Recording in progress. Good morning. My name is Mehul Desai, and thank you for joining us today for our morning session. I'm very excited to moderate today's session on the intersection of cancer pain and cancer rehabilitation. Thank you for making the time to be here with us this morning. So really excited about the faculty we've got here this morning. We've got Dr. Luke, who is the Interim Chair and Medical Director of Oncology Rehabilitation at the Department of Physical Medicine and Rehabilitation at the Ohio State University College of Medicine. She also runs the Cancer Fellowship and is really involved in sort of all aspects of cancer care. And we've got Dr. Kalea, who is the Program Director of the Interventional Spine and Pain Fellowship up in Rochester, New York at the Rochester Regional Health System. And he's the Editor-in-Chief of Advances in Clinical Medical Research and Healthcare Delivery. I'm gonna go through our disclosures very quickly here. For folks who are interested, you can peruse these at your convenience. And I'm gonna turn it over to Dr. Luke. In the interest of time, we're gonna get right into it. So Dr. Luke. Hi, welcome today to our talk. My name is Whitney Luke, as Dr. Desai said. So our objectives today is we're going to discuss common sequelae from cancer and cancer treatments. We're gonna elucidate some interventional pain management options for cancer pain, and then ultimately review implications of cancer pain on oncological rehabilitation. So for cancer pain, we know that pain is often a symptom for almost up to three quarters of our patients with advanced cancer stage of disease. For those that are cancer survivors or curative cancer, up to 33% of patients still continue to have pain complaints. Next slide. So when we think about cancer pain and why patients may complain of pain, we can often have tumor-related pain due to direct invasion of cancer into the bones, tissues, organs, or fascia. But then we often also will have pain related to their treatment. So post-surgical pain or radiation-induced fibrosis or plexopathies or chemotherapy-induced neuropathic pain. Next slide. So when we think about rehab and how to treat our patients, usually their ultimate goal is improved pain control, increased function, always returning home with their family. So a multidisciplinary approach is most important. For a multidisciplinary cancer rehab program, it's important to have all therapy lines. We have psychology embedded in our clinics. We work on the same floor as palliative care. We also have psychiatry and then interventional pain management. Collaboration is usually key for these patients. Next slide. So we're gonna go through some case spaces today of actual patients that were referred and go through kind of diagnoses, workup, and then any interventional treatment options for them. So this patient is a 62-year-old female with endometrial adenocarcinoma. She's status was chemotherapy and radiation. And she presented with significant right lower limb weakness that had been going on for about almost a year at the time I saw her, but it did not begin to six to nine months after her radiation was completed. She actually worked as a nurse in a nursing facility and it got to the point where she couldn't stand or walk or go to work. When she was referred, there'd been no imaging, no workup done. She had literally been just walking with a cane at home and to the point where she couldn't function. So she described the pain as very deep and burning in the right leg. And then it reminded her of when she had shingles previously. On exam, she had no patellar reflux. The left lower limb was fully intact, five out of five strength. The right lower limb, she had intact hip flexion and adduction, but nothing in her dorsiflexion and very weak plantar flexion. So the first thing we always think of is could there be metastatic disease somewhere, especially in someone a year later who hadn't had any imaging, no further workup. So we obtained an MRI lumbar pelvis in sacrum, which was negative. So the next thought was, okay, let's look at an EMG. Next slide. So for this patient, she ended up having a lumbosacral plexopathy due to radiation on EMG. In the right lower limb, that was the one that was mainly affected. She had positive waves and fibs in pretty much every muscle tested. When we started looking through this, she has from L2 all the way down to S1. We ended up getting then just an MRI of the plexus just to make sure, and it lit up due to radiation findings. And I find often that patients, when they get radiation, no one has talked to them that there is a delayed onset for radiation induced changes. So she'd actually been doing great. And then that six to nine months later is when this happened. So education is key, working with your radiation oncologist to make sure patients know the symptoms to be looking out for later. Dr. Kalia or Dr. Desai, anything? So yeah, this is, I think, a really interesting case and further solidifies the concept of a good rehabilitation model of care where an appropriate diagnosis and an appropriate treatment, if offered in a timely manner, we can not only improve patients' function, but also their quality of life. Exactly, and for this patient, we got her set up with an orthotist, got her an AFO, got her an appropriate mobility device. She wasn't able, unfortunately, to go back to working, but she has improved and she's able to garden and do the things that she likes to do. Yeah, so I think what you highlight there is sort of what are the best possible outcomes in this case, right? So in this case, the best possible outcomes are possibly resolution of pain, return to previous activities and quality of life. But it does sound like quality of life and improvement in symptoms was achieved. And I think that's a huge accomplishment in a patient like this. And it is a result, as you mentioned, as well as Dr. Kalia mentioned, that sort of integrated model that you guys, that you've already described. So it's a really, it is certainly an interesting case. Next slide. So this case is somewhat similar, but this is a patient who has a history of head and neck cancer, and he presented with neck and left arm pain. Same thing, he was treated with chemo radiation and he was one and a half years out. He developed neck and arm pain about eight months after his chemo radiation was completed. And at that time, he saw another physician, EMG was performed, which showed carpal tunnel syndrome. So he underwent carpal tunnel release. He came into clinic just upset, he'd had carpal tunnel release, still did not have improvement of his left arm pain and no further imaging or workup had been done. We did have the EMG to review, it did show carpal tunnel, but no other findings and he hadn't had a repeat EMG. So when thinking about this, again, always thinking about recurrence of disease, especially in head and neck cancer, radiation fibrosis of the neck potentially could be causing some brachial compression or a brachial plexopathy. Next slide. So on physical examination, he presented very similarly like a lot of head and neck cancers do, very ropey fibrotic changes in the left trapezius, levator and cervical paraspinals, significantly decreased range of motion of the neck. Shoulder exam, however, was intact. So just to rule out any cervical causes, we did get an MRI of both the cervical spine and the brachial plexus. Next slide. So here where those arrows are, that is the brachial plexus and it's lighting up significantly, which correlates with a radiation induced changes to the brachial plexus itself. Next slide. So this patient had tried antineuralgics, you know, you'd have the carpal tunnel release with no improvement. We got them into physical therapy to really work on neck range of motion, work on scapulothoracic strengthening, which is really important. I find often with some of our head and neck cancer patients that they haven't gotten referred to physical therapy since their treatment. They haven't been doing their home exercise programs, which is really important. And they also weren't aware that the delayed changes, especially in the musculature, you know, can be one, one and a half years later. So for this patient, you know, pain was his biggest complaint and we decided to try a spinal cord stimulator trial. So we placed the lead, went up to C2 to make sure we could get coverage of the entire plexus. And he actually had a very good outcome. He ended up with more than 60% pain relief during the trial and then we implanted him and he was doing well. Unfortunately, he did have recurrence of disease about a year and a half later, but was still very happy with his arm pain control. Any thoughts here? Yeah, I was just gonna ask you a question to see what your thoughts were and maybe Dr. Kali could also comment on this. So this is also another great case and I think this provides a really interesting sort of backdrop in order to have sort of meaningful discussions, but did you think about like, would you consider, I guess is a better way to ask this question, would you consider peripheral nerve stimulation in this patient, sort of between the fibrosis and the neck, or do you think it would just be too complicated based on the radiation? So for him, he had kind of, it wasn't just one trunk or, you know, area of the plexus. And then he was actually still undergoing serial MRIs. So with it not being MRI compatible for this patient, we chose to go with an MRI compatible stimulator just so that he could continue having his imaging. But I do think a peripheral stimulator could definitely be an option. Yeah, that's a great option. In fact, in our practice, if patients have pain in less than two or less than two dermatomes, we consider PNS as initial therapy first. And later on in the slides, I do have a case where we'll talk about a similar case with brachial plexus peripheral nerve stimulation. And I'm gonna just interrupt just, I think we've got a question from the audience and I thought that was relevant to these first two cases. So the question was, and I'll ask you both and feel free to both chime in, any role for epidural steroid injections for these patients, or would the application of steroids in this location be too far upstream? I'm not sure how efficacious it would be, especially if we have a brachial plexus lesion. I don't think it's unreasonable. Someone didn't want something more invasive like a peripheral stimulator or a spinal cord stimulator. But for me, the workup diagnosis is most important and then trying to find long lasting relief for this patient, which is why we chose the spinal cord stimulator route. I would second with Dr. Luke. Yeah, I agree with you as well. I think that sort of a longer lasting, more durable treatment option is probably best in this patient population, especially because of all the other things that they're undergoing. These are not people who have one appointment every couple of weeks or every couple of months, but these folks have appointments every day or every couple of days. And it's an emotionally and physically exhausting experience in addition to just dealing with their underlying cancer. I think that epidural injections in sort of maybe a very small subgroup may give you some relief, particularly if the patient just doesn't want to try anything else and just want something that might help short term or be somewhat palliative for a couple of weeks or months. But generally speaking, I don't think either of these patients would be responsive to epidural steroid injections. So with that, I'll pass it back to you, Dr. Luke, for the next slide. Next. All right, so this was one of my favorite patients. He was a 59 year old male and he presented with metastatic gastric adenocarcinoma and he had newly diagnosed lower metastases. He worked full time as a counselor in the prison and this was his life's work. This was the thing that was absolutely most important to him. He was still working full time while getting his chemo radiation and his treatments. And that was his ultimate goal is that he wanted to continue working. He wanted to make sure that he had mental clarity to continue his job. So he presents with kind of very classic symptoms, epigastric pain, radiating into the right upper quadrant and boring into the back. He did have a little bit of left upper quadrant pain as well. Worse with eating, he lost quite a bit of weight and he was on MS cotton 60 milligrams three times a day, as well as oxycodone 30 milligrams every three hours PRN. So it did significantly help his pain, but it was causing constipation and lots of fatigue and he didn't like the side effects. Next slide. So he was referred over, was there something we could do that could spare opioids that could allow him to continue functioning, going to his job and not interfering? So often when I get a referral, they just say, is there any kind of nerve block or something you can do? Our referral or referring sources, they know there's certain things that we can help with. They just never are sure. So for this patient, we actually talked about doing a celiac plexus neuralysis. So neuralysis is just fancy words for saying an intentional nerve injury. We can do that with chemicals. We can thermally ablate it. You can cryogenically ablate it, or you can do a surgical, like a sympathectomy. There's two options for a chemical neuralysis that we use, alcohol or phenol, usually phenol 6%. And they each have their pros and cons. So alcohol is easily injected. It spreads a larger area, but it also can be more painful for the patient. And actually in the last two years, for some reason, alcohol has become extremely expensive. So some people may be using phenol more due to the cost. So phenol is more viscous and harder to inject, but it does have anesthetic properties. So it doesn't hurt as much when we inject it, and then it can have less spread. Next slide. So when we're thinking of epigastric pain or abdominal pain from a cancer-related tumor, we're thinking kind of about the celiac plexus. So it's made up of three preganglionic splenic nerves from T5 down to T12. The plexus itself sits at L1 right in front of the aorta. Next slide. So that celiac plexus can transmit pain from around the stomach, bottom of the stomach, all the way over to the liver, and sometimes part of like the upper colon. And when we start looking at review articles, it's been shown that doing a celiac plexus neurolysis can help with a small decrease in pain scores, but it can significantly decrease someone's opioid usage. Must be done under image guidance, so we use fluoroscopy. Some of the GI docs, they can do this endoscopically as well. It can be performed multiple times. It usually lasts around three to four months. Next slide. So for this patient, I actually did a splenic nerve neurolysis. If you go at L1, you do have to go through the aorta, but you can often just put one needle in. So for this patient, these are just pictures of our imaging. We did neurolysis with alcohol and had very good spread here down to L1 and then up getting the smaller branches up to T11 and above. Next slide. So complications of this, your biggest ones are it can cause some diarrhea. One hard absolute contraindication would be if someone has a small bowel obstruction, which sometimes these patients do present with. It can cause hypotension, and then there is a very small chance of paraplegia. Next slide. And when looking in literature, again, like I said, that you can have a decrease in pain scores So this study showed there was a mean VAS decrease of four points at 12 weeks. However, there was over 72 oral morphine equivalent decrease per day. So a patient like this who wants to be on less oral opioids, this is a great first line to see if we can decrease his oral opioid consumption. Next slide. All right. Any questions about the pain score? So for this patient, all right. Any questions? This patient did really well with the block, and we have another slide to talk kind of about later on in his journey. Yeah, no, I think quickly I'm gonna mention there was a question that was relevant to the first few cases where someone talked about dorsal ganglion radiofrequency ablation. I don't think there's a lot of literature with regards to DRG-RFA. I mean, there is some European literature with pulse radiofrequency ablation. I don't know if either of you had any experience with ablating the DRG, but if we're gonna talk about the DRG as a target in a plexopathy type of situation, the other thing to consider also would be stimulating the DRG. So while both of those are off-label indications or uses for these disease states, they could be considered especially maybe in recalcitrant patients. Do either of you have any thoughts on that? I agree with you, Dr. Vaisa. I think you make a really good point. We should choose our therapies based on evidence. And in this day and age of evidence-based medicine, you know, we have very limited evidence for pulse radiofrequency ablation of dorsal root ganglion. Instead, we have emerging and more, almost level three evidence for stimulating dorsal root ganglion in lower thoracic and upper lumbar and sacral regions. Obviously the case in question is more cervical, which is off-label, but reviewing the evidence and choosing right therapies for right indications is the key for success. Yeah, and to some extent, or maybe to great extent, I mean, just because we have access to many, many different therapies doesn't mean we should apply them all, right? It goes back to when we do a lot of training, it's when we train residents or medical students or fellows, it's about sort of when not to do things. And so I think that's another thing to keep in mind. Dr. Luke, for your, for case three, for your patient, was that patient on any anti-neuropathic medications or nerve stabilizer? He was, he was also on gabapentin and I think either amitriptyline or nortriptyline, which could also have been contributing to some of his, you know, fatigue, sedation as well. And the only other thing I could think about, first of all, that's an awesome case. I think what you highlight about the decrease in morphine ameliorate equivalence is, is fantastic. And I think that's, that's a really important takeaway from that, from that case is that sort of, there are things that help with pain, things that help with, although, you know, if you look at these data in study design, usually they're looking at a two point or three point decrease in pain scores as being clinically meaningful. So four point decrease is nothing to sneeze at, but the 72 morphine ameliorate equivalent decrease is pretty amazing. So I think that's, that says a lot. The only thing I would add about that case was, I guess in some, in some specific patients you may be, you may consider there is some data for high frequency stimulation for abdominal pain that is, you know, kind of emerged over the last three to five years, that's a fairly compelling as well. But, you know, again, that's an implant versus this, which is something that can be repeated on, on multiple occasions. So our next patient was one of my younger patients. He actually had been diagnosed with rectal adenocarcinoma when he was 30 years old. He was diagnosed with surgical resection, chemo radiation. He was doing really, really well. He worked as a unit clerk and he was in nursing school. And about one and a half years later, they went, did his ileostomy take down, re-anastomosis and he began having this severe rectal pain. Again, it was very delayed presentation. It was burning and sharp in nature and worse with bowel movements. Next slide. So, you know, he'd been back to the surgeon a million times. And of course they said, well, nothing's wrong with your surgery, but your surgery went perfectly. Everything looks great, but he continued having this pain. So we tried a ganglion and parvlox, we tried a ganglion and parvlox, the ganglion and par is the last, you know, lower fused ganglion sitting behind the sacrum. And actually when I put my needle in, I'd been wondering if he had, you know, severe, you know, radiation fibrosis from the radiation. We could barely get the needle in. This is a picture of that. The needle's coming straight across there. And I could, I got maybe half a CC of contrast in. So he had severe scarring in that area, which likely contributed to, you know, his severe rectal pain. Next slide. So for this patient, he had a lot of confounding things contributing as well. He had psychosocial issues. He was in a same sex relationship. So he had a lot of psychosocial factors about sexual relationships with this, with his partner due to the pain. And he had had significant escalation of his opioids. He may have been on some of the highest opioids I've seen. He was on 120 milligrams of methadone a day, and he was taking anywhere from 40 to 60 milligrams of oxycodone, actually, yeah, of oxycodone prior to being rotated to Dilaudid. He kept going in and out of the hospital. And every time in the hospital, they'd escalate his opioids with no improvement. He was on multiple adjuvants of Lyrica, Amitriptyline. He'd gained almost 100 pounds, and he was not able to work anymore. Next slide. So he had significant depression and poor coping skills. Sometimes he would be compliant with his therapy sessions, PT, sometimes not. So we actually met as a multidisciplinary team with his oncologist, surgeons, palliative care providers, and then myself, beginning with a slow opioid wean. And I talked to him at length about a spinal cord stimulator. At his young age, you know, you could think about an intrathecal pain pump. However, due to his age, due to his other, you know, kind of depression issues, and then just long-term, what would be the best opioid sparing option for him was a stimulator. So we met with him monthly. Six months later, he was actually compliant with everything. They had decreased his opioids Next slide. So we went forward with a stimulator trial. And for him, you know, you place your leads based on whatever you're targeting. So we're targeting the rectal area. So place the lead here, stimulate in the conus. And actually just with one lead placement, we got really good coverage of his rectal pain. He decreases opioid usage, his breakthrough by like almost 70% at the time of the stimulator trial. So we went forward, implanted him, and he did really well after that. And they were able to actually admit him to the hospital and get him weaned off all his oral opioids. And he lost about 50 pounds and was back to work. Next slide. So I think highlighting this is we have to take into consideration, you know, is this patient cured of cancer? You know, how old are they? What are their goals? You know, and what is what is the least harmful thing that we can provide for a patient? You know, being on high dose opioids like that was one of the worst things for him. And it just escalated out of control. So it's also really important. This highlights, I think, you know, the importance of working as a team and working with the other team members for a patient's care to come up with the right treatment individually for each person. Dr. Kalia, do you have any thoughts on that case? Yeah. So I think it's a focal pain and conus stem is great. I think, again, exemplifying the importance of choosing the right therapies. Dorsal root ganglion stimulation also can be another target for this specific focal pain presentations. And there is more literature coming which talks about the sustainability of, you know, long term effects of dorsal root ganglion stimulation with focal pain management. So that's another therapy which can be kept in mind. Yeah, I think this brings to bear the concept we've been talking about so far in all the cases, which is that fundamentally, it's really about diagnosis and really understanding what the patient's goals are. And then the therapy often can be customized a number of different ways, right? So one person may apply a slightly different therapy than another. And it's sort of like, you know, how many different ways to skin a cat, so to speak, although that's a very bizarre saying. But in this case, I think it's understanding that there was radiation fibrosis and that the ganglion in part maybe was a reasonable target, but the fibrosis prevented any further treatment of that site. And then knowing that it was very focal rectal pain and the specific comorbidities that Dr. Luke described, I think this is an excellent choice. So I'll let you keep moving on here. Next slide. Okay, so this is a 48-year-old female. She had breast cancer with a likely rib metastasis at T9, and she had significant chemotherapy-induced neuropathy of the lower limbs. Again, talking about comorbidities that can also contribute to pain complaints. She had severe depression, and she was in the middle of separating from her husband. Next slide. So I think probably chemotherapy-induced neuropathy is one of the biggest complaints that we'll see in our cancer survivors. Important to get a very good history to identify what treatment patients have had. So we often will see CIN with platinum compounds or Benkristin. And then physical therapy from a rehab standpoint, when we're looking at what can we do non-medication is. We can get them into physical therapy. I have patients that do really well with kinesiotaping of the bottom of their feet, doing desensitization or using like a TENS unit for electrical stimulation. And often if you have a severe sensory ganglionopathy or sensory neuropathy gait training to make sure the patient has the appropriate mobility devices that, you know, their fall risk at home has been minimized. Even, you know, a home evaluation by PT or OT to make sure that, you know, the setup of their houses is appropriate. They have the appropriate devices in their bathroom, you know, elevated toilets or elevated, you know, toilet seats. And then obviously antineuralgic medications, gabapentin, Lyrica, even compounding topical ointments can be helpful for that, like sensitization of the feet. Next slide. So this patient was already on antineuralgics. We had gotten her into therapy, but she was still having quite a bit of pain in her feet and also in that chest wall. So did a spinal cord stimulator here and actually staggered the leads and we were able to get coverage of that chest wall pain as well as her feet. And this patient weaned off all her opioids. She was doing really well, was back to work and she was very, very happy with her outcomes. So this is just another example of, you know, an opioid sparing use of stimulation, but also kind of what can we do as PM&R rehab physicians, you know, that often these patients haven't had, you know, a full evaluation. They haven't had gait training. They probably haven't been in physical therapy since they're usually doing fairly well functionally overall. Yeah, it's kind of fantastic that you were able to get chest wall coverage in addition to her leg symptoms. That's pretty, pretty amazing and sort of, you know, two birds with one stone. So that's, that's fantastic. And I think, let's just go, can we see the next slide? Let's go back. Keep going. Can we skip this one? All right. So let's go back to our patient quickly with the gastric adenocarcinoma that we did the celiac plexus neuralysis to. So he actually did really well for four to six weeks, but he had progression of pain and he now had changed his goals where he wanted to spend as much time as he could with his family and he wanted to stay out of the hospital. He really didn't want to escalate his oral opioids because of all the side effects. So if we have a patient like this who maybe is having side effects from upper titration of their opioids, or, you know, they just really can't tolerate them. If we want to think about something else that we could offer would be an intrathecal pain pump placement. So you can say if, as long as prognosis is between three to six months, you know, it could be fiscally a good choice for a patient. Next slide. So next slide, please. So when we're talking about medications that we can put in an intrathecal pump, the first line agents and opioid, the two that are approved are morphine and zyconatide. You can always place a second line agent for my cancer patients. I always do high concentration of bupivacaine in the pump as well. And when we're thinking about just conversions of how this works, so 300 milligrams of oral morphine actually equals one milligram of morphine in the intrathecal space. So often, you know, we don't have those side effects that we do when we have to take it by mouth. Next slide. So this patient, we implanted the pump with a tip around like T6, did high concentration bupivacaine with Dilaudid, and he actually did really well post-implantation. He was off all oral opiates. I only had to see him one time. He was able to stay out of the hospital completely. After implantation, he went home with hospice and passed away at home about four months later. So I think when we think about especially severe cancer-related pain or someone with, you know, a shorter term prognosis, we also have to think long-term, is what can we anticipate that their pain needs might be so that we don't miss the window of, you know, implanting a pump, providing someone with significant quality of life improvement, significant pain relief. And I find that abdominal pain, you know, from a cancer state really does well with an implanted pump. However, a lot of times patients, you know, when we talk to them about this, they've just had so many things that they've gone through, so many surgeries that another surgery, it may not interest them. But I do think it's important to recognize earlier what we could potentially do to help someone and making sure that we get them referred to an interventional pain physician so that they know their options and that they know that this is available to them. Any comments, Dr. Khalid? Yeah, this is a great, great case, Dr. Luke. In patients who have prognosis of less than three months, you know, sometimes what we have done, and sometimes even if the prognosis is less than six months, as you said, as you mentioned, these patients don't want an implanted device. So, you can do a tunneled epidural catheter, and we have worked very closely with our hospice folks, and if they're not hospice yet, then they can have an external pump and do a temporary catheter epidural infusion with these medications instead. Yeah, and a couple points I'll make just for the audience. I mean, and I think Dr. Luke did mention these, but just to reiterate, the FDA approved drugs for interstitial delivery are morphine, zirconatide, which is a calcium channel blocker from snail venom, and also baclofen. The rest of the medications, there are consensus guidelines and NAC guidelines that talk about sort of how you combine therapies and combine drugs, and certainly folks who are interested, I would refer them to read those guidelines because it can be very helpful in terms of understanding or at least planning for these therapies. And then the only other comment I would make is that, you know, while those conversions are relatively true, they're just that relatively true. There is a person-to-person, case-to-case difference, and, you know, it's not as absolute as any of the three of us on this call probably would like it to be, but really an awesome case and really talks about that progression between what you might do in the beginning of care for someone and what you may do ultimately for them. And it's sort of probably the key reason that this patient agreed to a pump, honestly, was the relationship you built with them, right? So one of the things you talked about is sometimes patients just don't want a pump, which is fair and fine, but oftentimes they're getting referred to us at that sort of terminal junction where it's like the only option is a pump, and at that point there's so much fatigue from all the things that they've been doing, but the fact that you got this patient early, built a relationship and a rapport with them, probably, at least in my opinion, would probably go a long ways towards getting them a therapy that ultimately helped them stay out of the hospital and make their last several months much more comfortable than otherwise would be. All right. We can skip on to Dr. Kalia's slides if you'd like. Actually, I think it's okay if you do this case only because it sort of cuts up Dr. Kalia's discussion, and if you want to breeze through it, that's fine, obviously. Yeah. So this is a 34-year-old female. She was actually diagnosed when she was 29 with metastatic breast cancer, and she presented with a pathologic fracture at T12. She had significant back pain, worse with standing or walking, and she was diagnosed with a worse with standing or walking and better while laying down. Knowing she had breast cancer, you immediately do think compression fracture or pathologic fracture of the spine, but if this was a normal person with no cancer history or diagnoses, you kind of want to think, hmm, what could be going on? Someone like this shouldn't have a pathologic fracture of the spine. So workup would be basic x-rays. You can get a CT scan, usually faster than MRI, so if you're really concerned, get a CT. It can help you look for bony abnormalities, and then ultimately, MRI will start imaging to look at the acuity of the fracture. Next slide. So management, if we're talking just about a benign osteoporotic fracture, you can try bracing, you know, anti-inflammatories, low-dose opioids, TENS unit. These often improve on their own, and now, you know, guidelines are saying for benign fractures, you know, wait, you know, 8 to 12 weeks. If pain's still not better, then consider vertebral augmentation or like a vertebroplasty. For someone with cancer, often that will be the next step immediately is to augmentate with cement for stabilization and pain relief. Important things to look at on the imaging is to make sure there's not, you know, large retropulsion of fragments into the spinal canal, that you don't see significant epidural extension through the pedicles or really significant severe height loss, which is when we should refer to surgery at that time. Next slide. So here's just a picture of the needle through the pedicle, and then on the right, you can see the cement there, pretty nice flow and coverage there midline. So this is a great case. Thank you, Dr. Luke, and I think from here, I'm going to, in the next five minutes, what I'm going to try to do is I'm going to take you guys through the evolution of the therapy of neuromodulation and how far we have come and where we are going. Next slide, please. Okay. So if you look at this slide on the left-hand side, you can see the very first dorsal column stimulator implant, which was done by Dr. Norman Shelley in 1962 in Minneapolis, which was actually done for a cancer patient. For almost half a century, the field and the speciality of neuromodulation has been kind of stagnant. There was not a lot of evolution or innovation, which happened for almost half a century. Most of the improvements were done on the form factor of the neurostimulation devices. If you look at the graph and the evolution, which has happened in the last decade, I think we are at a pace where this is the most exciting time to be in the field of interventional pain and neuromodulation. That's what I tell most of my fellows and residents who rotate, that this is the time where you will be able to be at the forefront and see the innovation happening in this field right in front of your eyes. So on the right side, you see a slide which briefly talks about where we have come in just the last decade as far as the form factor of neurostimulation devices are concerned. And the future, next slide, will be a combination of crosswalks and cross integrations between artificial intelligence. There are a group of researchers currently working with the IBM Watson team to understand the impact of pain on function and quality of life and gather those parameters and do some modeling and understand how our neuromodulation and neurostimulation therapies would improve function and quality of life of our patients. We have come a long way from big, bulky, implanted or external battery packs to more wireless and miniaturized systems where the form factor has improved significantly over just last decade or so. And more novel sites and novel waveforms have come out to optimize our therapy in the last decade. Next slide. Truly speaking, we are in neuromodulation 2.0 now. Next. So which ranges for almost good half a century, we were playing around just tonic stimulation, which was limited to frequency parameters between 50 Hertz to max about 500 or 600 Hertz. We only had two different types of systems, either voltage-gated or current-gated systems. And there was not a lot of avenue to improve patient outcomes with just single way of delivering the energy packets into the spinal cord. Now we have access to really high-frequency stimulation ranging to 10,000 Hertz. We have certain very specific novel waveforms like burst stimulation. And obviously some novel sites of stimulation have come out in the last decade, which is the dorsal root ganglion, which has really revolutionized the field of neurostimulation. Concepts of high-density simulation. In fact, now we have DTM, which is the very specific way of delivering multiple layers of therapy programmed around dorsal columns and specifically stimulating the glial cells. And the sky is the limit. I think we're at a stage where utilizing these therapies either in monotherapy or in some cases, you have an option of using hybrid systems. That's where we will start learning about the true impetus of individual therapies moving forward. Next slide. So I really wanted to kind of talk about a really interesting concept of what we call a hybrid trial between dorsal column stimulation and dorsal root ganglion stimulation. Especially because as I previously mentioned, we are in the stage of evidence-based medicine. Currently we have level one evidences of these therapies in specific non-malignant pain populations. As far as cancer pain is concerned, we do not have specifically designed RCTs, but we can understand these therapies from the individual RCTs which were published and then apply that knowledge to improve our cancer patients' pain and quality of life. So one of the really challenging pain conditions is chemotherapy-induced peripheral neuropathy as Dr. Luke mentioned. And when pain is limited to two or less than two dermatomes, it becomes really challenging. We have been doing dorsal column stimulation for almost 50 years, and we have not had long-term sustainable solutions for patients with focal neuropathic pain condition. So what we tried was to do a hybrid trial where a patient would act their own control. We would give them one dorsal column lead and then give one dorsal root ganglion lead for the first three days in the trial. Patient would try a DRG system and for the next dorsal column stimulation system, we have three cases we just presented as opposed to our next slide where we tried a dorsal column octrode with a DRG, L5, S1, and L3. And in all these patients, next slide, they actually preferred the dorsal root ganglion stimulation system primarily because the dorsal column stimulation was providing them unnecessary paresthesia or stimulation in the areas where they didn't have pain. And we do have option of using non-paresthesia based system, but the dorsal root ganglion stimulation in these three patients was really impressive and impactful. And these patients are still doing great with, as you can see, close to 60, 65, 70%, 85% reduction in their VASC scores. Now, we also followed them through their functional scores and we have a paper coming out pretty soon, which we'll be talking about their functional improvement with this system as well. Next slide. There are a few challenges with dorsal root ganglion stimulation. Currently, the MRI compatibility is the biggest issue. So if you have cancer patients who we know that will be needing MRIs and for their cancer surveillance or treatments, then unfortunately the system is not a good option for them at this point. In our region, we are limited by the local coverage determinants for DRG and we've not been able to get more than two lead trial approved. So we are limited to two leads during the trial. And obviously, as I said, there's a dearth of literature in the field of neuromodulations for chemotherapy induced peripheral neuropathy. But I think, as I said, these are different tools and our toolbox is expanding. Initially, we only had dorsal column stimulation in our toolbox. Now we have novel sites of stimulation and novel therapies and novel waveforms, which can be utilized to improve patients, not only function, but as I said, their quality of life as well. Next slide, please. So we actually propose an algorithm where if patients have focal pain limited to two or less than two dermatomes, dorsal root ganglion stimulation and peripheral nerve stimulation makes perfect sense in that patient where the pain is getting modulated at either peripheral nerve level or DRG level. When the patient's pain is more diffused, more than two dermatomes, then obviously other neurostimulation platforms like tonic stimulation or HF10 burst and other new novel waveforms which are coming out and novel dosing platforms which are coming out will be helpful. In fact, in the last couple of years, we're trying to understand the neurostimulation therapy similar to a pharmacokinetic and a pharmacodynamic study of a drug. We're looking at the dose response curve of neurostimulation in dorsal columns where seeing improvements by changing the pulse dosing is really critical in improving the outcomes. And obviously if these patients stop or do not respond to neurostimulation therapies, then targeted drug delivery is a really humbling and satisfying therapy which can improve our cancer patients' pain and quality of life pretty significantly. Next slide. This briefly kind of captures some of the other neurostimulation platforms. I think we briefly talked about the brachial plexopathy patient earlier in the presentation. This is a peripheral nerve lead which was placed supraclavicularly in the brachial plexus to help that specific patient. This patient is still doing great. And this system is a full-body MRI compatible. So for PNS, the current platforms give you more opportunity and options to help these patients' pain with the MRI compatibility we are looking for. Next slide. This is, again, I think Dr. Lu really nicely captured these patients with the neurostimulation platform who are suffering with neuropathic pain after brachial plexopathy or post-mastectomy pain syndrome. Next slide. And I think Dr. Lu nicely talked about the importance of workable augmentation in metastatic workable lesions. There is one additional therapy which is available to us which is actually percutaneous radiofrequency ablation of the metastatic lesion prior to doing stimuloplasty. These are patients who are either not candidates for radiation or their pain is so severe that they are not even able to lie down flat on the radiation table or they have failed radiation or they're having recurrence of their metastatic lesions. These patients can be... Next slide. So these lesions in the workable bodies can be targeted with a bipolar radiofrequency ablation. There are a couple of systems where you can either do a thermal radiofrequency ablation or you can do a cooled radiofrequency ablation. And once the lesion is created, you can see the lesion is followed up with the cement later on. Next slide. Next slide. So this is a study which was published in radiology literature. The study came out from radiology but now this therapy has been adapted in the hands of most of the interventional spine and pain docs. This is osteocooled tumor ablation therapy where cooled radiofrequency ablation is done to ablate those metastatic lesions. And this was specifically looking at improvement in the pain scores and function at the three-month window. And since then, there are multiple studies which have come out looking at the long-term outcomes of radiofrequency ablation of the metastatic lesion first before following up with the cementoplasty. And it seems like the tipping point is towards the radiofrequency ablation with cementoplasty provides not only long-term pain relief but the immediate pain relief is pretty significant as well. Next slide. So I think to summarize, we are at the cusp of seeing the field of interventional spine and pain go through an evolution and innovation. These are the type of therapies which are currently in our repertoire to help our patients' pain and quality of life. But I do want to make a point here and say that these therapies by themselves are not going to do the wonders. I think the overall plan for the patient has to be individualized and a true functional rehabilitation plan which incorporates these advanced therapies is the key to have long-term successes. And as Dr. Luke said, the interdisciplinary approach is the key to address cancer pain and involve the cancer pain rehabilitation constructs into the compendium of care which we offer. So I think with that, we'll take questions. So first and foremost, I want to thank both Dr. Luke and Dr. Kalia because you guys crushed it and also we are well within time. So that is a enormous rarity. So thank you both so much for all the information you put together but also the timeliness of the information. So we had a few questions I think that are great that we'll start with. And then if we have other comments, we can address those as well. One of the questions that came across was in cervical spinal cord stimulation, where do you place the battery or the generator? I'll let each of you guys answer that and I'll answer it as well. Oh, go ahead. So in our practice, as we have stressed, it's individualized. We have a very long discussion with our patients. There are a couple of platforms which are available. One is a non-rechargeable, the other is a rechargeable system. And depending upon which system the patient is choosing, we have implanted in the anterior chest wall, we've done in the lumbar region. And we've tried to stay away from the chest wall because it can be painful to put the battery pack right on top of the ribs. But the anterior chest wall is where the regular pacemaker batteries go is also an option. Dr. Luke. So I usually place mine in the lumbar. It depends. You can either go lower and thread higher up, which some of our surgeons do. I usually will place my leads from higher and then tunnel the extra down to the battery just because it is more comfortable. The chest wall can be painful and sometimes they can also get some shoulder discomfort. So I think each probably physician is different where they put it. Yeah, I think there's a variety of factors that go into this. I agree completely that it should be individualized. I think that putting it into the chest wall requires you to flip the patient oftentimes and to come across the clavicle and possibly across the neck, which some people are uncomfortable with that concept because they're worried about some of the vessels and other structures in that area. But it's a shorter distance, which can play an important part in implanting a patient, but also revising the patient when the revision is necessary. I typically place mine in the flank or in some very few cases, but once in a while I'll put it in the buttock area. And that is a very tolerable region of the body for patients but the downside is that oftentimes it is a very long distance to tunnel. So you're having to use extensions which can affect your MRI compatibility or pardon me, conditionality. And then also there's a greater lever arm basically with regards to migration of the device, right? So now you've got an entire back to pull on those leads. So it should be individualized. I think we can all agree on that. And there are multiple areas. And with the newer technologies that are coming out, we now have devices that have a very small IPG, the size of a dime or an IPG less system. And so now you've got your ability to implant what would be IPG in a different location is significantly increased when you have a very, very small IPG. And so I think all those questions play a part as Dr. Kalia said, that very comprehensive conversation with the patient is the key. Dr. Luke, this question I think would be great for you. Do you have any assessment or treatment clinical pearls for cancer fatigue? So I think that's a great question talking about cancer rehab. I think that you need to do a very thorough evaluation with the patient to see what it is they're complaining about. Is it fatigue with certain activities? Is it constant fatigue? Is there progression of cancer which can cause fatigue or is it treatment related after their chemotherapy? Really working closely with your PTOT to work on energy conservation techniques too. So a lot of times it's patients wanna garden but they can't do the bending over frequently. So can you do a stool in their garden? Same with dishes. Can we wash our dishes sitting down versus standing up on our feet for a long time? If it seems that it's potentially more cancer progression or medication related or opioid use, then looking at augmenting with a neurostimulant such as I like to use Ritalin to start because it's short acting and it gives the patient choices of when to use it. I have some breast cancer survivors that only take their Ritalin during the week when they're working. They don't like to take it on the weekends but it does give them some control too over their symptom management. You can also look at a longer acting neurostimulant and it is individualized the same way but I think having a really good therapy evaluation, looking at what kind of energy preservation techniques we can use to give the patients because oftentimes when you talk to them about it, they've never even thought about it even though it seems common sense to us. They are really just trying to barrel through their activities of daily living every day and not even recognizing like, hey, I need to take a break or maybe I do need a rest or a nap and that's where I think therapy is key. Awesome, that's a great answer. The next question I'm gonna take real fast in the interest of time, which is why does MRI compatibility vary so much across the different options? Really quickly, there's no technology from a spinal cord stimulation or really any perspective that's MRI compatible per se, it's MRI conditional. I actually put the first MRI conditional spinal cord stimulator in the US and back in 2013. The challenge here is that it is an investment on the part of the manufacturer to apply for and ask for those kinds of conditionalities and under certain specific device circumstances or device settings to be able to have MRIs that are an option. So it really comes down to each and every one of the manufacturers doing a lot of testing internally to determine what those safety parameters look like or where their specific safety parameters should be set. With that, we'll take the last question and I think that's maybe five seconds for each person. What's your personal experience with long-term success rates with SES? So again, in the interest of time, make it really quick, Dr. Kalia. So spinal cord stimulation, I think as I said, we have come a long way. We now have novel waveforms and novel sites of stimulation. I think sky's the limit. Okay, and Dr. Luke? I agree. I also think though patient selection and making sure that confounding comorbidities with each patient and also emphasizing expectations too with a patient helps with long-term outcomes. Yep, those are fantastic answers. I think we're getting better as time goes on and I think the options that we now have allow us to be better, but you can have the best options in the world, but if you select the wrong patients, you're not gonna have the outcomes you're looking for. So with that in mind, thank you again to the faculty. Thanks everyone for being here and taking time in the morning to join us. Have a great rest of the day and enjoy the rest of the assembly. Thank you.

cancer pain

cancer rehabilitation

multidisciplinary approach

individualized treatment plans

interventional pain management

nerve blocks

spinal cord stimulation

peripheral nerve stimulation

neurostimulation therapy

quality of life