Episode 9 - Worth a Shot? Spinal Injections with Dr. Andrew Sumich
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Not to be mistaken with the epidural administered during pregnancy labor and prior to childbirth, injecting medication to the spine has been an option widely considered by patients with low back pain. Whether they experience leg pain or not, or if their inflammation is related to disc herniations, more people are asking for this type of treatment. But did you know that, in particular, epidural steroid injections are not the best course to treat back pain?
This week’s episode features Dr. Andrew Sumich of Carolina Neurosurgery and Spine Associates, whose expertise revolves around musculoskeletal medicine and interventional spine care. He dives deep into the role of spinal injections as it relates to alleviating back pain, particularly steroid injections. In particular, he makes the distinction of an epidural steroid injection, which is better for relieving symptoms and helping the physician make an accurate diagnosis.
Dr. Sumich shares the different techniques used to administer medication to the spine and what they’re typically comprised of. While these procedures are relatively safe, there are still some risks present. However, if the right equipment is used and a skilled doctor is following the processes, then the chances of any serious complications are minimal to none. Though this is the case, he also cautions about having too many injections done frequently. This means that the treatment may not be effective and a minimally-invasive surgical procedure may be a better alternative.
For Dr. Sumich and Dr. Lakhvia, common sense should rule when it comes to using spinal injections for back pain. You should always consult with your doctor to know which option is the best to treat this problem.
Key Moments In The Episode
- Role of spinal injections for back pain - 06:12
- What is an epidural steroid injection - 07:11
- Techniques to inject steroids for pain relief - 09:30
- Risk and complications - 11:24
- Transforaminal epidural steroid injection vs. selective nerve root block - 12:52
- Types of medication administered and what happens during the procedure - 15:02
- Risk for spinal cord injury - 16:32
- Deciding factors for choosing surgery over epidural steroid injection - 21:07
- Number of injections usually done - 24:38
- Other options for back pain - 27:51
- Research on biologic or regenerative agents for back pain - 30:56
- Challenges to disc healing - 34:29
- Personal approach to maintain health and wellness - 42:30
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia discusses vitamin D, which is not only essential to maintaining good health, but can reduce back pain. This is because this fat-soluble vitamin can control inflammation by lowering levels of C-reactive protein and inflammatory cytokines.
The correlation was seen in a study that showed a strong reduction of pain in patients who were given 3200 international vitamin D supplements every day for 5 weeks. More research is still being done, but the results have so far been positive. So, if you’re planning to consume more vitamin D, consult with your physician first and have your vitamin D levels checked.
Links Mentioned In The Episode
- Intracept procedure
- Preoperative Supplementation with Vitamin D, Attenuated Pain Intensity and Reduce the Level of Pro-Inflammatory Markers in Patients After Posterior Lumbar Interbody Fusion, Frontiers in Pharmacology Journal, May 2019
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery and Spine Associates, where providing personalized, highly skilled, and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 00:33
Welcome to the ninth episode of Back Talk Doc. Thank you for taking time to tune in. I cannot believe we've come up on this episode. Our first few months have been real exciting. Before I get started with today's guest, I want to take a moment and thank you, the listeners, as we've hit, nearly hit our 1500th download of our episodes, which really for me is quite exciting. Again, our goal on Back Talk Doc is to educate people about all things related to their spine so you can make informed decisions about your healthcare. So number one, thank you for that. It really inspires me to continue to put the work in and get good information out to you.
Sanjiv Lakhia: 01:11
Today's topic is one that we encounter routinely and that is the idea of spinal injections to help alleviate back pain and sciatic type pain. I have a real genuine expert, colleague of mine, Dr. Andrew Sumich today, who is going to really break down all things related to spinal injections for us and give us the true information and help kind of clear up some of the misinformation that's out there. Andrew, who we like to call Turtle, and I've known him for quite a while now, did his residency at Carolina's Medical Center and I had the pleasure of training with him during residency. He then went on to do a fellowship at the Interventional Spine and Musculoskeletal Medicine Orthopedic Specialists for the Carolinas, and has been with Carolina Neurosurgery and Spine Associates ever since. So I really enjoy practicing with Turtle and consider his knowledge to be indispensable and he's really been a good mentor for me and my career. So Turtle, thank you for taking the time and welcome to the show.
Andrew Sumich: 02:11
Thank you, Sanjiv. Great to be here, and thank you for the kind words.
Sanjiv Lakhia: 02:16
Absolutely. One thing I wanted to point out to the listeners is that you have done a fellowship in interventional spine care and I know many people understand medical school and residency, but can you tell patients out there who don't really understand what a fellowship is what that entailed for you on a day-to-day basis and how long that lasts?
Andrew Sumich: 02:33
It was an extra, in this case, an extra 14 months of training in a little bit more specific area of interest within the broader range of our specialty, which is of course physical medicine and rehabilitation. So my interest was in musculoskeletal and interventional spine. So I spent those 14 months with Dave O'Brien and went to Salem doing that fellowship, and it is very much kind of hands on patient care-driven. If I remember, I think I probably started out running my own clinic probably five or six half days a week, because that is something I would have been comfortable with from residency and then shadowing him in injections for those first four to five weeks and he slowly lets the reins off until you're... by the end of that 14 months, you're essentially having your own practice under his umbrella.
Sanjiv Lakhia: 03:25
So it's a lot of supervision by experts in the field to teach you how to perform these procedures safely and accurately.
Andrew Sumich: 03:33
Correct, and a lot of it's hands-on, just the mechanics of doing it. It's supplemented with didactics and reading and other internal clubs and other type of more book educational things that are necessary, but the real meat of the fellowship is kind of hands-on training and having somebody to show you how to do it and somebody with you to guide you as you're doing your first one.
Sanjiv Lakhia: 03:56
I know when we were in residency, we went through quite a bit for physical medicine and rehab from brain injury and spinal cord injury. Can you explain to our listeners what kind of directed you down the path of spine care and the fellowship in particular?
Andrew Sumich: 04:11
The answer to that is probably further back in medical school in taking physical medicine and rehabilitation to begin with. I had this idea, well, I guess the top of the decision tree was more do you want to be a surgeon or not? And I didn't have great experiences for me in my medical school rotation, so I kind of knew early on I didn't want to be orthopedics or general surgery or neurosurgery for that matter. I also was kind of interested in at the time what I would have called sports medicine and probably what I was really talking about was musculoskeletal medicine, and there's a couple ways to do that. One was through internal medicine or family practice, and the other was through physical medicine and rehabilitation. My rotation during that drew me to physical medicine and rehabilitation. I found it more interesting, more engaging, and kind of more useful to me.
Andrew Sumich: 05:04
Then as we got into residency, to your question, there was this musculoskeletal interventional spine which was kind of lumped together in a specialty at the time, and I did get drawn more to some procedural hands-on things, so that's how I ended up kind of more interventional spine.
Sanjiv Lakhia: 05:22
I think it's real interesting how our field is so diverse that even when you subspecialize like you've done, I think that training we had in residency still serves us on a daily basis as we evaluate patients, just to make sure we're not too boxed in to certain diagnoses. So I'm really glad you went the route you did and this has been really great practicing with you. Let's dive into our topic of the day, which is spinal injections, and in particular epidural steroid injections. Certainly there's a lot of press about epidural injections each year and the recommendation and the guidelines on how to perform these and take safety measures really evolves over the course of months to years. So as it pertains to lumbar disc herniations and low back pain with or without leg pain, describe to the listeners where you see the role for spinal injections in particular.
Andrew Sumich: 06:12
The role for injections really has to be separated from the back and leg pain part of things. The reality is, particularly epidural steroid injections, they don't do a great job for back pain. They can help and they do an okay job, but where I think there's much more value is for the leg pain, what we would call radiculopathy or that pinched nerve type pain going down the leg. An epidural steroid injection is much more useful and effective for that.
Sanjiv Lakhia: 06:40
If you're listening at home, that's a key point to write down, that the epidural steroid injections work far better for the radiating pain down your leg than for classic chronic low back pain so I'm glad you recognize that. Even backing up a step, I'm sure you get this question a lot, can you clarify for our listeners what exactly an epidural steroid injection is and how this may contrast with "epidurals" that are given to women during the childbirth process.
Andrew Sumich: 07:11
Sure. So an epidural steroid injection is placing steroid into the epidural space through an injection, that's typically done under fluoroscopic guidance which is x-ray guidance with the purpose being putting the medication into the epidural space at a particular level to help relieve symptoms and potentially help with diagnostic information. We will refer to those as epidurals. What is also referred to as epidurals is the epidurals that a woman would receive in labor or in delivery, and clearly these are different. They're with different purposes and different intentions and different techniques. The biggest difference is nobody's in labor, so that makes things a lot easier. The purpose of the pregnancy epidural, or the labor and delivery epidural, is to deliver anesthetic over an extended course of time, essentially the labor duration. So that is done by inserting a catheter into the epidural space and leaving it in there to distribute the anesthetic medicine over a course of time.
Andrew Sumich: 08:16
So one, that's a bigger needle in order to access that space, so it's a little more traumatic experience. The other really big difference is the use of the fluoroscopy or the x-ray. In our case for pain procedures, we can use it and it makes things a lot easier on the patient and the physician. In the case of pregnancy they can't use it, because they do not want to radiate the baby, and so it's done through good technique, but still more challenging because it's done through feel as opposed to visualization.
Sanjiv Lakhia: 08:50
Yeah, so it's a blinded technique versus a guided technique and there's not typically any delivery of steroids during the labor and delivery process. So that's a good clarification. Thank you for offering that up. Piggy back on that, what are the different techniques and approaches commonly used to inject steroids into the epidural space? Again, we're talking about injections for pain relief. There's two main categories which I'm really trying to get at and that's one that's called the transforaminal approach and then the other category is called the interlaminar approach. So again, see if you can break this down for the average Joe who really doesn't have any idea what I just said.
Andrew Sumich: 09:30
Sure. So it is... that was a good explanation. It's all about getting medicine into the epidural space, just how are you going to get it there? There's two, and really those two approaches are about which opening of the spinal canal are you going to use to access the epidural space and inject the medication. The interlaminar approach is more of a midline approach, and as the anatomy of the spine, there are little openings or little windows between the back part of the spine where you can access the epidural space with the proper technique and inject medication in there. The medicine tends to stay midline, it does spread over multiple levels so it can cover multilevel pathology, that's one of its advantages.
Andrew Sumich: 10:15
The transforaminal approach is using the opening on the side of the spinal canal. It's the same opening that the nerve exits the spine prior to going down your leg, so it's not a midline approach, it's a little bit more off to the side coming in at an oblique angle and it actually uses kind of the opening where the nerve is and the nerve itself is kind of a bit of a conduit to travel the medicine into the epidural space that way.
Sanjiv Lakhia: 10:45
You may have shared this analogy with me, Turtle. You think it's a good one where it's comparing almost like using a shotgun versus using a rifle in terms of how specific you can be with where do you want to place the medicine?
Andrew Sumich: 10:57
That's exactly right. I use that regularly with my patients. That transforaminal approach allows you to get a singular level and also a singular side and so particularly in one-sided unilateral symptoms with a specific pattern, it's a great procedure.
Sanjiv Lakhia: 11:18
Do you think there's a significant difference in terms of risk or complications between the two approaches?
Andrew Sumich: 11:24
I don't think there's a significant difference. I think there are different potential complications and risks. I think they both are safe procedures when done with the right equipment and right technique, but they each do carry their risks. For the most part, the more one technique is used, the more potential complications [inaudible 00:11:46], and I think the decision making should be driven by the symptoms that the patient has and what is the best injection choice to treat those symptoms as opposed to one being just exclusively safer than the other.
Sanjiv Lakhia: 12:02
All right, so that's a good breakdown of the interlaminar versus a transforaminal approach. I would also add that there's maybe a slightly different risk in terms of the risk of a spinal fluid leak based upon which technique you're choosing. At the end of the day, what he said is accurate. You really want to have someone who knows how to evaluate the MRI and your symptoms on clinical presentation and then the second aspect of that is the skill of the provider performing the technique correctly really makes all the difference.
Sanjiv Lakhia: 12:32
Another common kind of question I get from patients, and even referring docs and the surgeons in the group that probably warrants some clarification is maybe the difference between a transforaminal epidural steroid injection, or as we call it a TF ESI versus a selective nerve root block. Can you spread some clarity on these two things?
Andrew Sumich: 12:52
Sure. Well first, they're really close and they sometimes are used interchangeably, although technically that's not accurate. So with the transforaminal approach, again, it is using that opening on the side of the spine where the nerve exits to access the epidural space, so you would actually place the needle under imaging guidance and inject and typically watch the contrast and eventually the medication track up the nerve into the epidural space. So it is getting medication going through the nerve root itself, which is kind of the selective nerve root part of it. The medication is also going to the epidural space so it could potentially spread to the level, typically the level above it.
Andrew Sumich: 13:36
A selective nerve root block is putting the medication only on that singular nerve root, so staying a little bit outside of the spinal canal, outside of where that nerve exits, and coating the medication onto the nerve root itself and not allowing it to trickle in or flow into the epidural space.
Sanjiv Lakhia: 13:57
Okay. Very good. And that can be more useful when you're trying to diagnose exactly where the pain is coming from and in particular the neurosurgeons in our group really like that. It helps them sort out what is a relevant finding on an MRI versus one that doesn't really correlate with the symptoms and pain.
Andrew Sumich: 14:14
Sanjiv Lakhia: 14:15
Yeah. Anything else you want to add to that?
Andrew Sumich: 14:16
No. The selective nerve root block, it was almost exclusively used in a diagnostic setting. Otherwise the transforaminal would be the more common thing to use for therapeutic purposes.
Sanjiv Lakhia: 14:27
Okay. So now let's pretend that I am let's say a 55-year-old patient of yours and you've scheduled me for an injection, let's say an L5 transforaminal epidural injection, or you're trying to schedule me and walk me through a couple things. Number one, and this is for our listeners as well, let's talk about what types of medications the patient can expect to have delivered during the injection, and then number two, can you give us kind of a simple explanation for what someone may feel while going through the injection?
Andrew Sumich: 15:02
Sure. The medications used is there's a local anesthetic which is typically 1% lidocaine, which is the same kind of thing that you might get at the dentist to numb up your gums and your mouth, and that is done just to the skin and soft tissue at the injection site. Once the needle is placed, then you inject some kind of imaging contrast, typically Omnipaque or Isovue, it's the same kind of contrast that you might use for a CT scan. So that is injected as well. Then the kind of meat of the injection, which is the steroid. For all epidural injections, regardless of technique, it's recommended to use dexamethasone or a similar corticosteroid, mostly because of its molecular size and safety profile. Then with the steroid, some people will mix that with some lidocaine as well, just for patient comfort. Other people will mix that with just normal saline, and the purpose of that is just to get a larger volume distributing into the epidural space rather than just the single [inaudible 00:16:20].
Sanjiv Lakhia: 16:24
And then the big question that's on everyone's mind who is considering a spinal injection, and I want to get your perspective on this, is the potential risk for a spinal cord injury. Really, I just want to stick to the low back injections as it pertains to our topic today, but how do you go through that discussion with your patients?
Andrew Sumich: 16:39
Well technically with the lumbar spine, particularly below L2, there's no risk of spinal cord injury because as you know, Sanjiv, the spinal cord doesn't go that low.
Sanjiv Lakhia: 16:49
Andrew Sumich: 16:50
But that's not what people are asking. People are asking the risk of potential neurologic injury and that is a fair and important question. It is, again, it's with the fluoroscopic guidance and imaging guidance, in a very, very low risk and with the proper technique it should be almost nil. You should be able to see where the important structures are, at least where they are relative to the imaging that's obtained during the procedure, and as you inject the contrast it will outline nerve roots and even vessels which are another important thing we want to avoid.
Andrew Sumich: 17:27
If you just think of the ways like how would you cause this kind of neurologic injury? So there could be direct trauma to a neural structure to the nerve root. The reality is anybody that's had an injection before where the needle has gotten close to the nerve, you know it. It will give you that kind of zinger, almost like a hitting your funny bone on steroids. And if you hear the patient's feedback, you can reposition before you do any kind of damage, physical damage, to the nerve.
Andrew Sumich: 18:00
A second way that would be concerning is injecting into a vessel that would somehow occlude and stop the blood flow from going to a neural structure to the nerve root or the lower part of the spinal cord. That's why it's important why we inject the contrast under live fluoroscopy to make sure there is no vasculature uptake before we inject any of the medications. It's also why we use that particular steroid, dexamethasone. Its safety profile, because of its small molecular size, minimizes the chances of any kind of vascular injury to a neural structure.
Andrew Sumich: 18:38
The third one we worry about and you touched on this when contrasting the interlaminar injections with transforaminal, or we should have touched on it, I didn't, was some kind of hematoma, which is basically internal bleeding. So if you were to... if we're doing a transforaminal approach and there's internal bleeding or a hematoma, it would be outside of the spinal canal. So it would be uncomfortable, it would hurt, you'd probably have some local swelling, but no real long-term effects. If that same hematoma was actually in the spinal canal where it's a close space, you can imagine if that got bigger and bigger it could cause compression through the nerves that are in that same close space, in this case the spinal canal. That could potentially cause some neural injury, but that is very, very rare.
Andrew Sumich: 19:26
Those are the things we think about and I think because we think about and are looking for them, is why they rarely, if ever, happen.
Sanjiv Lakhia: 19:34
That's an excellent breakdown and I wanted to talk about that topic today. I think we should talk about it to inform and educate listeners and really the take home from what Turtle just broke down for you is that there are multiple strategies that we utilize to mitigate and lessen the risk, mainly the use of contrast dye during the procedure plus the use of the proper steroid preparation, which has a long track record of safety, and that when done properly with these risk mitigation techniques and someone who's trained and knows what they're doing, I think it's something that you should be aware of if you're a listener and are considering one, but I don't think you should necessarily be scared of it and I always like to compare treatment options and look at their relative risk.
Sanjiv Lakhia: 20:21
If you have just hurt your back or have some sciatic pain and it happened a week ago, and you haven't tried any medication or therapy, then the risk of injection is certainly greater than those conservative things, but if you've been through several weeks of conservative treatment, you're still having a lot of problems and now we're comparing the risk of an injection versus a surgery, I think you could feel a little better about taking that risk. That was an excellent kind of breakdown of that topic.
Sanjiv Lakhia: 20:47
Moving past that though, when you have patients that come to your clinic and you're considering an injection, what are your deciding factors when trying to determine if someone needs or benefits from an epidural steroid injection versus moving them on to see one of our neurosurgical partners for consideration of let's say a micro disc surgery.
Andrew Sumich: 21:07
Sure. I've always thought and I'll present it to my patients often this way that there are three potential reasons to do more in terms of treatment, and more might be at the beginning just showing up at the doctor, or it might be getting an MRI or in this case it might be an injection or even proceeding on to the surgical consultation. One of those is sort of outside of the patient's control, and that is if there is rapid or at least progressive neurologic loss. So somebody has lost control of their bowel or bladder, somebody has weakness, significant weakness, in their leg and it's rapidly progressing. I mean there isn't a whole lot of discussion. Honestly, we don't see a lot of that at our practice, because one, thankfully it's not very common and two, they usually end up in the emergency room. But if that kind of thing is going on, those people need to be seen quickly, have an MRI and depending on the results of the MRI, likely rapid surgical intervention. So those aren't really the people we're talking about.
Andrew Sumich: 22:16
The two other ones, the two other reasons to kind of do more meaning jump to surgery in this case versus proceeding with an injection is that the symptoms, and however those are manifesting itself with pain or oftentimes the secondary part of that is how it's affecting somebody's quality of life, mood, relationships is that they just can't take it anymore. The pain is so severe, things are so upside down that they don't have the desire or the time to do an injection and wait for a response, that seven to ten days that we like to see that maximal response, and they're just, "It hurts too bad, I can't do it, I just want to get it fixed." So that will steer somebody straight to surgery.
Andrew Sumich: 22:57
Then the third one is a little bit tougher to identify and a little bit softer endpoint. That is the person that's had persistent symptoms and just hasn't gotten better. So typically those people would have had, we would have done the injection or two and maybe it's helped some but not all the way and it's not that they can't handle their symptoms, they're just tired of handling those symptoms and they just want to have a more definitive response.
Sanjiv Lakhia: 23:21
Yeah, let me elaborate on that second point, which I forgot to mention prior. I'm glad you brought it up. Is that if you're considering a spinal injection for your pain, please understand that often the relief does take a little bit of time, so anywhere from seven to ten days or even up to a couple weeks. It's not necessarily a quick fix. You will get some brief immediate relief from the anesthetic in the injection, but then it does take a little time for the corticosteroid in the injection to help calm down that inflammatory nerve root response. As Turtle mentioned, if you're really in a lot of pain and the concept of waiting several weeks to see the outcome of the procedure is just one you can't bear, it's really not unreasonable at that point to get a surgical opinion and see if you can move up the timeline of your recovery.
Sanjiv Lakhia: 24:05
All right. So that has been a really good breakdown so far. One more question that I get quite a bit from docs and patients and I want your thoughts on is the idea of how many injections do you really do when you present with a problem? There's historically been this "series of three" and that has been somewhat modified by the literature, but also insurance coverage so there are a lot of factors that play a role in determining how many injections a patient should consider before they determine if the injections have really worked for them or not. What's your take on this, Turtle?
Andrew Sumich: 24:38
I think you're right. First off, the series of three, for multiple reasons, has fallen out of favor. I'm glad it has. I think we apply a little more common sense now in terms of when or if or the timing of repeated injections of how many, and it does... how many you do and how often you do them also matters on what's our alternative. Meaning if somebody is having this acute disc herniation and the alternative is again a relatively minor surgery in terms of minimally invasive, then you might not do many injections if either the first one or two isn't offering significant relief. Whereas if the patient's surgical alternative is nonexistent or unacceptable, so it's an elderly patient that would need a massive reconstructive surgery that they may or may not survive because of their medical comorbidities, then we're probably going to do more injections over a longer period of time, even if they're not home runs, if they're helping at all, because they might not be a great option but they might be our best option still.
Andrew Sumich: 25:53
So I still think the sort of series of three, I rarely do. I do have a relatively low threshold for a second injection if, if the patient gets a positive response to the first one. So if they get 70% relief or 50% relief and if it's short lived or if it starts coming back in four to six weeks, then it makes sense to repeat an injection. If you do that second injection and again it's just a few weeks of relief, I have a hard time justifying the third one. But if you do that second injection and now you've got four or five months of relief, then you may consider that third one at that point.
Sanjiv Lakhia: 26:31
Yeah, I really like that approach and that's a very similar approach that I adopt for my patients. I think the days of doctors giving patients five to ten epidural injections in a calendar year are hopefully over and behind us, because I don't think it serves anyone with that approach. It's nice to see it evolve.
Andrew Sumich: 26:47
No, I agree, Sanjiv.
Sanjiv Lakhia: 26:48
Andrew Sumich: 26:48
The other part is I'll say this, the patient is allotted... and we talk about insurance companies and then we worry about steroid exposure about how often we do them. But the reality is if you need five to six to seven or eight epidural steroid injections in a year, they're not working very well and we should seek other treatment for that reason, regardless of any insurance approval or potential overexposure to the steroid.
Sanjiv Lakhia: 27:20
Yes, folks. Let common sense rule the day. Really think for yourself as you consider these treatment options. So we've done a really good job today of breaking down epidural steroid injections in the low back, but that's not all, Turtle, I know that you do and offer your patients. You provide really comprehensive spine care. In particular, when epidurals aren't helping, what are some of the other options that you can discuss or offer from an interventional perspective, ones that are emerging that you want to share with the patients?
Andrew Sumich: 27:51
Sure. Well, when it comes to back pain, it always also... back pain is a symptom so it comes out to what is causing that symptom? Where is the pain generator? And oftentimes it's the disc can certainly cause chronic back pain as well as the facet joints, which are the small joints kind of on the back part of the spine. You can inject those joints with steroid, similar like we discussed with epidural steroid injections. There's also a procedure called radiofrequency ablation which can target those joints a little bit more definitively.
Andrew Sumich: 28:25
The second part is where there's some exciting new things that have happened in terms of what in the past we have called discogenic pain, which is back pain with the disc itself causing the pain and this is the typical degenerative disc disease pain. It would be back pain that just kind of stays in your back, it's kind of this nebulous pain that's worse with sitting or driving or being at your desk for too long. Bending, twisting tends to be difficult as well. The exciting new thing for the longest time we thought of that as the disc causing the pain and certainly it still plays a role. But the newer research has shown that perhaps it's the bone where the disc interacts with the bone and that inflammatory process that happens is causing the pain. This is where a new procedure called Intracept, I-N-T-R-A-C-E-P-T, has just been commercialized in the last 12 to 14 months, and it is where you can ablate, essentially heat up and burn the nerve that supplies that end plate where it interacts with the disc and relieve back pain that way.
Andrew Sumich: 29:31
In our little nerdy world, it was really a big leap forward and it wasn't just a new way to treat an old problem, it was a new way to think about an old problem, or a new way to think what was causing that old problem that led to this bit of a breakthrough.
Sanjiv Lakhia: 29:48
It's really fascinating. I think it could be a potential game changer. I know you've really just dipped your toe in the water on this recently and had some exciting results so far. It's something that I think I personally am going to watch the evolving research on and see if it really works. Historically, we've been searching in the spine world for the holy grail for disc-related pain. I mean even a few years ago there was the idea that is it infectious? Should we put everyone on antibiotics? Every few years there's something new and evolving but this approach makes sense to me from an anatomic perspective. It's consistent with how we try and localize the pain generator, so thank you for sharing that and if you're listening out there, just kind of keep your ears open and listen for this evolving technology.
Sanjiv Lakhia: 30:36
The other thing that I know you do is you've done some injections into the disc of platelet-rich plasma and then you also are rather involved with research into other what we call biologic or regenerative agents for back pain. Can you share with our listeners your experience with some of the clinical trials that you've taken part in in investigating some of these offerings?
Andrew Sumich: 30:56
Absolutely, I'd love to. One just quick overview is the regenerative medicine space is broad and very popular right now. The two broad categories are autologous material, which is basically harvesting some sort of cells from the person themselves and injecting them back into it, and then there's more of the biologics or manufactured. What I'm going to discuss is the more manufactured. So these are kind of commercially produced materials. Because they are manufactured, they're subject to FDA approval, and so where we've been involved with them is on the study level. We have been involved with three different companies for three different studies over the last seven years, each one with a little different take on where the cells came from. The first one wasn't true stem cells, they were juvenile chondrocytes, which are cartilage cells, which is what disc material is made of. So the idea was to inject these sort of infant-like cartilage cells into a degenerative disc to see if they regenerate. They had some initial encouraging results in their pilot study of 10 or 12 patients. The larger study has not been published, which usually means there was not great results.
Andrew Sumich: 32:15
The second one we were involved in was adult... they were true stem cells that were harvested from adult bone marrow and then proliferated in the lab, and that study has been completed for a couple of years now, had some initial positive results as well and still pending any sort of final publication.
Andrew Sumich: 32:33
The third one that we're involved with was actually just closed last week and so there's no results yet or even preliminary results to discuss, but their approach was unique because in some of the theories on why the initial [inaudible 00:32:50] stem cells in the disc weren't successful was that the hope and perhaps thought was if you put a stem cell into a disc space, it knows to become a disc. And when that wasn't as successful as anticipated, the next phase was do we need to somehow program these cells so they know to become a disc? And this most recent study that I referred to the third one that we just completed participation in, they were able to take cadaver disc cells and then retro-engineer them back to the stem cell state. So theoretically these cells have already been a disc and know how to become a disc. So that is why the hope that this time it would be different and more successful.
Andrew Sumich: 33:33
I think the broader point other than, and not as important as the details I just shared, is that it's progressing and progressing rapidly. Each new generation of stem cells for the disc that we're thinking about it a little bit differently, learning from the last iteration and trying to push it forward. So it's very encouraging, I think we will get there, but we are not there yet. So this is one of those, unless you are really... you want to be at the tip of the spear, you kind of let things play out a little bit to see what kind of bubbles to the top as the most effective and safest.
Sanjiv Lakhia: 34:06
That's fascinating technology that you're describing there, and very excited that there are a lot of people smarter than me that are working on this for my patients.
Andrew Sumich: 34:14
Oh my gosh, you're not kidding.
Sanjiv Lakhia: 34:17
What do you think... what makes it challenging? What about the disc itself makes it challenging to heal? What do you think patients should know about the disc that we kind of struggle with?
Andrew Sumich: 34:29
The two big things that I think of is one, it has a poor blood supply. It just doesn't get good nutrients it needs to heal. When we cut ourselves, the blood delivers all these repair type cells to that area and heals the skin. The disc just does not have a good blood supply so it doesn't get the cells to begin with and gets the nutrients it needs to heal.
Andrew Sumich: 34:51
The second part is it's under a lot of stress. I mean, biomechanically us being upright, there's a lot of strain on the lower back and so anything we do is going to put strain on it and continue to damage it. So even if a disc is injured and has the potential to heal, we are consistently kind of micro-injuring it with daily activities. I mean getting out of bed, putting on your shoes, pulling on your socks, and so there's a lot of kind of inherent things that the disc space has working against it.
Sanjiv Lakhia: 35:24
Those are some terrific tips. I think it's useful for people to understand why treating degenerative disc disease can be so challenging. Then we're going to close today's interview with, Turtle, just getting to a few of his personal health habits. We'll get to those questions right after this break.
Sanjiv Lakhia: 35:44
On today's health matters segment, I want to talk briefly about a vitamin that is near and dear to my heart and that is vitamin D. Vitamin D has an exploding amount of research over the last decade and the more we learn about vitamin D, the more I'm convinced it is essential to maintaining our health. In particular, I discuss with my patients the role of vitamin D and their pain, at least a potential role. I want to share with you a research article that was published in May of 2019 in the Frontiers in Pharmacology Journal, and the title of the article is the Preoperative Supplementation with Vitamin D, Attenuated Pain Intensity and Reduce the Level of Pro-Inflammatory Markers in Patients After Posterior Lumbar Interbody Fusion. That's a lot there, so essentially what they're saying here in this article is they researched the role of vitamin D and back pain for patients that had undergone lumbar fusion stabilization surgery. The way they kind of broke it down was they divided individuals into two different groups, both groups did receive rehabilitation exercise after their surgery. One group received 3200 international units of vitamin D a day for five weeks and then the other group received a placebo of vegetable oil. They just kind of tracked their outcome pain scores after the surgery.
Sanjiv Lakhia: 37:16
Now they didn't measure the vitamin D levels in the blood preoperatively. Vitamin D, in this country the recommendation is typically if you're over 20 nanograms per cc, you're considered to be low normal. In this study what they did is they found preoperatively the baseline level was about 25 for most and then they supplemented with roughly 3000 units of vitamin D for five weeks and the levels rose basically to 50 or doubled. They found a pretty strong correlation with the reduction in pain in the group that had the vitamin D supplementation versus the group that did not.
Sanjiv Lakhia: 38:01
So a little background on vitamin D. If you're not familiar, vitamin D is a fat-soluble vitamin and is synethesized from precursors in your skin after you're exposed to UVB radiation from the sun. There are vitamin D receptors really throughout the body, and in particular there are vitamin D receptors in your muscles and in your tendons, and also certainly along the bone so there are research articles that suggest when you're deficient in vitamin D that you'll have low-grade swelling in the periosteum, or covering of your bone. So that was an original thought put out there as to why you could have back pain, or chronic low back pain, with low vitamin D. We also now know that there's a strong correlation between low vitamin D and muscle weakness as well as gait disturbance. Why is that so? Well, vitamin D and the vitamin D receptors really control a lot of different processes in our body, in particular a process of inflammation.
Sanjiv Lakhia: 38:58
In this study they also looked at pre and post levels of pro-inflammatory cytokines, so these are immune cells in our body that are elevated during inflammation. They also measured a protein called C-reactive protein, which is another marker of inflammation. Many of you may have that checked as you're doing your annual physicals to look for evidence of heart disease. So what they found in a nutshell is that the individuals that were supplemented with vitamin D prior to surgery had lower levels of CRP and lower levels of inflammatory cytokines afterwards. So that's to keep it simple. I think it's a very powerful bit of information and one that you should consider discussing with your doctor. Do you get your vitamin D levels checked? I tend to offer it with my patients, although nowadays many times the vitamin D profiles are rolled into your annual physical, so make sure you check with your insurance plan and see how many times per year they will cover that.
Sanjiv Lakhia: 39:59
It appears when I scour the musculoskeletal research, an optimal level would be closer to 50 nanograms per cc. There are certainly seasonal fluctuations in your vitamin D level, certainly as you transition into winter, the levels are going to be the lowest and that's another rabbit hole that we can explore at some other point in terms of the correlation with low vitamin D and our increased incidence for illness during the wintertime. But as it pertains to this podcast and my passion for helping to reduce low back pain and educate you on how to take care of your spine, I think vitamin D has to have a role in your considerations.
Sanjiv Lakhia: 40:36
Now, one word of caution, vitamin D is a fat-soluble vitamin and what that means is it can store in your fat cells. You don't necessarily excrete it through your urine like some of the B vitamins, so there can be a level of risk of vitamin D toxicity, although it's quite rare and there are very few case reports in the medical literature on it. You do not necessarily want to go to your drug store and pick up a bottle of vitamin D and treat yourself. I think if this is something you want to explore, you need to talk with your physician and get your level checked. They will prescribe a recommended dose and I always recommend using vitamin D3 versus vitamin D2, it's just more physiologically active, and then you should likely have your level rechecked in two to three months and kind of monitor it that way.
Sanjiv Lakhia: 41:20
So add that to your toolbox, vitamin D, what's your status, what's your number, how is your low back pain? If you have mysterious low back pain or low back pain that no one can really explain, consider do you have a vitamin D deficiency or insufficiency and perhaps as you investigate that it might shed some light on your pain and lead to less pain overall. So I hope you take this under consideration as you consider all of your health matters.
Sanjiv Lakhia: 41:54
Welcome back now. We are wrapping up our interview today with Dr. Andrew Sumich on all things spinal injection related. He actually just broke down the entire topic in a way that is very useful and very informative and I know he's got to run, but I want to get a few personal health habit tips from Turtle. I know he values his health and fitness and wellness very much and as you know on this podcast, I'm all about that. So, Turtle, you see probably close to 150 patients a week and I know that's very demanding. Can you share with our listeners your typical approach to maintain your nutrition, exercise, and wellness?
Andrew Sumich: 42:30
Sure. I think first of all, it's a work in progress that's evolving, but the biggest thing I think I have going for me is I consciously try to do it. I'm not always successful, but it is a deliberate habit of mine to try to take care of myself. Exercise is always kind of easy for me. I've been active since high school and got into the habit of working out. It's evolved in the last decade or so as I've squarely reached middle age, but I'll do a lot more body weight type exercises two to three times a week. I'll go to a yoga class at least once a week, typically Wednesday morning, and on the weekends just kind of stay active with the kids, walk the dog, that kind of thing. So I'm usually doing two workouts at least four days a week and being active in my other days.
Andrew Sumich: 43:21
I also try to eat good and I'm successful most of the time. I cheat on the weekends a little bit, but it's typically... I've not cut out all meat. I'm eating less meat than I used to, more fish, lots of healthy vegetables and then the occasional Hershey bar, which is a weakness. Then I meditate regularly, I mean pretty much daily unless there's... I try to make time to do it. It works best for me in the morning, at least it seems to work best for me in the morning. I found that practice in the last two or three years to be very beneficial and really altering my sort of overall baseline stress level quite a bit.
Sanjiv Lakhia: 44:04
What's your approach to the meditation?
Andrew Sumich: 44:07
I prefer guided meditation. I have an app that I use called Insight Timer that has three or four morning meditations that are guided meditations that I'll use. It usually has a beginning of breathing exercises and then towards the end it will do some affirmation which I have really grown to like and helps kind of... I've found ones that I need throughout the day that I can call back on. If I don't have time to do it, they're usually between 10 to 12 minutes. If I wake up a little late or don't have time to do it or just hit the ground running, I'll just take a few minutes in the car or before the first patient and it might only be 45 seconds, but just a few breaths and a couple of mantras that I'll say to myself to kind of just center and hopefully carry it throughout the day.
Sanjiv Lakhia: 44:58
Yeah, so take home points there is number one, be intentional. I don't think it matters quite as much what your routine looks like at home, but as Turtle said, he's very intentional about his health and fitness and then I'm a big fan of meditation as I've talked about before. I'm currently just starting the Andrew Weil integrative medicine fellowship and we just finished our module on meditation and the medical benefits are outstanding now and very well established.
Sanjiv Lakhia: 45:24
All right, I'm going to close with the most important question of the day, Turtle. How far do you think my University of Dayton Flyers can go in the upcoming NCAA tournament as they are now up to number five in the country in men's basketball?
Andrew Sumich: 45:36
I think they lose in the Final Four national semifinals.
Sanjiv Lakhia: 45:39
Okay. I will take that. I will not delete this episode. You are safe, you are safe. All right, my friend. Thank you so much for taking the time to go over this information with us and the listeners. I really enjoyed the conversation. I look forward to continuing to work with you on exploring these new techniques for our patients. Thank you again, Turtle.
Andrew Sumich: 45:58
Thanks, Sanjiv. It was great. I'm glad you're doing this and thanks for letting me participate.
Sanjiv Lakhia: 46:02
All right, buddy. Have a good one.
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.