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Neuropathy and Its Many Facets with Dr. Ki Jung
Episode 53 • 8th September 2022 • Back Talk Doc • Sanjiv Lakhia - Carolina Neurosurgery & Spine Associates
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Have you ever sat in one position too long and had your foot fall asleep? And when you stood up, you felt a prickling or tingling that was almost painful? Or have you ever rolled over in the middle of the night and found your hand was numb? Each of these occurrences are considered positive symptoms of neuropathy — they are the presence of an abnormal sensation.

What exactly is neuropathy and what causes it? On this episode of Back Talk Doc, host Dr. Sanjiv Lakhia is joined by one of the newer partners at Carolina NeuroSurgery & Spine Associates, neurologist Ki S. Jung, MD to discuss neuropathy. Dr. Jung is newer to the practice, but not new to neurology as he offers over 18 years of expertise and is well-established in the community as a subject matter expert in his field. 

Dr. Jung walks listeners through a few examples of the various symptoms that bring patients to his office, as well as how to rule out the most common causes of neuropathy and test for sensory modalities to potential medications. He also discusses alternative technologies for pain management and relief.


💡 Featured Expert 💡

Name: Ki S. Jung, MD

What he does: As a board-certified and fellowship-trained neurologist, Dr. Jung performs on-site neuro-diagnostic testing and has over 18 years experience diagnosing and treating disorders of the brain, spinal cord, peripheral nerves, muscles, and other issues of the nervous system.

Company: Carolina NeuroSurgery & Spine Associates

Words of wisdom: “Our bodies, we have to treat them right. And you need fuel. That's what food does, but make sure that fuel is super unleaded. Make sure you get rid of all the bad stuff and just supply your body with the good stuff. So good nutrition, adequate hydration, get some exercise in, and rest.” 

Connect: Website 

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👉 If you enjoyed this episode of Back Talk Doc, check out our recent episode Botanicals and Back Pain with John Slattery

🔎 For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at CNSA.com.

Transcripts

Voiceover (:

Welcome. You are 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.

Sanjiv Lakhia (:

Anybody who has suffered from low back pain understands there can be other symptoms involved. One of the most concerning symptoms that I often encounter in my clinic is out of numbness, where you just can't feel your foot or your legs or even tingling in the hands.

(:

In medical terms we refer to this as neuropathy, and I'm really pleased today to bring with you an interview with my newest partner, Dr. Ki Jung. Ki, welcome to the show.

Ki Jung (:

Hey. Thanks Sanjiv. It's fantastic to be on your show. Been following along your podcast for other things, so it's nice to be a part of it actually.

Sanjiv Lakhia (:

Actually. Yes. Let me introduce you to the people listening. Ki's is board-certified and fellowship-trained in neurology and he's at more than 18 years of experience helping patients with neurologic disorders.

(:

He performs on-site neuro-diagnostic testing as needed and has the expertise to diagnose and treat disorders of the brain, the spinal cord, peripheral nerves, muscles and other tissues of the nervous system. Dr. Jung also helps patients who need treatment or testing related to headaches, stroke, dementia, seizures, epilepsy, MS and neuromuscular diseases.

(:

And he does neuro-diagnostic testing such as EMG and nerve connection studies and EEG. Medical school training was at Wake Forest School of Medicine. He did his residency at the University of Pittsburgh Medical Center and he did fellowship in clinical neurophysiology at the University of Pittsburgh Medical Center.

(:

So Ki is board-certified in neurology and by the American Board of Psychiatry and Neurology and he has also board-certification in clinical neurophysiology. So that's a mouthful.

(:

All of which to say is, folks, this guy knows what he's doing. He's fantastic addition to Carolina Neurosurgery & Spine and he operates out of the Huntersville office, right? Which is North Charlotte, for those of you who aren't in the Carolinas.

Ki Jung (:

Yeah, correct.

Sanjiv Lakhia (:

So Ki's had a lot of experience working up symptoms and I was happy that he agreed to come on board today. Numbness in particular can be very concerning for people and we haven't really touched on it through the podcast, which is focused mostly on discussing and educating about spine conditions and the rehab approach and potential treatments.

(:

But having a deep dive on this symptom makes a lot of sense to me and I'm glad to have you on. So what I'd like to do, let's do this first, let's introduce people, just give us your kind of broad overview of numbness and neuropathy. What does that actually even mean when you hear those words?

Ki Jung (:

Yeah, absolutely. So neuropathy this term that we use, it's a medical term that medical professionals use to describe a malfunction of the nerve endings. Now sometimes it gets transposed, for example, you could have a pinch nerve and have some numbness and tingling and pain down in an extremity, an arm or leg, and then sometimes that gets termed as neuropathy.

(:

Well, when medical professionals, especially neurologists, when we hear the term neuropathy, we have a different image in our head of what that is. So neuropathy would be a malfunction of the nerve endings. Now whether that's nerve ending damage, inflammation or irritation, it all produces very similar symptoms.

(:

And so the term neuropathy is just a overall encompassing term that says that the nerves aren't working right and you're feeling things that are not normal. Okay. So let's just say, for example, numbness. So we all talk about numbness and it's weird because when you talk to people about numbness and tingling, they kind of mumble it.

(:

Yeah, I got some numbness. And then you say, "I'm sorry, what do you have?" And they say numbness. And they look at you funny as if you don't believe them, because in their mind when you say numbness, you can't feel things, but yet they are feeling the numbness. So it's a strange way of saying it doesn't feel normal.

(:

And when they say numbness, it's truly a sense of something doesn't feel right. It doesn't feel normal. So there are different types of sensory abnormalities, which is probably a better descriptive term as sensory abnormalities rather than numbness. But numbness is what we would consider a negative symptom of neuropathy, meaning that it's an absence of normal sensation.

(:

So that's what we would call numbness. Now many of us have experienced numbness and tingling and pins and needles. Maybe we sat in one position too long and our foot fellas asleep and starts waking up and you get that weird prickling, tingling, it's almost painful kind of thing. It lasts for a few minutes and dissipates.

(:

Then you have, you roll over in the middle of the night and your hand's numb. You can't feel it. And literally you're like, I know it's there, but I don't really feel it until it starts to wake up and you get those weird pins and needles, the tingling.

(:

Now the pins and needles, the tingling, the burning, those are considered positive symptoms of neuropathy because they are symptoms that are not numbness or an absence sensation. It's a presence of an abnormal sensation.

(:

So that's what they call a positive symptom of neuropathy. There's nothing positive about it in terms of it's not a good thing to have, but it's positive in the sense that it's a tangible sort of it's an irregular symptom that you can feel.

(:

So when we say numbness and tingling, it kind of encompasses all of that. So when we're in the medical field, you go to your doctor and say, "I got numbness and tingling," we kind of understand and then we'll drill down.

(:

Well, tell me what it is that you actually feel, right? So is it numbness? Is it tingling? Is it pins and needles? Is it burning? Do your feet feel like they're encased in a block of ice? So those are the kind of things that we're looking at.

(:

And everybody that's listening in may have had at least some form of this at least once in their lifetime, some more familiar with it than others, but again, it's that same feeling as if a limb falls asleep and it starts to wake up. That's what we would consider the symptoms of neuropathy.

Sanjiv Lakhia (:

That's an excellent overview. And I think a take home point is when you hear the term numbness or neuropathy, it's more descriptive term and it's not a diagnostic term.

(:

So really if you're presenting and you're worried about it, and you're told just you have numbness or neuropathy, then the next step is to figure out the why. And that can be very challenging and is really in part why I got you on for today to help kind of walk us through your mindset.

(:

So I thought about how can I talk about this topic in a way that people can relate to? I'm thinking, let's just go with just a typical case and then we can get inside your head and you can tell us how you think about things and evaluate things if you're okay with that.

Ki Jung (:

Oh, yeah. Inside my head. That's a scary place, man.

Sanjiv Lakhia (:

All right. So a common presentation quite simply could be, let's say, a female in her mid-50s who is concerned because over the last six months she's noticed some tingling and numbness in her feet, particularly at nighttime things burn a little bit, seems to be uncomfortable when she's walking, but it can come and go.

(:

And maybe at times it's a little more down one leg than the other. She hasn't noticed much in the way of tingling in her arms or hands, but she does report a history that this "runs in the family."

(:

So when you hear that someone, comes into your office with some sort of presentation similar, kind of walk us through your initial thoughts and maybe from key things you're looking for on an exam as well and then what people could expect from a workup lens.

Ki Jung (:

Yeah. So come in with that particular presentation or that particular complaint, the first thing I'm thinking about is, hey, let's think of the most common things that in the medical world cause numbness and tingling. I mean, that's the first thing that just flashes through my mind.

(:

So for stepping inside my head to figure out what's going on, the things that I'm really thinking about are, hey, does this person actually have a neuropathy? Because it kind of sounds like. Now outside of neuropathy, there's a number of other reasons why a person can have numbness and tingling in their feet and their legs.

(:

And we'll get more into that in just a little bit, but the things you start thinking about is it neuropathy? And if it is, we got to start thinking, what are the most common reasons behind neuropathy? At least in our country, the most common reasons would be something like diabetes.

(:

So immediately I'm thinking, has this person been diagnosed with diabetes? Have they seen their physician in the last several years? Because let's face it, there's some folks that just don't go to the doctor unless they're sick. Right. So those are the first things that flash in my mind, do they have neuropathy?

(:

So when you approach the patient as far as how do you start digging into, delving into what's going on, you got to ask the what, where and how about this. And so you kind of gather more information from the patient about, okay, well, what is exactly what you feel?

(:

Kind of like what we talked about at the intro here about the different forms of just sensory abnormalities. Is it numbness? Is it tingling? Is it pins and needles? Is it a burning pain? Those are the kind of questions that I want to know. And then depending on what the patient tells me, then you start drilling down a little bit further in and start going, well, when did it start?

(:

Is it there constantly? Does it come and go? Just like you said in the initial presentation, is it symmetrical, are both feet and legs involved or is it just one side? That gives me a different idea of where I'm placing the possible cause. Is it in the nerve endings themselves down in the feet and the legs or is it somewhere higher up in the spine?

(:

So those are the things that I start thinking of. Then you want to find out obviously what the patient's background is. Do they have a family history? This person said, "Yeah, it kind of runs in the family." There's all sorts of different types of hereditary, what they call neuropathies.

(:

There's different types of things where maybe there's a strong history of diabetes in the family and mom had diabetes, grandma had diabetes and they all had the neuropathy associated with diabetes. So those things come into play that you want to delve a little bit further into the family history as well.

(:

And then really what's transpired over time. So it started this way, has it been getting worse? What other symptoms are you noticing? Are you noticing some problems with moving your toes? Have you noticed changes in the skin color of your feet? Are you having trouble with your balance?

(:

Can you stand in the shower, close your eyes, wash your hair without losing your balance? I mean, those are all sort kind of key indicators for me to think, hey, there could be this neuropathy going on in this person. So that's kind of where you start.

Sanjiv Lakhia (:

Okay. Elaborate a little bit on that. When you said, can you stand in the shower? What are you looking for there?

Ki Jung (:

That's a great question. And the whole reason for asking that question is all, when we're in the shower, we take our shampoo and we put in our hair, we don't keep our eyes open. We close our eyes so we don't get the shampoo in our eyes and the water in our eyes.

(:

But the ability to stand up with your eyes closed and keep your balance, there's a lot going on there. And just one of the things that really help us keep our balance is our ability to feel things with our feet. If your nerves and your feet are working properly, they can send the message to your brain that, hey, my left foot is here.

(:

My right foot is here. I know exactly where I am in this three dimensional space. But if you have a problem with those nerve endings, then the nerves in your feet cannot send that message to your brain. So your brain has kind of a generalized understanding of where your feet are on the floor, but not an exact coordinate of where your feet are on the floor.

(:

So you start to feel unsteady. You have to open your eye. Maybe you kind of keep an eye on something, or you have to lean on the wall to wash your hair. Maybe you sit down in a shower chair to wash your because you're afraid you're going to fall.

(:

And that's because of something called proprioception loss. And that's a fancy word for saying that you've lost your ability to understand where your feet and limbs are in space. And so that can be a symptom of neuropathy as well.

Sanjiv Lakhia (:

Excellent. Yeah.

Ki Jung (:

The better way to understand this is, again, if we were talking about how do you correlate that? How do you help understand what that means? Imagine your feet are like cars and your brain is the satellite out in space, right.

(:

We all know what a navigation system is, the GPS, call it what you will. Well, for that to work, the GPS navigation system in your car has to send the signal to the satellite in the space for the satellite to know where the car is on the map.

(:

Well, if your GPS isn't working, meaning your nerves are not working in your feet, there's no way to send that signal to the satellite, otherwise known as your brain, to tell your brain where your feet are on the map. So that's the best way to look at that.

Sanjiv Lakhia (:

Yeah. That's a lot of communication. Yeah.

Ki Jung (:

Exactly.

Sanjiv Lakhia (:

Excellent. All right. So then what are some kind of key things that you're going to check for with somebody who's in the office from an exam perspective?

Ki Jung (:

Well, definitely how you perceive sensation. So we check a variety of different what we call modalities of sensation. We want to check and see can you feel light touch, like just kind of touching your feet and your ankles and your lower legs.

(:

Can you feel that appropriately, or is there some sort of difficulty in feeling that, or does that touch, hurt or does that touch feel different to you? Does it make it tingle when I touch you? So there's this light touch sensation we check. The other thing we check is temperature sensation.

(:

So we have this little tool, it's a pretty much a basic musical tuning fork that we use, but it stays cold in the room because it's just exposed to the air and stays cold. It's metal. And we kind of touch that to your... The longest part of your body's nervous system is down in the toes.

(:

So we'll touch that cold metal tuning fork to your skin and see if you can perceive the sensation. Can I feel that cold temperature or does it feel like nothing but just pressure? And as I run it up your leg, if you start to notice, wow, that's gotten really cold all of a sudden around mid shin, you know that there's some difficulty with those nerves down low not working like they're supposed to.

(:

So we check those different sensory modalities outside of the temperature, the light touch. We also check how you perceive pinprick, how you can feel vibration. And then I move your toes up and down or your ankle up and down to see, can you tell if I just moved it up or down with your eyes closed?

(:

So that gives me some sense of understanding of what kind of sensation can you feel with the different modalities of sensation. And that'll tell me, okay, hey, the nerves are working right, or they're not working right.

Sanjiv Lakhia (:

And then addition to that, talk about the importance of the reflex testing.

Ki Jung (:

So for the reflexes to work, you have to have good sensory input. So it's a feedback loop. So whenever the doctor takes that little hammer and wax you on your knee and your leg jumps out, that's a normal response.

(:

But to be able to have that reflex response is that you have to be able to first feel that stimulus, that reflex hammer hitting your knee, that signal has to be generated and sent to your spinal cord, bounces back and then goes down to the muscles of legs, tells the muscles to move.

(:

But if the nerves aren't working properly, a lot of those reflexes start to become less and less and to a point where sometimes you'll lose those reflexes altogether.

Sanjiv Lakhia (:

And in particular, you mentioned earlier that diabetes is a very common cause. And that's something that we'll see as a diminishing of the deep 10 reflexes and it's just another clue. And folks, this is really meant to give you a 30,000-foot view.

(:

I mean, Ki and I could probably talk for an hour on every one of these elements, but I'm just trying to walk you all through how this should be assessed or can be assessed and give you some insight into how he looks at things.

(:

So you've seen this patient, she's come with the numbness in the feet. You've done your examination now. And now we're thinking about testing. What are some relevant tests that are typically part of your neuropathy workup?

Ki Jung (:

Absolutely. So we had mentioned diabetes and that seems to be sort of something that we're all sort of familiar with, but absolutely blood work would be one of the things that we would start with looking for not only diabetes, sugar testing, we'd be looking at vitamin levels. Certain vitamin deficiencies can cause neuropathy.

(:

We'd look at other metabolic parameters including thyroid, check your thyroid panel. See if that looks like there's a thyroid irregularity. And in some instances, depending on the person's risk factors, we might check other things like HIV, syphilis, those types of things, Lyme's disease can sometimes come up and cause neuropathy.

(:

So there's a host of blood tests that we would check for looking for the most common causes of neuropathy that can be checked with blood. So blood work is definitely an important aspect of the workup for someone with a possible neuropathy. There's another test called EMG or a nerve conduction study.

(:

There's sometimes used simultaneously in terms of the verbiage, but what that is, it's electric diagnostic testing. It's a way of objectively measuring how well the nerves work electrically and how well the muscle, the nerve and muscle interface and the nerve roots work using a tiny little needle that has a recording device.

(:

It's kind of a high tech cool thing, but that's a test that we use to of confirm and actually objectively measure whether or not there's nerve damage. So that's a really useful tool in our sort of armament in terms of evaluating patients who have potential neuropathies. And then outside of that, you could do some imaging or V-ray kind of stuff.

(:

A lot of times if we're going to do anything, we'd probably want to do an MRI scan. And you would ask, what would you MRI? Do you MRI the foot, the leg? Well, that's maybe depending on the situation, but really what we'd want to do is look at the spine. See if there's something going on in the spine that's causing a downstream effect into the nerves.

(:

The other thing, and this is sort of kind of doesn't really come up that much in neuropathy evaluations, but numbness and tingling, these sensory abnormalities, they can also happen in sort of more generalized neurologic conditions. Something called multiple sclerosis, which is a condition where your body's immune system has gone rogue and it's attacking itself.

(:

It attacks the brain, attacks the spinal cord, attacks nerve endings. So part of the evaluation could include an MRI of the brain or even though the spinal cord, depending on what the situation calls for. But ultimately those are the big sort of three ticket items, blood work, nerve testing and then maybe an MRI, depending on the situation.

Sanjiv Lakhia (:

What would be the situation where you as a neurologist would be interested in a nerve fiber biopsy?

Ki Jung (:

That's a great question because a lot of people they don't even know about biopsies. And so yes, you can do biopsies. What you're looking for there are what we would call small fiber neuropathy or vasculitis. Now this kind of goes back, so we're going to back up the train just a little bit here.

(:

When we talk about neuropathies, you have neuropathies that can affect what you call your large nerve fibers. These are the big thick nerve fibers that you can actually measure with that nerve testing I was talking about.

(:

And then you have small nerve fibers which are really, really tiny and you can't really measure them with this nerve testing we were talking about earlier, but small fiber neuropathy can also cause very similar symptoms of numbness, tingling, pins and needle, those burning, everything that we talked about before.

(:

Now there are several ways to check to see if you have small fiber neuropathy, but one of the ways to check it is to do a biopsy. It's a skin biopsy essentially to look at the tiny little nerve fibers and whether or not your biopsy shows a lack of those tiny nerve fibers, indicating that you could have this small fiber neuropathy.

(:

Now the other biopsy that they do is a nerve biopsy, but understand one thing, if you get a nerve biopsy, that nerve you took a sample of will no longer work downstream.

(:

So typically when we do nerve biopsies, it's with the understanding that this person has such a bad neuropathy that if you take that nerve, it's not going to impact them in any way, but it can give you information about the type of neuropathy this person has.

Sanjiv Lakhia (:

Yeah. Excellent. Thanks for that clarification. I want to touch on just kind of briefly, the common causes of peripheral neuropathy that you mentioned, certainly type 2 diabetes. And then the ones that I encounter like sense of alcohol exposure and then nutritional deficiencies, even B12 and folate, and more B12 with maybe seeing a little more with some of the plant-based movements.

(:

And what's interesting is a lot of these are, not all of them, but a lot of these are lifestyle-driven and preventable in nature. I do think there's a lack of education regarding them. A lot of patients that I see that work for doing an EMG or nerve conduction, studies on and we diagnose them with that and take a little more history, point to arrow at a certain cause.

(:

And the response is I never knew that could happen, though I think it's something that's worth talking about and kind of sharing with people, particularly alcohol. I think chronic alcohol exposure and too much is actually not as much as a lot of people think. And it's a cumulative effect.

(:

And many people are aware of kind of alcohol toxicity on the liver, but I always inform them about the neurologic consequences on the nerves. So long-term exposure causing a horrible painful neuropathy and alcoholic related dementia.

(:

So that's something that I think should get a little more pressed when we're talking about lifestyle, medicine and preventative medicine and preventative care. Would you agree with that?

Ki Jung (:

Yeah. No, absolutely. Diabetes is probably, if you look at the United States as a whole, diabetes is one of the number, actually it is the number one reason why most people will have neuropathy is diabetes that's a cause. Now it doesn't even have to be diabetes. It could be what they call prediabetes, right.

(:

Now you always go, "Hey doc, how's on blood work?" Oh, you know what? You're borderline diabetic, but you're good. The problem with that is prediabetes means that your sugar's not normal, but it's not bad enough to be diabetic range. Having said that though, it's all about having a normal sugar or an abnormal sugar.

(:

It's like a black and white here. It's either normal or it's not. There's no prediabetes in neuropathy. Okay? That means your sugar is either normal or it's not normal, but having that prediabetes range of sugar, can still affect your nerve endings and create a neuropathy as well.

Sanjiv Lakhia (:

Yeah. And by the time a lot of people get diagnosed. I think what you have to understand is you've had many years of chronic exposure causing what we call oxidative stress and damage to the nerve ending.

(:

So the numbness and pair of seizures and the neuropathy can be something that it's always a result of cumulative exposure. It didn't just happen overnight. And I think people just aren't aware of that.

Ki Jung (:

Yeah, absolutely. Absolutely. And that's the thing, right, it's a cumulative effect. And like you said, by the time somebody gets diagnosed with diabetes, you've had abnormal sugars for a while. And then in that cumulative effect of having abnormal sugars is what's really created the impact on your nerve endings.

Sanjiv Lakhia (:

Yeah. Okay. Let's pivot a little bit. So we've done a full history exam, ran some blood work, diagnosing someone with peripheral neuropathy. What are some of the, let's call them maybe symptom-based treatments? And then are you familiar with any emerging treatments or technologies that people who are suffering from painful neuropathy or peripheral neuropathy can look into?

Ki Jung (:

Yeah, absolutely. So the typical standard treatments for neuropathy are usually going to be medications that are designed to alter how you feel those abnormal sensations. There's a lot of different medications that are out there.

(:

Typically, first-line medications are medicines that affect your perception, right. How it alters your nerves perception of what it's feeling. So these are of the medicines like gabapentin. By this time, gabapentin, it's been around for so long that a lot of people already know what it is or have friends that have been on it.

(:

But these are medicines that were originally actually anti-seizure medications that were found to be helpful in helping to calm down the nerve symptoms and those who have neuropathy. So there's two that are really very commonly used. One is called gabapentin and another one called Lyrica.

(:

And they've been around for a while now and they've been the sort of the staple or first-line treatment options for neuropathy. And just to kind of, as a quick, I don't want to take too much time on this, but the basic premise behind using an anti-seizure medicine to help with treating neuropathy is really based on how seizure medicines help reduce seizure.

(:

So in a nutshell, seizures occur because brain cells become irritated and they short circuit. Well, with neuropathy, imagine the nerve cells becoming irritated and short circuiting and that's creating the nerve pain or the neuropathy symptoms.

(:

So medicines that can calm down short circuiting and brain cells typically can calm down short circuiting nerve cells because nerve cells and brain cells are very similar in their development. So that's kind of why we tend to use seizure medicines to help with neuropathy symptoms.

(:

Then there's other things, believe it or not anti-depression medicines. Some of the older ones like amitriptyline and newer stuff like Cymbalta. These are all anti-depression medicines that affect different neurochemicals to help ease the perception of nerve pain or neuropathy or tingling and pin and needles, that types of thing.

(:

So those are the first-line therapies that we tend to use. Then you have second-line therapies which are sort of more like the typical pain medications. For example, Tramadol, you have lidocaine patches or lidocaine cream that you can use, capsaicin patches, which is the kind of thing that can help really sort of help decrease the sensation that you're experiencing or the sensitivity that you're experiencing.

(:

And then you got third-line stuff which are the strong stuff, right? The morphine, the oxycodone, those are the third-line therapies. Believe it or not botulinum toxin or Botox, they use that these days to help in certain situations.

(:

And it's under the skin subcutaneously where they inject to help pretty much paralyze those sensory nerves, so you can't really feel the pain part.

(:

Now you're going to be left with numbness because again, that's an absence of sensation. You don't have anything that you can kind of eliminate because there's no sensation there, but the strong, painful sensations sometimes they'll do subcutaneous Botox.

(:

New-line therapies or technologies, there is something that we use and we actually have it here at Carolina Neurosurgery & Spine. We use Anodyne therapy. Now Anodyne therapy, that's the brand name of it, but what it is, it's infrared light therapy. So we take infrared light and literally we pulse it to the skin of the affected limb like the legs, the feet.

(:

And by pulsing this infrared light, or at least exposing the infrared light to the skin for a period of time, usually about 20 minutes per session, you're improving the microvascular blood flow that goes downstream into those nerve endings that are damaged.

(:

It tries to provide nutrients and oxygen to those nerve endings to see if we can actually help do some minor repair where you can start to feel things again. So Anodyne therapy has been pretty neat when it comes to helping our patients who have neuropathy. We often kind of do that in tandem with physical therapy, where the therapist works with them on gaining their balance.

(:

And if we can get them to start feeling things a little bit more with their feet using Anodyne, that goes hand in hand with improving their overall balance and stability. So that's one of the newer technologies that are around. We're all kind of familiar with cold laser therapy that sports medicine's been using for a lot of sport injuries, recovery from joint surgeries, muscle tears, things like that.

(:

Cold laser therapy is also becoming sort of popular in that sports medicine arena, where people are using that to do more and more sort to see what they can do to repair. Same concept, but this time focusing on the nerve endings to see if we can get those nerve endings to literally wake up a little bit.

(:

So those are some of the technologies that we are using to help improve neuropathy or at least minimize pain and improve sensation. And there's a lot of preclinical trials on different medicines that we already know and exist to see if they help with nerve generated pain, just a couple brief things, Metformin, which we often use to help treat diabetes.

(:

They're studying that to see if it can help block nerve signals, same thing with some of the cholesterol medicines like simvastatin, they're using that to kind of measure and see what kind of nerve, no susceptive or sensory blocking that they can do.

(:

And that's sort of a double edge sword and we'll probably touch on that a little bit later when we think about what are the things that we can lifestyle-wise to prevent developing neuropathy, but those are just a few of the things that are in preclinical trials out they're testing to see how that can benefit those with neuropathy.

Sanjiv Lakhia (:

That's fantastic. I'll add a few, just through my integrative medicine training and at least patients are aware of this and they come in on these sort of products, but alpha-lipoic acid, which is, essentially think of it as an antioxidant that can influence your body's glutathione levels.

(:

Does have some decent data using it for diabetic nerve disease. You do have to take it for probably a period of six months as a trial to see if it's going to help the symptoms. Certainly there's random articles on B complex utilized to help just with nerve pain.

(:

Most of that actually, more specifically for things like carpal tunnel syndrome which is really different than a peripheral neuropathy, but it's a fairly low risk intervention.

(:

Interestingly, St. John's-wort is a botanical that is quite well known for its use for mood support, but like Ki said, with the prescription antidepressants, that can be used off-label for nerve pain. So to, can you get benefit with the botanicals that are historically indicated for mental health stability, they do have some benefit for stabilizing nerve endings.

(:

Now one thing I would say about St. John's-wort, which is readily available over the counter is you have to be quite cautious with it as it has a lot of interactions with enzymes in what's called the cytochrome P450 system.

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So I would not advocate to anyone just jump on that without running it through their physician. And then lastly, one other area that I use sometimes with varying degrees of benefit would be compounded topical medications.

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So there are compounding pharmacies which will mix in topical form anti-inflammatory, muscle relaxer, nerve agents like gabapentin that a patient can apply a couple times a day to the affected area, and sometimes it works great.

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Sometimes they'll add in a little bit of lidocaine, which I think may be the primary benefit. One of the downsides with the compounded products is expense. It's not normally something that's run through insurance.

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So the bottom line is there are things that certainly can be tried and Ki just outlined several of those. And it's definitely worth seeking kind of an expert opinion for your specific situation. All right.

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Moving on from that, I want to wrap it up here in a little bit, but I just wanted to get your thoughts on kind of comparing and contrasting neuropathy from specific nerve issue versus how it differs from numbness related to the, let's say, lumbar spine and then also how sometimes it can present as a result of vascular or blood flow issues.

Ki Jung (:

Yeah. So earlier we were saying, as part of the valuation, depending on the situation we might get an MRI scan either of the brain or the spine. Well, when you look at the spine, obviously you've got your spinal cord that puts out all these nerve roots that literally go down into all the extremities and down to the toes, even.

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So you could have what everybody knows as a pinch nerve for maybe a bulging disc or some arthritic condition of the spine, where there's a bone spur pushing on one of those nerve roots. And it can create very similar symptoms, numbness, tingling, burning, shooting pains, zapping pains.

(:

So those are what we would consider sort of that pinch nerve type symptoms, but the difference is typically, not all the time, but typically something from the spine would be mostly asymmetrical. Would come in and you would think, oh, my left leg has really been giving me a problem. My right leg is fine. I do have a little bit of back pain, but it's not a big deal.

(:

Well, that could be something coming from the spine. So typically I look for asymmetry or symmetry in terms of involvement of which limbs are having the symptoms. So asymmetry is one of the differences. The other thing is positional, different positions can sometimes trigger more pain if it's coming from the spine.

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And bending over or twisting, or maybe you're tilting your head one way or the other and you get the shooting pain down your arm. I mean, those are all sort of indicators that maybe there is a spinal source behind the sensations that you're feeling.

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As far as from vascular disease, well, earlier I mentioned this thing called Anodyne therapy where the infrared light helps promote micro circulation to those damaged nerve endings. Well, vascular disease, those that have vascular conditions like high blood pressure, cholesterol problems, diabetes, those all affect your blood vessels.

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And if you're affecting the blood flow to the downstream nerves that they supply, you're going to have a problem with those nerves. And so you want to make sure that you're trying to live as healthy of a life as possible.

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If you have any of those conditions, you want to make sure you're working with your physician about how do I control that? What can I do to help minimize the long-term impact, not just on my nerves, but the rest of my body from those vascular conditions.

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So vascular disease, what they call hardening of the arteries, or I've got peripheral artery disease, I've got blocked arteries to, what everybody knows, the circulation issues in their legs and their feet, that can certainly impact those nerve endings and cause very similar neuropathy symptoms, if not the exact identical symptoms.

(:

And when you talk vascular, you also have to think about some of these autoimmune conditions that cause inflammation in the blood vessels, which they know as vasculitis, itis meaning inflammation, right?

(:

So vasculitis can have a very similar effect on the nerve ending. So if you affect the blood flow in any way, whether it's from inflammation of the blood vessels or blockage of those blood vessels from vascular disease, it's going to impact those downstream nerves.

Sanjiv Lakhia (:

That's excellent. I think it's a lot to consider. And the take home point there is that nerve symptom is not always just a nerve problem and understanding that and just getting yourself checked out is the key. Ki, I have one more question before we end with kind of the lifestyle health habits question that I always like to torture people with.

Ki Jung (:

Sure.

Sanjiv Lakhia (:

You touched on earlier a couple medications. And are there common medications that people should be aware of that can contribute to the development of peripheral neuropathy?

Ki Jung (:

Yeah, absolutely. So you hear a lot of different things, things that can cause neuropathy, but there are certain common medications that can certainly do that. For example, I mentioned early Simvastatin, which is a form of cholesterol medication.

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Even though they're evaluating its use now to help block some pain symptoms from neuropathy, it itself has been involved with some side effects creating nerve irritation and inflammation. So it's a very common cholesterol medicine and some people who take it, they don't respond well to it.

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Now the most common side effects of those cholesterol medicines, it's usually muscle aches and pains, but it can also involve your nerve ending. So that's a common medicine to kind of look out for. So if you've just been started on a cholesterol medicine and within a few weeks you're starting to notice this weird numbness and tingling and pins and needles in your toes or your legs or your feet.

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You should have a conversation with your doctor about it and say, am I having this now? It's not the most common side effect, but it can be a side effect of cholesterol medicines. So just kind of keep that in mind as well. The medicines that we see that cause definite neuropathy a lot is really those that have cancers and they're on chemotherapies.

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Chemotherapy is, it's very toxic. It's main purpose is the kill off the cancer cells before it kills off the healthy cells, but in doing so, it can definitely affect your nerve endings and create neuropathy. So there are very specific chemotherapies, particularly the platinum chemotherapies that can really affect your nerve endings.

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Are very toxic to the nerve endings, but if you're oncologist or cancer specialists says, this is the best treatment for you, understand that you may have that side effect of developing neuropathy, but there's things that we can do for you if that happens to help mitigate some of those symptoms of the neuropathy from chemo.

(:

But that's a really common thing. Another prescription medication is medicines designed for acid reflux. The way that those affect you is not so much that the medicine itself can cause nerve issues, it's that it can sometimes block absorption of some of those really important vitamins that we all need like vitamin B12 and folate, those types of things.

(:

So certain antacids or heartburn medications can certainly cause that as well. And then there's a whole slew of other medications that all have sort may cause numbness and tingling kind of thing in their little information packet that you get from the pharmacy, but those are the ones that come to mind or at least right off the bat.

Sanjiv Lakhia (:

Yeah. A couple that, I'll add to that, that are coming to my mind, fluoroquinolones, which is a class of antibiotic drugs and actually speaking from remote experience with it personally. And maybe I can elaborate on that at some other time, but definitely there can be some toxicity associated with that group of antibiotics and the common names are Cipro and Levoquin.

(:

So it's often prescribed where it used to be at least for things like urinary tract infections, but there has been label warnings put on that. So I think they're being prescribed a little more cautiously. And then actually one you mentioned earlier as something that's been researched is a fascinating drug.

(:

I think I could do a whole hour on Metformin. Metformin is associated with B12 deficiencies, but Metformin also has a fair amount of research on it as a longevity drug now looking at almost helping promote a fasting state in the body.

(:

So there's a ton of emerging research on Metformin, which for most people it's just a medication to help control their blood sugar, but that's very, very commonly used as well. But we could go on and on. There's probably at least another couple dozen that we could chat about, but not all of them, even though like he said that it's on the label, is it a common thing?

(:

So it's just something to be aware of that drug-induced toxicity and drug-induced nutrient depletions do exist and they're just worth thinking about as you're trying to explore what's going on with your symptoms. All right.

(:

So I'm almost numb from this conversation. It's been so in depth and detailed. My brain is just trying to absorb all the information that you've been sharing with people. It's been fantastic, but I do like to close with this and we can frame it the way you did earlier.

(:

I always just like to ask my guests, what are some habits that you've incorporated into your lifestyle to try and stay healthy and stay active and full of energy? And we can even pivot in terms of, because all the same stuff, but what are some things people can consider to do to keep themselves from developing any sort of neuropathy?

Ki Jung (:

Well, you had mentioned one particular source of neuropathy earlier is alcohol, right. We all feel that alcohol's pretty harmless, right? We drink gift for social occasions and have a good time, but yeah, honestly, all things in moderation. Right.

(:

So with alcohol, it is a cumulative effect, even though you don't may not drink heavily on a weekly basis, but if you drink weekly for many, many years, you can certainly develop neuropathy. So be cautious about your use of alcohol. I mean, again, all things in moderation.

(:

So that's one of the things from a lifestyle perspective is I personally, I may have an alcoholic beverage a couple times a year. I mean, that's not a big thing for me. I mean, I had my fair share in college, so I got it out my system early on. But in general, trying to stay healthy, you want to make sure you're drinking plenty of water.

(:

Hydration is something that's underrated. I think a lot of people don't understand that most of the time you're probably dehydrated. Unless you're drinking a minimum of 64 ounces of water a day, you're not getting enough water. And if you say, well, I only drink when I get thirsty. Man, you are behind already.

(:

Thirst is just a sign that you're dehydrated my friends. So keep up with your water and intake. It's probably the healthiest form of hydration. Regular exercise, it's very, very important. I tell a lot of my patients, "Listen, I'm just going to ask you for two days a week." And I get it, Monday through Friday, you're at work.

(:

You come home, you're exhausted. You just don't want to go exercise. But guess what? Saturday and Sunday, that's still two days a week. So do something healthy, go out and move. So go exercise, go walk. Now if you have bad knees, bad joints, listen, if you can find a place that has a year round pool like some of these health fitness centers around, utilize the pool.

(:

I mean, it's so easy on the joints, but yet you're still getting resistance training. So try to do some form of exercise. And then obviously nutrition. We talked about how nutrition is an important part of our health, but not only our nerves, but our health. Listen, eat right, eat regularly.

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Don't go hours and hours without eating. I mean, we all get busy and we skip breakfast. Maybe we skip lunch and just feed at early dinner. Listen, our bodies, we have to treat them right. And you need fuel. That's what food does, but make sure that fuel is super unleaded.

(:

Make sure you get rid of all the bad stuff and just supply your body with the good stuff. So good nutrition, adequate hydration, get some exercise in and rest. Don't forget to sleep, my friend. Get some good rest.

Sanjiv Lakhia (:

Yes. And you know, you are essentially a sleep expert as well and have observed the negative effects of poor sleep on the health in general. And I always feel like it's probably the most important domino from a lifestyle perspective that you want to make sure you're trying to optimize.

(:

And the other only thing I would add, particularly when we're talking about peripheral neuropathy and the most common cause being diabetic peripheral neuropathy, I think an underrated recommendation is to add in some degree of resistance training routinely. Building muscle mass, it shifts your body's metabolism.

(:

It lowers your fasting insulin levels. Your muscles are burning up the glucose. It helps lower your risk of falls and just promotes longevity in general. So even a 10 to 20 minute routine, twice a week, certainly helps with osteoporosis.

(:

There's just so many benefits that if I personally only had time to do that versus cardio, I would be doing the resistance training based on the research that I've observed. But anyway, just do something. Take care of yourself, like you said, when you put that, I like that, the super unleaded and let the engine move appropriately for you.

(:

So I hope that was helpful for everyone listening today. Again, Dr. Jung, he works out of our Huntersville office and we'll have links in the show notes to his bio and how to get ahold of him if you want to set up an appointment with him. And Ki, I look forward to having you on in the future. There's plenty in that brain of yours we can kind of pull out and share with the people for the better.

Ki Jung (:

Absolutely. Happy to help in any way. And thank you so much for having me on your show today.

Sanjiv Lakhia (:

All right. Awesome. Take care.

Ki Jung (:

You as well.

Voiceover (:

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.

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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.

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