Treat the Story, Not the Image | Dr. Brian Jacob

Automatic captions from YouTube, shown unedited apart from name spellings; they may contain errors, especially in medical terms.

And that's what I have to caution all the patients who watch this out there, which is make sure doctor is treating your story and not the image.

Hi, I'm Dr. Jason Siefferman and welcome to Care Beyond the Pain. In each episode, I will sit down with a provider, a person with pain, or a supporter to explore their experience and share their perspective on the pain journey. Together, we will navigate care beyond the pain.

Hi, I'm Brian Jacob. I am a general surgeon who is now specializing in pelvic pain, chronic abdominal wall pain, and sport injuries.

So lucky to have you. Thank you for joining us today.

Thanks, Dr. Siefferman. Great to be here.

To start, tell us about your background. You're a general surgeon, but most general surgeons don't get too deep into the chronic pain world. How did you stumble into that?

Great question. I started off as a general surgeon, then I became a hernia surgeon, and when you become a hernia surgeon, you end up having to treat a lot of the complications of hernia repairs, specifically inguinal hernia repairs, and one of those is chronic pain. Uh as it turns out, there's about somewhere between 40 and 70,000 new cases of chronic pain every single year in America after inguinal hernia repairs. Sounds like a lot, but it's represents about 1 to 3% of the population who get hernia repairs, and so they started coming in and to work them up, I sort of had to devise a way to figure out, okay, are these people suffering from chronic pain that started after a hernia repair, or were we dealing with something entirely different and the hernia repair was sort of a red flag, and that's how I got into it.

Right. And I I see a lot of those as well. They have hernias, they get the hernia fixed, but it may or may not have been involved in the original pain.

Correct. Biggest mistake most people make is they think the hernia is the cause of the pain and it was something else that could have been worked up before they went for surgery.

So, how do you approach the situation?

Great question. Uh approaching the situation requires diving into the history. Uh so so for most people that are out there who are trying to search for answers and they're trying to look at the the images for for what they can find a mass or what not, the answer's in the history. And so I came up with this acronym called SPORT. Uh, sport. And the S stands for starting event or story. And it's basically the patient's history surrounding the pain.

When did that pain start exactly and what were you doing? There's most of the time going to be some answer around that. And it's usually going to be either a hernia repair or surgery, a traumatic event or a sporting accident or some sort of abrupt trauma to the abdominal wall. And the last it could be some sort of emotional then. You know, they were really depressed in in college for the longest period of time and then they came out of that and they came home and they were also, "Wow, I have chronic pelvic pain."

So it's usually an emotional trauma, a physical trauma or hernia. And when that happened exactly and when the pain started is most important. There's other questions. Where is the pain located exactly? A lot of times when we're talking to patients, they'll point outside their clothes but I expose the area and we take a marker and we draw exactly on the skin where is the pain. That's really important and then we do something else. We say, "Does it radiate? Is the pain just in that one spot or does it move in different directions?

Hmm. What makes it worse? What makes it better? So, are there things like sitting, um, jogging that make the pain worse? Uh, does laying down make it better? We want those pieces of information because it helps. In the patients who have had an inguinal hernia repair, most important part of when it started is how soon after the hernia repair did the pain start? Immediate, a week to 3 weeks, or years? Uh and then of course we'll circle back to this or was the pain there before the hernia repair?

So, if it started immediately upon waking up, that is a what we call in our world an iatrogenic injury, something trapped a nerve, some new implant is causing a new pain that wasn't there before the surgery, and it's usually severe. 7 8 9 or 10 uh on a pain score. Those severe brand new pains have to be from the surgery. A lot of times you can fix them if you go right back. If you try to wait and start pushing those patients off, usually you never get to the cause until you reoperate.

If it's a week or 2 weeks or 3 weeks, that's usually a piece of hernia mesh that may shrink. Uh they all shrink a little bit. It could be a stitch that develops scar tissue around it, but something gets trapped slowly over time over the first week or two, and then that can cause pain. But if the timing is years, that could be a recurrent hernia. That could be something new. And then the hernia repair itself usually is not going to be the cause.

Yeah. We can dive into mesh later. So, those are some of the questions I ask initially, and of course the last thing I ask is how intense is this pain? And I mentioned uh seven out of 10. You know, the seven eight nine and 10s, those are the ones that I believe are ultimately going to lead to an operation. The ones, twos, threes, and fours, we're going to sit, probably not need to do much with, and the ones in the middle, I think are the ones that we definitely need to start sending out to pain medicine specialists, physical therapists, neurologists sort of to see what's going on.

Those are the ones that we don't want to operate on. We don't want to try non-operative. I see.

So, along with the original repair site or the actual hernia primarily, uh there's a lot of other things that cause pain in and around the pelvis. And you also treat some of these things. Can you tell us about some of those conditions?

Yes, I can. So, the other conditions that I treat uh include something called an anterior cutaneous nerve entrapment syndrome. And that is a a trapped cutaneous nerve of the abdominal wall that causes localized pain. Uh and then we also treat a bunch of sport injuries. So, uh rectus abdominis and adductor longus tendon tears. Um osteitis pubis. Um sometimes a sports hernia can cause nerve compression from within the inguinal canal and you can get radiating pain along some of those nerves.

Uh that can cause testicle pain as a secondary problem. Uh so, we'll treat sports hernias. Um we'll treat uh and especially in our female patients, which you have to really take into consideration that females and their anatomy um have their own specific things we need to think about. Um sometimes they don't get true hernias. They get things called canal of Nuck cysts. So, they get little cysts along the round ligament. There's also an entity called round ligament pain, usually in pregnancy.

Mhm.

Um but that pain can actually persist beyond pregnancy. Now, that pain can be cyclic. Uh meaning it gets worse when women have their periods and it's usually in the groins and that can be a little endometriosis on the round ligament. And so, we will go in and not only look for the nerves, but look for the round ligament as far as the cause. Uh what else could there be? There's intra-abdominal causes. So, chronic relapsing appendicitis. So, someone has a really low level appendix that's inflamed but doesn't show up really on CT scan, but it's can be there.

Uh you can have hydrosalpinx uh or any kind of low pelvic inflammatory disorder uh can also cause groin pain. Uh you can have diverticulosis. There's a thing called on the colon that these little fatty uh deposits called epiploica. They can twist and you can have epiploic appendagitis.

There's no short list.

I mean, I could I can keep going because the the the list of things that can be in there for someone who deals with chronic pain as a surgeon is very long and the way that I work is I had that list in my head.

Yes.

And as I ask my questions, I start narrowing it down in my head.

How do patients know if it is something internal or abdominal wall related in advance of coming to you versus the hip or the low back? How you know, many patients navigating this pain journey have difficulty knowing where to start. When might they know if they need to see you versus somebody else?

Great sign that you need to see a surgeon is that you have tried to work this up with your other doctors, your primary care doctors, your gastro doctors, um your psychiatrists, your gynecologists.

You've been around the block.

And they're not you're not getting anywhere. If if that's the case, you there there it's not that they're they don't know or that they're missing it. Is that some of these things that are in the differential, they just it's just not in their world. They don't know it exists and you don't know what you don't know.

Yeah.

Um that's a hint that you may want to go see a chronic pain surgeon or someone who deals with this as a specialty just to get an idea. And by the way, I will not operate on everybody. I mean, if you're not going to get better from a surgery, there's a chance that I'm not going to actually take you on and operate on you, but I will listen and I will sit with you for an hour if I need to and hear your story and really help you get on a path towards treatment.

Yeah. And short of people getting to know you specifically or coming to you specifically, how might people know what surgeons are good surgeons to see? Because it's certainly not typical of a hernia surgeon to do this deep dive or to consider other causes or even to know what ACNES is or how to approach it. How might a patient know how to choose the right doctor?

Right. So how do you choose the right doctor? I can tell you how you don't choose the right doctor. You don't necessarily have to trust the internet as far as reviews and stars and things like that. And while they can be um representative, uh as we all know, they're not necessarily accurate. I think the best way to figure that out is talk to other patients and just go online and see is this entity that I'm going to see that doctor for a specialty or just part of their practice.

Uh you want someone who's treating chronic pain every week to be the one that you see. Not someone who sees it once a month or or once a year. Once a month or once a year is not enough. Once a week is plenty.

Yeah.

I think the the volume that they see is important.

Absolutely. I mean, just to have the experience to have the differential and to recognize the the constellations of symptoms.

Correct. Yes.

Uh when when patients do see a surgeon and they are advised to have surgery, this is often where they'll come back and see me. And they'll say, "Well, this guy said this. This guy said this. What do I do?"

Right.

Uh how as a surgeon, how do you advise patients to navigate that journey?

I think if uh non-operative intervention has either not helped or led you in a direction that says surgery might help, then you do it. Um I have this wonderful document called an informed consent, which goes through all the risks of certain surgeries. And the truth of the matter is we will be we will do our due diligence and discuss all the risks, but one of the biggest risks is that you don't get better. There's also a chance that you are made worse.

Worse pain, new symptoms, etc. I could tell all different types of stories, but in the end, I can tell you that we do not make the overwhelming majority of patients worse. We either make them better or we don't help them. There are the exceptions to that rule. There are of patients who sometimes, unfortunately, will play victim and they will suddenly transfer their pain onto you, the surgeon, and say, "Okay, you caused this pain. You know, I came to you for the pain.

You didn't help me and now you've caused this pain." And so, we have stuff in the informed consent that explains to the patient that we are just trying to help you. We are going to either look for and take out a nerve, we're going to find a small hidden hernia and fix it. Um we're going to find a little neuroma and take it out, but we are not going to do anything that's going to make you worse. And and the concept that we would or the belief system that you create that we might is [snorts] simply a delusion that you're making to survive.

And so, we go through that with them, as well.

And we speak a lot about the psychological implications of chronic pain and the toll it takes on people's self-identity and taking away from their life, their ability to engage with their family, friends, work, all of these things is severe. Do you do you see a lot I mean, with pelvic pain, certainly intimate relationships are affected. Uh how much does that part play into your care for these patients?

A lot. So, it just the and I the the question really to me sounds like how much does the there's a patient's uh mental health well-being play into what I do with them and I don't know if that's what you were asking, that's what I heard.

It's a good opening to the question.

Fair enough. Um huge. So, mental health to me is really important and I think anxiety and depression, which are on a spectrum, we all have a little bit of it, uh play into this. And unfortunately, in this world of chronic pain, there's a lot of medical gaslighting. So, what happens is the patients are told, "I don't know" or "I didn't do anything." And while the intention of the the treating doctor is to say be honest with them and not mis lead them, they feel gaslit.

So, let's say a surgeon does a surgery, they do something, and then they don't either know how to treat, work up, or diagnose the chronic pain that maybe they caused, and they tell the patients, "It's not my fault. I didn't do anything." Patients see that as gaslighting. And then, they go see another doctor who doesn't know the answer. Now, they've seen two doctors, and they're like, "Listen, you don't necessarily have pain." But, the patient's really suffering. Well, that's crazy-making.

So, the patients then internalize that, and it takes them a while to find other people to see and tell about. And by the time they've seen the third person, they don't know how to treat it. Now, they don't trust doctors. The time they see [clears throat] an expert like you, or an expert like me, they're walking in guarded.

Yeah.

And the first line of defense is, "This person is not going to help me." So, we have to break down those barriers. We have to soften the the entryways so that they can appreciate that we're coming from a place of compassion, and we do think that we can help them.

And I I think there's a layer of safety that comes from skepticism.

Yeah.

And I mean, we speak a lot about this again with the psychology of pain, where there's a desperation that develops because patients have been dealing with something for some duration of time. They haven't been able to find answers. It's impacting their life. Like, every day is another day that's just difficult, and they want a solution. And anyone who provides a solution, like, it's it's not a tough sell. And it's And it's unfortunate because that desperation just lends itself and the natural trust that comes with doctors lends itself to the patient saying, "Oh, good, you have an answer.

Let's do it." Uh without, of course, themselves having the breadth of knowledge to understand the the implications and the ups or the downs or or having, you know, the capacity to really analyze all of that to know if it's really the best thing. They're They're just going off of one person and one well-intentioned, presumably, person opinion. Um so, that that can be difficult. And having that level of skepticism and having an understanding of a I don't want to say a good or bad doctor's approach, but I guess I just said that, but a a well-informed physician, a caring physician, a well-intentioned physician will in my opinion, talk out loud with the patient.

They just like you're doing physically, having them describe what they're feeling, mapping out what they're feeling, going through the radiology, correlating that, maybe using some diagnostic injections or something to prove the source of the pain, so that you can concretely write a story that hey, you have this pain, you have this structure, when we block that structure, this pain goes away. We think this structure is causing pain because this is happening to that structure. I have a plausible solution for that. Is that something that makes sense to you?

If so, great. Let's go fix it. As opposed to oh, you need surgery, I'll book you next Tuesday.

Right.

So one one of the motives of this podcast is really to expose some of the thought process among the physicians on the other side of the table uh into our side of the decision-making process so that we can best communicate with the patient what we see and also educate the patient to know what to look for when they're analyzing the doctor's thought process. Do you have any thoughts you want to add to it?

Well, I want to start by saying one of my mantras is treat the patient's story not the image. And no offense to all the other doctors that are out there, a lot of you treat the image. And or don't treat the image.

How many hernias don't show up on imaging?

Right. Well, we'll get back to we'll get to that in a second, but how about you know, you have an MRI that shows you've got an adductor longus aponeurotic tear on the left pubic tubercle with some Um and the patient is coming in with pain in, you know, the mid-left abdominal wall. Well, offering that patient a surgery for a sports hernia repair to me is treating the image and not the story.

Yeah. All right, so then dive into the story. So, I think it's important and and patients only understands and trust what what they read, right? So, they'll see the report and they'll think that that's relevant, but it's not relevant cuz their pain is up here. Uh and it happened to happen after a football catch, you know, so you can have an anterior cutaneous nerve entrapment syndrome in a dermatome along the rectus muscle, completely remote completely remote from the other MRI finding.

So, you go get this sports hernia repair and the pain doesn't get better and then the doctor says, "Well, I've done what I can. Sorry it didn't help." That's what I run into a lot and that's what I have to caution all the patients who watch this out there, which is make sure doctor is treating your story and not the image. So, I think it's important.

And it it also has to make sense in the context of the story. If we go back to pelvic pain as a diagnostic cluster, it's challenging because it's not always an A to B story. Sometimes it's an A to B to C to D story. I you know, the the source of the pain, the sports hernia for example, the sports hernia may actually be originating from a guarded hip. So, they're misusing the adductor and you know, years of misuse of the adductor leads to the sports hernia.

And even in that situation, you can surgically repair the sports hernia, but if you don't address the hip, that surgical repair may fail or they may continue to have strain at the adductor insertion. So, understanding the full breadth of the diagnostic cascade is important, too.

You do something very similar to what I do, which is you like to treat one entity at a time to see which portion of it improves. So, if there's a hip component and a general femoral nerve component, you'll bring them in, you'll block the general femoral nerve first, assess if that's done anything and then bring them back a second time to see if the hip improved and consequently figure it out. Not everybody approaches it like that, but you do. I mean, you're listening.

For pain diagnosis, I think it's essential. I

It's true. I don't

And again

Maybe maybe I was mistaken thinking it was obvious.

No, but I mean the other thing by the time patients to get get to us they've they've usually been to several other doctors. If it were something simple and straightforward they would have caught it and fixed it.

Yeah.

It

That's true.

I don't see simple disc herniations anymore because they're easy. They can go to an in-network doctor, get an epidural, get PT, and they'll be fine.

That's right.

It's it's the more complicated situations where there's a transitional vertebra or it is a primary hip issue that's causing an anterior pelvic tilt that's causing the quadratus lumborum to be hyperactive that's pulling on the cluneal nerve that's causing their gluteal pain. It's not actually in the glute. And if I don't see the whole picture and unwind it and treat the hip primarily I'm not going to have any durable success.

That's exactly right.

And and you see the exact same thing with the pelvis with these hernia repairs that have failed.

Yes.

So this is where we share a lot in common. That's why I wanted to bring we can really you know show this.

Yeah. It's it's a wild field. I mean there's just so many things that we even in our discussion we're jumping around the the differential list as if it's secondhand knowledge but a lot of the things we're talking about are not even in the the generalist's dialogue.

Uh it's really things that providers learn through practice um through experience. Uh and the key piece of this is having a process where you have a collaborative team of physicians that speak to each other and work together because we all do only what we can do. Uh I can isolate what's causing pain and what's not causing pain but I don't do surgery. And the surgeries are probably more successful if you know exactly what's causing pain based on a diagnostic injection before they go in for surgery.

Yes. And then the patient has to also trust you that you've done that for a reason and you have to trust the patient. You know how many times I've had patients come in and in the office I'll block them. And they're like, "Oh my god, I'm better." You got it. Okay? And I say to them, "Your pain's going to come back in 8 hours when the medicine wears off." Okay? Now, fast forward a month, they go see somebody else and they say the pain injection didn't work.

Now, the doctor writes the pain injection didn't work, but the reality is of course it worked. It temporarily blocked the pain and then the pain came back. Somewhere there was a miss uh this is just a temporary fix so we can make sure that and diagnose you as a trapped nerve. I get that a lot. And so you have to be able to trust the patient's story.

And this is why I insist on follow-ups after every injection.

And notes. You want to see somebody that's I didn't send you to, show me their note. I don't want you to be the interpreter of the visit.

Right. I just saw a patient yesterday who had an epidural with another physician and she's like, "Well, it only lasted 3 days." And I'm like, "Well, that that's not typical. Let me see the note." I see the note used dexamethasone. Dexamethasone lasts 3 to 7 days. I'm like, "Great. You had an anti-inflammatory response to a drug for the correct duration of that drug."

Right. And that's why you wouldn't know that without the note. I've had patients completely misrepresent the the the consult's opinion. And it's like, "Get the consult note. You know, I believe the patient, but then I read the consult and I'm like, 'Oh yeah, that's not what the doctor said.'"

So, the takeaway for patients, we don't expect patients to be able to read and understand and know the context of all these things, but having a working relationship with a physician who can help you interpret is essential.

I would say for the patients watching this, if you see a consult, even if it's not ready at the time the consult ends, ask them for access to their conclusion or a copy of their note and just make a folder so that the new doctors can read accurately what was recommended to you. Not doing that

[snorts]

um kind of makes that visit and that whole workup void.

Well, and I even suggest that patients record. So, we we make recommendations of uh some of the AIs that will do note-taking for patients that are meant to be HIPAA-compliant for patients. Because we do go through a lot, right? In the hour-long intake, sometimes it's longer. We also go through a lot. And when I'm explaining the rationale for why I want to block the hip when their hip doesn't hurt, it's a bit of a tough sell. I have to make sure that rationale is spelled out clearly.

And then from there, there there's often a dividing point, right? In the decision tree. If this happens, then we're going to do this. If this happens, then we're going to do this. And giving the context for them to understand that and to be able to look back and frame their response to whatever we did in that context is essential. Yeah. Um so, I don't This is my approach, and I I think your approach is simple, and I'll let you explain it as well.

But, if I'm here to educate. And I explain to the patient how I see things to the best of my knowledge and see if that feels true for them. And based on that, they can make a decision of what they want to do next.

For sure. We should have this little segment of the podcast be called AI in chronic pain. So, we can just like really just dive into how AI is transforming the workup and the the treatment algorithms of of chronic pain. But, if for me, I will use an AI tool even to help record the conversation on my end so that I get the story documented correctly, right? So, there's always this chance that they're saying something um a patient you're telling us a story, then we misinterpret it and then document it slightly off from what you said.

Well, now with AI tools, we're going to be able to word your story in in your own words. It's not just our words. So, now I've got the story correct as you tell it.

Yeah. I I also, for this very reason, uh we have a two-step process for intake. So, the patients will meet with the PA first, and then they'll meet with me.

Nice.

Just so there's two different people getting the story two different times. And of course, patients think well I already told my story I don't need to tell it again just talk to him I told him everything I'm like well there's a reason why we do this things will come up right retelling a story a second time or I might hear something and think something that he didn't think and you're really getting two sets of eyes in one go.

I love that that's a really good idea to get the two stories. Um and then we'll also use it for treatment algorithms and so I'll I'll tell I mean that my AI tool is now know my sport acronym so I'll say listen can you just please organize that story that they just told into the SPORT acronym and it'll do it boom and then I can put it into my note and it's accurate. And I can use it consistently between patients which allows me to go back and compare different starting events to you know different treatment cures and I can start looking at my outcomes yes.

That's fantastic that's essential for the practice of medicine.

I think so or at least the way I'm approaching chronic pain now which is making it a a specialty or even a specialty of a specialty it's almost like a specialty of hernia repair. Um there are a lot of people who want to be generalists and hernia repair and then there are very few people want to take on chronic pain and we we need a system face people so that we can make them better and not gaslight them anymore.

Yeah.

Really tough and the treatment algorithms range from things like taking out mesh taking out nerves fixing holes fixing tears um strengthening the the the inguinal canal cutting you know tendons that are hanging on by a thread so that they no longer hang on by a thread taking out appendixes putting in mesh taking out mesh we should maybe talk a little bit about mesh because I think

Let's do that.

Yeah I think I think mesh gets a bad rap online.

Yeah again patients always ask me about mesh and they say I don't want mesh I want a primary repair and I'm like well talk to your surgeon there's there's a lot of developments keep tell us about that.

Yeah so here we go chronic pain and hernia mesh class 101 all right, number one, mesh isn't bad. Now, all the mesh groups that are online in the Facebook groups, we hear you. We know that you've been hurt by mesh, and I agree in those situations, the the outcome was not anticipated. But mesh is like wallpaper. If you hang it well, if it's inserted properly, it will function properly. Mesh is not intrinsically bad. But you can't hang wallpaper with without glue and expecting it to stay there, it'll peel.

So, if your wallpaper peels, do you blame the wallpaper, or do you blame how it was installed? So, the first thing I say is that it just wasn't used correctly with the right hernia repair, it wasn't installed properly. The second is that mesh can shrink a little bit over time. And so, when that mesh shrinks, it can pull tissues with it. It can pull tacks, it can pull suture, it can pull if something's stuck to it, it can pull that as well.

Uh but mesh is not bad itself. So, mesh can be placed very safely, certain products inside the abdominal cavity, as long as the holes are closed, mesh can be placed between the first and and second deepest layer of the abdominal wall, uh as long as it has an anti-adhesive barrier, it can be placed under the muscle, as long as it's also done appropriately with a closed hole. The gynecologists use mesh to trick uh to treat um rectal prolapse, and they literally just suture the mesh to the rectum uh to do that.

Um you know, that's a whole different field, but mesh has got uh a lot of good qualities. But, if you are out there and mesh has been involved in your pain, then it may need to come out, but it doesn't mean that it's to blame entirely.

Yeah, it's a tool.

It is it's an adjuvant. I mean, we use it to This is the other thing. We use it to decrease your chance of getting another hernia. It's that simple. It's not like we want to put the any something in you that doesn't belong in you. If we repair your hernia with just sutures, it has been shown over and over again in randomized prospective trials that no matter what we compare it to, the recurrence rates are higher when we don't use a mesh implant.

Can you talk about with inguinal hernia or specifically? I know some surgeons will universally sacrifice the nerves, others spare the nerves. How do you approach this?

All right, the traditional Lichtenstein as promoted by my friend David Chen's mentor Parviz Amid involves the preservation of the ilioinguinal nerve and the genital branch of the genitofemoral. In fact, they suggest don't even take it out of the sheath. If you don't skeletonize it, it doesn't get hurt. That's the traditional way of doing it. The Jacob way of doing it is I try to eliminate the things that can cause chronic pain in the future. So, if there's a an abundance of dissection that's needed, I do what's called a selective neurectomy.

And a selective neurectomy is when, okay, your ilioinguinal nerve is definitely going to be adherent to this mesh, I'm going to take it out. Or the genital branch of the genitofemoral nerve running along the floor of the canal is going to get in the way of my closure of the of a big direct hernia sac, or may interfere with the mesh, so I'm going to put it I'm going to take it out. So, I do prophylactic neurectomy so that if they get pain, I know it's not from that nerve.

What's the side effect?

Neuroma pain.

Yeah, but what's the side effect of taking out the nerve? People get worried about numbness. You're just saying in the world I cannot explain it as the majority of my patients do not get numb ilioinguinal nerve pain.

There's a lot of cross-innervation. I mean, you you know this as much as anyone. Mapping out the ilioinguinal versus the iliohypogastric versus the genitofemoral into the anterior pelvis is very mixed, even pudendal. Yeah, it's unexpectedly mixed.

And a great question for you back at you is can you maybe describe mirror image pain? Because what'll happen is after a period of time, people go, "Hey, my other side hurts." And and I feel like there's this thing going on in the brain where it's it's creating a mirror image of the pain and now it's sending a signal to the other side.

see this frequently with the pelvis. Yes. And And it's it's interesting. So, generally when I approach pelvic pain, of course, I'm looking for anatomic drivers first, right? And I'll poke and prod and feel for hernias and, you know, visceral things, but also looking at the hips and the SI and the low back. And if the anatomy is pointing to an asymmetry where one side is more likely a pain generator, if if it's pudendal distribution or if it's, you know, ilioinguinal and iliofemoral distribution, I'll block that side first and see what happens.

Mhm.

And not infrequently the other side pain will go away.

Got it. There's um There's also something else that I want to add about uh when we take mesh out for chronic pain, cuz I think that'll come into some of the questions. So, um some of the patients out there that I've seen want to know if there's some sort of protocol for what we do with the mesh after we take it out.

Put it in a jar and put it on the fireplace?

There are patients who've been worried about chronic latent infections. There are There are patients who've been worried about um defects in mesh fibers and things like that. Uh you have to understand something when it with it with patients who might think that every mesh that comes out that needs to go to microbiology, the answer is it does not. If it was infected, it would have presented as a different mechanism. Number one. And number two, if it was infected and it's out and all of it's out, you would get better.

So, knowing that there was a staph aureus or streptococcus on a piece of mesh that's been into you for 10 years or it came out, it's going to be a contaminant anyhow. And so, if we swab that mesh and it comes back positive, it's a contamination. So, the the information's actually clinically useless. Uh we don't do it. I just wanted to get that clear for some of the patients that may say, "Hey, my mesh was taken out, but it wasn't uh sent to microbiology."

Oh, so if the mesh were infected, it would declare itself.

You would have

hasn't declared itself, it's not infected.

Correct. And then we go down this whole question of is, you know, is there um a mesh implant syndrome in the hernia world. So, um ASIA, which is basically um an anti an autoimmune syndrome induced by a mesh implant. Um is basically very divisive of the hernia experts out there. Um there are definitely people who understand that there's a foreign body reaction to an implant, and there are people who understand and accept that uh an implant can start causing an autoimmune reaction at a very low level that's very hard to diagnose.

Um and I have to tell you that in my clinical work, even though I believe in it, I believe that there must be patients out there that are susceptible that are are suffering from systemic symptoms related to a mesh implant of an inert product.

[snorts]

When we get those products out in those patients, even that the ones that I believe, I have not seen a lot of them report back to me that those other symptoms got better.

And it's tricky, too, cuz it may have taken on a life of its own. Like we see this with silicone, right?

Mhm.

And just taking out the silicone implant doesn't stop that process.

Doesn't stop the process. Uh isn't that important to convey though, because you may take out the mesh, and the symptoms that you came to have the mesh taken out for may continue in exchange for getting another hernia. I mean, we take out your mesh, you're going to get another hernia at some point.

it with mesh.

No, most of them don't want the product a new product placed back in once they got it out.

No. Yeah.

Yeah, they're they're so fixed on get the mesh out, get the mesh out, get the mesh out that the concept of putting a mesh back in uh is frightening to them.

Okay. But so if we take a step back at that point, there is an anatomic structural defect that's probably going to declare itself in the future.

Yes.

And the neurologic process that was causing the pain is probably sensitized at some level where just removing the mesh isn't going to take away all of that pain or the sensitization from that pain anyway.

That's correct. I could tell you about the case we just did this week. Um, a patient had a robotic inguinal hernia repair by a very good surgeon and woke up in excruciating pain. Like severe off the charts. He was a marathon runner. But never had a chronic pain beforehand. Long story short, after you know, imaging blah blah blah, there's they went back and they said let's just take out the mesh. Has to be the cause. They took the mesh out, of course the pain continued.

So, now everyone is saying well well we took out the mesh and this new pain that wasn't there before hernia repair is is still excruciating.

Yeah.

Um, like 10 out of 10 sensitivity. So, then you have to go down what else could be causing that. So, it's either a thermal injury to muscle which then got the nerve in the inside the the muscle or when they were robotically suturing closed the flap, they grabbed somehow cutaneous nerve here. You have to shift gears. Um, and then even then, you know, the pain is sort of in a distribution that they can't quite localize and so as the surgeon you have to say listen, we're going to go after sequentially where these nerves can be.

You block them, they get a little temporarily better, you know, what to work. In this one situation we had to first do one surgery, we took out a nerve, that part got better, but the other part did not.

Mhm.

We had to go back a second time, we waited 3 months and then found this cutaneous nerve that doesn't have a name. It's probably like a branch of T12 that comes that came through the rectus muscle, through the anterior rectus sheath and then dove straight down to the pubic tubercle.

Huh.

But coming from like the T12 level and I know that because we found and took out the ilioinguinal and the other iliohypogastric, so it was the next one up. Uh, but it had a branch that went all the way down. And that's why the patient had severe pain going straight down cuz that was stuck in the scar tissue. You just have to work very carefully, but there's a situation where taking out the mesh did not make them better, and we had to go to the next line.

And we thought process in the differential.

And and I'll generally explain to patients hernia pain comes from one of three sources usually, and get your thoughts on this cuz we haven't talked about this directly.

Okay.

So, the the hernia itself can cause pain. So, the viscera that is in, whether it's fat or actual omentum or viscera, that itself can be painful. And that is a sympathetic pain, which like you described, it's poorly localized. It's hard for the patient to describe, but it's excruciatingly painful.

Yeah.

Um the nerves within the canal can be irritated because whatever is in there is punching those nerves, and that'll give you the nerdy pain that goes down into the groin, and that's very typical.

Yeah, like almost like a burning pain.

Yeah. The burning, electrical, pins and needles, itching sometimes. Um sometimes there's bladder sensitivity, uh other things that are not classically thought of as hernia pain, but and then there's the abdominal wall because the abdominal wall is sustaining an insult from the hernia itself, and it's usually reacting in some way that may trigger an acne's response or cause some other abdominal wall pain. Uh and and so with hernias, primary hernias, we may see any three of these pains presenting initially. Uh and it the same thing after a repair.

Uh you know, if they developed an acne's, hernia surgery is not going to fix the acne's.

That's right.

Uh uh and the same thing that if the nerve is irritated from being punched from the hernia repeatedly, and we'll see this and of course, you know, only 40% of hernias show up on MRI, right? Uh so, if a hernia is coming in and out, uh each time it comes out, it punches those nerves, and it'll upset them, and it may go right back in, but those nerves are upset for a while.

Yeah.

Uh that that same irritation to the nerve may sensitize the nerve, and even though the hernia is repaired and the nerves are no longer getting punched, it can still be sensitized.

For sure.

Uh and sometimes all we have to do after a hernia repair is just go and block the nerve and reset it.

Yes. Also true.

I'm I'm curious, are there any other mechanisms of pain that you're thinking of anatomically?

Inflammatory.

Okay.

Um physical and emotional are the three types of of pain, but you know, what you're talking about is the physical. So, whether it's um the squeeze receptors on the viscera or the actual nerve itself getting irritated, which I think to me is usually burning. Um

[snorts]

those are the main ones. The The as you mentioned, not all hernias show up. We call those occult hernias or hidden hernias. Um common in women more so than men, but definitely doesn't care of the of the gender. Um you got to consider an occult hernia, which means you're going to have an exam that's normal. No one's going to feel your hernia. You're going to get imaging, it's normal. No one's going to see anything. That doesn't mean you don't have a hernia.

So, the next line of treatment there is is a diagnostic laparoscopy, which means a surgery. Uh and yes, those are considered, I guess, experimental surgeries or surgeries you're being used diagnose what you have. You don't know when you go to sleep what we're going to find, and you need to be able to give this blanket sense of of authorization to fix it.

endometriosis.

Oh, yeah, we didn't even get on the whole endometriosis world because I figured I've got an extra three or four experts on for that, but endo um is a huge source. I've I I've found endo on an appendix. I found endo on peritoneum within a hernia sac. I found ovaries with endo in the hernia. I found endo on the round ligament, as I mentioned earlier. You can have endo on the nerves. So, you

Yeah, I mean, of course, the brachial plexus is uh a known

Yeah, and when you have endo on the nerves, that that is impossible to see cuz

And it's impossible

Right. The only notion is that and and also to to block because if you uh if they're not in pain, you got to block them when they got to have the pain.

And and and it it's it's also difficult with those very proximal nerves because any block is going to turn the nerves off. So, it doesn't clarify why the nerves are having pain.

Right.

You you can clarify the distribution of the pain, but not the reason.

Correct. We've shared some very interesting cases of

[snorts]

neurologic and I'm sure it's just getting to those nerves and what to do with them is not necessarily And and be creative.

Right. And there's usually more than one target in the end, right? So, that's where the pelvic pain becomes more complex. Can Can we go back to the definition of occult because I I I always thought occult was just it didn't show up on imaging. But generally, I'll like I'll only get imaging if I get something on exam. So, if the patient's coming in with a hernia story and I poke and prod and they have pain where a hernia would cause pain and I pull out the ultrasound and I look on the ultrasound and I can get them to provoke a hernia on the ultrasound.

But then I send them for an MRI or CT and it doesn't show up. That's when the surgeons for me will generally call it occult and they won't want to operate. And I'm like, "Well, but my ultrasound. Look at my ultrasound." And they're like, "No, it wasn't on the CT or they don't know." And I'm like, "Okay, well, let me do a diagnostic block." And then I'll do the ilioinguinal and iliofemoral block, uh take the pain away, and they'll still not want to operate and say, you know, if they do end up going, they'll say, "Well, that wasn't occult hernia."

Okay.

How How do you slice that information?

you've not run into blind and experts. You run into people who follow the teaching that unless I have an obvious, palpable, reducible lump, I'm not doing a hernia repair.

So, rare is that present?

Well, yeah. And it's not that it's rare as much as it is an occult hernia, a hidden hernia, um is just a part of the differential someone whose main chief complaint is groin pain. So, it just shifts the the the recipe, right? So, they're used to treating inguinal hernias. This is groin pain. So, we're doing a surgery as a diagnostic modality for groin pain. If we find a hidden hernia, or in in a male situation, it could just be a spermatic cord lipoma,

Mhm.

and without an obvious hernia.

Mhm.

Um then you have to fix it. So, you're treating something different.

Yeah. Can we go off on a little tangent for that because I I do see cuz I'm I'm ultrasounding a lot of groins, right? And I do see a lot of fat in the inguinal canal, and there's a certain amount of physiologic normal fat in the inguinal canal, and you can have lipomas, and lipomas we know are inflammatory, whereas regular fat's not inflammatory. Lipomas are inflammatory, and they will irritate nerves.

Mhm.

Uh how do you distinguish if it is a hernia or if it's just fat in the canal?

Great. So, the tiebreaker goes to the MRI. Now, the MRI has two types of um cuts, T1 and T2.

Mhm.

T1 images are always more sensitive for fluid. Uh sorry, for fat, and T2 is more sensitive for fluid. Uh so, when you compare your sonogram to the MRI cuts, um on the T2, if there was an injury, you would see some fluid. On the T1s, you would see this really white ball

Mhm.

next to the spermatic cord, and it looks distinctly different than the fat color of the pampiniform plexus,

Mhm.

of the natural fat around the veins.

Okay.

And so, you can you can see it um pretty clearly. And that that's where the tiebreaker goes. And so, what I say is, "Okay, did they see a lipoma? Did they see a big meaty pampiniform plexus? Or did they see um you know, a little fat-containing inguinal hernia?" Uh next to those structures, the tiebreaker will go to the MRI. Now, you could say that the patient was laying flat for the MRI, therefore maybe it's not that for That becomes more challenging, at which point you can say, "Okay, you know what?

We don't have enough evidence to say you have a hernia that needs surgery. We know you're in pain. It seems to be related to this. Let's use time as our friend. Let's just not book anything. Let's just follow you for 6 months because this is not dangerous. And see how this evolves. And maybe it will become bigger because all hernias will become bigger over time. Mhm. It may take years, but they will. And so, if you really want to diagnose a hernia before operating, you have to they have to sign on and say, "Listen, I know you want you're in I am going to agree to follow you for two or three years and see if this thing gets better."

And then you have time to say it got bigger and then you operate. As opposed to operating just to get a case or an RVU or whatever they It's what other surgeons do. And then you quit what you're on.

Can we speak about hernia size? Because I've also heard, "Oh, that hernia is too small. It can't be causing pain."

Oh.

And from my perspective, I'm like, well, it would seem like in a small hernia, there's not a lot of space for the hernia, so the nerve's going to be more compressed. And I've seen plenty of extraordinarily large hernias. Like, I've seen older gentlemen where their pelvic floor was basically consumed by a hernia.

Mhm.

And they had no pain.

Right.

They were They were coming in for other pain issues. And I'm like, well, you have these massive hernias. They don't bother you. So, how how do you advise someone like a pain doctor try to educate uh hernia surgeon colleagues that small hernias can be painful?

Uh I heard from a old chairperson that surgeons are sometimes wrong, but never in doubt. Um so, just remember that when you're talking to a surgeon, they will always sound confident. They are always believable. And love that about surgeons. I mean, I definitely fit that category. I often times sound like I know what I'm talking about. This topic I do. Um but we're sometimes wrong. Uh the smaller the hernia, the more painful it is. For sure.

Um a big hernia, meaning the size of the defect, the size of the hole that something's going in and out of. The really big ones don't squeeze anything, so those stretch receptors, those squeeze receptors on the viscera are not causing any type of blockage. So, not to Just think about the tighter you squeeze, the harder it would hurt. That's why small ones can hurt more. The big ones are big wide open things, things are going in and out of it. They're uncomfortable.

But unless something gets pinched, they don't really cause that ouchy kind of pain. So, the the smaller and the more occult

The more hidden.

Um they actually can cause pain. And some of the problem is sometimes they're just they're natural fast. Sometimes we find things like these small hernias surgically and we think they're relevant, they turn out not to be.

Yeah.

You just don't know until you try.

Same thing with the disc herniations.

Oh, yeah, for sure.

All right, final thoughts. I'm curious who else is on your team. What other kinds of surgeons or interventionalists or medical doctors do you work with?

So, you're thinking about like Brian 2.0. So, like my next venture is going to be to create um a center for chronic light pain uh where there's an actual team of people under the same roof at the same institution uh so that we can keep all these patients under one roof. Right now, I don't have a set team. I'm just all a surgeon in an office treating hernias. I have three partners.

[snorts]

Um actually have four partners now, um but they don't specialize in chronic pain.

Mhm.

Um but they're wonderful surgeons, but they're just they're surgeons. So, nowhere else is there. So, I have reached out uh to expand my network to to really great practices like yours. Um to radiology groups that understand that when I send someone, we didn't talk about how I I order my radiology images, but I always get them uh with a radio opaque marker over the spot of pain. Most people just order an MRI or CT scan.

Mhm.

You know, my my prescriptions say with radio opaque marker, so the patients take these little beads and they put them on the spot of pain so that when I get the image, I can say, "Okay, here's the finding on the image that correlates to their story."

Yeah.

Otherwise, it doesn't matter. So,

the radiologists that I work with are part of that, and they understand the importance of that, and they now will remember it as well.

And and even relying on the radiology read, I mean, I think most patients assume that the radiologist is the expert in detecting hernias. Can you speak to that?

Um

No. Uh the truth is, and and I love all of you radiologists out there, and but you have to admit, you were not taught to read hernias the way you were taught to find other disease entities. And so, reports will often times miss small hernias. Every week, we find hernias that were not dictated, or we find things that were dictated as something [snorts] that is an actual hernia, but they're dictated based on your definitions of it. Didn't go above the level of the linea alba, or didn't There was no break in it.

And and in their defense, they're not seeing the patient. They don't know what's going on with the patient. So, they're they're not able to poke

I don't even

I'm not even holding them accountable.

No, of course, of course. But just so patients are aware, because patients will often not trust the physician when they have a report in writing. And that disconnect, I think, can be bridged by the understanding that you see the images, and you see inside the same patient, and and you've learned over the years to correlate those two things with more specificity than a radiologist could ever have experience to do.

Right. And and for me, I, you know, I see the image, I can ultrasound see the same thing, I can also poke the patient. Okay, I see this on your picture, does that hurt? Yes, that hurt. Okay, so that is relevant.

Yeah.

Uh versus something that's not relevant.

Correct. Just today, I had a young athlete, 18-year-old lacrosse player in the office, who had severe pain over his right adductor. He had heard a pop in February, the pain has only gotten worse. He'd failed all types of non-operative treatments. He's He lives about 2 and 1/2 hours away. And the MRI that they were working on said that there is no way adductor tear. And that's the report. I opened it up and I you know surgeons have to take a double take cuz I'm looking at the image and I'm like, "Oh my goodness, I there has to be an adductor tear."

I if that's really not an adductor tear, I need to go back to the textbook and relearn what I know, but I didn't you know, I don't know the radiologists. I don't know the radiology center cuz it's from a place 2 hours away. I don't want to call them and tell them they're wrong because I'm also not a board-certified radiologist, but it's very obvious to me. So, I'm now going to take the image and have it reread uh by somebody else that is a board-certified radiologist, but I said, "You look, you have an adductor tear and you don't have a traditional sports hernia.

You don't need a whole thing. You need an adductor tenotomy, which was my opinion." But based on my read of an image that was misread and being used to guide treatment for the last 3 months. So, it can be it can be challenging, but yeah, that's that's a interesting part is the radiology. Uh the other team member that we have is I always work with as many physical therapists as I can, whether they're the pelvic floor therapists or overall physical therapists or Pilates instructors, yoga instructors, stretch um types of uh masseuse, licensed massage therapists.

So, I have someone, you know, for each of those things on my Rolodex. And then mental health therapists, including above-ground stuff, traditional psychology, behavioral therapy, I think is very, very important. And then when all else fails, psychedelic assisted psychotherapy. So, getting people connected to those networks um just so that they even if they're ruminating and they can't get out of their ruminating head that we have ways to disrupt those circuits uh and help them see themselves in their mind-body connection through different methods.

often essential with chronic pain treatment.

It is. Yeah. So, we have all that.

Absolutely. Well, I appreciate you joining us today. Anything else you'd like to talk through?

No, I would just want to tell uh all your listeners that there are doctors out there willing to listen. Um some of us are not in insurance plans and you and mentioned this earlier and I think it's something that you may choose to to leave in your your podcast or not, but you can't spend an hour listening to patients and really care and expect to be able to survive always on an in-network rate. People don't understand that the in-network rates for consults can be as low as $22.

Um and while we would love to to live on $22, it's just not realistic. So

I mean, if we're going to talk about in-network surgery care versus other medical care, I think also a lot of patients don't understand when they see a surgeon and a surgeon provides care, you take them to the operating room, all of your care around that issue after the surgery is covered within your surgical fee.

Yeah.

You don't you don't get paid for follow-up care, for complications. It's all caught up in there and anyone can look up the Medicare reimbursement for a hernia repair surgery and it's generally not that much. So for people who do want really thorough, conscientious care, you kind of get what you pay for.

Right. It's you know, you you definitely can find amazing care with within network surgeons and in-network pain medicine doctors. So so that's not the point. What my point was was don't let the fact that some of us are out of network be the obstacle and the reason why you don't seek help. Um

Well, on that, we we work closely with insurance. So even though we are out of network, generally our patients our patients rarely pay much more than they would pay going to an in-network surgeon, especially with in-network sister surgical centers and other ways we have of making things work for the patient.

Yes. And even if I don't end up being the surgeon that operates on you, it's it's not a lot of money to come get your diagnosis. It doesn't cost you can still go get an in-network CT scan or MRI. You you we can work you up in-network and keep it affordable and then try to find you an in-network surgeon.

Well, and then that's the other thing for patients who may not have access to a hernia pain specialist because how many of you are there in the I like I know three. And outside that circle patients may just need an online consult. They may just need to talk through all of their findings and get some guidance and I do this for a number of pain consults just to help guide the next step.

Sure. Follow me on Instagram. Um hit me up by email, but you know, let me know if I can help you.

Great.

And this is this is really cool. I love talking about this.

Well, it's been a pleasure.

Yeah.

All right. Thank you.

Thank you.

Thank you for joining us on another episode of Care Beyond the Pain. The pain journey is rarely a straight line.

To learn more about how to navigate it, you may visit our website manhattanpainmedicine.com or read our book Pain Answered found on Amazon. Until next time.