulation and pre-ablation lidocaine administration, so 2 ml, 2% lidocaine, these three discrete but overlapping lesions that you can see in figure two were as administered at a temperature of 60 degrees Celsius and for approximately 2 minutes and 30 seconds per lesion. And so very encouragingly, the patient reported 95% reductions in phantom limb pain at 1, 3, and 6 months post-ablation. Patient reported being very satisfied with the procedure and the patient noted an increased ability to ambulate and participate in daily activities after undergoing the cooled RFA. And most excitingly, the patient no longer reports any functional limitation related to phantom limb pain. And we report a novel use of cooled RFA technology to treat phantom limb pain. But previous radiofrequency modalities have been trialed for PLP. Notably, Zhang and colleagues treated phantom limb patients with conventional radiofrequency ablation in a kind of runoff study in which the primary intervention was alcohol neurolysis. So individuals who did not respond well to alcohol neurolysis were given conventional radiofrequency ablation in both upper and lower extremity amputees. And then there's also a case report by Kim and colleagues where they used a pulse radiofrequency modality to treat a large sciatic neuroma. And there may be potential advantages for cooled radiofrequency ablation. Perhaps most notably is the ablation size. Cooled radiofrequency ablation provides an increased lesion expansion and diameter and an overall tissue volume captures increased relative to conventional RFA. Perhaps equally important is the lesion geometry that's produced in cooled RFA. The spherical lesion geometry of CRFA may facilitate neural capture and ablation in areas that are otherwise difficult to access using the parallel approach, or excuse me, perpendicular approach that traditional RFA offers. And to conclude, we report a novel cooled radiofrequency ablation application to phantom limb pain with a very exciting outcome. And we recommend further study of cooled radiofrequency ablation to treat phantom limb pain in larger carefully selected cohorts. And we believe that subsequent evaluations of CRFA for phantom limb pain should consider effects of this intervention, not only on pain, but also on physical function, mental health, and quality of life, as well as other secondary assessments as relative. And that's everything I have. Thank you so much for your time. I really appreciate it. I look forward to your questions. Thank you. Excellent talk, MS1 Sperry. It's exciting to see this technology, actually radiofrequency ablation, which came out of thermal RF, now expanding to cold RF, be applied to different areas. I'm sure there'll be some insightful questions going your way. All right. So we're going to do our third presenter. This is from Dr. James Mealing. He is currently a PGY-2 resident at the Mayo PM&R program. He graduated from Brigham and Young. And he got his doctorate, his DO, from the University of North Texas Health Science Center. And he just completed his prelim year in Weatherford, Texas. And we look forward to hearing from Dr. Mealing. Please go ahead. Hi. My name is James Mealing. And this is my presentation, Radiofrequency Techniques for the Alleviation of Post-Amputation Phantom Limb Pain, a Systematic Review. I conducted this study with Brandon Barnt, George Rom, Nicole Nguyen, and Christopher Ha, co-residents and friends who helped me out with this, and I'm grateful for that. So as a little background of this study, we were looking at post-operative pain and reasons people feel this pain and ways that it could be treated. One such way, or one such pathology was that of phantom limb pain. There are pharmacologic, interventional, and I think some surgical ways as well to treat this, but normally people kind of lean towards the pharmacologic route. With that being said, we found, we wanted to look for an interventional route that could be used to treat this, and we stumbled upon radiofrequency techniques. So radiofrequency has been used in the past and currently for spondylotic and facet-mediated neck and back pain. It's also used for osteoarthritic knees and pain that happens after a total knee replacement. And we postulated that since pain sensation is an afferently moving neural impulse, that if you modulate or ablate the proximal section of the nerve that produces the pain alleviating effect, that you might have a pain relieving sensation, even if the location that's contributing the pain isn't physically present, like that in phantom limb pain. So that being said, we did a review of the current literature regarding the efficacy of radiofrequency techniques, specifically including radiofrequency ablation, pulse radiofrequency, and low-temperature plasma radiofrequency ablation, or coablation, for the alleviation of phantom limb pain. So we used, as our methods, we performed a PubMed and database search through December of 2019. We constructed a search term using the following phrases, radiofrequency, radiofrequency ablation, radiofrequency neurotomy, and that of phantom limb pain. In order to be included in our literature search or our review, it had to pertain specifically to the treatment of phantom limb pain with any radiofrequency technique. And the articles had to be in English and published within the last 20 years. Articles that were not included were ones that discussed the treatment of other post-amputative complications, including neuroma or generalized stump pain, and in which radiofrequency was not used for treating, or was used for treating other non-phantom limb pain complications. So ultimately, out of all the articles that we were able to find, there were seven that fit into the criteria that we had laid out. And you can see those seven articles within the table on the left of the screen. The one of those articles was featuring radiofrequency ablation, five featured pulse radiofrequency, and one featured coablation. And I'll be going through each of these different types of techniques. So if you look on the right side of the screen, radiofrequency ablation, this one article featured four patients. Just as a background, radiofrequency ablation is where they take a high-temperature specific needle tip that induces a lesion to a specific nerve that then provides pain relief, essentially burns away in that area. And so when we looked at that, of the four patients, three of the four, 75% had complete relief of phantom limb pain. One of them, or the 25% that was left, had decreased levels of pain compared to pre-procedure. So ultimately, all had relief, but three actually had complete relief. Next were the five articles that consisted of pulsed radiofrequency. And within these, there were seven patients total. Pulsed radiofrequency differs from radiofrequency ablation in the way that ablation is a continuous effect at a high temperature that burns it away, whereas pulsed radiofrequency is more of a, it's more of a kind of a repeated pulse and silent periods in between, and it's done at a lower temperature. High temperature for ablative is more in that 60 to 80 degrees Celsius range, whereas the pulsed radiofrequency is below 42 degrees Celsius typically. And the structural damage is minimal and the temperature-related damage is not ablative in these patients. So four of the seven, or 57%, had clinically significant reduction of phantom limb pain. Three did not show significant relief of pain of those three. Two showed increased responsiveness to their pain medications, though, that they were taking after receiving this procedure. And one reported only transient relief for the first few days. The last article we found was that about coblation, or low temperature plasma radiofrequency. What happens in this one is that they excite a little bit excite electrolytes in a conductive medium, which then produces a energized plasma. The plasma is then brought into contact with the organic tissues and creates active radicals with enough energy that breaks molecular bonds, then causes tissue dissolution. So with this type of technique, we had one patient, just this case report, and they reported reduced phantom limb pain. And so as you can see, the seven articles that we had, they were all either case reports or case series, as there are no other retrospective trial, or trials out there at this time regarding these procedures. So that being said, though, if you look, nine of the 12, or 75% of the patients who did receive at least one of these radiofrequency techniques, whether ablation, pulse radiofrequency, or coblation, did receive significantly reduced phantom limb pain. And so in conclusion, despite a limited quantity and quality of evidence, considering they were all case reports or case series, using radiofrequency techniques for chronic pain, relief of phantom limb pain, has potential benefits. And we look forward to future studies that continue to help our patients who are amputees and those who experience phantom limb pain. Thank you very much for listening. Thank you very much, Dr. Meiling. I apologize, I mispronounced your name. Okay, so we're going on to the last presenter, the last abstract here. And that would be that from Dr. Chan. Dr. Chan is currently a third year PM&R resident at Stanford. He earned dual undergraduate degrees in molecular and cell biology, as well as nutritional science at UC Berkeley before attending Penn State Hershey College of Medicine. He completed his internship in internal medicine at Santa Clara Valley Medical Center. And he's a member of the AA PM&R SIS NAS, and his professional interests include musculoskeletal, spine, pain, and lifestyle medicine. He also has a special interest in quality outcomes improvement research, which is very important to our academy and our specialty. And in his spare time, he enjoys backpacking and scuba diving. So Dr. Chan, welcome, and we look forward to your talk. Hello, my name is John Chan, and I'm a third year resident at Stanford PM&R. It is my pleasure to tell you about our project, evaluating thoracic transforaminal epidural steroid injections for the management of thoracic spine pain, or TSP. TSP is not as common as low back or neck pain. Some estimate the lifetime prevalence ranging from 15 to 19% per year. TSP is also a major occupational health issue affecting one in five women and one in 10 men in the working population. TSP is most commonly caused by disc herniations, stenosis, or compression fracture. The most common presentation is pain in the thoracic region with or without radicular pain, referring to the anterior chest. First-line treatments are medications, postural adjustments, or exercises. For severe or refractory cases, epidural injections can be used. While transforaminals are commonly used for lumbar radicular pain, its effectiveness in TSP is less understood. Our study was a retrospective review of consecutive patients who underwent transforaminal epidural steroid injection for TSP between 2010 and 2018. Our patients were over age 18, had recorded NRS pain scores, and MRI imaging for review. Our imaging review process involved two spine physiatrists looking for disc herniation, degenerative stenosis, or both, with a third provider to resolve disagreements in imaging classification. We had 24 patients who fit our inclusion criteria. We classified a good outcome as greater than or equal to 50% improvement in pain. So what did we find? The first chart in the bottom left shows our patients' baseline statistics. Mean age of our patients was 59, two-thirds were male. Mean pain score was 6.1, and the mean duration of pain was 10 months. 12 out of 24, 50% of our patients reported radicular symptoms, and 12 out of 24 patients were on opiate pain medications at the time of their injection. None of our patients were on chronic opioid medications, and three out of 24 patients had prior thoracic spine surgery, and more broadly, 10 out of 24 patients had had prior spine surgery at any level. The second chart in the bottom left shows our follow-up statistics. We had a mean follow-up time of 32 days, a mean pain score at follow-up of 4.4, and that's down from 6.1, and we had no complications from any of the injections in our study. The gray graph shows our outcomes. Nine out of 24, or 38% of patients, had a 50% or better pain relief, and three out of 24, or 13%, had greater than 80% pain relief at one-month follow-up. The next two graphs show our outcomes data further stratified into those with disc herniation versus those with stenosis, and those with or without radicular symptoms. The graph in the top right corner illustrates our trend toward better outcomes in those with disc herniation, with eight out of 14 patients experiencing greater than 50% pain relief. The graph on the middle right side shows that in patients who had radicular symptoms, 33% experienced greater than 50% pain relief, and 25% had greater than 80% pain relief. This is compared to 42% of patients without radicular symptoms who experienced greater than 50% pain relief. I have to mention some limitations in our study. First off, that it is a retrospective chart review. Therefore, there was no control group, and as I mentioned before, overall, we had a small sample size of just 24 patients. So in conclusion, to our knowledge, this is the largest series of thoracic transforaminal epidural steroid injections for which we have outcomes data. The 24 patients over eight years demonstrates the overall low prevalence of patients with TSP who undergo interventional pain procedure. Overall, we had a low success rate of 38%. However, we did see a trend toward better outcomes with disc herniation. We may be able to improve outcomes through better patient selection. We're currently working with other academic institutions to compile and analyze a larger combined thoracic transforaminal epidural steroid injection data set. Thank you for your attention, and I'd like to open it up to questions. I just wanted to remind everybody that these four abstracts were among 480-plus that were submitted overall to the Academy this past year, and all of the abstracts were available. So I encourage everybody to ask questions by emailing the abstract presenters, and in the interest of time, so that we don't overlap into the next section, I'm going to start and ask a few questions. So Dr. Barrett, would you be able to touch upon patients who may have discogenic as well as facetogenic back pain, and how the treatment paradigm may differ or be complementary, and how one might be able to go and assess that? Yeah, it's a great, great question. As oftentimes, as we all know, sometimes it's difficult to figure out exactly what the pain generator is, which is usually how the paradigm starts for facetogenic pain to begin with. So I would say, in general, we would usually, if there is a consideration of facetogenic low back pain, try to rule that out as a source first. So we generally start with medial branch blocks and assess their response to that, and then, depending on their actual response, may progress to radiofrequency ablation. But in general, just given frequency of these problems and how well-studied medial branch block radiofrequency ablation paradigm is, would usually start there. And if there is continual low back pain, and we do see MODIC type one or two changes, and you become suspicious of vertebrogenic origin at that point, you might consider a vasovertebral nerve ablation thereafter. But in general, I think we should still stick to what is tried and true at this point, which, you know, medial branch block RFA paradigm. Terrific, thank you very much. Bo, MS1, spare, would you be able to discuss your thoughts on, in your particular presentation, on the utility of thermal RF versus cooled RF? Yeah, absolutely, with the caveat that obviously my practice is limited at this time. But we chose cooled radiofrequency ablation largely because of the lesioning geometries and the relatively complicated approach that was required for where that neuroma was located. But we think in neuromas that are particularly large, the combination of the lesion geometry and the increased volume of radiofrequency ablation and thermal element would result in kind of the necessary protein denaturation that could achieve a viable result. We would love to compare different RFA modalities in this population. And I think that's some future work that colleagues at the University of Utah are looking to undertake. Terrific, thank you, we'll keep an eye out. Finally, a couple more questions from Dr. Meiling. This treatment that you outlined was for alleviation of post-amputation limb pain. Would there be any utility in terms of changing the phenomenon of post phantom limb sensation with this technology? I guess there could, but I wasn't specifically looking at sensation. I was looking at pain more in this study. So I think I would have to kind of hit the books again a little bit and look a little further. Well, it would be an interesting concept in terms of central sensitization and the ability of the nervous system to be challenged or trained in terms of what it could feel later on in the future. In any case, we look forward to more research from you. And finally, from our last presenter, Dr. Chen, in terms of transforaminal epidural steroid injections, what are some of the major complications that can be seen in this patient population in this treatment modality? So we didn't see any complications in our cohort. I know that just because of the proximity of the region of the injection, there is potential for pneumothorax. There's also a potential for depending on, especially there've been some studies showing particulate versus non-particulate steroids. There is some potential for arterial dissection in that area. But again, I have to mention that there were no, although our sample size was small, there were no complications in our group. That's good to know. So it doesn't appear that there are any other questions from the audience. Do any of the presenters have any questions for their co-presenters that they might be able to pose? Yeah, I think I have a question for Dr. Sperry and I'm not sure if we missed it there. I may have missed something, but on the sciatic ablation there, was there any change? This is a thermal ablation, it sounds like. Was there any change in like knee flexion function that you're aware of in any of these patients since we were right around that sciatic nerve? There was no change in flexion that we observed. We saw the patient for follow-up at three months and six months and ablation was generally improved. Obviously, I think it's kind of a multifactorial issue when you consider like things like prosthesis fit. But no, there were like no mechanical deficits observed with ablating that area. Great, thank you. Okay, thank you gentlemen for sharing all of your thoughts. We at the Evidence Committee look forward to more contributions from you and your colleagues and we encourage your young and budding research career. Thank you for attending and please remember that these and all the other abstracts are available on the website. Awesome, thank you. Thank you. Take care.

pain

spine medicine

basal vertebral nerve ablation

chronic low back pain

cooled radiofrequency ablation

phantom limb pain

thoracic transverminal epidural steroid injections