Low-back pain; a technique for pain relief: Upstate Medical University's HealthLink on Air for Sunday, Dec. 24, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a close-up look at back pain. A doctor who specializes in physical medicine and rehabilitation discusses how low back pain is diagnosed and goes over an array of treatment options.

HeeRak Kang, MD: ... You may have pain in the lower back, but then it's also spreading to the back of your legs, which is different actually than radiating pain, which is back pain that goes down to the right foot. So it can be very challenging for patients because they're having pain kind of all over, and it's very hard for them to differentiate where this pain is coming from. ...

Host Amber Smith: And a pain medicine specialist explains neuromodulation and how it can relieve chronic pain for some people.

Vandana Sharma, MD: ... This is a better form of pain control because it is done in a nonpharmacologic way. So we are just using electrical signals to their best value and help modulate the pain signals. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn how neuromodulators relieve chronic pain in some people.

But first, an overview of how low back pain is diagnosed and treated.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Lower back pain is one of the most common reasons for people to miss work or to see a doctor. Today I'm talking about lower back pain with Dr. HeeRak Kang. He's an assistant professor of physical medicine and rehabilitation at Upstate, and he specializes in pain and chronic pain management. Welcome to "HealthLink on Air," Dr. Kang.

HeeRak Kang, MD: Thank you for having me on board, Amber.

Host Amber Smith: Can we begin with a bit of an anatomy lesson? I'm curious about the structures in the back that are involved in lower back pain.

HeeRak Kang, MD: Absolutely. So there's, in total, 24 what they call vertebral bodies in the spine. There's about seven in the neck, 12 in your thoracic area where your ribs are, and there's five lumbar vertebral bodies. They are usually the largest in size. And what I try to explain to patients is if you imagine a stack of cylinders, the one kind of at the lowest, or what we would medically say inferior, are the ones bearing the most weight, and they're generally the largest in size.

Host Amber Smith: So they're stacked?

HeeRak Kang, MD: Exactly.

Host Amber Smith: What holds them together?

HeeRak Kang, MD: So there's a lot of ligaments in place. Think of it as a stack of cylinders. In between are called disks, and they're kind of like the shock absorbers. There's joints, two on each side of the cylinder, that kind of connects on each end. So that allows you to bend forward, bend back, rotate, that kind of activities. And then there's also ligaments that kind of put everything in place, actually.

Host Amber Smith: So are they attached to muscles?

HeeRak Kang, MD: They're attached to muscles at every level. And then in addition to that, there's actually nerves that come out at each level as well.

Host Amber Smith: I'm curious about the nerves. Are they inside the bone, or where do they lay?

HeeRak Kang, MD: That gets a little complicated. There are what's called sinuvertebral nerves that are actually in the bone itself and outside of each disc. There's also nerves that come out at each level. So the spinal cord, I try to explain as kind of, like, you know how the power goes into your house, and it goes into that kind of circuit breaker, and at every level it kind of branches off each individual outlet? Those are what I would call the major nerves that kind of innervate your hands and your feet and your knees and that kind of big joints. And then you have smaller nerves that actually innervate various aspects of that just like in your lower back or even in the disk and the lumbar vertebral body itself.

Host Amber Smith: So when we have back pain, have we done something to injure the bone, or have we pulled muscles, or have we done something to the nerves? Like, where does the pain come from?

HeeRak Kang, MD: That's a great question. And to be quite honest, scientifically we're still trying to figure this all out. It's a very complex question.

What I try to do is I try to figure out what a person has been doing right before. If it's generally like a muscle sprain, or ligament strain, you'll have this pain, but you also have tenderness. And so if you touch it, it hurts, kind of like a bruise or if someone punched your arm.

Nerve pain's a little bit different. A lot of times you can have compression of a specific nerve, and a lot of times patients will say it feels like this shooting electric going down to my foot. And that is more indicative of a nerve pain.

That's not necessarily tender. I try to differentiate between pain and tenderness. Tenderness would be if I touched you and it hurt, whereas you can still have pain without the tenderness.

Host Amber Smith: I've heard of herniated disks, but I'm not really sure what those are or how important they are. Do you need to see a doctor if you have herniated a disk?

HeeRak Kang, MD: It really. You know, a lot of times a herniated disk can resolve on its own. Clinically you should see improvement on average, there's some studies that say six weeks up to nine months, it can sometimes take herniated disk to kind of reabsorb itself.

I try to explain herniate disk as kind of like a jelly doughnut. And the thing is, when you squeeze a jelly doughnut, and that jelly kind of bursts back. That in itself can be irritating to your spine and your spine nerves. There's actually a study that was done in the 1970s that looked at disk pressures, and they kind of looked at it in different positions. Actually, it's very interesting, and they actually found that bending forward and rotating can increase the disk pressure four times or 400% of what you would normally experience if you're standing up straight. So if I'm standing up straight, let's say my discs are experiencing, let's say, 100% of that pressure. If I bend forward and rotate, it's going to be about four times that.

And so, a lot of times usually my patients say they were reaching for something or lifting something farther away and twisting, and they experience this sharp pain that's going down their back. I will usually tell them that a lot of times that can resolve. If they're experiencing any weakness or abnormal sensation, at that point, I would say maybe you should look to see a doctor first and maybe get checked out.

Host Amber Smith: Is herniated disk the same thing as a slipped disk?

HeeRak Kang, MD: Yes, that can be interchangeable. With the disk, there's actually, interesting enough, there's different terminology that radiologists use. You know, it depends on the size of the disk that's protruding out back. You also have to realize, the body is a 3D structure, so a herniated disk not only can push back, but when it pushes back, it can actually push up and down as well. So if you squeeze, like I said with the jelly donut, it's not going back in one plane, it's, it's going in a lot of different planes as well. And so a lot of times an MRI is great for actually figuring how much of that is happening.

Host Amber Smith: So when you initially injure yourself, that's an acute injury or acute pain. When does acute pain turn into or become chronic pain?

HeeRak Kang, MD: Usually acute pain is defined as three weeks. I think medically we've kind of put these lines in the sand. And chronic pain is defined as three months.

So, subacute pain will be in between that. So it's less than three weeks is acute pain. Three weeks to three months is subacute. And then after three months is chronic pain.

Obviously for a patient, these terms don't really mean a lot to them. You know, they're in pain, they're in a lot of pain, and they want to figure out what I can do to help them. But that's kind of where we draw the line and try to figure out how we can help.

Host Amber Smith: You were telling us all the different ways that patients of describe the pain that they're experiencing, and it seems all across the board. Does lower back pain ever spread into other areas of the body?

HeeRak Kang, MD: Absolutely it can. You know, the challenge is, the spine is connected to all other joints, right? All the joints are connected to the spine, and spine is connected to all other joints in the body as well, right?

And so a lot of times we consider this what's called a kinetic chain. And so patients will generally have some kind of knee pain, and so their gait is altered. And then they'll start to have hip pain. And then they'll start to have back pain. And so sometimes it can be kind of challenging. It's almost like a Sherlock Holmes approach, where you actually have to kind of backtrack of when the pain started and to figure out what's causing this.

But yes, a lot of times we can have back pain that spreads as well. What we call that is referred pain. So you may have pain in the lower back, but then it's also spreading to the back of your legs, which is different actually than radiating pain, which is back pain that goes down to the right foot. So it can be very challenging for patients because they're having pain kind of all over, and it's very hard for them to differentiate where this pain is coming from.

Host Amber Smith: What happens if a person is in pain, and it doesn't get treated, they don't seek treatment, they don't get any care for it -- will the pain resolve on its own? Or will the pain just keep getting worse?

HeeRak Kang, MD: That's one of the challenges with chronic pain. A lot of times there's different methods of treating pain, whether it's medications or injections or conservative management, right? But a lot of times when you have ongoing untreated pain, what you generally have is a centralizaiton of pain. And what that means is, pain is not only what is happening, but also your perception of pain.

And so a lot of times, when patients have this chronic low back pain, they're very guarded with their movements. They can be very anxious and depressed. And so that kind of takes what is a pain, let's say a six out of 10 into a nine out of 10. And so now a lot of times the challenge is how do we treat the pain and also treat the perception of pain, which is very real. People are feeling this pain. It's not something made up in their head. Pain is very challenging in that way.

Host Amber Smith: So it is important to treat it?

HeeRak Kang, MD: Absolutely.

Host Amber Smith: So let's talk about what causes lower back pain. How often do you see people with congenital diseases?

HeeRak Kang, MD: I actually don't see a lot of patients with congenital diseases where I am at. What I see is someone has a herniated disk that happened all of a sudden, whether they were lifting something heavy, or a lot of times I see more chronic neck and back pain. Over time, there can be degenerative changes just as patients age, unfortunately.

Host Amber Smith: So arthritis, inflammatory diseases, things like that?

HeeRak Kang, MD: Exactly, exactly. And one of the challenges as patients get older is, the disks that act as a shock absorber between those lumbar vertebral bodies, which are kind of like the stacks of cylinders, they basically lose the fluid. So your jelly doughnut actually becomes just a doughnut. It loses that jelly. And so what happens is, it actually puts more pressure on the joints that are between the lumbar of vertebral bodies. And so that can lead to arthritis. And the challenge with arthritis is once you have bone on bone, ironically, that actually creates more bone, what are called osteophytes. And kind of similar to in the knee and the shoulder and things like that, you just, or the hip, you just have this narrowing. And that in itself can be very painful.

Host Amber Smith: Do you ever find that the back pain is actually because of a problem somewhere else in the body?

HeeRak Kang, MD: I do. I do. Usually I see it in hip pain, which is actually. Patients, when they say hip, they sometimes get confused because they think of the fashion hips at the waist. But hip pain is actually more groin pain And then also sometimes with knee pain as well. And a lot of times it's because they're just because they're painful on one side, they're shifting their weight to the other side, and so now their back is actually taking a bit more load there. And so therefore I can definitely see where their pain is coming from.

Host Amber Smith: Let's talk about risk factors for developing low back pain. Why is it that back pain becomes more common as we get older?

HeeRak Kang, MD: You know, unfortunately a lot of it is patients are getting older, they've had a long history of maybe treating their body a little bit more aggressively, they put on a little bit of weight, maybe they're smoking and drinking alcohol. And so a lot of these can have a detrimental factor for low back pain. Maybe their work is very sedentary, and they're not moving around as much.

With back pain we're kind of focused on keeping that core strong. And so, especially in Central New York, there's a big risk factor, especially for females, for osteoporosis. And a lot of times that can lead to compression fractures, which is at that thoracic lumbar junction. The thoracic is kind of where your ribs are and your lower back. And the reason why that is, is because the thoracic area is very stiff, and the lower back is very flexible. And so generally you have a compression fracture in that stiffness and the kind of flexible portion.

A lot of times we'll see this, and it's very unfortunate, because these patients, you know, we aren't the sunny state of Syracuse. And so their bone structures are not the greatest, and then they'll have some kind of fall, and then that can lead to compression fracture, which can lead to a lot of significant mid-back and also low back pain as well.

Host Amber Smith: So that's an issue for women in Central New York, because we don't have the sunshine like Florida or California?

HeeRak Kang, MD: Exactly. We're just at risk for more osteoporosis, which you know makes your bone brittle, unfortunately.

Host Amber Smith: Because we need that vitamin D.

HeeRak Kang, MD: Yes. Yes. So, it's a prescription for a flight to Florida, actually.

Host Amber Smith: OK. Well, let me ask you about a person's fitness level. Does being active increase or decrease your risk of developing lower back pain?

HeeRak Kang, MD: It can definitely increase it if you're at that kind of extreme level, but for most patients it definitely decreases your risk, especially if you're flexible. You're preserving what's called your range of motion with your back and your legs, and your focus on that core strengthening. Increasing fitness level is helpful in a lot of aspects.

Host Amber Smith: And what about weight?

HeeRak Kang, MD: Weight, unfortunately, isn't the greatest for low back pain. There's a lot of more research actually for knee pain. If you lose a lot of weight, you can actually decrease your knee pain and your hip pain and your lower back pain as well. And so I always tell patients that it's really beneficial for them. Let's say they can try physical therapy or even just looking at the local YMCA or the local gym to get a better handle on that.

Host Amber Smith: Let me ask you about mental health. Does that have an effect on back pain?

HeeRak Kang, MD: Absolutely. You know, patients want to get better. I think that is a struggle. They're trying to figure out ways, and they're trying to get out of this process where they have this back pain. And a lot of times, maybe their coping mechanism is to smoke or to drink or to eat, and so therefore they're putting on weight or they're using these crutches. And so, a lot of times they end up being depressed and anxious, and they're very stressed out. And so it kind of creates this cycle. And, I feel like, as providers. We don't really talk enough of how we can help mental health first, and then that can also help with their back pain.

Host Amber Smith: Please stay tuned to Upstate's "HealthLink on Air." We'll be back after this short break.

Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith. I'm talking with Dr. HeeRak Kang. He's an assistant professor of physical medicine and rehabilitation at Upstate, specializing in pain and chronic pain management.

What do you do for someone who comes to you complaining of lower back pain? What's involved in the diagnosis?

HeeRak Kang, MD: I try to get a, first, good, solid history. My role is to try to figure out where this pain is coming from, how this pain occurred, where it's going. I try to correlate it to a specific dermatome (areas with connections to spinal nerves) map. Or, if it's, let's say a radiculopathy, a lot of times I'll start with a lumbar X-ray before I progress with an MRI.

Host Amber Smith: I'll usually prescribe them a home exercise program or physical therapy. If it's a certain nerve distribution that I'm suspecting, I'll order what's called an EMG, a nerve conduction study. It's kind of an uncomfortable exam, but it really tries to isolate what specific nerve could be involved. Well, starting with acute pain, let's talk about how back pain is treated.If someone comes in with acute back pain, and you are able to sort of determine what you think is the cause, how do you begin treatment?

HeeRak Kang, MD: We're kind of at this phase now, where we're moving away from bedrest, to be quite honest. A lot of times if it's acute back pain, we'll start with kind of the "RICE," you know, with the rest, ice, compression, elevation. Back pain is kind of hard to elevate, to be quite honest. And rest is relative rest. It's not you're actually in bed.

We're also trying to move away from back braces as well, unless you have a specific issue like a compression fracture. A lot of the recent literature has shown that back braces can kind of lead to weakness in the back, and that's not what we're trying to do. We're trying to strengthen those back and core muscles like the abdomen. We'll also start with some basic Tylenol, ibuprofen, naproxen, or I can also prescribe what's called meloxicam, which is a long-acting NSAID (nonsteroidal anti-inflammatory drugs).

Host Amber Smith: Now what about, I guess with the RICE, ice is part of it. Does heat ever get used? Do you switch over to heat at some point?

HeeRak Kang, MD: Usually I will start with ice, because the thought process of any kind of acute process is that you have an inflammatory process. And so ice is supposed to kind of calm that down. And so heat is generally not something that will help in an acute phase.

In a chronic phase, to be quite honest, I've had a lot of patients that say heat really helps. And so I always trust what the patient is telling me and try to go by what works with them. And so a lot of my visit with a patient is trying to figure out what they've tried before and what else they haven't tried. And so, heat can definitely be helpful.

Host Amber Smith: So for people who have chronic low back pain, let's talk about what their options are for treatment. So these are people that have had pain for more than three months generally.

HeeRak Kang, MD: Yeah. I always tell my patients that there's generally, with myself or any other provider, there's five things you can really do. One, you can do nothing, and you can live with it, which is probably what a lot of patients have done.

Two, you can try conservative measures such as like acupuncture, chiropractor, physical therapy, home exercise program. Three, you can try medications. And I try to explain to them medications do have side effects, and I can list those specific ones for the patients.

Four, you can try injections, and understanding that there's always risk and complication with any kind of intervention.

And five, you can do surgery, understanding there're risks and possible complications. But surgery would be something I would actually refer them out to.

Host Amber Smith: So you actually go over those five options with the individual because there's got to be pros and cons for each of those, right?

HeeRak Kang, MD: Absolutely. I try to go through those five options mainly because I want to also figure out what they've tried. A lot of times they've said they've tried chiropractor or tried PT (physical therapy), but they haven't tried acupuncture. Or they've tried some medications but maybe they haven't tried them all. So it's kind of my role to figure out what they haven't tried and see if if it's worth it.

Host Amber Smith: Have you seen people where conservative measures like acupuncture or physical therapy or the chiropractor, have those been effective? Do you have patients that have gotten relief through conservative measures?

HeeRak Kang, MD: Absolutely. You know, a lot of times herniated disks get better with conservative management. And I would argue that a lot of times they get better without any providers being involved. And so, I always recommend to my patients, "You don't have to see me. You don't have to see a physical therapist. You don't have to see a chiropractor. You know, you could sign up for the YMCA and use the therapy pool for the next four weeks and see if that will help."

You know, if they're not in severe debilitating pain, they're not having neurological symptoms, weakness, that kind of strange sensation down their leg. If they're not having bowel or bladder issues, then I absolutely encourage patients to do that.

And, you know, a lot of them actually, they get better. And, it's a win for the patient and for myself, even though I don't see them as much as I want to. It's, you know, I, I consider that a win.

Host Amber Smith: In terms of medications, are there medications that can relieve pain that are not opioids, that a person won't be at risk of becoming dependent on?

HeeRak Kang, MD: Absolutely. There's a few medications. We call them neuropathic pain medications. The big one is probably what a lot of people have heard of, gabapentin. Not everyone finds success with these, but a lot of studies show that an effective dose of gabapentin, let's say, is 1,200 to 800 (milligrams). And a lot of literature shows it can reduce pain by 30% to 50%. And I try to be upfront with patients in saying, "Hey, if this medication works for you, and we're able to get up to that level, this is kind of what I would expect as a win. And if that's acceptable to you, then I think we can definitely try it."

And so I think managing patients' expectations on what they can expect, and what the side effects are, such as nausea, dizziness, fatigue, abdominal pain, and if they're able to kind of weigh the pros and the cons, I think it's definitely a good option for a lot of patients.

Host Amber Smith: You mentioned injections, and I wanted to learn more about that. Is that a one-time thing where you get an injection of something, and that takes it away for good?

HeeRak Kang, MD: So unfortunately, injections do have a limitation under the duration, right? And so a lot of times what I try to determine is whether this is a therapeutic or a diagnostic injection. And a lot of the injections I do is for the spine, neck and the lower back.

And a diagnostic injection is one where I just use a anesthetic. It's not a steroid. It's really if the patient is planning for surgery. And usually I do it in coordination with ortho spine or neurosurgery. And that's really to confirm the surgical level that they're having the surgery.

A therapeutic injection, that's where I'm just using a mixture of anesthetics, like lidocaine or bupivocaine and a steroid. And that is for patients with a severe chronic pain that's kind of radiating down their legs, let's say. It doesn't have to go right down their legs. You know, a good block can be on average three to four months. And so, at that point, my question to the patient is, "we can try this, see if it works for you. We can try to do a mixture of the injection and the medication to try to elongate that, but it will most likely if you have chronic pain, be something you may need on a routine basis."

And I try to have an ongoing conversation with the patient about that. I also offer them physical therapy as well, so they can try to figure out what, if there's any stretches that they can do to kind of prevent the pain. But unfortunately, there is no one injection that's going to last forever.

Lower back pain is just so prevalent, and you hear about people that struggle with it, but you do have patients that you've seen who've been able to eliminate the pain and get on with their life, is that right?

Absolutely. And it's great. I had a woman last week talk about how she's been able to go grocery shopping without pain. And she said she didn't realize she could do something simple like that and have no pain. She was amazed. She was walking up and down the aisles. And I'm thankful for that. I'm thankful for the opportunity to be here serving the patients of Central New York and trying to add value to their lives in some meaningful manner.

Host Amber Smith: Dr. Kang, thank you so much for making time for this interview.

HeeRak Kang, MD: You're very welcome.

Host Amber Smith: My guest has been Dr. HeeRak Kang. He specializes in pain and chronic pain management at Upstate, where he's an assistant professor of physical medicine and rehabilitation. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," how neuromodulators relieve pain.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Chronic pain can be frustrating to live with and a challenge to treat effectively. Today, I'm talking about one potential solution called neuromodulation with Dr. Vandana Sharma. She's an anesthesiologist and the director of Pain Management Services at Upstate.

Welcome back to "HealthLink on Air," Dr. Sharma.

Vandana Sharma, MD: Thank you, Amber. Thank you for having me on air.

Host Amber Smith: I understand a neurosurgeon implanted the first device designed to relieve intractable pain more than 50 years ago.

It's more recently that these devices have proven themselves. What can you tell us about neuromodulators?

Vandana Sharma, MD: I will go back to the very basics and talk about neuromodulation. In very simple terms, neuromodulation is a way to regulate the nervous system. This is what it technically means when we use that in the sense of chronic pain, as we all know that chronic pain is carried by nerve fibers that go to and from the spinal cord.

So neuromodulation is basically using electrical signals to modulate or regulate the response of the body so that the chronic pain can be modified with more pleasant stimulation.

Or the pain can be masked in a way that it doesn't bother the patients as much as it would without neuromodulation.

Now, we know that opioids or pain medications could do that, but this is a better form of pain control because it is done in a nonpharmacologic way.

So we are just using electrical signals to their best value and help modulate the pain signals.

Host Amber Smith: Is the neuromodulation used on a temporary basis, or is it a permanent thing? In other words, if you start taking over for the nerves in a particular area, is that forever?

Vandana Sharma, MD: It can be done both ways, actually.

Neuromodulation can be done at three levels.

It could be done at spinal cord level, what we call spinal cord stimulators.

It can be done at the level of peripheral nerves, and it's termed as peripheral nerve stimulation.

And occasionally, neurosurgeons or pain physicians might also modulate at the level of dorsal root ganglion, which is, again, a part of the central nervous system as it comes out from the spinal cord, and these are called DRG stimulators, or dorsal root ganglion stimulators.

So, to answer your question whether it's temporary or permanent, it starts out as a temporary trial. That's where we actually place the percutaneous (passing through the skin) leads. These are cylindrical plastic leads that are placed around the spinal cord. I would talk more about spinal cord stimulation here, but the similar things can be done for peripheral nerve or for DRG stimulation as well.

And these leads are placed first temporarily. These are percutaneous leads, and they're externally connected to a generator, and then the rep (device provider's medical representative) could actually stimulate the generator and see whether it covers the area of pain.

It's temporary left in the patient's body, for about five to seven days. And during this time, the patients are made to do the routine activities, except for bending or twisting, so that the leads do not migrate. And we want to evaluate them very closely during this time: how much pain reduction they get or what are the things they couldn't do before that they could do while the neuromodulation is in effect.

If the patients report a good, sustainable pain relief, which is at least 50%, and again, 50% may make a meaningful change in somebody's life and sometimes may not make a meaningful change in somebody's life.

So, it's more important for us to know if it made a change in your quality of life. And if that happens, and you think it was useful to you, then we go ahead and do the permanent placement. We first remove the temporary leads, give the body rest for a few weeks, and then go ahead with the permanent placement.

And in that case, in addition to those leads, we also placed this pulse generator under the skin permanently.

Host Amber Smith: I see. Now you used the term DRG stimulation. What is that?

Vandana Sharma, MD: DRG stimulation, the full form is dorsal root ganglion stimulation. It is a fairly new form of neuromodulation, and in this, FDA (Food and Drug Administration) has only cleared very certain levels which can be modulated that way, just because of the complexity of the procedure and sometimes not very well tolerated.

So, spinal cord stimulation still remains one of the most widely used ways of neuromodulation.

Host Amber Smith: So which patients are candidates for spinal cord stimulators?

Vandana Sharma, MD: Basically any patients who have intractable neuropathic pain, and neuropathic pain means when it's originating from dysregulation of the nervous system in some part of the body.

The most common indication for placement of spinal cord stimulators is for failback surgery, which is, again, a loosely coined term for patients who undergo surgery for back pain or for neck pain, but in the end, the surgery does not relieve the pain, and they continue to have back pain and/or leg pain after the surgery.

So those are the patients that show most benefit from spinal cord stimulation.

Other than that, it can also be used for complex regional pain syndrome, which is also not very common, but a cause for severe neuropathic pain in arms or in legs. It's also used, very rarely, for peripheral neuropathic pain.

And actually, recently FDA cleared spinal cord stimulators for diabetic peripheral neuropathy. and we are using it, if in patients who have well-controlled diabetes, but the neuropathic pain bothers them the most, we could use neurostimulation for treatment of those patients as well.

Host Amber Smith: What does the stimulator, the piece that goes under the skin, what does that look like? And can you feel it or see it once it's implanted?

Vandana Sharma, MD: So there are two parts of what goes inside the body. One, as I mentioned, are the percutaneous leads. These leads are plastic cylindrical devices, and at the end of the tips of those leads are the contacts. These contacts are made of metal, and it's an inert metal, mostly platinum-based alloys. So these are the contacts that actually generate the electricity or stimulate the electric signals. The other end of this lead, two leads, is connected to a pulse generator, and that's the implantable pulse generator.

It's a thin disc, almost like a vanilla wafer thickness. And that can be implanted under the skin very next to the paraspinal (adjacent to the spine) area, so like almost four or five inches away from the midline. And in between, these leads are tunneled under the skin, so the patients do not feel the lead part of it, but they do feel the IPG (implantable pulse generator) part of that, which as I said is a thin, metal device, and it's put in like almost a centimeter to 1.5 centimeters under the skin. So if they would want to touch it, yes, they could touch it, and feel it, but it's not something that would interfere with any kind of their functioning or even laying down on that side.

One more thing I would want to mention there is that when we are planning for a spinal cord stimulator placement, we always ask the patient about their sleeping patterns, like if they sleep on one side of the body versus the other, and having this thin plastic or metal thing under their skin, would that interfere there with their sleeping position in any way?

In that case, we would just put it in an area where patient would prefer it. So that discussion, all that about where to implant it, and what kind of stimulator they would need and all those, and we'll talk about that further as well. All this discussion happens beforehand.

Host Amber Smith: How long is it good for, or will it have to eventually be replaced or batteries changed or something?

Vandana Sharma, MD: That's a great question. And that's one discussion that I always make sure that I do before we select the patients for this kind of a procedure. There are two kinds of IPGs, rechargeable, and nonrechargeable. The rechargeable ones are the newer ones, and they are made of lithium-ion batteries.

The patients have to, for a few hours in a week, they have to charge those batteries, and it definitely extends the battery life. it also depends how often you are using the spinal cord stimulation. Suppose you're using it for several hours during the day, so you know that the battery's going to be expended very soon, and that's where the rechargeable ones are better.

But even though they're rechargeable, they still have a certain battery life, and most companies say that it's anywhere between seven to 10 years. On the other hand, the more traditional ones were nonrechargeable ones. And once you placed them, they were good for about four to five years, and at the end of that period, you had to remove them and put the fresh IPG in with a new battery.

And again, it was dependent upon how much you were using and what settings you were using. So obviously if you're using it for longer time and stronger settings, the battery would run out sooner and the patient at some point, again, would need a surgery to replace it.

Host Amber Smith: You're listening to Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Dr. Vandana Sharma, the director of Pain Management Services at Upstate.

For patients who want to try a neuromodulator, is this something they can seek as a first therapy, or do doctors generally want them to try medications or surgery or physical therapy before they embark on a neuromodulator?

Vandana Sharma, MD: So, again, it depends upon what kind of pain syndromes you have, and sometimes we feel that acting faster is in the best interest of the patient. But again, I would not offer an invasive procedure as my first-line management right away. And I would want to try the non-invasive or more conservative management first as the patients arrive to our clinics.

We start out with pharmacologic physical therapy, and along with that, epidural injections or some kind of injections to help them with their pain, in the beginning. But after we have seen, and we quickly arrive to a decision, in their treatment plan, how they responded to both medications, therapy, as well as the injections.

If we see a great response from the injections and medications, then we move ahead and stay on that path. However, if we do not see a great response and we are seeing a rapidly progressing neuropathic pain, for example in complex regional pain syndrome, then it's best to start with neuromodulators early on rather than waiting and letting it become more complicated.

Host Amber Smith: I was interested by how you were explaining really they get kind of a trial period with this, to see whether it's going to help them, before it actually gets implanted. Do we know about the effectiveness of modern neuromodulators? Do most patients get some relief?

Vandana Sharma, MD: For the most part, patient selection is what matters the most.

If you have selected your patient very well, and if you have prepared them psychologically as well, like what to expect and how much pain relief you get out of that. Just with any other therapy, like not just for chronic pain management, but for any other treatment plans. If the patients know exactly what to expect from the treatment and you chose it for the right indication, for the right kind of pain management, they work tremendously well, like really seriously well. But then, if you are falling out on any of these parameters, the chances of success go down. With all that said, sometimes there are complications related to the device itself.

For example, lead migration happens or lead fracture happens, and the device, which may be functioning in the beginning, may not function after that. In certain cases where we are not a hundred percent sure whether this is going to work or not, but we still feel that we have tried everything else, and this is one last resort that is left to help a patient, that's where our trial period helps us a lot, which is more like just placing two epidural leads, like you would get epidural catheter, but these are two of them and using a bigger-bore needle. So it's more invasive than just placing an epidural catheter, but it is done in an outpatient setting, requiring some minimal to moderate sedation and some local anesthetic.

The patients could just arrive in an ambulatory surgery center and could get these leads placed, which stay in for five to seven days. And this gives them a good time to check whether this is a great treatment option for them or a useful treatment option for them, and, if not, then they can always decide not to go ahead with the permanent implantation.

Host Amber Smith: What are the devices made of, and do you ever see patients who have, their bodies have, like, a reaction to the material?

Vandana Sharma, MD: Just like any other implantable material, there are chances of body reacting, like tissue reaction might happen. It's not very common though. Like, in my own personal practice, I have not seen that happening a whole lot.

But yes, there are case reports of that happening. The leads are mostly made up of plastic, but at the end, the contacts could be made of metal alloys. As I was saying, it's mostly platinum-based inert material that does not stimulate the tissue reaction.

IPG, on the other hand, again, is made of inert alloys, but they're metal.

More commonly than tissue reaction, what is seen is occasionally skin sensitivity at the site of the IPG implantation. I wouldn't say it's very common, but it can happen. And if it happens, it can be a very annoying complication from this, occasionally leading to explant (removal) a nicely functioning device.

Host Amber Smith: What do patients need to know about how the surgery is done?

How do you tell them to prepare?

Vandana Sharma, MD: So, as I was referring to earlier, the initial part, which is the percutaneous lead trial, is not really a surgical part, where we are just using two needles to place the percutaneous wires at that point. However, the second part, where we are doing the permanent implantation, this is done under general anesthesia because it's at that point that we do not need the patient's input.

We have already trialed and tested the placement of these leads at a certain level, and patients have certified pain benefit out of that. So, our job is to just mimic what we did during the trial at this time, so patients can be put to sleep. And this is a little bit more uncomfortable part of it. That's why general anesthesia works the best.

We make two incisions, close to 4 to 5 centimeters. One is made right in the center, in the midline. And from there, the epidural needles are again placed, the same two needles as they were placed for the trial, but this time through the incision. And then the wires, the other ends of the wires that are coming out of the spinal canal, are tunneled under the skin, using a metal tunneler, and then connected to another incision, where the pulse generator is placed. And as I was saying earlier, this is about one to one and a half centimeters under the skin. It is nicely, joined and locked in place, the leads are anchored to the skin and underlying fascia (connective tissue), and that's when the device is ready to go.

Host Amber Smith: How long does that take?

Vandana Sharma, MD: It's about a couple hours, I would say close to like two, two and a half hours.

Host Amber Smith: And how soon until the patient feels a difference?

Vandana Sharma, MD: There is some incisional pain that we anticipate, right after the procedure is done, which could stay for a few days, like two to three days to up to a week after the permanent implantation. But after that, the patients come in for a follow-up visit at our clinic. That's when the sutures are removed, and we check for any signs of infection or any complications at that point.

If everything is cleared at that point, then that's when the medical reps also come and meet the patients on the same visit, and they start increasing the settings, because in the very beginning, the settings are kept at a minimal to keep patients comfortable. And it's only at the postoperative visit when we start increasing the settings to make patients more comfortable. Sometimes it might take a few weeks for us to reach the final settings, and that's when the patients get the best benefit.

Host Amber Smith: How might life change for someone after they've recovered from the surgery?

Vandana Sharma, MD: So right in the very beginning, once either the trial leads or even the permanent leads are placed, we tell the patients not to bend or twist or do anything that would make the lead migrate, as I was telling you before that one of the commonest complications from this procedure is lead migration.

And that could also cause the device to fail. I mean, after all that the patients go through to get this placed, you do not want the leads to migrate from the initial spot. And that's why no strenuous activity is advised for first three to four weeks after the permanent implantation, and slowly the body starts creating fibrous tissue around those leads, so it's hard for them to move afterwards. But the first few weeks are when they could move the most, so no such activities like bending, twisting, lifting, heavy weights or any strenuous kind of activity like running or all that should be done in the beginning.

Apart from that, patients are also advised not to turn this on when they're driving because sometimes the leads are transmitting these electrical signals, and they could go on a setting that may take your attention off from the road onto this buzzing sensation that could happen in your back. So we do not advise patients to drive with the stimulator on.

If they are going to have any surgeries later on for any other reason, it's best to turn the device off because use of electrocautery during the surgery, especially if it's closer to the device, could cause permanent damage to either to the device or the leads that are going into the spinal cord. Almost like a cardiac pacemaker or a defibrillator, where you want to be very careful about the electrocautery that is used for the surgery. So those things might change some of the ways you would want to proceed.

Host Amber Smith: Does someone with a neuromodulator, does that affect any other health conditions they may have, either positively or negatively?

Vandana Sharma, MD: As I very briefly referenced to cardiac pacemakers or AICDs (automated implantable cardioverter defibrillators), it's not a contraindication (sign that treatment is inadvisable) to have a neuromodulating device when a patient already has a pacemaker or a defibrillator in place, but it could interfere significantly with electrical signals that are going that way.

So anytime we are implanting the spinal cord stimulators, in these patients, we make sure that first they talk to their cardiologist. So the team that is managing the pacemaker or a defibrillator should be consulted first. They should make concrete plans on what would happen and how close would these leads be from the pacemaker leads, because the spinal cord stimulators could be placed anywhere in the thoracic spine or up in the cervical spine, and there could be a possible interference with the electrical signals going to the heart.

So that all has to be, like a multimodal or a multi-team, kind of a multi-specialty approach to ensure that it's safe to proceed with this procedure.

Host Amber Smith: Can someone with a neuromodulator safely take aspirin or ibuprofen for a headache or something?

Vandana Sharma, MD: Yes, yes they can. But at the same time, with the patients on anticoagulants, or blood thinners, they are at higher risk for developing spinal hematomas (swellings filled with blood) in the epidural space or in the spinal space.

So, we take extra precautions in those patients for stopping these medications before we even place the spinal cord stimulator device. Anyone afterwards, we tell them to be careful, and if there are any signs or symptoms that could suggest hematoma formation, they are told to go to ED (hospital emergency department) because this can be a catastrophic complication.

Host Amber Smith: Is there maintenance involved in keeping the neuromodulator in good working order?

Vandana Sharma, MD: That information, for the most part, is given to the patients by the reps as well. And most often what I mean by that is how often to charge it, how to charge it, how to keep your charger in the best possible shape, or even a remote-control device that helps you program or go up or down on the settings.

So all those things the patients are given very thorough instructions onas soon as the device is implanted, and even further on, if they have any questions, concerns, these reps are available at a phone call away.

Host Amber Smith: Well, before we wrap up, Dr. Sharma, can you tell us about intrathecal pumps? .

Vandana Sharma, MD: Yes, absolutely. Intrathecal pumps are, instead of neuromodulation, they are actually directly depositing the opioid or any other form of pharmacological pain medications into the spinal canal directly. So when we take an opioid medication, or any pain medication for that matter, through the mouth or through the intravenous form, the medication has to be absorbed by the body, and then it goes to its receptors and most of these receptors are present in the spinal cord.

From there they work, and also in the peripheral nervous system as well, but spinal cord is the major place where these medications act.

So the goal of doing an intrathecal pump is to place the medication very close to the targeted area. So a, plastic catheter is placed in the spinal space, and just like a neuromodulating spinal cord stimulator, the other end of this plastic catheter is connected to a reservoir that's implanted under the skin. And this reservoir has to be filled with the pain medication every month, or depending upon how quickly the medication is being dispensed, it has to be periodically filled with the medication.

They have to come to a physician's office for that, and it continuously delivers the medication right into the spinal canal.

Host Amber Smith: So patients who qualify for a neuromodulation device, would they also be candidates for intrathecal pumps, and would they have to choose between one or the other?

Vandana Sharma, MD: Basically, the answer to this depends upon their etiology (cause) of pain.

Suppose the pain etiology is more neuropathic pain, where it's stemming from nervous system disorder, like, as I said, CRPS (complex regional pain syndrome) or failback surgical syndrome or any other neuropathies. Then neuromodulation would be the best treatment option for them. However, if we are seeing patients who are requiring opioids or other pain medications, for example, someone has spastic cerebral palsy and are requiring baclofen and require the medication to be put in close to the spinal cord at that level. Then, the intrathecal pumps would be used there.

Sometimes we see patients with both etiologies, where they have neuropathic pain and they have required opioids for a very long period of time, and you want to cut down on the amount that they would use. Then they may be candidate for both, but it's a very rare indication.

Host Amber Smith: So it sounds like this pain management is really individualized, and it's encouraging that there's a lot of options these days.

Vandana Sharma, MD: There are several options at this point, and as the technology is emerging, even talking about the spinal cord stimulators, in the last 10 years, there has been such a tremendous change in how the different programming options are available, different kinds of IPG, the battery options available, rechargeable versus chargeable. Their sensitivity to MRIs has changed so much. In the past, we couldn't do MRIs on the patients who had neuromodulators in place, but nowadays most of these companies are making spinal cord stimulators that are MRI compatible.

So patients have several different things to choose from, and talking about the pain treatments per se, there are several advances in the technology as well as in the pain treatment options to help and offer to the patients as they need it, based on what kind of pain syndrome they have.

Host Amber Smith: Well, Dr. Sharma, thank you so much for taking time to share this information with us. I appreciate it.

Vandana Sharma, MD: Thank you for having me. It's my pleasure.

Host Amber Smith: My guest has been anesthesiologist Vandana Sharma, the director of Pain Management Services at Upstate.

I'm Amber Smith, for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Poets have a way of finding the truth of an experience, even in the seemingly quiet, undramatic moments of illness. Mary Beth O'Connor from Ithaca, New York, recalls the moments of sitting vigil with a friend who can no longer communicate in her beautiful poem "what is time to her?":

time that passes so slow

for us visitors

reading to her, holding

her hand, longing for her

to open her eyes,

to smile at us, trying

to coax her back ...

maybe all those months

seemingly sleeping, she's been

busy beyond interruption

weaving a shroud

like in the fairy tale

getting ready

the way creatures

know how to prepare

nests, store black walnuts

learn to fly ...

and we, so well-meaning

and bereft, cannot seem

to just let her

David Dixon is a physician and poet from North Carolina who describes the ache of sitting with a parent who is slowly dying, in his poem "Still Life with Dad and Shade Tree."

After he's gone, what is it we keep?

What is it we scoop and carry like apples

in apron folds

clutched tightly to a chest?

And where would we even store

such a harvest? For surely

it's written somewhere that

both the plucked and the fallen

are gathered, one bushel at the time,

then taken to the same prepared places

of light and laughter. Sorted by size,

separate from the rotten fruit

so they don't spoil the lot,

hidden in cool cellars.

Such a tasty, sweet metaphor for memory,

is what I think,

even as there is still an answer on the phone,

still the welcome of your crooked hug

in the doorway,

still no idea what I'm missing:

no better than half-a-peck

of pretense,

trying to write this poem

as we sit here together.

Waiting.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.