Transcription:
Back Pain and PNS

Bill Klaproth (Host): If you're suffering from back pain, you know how debilitating it can be at times. Quite frankly, chronic back pain is a bummer, but for certain candidates, peripheral nerve stimulation or PNS can provide relief to that chronic pain and give you quality of life back. So let's learn more with Dr. Ethan Colliver of physical medicine and rehabilitation physician and fellowship-trained sports and spine care specialists at Valley Sports in Spine Clinic, as we talk about back pain and peripheral nerve stimulation. This is the Top Docs Podcast. I'm your host, Bill Klaproth. Dr. Colliver, thank you for being here.

Ethan Colliver, MD: Hi Bill. It's great to be here. Thanks for having me.

Bill Klaproth (Host): You bet. So I am a chronic back pain sufferer, so I'm so excited to talk to you about this. Why is chronic back pain so difficult to manage for many people? Me included, I have had back issues for most of my life now?

Ethan Colliver, MD: Yeah, a great question. I get asked that a lot. Back pain is so common especially in Western civilizations because of the way we live. So we sit on chairs, we work at desks, we drive cars, and we don't really have an agrarian lifestyle anymore where we work in the fields all day and we bend and twist and move in ways that are probably beneficial to us. Also, we struggle in western societies to have a regular formal exercise routine. So nothing has really been helpful for preventing back pain except for exercise. And by that I mean, you know, 180 minutes a week of dedicated exercise.

Bill Klaproth (Host): So our sedentary lifestyle really affects us when it comes to our backs.

Ethan Colliver, MD: Oh yeah, for sure. For sure.

Bill Klaproth (Host): Yeah. So for those of us with back pain, we know the drill of physical therapy, of stretching, of aspirin, all of that. So when all of that doesn't work, when we've exhausted all of that, it might be time to consider something new. So what is PNS pain management?

Ethan Colliver, MD: Yeah, So PNS stands for peripheral nerve stimulation. It's a part of medicine that has actually been around for many decades. Neuromodulation, if you think of a pace, For example, a lot of people get that if they have an irregular heart rate that's the same concept. It's using computer and pacer and electrical impulses to influence the body's functions. In this case, a pacemaker is stimulating the pacemaker of the heart and replacing it and telling the heart, wind to beat and giving the necessary impulses to make it beat.

For peripheral nerve simulation, our target is instead nerves in outside of the spine and outside the brain that transmit pain signals. Now, all nerves, I mean all structures in the body have nerves that supply it and we have pain signals that transmit pain back to our spinal cord and to our brain so that we can perceive that brain with a lot of those nerves. There are also nonpain sensing nerves, for example, light touch or you can feel vibration, you can feel pressure, you can feel temperature. So all these other nerve signals can be targeted with peripheral nerve stimulation and selectively target those non-painful nerves.

And that flood of nonpainful stimuli goes into the spinal cord in the brain and works to turn down the volume of pain perceived in the brain, basically. So if there's a nerve in the body, then you can put a peripheral nerve simulator on it to help control pain.

Bill Klaproth (Host): So we're basically turning off the pain, if you will. It's there, but we're telling the brain, Yeah, this doesn't hurt.

Ethan Colliver, MD: Right.

Bill Klaproth (Host): Wow, that's really interesting. And what is the overall efficacy of this?

Ethan Colliver, MD: It's great actually. So, some recent studies that came out have shown in a case of 39 people who have had chronic pain had failed. Spinal cord stimulators or do root ganglion stimulation really the end of the road. They don't need, surgeons can't help them. 71% of their pain complaints were diminished in that group. And of that another instinct fact was, about 80% or higher, closer to 85, I think, of people who were using opiates to help control their pain, were able to decrease their usage of opiates by at least half.

Bill Klaproth (Host): So this is a game changer for people that other modalities of treatment haven't worked?

Ethan Colliver, MD: Yeah, for sure. And, I think its utility is going to explode going forward. As technology improves, the technology needed to run the peripheral nerves stimulation gets smaller, better, more reliable, and can last.

Bill Klaproth (Host): And from what you said, a side benefit of this is it gets people off of medication.

Ethan Colliver, MD: Yeah. We've learned with opiates. I went to medical school in a time when I had lectures where they told us that we were undertreating, pain, opiates are safe, give opiates we were wrong. was very wrong. And in fact, people who are on long-term opiates actually perceive pain more than people who are not.

Bill Klaproth (Host): Wow, that's really interesting to hear. So how does PNS work? How does this get implanted in the body?

Ethan Colliver, MD: Yeah. So, the candidate for peripheral nerve stimulation is someone who can identify to me where their pain is. So if they could, in general point to it with their hand, then there are a potential target for peripheral nerve simulation as opposed to someone who has bilateral leg pain going down the left and the right leg. can only at this point put in one peripheral nerve stimulator at a time as covered by insurance. So, that person might be better suited if they have. Both legs hurting by having something like a spinal cord simulator that's placed in the spinal cord.

And so both pain signals for the legs come up to the spinal cord and go up, and so the spinal cord simulator can address both. But in this scenario where someone has a painful arm or a painful leg, say you have back pain with sciatica. I can find the sciatic nerve in that example under ultrasound and with a procedure in the office, basically using my ultrasound machine. I can see the nerve. Place in a needle. And then instead of injecting medication, I basically thread a little wire about the thickness, I usually pull out a pen at this point and say about the thickness of the tip of my pen, and I insert that into the wire down towards the nerve that I'm targeting.

Once it's in place, the person then undergoes a trial. What that means is the other end of that wire connects to a battery that I'm holding in my. with a little computer in it, and I'm turning on the stimulation in the clinic and I have the patient walk around the clinic for like 30 minutes or so. During that time, I ask them if their pain is any better and if their pain is at least 50% improved their candidate for the permanent one. Nonetheless, in 30 minutes I have them sit down. I simply just pull on the wire, the wire comes back out and they're back to the way they were. If they want the permanent one, I just have to bring them back in two weeks.

In that case, we numb up the skin, make a little tiny incision, and then I use a needle, a special needle introducer to put the lead next to the nerve that I'm interested in. And then I usually have to put in a stitch or two. But after about, 15, maybe 30 minutes of the procedure, they're done. We put on a bandage. And they can even walk out the door with the stimulation on and start giving relief immediately.

Bill Klaproth (Host): That's amazing. So you mentioned this is like a pacemaker, so it's self-contained. There's not an external battery or anything?

Ethan Colliver, MD: So this is unique. The one that we use is Bioness and it's unique because they don't have a battery that gets implanted. Like you mentioned, people who have a pacemaker, they have to have a battery that's implanted underneath the skin. And so a lot of times you can look at their chest and actually see the battery there. Plus, a lot of times that's a point of failure. So a lot of spinal cord simulators or pacemakers. Over the span of seven years, sometimes as short as five years, that battery will, die basically, will drain and you'll have to replace it.

So they have to undergo another surgery where they make an incision, pull out that battery and put in another one, which any surgery is a chance of infection. So we try and limit that. This one has a battery that tapes on top of the skin. So if I targeted the sciatic nerve in our example that we're using, that might be in someone's buttock region or their thigh they basically take this battery over where I put the lead and they use it for 20 minutes or so, take off the battery. And it lasts for hours or days. Meanwhile, they can recharge the battery at home, at their bedside. They just plug it into the wall and so when they need it again, they just take it and put it on.

Bill Klaproth (Host): So they recharge it as they need it.

Ethan Colliver, MD: And so there's no secondary surgery to replace a battery. There's no internal battery hardware that can fail. So that's another problem with pacemakers and spinal cord Stimulators.

Bill Klaproth (Host): And how long will this generally last? 10 years. 20 years? Forever?

Ethan Colliver, MD: Yeah, you can have it forever. once it's in there, it's safe. It's this inert piece of wire. That's You can even have an MRI with it. You can remove it. So in cases where people have, we've had cases where people have painful rib pain after, surgery for breast cancer. And in this case, the person was in horrible pain and they wanted some relief, but we knew that they had to have chemotherapy or radiation in the future. They would have to have things like MRIs of that region, and it does obstruct the MRI. You can have an MRI, but it does obstruct the image. In that case, you can actually go and remove the wire, have the MRI that you want and replace it afterward.

Bill Klaproth (Host): Yeah, that's really interesting. So you mentioned earlier this is good for people with sciatica, which a lot of people suffer from. Who else is a good candidate for this?

Ethan Colliver, MD: Like I said, if, you can take your hand and you can point to where the pain is, whether it's in the shoulder, hip, knee, I've done it for headaches. anywhere where there's a nerve basically you can target. So the sky's the limit as far as I'm concerned.

Bill Klaproth (Host): So again, this really is a game changer, as far as people suffering from constant back pain. You mentioned neck too. So this can work really anywhere on the body?

Ethan Colliver, MD: Yeah, so I use it as well, and people who have radiculopathy into the arm. I have an elderly patient that is too frail to undergo neck surgery and she's miserable, so I can actually go in, she's awake during the procedure, and use a little bit of lidocaine or numbing medication. 15 minutes later she can walk out and start getting pain relief.

Bill Klaproth (Host): Yeah, that is good news. So I'm sure this is a big question you get all the time. What insurances cover this?

Ethan Colliver, MD: Yeah. We're hoping more will join in the future, but as of right now, the major insurance provider that covers it is Medicare, straight Medicare. Medicare will also have what's called Medicare Advantage, and that's where private health insurance like Anthem or Aetna will cover your Medicare and will control your Medicare dollars. We're negotiating with them to try and get them to approve it as well. The other group that we think we're very close to allowing this technology to be used on their patients is the VA system or TRICARE system

Bill Klaproth (Host): Okay. And if everybody has any questions about insurance, they of course, can always just ask you.

Ethan Colliver, MD: Yep, of course. Yeah.

Bill Klaproth (Host): Anything you wanna add, Dr. Colliver, as we wrap up our discussion about this today?

Ethan Colliver, MD: Yeah. this has, really, I think, like you said, it's a game changer. I've had patients for years that I've been so frustrated with not having enough tools to be able to help 'em or a surgeon couldn't help him. Another case where a lady had, horrible carpal tunnel syndrome and had to have surgery and the nerve got sliced and they developed a neuroma. And multiple surgeries later still, the pain was unbearable. She couldn't even hold my hand because it hurt too much. to be able to, on the day that she came in and get the implant and have her leave and just have tears in her eyes with how happy she was, that she wasn't in horrible pain, really just, makes it all worth and I love those stories.

Bill Klaproth (Host): Yeah, that's gotta bring you great satisfaction as. For sure. Dr. Colliver or someone who wants to learn more or book an appointment with you, what should they do?

Ethan Colliver, MD: Well, so you can reach Valley Sports and Spine Clinic at our phone number 540-443-3832, and our website is valleysportsandspine.com. And we're located in Virginia and kind of near the Virginia Tech campus if anyone's a hockey fan.

Bill Klaproth (Host): Sounds great. Dr. Colliver, this has really been informative. Thank you so much for your time. We appreciate it.

Ethan Colliver, MD: My pleasure. Thanks for having me.

Bill Klaproth (Host): You bet. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library. For topics of interest to you, this is the Top Docs Podcast. I'm Bill Klaproth. Thanks for listening.