Pain Management for Hernia Complications

Episode 163: Pain Management for Hernia Complications | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Welcome everyone. It’s Dr. Towfigh, your hernia and laparoscopic surgery specialist. Today is another great Tuesday. We call it Hernia Talk Live. Thanks for everyone who’s joining me live on Facebook as a Facebook Live and on Zoom. You also know you can find me on Twitter and Instagram at hernia doc at the end of the show. This episode and all prior episodes will be hosted on my YouTube channel, so go there if you want to catch up and if you prefer podcasts, eventually this will be up as the podcast, but there’s plenty of other episodes from before that are here as podcasts. So I’m super excited because we’re making Hernia Talk Live history. For the first time ever, we’re having two guests at one time. We have Dr. Faisal Lalani and Dr. Nadiv Samimi, both excellent board certified pain management specialists. They’re right across the street from me at the Pain and Healing Institute in Beverly Hills. I’ve known them since I used to work at Cedars-Sinai, and I’ve been big fans of theirs. You can follow them on Instagram at pain underscore and underscore healing. Nadiv. And is it Feisal or Faisal?

Speaker 2 (00:01:26):

Faisal. You could say

Speaker 1 (00:01:27):

Faisal Faisal. Welcome, welcome, welcome. Thanks so much for joining me guys.

Speaker 3 (00:01:33):

Thank you for having us.

Speaker 1 (00:01:35):

So I was kind of going through a little bit of your story. Was it Nadiv? Was it you that used to go to USC? Did you train at USC?

Speaker 3 (00:01:44):

We both trained. We did our fellowship. We did our residency and anesthesia at USC together. I think that we were there. Well, we were just residents. And you’re an attending team. I

Speaker 1 (00:01:54):

Understand. Did you know me then? Yes,

Speaker 3 (00:01:57):

We knew you. Really? Yeah.

Speaker 1 (00:01:59):

Oh, that’s so cool. Yeah. Okay. I left in 2008.

Speaker 3 (00:02:06):

You used to always operate in the new hospital. We were there when they moved from the old county to the new county, and I remember doing laparoscopies with you. And you were training residents or fellows?

Speaker 1 (00:02:20):

The laparoscopy fellows. We had a fellow. I was there right before I helped part of the transition. So I left right after the transition was made. I

Speaker 3 (00:02:27):

Remember it was like a few months after or a year, whatever.

Speaker 2 (00:02:31):

Yeah, I think it was 2008, 2009 is when they transitioned to the new county,

Speaker 1 (00:02:36):

Which was great. I really love my job there. I loved USC. It’s a great place and

Speaker 2 (00:02:43):

Pathology, the types of patients you see, you give back. It’s a fantastic hospital. Good learning.

Speaker 1 (00:02:50):

Agreed. And then you both came to Cedar-Sinai for your fellowship

Speaker 3 (00:02:56):

At the same time,

Speaker 1 (00:02:58):


Speaker 3 (00:02:59):

We did our of our anesthesia residency together and our pain fellowship training.

Speaker 1 (00:03:04):

And you’re still friends together and you’re in

Speaker 2 (00:03:06):

Then We both got married right after

Speaker 1 (00:03:08):

Met each

Speaker 2 (00:03:09):


Speaker 1 (00:03:12):

That’s so amazing. That’s really, really great. There’s a handful of people that I know that were together since residency. They’re still practicing together and that’s a very special bond.

Speaker 3 (00:03:23):

Yeah, we’re very lucky.

Speaker 1 (00:03:24):

Yeah. Has anyone told you both kind of look like each other?

Speaker 2 (00:03:28):

Oh yes. Many times

Speaker 3 (00:03:29):

We’ve solely morphed into it. I’m the one, the man bun and he has the short hair.

Speaker 1 (00:03:36):

Excellent. So we

Speaker 2 (00:03:38):

Do a different type of yoga slash He’s a yoga instructor, so we kind of Exactly Pilates.

Speaker 1 (00:03:49):

So the reason why I brought you on is I have a lot of questions because we share a lot of patients and you’ve been really great at figuring out a lot of stuff here. You’re thinkers. So I like to connect myself with thinkers and not just doers where I think the beauty of medicine is, and we have a lot of people that ask about pain management stuff. So I thought that would be kind of good to bring on your expertise. We already have questions being submitted, but I told you there are a lot of questions submitted already before today. So we’ll go through that and maybe briefly talk about your specialty. What does it take to become a pain management specialist and how are you different than let’s say a neurologist or a family medicine doctor?

Speaker 2 (00:04:43):

So to get into pain management, there’s three ways you could go into it. You first either could do residency in anesthesiology or neurology or there’s another branch called physiatry, which is physical medicine and rehab. What me and Dr. Samimi did is we did anesthesiology. You do three years of an anesthesiology residency and then you do a year fellowship in interventional pain management. And that’s during that year. You kind of rotate with psychiatry, what is it? PM and r, A little bit of anesthesia as well too. So you could kind of get that comprehensive approach because dealing with chronic pain, there’s more than just sticking a needle in someone. It’s like treating the patient as a whole and figure out all types of aspects of pain, whether it be anatomical, psychological, all that.

Speaker 1 (00:05:42):

And I mean there are pain management specialists all over the nation. Is there a pain management specialist outside the US too? Is that a specialty?

Speaker 3 (00:05:53):

Oh yeah. There’s a World Congress of pain management. Some of the bigger conferences are in Europe.

Speaker 1 (00:06:01):

Oh, really? Good to know. And then the one thing that I’ve always not liked about pain management is I feel like they only think all pain problems are nerve related. So they just attack the nerve and you see my patients, so they can have pain because of hernia recur. They can have pain because of the mesh, because of sutures, because of nerve injury as well. But there are other reasons for, and I really like that you guys understand that, but the issue that in our society we have is we don’t encourage patients to be immediately sent over to pain management because most pain doctors don’t understand what hernia surgeons do or what the surgery wise. And so they start with narcotics and then they go to do nerve blocks and they go to spinal stimulator. That’s like the plan and it’s not even a nerve problem often most of the time actually. So what are your comments about that?

Speaker 3 (00:07:00):

Well, I mean I think that we’re kind of spoiled in so far as that we’ve known you for so long. So we have a different understanding of if we didn’t know you and I mean just practicing in southern California or this area, you have to understand a lot. I think when a lot of times when you don’t understand anything, well, what is that saying? When you have a hammer, everything looks like a nail.

Speaker 3 (00:07:23):

So if you know how to do nerve blocks and there’s no one that you trust to send or there’s a hernia surgeon in the area, I think that we just try to help them just because it’s with nerve blocks to numb everything up and then block the pain signal with the spinal cord or peripheral nerve stimulators. I mean, we are taking people out of pain with the skills that we have. But yeah, there should be more wide education as is saying that a lot of these people I think need to be evaluated by an abdominal wall surgeon who specifically trained in abdominal wall surgery.

Speaker 1 (00:07:55):

Sometimes a mesh is balled up. We can call that a meshoma, like a balled up mesh. There’s no amount of pain medication that’s going going to treat that. You just have to physically remove that offending Mesh. But I’ve seen people that are scheduled not by you guys, but that are scheduled for spinal nerve stimulators. All they need was the mesh removal, something like that.

Speaker 3 (00:08:17):

I mean, I think that we’ve known since you have told us if there’s ever a question, you get that abdominal wall MRI or the abdominal wall CT to see what’s going on before you start sticking needles in.

Speaker 1 (00:08:31):

Yeah, and we make that readily available. That’s on my website or it’s also posted on social media, but you can just download that protocol for anyone and just give it to your radiologist and see if they’ll use it. So we have a couple questions. I guess one question is this whole issue of chronic pain in the surgical literature, they describe pain as any pain lasting longer than three months. What is your definition of chronic pain and how you see it?

Speaker 2 (00:09:05):

So usually in our definition, any type of pain lasting longer than three to six months, that’s usually cut off where it starts affecting their daily life, it starts affecting their mood and it’s a vicious cycle because it could affect someone’s mood, they could develop depression, anxiety, and then you’re dealing with the pain itself, but then you’re also trying to fix the patient’s mood, whether it be anxiety or depression. So it gets a little bit hard to tell, and that’s where you come in with that comprehensive approach where we have you as a surgeon, you have us, and then we have, if it is chronic pain, you have therapist psychiatrist on board as well too.

Speaker 1 (00:09:51):

So one doctor told me, if you have more than nine months of chronic unaddressed pain, that’s when you start getting this centralization issue. Is that still correct or what

Speaker 3 (00:10:06):

Do you mean? I don’t know that we know an exact time, but yeah, I think that even, I always equate it to patients to taking a walk on grass. If those signals are being sent enough to the brain, it’s just walking on the same part of the grass, eventually you’re going to create this pathway that is really hard for the grass to grow back in. So if you have unrelenting pain for a long time, even if you fix what’s underlying, it takes a while for the grass to grow in and for that new pathway to disappear because your body’s just used to sending pain signals all the time. Even when the offending thing is there, you’re still going to get some of those pain signals.

Speaker 1 (00:10:44):

Yeah, interesting. On that same note, there’s a question, let me share a screen with you so you can see the question again. It’s about centralization of pain. So it says in the field of post hernia surgery pain, there’s, there’s mention of peripheral nerve and central nervous system sensitization. What are your thoughts as to whether any additional surgery may further aggravate the sensitization? Maybe we can talk about CRPS first and then I’m curious how we could handle those patients if they need surgery. Let’s say they’re already sensitized because to me, I’m like, I don’t touch them and I’m a big fan of not touching nerves. There’s this whole thing about triple neurectomy in our world, patients have problems with their hernia repair and then they go to a certain oh triple, and I feel like I think I’ve discussed with you before, cutting nerves is not without risk. So we looked and published on our patients with neurectomy,

Speaker 3 (00:11:54):

Which are the three nerves I know the two,

Speaker 1 (00:11:57):

Yeah, ilioinguinal, iliohypogastric, and the genital branch of the gen femoral nerve. Those are the three that can be injured directly with the inguinal hernia repair. And so what surgeons do when they come in with what they call post inguinal hernia morphy pain, which is take out the mesh triple neurectomy or just triple neurectomy. Now of course that doesn’t make sense. If your problem is not the nerve or if you have a perfectly good iliohypogastric nerve, why should you cut it? That’s called selective, which is what I do, but it takes a little bit more time to figure out what the nerve is instead of like, oh, if we cut all of it, you’re going to do better. But we looked at our data and we published it and we saw people who came in with nerve pain and had a neurectomy. They had a 4% risk of neuroma and people who came in with no nerve pain but got their nerve cut anyway for another reason had zero risk of neuroma, but 4% is 4% in above that 4%. There are a handful that get this centralization. So what can you teach us about centralization risk, whether it’s surgical or nerve related, like cutting nerves, and then how do we handle those patients

Speaker 3 (00:13:18):

If we think that there is some central sensitization and these patients typically have some anxiety as well, and what came first, the anxiety, the depression or the pain, but they all seem to coexist at the same time, typically for patients who are experiencing some of these central sensitization phenomenon. So I think the knee and faso are typically of the thought that we try to avoid doing any more manipulations because a lot of times when we try to fix things, we make them worse focusing on some of the other ways of treating it. I think that we are huge believers in pain psychologists and using neuroplasticity that they use to try to rework some of those. The way you’re sensing pain in your brain is important. I think the ketamine is huge. Any NMDA activity, so using either IV or oral ketamine to try to lower the amount of pain, the pain psychology, even using a small bit of methadone can be helpful, although we try to use less methadone these days, but methadone is great for some of these sensitization just because of the N-M-N-D-A activity. And then once things are a little bit more calm, then going ahead and trying to fix something afterwards tends to be, I think our approach. So being conservative at the beginning and aggressive at the end versus starting out aggressively.

Speaker 1 (00:14:41):

Can you predict who may be higher risk for CRPS complex regional pain syndrome? And just for those of you out there, you don’t want to get this. This is the worst disease I can think of from a pain standpoint, right?

Speaker 2 (00:14:54):

It’s really bad. Bad, so bad. CRPS bad. It’s a great question you bring. Well, me and Dr. You’ve seen is patients who have a preexisting either anxiety, very, very common anxiety, severe OCD depression. We see that there are higher risk developing CRPS. So CRPS used to be called formula alone is RSD. So it’s basically where your sympathetic system is an overdrive and you want to be very careful people getting surgery with patients with this type of condition because any type of manipulation can actually make the pain much worse.

Speaker 1 (00:15:34):

Manipulation of nerves or any surgery,

Speaker 2 (00:15:38):

Any type of surgery, and that’s where you want to go centrally. What Dr. Mimi was saying is kind of desensitize that whole phenomenon where it’s, if you could desensitize that, you talk about plasticity. So the way you desensitize that is with therapy, ketamine, once you have that on board, then you could retrain the brain. Once everything calms down, then you could go in there and fix the underlying issue. So it’s this calming where the nerves are just constantly being activated.

Speaker 3 (00:16:16):

So I’m also looking at what puts you at risk for some of this central sensitization. Typically, this is all anecdotal. I’m not totally familiar with the research off the top of my head, but typically these people are typically depressed and or anxious, and then there’s a lot of catastrophization. I mean,

Speaker 1 (00:16:35):

That’s mostly nice things.

Speaker 3 (00:16:39):

Just turn on the hose. It’s

Speaker 1 (00:16:40):

Pretty high.

Speaker 3 (00:16:42):

It is high and we don’t blame anyone for it.

Speaker 1 (00:16:46):

It’s living in society. Most of the people that I know, I shouldn’t say know. I would say there’s a fair number of people with anxiety and or depression in our society. Okay. So here’s a question that maybe can link as well talking about spinal cord modulation. So the question presented here is can you describe the difference between spinal cord modulation and dorsal root ganglion stimulation for treatment of post inguinal hernia morphy pain, or what are those

Speaker 3 (00:17:21):

Towards a little bit more broad where they’re putting these wires along the spinal cord, and the way I liken to explain this neuromodulation is the body is speaking to the brain and saying, Hey, there’s this pain signal here, but the signal doesn’t always get to the brain because you’re sort of yelling over the signal. I liken it to two people sitting at a restaurant and you’re trying to have a talk, and then someone comes in middle and starts yelling. You can’t hear each other. So the spinal cord stimulators, I think work the same way they’re sending in these other signals like the pulsating or the vibrating or all that stuff, which is telling the brain pay attention to that and not to the pain. The hope is that people are, oh,

Speaker 1 (00:18:06):

So it’s starting more. Is it distracting your nervous system to something else or it’s

Speaker 3 (00:18:12):

Distracting it? We’re not letting those signals get to the brain versus the dorsal root ganglion. They’re going right around one single nerve root, and if it’s for the Hernia that I’m guessing it be L one or T 12 or L two, which depending on where it is on the abdomen and they’re trying to just get one single level, but they’re getting a better, more distraction of that nerve root as opposed to just sort of the shotgun approach, which is

Speaker 2 (00:18:42):

It’s more localized, the dorsal roots

Speaker 1 (00:18:44):

And these

Speaker 3 (00:18:45):

And work better.

Speaker 1 (00:18:47):

The wires go into your spine or into your groin?

Speaker 3 (00:18:50):

One for both. One, they’re going into the thoracic spine where they’re just blocking everything, all signals coming from the body up, and the other one is going into a neural frame in so where the nerves are exiting, but they’re all put in the spine. There’s a newer form of neuromodulation called the peripheral nerve stimulators, and then those are I think much more interesting and may work better.

Speaker 1 (00:19:16):

I mean, those nerve are small in the groin. How do you even know that you’re nearby?

Speaker 3 (00:19:22):

Say that again?

Speaker 1 (00:19:23):

Those nerves in the groin are so small. How do you know that you’re nearby

Speaker 2 (00:19:26):

And it gets harder? People who’ve had prior surgery, you’re right. Yeah, prior surgery, yeah, it’s hard to visualize because they may have been manipulated, but usually you use ultrasound, but like you’re saying, it can be difficult.

Speaker 3 (00:19:38):

Wow. You typically will go into the triple nerve area where you were discussing earlier, not much into the area of pain.

Speaker 1 (00:19:47):

Here’s another question. They tried a nerve stimulation injection from my inguinal hernia pain, but they couldn’t find the proper spot to do the injection. They said I only had one layer of my abdomen and they’re supposed to be three layers. They couldn’t give me an injection where my other two abdominal go. I had a foot of my colon removed many years ago, but I think this patient, I don’t know, I think does it age make a difference on how thin your muscles are and the effectiveness of these?

Speaker 2 (00:20:15):

It sounds like they had a tap lock. Is that what they had done?

Speaker 3 (00:20:20):


Speaker 1 (00:20:22):

Yeah, but I think going through the layers, those are the obliques, right? So that’s more

Speaker 2 (00:20:26):


Speaker 1 (00:20:28):

Yeah, you got to use an ultrasound for that to make sure I don’t go the wrong way. Okay. So with regard to the spinal, oh, here’s another question. With regards to peripheral nerve stim, is there any value to a TENS unit? Oh, that was going to be my question. And what about a tens unit? TENS?

Speaker 3 (00:20:48):

It’s so interesting because you think of them as the same as you’re putting in this modulation where you’re stimulating a tens like thing, but tens works in a different properties, so tens you’re depolarizing the nerves fiber, so they just can’t send nerve signals for a while, but eventually they’ll be repolarized and they can send, versus the peripheral nerve stimulators, you typically need 200 hours of stimulation to actually see a noticeable benefit. And we’ve been seeing a lot of benefit to that because working more on the neuroplasticity by having these afferent messages stop being sent or distracted again, your brain starts unlearning the memory to this pain and just ignoring it for good. They seem to work pretty well.

Speaker 1 (00:21:36):

Here’s a comment, which I completely believe agree with. It says, say no to triple neurectomy, perform laparoscopically up high close to the spine. Agreed. We used to do that. We called it radical neurectomy. We thought it was a good idea. If you can cut it in the groin, why not go all the way where it comes out of the spine, not understanding that there’s a lot of motor nerve activity of those ileal. I hypo gastric noses before it hits the

Speaker 3 (00:22:00):

Blank. You guys were doing it?

Speaker 1 (00:22:02):

Yeah, laparoscopically. We’re pushing, pulling the colon over and going out just behind the SOAs, cutting the nerve there.

Speaker 3 (00:22:09):

Wow. It’s a single nerve branch at that level.

Speaker 1 (00:22:13):

Yeah, it’s a single big nerve branch. So you can see it and cut it

Speaker 2 (00:22:17):

Around what? T 11? T 12 L one?

Speaker 1 (00:22:20):

Yeah. So you find the 12th rib, you go below it and you find L one. Iliohypergastric iliohypergastric come off of it, but there’s no book that says there’s a motor function to the ilioinguinal or iliohypergastric nerve. It always talks about the groin. So we’re like, oh, if you failed in the groin or you don’t want to go in the groin, you’re in their laparoscopically. You can just cut it there. And then people started getting these adverse bulging of their lower abdomen because you’re capturing it approximately where there’s a lot of motor nerve function that we were never taught about. Don’t do it. This patient had it done. This procedure has caused derivation of the abdominal wall resulting in bulging, which is painful and there’s no cure. That’s very true. When I asked what side effects result from this procedure besides numbness, I was told there were none.

Speaker 1 (00:23:10):

But now we know that’s not true. I hope it is not a practice anymore. It actually is practice, and one of the reasons why practice is the only papers on it show what a great procedure it is, and no one has written a paper saying these are the people that are hurt from it, and I feel like I just need to write an editorial paper. No one’s studying the aftermath. And the only paper that had a large enough population to show it failed to disclose the number of patients that had the denervation. Even though they had it, they just didn’t put it in the paper. It’s kind of crazy.

Speaker 1 (00:23:54):

I had one done and now having problems in my lower abdomen and pain all over my body. Okay. Let’s go through some more questions. I, let’s see. Okay, here’s a patient who’s asking about pain management and surgical approaches where it says, as a patient who had surgery, how can you tell when a patient pain management referral hides a surgical failure? Is treatment time? The only aspect to consider that I get asked that a lot. They’re like, oh, I don’t want the nerve block because that’s just going to mask my pain. I’d rather you cut the nerve. But I try to explain that you may, I mean, don’t nerve blocks, hydrocele, dissection, steroids, whatever. Can’t those actually help you heal any nerve injury?

Speaker 2 (00:24:46):

Yeah, sometimes. So the goal of these nerve blocks is we usually put a steroid. So if we could reduce, if the nerve is angry and inflamed, the goal is if you get near the nerve and flood it with cortisone, you could reduce the swelling and kind of slow down that firing so you can help with the swelling, which in turn can help with the pain. So that’s what we can do. It doesn’t necessarily mean it’s already damaged, you got to go straight to surgery. Sometimes we can get this calmed down with injections

Speaker 3 (00:25:20):

And people always thank you. Even in the back when you have sciatica, people think that the compression of the nerve is what’s causing the pain, but it’s not just a compression. It’s a compressor that’s causing the release of inflammatory mediators that are telling the pain signals to go out. So we sometimes see patients relate this to the spine who have such bad compression, they shouldn’t be able to walk or they shouldn’t be able to do anything, yet they’re not in pain, so you don’t fix it. Similarly, I’m sure in your position, if you can get a nerve to calm down, it doesn’t always have to be in pain. So taking drastic measures at the beginning, sometimes a shot in the foot, you just want to lower the inflammatory markers and the body can adapt. I think human bodies can adapt to a lot of stuff if we let that,

Speaker 2 (00:26:07):

And we always tell our patients, you treat the patient’s clinical symptoms. Sometimes people are always fixated on the imaging, the MRI findings.

Speaker 1 (00:26:16):

That’s true.

Speaker 2 (00:26:17):

Yeah. If you could fix her clinical symptoms and they’re fine, that’s sometimes more advantageous instead of having a perfect looking MRI.

Speaker 1 (00:26:26):

Going back to the stimulation question, is there a risk of lead migration with lead migration? Yeah. Leads with dorsal root ganglion stimulation to a greater extent than for spinal cord manipulator?

Speaker 3 (00:26:43):

That’s a reasonable question. I think that it depends on whether or not they’re using leads that are the single leads that like a pain doctor can put in or there’s what’s called a paddle lead that it’s typically a surgeon will put in. I think the paddle leads tend to migrate much less than the single leads that are put in. And I think that the dorsal root ganglion leads tend to migrate less too, just because they’re more stuck in a smaller area. So

Speaker 1 (00:27:10):

When they migrate, they just move to a different part of the nerve.

Speaker 3 (00:27:13):

Correct. They just won’t move. Even small millimeters or a half centimeter movement of it being pulled back just will cause a huge difference in the stimulation

Speaker 2 (00:27:25):

And the coverage might be lost too. So that’s one of the things. Sometimes if you get lead migration, you might not get that same adequate pain coverage.

Speaker 1 (00:27:34):

And what is it when they say they do a trial like, oh, I had a trial and it worked or it didn’t work. What does that mean? Just where do you put the leads?

Speaker 2 (00:27:43):

So when you’re doing a spinal cord stimulator, what you do is you don’t implant it permanently. You basically implant the leads through the epidural space. You have a rep, you wake up the patient and you test and you see if the coverage of where their pain is is being covered with a stimulation. If they say yes, then they basically, you put adhesives on, tape it up, and you try and offer a week. If a patient says, Hey, you know what, I notice a big difference. My pain is 70% better than you could do the surgical implant, which is permanent.

Speaker 1 (00:28:24):

Wow. Okay, cool. Does anchoring the dorsal root ganglion lead also become a potential source of pain? I don’t even know where these questions come from.

Speaker 3 (00:28:39):

Wow. I mean, that’s a

Speaker 1 (00:28:40):

Lot of questions.

Speaker 3 (00:28:42):

Possibly. I’ve not heard that be a big problem, but it’s certainly possible.

Speaker 1 (00:28:49):

Wow. Okay. Let’s go to some of easier questions. Can you minimize the side effects of different pain management options such as gastric lesions for NSAIDs or dizziness and nausea for opioids?

Speaker 3 (00:29:11):

I mean, we very much are anti opiate, so sometimes the side effects, we’re not looking to do them stop them just because most people should not be on chronic opiates unless you’re going to be dying in six months to a year long-term opiate use typically always causes increase in pain. I can say anti. Really? Yeah. I’ve never seen a patient.

Speaker 1 (00:29:38):

That’s the paradoxical effect of opioids, right?

Speaker 3 (00:29:41):

Yes. I mean, if you think about it, whenever your body sees something it likes or it doesn’t like it just as a receptor, it’s going to build more receptors. So if you’re putting opiates into you, your body’s going to build more opiate receptors, and over time, that’s just going to be sending more pain signals. And

Speaker 1 (00:29:58):

How long does it take for that to happen?

Speaker 3 (00:30:00):

Sorry. I think it’s vastly different percent

Speaker 1 (00:30:03):

People, like months or years.

Speaker 2 (00:30:05):

We could see it after week, I think

Speaker 3 (00:30:06):

Six months.

Speaker 1 (00:30:07):


Speaker 2 (00:30:09):

It’s interesting. When me and Nad worked at Cedars, we used to see a lot of patients with chronic abdominal pain. And as you know, these are some of the toughest patients to treat. And many of the times they

Speaker 1 (00:30:23):

All have hernia, but okay,

Speaker 2 (00:30:25):

Yeah, these patients get placed on high dose opioids. And like Dr. Samimi was saying, it kind of does the reverse. It causes slowing sludging of the bowels. It could cause a thing. It’s called opioid bowel syndrome, where you get the reverse, that paradoxical effect of being on chronic opioids where you’re in more pain even though you’re taking these opioids. So it gets very, very tricky now, patient who has a surgery acutely for a week to two weeks, but after that, that’s when you run into more problems. Unfortunately,

Speaker 3 (00:31:01):

There’s these crazy studies that they show that people who have had surgery and exposed to zero opiates afterwards have something like 95 less percent chance of developing any chronic pain syndromes from said surgery. So if you talk to most pain doctors, I think that all of us would avoid opiates unless they were forced upon us. For the most part, dealing with the pain in the short term is much more worth it. But yes, I mean there’s stuff that’s obvious like Zofran and for the NSAIDs, one of the biggest generic, one of the biggest drugs when we first started was combining ibuprofen and what was it? Famotidine?

Speaker 1 (00:31:41):

Yeah, yeah, yeah.

Speaker 3 (00:31:43):

I think they say it’s like 80% less gastric ulcers, but even long-term NSAID use is dangerous. The only one that seems to be guilt-free is taking Tylenol every day. Yeah.

Speaker 2 (00:31:53):

I mean they have the Celebrex, which works on Cox too, which could help with, apparently it could reduce some of the gastric inflammation with the NSAIDs.

Speaker 1 (00:32:04):

Celebrex just as good as NSAIDs for their it’s, yeah. Yeah, yeah. Okay. Here’s a question. So being placed on theone or methadone by the pain clinic is not a recommendation from you all?

Speaker 3 (00:32:20):

That’s a question. If you have to be on chronic opiates, methadone seems to be the methadone or buprenorphine seem to be the best long-term just because people only need to go up on the methadone dose typically once or twice, versus traditional short-acting opiates, you’re just going up on the dose every several months or for some people or need a higher dose, but they don’t get it. But methadone, it’s just hard in the environment now where all the doctors are being asked to not prescribe or there’s so many hoops. I had a long-term problem, I probably would be on methadone just because of how long in

Speaker 1 (00:32:54):

The system when I was arrested, we were taught you can’t be taken off methadone. Is that false?

Speaker 3 (00:32:59):

Oh, yeah. We’ve taken a lot of

Speaker 2 (00:33:00):

People off. It’s challenging.

Speaker 3 (00:33:02):

Takes a long time.

Speaker 2 (00:33:03):

Yeah, it’s a long

Speaker 1 (00:33:07):

Oh, got it, got it, got it. Question

Speaker 3 (00:33:10):

50 hour half-life

Speaker 1 (00:33:11):

Forgabilin. So I guess gabapentin for forgabilin, those kind of nerve, I call ’em nerve modulators. I don’t know if that’s the right kind of

Speaker 2 (00:33:19):

Late. Yeah.

Speaker 1 (00:33:22):

Do you think pregabalin at 250 milligrams per day is an adequate treatment for post Hernia surgery pain? Or is it similar to paradoxical opioid effect you just described? So I have a question about that. Huh?

Speaker 3 (00:33:34):

Yeah, I’ve never heard of Lyrica or Pregabalin causing increased pain over time. It’s not something you get addicted to, like the opiates.

Speaker 1 (00:33:42):

So there’s a trend to use Gabapentin, Lyrica, neuro, those kind of medications for pain around the time of surgery. Can it be used instead of, or it’s just to reduce how much opioids or NSAIDs you may need?

Speaker 3 (00:34:00):

Yeah, I think it’s great to use it and try to minimize the amount of opioids using that with some NSAIDs and Tylenol and Ty absolutely through

Speaker 2 (00:34:09):

In Europe, they do more Tylenol with the OIDs and people have done well.

Speaker 1 (00:34:15):

And is that an appropriate dose for a 70-year-old?

Speaker 3 (00:34:21):

Two 50 is a lot. So if they’re naive, no one should be started. Normally the naive patients are started like 75 milligrams twice a day or three times a

Speaker 1 (00:34:30):

Day. Oh, that is very large.

Speaker 3 (00:34:33):

And if they’re older, then even lower. Sometimes

Speaker 1 (00:34:35):

It causes a lot of, is it because it has organ damage or it causes a lot of,

Speaker 2 (00:34:39):

It causes more sedation. In my experience, I think with Lyrica around 150 to 200, and then when you get higher, you get more side effects, and I don’t see it as beneficial. What do you think doctors mean? I get

Speaker 3 (00:34:57):

Swelling too. Yeahs the one that limits a lot of it.

Speaker 1 (00:35:03):

What are the most promising innovative therapies that have shown increased effectiveness and fewer side effects when compared to traditional therapies? What do you guys like?

Speaker 3 (00:35:13):


Speaker 2 (00:35:14):

Or procedures?

Speaker 1 (00:35:17):

Let’s start with medications and then we’ll ask for the newer procedures.

Speaker 2 (00:35:23):

I think ketamine is a very, very interesting medication. You’re hearing a lot about ketamine. I think now maybe because of the abuse with some maybe celebrities that took it, but ketamine on my partner was saying it works on NMDA, which is responsible for nerve pain. It also works on serotonin, norepinephrine, which are also responsible for nerve pain. And interestingly enough, it’s responsible for patients’ mood. People with chronic pain do have lower levels of serotonin, norepinephrine, ketamine can actually help increase the re-uptake of that. So that adjunct with therapy, I think that can be a promising therapy for no.

Speaker 1 (00:36:10):

And what about procedures? What are some newer procedures you guys are liking?

Speaker 3 (00:36:15):

One more thing about medicines and the people listening to this have probably heard of it, but we’ve been using or trying to use more and more low dose naltrexone. You’ve heard of this?

Speaker 1 (00:36:24):

Oh, low dose naltrexone. There’s a question on mushrooms coming up too.

Speaker 3 (00:36:30):

On mushrooms? Yeah, on psychedelics.

Speaker 1 (00:36:33):

Yeah, microdosing.

Speaker 2 (00:36:34):

Yeah. There’s a shaman, right? I think I may have spoke to, I think you got me.

Speaker 1 (00:36:38):

Yes. I had to speak to our shaman.

Speaker 2 (00:36:41):


Speaker 3 (00:36:43):

So this low dose naltrexone known for people who have pain, especially I think you mentioned someone had a question about all over body pain. I think that we find this to be one of the best treatments, but then it doesn’t get publicized and it’s not new because there’s no drug marketing. Since it’s a generic drug, it has to be compounded for people. But the low dose naltrexone, just all it does is block the opiate receptor. And we think the way it works is by telling the brain to make more endorphins. You don’t think you have enough, which you’re just increasing your overall opiates in your body. So you’re self-treating your own pain.

Speaker 1 (00:37:19):

Wasn’t Naltrexone used for people to not withdraw from opioids? Wasn’t

Speaker 3 (00:37:25):

That No, it was used to reverse opiates. So naloxone is like the IV form and naltrexone is an oral form of the same medicine,

Speaker 1 (00:37:35):

But it can also be used for pain.

Speaker 3 (00:37:37):

Yes. And they’re actually used for alcohol at higher doses too. Seems to block some of the desires for addictive behaviors.

Speaker 1 (00:37:47):

That’s so interesting. And then could eating be addictive to behavior? Could this be the new weight loss medication

Speaker 3 (00:37:54):


Speaker 2 (00:37:55):

After ozempic?

Speaker 1 (00:37:56):

Yeah, why not?

Speaker 2 (00:38:00):

Oh man, if I had a nickel for every time someone discusses ozempic every day,

Speaker 1 (00:38:08):

I mean they’re all on it. That’s why

Speaker 2 (00:38:09):

Everyone’s on it,

Speaker 1 (00:38:10):

Everyone in la.

Speaker 3 (00:38:12):

But to speak to the innovative procedures, I think that this peripheral nerve stimulator has been, is becoming, I hate this term that a little bit of a game changer. Before there was all these pains that we couldn’t do anything about. And using those peripheral nerve stimulators, which are only temporary, they put in the muscles and your nerves in your body, people get 70, 80% pain relief, which is unheard of in our field for long periods. Even with from

Speaker 1 (00:38:39):

Peripheral nerve stimulation

Speaker 3 (00:38:41):

From these peripheral nerve stimulation. Lemme

Speaker 1 (00:38:42):

Ask you

Speaker 3 (00:38:43):

This, A real complication. Yeah.

Speaker 1 (00:38:45):

So if you have someone who benefits from peripheral nerve stimulator, does that mean surgical neurectomy or nerve ablation should also treat that as a cure?

Speaker 2 (00:39:00):


Speaker 3 (00:39:00):

Necessarily, but that’s my question for you. When you do these neurectomies, you’re left with some paraesthesia afterwards and some people are bothered as much by the paraesthesia? No. Yeah, they get,

Speaker 1 (00:39:13):

Some of them get paraesthesia mostly. They get numbness. But a good 4% get neuromas or need more injections and stuff because yeah, it’s a problem.

Speaker 2 (00:39:25):

I think

Speaker 3 (00:39:25):

The other thing that we’ve seen are doing neurectomies with phenol or hydrocele dissection with phenol, which kills the nerve endings in the area. Alcohol.

Speaker 1 (00:39:34):

Yeah. Alcohol based ablations. Correct. Yeah. What do you think of that?

Speaker 3 (00:39:41):

I’ve seen it work pretty well. I mean, I think that you’re the ultimate.

Speaker 2 (00:39:44):

Yeah, I’ve seen both. I’ve seen it be affected. Sometimes it doesn’t do anything, unfortunately. So

Speaker 1 (00:39:51):

In doing our paper on neurectomy, we’re like, okay, maybe we should be doing ablation. Is ablation less injurious to the nerve than a surgical? There’s no papers out there that I could find that it talks about the risk of neuroma after an ablation,

Speaker 3 (00:40:09):

A non-surgical ablation,

Speaker 1 (00:40:10):

Non-surgical ablation.

Speaker 3 (00:40:13):

I mean, we know that it exists because a phenol was being used, alcohol was being used a lot for the intercostal nerves, and some percentage of them still develop neuromas afterwards. So after the alcohol wears off, six months later, they can be left with more pain.

Speaker 1 (00:40:28):

Yeah. Got it. Okay, cool. Should we talk about CBD and THC? Sure. I’m a big fan of CBD. I think it’s a great anti-inflammatory. I’m not as knowledgeable as to how much I’ve been told. You need a little bit of THC less than five milligrams to augment the CBD, but I’m not sure that’s true.

Speaker 2 (00:40:55):

It depends how much, because the problem with THC is, like you were saying, if you take too much, you get dizzy, you’ll probably eat a lot more food. So yeah, I usually tell patients around like 2.5 milligrams. You do need a little bit with the CBD. The CBD works more with the inflammation. I think the THC works more centrally, so that’s why people see more of a benefit.

Speaker 3 (00:41:22):

I typically tell people, just try the CBD first. If it didn’t work, they can try it with some THC. So different.

Speaker 1 (00:41:29):

True, true. And the dosing. So the lower doses, like 10 milligrams, it’s starting for C, B, D. But then I think I have my patients sometimes 40 or 60 milligrams if they need more. I like the anti-inflammatory aspect of CBD. Do you guys think that’s a good thing?

Speaker 3 (00:41:49):

Yeah, absolutely. And starting at a low dose and working your way up is a lot safer than vice versa. So you just go up and see how much you can tolerate.

Speaker 1 (00:41:58):

Okay. Yeah. Here’s a question. How do you actually use these peripheral nerve stimulators to address postic pain? When and where and how are the stimulators placed? We kind of discussed that already. Oh, so kind of like,

Speaker 3 (00:42:14):

But in the low abdomen,

Speaker 1 (00:42:15):

One L two. Yeah. Okay.

Speaker 3 (00:42:18):

They don’t do it in the back for this kind of stuff. It’d be done more in the abdominal wall

Speaker 1 (00:42:22):

For the peripheral nerve. And then where’s the little battery or whatever

Speaker 3 (00:42:26):

You stick it on the skin, the nerve, the wires come out of the skin and you cover it. You change the dressing every two days. There’s a battery you can disconnect to go into the shower and you just reconnected it afterwards. And

Speaker 2 (00:42:39):

You have a little remote control. You can control the stimulation.

Speaker 1 (00:42:43):

And it doesn’t get infected?

Speaker 2 (00:42:44):


Speaker 3 (00:42:45):

No. Because it is a coiled product. When within a few days the skin grows into the coil and it’s pretty good protection from Oh, like a central line.

Speaker 1 (00:42:57):

Wow, that’s so cool. Do you have patients that take without increases in pain? I have a lateral femoral cutaneous nerve, nerve injury, but I can’t use a stimulator due to foreign body response since I can’t have anything implanted. This is true. She’s reacted to everything that’s ever been implanted in her. What is tapentadol?

Speaker 3 (00:43:20):

It’s like the newer form of tramadol.

Speaker 1 (00:43:23):


Speaker 2 (00:43:24):

It’s a little bit stronger than the tramadol,

Speaker 3 (00:43:27):

But be

Speaker 1 (00:43:28):

On nerve properties.

Speaker 2 (00:43:29):

Yeah, it works on norepinephrine. And what is the serotonin? So you do have a little bit of nerve.

Speaker 1 (00:43:36):

It’s an opioid.

Speaker 2 (00:43:38):

Yes, it works.

Speaker 3 (00:43:38):

Partial opiate, partial centrally acting and partial like opiate agonist acting.

Speaker 1 (00:43:46):

Okay. Very interesting. Okay, here’s another question. It says is some degree of chronic pain expected after multiple surgeries. On a scale of one to 10, what do you think is the maximum amount of pain that complex patients should treat conservatively before investigating the need for further surgery? That’s a hard

Speaker 3 (00:44:12):

Question. That’s a pretty loaded question. Yeah, that’s all subjective.

Speaker 1 (00:44:17):

Everyone’s different, right?

Speaker 2 (00:44:19):

Everyone’s different. We have some patients who’ve undergone 15 surgeries and they’re playing basketball, walking, doing everything. We have patients who have three surgeons, but unfortunately they’re bedridden. They’re in so much pain.

Speaker 3 (00:44:35):

I think for a person like that, if there’s really a question, I think having a few sessions with a pain psychologist to really explore what their expectations are and help set things, even though people all think it’s, oh, just mumbo jumbo. It’s so effective. Pain psychology. Can you

Speaker 1 (00:44:54):

Talk about hydrocele dissection and what that is?

Speaker 3 (00:45:01):

Ba you want me to talk?

Speaker 2 (00:45:03):

Yeah. Hydrocele dissection is basically dissecting a nerve using water. So imagine a water pick which you use to clean your teeth. There’s some thought where you could dissect the nerve. There’s some scar tissue around. I don’t do too much hydrocele section. I know there’s some colleagues who do do it and they swear by it, but that’s using a high frequency.

Speaker 1 (00:45:25):

I see some amazing,

Speaker 2 (00:45:27):


Speaker 1 (00:45:28):

Improvement with that.

Speaker 2 (00:45:30):

Yeah, and it’s fairly safe.

Speaker 3 (00:45:35):

We’ve been trying to start a protocol where we do hydrocele dissection with PRP so as to not give them steroids, but at least have some anti-inflammatory in there and seeing if that will last longer. And hopefully we can expand that.

Speaker 1 (00:45:48):

And can you explain what PRP is and how it works?

Speaker 3 (00:45:53):

PRP is where we take your blood. We take out the red blood cells, the white blood cells. You’re left with some growth factors, some platelets, and we use that as a natural anti-inflammatory to sort of treat your own pain. I mean, I always tell people, if you get hurt, your blood has a lot of this stuff, it needs to fix you, right? That’s your blood. So we can hijack that process by taking out some of the stuff that causes more pain and putting that there and trying to encourage the body to heal itself.

Speaker 1 (00:46:25):

And is there a risk to do NPRP besides, it’s

Speaker 2 (00:46:29):

Fairly safe because like he was saying, it’s using your body, it’s using your plasma to start the whole healing process.

Speaker 1 (00:46:36):

I mean, these NBA players, they’re all getting injections of that, right?

Speaker 2 (00:46:39):

Oh yeah. You don’t have to worry because unfortunately with steroids sometimes, sometimes you do more harm than good. So it’s much safer because I guess the worst that can happen is it won’t work. But you don’t have the side effects at all. Like the medications, like the steroids,

Speaker 3 (00:46:56):

How so much safer.

Speaker 1 (00:46:59):

Okay. How is that different than stem cells? So

Speaker 3 (00:47:03):

Stem cells are using cells that we think are pluripotent or can change into something else. PRP. We’re not looking to change those cells into something else. We’re just trying to treat your own inflammation and maybe encourage local healing versus stem cells that are hoping that they give you a cell, either whether it comes from the fat or the bone marrow or placental tissue or I don’t think there’s an agreed upon definition on how it’s being used in regenerative medicine and everyone does their own way. But you’re hoping that this cell, say you’re injected into your knee, is going to turn into a meniscus cell. So you’re rebuilding your meniscus for some like PRP or just hoping for less inflammation and pain mediators being released.

Speaker 1 (00:47:47):

Does injecting PRP also, also, we talked about sports hernias before we started the show, and the questions like, what is a sports hernia? So there are four different reasons why you can get a sports hernia. One is you have a rectus tear off your bone. The other one, it could be a partial tear. The other ones you get an adductor tendon tear off your pubic bone. Third is you can have an actual fascial tear of the external oblique. So the rectus tear, I think, was it natal? Did you add that? Yeah. And then the adductor tear is like LeBron injury. You got a fascial tear, which is number three, which is the external oblique epi neuro. So you can just tear it kind of like a fabric. You can have that tear plus a nerve underneath it, where now you have a little slit in the fascia, a little nerve underneath it. So every time you engage her, you cause abdominal pressure. You’re pushing the nerve in. So it causes Neuralgia. That’s the fourth way. And the fifth one is there’s so much injury with scar tissue that they’re now entraps nerve. Those are all spore hernias, none of which are really hernias.

Speaker 3 (00:49:00):

So you don’t operate on that yourself? Do you operate on that?

Speaker 1 (00:49:04):

I get referred them. They’re almost always non-operative. And what they really need are injections and well rest, sometimes steroids, anti-inflammatories, and then injections. So usually we do local with steroids first and then we graduate to PRP. The professional athletes, they go straight to PRP. They don’t even wait for the rest part as much. But my thought is that you inject PRP with the goal of healing the tears and healing, right?

Speaker 2 (00:49:40):

Correct. So imagine when you fall, right, and you get a scar. So it basically tells the body, listen, there’s an injury, let’s start the whole healing process. So it tells all your body, the fibroblasts, everything comes in there and it starts the whole healing. So it signals the body that there’s an injury, there’s pain, and it basically starts the healing process.

Speaker 1 (00:50:01):

Got it.

Speaker 3 (00:50:02):

There’s some, oh, go ahead. Sorry. There’s some of these before and after pictures where the MRI shows improvement with the stem cells. There’s less of those that you see with the PRP, but I don’t think it’s been systematically studied. I think for financial reasons, there’s no one place that’s doing it all the same way. So people are calling PRP, but doing it differently. So there isn’t a standard eyes way of doing it yet.

Speaker 1 (00:50:30):

Oh, okay. Follow up question. PRP has been described to cause bony calcifications. Have you heard of this?

Speaker 3 (00:50:42):

I mean, you can get weird things that happen to anything they reject, but it’s definitely not a comment thing.

Speaker 1 (00:50:48):

Yeah. Someone wrote, I tried ozone IV and it was taxing. What is ozone iv?

Speaker 3 (00:50:55):

Oh man.

Speaker 1 (00:50:56):

Is that one of those,

Speaker 3 (00:50:57):

It’s very controversial. Yeah. The guy who promotes it the most claims that he can solve any disease with it. So there’s some data that proves that it works. You can inject it into your knee. Some people take your blood out, ozonate it, and then re-inject it into yourself. Oh, the studies I think,

Speaker 1 (00:51:17):

Is that like oxygenated water? Have you heard that?

Speaker 2 (00:51:22):


Speaker 3 (00:51:23):

Yeah, that in the hydrogen water.

Speaker 1 (00:51:26):

Hydrogen water or hydrogen water, there’s oxygen water, hydrogen water. I don’t know.

Speaker 3 (00:51:31):

I haven’t found there is some good evidence, especially for joint injections with ozone, but I haven’t seen any good evidence for anything else.

Speaker 1 (00:51:41):

Here’s another comment. This is such an excellent discussion. Do you three doctors think you can accurately distinguish somatic pain from neuropathic pain?

Speaker 3 (00:51:52):

I don’t know that there is anyone who can do that. A hundred percent.

Speaker 1 (00:51:56):

Yeah. My concern is that so many surgeons think all post-op pain is neuropathic pain.

Speaker 3 (00:52:06):

No. Which

Speaker 1 (00:52:07):

Is actually the direct opposite. Most are not, but

Speaker 3 (00:52:12):

Yeah, you see the nerve type pains come later on, not early.

Speaker 1 (00:52:16):

Yeah, I directly injured it.

Speaker 2 (00:52:19):


Speaker 1 (00:52:23):

Let’s see. I have a pretty good pain response to my groin post-op surgery pain to topical lidocaine. Unfortunately, my mild tinnitus is aggravated by this and becomes intolerable. Oh, lidocaine, tinnitus.

Speaker 2 (00:52:37):

It can cause that

Speaker 3 (00:52:38):

Some people, but it gets into the blood.

Speaker 2 (00:52:40):

Why doses of lidocaine can cause

Speaker 1 (00:52:42):

Tinnitus. I didn’t know that. Is there any strategy to get around this issue? It requires a substantial amount of topical lidocaine to apply. Can you do anything about that? No, I guess not.

Speaker 3 (00:52:54):

It’s kind of lower. You could try a different anesthetic. So some people will compound bupivacaine or you could try some of the ELA cream. I think that they’re not going to get as much ion,

Speaker 1 (00:53:05):

So instead of lidocaine, use bupivacaine, which you have to get from the pharmacy, there’s no overthe counter,

Speaker 3 (00:53:12):

Right? All the rest of them you have to get from a doctor. So talking to a compound pharmacist and they may be able to hook you up with a local doctor that’ll write for you.

Speaker 1 (00:53:21):

Got it. And then Emma? Cream. Yeah, cream, which is another type of topic, I

Speaker 3 (00:53:27):

Think. I think,

Speaker 1 (00:53:29):

Yeah. There’s a question about CBD, but you missed it. We already talked about CBD.

Speaker 3 (00:53:35):

We supported it.

Speaker 1 (00:53:37):


Speaker 3 (00:53:38):

We support it. The CBD. Yeah.

Speaker 1 (00:53:40):

Yeah. I think CBD has been a great addition for a lot of people with pain issues. Next question. Is it possible to reject mesh with just signs of high inflammation levels and then going around organs, heart and lungs? I mind, we’ve moved no issues since two years. So I’ll answer that in terms of mesh is an inflammatory implant. So we’re starting to see more of what we call mesh implant illness, which is an autoimmune or inflammatory response to meshes. But there is a growing risk of implant related reactions, whether it’s a hip implant or spinal implant or breast implant dental implant. So mostly the western world too. So I think they’re doing something with these implants that’s not good for you.

Speaker 3 (00:54:30):

I’m curious, is there any drive towards testing people for allergies before implanting? Do you send people? Good

Speaker 1 (00:54:38):

Question. So not yet. I do that. Oh, amazing. Mostly because I’m trying to learn from it. So we published our paper on mesh implant illness, which are people that we feel we’re doing fine and they got an implant, specifically the Mesh, and then now they’re disabled for whatever reason. They’re got brain fog, hair loss, tinnitus, visual changes. They get weird skin rashes, joint pain, tingling in their fingers and toes, concentration problems, sleeping problems. And then they take out their Mesh and then they’re back to normal again. So it’s not common. We’re studying it to see what is the most likely that a risk factors for it. It seems to be female, gender is one, female, sex is one. And then of personal or family history of autoimmune disorders seems to increase your risk of that. So now my practice has changed because of that experience. I have the highest experience in the world for this. Now I choose not to put meshes in people if I can, who already come to me with rheumatoid arthritis or lupus or certain things, or if they’ve had their breast implants removed from breast and platinum illness.

Speaker 3 (00:56:06):

This is a crazy question. Can you make a biological Mesh out of someone’s body tissue of some sort?

Speaker 1 (00:56:13):

Well, before there was mesh, they were taking the tensor fascia lata using that as mesh. But that’s a big operation. It’s a big thigh incision. Take off the tensor flush and used that for the abdominal wall. Was it effective doing that? No. No. It recurs everything. Recurs. It’s biologics. So whether it’s now we have synthetic biologics, which are absorbable, and we have cadaver biologics, which are also absorbed. None of that have been shown to work effectively permanently. But there are certain times when we use it. And then what I do is in the patients that I either think make it have mesh and S or at risk for it, and I don’t know what I can use, can I use polypropylene? Can I use certain sutures or what? I’ve partnered up with the allergist to do the allergy testing and to date. So I give ’em samples of matched samples of sutures. And I said, test these on the patient to date. What we’ve noticed is if it’s positive, it’s helpful, but it’s about a 40% false negative rate. So it’s not considered standard right now to do that, but maybe at some point we’ll be able to have, and their blood tests are almost always normal. So yeah, it’s possible, but it’s not. There’s no standard yet. We’re still there learning.

Speaker 3 (00:57:41):

If you have someone who comes to you with chronic abdominal pain, you suspect that there’s a small hernia. You get imaging but don’t see anything. Would you ever still operate if your clinical suspicions are high enough?

Speaker 1 (00:57:53):

Unlikely. But I read my own imaging because the majority of those negative CTs or MRIs are not negative.

Speaker 3 (00:58:03):

Her and you Valsalva?

Speaker 1 (00:58:05):


Speaker 3 (00:58:05):

You’ve heard Valsalva with them?

Speaker 1 (00:58:08):

Yeah. CT with Valsalva. You can do MR MRI with Valsalva. And then the ultrasound should always be with Valsalva. Yeah. It will show them like belly button. Hernias often don’t present with hernia at the belly button. It’s to the left or to the right of it. So people are looking to the left or right looking for the problem. But the problem is at the belly button, you fix the belly button hernia and that pain to the side goes away.

Speaker 3 (00:58:30):

Can we ask you the questions or are we done?

Speaker 1 (00:58:32):

Yeah, no, we got one more minute.

Speaker 3 (00:58:35):

Can you tell us about ACNES? Yeah.

Speaker 2 (00:58:37):

Acne. I have a, I just saw, I wanted to see your, what are you thinking?

Speaker 1 (00:58:42):

Sure. So ACNES is an acronym. It stands for anterior cutaneous nerve entrapment syndrome. These are intercostal nerves that come down in right around the junction of the lateral border of your rectus muscles. The nerve split and the posterior nerve also splits again. So where these two areas split, either along the semi linear line, which is a outer border of the rectus muscle or where the posterior one splits to go anteriorly. So it’s kind of mid-rectus if they have point tenderness, not tenderness, point pain, one specific area. And it’s always with muscle engagement where it kinks the nerve every time they use their muscles. So usually sitting up from bed twisting to get grab a bag from the backseat, coughing. Then that may be ACNES. And what you do is you take ultrasound and you block the nerve right before it splits.

Speaker 3 (00:59:45):

Do you see it on ultrasound?

Speaker 1 (00:59:47):

No. It is like a tap block.

Speaker 3 (00:59:49):


Speaker 1 (00:59:49):

Got it. So you basically go between the layers tap block, right? Just laterally. You grab that. And you can also go at the, if it’s more of a rectus muscle area, you take your ultrasound, you do an anterior rectus and post rectus block. So between the fascial layers, that’s where the nerve runs below and above the, and see if their pain goes away. And we actually had a good experience with that. We published our results on that. We found half the patients only need nerve blocks between three to five nerve blocks every two weeks. And the other half needs surgical. They get better, but they never really get cured.

Speaker 2 (01:00:32):

That’s the patient I had. He’s had multiple blocks. He would do well for a week and the pain will come right back, unfortunately.

Speaker 1 (01:00:39):

Oh, that’s good. That means he’ll do well with surgical neurectomy. Got it. And we cut the nerve right before it splits.

Speaker 3 (01:00:47):

Got it. And it’s typically one of them. There’s not multiple that occur.

Speaker 1 (01:00:52):

It’s uncommon. But I’ve had patients with multiple ones. I’ve had maybe three or four of them on either side up and down. And it happens and they get cured when you fix it. So it’s a very satisfying little procedure to do for these patients.

Speaker 3 (01:01:13):


Speaker 1 (01:01:14):

I think we’re done. We have a lot more questions, but we’re going to have to call it a night. Thanks guys. Thanks for joining me.

Speaker 3 (01:01:22):

This was a lot of fun. Happy to do it again soon if you want to save some of those questions.

Speaker 2 (01:01:27):

Thank you so much.

Speaker 1 (01:01:27):

Thank you. Thank you so much. And to all of you who were gracious enough to bring in live questions tonight and also before, I really appreciate you. a lot of questions tonight. Thanks, Dr. Samimi and Dr. Lalani, we love you. You’ve been so great to my patients. You really have, there’s a handful of patients and we’re very, very difficult and you cured them. So I’m I’ll never forget that. And that’s it for Hernia, Talk Live. Thanks everyone for joining me, and I’ll see you again next week with another great episode. We’re here every week, Hernia Talk Tuesdays. Don’t forget to subscribe to my YouTube channel to catch up on all the episodes and learn more and share. And if you prefer the podcast, you can go to Hernia Talk Live as podcast wherever podcasts are listened to. See you all next week.

Speaker 4 (01:02:19):

Thank you. Bye bye.