Stony Brook Medicine: Jonathan Raanan, MD, Discusses Physical Medicine and Rehabilitation for Back Pain

By Hillary Eames
Tuesday, August 25, 2020

Jonathan Raanan, MD, a board-certified physiatrist and Director of Outpatient Services for Stony Brook’s Neurosurgery Spine Center, is also Assistant Professor of Neurosurgery and Physical Medicine and Rehabilitation (PM&R) at Renaissance School of Medicine at Stony Brook University. In practice at Stony Brook Medicine since 2006, Dr. Raanan uses interventional procedures to treat back pain, including the highly-effective Intracept procedure.

“Physiatry, also known as physical medicine and rehabilitation, is a medical field that encompasses a wide array of diagnoses that require rehabilitation,” Dr. Raanan explains. “This can apply to orthopedic or neurological conditions, spinal conditions, traumas such as amputations, or chronic illnesses that cause deconditioning.”

Dr. Raanan focuses his practice on musculoskeletal spine conditions, with a particular interest in helping patients with back pain. He focuses on providing a wide array of nonsurgical options, often prescribing physical therapy, exercise and ergonomics to help patients compensate for the wear and tear that can come with aging. In order to maximize participation and implementation of these treatments, Dr. Raanan also performs injections and minor procedures to the spine to minimize pain.

“Back pain is a very common problem, and its incidence increases with age,” he says. “From a physiatry standpoint, there is great potential for patients to adapt to the way their bodies change with age. Some patients may need medications and injections to optimize that rehabilitative process. A small percentage may require surgery, but having degenerative changes in your spine does not mean you are destined for an operation.”

“As an intern, I was drawn to the fact that PM&R involved a full rehabilitative process, from the initial deficit to complete recovery or restoration of optimal function. I chose to specialize in physiatric care of the spine as I became comfortable and adept at applying this approach to back pain. I enjoy helping patients return to their previous levels of activity.”
— Jonathan Raanan, MD, board-certified physiatrist; Director of Outpatient Services, Stony Brook Neurosurgery Spine Center; Assistant Professor of Neurosurgery and Physical Medicine and Rehabilitation, Renaissance School of Medicine at Stony Brook University

Advancement in Treating Chronic Vertebrogenic Lower Back Pain

Disc degeneration is common with patients over the age of 50, according to Dr. Raanan, to the point where he considers the condition synonymous with aging.

“There is ongoing research to figure out how to regenerate discs between vertebrae to compensate for or repair degeneration,” he says. “It’s been dealt with in a variety of ways, but nothing has been overwhelmingly successful.”

This is partially due to the wide variability among patients with degenerated discs; however, Dr. Raanan states that the source of back pain may not always come from the discs themselves.

“Pain from degenerative discs may still be present, but it appears more likely the adjacent vertebral endplates are the primary source of pain for patients who have these changes,” he explains. “Since the 1980s, physicians have looked at MRI studies and noted degenerative changes in the endplates where the vertebrae meet the disc, which are called Modic changes. Recently, these changes have been demonstrated to be a source of pain.”

Specifically, research has validated that vertebral endplates are a significant generator of chronic low back pain. This vertebrogenic pain is transmitted through the basivertebral nerve, which innervates the endplates.

The Intracept® Procedure

As a result of these observations, treatment options for chronic vertebrogenic back pain now include a method to target the basivertebral nerve rather than the degenerated discs. This method is called the Intracept® Procedure, which Dr. Raanan has offered to his patients since spring 2019.

“Some aspects are similar to other minimally invasive spinal procedures,” Dr. Raanan says. “The physician inserts a cannula into the patient’s vertebra and locates the place where the trunk of the basivertebral nerve is present but has yet to reach the endplates.”

After Dr. Raanan places the cannula, he inserts an Intracept® radiofrequency probe. A radiofrequency generator heats the probe, which ablates the basivertebral nerve before it branches to the endplates. Once destroyed, the basivertebral nerve is no longer able to send pain signals to the brain.

“We’ve been doing this for decades to the nerves of arthritic joints in the spine,” Dr. Raanan says. “However, only recently has there been focus on vertebral endplates as a significant source of pain, leading to the development of this procedure to ablate the nerve responsible for transmitting that pain.”

The success of radiofrequency ablation for arthritis suggests similar outcomes for the Intracept® procedure, with an additional benefit: the basivertebral nerves located within the vertebrae are not myelinated and will therefore be unable to regrow over time.

“The expected time frame for pain relief from radiofrequency ablation of nerves to arthritic joints in the spine can range from 6 to 24 months,” Dr. Raanan says. “With the Intracept® procedure, the ablation is a permanent change, and the benefit should be indefinite.”

The procedure is performed under fluoroscopic X-ray guidance to ensure the cannula and probe are inserted as close to the basivertebral nerve as possible, without causing damage to other neural structures.

While research regarding the procedure continues, Dr. Raanan and many others have seen exciting results. Findings from a recent clinical study published in The Spine Journal showed such a superiority over standard treatment at the three-month mark that enrollment was ended early and the standard group participants were offered Intracept.

Helping Patients Adapt with Age

In addition to physical therapy, exercise and the Intracept® procedure, Dr. Raanan also utilizes epidural and joint injections as well as radiofrequency ablation for arthritic, sciatic or degenerative disc back pain. During treatment, Dr. Raanan makes patient education a high priority, teaching patients how to navigate their day-to-day lives in a way that helps minimize wear and tear and prevent further injury.

“There’s nothing that works universally, so you have to work with every patient to find the best solution for them,” he says. “That’s why I got into medicine in the first place: I enjoy working with people.”

Dr. Raanan also works closely with referring physicians and other providers when helping patients manage their pain. This includes forwarding clinic notes and other necessary data to referring providers.

“The overwhelming majority of my patients have problems that will not go away, such as arthritis, stenosis or degenerative discs,” he says. “Keeping a patient’s other providers abreast of their conditions is important because they need to be aware of what treatments patients are currently receiving, should other symptoms arise. For many patients, their pain also waxes and wanes, and knowing what they have tried in the past keeps providers from having to begin at square one.”

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