Tech-Driven Treatments for Neck & Back Pain

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: November 15, 2025
Expiration Date: November 14, 2026

Estimated Time of Completion:  30 minutes

Tech-Driven Treatments for Neck & Back Pain
Trishul Kapoor, MD

Description
Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.
  
  Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Andreas Alexopoulos, MD, MPH
Epilepsy Center

Additional Planner/Reviewer

Cindy Willis, DNP

Faculty

Trishul Kapoor, MD
Center for Pain Management

Host

Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Tech-Driven Treatments for Neck & Back Pain
Trishul Kapoor, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Glen Stevens, DO, PhD

DynaMed Consulting

All other individuals have indicated no relationship which, in the context of their involvement, could be perceived as a potential conflict of interest.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast Novembe 15, 2024 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org.

Copyright ©2025 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries, and clinical advances in the fields of neurology, neurosurgery, neurorehab, and psychiatry.

Glen Stevens, DO, PhD: Neck and back pain are among the most common conditions affecting people worldwide, but behind the persistent discomfort lies a story of innovation, one that includes emerging technologies, minimally invasive procedures, and a shift towards personalized data-driven care. In this episode we'll explore how treatment for spinal pain has evolved in recent years, what it means for patient recovery and quality of life, and how technology is reshaping the future of musculoskeletal care.

I'm your host Glen Stevens, neurologist, neuro-oncologist in Cleveland Clinic's Neurological Institute, and joining me for today's conversation is Dr. Trishul Kapoor. Dr. Kapoor is a pain medicine physician in spine and pain medicine at Cleveland Clinic's Neurological Institute. Trishul, welcome to Neuro Pathways.

Trishul Kapoor, MD: Thank you for having me. It's a pleasure.

Glen Stevens, DO, PhD: So, Trishul, let's start by having you introduce yourself. Tell us where you did your training, how you made it to Cleveland, and what you do on a daily basis.

Trishul Kapoor, MD: Great. Yeah, I actually started out in general surgery residency at Mayo Clinic in Rochester, and after three years I came to my senses and switched over to anesthesiology at University of Michigan. After completing my residency training there, I came to Cleveland Clinic for fellowship in pain medicine and then did some locums work in anesthesia for a few months and had the opportunity to come back to be on staff, and now I'm here within the Spine Center and Neurological Institute within the Department of Pain Management.

Glen Stevens, DO, PhD: So, I'm sure we've all had neck and back pain, at least transiently. You sleep bad some night, you got a little crick in your neck, so we've all had that. But what percentage of the population has fairly persistent neck or back pain problems?

Trishul Kapoor, MD: It's a great question. According to more recent surveys that we've looked at and just overall epidemiological data, it's rising on a year-to-year basis, and it's anywhere between 70 to 80% will experience some episode of back or neck pain. And how persistent it is tends to be a lower percentage, but it is increasing.

Glen Stevens, DO, PhD: Mm-hmm. So obviously somebody comes in to see us that has back pain, we're going to take a very detailed history, we'll do an exam. How do you decide are you going to do imaging on these patients?

Trishul Kapoor, MD: Generally speaking, I look for some form of imaging to start with, because when patients come in with back pain, there can be numerous pathologic sources for it, anywhere from bones, muscles, ligaments, nerves. So to get a basic infrastructure of understanding, we start with x-rays with flexion and extension to see, is there any stability loss with dynamic motion or just at a baseline when they're standing up straight? With that, it gives us enough understanding to see small hints of degenerative disc disease, facet-related arthritis, maybe instability where there's spondylolisthesis, where there's shifting of the bones. And then depending on the symptoms that they're having, whether it's nerve-related or whether it's joint-related, we can then go into more advanced imaging techniques like MRI or CT scans on an as-needed basis.

Glen Stevens, DO, PhD: So, I'm sure if you image an old guy like me, you're going to see lots of little things here and there, and I'm going to have some nonspecific complaints. I imagine it gets very complicated to figure out what's causing what. Talk to me a little bit about the technology that's now at your hand that you can use to help define if what you're seeing on the imaging study is correlating with my problem.

Trishul Kapoor, MD: In terms of the current technology that's available is... Our go-to gold standard is an MRI. Magnetic resonance imaging comes either in a closed format, which is a standard mechanism, or an open MRI if there's other restrictions based on patient's claustrophobia or just body mass index, and so moving forward from there. The basic mechanism for us is to look at an MRI of the lumbar spine if that's the region of pain that's causing the issue, or two, looking at the cervical spine. Rarely it ends up being a thoracic spine issue. Based on that, then subsequently we go on to looking at other modalities such as EMGs. So an electromyogram will correlate the findings within an MRI or vice-versa to say where exactly the pathology could be, because the nerve itself can have a route all the way from your spine to an end terminal point, including the foot, the hand, whatever it may be. And anywhere along the way in its journey, it could potentially have a pathology.

Glen Stevens, DO, PhD: Any other diagnostic tools that you're using?

Trishul Kapoor, MD: Yeah, great question. So outside of the normal sequencing, we're looking at new sequencing techniques that are not currently available, but research has shown things like 3D isotropic sequences, which is a high-resolution image with isotropic voxels, as they call it, and it's basically representing a value in a three-dimensional regular grid. It allows us to create multi-planar reconstruction and helps improve visualization of the anatomy, especially in the spine. That's one thing.

The other thing is we realized that MRIs tend to be long and arduous, and so the question is, well, what can we do at a minimum to get away with constructing the other images? So we started looking into things like synthetic MRIs. This is a technique that allows us to generate multiple contrast views, T1, T2, STR imaging from a single acquisition, which could potentially have the scan time and provide quantitative T1, T2, and proton density maps for further analysis. That's one thing.

If there's contrast issues, where the patient has allergies, we can use something called a CISS sequence, C-I-S-S, or FIESTA-C, which is basically sequences that are designed to minimize banding artifacts and maximize CSF signal, so making them useful for visualizing the spinal cord, nerve roots, and CSF flow dynamics. With the advent of AI, we've started looking more and more into deep learning reconstruction, so basically utilizing a mechanism and a technique to leverage neural networks to learn complex relationships between raw MRI data and high-quality images. So this helps us to be much faster and potentially have more efficient image reconstruction. For example, if you have spinal stenosis, we can use deep learning to improve the visualization of the narrowed spinal canal. If you have herniated discs, we can utilize specifically deep learning mechanisms to visualize the disc bulges and protrusions. If you have spinal tumors, for that matter, we can help better delineate the tumor boundaries and characteristics. If you have infection, it's better improved visualization of the infected areas within the spine. And there's many more applications of it.

The other thing we're looking at is something called the zero echo time sequence, which means we're looking at imaging tissues with a very short T2 value. So all that means is we're looking at specific values to visualize bone tendons and ligaments, which generally appear dark and are not very well-visualized in normal conventional MRI sequences. Outside of these mechanisms within the MRI, I think we're starting to move towards 3D and 4D imaging. The difference between the two is 4D, you can actually start seeing dynamic movements of the spine. So we're becoming more sophisticated in how exactly we visualize the spine.

Glen Stevens, DO, PhD: How do you decide if you're going to give contrast?

Trishul Kapoor, MD: So generally speaking, in the imaging techniques, we start off with, for basic back/neck pain, we don't necessarily use contrast. We do it without. If there is a concern for a CSF leak for some reason, or intercranial hypotension, then we start thinking about using contrast. If there's concern for potential spinal oncology, tumors or other mechanisms that we're concerned about, then contrast gives us a better visualization. Those are the two basic mechanisms.

Glen Stevens, DO, PhD: And all the techniques that you just went through, are these ready for prime time, or are these all done on a clinical research trial?

Trishul Kapoor, MD: Yeah, so the CISS sequence is something we utilize currently. The other mechanisms are currently investigational and hopefully being able to deploy at some point into sort of a standard market.

Glen Stevens, DO, PhD: And strength of magnet that you're typically using?

Trishul Kapoor, MD: Most of the MRIs that we're using are anywhere from two to three tesla. I believe the MRI machines that we've utilized mostly are anywhere between the two.

Glen Stevens, DO, PhD: Mm-hmm. Are you using the seven-tesla at all, or is there a utility of that?

Trishul Kapoor, MD: Not to my knowledge, but I'm sure it could be very useful. It's not something I'm familiar with.

Glen Stevens, DO, PhD: Are there specific patient populations or other comorbidities that benefit more from these techniques than others?

Trishul Kapoor, MD: Yeah, especially patients who are claustrophobic, I think it would help with being able to acquire these images quickly too. We also have the thought of getting it approved in terms of insurance coverage. It becomes a big issue because of the fact that we know clearly a patient needs this kind of imaging modality to make the proper diagnostic evaluation, but sometimes we're limited because there's specific criteria, that the patient has to go on complete physical therapy or fail a course of physical therapy before having this image. And if we can show that we can utilize the same kind of imaging format with a lower scan time, perhaps the cost of it could be reduced for us to make this more available in terms of a mechanism of diagnostic modality.

Glen Stevens, DO, PhD: So, talk a little bit about neuromodulation and wearable tech. In the brain tumor field, we're doing a study looking at wearable tech, and a lot of it just has to do with telling us the right arm's not moving as much as the left arm, or the gait is down, and it can sort of help with those types things. How are you guys utilizing it?

Trishul Kapoor, MD: Smart devices and variables in a general mechanism, I think we're looking at things from monitoring and tracking, so smartwatches, pain patches, tracking pain levels and activity and treatment effectiveness as a mechanism just to keep track of data over time. In terms of other mechanisms, we look at posture correction. Sometimes these devices can alert users in terms of poor posture and helping them prevent further strain and pain.

And from a neuromodulation perspective, I think the FDA indications have expanded drastically over the course of few years, and we're becoming more and more confident in the pathway we're taking, because it's taking the same path and journey cardiac pacemakers and resynchronization devices took before when we started out with neuromodulation. It was a basic concept and mechanism of placing a lead in the epidural space to be able to stimulate mechanisms to stop pain signaling from going to the brain, and we think that's still the mechanism of its function. But over time, we had no mechanism of understanding what the response was to the stimulus we were providing.

So, in recent times, we've taken a much more focus in being able to sense data, and that comes from a concept called evoked compound action potential, or ECAP. I think the newest generation of spinal cord stimulator programs and devices over the last three to five years have been able to take on this sort of mechanism to sense a stimulus that was delivered and what the response to the spinal cord was and to adjust the mechanism by which we're providing that signal. Over time, what's happened was that when we were placing these devices, we kind of were just sending a general signal without any understanding of long-term effects. And we focused on a few parameters, which one of the biggest things we hear in neuromodulation is frequency, so almost an equivalent of strength over time, and it ended up being that the higher levels we stimulated the spinal cord, over time it does adapt, and the efficacy of that treatment doesn't last. So it became more and more important for us to understand, what exactly are we receiving back when we send a stimulus and so we don't overload and create this sort of adaptive tolerance?

Glen Stevens, DO, PhD: So, you had mentioned the postural devices so a patient can understand how their posture. Is this feedback in real time, or it would only be later that, hey, last week you were bent over 40 degrees 70% of the time?

Trishul Kapoor, MD: Yeah, great question. It can be both, but in more recent times, it's actually feedback in real time. In fact, your phone is able to do it, too, but again, there's limitations with the fact of, how often are you carrying these devices? How easy is it to be with it on a 24/7 basis? Wearable devices such as watches have accelerometers and gyroscopes within it, so they're able to be able to measure positional changes from a large scale, sitting, standing. From a posture perspective, it has to be correlated with certain other wearables to be able to measure exactly if you're flexed too much, if you're too high from the ground, too low from the ground from a baseline. So there is some potential in real time right now, but it's not perfect.

Glen Stevens, DO, PhD: So, from a tech-driven treatment standpoint, you mentioned the wearable postural correction, which sounds like a good idea. You mentioned a little bit about spinal cord stimulators. Who needs the spinal cord stimulator? When do you decide to use that?

Trishul Kapoor, MD: Yeah, that's a great question. Traditionally, our focus with spinal cord stimulation had always been post-surgical patients who did not have the relief that was intended, and I think the traditional term or diagnosis they were given was failed back surgery syndrome, which then became post-laminectomy syndrome, and I think the newer term that's now being trying to come into as a replacement is persistent spinal pain syndrome. We generally saw it as a mechanism to treat those patients because they were not candidates for any further surgical revision or additional surgery, so this was sort of the saving grace to treat them. However, we were cautious in providing this as a treatment modality for patients who did not have surgery. That has since expanded broadly because of the fact that, one, patients don't want surgery, two, they're not surgical candidates for a number of reasons or don't have surgical options. So now we have non-surgical back pain as a mechanism to treat and utilize neuromodulation therapy.

We've expanded our indications to include diabetic peripheral neuropathy, and these patients, the neuropathic pain that they have due to either properly controlled or poorly controlled diabetes mellitus could be severe, and no medications and number of other alternative treatments or injections have helped them, but we've seen very, very promising results of applying spinal cord stimulation to these patients. We started looking into peripheral arterial disease as a mechanism to treat. There are a whole host of indications that are expanding, from headaches to cervical migraines, all the way to the classic radiculopathy, spinal stenosis.

Glen Stevens, DO, PhD: And are the spinal cord stimulators MRI-compatible?

Trishul Kapoor, MD: Most of them at this point are or conditional or are conditional approval, but majority of them are MRI-compatible at this stage, yes.

Glen Stevens, DO, PhD: And does it go at a standard level, or you can do it at different levels in the spinal cord?

Trishul Kapoor, MD: You can do it at different levels.

Glen Stevens, DO, PhD: Mm-hmm. And we'll move on to radio frequency ablation. Tell the audience what that is and how it would be used.

Trishul Kapoor, MD: Yeah, radio frequency ablation is a mechanism... There's two forms, but the traditional term is thermal radio frequency ablation. All that means is we're targeting a specific nerve structure and creating a energy field around that area to essentially burn or damage the nerve ending in some way, shape, or form so the signaling mechanism stops. We use it traditionally for joint-related pain, particularly patients who have, let's say, low back pain. The joints in the lower back become arthritic in nature over time, they become large and painful, and it's very hard to treat. However, there are certain nerve branches that come from the larger nerve roots that supply these joints. Traditionally what we were doing is we were injecting the joint directly, but we saw that the evidence behind it wasn't that great because, one, we could rupture the joint, and two, the joint itself is so arthritic, it's not taking any medication.

When we started targeting what we call the medial branches, which are the small little nerves that come off the nerve root, we started seeing a better relief. Traditionally you'd have to do a couple of diagnostic injections with some local anesthetic and steroid to prove that that's the source of the pain. Once that's done, we complete the same procedure with tiny little needles that are capable of creating this thermal energy to burn those nerve branches, and it creates a very focused field of energy without going past the needle tip itself. And then over time, the nerve branches do grow back, so it has to be repeated.

This technology has since expanded and advanced to multiple different modalities. Now we're doing radiofrequency ablation in the center of vertebra to burn what we call the basivertebral nerve, which is a common cause of vertebrogenic pain, or bone-related pain. We're using radiofrequency ablation methods to treat spinal metastases, so spread of cancer into the bones itself, in a mechanism to get rid of some of our vertebrogenic pain from another oncologic source. So there's a pretty wide expanse of ability. And we're innovating on the needle types because the traditional form created an oval type of lesion, but it's very difficult to get that needle into the right position because it has to lay flat against the nerve itself. So you have to be pretty skilled to be able to do that. With using fluoroscopy techniques over time, we've innovated on the needle design where you can come end-ons directly on top of the needle through something called cooled radio frequency ablation, where you're able to create a spherical lesion beyond the needle tip so that you don't have to take this very difficult technical approach. And it continues to expand in terms of innovation.

Glen Stevens, DO, PhD: Are you doing anything with virtual reality as sort of a distraction for patients? Does that help?

Trishul Kapoor, MD: Personally, no, but I did a lot of work specifically in terms of focusing my research on this prior to coming to the Cleveland Clinic, especially trying to develop something called the Digital Therapeutics Program. We believe, I believe especially, and research supports it, that pain relief has to be interactive from multiple modalities, not necessarily just targeting musculoskeletal structures, but from a mechanism of cognitive redirection. So interactive pain relief, especially with virtual reality applications, engages and motivates not only prevention in terms of exercises, like diet and physical therapy routines and helping manage back pain, but it also serves as distraction relaxation during the time of when we're doing a procedural intervention, or when there is a pain exacerbation to promote relaxation and reducing pain perception. But accessibility is really the bigger issue at this point, and creating sort of a therapeutic line across multiple pathologies is what really needs to be the next step.

Glen Stevens, DO, PhD: Yeah, and I think it's fairly obvious, but talk to us a little bit about the current limitations or challenges in adopting these technologies in a larger scope.

Trishul Kapoor, MD: The biggest thing is technical literacy would be the first thing, because we have such a wide variety of patients who come in from different generational times, so their exposure to technology can be limited. They may have predisposed opinions already formed about it, or their ability to use it may be limited because of the fact that we can prescribe any number of these technologies to be used, but how well they understand it, how well they use it, and how well they follow with it... Because setting their expectations becomes a huge issue.

But the other big problem is that within a healthcare ecosystem and infrastructure, cybersecurity has become a massive, massive issue, especially due to ransomware attacks. Healthcare organizations are prime targets for ransomware, which can cripple the system and disrupt care while demanding ransom for data access. There's data breaches as well associated with that. The medical device vulnerabilities are another issue, phishing attacks, insider threats. And the legacy systems that we have sometimes have outdated software and systems that not only have vulnerabilities, but limitations in being able to capture data outside of a healthcare system or a standard device that a traditional EHR is able to take on. So it really becomes... The first and biggest problem is helping educate patients, having a clear user interface to be able to interact with a simple task, and then making sure it's safe to use and capture health data and it's captured within our electronic health record.

Glen Stevens, DO, PhD: So, it starts to get pretty complex. You've gone through a lot of options here. So you see a patient; I guess the question is how are you deciding what tech-driven evaluation or treatment's going to be ideal for them?

Trishul Kapoor, MD: That's a great question. It really first starts with the patient's comfort with technology and how well they understand it versus not. Depending on their familiarity with it, then we would start with something more simple versus advanced. But it also comes based on their overall path of physiology. For example, if a patient has undergone numerous different conservative measures, physical therapy, multiple medications, injections, and we're at the point of deciding between surgery or some intermediary step before surgery, then the question becomes, is the patient interested in surgery or not? If not, then neuromodulation is really the go-to step. So introducing it to them at that point as a mechanism to potentially delay any large surgical intervention is great.

If for another mechanism they do want to pursue surgery and they want to increase their functional capacity, having ancillary mechanisms of incorporating virtual reality, or even mechanisms for them to participate in physical therapy through AI-assisted programs, through a camera-based mechanism at home can help with them to have pre-habilitation and post-operative rehabilitation. So it depends on the context and situation. I do think there is a mechanism to incorporate in all different ways. It's just when and how and what the patient's situation is.

Glen Stevens, DO, PhD: Yeah, it's just, like a lot of things in life, you do the ABCs first, right, the standard things, see how that works. Because there'll be a percentage of the population you just do the regular, standard... do a good exam, send them to physical therapy, and they get better. You don't have to go that other direction. Talk to me a little bit... Are you involved with working with a multidisciplinary group?

Trishul Kapoor, MD: So, I work with a multidisciplinary group as part of our practice because our department actually has access to multiple individuals from various disciplines, including neurology, psychiatry, physical therapy, physical medicine, rehabilitation. But I also participate in our spine tumor board as well, which includes oncologists, radiologists, radiation oncologists and so forth. So it depends on the patient base that we see and which group they fit into, but it's generally important to have multidisciplinary perspective to treat the patient. Because pain never tends to be just musculoskeletal. It has a very complex relation, very eclectic, and that mechanism that your emotional tolerance and intelligence, including your past trauma, emotional exposure in the past, security, any kind of traumatic events, can all play a big role in how you understand pain, how you respond to treatments, what your expectations are, and how you see an outlook for success in the future.

Glen Stevens, DO, PhD: So, a new technology comes out; do you guys have a protocol for evaluation of it?

Trishul Kapoor, MD: There is somewhat of a standard protocol. I'd say one is we obviously wait for some kind of FDA clearance, whether it be a fast-track clearance or a traditional mechanism to go through it. If it's investigational, we do take on a T-code, which would allow us to do a clinical trial where patients generally would be offered a mechanism directly from a sponsoring partner with an industry to try this kind of a tool. But we take on a very specific focus to understand how clinical trial data prior to offering it to our patients look like. Was there actual measurement of success in their standard measures? Which we look at pain scores, which is on a visual analog scale; we look at functional capacity, whether it's their amount of time they can stand and the distance they can walk, or specific tasks that they can complete depending on what exactly the therapy is; and then looking at standardized measures such as the disability index or a scale or a score to understand, has their functional capacity meaningfully changed on the standardized survey from before and after the therapy?

But obviously this is a pretty long journey and a process. We have specific trials that look at measuring whether it's, one, safe to use; two, is it advantageous to the current therapies that are available; and three, how does it really function in the real world outside of a specific inclusion/exclusion-based clinical trial? I think things change drastically when we look at real-world data because we know it works at one point, but the question that remains with the majority of technology that we try to integrate within our specialty is, how long does it last? And that's where we're starting to focus on a lot more on modeling.

Glen Stevens, DO, PhD: Yeah, and I guess that's maybe the answer to the next question. You look at modeling, but how do you evaluate a new technology?

Trishul Kapoor, MD: It depends first on the safety and the mechanism. For me, personally, it's understanding what exactly is the technology, from an engineering perspective, what exactly is it trying to accomplish; two, the safety mechanisms behind it in terms of exposure; and then, three, from an anatomic perspective, does the application of that specific technology really make sense with the anatomic principle you're trying to achieve? Because specifically speaking, when we looked at even spinal cord stimulation, it's a pretty general mechanism of treatment, but it becomes much more sophisticated because of the fact that now when we had spinal cord stimulation, the programming mechanisms was just a basic form, and now we have probably a dozen or more different programs that target various mechanisms of the spinal cord itself, whether it's the dorsal column, whether it's the dorsal root entry zone, whether it's other mechanisms of glial cell function and how exactly they're producing inflammatory markers. So there's a huge mechanism that we have to look at as to how exactly the technology applies, so it's unfortunately not easy.

Glen Stevens, DO, PhD: No. Innovations on the horizon that are getting you excited?

Trishul Kapoor, MD: I think the biggest thing on the horizon, and I'm sure everybody's talking about and it's the biggest focus, is integration of artificial intelligence into current mechanisms of clinical practice. I think with neuromodulation, as I said, we're in very nascent stages. It's a very exciting time because we're taking the journey that pacemakers took for cardiology, and we're just at the initial steps. First, we were able to send signals, now we're able to listen to some signals, but the big question still remains, it's not as simple as the heart. Whereas you just standing in a free space, there are signals from sensation, posture, orientation all going through the spinal cord, so what we're measuring is if I send a signal, what kind of a response do I get? But how do we get a baseline score of what kind of signals actually correlate with pain? That's not clear just yet.

I think with the application of deep learning models and larger-scale data sets, utilizing free and open source models and larger engines, we're probably going to be able to ingest a lot more data than we ever did. And that's what seems promising to be able to even look at personalized programming patterns that I don't think has been looked at before.

Glen Stevens, DO, PhD: Final takeaways or things that we didn't mention that you think are important?

Trishul Kapoor, MD: I think technology is going to be a huge proponent of any clinical practice, and adoption and introduction to patients is going to be crucial. It's just figuring out within the patient journey at what point which technology plays the greatest impact, and knowing that there's various roles at different times.

Glen Stevens, DO, PhD: Well, Trishul, I really appreciate your joining me today. I think I was unaware that spinal cord stimulators could be beneficial with patients in peripheral neuropathy, so I found that quite interesting, although I don't look after this patient population at this point. But appreciate your time today and all the great things you're doing, and I'm sure the field is moving at a rapid pace these days, so we'll wish you well keeping up with it.

Trishul Kapoor, MD: Thank you for your time, and I appreciate the opportunity.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's @CleClinicMD, all one word. And thank you for listening.