Speaker 1 (00:01):
Hi everyone, this is Dr. Shirin Towfigh. Welcome to Hernia Talk Live. We’re here on a yet another hernia talk Tuesday where we will be answering your questions live as they come. Thank you for joining us on Facebook Live and on Zoom. Many of you are also following me on Twitter and Instagram at hernia doc. Today’s guest panelist is a very good friend of mine. His name is Dr. Payam Vahedifar. He is a pain management specialist and board certified in physical medicine and rehabilitation. You can follow him at NEVO Spine and Sports on Facebook. And please welcome Dr. Vahedifar.
Speaker 2 (00:43):
Hi, she, thanks for having me.
Speaker 1 (00:44):
How are you?
Speaker 2 (00:45):
Speaker 1 (00:47):
Thanks for joining me. So we kind of had a discussion before, but for those of you that are coming on, Dr. Vahedifar is a pain specialist, your board certified in physical medicine rehabilitation. There are other pain specialists that are board certified in anesthesia. So you have a little bit of a different take and you take care of a lot of my patients and they’re very, very grateful for you helping them out. So I do appreciate that. I actually have known Dr. Far since high school. I think were You were ahead of me, but we were in the same, I think we sat next to each other in calculus. Is that right?
Speaker 2 (01:29):
I don’t remember. It’s a while ago. But yeah, we had classes together. Yeah, you were a little ahead of your class I think at that point
Speaker 1 (01:36):
I was a big math nerd, so I did my calculus early and I think we were in the same class together. So I’ve known him, but then I knew he kind of went on to medical school, but I didn’t really know. And then we’re now linked back together and I’m so grateful to have you because you’ve always been very kind and generous with your time and you’re caring for the patients and that’s definitely what my patients need because they can often be very complicated. So thank you.
Speaker 2 (02:08):
Speaker 1 (02:10):
So can you just briefly tell us, we’ll go, going to go straight into some questions. I have some questions that were already presented through social media before, but maybe what we can first start with is just what does a pain management specialist offer? So what are things that you see when related to hernia patients, and then how does your specialty in physical medicine and rehabilitation affect how you treat patients
Speaker 2 (02:41):
In general? Pain management is sort of this specialty that treats both chronic and acute. Okay. Yes. So things like if somebody gets a disc herniation or somebody gets knee pain from an injury or that kind of thing that we treat more acutely. And then patients that come in that have had chronic nerve pain from diabetes, from hernia, from in inguinal pain from in the groin area. So chronic conditions that either have had surgery or can’t have surgery or they’re not getting better. So there’s all kinds of different avenues where you could try to get into pain management and with regards to hernias, and we got regard to inguinal pain or pain in that area. Usually that’s more on the chronic side that I see those patients. So you see them either after they’ve had hernia repairs or other injuries, sometimes sports injuries that can mimic hernia or hernia pain.
Speaker 2 (03:50):
You see those two. And then going on to physical medicine, rehab, physical medicine, rehab is a different specialty than, for instance, anesthesia going into pain. We get trained in for about three years in musculoskeletal medicine and that includes nerve pain. We do electromyography, which testing nerves. So we have to know the anatomy a little bit when it comes to that. We do inpatient rehab for stroke patients, but the bulk of what I did was on the musculoskeletal side of it. That was my area of interest. And so I did a lot of sports medicine, a lot of musculoskeletal treatment, a lot of nerve pain treatment. And that’s sort of the difference. It’s sort of in a way a nonsurgical orthopedist or a interventional neurologist. Those are sort of the hodgepodge of things that we do in physical medicine rehab.
Speaker 1 (04:43):
And I feel that that’s very important for our patients because hernia patients deal with pelvic floor and abdominal wall and all of those are muscles. And so the whole connection between muscles and pain and hernias and nerve entrapment and pain is something that I think your specialty in PM&R kind of sees it differently. And what I’ve gotten feedback from my patients who see you is that you’re able to offer them some kind of anatomical insight to their pain and also provide them with some advice based on exercises and posture and so on that maybe a doctor that’s not PM&R, maybe usually anesthesia that goes into pain management. They tend to be more about pain medication, narcotics and so on. So I feel that yours seems to be a bit more, I don’t want to use the word holistic because it’s not that, but you do have a bit more of the, you have a different take on it.
Speaker 2 (05:51):
Yeah, I say that it’s just a different angle trying to treat the same thing and there’s different reasons for doing different things. And I got trained by anesthesia pain doctors. So what I learned is from them and a lot of what I learned from physical medicine, rehab, I try to integrate in my specialty and how I treat pain.
Speaker 1 (06:13):
Got it. We have a lot of questions coming in already. Let’s see, we have a couple questions related to nerves, so if you’re okay, we’ll go right into it. The first question has to do with just what is nerve pain and neuromas and talking about neurectomies. So maybe you can just tell us what’s a neuroma and how were they detected and then we’ll delve into some more nerve questions.
Speaker 2 (06:45):
So it’s interesting, when I was in medical school, my research project was on neuromas and it was, oh, okay. Peripheral nerves in the hand. I worked with a neurosurgeon back then it was the top peripheral Nerf surgeon in the world where it came to the hands. And our research was trying to find out what is it in neuromas, what do they have fibrous tissue. So neuroma in a general sense is if you’ve ever cut a cable and like a TV cable and you see this brush of endings that look like an end of a broom, that’s sort of what happens with a neuroma. It’s this still cut up or fibrous nerve that’s been damaged and that’s what a neuroma is in a lot of ways. And neuromas actually, one of the insights from that study was that there are actually opiate receptors on these neuromas and they increase.
Speaker 2 (07:49):
So obviously the body knows that there’s pain there and it increases its receptors to try to decrease pain and try to help your natural endorphins. So neuromas are these endings of nerves that are in a way damaged and can cause pain and we try to figure out different ways to treat that pain and that that’s what a neuroma is. And with a neurectomy, one of the risks that you could get this sort of fibrous layer that you actually can have pain and detection of neuromas can be, I mean MRIs sometimes give you some insight with them. Sometimes it’s just pain that is associated and there’s an assumption. Sometimes an ultrasound, it’s very hard, but a really, really good ultrasound can show some changes in the fibrous slayer, the thickness of the nerve.
Speaker 1 (08:42):
Yeah, I’ve had some luck with ultrasound showing like a abnormal density from at the end of a nerve as a neuroma, MR Neurography helps, but I feel like for the peripheral nerves that are very distal, the are so small, it only shows a neuroma if it’s a pretty big neuroma where it’s, and it looks like a ball for people that think neuroma means ball. So neuroma is like a ball. So the area of the nerve that’s injured or cut can develop a ball. And then just to clarify, that in and of itself causes nerve pain, which is called neuralgia. But what are the different treatment options for a neuroma or even neuralgia I should say, which is not necessarily due to a neuroma, but any nerve pain that’s in the groin from a hernia surgery or a trauma, your algorithm for treating those.
Speaker 2 (09:38):
So the algorithm, I guess I don’t have a specific algorithm. It all depends on the patient, but the treatment are the more conservative treatments. Those include medications in ilio, inguinal plane. Sometimes if patients anatomy does allow it, topical medications sometimes do work. Those topical medications are compounded medications. These are things that have nerve pain medication in it, a numbing medication, anti-inflammatory. Next step is oral medications and I’m staying with conservative right now. So those things would be things like Lyrica or Gabapentin. These are specific medications that help stabilize nerve endings and decrease the firing of abnormal nerve firing and decreased pain. There’s other medications as well. There’s medications that are antidepressants that could do the same thing. Those are some of the things that you can do as far as therapeutic treatment. A great pelvic floor therapist, if they could get rid of any scar or fibrous tissue around the nerve and release it, that can help too.
Speaker 2 (10:49):
So that’s the conservative side. When you go to the procedural side, a lot of times you got to start with a diagnostic injection and before ultrasound became so popular, we used to use a nerve stimulator to find the nerve and the patient was awake and we tried to find it where the nerve is using anatomical markers and then stimulating and then say, oh, that’s the pain, that’s the pain. So we know where you are and then you inject along that area. Ultrasound has come to a point where you could use ultrasound to inject nerves. You get a pretty good result and that’s sometimes we do that and it will help with the nerve. Then you go to something called pulse radio frequency ablation. That’s where you use a electrode and ultrasound, I like to use both. Some people just use ultrasound and use a special machine that gives a pulsed heat in the area and that will help decrease the pain and it could last about three months to a year. In a way, you’re causing the nerve not to function as far as, and you won’t feel from that area for about three months, six months, sometimes up to a year.
Speaker 1 (12:00):
So what does that do that either burns or freezes the injured nerve?
Speaker 2 (12:04):
So yeah, there’s two different ways of it. The pulse radio frequency burns the nerve. I don’t like using burn is the term, but it causes the nerve not to function and you do it for a period of time, it it’s pulse, so it doesn’t cause any specific damage to other tissue in the area. It’s very pinpoint. It’s only at the site around the tip of the needle that’s placed in the area to try to the pain, pain and that can actually relieve pain from, there’s a lot of case studies and there’s some, there’s no big study with this, but there are some studies that looked at all the studies and put ’em into one and they found about 70, 80% of people do pretty well for about three months.
Speaker 1 (12:50):
I thought it was more permanent if it works. Well,
Speaker 2 (12:54):
If you do, cryoablation sometimes works a little bit better for a longer period of time. Most of the time peripheral nerves will regrow. Okay. Now sometimes when they regrow, the pain doesn’t come back. But most of the studies have shown really good results in about three to six months. And sometimes it does need to be repeated. There’s even more to that. If the pain does not get relief for whatever reason from the ilio inguinal area, you could go up to what’s called a dorsal rami or the dorsal root ganglion of the back T one, T 12 and L one and do an injection, see if the pain goes away and then do a pulse radio frequency. At that level, that is a lot more advanced. It’s something that is only done for really severe refractory pain. Right. Another thing, and then it’s even more, I’ve done a lot of stimulators and I’ve done a few on some of your patients where we put electrodes into the area to stimulate the nerves so that the pain does not, your brain does not perceive it.
Speaker 2 (14:04):
Electrical stimulation of the nerve will kind of distract the nerve and your brain will not feel it. You’ll feel a different sensation rather than that kind of nerve. And one of the explanations I always have is that if you go trains on a train track and you want to alter the movement of the train, you change the direction of the track and all of a sudden the pain, the train is in a very different direction. This sort of treatment changes that perception of pain from pain to either a seltzer water feeling or a completely gets rid of it. And there’s two different types of stimulation. One at the site where you put it actually along the area of the nerve and use ultrasound guidance and one in the back you go upstream from where the pain is and stimulate it so your brain doesn’t register that pain.
Speaker 1 (14:54):
So when you’re stimulating the nerve your, was it like electrical pulses? Yes. And then you would think that it would kind of turn on the nerve more and make it more painful?
Speaker 2 (15:05):
No, the there’s special frequencies that it’s pulse stat than the, and those frequencies and basically it’s very technical, but it’s not only the frequency is how of, it’s the strength of it. And all of these are taking consideration when putting on the peripheral nerve so you don’t feel it. So instead of feeling the nerve pain, you feel either a buzzing feeling like a seltzer water feeling in the area, which is a lot better than pain. And some of the new techniques used what’s called high frequency and some of the new devices are, one particular one uses a high frequency where basically your brain does not register the pain at all anymore. And that is more the phasix behind what’s going on and there’s a lot more that happens. But yeah, the basics are that
Speaker 1 (15:55):
I heard there was one that was recently approved by the FDA specific for pelvic pain, is that right?
Speaker 2 (16:02):
There’s a couple different ones that have come out and I did a study with a company that did peripheral nerve stimulation and I think those companies have changed and got FDA approval through hernia for I inguinal or pelvic pain.
Speaker 1 (16:19):
Oh wow, okay. Is that more a marketing thing, it just be or it truly is different in that region of the body?
Speaker 2 (16:26):
Well, anytime you treat a specific region of the body, you have to go through a FDA approval for overall got it for it. So if you want to treat back pain, you have to treat, get the FDA approval for back or back. If you want to treat diabetic neuropathy, you have to go through FDA process. A lot of times the process that they go through is to get it on-label use for that particular diagnosis. Although the technology has been there for a while and most, a lot of times in the past and now that we’re getting more on-label use, it makes it easier for coverage for patients. But in the past we always, not always, but sometimes we have elected to use off-label use of it to try to help with.
Speaker 1 (17:11):
And then explain to me the theory of either burning or, sorry, using that term burning or freezing the nerve. So are you basically injuring the nerve?
Speaker 2 (17:23):
So in a way you’re doing an ablation, so how do I put it? You’re stunning. The nerve. Okay. At the area so that the area that’s distal to that or further downstream from the area you blade, you don’t feel from now anything upstream should work a little pretty well. Okay, okay. But you are in a way causing a chemical, I’m sorry, a heat destruction. There’s also chemical ways of doing it. Sometimes you use a special type of alcohol that could do the same thing, but peripheral nerves do regrow and sometimes if you get rid of the pain and they regrow, they don’t have the same sort of pain level as they did before and then you don’t have to repeat it.
Speaker 1 (18:11):
So neurectomy is another way to destroy a damaged nerve end. And we just presented our data where 4% in my practice, 4% of patients that undergo neurectomy for whatever reason, then got a neuroma and then they get another neurectomy to treat it. What are your thoughts about that? Does it make sense to do,
Speaker 2 (18:45):
I don’t know specifically the data as far as treatment for neurectomies, but yeah, I’m one of the more conservative guys out there and I think that if the first neurectomy does not work, electively doing a second one. If somebody is more prone to actually producing neuromas and that is genetic in nature as well, then maybe it’s a better idea to do an ablation or some other procedure. Again, this is more, I don’t have data to support that, but I’m just saying that my feeling is, and that’s something maybe better if the second neurectomy, how often and how successful is the second one. And if they’re not that successful, then maybe in the long term one and then go to other management.
Speaker 1 (19:34):
So if you have a huge neuroma is ablation not neuralgia, I understand really without a neuroma. I think of it as a lower level, not like end stage nerve pain. It’s kind of a lower level nerve pain tends to be less resistant to treatment. Neuromas tend to be highly resistant to medications and injections and so on. So do you feel that an ablation is an appropriate next step for neuroma treatment?
Speaker 2 (20:11):
I think if it’s a large neuroma and a resection has been done and the pain continues block and maybe try a radiofrequency ablation. If that doesn’t work, use one of the smaller stimulators in the area directly to see if it will help. And the smaller,
Speaker 1 (20:29):
The stimulator is permanent.
Speaker 2 (20:32):
So one of the stimulators, again, I did a clinical trial on one of these stimulators and I think it’s one of the better ones in that area. It it’s permanent. The electrodes are permanently placed over the nerve, but the outside part of it is something that patches on and just transmits the energy to the electrode in the direction of the nerve. So you don’t have to have a implanted stimulated stimulator that’s external only. The electrode is internal and that could give a lot of relief.
Speaker 1 (21:06):
But is that a lifelong
Speaker 2 (21:08):
Speaker 1 (21:09):
Speaker 2 (21:10):
Speaker 1 (21:12):
There’s a question about stimulators. Is a spinal cord stimulator better or worse than a D R G stimulator for chronic groin pain?
Speaker 2 (21:20):
DRG is more specific that that’s sort, that’s a million dollar question. The studies that do with D R G stimulation have done really, really well, but it, it’s a tougher way to do the procedure. It’s not as easy. Sometimes the D R G method does put a little pressure around the nerve ending that exits, so you always worry about that in the end. It really depends on what helps the most for the patient. So I think the DRG method is a lot more specific and if that is perfected or if you go to somebody that really knows what they’re doing with that method, yeah, it’s probably the one that I would say is a little bit better. But you have to go to two different segments on the DG T 12 and L one to try to get the full nerve and you really have to do a stimulation or a trial to figure out what works. The spinal, the spinal cord stimulator can get that area. It’s not that it can’t, the D R G method is probably the better method. It’s just that the mastery of the person putting it in.
Speaker 1 (22:32):
Got it. And also with ablation, doesn’t that also have to do with some mastering because the nerve alone is very, very narrow and then the tip and the circumference or the diameter at which it affects is also narrow. So do you need more than one ablation to be able to adequately address most nerve pain?
Speaker 2 (22:59):
Not really. And that’s why I think the dual method of using electrical stimulation, basically it’s a specialized needle that has an electrical impulse in it, and you use that with the ultrasound once it’s in the right area on the ultrasound, you stimulate it, then you ask the patient if you’re feeling pain. A lot of times they start getting one of the nerves that go down into the front of the leg. Yes, the lateral femoral cutaneous nerve. So you just have to adjust that. But that kind of dual method helps adjust directly over the area. And number two, you got to use a needle that’s really small so that the tip is really small, so you’re not getting any tissue around that area, but you are sort of encapsulated with two layers of muscle, although they’re thin. Okay. Yeah.
Speaker 1 (23:47):
Now what do you think of Sometimes I have people, and we have a question about that as well, that have pain at the belly button from let’s say a hernia repair and they think that it’s nerve pain. My thought is by the time the nerves get to the midline of the belly because they start the back and they start large in the back and then they keep branching, branching, branching around the abdominal wall to the front. By the time they get to the midline of the abdomen, you can’t even see the nerves. And so nerve pain is not really the primary, an actual visible nerve pain is not the cause of the pain. It’s more likely related to a suture or a Mesh or something mechanical. But what do you think about nerve pain in the midline? Is that something that should be treated or can’t be treated,
Speaker 2 (24:36):
Speaker 1 (24:36):
Tested? Do you test these things?
Speaker 2 (24:39):
There’s not a whole great way to test nerves in the midline. There are some physical tests that show the nerves are sensory and motor nerves and they go into the abdominal muscles. So if you sometimes get the patient to sit up in one side of the body there tense tenses up the other side, then there’s nerve damage to those areas. There’s no specific test, although nerve conduction studies can be done for larger nerves, but those small nerves are hard to test that way. Sometimes you could do a block, a tap block to try to see if that will help some of that pain, but in the belly button and lower it’s harder area to really reach. My feeling is that that’s probably more mechanical than it is nerve related. It’s just hard to get into the smaller fibers.
Speaker 1 (25:36):
Yeah. Yeah, I agree. Okay. Should we move on to more treatments of chronic pain? There’s one question which I’ll post up. Give me a second. It’s a little bit complicated, but I told you, I warned you. My patients are very, very knowledgeable. So this patient has had several two week six sessions of ketamine infusions. This is the recommended protocol. Ketamine is an N M D A inhibitor blocking those sites in the spinal cord. Do you do ketamine infusions and why do they not always work for chronic pain patients?
Speaker 2 (26:20):
So I don’t specifically do ketamine infusions, but it’s something I do refer out for some patients ketamine infusions, just like any other treatment, if I inguinal nerve pain gets better with an injection, then we wouldn’t meet. If a hundred percent of got better, we wouldn’t need ketamine. Ketamine worked on a hundred percent of people and no side effects. We won’t need it. Ketamine, it has been shown to help a lot of people with chronic pain, but I think specific nerve pain is a little harder to treat with that. What I recommend usually is for something that I’ve talked to you about and did, I did that book chapter for you. Yes, you did. Is for more complex regional pain syndrome. I think there’s a big reason that it works better in complex regional pain syndrome. And let me try to explain that. When you have a peripheral nerve pain that is very specific, it’s not a targeted area that centralized, how do I put it?
Speaker 2 (27:35):
It’s so specific that targeting that area is a lot better. But when you get a sympathetically mediated pain, which is something like complex regional pain syndrome, then ketamine works better because that is more of a systemic type of nerve pain. Even though it affects a limb, it’s not one of the cables, it’s a Mesh of the sympathetic nerves. If you look at pain fibers, there’s two different types of pain fibers when it comes to pain in this sense. One is a cable, which is the one that goes into the body any like the I inguinal nerve. The sciatic nerve, that’s one specific nerve and you get a pain pattern that’s specific to that nerve. Okay. When nerves sort of short circuits and then it causes a pain that’s much worse than it, it should be given the circumstances. And you get other types of changes, which includes redness in the skin, hypersensitivity changes in temperature, changes in the texture of the skin, scaling of the skin. Then that becomes, what’s that? That’s involving the Mesh of pain fibers that are part of the sympathetic tree. Think of it more of the spider web instead of a cable. And that’s ketamine seems to be the realm where ketamine works for that a little bit better. But the reality is ketamine doesn’t work for everybody and it’s mostly because each person’s different and we all have different receptors in our body and some people respond better to some medications, some respond better to ketamine, some to neuropathic medications.
Speaker 1 (29:14):
So what do you, you go to a clinic and they give you IV ketamine
Speaker 2 (29:18):
And some your airway. Yeah, it has to be monitored. You go to either, some surgery centers do it, some outpatient infusion centers do it. They need a monitored, you need to monitor the patient when they’re doing it. So a lot of this is more of the realm with a lot of anesthesiologists do this. There’s some PM&R pain guys that do it, but it’s mostly the anesthesia pain guys. Got
Speaker 1 (29:40):
It. Let’s go back to some more nerve questions because they’re coming in. Sure. How do you test for nerve function, whether it’s for pain or paralysis? What tests are available?
Speaker 2 (29:55):
Well, depending on the nerves, electromyogram is one of the main things that’s electromyography and nerve conduction studies. Those test peripheral nerves. So it’s like finding a shorten a wire, okay. There’s a stimulation. It’s an electrode that actually looks like a cattle prong unfortunately. And you put electrodes distal or downstream from that impulse and you see how fast that impulse goes to that particular site. And then you compare that to the normal population and if it’s slower or faster, it will tell you if there is any nerve damage or the quantify the nerve damage. Sometimes in younger patients you have to compare sides because they will be well within the normal range. But when you see one limb versus the affected limb, you’ll see that there’s a 20% difference. So even though they’re in the normal range, you got to test both sides to compare because younger patients are more resilient. They’re going to come on average a lot faster. The nerves are going to function faster, do better. You got to compare sides with them. That’s one of the ways to actually find out if there’s damage to the nerve.
Speaker 1 (31:08):
And if you have, so I have some people who have one area, their belly is further out, almost paralyzed compared to the other. Usually that’s a nerve problem and not a hernia. What is your kind of recommendation from working that up?
Speaker 2 (31:28):
Yeah, to quantify it to really see how much nerve damage or which nerve it is, that could still be done with electromyography. That’s the other side of this test. Nerves in all our bodies start from the spinal cord and go into the area. The nerves that innervate, the abdominal muscles come mostly from the thoracic spine.
Speaker 2 (31:52):
So electromyography is a needle is placed in the muscle group specific to whatever nerve that comes off the back. That electrodes can give you normal findings. It’s called electromyography like electrocardiography. It’s like an EKG for the muscle. And we are really finding out is the pattern of the nerve firing? Yes, nerves fire in a certain pattern. When the nerve is damaged, they fire so spontaneously and they fire in an abnormal way. And that’s where you could find out and it’s sort of working backwards. You find out which muscles are involved, work backwards to see which nerve roots are involved.
Speaker 1 (32:34):
So I’m going to explain a scenario to you. Back in the nineties as we really had a surge in hernia based groin repairs, al hernia repairs, we also started seeing the complications and one of our local surgeons here actually became very famous in instituting what’s called a triple. So the ilio nerve, the ileo hypogastric nerve, and the general branch of the general femoral nerve, which are the three main nerves that can be injured during a hernia repair for the groin. If you had chronic pain, he would remove the Mesh and then do what was called a triple neurectomy. And before he wasn’t doing triple neurectomies and he was just dealing with whatever nerve he thought was the problem and he looked his data and the people that got a triple neurectomy had much better outcomes in terms of getting their pain resolved than what we call selective.
Speaker 1 (33:33):
So I have an issue with that in that I don’t think less is more. So I don’t like to touch nerves if I don’t have to surgically and I would only resect a nerve if it’s part of the surgical process of roughly removing a Mesh and I am personally damaging the nerve from doing so or that there’s an obvious neuroma at the time of surgery as I practice what’s called selective. But the thought is that triple neurectomy works because nerves talk to each other and if you get rid of all the nerves that talk in that one region, then your pain will go away more likely than doing selective neurectomy. My theory, and it’s based on no great knowledge, is that if you don’t take a very detailed history and don’t really hone in on what the nerve is, then yeah, take out all three nerves and you’re always going to be right. Whereas if you spend more time with the patient, the chances of you tailoring it to their knees and therefore touching less nerves may have a similar outcome. What do you think about this idea that nerves talk to each other and so you got to get rid of all of them?
Speaker 2 (34:49):
Unfortunately, I’m biased and I see the downstream problems of touching nerves because most people will do fine with it, but there’s some people that will have neuros, some areas will get damaged, were weren’t painful before. True. Anytime you have any sort of thing in the nerve, you could cause these things like the complex regional pain syndrome. So
Speaker 1 (35:13):
Speaker 2 (35:14):
And my feeling is always less is more. Now, again, I don’t know the outcome studies and it certainly sounds like there’s, but the reality is nerve root, the area where that cable comes from have a common cable a lot of times. So if you go upstream from it, a lot of those nerves are branching off. So you’re just basically cutting off any supply to that area. But what else is it causing problems to you? And if you don’t need to do it? Yeah, no, it would be interesting if you could actually do a electro test for the patient before you have surgery and see which of those branches cause the pain and do a selective neurotomy on those areas that way and see what the outcomes are versus triple nerves. Because I think that’s going to probably show better outcome because you’re not going to have any other problems coming up from nerves that weren’t injured with damage.
Speaker 1 (36:10):
How do you do that? Is that something you can order?
Speaker 2 (36:13):
Yeah, most of the anesthesiologists, especially in the center that we go to have this little device that stimulates, it’s a nerve stimulator and it it’s easily found. You could order it, I don’t know, but it basically is, it’s an electrode attached to a special type of needle that you put in there and it beeps when you get closer to the nerve and then when you get there, or it gives an electrical signal so that the patient while they’re awake can tell you that’s the nerve, that’s the pain. Those areas don’t have pain. When you selectively do that, I think that would probably be the best of both worlds can limit it. And if you need to do all three, you do all three. If you could limit it to one or two, you do that.
Speaker 1 (36:58):
That sounds pretty cool. Okay, next question. Oh, let’s go back to the implants. So one of the questions is, I’ve heard it is best to have a neurosurgeon implant, the spinal cord stimulator or Dr. R g as opposed to a pain specialist or anesthesiologist who specializes in pain management. I’m sure it’s based on experience, but how do you choose?
Speaker 2 (37:23):
That’s a great question. I’ve actually had a neurosurgeon tell me that it doesn’t make sense for a neurosurgeon to implant a peripheral stimulator when you’re trying to decrease the amount of surgery. So the answer is it depends. And the answer is it depends on anatomy. Electrodes do move, and when you put in the electrode into the back, especially a spinal cord stimulator, there is a good chance of movement. But usually each of these leads have six electrodes, I’m sorry, eight electrodes on each. Those eight electrodes can overlap. So even if they move, you have a lot of redundancy in it. And that’s the only reason to have a neurosurgeon put it in place because the reason you have neurosurgeon put it in place is because you’re worried about movement or there’s something anatomically that keeps you from being able to do it just with a needle.
Speaker 2 (38:24):
I mean, the difference is with a surgeon, they take a piece of the bone out, a lamina or it’s it, and they go inside and place the electrodes surgically underneath the laminate or the bony parts of the spine of the back. So it’s actually a real surgery. It’s not. And I’ve had patients that had to have that. There’s no other way to get the electrodes in the right spot. Every patient has to go through a trial. The trial is a seven day period. Those trials are all done by pain management people. And the reason is that it’s a noninvasive, minimally invasive, I say minimally invasive. There’s always risk with these procedures leading infection, nerve injury, that risk is always there.
Speaker 2 (39:14):
But these electrodes are placed with a needle similar to when people get a catheter placed in their back when they have a, they’re going through pregnancy and they get a epidural catheter, needle placed in the area, the electrode is placed in, the needle’s taken out, and it’s on a pouch and an outside stimulator, and then you try it for a week and then you have the procedure done. So I think if there’s concern for movement, you’re better off having a neurosurgeon do it. But if you want to stay away from surgical techniques that remove bone, the stimulator works well for patients that don’t get surgery and we have enough technology and redundancy that even a little bit of movement, we have enough on that electrode that we could get.
Speaker 1 (40:07):
I see. So does that mean that in general you would go to a pain specialist who does this often and then if it moves, then you’re going to need to go to a neurosurgeon? If there’s a complication,
Speaker 2 (40:23):
You could go to the pain specialist first and do the trial and at that point you could the pain specialist. And I’ve had this done. I, I’ve done the trial, but I was like, this is not easy to do and we’re not going to have a good outcome implanting it with a needle and we have a switch involved with it to put it in.
Speaker 1 (40:45):
Got it. It it’s the way it’s introduced either by needle or by a hole. Got it. Got
Speaker 2 (40:50):
It. Okay. I could tell you that the first time I ever got experience with this, also medical school by a neurosurgeon. Oh, really? Did this a lot before.
Speaker 1 (41:00):
Where’d you go to medical school?
Speaker 2 (41:02):
I went to Tulane in New Orleans and I did two years of research with the neurosurgeon. I was going into neurosurgeon, but I decided I’d like daylights and I decided to do that.
Speaker 1 (41:14):
Yes, yes. You like your life more.
Speaker 2 (41:19):
They work really hard through residency and it’s a God bless.
Speaker 1 (41:24):
Yeah, grocery, it’s a brutal residency at UCLA. I think it was like nine years or something crazy like that. And that’s not even after that. They do specialties. Yeah. Okay. Can you talk to me a little bit about P R P and stem cells and their role in treating areas of pain and what is P R P?
Speaker 2 (41:48):
So P R P is basically platelet plasmas.
Speaker 2 (41:55):
Platelets have a lot of function with proteins that they produce to help our body heal. For instance, if you get a cut, and I have this cut right here, I don’t remember which wall I punched, but I have a cut. It takes about six weeks to go from this to not even having a scar. It’s because all the proteins in your blood and you have good blood supply in your skin and it allows it to heal. There’s areas in our body that don’t have good blood supply. Because of that, these special proteins don’t get into that area very well. And that area gets stuck in the inflammatory cascade. Inflammation is a good thing. It helps our body heal, but if it gets stuck in one phase of it and can’t move forward, it doesn’t work very well. That phase, if you think of it as sort of like a building, you got the demolition team coming in and they get stuck and they keep hounding at the walls and the construction team hasn’t come in to kick ’em out.
Speaker 2 (42:58):
And that’s what happens in areas with not good blood supply. So we found that, and we, not me, but people in medicine have found that if you concentrate these proteins in a specific way in [inaudible] and get rid of some of the things that could irritate the area and concentrate these in a very concentrated form, you could inject it into area and they get a real high concentration there. And that will allow the area to heal. One step further is the cells, stem cells are injected into the area to help the environment to rejuvenate the cells. Not only the proteins going in there, but some of the cells start kicking in. And there’s a lot of other things. There’s something called stem cell secretions, which called exosomes, and people are finding that some of the function of stem cells are taking these secretions and that’s activating the local environment, not exactly the stem cells themselves.
Speaker 2 (43:58):
So there’s another field where they’re saying, skip the stem cells, just get these secretions from a Petri dish that forms it, inject it into that area and get your own cells producing all the things that these stem cells that are not part of your body doing. So you’re really trying to get your body to heal. That’s what really it’s, it’s doing, it’s just a natural way of helping your body heal. The unfortunate thing is our body’s much more complex than we have to knowledge, and it’s more like a cocktail of things. And right now it’s hard to find out what that perfect cocktail is. And there’s a lot of studies going on to try to figure out what particular cocktail works on that second phase, the construction phase, what do we have to get rid of in that demolition phase to allow it to go on? Our body has a harmonious way of doing that. But when we’re trying to do it without the knowledge of what your body’s doing exactly, you’re just kind of testing to see what works better.
Speaker 1 (44:54):
So can you inject P R P, I understand the use of P R P during the recovery phase of when you’re trying to heal, but can you use it like 10 years later for an injury that’s 10 years old or five years old?
Speaker 2 (45:09):
It depends. It depends on if there is continuous acute trauma there. PRP is not going to work on a nerve that’s not functioning. However that I is even there, there, there’s been shown stem cell research at UCLA that injection of stem cells have helped people that were paralyzed start improving function. Wow. So the answer is, yeah, it doesn’t make sense that tissue that’s been damaged for years and years that it work on, but it also works on inflammation cascade not only trying to regenerate the cells. So if you could decrease inflammation in a natural way instead of steroids, it might have better results for longer term.
Speaker 1 (45:54):
That was pretty cool. Okay. Next one’s going to be another complicated question. Well, okay, let’s stay with platelet rich plasma. So P R P, can it be effective for chronic injury? Okay. Where already discussed that. Let’s do the next one. Does platelet-rich plasma or P R P cause ossification where it’s injected? Have you ever heard of that where it causes extra bone formation?
Speaker 2 (46:25):
I haven’t seen it. Now. There are other biological
Speaker 2 (46:32):
Proteins that in concentrated form has shown ossification there. There’s there. And they were used to help heal areas faster. And what they found is in some patients it causes ossification. Some of those treatments were used in spine surgery to help the area heal faster. So depends on what you’re looking at. I, I’d have to look at the study, but the general run of the mill P R P or some of the sort of more filtered PRP, I haven’t seen it. I haven’t seen a whole lot of literature about it, but I can’t say that it’s not, because like I said, there’s a million of proteins and if you concentrate some of these proteins at a higher level that actually help promote calcification, which is part of our cascade. Anyway, you can do that. But I think that’s a very specific type of protein that does that. It’s not all PRP.
Speaker 1 (47:33):
Are you treating patients by telehealth video chat now?
Speaker 2 (47:38):
Speaker 1 (47:40):
Okay. So how do you that as a pain doctor?
Speaker 2 (47:43):
Well, most of my patients are referred after they’ve seen a couple of different doctors specialists. So they’ve already had sort of a lot of things filtered out. So they come in mostly with me for neck back knee pain. They have MRIs, I have other doctor’s notes. I do an exam on them. I usually try to have somebody in the room with them that could assist and I tell ’em what to do. But there are some patients where I say, look, I did what I can, but I’m still not sure what we need to do and have them come in. Unfortunately, with the surge in California and Los Angeles right now, we’re getting a problem with all of that, but hopefully that will be overseen. But
Speaker 1 (48:29):
Yes. And this is a related question by someone who’s dealing with chronic pain. So this gentleman has a refractory case of groin pain, unresponsive to injections of anesthetic or steroids. Surgical treatment has been delayed because of the pandemic. I notice the pain is also superficial, possibly the subcutaneous tissues, although I do not have skin hypersensitivity. How can you tell whether the delayed treatment and now chronicity of the problem, whether the pain has become neuropathic with centralization of pain due to changes in the involved dorsal root? What is this idea of centralization and what are the risks of delaying pain treatment in centralizing neuropathic pain?
Speaker 2 (49:17):
So one of the best things to try to tell you how centralization of pain works is when patients have gangrene in their foot and then the limb is amputated for whatever reason, because of the angry, there is this phantom pain, and that’s sort of a way of centralized pain. Your brain still perceives the pain even though it’s not there.
Speaker 2 (49:44):
But it had to be there to begin with to do that. So it becomes this vicious cycle of an area that causes pain. It goes on chronically long enough for it to be centralized. And this nerve pathway is etched in your brain that that area is painful, and then you got to do these injections and you don’t get relief from ’em. But the chronicity is usually not it. It’s something that has to have happen for a long period of time. There’s no study that I know of that specifically tells you if it’s six weeks or longer. The chronic pain usually is six weeks or longer, but this centralized pain could be six weeks. It could take six years. It’s hard to tell. One of the things that this patient says is unresponsive to anesthetic and steroid injection. Yeah. My question is then anesthetic. If you’re numbing the area, that’s a source of the pain with anesthetic, unless this patient is just, and some patients are, don’t respond to anesthetic in any way or require high doses, then maybe there’s not the right spot.
Speaker 2 (50:47):
And I, I’m paying Monday morning quarterback here. I don’t know, maybe there’s some other source of pain. Maybe this is sympathetically mediated pain. I know in the book chapter I wrote, I said, we call something complex regional pain syndrome. When it’s at one extreme of that sympathetic remediated pain, it doesn’t mean that you still don’t have sympathetically mediated pain, but if you have sympathetic remediated pain that causes X, Y, and Z, then it’s called complex regional pain syndrome. He didn’t have Caledonia. He doesn’t have hyperesthesia. But there is a possibility that this is some sort of sympathetic remediated pain. And that’s sort of where it, it’s trying to figure out and tease that out. I is not easy in some patients. Is it the anesthetic that it’s not working? Is it something that the body is not or is it sympathetically mediated? I always try to figure out if there’s anything that can be done to numb the area that at least we know a diagnosis.
Speaker 1 (51:47):
And then how do you distinguish neuropathic pain, which is nerve pain versus somatic pain? How does that
Speaker 2 (51:57):
Yeah, it’s a usually diagnosis of exclusion. I mean, if you look at all the different nerve fibers and try to inject along those areas, if this patient, I didn’t remember exactly, but if it’s groin pain and it’s refractory, did they look at the MRI of the lumbar and thoracic junction? Is a disc problem there? Is there a lot of people look only at disc problems, but what if there is arthritic joint, beset joint, which is behind the nerve? And that’s so arthritic, that’s putting pressure on the nerve. That’s very common in the neck. This problem are sometimes the cause of pain, but a lot of times it’s the arthritic joints that irritates the nerve root. So there’s all these little very specific things that you got to look at to see if, where this pain is coming from. But he’s got some tissue pain or sensitivity in the area. And that may be more cutaneous nerves. And if it’s not, it may not be related to some of the pain from the ilio inguinal or ilio hypogastric. I it, it’s hard to say in this setting, but exam, diagnostic test and diagnostic, there has to be something that relieves the pain before going into sort of more advanced treatments.
Speaker 1 (53:14):
It seems an aesthetic worked Lyse, the steroids didn’t give much long-term relief.
Speaker 2 (53:20):
So that tells me there’s a lot of mechanical pressure on the nerve. It’s inflammatory in any way because inflammation would’ve calmed down with the steroids. If the anesthetic worked transiently, even if it was for a couple hours and it was significant, then you have a diagnosis, then it becomes a mechanical issue that there’s something putting pressure on the nerve. Yeah. That’s causing the pain.
Speaker 1 (53:43):
Yeah, that’s pretty fascinating.
Speaker 2 (53:46):
And then short of, you could do neurotomy for, I’m sorry, a radiofrequency ablation for this. If you have a diagnosis and if it’s pain only and there’s not other factors, that’s something that could be considered.
Speaker 1 (54:01):
What’s the risk of after ablation? What’s the risk of neuroma or other kind of recurrence with ablation?
Speaker 2 (54:09):
Neuroma is low because you’re not actually cutting the nerve or anything like that. The risk for the random risk for complex regional pain syndrome or some sort of host procedure is there. I don’t know the exact statistics on it, but again, when you use the combined treatment with a ultrasound and the electrode, it reduces the risk of any adverse effects. But there is risk for any time to go anywhere near the nerve, whether injection or radiofrequency. There’s a risk of neuralgia, nerve injury, bleeding, an infection, and a really, really, really low risk of complex regional pain syndrome or this sort sympathy mediated pain.
Speaker 1 (54:55):
Yeah. Complex regional pain syndrome’s a horrible complication. Is there a cure for that?
Speaker 2 (55:02):
No. It’s just treatment and letting your body it, in most cases it does die down over a period of time. But the severity is so much that no, not many people can tolerate it. And if you look at people that have the full-blown case, their legs look like they’ve been sunburned. I mean it’s a very, yeah, it’s not a pretty sight. And yeah, they go through a lot and it will get better, but it’s that period of time from, and it could be chronic, but usually there’s a period of time where it does get better.
Speaker 1 (55:36):
Speaker 2 (55:37):
In severe reason.
Speaker 1 (55:38):
Yeah, you certainly don’t want to be the cause of that. Again, I think less is more. And I do appreciate that you are able to provide kind of a multi-level approach to this. I strongly discourage radical operations for chronic pain. I mean, surgery is great for some patients, but if many of the patients can get better with just nerve blocks or whatever the situation is, it’s better. At the same time. I personally feel that if there’s a treatment, even though it’s invasive, that can cause a cure. I think that’s better than submitting someone to a nerve stimulator for the rest of their life. I’ve seen patients with twenties that have had nerve stimulators put in.
Speaker 2 (56:31):
I agree. I think the problem is that one, find out the anatomy, find out why. The problem is number two, if there is a treatment that is permanent, do that first.
Speaker 1 (56:43):
Speaker 2 (56:43):
And number three, if there’s something that didn’t work permanently or there was no treatment, then all these other techniques are available.
Speaker 1 (56:51):
The last question’s going to be a complicated one. It’s about sports hernia or what we call athletic pubalgia or groin strains. Do you treat those?
Speaker 2 (57:01):
I have. And what I’ve found is diagnostic injections first to find out if the source of the pain gets better with the injection. I have never, and this is my experience, I haven’t seen steroids work very well for them. But I have seen P R P work and I need to get probably this into paper, but the patients that I have seen with PRP have done really well. But this is sort of anecdotal. It’s not
Speaker 1 (57:32):
Even years out.
Speaker 2 (57:34):
Even years out. Yeah. Yeah. I’ve had patients that have had pretty good results for two or three years. I’ve had people that it didn’t work for. So it, it’s not perfect and it’s not something that it always works. But the first thing is a diagnostic injection. And number two, making sure that we’re correct about the anatomy hernias and sports hernias. A lot of the pain is very similar. And I, if I see in, you’ve probably seen some of my patients, I think,
Speaker 1 (58:05):
Yeah, I have.
Speaker 2 (58:07):
If I see a sports hernia, I make sure they see you first because I want to make sure I’m not missing a hernia. That’s not my area of expertise. And if it is a hernia that needs to be treated, if it’s not, then we move forward and treat the sports hernia.
Speaker 1 (58:20):
Yeah. When LeBron James comes to your office, can you please send ’em to me?
Speaker 2 (58:24):
Speaker 1 (58:26):
I need to make sure his chronic groin pain is not due to a MS hernia. I think that’s very important. I give him my expert opinion on that.
Speaker 2 (58:36):
Speaker 1 (58:37):
Any of you guys out there know LeBron James? Have him give me a call. I’ll see him. All right. That is the end of our hernia talk. I just want to say a big thank you to Dr. Vahedifar. He’s a close friend. He’s actually been my doctor when I had to deal with pain from my spine issues. And he was just a godsend. He’s actually the one who diagnosed me, believe it or not. I didn’t think I had a cervical athletic muscle pull. He’s like, Nope, you got a disc. Which I was in disbelief, but then I got my MRI, which he ordered, and there it was. So he was very gracious in helping me through my pain. He’s helped so many of my friends, a lot of my patients, and tonight donated his time to all of you guys on hernia talk. We will make sure that this very informative hour is available to you on YouTube. I’ll post all the links on my different social media platforms, including Instagram and Twitter at hernia doc. And on that note, Dr. Vahedifar, thank you very much for your time. You’re
Speaker 2 (59:46):
Welcome. Always a pleasure.
Speaker 1 (59:48):
Thank you. Hope you have a good evening. Stay safe, COVID free and have a great holiday.
Speaker 2 (59:54):
Speaker 1 (59:55):
So much. Bye. Thank you,
Speaker 2 (59:56):