Dr. Yousef Saeed joins us today virtually to discuss current concepts in the treatment of low back pain. Dr. Saeed graduated from the University of Louisville with both a bachelor's and master's degrees in electrical engineering. He then completed a master's degree in public health at University of Kentucky, where he also went on to medical school. He completed a research fellowship in sports medicine at the Mayo Clinic. He then continued his internship and training at the University of Pennsylvania in physiatry and his occupational medicine residency at West Virginia University. Dr. Saeed is the new deputy chief of staff at the Columbia, South Carolina Veterans Administration Health System. He's an interventional pain management physician and also board certified in occupational environmental medicine. He's a clinical assistant professor at Uniformed Services University for the health sciences and the departments of PM&R. He recently arrived to this faculty position at VA after serving as the director of surgical services at the Texas Coastal Bend VA and also previously to that of the National Intrepid Spirit Center at Eglin Air Force Base, where he was the director of pain medicine and functional rehabilitation. This facility was the Air Force's first facility dedicated to treating the polytrauma of traumatic brain injury, PTSD, and chronic pain. Dr. Saeed has had the honor of serving his community in many ways, first as the assistant to the commissioner for public health for the Commonwealth of Kentucky. He is now currently serving on the US FDA medical device advisory panel, the orthopedic and rehabilitation device panel, and previously the plastic surgery and general hospital device panel, where he is an expert consultant and full voting advisory member. He's had the privilege to work with both CDC NIOSH and the Department of Labor, or OSHA, to improve worker safety and medical management of workers who suffer injuries on the job, and is currently a researcher to develop treatments and prevention strategies to reduce injuries in sonographers and providers who utilize ultrasound. The first registry of its kind in the United States, he also published the OEM competencies, the heat stress guidelines, and chaired and published the work-related musculoskeletal disorders and sonographers practice parameters for the AIUL. He, as I said, he's joining us virtually, and in the event of technical errors, we have pre-recorded, so we are going to jump into a pre-recorded thing that he has done. He will be available to answer questions live and in the chat. Hi, everyone. It's good to be with you. Sorry I couldn't be with you in person, but nonetheless, I will be able to attend and answer some of your questions to help elucidate some of the robust information you're going to hear in today's lectures. This particular lecture is focused on the low back. I'll also be doing some upper extremity disease, as well as the knee, but this is a fairly robust lecture, so hopefully we can get through it in an hour. I don't have any financial disclosures. I am an assistant professor of PM&R at UCIS, and effective today, I'm actually the director of surgical services at the VA Texas Coastal Bend, but at the time of the presentation, when, or I should say, the time of the symposium, I will be the deputy chief of staff for the VA in Columbia, South Carolina. So without any more ado, we'll get started. So the objectives of today's talk are really threefold. We want to improve clinical skills, improve your diagnostic imaging, and improve how you understand and utilize treatment care as it relates to low back pain, both with the VA and DOD guidelines. Today, we're going to talk about the spine. It's the largest segment of the body. It has the most significant function in terms of the range of motion. It's also an integrated role in both the upper extremity, lower extremities, as it articulates both with the bony pelvis and the rotator cuff segments, but you know, just distal to the scapular border. In addition, there's relatively few degrees of movement between each segment or each vertebral body, but collectively there is a large range of motion. It allows you to flex and extend rotation and side bending. There's lots of movements to the spine. Interestingly, when we talk about low back injuries, the primary mechanism is really when you're into that forward flexion position past that 50 degree mark where the moment has moved across the spine and bony pelvis and puts most of the load most severely on the lumbar spine segments, as you can see here. So I'm an engineer. I'm an electrical engineer, so I love talking about force and vectors, moments of inertia and certainly torque and shear and stress. And so when, again, when you're into that forward flex position, you can see that moment has now distributed more forward, which puts more disc pressure on the lumbar spine. So the same thing is true when you're in a seated position. When you're in a seated slash position, you have more, you have, you move that moment forward, you have more anterior disc pressure. And as you load the anterior disc, guess where the force has to translate to the posterior disc. So that's the biomechanics on how many disc herniations occur in the body. So when you load the spine, when you go into that normal standing position where the load is normal, but when you go into that slouched sitting position, again, the load is much higher on the L3 disc, which is the disc, one of the discs that's most vulnerable in this position. As we talk about COVID-19 and how many of us have had very sedentary lives and have been doing a lot of telework, this is going to be a critical, critical injury pattern that you see in those types of workers. The sedentary workers are the people that have been working virtually. I wouldn't be surprised if many of our colleagues that have been working virtually have injured their spine because of long periods of time of sitting into that slouched position. When we talk about lumbar support, the reason that we add those lumbar supports in the recumbency of our chairs is to ease some of that disc pressure. So it helps to deload that L3 disc when you add that component of the lumbar spine pillow or support along with recumbency to allow you to lean back in your chair. I want to talk about facet joints. The facet joints are the articulation of both the superior articular process and the inferior articular process. When those processes align, you get what's called the facet joint or the zygo-apophyseal joints. And so those z joints are just synonymous with facet joints and each vertebral body articulates with the next one. And so in this sagittal image, you can see that foramen where the nerve root exits and you can see this nerve that comes off of the lumbar nerve root and cervical nerve roots and innervates the joint. And so this is the pathophysiology on why people get facet joint mediated low back pain is that when this joint degenerates and it's a capsular joint, much like the knee joint, when you injure the capsule, you introduce many of those inflammatory mediators that allow deterioration of the joint itself. And just like in the knee joint, when we did minisectomies, virtually hundreds and hundreds of minisectomies in a day per surgeon, or I should say in a week per surgeon, were performed because of meniscal tears. Well, we don't do that anymore. The reason is when you introduce a camera into the capsule in the knee joint, it actually accelerates degenerative joint disease. And so much is the same when you tear the capsule in these facet joints and introduces inflammatory mediators and you get degenerative joint disease. And so one takeaway here is that I want to just point out that each medial branch nerve innervates the facet joint. It's a dual innervated joint. So the medial branch nerve below innervates it as well as the medial branch nerve above. And so if you're talking about medial branch blocks, the only way you can block one of the joints is to block both nerves. And so if you're doing a medial branch block to block three facet joints, you actually have to perform four blocks. So, excuse me, I want to talk about, I want to talk about discs and talk about the biomechanics of discs. They're actually very unique. They're shock absorbers of the spine. They're capable of resisting a shear and stress, torsion and compression of the spine and rotary torsion as well. And they are very durable in withstanding those forces. They're made up of two layers, the nucleus pulposus, which is that jelly-filled layer and the annulus, which is that fibrous layer that surrounds the disc. When you have a disc herniation or a tear in the annulus, those can be problematic also. But when you have a tear in the annulus, the nucleus pulposus may herniate out. When it herniates out posteriorly, if you're in the cervical spine, that could mean that you could get spinal cord compression or symptoms of myelopathy. If that occurs, you really need disc decompression, especially if patients are suffering from symptoms of myelopathy. When it herniates out and to the side, then you can get nerve root impingement. And those patients would have symptoms of radiculopathy or dermatomal, myotomal loss down the arm or the leg. Interestingly, in the lumbar spine, there is no cord, right? And so when you have a herniation that's a central herniation, if it's not laterally, you don't have a lot of pathology. So many people come in and they'll tell me, hey, I have this huge disc herniation at the L4 vertebral body. And I say, okay, well, what are your symptoms? And now I have pain in the back. It's not from the disc generally, unless they have discogenic pain, which I'll talk about later. If they have a posterior herniation and it moves laterally, then you can get symptoms of lumbar radiculopathy. And those symptoms generally are pain down the leg, weakness down the leg, et cetera, et cetera. And so when we talk about degenerative disc disease, this occurs over time. Many people have thought that the end plates are the problem with the disease. So you will see innervations in and around the end plates nowadays to try to help to restore the end plate so that the disc remains healthy. And I've talked about that in multiple occasions in my regenerative medicine talk. But as the end plates tends to sclerose, the degenerative disc starts to compress and it becomes more friable. And eventually you'll get collapse of that disc and osteophyte formation, which can be very painful. So this is what it looks like, a well hydrated disc on the left and a degenerated disc on the right. And you can see how fibrous that disc is on the right. And it doesn't allow for much distribution of the force across it because it's just lost its water content and its ability to resist some of those forces that we talked about. So when you're looking at plain film, although you can't get a definitive imaging of the disc themselves, you can only get that with MRI, what you can look for is incidental findings. So here, this is what the normal disc would look like. You can see a little bit of shadowing here, but overall that's a good disc height. You've lost the disc height here. You can easily say that's degenerative disc disease. You have no idea if there's a herniation though. You would need an MRI to investigate that. So again, disc herniation, torn annulus, the disc herniates out, compresses the nerve root. That's how you get symptoms of radiculopathy. Interestingly, if you only have a disc tear, if you have this annulus that's torn without a nucleus pulposus herniation, then you can get something called discogenic pain syndrome. And what that is is, I'll explain this to you here. As that annulus is torn, the body tries to repair it. It sends blood vessels to the area to perform the repair, bring some of those inflammatory modulators to start building fibrin back into that disc layer. What is the problem here with discogenic pain, much like pain in many other places of the body, when you bring vascular supply to heal, you also bring nerve fibers with it. And so as those nerve fibers attach to the annulus and the annulus is compressed, maybe it hasn't healed appropriately, those nerve fibers begin firing. Patients describe that pain usually in the midline without radiation. The facet load is negative when you put those patients into that lateral rotation and extension to try to grind the facet joint together. Those are all negative tests, but they will point to the middle of their back usually and say, this is where my back hurts. You sometimes can correlate that with an MRI. Sometimes you can do discography into the disc to try to pressurize the disc and cause discomfort. I'm not a big fan of that. I feel like there's a lot of diagnostic errors that occur with discography, but it is a tool at your disposal. So when we talk about back pain in the community, obviously primary care physicians see back pain the most, along with the specialists that see back pain at high rates also. When you talk about the lifetime incidence of acute low back pain, it's about 60 to 90%. And the annual incidence is just about 5% of the population. So it's the second to fifth chief complaints in primary care specialists. The natural history of acute low back pain is usually favorable. That's why many of the references and the practice guidelines will tell you not to do anything for 6 to 12 weeks. And that's generally true unless you have some symptoms of some type of nerve injury. And so if people are displaying symptoms of neuropathy or radiculopathy, you should start to investigate those symptoms first so that you can get them back to work, number one, and you can inflect their impairment and disability. Usually when it talks to chronicity now, that when you're out of that subacute phase and into the chronic phase, that's when you get real disability in this country. And back pain is the number one cause of disability in the U.S. for people under 45. In the VA, so as you know, I'm a VA clinician, but severe pain is 40% greater in veterans than non-veterans. So the reason that we suspect that is, is you think about the occupational exposures for our veterans. It's not just the rucking, but it's the door breaches. It's the blast exposure. If you're a paratrooper, it's the jumps. Those are those high velocity acceleration, deceleration injuries, much like in motor vehicle accidents. So in motor vehicle accidents, you get that whiplash injury, which actually tears the capsules in the facet joint. So a lot of people that have whiplash injury and have neck pain, it's related to their facet joints. And the treatment of choice is medial branch block and RFA for those patients. Interestingly, those patients have negative MRI findings, but have significant pain, and we all think it's because the capsule has been torn. However, the inflammatory cells have not degenerated the facet joints at the time of their injury. And so we have always suspected as time goes on and progresses, those patients would probably have higher rates of impairment and disability as they move through life. Also, 65.5% of US military veterans reported pain in the previous three months. Generally, low back pain is axial in 20% of patients. Some patients have sciatica. What I have found in my time, both in the Air Force, the DoD as a civilian, and as a VA employee, is that there's a lot of spondylosis. And we think that the amounts of facet joint arthropathy are much more significant than the general population. In fact, when you look at the odds ratio, veterans have a one and a half times higher odds of having severe pain than non-veterans. So a very statistically significant number. So let's talk about some classification and duration of symptoms. So acute is less than a month. Subacute is one to three months. Chronic is anything greater than three months. So where you want to do your inflecting is here in that subacute to chronic phase. If you wait too late and you let this injury go from subacute to chronic, you're going to see a poor return to duty. So when we talk about low back pain guidelines, and I'm going to hit the highlights from the VA DoD guidelines recently updated. But when clinicians conduct a history and physical exam, that is really a primary thing that needs to occur. And so sometimes there are veterans and active duty members that are seen prescribed anti-inflammatory medication without performing a good history and physical. And those patients, if they're lost to follow up, can lead to medical misclassification. Or they will end up medically retiring, unfortunately, because we didn't inflect their disease process early enough. So obviously understanding some of the psychosocial factors that are inclusive of any injury are important to performing good mental health screen. Make sure that you're recommending imaging for patients that don't have just localized pain, right? They have to have radiating neurogenic causes of pain. So if you suspect radiculopathy, go ahead and order the MRI. If there's inconclusive evidence, really for any type of other diagnostic imaging for patients with low back pain greater than a month, you should think about ordering some other imaging to find out what is going on in that patient. So obviously CBT is a primary indicator for treatment for acute low back pain, getting those patients mobilized in a multimodal program. What we used to do in the Air Force was a functional rehabilitation. So we did a clinician-driven exercise program where the clinician is in the room, the spine physician, and exercise with those patients to counsel those patients that, yes, you are going to have pain and that's normal. And as you progress, you may have more pain for about six to eight weeks. And once you hit that plateau in exercise, your pain will get better. But we're really there for a resource to help to construct their mental health pathway in a way that provides some positive feedback. Also mindfulness, clinician-directed exercises are great mobilization either through physical therapy or one of those functional rehab programs, acupuncture, and then exercise outside of their normal physical therapy. Some pharmacological approaches, obviously you can give anti-inflammatory medication like Celebrex, Diclofenac. You have to be careful. Gone are the days that you prescribe NSAIDs end on end forever, right? Because that large study that came out in BMJ that said that people that take anti-inflammatory medications are at higher risk for stroke and heart attack as well as increased blood pressure and kidney injury. And so what I tend to do with the anti-inflammatory medication, if they're in an acute or subacute population, I will prescribe them medication for two weeks on, and then they take a drug holiday off of it. If their back pain is still there after four weeks, then you can restart the anti-inflammatory two weeks on, two weeks off. You can also give them muscle relaxers that are non-benzoid in nature. Those would be things like Robaxin, Sclaxin, et cetera, et cetera. I'm not a big fan of Flexeril because we don't know the mechanism of action of the medication. In some patients it does work in, but I choose to use methocarbamol primarily because we do know the mechanism of action. It is a sedating medication, so I tend to tell patients to use a QHS at first. And if they're not sleepy after the first couple of weeks, then you can add it during the day if you want to do a BID dosing pattern for them. Other things that you can use are corticosteroids, oral prednisone. Those tend to work for people that have multiple complaints is all. You have to be very careful in obviously prescribing opioid medication. I would say that there's lots of alternatives before moving to that opioid, just because on the VA side we've seen it is very difficult to get people off of opioid narcotic medication as time has gone on. Obviously acetaminophen is a potent pain reducer. It's just not prescribed appropriately. So remember, you can get up to 3,500 milligrams of acetaminophen as long as you don't have hepatic disease, so hepatitis or you're not a heavy drinker. In order to get the pain relief effect of acetaminophen, you have to be above 2,000 milligrams. And so if it's the extra strength Tylenol that people are taking, that's usually 650 milligrams, you have to take it three or four times a day to get up to a therapeutic effect. It's a potent fever reducer, right? As patients are febrile, you can give it to your kids. At very low doses, it tends to reduce fever, but not for pain. And so I tend to tell patients, hey, you're not taking your Tylenol, right? Take some Tylenol. It really works. You gotta just take it throughout the day. You can't give them 2,000 milligrams in one dose. It has to be spread through the day or else you will have a patient that goes into acute hepatitis. Some other medications, and I'll share this, my talk in a PDF form so that you can review it. But these are dosing for select pharmacologic agents that I use both in the muscle relaxers. Antidepressants work very good for chronic pain. And so I tend to use the Loxetine or the Cymbalta for patients that have complaints all over their body. Remember, you have to load those patients up slowly. You have to check them for suicidal ideation or homicidal ideation as you're dosing them appropriately. All right, so now let's move into some of the interventional treatments for low back pain. So for patients that have symptoms of radiculopathy, the BADOD guidelines do give you the option of offering an epidural injection. And so there's many different ways to perform an epidural injection. The most familiar for many clinicians is an interlaminar epidural injection. It's the same type of injection that occurs in pregnancy as patients receive their anesthetics prior to their blocks before delivery. You do get some benefit from epidural injections. I tend to use, in the lumbar spine at least, I tend to use a different approach, which I'll describe to you. It's a very old approach, but I've seen much more efficacy in this approach versus the interlaminar. Now, the caudal epidural is what I'm referring to. It's kind of the shotgun approach. It treats multiple disc levels in the lumbar spine. That's why I like it. There's one other approach called the transforaminal approach. I don't ever do transforaminals in the cervical spine because you're at risk for injecting into the vertebral artery, but I will do transforaminals in the lumbar spine. The caudal is like the shotgun approach. The sniper approach is more like the transforaminal injection. So you're entering the nerve root itself and injecting injectate to help to reduce the inflammation. There are some other ways that we can intervene. You can do facet joint blocks. Now, I'm not a big fan of facet joint blocks. And the reason is we know that steroids tend to, when we put them in the knees, when we put them in the shoulders, it tends to deteriorate. It has a toxic effect to the chondrocyte. It has a toxic effect to the tenosyte. And so what we tend to do nowadays is, is yes, we still offer steroid injections for various diseases, but we limit how much steroid dosage that you receive in a year. You want to be careful of adrenal gland insufficiency as it relates to steroid dosing too. So no more than three to six doses of steroid, whether it's oral or a local injectate per year, as you want to try to remove some of those deleterious effects. Some other injectates that you could try are not in the spine necessarily, although we are doing PRP into the spine now. And I'll talk about that later. According to the VA DOD guidelines, there's inconclusive proof that medial branch blocks and RFAs work. I can tell you from our approaches to spine, spondylosis in particular, without any other symptoms. And so, and many times the VA patients that I receive, it's not one disease, right? They have, not only do they have spondylosis, they have listhesis, they have degenerative disc disease, they have disc herniation and radiculopathy. So you try to remove symptoms one at a time in their treatment pathway until the patient has really become more functional in their life again. And so remember, time is of the essence. So you have 12 weeks to really inflect the disability curve. And so 12 weeks is that magic number. If you don't get those patients in that subacute phase, which extends to three months, mind you, which is longer than that 12 week mark, it's right at the 12 week mark, I should say. But if you don't catch them in the subacute phase and they move to chronic, their chance of disability is much higher. And so one thing that you should all be doing in your history and physical is looking for red flags. And so what are some of those findings? The cauda equina syndrome is probably number one. So it occurs, although this image is probably not the best image, because this looks like L4, but there's no cord at L4, so it'd be much higher in the spine. But let's say for instance, there is a disc herniation that's compressing the cord at a higher level, and it's causing a neurogenic bladder or incontinence of the bladder or spasticity of the bladder. Those are all reasons to order higher levels of imaging tests and immediate referral to a neurosurgeon. So some other red flag syndromes, some other red flags that you should be looking for are cancer, don't ever forget about multiple myeloma, prostate cancer, primarily metastasizes to the lumbar spine, fracture in your older patients, and even your jumpers can have vertebral body compression fractures. And you have to get to those patients in a very limited time, because in order to stabilize those vertebral body compression fractures, you have to inject cement into those, it's called kyphoplasty. Kyphoplasty helps to retain the articular surfaces of the vertebral body, it does not help in pain, and actually it's probably a pain generating procedure. But as the patients age, if you have not intervened and performed kyphoplasty in a vertebral body compression fracture, what will happen is the vertebral body will slowly compress over time, and it will cause listhesis of one vertebral body over the other, which ends up causing nerve root entrapment, degenerative disc disease, facet joint hypertrophy, all those concomitant injury patterns that we see in the spine world. Other things that you can also order is obviously your SED rate, your white count, you want to make sure that the patient does not have meningitis, make sure you order the UA, MRI, CTs, but remember, don't wait while you're getting the MRI, just go ahead and refer to the surgeon. So for a diagnosis of cauda equinae, this is the functional criteria. They only have to meet one of these for them, for you to refer, bladder or bowel dysfunction. So that's why in every history and physical I take, I ask them about their bladder or bowel function. And the veterans, they generally already have bladder dysfunction as they have elevated PSAs. However, I always ask questions related to, have you had any new changes in your bowel and bladder continence? Any sexual dysfunction? Do they have impotence? Do they have problems with point and shoot? All those are related symptoms and certainly paracetamol in the saddle area. Some of the features that you should be looking at, obviously in young men in your active duty population, you should be ordering HALB27 if those patients, there's some concern of ankylosing spondylitis. And so remember the onset is usually 40 years old. So it's in that active duty population. If you see on x-ray, if you see fusion of the SI joints, but without involvement of the lumbar spine, go ahead and order the MRI to confirm, give you some secondary ideas of what's going on in the lumbar spine. If you see that bamboo spine on x-ray, go ahead and order the HALB27 because if you can put that patient on disease modifying medication, you can save their quality of life as they age through time. It's very important that you do that. If you see fusion at the, it's much like avascular necrosis. You may not catch it on the x-ray, but on the MRI, if you're able to catch AVN of the femoral head, you could do cord decompression, and that's a good synonymous case with ankylosing spondylitis. So obviously intra-abdominal pain is very concerning. You should be ordering your KUVs, the ultrasound of the abdomen, all those normal CT of the abdomen, obviously to look for pancreatitis, prostatitis, pelvic infection, et cetera, et cetera. Don't forget about herpes zoster. So herpes zoster is, you get that dermatomal pattern around the abdomen or the thoracic chest. It usually involves multiple dermatomes, so don't be fooled. Interestingly, it's usually unilateral. And so I have seen cases of herpes zoster. I have treated them with a thoracic epidural injection, which helps to limit the duration of their symptoms. So don't forget, you can do some interventional procedures to help people get through their time-limited disease too. So when it comes to pain diagrams, don't get them because this is what you get back. Most of the veteran patients, they do have pain everywhere because they have a lifetime of occupational exposure that has caused multiple areas of concern for them. So the way that I tend to approach pain, obviously it's an unpleasant sensory and emotional experience, but pain is generally subjective. So we've moved away from the VAS scale to more functional goals. So what can I do to help you with your ADLs, for instance, or what kind of sports do you play? Do you play golf? What's limiting you in your golf game? You can't rotate? Well, maybe you have spondylosis that we can help you with. Other, you know, I tend to watch patients walk into the office and look at their pain behaviors as they come to see me and as they exit as well. See if they have any braces or collars. You know, the famous Waddell signs will certainly teach you as you practice medicine for long periods of time that there are always other reasons for secondary gain or somatization and realizing that will help you in your exam. So when I'm looking at the gate as they walk, I'm looking for their arm swing, I'm looking for the cadence, I'm looking to see if they have any leg circumduction, how their stance time, you know, what their swing time looks like of their feet, how their heel strike looks. Sometimes you can gauge whether or not this is really back pain, or maybe this is more hip osteoarthritis, or maybe this is a can deformity, or, you know, maybe there's something else going on in the hip that we need to look at either diagnostically or therapeutically for the patient. I like to also perform a static stance evaluation. Usually the dimples on the low back are right at the PSIS. At L4-5 is usually where you wear your belt. And so I tend to tell patients, and if I'm trying to figure out where their low back pain, is it above the belt or is it below the belt? Or is it at the belt line? If it's at the belt line, that's a little bit harder to understand because it could be the facet joints. But if they say it's at my belt line and above, I tend to lean towards a facetogenic pain or discogenic pain. If it's at the belt line and below, I tend to look at problems in the sacroiliac joint, the piriformis muscle, the cuneal nerve, et cetera, et cetera in the posterior thigh. And so that's a good defining moment for you in your exam. I always like to talk about motor strength testing because I do a lot of chart reviews. As the chief of my service and soon to be deputy chief, I have to do a lot of peer reviews. And so when I'm in the process of doing peer reviews, especially from many of my colleagues, they don't really understand motor strength testing. There's no four plus, there's no three plus in motor strength testing. There's just five, four, three, two, one. And so this is the definition of them. And please use this primarily in the way that you're providing your feedback for other clinicians. When you talk about dermatomes, so dermatomes, this is that classic dermatomal pattern that you see in up-to-date. I tend to do a pinprick if I'm trying to isolate a level where the patients have radiculopathy. And so remember, when you're doing your pinprick, the dull side is not sensitive. The only side that's sensitive is sharp to pain and temperature. And so I tend to use sharp all the way down the leg. And I tend to just to throw in a dull just to keep the patient entertained, just so that they know that I'm not really testing sharp all the way through. But sharp is the diagnostic test. It is not the dull. Okay, core stability testing. So in your patient population, active duty members, the core should not be as much of a problem as it is in the veteran population. But understanding people's core stability will help you understand whether or not they're gonna have good functioning in a physical therapy program, especially if it's not a high-end athletic training program that we see in our special forces soldiers. If it's a Pentagon leader, for instance, they may not have as tight of a core and you may put them into a core stabilizing program to help to improve their low back pain. Remember your reflexes, the patellar reflex is L234. The Achilles is S12. Remember it goes from two plus to one plus to no reflex, right? And so just remember that hyporeflexolia is one, no reflex is a zero. All right, and then just remember if they have a very active and brisk reflex, that's a three plus. If they have a reflex on the contralateral side, which happens, especially in patients with cord issues and or significant radiculopathy, they may have clonus on the contralateral side. So keep an eye on them. So dural tension signs, this is how we evaluate patients for signs of radiculopathy. Remember one diagnostic test is not conclusive in terms of exam findings. You really need to perform multiple tests to see if that patient is really a positive for dural tension. And many times the dural tension tests will be negative and they still have symptoms of radiculopathy. And that's okay. You treat them as they come. And if they have those findings, a positive straight leg raise, a positive slump test, you can see here we're doing a femoral nerve stretch. I wanted to put the picture in so you know what that looks like. This is the seated slump test or a seated straight leg raise. As you can see, you can put that patient into a really forced flexion. And what you're looking for is symptoms down the leg. When you ask them to lift their neck up, it can propagate down the leg also. So just keep that in mind when you're performing the normal straight leg raise when the patient is prone on the table. Remember, people will raise the leg up to 70 or they'll leave it below 30. Those are not sensitive areas for the test. You have to be within the 35 to 70 degree mark for you to make a conclusive test. So make sure you're performing the test correctly. Let's talk about the epidural space. So the epidural space, you can see here, this is the pedicle. These are the pedicles as they kind of come around. And that tent-like structure is the epidural space. And because it's tent-like in the posterior end, it allows entry either by needle or by catheter if you're coming in lower. The problem, and this is the reason that my preference is not to do interlaminar injections. Interlaminar injections, you come from right next to the spinous process into this tent-like structure and you inject steroid in this tent-like structure. When you inject it, it goes up and down. Well, that's not where the problem is, right? The problem is at the disc. It's anterior to the epidural space. And so the only injections that will get to the anterior disc are transforaminal injections, or if you come from below and inject above, the caudal injection. And so I will try interlaminar injections if I can access it through a caudal or a transforaminal injection. All right, so when we're doing a transforaminal approach, this is where we're trying to enter at. And so you can see this large plexus of arteries and veins is in the way if I try to approach it posteriorly or straight in. Can't do it. You have to turn into an oblique position. So remember that targeted approach from the side allows entry right next to this nerve root. And it's the only procedure that can inject right at the nerve root that the problem is in and to help to decompress that disc. This is the caudal approach. Now, the caudal approach is fantastic. I can get injected. The sacral hiatus is right at the top of the butt crack, basically. That's where the entry point is. You bring your needle in, you enter through the sacral hiatus. And when I have injected contrast through the sacral canal, it forms this column that travels all the way up all the spine segments, usually till about the L2 disc. And so I am very confident in treating disc herniations at L3, L4, L5 using a caudal approach because I know that my injectate will travel that high superiorly. Now when you approach it below and that disc herniation is out and it's herniating inferiorly, what I like about the caudal is it's the only approach that allows you to put pressure on that disc up that column to try to repressurize this, try to get that disc mobile off the nerve root. And so you're not just flushing the disc out with inflammation, but the goal is to repressurize that disc and get it more mobile. And so I found that to occur. There's been a small study out of Korea that actually showed that when you do epidural injections, patients go from large disc herniations to smaller disc herniations. And sometimes that happens in time too. These disc herniations, they propagate out and they coalesce back in on their own, which is why we say you should watch and wait for some time. But if they're having symptoms, neurogenic symptoms, then you should evaluate them by MRI and see what the problem is. So going back to those facet joints, if you remember, I told you that they're innervated both by the superior medial branch nerve and the inferior medial branch nerve. And so that dual innervation allows you to, in order to block one joint, you have to denervate two medial branch nerves. And the process of denervating that medial branch nerve, you may affect the multifidus muscle. And so that is one thing that we found when we do RFAs is there have been some reports of atrophy of the multifidus muscle. However, if patients are in a core stabilizing program, that helps to keep that multifidus activated. And there are other ways that the multifidus gets innervated much, much higher by that intermedius, that intermediate branch in the lateral branch too. So ensuring that they have good paraspinal recovery after RFA is really very important. I prescribe all of my patients core stabilization after RFA, radiofrequency ablation. So now let's talk about some controversy. So when we talk about medial branch blocks and whether or not a patient gets relief, whether it's 50% relief, which is just a flip of a coin. So that's why we tend, at least the good interventionalists don't perform one block anymore. We perform two blocks. So if we do comparative medial branch blocks with greater than 80% relief in their symptoms, then the false positive rate drops to around 27 to 29%. Now, when you increase the odds, so that's that concordant comparative medial branch block that gets you up to 80%. If you have 80% relief, you can be more confident that the RFA will work for the patient. And so that's why we do two blocks nowadays. And it gets you at almost perfect versus the one block or no blocks. Now, whether that is financially acceptable to the healthcare system is another story because now we're adding a second procedure. Although it's a fairly risk-free procedure, it's still adding another procedure to the system. So we will, as a society and as a group, will need to take that to task. Interestingly, when we do that intra-articular block and we increase our threshold for pain, if those patients get 100% relief in their symptoms, the false positive rate drops even lower. And so what I want to encourage you is for your interventionalists that you're referring your patients to, find out what their diagnostic criteria are. And so I tend to look at that 80% mark. I would say 90% of my patients at this point, I do about 3,000 a year, 90% of my patients have 100% relief in their symptoms as it relates to the low back. If they get 50 to 60% of relief in their low back, I do make them do a second block because I think that it's important to really give them perspective on what their relief will look like after RFA. I love to hit home runs, but it's very difficult, especially in our patient population with multiple painful etiology and their exposures primarily. So now let's talk about RFA, another controversy. So at least 80% relief following the controlled medial branch blocks. In this particular study, 87% of patients had 60% of relief that lasted 12 months, where 60% of the patients had 90% of relief lasting at least 12 months. So they use big electrodes here, 16 gauge electrodes with two lesions. Interestingly then, when we look now at the next study, this is the McVicker study, which had much more, a larger study population, and they had 100% relief of pain following controlled comparative medial branch blocks. So 56% of patients obtained 100% relief for at least six months. The pain relief corroborated by complete resolution of their ADL cessation of medication, and they went back to work. The median duration of pain relief was 15 months, and they had 100% relief in their medial branch blocks previous to the RFA. Now let's look at the Dreyfus study. So 60% of patients, that's that first study, and this is a smaller patient population. It's the first study that I talked about. I actually put that slide in twice. So when we look at some of the level one evidence, and this is the problem in much of the medical literature is, in the level one evidence, the studies aren't very well done. And so you can see there's really no benefit or minimal benefit that many of the level one studies have shown. And they don't use medial branch blocks. They're performing intra-articular blocks, which we don't do anymore. They're doing single blocks instead of that dual comparative block. And 50% relief is not high enough relief. It's a flip of a coin. You can attribute some of that to the placebo effect. They use really poor technique also. They're anatomically inaccurate. The electrode is not perpendicular to the nerve as it should be, and they use these small gauge electrodes. And so here's a study that is cited routinely in some of the practice guidelines, and this came out in the Clinical Journal of Pain by Von Widgick and Gertz. And you can see I've put my magic marker and I put some electrodes where they should have been placed and how they should have been placed on the spine to show you why this level one study is a fairly poor study. So this is where the medial branch nerve should be. You can see these electrodes are nowhere close to where that medial branch nerve is. So you cannot be performing neurotomy at these levels unless you're on the nerve. And so you have to be on the nerve. You want to get the largest cross-sectional area, so that's why you use that perpendicular approach to these nerve burns. So let's move on to the next subject, which is the sacroiliac joint. It forms a closure that is really a dual closure, and so there's really nothing that connects the sacrum to the iliac bones, except for a couple of muscles and ligaments that forces it closed anteriorly, and then it forms a closure posteriorly. But what it's important for is the motor control, the timing, and sequence of muscle activation and release. So how do you activate, or how do you assess, I should say, the SI joint? So you can do a sacral winging where you grab the PSIS and you pull down, and you're trying to grab the SI joint together. You can see that here. You can force the GTBs together when the patient is standing, and sometimes they'll feel pain relief with that maneuver. But some other tests that you can do are the Patrick's test, also known as the Faber's test, flexion, abduction, external rotation, Gainsland's prone hip extension, and compression testing. So just like any other testing, one test isn't enough for you to make a diagnosis. If you have two, three tests, three provocative tests that show pain below the belt line in the same area that you're testing in, then you can conclusively say, I suspect this is sacroiliac joint dysfunction. How do you intervene at the SI joint? You put a needle in it. So you put a needle in it, you can inject a steroid, you can inject PRP, you can inject bone marrow aspirate, some of those regenerative medicine techniques to help the patient with their pain. And generally, if they have spondylosis, this does not help pain above the belt line. This is only for relief below the belt line at the SI joint. So some common back pain misconceptions that I should rest my back until my back pain goes away. My back pain means I have really significant biologic damage. This is some of that re-education and counseling that you have to perform with your patients. X-rays and CTs can always identify the source of my back pain, and that we can cure your back pain 100% of the time. I never tell my patients that, and I always try to reinforce with my patients that, hey, I may not be able to fix everything, but I'll do my best. And I think I can improve the quality of your life. One thing that I want to mention here is when you order an MRI, MRIs aren't, don't tell the whole story. So remember that Wittenberg and the SAVAGE study showed that really, if you perform 100 MRIs on patients, 90% of those patients will have imaging findings consistent with the pathology, but they are actually not pathologic. And so just be careful. This is what degenerative disc disease looks like. You can see on this T2-weighted image, it's dark. This is a disc herniation. This is a disc herniation hitting the cord, okay? This is what the disc normally should look like, nice and bright, just like in these 2T images here. It's a well-hydrated disc, okay? If you see a disc herniation, what you'll notice is that nerve root exits, you'll see a little outpouching of the disc material here compressing that nerve root against the bone as it exits. And so that's what you would look for in an axial slice on MRI. So make sure you're getting your patients back to activity right away. Obviously, they're worried about reinjury. That's going to happen one way or another. And so if they do less at the acute and subacute time, they're going to have worse debilitation as they age in the injury itself. When those subjective concerns exceed any of the objective findings, you should certainly move away from a focus on pain and move towards that focus on function. What can you do with your life? You know, what can you do now? Because you may not get better from this. Remember, the primary disabling feature of low back pain is a diagnosis of low back pain. So once you have it, it's hard to get rid of it. So I hope that helps you clinically. And we'll move on to our next subject now. Thank you. Saeed is on live and would like to talk about some of the difference between General Achmed and Active Duty Achmed. Would you guys like me just to bring him on live? Sure. All right. Let's me. Hi, everyone. It's good to be with you. It's good to be with you, too. And screen sharing has stopped. Good. Dr. Saeed, can you hear me? You're muted. Yeah, I see that. Let me see. Stand by. We have you muted out there. Now, you can now unmute yourself, sir. Very good. Very good. There we go. We got you. All right. So as you saw the video stop there, so we'd like you to go ahead. And if you have anything you'd like to say about maybe associating back to General Achmed from the active duty population, that would be a good place to pick up. Sure, sure. I'm happy to talk about that. As it comes to the active duty population, obviously, there's lots of occupational exposures, including rucking door breaches, firing the carl goose off, jumps and deployments. Obviously, all of those exposures really predispose our veteran population to lots of low back pain. And so, obviously, what we see in the VA are facetogenic complaints, are discogenic complaints, or some compendium of both of those pathologies. And so, it really has predisposed us to really looking at both of those disease pathologies in the continuum of care. And so, we will oftentimes perform medial branch blocks and RFAs and epidural injections to try to treat, you know, pathologies as they come up. You know, obviously, we want to avoid some of those fusion surgeries, the T-lifts and P-lifts, because obviously, we have lots of issues compared to adjacent segment pathology. And so, that's kind of where we are in the VA and the DOD. I'm happy to take questions as it relates to spine pathology, especially in the lumbar spine, and certainly the cervical and thoracic spine as well. Anyone have any questions, comments? Some of our physicians are involved in the disability rating system as well. Any comments? All right. We are coming off of a postprandial lecture here. So, the room is kind of quiet, but I don't have any current… Nope. Sure. I have one question. How many steroid epidurals would be the maximum supply, even for a short period? I mean, at the beginning, no chronic use, but initially, how many? In the acute or subacute phase? Acute. In the acute phase. The question is, in the acute phase, what is the appropriate amount of steroidal epidural injections to treat them without over-treating? Yeah. So, excellent question. And so, when it comes to the serial injections, gone are the days that we used to do a serial three, serial four epidural injections. So, what I would recommend, per the latest guidance from not just the ASA, but the Spine Intervention Society is, you do an intervention and you evaluate that patient in continuity and see how durable the effect is. And so, what I generally tell my patients are, you know, kind of the following. You know, I'll do an epidural injection, whether it's a caudal epidural, transforaminal, interlaminar injection, and I'll evaluate you in time. And so, let's say, for instance, you get six months of durability, and then your symptoms start to come back, I will intervene again at the six-month mark to try to help alleviate the symptoms. But gone are the days where that serial three has kind of gone without any outcome evaluation. Those days are over for the pain community, just so everyone's aware of them. Yes, sir. Could you address the PRP and prolotherapy? Did you hear that question? Yeah. That's an excellent question, actually, because, you know, that is my bread and butter right now. So, when it comes to orthobiologics, PRP, prolotherapy, so to speak, i.e. using dextrose to try to inflame tissue, those therapies have shown great evidence in soft tissue. And so, for those patients that suffer from, let's say, tendinosis, chronic tendinosis, tendinopathy, orthobiologics seems to be the go-to mechanism with and without tenotomy. And so, I would counsel those clinicians that are making those recommendations for orthobiologics to also include the tenotomy injury to the tendon to restart that regenerative pathway, and then introducing the PRP, the orthobiologic, to vascularize the tenocyte in that the inflammatory phase recycles and starts into an acute phase. Those are all excellent procedures at this point. Now, when it comes to joint disease, the literature is to be determined. And so, we are waiting to see how the literature elucidates some of the mechanisms of the chondrocyte in restoring the chondrocyte levels and restoring, I should say, remissing some of the osteophyte levels. That is to be determined at this point. There is some good evidence now when you introduce visco-supplementation with orthobiologics. There is some preponderance of the evidence that shows that that may be the more efficacious treatment for joint disease. So, for soft tissue disease, PRP, orthobiologics may be the gold standard at this point compared to steroid injections. For joint disease, the literature is to be determined at this point. Excellent question. I love hearing that. In our veteran population, I generally talk about the dichotomous nature of steroids and orthobiologics. And most of the veteran population that I see choose for, they make a choice for autologous orthobiologic treatment versus the steroid injection currently, just so everybody is tracking that. Awesome. Great. Well, thank you very much, sir. I greatly appreciate the presentation. Happy to be here with you all. Thank you, sir. Talk to you soon. Thank you. We look forward to seeing you in person at a future meeting. Very good. Happy to be there. All right. God bless.

pain management

low back pain

Dr. Yousef Saeed

lumbar spine

epidural injections

radiofrequency ablation

orthobiologics

PRP

veteran health

COVID-19 remote work