Are you struggling with chronic pain and looking for innovative ways to alleviate your discomfort? Join us as we sit down with Dr. Steven Aydin – a double board-certified physiatrist – to discuss the world of interventional pain management and physiatry. In our engaging conversation, we delve deep into the most common musculoskeletal conditions, such as herniated discs and spinal stenosis, and how a combination of diagnostic techniques, imaging studies, and injection therapies can help manage pain and improve your quality of life.
We also explore how multidisciplinary collaboration among healthcare providers is crucial for achieving the best possible outcomes for patients, all while addressing the challenges of pain being referred from different areas. Dr. Aydin shares his expertise on nerve-blocking techniques, minimally invasive procedures, and addressing pain associated with osteoporosis through methods like vertebroplasty and kyphoplasty.
Finally, we dive into the fascinating realm of regenerative medicine, discussing cutting-edge biological therapies like platelet-rich plasma and bone marrow aspirate. Dr. Aydin enlightens us on how these treatments can provide essential components for healing that may not be present locally, offering a greater chance for a pain-free life. Don't miss this informative and hopeful episode with our esteemed guest, Dr. Steven Aydin.
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Episode Transcript
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Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho Podcast.
Today is June 6th, 2023.
And we're so privileged to havewith us today our own
interventional pain managementspecialist, dr Stephen Aiden.
Dr Aiden is a board certified,fellowship trained physiatrist
who's double board certifiedHe's board certified in the
(00:21):
field of interventional painmanagement, but he's also board
certified in the field ofphysiatry.
And we're so happy to have DrAiden with us today because
there is such a dire need forinterventional pain management.
Unfortunately, so manyAmericans suffer from either
acute or chronic pain And thankGod, there's doctors like Dr
Stephen Aiden there for them tohelp alleviate their pain and
(00:45):
discomfort on a daily basis.
So welcome to the podcast, drAiden.
Thank you for having me, drKale, it's my pleasure.
That's my pleasure.
We're so happy to have you withus.
So, before we get started, drAiden, why don't you just give
us a quick summary about yourformal education?
Steven Aydin, DO (01:00):
Sure.
So I completed my medicalschool at the University of
Medicine in Dentistry in NewJersey in 2005 and then went on
to do my residency at UMD and Jin Newark and then went on to do
a pain fellowship at theUniversity of Michigan, which
was an additional year oftraining and board certified in
(01:21):
both specialties of physiatry orPM&R, as well as pain
management.
Robert A. Kayal, MD, FAAO (01:26):
Great , Thank you for that.
So let's get started and justdefine for our viewing audience
what is the field ofinterventional pain management
and what is the field ofphysiatry.
Sure.
Steven Aydin, DO (01:38):
So I'm going to tackle the physiatry first,
because physiatry itself is avery broad specialty that kind
of covers the gamut of differentmedical conditions for
different conditions likerelated to spinal cord injury,
stroke and musculoskeletalmedicine.
So as far as my focus inphysiatry, I've kind of pivoted
(02:01):
into the nonoperative side orthe nonoperative orthopedic side
of physiatry where I reallyfocus on musculoskeletal
medicine.
So many times a physiatristwill deal with the
rehabilitative needs as well astreatments of patients for
nonoperative orthopedic needssuch as knee pain, arthritis,
back pain, neck pain.
(02:22):
Many times we'll manage theseissues with injection therapy,
trigger points, physical therapy, chiropractic care and just
indicating patients for a lot ofdifferent treatments to prevent
them from seeing you really.
But obviously many times thereare reasons why we have surgeons
and our treatments and ourmedications or indications don't
(02:45):
work for patients.
As far as interventional painmanagement is a subspecialty
that kind of focuses on anonoperative management of
symptoms that are related toeither spine conditions or other
musculoskeletal conditions, inwhich injection therapy or
minimally invasive procedures ortechniques are utilized to
(03:06):
treat these patients' conditionsAnd the goal is really either
to manage their symptoms so thatthey don't need surgery or
manage their symptoms whensurgery isn't as perfect as we
always want it to be.
The human body is very uniqueand is very complex, and
sometimes it's not as easy asjust replacing a battery or a
(03:28):
carburetor on the car.
We're treating a human being,so not everything always goes
perfectly and our goal is tomanage these symptoms with
different kinds of techniqueswhether it's injections or
surgeries to getting the patientfunctional and improved.
So that part of my specialtyand my focus was my focus, where
we really focus oninterventional pain management
(03:51):
is really goal to manageconditions with injection
therapy and different kinds ofnoninvasive procedures to get
the patient functional andimproved in their quality of
life.
Robert A. Kayal, MD, FAAO (04:05):
Thank you for elaborating on all of
that.
On that note, give us someexamples, dr Aden, of some of
the more common musculoskeletalconditions that can be
alleviated with yourintervention.
Steven Aydin, DO (04:18):
Sure, so many times in interventional pain we
focus on the spine, but we canalways focus on other regions
that are painful for patientsthat become chronic or
sub-subacute for theirconditions.
The most common thing that Isee within the practice is
things related to neck pain andback pain, such as herniated
discs, sciatica, lumbarridiculopathy, spinal stenosis
(04:43):
and even facet pain.
The most common thing that Ikind of see and manage with
patients is doing injectiontherapy for these conditions,
such as lumbar or cervicalsteroid injections that focus on
the epidural space And the goalof that is really to try and
manage like a pinch nerve, as wecall, or a sciatica, to try and
(05:04):
get this patient functional andimproved where they don't
require medications, bed rest oreven, you know, invasive
surgery.
Some of the other proceduresthat we'll kind of have for
patients for differentconditions is facet injections,
which are really to focus onmanaging the axial back pain or
neck pain, meaning the pain thatcomes from the small joints in
(05:27):
the spine, and so we'll do manyof these procedures with image
guidance.
So it's a very exact kind ofspecialty where we're not just
putting a needle into the bodyand hoping that a medication
gets there.
We're very specific and verytailored to a patient's
conditions and needs.
You know you asked me the typesof conditions we try to treat.
(05:48):
But we can't do any of thiswithout imaging and you know,
physical exam and diagnosis andother specialties kind of seeing
the patient and getting an ideaof what the real condition is.
You know, many times patientshave multiple different kinds of
generators of pain and we haveto be very focused, you know,
(06:09):
and work together as a specialtyand different specialties to
kind of get this target done.
Most of these procedures aredone with x-ray guidance or
ultrasound guidance and the themajority of the outcomes is good
.
You know, obviously it's not apermanent fix.
We don't always end up with ahundred percent resolution of
(06:31):
these symptoms, but the goal ofwhat at least I've taken on in
the practice is to try and getpatients functional to a level,
especially if they're elderly orthey're not great surgical
candidates to allow them toenjoy their life, be pain-free
and be functional.
Really our goal is to getfunction and pain improvement
with the least amount of work,if you will.
Robert A. Kayal, MD, FAAO (06:53):
Great .
So, with respect to yourinterventions, before we go
through these common conditionsone by one and explain how you
actually perform some of theseprocedures and what your goal is
in addressing the disease thatyou're treating, why do these
injections even work?
For instance, what medicationsare you injecting typically
(07:18):
during your interventional painmanagement procedures, and what
is their mechanism of actionthat would allow the patient's
pain and inflammation to subside?
Steven Aydin, DO (07:28):
It's a great question and really relates to
you know, what are we reallyinjecting?
what are we reallyaccomplishing right?
There are many studies outthere that kind of look at the
different kinds of things weinject that may or may not work.
The majority of injections willhave cortisone in it, but we
don't want to be focused on justsaying that we're injecting
(07:50):
steroids into the body or thatevery injection has to have
steroid in it.
Much of what I do is reallytrying to make the diagnosis.
So many times.
It'll include a local anesthetic, such as lidocaine or marcaine,
which is a cousin of somethingthat used to be around called
novacaine, the numbing medicinethat we use Many times that's
(08:11):
mixed with cortisone and thatcortisone is really to introduce
into the body or in theenvironment where I think this
problem is coming from, like aherniated disc or an inflamed
nerve, and try to reduce theswelling.
So we've talked about twocomponents so far.
So the local anesthetic, which,just in simple terms, is really
used to reset the nerve, turnoff the thermostat, reset it as
(08:35):
well as allowed to turn off thepain, if you will.
So many times patients will geta nerve block quote-unquote and
the nerve block is a temporarytreatment for me to kind of get
an idea of where the pain iscoming from or if I got the
medication to the right target.
The nerve block is notsomething permanent and has a
(08:56):
short half-life of whateverlocal anesthetic we injected.
But really gives me a good ideais if a patient had
impossibility, difficulty tryingto get onto a table because of
the severe pain, and i do theepidural around the nerve and i
block that nerve, then they getoff the table without too much
difficulty and it puts me in theright neighborhood that i block
(09:18):
the nerve.
So that's the local and thesteroid which is kind of the lag
medication is injected into theenvironment to reduce the
inflammation.
So steroids are often used totry and reduce swelling
inflammation in the body, buthere we're using it specifically
right around the environmentthat's injured or herniated or
(09:39):
inflamed and that over time overusually about a few days to a
couple weeks will kind ofmetabolize and do his job to
cool off the fire around thisinflammation.
And then the third thing thatwe'll often inject is sterile
salt water.
So you need a medium with thesethings to kind of inject the
medication and the goal of that,at least in my opinion is to
(10:02):
flush the area.
And many times you know you'llget these herniations or these
inflammatory environments andthere's just so much
inflammation there from thechemical reaction that the body
has.
And our goal is to mitigatethat and try and slow that down
so that there isn't too muchpain and that the body can kind
of take over and say, well, youcooled off the fire for me and
(10:23):
now i can kind of control thisover response that i had.
And allowing that area to beflushed with maybe just like a
little power wash, if you willfrom the saline Will allow the
body to kind of free up thatnerve or free up the environment
of that, you know, inflammation.
Robert A. Kayal, MD, FAAOS (10:41):
So you so beautifully explained all
that.
Some of these concepts that DrAiden is speaking about can be
extrapolated into many otherfields of orthopedic medicine.
So essentially what he'sdescribing is a concept that we
as healthcare providers callinjections for diagnostic,
(11:01):
hopefully therapeutic outcomes.
So what that means is sometimeswe're not exactly sure What
body part or what nerve iscausing the patients pain and
symptoms.
So a lot of times what we'll dois inject local anesthesia into
that joint or around the nerveto numb the nerve, essentially
(11:23):
numb the nerve, and if the nervenumbs or if the joint No longer
hurts, than that tells thehealthcare provider that that
nerve or that joint is theideology of the patients.
Symptoms and pain.
When that is helpful, veryoften simultaneously will inject
(11:44):
a corticosteroid like he'sdescribing now.
Steroids are the most potentanti-inflammatories.
Inflammation is commonlyassociated with redness, warmth,
swelling and pain.
So when you put ananti-inflammatory around a joint
, a tissue or a nerve, thatinflammation subsides and those
(12:05):
four characteristics associatedwith inflammation redness,
warmth, swelling and pain alsosubside.
And so very often we aspractitioners will perform
injection therapy where we'llgive a numbing medicine like a
lidocaine or a marcane or anovacaine derivative Into an
area.
Combined with a corticosteroid.
(12:27):
For instance can a log depa,medrawl, something like that,
and we'll mix that into acocktail and inject that into a
joint or into a tissue or into,and so we'll give a numbing
medicine.
That's typically only transient, it's only temporary.
It's like going to the dentist.
When the dentist numbs you fora few hours three to five hours
(12:51):
That's because of the numbingmedicine that he placed around
the nerves of the job Or of thetooth.
Same thing happens inorthopedics and pain management
will numb the area for three tofive hours and then the second
Medication, typically acorticosteroid, will kick in,
typically in about two to threedays.
So very often we'll get a verylong period of time And then
(13:18):
they might actually be in painagain, or even a little more
sore, from the actual procedureuntil two to three days or three
to four days after theprocedure when the
corticosteroid kicks in, andthen they'll have to be in pain
again, or even a little moresore, from the actual procedure
until two to three days or threeto four days after the
(13:41):
procedure when thecorticosteroid kicks in, and
that injection Medication willthen give them a much longer
pain relief.
So that's a diagnostic andtherapeutic procedure that we do
to help the patient, but italso gives feedback to the
healthcare provider That we'reactually treating the right area
, the right body part, the rightnerve.
(14:02):
Sometimes pain can be referredfrom a different area.
The case in point would be Painaround the shoulder.
Is that shoulder pain or isthat referred pain from the neck
?
pain around the hip is that hippain or referred pain from the
sciatic nerve of the lower back?
These are things that we don'talways know 100%.
So we'll treat one of theconditions with a diagnostic and
(14:26):
therapeutic type of injectionand then reassess the patient in
a couple days And if thatpatient feels better, very
likely the area that we injectedwas the etiology of the pain.
If not a follow up, we mayconsider injecting the other
area to see if it was referredpain stemming from that other
area.
So that is just furtherelaborating on what Dr Aiden
(14:50):
said.
So thank you for that, dr Aiden.
Steven Aydin, DO (14:52):
Dr Kail you bring up two very common
diagnosis that we often worktogether with the shoulder and
the neck, and the hip and theback, and so many times we'll
see patients together, or I'llsee someone first and then
you'll see someone, or viceversa, and we're dealing with
these diagnoses and we can'tdetermine significantly or just
(15:14):
from examining them or justimaging, to say, is it the neck
or is it the shoulder, becausethe two really live together, or
is it both Right, and sometimesit's both.
I mean, you know and we seethat all the time, all the time.
So it's really important thatyou know, as practitioners and
orthopedists andinterventionalists a
rheumatologist, a sportsmedicine doctor that we all work
(15:35):
together and kind ofaccomplishing the same goal for
the patient 100% and it'sactually great for the patient
because it gives us morefeedback about what the the the
main source of the pain is.
Robert A. Kayal, MD, FAAOS (15:50):
For instance, if the pain is is
associated with both regions, atleast we can be honest with the
patient and and notify themwhat our expectations are, so
that we are all on the same page.
If a patient is undergoing aninterventional pain management
procedure, like a nerve block oran epidural steroid injection
(16:11):
for the neck, but they also havea rotator cuff tear in the
shoulder, dr Aiden can then saylook, i'm going to associate,
i'm going to alleviate some ofthe pain and discomfort in the
shoulder, but not all of it,because you also have a rotator
cuff tear And when I'm done withthis, you may have to see Dr
Kale for an injection in yourshoulder, type of thing, and and
vice versa.
So it helps give us moreinformation so that we can guide
(16:35):
our patients with respect towhat our expectations are in
regarding their degree of painrelief.
So it's very, very helpful.
Steven Aydin, DO (16:43):
Pivoting off of that.
You know, diagnostically, wetalked a lot about injections
and what we do as practitioners.
But at the same time, mri, catscan, x-ray these facilities
that we have available right onsite within our practice and
having that imaging available tome every single time the
patient comes back, i just loginto the computer.
(17:05):
We have our MRIs, our CAT scans, our x-rays, nothing is missed.
And then if say, somethingdoesn't work, whether it's an
injection that you performed orI performed, we don't have to
fumble around and say, well, didyou bring your CD last time?
I have to pull up your report.
I just go right into our systemand that image of their spine
that they had or that image oftheir shoulder that they had is
(17:26):
right, available, and say, well,what did we miss that time?
And then we also do electrodiagnostic studies.
So within the specialty ofphysiatry which I've trained in,
i perform EMG.
So EMG is a nerve conductionstudies.
Allow us to use a moreobjective electro diagnostic or
kind of like a nerve study or anerve test to figure out which
(17:48):
nerve root is irritated, how badit is.
Is the nerve so damaged thatthe wires are, are snapping
inside and you're gettingpermanent nerve damage.
Which level is it involved inthe neck or the back?
Is it carpal tunnel syndrome?
is there some other, what wecall a mono neuropathy, meaning
a pinched nerve outside of thespine that's present.
(18:09):
Do they have some sort ofneuropathy or other systemic
disease that we're missing, thatwe're getting fooled by the
body, and so we can use theseother studies like EMG, nerve
conduction studies, mris, x-rays, cat scans, ultrasound, to
really direct us to gettingoptimal improvement and
diagnostic treatment for thepatient, so that they have, you
(18:32):
know, their life back, if youwill, yeah nerve pain is clearly
the most painful type of painpatients can experience,
something we call neuropathicpain.
Robert A. Kayal, MD, FAA (18:43):
Nerves don't like to be compressed.
Irritated, stretched nervesobviously are extremely,
extremely sensitive, and whatwe've learned in the field of
surgery can often beextrapolated to the clinical
practice as well andinterventional pain management,
(19:03):
and that is the concept ofpreemptive anesthesia.
Can you elaborate on thatconcept of preemptive anesthesia
and how it's so important tostay ahead of pain in the field
of medicine as opposed toplaying catch up to address pain
?
Steven Aydin, DO (19:18):
Oh, absolutely Well.
I mean it's multifaceted.
We've kind of gone through, youknow, a pendulum swing of where
we were using a lot ofnarcotics for pain control you
know whether it was a high doseopioids before surgery or after
surgery.
In your specialty, where you'redoing a joint replacement, the,
the paranoid shift has been toless hospital stay, get him home
(19:40):
quicker, even outpatient.
So the last thing that we wantis a patient to be in
significant amount of pain witha joint replacement or some sort
of intervention or surgicalintervention to a joint or the
spine, and be so out ofcommission where they can't go
home or they can't be dischargedfrom the hospital within
reasonable time for thatinstitution.
(20:02):
So regional anesthesia andnerve blocks are preemptive.
Anesthesia blocks are extremelyhelpful in a few different ways.
One is it allows the doctor toperform the procedure with much
less pain that the patient isReceiving during the actual
procedure.
So if you're someone who isgetting anesthesia for this
(20:24):
procedure whether it's fullsedation where they put a tube
in your throat, or is just IVsedation, whether using propofol
or some sort of sedatives Theamount that you'll need will be
much less so because you won'tbe feeling the amount of pain
that you should be feeling.
The conduction of that nervefor that region is blocked now,
so you can perform yourprocedure almost with the
(20:46):
patient completely awake.
So that's the first step.
So less than the second step is.
Many of these blocks last a longtime, meaning 48 to 72 hours,
depending on the type of localanesthetic that the
anesthesiologist uses or thepost anesthesia care that they
get in the institution.
(21:06):
So many times your need for postoperative medication is much
less, so you won't neednarcotics for 10 days.
You'll only need it within twoor three days after you've gone
home, and many times the worstSwelling inflammation is within
the first 72 hours.
So if we can kind of controlthat with minimal medication
(21:30):
from a nerve block beinginvolved and the patient doesn't
need a lot of medications onboard, It then means that they
get to rehab in physical therapy.
They're walking around fasterand quicker, their medical
complications drop down so theydon't end up with a cloth that
can travel somewhere causeanother problem.
They're eating quicker becausethey had less anesthesia.
(21:51):
They're not as nauseous afterthe anesthesia.
So regional anesthesia or thenerve blocks that help you guys
perform your surgicalinterventions, i think are so
valuable in many of the thingsthat we perform within our scope
of practices, because it justlowers the risk for a lot of the
things that we've learned inthe past.
(22:13):
That can really result with badoutcomes 100%.
Robert A. Kayal, MD, FAAOS (22:18):
It's rare for us to do a surgical
procedure, especially a bigsurgical procedure, without
regional anesthesia delivered bythe anesthesiologist prior to
surgery.
The concept is essentially, asDr Aiden mentioned, that we want
to essentially block the brainfrom ever sensing the pain from
(22:40):
the incision, and so if thatnerve can be blocked before the
surgery, then when the surgeonmakes the incision, the concept
is that the spinal cord and thebrain do not even appreciate
that pain pathway that'semanating from the surgical
(23:02):
incision, and so patients willhave much, much less pain
postoperatively, and so it's apreemptive block.
But along those lines of doingpreemptive anesthesia, regional
anesthesia, can you elaborate onanother very, very important
concept in the area of painmanagement and that is
multimodal anesthesia and themultimodal approach to
(23:25):
preemptive pain management?
Steven Aydin, DO (23:28):
So multimodal approach just basically means
you're using a lot of differenttechniques instead of one
technique to getting paincontrol.
So multimodal basically meansand obviously every case is
different, every limitation thatcomes in is very patient
dependent But usinganti-inflammatories, using nerve
blocks, using opioidmedications, using, you know,
(23:51):
electrical stimulation, doingphysical therapy, massage
therapy, acupuncture, all thesethings have a component of
controlling some of the pain.
So I'm not saying that allthose things are what every
patient is going to get.
But that multimodal approach,whether it involves medications,
nerve blocks, acupuncture,chiropractic manipulation, kind
(24:14):
of things, along with theirpostoperative and preoperative
care, can really improve boththe outcome of the surgery and
the discomfort during andpostoperatively.
Robert A. Kayal, MD, FAAOS (24:26):
You know, pain is a very complicated
concept.
It's so important now in thefield of medicine to assess pain
and adequately treat it thatit's become what we call the
fifth vital sign.
It's so important to stay aheadof it.
And it's complicated andcomplex and that led to the
(24:48):
field of multimodal attack ofthis pain from many, many
different angles.
And it's very, very important.
I can't emphasize it enough howimportant it is to stay ahead
of the pain.
And so, just like inorthopedics, when somebody has
an overused condition like abursitis or a tendonitis that is
exacerbated by a certainactivity, for instance running,
(25:11):
if a runner had patellartendonitis, i would tell that
runner that it's okay to run,make sure you stretch beforehand
and I would consider taking aanti inflammatory preemptively.
So if you know you're going togo out for a five mile run and
typically that run willexacerbate your patellar
(25:31):
tendonitis around your knee, iwould suggest that that patient
take anti-inflammatory likeMotrin, advil, aleve or
Ibuprofen preemptively beforethe run, because it's easier to
manage that inflammation beforethey go out running as opposed
to trying to play catch up andmanaging it after the fact.
And the same concept can beextrapolated to surgeries where
(25:55):
we block the nerve before thesurgical procedure And also in
the management of pain.
If you're in pain, it wouldcertainly behoove you to come
see one of us, especially DrAiden, who can preemptively
address the pain before thatinflammation gets too far out of
control.
It's a downward spiral and it'svery hard to manage chronic
(26:17):
pain.
This is well published in theorthopedic and pain management
literature.
Patients going into surgery inpain have much more pain after
surgery.
So the onus is on us as yourhealthcare providers to try to
decrease that pain, decrease theinflammation, and very often
we'll use a multimodal approach.
(26:38):
We'll use some medications,like the local anesthetics, to
block the nerve.
We'll use anti-inflammatoriesaround the nerve.
We'll use anti-inflammatoriesin joints, like cortisone
injections, different thingslike that.
Some of the pain is from thenerve itself, a concept we call
neuropathic pain, and sometimeswe use agents like Lyrica or
(26:59):
Gabapentin, neurontin, to helpmanage the nerve component of
the pain.
So it's a complicated topic.
But we have experts here at theKale Orthopedic Center and
certainly Dr Stephen Aiden is adouble board certified
interventional pain managementspecialist as well as
physiatrist, who is highlytrained, skilled and experienced
(27:21):
in the field of acute andchronic pain management.
So, dr Aiden, we spoke aboutthe types of procedures that you
do and the medications that areincluded in those injections,
and we talked about the conceptof preemptive anesthesia and
multimodal approach to painmanagement and inflammation.
(27:44):
But let's try to hone in alittle bit on some of the very
common conditions you and Itreat on a daily basis.
The patients that we seeprimarily for discurriations in
the cervical spine, the lumbarspine and the lumbar spine very
commonly known as sciatica, andalso potentially in the elderly
(28:07):
population where we see acondition called spinal stenosis
and shopping cart syndrome,neurogenic clotication, and we
can refer patients to anotherpodcast that we recently did
with Dr Paul Bhavi on thosespine conditions.
We're not going to elaborateagain on those, but I think we
should now try to talk aboutsome of the interventional pain
management procedures that werefer to in that podcast that
(28:30):
actually you do for cervicaldiscurriations, radiculopathy,
lumbar disc herniation, sciatica, spinal stenosis And even a
condition we call facetogeniclow back pain, where people can
get arthritic changes in theirfacet joints that's exacerbated
when they're standing up andextending their spine.
So, regarding those threecommon things that you see on a
(28:54):
daily basis, just take usquickly through how you talk to
patients about scheduling themfor these procedures.
What you say to them, where youdo these procedures, is
anesthesia required, things likethat.
Steven Aydin, DO (29:10):
Sure.
So you mentioned a fewdifferent diagnoses, so we'll
start at the top.
First, with herniated disc, orwhat we commonly know as
radiculopathy, so that radiatingpain that's coming from a
pinched nerve, as we describe it, sciatica at the back or
sciatica at the arm, as I callit with some patients, and the
goal of that is to performsomething called an epidural
(29:31):
steroid injection.
And what that is is an imageguided.
I use live x-ray to place theneedle at the level or next to
the level where this disc ornerve is being pinched or kinked
, and the goal of that is toapply that lidocaine, saline and
cortisone mixture into thatarea to flush it, reset it and
(29:53):
reduce the inflammation, andmany times patients will get
significant improvement withthat.
That doesn't require some sortof surgical intervention.
So that's a typical treatmentfor a herniated disc with an
epidural steroid injection.
How many of those do youtypically do for an acute
problem?
So we usually try with doingone.
(30:13):
There has been a lot of socialacceptance of doing three in a
row, which is not what we reallydo for epidurals anymore.
The goal is to do one and getas much as we can, or the
biggest bang for the buck out ofone shot for the patient.
Now if it doesn't work, we goback to the drawing board.
If it works and we don't get aslong, or we only get 50% or
(30:35):
more and we need some more, thenwe'll talk about a second
injection.
Within our practice we're not acookie cutter kind of approach.
We look at every patientindividually and we take every
diagnostic therapeutic injectionin stride because we don't know
if we'll even do the same shot.
I may change the approach, imay change the level.
So there's a lot of differentthings.
(30:56):
That kind of go into it beforewe say, oh, we're going to do a
series of these, so we try andjust do one, and kind of focus
on how their progress is afterthat.
As far as facet pain or theaxial low back pain, so we think
of the back in two directions,kind of leaning forward and
leaning backwards, and leaningforward generally means that
(31:17):
it's a herniated disc andleaning backwards generally
means it's an arthritic or afacetogenic pain, and so there
are epidurals for radiculopathyor pinched nerve symptoms.
But then there are facetinjection or facet medial branch
nerve blocks that we perform todiagnose the back pain coming
from arthritis, and the goal ofthat is to potentially either
(31:40):
resolve those symptoms with thatand diagnose it with that shot,
but then also to potentiallygive you a longer improvement
with something that's calledradio frequency ablation, which
is basically a quarterization ofthe very small, tiny nerve that
goes to that joint individuallynot the nerve that controls the
leg or the nerve that doesmovement, but the nerves that do
(32:02):
these small little finger jointsize, if you will, in your neck
, your back or your mid backthat can give you referred
arthritic pain And that cansometimes even give you sciatica
.
And that's why it becomes soimportant to being a good
diagnostician as to where yourpain is being generated from.
So that's kind of how weapproach what's called
facetogenic pain.
(32:23):
You also mentioned spinalstenosis, and spinal stenosis is
basically a narrowing of thecanal or the foramen, which is
where the nerves go down and outfrom the side, and we try to
manage those symptoms witheither an epidural or some sort
of other injection therapy.
Many times, as Dr Baggy may havetalked to you about, is that we
(32:46):
do decompressions for reallybad stenosis, But many patients,
especially elderly patients whomay not be able to go through
an invasive surgery or they justdon't want to explore surgery,
and they've been responding toepidurals and the epidurals
aren't lasting along as long asthey used to, or we've hit the
limit of how many they'reallowed to have.
(33:07):
Per their insurance carrier willexplore something called a
minimally invasive lumbardecompression or a pericutaneous
decompression of the ligamentthat's thickened, that's causing
this spinal stenosis, and it'sa procedure that's a little bit
more than just a shot.
It does sometimes require alittle bit of anesthesia, but
(33:28):
the bounce back and the recoveryand the return on this
procedure is so wonderfulcompared to, say, something more
invasive like a laminectomy ora fusion.
So that's something that we'vebeen offering for the last
couple years in our practice,has gotten a lot of traction and
has been around for about adecade now.
I'm within the specialty ofpain management and you know,
(33:52):
with any tech or new tech thatwe bring into the practice,
whether it's pain or within theother specialties, we take the
onus upon us to make sure thatthe research matches our
clinical outcomes and within thepractice, under the umbrella of
pain management, i reallytaking that ownership of that.
So we really don't offerprocedures that we don't see
(34:13):
good outcomes or don't seereplicated within the literature
.
So that's a kind of somethingthat I've always had ingrained
in me and I think is reallyworked in our practice very well
.
Robert A. Kayal, MD, FAAOS (34:24):
Yeah , you've really pioneered that
technology in this area, forsure.
You've done so many of thosealready.
So, I brought with us today aspinal model.
I thought it would be veryhelpful to have Dr Aiden explain
some of the procedures that hejust referenced, specifically
cervical epidurals, lumbarepidurals, the mild procedure
(34:47):
for spinal stenosis, as well asmedial branch blocks for
facetogenic low back pain.
So why don't you take it fromhere, dr Aiden, and go through
your thing?
Steven Aydin, DO (35:00):
So many times when we talk about epidurals
we're really talking aboutgetting into the epidural space
and what we do is we use livex-ray, which is very similar
looking to what we're seeinghere, only gives me outlines of
where the bones are, and it'sgreat for bone anatomy, but it
doesn't tell us about where thesoft tissues are.
So a lot of what I do is reallyby feel followed by the image
(35:24):
guidance.
So something like an epiduralfor the neck or the lower back
is really targeted to go in thisspace here, and epi, meaning
around the dura, goes into thearea around where the spinal
cord is And that's bordered bythe discs, the nerves and the
facets.
So for a lumbar epidural weoften will target somewhere in
(35:45):
between here or here and try andplace the needle into that area
and then inject into that area.
There's another epidural whichwe call a transferaminal, where
we go in from the side.
So many times you can kind ofsee this red disc herniation
that's inflamed and swollen andtouching the circuit board of
the nerve root, which isprobably the most intense pain,
(36:06):
as we talked about, and whatI'll do in these situations is
I'll place a needle right atthis level, along where this
inflammation is under x-rayguidance to get that medication
there In the cervical spine.
We'll kind of look at this areaand we'll go in between these
bones to get into the epiduralspace, or we'll go in from the
(36:27):
side here, which is done alsounder x-ray guidance, to place a
needle along the nerve root,whether it's here here or here.
Now, many times we'll also talkabout the facets as being a
treatment option, and now thefacets are basically these
little lines that you see.
Here The bones stack up on eachother and many times we'll talk
about the disc kind of being thesupporter of the spine.
(36:50):
But the back of the spine, orwhat we call the posterior
elements of the spine, are madeup of the facet joints and these
small joints kind of take a lotof the brunt when you lean
backwards or when you twistaside from the disc.
And we'll either do injectionsinto this actual joint or we'll
perform what's called a medialbranch block, where we'll block
(37:14):
the nerve that lives right alongthis little gully here and
we'll place a needle into thatarea and block the nerve with
that diagnostic injection thatwe talked about And that can
also be performed here in theneck where we block the small
nerves that go to these littlejoints that are comprised right
here.
We'll place a needle alongthese areas and block those
(37:35):
joints, followed withimprovement.
We'll do a series of these manytimes and if it's short lived
we'll talk about the radiofrequency, as we mentioned
earlier on.
As far as the mild procedure,that's a procedure where we
actually there's a thick saranwrap like ligament that thickens
over time.
(37:55):
So many times I'll tellpatients that that ligament
thickens as if we're in a roomfor 10,000 days throughout their
life and we put a coat of paintor wallpaper on the wall.
Eventually those layers startbuilding up, start cracking,
peeling and they start creatingpressure onto the canal there.
And what we do with the mildprocedure, that minimally
(38:15):
invasive lumbar decompression,is I take little scrapes of the
back of that ligament to allowit to bow back from all the
pressure that's built up overthe years.
And the research has said thatif I could increase that surface
area just a little bit by 14%is what they say in the
literature But if we can createjust a little bit of space for
(38:38):
the nerves that are living orthese yellow nerve structures
that are shown here, then thepatient should have significant
symptomatic relief, less what wecall claudication or that
radiating pain that gets worseas they walk and then they stop
and it goes away and that cyclestarts over again.
Less of that leaning forwardpain that they need to kind of
(38:58):
open up their spine.
So that's the mild procedure.
So we also talked about where weperform these procedures.
So many of these procedureswill often be done under live
x-ray within a procedure room orsuite, which we have a couple
in different offices, and thensome of these will be done in a
surgical center, whether it'sjust because that's where it's
(39:21):
convenient for the patient tohave it done or if they require
anesthesia.
So anesthesia or IV sedationfor these patients can sometimes
be offered, and it's not alwaysnecessary.
You know, for many of theprocedures that we perform, many
of them can be done with localanesthetic, where I just numb
the patient up and I perform theinjection within three to five
minutes.
But some of the more invasiveprocedures we need IV sedation.
(39:44):
The patient will be put tosleep, they wake up and the
procedure is done.
Or if a patient has a lot ofanxiety about needles or having
a procedure done, we'll providethat service for them as well.
Robert A. Kayal, MD, FA (39:55):
Another , now that you have the spine
model here.
Another fairly common problemin our field in orthopedics is
bone metabolism issues andosteoporosis osteopenia,
osteoporosis And we're seeingmore and more elderly patients
suffer from what's called aninsufficiency, compression,
fracture of the lumbar spine,thoracic or lumbar spine.
(40:17):
Is there anything you can do asan interventional pain
management specialist to addresssome of the pain associated
with these pathologicalfractures?
So these are the vertebralbodies, and sometimes when
patients' bones become brittleand frail with a very low energy
(40:40):
trauma, like even a fall ontotheir buttocks, sometimes that
can cause a significant fractureor compression And typically
these bones become wedged.
And because the structuralintegrity of the bone is lost
with age due to osteopenia orosteoporosis, and when these
(41:02):
bones collapse, these patientsoften will assume a hunched over
deformity and it's extremelyuncomfortable as well.
Sometimes, when the fracturesare so severe, the bone not only
can get compressed but it candisplace posteriorly into the
area of the spinal cord or whatwe call the thickelsack and the
(41:24):
lumbar nerves, and so sometimesthat can be extremely painful
and it can cause symptoms verymuch analogous to spinal
stenosis or what we callradiculopathy, when nerve roots
get compressed.
So very often we'll refer thesepatients to Dr Aiden, who can
perform interventional painmanagement procedures to
(41:46):
immediately alleviate thesepatients from the pain
associated with these fractures.
Steven Aydin, DO (41:52):
Can you speak to that Sure?
So that's probably one of themost rewarding procedures that I
perform within my specialty.
When a patient develops acompression fracture, it's
extremely painful for them Andmany times in the early portions
of this they're almost laid upin bed and they can't move.
And I always express this topatients is like if you break a
(42:13):
bone.
The first thing that Dr Kale orany orthopedist is going to do
is they're going to say well, weneed to put you in the cast,
you can't use it, you can't putweight on it And we'll see you
back in six to eight weeks.
Right, how do you do that forsomeone's spine Sure, whether
it's their lumbar spine or theirthoracic spine?
So there is a subset ofprocedures that we call
vertebral augmentation, where weactually go into the vertebrae
(42:36):
and try to reestablish theheight and try to inject cement
or a stent or a combination ofthe two to get that height back
and in turn stabilize the bonewith that cement, so something
like a vertebral plasty.
When someone gets a compressionhere, where this becomes a
wedge or they lost the height ofit, and we use imaging
(42:57):
obviously to demonstrate thatand certain MRI sequences or
scans can show me.
If the bone is inflamed and nothealing or delayed healing, we
can kind of make a judgment ondo we attack that bone and try
to stabilize it?
So vertebral plasty is verysimply we go in there and we
inject cement under live x-ray.
Kypho plasty is where we go inthere and we put a balloon in to
(43:20):
establish the height or we puta stent in to establish the
height and then we inject thecement.
So there's multiple approachesfor this and every patient is
treated and looked atindividually and differently
based on how the fracture looks.
You mentioned something calledretro pulsion, where the bone
actually migrates into the backof the spinal canal.
(43:40):
In very mild cases we canmanage that with a vertebral
plasty or a kyphoplasty.
In very severe cases we reallyhave to weigh our options and
establish if that's really asurgical emergency and where
someone like Dr Dabagi or DrDenizzo needs to be involved.
But this is one of thoseprocedures where you know my
(44:02):
approach to patients with a lotof injection therapy is you need
to make the decision if this issomething that you want.
As far as compression, fractureand vertebral augmentation, i'm
usually quite aggressive andsaying this is something you're
gonna need to do, especially ifyou're totally out of commission
for several weeks, because thenit becomes a risk as far as
(44:25):
decline in function.
You become dependent onmedications, your quality life
goes down and then you become ahigh risk for another fracture.
The other thing we really needto pivot here and we offer this
within our practice is bonehealth management.
So, yes, i can fix any fracture, i can get in there and put
cement, but the problem is thatthe patient has soft bones.
(44:48):
So we as practitioners need tobe very aggressive in offering
osteoporotic management so thatthe patient's bone health is
better, to prevent anotherfracture.
Because once you get onefracture, whether you do a
kyphoplasty or vertebralaugmentation or don't, you are
almost 80% or higher to gettinganother fracture without
(45:09):
treating it.
So yeah, 100%.
Robert A. Kayal, MD, FAAOS (45:11):
I agree it's very important.
We do have an osteoporosis bonemetabolism center at the Kale
orthopedic center and we'realways on top of that with our
patients because of the risingrate of compression fractures,
hip fractures, distal radiuswrist fractures, etc.
So it's very, very important toaddress the underlying disease,
not just the condition that thepatient is presenting for.
(45:34):
With respect to kyphoplastyversus vertebral plastic, how do
you make a decision, which oneto do?
and you mentioned also you'reinjecting cement.
Are you really injecting cementinto the ball?
Steven Aydin, DO (45:47):
Yeah, so vertebral plastic and
compression kyphoplasty aresimilar but different.
You know, one is purely justinjecting the cement and the
other is injecting cement afteryou've created a cavity or space
for the cement.
90% of the time I'm approachingwith doing a kyphoplasty
because it has less risk ofcement migration.
(46:07):
But there are certainsituations, like if there isn't
Significant amount of heightloss or there's just a line of
fracture in this, in the top ofthe bottom of the vertebrae, and
I just need to get a little bitof cement in that area, then
I'll just perform a vertebralplastic Where we just inject the
cement.
So the cement is it is abiologic cement called PMMA,
(46:30):
which is very common in theorthopedic world.
So it's not like we go to youknow hardware store, we get
cement, pick it up.
It's a biologic cement that'smixed at the time of the, the,
the procedure.
The cement hardens within 90seconds after being put into the
body.
It has a reaction that thenstabilizes interdigitates within
(46:51):
the bone and kind of reinforcesthat instability that you have
in that fracture.
Robert A. Kayal, MD, FAAOS (46:56):
Yes, so it's.
We do call it cement, but it'spolymethyl methacrylate and it
is a material that we use to fix, a lot of times, new
replacements to bone,replacement to bone, shoulder
replacements to bone, anklereplacements to bone.
It's the same polymethylmethacrylate, pmma, that is used
to I be injected into thesecompression fractures and we
(47:20):
call it cement because it'scementing the bone together.
So fractures her, broken bonesher, because there's movement,
either macro or microscopicmovement, between the bone
fragments and once you cementthem in place there's no
movement and the painimmediately goes away.
So I'm very proud to have DrAiden with us at the Kaila
(47:41):
orthopedic center.
He's he's done so many of thesekyphoplasties and vertebral
plastic and mild procedures andcertainly at cervical and lumbar
epidurals and ficep locks.
He's incredibly skilled,trained, personable, amazing
bedside manner.
We're just so happy to have him.
One last thing before we go, drAiden, if you could just talk a
(48:02):
little bit about up and comingfields of interventional pain
management, for instance,potentially the field of
regenerative medicine.
Regenerative medicine is a hottopic in orthopedics, where
we're regrowing things andallowing things to heal, as
opposed to replacing things Andfixing things with hardware.
(48:25):
We're using our own body, stemcells, platelet rich plasma.
You know different things likethat.
Can you speak to where we arein two thousand and twenty three
In the field of regenerativemedicine as it applies to
interventional pain management?
sure?
Steven Aydin, DO (48:43):
so regenerative medicine is a very
broad topic.
All of a sudden, within thelast twenty years, it's kind of
gotten a lot of traction withinmultiple specialties.
So when we say the wordregenerative medicine, really
talking about utilizing thingslike platelet rich plasma, bone
marrow concentrate, and thenthere's the wordage of stem cell
(49:03):
, that kind of comes in, whichwe kind of have to be careful
with because technically a lotof what we do doesn't involve
stem cell But PRP and bonemarrow or FDA cleared.
You can do and perform theseprocedures where you take the
patient's own blood, process itwithout manipulating it too much
And injecting it into regionswhether it's an arthritic joint,
(49:27):
a disk or a muscle or attended,and what you're doing is you're
promoting this inflammatoryresponse or bringing the.
As I like to say, you'rebringing the kind of tools that
the tendon, ligament, bone needs, that maybe the blood of that
patient is not bringing or thereisn't a good blood supply to
(49:48):
that region or a chronic injurythat's going on That just has
burnt out.
From bringing the nutrients andthe different factors that are
responsible for healing.
We've seen a lot of greatresults.
There's a lot of research,there's a lot of data that is
out there.
I always tell patients thatit's not snake oil, it's not the
(50:09):
at all answer.
You know it's not the thingthat's going to cure everything,
but it works as well as much ofwhat we already have.
So to have it as a tool withinour practice and provide it to
our patients whether it's forspine or joint issues, muscle
tendon issues I think it'sparamount.
I mean, you have to be able toprovide cutting edge technology
(50:33):
and treatments to patients,especially when the research is
kind of going in that directionand patients want that.
You know, they don't want toalways undergo surgery.
And if there is a mild tendontear and we put a little bit of
PRP or bone marrow concentratein that area and it allows it to
heal without undergoing asurgical procedure, and that's
(50:54):
great, you know, absolutely.
Robert A. Kayal, MD, (50:56):
Absolutely .
I'm so excited to know thatyou're offering this for our
patients in the area ofinterventional pain management.
In orthopedics we firmlybelieve in using biological
therapies and regenerativemedicine to address some
conditions not all conditions,but some conditions that have
(51:16):
the ability potentially to healif we could just add a little
more biology.
So in general in orthopedicsthings that are white,
anatomical structures that arewhite, tend to be fairly denuded
of blood supply.
The blood supply to those whiteanatomical structures tends to
be tenuous and precarious atbest.
(51:36):
Things like bone muscle have avery robust blood supply, so
when they break they heal, whenthe muscles rip they heal.
But certain things likeligaments, tendons, cartilage,
things that are white, have avery low propensity to heal
(51:58):
biologically without surgicalintervention.
Now we offer regenerativemedicine.
We offer the ability to addbiological therapies like
platelet rich plasma, bonemarrow aspirate, etc.
Like Dr Aiden was referring to,to help the patient heal
biologically, providing thosenecessary ingredients that are
(52:21):
not present locally at that site, like Dr Aiden so eloquently
described.
So we're very excited to offerthese services at the Kaila
Orthopedic Center.
We're so happy to have Dr Aidenwith us for many, many years
now and we hope that thispodcast was helpful for you.
If you would like to set up anappointment with Dr Aiden, he is
(52:42):
available in Northern NewJersey, in New York.
Just call 844-777-0910 or go tokailaorthocom and we'll be
happy to oblige.
Thank you so much for your timetoday.
It was a great, great timespent with you today and very
informative and educational.
Hopefully our viewing audiencethinks the same, thank you.
(53:05):
Thank you very much.
Hello and welcome to another edition
of the Kale Ortho Podcast.
Today is June 6th, 2023.
And we're so privileged to havewith us today our own
interventional pain managementspecialist, dr Stephen Aiden.
Dr Aiden is a board certified,fellowship trained physiatrist
who's double board certifiedHe's board certified in the
(00:21):
field of interventional painmanagement, but he's also board
certified in the field ofphysiatry.
And we're so happy to have DrAiden with us today because
there is such a dire need forinterventional pain management.
Unfortunately, so manyAmericans suffer from either
acute or chronic pain And thankGod, there's doctors like Dr
Stephen Aiden there for them tohelp alleviate their pain and
(00:45):
discomfort on a daily basis.
So welcome to the podcast, drAiden.
Thank you for having me, drKale, it's my pleasure.
That's my pleasure.
We're so happy to have you withus.
So, before we get started, drAiden, why don't you just give
us a quick summary about yourformal education?
Steven Aydin, DO (01:00):
Sure.
So I completed my medicalschool at the University of
Medicine in Dentistry in NewJersey in 2005 and then went on
to do my residency at UMD and Jin Newark and then went on to do
a pain fellowship at theUniversity of Michigan, which
was an additional year oftraining and board certified in
(01:21):
both specialties of physiatry orPM&R, as well as pain
management.
Robert A. Kayal, MD, FAAO (01:26):
Great , Thank you for that.
So let's get started and justdefine for our viewing audience
what is the field ofinterventional pain management
and what is the field ofphysiatry.
Sure.
Steven Aydin, DO (01:38):
So I'm going to tackle the physiatry first,
because physiatry itself is avery broad specialty that kind
of covers the gamut of differentmedical conditions for
different conditions likerelated to spinal cord injury,
stroke and musculoskeletalmedicine.
So as far as my focus inphysiatry, I've kind of pivoted
(02:01):
into the nonoperative side orthe nonoperative orthopedic side
of physiatry where I reallyfocus on musculoskeletal
medicine.
So many times a physiatristwill deal with the
rehabilitative needs as well astreatments of patients for
nonoperative orthopedic needssuch as knee pain, arthritis,
back pain, neck pain.
(02:22):
Many times we'll manage theseissues with injection therapy,
trigger points, physical therapy, chiropractic care and just
indicating patients for a lot ofdifferent treatments to prevent
them from seeing you really.
But obviously many times thereare reasons why we have surgeons
and our treatments and ourmedications or indications don't
(02:45):
work for patients.
As far as interventional painmanagement is a subspecialty
that kind of focuses on anonoperative management of
symptoms that are related toeither spine conditions or other
musculoskeletal conditions, inwhich injection therapy or
minimally invasive procedures ortechniques are utilized to
(03:06):
treat these patients' conditionsAnd the goal is really either
to manage their symptoms so thatthey don't need surgery or
manage their symptoms whensurgery isn't as perfect as we
always want it to be.
The human body is very uniqueand is very complex, and
sometimes it's not as easy asjust replacing a battery or a
(03:28):
carburetor on the car.
We're treating a human being,so not everything always goes
perfectly and our goal is tomanage these symptoms with
different kinds of techniqueswhether it's injections or
surgeries to getting the patientfunctional and improved.
So that part of my specialtyand my focus was my focus, where
we really focus oninterventional pain management
(03:51):
is really goal to manageconditions with injection
therapy and different kinds ofnoninvasive procedures to get
the patient functional andimproved in their quality of
life.
Robert A. Kayal, MD, FAAO (04:05):
Thank you for elaborating on all of
that.
On that note, give us someexamples, dr Aden, of some of
the more common musculoskeletalconditions that can be
alleviated with yourintervention.
Steven Aydin, DO (04:18):
Sure, so many times in interventional pain we
focus on the spine, but we canalways focus on other regions
that are painful for patientsthat become chronic or
sub-subacute for theirconditions.
The most common thing that Isee within the practice is
things related to neck pain andback pain, such as herniated
discs, sciatica, lumbarridiculopathy, spinal stenosis
(04:43):
and even facet pain.
The most common thing that Ikind of see and manage with
patients is doing injectiontherapy for these conditions,
such as lumbar or cervicalsteroid injections that focus on
the epidural space And the goalof that is really to try and
manage like a pinch nerve, as wecall, or a sciatica, to try and
(05:04):
get this patient functional andimproved where they don't
require medications, bed rest oreven, you know, invasive
surgery.
Some of the other proceduresthat we'll kind of have for
patients for differentconditions is facet injections,
which are really to focus onmanaging the axial back pain or
neck pain, meaning the pain thatcomes from the small joints in
(05:27):
the spine, and so we'll do manyof these procedures with image
guidance.
So it's a very exact kind ofspecialty where we're not just
putting a needle into the bodyand hoping that a medication
gets there.
We're very specific and verytailored to a patient's
conditions and needs.
You know you asked me the typesof conditions we try to treat.
(05:48):
But we can't do any of thiswithout imaging and you know,
physical exam and diagnosis andother specialties kind of seeing
the patient and getting an ideaof what the real condition is.
You know, many times patientshave multiple different kinds of
generators of pain and we haveto be very focused, you know,
(06:09):
and work together as a specialtyand different specialties to
kind of get this target done.
Most of these procedures aredone with x-ray guidance or
ultrasound guidance and the themajority of the outcomes is good
.
You know, obviously it's not apermanent fix.
We don't always end up with ahundred percent resolution of
(06:31):
these symptoms, but the goal ofwhat at least I've taken on in
the practice is to try and getpatients functional to a level,
especially if they're elderly orthey're not great surgical
candidates to allow them toenjoy their life, be pain-free
and be functional.
Really our goal is to getfunction and pain improvement
with the least amount of work,if you will.
Robert A. Kayal, MD, FAAO (06:53):
Great .
So, with respect to yourinterventions, before we go
through these common conditionsone by one and explain how you
actually perform some of theseprocedures and what your goal is
in addressing the disease thatyou're treating, why do these
injections even work?
For instance, what medicationsare you injecting typically
(07:18):
during your interventional painmanagement procedures, and what
is their mechanism of actionthat would allow the patient's
pain and inflammation to subside?
Steven Aydin, DO (07:28):
It's a great question and really relates to
you know, what are we reallyinjecting?
what are we reallyaccomplishing right?
There are many studies outthere that kind of look at the
different kinds of things weinject that may or may not work.
The majority of injections willhave cortisone in it, but we
don't want to be focused on justsaying that we're injecting
(07:50):
steroids into the body or thatevery injection has to have
steroid in it.
Much of what I do is reallytrying to make the diagnosis.
So many times.
It'll include a local anesthetic, such as lidocaine or marcaine,
which is a cousin of somethingthat used to be around called
novacaine, the numbing medicinethat we use Many times that's
(08:11):
mixed with cortisone and thatcortisone is really to introduce
into the body or in theenvironment where I think this
problem is coming from, like aherniated disc or an inflamed
nerve, and try to reduce theswelling.
So we've talked about twocomponents so far.
So the local anesthetic, which,just in simple terms, is really
used to reset the nerve, turnoff the thermostat, reset it as
(08:35):
well as allowed to turn off thepain, if you will.
So many times patients will geta nerve block quote-unquote and
the nerve block is a temporarytreatment for me to kind of get
an idea of where the pain iscoming from or if I got the
medication to the right target.
The nerve block is notsomething permanent and has a
(08:56):
short half-life of whateverlocal anesthetic we injected.
But really gives me a good ideais if a patient had
impossibility, difficulty tryingto get onto a table because of
the severe pain, and i do theepidural around the nerve and i
block that nerve, then they getoff the table without too much
difficulty and it puts me in theright neighborhood that i block
(09:18):
the nerve.
So that's the local and thesteroid which is kind of the lag
medication is injected into theenvironment to reduce the
inflammation.
So steroids are often used totry and reduce swelling
inflammation in the body, buthere we're using it specifically
right around the environmentthat's injured or herniated or
(09:39):
inflamed and that over time overusually about a few days to a
couple weeks will kind ofmetabolize and do his job to
cool off the fire around thisinflammation.
And then the third thing thatwe'll often inject is sterile
salt water.
So you need a medium with thesethings to kind of inject the
medication and the goal of that,at least in my opinion is to
(10:02):
flush the area.
And many times you know you'llget these herniations or these
inflammatory environments andthere's just so much
inflammation there from thechemical reaction that the body
has.
And our goal is to mitigatethat and try and slow that down
so that there isn't too muchpain and that the body can kind
of take over and say, well, youcooled off the fire for me and
(10:23):
now i can kind of control thisover response that i had.
And allowing that area to beflushed with maybe just like a
little power wash, if you willfrom the saline Will allow the
body to kind of free up thatnerve or free up the environment
of that, you know, inflammation.
Robert A. Kayal, MD, FAAOS (10:41):
So you so beautifully explained all
that.
Some of these concepts that DrAiden is speaking about can be
extrapolated into many otherfields of orthopedic medicine.
So essentially what he'sdescribing is a concept that we
as healthcare providers callinjections for diagnostic,
(11:01):
hopefully therapeutic outcomes.
So what that means is sometimeswe're not exactly sure What
body part or what nerve iscausing the patients pain and
symptoms.
So a lot of times what we'll dois inject local anesthesia into
that joint or around the nerveto numb the nerve, essentially
(11:23):
numb the nerve, and if the nervenumbs or if the joint No longer
hurts, than that tells thehealthcare provider that that
nerve or that joint is theideology of the patients.
Symptoms and pain.
When that is helpful, veryoften simultaneously will inject
(11:44):
a corticosteroid like he'sdescribing now.
Steroids are the most potentanti-inflammatories.
Inflammation is commonlyassociated with redness, warmth,
swelling and pain.
So when you put ananti-inflammatory around a joint
, a tissue or a nerve, thatinflammation subsides and those
(12:05):
four characteristics associatedwith inflammation redness,
warmth, swelling and pain alsosubside.
And so very often we aspractitioners will perform
injection therapy where we'llgive a numbing medicine like a
lidocaine or a marcane or anovacaine derivative Into an
area.
Combined with a corticosteroid.
(12:27):
For instance can a log depa,medrawl, something like that,
and we'll mix that into acocktail and inject that into a
joint or into a tissue or into,and so we'll give a numbing
medicine.
That's typically only transient, it's only temporary.
It's like going to the dentist.
When the dentist numbs you fora few hours three to five hours
(12:51):
That's because of the numbingmedicine that he placed around
the nerves of the job Or of thetooth.
Same thing happens inorthopedics and pain management
will numb the area for three tofive hours and then the second
Medication, typically acorticosteroid, will kick in,
typically in about two to threedays.
So very often we'll get a verylong period of time And then
(13:18):
they might actually be in painagain, or even a little more
sore, from the actual procedureuntil two to three days or three
to four days after theprocedure when the
corticosteroid kicks in, andthen they'll have to be in pain
again, or even a little moresore, from the actual procedure
until two to three days or threeto four days after the
(13:41):
procedure when thecorticosteroid kicks in, and
that injection Medication willthen give them a much longer
pain relief.
So that's a diagnostic andtherapeutic procedure that we do
to help the patient, but italso gives feedback to the
healthcare provider That we'reactually treating the right area
, the right body part, the rightnerve.
(14:02):
Sometimes pain can be referredfrom a different area.
The case in point would be Painaround the shoulder.
Is that shoulder pain or isthat referred pain from the neck
?
pain around the hip is that hippain or referred pain from the
sciatic nerve of the lower back?
These are things that we don'talways know 100%.
So we'll treat one of theconditions with a diagnostic and
(14:26):
therapeutic type of injectionand then reassess the patient in
a couple days And if thatpatient feels better, very
likely the area that we injectedwas the etiology of the pain.
If not a follow up, we mayconsider injecting the other
area to see if it was referredpain stemming from that other
area.
So that is just furtherelaborating on what Dr Aiden
(14:50):
said.
So thank you for that, dr Aiden.
Steven Aydin, DO (14:52):
Dr Kail you bring up two very common
diagnosis that we often worktogether with the shoulder and
the neck, and the hip and theback, and so many times we'll
see patients together, or I'llsee someone first and then
you'll see someone, or viceversa, and we're dealing with
these diagnoses and we can'tdetermine significantly or just
(15:14):
from examining them or justimaging, to say, is it the neck
or is it the shoulder, becausethe two really live together, or
is it both Right, and sometimesit's both.
I mean, you know and we seethat all the time, all the time.
So it's really important thatyou know, as practitioners and
orthopedists andinterventionalists a
rheumatologist, a sportsmedicine doctor that we all work
(15:35):
together and kind ofaccomplishing the same goal for
the patient 100% and it'sactually great for the patient
because it gives us morefeedback about what the the the
main source of the pain is.
Robert A. Kayal, MD, FAAOS (15:50):
For instance, if the pain is is
associated with both regions, atleast we can be honest with the
patient and and notify themwhat our expectations are, so
that we are all on the same page.
If a patient is undergoing aninterventional pain management
procedure, like a nerve block oran epidural steroid injection
(16:11):
for the neck, but they also havea rotator cuff tear in the
shoulder, dr Aiden can then saylook, i'm going to associate,
i'm going to alleviate some ofthe pain and discomfort in the
shoulder, but not all of it,because you also have a rotator
cuff tear And when I'm done withthis, you may have to see Dr
Kale for an injection in yourshoulder, type of thing, and and
vice versa.
So it helps give us moreinformation so that we can guide
(16:35):
our patients with respect towhat our expectations are in
regarding their degree of painrelief.
So it's very, very helpful.
Steven Aydin, DO (16:43):
Pivoting off of that.
You know, diagnostically, wetalked a lot about injections
and what we do as practitioners.
But at the same time, mri, catscan, x-ray these facilities
that we have available right onsite within our practice and
having that imaging available tome every single time the
patient comes back, i just loginto the computer.
(17:05):
We have our MRIs, our CAT scans, our x-rays, nothing is missed.
And then if say, somethingdoesn't work, whether it's an
injection that you performed orI performed, we don't have to
fumble around and say, well, didyou bring your CD last time?
I have to pull up your report.
I just go right into our systemand that image of their spine
that they had or that image oftheir shoulder that they had is
(17:26):
right, available, and say, well,what did we miss that time?
And then we also do electrodiagnostic studies.
So within the specialty ofphysiatry which I've trained in,
i perform EMG.
So EMG is a nerve conductionstudies.
Allow us to use a moreobjective electro diagnostic or
kind of like a nerve study or anerve test to figure out which
(17:48):
nerve root is irritated, how badit is.
Is the nerve so damaged thatthe wires are, are snapping
inside and you're gettingpermanent nerve damage.
Which level is it involved inthe neck or the back?
Is it carpal tunnel syndrome?
is there some other, what wecall a mono neuropathy, meaning
a pinched nerve outside of thespine that's present.
(18:09):
Do they have some sort ofneuropathy or other systemic
disease that we're missing, thatwe're getting fooled by the
body, and so we can use theseother studies like EMG, nerve
conduction studies, mris, x-rays, cat scans, ultrasound, to
really direct us to gettingoptimal improvement and
diagnostic treatment for thepatient, so that they have, you
(18:32):
know, their life back, if youwill, yeah nerve pain is clearly
the most painful type of painpatients can experience,
something we call neuropathicpain.
Robert A. Kayal, MD, FAA (18:43):
Nerves don't like to be compressed.
Irritated, stretched nervesobviously are extremely,
extremely sensitive, and whatwe've learned in the field of
surgery can often beextrapolated to the clinical
practice as well andinterventional pain management,
(19:03):
and that is the concept ofpreemptive anesthesia.
Can you elaborate on thatconcept of preemptive anesthesia
and how it's so important tostay ahead of pain in the field
of medicine as opposed toplaying catch up to address pain
?
Steven Aydin, DO (19:18):
Oh, absolutely Well.
I mean it's multifaceted.
We've kind of gone through, youknow, a pendulum swing of where
we were using a lot ofnarcotics for pain control you
know whether it was a high doseopioids before surgery or after
surgery.
In your specialty, where you'redoing a joint replacement, the,
the paranoid shift has been toless hospital stay, get him home
(19:40):
quicker, even outpatient.
So the last thing that we wantis a patient to be in
significant amount of pain witha joint replacement or some sort
of intervention or surgicalintervention to a joint or the
spine, and be so out ofcommission where they can't go
home or they can't be dischargedfrom the hospital within
reasonable time for thatinstitution.
(20:02):
So regional anesthesia andnerve blocks are preemptive.
Anesthesia blocks are extremelyhelpful in a few different ways.
One is it allows the doctor toperform the procedure with much
less pain that the patient isReceiving during the actual
procedure.
So if you're someone who isgetting anesthesia for this
(20:24):
procedure whether it's fullsedation where they put a tube
in your throat, or is just IVsedation, whether using propofol
or some sort of sedatives Theamount that you'll need will be
much less so because you won'tbe feeling the amount of pain
that you should be feeling.
The conduction of that nervefor that region is blocked now,
so you can perform yourprocedure almost with the
(20:46):
patient completely awake.
So that's the first step.
So less than the second step is.
Many of these blocks last a longtime, meaning 48 to 72 hours,
depending on the type of localanesthetic that the
anesthesiologist uses or thepost anesthesia care that they
get in the institution.
(21:06):
So many times your need for postoperative medication is much
less, so you won't neednarcotics for 10 days.
You'll only need it within twoor three days after you've gone
home, and many times the worstSwelling inflammation is within
the first 72 hours.
So if we can kind of controlthat with minimal medication
(21:30):
from a nerve block beinginvolved and the patient doesn't
need a lot of medications onboard, It then means that they
get to rehab in physical therapy.
They're walking around fasterand quicker, their medical
complications drop down so theydon't end up with a cloth that
can travel somewhere causeanother problem.
They're eating quicker becausethey had less anesthesia.
(21:51):
They're not as nauseous afterthe anesthesia.
So regional anesthesia or thenerve blocks that help you guys
perform your surgicalinterventions, i think are so
valuable in many of the thingsthat we perform within our scope
of practices, because it justlowers the risk for a lot of the
things that we've learned inthe past.
(22:13):
That can really result with badoutcomes 100%.
Robert A. Kayal, MD, FAAOS (22:18):
It's rare for us to do a surgical
procedure, especially a bigsurgical procedure, without
regional anesthesia delivered bythe anesthesiologist prior to
surgery.
The concept is essentially, asDr Aiden mentioned, that we want
to essentially block the brainfrom ever sensing the pain from
(22:40):
the incision, and so if thatnerve can be blocked before the
surgery, then when the surgeonmakes the incision, the concept
is that the spinal cord and thebrain do not even appreciate
that pain pathway that'semanating from the surgical
(23:02):
incision, and so patients willhave much, much less pain
postoperatively, and so it's apreemptive block.
But along those lines of doingpreemptive anesthesia, regional
anesthesia, can you elaborate onanother very, very important
concept in the area of painmanagement and that is
multimodal anesthesia and themultimodal approach to
(23:25):
preemptive pain management?
Steven Aydin, DO (23:28):
So multimodal approach just basically means
you're using a lot of differenttechniques instead of one
technique to getting paincontrol.
So multimodal basically meansand obviously every case is
different, every limitation thatcomes in is very patient
dependent But usinganti-inflammatories, using nerve
blocks, using opioidmedications, using, you know,
(23:51):
electrical stimulation, doingphysical therapy, massage
therapy, acupuncture, all thesethings have a component of
controlling some of the pain.
So I'm not saying that allthose things are what every
patient is going to get.
But that multimodal approach,whether it involves medications,
nerve blocks, acupuncture,chiropractic manipulation, kind
(24:14):
of things, along with theirpostoperative and preoperative
care, can really improve boththe outcome of the surgery and
the discomfort during andpostoperatively.
Robert A. Kayal, MD, FAAOS (24:26):
You know, pain is a very complicated
concept.
It's so important now in thefield of medicine to assess pain
and adequately treat it thatit's become what we call the
fifth vital sign.
It's so important to stay aheadof it.
And it's complicated andcomplex and that led to the
(24:48):
field of multimodal attack ofthis pain from many, many
different angles.
And it's very, very important.
I can't emphasize it enough howimportant it is to stay ahead
of the pain.
And so, just like inorthopedics, when somebody has
an overused condition like abursitis or a tendonitis that is
exacerbated by a certainactivity, for instance running,
(25:11):
if a runner had patellartendonitis, i would tell that
runner that it's okay to run,make sure you stretch beforehand
and I would consider taking aanti inflammatory preemptively.
So if you know you're going togo out for a five mile run and
typically that run willexacerbate your patellar
(25:31):
tendonitis around your knee, iwould suggest that that patient
take anti-inflammatory likeMotrin, advil, aleve or
Ibuprofen preemptively beforethe run, because it's easier to
manage that inflammation beforethey go out running as opposed
to trying to play catch up andmanaging it after the fact.
And the same concept can beextrapolated to surgeries where
(25:55):
we block the nerve before thesurgical procedure And also in
the management of pain.
If you're in pain, it wouldcertainly behoove you to come
see one of us, especially DrAiden, who can preemptively
address the pain before thatinflammation gets too far out of
control.
It's a downward spiral and it'svery hard to manage chronic
(26:17):
pain.
This is well published in theorthopedic and pain management
literature.
Patients going into surgery inpain have much more pain after
surgery.
So the onus is on us as yourhealthcare providers to try to
decrease that pain, decrease theinflammation, and very often
we'll use a multimodal approach.
(26:38):
We'll use some medications,like the local anesthetics, to
block the nerve.
We'll use anti-inflammatoriesaround the nerve.
We'll use anti-inflammatoriesin joints, like cortisone
injections, different thingslike that.
Some of the pain is from thenerve itself, a concept we call
neuropathic pain, and sometimeswe use agents like Lyrica or
(26:59):
Gabapentin, neurontin, to helpmanage the nerve component of
the pain.
So it's a complicated topic.
But we have experts here at theKale Orthopedic Center and
certainly Dr Stephen Aiden is adouble board certified
interventional pain managementspecialist as well as
physiatrist, who is highlytrained, skilled and experienced
(27:21):
in the field of acute andchronic pain management.
So, dr Aiden, we spoke aboutthe types of procedures that you
do and the medications that areincluded in those injections,
and we talked about the conceptof preemptive anesthesia and
multimodal approach to painmanagement and inflammation.
(27:44):
But let's try to hone in alittle bit on some of the very
common conditions you and Itreat on a daily basis.
The patients that we seeprimarily for discurriations in
the cervical spine, the lumbarspine and the lumbar spine very
commonly known as sciatica, andalso potentially in the elderly
(28:07):
population where we see acondition called spinal stenosis
and shopping cart syndrome,neurogenic clotication, and we
can refer patients to anotherpodcast that we recently did
with Dr Paul Bhavi on thosespine conditions.
We're not going to elaborateagain on those, but I think we
should now try to talk aboutsome of the interventional pain
management procedures that werefer to in that podcast that
(28:30):
actually you do for cervicaldiscurriations, radiculopathy,
lumbar disc herniation, sciatica, spinal stenosis And even a
condition we call facetogeniclow back pain, where people can
get arthritic changes in theirfacet joints that's exacerbated
when they're standing up andextending their spine.
So, regarding those threecommon things that you see on a
(28:54):
daily basis, just take usquickly through how you talk to
patients about scheduling themfor these procedures.
What you say to them, where youdo these procedures, is
anesthesia required, things likethat.
Steven Aydin, DO (29:10):
Sure.
So you mentioned a fewdifferent diagnoses, so we'll
start at the top.
First, with herniated disc, orwhat we commonly know as
radiculopathy, so that radiatingpain that's coming from a
pinched nerve, as we describe it, sciatica at the back or
sciatica at the arm, as I callit with some patients, and the
goal of that is to performsomething called an epidural
(29:31):
steroid injection.
And what that is is an imageguided.
I use live x-ray to place theneedle at the level or next to
the level where this disc ornerve is being pinched or kinked
, and the goal of that is toapply that lidocaine, saline and
cortisone mixture into thatarea to flush it, reset it and
(29:53):
reduce the inflammation, andmany times patients will get
significant improvement withthat.
That doesn't require some sortof surgical intervention.
So that's a typical treatmentfor a herniated disc with an
epidural steroid injection.
How many of those do youtypically do for an acute
problem?
So we usually try with doingone.
(30:13):
There has been a lot of socialacceptance of doing three in a
row, which is not what we reallydo for epidurals anymore.
The goal is to do one and getas much as we can, or the
biggest bang for the buck out ofone shot for the patient.
Now if it doesn't work, we goback to the drawing board.
If it works and we don't get aslong, or we only get 50% or
(30:35):
more and we need some more, thenwe'll talk about a second
injection.
Within our practice we're not acookie cutter kind of approach.
We look at every patientindividually and we take every
diagnostic therapeutic injectionin stride because we don't know
if we'll even do the same shot.
I may change the approach, imay change the level.
So there's a lot of differentthings.
(30:56):
That kind of go into it beforewe say, oh, we're going to do a
series of these, so we try andjust do one, and kind of focus
on how their progress is afterthat.
As far as facet pain or theaxial low back pain, so we think
of the back in two directions,kind of leaning forward and
leaning backwards, and leaningforward generally means that
(31:17):
it's a herniated disc andleaning backwards generally
means it's an arthritic or afacetogenic pain, and so there
are epidurals for radiculopathyor pinched nerve symptoms.
But then there are facetinjection or facet medial branch
nerve blocks that we perform todiagnose the back pain coming
from arthritis, and the goal ofthat is to potentially either
(31:40):
resolve those symptoms with thatand diagnose it with that shot,
but then also to potentiallygive you a longer improvement
with something that's calledradio frequency ablation, which
is basically a quarterization ofthe very small, tiny nerve that
goes to that joint individuallynot the nerve that controls the
leg or the nerve that doesmovement, but the nerves that do
(32:02):
these small little finger jointsize, if you will, in your neck
, your back or your mid backthat can give you referred
arthritic pain And that cansometimes even give you sciatica
.
And that's why it becomes soimportant to being a good
diagnostician as to where yourpain is being generated from.
So that's kind of how weapproach what's called
facetogenic pain.
(32:23):
You also mentioned spinalstenosis, and spinal stenosis is
basically a narrowing of thecanal or the foramen, which is
where the nerves go down and outfrom the side, and we try to
manage those symptoms witheither an epidural or some sort
of other injection therapy.
Many times, as Dr Baggy may havetalked to you about, is that we
(32:46):
do decompressions for reallybad stenosis, But many patients,
especially elderly patients whomay not be able to go through
an invasive surgery or they justdon't want to explore surgery,
and they've been responding toepidurals and the epidurals
aren't lasting along as long asthey used to, or we've hit the
limit of how many they'reallowed to have.
(33:07):
Per their insurance carrier willexplore something called a
minimally invasive lumbardecompression or a pericutaneous
decompression of the ligamentthat's thickened, that's causing
this spinal stenosis, and it'sa procedure that's a little bit
more than just a shot.
It does sometimes require alittle bit of anesthesia, but
(33:28):
the bounce back and the recoveryand the return on this
procedure is so wonderfulcompared to, say, something more
invasive like a laminectomy ora fusion.
So that's something that we'vebeen offering for the last
couple years in our practice,has gotten a lot of traction and
has been around for about adecade now.
I'm within the specialty ofpain management and you know,
(33:52):
with any tech or new tech thatwe bring into the practice,
whether it's pain or within theother specialties, we take the
onus upon us to make sure thatthe research matches our
clinical outcomes and within thepractice, under the umbrella of
pain management, i reallytaking that ownership of that.
So we really don't offerprocedures that we don't see
(34:13):
good outcomes or don't seereplicated within the literature
.
So that's a kind of somethingthat I've always had ingrained
in me and I think is reallyworked in our practice very well
.
Robert A. Kayal, MD, FAAOS (34:24):
Yeah , you've really pioneered that
technology in this area, forsure.
You've done so many of thosealready.
So, I brought with us today aspinal model.
I thought it would be veryhelpful to have Dr Aiden explain
some of the procedures that hejust referenced, specifically
cervical epidurals, lumbarepidurals, the mild procedure
(34:47):
for spinal stenosis, as well asmedial branch blocks for
facetogenic low back pain.
So why don't you take it fromhere, dr Aiden, and go through
your thing?
Steven Aydin, DO (35:00):
So many times when we talk about epidurals
we're really talking aboutgetting into the epidural space
and what we do is we use livex-ray, which is very similar
looking to what we're seeinghere, only gives me outlines of
where the bones are, and it'sgreat for bone anatomy, but it
doesn't tell us about where thesoft tissues are.
So a lot of what I do is reallyby feel followed by the image
(35:24):
guidance.
So something like an epiduralfor the neck or the lower back
is really targeted to go in thisspace here, and epi, meaning
around the dura, goes into thearea around where the spinal
cord is And that's bordered bythe discs, the nerves and the
facets.
So for a lumbar epidural weoften will target somewhere in
(35:45):
between here or here and try andplace the needle into that area
and then inject into that area.
There's another epidural whichwe call a transferaminal, where
we go in from the side.
So many times you can kind ofsee this red disc herniation
that's inflamed and swollen andtouching the circuit board of
the nerve root, which isprobably the most intense pain,
(36:06):
as we talked about, and whatI'll do in these situations is
I'll place a needle right atthis level, along where this
inflammation is under x-rayguidance to get that medication
there In the cervical spine.
We'll kind of look at this areaand we'll go in between these
bones to get into the epiduralspace, or we'll go in from the
(36:27):
side here, which is done alsounder x-ray guidance, to place a
needle along the nerve root,whether it's here here or here.
Now, many times we'll also talkabout the facets as being a
treatment option, and now thefacets are basically these
little lines that you see.
Here The bones stack up on eachother and many times we'll talk
about the disc kind of being thesupporter of the spine.
(36:50):
But the back of the spine, orwhat we call the posterior
elements of the spine, are madeup of the facet joints and these
small joints kind of take a lotof the brunt when you lean
backwards or when you twistaside from the disc.
And we'll either do injectionsinto this actual joint or we'll
perform what's called a medialbranch block, where we'll block
(37:14):
the nerve that lives right alongthis little gully here and
we'll place a needle into thatarea and block the nerve with
that diagnostic injection thatwe talked about And that can
also be performed here in theneck where we block the small
nerves that go to these littlejoints that are comprised right
here.
We'll place a needle alongthese areas and block those
(37:35):
joints, followed withimprovement.
We'll do a series of these manytimes and if it's short lived
we'll talk about the radiofrequency, as we mentioned
earlier on.
As far as the mild procedure,that's a procedure where we
actually there's a thick saranwrap like ligament that thickens
over time.
(37:55):
So many times I'll tellpatients that that ligament
thickens as if we're in a roomfor 10,000 days throughout their
life and we put a coat of paintor wallpaper on the wall.
Eventually those layers startbuilding up, start cracking,
peeling and they start creatingpressure onto the canal there.
And what we do with the mildprocedure, that minimally
(38:15):
invasive lumbar decompression,is I take little scrapes of the
back of that ligament to allowit to bow back from all the
pressure that's built up overthe years.
And the research has said thatif I could increase that surface
area just a little bit by 14%is what they say in the
literature But if we can createjust a little bit of space for
(38:38):
the nerves that are living orthese yellow nerve structures
that are shown here, then thepatient should have significant
symptomatic relief, less what wecall claudication or that
radiating pain that gets worseas they walk and then they stop
and it goes away and that cyclestarts over again.
Less of that leaning forwardpain that they need to kind of
(38:58):
open up their spine.
So that's the mild procedure.
So we also talked about where weperform these procedures.
So many of these procedureswill often be done under live
x-ray within a procedure room orsuite, which we have a couple
in different offices, and thensome of these will be done in a
surgical center, whether it'sjust because that's where it's
(39:21):
convenient for the patient tohave it done or if they require
anesthesia.
So anesthesia or IV sedationfor these patients can sometimes
be offered, and it's not alwaysnecessary.
You know, for many of theprocedures that we perform, many
of them can be done with localanesthetic, where I just numb
the patient up and I perform theinjection within three to five
minutes.
But some of the more invasiveprocedures we need IV sedation.
(39:44):
The patient will be put tosleep, they wake up and the
procedure is done.
Or if a patient has a lot ofanxiety about needles or having
a procedure done, we'll providethat service for them as well.
Robert A. Kayal, MD, FA (39:55):
Another , now that you have the spine
model here.
Another fairly common problemin our field in orthopedics is
bone metabolism issues andosteoporosis osteopenia,
osteoporosis And we're seeingmore and more elderly patients
suffer from what's called aninsufficiency, compression,
fracture of the lumbar spine,thoracic or lumbar spine.
(40:17):
Is there anything you can do asan interventional pain
management specialist to addresssome of the pain associated
with these pathologicalfractures?
So these are the vertebralbodies, and sometimes when
patients' bones become brittleand frail with a very low energy
(40:40):
trauma, like even a fall ontotheir buttocks, sometimes that
can cause a significant fractureor compression And typically
these bones become wedged.
And because the structuralintegrity of the bone is lost
with age due to osteopenia orosteoporosis, and when these
(41:02):
bones collapse, these patientsoften will assume a hunched over
deformity and it's extremelyuncomfortable as well.
Sometimes, when the fracturesare so severe, the bone not only
can get compressed but it candisplace posteriorly into the
area of the spinal cord or whatwe call the thickelsack and the
(41:24):
lumbar nerves, and so sometimesthat can be extremely painful
and it can cause symptoms verymuch analogous to spinal
stenosis or what we callradiculopathy, when nerve roots
get compressed.
So very often we'll refer thesepatients to Dr Aiden, who can
perform interventional painmanagement procedures to
(41:46):
immediately alleviate thesepatients from the pain
associated with these fractures.
Steven Aydin, DO (41:52):
Can you speak to that Sure?
So that's probably one of themost rewarding procedures that I
perform within my specialty.
When a patient develops acompression fracture, it's
extremely painful for them Andmany times in the early portions
of this they're almost laid upin bed and they can't move.
And I always express this topatients is like if you break a
(42:13):
bone.
The first thing that Dr Kale orany orthopedist is going to do
is they're going to say well, weneed to put you in the cast,
you can't use it, you can't putweight on it And we'll see you
back in six to eight weeks.
Right, how do you do that forsomeone's spine Sure, whether
it's their lumbar spine or theirthoracic spine?
So there is a subset ofprocedures that we call
vertebral augmentation, where weactually go into the vertebrae
(42:36):
and try to reestablish theheight and try to inject cement
or a stent or a combination ofthe two to get that height back
and in turn stabilize the bonewith that cement, so something
like a vertebral plasty.
When someone gets a compressionhere, where this becomes a
wedge or they lost the height ofit, and we use imaging
(42:57):
obviously to demonstrate thatand certain MRI sequences or
scans can show me.
If the bone is inflamed and nothealing or delayed healing, we
can kind of make a judgment ondo we attack that bone and try
to stabilize it?
So vertebral plasty is verysimply we go in there and we
inject cement under live x-ray.
Kypho plasty is where we go inthere and we put a balloon in to
(43:20):
establish the height or we puta stent in to establish the
height and then we inject thecement.
So there's multiple approachesfor this and every patient is
treated and looked atindividually and differently
based on how the fracture looks.
You mentioned something calledretro pulsion, where the bone
actually migrates into the backof the spinal canal.
(43:40):
In very mild cases we canmanage that with a vertebral
plasty or a kyphoplasty.
In very severe cases we reallyhave to weigh our options and
establish if that's really asurgical emergency and where
someone like Dr Dabagi or DrDenizzo needs to be involved.
But this is one of thoseprocedures where you know my
(44:02):
approach to patients with a lotof injection therapy is you need
to make the decision if this issomething that you want.
As far as compression, fractureand vertebral augmentation, i'm
usually quite aggressive andsaying this is something you're
gonna need to do, especially ifyou're totally out of commission
for several weeks, because thenit becomes a risk as far as
(44:25):
decline in function.
You become dependent onmedications, your quality life
goes down and then you become ahigh risk for another fracture.
The other thing we really needto pivot here and we offer this
within our practice is bonehealth management.
So, yes, i can fix any fracture, i can get in there and put
cement, but the problem is thatthe patient has soft bones.
(44:48):
So we as practitioners need tobe very aggressive in offering
osteoporotic management so thatthe patient's bone health is
better, to prevent anotherfracture.
Because once you get onefracture, whether you do a
kyphoplasty or vertebralaugmentation or don't, you are
almost 80% or higher to gettinganother fracture without
(45:09):
treating it.
So yeah, 100%.
Robert A. Kayal, MD, FAAOS (45:11):
I agree it's very important.
We do have an osteoporosis bonemetabolism center at the Kale
orthopedic center and we'realways on top of that with our
patients because of the risingrate of compression fractures,
hip fractures, distal radiuswrist fractures, etc.
So it's very, very important toaddress the underlying disease,
not just the condition that thepatient is presenting for.
(45:34):
With respect to kyphoplastyversus vertebral plastic, how do
you make a decision, which oneto do?
and you mentioned also you'reinjecting cement.
Are you really injecting cementinto the ball?
Steven Aydin, DO (45:47):
Yeah, so vertebral plastic and
compression kyphoplasty aresimilar but different.
You know, one is purely justinjecting the cement and the
other is injecting cement afteryou've created a cavity or space
for the cement.
90% of the time I'm approachingwith doing a kyphoplasty
because it has less risk ofcement migration.
(46:07):
But there are certainsituations, like if there isn't
Significant amount of heightloss or there's just a line of
fracture in this, in the top ofthe bottom of the vertebrae, and
I just need to get a little bitof cement in that area, then
I'll just perform a vertebralplastic Where we just inject the
cement.
So the cement is it is abiologic cement called PMMA,
(46:30):
which is very common in theorthopedic world.
So it's not like we go to youknow hardware store, we get
cement, pick it up.
It's a biologic cement that'smixed at the time of the, the,
the procedure.
The cement hardens within 90seconds after being put into the
body.
It has a reaction that thenstabilizes interdigitates within
(46:51):
the bone and kind of reinforcesthat instability that you have
in that fracture.
Robert A. Kayal, MD, FAAOS (46:56):
Yes, so it's.
We do call it cement, but it'spolymethyl methacrylate and it
is a material that we use to fix, a lot of times, new
replacements to bone,replacement to bone, shoulder
replacements to bone, anklereplacements to bone.
It's the same polymethylmethacrylate, pmma, that is used
to I be injected into thesecompression fractures and we
(47:20):
call it cement because it'scementing the bone together.
So fractures her, broken bonesher, because there's movement,
either macro or microscopicmovement, between the bone
fragments and once you cementthem in place there's no
movement and the painimmediately goes away.
So I'm very proud to have DrAiden with us at the Kaila
(47:41):
orthopedic center.
He's he's done so many of thesekyphoplasties and vertebral
plastic and mild procedures andcertainly at cervical and lumbar
epidurals and ficep locks.
He's incredibly skilled,trained, personable, amazing
bedside manner.
We're just so happy to have him.
One last thing before we go, drAiden, if you could just talk a
(48:02):
little bit about up and comingfields of interventional pain
management, for instance,potentially the field of
regenerative medicine.
Regenerative medicine is a hottopic in orthopedics, where
we're regrowing things andallowing things to heal, as
opposed to replacing things Andfixing things with hardware.
(48:25):
We're using our own body, stemcells, platelet rich plasma.
You know different things likethat.
Can you speak to where we arein two thousand and twenty three
In the field of regenerativemedicine as it applies to
interventional pain management?
sure?
Steven Aydin, DO (48:43):
so regenerative medicine is a very
broad topic.
All of a sudden, within thelast twenty years, it's kind of
gotten a lot of traction withinmultiple specialties.
So when we say the wordregenerative medicine, really
talking about utilizing thingslike platelet rich plasma, bone
marrow concentrate, and thenthere's the wordage of stem cell
(49:03):
, that kind of comes in, whichwe kind of have to be careful
with because technically a lotof what we do doesn't involve
stem cell But PRP and bonemarrow or FDA cleared.
You can do and perform theseprocedures where you take the
patient's own blood, process itwithout manipulating it too much
And injecting it into regionswhether it's an arthritic joint,
(49:27):
a disk or a muscle or attended,and what you're doing is you're
promoting this inflammatoryresponse or bringing the.
As I like to say, you'rebringing the kind of tools that
the tendon, ligament, bone needs, that maybe the blood of that
patient is not bringing or thereisn't a good blood supply to
(49:48):
that region or a chronic injurythat's going on That just has
burnt out.
From bringing the nutrients andthe different factors that are
responsible for healing.
We've seen a lot of greatresults.
There's a lot of research,there's a lot of data that is
out there.
I always tell patients thatit's not snake oil, it's not the
(50:09):
at all answer.
You know it's not the thingthat's going to cure everything,
but it works as well as much ofwhat we already have.
So to have it as a tool withinour practice and provide it to
our patients whether it's forspine or joint issues, muscle
tendon issues I think it'sparamount.
I mean, you have to be able toprovide cutting edge technology
(50:33):
and treatments to patients,especially when the research is
kind of going in that directionand patients want that.
You know, they don't want toalways undergo surgery.
And if there is a mild tendontear and we put a little bit of
PRP or bone marrow concentratein that area and it allows it to
heal without undergoing asurgical procedure, and that's
(50:54):
great, you know, absolutely.
Robert A. Kayal, MD, (50:56):
Absolutely .
I'm so excited to know thatyou're offering this for our
patients in the area ofinterventional pain management.
In orthopedics we firmlybelieve in using biological
therapies and regenerativemedicine to address some
conditions not all conditions,but some conditions that have
(51:16):
the ability potentially to healif we could just add a little
more biology.
So in general in orthopedicsthings that are white,
anatomical structures that arewhite, tend to be fairly denuded
of blood supply.
The blood supply to those whiteanatomical structures tends to
be tenuous and precarious atbest.
(51:36):
Things like bone muscle have avery robust blood supply, so
when they break they heal, whenthe muscles rip they heal.
But certain things likeligaments, tendons, cartilage,
things that are white, have avery low propensity to heal
(51:58):
biologically without surgicalintervention.
Now we offer regenerativemedicine.
We offer the ability to addbiological therapies like
platelet rich plasma, bonemarrow aspirate, etc.
Like Dr Aiden was referring to,to help the patient heal
biologically, providing thosenecessary ingredients that are
(52:21):
not present locally at that site, like Dr Aiden so eloquently
described.
So we're very excited to offerthese services at the Kaila
Orthopedic Center.
We're so happy to have Dr Aidenwith us for many, many years
now and we hope that thispodcast was helpful for you.
If you would like to set up anappointment with Dr Aiden, he is
(52:42):
available in Northern NewJersey, in New York.
Just call 844-777-0910 or go tokailaorthocom and we'll be
happy to oblige.
Thank you so much for your timetoday.
It was a great, great timespent with you today and very
informative and educational.
Hopefully our viewing audiencethinks the same, thank you.
(53:05):
Thank you very much.
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