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A-1188 Applications of new technologies and techniques in the surgical management of chronic postoperative pain
Ivica Ducic, USA
Friday, June 15, 2018 · 5:41 p.m. · 20m 08s
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thank you for everybody
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everybody break on one now
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so um i was asked talk about new technologies in management of chronic pain
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i actually have a beautiful paint dog but i to stick exactly to
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was asked to talks over body ago common couple the things
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um i practised pretty much in the past seventeen years as you can see behind here changed quite significantly
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yeah and uh since two thousand tan i'd nearly gay button
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tire plastic surgery and doing their surgery altogether only now
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um as the disclosure part i the medical director for oxygen
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but not of my ninety plus papers ever anybody funded
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so i'm free to speaking anyway as a clinician i can i want to get back to your comment what you said about
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i'm a collaboration entered into discipline reproach on in two thousand eleven
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twelve and i was present of a. s. p. n.
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i try to get the uh equivalent of the pain management colleagues to comment have be
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panel to talk a bit about that and i just couldn't get people on the same table to actually talk about it so
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it should be a lot of my concluding slides later on but the communication between specialist it's kind of
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qualified by me as horrible i think b. s. uh colleagues need to work much more together
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there is so much to give and there's so much to get from each other
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so most neurology call it's in pain management colleagues bit
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surgical specialities you can definitely do much more
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then basically we're doing today somehow we'll get into all look cages and to do all that stuff
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but we all know not everything work the way you want to work so
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and then they try to ask for help and they can build it too difficult because once you go from
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very for since it position into central since it position mode
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is you know complexity of the treatment becomes extremely difficult
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and just look put comment on on on the stock you know for example then you get c.
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r. p. s. some are is the or is you go said that twenty five million
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definitions of the same problem technically um and um uh at that
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level there's so many colleagues united states to say you
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know you should never operate and person in its e. r. t. s. and r.s the specially non surgical comics
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but if you draw the line i think logically a bit respect every special t.
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if there is in my humble opinion about past seventeen years of the practised
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solid two thirds of the patients who came to b. b. c. r. p. s. r.
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r. as the head on recognised in on three did nerve injury in the past
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that's actually really frustrating and set and then this people over time develop centre since it is asian
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and they're they're gonna continue to be a problem as long as that the roll my sitting there and drilling
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on their part in getting them pay so this concept that you should never operate on people with
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b. r. as the o. c. r. p. s. you just a suicide uh purses 'cause bush and for the for the patient because
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it just continue with their pain and depression set us i think we need to use a common sense in terms of
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they don't beat should just say yes you do it or don't do it you should justify
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what you're saying by saying yes but they should bit centre since it is asian
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you can clearly make worse there's no question about it because you actually then
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getting married to a patient who has about twenty five problems versus one problem or
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two when there were like twenty us in a pasta ten years apart so
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uh it's it really complex issue we could talk for they just about this detail but just
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don't be so much afraid of patients it's e. r. p. s. or or is the uh the the mean
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are is the you know stands for really stupid that knows is at the end of the day
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because we really have no clue so to speak with the t. is and then there is
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fifteen treatments and none of them works in an event long introduction the bottom line
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uh any trauma or any surgery can cause nerve injury anywhere
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in human body you don't need lecture about that we
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know that but the start that that point that want to make with the slide is up in the title
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we need to focus on the cause of the problem very often people
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are throwing back knows is uh the treatments this or that
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we really don't have bell define calls and you know if you have
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a heart problems and your cardiologist says well let me give
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you this drug i really don't know what's wrong with you but just take it help you may actually kill you with that
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so i'm not so sure we would so easily embrace that concept somehow
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with pain business it's very cavalier approach to kind of go
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ahead and start applying treatments that might have a problem you know
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two thousand thirteen fourteen i published in that analysis for headache
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patience i don't about four thousand headache soldiers is far published about twelve studies about that and i really
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look hard into people who had radio frequency immigration there stimulate us what impressed me the most
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actually got really hard at my residence because they say you know the only three papers that discuss
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a radio frequency they should fall out of one year i said you out of
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your mind it's impossible in two thousand fourteen only three papers in the literature
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well the fall ops truly worked three months six months whatever
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and that's you know not to breed really good quality
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form especially big null because our fate recurrence by
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even eighty percent by six months even more than that stimulate there's forty thousand dollar device united states
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uh people do it for all kind of stuff uh what they're forgetting to disclose
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to the patient is that only about half of them are still affective
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from that analysis we actually that beyond three years only half of
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that so we got to be a little bit more careful
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throwing some procedures around and saying i like to do this i like to that because
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it that's you leave that your mother it that your child and then you see that crying everyday going
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to bad making up with the same problem because you'll get didn't treatment that technically wasn't taught through
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sure that are starting to the different that so this is where the two different
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difficult subject to talk publicly but you you you got to kind of
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sympathise with that patient looked into that and figure out what the cause of
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the problem before you start throwing million and one procedure on that
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this kind of slide i was supposed to advance before um yeah in terms of
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common sense there's gonna be first non operative treatment you figure out
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a. b. c.'s what potentially might be problem with the patient
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a pain specialist certainly in physical therapy should should should
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port initially a a non medical treatment and obviously
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sort of number of the people do find it if you don't need to take a night
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and jump on the patient first time they say at the paint that's that's abuse of the
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position we need to allow a reasonable period of time for the patients to kind of
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find out their way into find how how they're going to sort
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of problem but this observation period shouldn't be three year s.
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fifteen different regiments medically and all kind of other interventions in average if you're not getting better
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but three months later six months with a chronic pain you have ninety plus percent chance
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with my current experience of twenty years to kind of continue with a chronic
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pain so you got to start making drop in terms of treatment
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of these patients somewhere in that range rather it be telling kate there
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can take here to just go home cry take some more medications
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made for depression to hit you and then we can talk about other procedures we
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can do and you so uh having said this in terms of surgical treatment
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uh i get the top today i don't want to drill too much into this part but winter in terms
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of surgical p. treatment or is it another chaos on the other side of the street and days
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uh the afford piece to do this that procedure that procedure
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uh i agree beautiful top with the ultrasound yesterday for example it opens your allies all
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of us i thought that a. i. n. syndrome is basically in the four on
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it was all i don't let them mister yes you need to think outside the box with these things so
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you know are we gonna use conduit for surgery are we gonna use autographed out abrupt
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uh do we do this uh about a a kind of device that device
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who is paying for your dinner that you're going to top next day or not all this stupid thing so
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so to speak factor and when you're delivering message and that's why at the end of the day
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pretty bad messages kind of been delivered out there i have some people
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who religiously say that you should always use only this drug for
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the statement of x. headache because that's best for you obviously isn't
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the speakers bureau for the past seven years for the company
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so uh what again uh as medical director of another company this
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is pretty far kind of funny what i just said
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but i'm very transparent what i do because i'm clue clinician and so jen and
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as you know i can for you today tell you whatever i want
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you'll go home gonna figure out that i just sold you a story you gotta think of me next time
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when you see me anything look at that idiot he told me something that really doesn't work so
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we got a little bit more responsibility than to speak publicly what we say to the people similarly
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or rather been focused really aggressively into what do we do in terms of from the
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reconstruction cetera this slide here shows basics that
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probably seven out of ten surgeons really
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failed to acknowledge properly how to dress the the um
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it's a good of that so how to address on you know in
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the reconstruction if you didn't reset enough of than the roma
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if you missed selling the fibres if you waited three years to operate if you put too much tension on that there
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i mean the reset in any in the wrong or that the sitting there in continuity or anything else morgan several weeks
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you have no way of bringing those two nerve sent together you're just lying if you're saying you're doing that so
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uh the the this a. b. c. is what i would call it's not just about technology although the stock is technology
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it's about technique and this is as basic as it should be so once event or with these detail here
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then they need to figure out so what do we do with that patient and
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as you know in terms of under reconstruction there is a day and age
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we need to go ahead and reset the nerve and reconstruct that most of the time talking about that language
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uh if you you can do primary care what i just said you can 'cause
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would buy that option because by the time you're set the damage part
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very difficult to put the rent together me frankly impossible or you can use out about or
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you can use one of those morse like kind of options in front of you
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i recall and i said this today's standard of care i said also
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today i have no clue what anymore standard of care is
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because it's standard of care is that prime during the reconstruction birds
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fifty sixty seventy percent that's a horrible standard of care
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we definitely shouldn't benchmark ourselves with that part so that
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you know technology moved forward conduits came aboard the
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orbits psyched about using them and it was really great number of different issues bunch of papers published
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and then we realised well you know they're really not working for three four centimetres that
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that they i mean people are people like for example publishing one
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millimetre nair growing to formula forced on your lawn conduit
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and saying they got in normal sensory education but there is not
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the paper in study kind of backing that up so again
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a a literature is really great because we couldn't use it in our advantage
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in this day and age because we don't need to invent so to speak with that
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worked we have so many study we can use them as an at an
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hours or whatever but that that allows a difficult to do but at least as
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the data review out there were i'll look up is the process human either
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that is washed in a very specific way and functionally at the end
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serves as the left lowers a slide on the screen um uh
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as the base a lame enough my could you use that are going
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to allow growth often they're from point a to point b.
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again a bunch of different studies out there uh in terms of
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published for the past since two thousand nine an average
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uh and really uh uh the uh the the the one edition of the of the
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data are it shows some difference between sensory motor but has actually they are respectable
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fact i suppose for sensory and motor one what on unfortunately there are more
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in all their injuries so from that perspective they take a bit longer
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to kind of grow so we had box autographed and i'll grab
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why the show this slide it's interesting i'm gonna talk about clinical cases in the second
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imagine you had injury off your let's say superficial parody on their somebody cut it for you
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and i'll i want to reconstruct that they're a bit five sign your autograph because that's a gold standard right
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so i will tell you lay either take you are from the other like
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or dislike i'll give you permanent known as they are to restore
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potentially restored sensation in is the error then is that patients gonna look
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at you like you're crazy viable harm in the other way
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then i have a problem on this leg so the trade was not
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that good actually this is for all abrupt change tremendously for me
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in terms of changing it that for a second time not speaking as a medical director speaking
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as a surgeon because i struggled with this issue at people who later told interface
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why would they allow you to get minimum is there to potentially gain on the somewhere else
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people are not stupid you know they will tell you what they mean but that so that no it you can
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forward as well and reason i'm bringing this nerve connectors it really g. actually mentioned a few minutes ago
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the the coughing component so the arts about their connector is basically portion so because
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of one specifically talking about this is the real muscular visitation of this product
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is significantly different in college and then i need to go in and do re do carpal tunnel
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cubicle panel or person where the college in their rep and enable he'd who did that
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it behaves like a leather it's completely in their uh in that uh material well the boss christ
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a person sub because uh basically behaves very biologically next to that there
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so it allows you also to illuminate the nice alignment there
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to detention technically if you have a small got over there and obviously to
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you serve it is in a wrap around in there to rebuild
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them european room after you strip that stopping at doing that we do
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surgery for the compression so how does this all equate clinically
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there are a number of the studies out there talking about all the graft reconstruction for than their pain
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and why is that important this is where i live over here in my practised in terms of
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in in terms of a regeneration uh and uh i would cut them there
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two minutes of it and i'll be caught in there and i implanted into the most
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the hurt people still implanting that into the bone and we actually don't do
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that back over c. anymore so um problem is that this there will
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definitely still formed around the question is is gonna be symptomatic are not
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likely it is really not most of the cases but it would
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what are we doing now we're going the rebuilding their whenever we can't so going to couple clinical cases over here
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the image nerve over here at two different area with the roma over there
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uh on the index finger gap is only five millimetres so i can use a connector and signing here on the on the this is
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me and the little finger and suddenly on the index finger so i used to different devices for two different gets over there
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this is median their branch in the wrong button in a in a in the uh to the to the hand
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hi they i don't need m. r. i. no rhyme or eyeballs scan
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ultrasound x. ray or i don't know what actually to diagnose this
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listen to the patient examined them if you know to into what the anatomy
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here is your diagnosis in about three seconds talking to the patient
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so here re section of than the wrong but to some your different reconstructed our group
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this is stronger um the roaming continue to following the gas that was section over here
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this patient couldn't sit as we normally sit because back up the like we're just driving him crazy
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sorry section of the neural reconstructed i'll grab the wrong or component is immediately taken
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care of class you allowing this never to re grow sensation back again
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top of the foot injury same principle ten years ago i would you if you come to my office with this
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i would cut that there and i would imply the superficial per new with muscle because i didn't have any better technology than
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now i will go and selectively reconstruct the number and i will use the nerve connectors ups what is this oh
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this i'm sorry i will use the nerve connectors all over here on the top
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uh to actually caught the cooperation because as they read you showed you
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actually preventing that's some uh sprouting read it in minimising pain control
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this is seven centimetre superficial tyranny under the fact that the chronic pain
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following the war effort to phoebe lot same way again there is the replacement
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of than the red and reconstruction of the interview actually giving person
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chance to rebuild that got back again this is recurrent redo of the
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redo of the morton syndrome of failed everything right when they had
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re constructed actually the branches of the media punter nor and rebuild
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them already or patient technically over here is saying okay
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after surgery oh no
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so before obviously she couldn't do that link well i've enjoyed after
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the oral surgery can actually give you bring up the town
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so what you can do for this patient all graft is really great because i don't need to go to the leg anymore and harvest
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i don't need to put people whatever pain palm source at wrote you go in there you reset the link on the
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roaming the mouth you reconstruct the mean all brought in actually
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have about ninety plus percent of the generation backward
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in free rowdy all orders similarly have to dental procedures of their uh their root
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canals of the dental implants can ensure the in fury over can never
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you can similarly reconstruct this nearly the other brought in you can do the same stuff for the two more but i'm
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up a storm but currently people unfortunately not doing that this
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is a case from the oral surgery with the um
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with the to to kind of be a root canal over here that literally fried you
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can appreciate the impurity owner operator arrow is looks like a mushroom with that part
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in the interest of time gonna skip this slide here and i'm gonna
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conclude this with this case it's actually very interesting hand injury
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chronic pain known as burning in the t. in our area i went in there
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id the carpet on the really spots about allows me actually in a
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very elegant way just to place the sheet around in there
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i don't need to fuss with those big flirt with all respect to the previous speaker to go and the second
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half of the hand give us clark's apartment actually can rebuild that new opinion if you're fairly elegant rate
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while the part that the news media branch in the romantic you see
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right over here again ten years ago i would just cut it
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implemented into the muscle ankle the day awfully person on first the fees like now i rebuild
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that the the autograph in order to allow this patient to have a sensation our
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lastly out to grab doesn't come for free there are don't or side effects down the ramos
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they can be infections et cetera so we need to be observant in cognition to
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work towards that area the and number of different reconstructed tool that i actually
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found in my practised changed significantly because i can that's fairly elegant they address the problem
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and you got to go head individualist patient treatment
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um and and provide surgical solution for them
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i don't treat everything this way you treat suitable cases they want to show you how
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i apply new technology to problem that i wasn't able to store before
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with the similar pay so i'm gonna stop now thank you
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