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Caitlin Whyte (Host): As the opioid epidemic continues across our country, many are looking for alternatives to pain management. Joining us to share some of those options is Dr. Gurtej Singh, an Interventional Spine and Pain Medicine Specialist at the Center for Advanced Orthopedics with the Orthopedic Associates of Central Maryland. This is A Bone To Fix from the Orthopedic Associates of Central Maryland Division. I'm your host, Caitlin Whyte. Now for people with severe or chronic pain, I'm sure there are a lot of questions when it comes to trying out alternatives to opioids. What are some non-opiate medications that are available to manage pain nowadays?

Gurtej Singh, MD (Guest): Well, thank you so much for this opportunity. It's a great topic and so much we can spend time on. When it comes to non-opiate medications, there are at least four or five different categories of medications that we can try for patients, whether they are steroids or nonsteroidals, the NAIDS as a lot of people know them, as well as muscle relaxers, various types of nerve pain medications can also be used. And we find that when we combine these medications together, we end up getting a better result than using any one by themselves.

Host: Now what about injections? I hear that's another option as well.

Dr. Singh: So, there are so many different types of pain injections that we can offer patients these days for essentially almost any type of orthopedic or bone, spine problem. Pain injections everybody knows them as cortisone shots. We typically don't call them cortisone shots. What we will actually call them is the actual location of where we're placing the needle. So, if we're doing a knee injection or a shoulder injection or a spine injection, that's typically how we sort of refer to them. Many times they will contain both a steroid which a lot of individuals know that as cortisone and mixed with a novacaine or a numbing anesthetic.

And so, depending on a patient's scenario, sometimes we do the injection with both medications. Sometimes we do the medication with just the Novacaine alone. So, sometimes patients have allergies to steroids, or if they're diabetic, there are some reasons not to use the steroid. And when we do those types of procedures with just the Novacaine, it helps us to just target where's the actual site of the pain coming from. And so a lot of times with these types of procedures, our goal ultimately is to get the patient well so that they can get back to doing all the different things physically that they want to do. But sometimes our goal is actually just trying to narrow down where exactly is your pain coming from, and by doing these various types of injections, whether they're with cortisone and steroid or whether they're without, it helps us to narrow things down. A lot of people sometimes can find it frustrating. And especially when we're talking about spine patients, you know, an MRI and an x-ray, you know, they don't tell us about the pain. They really tell us what the anatomy looks like. So, what does the disc look like? Not whether or not that is the painful disc or, you know, if the nerve is pinched, not if the nerve is the one causing pain. So, part of the injection process is to really hone in, find that one spot so that if a surgery is needed or if a second injection is needed, we'll be able to target that patient's problem much, much better.

Host: Now, moving on to other types of treatment that don't involve medications. I'd love to hear more about neuromodulation.

Dr. Singh: So, neuromodulation is a fascinating way in which we're able to help patients with chronic pain symptoms. And so not only are they individuals that have had orthopedic problems, but even individuals that have chronic nerve problems. What we are able to do for a patient is we actually, it's a two-step process, I guess, the best way to think about it. Step one is sort of understanding what it is. So, I tell a lot of my patients, think about your friends who have a pacemaker. And for those of us who know about pacemakers, you know, a patient gets two leads. They get that lead placed in and around the heart and it helps the heart to beat correctly, right?

So, they have some sort of abnormal heartbeat. And then the wire, the pacemaker wires are placed and the battery helps the heart to beat normally. So, in similar fashion, when patients have chronic pain, essentially the nerves are not signaling correctly and they're not firing a normal signal up into the brain. So, what we're able to do is place two wires into the back of the spine and through a remote battery, we can help to alter that sensation and that nerve signal that ends up in the brain. So, when patients sort of understand what it is and especially how similar it is to a pacemaker, it really puts them at a lot of ease to know that it's not as a serious procedure as like a spinal surgery.

What then happens is we take a patient on a test drive and it's very much like how most of us would go buy a car. I don't really know anybody who would say, hey, here's $30,000, just bring me the blue one from behind the shop. So, you know, what we end up doing is we take them on a one week test drive.

So, for one week they will have these two wires temporarily placed into the back of their spine. And so they have the remote is on the outside of the body, but the wires are still on the inside. And I tell my patients, please go do everything you want to do, you know, go out to the restaurant, go take a walk around the block, go see your kids or your grandkids' soccer game.

Because I want to know when you come back after that week, I have to take the trial out. Right. So, it's only temporary. So, you have to return the test drive back. But then I want to know if it made the impact that they're looking for. So, you know, once we're able to get that trial done, then the rest of it becomes easy and yes, it is an outpatient surgical procedure.

Nobody spends the night in the hospital, recovery is, you know, within a couple of weeks. So, it's tolerated very, very well. I think the biggest take home point with neuromodulation is that what patients out there and even some physicians don't know is that for so many of the orthopedic problems that patients suffer from, neuromodulation is really able to take 50, 60, 70% of that pain down, or for a lot of patients who are on opiates and other narcotics, we're able to cut those doses down significantly. So, it's really not just a way to increase one's function and get them out and moving, but their quality of life, their mood, their sleep, the family around them, all of them, see, wow our loved one is doing so much better and we do that through neuromodulation.

So, a lot of patients who have had neck surgery, lower back spinal surgery, patients that have had knee replacements, foot and ankle surgery, hand surgery that just continue to have these chronic nerve pains. A lot of patients will come to me and say, well, the surgeon said that my knee joint looks perfect, but why do I still have pain? And unfortunately, this comes from a nerve derived problem. So, you have to look for nerve answers and neuromodulation has been very successful in doing that.

Host: Oh, my gosh. Wow. And wrapping up here, let's talk about micro invasive procedures. What do those entail?

Dr. Singh: So, micro invasive procedures of the spine are really sort of like the new cutting edge way in which we can help patients and not essentially open up the spine to do it. So, more and more, we are able to help treat disc herniations. We're able to treat spinal fractures. We're able to treat spinal stenosis in ways 10 years ago, even five years ago, a patient would have a large incision, would end up in the hospital for a day or two. An older patient may end up in a rehab or a nursing facility for a week or two. Now we can do all of these things microinvasive, same day, go home that night. So, one option is what's known as, endoscopic spinal decompression.

So, patients who have a disc herniation, that's pushing on a nerve and they have that nerve pain or what everyone likes to call sciatica going down the leg, instead of having a large incision, you can make a literally a less than a centimeter incision, place a small camera and tube down to that disc herniation. And with the camera, physically see that you can remove that disc out of place and it helps to free up the nerve. Another procedure in that same realm is what are known as sort of interspinus and interlaminar spacers. So, a patient with spinal stenosis and most of us know these sort of folks, right? So, they're going to be our older parents or our grandparents.

They're kind of hunched over when they walk. They're not able to make it through the grocery store without using the shopping cart to lean on. You know, what they used to be able to do to walk around the block or walk down the driveway, they have to stop and take a break. And so what happens is you get crowding in that spinal canal. I kind of tell patients, you know, think of the highway in your local town. Normally it's five lanes and in the middle of the day everyone's driving, you know, probably over the speed limit, you know, as we all get older, that five lane very quickly, it becomes three lanes and even down to one lane. So, you know, that highway with one lane during traffic, you know, you have a lot of upset drivers.

And so, patients very quickly realize, boy yeah my nerves really feel upset when I have to make it all the way down to the end of the driveway to get my mail. And so we're able to open up the back of the spine in a minimally invasive way. Patients get to go home that same day. And it's very rewarding when they're able to just do those simple tasks at home without relying on walkers or other loved ones.

Host: Great. Well, doctor, so many incredible options here. Is there anything we didn't touch on that you want to add?

Dr. Singh: Well, I think the best thing that I can offer out to our listeners today would be to say that the old way of doing things, taking a Percocet or some Vicodin is just not the way we do things anymore. Studies have come out and shown that these medications don't actually treat the problem. These medications unfortunately, can be very addictive and have their own consequences and side effects. And so technology has advanced tremendously over the last five years, to allow patients a non-opioid way, a non-addictive way of actually fixing the problem and improving their function and hopefully improving, you know, what they want to do in life.

Host: Well, thank you so much, doctor for joining us and sharing these alternatives with us. That was Dr. Gurtej Singh, an Interventional Spine and Pain Medicine Specialist at the Center for Advanced Orthopedics with the Orthopedic Associates of Central Maryland. Find out more about us online at mdbonedocs.com. And please remember to share the show with your friends and subscribe to this podcast. Thank you for listening to A Bone To Fix. I'm Caitlin Whyte. We'll see you next time.