Maggie McKay (Host): Welcome to the Health Podcast from Pullman Regional Hospital. I'm your host, Maggie McKay. Joining us today is John Schirmer, a certified registered nurse anesthetist and non-surgical pain management certified at Pullman Regional's Interventional Pain Management Clinic to discuss Iovera Cryoneurolysis Pain Management. Thank you so much for being here today, John.

John Schirmer, CRNA: Thank you so much for having me.

Host: Let's just start with what is Iovera cryoneurolysis?

John Schirmer, CRNA: Yes. So, what it is it's a cold therapy where we actually have a specialized needle that gets us cold as negative 80 degrees Celsius. And what it does is it freezes a sensory nerve. And it has an effect where kills pain for about three months. It can be more. it can be more than three months. But our expectations are at least three months of pain or relief by freezing a nerve.

Host: That is amazing. It kind of reminds me of those shots you get like—

John Schirmer, CRNA: Steroids shots.

Host: yes. It's different than that though, right?

John Schirmer, CRNA: It is different because we're actually not injecting any medication. What we're doing is we're using ultrasounds to find nerves. They're called sensory nerves, which means they're nerves that don't do motor function. They're nerves that don't do other function. Like, they don't go to your organs. They just transmit sensory input. And we use ultrasound to find those nerves. And then, we guide the Iovera needle to those nerves under their ultrasound guidance. And we push the button, which makes the needle freeze, which then freezes the nerve.

And so, the most common question I get was, "How does that needle freeze?" And what it is is there's liquid nitrogen that goes internally in the needle. So, it's not being injected into your body, it just goes internally into the needle, which makes that needle get down to negative 80 Celsius. And yeah, freezes that nerve and knocks out its function to kill your pain.

Host: Who would be a good candidate for Iovera cryoneurolysis, and who would not be a good candidate?

John Schirmer, CRNA: Great question. There's a long list of people that would be a good candidate. So, I'm going to go through conditions that we could help with. One is we could do that with headaches. There are certain nerves we could find and do this Iovera cryoneurolysis for headache pain. There's shoulder pain that we could treat. There's knee pain that we could treat and there's types of foot pain that we could treat too. There's also types of rib pain that we could treat as well. And there's even some select certain types of pain in the muscles of people's abdomen that I've been able to treat with this as well.

And so, that's the simplest answer I could give to you, is if you're feeling any of those types of pain, then come see me, and then I'll tell you whether or not you're a good candidate based off of my assessment. People who wouldn't qualify for that would be somebody who has things called Raynaud's syndrome, which is where they have a problem with cold. It's where if someone is subjective to cold, then it could cause other issues. So, we just need to know that. We'd be careful about doing Iovera cryoneurolysis with someone that has Raynaud's syndrome. But, yeah, that's the simple answer.

Host: You touched on it a little bit, but could you describe the experience of receiving Iovera cryoneurolysis?

John Schirmer, CRNA: You would come into our clinic there at Pullman Regional Hospital. We would bring you into a room. We would take your vital signs. We would go over all the risks and benefits of the procedure. The benefits are that we hopefully are reducing your pain. That's certainly the goal.

The risks are actually pretty minimal. We would go over that with the patient. Then, we would get the patient positioned on our little bed and have the ultrasound probe on their area that we're treating. We would clean the area off with some antiseptic. The only thing the patient needs for anesthesia would be local anesthesia. So, we don't need to have somebody be asleep. They could be awake. We'll all be talking through this the whole time. We will then use local anesthesia, then place the Iovera needle. And then, we'll freeze the nerves. It should be what I would call mildly uncomfortable. Nobody likes having a needle put in them, right? But there's going to be some mild discomfort. There should not be excruciating pain. And the effects of the pain relief should start to be felt almost immediately after we're done.

Host: Wow. That is amazing. John, how does this treatment stand out compared to others? We talked about like steroid shots or just other treatments.

John Schirmer, CRNA: Yes. So, comparing it to other things that we do for pain, comparing it to steroid shots, we're not injecting steroids. So, some patients can't have steroids because of comorbidities or allergies. By comorbidities, I mean things like if someone's diabetic, we have to be careful of the steroids we're giving them.

So, having it being a non-pharmacological treatment means that we're not just putting meds on an issue. We're actually treating the functional issue involved with the pain by knocking out the sensory nerve that's causing pain. So, that's one difference with an alternative being steroid injections.

Another one there is a procedure called radiofrequency ablation where, instead of freezing the nerve through cold therapy, we actually do a thermal burn of the nerve, which is also a good procedure, that's a good thing to do. I'm not putting that down at all. We do that. So, it's not a bad thing to do. It's just that the advantage to the Iovera cryoneurolysis is it starts to work immediately, whereas the radiofrequency ablation can take up to a couple weeks to start working.

The third advantage, which is something I probably should've touched on earlier, there is emerging evidence and more and more evidence that Iovera cryoneurolysis is very effective in helping people control their pain before they have to go into surgery. So specifically if someone needs a total knee replacement, we could do the Iovera cryoneurolysis for that knee a couple weeks before their surgery. And there's a lot of data showing that it actually helps with reducing the pain after your surgery. And that's something no other procedure that I'm aware of does that.

Host: So, what are the benefits and the risks involved with undergoing Iovera cryoneurolysis?

John Schirmer, CRNA: So, the benefits are decreased pain. Risks, anytime we put a needle in someone, we could hypothetically cause an infection. I've never done that, but it's possible. We mitigate that risk by using antiseptic technique. Another risk that could happen is that we could hit the wrong nerve and cause motor nerve damage. We mitigate that risk by using ultrasound guidance. So, we always keep our needle in view. And we always put the needle where it belongs and keep it away from where it doesn't belong. And I've also never had that complication. But hypothetically, I go over that with all my patients, you know, go over all the hypotheticals. Those are the two big ones.

As far as more common things that I've seen is that there can be a small blister on the skin after doing the Iovera cryoneurolysis. There could be a little bit of scabbing. The other thing that could happen is that there can be multiple causes of pain that needs to be addressed. And so, therefore, Iovera cryoneurolysis, in and of itself, may not treat the pain. That does happen rarely. So, this is just something I'd just like to discuss with patients that sometimes we need to do more than just that to control someone's pain, depending on how chronic and how severe their pain is.

Host: John, how long has this option been available?

John Schirmer, CRNA: It's only been available in our area for three years. So, in the grand scheme of things, it's fairly new. I would put it under very new, for our area. Three years is nothing compared to everything going on in our world. So, yeah, that's how new it is. It is FDA-approved. It started off being more popular in the eastern part of the United States and it's kind of come out west. So, It is something that has been done in total for many years. But in this area, it's only about three years old.

Host: Are there any alternatives to receiving Iovera cryoneurolysis?

John Schirmer, CRNA: I would say the radiofrequency ablation is one alternative. And that's where we're thermally ablating the nerves, which is actually applying heat to the nerves rather than freezing it. That is probably the most common alternative.

Host: And in your experience, how has this treatment impacted the lives of the patients who receive it?

John Schirmer, CRNA: I have seen increased functionality afterwards. So in other words, we're measuring if someone could only walk half a mile before receiving Iovera to the knee—and I'm just picking a knee for conversation. And then, we do the Iovera cryoneurolysis. And now, they're walking two miles. I would consider that a pretty big increase in functionality.

We see increased range of motion afterwards. We also see decreased needs for oral pain medications. So, that's probably the three most common things we see. But I've also seen people have tears and joy, because they feel like they haven't had that kind of pain relief till after they've experienced it. So, yeah.

Host: That's so encouraging. In closing, is there anything else you'd like to add that you would like people to know?

John Schirmer, CRNA: I just like to say that I have a passion for taking away people's pain. I just love it. So, I love seeing patients that I have been able to help. I can't help everyone obviously, but the people that I can help are very—it warms my heart.

I would just like to say that how I got into this love of taking away pain, I was a combat medic in Iraq, 20 years ago now. In those days, there was data coming out showing that, if you could control someone's pain within the first 72 hours of traumatic amputation, then you really reduce the odds of them having chronic phantom pain in the future. And so, at the time, we were putting catheters next to nerves right after traumatic amputations. I mean, in some cases within hours of traumatic amputation, we would put these catheters in that would give drips of local anesthetic to kill their pain for three days straight in hopes that we would treat that phantom pain for years to come. And doing that and being an assistant in those procedures is what started my interest. And, hey, killing pain is just awesome. It's a very rewarding thing to do, something I love. It's a passion of mine, like I said. And then, after being a medic in the Army, went and used my GI Bill and here I am. Now, I'm able to apply that concept of killing pain, you know, in the way that I love.

Host: That is amazing. Thank you so much for sharing your expertise. This has been so fascinating and very informative. And we really appreciate your time.

John Schirmer, CRNA: You're very welcome. Thanks for having me.

Host: Of course. Again, that's John Schirmer. learn more about Pullman Regional Hospital's Interventional Pain Management Services, please visit pullmanregional.org/pain. I'm Maggie McKay. Thanks for listening.