Are you struggling with chronic pain and looking for innovative ways to alleviate your discomfort? Join us as we sit down with Dr. Steven Aydin – a double board-certified physiatrist – to discuss the world of interventional pain management and physiatry. In our engaging conversation, we delve deep into the most common musculoskeletal conditions, such as herniated discs and spinal stenosis, and how a combination of diagnostic techniques, imaging studies, and injection therapies can help manage pain and improve your quality of life.
We also explore how multidisciplinary collaboration among healthcare providers is crucial for achieving the best possible outcomes for patients, all while addressing the challenges of pain being referred from different areas. Dr. Aydin shares his expertise on nerve-blocking techniques, minimally invasive procedures, and addressing pain associated with osteoporosis through methods like vertebroplasty and kyphoplasty.
Finally, we dive into the fascinating realm of regenerative medicine, discussing cutting-edge biological therapies like platelet-rich plasma and bone marrow aspirate. Dr. Aydin enlightens us on how these treatments can provide essential components for healing that may not be present locally, offering a greater chance for a pain-free life. Don't miss this informative and hopeful episode with our esteemed guest, Dr. Steven Aydin.
Are you struggling with chronic pain and looking for innovative ways to alleviate your discomfort? Join us as we sit down with Dr. Steven Aydin – a double board-certified physiatrist – to discuss the world of interventional pain management and physiatry. In our engaging conversation, we delve deep into the most common musculoskeletal conditions, such as herniated discs and spinal stenosis, and how a combination of diagnostic techniques, imaging studies, and injection therapies can help manage pain and improve your quality of life.
We also explore how multidisciplinary collaboration among healthcare providers is crucial for achieving the best possible outcomes for patients, all while addressing the challenges of pain being referred from different areas. Dr. Aydin shares his expertise on nerve-blocking techniques, minimally invasive procedures, and addressing pain associated with osteoporosis through methods like vertebroplasty and kyphoplasty.
Finally, we dive into the fascinating realm of regenerative medicine, discussing cutting-edge biological therapies like platelet-rich plasma and bone marrow aspirate. Dr. Aydin enlightens us on how these treatments can provide essential components for healing that may not be present locally, offering a greater chance for a pain-free life. Don't miss this informative and hopeful episode with our esteemed guest, Dr. Steven Aydin.
Hello and welcome to another edition of the Kale Ortho Podcast. Today is June 6th, 2023. And we're so privileged to have with us today our own interventional pain management specialist, dr Stephen Aiden. Dr Aiden is a board certified, fellowship trained physiatrist who's double board certified He's board certified in the field of interventional pain management, but he's also board certified in the field of physiatry. And we're so happy to have Dr Aiden with us today because there is such a dire need for interventional pain management. Unfortunately, so many Americans suffer from either acute or chronic pain And thank God, there's doctors like Dr Stephen Aiden there for them to help alleviate their pain and discomfort on a daily basis. So welcome to the podcast, dr Aiden. Thank you for having me, dr Kale, it's my pleasure. That's my pleasure. We're so happy to have you with us. So, before we get started, dr Aiden, why don't you just give us a quick summary about your formal education?
Steven Aydin, DO:Sure. So I completed my medical school at the University of Medicine in Dentistry in New Jersey in 2005 and then went on to do my residency at UMD and J in Newark and then went on to do a pain fellowship at the University of Michigan, which was an additional year of training and board certified in both specialties of physiatry or PM&R, as well as pain management.
Robert A. Kayal, MD, FAAOS:Great, Thank you for that. So let's get started and just define for our viewing audience what is the field of interventional pain management and what is the field of physiatry. Sure.
Steven Aydin, DO:So I'm going to tackle the physiatry first, because physiatry itself is a very broad specialty that kind of covers the gamut of different medical conditions for different conditions like related to spinal cord injury, stroke and musculoskeletal medicine. So as far as my focus in physiatry, I've kind of pivoted into the nonoperative side or the nonoperative orthopedic side of physiatry where I really focus on musculoskeletal medicine. So many times a physiatrist will deal with the rehabilitative needs as well as treatments of patients for nonoperative orthopedic needs such as knee pain, arthritis, back pain, neck pain. Many times we'll manage these issues with injection therapy, trigger points, physical therapy, chiropractic care and just indicating patients for a lot of different treatments to prevent them from seeing you really. But obviously many times there are reasons why we have surgeons and our treatments and our medications or indications don't work for patients.
Steven Aydin, DO:As far as interventional pain management is a subspecialty that kind of focuses on a nonoperative management of symptoms that are related to either spine conditions or other musculoskeletal conditions, in which injection therapy or minimally invasive procedures or techniques are utilized to treat these patients' conditions And the goal is really either to manage their symptoms so that they don't need surgery or manage their symptoms when surgery isn't as perfect as we always want it to be. The human body is very unique and is very complex, and sometimes it's not as easy as just replacing a battery or a carburetor on the car. We're treating a human being, so not everything always goes perfectly and our goal is to manage these symptoms with different kinds of techniques whether it's injections or surgeries to getting the patient functional and improved. So that part of my specialty and my focus was my focus, where we really focus on interventional pain management is really goal to manage conditions with injection therapy and different kinds of noninvasive procedures to get the patient functional and improved in their quality of life.
Robert A. Kayal, MD, FAAOS:Thank you for elaborating on all of that. On that note, give us some examples, dr Aden, of some of the more common musculoskeletal conditions that can be alleviated with your intervention.
Steven Aydin, DO:Sure, so many times in interventional pain we focus on the spine, but we can always focus on other regions that are painful for patients that become chronic or sub-subacute for their conditions. The most common thing that I see within the practice is things related to neck pain and back pain, such as herniated discs, sciatica, lumbar ridiculopathy, spinal stenosis and even facet pain. The most common thing that I kind of see and manage with patients is doing injection therapy for these conditions, such as lumbar or cervical steroid injections that focus on the epidural space And the goal of that is really to try and manage like a pinch nerve, as we call, or a sciatica, to try and get this patient functional and improved where they don't require medications, bed rest or even, you know, invasive surgery. Some of the other procedures that we'll kind of have for patients for different conditions is facet injections, which are really to focus on managing the axial back pain or neck pain, meaning the pain that comes from the small joints in the spine, and so we'll do many of these procedures with image guidance. So it's a very exact kind of specialty where we're not just putting a needle into the body and hoping that a medication gets there.
Steven Aydin, DO:We're very specific and very tailored to a patient's conditions and needs.
Steven Aydin, DO:You know you asked me the types of conditions we try to treat. But we can't do any of this without imaging and you know, physical exam and diagnosis and other specialties kind of seeing the patient and getting an idea of what the real condition is. You know, many times patients have multiple different kinds of generators of pain and we have to be very focused, you know, and work together as a specialty and different specialties to kind of get this target done. Most of these procedures are done with x-ray guidance or ultrasound guidance and the the majority of the outcomes is good. You know, obviously it's not a permanent fix. We don't always end up with a hundred percent resolution of these symptoms, but the goal of what at least I've taken on in the practice is to try and get patients functional to a level, especially if they're elderly or they're not great surgical candidates to allow them to enjoy their life, be pain-free and be functional. Really our goal is to get function and pain improvement with the least amount of work, if you will.
Robert A. Kayal, MD, FAAOS:Great. So, with respect to your interventions, before we go through these common conditions one by one and explain how you actually perform some of these procedures and what your goal is in addressing the disease that you're treating, why do these injections even work? For instance, what medications are you injecting typically during your interventional pain management procedures, and what is their mechanism of action that would allow the patient's pain and inflammation to subside?
Steven Aydin, DO:It's a great question and really relates to you know, what are we really injecting? what are we really accomplishing right? There are many studies out there that kind of look at the different kinds of things we inject that may or may not work. The majority of injections will have cortisone in it, but we don't want to be focused on just saying that we're injecting steroids into the body or that every injection has to have steroid in it. Much of what I do is really trying to make the diagnosis. So many times.
Steven Aydin, DO:It'll include a local anesthetic, such as lidocaine or marcaine, which is a cousin of something that used to be around called novacaine, the numbing medicine that we use Many times that's mixed with cortisone and that cortisone is really to introduce into the body or in the environment where I think this problem is coming from, like a herniated disc or an inflamed nerve, and try to reduce the swelling. So we've talked about two components so far. So the local anesthetic, which, just in simple terms, is really used to reset the nerve, turn off the thermostat, reset it as well as allowed to turn off the pain, if you will. So many times patients will get a nerve block quote-unquote and the nerve block is a temporary treatment for me to kind of get an idea of where the pain is coming from or if I got the medication to the right target. The nerve block is not something permanent and has a short half-life of whatever local anesthetic we injected. But really gives me a good idea is if a patient had impossibility, difficulty trying to get onto a table because of the severe pain, and i do the epidural around the nerve and i block that nerve, then they get off the table without too much difficulty and it puts me in the right neighborhood that i block the nerve.
Steven Aydin, DO:So that's the local and the steroid which is kind of the lag medication is injected into the environment to reduce the inflammation. So steroids are often used to try and reduce swelling inflammation in the body, but here we're using it specifically right around the environment that's injured or herniated or inflamed and that over time over usually about a few days to a couple weeks will kind of metabolize and do his job to cool off the fire around this inflammation. And then the third thing that we'll often inject is sterile salt water. So you need a medium with these things to kind of inject the medication and the goal of that, at least in my opinion is to flush the area.
Steven Aydin, DO:And many times you know you'll get these herniations or these inflammatory environments and there's just so much inflammation there from the chemical reaction that the body has. And our goal is to mitigate that and try and slow that down so that there isn't too much pain and that the body can kind of take over and say, well, you cooled off the fire for me and now i can kind of control this over response that i had. And allowing that area to be flushed with maybe just like a little power wash, if you will from the saline Will allow the body to kind of free up that nerve or free up the environment of that, you know, inflammation.
Robert A. Kayal, MD, FAAOS:So you so beautifully explained all that. Some of these concepts that Dr Aiden is speaking about can be extrapolated into many other fields of orthopedic medicine. So essentially what he's describing is a concept that we as healthcare providers call injections for diagnostic, hopefully therapeutic outcomes. So what that means is sometimes we're not exactly sure What body part or what nerve is causing the patients pain and symptoms. So a lot of times what we'll do is inject local anesthesia into that joint or around the nerve to numb the nerve, essentially numb the nerve, and if the nerve numbs or if the joint No longer hurts, than that tells the healthcare provider that that nerve or that joint is the ideology of the patients. Symptoms and pain. When that is helpful, very often simultaneously will inject a corticosteroid like he's describing now.
Robert A. Kayal, MD, FAAOS:Steroids are the most potent anti-inflammatories. Inflammation is commonly associated with redness, warmth, swelling and pain. So when you put an anti-inflammatory around a joint, a tissue or a nerve, that inflammation subsides and those four characteristics associated with inflammation redness, warmth, swelling and pain also subside. And so very often we as practitioners will perform injection therapy where we'll give a numbing medicine like a lidocaine or a marcane or a novacaine derivative Into an area. Combined with a corticosteroid. For instance can a log depa, medrawl, something like that, and we'll mix that into a cocktail and inject that into a joint or into a tissue or into, and so we'll give a numbing medicine. That's typically only transient, it's only temporary. It's like going to the dentist. When the dentist numbs you for a few hours three to five hours That's because of the numbing medicine that he placed around the nerves of the job Or of the tooth. Same thing happens in orthopedics and pain management will numb the area for three to five hours and then the second Medication, typically a corticosteroid, will kick in, typically in about two to three days. So very often we'll get a very long period of time And then they might actually be in pain again, or even a little more sore, from the actual procedure until two to three days or three to four days after the procedure when the corticosteroid kicks in, and then they'll have to be in pain again, or even a little more sore, from the actual procedure until two to three days or three to four days after the procedure when the corticosteroid kicks in, and that injection Medication will then give them a much longer pain relief. So that's a diagnostic and therapeutic procedure that we do to help the patient, but it also gives feedback to the healthcare provider That we're actually treating the right area, the right body part, the right nerve.
Robert A. Kayal, MD, FAAOS:Sometimes pain can be referred from a different area. The case in point would be Pain around the shoulder. Is that shoulder pain or is that referred pain from the neck? pain around the hip is that hip pain or referred pain from the sciatic nerve of the lower back? These are things that we don't always know 100%. So we'll treat one of the conditions with a diagnostic and therapeutic type of injection and then reassess the patient in a couple days And if that patient feels better, very likely the area that we injected was the etiology of the pain. If not a follow up, we may consider injecting the other area to see if it was referred pain stemming from that other area. So that is just further elaborating on what Dr Aiden said. So thank you for that, dr Aiden.
Steven Aydin, DO:Dr Kail you bring up two very common diagnosis that we often work together with the shoulder and the neck, and the hip and the back, and so many times we'll see patients together, or I'll see someone first and then you'll see someone, or vice versa, and we're dealing with these diagnoses and we can't determine significantly or just from examining them or just imaging, to say, is it the neck or is it the shoulder, because the two really live together, or is it both Right, and sometimes it's both. I mean, you know and we see that all the time, all the time. So it's really important that you know, as practitioners and orthopedists and interventionalists a rheumatologist, a sports medicine doctor that we all work together and kind of accomplishing the same goal for the patient 100% and it's actually great for the patient because it gives us more feedback about what the the the main source of the pain is.
Robert A. Kayal, MD, FAAOS:For instance, if the pain is is associated with both regions, at least we can be honest with the patient and and notify them what our expectations are, so that we are all on the same page. If a patient is undergoing an interventional pain management procedure, like a nerve block or an epidural steroid injection for the neck, but they also have a rotator cuff tear in the shoulder, dr Aiden can then say look, i'm going to associate, i'm going to alleviate some of the pain and discomfort in the shoulder, but not all of it, because you also have a rotator cuff tear And when I'm done with this, you may have to see Dr Kale for an injection in your shoulder, type of thing, and and vice versa. So it helps give us more information so that we can guide our patients with respect to what our expectations are in regarding their degree of pain relief. So it's very, very helpful.
Steven Aydin, DO:Pivoting off of that. You know, diagnostically, we talked a lot about injections and what we do as practitioners. But at the same time, mri, cat scan, x-ray these facilities that we have available right on site within our practice and having that imaging available to me every single time the patient comes back, i just log into the computer. We have our MRIs, our CAT scans, our x-rays, nothing is missed. And then if say, something doesn't work, whether it's an injection that you performed or I performed, we don't have to fumble around and say, well, did you bring your CD last time? I have to pull up your report. I just go right into our system and that image of their spine that they had or that image of their shoulder that they had is right, available, and say, well, what did we miss that time?
Steven Aydin, DO:And then we also do electro diagnostic studies. So within the specialty of physiatry which I've trained in, i perform EMG. So EMG is a nerve conduction studies. Allow us to use a more objective electro diagnostic or kind of like a nerve study or a nerve test to figure out which nerve root is irritated, how bad it is. Is the nerve so damaged that the wires are, are snapping inside and you're getting permanent nerve damage. Which level is it involved in the neck or the back? Is it carpal tunnel syndrome? is there some other, what we call a mono neuropathy, meaning a pinched nerve outside of the spine that's present. Do they have some sort of neuropathy or other systemic disease that we're missing, that we're getting fooled by the body, and so we can use these other studies like EMG, nerve conduction studies, mris, x-rays, cat scans, ultrasound, to really direct us to getting optimal improvement and diagnostic treatment for the patient, so that they have, you know, their life back, if you will, yeah nerve pain is clearly the most painful type of pain patients can experience, something we call neuropathic pain.
Robert A. Kayal, MD, FAAOS:Nerves don't like to be compressed. Irritated, stretched nerves obviously are extremely, extremely sensitive, and what we've learned in the field of surgery can often be extrapolated to the clinical practice as well and interventional pain management, and that is the concept of preemptive anesthesia. Can you elaborate on that concept of preemptive anesthesia and how it's so important to stay ahead of pain in the field of medicine as opposed to playing catch up to address pain?
Steven Aydin, DO:Oh, absolutely Well. I mean it's multifaceted. We've kind of gone through, you know, a pendulum swing of where we were using a lot of narcotics for pain control you know whether it was a high dose opioids before surgery or after surgery. In your specialty, where you're doing a joint replacement, the, the paranoid shift has been to less hospital stay, get him home quicker, even outpatient. So the last thing that we want is a patient to be in significant amount of pain with a joint replacement or some sort of intervention or surgical intervention to a joint or the spine, and be so out of commission where they can't go home or they can't be discharged from the hospital within reasonable time for that institution. So regional anesthesia and nerve blocks are preemptive.
Steven Aydin, DO:Anesthesia blocks are extremely helpful in a few different ways. One is it allows the doctor to perform the procedure with much less pain that the patient is Receiving during the actual procedure. So if you're someone who is getting anesthesia for this procedure whether it's full sedation where they put a tube in your throat, or is just IV sedation, whether using propofol or some sort of sedatives The amount that you'll need will be much less so because you won't be feeling the amount of pain that you should be feeling. The conduction of that nerve for that region is blocked now, so you can perform your procedure almost with the patient completely awake. So that's the first step. So less than the second step is.
Steven Aydin, DO:Many of these blocks last a long time, meaning 48 to 72 hours, depending on the type of local anesthetic that the anesthesiologist uses or the post anesthesia care that they get in the institution.
Steven Aydin, DO:So many times your need for post operative medication is much less, so you won't need narcotics for 10 days. You'll only need it within two or three days after you've gone home, and many times the worst Swelling inflammation is within the first 72 hours. So if we can kind of control that with minimal medication from a nerve block being involved and the patient doesn't need a lot of medications on board, It then means that they get to rehab in physical therapy. They're walking around faster and quicker, their medical complications drop down so they don't end up with a cloth that can travel somewhere cause another problem. They're eating quicker because they had less anesthesia. They're not as nauseous after the anesthesia. So regional anesthesia or the nerve blocks that help you guys perform your surgical interventions, i think are so valuable in many of the things that we perform within our scope of practices, because it just lowers the risk for a lot of the things that we've learned in the past. That can really result with bad outcomes 100%.
Robert A. Kayal, MD, FAAOS:It's rare for us to do a surgical procedure, especially a big surgical procedure, without regional anesthesia delivered by the anesthesiologist prior to surgery. The concept is essentially, as Dr Aiden mentioned, that we want to essentially block the brain from ever sensing the pain from the incision, and so if that nerve can be blocked before the surgery, then when the surgeon makes the incision, the concept is that the spinal cord and the brain do not even appreciate that pain pathway that's emanating from the surgical incision, and so patients will have much, much less pain postoperatively, and so it's a preemptive block. But along those lines of doing preemptive anesthesia, regional anesthesia, can you elaborate on another very, very important concept in the area of pain management and that is multimodal anesthesia and the multimodal approach to preemptive pain management?
Steven Aydin, DO:So multimodal approach just basically means you're using a lot of different techniques instead of one technique to getting pain control. So multimodal basically means and obviously every case is different, every limitation that comes in is very patient dependent But using anti-inflammatories, using nerve blocks, using opioid medications, using, you know, electrical stimulation, doing physical therapy, massage therapy, acupuncture, all these things have a component of controlling some of the pain. So I'm not saying that all those things are what every patient is going to get. But that multimodal approach, whether it involves medications, nerve blocks, acupuncture, chiropractic manipulation, kind of things, along with their postoperative and preoperative care, can really improve both the outcome of the surgery and the discomfort during and postoperatively.
Robert A. Kayal, MD, FAAOS:You know, pain is a very complicated concept. It's so important now in the field of medicine to assess pain and adequately treat it that it's become what we call the fifth vital sign. It's so important to stay ahead of it. And it's complicated and complex and that led to the field of multimodal attack of this pain from many, many different angles. And it's very, very important. I can't emphasize it enough how important it is to stay ahead of the pain. And so, just like in orthopedics, when somebody has an overused condition like a bursitis or a tendonitis that is exacerbated by a certain activity, for instance running, if a runner had patellar tendonitis, i would tell that runner that it's okay to run, make sure you stretch beforehand and I would consider taking a anti inflammatory preemptively. So if you know you're going to go out for a five mile run and typically that run will exacerbate your patellar tendonitis around your knee, i would suggest that that patient take anti-inflammatory like Motrin, advil, aleve or Ibuprofen preemptively before the run, because it's easier to manage that inflammation before they go out running as opposed to trying to play catch up and managing it after the fact. And the same concept can be extrapolated to surgeries where we block the nerve before the surgical procedure And also in the management of pain. If you're in pain, it would certainly behoove you to come see one of us, especially Dr Aiden, who can preemptively address the pain before that inflammation gets too far out of control. It's a downward spiral and it's very hard to manage chronic pain. This is well published in the orthopedic and pain management literature. Patients going into surgery in pain have much more pain after surgery. So the onus is on us as your healthcare providers to try to decrease that pain, decrease the inflammation, and very often we'll use a multimodal approach. We'll use some medications, like the local anesthetics, to block the nerve. We'll use anti-inflammatories around the nerve. We'll use anti-inflammatories in joints, like cortisone injections, different things like that. Some of the pain is from the nerve itself, a concept we call neuropathic pain, and sometimes we use agents like Lyrica or Gabapentin, neurontin, to help manage the nerve component of the pain. So it's a complicated topic. But we have experts here at the Kale Orthopedic Center and certainly Dr Stephen Aiden is a double board certified interventional pain management specialist as well as physiatrist, who is highly trained, skilled and experienced in the field of acute and chronic pain management. So, dr Aiden, we spoke about the types of procedures that you do and the medications that are included in those injections, and we talked about the concept of preemptive anesthesia and multimodal approach to pain management and inflammation.
Robert A. Kayal, MD, FAAOS:But let's try to hone in a little bit on some of the very common conditions you and I treat on a daily basis.
Robert A. Kayal, MD, FAAOS:The patients that we see primarily for discurriations in the cervical spine, the lumbar spine and the lumbar spine very commonly known as sciatica, and also potentially in the elderly population where we see a condition called spinal stenosis and shopping cart syndrome, neurogenic clotication, and we can refer patients to another podcast that we recently did with Dr Paul Bhavi on those spine conditions. We're not going to elaborate again on those, but I think we should now try to talk about some of the interventional pain management procedures that we refer to in that podcast that actually you do for cervical discurriations, radiculopathy, lumbar disc herniation, sciatica, spinal stenosis And even a condition we call facetogenic low back pain, where people can get arthritic changes in their facet joints that's exacerbated when they're standing up and extending their spine. So, regarding those three common things that you see on a daily basis, just take us quickly through how you talk to patients about scheduling them for these procedures. What you say to them, where you do these procedures, is anesthesia required, things like that.
Steven Aydin, DO:Sure. So you mentioned a few different diagnoses, so we'll start at the top. First, with herniated disc, or what we commonly know as radiculopathy, so that radiating pain that's coming from a pinched nerve, as we describe it, sciatica at the back or sciatica at the arm, as I call it with some patients, and the goal of that is to perform something called an epidural steroid injection. And what that is is an image guided. I use live x-ray to place the needle at the level or next to the level where this disc or nerve is being pinched or kinked, and the goal of that is to apply that lidocaine, saline and cortisone mixture into that area to flush it, reset it and reduce the inflammation, and many times patients will get significant improvement with that. That doesn't require some sort of surgical intervention. So that's a typical treatment for a herniated disc with an epidural steroid injection. How many of those do you typically do for an acute problem? So we usually try with doing one. There has been a lot of social acceptance of doing three in a row, which is not what we really do for epidurals anymore. The goal is to do one and get as much as we can, or the biggest bang for the buck out of one shot for the patient. Now if it doesn't work, we go back to the drawing board. If it works and we don't get as long, or we only get 50% or more and we need some more, then we'll talk about a second injection. Within our practice we're not a cookie cutter kind of approach. We look at every patient individually and we take every diagnostic therapeutic injection in stride because we don't know if we'll even do the same shot. I may change the approach, i may change the level. So there's a lot of different things. That kind of go into it before we say, oh, we're going to do a series of these, so we try and just do one, and kind of focus on how their progress is after that. As far as facet pain or the axial low back pain, so we think of the back in two directions, kind of leaning forward and leaning backwards, and leaning forward generally means that it's a herniated disc and leaning backwards generally means it's an arthritic or a facetogenic pain, and so there are epidurals for radiculopathy or pinched nerve symptoms. But then there are facet injection or facet medial branch nerve blocks that we perform to diagnose the back pain coming from arthritis, and the goal of that is to potentially either resolve those symptoms with that and diagnose it with that shot, but then also to potentially give you a longer improvement with something that's called radio frequency ablation, which is basically a quarterization of the very small, tiny nerve that goes to that joint individually not the nerve that controls the leg or the nerve that does movement, but the nerves that do these small little finger joint size, if you will, in your neck, your back or your mid back that can give you referred arthritic pain And that can sometimes even give you sciatica. And that's why it becomes so important to being a good diagnostician as to where your pain is being generated from. So that's kind of how we approach what's called facetogenic pain.
Steven Aydin, DO:You also mentioned spinal stenosis, and spinal stenosis is basically a narrowing of the canal or the foramen, which is where the nerves go down and out from the side, and we try to manage those symptoms with either an epidural or some sort of other injection therapy.
Steven Aydin, DO:Many times, as Dr Baggy may have talked to you about, is that we do decompressions for really bad stenosis, But many patients, especially elderly patients who may not be able to go through an invasive surgery or they just don't want to explore surgery, and they've been responding to epidurals and the epidurals aren't lasting along as long as they used to, or we've hit the limit of how many they're allowed to have.
Steven Aydin, DO:Per their insurance carrier will explore something called a minimally invasive lumbar decompression or a pericutaneous decompression of the ligament that's thickened, that's causing this spinal stenosis, and it's a procedure that's a little bit more than just a shot.
Steven Aydin, DO:It does sometimes require a little bit of anesthesia, but the bounce back and the recovery and the return on this procedure is so wonderful compared to, say, something more invasive like a laminectomy or a fusion. So that's something that we've been offering for the last couple years in our practice, has gotten a lot of traction and has been around for about a decade now. I'm within the specialty of pain management and you know, with any tech or new tech that we bring into the practice, whether it's pain or within the other specialties, we take the onus upon us to make sure that the research matches our clinical outcomes and within the practice, under the umbrella of pain management, i really taking that ownership of that. So we really don't offer procedures that we don't see good outcomes or don't see replicated within the literature. So that's a kind of something that I've always had ingrained in me and I think is really worked in our practice very well.
Robert A. Kayal, MD, FAAOS:Yeah, you've really pioneered that technology in this area, for sure. You've done so many of those already. So, I brought with us today a spinal model. I thought it would be very helpful to have Dr Aiden explain some of the procedures that he just referenced, specifically cervical epidurals, lumbar epidurals, the mild procedure for spinal stenosis, as well as medial branch blocks for facetogenic low back pain. So why don't you take it from here, dr Aiden, and go through your thing?
Steven Aydin, DO:So many times when we talk about epidurals we're really talking about getting into the epidural space and what we do is we use live x-ray, which is very similar looking to what we're seeing here, only gives me outlines of where the bones are, and it's great for bone anatomy, but it doesn't tell us about where the soft tissues are. So a lot of what I do is really by feel followed by the image guidance. So something like an epidural for the neck or the lower back is really targeted to go in this space here, and epi, meaning around the dura, goes into the area around where the spinal cord is And that's bordered by the discs, the nerves and the facets. So for a lumbar epidural we often will target somewhere in between here or here and try and place the needle into that area and then inject into that area. There's another epidural which we call a transferaminal, where we go in from the side. So many times you can kind of see this red disc herniation that's inflamed and swollen and touching the circuit board of the nerve root, which is probably the most intense pain, as we talked about, and what I'll do in these situations is I'll place a needle right at this level, along where this inflammation is under x-ray guidance to get that medication there In the cervical spine. We'll kind of look at this area and we'll go in between these bones to get into the epidural space, or we'll go in from the side here, which is done also under x-ray guidance, to place a needle along the nerve root, whether it's here here or here. Now, many times we'll also talk about the facets as being a treatment option, and now the facets are basically these little lines that you see.
Steven Aydin, DO:Here The bones stack up on each other and many times we'll talk about the disc kind of being the supporter of the spine. But the back of the spine, or what we call the posterior elements of the spine, are made up of the facet joints and these small joints kind of take a lot of the brunt when you lean backwards or when you twist aside from the disc. And we'll either do injections into this actual joint or we'll perform what's called a medial branch block, where we'll block the nerve that lives right along this little gully here and we'll place a needle into that area and block the nerve with that diagnostic injection that we talked about And that can also be performed here in the neck where we block the small nerves that go to these little joints that are comprised right here. We'll place a needle along these areas and block those joints, followed with improvement. We'll do a series of these many times and if it's short lived we'll talk about the radio frequency, as we mentioned earlier on.
Steven Aydin, DO:As far as the mild procedure, that's a procedure where we actually there's a thick saran wrap like ligament that thickens over time. So many times I'll tell patients that that ligament thickens as if we're in a room for 10,000 days throughout their life and we put a coat of paint or wallpaper on the wall. Eventually those layers start building up, start cracking, peeling and they start creating pressure onto the canal there. And what we do with the mild procedure, that minimally invasive lumbar decompression, is I take little scrapes of the back of that ligament to allow it to bow back from all the pressure that's built up over the years. And the research has said that if I could increase that surface area just a little bit by 14% is what they say in the literature But if we can create just a little bit of space for the nerves that are living or these yellow nerve structures that are shown here, then the patient should have significant symptomatic relief, less what we call claudication or that radiating pain that gets worse as they walk and then they stop and it goes away and that cycle starts over again. Less of that leaning forward pain that they need to kind of open up their spine. So that's the mild procedure.
Steven Aydin, DO:So we also talked about where we perform these procedures. So many of these procedures will often be done under live x-ray within a procedure room or suite, which we have a couple in different offices, and then some of these will be done in a surgical center, whether it's just because that's where it's convenient for the patient to have it done or if they require anesthesia. So anesthesia or IV sedation for these patients can sometimes be offered, and it's not always necessary. You know, for many of the procedures that we perform, many of them can be done with local anesthetic, where I just numb the patient up and I perform the injection within three to five minutes. But some of the more invasive procedures we need IV sedation. The patient will be put to sleep, they wake up and the procedure is done. Or if a patient has a lot of anxiety about needles or having a procedure done, we'll provide that service for them as well.
Robert A. Kayal, MD, FAAOS:Another, now that you have the spine model here. Another fairly common problem in our field in orthopedics is bone metabolism issues and osteoporosis osteopenia, osteoporosis And we're seeing more and more elderly patients suffer from what's called an insufficiency, compression, fracture of the lumbar spine, thoracic or lumbar spine. Is there anything you can do as an interventional pain management specialist to address some of the pain associated with these pathological fractures? So these are the vertebral bodies, and sometimes when patients' bones become brittle and frail with a very low energy trauma, like even a fall onto their buttocks, sometimes that can cause a significant fracture or compression And typically these bones become wedged.
Robert A. Kayal, MD, FAAOS:And because the structural integrity of the bone is lost with age due to osteopenia or osteoporosis, and when these bones collapse, these patients often will assume a hunched over deformity and it's extremely uncomfortable as well. Sometimes, when the fractures are so severe, the bone not only can get compressed but it can displace posteriorly into the area of the spinal cord or what we call the thickelsack and the lumbar nerves, and so sometimes that can be extremely painful and it can cause symptoms very much analogous to spinal stenosis or what we call radiculopathy, when nerve roots get compressed. So very often we'll refer these patients to Dr Aiden, who can perform interventional pain management procedures to immediately alleviate these patients from the pain associated with these fractures.
Steven Aydin, DO:Can you speak to that Sure? So that's probably one of the most rewarding procedures that I perform within my specialty. When a patient develops a compression fracture, it's extremely painful for them And many times in the early portions of this they're almost laid up in bed and they can't move. And I always express this to patients is like if you break a bone. The first thing that Dr Kale or any orthopedist is going to do is they're going to say well, we need to put you in the cast, you can't use it, you can't put weight on it And we'll see you back in six to eight weeks. Right, how do you do that for someone's spine Sure, whether it's their lumbar spine or their thoracic spine?
Steven Aydin, DO:So there is a subset of procedures that we call vertebral augmentation, where we actually go into the vertebrae and try to reestablish the height and try to inject cement or a stent or a combination of the two to get that height back and in turn stabilize the bone with that cement, so something like a vertebral plasty. When someone gets a compression here, where this becomes a wedge or they lost the height of it, and we use imaging obviously to demonstrate that and certain MRI sequences or scans can show me. If the bone is inflamed and not healing or delayed healing, we can kind of make a judgment on do we attack that bone and try to stabilize it? So vertebral plasty is very simply we go in there and we inject cement under live x-ray. Kypho plasty is where we go in there and we put a balloon in to establish the height or we put a stent in to establish the height and then we inject the cement. So there's multiple approaches for this and every patient is treated and looked at individually and differently based on how the fracture looks. You mentioned something called retro pulsion, where the bone actually migrates into the back of the spinal canal. In very mild cases we can manage that with a vertebral plasty or a kyphoplasty. In very severe cases we really have to weigh our options and establish if that's really a surgical emergency and where someone like Dr Dabagi or Dr Denizzo needs to be involved. But this is one of those procedures where you know my approach to patients with a lot of injection therapy is you need to make the decision if this is something that you want.
Steven Aydin, DO:As far as compression, fracture and vertebral augmentation, i'm usually quite aggressive and saying this is something you're gonna need to do, especially if you're totally out of commission for several weeks, because then it becomes a risk as far as decline in function. You become dependent on medications, your quality life goes down and then you become a high risk for another fracture. The other thing we really need to pivot here and we offer this within our practice is bone health management. So, yes, i can fix any fracture, i can get in there and put cement, but the problem is that the patient has soft bones. So we as practitioners need to be very aggressive in offering osteoporotic management so that the patient's bone health is better, to prevent another fracture. Because once you get one fracture, whether you do a kyphoplasty or vertebral augmentation or don't, you are almost 80% or higher to getting another fracture without treating it. So yeah, 100%.
Robert A. Kayal, MD, FAAOS:I agree it's very important. We do have an osteoporosis bone metabolism center at the Kale orthopedic center and we're always on top of that with our patients because of the rising rate of compression fractures, hip fractures, distal radius wrist fractures, etc. So it's very, very important to address the underlying disease, not just the condition that the patient is presenting for. With respect to kyphoplasty versus vertebral plastic, how do you make a decision, which one to do? and you mentioned also you're injecting cement. Are you really injecting cement into the ball?
Steven Aydin, DO:Yeah, so vertebral plastic and compression kyphoplasty are similar but different. You know, one is purely just injecting the cement and the other is injecting cement after you've created a cavity or space for the cement. 90% of the time I'm approaching with doing a kyphoplasty because it has less risk of cement migration. But there are certain situations, like if there isn't Significant amount of height loss or there's just a line of fracture in this, in the top of the bottom of the vertebrae, and I just need to get a little bit of cement in that area, then I'll just perform a vertebral plastic Where we just inject the cement. So the cement is it is a biologic cement called PMMA, which is very common in the orthopedic world. So it's not like we go to you know hardware store, we get cement, pick it up. It's a biologic cement that's mixed at the time of the, the, the procedure. The cement hardens within 90 seconds after being put into the body. It has a reaction that then stabilizes interdigitates within the bone and kind of reinforces that instability that you have in that fracture.
Robert A. Kayal, MD, FAAOS:Yes, so it's. We do call it cement, but it's polymethyl methacrylate and it is a material that we use to fix, a lot of times, new replacements to bone, replacement to bone, shoulder replacements to bone, ankle replacements to bone. It's the same polymethyl methacrylate, pmma, that is used to I be injected into these compression fractures and we call it cement because it's cementing the bone together. So fractures her, broken bones her, because there's movement, either macro or microscopic movement, between the bone fragments and once you cement them in place there's no movement and the pain immediately goes away. So I'm very proud to have Dr Aiden with us at the Kaila orthopedic center. He's he's done so many of these kyphoplasties and vertebral plastic and mild procedures and certainly at cervical and lumbar epidurals and ficep locks. He's incredibly skilled, trained, personable, amazing bedside manner. We're just so happy to have him.
Robert A. Kayal, MD, FAAOS:One last thing before we go, dr Aiden, if you could just talk a little bit about up and coming fields of interventional pain management, for instance, potentially the field of regenerative medicine. Regenerative medicine is a hot topic in orthopedics, where we're regrowing things and allowing things to heal, as opposed to replacing things And fixing things with hardware. We're using our own body, stem cells, platelet rich plasma. You know different things like that. Can you speak to where we are in two thousand and twenty three In the field of regenerative medicine as it applies to interventional pain management? sure?
Steven Aydin, DO:so regenerative medicine is a very broad topic. All of a sudden, within the last twenty years, it's kind of gotten a lot of traction within multiple specialties. So when we say the word regenerative medicine, really talking about utilizing things like platelet rich plasma, bone marrow concentrate, and then there's the wordage of stem cell, that kind of comes in, which we kind of have to be careful with because technically a lot of what we do doesn't involve stem cell But PRP and bone marrow or FDA cleared. You can do and perform these procedures where you take the patient's own blood, process it without manipulating it too much And injecting it into regions whether it's an arthritic joint, a disk or a muscle or attended, and what you're doing is you're promoting this inflammatory response or bringing the. As I like to say, you're bringing the kind of tools that the tendon, ligament, bone needs, that maybe the blood of that patient is not bringing or there isn't a good blood supply to that region or a chronic injury that's going on That just has burnt out. From bringing the nutrients and the different factors that are responsible for healing.
Steven Aydin, DO:We've seen a lot of great results. There's a lot of research, there's a lot of data that is out there. I always tell patients that it's not snake oil, it's not the at all answer. You know it's not the thing that's going to cure everything, but it works as well as much of what we already have. So to have it as a tool within our practice and provide it to our patients whether it's for spine or joint issues, muscle tendon issues I think it's paramount. I mean, you have to be able to provide cutting edge technology and treatments to patients, especially when the research is kind of going in that direction and patients want that. You know, they don't want to always undergo surgery. And if there is a mild tendon tear and we put a little bit of PRP or bone marrow concentrate in that area and it allows it to heal without undergoing a surgical procedure, and that's great, you know, absolutely.
Robert A. Kayal, MD, FAAOS:Absolutely. I'm so excited to know that you're offering this for our patients in the area of interventional pain management. In orthopedics we firmly believe in using biological therapies and regenerative medicine to address some conditions not all conditions, but some conditions that have the ability potentially to heal if we could just add a little more biology. So in general in orthopedics things that are white, anatomical structures that are white, tend to be fairly denuded of blood supply. The blood supply to those white anatomical structures tends to be tenuous and precarious at best. Things like bone muscle have a very robust blood supply, so when they break they heal, when the muscles rip they heal. But certain things like ligaments, tendons, cartilage, things that are white, have a very low propensity to heal biologically without surgical intervention.
Robert A. Kayal, MD, FAAOS:Now we offer regenerative medicine. We offer the ability to add biological therapies like platelet rich plasma, bone marrow aspirate, etc. Like Dr Aiden was referring to, to help the patient heal biologically, providing those necessary ingredients that are not present locally at that site, like Dr Aiden so eloquently described. So we're very excited to offer these services at the Kaila Orthopedic Center. We're so happy to have Dr Aiden with us for many, many years now and we hope that this podcast was helpful for you. If you would like to set up an appointment with Dr Aiden, he is available in Northern New Jersey, in New York. Just call 844-777-0910 or go to kailaorthocom and we'll be happy to oblige. Thank you so much for your time today. It was a great, great time spent with you today and very informative and educational. Hopefully our viewing audience thinks the same, thank you. Thank you very much.