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Gabby Cinnamon (Host): Welcome back to the Well Within Reach Podcast. I'm your host, Gabby Cinnamon. And today, I'm very excited to be joined by Dr. Mohammad Issa, a pain management specialist at Riverside, to talk about spine interventions. Thank you so much for coming on the podcast today, Dr. Issa.

Dr. Mohammad Issa : Thank you so much for inviting me and hosting me. Thank you so much.

Host: I think this is your first episode with us. Can you tell us a little about yourself?

Dr. Mohammad Issa : Of course. Yeah. I am an interventional pain specialist. I've been practicing at Riverside for almost five years now. I trained in Physical Medicine and rehab. I did my residency at Baylor College of Medicine. And then, I did my fellowship at Johns Hopkins in Baltimore and then moved back to the Midwest. Originally from the Midwest, from Milwaukee, that's where I was born. So, I have a lot of family there. And I wanted to stay in the Midwest, and I found the perfect fit with Riverside and I've been since then here.

Host: Wonderful. very excited to talk to you today. So, for those who might not know, can you explain what interventional pain medicine is and kind of what a pain management physician can help with?

Dr. Mohammad Issa : Of course. So, interventional pain is basically a specialty that aims to improve patient's quality of life by using minimally invasive procedures to treat pain. And that's really our goal, is to get our patients moving and enjoy their lives and be able to do their activity of daily living. So yeah, that's kind of our focus.

Host: So today, we're specifically talking about spine interventions. What are some common issues or injuries that might cause your patients to experience spine pain?

Dr. Mohammad Issa : Yeah. So, one of the most common conditions that we treat in our spine clinic is osteoarthritis of the spine, which many or everyone is going to develop some form or some level of arthritis during their lifetime. And that's really what we see most commonly. Obviously, there are other injuries to the spine that can happen like compression fractures or disc herniations that can cause pain. But I would say osteoarthritis is the most common. Now, there are types of osteoarthritis or regions in the spine that can be affected by osteoarthritis, and that could be the joints in the spine, which we call the facet joints. It can also be pain from the discs, whether there's a herniation or degeneration. Degeneration is basically the wear and tear over time. Herniation can happen due to lifting a heavy object or twisting the wrong way or sometimes falling. So, that's another structure in the spine that we treat. Also, there are other structures like the SI joint. SI joint connects the spine to the hip that can also get inflamed due to different reasons, whether it's due to the wear and tear over time, or maybe a strain.

In addition to that, there is a very common condition called spinal stenosis. A lot of our elderly patients experience that, and that's usually also due to wear and tear and narrowing of the spinal canal. That can happen due to thickening of the ligaments in the spine. It can be caused by arthritis of the joints in the spine, disc herniations, or the combination of all of that together. So, those are just some of the conditions that we treat in our clinic. Hopefully, I didn't miss any of the major conditions, but I would say that's a good summary.

You know, another condition that's very common, and we talked about herniated disc, right? You see patients complaining of sciatica. What is sciatica? It's basically a pinched nerve in the spine that can happen because of a herniated disc that can push on the nerve in the spine and cause that severe pain that shoots down the leg. And it can be really debilitating. So yeah, those are kind of majority of the common conditions we see in our clinic.

Host: At what point would someone be referred to you for treatment? I'm sure there's a few different paths to get to you, but when would that happen?

Dr. Mohammad Issa : Yeah. So, that can happen typically after conservative measures have failed, meaning that if someone has tried rest, medications like muscle relaxers, anti-inflammatories, sometimes oral steroids, or they've tried physical therapy, but they're still struggling with the pain, typically that's when we get involved after the patient being referred by the primary care physician or our colleagues in other specialties like neurosurgery or orthopedics. That's when we try to offer our patients these interventional procedures or injections.

In other situations, we get involved early on before even these conservative measures are tried because the patient is in severe pain and they probably can't tolerate physical therapy, right? They're trying some anti-inflammatories or medications. Nothing is helping. We try to intervene sooner rather than later.

Host: Yeah. Back pain is definitely one of those things that are just awful, because it affects so many walking, anything you're doing, any kind of those mess. So, what are some of the common spine interventions that you can do right in your office?

Dr. Mohammad Issa : So, there are many injections that target different structures in the spine. And like we've mentioned just a few minutes ago, I went over some structures in the spine. So, each one of these structures can be targeted with an injection. Now, the most common type of procedure or injection that I perform is lumbar epidural steroid injection. Not to be confused with the epidural that pregnant ladies get, right? This type of injection, the goal of it is to place medicine in an area where we have a disc bulge that's pushing or irritating a nerve. So, that's used for sciatica type of pain, or what we call pinched nerve in the back. That's lumbar epidural steroid injections.

Another type of injections is called facet injections. Facets are the joints in the spine that can also cause pain with twisting, bending. These joints can be also targeted with injections and later on with something called radiofrequency ablation. So if someone gets benefit with these joints injections, we can do an ablation on these little nerves that live in the joints and try to deaden the pain signal from those joints. So, that's called radiofrequency ablation. And it does last anywhere between six months to a year. So, it's something that can be repeated.

And other types of injections, we have the SI joint injections that I mentioned also previously. This can help with SI joint pain, mainly in that buttock area to lower back area. And sometimes it radiates down the legs, so it can mimic sciatica. So, that's another type of injection that we can perform, obviously after evaluating the patient and confirming the pain is coming from the SI joint. There are some maneuvers in specific that we do in clinic during our visit to confirm the presence of SI joint dysfunction.

Other types of procedures that we do also is nerve blocks in general. You know, nerve blocks, again, we can target nerves in the spine or nerves in other body parts. That's a very common type of injection. And in addition, we do spinal cord stimulation. So, spinal cord stimulation is basically a device that we place in the spine to try to mask the pain. And we use this in patients who are either not good candidates for surgery, spine surgery we're talking, or patients that have had spine surgery but still have severe pain in the lower back or down their legs. We can offer them spinal cord stimulator. And I work very closely with my colleagues in Neurosurgery, where I do the trial part. So basically, we place a temporary wire in the spine. And then, we keep it there for about a week and the patient can try the device. If they get major relief with it, then they are a candidate for the implant, which is then performed by our neurosurgeons. So, this is a summary of some of the interventions that we offer our patients.

Host: That's great. There's a lot that you can do that's minimally invasive, so that's good to know for sure.

We're going to take a quick break to talk about primary care at Riverside. Riverside knows that health is your greatest asset and having a primary care provider you trust is important to maintaining your overall health and well-being. Don't have a primary care provider or looking for a new one? Great news! Riverside has a team of primary care providers accepting new patients. To find a primary care provider at Riverside, visit riversidehealthcare.org/primarycare.

Now, back to our episode with Dr. Issa. So, who is a good candidate for these interventions that you just talked about versus, you know, needing something like surgery?

Dr. Mohammad Issa : Candidates for interventions are patients that failed conservative measures, like physical therapy and medications or patients who are not great candidates for surgery. Patients that we advise to be evaluated by neurosurgeons are typically patients that have neurological deficits, meaning someone who has weakness in their legs, or their leg is numb, and it's not getting better, and it's progressively getting worse, or someone who is having a red flag symptom, like losing their balance, losing their ability to control their bowel and bladder or having numbness and tingling in the groin area. Those are symptoms that indicate that surgery is needed as soon as possible. So, as long as we don't have any progressive neurological deficits, then patients can benefit from our procedures or minimally invasive injections.

Host: Can you talk about the procedure process and kind of what a patient can expect if they're going to be getting one of these interventions?

Dr. Mohammad Issa : Yeah. So, after we see our patients in clinic, we start the process of getting approval for the injections and setting it up at Riverside Hospital. At that point, the patient will be contacted by our team and given all the details needed to prepare them for the day of the injection. On the day of the injection, we get them ready by checking their blood pressure, confirming their medications, putting them in a gown. And then, we bring them on a bed to the procedure room where I will be waiting for the patient. Then, we place the patient on a table and there's an x-ray machine that takes live x-rays of their back. And then, I basically clean the back with cleaning solution. After that, we specify the area where the needle will be entering and then numb that area or, in some cases, we give light sedation for patients who are uncomfortable when laying on their stomach or have a bit of anxiety to relax them.

And then after that, I place the needle and navigate it into the area that it needs to be in using the x-ray machine. Once I'm in that region, let's say we are doing an epidural injection or a nerve block in the spine. Once I'm in the area where the needle needs to be, I inject some dye material to confirm the spread of the medicine and to ensure that the needle is exactly where we need it to be in. And then after that, I place the medicine. What's the medicine? Most commonly, we use a combination of anesthetic medicine and steroid. We use steroids, because they are a very strong anti-inflammatory, and they help decrease that inflammation in the region that is causing the pain. After the injection is completed, we basically clean the patients back, put them back in their bed, and then watch them for about 15 to 20 minutes after the procedure to make sure that they don't have any adverse reactions to the injection. And after that, they are basically discharged back home.

Host: Are there any risks associated with getting a injection like that, or some of the spinal interventions you talked about?

Dr. Mohammad Issa : So, the risks are minimal. But there are always risks with any time you place a needle in the human body, and those risks are typically bleeding. That's why we recommend for most of our patients to stop their blood thinners to avoid that. Infection, that's why we do these procedures in a clean environment, in a procedure room. We clean the back really well before we start. Third is allergic reactions. That's why we confirm with the patient if they have any allergies that possibly would prevent them from getting the injection.

Injuries, that's why we use an x-ray machine. It's very technical and very accurate to avoid any type of injury to the nerves. And, in addition to the x-ray, we use the dye material. This way, we are double confirming the safety of the injection before we inject the medicine. So, those are from a procedure perspective, those are the most common possible side effects. But they are very, very minimal, given that we take all our, precautions.

Things that we have to keep in mind with steroids, the overuse of steroids can cause bone thinning. It can decrease bone density, changes in hormones in the body, increased sugar level. Those are some of the possible side effects. But if we use it sparingly and only when needed, we can avoid that. You know, the recommendations is to try to limit it to three to four a year, not more than that. And not all of our interventions include steroids, but the majority do. And in that case, we have to be cognizant of the fact that we cannot overuse these steroids too. So, we do a very good job keeping an eye on our patients, making sure they're not getting too much steroids in their system because our job is to help them and try to avoid or decrease the possible side effects to absolute minimum.

Host: After getting an injection or an intervention, when does someone start to feel relief?

Dr. Mohammad Issa : Excellent question and very commonly asked questions by patients. It depends on the procedure. But procedures that include cortisone or steroid, we typically ask our patients to give it a couple of days to up to a week, because that's how long sometimes it takes for the steroid portion to kick in. The numbing medicine portion kicks in instantly within minutes. So, sometimes what patients can experience is an improvement in that pain level. And then, shortly after, you know, eight hours later or so, they would have an increase in the level of pain again. But then, the cortisone kicks in in a couple of days or so, and then they get that longer lasting relief. And that's our hope always.

Host: So if someone listening, you know, has been experiencing this chronic spine pain we've been talking about, and maybe think, "Hey, this would be a great option for me," where do they start and who can they talk to?

Dr. Mohammad Issa : They can start by contacting their primary care physician, maybe getting a referral to our clinic. They can also contact us directly, and we're happy to guide them through the process if we need a referral, or we need some imaging prior to their visit. So, I would say start with your primary care physician or contact us directly. Yeah, we're happy to help.

Host: Before we go, is there anything else you would like to add?

Dr. Mohammad Issa : I would like to thank you so much for this opportunity. I think these type of sessions and podcasts are very informative and important for our community. And we look forward to helping our patients and community here around Riverside. So, thank you so much.

Host: That's a great note to end on. Thank you so much, Dr. Issa, for coming on the podcast today. And thank you, listeners, for tuning in to Well Within Reach, brought to you by Riverside HealthCare. To learn more information about interventional pain management at Riverside, visit riversidehealthcare.org. Also, make sure to rate and leave a review for Well Within Reach on Apple, Spotify, or wherever you listen to podcasts.