Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. We have two UAB physicians in a Thought Leader panel for you today to highlight restorative neurostimulation, a new treatment paradigm for chronic low back pain. Joining me is Dr. Prentiss Lawson, Jr. He's an Anesthesiologist, a Specialist in Pain Medicine, and an Associate Professor.

And Dr. Christopher Paul, he's an Anesthesiologist, a Specialist in Pain Medicine, and an Assistant Professor. Doctors, thank you so much for joining us today and Dr. Lawson, I'd like to start with you. We know that low back pain, low back problems are an increasing burden on society. Can you please start with the prevalence and burden of low back pain, the effect on the quality of life of patients that you see?

Prentiss Lawson, Jr., MD: Yes, thank you so much for having us here today. Chronic low back pain is a major burden affecting millions globally. In fact, it's been stated that up to 80 percent of adults at some point in their lives may experience low back pain. Typically, this is something that can really impact not only individual's lives, but also productivity in society. It's definitely a major cause of disability in patients that we see on a daily basis.

Host: Well, thank you for that. It's really a bigger issue than we realize. So, Dr. Paul, up till now, what have been the most common treatments? Tell us a little bit about the evolution of treating low back pain.

Chris Paul, MD: So the evolution of low back pain treatment really has consisted of physical therapy, certain interventions such as epidural steroid injections, things such as trigger point injections, and frankly, time. And failing those things, surgery is a potential option for some patients.

Host: Dr. Lawson, tell us about multifidus muscle dysfunction and how does stimulating this muscle with electricity help chronic low back pain. We're going to get into the procedure itself, but tell us a little bit about this type of dysfunction.

Prentiss Lawson, Jr., MD: m So, the multifidus muscle is a deep muscle in the lower back. When it weakens or doesn't function properly, which is something that we can see after a back injury or lumbar degenerative disc disease, really that spine is not able to stabilize in the same way it was able to pre-injury. Multidifus stimulation, as a treatment uses electrical pulses to stimulate the nerves that control these muscles, helping it to regain strength and function and overall improve that patient's spinal stability.

Host: Dr. Paul, I'd like you to tell us about the studies that found that patients with chronic mechanical low back pain can benefit significantly from the episodic contraction that results from stimulation of the medical branch of the L2 dorsal ramus. What are the outcomes from these clinical trials that evaluated multifidus stimulation?

Chris Paul, MD: With the published three and five year data, 77 percent of participants had a greater than 50 percent reduction in pain scores with approximately 62 to 63 percent of participants having a decrease in their Oswestry Disability Index by greater than 20 points, which is clinically significant as well as statistically significant.

This equates out to dramatic improvements in quality of life for these patients. And it also shows that this is a durable therapy and not something that is, a short lived palliative therapy. These are true gains in function and improvements in quality of life

Host: Dr. Lawson, and I feel that this represents one of the most important aspects of our discussion today, but why does this represent a new treatment paradigm? Why really are we looking at this as a game changer?

Prentiss Lawson, Jr., MD: So, traditional treatments for chronic low back pain, unless surgery is indicated, often focus on managing symptoms rather than addressing underlying causes. This is different because for the first time, we really can start addressing dysfunction, and specifically the pain at its cause, because we're targeting the dysfunctional muscles themselves; as a potential to provide more long lasting relief and improve function in a way that previous treatments were not able to.

Host: Well then for other providers listening, Dr. Paul, how is this different than spinal cord stimulation, which has been around a while?

Chris Paul, MD: Correct. So this marks a dramatic departure from other treatments as Dr. Lawson alluded to. Spinal cord stimulation, dorsal, or also known as dorsal column stimulation with stimulation of the nerve fiber tracts in the dorsal column, is generally considered to be a palliative therapy. It's essentially kind of masking those pain signals as they go up.

This is a true restorative, regenerative therapy, and ultimately is causing improved stability and correction of the microstability, I should say, in these patients' spine. And that is leading to improved outcomes and pain control.

Host: Dr. Lawson, I'd like you to speak about patient selection. Who would be a candidate for multifidus stimulation and why?

Prentiss Lawson, Jr., MD: So that's a very important question. Multifidus stimulation is not right for everyone. It's typically most effective for people with chronic low back pain that's primarily caused by mechanical problems, such as a degenerative disc or joint dysfunction. It also is important that patients, that they've tried other conservative treatments without success and are not a candidate for surgery.

 We certainly do not seek out to provide this therapy for patients if surgery is indicated. But as Dr. Paul alluded to, from the mechanism of providing restoration of the function of that multifidus muscle, those are really the patients that we're selecting for this therapy. A careful evaluation by a pain specialist is crucial to determine if patients have dysfunction of the multifidus muscles and if multifidus stimulation is appropriate.

Host: Dr. Paul, speak about risks associated with the therapy and speak a little bit about the procedure itself. Is this minimally invasive? Tell other providers as you're communicating with them what type of procedure it actually is.

Chris Paul, MD: Multifidus stimulation is a minimally invasive procedure that involves implanting a small device on the medial branches to stimulate the multifidus nerve.

There's also an implanted pulse generator or battery that powers the electrical pulses that are sent to the multifidus muscle. As with any medical procedure, there are risks involved. Namely, infection and bleeding potentially, as well as device malfunction. But these are generally considered to be very low.

But with any medical procedure, the risks and benefits associated with this device and those would be discussed with the patient.

Host: I'd like to give you each a chance for a final thought. So, Dr. Lawson, starting with you, what do you see as the medical impact of this procedure today? How important is this going to be as we look forward to the future for patients suffering from low back pain?

Prentiss Lawson, Jr., MD: Well, time will definitely tell, but this is definitely an exciting time to be implementing therapies such as this that appear to restore function in patients. When we treat people for chronic pain issues, we're looking to not only minimize the pain they feel, but also the impact in their lives. And so anytime we can restore function in their lives, that really is the ultimate treatment goal.

Host: Dr. Paul, last word to you. What are the conditions under which you believe patients would benefit most from your experience, Dr. Lawson's experience, and this procedure? I'd like you to speak to other providers about the importance of this in looking towards the future.

Chris Paul, MD: Yeah, so I think the patients that are going to be most profoundly impacted by this are patients with axial low back pain, once again that are not surgical candidates or not had any previous history of spine surgery. A lot of these patients have tried and failed other therapies such as lumbar radiofrequency ablation, et cetera.

And this once again, represents a fairly significant departure from a lot of the procedures that we would normally perform as pain physicians that tend to be more palliative in nature and more just essentially going after symptomatology. This really is kind of attacking the underlying cause of some of these low back complaints.

Host: Fascinating interview. It was a great discussion. Doctors, thank you so much for joining us today. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.