Well, I think we'll just go ahead and get started. I'm sure people will be kind of rolling in depending on their schedules this morning. I'd like to say welcome to everyone. My name is Carly Sautter. Ravi Kasi and I will be hosting the program today. I'd also like to introduce Candice who is our, is from, where did she go? There she is. Candice from AAP who's been helping out and you guys will, she's our, our, what's the best way to say it? We couldn't do it without her, let's put it that way. And so this morning, what we want to do is just introduce this program for today. We're going to be, this is a continuation of yesterday. Some of you are familiar faces, some are new today, depending on all of your responsive, other responsibilities. For today, we would really love if everyone would put their cameras on. It helps us kind of get to know you and for you to get to know each other. If you would like to put your, if you would like to put your, your institution and maybe your year in, in your title, that would be great too. Again, just thinking about ways that we can connect with each other. So I'm from the Medical College of Wisconsin. I'm an associate professor. I do mostly outpatient medicine and with the AAP, I am part of the Medical Student Educator Council. Today, our plan is to have a few speakers, a little didactic, a lot of interactive discussion and a quiz bowl at the end. So I'll let Dr. Kosty introduce himself and give a little more information and introduce our speaker for the day, for the morning, first speaker for the day. Is everybody hearing Dr. Kosty? Oh, I, I'm not. It's my first time using Zoom, so I didn't know there's that mute button. Oh, man. Got it. All right. That was a good intro, but now I got to redo it. Hopefully I do a better job this time. So I'm Ravi Kosty. I'm the program director at Rush in Chicago, Illinois. You know, just like yesterday, you know, pay attention very closely because we are doing that quiz bowl for a hundred bucks on Amazon and then a free membership to the AAP. So, you know, if you were able to read the articles, great, but otherwise we'll be going over a lot of the topics over the course of the next several hours. So without further ado, we want to start with our first speaker. It's Dr. Larry Frank. He is working at Elmhurst Hospital in Chicago, Illinois. He is board certified like our speaker yesterday in everything you could think of. So PMAR, EMG, pain medicine and sports medicine, according to my research that I did on the internet. And also, if you've ever got an opportunity to be taught by Dr. Frank, he is just an incredible teacher, which will really put you to shame if you think you're a good teacher, because I remember one time Dr. Frank came and gave us a lecture and he walked in. He's like, what are we talking about today? And we're like EMG. And the talk, he's like, okay, cool. And then came on the whiteboard, gave an incredible lecture. And I was like, that's how smart you got to be to be an incredible teacher. You don't even have to even know the topic and you can just knock it out of the park. So we're hoping this TED Talk will inspire you to become the next Dr. Frank. And so Dr. Frank, the floor is yours. So tell us your story and all the things that made you, you. Great. Thank you. Thanks everybody. Good morning. The interesting thing about giving a talk like this, Robbie says, Hey, Dr. Frank, you want to talk about this? I said, yeah, but only old people get to talk about their lives and about, this is the easiest thing I've ever prepared for because, I don't have to prepare. It's just, talk about yourself. Like, wow, is that interesting? I don't know. I guess to be determined, I guess. So we'll go ahead with this. So I just introduced myself a little bit, Robbie did a little bit of that academic stuff, but I've been in practice for, I can't believe it, 27 years actually. And so I've been in all sorts of practice environments, including a small group of PM&R doctors, a large surgical group. I own my own practice for 11 years. I work presently for a large hospital system, multi-specialty group. So I've always been in private practice, but I've had this academic corner of my practice, including teaching residents. And I've had 11 fellows. I ran a fellowship program at one point in time. I have an academic appointment at Rush and PM&R and also in neurosurgery because at one point I was part of a neurosurgery group. So I really have had a very, really great opportunity of being able to teach surgeons about what we do. And I don't know, I think it's like trying to convert their minds a little bit into what PM&R is. And I'll talk, get back to that a little bit later on, why that's important. So anyway, and my practice is spine and mostly spine medicine. I do sports medicine as well. Last time I went to a football game, I've been covering on the field football for as long as I can remember as well. So it's kind of a widespread diverse practice. It keeps me from getting bored and it's pretty cool. It's a good, it's the best thing on the planet. So I'm going to PM&R. So how did I get into this? So I, interesting, I'm kind of curious, are there any people in the crowd here that have a degree in engineering? No. Okay. Well, that was me. I was an engineer. I went to the University of Illinois and I started off being an electrical engineer and I had no idea that I was going to medicine at all, not one bit. And at the U of I, there's many subspecialties in engineering. And so you had to declare one, you know, your, your sophomore year, like, where are you going to go into? You're going to go into, you know, power lines or laser beams or whatever. So I looked through the catalog and none of this stuff appealed to me at all. It was so abstract. I didn't know what the, you know, what, what was, what they were talking about. And it's such a mathematical abstract specialty except for one. And it was biomedical engineering, which was a new thing at the time. And they didn't have a major for that. So I said, well, that's something I could kind of sink my teeth into. And I swear I didn't, I was not interested in medicine whatsoever. I had no inkling. I had no physicians in my family. Nothing like that. We're, we're German. So we're engineers. We build stuff, you know, it's, it's kind of my family. So anyway, so I was moving along in that field. And then, you know, the, I call it the holy two by four. I half joke that God, you know, took a two by four and cracked me over the head and said, you need to go into medicine. And the way that happened was my mom was diagnosed with breast cancer and now she survived for another 20 years or so. And so I was kind of doing this biomedical stuff. I said, like, you know, why would I do the, the engineering stuff when I can do the medical stuff? I mean, I need to cure cancer. I sort of got it. That's, that's, that was kind of the, the thing that happened to me. And it goes to show you how the pathway to medicine, the pathway to your specialty is, it's not so straightforward all the time. And, and that's normal and that's good, I think. So, so I'm kind of like, well, you know, I'll go to medicine. I said, well, well, what kind of medicine? You know, I don't know. I have no idea. And in one of my courses in my electrical engineering curriculum, they had a, it was a, a lecture on the practical applications of engineering and medicine. And I'm going to show you guys a video. I'm not really, really good at this, but hopefully this will work. About, it's kind of what I saw and how it changed my life. And here it is. So let me just see if I can get this for you here. This is the video. Something you're probably not familiar with, but blew my mind. Hopefully this will work. Okay. So I'm not going to go on with that forever, but you can kind of see what it was. And that is, this is a much nicer video of what I saw at the time. But the interesting thing, I mean, I don't know that it still sends chills down my spine. Anybody know what that is? Can you guys hear me? Okay. Yeah. All right. Let me just make sure that we get this right here. So that's called functional electrical stimulation for ambulation. And I was so blown away by that. I said, you know, I don't know what field of medicine that is. I don't know where you trained for that. I don't know anything about this at all, but I want to know what field of medicine that is. And I want to know who, where you can get trained for that. And it was like the lightning bolt for me, like I want to do that. That's what I want to do. And so I kind of looked into it and I found out the specialty called PM&R. And then of course, in my course of, you know, training and all the rest, I kind of went around and asking like, well, where do you do this? And I went into medicine, like, well, you know, I found this is, you know, PM&R and all my rest of my medical students are like, well, what's PM&R? I said, what's this thing where they get people to walk? I said, you know, it's like, I don't know. It was just, it was the wildest thing. And so I, that's what I did. I mean, if you get turned on by that, if that's inspires you, if that brings a tear to your eye, you need to go into PM&R. I mean, I don't know. That's kind of what it was. So I definitely, that was my kind of my turning point of what is PM&R and where am I going? So I knew right away where I was going to go. I'd never heard of PM&R before then. So I went to, I eventually fortunately got into medical school. And I had that in mind. I looked in some other specialties as well. Orthopedics, again, is, might be a natural thing to think about. And I met the orthopedist and I found the personality is extremely distasteful. And so I didn't do, I just couldn't handle working with people like that, at least at that point in time. I did a rotation at, that was formerly called the Rehab Institute of Chicago, which is the Shirley Ryan Ability Lab. And I was blown away by the quality of the residents. They were the smartest and most sociable residents I'd ever met. And that was also true. I went to the University of Illinois Medical School and I hung out with a couple of PM&R residents who are right now extremely famous people at this point. And they were just the coolest, nicest, most fun group of residents. So it's people I wanted to hang out with. It was something that I was called to do. I didn't think about this. I didn't cogitate about going to PM&R, but it kind of found me a little bit. So anyway, that's kind of my story to PM&R. In medical school, then I wanted to get into the best PM&R program that I could. And I sought out research. I was advised by one of my advisors to do a little bit of research. So I did some research. I did it at the Medical College of Wisconsin, in fact. And so I highly recommend that, especially if you're interested in some of the more competitive or any residency program, you'll get the best residency program. And also the participating research gives you an idea of whether it's something you want to do or not. It just kind of gives you that feeling. It's always good to keep on investigating and reconfirm whether this is what you want to do. I eventually did do residency at the Rehab Institute of Chicago, and I did some research into functional electrical stimulation. And the interesting thing, I still love it, but I realized there was some limited utility of this process. I mean, if I really wanted to be a researcher, then I would probably continue into that field. But I wanted to treat patients, and I realized it was this limited utility and a very high cost. So going through all the various aspects of PM&R, I was exposed to musculoskeletal medicine. And the interesting thing about it, it's not really that different than FES. I mean, my whole career has been getting people to walk. I mean, really, I do a lot of spine medicine, and people can't walk. That's really the problem with spine medicine when it comes to spinal stenosis or arthritic changes of the spine. And so I was exposed to some great mentors. I think when people go into a specialty of medicine, it's really the mentors that bring them towards things. Why would you be a subspecialist, a PhD in microvirology of a certain virus? Why would you do that? Well, you were exposed to great mentors, and you bonded with them, and it was something that was meaningful to you. So it's the same kind of thing in PM&R in any profession. The other thing about musculoskeletal I thought was interesting was the procedural aspect. It was kind of blew me away that people in our field could do procedures with their hands, including spine and joint injections. And the interesting thing about that, it was something that I could do to help people walk, whereas PM&R is like, well, you kind of develop a program, and then other people implement it. The therapists do the work, which is great, and they continue to do a lot of the work, but it was something somehow that appealed to me that I could use my hands to help somebody get up and walk. So I thought that was a cool part of it. I eventually got into a fellowship, and what's interesting about that is that there were no fellowships back then. I think before me, there was maybe four or five people that I knew of that did a fellowship in spine and musculoskeletal medicine. And I backed into that because I was very arrogant. I was looking for a position in Chicago, of course, because I'm a Chicago guy, and I wanted to stay here. And I wanted to do an academic position. I wanted to do half inpatient because I really, really, I felt called to treat the disabled, and then also half musculoskeletal. Well, I didn't realize that nobody had a position like that, and I looked around, and I was the last person in my residency class to get a job. It was really humbling for me, and it was good for me as well. So through some friends, actually, I backed into this fellowship. I found out a fellowship was available. I said, I don't even know what a fellowship is, but I ended up backing this fellowship, which was in Chicago. And it was exactly sports and spine. It was new. I didn't know the fellowship director very well, and I was very, very surprised by what happened because I got there, and he said, well, we do sports medicine. We cover football on the field. We take care of joints and knees and elbows and shoulders and spines, and I'll teach you how to do back injections and things like that, and that was kind of pretty cool. But then I walked in the door, and my fellowship director said, well, we got something good happened. I said, what's that? Well, we're going to be team physicians for the Chicago Bulls. I said, the Chicago Bulls? He goes, yeah. Michael Jordan shoot baskets? Yes, that. I said, are you kidding me? How did that happen? So literally, in my fellowship, we were the team physicians for the Chicago Bulls during the Michael Jordan era. It was an incredible experience. I certainly did not plan that, and I don't know. It was just the coolest thing. The other thing that happened was that my fellowship director was very involved in teaching and writing and in national societies, and he would kind of sign me up for stuff. Like he'd say, you know, by the way, Larry, you're going to be on this committee. I'm like, I am? What committee? Oh, yeah. So you're going to be on this workshop committee, and I'm like, workshop? For what? You know, for teaching people how to do EMGs. Well, you know, and I ended up being involved with the AANM, the AAPMNR, and I got to meet the leaders in the field by doing that. I was just like a, I was nobody, right? So, and it was through that that I was, I got more involved with the academy and the various organizations and societies, and, you know, I got to a pathway by which I could actually replicate that later on and actually start a fellowship myself and teach people. So I enjoy teaching, and I still do to this day. So what a weird little pathway. I mean, I don't know, a lot of fortunate things, a lot of things I never planned. You know, so in my career, again, I started off working with my fellowship director for a while, about three years. Then I joined up a large neurosurgery group, and that was really interesting because I got to see how surgeons think very, very differently than PMNR doctors. It's good, and it's a good viewpoint to have because it's a valid one that we really don't get a lot, particularly when it comes to spine medicine. So, you know, I was with a group for a long time, and they hit hard financial times. And then I decided, well, you know, I might just do this on my own. And fortunately, my wife, very talented person, she ended up being my office manager. We worked together for 11 years, which was amazing. I live close to home. Our practice was close to our home. We have four kids, and I was able to attend most of their events growing up in life. And that was really good for my work-life balance, an amazing thing. And then as time went by, the economics of being in a solo practice just became untenable, and I ended up joining a large multi-specialty practice, which is what a lot of you probably will be going into, or academics. So, you know, when it comes to personal interests, I know Robbie asked me to do this. I want to kind of finish up, allow you guys to ask some questions, too. But, you know, how do I keep myself balanced, you know, in life? And really, to me, the most number one thing is my family. I've been married 31 years, believe it or not. I can't believe it. I have four kids from age 19 to 26. One of them has an interest in medicine. The rest of them are all engineers. We're nerds. My wife was an engineer, too. You know, I don't know what it is. We do everything hard. They all ran cross-country instead of doing other sports. I mean, you know, why would you do that? And then you do engineering. Why would you do the hardest possible thing, you know, to try to squeeze your mind into little, you know, like little knots? Why would you want to do that? We're just kind of nuts like that. So, my family keeps me grounded in reality. it kept me from getting too wealthy. That's a good thing I think um it it it it kind of provides focus um it combats the distraction of my free time. I I know what I'm supposed to be doing all the time. I'm not like thinking what am I supposed to do now. It's actually comforting actually to me. It's a source of unconditional love. I mean it's just kind of you got to have that somewhere in your life I think. It's just really critical. Um other than that um you know I like outdoors and nature. I have a native plant garden in my backyard. Um it keeps me grounded in reality literally grounded. Like you know I I go out and I pick weeds and what's really cool it's like mental psychotherapy for me because my patients are kind of you know needy sometimes and what happens with that is you go out and you do a project it actually gets done. So you see a you know bad plant okay you pull it. Good plant you leave it you water it. So that's like simple decisions. Amazing. So to me uh being outdoors our vacations mostly involve going to national parks. You know hiking, canoeing, biking, things like that. Um and exercise. Um I am fortunate enough to live close to my work and if you can live close to work I think that's very very helpful and valuable. I bike six miles a day to and from my my work. I have a awesome bike parking lot uh indoors. Um we take a yearly bike trip from Chicago to Michigan with my family. My kids all come along. Um so um you know as I'm getting older too it keeps me from feeling achy. You know now when my patients complain of aches and pains I can actually um you know uh uh uh have empathy with them. Um so anyway I um those are a couple things I just figured well I'd tell you guys about and I can I'm happy to be open uh for questions as well. Hopefully I left some time for that. So I'm sorry. Let me have time for questions. So please ask questions because I have some questions. Yeah sure. I'll start with one. So you know I think a lot of residents or not you know medical students, residents, physicians they all go through different adversity and and it's a lot of fear of like what's that next adverse adverse experience that's going to happen for you. What was your biggest kind of roadblock or adversity and kind of how did you get out of it or get over it and then what did it kind of teach you? Yeah you know um what's interesting uh in terms of career challenges you know early in your career um what's interesting about me I was I had a challenge to find a home in medicine. It was kind of like well where does PM&R fit with everybody else? And uh what's interesting because nobody knew what I did you know so I went to primary care doctor said well I'm a PM&R doctor you should refer to me like what's that? And so I had to sit there and explain that you know to people all the time and um you know I I there I resisted becoming a label as a as a a dumping ground or a pain physician. That was not my idea of what kind of medicine I wanted to do just to kind of just give people narcotics. I wanted to fix people and get them to walk and so it's really hard to explain physiatry is kind of a specialty that I think is a um it's almost a philosophy because what's interesting is that um the things that PM&R doctors do particularly musculoskeletal medicine other specialties do as well. So there are other specialties that do spinal injections, there are other specialties do joint injections, there are other specialties that do ultrasound guided injections, there are other specialties that do EMG, there are other specialties that prescribe PT. Um you know so what does PM&R do? Well PM&R puts it all together and actually helps somebody um but that's a it's a concept um that is a difficult one to it just took me about five minutes to explain that to you. Um it's it's it's it's kind of PM&R is like a philosophy or a concept but um you know if you're like watching that video if that like strikes you as something you want to do then that's you know it it it it a few pictures and a short video will tell you what it is that you want to do. Um so anyway that was kind of my adjustment and what's interesting at participating in academy leadership helped me a lot because I realized that a I wasn't the only one having those kind of challenges and everybody else was too and I listened to the the smartest people in the around the country try to figure out how to how to navigate these things and in the end I think it all ends up being something very very simple it's more about education. So you constantly have to market your specialty a for your own personal survival so people can actually send you patients to know who to send you but b also kind of your educating people about a specialty that I think that they don't know about. Um I mean even though I was doing you know uh my residency I'd have the you know we would have the consultants from other specialties combined I said well how can you deal with these patients they're so ill and they're so you know disabled and they're going nowhere I said no no no no no watch this video watch what these people can do and so um you have to constantly kind of change minds and hearts I think a little bit when you're doing the specialty and I think that that occurred then and it still occurs today. Big answer, short question. I also have a question. Oh yeah go ahead. Can you hear me? Um hi so looking at the background of the video do you think you said you were German do you think that um the location of the video at the Brandenburger Tor in Berlin had any effect on you on your decision kind of influenced you in a way because you said you're a German? Well I grew up speaking German but I was born in the U.S. I'm born in Chicago and I never left very far I'm not very adventuresome but um no actually being German has nothing to do with it actually that wasn't the exact same video that was a much nicer looking video um the one I saw was very very clinical it was in a um a uh uh like a like a PT gym and um again these these these are um paraplegic patients paralyzed from the waist down paralyzed from the waist down and they were um had these electrodes attached to their quadriceps and buttocks and etc and the computer um you know managed um the sequence of activation of the muscles and I saw these people get up and walk up and down the stairs I said you know that's the thing it's the person not the location it was the it was the the fact that you could help a person become more human. And did you get to be involved in um development of these technologies? I did I actually um I observed I tried to get research in it but they didn't have the money and I and I needed the money I I needed um a tuition assistance uh so I did ended up I ended up going to pediatric research uh believe it or not and then but I also did PM&R research unpaid um in um something that people don't use very much anymore called total contact casting um when I did my PM&R residency I did functional electrical stimulation for cough assistance uh in um in quadriplegics um so they would attach electrodes onto the abdominal musculature and allow them to cough and clear their airway and lungs so I did FDS research and I I did a fair amount of um looking around um uh for opportunities in that area because that was what spoke to me first. Thank you. Sure. Dr. Frank thank you so much for sharing your story. Um I wanted to ask about you mentioned that you have been a part of multiple different practices or multiple different like practicing in multiple different settings and I wanted to see if how much of that was um like a personal decision or you had mentioned it was you know like they're changing times and it became less affordable to be like a private practice physician. I feel like I I don't have much knowledge about what comes after residency and how you or fellowship and how you would make those decisions into what your practice what you want your practice to look like so do you think you could talk a little bit about like how you made those transitions in your career um to make it what you had hoped your patient population was your breakdown between like education research clinician stuff like that? Yeah that's that's a big question um I think when it comes to transitions um you know I think it's important to live life with a plan uh uh but I also on the same tone I think it's important to be flexible with your plan uh because I think you have to have something in mind you know you guys are all driven people you go into medical school you you know what you need to do to get places that you need to go so that's you all have plans but I think the thing that people have the most difficulty with is actually being flexible with their plans um again and uh and and so you know um I I had a plan initially and I thought it was going to be half inpatient half musculoskeletal and do no fellowship well that wasn't available so what am I going to do now um well I guess I'll do all musculoskeletal um so um now when it comes to to practice transitions I think you know sometimes people come out of medical school and residency they would say I want to do academics so people do that for a while and there's pros and cons to academics and um um some people um really really you know love the academic environment the teaching the camaraderie the the the research um um all of it and there's some cons with that as well so um you know I think when people just kind of go into the thing where their heart leads them and then when they get involved in the reality of it then they discover well you know um this is something I want to the pros outweigh the cons I want to continue with that or or maybe I need to change maybe um a life event happens where you um get married or um get divorced um um um have kids um that changes whether you want to work full-time part-time and I think the key thing is always to keep your mind open keep your contacts open never burn any bridges um and by burning bridges just you know be kind to everybody and everybody has different viewpoints and maybe you don't agree with them completely but um I think that's really important and then by having a strong network um opportunities will often arise that you can take advantage of um and it's true that things happen that are out of your control almost everything I mean honestly if you looked at what I just talked about nothing was under my control I mean I nothing I mean yeah it was under my control to study and do well in school and be able to complete my hurdles and things like that and I decided yeah I was going to do be board certified and everything and all that stuff but um but honestly it when it comes to getting a job and a career I think you need to be flexible um and things happen you can't plan for and by keeping your network open and by keeping your mind open to be not too not too rigid about your um plans being flexible to what happens it it allows you to make those changes well now I'm not telling you there was no stress uh when I opened my own practice I swear to god I I I told my wife I said listen uh us and the kids are going to have to eat cat food for a year because I I really didn't I had no idea if we were going to make enough money to to make ends meet I mean honestly it was we had a house and four kids it's a lot of responsibility um but um you know uh I was motivated and uh again use my contacts and use my my network and uh fortunately we did you know quite well so um and then again when that you know my dream was there I had my dream right and then the economics of medicine changed it's like well do I have to um uh drop some of my independence um uh for the ability to survive and the answer is yes and as I am I able to do that yeah well not as well as I want to sometimes but yeah I do so I don't know it's more of a philosophical question versus a uh what to do when this happens I hope I answered something for somebody yes thank you that was great advice sure um so I have a question first of all thank you so much for sharing your story it was actually one of the most grounded experiences I've heard of anyone kind of going into specialty path which I really appreciated how candid you were about your experience yeah but yeah so I know that all of us are really interested in this and so we're looking at all the pros um can you tell us about any of the challenges that we're currently facing in PMNR like or that you expect us to face in the future yeah that's another big philosophical question again those things are a little bit out of our control um and and that's good you know but it's good to know can I keep your eye on the ground uh first of all I think anytime you want to if you're going to go into PMNR you you you got to do something you love so if if that video kind of speaks to you you'll be able to tolerate any changes or any annoyances or any um you know whatever it is that that happens in the future so yeah I mean you know are there things happening in the future yeah well the way things get paid uh is going to change I mean right now doctors work like a piecemeal so you see 20 patients in a day you get paid more than if you see 10 if you do a procedure you get paid a certain amount for doing a procedure that you wouldn't get paid if you didn't do a procedure but that's in the future I'm thinking that that's going to be changing where the way that things get paid as hospital systems will get paid for managing populations so let's just say my town has about 50,000 people in it in the surrounding towns there's maybe like 250,000 people around my area well if my hospital gets charged with the care of all those patients the way people are doctors going to get paid is the hospital is going to get paid by the government or a payer and say here I'm going to give you um you know two billion dollars uh to take care of all the musculoskeletal and spine care for a year um and then um what happens then is that how are you going to get paid well the hospital is going to pay you well how do you know that the hospital is going to pay you well versus the orthopedic people or the other people well that means that you need to get involved in the hospital and be be uh well known to the administration look for the committees that make those decisions uh and be part of that committee and vote and um speak on behalf of your specialty because you know nobody else makes people walk like we do so that's very important actually uh so um um so that's like the future is is there a um a threat to inpatient rehabilitation yeah there is a threat to inpatient it's very very expensive and uh the payers are looking at ways of any way they can to get rid of inpatient rehabilitation or cheapen it or to and this is across all fields um to use nurse practitioners and and and advanced practice nurses instead of physicians um you got to watch that stuff and you need to kind of be aware and be involved because if you're not involved then you've got nothing to say that's fair yeah thank you so much yeah yeah it's it's hard stuff to kind of swallow when you're a medical student but it all happens it's not you know i gave you my whole life and you're like wow i can't do all that of course you can't um because it happens unfolds over years and years and things kind of gradually nudge nudge you in various directions awesome thank you so much dr frank that was incredible um we uh we have to move to our next speaker yeah otherwise we'd be talking to you for the next couple of hours so sure sure if there are any specific questions for dr frank um please uh let us know in the chat and then candace if you can just give us the information i can connect them with dr frank as well um we want to move on to our next speaker uh dr bajaj um who is from loyola university medical center here in chicago illinois he is board certified in physical medicine rehabilitation and in pain medicine um he has been gracious uh to be a speaker today um he was going to help mentor some medical students who was going to do a debate to talk about a controversy in spine medicine so dr bajaj the floor is yours so we can spend the next couple of i think next 30 40 minutes to talk about these controversies great hey guys how are you doing dr frank that was great to listen to you again always hey how's everything all right good dr one of our um lecturers all the time that it would come in uh it was one of our favorite lectures to attend because he made understanding spine anatomy so much more easy for us and just in a in a much more um functional way so his uh functional we always call it functional anatomy because it is it's an anatomy thinking you would as it function right so it made it so much more better so thank you for all that dr frank um well my name is pimpy bajaj i'm actually at loyola university medical center um i'm a uh my background is actually osteopathic medicine as well as i've seen a lot of the students are from osteopathic schools and as i told uh the students that are going to be doing uh this uh we i like what ruby said it's like a pseudo debate but it's more like a wwf uh competition where we're kind of prepared so it's a little rehearsed uh so don't don't mind the rehearsal um but uh so my background again i'm osteopathic i told them that you know from coming from osteopathic background i think pm and r was a very nice transition um you know in osteopath in osteopathy we're looking at the functionality we're looking at the person as a whole and i thought you know uh what other field would allow me to um get that type of exposure i was always interested in sports i was always interested in uh doing something musculoskeletal related and in my background my brother's orthopedic surgeon and i was i didn't even know about pm and r to be honest in my third year of med school um that's the problem there's a lot of schools that just they're not exposed early on and um the person that introduced me to pm not was my brother actually um so i was i had seven orthopedic rotation setup i was from high school i was like i'm going to do orthopedic surgery not knowing you know what surgery really entails but just hey i'm going to be in orthopedics or you know and so i go do my first rotation i get stuck in a 15 hour trauma case and i'm like oh god i don't want to do this so you know i tell my my brother tells me you know let's look about other fields and we talked about it and i enjoyed neurology i enjoyed sports so he's like why don't you look into pm and r and that's kind of how i got involved with pm and r and uh ever since then i've been in love with pm and r and uh in terms of what my specialty i do a lot of uh sports medicine but i do a lot of spine care uh kind of like dr frank i i kind of do all kind of both procedure as well as outpatient care um i actually got introduced to uh uh the spine aspects of pm and r in residency our residency was very involved we had a good amount of physicians that did interventional spine. And I found it that this was a quick way to go into a procedure room. You didn't have to sit in the OR like you did an orthopedic surgery yet you made a dramatic improvement in someone's functionality. And PMNR is about functionality, right? It's improving a patient's function, improving the person's ability to live their life with less stress and less burden, whether it's from an amputee care, whether it's from a spinal cord injury, brain injury, or in terms of pain, right? So that's kind of where I got involved with that. And then my fellowship in University of Chicago, I did my residency at Loyola and came back to Loyola basically and been practicing at Loyola for a long time. I'm old now, even though I don't think I am getting old. So with that in mind, we'll start our pseudo debate and I'll introduce, we got Jonathan, we got Neil, where are you? I don't see, oh, Neil, and then I see Chandan. So these are medical student counterparts that are gonna be kind of introducing the debate. The debate is basically, it's gonna be about epidural injections, when to use a transframinal, when to use a interlaminar and what are the advantages, disadvantages of both. And it's just, honestly, there's no right or wrong answer. That's why I think it's not much of a debate in terms of, it's really gonna be based on what we see the patient. So it's case-based scenarios, right? And that's what we did, we created different cases. So Chandan's gonna be like a pseudo moderator because he's gonna be the guy that's the commentator in this boxing match that's gonna be going back and forth. I believe Jonathan's gonna talk about interlaminar and Neil's gonna be talking about the transframinal. So I'll let them take over and then we'll meet again afterwards. And whether you guys want me to do a little presentation or just talk about in general, we can do that either. Make it simple. All right, guys, you guys take over. Thank you, Dr. Bajaj. Hi guys, my name is Chandan, fourth year medical student from Midwestern University. I have Neil and Jonathan, you wanna introduce yourself? Hey, I'm Neil, I'm a fourth year medical student from A.T. Still University. And hi, I'm John, I'm a third year at Chicago Midwestern. But yeah, so yeah, our debate will be focused on cases and I think the cases will help tease out kind of the differences between a interlaminar versus, yeah, interlaminar versus transframinal epidurals. And to start off, we have case one. Let me just move this, there we go. Case one would be a 61 year old male with past medical history or two motor vehicle accidents who comes into the office for numbness and tingling down his left arm and it's affecting his occupation as an Amazon warehouse worker. He has tried already conservative modalities such as physical therapy, eating ice and Tylenol. He's allergic to kevapentin, which causes him hives. Cervical MRI has shown degenerative joint disease and spinal stenosis affecting the C4 to C6 region. And on physical exam, you find decreased bicep reflex, three plus out of five shoulder abduction strength, but a normal triceps reflex. How would you approach this patient's cervical radiculopathy? And yeah, we can start with Neil. Okay, so I would like to start by saying that the patient has a pathology above the C6 level where intervertebral spaces are generally narrow. And so in that frame of mind, interlaminar approach is typically not as recommended. Instead, I would advocate for a transforaminal approach with the use of fluoroscopy and digital subtraction angiography to allow for a more targeted approach and to visualize the vertebral artery, which does have an increased risk of penetration with the transforaminal. But I'm advocating for the frame of mind of using this approach in the safest way possible. So we have the digital subtraction angiography to analyze said artery, and then also the use of a non-particulate steroid versus the particulate steroid. So dexamethasone essentially to minimize the risk for vascular occlusion and uptake. I've also read studies that show that the transforaminal approach is utilized with ultrasound Doppler imaging. These are like small cases, so there is a need for more studies on this, but the logic behind that is similar to the digital subtraction angiography, which is essentially to allow for Doppler flow to see the arteries in the area of the injection point. And so the ultrasound Doppler imaging is another way to utilize the transforaminal approach in a safe way to minimize this risk of embolization essentially. And then I do wanna mention that transforaminal approaches have its own risk profiles, like increased radicular pain, possible vasovagal reactions, dural punctures, lightheadedness, global amnesia, cerebellar infarction is a large one as well. And then of course the vertebral artery uptake. However, the interlaminar approach does also have its own set of complications as well, like dural puncture, hematomas, epidural abscesses as well. And so like Dr. Bajaj kind of mentioned in the beginning, the preface of this debate is that we really need to do a thorough exam of the patient and kind of take it case by case to see what ways we can maximize the overall benefits versus the risk of either approach. And so essentially I would say if we are using transforaminal, there are ways to make it as safe as possible for this kind of approach. So if Jonathan wants to add to this. Okay. Yep, so I will be advocating for an interlaminar approach to this patient because in the cervical spine, as Neal was saying earlier, that you kind of have the risk of puncturing the vertebral artery, as you can see in this bottom left photo with the needle, the lower needle. And if you do puncture that, you do risk of occluding those vessels and that can cause like a stroke or a seizure and even anterior cord syndrome. So in the C-spine, it's especially, it's a little safer to go interlaminarily rather than transforam, or interlaminar versus transforaminal. And then to Connor's point about the whole narrow intervertebral spaces where you kind of have a limitation of going only below C6, with interlaminar approach, the solution actually spreads eventually and then colly and granually. So even though this specific pathology is at C5, you still are gonna get relief, even if you go lower because the solution will spread up there and target the specific level. And also I've been reading, there are articles out there that kind of show that there's no really a difference between reduction in pain and disability between the two injections, but it kind of becomes more of a cost benefit weigh in where do you do more complicated procedure with fluoroscopy and the DSA, or do you kind of just go interlaminarily, which you can do kind of blindly and with the patient not sedated. And it's kind of just weighing in what you consider to be necessary. Yes, essentially is that even though with transforaminal, you have Doppler imaging to help guide this maze of arteries per se, there's still a high chance of rupturing any of these arteries and specifically the vertebral artery. And so the general consensus is that interlaminar is just the preferred method because you just avoid all of this and it's just one shot and you can get pretty good pain relief. But yeah, so in terms of the cervical epidurals, interlaminar is the way to go. I don't know if there's anything you would want to add to any of this, Dr. Bajaj. Yeah, well, the question I guess for any one of you guys would be is based on the history, you explained a patient has diminished biceps reflex, weakness in his abduction of the shoulder. So you said he has a cervical radiculopathy. I'd like you guys to say, explain what level do you think is involved and which type of radiculopathy? Is it a C5, C6, C7? The history, like you said, the history of the examination is very important. The history is guiding us right there. So what do you think is going on? Any one of you guys can answer. Go ahead. Anybody, you know, anybody, you're right. Go ahead, Shonda. Go ahead. Okay, yeah, so C5 radiculopathy just because of the bicep reflex, but the history of the motor vehicle accidents causing a predisposition to degenerative joint disease and having the transfemoral narrowing, the C5 level, kind of pinging upon this nerve root is causing these symptoms. It's a C5 radiculopathy, right? That's kind of the answer, right? So in this case, the nerve that's affected is C5. So when we're talking about targeting a specific nerve root, that's the nerve root that we would be targeting, right? And in terms of approach, this is what they were talking about. You know, what is the best approach? And there's, again, to be honest, there's no right or wrong answer to this, right? It's about how you approach the patient. A few important questions that you're always gonna ask, and, you know, number one, you're gonna look at the x-ray. You're gonna look at how is the best angles can you get in, right? For transferaminals, for interventional spine, it's all about angles. Can you guys still hear me? I'm sorry. I think I got, okay, good. I got kicked out for a second. Okay. So when we're talking about transferaminal, there are certain risks, and this is kind of what they were talking about. And when we're talking about interlaminar, there are certain risks. In the end, you're gonna make the decision based on looking at all those identified risks. If this person has a C5 radiculopathy, but they're so severely tight foraminally, there's not gonna be much space to enter. You're gonna potentially risk hitting the nerve root. You're gonna potentially risk arterial dissection. You're gonna potentially risk any of those things. You're not gonna do that approach. You're gonna do interlaminar. If he's severely stenotic and you do an interlaminar and they don't get any significant relief because they're so tight centrally, they can't get the dye pattern up there, then you may choose a transferaminal. So it depends on the MRI reading. It depends on, so all that comes in preparation before you pick the procedure. So good. Excellent job, guys. Any questions on that case from the students? I have a question. It's Dr. Frank really quickly. You know, behind the C, there's two, three, four, C4, C4, five, and the spinal cord, there is a T2 weighted image. So you can see the fluid around either side of the spinal cord. There actually looks like there's edema in the cord. And one of the interesting things about that is that when you're doing an epidural injection and you're putting fluid inside the epidural space, when there is no epidural space, there is a risk of actually worsening that myelopathy. So that means that the spinal cord there is damaged. I'm not sure whether that is just an artifact of the slices that are there or not, but this may be a case, if that's actually the patient that we're talking about, you might wanna avoid doing an epidural injection because you may actually do some harm. So we have to be a little bit careful with the super tight stenosis. As Dr. Bajaj already mentioned that in the foramen, but also even more importantly in the central canal, you don't wanna convert this guy from a person that has arm pain to a guy that needs a wheelchair. So that's just another consideration. Correct. And if we're looking at central stenosis, what Dr. Frank's talking about is the severely stenotic myelopathic patient comes in, that if someone comes in, they're bumping into walls, they're not able to walk straight, they're having a toxic gait, they're urinary incontinence, these type of issues, you're gonna be talking to the surgeon at that point. You're not gonna be doing an injection on that patient, right? So it's very important what Dr. Frank is saying is to look at the case and each case is unique. I hate it when pain doctors start with one procedure, go to the next, do the next. There's no such thing as a cookie cutter, cookbook of pain, right? You have to look at everybody individually, you have to plan it ahead. And planning is the essential part of pain medicine. That's kind of why I feel PM&R has a little bit of an edge compared to other fields because our examination skills, our historical skills, everything is a little bit more in tune to exactly kind of improving the whole patient as the functionality of the patient as a whole. All right, you guys wanna go to the next case or any more questions on that one? All right, let's go to the next case. All right, case two, 75-year-old female with worsening back pain over the last year. She's been experiencing difficulty with prolonged standing and also having experiencing cramping in both legs whenever she walks. At the grocery store, she can't walk without a shopping cart. She's currently experiencing electric shooting pain down the posterior side of her legs to her toes bilaterally. Prescribed or prescribed medication prescribed oral medications have failed to provide any pain relief for her. Lumbar x-ray shows significant DJD and Arthropathy and L4, L5, and L5-S1. What approach would you take with this patient to get the best bang for their buck, per se, in treating her pain and minimizing complications? We can start with Jonathan. Okay, so before we begin anything, does anyone know what nerve roots are affected in this specific case and what condition that she has? L4, L5, and she's got lumbar spinal stenosis. Okay, so she has spinal stenosis, but the nerve roots that are affected are actually L5-S1. So for here, I think it's better off if we start with a transforaminal approach argument. So Neil, if you could take off first. Yeah. Can you explain why you think it's L5-S1 before you go to the next thing, Jonathan? So yeah, so with the degenerative disc generation, it's the nerve below it, so L4, L5, L5 is below it, and then L5-S1, S1 is below it, so those two are the nerves that are the ones being problematic in this case. Also look at the pain patterns, guys. So pain patterns, she's describing pain in the buttock, posterior thigh, posterior lateral calf, to the top of the toes, right? So when we're describing that, there's a little pattern involving both the L5 and S1. So just remember with dermatomes, remember how pain patterns for the L4, L5, and S1 run, and based on that, then you can look at this. So just remember the history is very, very important, right, so looking at the patient's history and correlating it with your exam is important, so, okay? All right, and so I also wanted to preface the different approaches just in case anyone's not aware. So essentially, the interlaminar approach is taking an epidural injection between the lamina of two vertebrae, so it's kind of coming from a posterior to anterior approach. Transforaminal is looking at the neuroforamen from a lateral to medial approach, and it's typically more of like a unilateral injection. It covers like one side at a time. So I just wanted to preface that before we continue this debate. And so with this case, I would want to advocate for the transforaminal approach at the L5 and S1 region. Again, looking, excuse me, looking at the pain patterns involved. And I would say that we could target this bilaterally. Transforaminal epidural injections are typically well-suited for lumbar spinal stenosis or disc herniations that cause specific nerve root injuries in the lumbar spine. And also, it does typically provide better anterior spread to alleviate this radicular pain in the lumbar region. And I also want to point out with degenerative joint diseases in specifically this L4 to S1 region, the idea that there's various approaches for transforaminal, so like you can do a sub-pedicular approach, a retroneural or a retrodiscal, might be advantageous depending on the altered anatomy of the patient in case you need to have different ways to use this injection. There's also a study, it was a retrospective cohort study of 721 patients who received two-level transforaminal epidural injections at L3 or below. And it showed that 57.7% of these patients had over a 50% reduction in their numerical rating scale, which is essentially a pain scale where one is not that much pain and 10 is severe pain. And this had a power of less than 0.05 and a high confidence interval. And then the study also showed that 51.7% of these patients had a greater than 40% reduction based on their OS3 disability index. And what this is is essentially a questionnaire asking patients how they can tolerate their pain with their activity of daily living, whether that's pain intensity, personal care, lifting objects, walking, sitting, sexual activity, sleeping, things of that nature. And so these patients had a greater than 40% reduction on their disability scale at a two-week follow-up for both of these metrics. And then about a third of the patients had complete pain relief utilizing this numerical pain rating scale at the two-week follow-up. So essentially, there are studies supporting using two-level transferaminal injections for radicular pain coming from spinal stenosis in the lumbar spine. Although there does require more studies on it, the single-level transferaminals have more studies for it. There is a good start in cases supporting this approach. So Jonathan, if you want anything to add to that? Yep, so historically kind of the transforaminal approach is kind of the more accepted way to treat lumbar pathologies, but in this specific case there's two nerves that are affected, so I think that the intralaminar approach would be more beneficial. There have been studies that show that in spinal stenosis specifically that the intralaminar approach is just as effective as a translaminar or transforaminal approach, and so with the transforaminal in this case you kind of have to do it bilaterally at the L5 and S1 region, which is four different injections, which seems a little too much, but with the intralaminar approach you can just do the one injection just because it does have the circumferential dispersal pattern and it travels caudally and cranially. There was a small study that showed that the patients who received an intralaminar injection for spinal stenosis, 9 out of 10 had a 360-degree dispersal pattern, meaning that even though you're injecting the solution posteriorly, it's going to get actually 9 out of 10 times according to the study, so I think that especially since her pain is more diffused that she'll benefit more from the intralaminar approach than rather than the transforaminal. All right, that's a very good point that you brought up, Jonathan, that the fact that you have to do four different injections because in this condition there's two different disc levels that are being affected, and when it comes to insurance, especially with Medicare, they can only approve two injections, and so for her she would have to get an injection here, injection here at one nerve level, and then another one at the one above it, but with the intralaminar, it's just one and done, and yeah, just a lot less injections, and insurance will better approve that in this situation, and also please excuse that this is a cervical in the region, just use it for example of a transforaminal approach. Yeah, so good. Basically, when we're talking about transforaminal, this is kind of what Neil was talking about, is we're trying to isolate down into the nerve root more anterior epidural spread, and I think the study Jonathan was talking about was, you know, that you do get some epidural spread from anteriorly from the intralaminar. The question is, you know, how much and how much fluid do you need to inject? Those are all two things that you have to remember, that if you're doing intralaminar, volume is a little higher, you need to spread it up, it will go up to three levels, it will go down, so you get more of a diffuse spread. In this type of patient who has spinal stenosis, the posterior elements are likely more involved, as we said, the facet joints are involved, she probably has a little bit of facetotropathy, as we already know, she has spinal stenosis, she has the L5, S1 nerve roots being involved, she had a problem at L4, 5, and 1, so targeting all those levels with a transforaminal may be difficult to do, also possibly poorly tolerated by the patient. So you may want to consider doing intralaminar with the larger volume, but again, the larger volume may also create a problem, as Dr. Frank was mentioning earlier, with a centrally stenotic patient, right? So it's a relative thing that you have to decide, you have to prepare yourself ahead of time, you have to look at the x-rays, you have to look at the MRIs, and based on those, you're going to come up with a plan, and the plan is going to be based on your clinical exam, your history, as well as your imaging. So good, very good points there, guys. Let's go, any questions on this case? And notice I didn't pick one versus the other, because they both work, they both are correct, it's not incorrect, so this wasn't a debate about which is better or worse, it's about how you approach both the patients in both ways. I do have a question, Dr. Fajardo, if that's okay, if we have time. So when we talk about pain reduction with these injections, how reliable is the data that we have saying that the pain reduction is actually caused by the injection, if the cause for the back pain that a lot of, or that, you know, if the cause of the back pain is often difficult to determine, because it seems like there's often no correlation between the severity of back pain and what we see on imaging studies. Is my question making any sense? So first of all, I mean, if the MRI came back completely clean, right, we probably wouldn't be injecting this patient, right? I mean, we have to figure out what's going on, that's what we have to use our other clinical skills, EMG sometimes will help correlate, so those are the things, but in this case, you know, you have a MRI that does correlate, she has stenosis centrally, she has a irritation of the L5-S1 area causing the pain pattern, so there is actually MRI correlation with the pain, so it's not about just getting, so you can get her MRI on random people and it's going to show pathology, but does it clinically correlate with their history and their clinical exam, right? That's when we talk about treating the patient appropriately, right? And you want to fail conservative treatment, you're not going to do interventional spine procedures as the first step, you're going to get them in physical therapy, you're going to focus on a William's flexion-based program for this patient, right? She's spinally stenotic, she has the shopping cart sign as you can see on the drawing there, so once those conservative measures fail, what other treatment options do we have, right? Are we going to send this 75-year-old patient for a decompressive laminectomy, right, for spinal stenosis? Well, there's risks and complications to that too, so we're not going to do that as a first step, right? So this is a nice gauge, you know, it's you gauge your patient and you go appropriately with the steps of treatment. If a patient gets an epidural injection, whether it's a transforaminal or epidural interlaminar, and they're getting four to six months of relief of pain, and in that amount of time they can function better, they can improve their ODI scores, they can improve their numeric rating scores, the WES scores, whatever way you're kind of quantifying the measures, and more importantly, they can improve their functionality in life, right? They can do more. When they can do more, they can do their exercises better. When they can do their exercises better, which is the key thing, the injection, I always tell my patients, this is a tool in my toolbox, right? I'm using this to improve your function and pain so that you can do a better job with your exercises, right? So it's a combination of the injection improving the pain, followed by the proper conditioning program to strengthen the core to stabilize the spine that's going to improve their functionality in pain, you understand? So ultimately, there has to be, and the MRI has to correlate with the clinical exam, right? We're not going to, if this patient had an L1-2 disc herniation or stenosis laterally, and they're presenting with an S1 radiculitis, there's less correlation. I'm not going to go and inject the L1-2 level, right? I've seen that happen way too many times where we're treating the MRI and not the patient, okay? So you have to have the clinical correlation. Does that answer your question? Yeah. Okay. Yes. Yeah. Ready? Yeah. All right. Case three, a 25-year-old male weightlifter. He was deadlifting when he experienced a sudden pain in his lower back that shoots down the posterior side of his left leg. The pain has caused him to suspend his career thus far. He goes to his local physiatrist who gives him a referral for PT. Of course, when the product's in a trial, he got sent in. Completion of PT medication provide no pain relief, and patient would like to seek further medical management. MRI shows paracentral disc herniation at L4-L5. Physical exam shows weakness in his left foot causing foot drop, left ankle inversion, and weakness in his extensor hallucis longus. He also has diminished medial hamstring reflex. For the audience first, what nerve do you think is affected? Anyone can answer. Put it in the chat, or feel free to unmute yourself. Could it be L5 with a foot drop? Yeah, definitely L5 with a foot drop. Thinking as well? Correct answer. I just wanted you to make sure that you're thinking it appropriately. Excuse me, I didn't understand the question. I'd like you to explain your thought process. Your answer is correct. I just want you to explain the thought process so the rest of the students can understand. So I remember, yes, lower back shoots down the posterior side of his left leg. And so I do remember that L5, so that the foot extensors are elevated by L5. And then left ankle inversion, that was also L5. When I read ankle, I was also thinking maybe the common peroneal nerve, but that injury would be more associated with pressure around that area, because that nerve is so sensitive. And that doesn't seem to be anything in the history of the patient. And then extensor house is as long as the foot extensor. So that was basically it. Excellent, good job. And then the medial hamstring also is a good indication of why it wouldn't be peroneal also. So good, excellent job. Good, let's go to the next, go ahead. Yeah, so what would be the best approach in alleviating this patient's pain? And at this time, we can start with Joe and Jonathan. Okay, so my argument for the intralaminar approach for this is that there have been study, there's been a study that showed that if you do a peristaginal intralaminar approach rather than a complete midline injection, it actually was the same amount of decrease in pain as compared to a transforaminal. And so it kind of becomes a question of the intralaminar is quicker because you don't have to go under sedation and stuff like that. It's less exposure. And then you still have the lower risk of adverse effects. But the caveats of this with the intralaminar approach is that sometimes in order to get the same amount of release for these kind of things, especially with a single nerve that's affected, you have to inject more solution into the space. And then that kind of just leads into what Neil will discuss also. Yeah, so I think Jon brings up a good point. Dr. Bajaj mentioned it earlier, the more volume into a space equals the more pressure, which typically equals more pain. And so to kind of have that understanding and, you know, we want to minimize the pain that a patient will have with the procedure itself, you know, that's always a plus on our end. There's also a case study that I read up on. It showed that it took like 40 patients with lumbar herniations, like paracentral herniations, similar to this case, and compared the results between transforaminal and intralaminar approaches. And so essentially using a similar pain scale, this one is called the verbal numerical rating, where it's still 0 to 10, 10 being the worst pain, was the gauge between the pre-injection immediately after, typically around an hour, and then around like a two-week follow-up. And then they also measured the need for repeat injections and surgical intervention on a one-year follow-up. And so basically what I found was that the transforaminal approach typically had around like nine patients who required out of the 20, so it was 20 and 20 by the way, so 20 out of 20 patients doing the transforaminal, nine patients required one or two repeat injections and two had required surgical interventions at one year follow-up. And then the other patients, the rest of the patients had an improvement of two or more points on the verbal numerical scale, where the intralaminar approach had around eight patients with one or two repeat injections, and then five patients requiring surgical interventions, where nine had an improvement of two or more on this verbal numerical scale. So although, you know, the study, the sample size is small, I found through research and I think John and Jundin also found that there isn't a whole lot of research with pain in the spine. And so this kind of begs the question of, you know, having more recent research with this case and just spine injections in general. But I just want to conclude with saying that transforaminal approach in this case will be better because it decreases the possibility of surgical interventions. It's a more targeted approach with less volume involved, therefore less pain involved into the injection site. And then having the better numerical pain scale would also advocate for this approach. So I just want to end with that. Yeah, definitely. So when I, from what I gathered, transforaminal seems to be the go-to choice for disc herniations. And then just based on the MRI, especially if you're injecting volume into this space, and if you do intralaminar, it's a lot of volume for an already narrowed area. And so just transforaminal by that in itself, you're injecting less volume. And I think that's one of the main reasons, but then also for all the reasons that Anil had said in terms of just better efficacy and lower complications. Anything else you would like to add, Dr. Bajaj? Yeah, I mean, the good thing is, guys, so, you know, this guy has a disc herniation, paracentral disc herniation, L4-5. It's always a board question. So when you have a paracentral disc herniation at L4-5, what nerve is getting hit? Now, we knew that history, based on history and the clinical exam, you answered L5 radiculopathy. That's correct. But you could have also looked at the MRI and said, hey, there's a paracentral disc herniation. So when we talk about disc herniations, there's many different types, right? You can have a central, you can have a far lateral, you can have a paracentral. So this is just for everybody. So if you have a central disc herniation, that's purely central. So you have this circle, and it's coming right in the middle. What nerve roots do you think are going to get hit? And what are the complications? What are the things you're thinking about? I heard below, right? So that would be S1. Central disc herniation, yes. The nerve roots below are going to get hit. Which nerve roots in a central disc herniation versus a paracentral? So S1? Correct. So if it's a central disc herniation at L4-5, for example, right, you're hitting the lower sacral nerve. So you worry about quadriaquina, you worry about those type of things that can develop, right? So now if someone has loss of urine functions, bowel bladder incontinence, weakness, diminished reflexes, right? These are all emergent findings, right? Then we're going to be sending them to surgery, right? We're going to be talking to the surgeon about it. So looking at the clinical picture is important, but also looking at the MRI makes sense. So if it's a central disc herniation, it's going to hit the sacral nerves, right? If it's a paracentral disc herniation at this level, L4-5, what nerve root are we hitting? And we talked about that a little bit. So I think you guys answered that was an L5, right? So if it's a paracentral disc herniation at the level above, it's going to hit the level below, right? So at L4-5, it's hitting the L5. At L5-S1, it's hitting the S1. So think of it that way, versus a far lateral disc herniation is going to hit the level at where the disc herniation is. So at an L4-5 disc herniation that's far lateral, it's going to hit the L4 nerve. Do you understand? So that's just general understanding. And then looking at the clinical picture is always going to make a big difference as well. In terms of which injection you use, there's evidence on both, yet there's lack of evidence in everything. This is what he was talking about in terms of interventional pain. So for those guys that are interested in research, interested in doing more for interventional pain, it is difficult to do pain studies, number one, because you can't really control very well. You can't blind people very well. I have studies that we've been doing, and it's difficult to blind yourself to do a procedure. You can't. We're doing a transforaminal study that we've gotten approval on. We're on the recruiting stages right now, which we've been doing for a while, but it's hard again to recruit patients, number one. Number two, it's hard for patients to follow up. If they're not in pain, they're not going to follow up. And if they're in pain, they're going to follow up very often. So in terms of studying these patients, it's difficult, but guess what? You can actually do it. There's still good data out there. In terms of dye patterns, we talk about transforaminal versus interlaminar. When we're doing a transforaminal, volume doesn't need to be high, and the majority of the epidural spur is going to be anterior, get the level of the nerve of the disc. When we're doing interlaminar, you have to put higher volume to get the dye pattern to go more anteriorly. A lot of that's going to be posterior, right? So this is kind of what they were talking about, that you need more larger volume to get the dye pattern to go more anteriorly. So with those in mind, I mean, this is just the basics of interventionalism. You know, there's a lot of complexities, but in general, look at your patient, evaluate your patient, examine your patient, correlate it with your films. So your history is very important. Your exam is very important. Then you get the MRI, you correlate it, and then you go with the treatment options. And always the treatment options would be starting conservative, going aggressive, right? You're not going to start aggressive and then go conservative. So always start conservative and go gradually aggressive. Now, the caveat is if there's neurological issues, if there's neurological involvement, we do not want to create issues for our patients. We want to get them treated accordingly and aggressively if they have a foot, you know, if they're having urine loss of function, if they're having quadriquinone symptoms, if they're having cervical myelopathy, as Dr. Frank had stated, those are emergent patients that you need to be able to identify and send them to the right place. And you will see that. Okay. Any questions on that, guys? Any questions for me, from anybody about anything? Good. I wish- Thank you. Yeah. Yeah. Thank you so much, Dr. Bajaj. That was amazing. Yeah, this is more than what we expected when we thought of the debate. So you guys crushed it. So thank you so much to the whole group and especially you, Dr. Bajaj. What we'll do is we have a speaker that's ready, but I think it'd be good for everyone to take a bathroom break. So why don't we just take a quick three-minute bathroom break and then we'll meet up at 1028 Central Time. Okay? Thanks, Robbie. Thank you. All right, everybody, I think we're ready to jump back in. I hope everyone had at least a four-minute break, so apologies on that. We just have some good speakers, so we keep going over the time. So hopefully it's okay, but you're able to grab a snack and eat as you participate. Our next speaker is Dr. Vital Nagar. He is from the Kinesi Institute for Movement. He is board-certified in physical medicine, rehabilitation, and in pain medicine. He was going to come and speak to us about lumbar discogenic pain 101, clinical presentation, diagnosis, and management. The floor is yours. Yeah, sure. Thank you, Dr. Cassie. Hi, good morning, everyone. Can you all hear me? Yes. Okay, good. Yeah. So just as a quick intro about myself, my name is Vital Nagar. I did my PMR residency at University of Kentucky, and also did my pain fellowship at the Kentucky. Currently, I'm in private practice. I have created this PowerPoint, but I don't have any case scenarios in between. So I'll quickly go through this PowerPoint as a PDF, like how you all have. And I'll give maybe like 30 seconds or one or two minutes break for question and answers after each slide. So today, I'm just going to highlight a few things about the discogenic pain diagnosis and management, Dr. Bajaj, and you all already have gone through several aspects of disc-related issues. Today, I'm going to start with the first slide. So when we talk about disc pain, in general, back pain is pretty common in practice. So almost 60% of patients will have some back pain in their lifetime. So the back pain could be coming from either muscles or from fascia, or it could be coming from the facet joints, and it could also be coming from the nerve roots or disc-related pain. So I think as clinicians, our main purpose should be to highlight the pain generator. In that way, we can address the patient's need, and we usually start with the most conservative options, as you all discussed. So I did send two articles. The first article was about the nomenclature by Dr. Fardon et al. So this highlights mainly about the consistency in nomenclature across the board, which helps in evaluating patient and also across the board with radiology and also with PMR, pain, anesthesia. Everyone can have a kind of common understanding about the nomenclature. So if you all can see this slide here, so we have nucleus pulposus and also annulus. Annulus, I always explain to our patients, saying that annulus is more like a tire or the more rigid structure, and the nucleus is more like a jelly that's inside. And you all know, based on anatomy, that most of the blood supply comes through metaphyseal arteries, and just through osmosis, the nutrition goes to the disc. And the nucleus pulposus, and most part of it, is avascular in nature. So looking at the normal disc, normal disc should have a clear white nucleus pulposus in the middle and a concentric annulus around it. So there is a common terminology saying that there is an annular tear. So in our practice and in general, we try not to use the term tear because it gives patients a kind of idea, thinking that it all started with a trauma. So we don't want to associate a etiology with a word. So that's why it is better to use annular fibrosis and fissures as a replacement for annular tear. So here you can see that there is a concentric tear. So when we talk about disc itself, the thickness, it starts from the cephaloid, the topmost portion, and the bottom most, the caudate portion of it. So it usually starts from the inner aspect here, and it goes all the way across. So it's more of a concentric tear, and a transverse tear is just going horizontally across the annular fibres. And then there could be radial tears also here, which just goes through and through the annulus tissue. So what are these annular fibres made up of? These are made up of proteoglycans and collagen fibres. So based on the different etiologies, if it is age-related, there could be some loss of water, and there could be some just age-related changes with the cells in that area, which causes these kind of breaks. So these breaks or annular fissures do not mean that patient will have pain. It could be like an incidental finding. Patient may not present with any pain if they have it. So this is, again, just for nomenclature, we always have to associate the clinical picture with the MRI findings. So let us go to the other part of this here. So this is based on the CT evidence as to when we always, as clinicians, evaluate patient based on clinically, but several studies do document that provocative discogram as a way to identify discogenic pain. So when we do discograms, there could be tear extending just to the inner one-third of the annulus. So that's called as, based on this classification here, it's called as grade one. If it extends more than one-third, so if it's more than one-third, then it is, if it's a two-third or more, then it is grade two. And grade three is throughout the annulus. And grade four is when the disc materials, when we do discogram, it seeps out through this annulus space. So that's, we have different ways of classifying disc pathology. So this is one of the way in which the different region of annulus breaks in that annulus. We use that as a criteria to differentiate the discogenic pathology or just as a nomenclature. I don't want to use pathology, but as a finding within a discogram. So here, I think Dr. Bajaj already talked about the central, paracentral, and also for lateral herniation. So this is another way of differentiating the different zones of the disc area. So this is the central zone, which goes just around the spinal cord and with the core of the disc materials. And this is subarticular, just sitting below the disc, just sitting below the facet joint area. And this is a foraminal zone, which corresponds to the pedicular region. And this is extra foraminal zone, which is lateral to the pedicle, the outer border of the pedicle. So for the subarticular zone, so it's the medial aspect of the facet joint and the lateral aspect of the facet joint are considered as the boundaries. So depending on where there is a disc bulge or herniation, we utilize this nomenclature as to where the disc bulge is in this different. This is based on, again, looking at the axial films in the MRI. So if you look at the sagittal films, when you look at MRI or any CT scan, we differentiate it based on pedicular region, which is very prominent here, and suprapedicular region, which is just above the pedicle and infrapedicular region. So this is a way to identify the disc bulge or protrusion in the sagittal plane. So any questions about this till now? Any concerns or questions? Okay. Okay. I'll just take it as no questions. So let's go more with the different changes that happens in the disc area. As I said before, age can lead to loss of water in the disc space. And there is a terminology that's used. It is called spondylosis deformans, which means there could be some subchondral cyst that could be formed here. And there could be some osteophytes, which could come from the apophyseal area of the vertebral body. And it's usually not considered as associated with any major pathology. But if you see like osteochondrosis or intervertebral osteochondrosis, where there will be more severe degenerative changes in which there will be loss of disc height. There will be changes. There will be no differentiation between nucleus pulposus and also with the annulus. And there will be more osteophytes and loss of significant disc height loss can be seen. And this osteochondrosis is most commonly associated with pathology. So pathology means it could be just a systemic inflammation in the body. So increasing interleukins or tumor necrosis factors or other associated systemic inflammation can cause this kind of changes in the disc space itself. And again, if there is any kind of trauma or any other, like if there is any fractures or any kind of dislocation associated with this changes, then again, you had to associate the clinical findings history to kind of identify the etiology. So we should not be associating etiologies when we are talking about these nomenclatures here. So quickly go through this part of this. So lumbar disc herniation. So herniation is a more general term in which if there is any displacement of the disc material from its normal morphological area, then it is called herniation. So depending on the size of this herniation. So if we consider this as a base, so if we consider this as a base, so when this outer diameter of this is less than the base, it could be in any plane. It could be in the sagittal or it could be in coronal plane. If the diameter of the base is more than the outermost margin, then it is called protrusion. So when disc extrusion is when the base, the diameter through and through of this base is smaller than the outermost margin of this. So then it is called an extrusion. Again, it is really difficult to say the contents of this protrusion or extrusion. It could be different from patient to patient. It could have some nucleus purposes. It could have some annular fibers. There could be some osteophytes which could be there. So depending on the etiology and depending on what led to this disc herniation, the contents of this extrusion could be different. Extrusion or protrusion could be different. So sequestration is again where, which is, I would say that it's further progression of this disc extrusion where the content of the disc gets separated from the base. And it just stays in that, outside of that, the disc border. So it could be pressing on nerve. It could be pressing on spinal cord depending on where this sequestration is. So it's, I have a diagram here. So always look at the diameter of the base, diameter of the migrated portion of this disc. And that way you can identify where the disc, the nomenclature for this herniation. And there, and if you look at MRI, you'll see a lot of small nodules, which is nothing but extension of this disc content into the vertebral body, into the cartilage. And there is not much of extension into the foramen or to the spinous canal when you see small nodules. Again, the etiology could be different for different patients. So we had to just look at nomenclature as when we look at imaging with this. Any questions on this till now? I have a quick question. Is this a progression? Like would you go from protrusion to extrusion to sequestration, or do they happen separately from each other? So there need not be a sequence of events, but many times these, if you look at them based on studies, the natural history of protrusion, the size shrinks. If we do the right treatment with physical therapy, or if a patient gets an epidural, and if they follow the core strengthening protocol, the size of protrusion shrinks. So there need not be protrusion to extrusion to sequestration. And many times I have not seen that extrusion going to sequestration all the time, you know? So I think it's not a chain link always, but it can happen in some patients. Yeah, good question. Okay, any other questions? Okay, so this is probably a redundant slide based on the previous talk. You already know where the read this. I just highlighted some aspects of different radicular pain patterns based on the pain referrals and based on the motor strength wise. So you already know that L4 is medial leg motor. It helps with ankle dorsiflexion sensation. It's mainly the medial ankle and knee jerk is what you look for L4. L5, it's more of lateral leg dorsum foot and it is EHL, extensor hallucinus longus dorsiflexion. Usually the sensation which will be impaired is that between the first and second base of the toes and no specific reliable reflex, but S1, when you look at ankle reflex, there is some component of L5 also there, but ankle jerk mainly has S1 component and the pain pattern is mainly like the posterior calf, lateral sole aspect, where is the pain referral pattern and the motor aspect of S1 is more of a plantar flexion. So many times we ask patients to do heel rise, toe rise, and we make patients walk on their heel, walk on their toe to kind of identify which region is affected. They have a foot drop and other things, depending on which nerve is impinged, we can identify the source of the problem. Any questions on this? And I just want to highlight one more thing. So if it is a central disc protrusion, then it is usually the level that is one below. So that's a bold question. So for example, if there is L4, L5, I think Dr. Bajaj already highlighted about this, usually the upper sacral, S1 nerve root is affected. And if it is paracentral, which is just outside of the central foramen, then the one below that the L5 is affected. And if it is far lateral, then the same level is affected. Okay, so that's something that we all have to keep it in mind when looking at MRIs. Any question on this? Okay, good. So this is, till now, I think we just went through nomenclature and some of the pain referral patterns. So usually the most common level that is affected is L4, L5, and L5, S1. And depending on the source of pain, there could be inflammatory changes. There could be a lot of substance P, tumor necrosis factor, like neprostaglandins, interleukins. So many chemical mediators might be there along with the disc protrusion, which could act as pain generators in that area. And that would be the source of nociceptive pain. So nociceptive pain is more of a pain where it is coming from not a nerve-related thing. There is a source where there is a chemical or a mechanical issue causing the pain. And whenever a patient has pain in sitting position, then you have to think more about the disc-related pain. So if you look at, there are several studies which look at biomechanical stresses in the different regions of our spine. When we are sitting, our spine disc gets more stressed. So even bending forward, so when patient has pain with lumbar flexion, then it puts more stress on the disc. So flexion-based pain and also sitting pain is more classic of disc-related pain. And depending on which region, so radiculopathy or disc degeneration can happen at L1, T12, or L2. So this thing just highlights below knee just only for this, L4, L5. So it's not a common thing. I just highlighted this as an association with this. So if it is L1, then it's more in the upper L2, then it is L1, L2, then it is more of the anterior thigh, could be even in the groin if it is T12, L1, and if it is L3, anterior thigh. So depending on where the nerve is being pinched, you will find pain patterns or referral patterns based on that. And this SLRT is, again, specific only for L5 or S1 related thing. And it is very sensitive, but not specific. That means there will be a lot of false positives. And cross leg, straight leg rising test, that means you are rising the right leg, patient will feel pain on the left side. And it's, so if a patient has pain on the left side, and if usually SLRT and straight leg rising test means you rise the left side, patient will have pain on the left side. Cross leg rising test means you're rising the right side lower limb between 30 to 40, patient will have pain in their low back. There is one more test called a slump test where you do similar stretching of the leg in sitting position. When you do slump test, you have to straighten the leg with patient sitting position, but you have to dorsiflex the ankle. So that creates more of a stretch to the nerve roots. So this disc degeneration and radicular pain based on the natural history of things, if your studies have shown that one third of patients who have this pathology, or I don't want to call it pathology, who have this disc degenerative MRI kind of findings may not have any symptoms at all. So one third can be just walking on streets without any problems, without any clinical pain. The other one third might have some pain, but they usually get better with the conservative options, more of physical therapy, maybe injections or other medication management like gabapentin or other things. And other one third might need more invasive surgical treatment. So when you look at 66% of patient do not need aggressive surgical fixation, it is a good, favorable outcome. So even large disc excruciants, there are several studies which show that when they get a couple of epidurals or if they do physical therapy protocol for several weeks or months, they, even the disc extrusions and the foot drop changes do get better. So overall, disc disease has a kind of favorable prognosis at a broad spectrum at a bigger picture. Any questions on this? Okay. So I think we had to keep one thing in mind based on this is there are different pain generators. We have muscles, we have fascia, we have got facet joints. Many times disc pathology or disc etiology or pain generator does not exist in itself. So there will be associated some facet arthropathy, there will be some myofascial pain. So you had to kind of differentiate what is the main pain source or pain generator in this patient. So it's all based on your history and physical examination. So if there is more of leg pain, so I usually ask patients to say, if you have more pain in the leg or back, so do you have 50% pain in the back or 50% in your leg? You have 80% in your back, 20% in leg. So if they say 80% in their leg and 20% in back, then it is probably some radicular pain. So if they say it's 80% in back and 20% in leg, so you had to look at other facets and other regions as pain generators. So, and also you can do this examination, the SLRT, straight leg raising test. And if they have any foot drop or other neurological deficit, if they have tingling numbness in certain dermatomal distribution, it gives you a positive association for this radicular pain. And if they don't have tingling numbness or any weakness, then it is probably somatic. They are, it could be facet, it could be muscle. So you had to differentiate that based on history and physical examination, which is the tough part because when you submit a request for insurance, for injections, these injections do cost a lot, you know? So, and nowadays people are denying, insurance companies deny these treatments frequently. So we had to have a good physical examination, good assessment whenever we request it, request a procedure. So any questions on this? Okay, okay, so we'll go to the next one. So I had just highlighted something about neurogenic claudication here. Neurogenic claudication means a patient has the pain and weakness in the legs when they walk long distance. So, and it usually gets better if patient sits or if a patient leans onto a cart. So it's different from vascular claudication. Many times surgeons ask for ankle brachial index to assess for any kind of vascular compression to rule out any vascular claudication etiology. And I have seen that many times we think that it could be neurogenic claudication from spinal stenosis or foraminal stenosis. There could be some vascular etiology. And I've seen patients getting iliac stents and other stents to fix that vascular etiology. So I think we had to look at claudication as vascular and neurogenic. And if it is neurogenic, if it is because of the nerves being pinched, it can be differentiated as a central depending on where the nerve is being pinched. And this pain pattern could be different depending on which region the nerves are being pinched. Patient can have buttock pain, leg pain, if it is the L4, L5, and it's very positional. So that means a patient will have pain mainly with walking and with ambulation. And if it is a central disc kind of claudication, then the patient will have weakness. They might have foot drop. They might not even have foot drop, but they feel like their legs will give away when they walk. It's more of a subjective weakness is what they say. If it is lateral recess, which is just outside of this facet, which is just between this facet joint and the outer border of the central disc area, then patient will have more of claudication pain and the radicular pain just because the nerve root is involved. Here, it is more of the trunk involvement. Here, it is being more of the nerve root involvement. So you will see more of the radicular pain if it is lateral recess, or even with foraminal compression, you will see some radicular pain. And it also depends on where the nerve is being pinched. So depending on that, there could be some dermatomal involvement. Depending on L4, L5, there could be some burning sensation and tingling complaint. And it does not change much with position. Patient may have it even in sitting, standing, walking. They might have it all the time if it is more of the foraminal pain. Any questions on this? And just to highlight a few things here, if it is in classic neurogenic claudication, epidural, for spinal stenosis, there is not good, strong data to support epidural. So we'll talk more about that when we talk about treatments. So let's quickly go through intervertebral disc degeneration. So this is Furman scale, which usually, which mainly looks at nucleus pulposus and also annulus region. And depending on the morphology and the structure of the nucleus pulposus, this is a classified normal. The classic is, as I said, it's more like a tire kind of disc with black structures around it. And this is based on T2 MRIs. So as you know, T2 highlights more of a CSF and the fluid. That means the bright signals that you see there, it's more coming from the fluid in the T2 images. So this is normal, but at the type and grade two, even there you can see some of the nucleus pulposus, but it becomes more of a ISO intense. It becomes more of a fuzzy kind of change in this nucleus here. And in grade three, so the distinction between this nucleus and this annular region becomes less clear. Now it becomes more of a intermediate changes. So you had to look at all this in T2 weighted images, and this is a Sagittal view that you're looking at. And as you progress more to like grade four and grade five, so it's more severity generated changes. And many times whenever this nucleus pulposus shrinks in size, it creates a bulge on the backside because that's where there is least resistance. So it just goes backside. It could be central, far lateral depending on the patient and what the source of the problem is. So this is just one of the commonly used scale to look at the disc height and also the changes in the nucleus and also annulus region in the MRI. It's really hard to see all this in a CT scan. In CT scan, you will see a different kind of thing. It is called a vacuum phenomenon, which is similar to like seeing like a black round spot in between the, in the intervertebral space. usually the nitrous oxide is the gas that sits in that in that region. It's mainly the nitrogen. Um, and, uh, that's really common with, uh, if you're looking at CD scan in x-rays, if it is severe degenerative changes, you will see grass despite loss. So in excess, that's what you can see. Any questions on this here? Um, okay. So, um, we're again going through this modic changes. Um, so, um, this MRI findings and all this, uh, um, classifications, it's, uh, based on the region of the disc that is affected. Here in modic changes, you're looking at the bone marrow and the apophysis of, so you're looking more, not mainly at the disc, you're looking at this, um, cartilage and the apophysial region, and also the bone marrow. So here, that's the main, uh, kind of, um, the, um, the classification. So we are looking at the different aspects of the disc disease based on the different changes that we see in MRI. So in type one modic changes, um, there is disc degeneration. It could be, um, age related. It could be congenital or other source, um, causing, uh, even a trauma. We don't know the etiology, but there is some, uh, hypo signal in the T1 images and the T2 images. So what happens microscopically? Microscopically, there will be, um, more of, uh, um, vascular, um, it is more of hypervascular state there. And, uh, you will see a lot of chemical, um, chemicals there, vasoactive, um, and neural growth factors. Um, so all those substance P chemicals will be there, which will be creating a hypervascular zone in this area. And that's why you will see in the T2, it looks like there is some swelling or edema in this area. So this, you should not confuse this with compression fractures. So in, um, uh, in compression fractures in acute phase, um, in acute stage, you will see somewhat similar kind of presentation where there will be edema in that region. Um, so you had to associate with the clinical history and, um, and, uh, and if you are now, and usually you see more on the bilateral aspect of this, you know, modic changes, because it's more of compression between the two vertebral region. If it is compression, then it is usually one region and a compression fracture, and there will be loss of cancellous or, um, cancellous bone, uh, continuity in a compression fracture. But here you don't see all that. Um, it's more of a swelling or edema is what you've seen in type one modic changes. In type two modic changes, um, it's again, you're looking at this, um, uh, here it is, uh, uh, in a type two images, you can see that it is more of a hyper intense and it becomes hyper intense in both the, uh, T1 and T2 images. So T1 and T2, again, there is more of proliferation, but here you are, you are seeing at a stage where there is some fibrosis that is happening. So it is not just the fluid. So fluid in T2, um, show it shows up in modic one, but here it is more of fibrosis. There is some vascularity. It has tried to, um, kind of, uh, re, um, regenerate, but it has not been successful or due to the changes. There is some fibrosis. So now you are seeing more of changes or more hyper intense signal, both in type T1 and T2 images. And in T3, you are seeing more of hypo intense signals in T1 and T2 images. Again, these are the changes that our body has already tried vascularization fibrosis. Now it is probably turned into a fat or other structure, which is not sending hyper intense signal to the MRI. Um, so that's how, depending on the region of the disc, um, uh, degeneration. Um, so this modic changes just looks at bone marrow and also the outer border of the, um, of the cartilage. Um, there is also a terminology that is used in studies that they talk about high intensity zones. High intensity zones are nothing but, um, some of the, uh, annular fissures, which are happening at the outer border of the annulus, but there, uh, it is usually associated with some granulation tissue. And since it has some granulation tissue and it has some fluid, it will have a enhanced, uh, uh, gadolinium, um, enhancement in T2 images. So some of the studies do argue that if, um, if you see high intensity zones, the, that could be the main pain generators, but, um, there are no consistent validated studies to kind of grow it. Um, but some studies consistently talk about a high intensity zone or modic changes as the main pain generators, um, uh, for discogenic, um, pain. Any questions till now? Yeah, I have one question. Um, for modic changes, the patterns in them, is there any, um, understanding of etiology based off of that? Or is that purely just for like diagnosis? This is happening. You still have to work up etiology separately. Yeah. Yeah. Again, these are just the nomenclature based on MRI. So etiology, you had to work up because it is, uh, age predisposing this to, um, have this kind of degenerative changes because age as such leads to loss of water, loss of proteolikons. And it, was there anything that they lifted recently that predisposed to this? Again, each is subjective, patient specific. So it does not associate with the etiology. Okay. Okay. Any other questions? Yeah. Yeah. I have one question. Um, so I've recently learned about like the basal, basal vertebral nerve ablations that can potentially help with this pain. Have you ever sent your patients for that or have patients that have had that in the past? And if so, how did they do? Well, I have not seen patients personally, um, uh, getting that in my practice, but I have looked at several studies, um, in conferences, they talk about it. Um, but I think that there is some promising evidence, um, but it's as such the main concept with this basic vertebral ablation or with the radio frequency ablation is to do the heat, the nucleus purposes or granular fibrosis and to shrink it. Now, so we are ablating the artery and shrinking it so that the pain generators or the substance P or whatever, the nociceptive fibers, um, are, are ablated now. So I, I had not done it in my practice, but as I said, there are some studies which talk, um, highly about it. Um, so, um, I think I had to do it to kind of give you a good answer about this. Okay. But it looks like it is more promising, uh, because, uh, but as such I'm, I'm 50, 50 on it just because it's all avascular nucleus purposes is avascular. Um, and also most of it is through diffusion, um, and osmosis. So they, I don't think there is any major randomized controlled studies on this. So more studies is probably needed. Thank you. Okay. Any other questions? Okay. So let's go to the next one. I think, uh, based on the previous talk, I think, um, everyone knows that we always start with the most conservative options. You start, you give them Celebrex or, um, other, uh, Gabapentin. Um, sometimes you can even do like Medraldo's pack, uh, depending on the source of the pain. Um, if you see some associated spasms, you can give Flexeril, Pizanidine or other, um, agents as, as a adjunct, um, pain relievers. Um, you can send patient to physical therapy for core strengthening, but the physical therapy thing, it should be, you should educate patient that it's not like going there for two days and being done with it. You know, so you had to, they had to go there for a few days, learn those exercises and they had to do it religiously at home, at least four times a week, at least for two to three months to see some improvement, you know, um, because it's like building any muscle in our body. You don't, uh, get a good biceps just lifting a dumbbell once or twice, you know, you had to work hard for several months to build a tone and bulk. So the same concept applies for the, um, for the stomach, external oblique, internal oblique or transverse abdominus. The studies do talk about transverse abdominus or other muscles and multifidus kind of strengthening would help. Um, so we need, um, to educate patient about consistency with physical therapy, um, and acupuncture, again, there is some equivocal evidence of this, not any, um, level one studies, but, uh, um, coping strategies is always good. Um, and learning about cognitive behavioral therapy, it just helps with, uh, desensitization. So many times with pain, what happens is that patients get central sensitization. That means even non-painful activities make them feel pain. So if a patient, um, has, uh, um, has hurt their back while running on a treadmill. So whenever they go to, and they came out of it and they are out of any kind of, uh, radical pain now they're feeling okay. But even now, if they go closer to the treadmill, they feel kind of anxious. And, um, and if they start running maybe like 10 minutes, they might have some anxiety and they might feel pain because some of the pain, uh, generators, they, as I said, central sensitization is more of a cross-talk that happens, you know, there is lateral spinothalamic crack and dorsal spinothalamic crack. So there will be some cross-talk between the nerves of dorsal spinothalamic crack with lateral spinothalamic crack. That's what causes, uh, central sensitization. It's more about neuroplasticity that happens within the spinal nerves that causes central sensitization. So I think that is very well addressed with cognitive behavioral therapy, um, with any kind of, um, chronic pain, whether it is discogenic pain or facet pain or any chronic pain, cognitive behavioral therapy helps with that. Epidural, um, steroid injection as, um, we talked about depending on interlaminar, transparaminal, it does help, but mainly for short term. So here, um, basal vertebral ablation or the baculoplasty, um, there is the main thing is with these kind of, um, uh, based on whatever studies I have seen is that there is a risk of damage to the adjacent structures or, um, there was no, uh, really like a randomized control studies, robust randomized control studies to support this. Um, so I, I am not seeing too many providers around my region doing this, um, regenerative medicine can be tried. We'll talk more about this. I'm going to talk about these the four things in the next few slides, as, um, I do, um, work on some of this in my practice. So any questions on this? Um, I have a question. So I was wondering if there have ever been any, um, studies done using hyaluronic acid or something after giving steroid injections, um, to patients who have back pain caused by, um, arthritis, um, after the swelling goes down and everything to help with the mobility and lubrication. So hyaluronic acid injection to the disc or to the facet joints? Um, to the facet joints and facet joint arthritis. Yeah. Yeah. And there are no great studies. As I said, um, there are some case reports and case series which talk about that. Um, but no promising evidence just because the facet joint as such holds only like half CC or one CC of, um, so I know we'll feel it, you know, especially when patient has degenerative changes, the volume decreases more. Um, whereas in the knee joint, it can hold five ml, six ml or more, you know, uh, hip more, you know, 10 ml. So when the quantity of medication that goes to a small joint is that low, it's really hard to argue long-term benefits for that, you know? Um, but as I said, there are some case series, um, which talk about it. Good question. Thank you. Let's go to the next one. I think you all talked about different aspects of, um, interlaminar, transforaminal, caudal epidural during the last talk. I don't want to really go dig too much into this. Uh, interlaminar is done more, um, in the midline and some studies talk about some lamina or some demarcation between right and left that, uh, that, uh, but there is no real data to kind of, um, say that there is right and left demarcation. So I've seen this area I've seen in my practice that it's both on the right and left side. Um, if you do it right through the paramedian approach. Um, so transforaminal, if you hear you are targeting this, the neural route itself, but there will be some epidural spread. And this is good. If you have any radical pain and you know that it is coming from L5, you know that it is coming from L4, that's when you can use a transforaminal. Caudal, you can use it if patient had a history of lumbar fusion and, um, they are fused, uh, throughout their spine and it is hard to access this, uh, space, then you can do caudal epidural, but, um, in many places they do caudal epidural because it is more safe. Um, transforaminal has increased the risk of, uh, causing, um, spinal infarct depending on which steroids that you use, you know, so the vascular injury risk is really high with the transforaminal vascular injury, but interlaminar, it's, um, it's less, um, there could be some venous spread, uh, depending on how deep you go, but there are different techniques that you have to use, um, to make sure that you are in the right, uh, region. So the studies that talk about, um, the epidurals helping the, um, the disc related pain, um, and as I said, it's like maybe for short term, uh, six months, two months, I've seen patients getting short term relief, um, in my practice. Um, it's really hard to argue for long term relief with just an epidural, um, because you know that the steroids, whether you use, whether you use DepoMetrol, Dexamethasone, they have half-life and six weeks is the maximum that they are going to stay, whether it's like, uh, if you are using the two or three times of P-HALF, then it's not going to last long duration, you know, um, but the main thing that you have to do when you do these kind of procedures is make sure that they have stopped their blood thinning medications. Um, if they are an Eliquis, Warfarin or other medications, then you have to stop it based on their P-HALF, usually based on ASTRA guidelines, um, um, they usually recommend three times P-HALF. That means if Eliquis lasts only for, stays in your body for maybe like, uh, 12 to 24 hours, then you have to stop that medication for two days because you are giving that window of opportunity. It's in that way you are safe. So you should have a good team to look into all of this. Um, are you going to stop, um, maybe aspirin for transpram now. Some studies argue whether to stop or not, but it's better to be cautious than to say, sorry. So any questions on this? I heard that you all talked about this a lot during last talk. So I don't want to talk much about this. Any questions? Okay, so regenerative medicine or biomaterials in the degenerative disc. So mesenchymal stem cells, you know, there are some case studies which talk about it, mainly helps with analgesia, helps with pain, and it increases the fluid content, but not so much with the height. PRP has been seen. I had done some of this PRP things, but I'm not seeing too much benefit in my practice. They even do amniotic fluid. I've not done amniotic fluid, but amniotic fluid studies also are there to the disc, which are again, if we vocal or not, we don't have any long-term studies, robust level one studies. Chondrocyte transplant, again, these all are small studies. So we had to make sure that there is no ectopic calcification when we do these chondrocyte transplant. I don't do any of this in my practice. You know, I had done PRP for some patients, but not recently. It's been more than a year that I had done it. Maybe I'd done for like 10 patients. And based on what I had done, I had not seen a robust long-term relief with this. This is one of the interesting things that have come out recently. I had done maybe like one or two till now. One, and we have one more schedule coming up. It's more about the wire disc. It's a, so here they will have a material which looks or feels somewhat more like a nucleus of pulses. You mix that nucleus of pulses material and you inject, you use the discogram technique and you go, it's just like doing a discogram and you will just inject that fluid, which is kind of semi-solid into that disc space you're trying to cover. And this is good if you see any kind of loss of disc height. And if you are seeing more of not just the modic changes, if you are seeing like a grade three or four per month changes, then it does help. And some of the studies talk about 12 months of relief with this. And again, I'd done only one till now. So I cannot say whether it would be effective that much or not, but there is a FDA approval for this. The basic thing that goes on here is in our body, whether it is a skin or any structure in our body, there is always a fight between catabolic and anabolic changes. So in disc degeneration, there is more of a catabolic changes that's what leads to this disc height loss. So we are trying to decrease this catabolic change and add some component, which will not be anabolic, but it is kind of neutral, which maintains the disc height. Any questions on this? Okay. But again, the only few insurances approves this, just Medicare approves it. Other insurances have to kind of approve it. So spinal cord stimulation, this is done in two ways. One is this is dorsal column stimulation and dorsal root ganglion stimulation. I have done several of this. So it does help with pain, discogenic pain, it is good. And if you have a pain pattern, usually patients would have like a laminectomy changes, laminectomy or failed back surgery. So they have a disc pathology or discogenic pain, but they have tried microdiscectomy, they have done laminectomy, but even then nothing is helping them. So this acts on a, we are not fixing the problem here. So we are not trying to decrease the disc bulge or anything. It acts on a gate control theory. That means if I bang my elbow, the first thing I do is I rub that region. So by rubbing it, I'm creating a sensation of vibration, friction. In that way, we are trying to send a different signal through our spinal cord. So you know that different columns, lateral and dorsal spinothalamic tract. So the same concept that we use with the spinal cord stimulation. So we are not going to rub the patient's back or leg constantly, but we are creating a sensation of vibration or kind of different sensation that goes through the dorsal spinothalamic tract, which kind of masks the perception that goes through the lateral spinothalamic tract. So it acts on like the brain mapping is a similar concept. So depending on where the pain is, if the pain is in the back, usually the leads are placed at the T7 area or T8 area. There are different companies which sell products, which are MRI compatible, which are non-MRI compatible. And I work with almost all companies out there. So you had to talk with patients about the MRI compatibility and also charge and recharge burden. So some of these are chargeable, some of these are non-rechargeable. So most of these batteries will last for five to seven years if it is non-rechargeable, depending on how much patient uses. So this is nothing but electricity that goes through those wires. So you can increase the amplitude of the signal that goes through this. You can increase the pulse width. You can increase, sometimes you can change the frequency depending on the company, but sometimes you cannot. If it is Abbott or other companies, then the frequency stays at 500. But depending on the company, you can tweak these changes and patients can pursue some of the buzzing sensation where the leads are placed. Sometimes they don't, depending on how much frequency you are sending through those wires. So it's a good treatment, but we are not fixing the problem. So it's just masking the pain. So you had to make patients aware of that. And the DRG had done several of this, but again, it's not good for disc extrusion or any kind of disc. If you know that there is some impingement on the nerves, then don't do it. It's a contraindication. But you know that there is a pain generator coming from that specific level, and you had done epidural, they had had surgery, nothing is fixed, not fusion, but laminectomy or other changes. So then you do a DRG. DRG is good mainly for focal pain. If there is CRPS pain, if you know that it is yellow and radiculopathy, then you do it. It's, you know the level, that's when DRG is done. Yeah. Any questions on this? I know that some patients who have this can get off of opioids after the fact. You, have your patients been able to do that? And if so, when would you, would you take them off of opioids before in preparation that this would help with the pain, or would you wait? Yeah. So my practice is not really too much on opioids. I do prescribe opioids, but at a very low dose. I've seen patients coming off of opioids on this, you know? So if patients have been on oxycodone or hydrocodone, I have seen them going off of it. Many patients, I've seen more than 10 for sure. When do we do that? But we usually kind of talk about this when we plan for the procedure. So any time when we come up with some plan, we usually like to set up some goals with patients, you know, as to expectations. So I usually say that if we are doing this, I'm hoping that we would cut down on the opioids. And if they do, if they are on three times of hydrocodone, then I'll say that after this procedure, I'm thinking about cutting down to like one tablet a day, or like a two tablet a day, depending on how much they are using. And whenever they agree, I usually do cut them after. If they get trial, I don't cut them during the trial. So after the implant with me, after maybe like a two or three, maybe after two or three weeks, I will do it. And I had done it many times. And it's the patients do get relief. And I don't know if I answered your question. Yeah, you did. Thank you. That's great. That's really promising. Okay. Okay. So any other questions on this? Okay. So we'll quickly go through a few other slides. So there are some surgical randomized control trials, which have been really been out there, which you kind of argue for or against the surgery. So the first one was done in 2007. So here, most of these patients got, so they divided them as conservative treatments and as a surgical cases. So microdiscectomy is what was done. And some of these centers are in Europe and in some centers in Canada and also in America. So they have seen that even though patients, if you look at this graph here, there is some initial decrease in pain, but eventually after certain, maybe after a few months, it flattens. It becomes the same as a conservative treatment. So whether you're looking at a Ronald Morris disability scale or visual analog scale. So after maybe like 36 to 40 weeks based on this first study where they had more than a hundred patients in each thing, they did not see any long-term good outcomes because they all kind of had the same thing. But in some of these next studies that they have done, again, they had done microdiscectomy prospective study, 64 patients in each group. Here they have seen significant improvement in the surgical group compared to the non-surgical, which is interesting and which is new. And I think maybe they have done a good job in cherry picking the patients when they are done microdiscectomy. So that does help, surgery does help if they have the real disc extrusion, disc protrusion, it's a mechanical problem, they are taking out the mechanical source of pain so that the nociceptors signal gets blocked. So this study shows that it does improve when you talk about the non-surgical group, which is physical therapy injections or other options. So the recent study shows that the microdiscectomy of surgery helps, but the old study has said that it's kind of equivocal at the long term. But here they have looked at only like a six months to one year. We don't know the more further out what happens after one year. It's probably going to be done sometime in future. So any questions on this? Studies. But I do refer patients to surgery when we have the right need, or if patient has a foot drop, or if patient has a ball or bladder related issues. If it is a severe spinal stenosis just because of a disc issue, then we do have a neurosurgeon and two spine surgeons. One is a neurosurgeon and the other one is an orthospine surgeon. They do a good job in fixing these patients. And again, we are talking about the discectomy or disc replacement, not fusion. So here the studies is more about discectomy. I don't think that there is a much evidence for lumbar fusion in this kind of discogenic pain. If it is a disc replacement or disc replacements works better if it's cervical level. With the lumbar, based on whatever I heard from surgeons, they say that it's 50-50 because it's too mobile. So the disc replacement and micro discectomy helps for the right patients, yes. Any other questions? Okay, sorry, I took a lot of time. You know, I think I went double my time. I'm sorry, I don't have any cases or scenarios, but I will share my email with all of you all. So if you have any questions, you can ask me questions at any time. Okay, I don't see any other questions on this chat box. Okay. Okay, yeah. Thank you. Thank you all. Thank you for your time. Oh, thank you so much for coming. Thank you. Thank you, thank you. That was wonderful, thank you. Thank you. We were, we figured we've got only about 10 minutes left, so we'd like to give you some money away. So if you click the Socrates student login and you log into, oh, 3-2-0, that's the room number, we can get started. I think Carly will take the lead on leading this. I can just be the computer person here. That sounds great. Can you guys hear me okay? Robbie, can you hear me okay? Yeah, yeah, I can hear you. Okay, cool. All right, guys, so there are explanations for all of these. We, once we get to the end, we'll see who gets the most questions, right? The explanations we can look at if needed or in down the road, if you guys are interested. I believe we covered all of these topics today, but if not, it would have been covered in your readings. So those of you who have done their reading ahead may have a slight advantage. So we'll run through this pretty quickly. I'll start with number one. Which of the following is not true regarding the use of MRI for lumbar spine pathologies? Remember, not true. So you can plug your guys' answers and so far I see one of you has answered. Carly, are a couple of students not yet logged in? Oh, that could be the case. Yeah, we'll give you guys a couple minutes. Yeah, let me know if you're having trouble logging in, please. Yeah, please take your time. Okay. All right, looks like we have one more left. Anybody having trouble getting logged on? Looks like we're still getting logged in. I think we're good. Okay, so let's go ahead and end this question. So, C is the answer. So, which is not true? So, as you guys know, MRI is an excellent test for those soft tissues. And looking at spinal stenosis, the difference here is that in patients that are symptomatic, MRI can add some additional value. And those patients who are not symptomatic from abnormal degenerative findings, the MRI does not add a lot of extra in comparison to the CT. Question two. All right, patients on anticoagulants must discontinue them before undergoing lumbar epidural injections. All right, so this is a real, it's kind of a trick question, apologies for that. In most practices, anticoagulants are discontinued, that, and in general, that is what most practices are doing. There's a bit of a debate out there. If you pop open the explanation, Ravi, what we have found is this is now considered, you know, an intermediate risk procedure where the actual risks of hematoma are low, and the potential risks of stopping anticoagulation are real, and potentially a higher risk than the hematoma that might occur. So up for debate. In general, it's not a must, though most practices do require it at this time. All right, number three, Bic dimension, the cutoff between a focal and a bulging displacement of the lumbar disc material is what percentage of the circumference of the disc. I'm thinking about the difference between a focal displacement and a disc bulge. So when we look at focal, in other words, the difference between a herniation and a bulge. All right. Good. Yeah. So it's 25%. So 25% is that cutoff. So a bulge is going to be more than 25% of the circumference of the disc. A focal displacement or a herniation is going to be less than 25%. The nomenclature is really helpful. I use that with all my students. It's just having a common language is huge. So just keeping that in mind when we think about the difference between a bulge and herniation. Question four, which of the following is the most common complication of lumbar discectomy? All right, we have everybody's answers. All right, well done. So dural tear is going to be the most common injury. So dural tear, just given the the type of procedure, is going to tend to be a little bit more likely in comparison to vascular injury. Radiculopathy is an interesting question, you know, you could have a root injury with this also, but dural tear is going to be our number one complication off that list. All right, number five, patients with surgical treatment for disc herniation showed a significant difference in improvement in bodily pain and physical function compared to non-op treatment. So guys, let's think about this in the context of that acute, the reference which is the sports study, so that acute six to 12 weeks of pain. And let's say at a year, sorry, this question could have been tweaked a little bit. So thinking about that sport trial, the six weeks of, six to 12 weeks of initial symptoms, discectomy versus non-surgical treatment, the outcomes at a year. Good, yep, and so they both get better, right? Some of the newer studies with the more chronic or subacute to chronic symptoms are different, but in this case, everybody ends up at the same place at a year based on those initial support trial studies. All right, next, which of the following is a distinguishing factor of early painful intervertebral disc degeneration? So thinking about the mechanisms here and thinking about pain associated with the disc degeneration. Come on, three more. Here we go. Keep them coming. All right, let's look at the results. Good. Well done, guys. So you guys are right that there is loss of proteoglycan and water content as part of the degenerative cascade. The early painful changes come from the pro-inflammatory cytokine production. So good, you guys were on track with all that. Number seven, all right, which of the following is not recommended treatment or management option for chronic low back pain? And this is a chronic low back pain, not radiculopathy. Good job, guys. So epidurals are indicated for leg pain, not back pain. So that's kind of the kicker with that question. All of these other things have been shown to be helpful in studies of conservative care. So they are indicated for the leg pain more so than the back pain. Low back pain is a purely biomechanical and physiologic process. True or false? Good job, guys. So psychology and other factors certainly play into this, which is one of the reasons we ask some of those questions of our patients. So while there are predominant physiologic issues here, there are other factors. Remember that pain in general is not just a physical process. It's actually the interpretation of those physiologic signals in your brain. And so certainly other things can impact it. Okay. Which of the following is the most important indicator for spinal surgery in patients between and 80 years old? Three, two, one. Good, ooh, toughy, guys. Okay, so let's think about this. In patients that are 60 to 80 years old, if you go out and scan asymptomatic patients between 60 and 80 years old, the vast, vast majority are going to have herniated disc, bulging disc, degenerated disc, and spinal stenosis. Seeing those things on an MRI is not an indication that they need surgery. Disability related to those or other findings is potentially a indication. So remember, we want to base this on their clinical condition more so than on the imaging findings, which are always going to be abnormal in an older person. All right. Type one modic changes on MRI are most commonly seen with which of the following types of pathology? All right, almost there. Three, two, one. Good. Excellent, guys. Yep. So motor changes in general are considered to be associated with degenerative disc disease. There are a lot of other findings with the other thing. OK, transforaminal epidural injections are more efficacious compared to interlaminar epidural injections for chronic unilateral lumbosacral pain secondary to a disc herniation or disc degeneration. Good job, guys. So interesting question. As we talked about in the debate, much of this is dependent on the patient presentation. And so in this case, there is probably an argument to be made for either one of these injections. And based upon the study below, for this particular type of problem, there is probably equal efficacy. All right, number 12, which of the following complications is more common with a transforaminal epidural steroid injection in comparison to an interlaminar injection? Yep, good job guys, yep. So intravascular injection is going to be some, a lot of these are otherwise of an equal frequency, dural puncture is probably more with a translaminar. Intravascular injection, just thinking about the anatomy of the spine is going to be more common with a transfemoral. Which of the following is the difference between a protruded disc and an extruded disc? Almost there, give you another few seconds. Good, that was the tricky one. Yeah, I mean, so the mechanism is gonna be the same. In other words, how it occurs. Both of these represent disc displacements rather than what a lot of you seem to do number or letter B, but really ultimately this is the shape of the herniations. So these are disc herniations with different configurations. Okay, in order for a disc to be considered migrated, fragments from the herniated disc must be discontinuous from the disc of origin. One more, this will be the last question for today. Three, two, one. Good job. Okay, well, some of you guys, you are on the right track here. So when we think about the foramen, so where the nerve is exiting, that is going to be hitting the exiting nerve root. So the nerve that exits at L4 to five is the L4 nerve. If it were a pure central disc herniation, it would ding L5. So these are tricky. These are gonna be on all your quizzes. So just keep working on that. Take some memorization. And remember that the exiting nerve in the cervical spine is different. So just to make things even more tricky. Okay, great job, everybody. So let's see who our winner is. And if we have a tie, we will do the number thing again, I think. Yeah, we have two winners. It's two high scores. It's Priya and John, Priya Patel and John. All right, good job, guys. Okay, let me see. Where's Priya? Oh, there's Priya. Okay, and John. Okay, so I am going to write down a number between one and 100. And I may or may not use the same technique that Dr. Kasi used yesterday. So I'll give you five seconds to choose a number. All right, Priya. 22. Jonathan. Let's say 63. And the number is, oh God, talk about suspense. Oh my God. My background, it's 72, I swear. There it is, 72. Jonathan, congratulations. All right, guys. Jonathan, make sure you drop your email in the chat so Candace can get that to us. Well done, everybody. This was a hard quiz that I think most of you did really, really well on. So nice work. I can tell you all learned a lot today. So that wraps it up for our section. Just in terms of last comments, you guys, it was great to have you all. We were really happy to have you here for the program and we're really excited about seeing you in PM&R in the future. If you have questions, if you have any, anything about like PM&R or applications or anything like that, Dr. Kasi and all of our team members would be very happy to answer that and do our best to kind of help steer you in the right direction. If you have clinical questions, residency application questions, anything like that. Dr. Kasi, any closing comments? Nope, enjoy the day. Thank you for- Great to meet you all. We'll see you around, okay? Thanks guys. Thanks for setting this up. Thank you so much. Bye, thank you. All right. Oh, Candace, if we can just email Carly the email. I sure will. Thank you so much for this. This is wonderful. And Carly, you can send the card. Yeah, no problem. Yep, I'll do that. I'll send it to Jonathan. Well, that was a lot of fun, Candace. So just maybe send us, sorry, I've got a total malfunction in my computer. So I'm on my audio on my phone and my video on my computer because otherwise I couldn't really see anything. So I don't know what's going on. I've got to, I restarted it twice, but oh, whatever. I think it worked out okay. You guys can hear me all right. So all right. Have a good call, Robbie. All right, see ya. Bye. See you guys later. See you today. Take care.

Dr. Pampi Bajaj

epidural injections

cervical radiculopathy

interlaminar approach

transforaminal approach

advantages

disadvantages

puncturing the vertebral artery

pain reduction

disability

lumbar discogenic pain

clinical presentation

diagnosis

management

annular tears