Jay Karri, MD, MPH
@JayKarriMD
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Interventional Pain and PM&R physician. Clinical interests: #MedEd , #neuromodulation , #MSKUS . Not medical advice. Views/opinions my own.
Baltimore, MD
Joined July 2019
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Pinned Tweet
Radiofrequency denervation of the lumbar facets is the most evidenced procedure for treating facet mediated low back pain. But is it helpful or harmful?🧵
@Ryan_S_DSouzaMD
@VinnyFrancioMD
@ZackMcCormickMD
@Sympathy4TheDr
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Ligamentum flavum (LF) gaps are extremely common in the cervical spine! ⚠️
- Highest prevalence of "full" LF gaps? C7-T1 (~68-93%)
- Most common access point for cervical ILESIs? C7-T1
- Are LF gaps commonly reported on MRI? Never
This is my take on cervical LF gaps🧵
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#teachingimages
The epidural space is likely contiguous with surrounding fascial planes!
Shown here is spinal needle placement outside the L5/S1 neuroforamen, but presumably in erector spinal plane, yielding epidural contrast spread.
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Glial cells comprise 90% of the spinal cord but have previously received little attention in pain modulation studies.
Thank you Dr.Watkins for your groundbreaking work uncovering the roles of glial cells in pain neuroexcitation!
#NANS2020
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#billingandcoding
Trigger point injections!
How I do it, upon review of CMS criteria 🧵
*salient points and documentation pearls
CPT 20552 (1-2 muscles)
CPT 20553 (≥3 muscles)
ICD M79.10 (myalgia, unspecified site)
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#billingandcoding
sacroiliac joint injections (SIJIs)
How I do it, upon review of CMS LCD criteria
*salient points and documentation pearls
CPT 27096 (50 modifier if bilateral)
ICD M46.1 (sacroiliitis, not classified)
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Check out our review on emerging evidence in intrathecal management of neuropathic pain following SCI! Great collaboration with current and former members of the alliance.
@BCM_PMandR
@UTHPMR
@SCI_MS
New Research: Emerging Evidence for Intrathecal Management of Neuropathic Pain Following Spinal Cord Injury
#pain
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Is Cyclobenzaprine a "tricyclic" muscle relaxant?
Why or why not?
They have nearly identical molecular structures, even more similar than gabapentin and pregabalin!
#painmedicine
#pharmacology
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Serotonin syndrome is rare, but it can be lethal if not recognized and treated early!
Chronic pain patients are especially at risk since many psychiatric and pain medications have serotonergic properties.
Here’s a quick list of commonly implicated drug classes/medications. 🧵
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Ultrasound guidance should be standard of care for GON and LON interventions including diagnostic blocks, pulsed radiofrequency, peripheral nerve stimulation, etc.
The proximal approach to the greater occipital nerve block at the level of C2 gained popularity after the team of Professor Bernhard Moriggl showed that this approach had a 100% block success rate versus 80% of the classical technique at the level of the superior nuchal line.
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Knee OA may seem simple, but it's actually highly complex! It results from a combination of mechanical, inflammatory, psychological, and many other factors.
Here are 8 specialties that can see and treat these patients. Here's what each of them offer!
(*with likely overlap)
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What's the risk of inadvertent dural puncture (IDP) w/ percutaneous SCS lead placement?
Low, 0.48% in 90,952 cases
Mostly seen in young (<50) females with prior IDP
But only *14%* of IDP cases identified intra-op!
@nasir418
@Ryan_S_DSouzaMD
@JNeuromod
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Cluneal nerve pain syndromes may be overlooked, check out our latest article for more!
@AlaaawnyAbd
@VwaireO
@ManiPSinghMD
@MihirJoshiMD
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There are numerous ways to do most procedures!!! Fellowship is the time and place to learn and trial alternate techniques. In addition to increasing procedural competence, this enhances your anatomical and procedural understanding.
14/ To my attending colleagues who recently completed fellowship, any additional advice to add?
@JayKarriMD
@DrCwoods314
@nasir418
@NickCanzanello
@GDPanjetonMD
@Dr_Ankur_Patel
@RamiDiab
@DZhengMDPhD
@flanaonlyonce
@AbdullahNewaj
@NasirKhatriMD
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Here’s a quick guide for ICD-10 codes for epidural steroid injections, as determined by CMS.
This covers codes I use >99% of the time in practice. Not exhaustive, but highly practical!
#painmedicine
#billingandcoding
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Check out our latest study in RAPM! Addressing gender disparities in research authorship is vital.
#WomenInMedicine
#HeforShe
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#teachingimages
#knee
“True AP” image of the knee:
1) femorotibial joint space opened
2) femoral and tibial condyles symmetric
3) tibia superimposes medial half of fibular head
4) intercondylar eminence in center of intercondylar fossa
Save this new graphic! Note the important anatomical landmarks on knee x-ray📌
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@jonhagedornmd
mental and physical strengthening and flexibility
also, prophylactic spinal cord stimulator
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As pain physicians we should always question the utility of antecedent and/or “prognostic” tests before definitive treatments.
SCS trials…genicular nerve blocks…medial branch blocks…SI joint injections with anesthetic…
Are these tests clinically useful or needless barriers?
'Diagnostic' block prior to peripheral nerve stimulation is a good 'diagnostic' tool, but is not a good 'prognostic' tool. Our study shows that diagnostic blocks don't predict long-term relief
#neuromodulation
@SMoeschlerMD
@nasir418
@JayKarriMD
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Neuropathic pain medications with anticholinergic properties, like Cymbalta, can lead to AAC glaucoma and irreversible vision loss.
Should we be counseling patients of this risk?
@AmerAcadPainMed
@ASRA_Society
@NANSRFS
@Ryan_S_DSouzaMD
@ShravaniD_MD
@Talktoratan
Study analyzed the association between 13,531 patients with acute angle closure and 949 prescribed drugs. A total of 61 acute angle closure-related drugs and their risks were identified, including those not previously reported.
#Research
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The FDA has issued "black box" warnings for many commonly used pain medications due to significant risks for serious side effects. ⬛⚠️
Are you aware of these medications and their labeled risks? 🧵
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I’m thankful for supportive and encouraging mentors like
@BBruelMD
!
Out in Early View 🗣 Karri J & Bruel B 👉 “
#DorsalRootGanglion
Stimulation for Post‐
#LymeDisease
Chronic Peripheral
#Neuropathic
Pain” 👉 -
#neuromodulation
#DRG
@wileyneurology
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This is a great graphic for the buttock pain differential! Buttock pain isn’t uncommon and can be difficult to diagnose.
Chronic buttock pain is common and challenging to diagnose. I made this slide summarizing the most important differential diagnosis of chronic buttock pain.
Also in this lecture, I go over the posterior femoral cutaneous nerve pain, block, and management:
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Many point of care physiatry procedures warrant special consideration during Covid-19.
@MVGutierrezMD
@PJayaramMD
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There is a lack of "renally-safe" pain medication options, and many CKD patients use OTC (non-selective) NSAIDs despite their risks.
Is using COX-2 selective NSAIDs in select patients with CKD rational or reckless?
@Ryan_S_DSouzaMD
@IARS_Journals
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Fire content by
@Ryan_S_DSouzaMD
!
Spine physicians should be able to identify “benign” degenerative Modic changes…but also maintain acute compression fractures, discitis/osteomyelitis, or malignancy in the differential!
These conditions can look similar.
Differentiate Modic changes on MRI📌
-Type 1 (inflammation): T1 Low signal; T2 High signal
-Type 2 (yellow marrow replacement): T1 high; T2 Iso to High
-Type 3 (bony sclerosis): T1 Low; T2 Low
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There is a huge variance in the pain medicine evidence, but systematic reviews and meta-analyses can clarify this data and optimize patient outcomes…but only if well designed and conducted!
#painmedicine
@RAPMOnline
@AmerAcadPainMed
Guideline on writing systematic reviews/meta-analyses is finally published in
@RAPMOnline
and featured on the front cover! 🎉📚
👉🏾Part 1: (FREE ACCESS)
👉🏾Part 2:
@sites_brian
@nasir418
@saraamaralMD
@alopipatelmd
@JayKarriMD
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Can’t be said enough. Biopsychosocial determinants highly impact chronic pain outcomes.
From Huffman et al. in this month’s Journal of Pain: “lower education levels and minority status are predictive of poorer (chronic) pain treatment outcomes”
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The proposed technique for multifidus sparing lumbar facet denervation!
Requires a tined RFA system to perform.
@DrMarcRusso
@DrAmitSharmaMD
@JayKarriMD
@Ryan_S_DSouzaMD
@VinnyFrancioMD
@ZackMcCormickMD
@Sympathy4TheDr
Or we can look into an alternative technique
#nimbus
# radiofrequency
#backpain
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Safety: multi-planar fluoroscopy is the best measure to prevent spinal nerve injury.
Lesion optimization: outcomes are likely better dictated by larger lesions with appropriately placed probes, than positive sensorimotor feedback.
@MaxEpsteinMD
@Sympathy4TheDr
@ZackMcCormickMD
#medtwitter
pain peeps - For lumbar RF neurotomy, do you perform sensory and/or motor stimulation before ablation? Why or why not?
@ASRA_Society
@NANS_ION
@ASPN_PainNeuro
@ASIPP
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Shown here is an axial cut from a T2 weighted MRI sequence across the superior aspect of the L3 vertebral body.
What's the most* abnormal finding?
What are the patient's symptoms?
#painmedicine
#teachingimages
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For anyone interested in pain medicine and innovation!
@ShravaniD_MD
is a fantastic host for the new AAPM podcast.
Hey! I’m honored to host this podcast for the
@AmerAcadPainMed
. Join us as we focus on medtech entrepreneurship, what it means to be an innovator, and how to improve patient care by bringing new solutions to market!
@bryanjmara
@DrYeshMD
@AmolSoin
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Thanks for highlighting our work!
@SergMNavarro
@AlaaawnyAbd
Exploration of Gender-Specific Authorship Disparities in the Pain Medicine Literature - "we found that male authors were favored over female counterparts with statistical significance"
@andreanicolmd
@dr_rajgupta
@ESchwenkMD
@AmyPearsonMD
#ASRAFall19
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If you perform
#PNS
for treatment of chronic pain conditions, please help us by sharing and completing this short survey
#neuromodulation
@ASRA_Society
@NANSRFS
@AmerAcadPainMed
@AAPMR
@WAPMUScot
We’re conducting a survey about peripheral nerve stimulation practice patterns, as part of a research study. We’re hopeful this data will help direct future studies and guidelines. Please answer this short survey!
@JayKarriMD
@Ryan_S_DSouzaMD
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Fun facts about C Norman Shealy:
1) he’s still alive and has a holistic health clinic in Missouri!
2) he also created TENS and helped develop facet rhizotomy
Has anyone read the FIRST case report on spinal cord stimulator implantation by Shealy/Mortimer/Reswick? The article is free and very cool. They even tell you the date/time stimulation was started.
Link:
#neuromodulation
@nasir418
@JayKarriMD
@RushnaAli6
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When assessing for radicular pathology, an MRI is only a complement to a full neuro exam testing reflexes and looking for dermatomal and myotomal deficits!
Excellent diagram that displays the myotomal distribution of nerve roots📌
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1. Steroid induced toxicity to joints/tendons is under appreciated.
2. Toradol May be a good non-steroidal option for joints/bursa pathology.
3. Follow
@MaxEpsteinMD
for great content!
Have been increasing my use of intra-articular and/or bursa Toradol (ketorolac), particularly when diagnosis is not clear or multiple pain generators
1/n
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Highly recommend this podcast for anyone in
#painmedicine
!
@ShravaniD_MD
and
@mbroach4
are fantastic and always invite great guest speakers to discuss a broad range of topics.
We're thrilled that
#PainMattersPodcast
is making waves in the world, ranking among top 10% of all podcasts.
Host
@ShravaniD_MD
Co-host
@mbroach4
@DrSeanMackey
@kchopraMD
@TrentDEmerick
@SiyunXieMD
@KohanLynn
@AntjeBarreveld
@JayKarriMD
@ZackMcCormickMD
@nwarnerMD
@BethDarnall
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@Sympathy4TheDr
@UTHSA_RehabMed
@NarouzeMD
@DrNatStrand
@NatSchusterMD
@AmyPearsonMD
@eckmann_max
@doctdeer
Physiatrists are particularly apt at diagnosing peripheral neuropathic pain conditions, so I suggest PNS indications and utilization.
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@Ryan_S_DSouzaMD
There’s a lot of heterogeneity in PRP for knee OA literature with regard to patient selection, PRP preparations, outcomes, etc. But several meta-analyses show PRP to be effective/possibly superior to IA steroids or HA.
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With increasing data coming out about LDN ineffectiveness for fibromyalgia, there still exist good studies from Mayo (Driver & D’Souza) and Stanford (Youngner and Mackey) that suggest otherwise.
More research into patient phenotypes is needed.
🌈 Still a believer in Low Dose Naltrexone
#LDN
for generalized pain! Recognizing it's not a one-size-fits-all, as responses vary among patients. 🔄 Here are some exciting analgesic outcomes in our study highlighting potential of LDN! 📚💊
FREE access:
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Dr. D’Souza’s praise doesn’t come easy! I highly recommend Pain Rounds for all trainees!!!
Hear from
@Ryan_S_DSouzaMD
anesthesiologist & pain medicine physician at Mayo Clinic, about why Pain Rounds is a game changer for pain medicine fellows!
Hosted by
@ShravaniD_MD
Pain Rounds is a comprehensive video curriculum that dives deep into neuromodulation (con't)
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Despite the 2020 consensus guidelines, many use varying technical parameters for lumbar facet RFA.
This is my approach, what do you do?
Cannula orientation: cephalad, near-parallel
Cannula/electrode type: tyned, 18g
Lesion temp and time: 90deg, 100sec
Pre-injection: lido 2%
🔍 Fascinating study alert! 📊
When doing RFA of the lumbar medial branch nerves, is there significant functional improvement associated with temperature of 90°C compared with 80°C? This study suggests 90°C was superior to 80°C for duration of relief.
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In the cervical spine, 18g needles (compared to 20g) may have a greater risk of superficial burns, neuritis, and (with a 120sec lesion) may place cervical roots at risk…
I use a 20g needle with 10mm active tip placed halfway across the articular pillars, 90deg x 90secs.
@JayKarriMD
@VinnyFrancioMD
@Ryan_S_DSouzaMD
@MaxEpsteinMD
@JSinghMD
@nasir418
@JoelCaste11anos
@darthglader
@GDPanjetonMD
Similar to
@Ryan_S_DSouzaMD
for me but I’ve switched to a single burn. 90 degrees C for 90 seconds parallel to nerve. 18g for lumbar, 20g for cervical, 2% lidocaine prior to burn.
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What’s going on here?
Shown are AP and lateral Xrays of a young patient with an L5-Sacral “fusion” and what looks like an L5 laminectomy.
*But she doesn’t have a surgical history*
#teachingimages
#painmedicine
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The recent studies “unmasking” liposomal bupivacaine as a wonder drug are especially fascinating as they shows how strong our implicit biases are!
Without this research, I’m now sure how long (if ever) it would take us to learn this information with clinical practice alone.
Just published in Anesthesiology! More data showing that liposomal bupivacaine is not a wonder drug for peripheral nerve blocks.
@ASRA_Society
@ESRA_Society
@RegionalAnaesUK
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I have a Medicare patient with T12/L1 and L1/L2 facetogenic pain (adjacent segments to a fusion). Does Medicare really want these two levels to be treated on separate days (MBB and RFA)?
See Q7 from Noridan website.
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4/ Final thoughts?
Failure to recognize and avoid LF gaps might lead to catastrophic complications of cord injury with C-ILESIs.
Given these risks and wide prevalence of LF gaps, some have also proposed that C-TFESI with imaging review and non-particulates may prove safer!
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5/ So what's the right answer?
We shouldn't homogenize all patients with facet mediated pain into standard algorithms.
- recognize and consider risks of RFA of lumbar facets
- emphasize spinal conditioning for all
- consider non-ablative treatments (e.g. PNS or PRF)
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Do you typically use live (“continuous”) fluoroscopy when performing lumbar interlaminar injections? Why or why not?
#painmedicine
#proceduraltechnique
*rephrased for clarity
Yes
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No
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Anecdotally, I found success with using Nortriptyline for patients with whiplash and work related neck injuries, especially with a confluence of myalgic and neuropathic pain with overlapping migraines, anxiety, post-traumatic stress.
Have you found similarities in clinical use?
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@jonhagedornmd
@SMoeschlerMD
@AmyOxentenkoMD
@JulieSilverMD
@DrHowardLiu
@ellenbraaten
@AmandaMorin
@echamblet
@DouglasMGriffin
@Ian_Willoughby
@raneutill
@TomVargheseJr
@LauraFlowersE
@DrDanielGih
@MVGutierrezMD
@SAStrongMD
@ShikhaJainMD
@TalyaFlemingMD
@SarehParangiMD
@EMARIANOMD
@ETSshow
@DrJewelKling
@DrNatStrand
@CourtHarrisMD
@HeartOTXHeartMD
@AmyPearsonMD
@CatRichert
@emilysharpe
@SVanterpoolMD
@Ryan_S_DSouzaMD
@AlexDresslerMD
@KeithschmidtMD
@ChrisHaDO
@JoshuaRomeroMD
@stevenchar_
Ishiguro is one my favorite authors! For anyone into dystopian fiction :)
…but of course my current reading are the latest NACC recommendations 😂
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@Ryan_S_DSouzaMD
@NANS_ION
@MayoAnesthesia
You’re welcome
@Ryan_S_DSouzaMD
. As a mentor, I feel the same gratitude when I see my mentees achieve great things.
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Why isn’t Buprenorphine commonly used as a 1st line opioid in patients with chronic pain without OUD?
#buprenorphine
#opioid
#chronicpain
@Ryan_S_DSouzaMD
@nasir418
@DocAnitaGupta
@Sympathy4TheDr
@drchadb
@Talktoratan
@MateuszGraca
@CalcaterraSusan
@KohanLynn
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@JeanWooMD
@BCM_PMandR
@ndarji102
@BobbySong9
@MaxEpsteinMD
@JSinghMD
@SharifPalmerMD
I can only assume the size of the photo correlated with how much you appreciate us?
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6/ But I don't know the right answer! There are likely phenotypes of degenerative LBP for whom different treatment modalities need to be incorporated. What are your thoughts?
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1/ Lumbar medial branches are mixed nerves! They innervate not just the facet joints (sensory), but also the multifidus (motor).
Increasing evidence including the recent study in PAIN by Guven et al. have shown radiofrequency neurotomy could cause multifidus atrophy.
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Don’t miss the NANS RFSYN reception on Thursday evening (1/18)!
Open to students, residents, fellows, early career physicians, and anyone who wants to engage with RFSYN!!!
@NANS_ION
#painmedicine
#neuromodulation
Save the date! Join us on 1/18/2024 for the NANS Annual Meeting Residents and Fellows Reception!
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TIL…Gabapentin is commonly used to treat pain in dogs.
A resourceful new patient diagnosed herself with a radiculopathy and started taking her dog’s gabapentin. She is happy with 600mg QID. How would you proceed?
@Ryan_S_DSouzaMD
@nasir418
@MaxEpsteinMD
@JSinghMD
@SounSheen
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Given recent data (albeit slightly mixed) for CSI associated RPOA in the hip, I’ve been more selective in who I inject. When I do, I use conservative steroid doses, saline, and little (if any) ropivacaine in the injectate. What are others doing?
#Ortho
#Physiatry
@AAPMR
@TheAMSSM
Corticosteroids are toxic for cartilage, more when paired with local anaesthetics (common). Intra-articular CSI increases the risk of joint collapse in at-risk individuals & infection after THR. Screen closely, discuss risks with pt & try load Mx first!
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In a randomized study of labor epidurals, women told they would “feel a bee sting” with local anesthesia had more procedural pain than those told they were getting an anesthetic “to numb the area”.
@benjamin_gill
@MateuszGraca
@SounSheen
@BrandonSmith_MD
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@VeenaGraffMD
@NarouzeMD
@DProvenzanoMD
@CARLOSPINOMD
@AmyPearsonMD
@garyschwartzmd
@ASRA_Society
@PainDocGoel
@KohanLynn
@ShaliniShahMD
@SinglaPriya1
@magedguirguis1
@MagdaAnitescuMD
@drchadb
@anniechadwickmd
@kchopraMD
@DElmofty
@Ryan_S_DSouzaMD
@dr_rajgupta
@VinnyFrancioMD
@VinitaSinghMD
When patients with cervical radicular pain can’t stop their anticoagulants or get an MRI, I defer ESIs and perform retrolaminar blocks with very good benefit!
After my billing department got mad, I’ve moved to additionally doing and billing as TPIs.
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What are your impressions and experiences for NSAID vs Steroid injections into the joint or bursa?
@DrJN_SportsMed
@TheDrROBO
@DrRyanNuss
@Sympathy4TheDr
@egoncalves_md
@JayKarriMD
The studies basically show ketorolac and triamcinolone are comparable in efficacy. My experience does not match that.
I tell patients pros and cons and they can decide. Very similar indications. Adverse effects and contraindications help decision making
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CPT 20553: "injection(s) into 3 or more muscles".
Guess which muscles I have included in my procedure note template!
#painmedicine
#billingandcoding
Important paraspinal muscles to memorize on axial T2 MRI of the lumbar spine📌
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If you perform
#PNS
to treat chronic pain, please help us by sharing and completing this short survey!
#neuromodulation
@ASRA_Society
@NANSRFS
@AmerAcadPainMed
@AAPMR
@WAPMUScot
Please answer this short survey about PNS practice patterns, as part of a research study to help characterize practice patterns for PNS utilization. This data will help direct future studies and guidelines. Survey deadline is next Wednesday, February 14:
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Sharing again….is COX-2 selective NSAID use rational or reckless in people with CKD?
@SounSheen
@MaxEpsteinMD
@JSinghMD
@MaxEpsteinMD
@VinnyFrancioMD
@kchopraMD
#COX
-2 Selective
#NSAIDs
in the
#ChronicKidneyDisease
Population: Are They Rational or Reckless?
#CKD
#anesthesia
#pharmacology
@JayKarriMD
@Ryan_S_DsouzaMD
@MayoClinic
@HopkinsPain
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@Ryan_S_DSouzaMD
Also PRP may not have facilitated cartilage regrowth but we certainly know (from high level studies) that IA steroids are chondrotoxic.
Interesting study, thanks for posting it!
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5/ References
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@MateuszGraca
@SShergill_MD
@NANS_ION
@ASRA_Society
@ASPN_PainNeuro
@ASIPP
@AmerAcadPainMed
DP still happens (and is under recognized)…
@nasir418
@Ryan_S_DSouzaMD
and I estimate it occurs inadvertently in ~0.5% of cases…interestingly, in ~80% of those cases it wasn’t identified at time of SCS lead placement! (patients presented later with PDPH)
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@benjamin_gill
@MateuszGraca
@SounSheen
@BrandonSmith_MD
It may seem trivial, but perceptions and experiences with local anesthesia influence a host of nocebo, somatization, and psychological parameters.
Lower SQ scores correlated with improved L-ESI outcomes!
@SiyunXieMD
@EKubrova
@achamess
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This was a very helpful NEJM clinical practice review on non-specific low back pain.
Critical to be able to distinguish nonspecific low back pain from cancer-related back pain in our patient population. Great review on nonspecific low back pain in
@NEJM
#Physiatry
#CancerRehab
Nonspecific Low Back Pain | NEJM
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Should we even use local anesthetic for our non-diagnostic (therapeutic only) lumbar ESIs? Thoughts?
Should I use local anesthetic in my cervical interlaminar epidural steroid injections?
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Correcting inequalities in education may be a small but meaningful step towards making our world a better place.
Please consider donating to Khan Academy whose servers are at increased capacity with
#COVID
-19.
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@ScottPritzlaff
These biologics failed to show any “regenerative” capacity for knee OA pathophysiology.
While these biologics failed to show relative superiority, they’re certainly not as directly harmful as repeated intra-articular steroids and anesthetics.
@MaxEpsteinMD
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@Ryan_S_DSouzaMD
Nagy Mekhail previously also showed superiority of 90deg with no meaningful increase in adverse outcomes!
So I always use 90deg consistently…in the neck, the lower back, the knee, the shoulder…
I also don’t believe there’s a difference in patient tolerance with 90 or 80deg.
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@Ryan_S_DSouzaMD
@SMoeschlerMD
@nasir418
Based on this graph, dare I say that diagnostic nerve blocks prognosticated worse outcomes with PNS? 😂
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A special congrats to
@BeiZhangMD
on this very important work!
Hot off the press!
Many Faces of the Hidden Souls: Medical and Neurological Complications and Comorbidities in Disorders of Consciousness
@BeiZhangMD
@CraigDiTommaso
@ko400
@jay_karri
#TIRRmh
,
#DoC
via
@MDPIOpenAccess
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@TTUHSCPMR
@PmrScholars
@BeiZhangMD
is brilliant and these trainees will be lucky to have her mentorship!
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Lucky to have collaborated with long time friend and incoming
@BCMCancerCenter
faculty
@RTxDoc
!
Excellent resource and contribution to the late radiation toxicity literature from
@jay_karri
! Especially relevant as the number of long-term cancer survivors increase.
@bcmhouston
@BCMCancerCenter
#cancer
#radiation
#toxicity
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In my field of interventional pain medicine, at least Medicare doesn’t over regulate care for simple things like sacroliliac joint and facet joint procedures!
#painmedicine
@MaxEpsteinMD
@JSinghMD
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A timely topic discussed with thoughtful and scholarly analysis. A must listen for all Neuromodulators!
We break down Cochrane Library’s recent article on the effectiveness of Spinal cord Stimulation (SCS) with host
@ShravaniD_MD
, co-host
@mbroach4
and guests
@ZackMcCormickMD
,
@NatSchusterMD
,
@VwaireO
& David Caraway, MD, Ph.D.
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This is a common finding in patients with spinal bifida occulta!
Extensive posterior deficits (typically across multiple levels) may suggest meningocele (protrusion of meninges) or myelomeningocele (additional protrusion of neural elements), which are better evaluated on MRI.
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@DrPayItBack
Very clearly shown before….non-organic signs correlate with treatment failure (with cervical epidurals).
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2/ So what, aren't there other supportive spinal muscles?
The multifidi contribute up to 2/3 of necessary spinal stability during dynamic movement!
Also, the L5 dorsal ramus target if ablated could additionally compromise the erector spinae.
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@Ryan_S_DSouzaMD
@nasir418
@MateuszGraca
@jeffreyhuangmd
@RobertPaganMD
@benjamin_gill
@anterpreet_md
@saraamaralMD
@alopipatelmd
@VinnyFrancioMD
@EKubrova
@BrianBrennerMD
@CrystalJosephMD
@ross_barman
@SamLinaresMD
@parkash_anish
@MariamElSaban
1. Learn about other different practice types (group, employed, etc) which you’re not exposed to.
2. Learn about healthcare economics and policy- both have immense influence on our field!
3. Start building a financial plan. There is no shame in caring about money and investing!
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@Dr_Oubre
Thanks Dr. Oubre! You should create an entire course on appropriate documentation…I’d take it!
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@Ryan_S_DSouzaMD
@nasir418
@emilysharpe
@MateuszGraca
@JohanaKlasova
I have a circle of colleagues I text with daily-weekly and we share updates, perceptions, and experiences!
Evidence is one thing, but contextualize with real world practice is invaluable!
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@ZackMcCormickMD
@Sympathy4TheDr
@Ryan_S_DSouzaMD
@Dr_Ankur_Patel
@JSinghMD
@BBruelMD
@MaxEpsteinMD
@iSpineDoc
@GDPanjetonMD
@nasir418
@SounSheen
@ByronJ_S
Thanks a ton for the insight, I completely agree! We certainly need updated LCDs addressing these situations.
Does the SIS advocacy group help to rectify such concerns?
@MaxEpsteinMD
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I hope everyone comes away from the
#TexasFreeze
with an increased empathy for the homeless and appreciation for global warming.
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Large disc herniations/extrusions at higher levels, especially if paracentral, can demonstrate evidence of polyradicular symptoms!
Maintain higher level disc pathologies on the differential when L4, L5, and S1 deficits are manifested collectively.
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