Have you ever been told you have “Uncle Arthur,” more commonly known as arthritis? This ailment affects so many that either you or someone you know likely has pain from arthritis. With so many ways for a back to hurt, how do you tell if your back hurts from arthritis?

Back pain from arthritis is a somewhat different affair than disc pain or structural pain. Instead of the pain radiating, it stays fairly localized to the facet joints, which Dr. Lakhia refers to as “the knuckles of the spine.”

Back Talk Doc guest Dr. Stephanie Plummer walks through a specialized treatment that she performs called a radiofrequency ablation that is used to treat arthritic back pain. In short, the procedure “burns” the nerve that is causing pain, disrupting the signal from the nerve to the brain with few side effects.

To determine whether an ablation will be beneficial, patients go through not one, but two injection procedures called medial branch blocks. These are short-term anesthetic treatments to see if the targeted area gets relief from numbing various nerves. If both treatments are effective, the patient and doctor can decide whether radiofrequency ablation is right for them.

“Despite all the positives, patients should know that the results are not permanent. Over time, the nerves do repair and come back together,” says Dr. Plummer. If successful, patients can expect six months to two years of relief from radiofrequency ablation.

Ready the Full Show Notes on our website BackTalkDoc.com

💡 Featured Expert 💡

Name: Stephanie Plummer, DO

What she does: While she’s a new partner at Carolina Neurosurgery and Spine, Dr. Plummer has been a practicing interventional spine physiatrist since 2013. Dr. Plummer completed her osteopathic medical school training at the Osteopathic School in New Jersey, served as a resident at East Carolina University and worked as a fellow in interventional spine through the Orthopaedic Specialists of the Carolinas in Winston-Salem, North Carolina.

Company: Carolina Neurosurgery and Spine

Words of wisdom: “My patients know that I talk a lot about core strength and core stability. I really think that that can't be underestimated and I don't know that any of us can ever be too strong in our core. I really try to make sure that I'm doing my job of keeping my core healthy by doing exercise for core strength and core stability a couple of times a week.”

Connect: Website

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Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly skilled, and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.

Welcome to another episode of Back Talk Doc. Today, I'm really, really excited to discuss a topic that has become very commonplace in the world of spine care, and that is the procedure known to many as radiofrequency ablation, and I'm really excited to have a conversation with my newest partner, Dr. Stephanie Plummer, regarding this issue. So Stephanie, welcome to the show.

Thank you, Dr. Lakhia. It's great to be here.

Absolutely. So by way of introduction, Stephanie is new to Carolina Neurosurgery & Spine, joined our group in 2021, but she's not new to the Charlotte area. She has been a practicing interventional spine physiatrist, really since 2013. And prior to that, she did her osteopathic medical school training at the Osteopathic School in New Jersey. So like me, she's a fellow DO. Then Stephanie did her physiatry residency at East Carolina University, and followed that up with a fellowship in interventional spine through the orthopedic specialist with the Carolinas in Winston Salem, North Carolina. And correct me if I'm wrong, Stephanie, but that's the same fellowship that our friend and colleague, Andrew [Sumich 00:02:23], attended.

You're correct. That's the exact same fellowship.

Yes. And for those of you who haven't heard the episode we recorded just before today's interview, Dr. Sumich, and we talked about intercept. Now, intercept is a procedure that can be done for people with chronic back pain, where you target what's called the vertebral end plates. But today we're going to talk about a procedure for chronic back pain as well that's really more related to back arthritis, to put it in layman terms. So for those of you who are out there who have been told you have "Uncle Arthur" in your spine, listen up to this episode, and I think you'll find the information to be useful.

So Stephanie, let's jump right into the kind of topic questions for today. And I think the first question would be this. How do you know if you were someone who's listening to the podcast and your back hurts, are there any specific clinical characteristics, symptoms that should make you pause and think, "Well, maybe it is a degree of spinal arthritis or facet joint pain that could be contributing."?

So that's a really good question. And I think it's a difficult one for us to know. I think we're all fairly in tune with our own bodies in terms of when something doesn't feel right or when it hurts. And the thing about back pain or spine pain in particular... And if you've listened to any of the other episodes that you've done, you know that there's a lot of different things in the spine that can cause or generate pain. Arthritis is just one of those things. But there are some certain characteristics. So if you're experiencing any of these signs or symptoms, it may be the issue at play. First and foremost, it's generally pain that stays related to the back or the spine itself. So we call that axial pain. And what that means is the pain generally doesn't radiate very far away from the source, although it can radiate a little bit.

So classically it's common to see arthritic changes in the very lower part of the back. A lot of people have low back pain, and that can come from arthritis. And typically that will stay in the lower part of the back, but it can radiate out towards the buttock area sometimes. And it usually doesn't cause, like I said, the pain that radiates down the leg that people think of sciatica as sciatica, unless there's something going on that also involves the nerve roots. So if it's just localized to the back, not going to many other places, it might be arthritis.

Yeah. And what's interesting is that we know that there are these referral pain maps out there per joint. So for example, the L4 5 facet joint. And if you're listening to this and you don't really have a good understanding of anatomy, the facet joints or facet joints or Z joints, they're like the knuckles of the spine. They're the tiny little joints and they have small degrees of movement, but there are pain maps out there where you can kind of look at and say, "Well, if it hurts here, it's coming from this joint." And my understanding is that those are much more accurate in the cervical spine versus the lumbar spine, which can make it a little more challenging. Has that been your experience?

Yeah, that's correct. The facet joints, and that's what the joints of the spine are called most commonly, if you look in the cervical spine, the upper cervical facet joints radiate more towards the head and the mid part of the neck. And then as you move into the mid part of the spine, it can come down more into the shoulders. And there are actually very discrete maps that have been drawn based on following people with facet joints in a number of studies over a number of years and just having people map out where their pain is, and there's these overlapping patterns that keep coming up over and over and over again. And in the cervical spine, in the neck in particular, it can be pretty easy to pinpoint where the problem area might be based on where you're feeling the pain and discomfort.

I think that just speaks to the complexity of low back pain and the different pain generators that people struggle with. If you were assessing a patient, how would you kind of think in your mind and differentiate between joint pain versus disc pain?

Sure. Just thinking about the anatomy me of the spine itself, if you think about where the facet joints are in the spine, especially in the lower part of the back, they're more in the back part of the spine, the posterior aspect of the spine. The discs are more in the anterior part of the spine. So if you do something that places pressure either onto either part of those, either the front or the back of the spine, you're loading different areas that could cause pain.

So it's the facet joint, which is in the back of the spine, if I have a patient standing in front of me and I lean them backwards, or even twist a little bit to one side or the other to place a maximal load onto that area where the joint is and it reproduces pain, then it's probably the facet joint. If it's pain that's more common with bending forward per se, then it's probably coming more from of the disc and maybe related to disc degeneration or wear and tear changes.

Yeah, that's a good point. And we actually touched on that when I interviewed our physical therapist, [Jackson Bellas 00:07:30], who talked about the flexion-based discogenic pain or disc-related pain. Now, what are some risk factors for developing back arthritis? Is this something that everyone's going to get?

So I'm sure it's been your experience. Arthritis is one of those things. It's a wear and tear change problem of the body. It's a degenerative change. So you can use a lot of different analogies. The car one always seems to come up. If you put enough miles on a vehicle, it develops some wear and tear changes. Your body's no different, and your joints can be one of those areas that can develop these wear and tear changes or arthritis type changes. So in terms of risk factors, age is certainly one. The more years you have under your belt, the more likely it is that we're going to see some of these arthritis type changes if we were to do imaging, such as an x-ray.

Sometimes if you've had a history of a traumatic incidence to that area of the spine, and usually pretty fairly pronounced injuries, you can be more prone to developing an arthritic change if you have wear and tear changes, degenerative changes and other joints in your body. So say you have arthritis in your knee or your hip or your hands, especially. You talked about the facet joints being the knuckles of your spine. And I love that because that's the analogy that I use all the time to help people understand what the facet joints are doing in their back. If you have arthritis in those places, more likely that we're going to see arthritic changes in your spine as well.

And then there's a bunch of other things. Certainly there's a genetic family history component to it that can be a predictor for developing these changes. You hear a lot about people talking about, "Oh, I did this activity in my life. I did a lot of heavy manual labor. I was very athletic," or, "I did a lot of high-impact sports." Possibly, that could be something that could contribute to it. But from my own personal practice, I see these changes just as commonly in folks who have had sedentary, kind of unexciting jobs their entire lives just as often as I see it in folks who have done more heavy physical labor.

Yeah. Here's what, in my opinion, makes this very, very interesting, is that... and you touched on it just a little bit about imaging... is that you and I both know we can image with x-ray or MRI 100 patients in certain age group and demographic. And almost a majority of them will have "degenerative" facet changes, but not all of them will have significant back pain or problems. And this is why I think the procedure radiofrequency ablation or neurotomy, what I like about it is there's a method to it in terms of confirming the diagnosis before you go into the procedure because what you don't want to do is treat every single person who has a degenerative facet on an imaging study. Would you agree with that?

Yeah, absolutely. And I think that's where we were talking a little bit before we recorded this episode about how there's a lot of sometimes confusion that goes into understanding how to get to the point of actually doing radiofrequency ablation. And I think a lot of it has to do with the diagnostic process that leads to it.

As you said, the majority of patients that we image will have some sort of degenerative changes generally in their facet joints in the spine, but not all of those facet arthritis changes cause pain. It's not uncommon to have someone come in who's got just... You expect to hear them complain of a lot, a lot, a lot of pain based on their imaging findings, and they have almost no pain or they have something unrelated going on. And then you can see a joint that perhaps doesn't look too terrible on imaging, but as you work through the physical exam process, you start to think, "Oh, this is probably facet-related just because of how it behaves, where it's located." So you really have to get into the diagnostic process to determine if radiofrequency is going to be an appropriate and beneficial treatment for these patients.

Yeah. And what's interesting for both you and I who went through osteopathic medical school, during medical school training, looking at the facet joints, we looked at it more from a lens of alignment, position, motion, and we'd intervene with muscle energy techniques or high velocity, low amputate adjustment techniques to reestablish proper alignment and function. And many times you would see improvement in pain. But let's fast-forward. Let's say we've done that. People have gone through PT, et cetera, and their back is still hurting. Let's talk about the process of radiofrequency ablation. So first, if you can for the listeners, define what exactly that even means, and then talk a little bit about kind of the diagnostic process and how you get to the point in determining if someone's a candidate.

Sure. As you know, it is quite a process. So if you need to jump in and clarify anything as I'm going through this, please don't hesitate to interrupt me, but basically, radiofrequency ablation, a lot of your listeners may have heard it as that procedure where they burn the nerves in my back. And to be a little bit more precise about it, it's a procedure where we take a very specialized... what looks like a needle, really an electrode, and we use that to deliver heat to a nerve.

And in this case, because... You're going to stop me here, dear listener, and say, "We're treating a nerve? I thought you said we were treating a joint and arthritis?" Well, yes. Both things are true. The joints that we have in our back, the facet joints, each one has two nerves called medial branch nerves, that basically are the signaling pathway to take any painful signal from the joint back to your brain. And that's how your body interprets that it's painful. So when we're doing radiofrequency ablation, it's not so much that we're treating the arthritis itself, but we're blocking that pain pathway. So the radiofrequency ablation, as I was saying, it really delivers heat very specifically to that one nerve and then prevents it from transmitting its signal along the path of the nerve.

That sounds like a lot. And it's a bit more to it than just what most listeners might be familiar with, with standard cortisone injections or epidural steroid injections. When we're doing the procedure, we actually have this machine, the radiofrequency generator, produces this electrical current. We use a grounding pad that's applied to the patient. And then like I said, we have these specialized meals. And using that, basically that circuit, that's how we get the electricity and the heat to the tip of that needle to heat up and make a lesion on the nerve.

How do we get to that point? So like I said, there's a lot of work that that goes into this. It sounds like a lot, but really it'll make sense once we get through it, and you'll see why it's needed. So we kind of already touched on why we need to do the diagnosis part of it. And that's because we can't tell which joints always are the painful ones.

So the diagnostic procedure or the test procedure is something called a medial branch block. I already mentioned those nerve nerves that we're treating are called the medial branch nerves. So the block is a test procedure, or as I like to describe it, a simulation, something where we can see, "Hey, if we can temporarily interrupt this signal in this nerve, is that something that's going to both reduce pain for the patient and allow them to restore their function?"

So the test procedure is pretty straightforward. We would bring you to the procedure room. It's done under live x-ray or fluoroscopy. We find our target points for where we know those nerves to lie along the bony parts of the spine, and we basically go right down to that spot and inject a small amount of an anesthetic or a numbing agent.

And there's a couple different types of numbing agents that we can use, but we have in mind how long that should produce an effect for. So if we numb that nerve with a certain agent, it should last for perhaps this many hours or perhaps a few hours longer. So when patients come in for this procedure, it's actually really important to us that they're having their usual pain or discomfort. It's not uncommon for people who have pain primarily when they're... After they've been standing for a long period of time or walking, we might actually ask them to go out into the lobby or the waiting area and stand for a while or walk around or do something to be reproduce that pain because once we do the test, we want to know if it made a difference. If you're not having the discomfort on the day of the procedure, it's hard for us to know if we're... Again, we're trying to figure out is this the joint that we want to be treating or blocking?

So for each joint that we're doing, there's actually two of those medial branches that we'll go into and do a block on. So if it's your, just for example, your L5-S1 facet joint on the right side, we would actually be treating two medial branch nerves for that one joint. If there's three joints or two joints in a row... Excuse me. So your L4-5, L5-S1 facet joint, we would do three nerves because there's an overlapping one there in the middle.

It's pretty straightforward. Most patients tolerate that procedure extremely well. It goes pretty quick. And then we provide the patient with a pain diary. So we want to know how patients are feeling right after we do the procedure. And then for the rest of the day, basically, go home. We tell them, "Do your normal activities. Do things that it might normally bother it or that you would maybe be hesitant to do because of the pain." And we want to see how people respond. We want to make sure that it reduces the pain and improves function. And there's specifics that we're looking for to know if it's a positive test or not.

Yes. That was an excellent breakdown. I would just [inaudible 00:16:53] up right there. I want to make a couple of points that You touched on and I want to kind of reemphasize it. First of all, these nerves that we're blocking and maybe ablating, I get asked the question all the time about, "Well, don't I need those?" And the answer is largely no. We know they do innervate some of the deeper muscles around the spine, but the studies have played out from what I reviewed that they're not functionally relevant. So in that regard, I think that's a fear people may have that is something that is a little bit unfounded. Do you agree with that?

Yeah, that's absolutely correct. And actually, I reviewed one of those articles just the other day as well, and I haven't seen anything to the contrary in nine years of having practiced these types of procedures both from continuing education or what we've learned in training. So that's absolutely correct.

The other thing I would say is just to emphasize with those listening, what Dr. Plummer just described, the order of this is you get medial branch blocks followed by radiofrequency ablation, but the medial branch blocks are not a treatment. There is no corticosteroid used. So when you receive that procedure, think of it as no different than going in to get an x-ray or an MRI. It's a test, and we're looking for the result. But the key difference with branch blocks versus most other spinal injections is that we typically tell people after epidural steroid shots to rest a little bit. Medial branch blocks are a test to assess both pain and function.

So she's absolutely correct. If you come in for that procedure and you're not in pain, your pain's a 1 out of 10, it's really difficult to gain any value from doing a test injection. So we may ask you to move and kind of provoke the pain. And then when you go home with your pain diary, we will always tell you, "We need you to kind of reproduce activities that typically provoke the pain and document that for us so we can assess the efficacy of it." So just a couple of points that I wanted to toss in there because this can be extremely confusing for people.

It's definitely confusing. And I would say it's probably the most confusing procedure, or I guess really, as you've described, a diagnostic test that we do. The expectation is that if I'm getting a shot, I should feel better, right? Well, the shot isn't... It's leading hopefully to the procedure that will help you feel better, but we just have to do some diagnosis and then confirmation first. So say good news. You had a great response to your first round of medial branch blocks. We can move on to radiofrequency, right? Not exactly. And the reason why, we talked about how facet pain or facet arthritis is very common on imaging. Unfortunately, it's also common to have a false positive response to one of these medial branch blocks.

And there's a lot of different reasons for that. One is that we know that people are very eager to move on to something that's going to help improve their pain, and that can influence sometimes how we grade our responses. But also, there's a lot of different things that can cause low back pain, not just as we already mentioned, not just facet arthritis or joint arthritis. So there could be a component of other things going on too, disc pain, muscular pain, myofascial soft tissue pain. So we really just want to be sure that before we go forward with radiofrequency that we can confirm and reproduce the same valid response to treating those medial branch nerves.

So if your first medial branch procedure is deemed successful and positive, we actually bring you back in and we do the same thing one more time. And like I said, that's just because we want to reduce that likelihood that maybe there was a false positive response, and we really want to make sure that we're treating the right area for you.

Yeah. And that's a difficult concept to understand, but it is so critical here because of, like you just said, the high prevalence of nonspecific back pain, the high prevalence of imaging, and it brings up a kind of a question that I skipped over before, but I want to come back to now. What are your thoughts on imaging to determine if the pain is arthritic or not? And by imaging, we have x-rays, we have MRIs, and we have bone scans. What's been your experience with the validity of using those to help assess for arthritic back pain?

When you do look at the studies for how to diagnose arthritic back pain, really, the gold standard is the medial branch block procedure. But certainly, you want to make sure that the joint you're targeting likely has signs of arthritis. So that's why you need the x-ray and MRI. The bone scans, I've used them in the past, especially if maybe the medial branch procedure produced some conflicting response in some way, or we weren't 100% certain. Perhaps there was prior surgery and there's a question of which levels we need to target. Maybe they're not at the same area, but we think only one is potentially problematic. And you can see in a joint that's undergoing active arthritic and inflammatory change that that shows up on a bone scan, and it can help you be a little bit more precise, but it's not really the gold standard for diagnosing facet pain.

What about using steroid injections into the facet joints?

So good question. Those used to be a lot more common, and that's essentially been... We're not using that anymore as a way to diagnose facet pain in the spine. They're not as reliable and they're not as good at treating facet arthritis in the back.

Yeah. I mean, to be more specific, we used to do a lot of corticosteroid injections for back pain where we inject the joints. And I think what's happened over the last period of 5 to 10 years is the literature has compared these steroid shots in the facet joints to saline injections, and at times found there to be not much of a difference. So yeah, that's an area where academically and scientifically, we've evolved, and you're correct. The gold standard really, if you're suspicious of joint pain in the low back, the gold standard is two diagnostic medial branch blocks. But again, the other part about that is physicians are not going to tell you what to expect from the branch blocks. We're not going to tell you what anesthetic we're using, when the pain release should start, or how long it should last. And as a potential patient, that shouldn't be a point of frustration.

It's done to get a more objective response because even going through medial branch blocks, there's false findings, false positives. In fact, when I came back from recent training, I guess last year, the thought was that to really get... So if you get two positive branch blocks, the predictive success for radiofrequency ablation of those joints is around 80%. And to get to 90% or higher, we'd have to have people go through three, four, or five rounds of branch blocks, which no one's going to do for many, many reasons. We'll walk it forward. Let's say someone has come to see you. You've done medial branch blocks for their lower facet joints. They had a great response twice. They went through the radiofrequency procedure. So what could be someone's expectations for results? So for example, when should they start to experience relief and how long should it last?

Yeah. Again, different from other procedures that we might do from the spine where you're receiving steroid or cortisone. I tell my patient that we need a little bit of patience with this one, and reason being again, you're creating a lot of heat around that nerve and the tissues that surround it. It's a very small lesion, but there's thought that that causes some discomfort as well, which is generally different from the pain that you were experiencing before. But we want to let all settle down a little bit before we come back and see you and reevaluate you in the office to make sure that we're on the right path and make sure that the procedure was a success.

So I typically see people back between four and six weeks after radiofrequency ablation, which is a little different than after, say an epidural steroid injection where it might be just two or three weeks. But we want to give little bit of time just to make sure that that area has had a chance to heal and that you've been able to hopefully resume normal activities and see how it's treating you on a day-to-day basis. If it's successful, then we really expect that the results should last anywhere from six months to two years.

Yeah. It's a wide range. It is.

It is a wide range. Yeah. And there's a lot of reasons for that as well, just like the responses to the medial branches can be varied, but hopefully, on the longer side of that, the better.

Yeah. So I myself, I do the medial branch blocks. I do not do the radiofrequency treatment. But what I have observed is that this is all about patient selection, ruling out other potential causes first, and then setting proper expectations. And on average, I would say when successful, people are getting around 9 to 12 months of good relief. One of the reasons that it doesn't last "forever" is, correct me if I'm wrong, but there's a bit of regeneration of those nerves that were burnt.

Sure. There is. And to get a little bit more technical, what's actually happening is that you're coagulating the proteins in and around the nerve. So it's not so much that you're making a heat burn across the nerve or slicing through the nerve like you would slice through a slice of bread. You would actually get different types of nerve injury if that happened. But I'm actually going to borrow the analogy that is used in the spine intervention societies guidelines and principles on radiofrequency ablation because I think it makes a lot of sense and I think it'll make sense to the listeners.

So instead of this being like a telephone wire that's being cut where to repair it maybe you just have to put the two ends back together, put some wire insulation around it, and it starts conducting that signal again, think of this procedure more as like a mine shaft that's collapsed. So you have all these little parts that are broken down around it. And to get it to function appropriately, again, you have to build back all of those little pieces. So it takes longer.

That's great. I have not heard that. That's actually conceptually easy to understand and that does make a lot of sense. So thank you for that. We touched a little bit on why sometimes the radiofrequency may not work. You still can have two great branch blocks go in and get the ablation. And sometimes, people come out of there saying it just didn't seem to do much. It's just there's false positives. And there are so many other factors for back pain.

False positives, and there's a lot of different reasons for back pain, like we touched on. You can have a strong component of arthritis pain in your back, but arthritis doesn't develop on its own or in a vacuum. It usually goes along with other wear and tear changes. It comes along with other changes in our lifestyle. Perhaps we've gotten more sedentary over time. Perhaps we're not as strong in our core. Perhaps our muscles become more fatigued easily when we stand and move things, and that's what we're experiencing as pain and discomfort. Perhaps we do repetitive activities that are always going to reproduce some level of discomfort no matter what we've done to try and address different areas of wear and tear changes.

But that's why we're really selective with this. And that's why we go through the trouble of doing the two rounds of the medial branch blocks, because we really want to see this be successful for patients, and we want to apply it to patients who are going to have the most successful outcomes with it. We don't want to have you go through all of this and then still not feel great on the other side of it.

Right. And the other consideration is that in the world of spine care, particularly with painful spinal arthritis, surgery isn't all that helpful for just localized back pain. This is why these techniques have evolved and developed. And I think it's been a huge addition to our toolbox and how we can help people who are suffering from that type of debilitating pain. A couple special considerations I wanted to get your opinion on before I let you go. Number one is as you and I know, we work in our neurosurgery group and we do get a lot of patients referred to us who have a spondylothesis, which is a slight bone slippage. And then the other scenario I want to get your opinion on is people who have had previous lumbar fusion, and maybe they're getting pain above or below the fusion, and we're asked to work that up. What's been your experience with those two types of scenarios?

Sure. So a couple of things. So the first condition that you mentioned, spondylothesis, where you have an abnormal alignment of the spine, perhaps there's abnormal motion that goes along with it, that can certainly be a source of pain and discomfort. And the reason that develops why you end up with these alignment changes is because of that cascade of development of arthritis in the joints, to some degree development of wear and tear change in the disc. But if there's still a large component of joint-related pain or arthritic joint pain with the spondylothesis, those patients can still be good candidates for radiofrequency ablation.

The same exact principles apply. We'd have to go through the medial branch blocks at the level which we think is causing the pain. If there's a spondylothesis, there's not really any additional special considerations other than when you're actually performing the procedure. You just have to make sure that you've identified the targets correctly because sometimes, it can make the anatomy a little more misleading under live x-ray. So you just have to make sure that you've taken all of that into consideration. And folks who have been doing these procedures for a long time, that's not something that's going to trip them up. They're going to be very experienced in that and be able to target those medial branches very effectively just the same as in someone who didn't have that problem.

Yeah. I agree.

The other issue related to spondylothesis, at least in my experience, I do think that if there's motion associated with it or instability, where that segment of the spine is moving abnormally as maybe you bend or twist or extend, that in and of itself sometimes can be painful, and I think that the radiofrequency ablation in those cases has a chance of being somewhat less successful just because there's a mechanical motion pain component to it as opposed to just the joint is inflamed and arthritic. But not necessarily. Like I said, it's still worth going through the process to make sure that someone's a candidate for radiofrequency ablation.

Yeah. I agree totally with that idea, because it's still a relatively low risk, high yield procedure for most people.

Exactly. And then you mentioned, you asked about fusion as well. So someone's had a spinal fusion. I'm sure you've seen this. I see this. When someone's had a fusion, it's not uncommon then to start to develop some arthritis changes either above or below the fused segments, and certainly, radiofrequency ablation can be done for those segments as well.

I have had patients referred to me by providers who would like me to consider doing the medial branch blocks or radiofrequency ablation at levels that have been fused. However, if there's hardware that goes into the spine at those locations, typically, the hardware obscures where that medial branch would've been anyway. So that's usually not something that's practical or that's able to be done as easily. But certainly, above and below, if those joints show sign of arthritis and we can get to those medial branches safely, we can do that.

We do have to take care of the hardware, make sure that we're not heating up around the hardware that's in place, the metal that's in place, if we're to do radiofrequency.

Yeah. Certainly very high level stuff. You want someone who's experienced and looking at these sort of conditions and when you're doing the procedures. I don't have anything to add to that. I totally agree on how you approach both of those conditions.

So I think we've done a really good job today breaking down radiofrequency ablation, kind of what it means, who it could be for, and when it's appropriate. So I've enjoyed the conversation. I always try and grab a few personal things from my interview guests. And I got to say, you're one of the more interesting people that I've had on the show. Just getting to know you and know of what you do outside of work, I find it to be really fascinating. So I always ask, share some daily health strategies, books, podcasts, et cetera that you think listeners could benefit from. But honestly, for you, Stephanie, why don't you tell the listeners if you're comfortable with it, a little bit about some of your exercise endeavors and then maybe your side hobby in aviation.

Sure. Yeah. I can absolutely do that. That ties into the podcast a little bit. Yeah. We'll start with the daily health strategies. I know you're big into preaching healthy lifestyles in general, right?

Yeah.

I'm a big believer in practice what you preach as well. So my patients know that I talk a lot about core strength and core stability. I really think that that can't be underestimated and I don't know that any of us can ever be too strong in our core. So I really try to make sure that I'm doing my job of keeping my core healthy by doing exercise for core strength and core stability a couple times a week. Part of that I do as well because I'm a big runner, and I think that core strength and stability is really important for running biomechanics. I will say I've been catching up on your previous podcast episodes as well.

So I've kind of been going back through them since I joined the practice. And I listened to the... I think it was episode three where you talked with our colleague, Dr. [Cheadle 00:35:18] about spinal stenosis. And he's a runner as well. And he mentioned everything in moderation, that he wouldn't think too much of running a couple of marathons in a year, but maybe not six or seven. Well, I ran five marathons in 60 days last fall. So I don't know if I fall into his recommendations for moderation.

Did you not run two in a week?

I ran three in a week. I ran three in eight days. Yeah. I did the London Marathon on October 3rd, the Chicago Marathon on October 10th, and then the Boston Marathon on October 11th last year. [crosstalk 00:35:53]-

Folks, if your back hurts, I'm not recommending you do that.

I wouldn't, either.

That's good. Sounds like you're really passionate about running.

Yeah. It's been good for me and it's been good for just my overall health. And I guess you could say it's mental wellbeing too. To me, exercise is really important just to be able to... That's my time when I go out for a run. No matter what the distance is, I can kind of debrief my day. I can process things that are going on, whether it's at work, whether it's at home with family, friends, and it just helps me kind of organize and prioritize my life while I have that time to myself and while I'm getting some exercise in. I think that's... Yeah.

And then when you're really stressed, you take to the clouds, right?

Exactly. That's definitely my weekend hobby and passion and my other stress reliever is flying. So I do a fair amount of flying. Started off actually while I was in residency. I had a friend who was a husband of one of my co-residents and was a flight instructor, and just getting to know them and becoming friends with them, I got into flight training and went on to get my private pilot certificate. And didn't really want that to end there. I wanted a way to continue learning, and I like the idea of continuing education and just being as proficient at something as possible. So I went on to get my instrument rating so you can fly on less-than-ideal-weather days, a commercial certificate, so there's limited things that I could do for hire if I wanted to, and a multi-engine rating as well. So on the weekends now, I use that sometimes to fly sky divers.

Wow. And you mentioned you've been on some podcasts about aviation?

Yeah. There's a podcast that I've been involved with for, gosh, over five years now. It's called the Airline Pilot Guy show and it's started by an airline pilot, of course. And the premise of the show is to discuss aviation news, usually related to commercial aviation. But over the years, he's brought on a number of us that bring in some different perspectives. The other participants are all airline pilots. I'm the outlier there, but it's nice to bring a little bit of a different perspective to the discussion.

Well, make sure you share this episode with them. I'm sure the pilots' backs don't feel so good after long flights. So there you go.

I'm sure not. Yeah.

Thank you for sharing that. Really fascinating. I love it. Practice what you preach, and then you kind of pursue other interests outside of medicine. I think that makes you a better clinician when we live lives that are a little bit more balanced and relatable to people. So thank you so much for your time today. I think we did a great job breaking down a difficult topic, and I look forward to speaking with you again.

Absolutely. It's been my pleasure. Thank you so much, Sanjiv.

Thank you for listening to this episode of Back Talk Doc brought to you by Carolina Neurosurgery & Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.