Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And joining me today to discuss options for chronic low back pain and complex regional pain syndrome is Dr. Justin Davanzo. He's a neurosurgeon with the Allegheny Health Network.

Dr. Davanzo, it's a pleasure to have you join us. Thank you so much for being with us. And I'd like you to start by giving us a bit of an overview of your role at AHN and your expertise in this field.

Justin Davanzo, MD: Thanks for having me. I'm a neurosurgeon at AHN, like you said, and my background is in Functional Neurosurgery. And I spend a lot of my time treating chronic pain patients with neuromodulation and other modalities. And we've had some kind of exciting breakthroughs over the last couple of years in this area, and we're doing new and exciting things, and I'm excited to discuss that.

Melanie Cole, MS: Well, thank you for sharing that. So, I'd like you to tell us about the current state of chronic low back pain and complex regional pain syndrome, different things. Tell us a little bit about what you've seen in the trends and especially with chronic low back. You know, we hear about really the burden that it places on society. Talk about those things, the trends and the prevalence.

Justin Davanzo, MD: Well, I think as our population ages, we're seeing more and more chronic low back pain. It's something that affects almost everybody at some point in their life. And if you have chronic low back pain, it affects you day to day and affects your quality of life pretty significantly. And a lot of times these patients are left without a great option from a treatment standpoint. And we've had some developments of things that are working very well for those patients and are giving them some relief and allowing them to get some quality of life back. So, we certainly want to be able to offer those to as many people as we can and help as many people as we can, hopefully, fight chronic low back pain and get back to some higher level quality of their life.

Melanie Cole, MS: Now, speak about complex regional pain syndrome because not all providers even really understand what that is. Speak about this condition and where are you seeing it?

Justin Davanzo, MD: Complex regional pain syndrome is definitely a more rare diagnosis that we see, but it's a very significant diagnosis for the patient. And again, this was something that there wasn't a great treatment for up until maybe over the last 10 years or so. It made some breakthroughs in that area. The best way to describe complex regional pain syndrome is sort of a haywire firing of the nerves in a particular area. And it can be caused by an injury to that nerve or sometimes it can even occur spontaneously. We see things like hypersensitivity, color changing of the skin, swelling of the skin, changes in sweating patterns in an area of the pain, and those are the things that we really look for. Like I said, it can be a spontaneous thing where we're not really sure where it came from or it could be maybe after a an injury or a surgery where the nerves are not functioning the way they're supposed to. And they're sending really crazy signals back through the spinal cord to the brain and causing a lot of really significant symptoms for the patient.

Melanie Cole, MS: I'd like to discuss your multifaceted approach to pain because we're learning more about multimodal and different treatment options. But before we do, since pain is somewhat subjective, how do you measure it? Whether it's low back pain or complex regional pain syndrome, how are we measuring that amount of pain?

Justin Davanzo, MD: Well, like you said, it's very subjective, and we rely a lot on what the patient tells us. We use some basic scales about where their pain is. We do a promise questionnaire before every visit in our office, and that helps us trend different values across the pain scores. And then, just basic questions of on a scale of one to 10, how bad is your pain? I focus a lot on some more objective things. How are they sleeping? What are their daily activities like? How far can they walk? Different things like that help me determine where we are on the pain spectrum, but as you said, pain is very subjective. So, what is to one person may be completely different to someone else.

Melanie Cole, MS: Well, then let's start with some non-surgical approaches to pain management. What do you try first with patients? And where in the spectrum of you looking at these treatment options is the patient involved in this decision-making and shared decision-making?

Justin Davanzo, MD: Well, I think we all can agree that we want to start from the most basic things and work our way up to surgery, with surgery certainly being the last option for most patients, or at least near the end of options for most patients. We certainly try medications prior to any kind of surgical intervention. That could be anything from anti-inflammatory medications to muscle relaxers even pain medication in the right situation. And then, we kind of work our way up from there. Sometimes these patients can benefit significantly from physical therapy. Sometimes they can benefit from different types of injections, whether that's in their back or other parts of their body, based on the location of their pain. And then, ultimately, from that point, if they've failed all of those things and have really not made any progress with regards to their symptoms, then, at that point, that's when we start to talk about surgical options to help with their pain.

Melanie Cole, MS: What's exciting right now, Dr. Davanzo, as far as surgical options? What's exciting in your field that really you're seeing great patient outcomes with?

Justin Davanzo, MD: Well, I think there's quite a few things that we're doing now that are really exciting from my standpoint. I think a lot of people know about the traditional spine surgery that we do as neurosurgeons and as orthopedic surgeons do from time to time. And those have been around for quite some time and they do help people in the right situations, but there are plenty of people where that's maybe not the best option. That's maybe not something that's going to give them the most relief. And we certainly don't want to put somebody through a bigger surgery like that if we, if it's not going to help them.

So, we're doing things now like spinal cord stimulation, which has been around for quite some time, but we're doing a lot better with coverage of back pain at this point. And we've had a lot better success with that at this time. And then, dorsal root ganglion stimulation is another thing that's relatively new. We use that a lot in the area of complex regional pain syndrome. We can focus the stimulation in a particular part of the body and that helps us cover that area better and get better coverage of those painful symptoms that the patient has. We're also doing some peripheral nerve stimulation in the back now, which is geared at treating muscle atrophy in the back. And that tends to be a pretty significant pain generator for a lot of patients. And we started to do that more and more, and we're seeing good results again in the right patient population.

And then, the last thing that we're really excited about is we're doing some different nerve ablations now. The big one that we're doing is called the basivertebral nerve ablation, and that's where we're ablating the nerve that's within the vertebral body itself, and that seems to have really good results, again, in the right patient population. But we're 75-80% of our patients come back with 50% or more reduction in their back pain, and that's obviously a big victory for us in the back pain area.

Melanie Cole, MS: Speak a little bit about patient selection for the basivertebral nerve ablation since this is a newer procedure and technique. Tell other providers specifics about patient selection, why that's so important.

Justin Davanzo, MD: What we're really looking for is anterior column pain. So when we talk about the spinal column, we talk about the anterior column, which is basically the vertebral body and the discs, and then the posterior column, which are the joints, the pedicles and the lamina in the back of the spine. For these patients, we're really looking at anterior column pain. And that can be anything from pain with prolonged sitting, pain with prolonged activity, pain with prolonged standing, or pain with flexion, so bending over to tie their shoes or something like that.

The other thing that we really look for is something called modic changes or endplate changes on their MRI. And what that suggests is that the disc has broken down the endplate to some degree and caused inflammation into the endplate. And the reason that's important for us from the perspective of basivertebral nerve ablation is that nerve pierces the posterior cortex of the vertebral body, and then spreads out like tree branches to the superior endplate and the inferior endplate. And when that inflammation comes from the disc into the endplate, that nerve fires pain signals back through the nerves into the spinal cord and into the brain. And that nerve doesn't serve any motor function or sensory function. So, we're able to go in and ablate that nerve and give the patient some relief from their back pain.

Melanie Cole, MS: What about patients who've previously been told nothing can be done about their pain? How do you personalize treatment, Dr. Davanzo, for plans with these patients with conditions when maybe there is no structural cause noted or chronic abdominal pain, they've got groin pain, but you can't find the specific cause?

Justin Davanzo, MD: Yeah. Definitely, patients that have been told in the past that there's nothing to do about their pain, some of the most rewarding things that I get to do because there are new options now out that some of those patients fit into that category. And when they come back and tell you that they're doing better and, you know, they previously thought nothing could be done, that's a really great thing for us and really rewarding and really great from the patient care perspective.

What I would encourage is if you have somebody who has been told previously there's nothing to do about their pain, and it's been a little while since they've seen somebody about it, it may be worth having them re-evaluated by a neurosurgeon to see if there's something that can be done at this point.

And you mentioned some of those other things that we don't see a lot of as neurosurgeons, but we get from our pain colleagues or other general surgeons, orthopedic surgeons like abdominal pain, knee pain, groin pain, these are things that we're treating fairly successfully with dorsal root ganglion stimulation. And the nice thing about that treatment is there's a trial period where we put wires in along a particular nerve, along a particular dorsal root ganglion based on the location of their pain. And they get to test that stimulation out for about five days prior to having the permanent device implanted.

We tell patients that if you had a good trial, there's no reason to believe you wouldn't have a good permanent implant. So most, if not, you know, the majority of patients that have a good trial go on to then have the device implanted and do very well with that or at least similar to what they did during the trial period. So, it's nice because the patient can get a little taste of what it would be like to have this put in prior to doing that permanently. And we don't get to do that a lot in medicine. Most things we kind of have to go forward with and follow the outcomes after. This gives us an opportunity to look at it beforehand and see how the patient would do.

Melanie Cole, MS: What an exciting time in your field, Dr. Davanzo. I'd like you to wrap it up with a summary for other providers, the key takeaways from our episode today. What advice you'd give clinicians who are new to managing chronic pain conditions such as these?

Justin Davanzo, MD: Well, I would encourage anybody who's managing patients with chronic pain to involve us in the care of those patients. We have a great collaborative group here at the Allegheny Health Network. And if you see one of my partners and they think you're better suited to see me for one of the things that I do more specifically, we'll get you to where you need to go and we'll get the patient to the right provider.

All of these are options in the right situation and we're really excited about all of them. Spinal cord stimulation, dorsal ganglion stimulation, peripheral nerve and muscle stimulation, and then basivertebral nerve ablation. Really, it's limiting the number of patients that come in that we really don't have any options for. That group is getting smaller and smaller and smaller by the day, and we hope it continues to have that trend.

So, my parting statement or my takeaway from this is if you have somebody who has chronic pain that's very difficult to control, kind of regardless of the location, back, abdominal pain, knee pain, groin pain, feel free to send them to us or our colleagues in Pain Management here at AHN, and we'd be happy to evaluate them and see if there's something we can do to help them with this chronic pain they're having.

Melanie Cole, MS: Thank you so much, Dr. Davanzo, for joining us and sharing your incredible expertise today. To learn more or to refer a patient, please call 844-MD-REFER or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. Please always remember to subscribe, rate, and review AHN Med Talks on Apple Podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.