Send us a text with a question or thought on this episode ( We cannot replay from this link)
Have you ever wondered what it’s like to navigate the intricate landscape of endometriosis surgery? This episode features a conversation with Dr. Nick Fogelson, a renowned expert in minimally invasive gynecological endometriosis surgery, who guides us through his transformative journey from general OBGYN to one of the leading specialist in this challenging field. Dr. Fogelson shares in a candid discussion about the advanced surgical techniques he employs, akin to those used in oncologic procedures, and the critical role of radical excision in improving patient outcomes.
As we unravel the complexities of endometriosis, Dr. Fogelson sheds light on the often misunderstood connection between pelvic pain, nerve involvement, and the importance of early intervention for nerve-invading lesions. We venture into the specialized realm of neuropelveology, examining the challenges in diagnosing conditions with invisible lesions and the profound impact patient history has in understanding pelvic pain. Dr. Fogelson shares his expertise on the different types of nerve compression and the meticulous surgical care required for cases involving major nerves, broadening our perspective on the nuances of treatments for conditions like pudendal neuralgia and piriformis syndrome.
The episode concludes with a reflective conversation on the evolving field of neuropelveology, where skepticism turns into advocacy, and the nuances of patient selection for surgery come to the forefront. We focus on the diversity of pain management techniques—from neuromodulation to acupuncture—and the importance of tailoring treatments to enhance quality of life. Dr. Fogelson’s insights challenge common misconceptions about hormonal manipulation for endometriosis and exemplify the need for an open-minded approach to treatment modalities. This dialogue promises to leave you inspired and equipped with a deeper understanding of the resilience required in the face of such complex conditions.
Website endobattery.com
Exploring Endometriosis Surgery and Expert Insights
Speaker 1
0:03
Welcome
to
Indobattery
,
where
I
share
about
my
endometriosis
and
adenomyosis
story
and
continue
learning
along
the
way
.
This
podcast
is
not
a
substitute
for
professional
medical
advice
or
diagnosis
,
but
a
place
to
equip
you
with
information
and
a
sense
of
community
,
ensuring
you
never
have
to
face
this
journey
alone
.
Join
me
as
I
navigate
the
ups
and
downs
and
share
stories
of
strength
,
resilience
and
hope
.
While
navigating
the
world
of
endometriosis
and
adenomyosis
,
from
personal
experience
to
expert
insights
,
I'm
your
host
,
elana
,
and
this
is
Indobattery
charging
our
lives
when
endometriosis
drains
us
.
Speaker 1
0:42
Welcome
back
to
Indobattery
.
Grab
your
cup
of
coffee
or
your
cup
of
tea
and
join
my
guest
host
,
chelsea
and
I
at
the
table
as
we
welcome
Dr
Nick
Fogelsen
of
Northwest
Endometriosis
and
Pelvic
Surgery
.
Dr
Nick
Fogelsen
is
a
board-certified
fellowship-trained
gynecologist
and
is
a
minimally
invasive
gynecological
endometriosis
surgeon
in
Portland
,
oregon
and
the
founder
of
Northwest
Endometriosis
and
Pelvic
Surgery
.
Thank
you
,
dr
Fogelsen
,
for
joining
us
today
.
I
have
Chelsea
along
with
me
because
this
topic
in
particular
is
really
important
to
her
,
because
she's
dealt
with
a
lot
of
what
we
are
going
to
talk
about
today
.
So
thank
you
so
much
for
taking
the
time
and
joining
us
.
I
appreciate
it
.
Speaker 2
1:25
Absolutely
.
Thank
you
for
inviting
me
.
Speaker 3
1:27
Yes
,
yes
,
I
followed
you
for
years
.
I
think
that
the
way
that
you
practice
is
a
little
bit
different
than
what
we
see
with
your
typical
excision
surgeon
.
So
I
wanted
to
see
if
we
could
start
by
just
discussing
the
education
that
you
have
and
the
different
types
of
trainings
that
you've
received
.
Speaker 2
1:46
Well
,
I
mean
some
of
it
is
similar
to
what
other
subspecialists
.
There's
different
pathways
to
becoming
kind
of
an
endometriosis
surgeon
.
Everyone
has
had
some
sort
of
advanced
surgical
training
,
like
there's
very
few
excision
surgeons
that
were
just
general
OBGYNs
and
started
and
got
into
this
although
that's
how
red
wine
started
.
But
these
days
most
people
have
done
like
a
mentally
invasive
surgery
fellowship
and
had
some
other
experience
.
So
my
pathway
is
actually
I
did
a
general
OBGYN
residency
and
then
I
was
out
in
practice
for
about
six
years
as
a
general
OBGYN
in
academic
practice
I
worked
for
two
different
universities
teaching
and
I
did
a
lot
of
surgery
but
my
skills
at
that
point
were
,
I
think
,
good
for
a
general
OBGYN
but
nowhere
near
where
it
is
now
.
And
then
I
decided
to
go
back
and
do
a
fellowship
and
I
actually
did
a
year
of
what
was
effectively
an
oncology
fellowship
at
Emory
University
.
They
have
kind
of
an
advanced
pelvic
surgery
fellowship
but
it's
within
the
division
of
GYN
oncology
and
they
don't
have
an
oncology
official
fellowship
,
so
that
that
fellow
is
really
kind
of
an
oncology
fellow
and
so
oncologic
surgery
is
really
kind
of
the
most
difficult
blood
and
guts
kind
of
surgery
in
gynecologic
surgery
very
advanced
anatomy
,
advanced
techniques
,
and
it
kind
of
turns
out
that
endometriosis
surgery
,
done
well
,
is
very
much
like
oncologic
surgery
because
we're
really
trying
to
be
very
,
very
radical
about
removing
all
the
disease
just
like
you
would
be
really
radical
removing
all
ovarian
cancer
or
endometrial
cancer
when
it's
not
going
to
be
treated
by
other
methods
like
chemotherapy
or
radiation
.
But
your
general
OBGYN
doesn't
get
the
kind
of
training
the
oncologists
have
,
particularly
in
anatomy
and
kind
of
the
deep
retroperitoneal
anatomy
where
back
behind
the
skin
and
the
pelvis
where
the
big
arteries
and
nerves
and
vessels
are
A
lot
of
times
general
OBGYNs
.
In
that
training
you
get
kind
of
some
education
in
that
but
usually
not
enough
that
you're
really
comfortable
doing
surgeries
in
that
area
that
are
very
complex
and
so
in
gynecologic
oncology
you
do
that
all
the
time
.
Speaker 2
3:45
So
I
spent
a
year
doing
that
,
did
a
lot
of
cancer
surgery
and
a
lot
of
it
was
open
cancer
surgery
as
opposed
to
being
laparoscopic
.
But
then
I
went
on
and
I
was
at
Emory
for
another
four
years
where
I
was
sort
of
a
minimally
invasive
gynecologist
surgeon
and
at
that
point
I
started
kind
of
my
path
of
really
being
very
,
very
interested
in
endometriosis
.
And
a
lot
of
why
I
did
that
fellowship
was
I
wanted
to
do
endometriosis
and
I
thought
that
was
a
really
good
way
to
learn
the
skills
I
needed
to
learn
and
so
I
did
more
and
more
endo
while
I
was
at
Emory
and
it
was
a
really
good
experience
because
I
had
such
a
wide
variety
of
colleagues
who
were
also
very
,
very
good
surgeons
and
urologists
and
colorectal
surgeons
and
cancer
surgeons
and
they
were
all
very
welcoming
to
me
and
great
collegial
relationships
.
So
I
learned
how
to
do
bowel
sections
and
learn
how
to
do
really
gnarly
retroperitoneal
things
.
A
renal
surgeon
and
I
did
some
like
crazy
cancer
that
we
removed
through
the
vena
cava
.
You
know
it
was
just
like
insane
stuff
.
Speaker 2
4:39
Wow
,
I'm
not
insisting
in
that
because
I'm
not
the
primary
surgeon
in
that
kind
of
thing
,
but
I
got
a
lot
of
experiences
that
were
well
outside
of
what
most
gynecologists
would
do
and
even
people
that
had
done
minimally
invasive
gynecologists
,
because
I
spent
a
lot
of
my
kind
of
free
time
just
in
the
operating
room
with
people
doing
cool
stuff
.
Like
if
I
had
an
afternoon
off
,
I
was
just
kind
of
a
surgery
nerd
and
a
dork
and
I
mean
I
would
do
,
I
go
and
do
whatever
,
or
do
I
just
could
say
,
oh
,
what's
in
the
operating
room
?
It's
all
somebody's
doing
,
that
I
was
cool
,
okay
,
I'll
go
and
hey
,
can
I
come
scrubbing
on
this
and
then
say
sure
,
so
.
So
now
,
honestly
,
like
when
you're
a
medical
student
,
people
do
that
,
but
at
that
point
in
your
career
,
most
people
aren't
doing
that
.
Speaker 2
5:18
Most
people
are
going
and
you
know
,
I
don't
know
doing
something
else
for
their
life
.
So
so
that's
a
little
unusual
.
So
I
did
a
lot
of
.
I
still
learned
a
lot
of
different
stuff
.
And
then
I
left
Emory
and
got
into
a
private
practice
and
I
became
increasingly
focused
in
endometriosis
and
then
eventually
started
my
own
practice
that
I
have
now
with
just
Northwest
endometriosis
and
pelvic
surgery
where
we're
just
exclusively
doing
endometriosis
and
complex
pelvic
pain
.
And
when
I
was
at
Emory
there
was
a
lecture
by
a
guy
named
Nusselli
Olemos
who
is
one
of
the
early
neuro-palveology
people
.
He
trained
directly
under
Mark
Posseover
,
who
is
the
founder
of
this
neuro-palveology
that
we
can
talk
about
a
little
bit
and
I
found
that
really
fascinating
.
And
when
I
find
something
fascinating
that
I
don't
know
about
I
go
like
I
got
to
know
about
that
.
That
seems
cool
.
Speaker 2
6:02
And
so
I
started
the
training
program
with
Mark
Posseover
Institute
of
Neuro-Palveology
in
Zurich
,
switzerland
,
and
it
was
interesting
like
I
started
all
the
didactic
study
for
that
right
kind
of
into
the
teeth
of
the
pandemic
.
I
started
it
about
a
year
before
the
pandemic
.
It
was
really
heady
difficult
stuff
.
Basically
,
what
neuro-palveology
is
is
taking
everything
that
you
probably
learned
in
medical
school
about
neurology
and
then
forgot
and
kind
of
relearning
it
and
then
applying
it
to
pelvic
pain
and
sometimes
to
other
kinds
of
pain
as
well
.
It's
nothing
new
.
What
it
is
is
it's
everything
that
every
doctor
learned
and
they
had
to
take
a
test
and
then
they
pulled
the
chute
and
jumped
it
so
they
could
put
something
else
in
there
for
a
while
,
like
when
you're
in
medical
school
you're
just
learning
so
much
stuff
and
you
it's
like
you're
trying
to
stuff
your
brain
with
hematology
and
then
when
you
take
that
test
,
then
you
got
to
kind
of
dump
a
bunch
of
that
and
stuff
it
with
something
else
.
Speaker 2
6:54
And
then
if
you
become
a
hematologist
,
you
learn
it
again
,
and
so
neuro-palveology
is
not
an
invention
as
much
as
it's
a
application
of
neurology
peripheral
nerve
neurology
into
pelvic
pain
in
a
way
that
makes
sense
and
opens
up
some
new
areas
on
how
to
treat
some
kinds
of
pelvic
pain
.
I'm
an
endometriosis
surgeon
but
I
try
to
think
of
myself
as
a
pelvic
surgeon
that
addresses
a
lot
of
complex
pelvic
issues
,
and
I
do
think
that
some
endometriosis
surgeons
just
kind
of
think
like
,
well
,
I'm
just
going
to
remove
all
the
endometriosis
,
and
if
that
doesn't
work
,
well
then
I
don't
know
what
to
do
,
whereas
I'm
definitely
looking
at
it
a
little
.
I
mean
,
I
don't
know
what's
in
other
people's
brains
,
I
don't
know
what
other
people
think
,
but
I
definitely
don't
go
into
it
as
saying
,
well
,
all
problems
are
endometriosis
,
because
not
all
problems
are
endometriosis
and
in
fact
some
people
have
endometriosis
but
that
isn't
a
problem
or
it
is
only
a
part
of
their
problem
.
So
I
did
,
I
did
all
this
didactic
stuff
and
then
I
was
going
to
go
to
Zurich
and
finish
,
do
more
of
my
sort
of
in-person
neuro-palveology
training
in
Zurich
with
Mark
Posober
,
and
then
the
pandemic
happened
and
so
it
was
like
impossible
to
do
that
,
but
I
pretty
much
slowly
did
a
lot
of
these
surgeries
myself
,
did
some
cadaver
work
.
Speaker 2
8:05
I
bought
a
few
cadavers
and
did
some
dissections
.
I
mean
,
this
is
like
mad
scientist
shit
.
Like
you
know
,
I'll
say
well
,
I
don't
want
to
do
this
on
a
live
person
right
away
.
So
I
went
and
did
some
cadaver
surgeries
and
then
slowly
started
to
do
some
neuro-palveologic
surgeries
.
But
I
couldn't
believe
.
Speaker 2
8:16
I
trained
לכ
and
human
%a
closed
for
a
very
short
period
of
time
and
,
yeah
,
definitely
leave
to
do
that
again
,
let's
do
some
on-m
у
interfere
,
aerobic
therapy
,
follow-up
therapy
,
and
when
you're
starting
to
do
things
that
you
don't
really
know
how
to
do
,
that
well
and
inevitably
you
go
as
far
into
it
as
you
can
until
you
feel
like
you're
you've
gone
as
far
as
you
safely
can
because
you
don't
want
to
endanger
the
patient
,
right
,
you
know
.
So
it
started
out
not
doing
neuro-palveology
surgeries
,
necessarily
very
well
,
I
thought
.
But
I
mean
that
was
the
pathway
to
getting
there
,
right
?
So
I
spent
a
couple
years
sort
of
teaching
myself
in
a
way
,
because
the
more
formal
training
wasn't
available
,
and
then
eventually
I
was
able
to
go
to
Zurich
and
do
the
next
level
of
neuro-palveology
training
.
So
I'm
certified
in
what
they
call
level
two
neuro-palveology
,
and
did
a
lot
of
cadaver
work
with
Dr
Posova
and
a
lot
of
lectures
with
Dr
Posova
which
are
kind
of
mind
blowing
.
Speaker 1
9:00
And
so
now
I
do
that
.
Speaker 2
9:01
So
neuro-palveology
it's
interesting
,
like
some
of
it
is
sciatic
endometriosis
.
I
mean
,
I
think
a
lot
of
people
when
they
have
sciatic
pain
they
say
,
oh
,
I
have
sciatic
endometriosis
.
But
it's
actually
quite
rare
.
I've
only
seen
a
couple
cases
of
true
sciatic
endometriosis
in
my
career
and
people
come
to
me
for
these
things
,
and
so
actually
a
lot
of
cyclic
nerve
pains
are
vascular
entrapments
where
you
have
a
very
big
network
of
veins
in
the
pelvis
and
there
can
be
certain
configurations
of
veins
that
will
create
compressions
on
nerves
.
And
so
there
are
a
fair
number
of
people
that
have
cyclic
nerve
pains
that
actually
come
from
just
unusual
anatomical
situations
with
veins
and
it
doesn't
have
anything
to
do
with
endometriosis
per
se
.
So
that
was
kind
of
my
pathway
.
Speaker 2
9:45
So
now
in
my
practice
I
do
quite
a
lot
of
endometriosis
surgery
but
I've
always
got
my
eyes
out
for
,
like
huh
,
is
this
particular
patient's
complaint
maybe
related
to
something
else
like
a
vasculent
trapment
?
And
then
we
do
some
sciatic
endometriosis
cases
,
sacroverine
neuro-route
endometriosis
cases
,
and
a
lot
of
that
becomes
an
extension
of
what
one
would
do
anyway
.
If
someone
has
a
colon
endometriosis
case
,
most
endometriosis
surgeons
would
effectively
remove
that
piece
of
colon
and
a
lot
of
other
endometriosis
.
But
I
may
do
a
little
bit
more
and
we
may
actually
dissect
out
the
sacronerverine
.
It's
really
thoroughly
because
I'm
concerned
anatomically
by
the
way
,
that
that
where
that
disease
is
going
and
so
the
techniques
are
going
to
vary
slightly
.
It's
not
radically
different
from
what
other
people
are
doing
,
but
it
is
different
and
in
some
cases
it's
going
to
lead
to
a
different
outcome
not
in
every
case
,
and
I
think
that's
really
important
.
Speaker 2
10:34
Is
that
not
everyone
that
has
unsolved
pain
after
endometriosis
surgery
?
Like
the
answer
is
neuro-palveology
?
And
sometimes
I
get
that
where
I'll
get
people
calling
me
that
have
had
problems
that
have
not
been
able
to
solve
,
and
this
is
the
answer
.
It
is
sometimes
,
but
not
always
,
and
so
I
would
say
that
it's
another
way
to
look
at
pelvic
pain
.
It's
another
set
of
tools
that
opens
up
a
pathway
that
may
not
have
been
available
before
,
but
it
still
doesn't
cover
everything
,
but
it
does
open
up
a
few
areas
that
weren't
there
before
.
Speaker 1
11:04
Long
answer
,
I'm
sorry
,
no
,
that's
perfect
.
It
leads
us
to
the
next
question
is
how
often
do
you
see
nerve
and
vascular
compression
associated
with
endometriosis
,
and
is
it
always
associated
with
endometriosis
or
is
the
endometriosis
on
the
nerve
?
Specifically
,
how
many
of
your
cases
do
you
see
of
that
where
the
endometriosis
is
on
the
actual
nerve
?
Speaker 2
11:29
Well
,
I
mean
to
start
out
with
.
There's
going
to
be
a
tremendous
selection
bias
in
that
answer
,
because
those
patients
come
to
me
.
So
how
often
do
?
Speaker 2
11:37
I
see
it
as
not
necessarily
representative
of
how
common
it
is
in
the
universe
.
It
is
not
that
common
.
I
would
say
that
it
is
frequent
that
there
is
endometriosis
in
locations
that
I
think
anatomically
is
probably
irritating
nerves
.
I
mean
all
endometriosis
pain
is
nerve
irritation
in
one
way
or
another
.
I
mean
all
pain
is
nerve
irritation
in
one
way
or
another
,
whether
it's
endometriosis
pain
or
any
kind
of
pain
like
you've
got
to
be
irritating
a
nerve
to
cause
pain
.
There's
plenty
of
people
that
have
endometriosis
in
common
locations
where
people
have
endo
,
where
anatomically
it
makes
sense
what
their
symptoms
are
.
Speaker 2
12:12
For
someone
that
has
a
dull
,
aching
pain
radiating
to
their
back
,
that
is
cyclic
,
and
then
they
have
endometriosis
is
in
their
uterus
sacral
ligaments
.
It's
not
necessarily
directly
invading
nerves
but
it
makes
all
the
sense
in
the
world
because
the
hypergastric
nerve
plexus
is
like
half
a
centimeter
underneath
those
lesions
and
so
it's
going
to
cause
enough
inflammation
that
those
nerves
are
going
to
be
irritated
.
And
if
you
irritate
the
hypergastric
nerve
plexus
you're
going
to
get
dull
,
aching
pain
radiating
into
your
back
.
You're
going
to
get
potentially
avoiding
dysfunction
.
You
can
get
failure
to
empty
your
bladder
,
you
can
get
urgency
to
urinate
,
you
can
get
a
variety
,
and
then
you
can
have
bowel
dysfunction
too
,
where
you
can
have
intermittent
constipation
and
diarrhea
and
dyschysia
,
which
is
painful
bowel
movements
Endometriosis
Speaker 2
12:54
.
Speaker 2
12:54
All
that
can
come
from
a
lesion
that
isn't
necessarily
invading
a
nerve
but
it's
close
enough
to
be
inflaming
the
nerves
.
Speaker 2
13:01
And
then
there
are
some
cases
that
literally
are
invading
nerves
and
they're
not
that
common
like
there's
a
subset
of
them
where
there
is
endobiotreosis
in
the
pelvis
.
Speaker 2
13:11
That's
just
really
bad
and
it's
extending
out
wide
enough
that
it's
gotten
kind
of
onto
the
nerves
.
And
then
there's
another
subset
where
they
literally
have
what
I
would
call
skip
lesions
,
where
the
pelvis
doesn't
look
too
bad
but
if
you
dissect
all
the
way
down
to
the
nerve
you'll
find
a
lesion
right
on
the
nerve
that
was
not
contiguous
with
lesions
in
the
pelvis
.
And
those
are
the
ones
that
are
going
to
be
really
hard
to
ever
find
without
neuro-paleology
thoughtfulness
,
because
it
is
the
history
of
the
patient
that
tells
you
that
the
lesion
is
there
,
by
the
patient
giving
you
a
history
and
maybe
a
physical
exam
that
leads
you
to
suspect
a
lesion
on
a
particular
nerve
.
And
then
you
operate
and
you
don't
see
anything
in
the
pelvis
that
would
be
extending
into
that
area
.
But
you
go
down
and
dissect
out
that
nerve
anyway
and
you
find
the
lesion
on
the
nerve
Like
that
is
something
that
without
neuro-paleology
training
you're
probably
never
going
to
solve
,
because
Nobody's
going
and
making
a
cadaver
to
section
out
of
pelvic
nerve
roots
for
no
reason
.
Speaker 1
14:07
Right
.
Speaker 2
14:07
And
so
you
better
have
a
really
good
reason
to
be
doing
it
,
because
you
could
injure
the
patient
if
you're
not
technically
good
at
what
you're
doing
.
And
also
those
areas
are
very
vascular
.
There's
big
vessels
down
there
and
if
you're
not
very
careful
you
can
get
into
a
concerning
amount
of
bleeding
,
and
so
those
kinds
of
things
are
rare
,
but
they
do
come
up
and
to
some
extent
they're
more
often
when
you're
really
paying
attention
to
them
being
like
,
I
see
them
a
fair
bit
,
partially
because
they
come
to
me
,
but
also
I
think
I
make
diagnoses
that
sometimes
other
people
wouldn't
make
,
because
I
think
I'm
thinking
about
it
a
little
bit
differently
,
and
it
leads
one
to
sometimes
pick
up
on
things
that
you
know
.
It's
always
hard
to
say
,
like
I
don't
know
what
other
doctors
think
,
I
don't
know
what
other
doctors
do
,
but
there
are
certainly
times
where
I've
had
patients
that
have
seen
other
doctors
who
are
,
who
are
good
doctors
,
who
didn't
pick
up
on
something
that
I
picked
up
on
,
and
probably
vice
versa
too
,
like
I
hate
.
I
never
mean
to
be
disparaging
of
anyone
.
That's
never
my
point
.
Speaker 2
14:58
It
is
entirely
likely
that
someone
picked
up
on
something
like
this
too
,
you
know
,
at
one
point
,
but
sometimes
the
patient
tells
you
a
story
that
really
leads
to
think
of
a
very
specific
lesion
in
a
very
specific
location
.
And
sometimes
you'll
operate
and
don't
see
anything
in
the
pelvis
that
you
think
is
going
to
extend
into
that
area
and
yet
.
So
then
you
just
dissect
into
that
area
specifically
and
indeed
find
something
,
and
sometimes
you
find
it
on
MRI
.
A
lot
of
times
those
cases
are
vascular
.
You
know
where
there's
going
to
be
like
a
little
tight
band
of
vein
around
there
which
you
never
was
into
endometriosis
,
so
there
was
no
reason
for
it
to
be
extending
from
anything
.
But
indeed
there
is
a
lesion
somewhere
that
is
anatomical
.
Speaker 2
15:36
And
then
there
are
the
occasional
,
like
truly
invasive
sciatic
endometriosis
where
there's
a
big
knot
of
endometriosis
right
or
on
top
of
or
around
the
sciatic
nerve
.
They're
quite
rare
but
they're
gnarly
.
In
those
patients
they
really
need
surgery
quickly
because
they
go
from
having
pain
menstrually
to
having
pain
continuously
,
to
losing
function
in
their
leg
for
the
rest
of
their
life
over
a
period
of
three
to
five
years
.
And
like
when
they
hit
that
point
,
like
their
leg
is
done
,
like
the
endometriosis
has
eaten
their
sciatic
nerve
basically
,
and
there's
not
.
You
can
get
some
recovery
eventually
,
but
like
you
have
to
find
it
before
that
happens
,
or
you're
going
to
have
permanent
problems
.
Speaker 1
16:15
Yeah
,
and
the
difference
with
that
is
not
a
lot
of
patients
have
that
,
but
they
might
have
something
similar
like
a
vascular
compression
issue
or
frozen
pelvis
or
nerve
compression
issues
.
What
is
the
difference
between
vascular
compression
and
nerve
compression
,
or
can
they
be
intertangled
,
so
to
speak
?
Speaker 2
16:35
Well
,
I
mean
,
nerve
compression
is
just
anything
pushing
on
the
nerve
.
So
the
general
category
of
nerve
compression
is
there's
something
pushing
on
the
nerve
,
so
it
a
vascular
compression
is
one
mechanism
for
creating
nerve
compression
.
Fibrosis
is
another
mechanism
for
creating
nerve
compression
.
So
if
you've
had
bleeding
into
an
area
that
over
time
creates
scarring
that
can
compress
a
nerve
and
then
you
have
endometriosis
around
a
nerve
,
you
may
have
fibrotic
compression
,
because
the
endometriosis
is
a
fibrotic
thick
scar
tissue
but
also
it's
inflamed
,
so
there's
creating
inflammation
that
is
directly
inflaming
the
nerve
.
So
it's
both
sort
of
a
physiologic
inflammation
and
a
physical
compression
,
whereas
a
vascular
compression
is
just
a
physical
compression
.
It's
not
inflammation
really
.
Speaker 1
17:17
Okay
,
okay
Pelvic Nerve Compression and Treatment
Speaker 1
17:18
.
You've
done
a
lot
of
this
.
Well
,
some
few
other
types
.
Speaker 2
17:21
I
mean
you
can
get
a
like
a
pudendal
neuralgia
.
Some
people
that
have
pudendal
neuralgia
have
a
compression
that
is
an
anatomic
compression
,
where
they
have
a
very
narrow
canal
between
their
sacro
tuberous
and
sacrospinous
ligament
and
that
creates
a
very
narrow
space
and
when
they
sit
they
narrow
that
space
further
and
they're
creating
compression
on
their
pudendal
nerve
.
Or
they've
created
scarring
in
that
area
by
bouncing
up
and
down
on
a
horse
saddle
for
20
years
or
by
being
a
serious
bicyclist
forever
and
they've
been
basically
creating
micro
injuries
in
that
place
for
a
decade
or
two
decades
and
now
they've
got
like
a
fibrotic
compression
that
has
been
created
over
decades
of
micro
trauma
.
Interesting
.
Speaker 2
18:04
So
that's
another
kind
of
compression
where
it
wasn't
destined
to
happen
,
but
it
was
something
they
did
over
the
course
of
their
life
,
and
so
there's
a
lot
of
different
.
And
then
there's
muscular
compressions
too
.
There
are
some
places
where
nerves
travel
through
muscle
.
Basically
,
the
pudendal
nerve
actually
travels
through
the
.
The
distal
part
of
the
pedendal
nerve
travels
through
muscle
,
and
so
if
that
muscle
is
in
spasm
it
can
create
compression
on
the
nerve
.
Speaker 1
18:28
Yes
.
Speaker 2
18:29
And
usually
the
answer
to
that
is
to
put
botoxin
in
the
muscle
.
It's
not
usually
to
operate
.
Speaker 1
18:33
OK
,
interesting
.
Speaker 2
18:34
And
then
there's
a
piriformis
syndrome
,
where
part
of
the
cytokine
nerve
is
actually
going
through
the
piriformis
.
The
cytokine
nerve
and
its
roots
are
supposed
to
go
around
the
piriformis
,
but
there
are
some
anatomical
situations
where
the
nerve
is
literally
piercing
the
piriformis
muscle
and
if
that
muscle
is
then
in
spasm
then
you're
going
to
create
compression
around
the
nerve
.
So
again
,
it's
like
these
are
different
things
and
there's
lots
of
different
things
.
They're
hard
to
diagnose
too
.
It's
not
like
I
can
talk
and
wax
philosophical
about
this
,
but
it's
not
always
that
easy
to
figure
this
stuff
out
.
Sometimes
you'll
see
it
on
imaging
,
Sometimes
you'll
get
it
from
history
.
But
there
is
a
difference
between
being
able
to
talk
smart
about
something
and
necessarily
being
able
to
solve
it
all
.
I
can
solve
some
of
it
,
but
not
necessarily
all
of
it
.
Speaker 3
19:15
Yeah
,
one
of
my
favorite
things
about
you
as
a
doctor
is
that
it
seems
like
you
take
the
entire
picture
into
account
,
as
opposed
to
us
.
Speaker 3
19:27
As
a
patient
,
I
know
Alana
and
I
have
both
had
many
experiences
where
it's
all
about
our
organs
it's
all
about
the
uterus
,
it's
all
about
the
ovaries
,
it's
all
about
your
tubes
and
your
cervix
and
those
things
,
and
I
love
that
you
actually
acknowledge
that
we
have
blood
vessels
in
our
pelvis
that
may
be
causing
issues
for
people
.
I've
heard
you
talk
previously
about
pelvic
congestion
syndrome
,
or
I
think
now
they're
calling
it
pelvic
venous
insufficiency
,
and
talking
about
those
types
of
things
that
are
putting
pressure
on
these
nerves
,
and
it's
just
really
refreshing
,
I
think
,
because
I
think
once
Alana
and
I
don't
have
any
organs
left
for
you
to
take
.
But
I
still
had
residual
pain
.
It's
like
what
are
my
options
?
And
I
was
lucky
because
my
mom
had
similar
issues
and
so
I
grew
up
with
the
knowledge
of
PCS
and
some
of
these
other
vascular
compression
type
things
,
and
so
it
was
easy
for
me
to
figure
out
and
I
was
able
to
be
treated
for
it
,
but
I
just
love
that
that
.
Speaker 2
20:23
Was
that
helpful
.
Do
you
have
vascular
treatment
?
Speaker 3
20:25
So
yeah
,
so
I
have
Matherner
syndrome
as
well
as
Nutcracker
syndrome
,
and
so
I
have
a
stent
placed
for
the
Matherner
.
And
then
Could
it
help
?
Oh
,
mind-blowingly
it's
so
much
better
.
Speaker 2
20:36
Amazing
.
I
would
love
to
talk
to
you
about
that
,
not
on
the
podcast
.
I
want
to
know
in
detail
about
that
.
Speaker 3
20:41
Yeah
,
no
,
I'd
love
to
share
with
you
,
but
it's
really
frustrating
as
a
patient
to
have
continued
pain
.
You
go
back
to
your
endosurgeon
.
They're
like
it's
not
endo
,
which
they
were
right
,
it
wasn't
endo
for
me
,
but
I
love
that
you
see
it
as
a
whole
picture
and
you
put
all
of
these
pieces
together
and
you're
not
just
ignoring
the
fact
that
there's
pain
.
Speaker 2
21:02
Well
,
a
little
bit
of
that
is
the
neuropalveology
,
because
the
neuropalveology
I
mean
one
,
I'm
just
kind
of
a
curious
nerd
but
one
of
the
fundamental
tenets
of
neuropalveology
is
that
start
out
with
what
is
the
pain
,
what
does
it
feel
like
,
where
is
it
coming
from
,
how
does
it
travel
?
And
then
don't
start
out
with
,
ok
,
well
,
they
must
have
this
disease
state
.
Start
out
with
what
are
the
nerves
that
would
be
irritated
or
be
activated
to
create
the
pain
that
this
person
is
describing
?
And
then
what
are
the
disease
states
that
this
person
could
have
that
might
cause
those
nerves
to
be
irritated
?
Speaker 2
21:40
And
enemy
treatise
is
always
on
the
list
,
but
it's
not
the
only
one
.
And
so
if
you
jump
to
,
this
person
has
pain
,
this
person
has
enemy
treatise
.
Well
,
I'm
just
going
to
go
cut
out
all
the
enemy
treatises
and
cure
them
.
It's
like
,
well
,
yeah
,
you're
going
to
help
a
lot
,
no
doubt
.
I
mean
,
I'm
not
saying
that
you
shouldn't
do
that
and
of
course
you
should
,
but
that
is
not
the
only
Treatment and Collaboration in Medical Practice
Speaker 2
21:58
answer
.
Like
there
are
other
things
that
can
cause
nerves
to
be
irritated
and
there
are
also
centralized
nerve
problems
.
Like
I
think
sometimes
when
people
have
recurrent
pain
and
then
some
people
will
say
,
well
,
they
have
central
sensitization
and
there
are
some
factions
online
that
say
,
oh
,
that's
nonsense
,
it's
because
their
enemy
treatise
wasn't
completely
removed
.
I'm
like
hello
.
Speaker 2
22:19
Central
sensitization
is
a
completely
well
proven
thing
.
This
is
not
made
up
.
There
are
central
nervous
system
pain
disorders
,
and
central
sensitization
from
nerves
is
you
can
document
it
and
experiment
with
it
and
it's
real
.
That
doesn't
mean
you
can't
treat
it
or
there
aren't
anything
,
nothing
you
can
do
about
it
,
but
by
denying
its
existence
you're
not
really
doing
people
any
favors
.
So
my
goal
always
as
a
physician
is
just
I
guess
I
take
it
all
pretty
seriously
and
I
take
it
all
pretty
personally
.
Like
I
don't
like
it
when
a
patient
I
can't
help
or
when
what
I've
done
didn't
work
well
and
it
bugs
me
and
I'm
like
,
of
course
it
bothers
a
patient
.
They're
upset
,
they're
disappointed
.
Speaker 2
23:00
I'm
like
,
okay
,
how
can
?
What
can
we
do
more
to
try
to
help
?
And
you
just
keep
pushing
and
pushing
and
pushing
and
learning
more
.
And
it's
very
gratifying
when
you
do
spend
a
lot
of
time
maybe
thinking
about
things
in
a
little
bit
different
way
and
then
suddenly
you've
helped
somebody
that
you
wouldn't
have
helped
,
thinking
about
it
the
way
I
used
to
think
about
it
and
it's
not
every
time
but
you
start
to
pluck
off
a
few
here
and
there
You're
like
,
wow
,
I
mean
that
person
really
benefited
by
the
fact
that
I
was
crazy
about
this
,
and
so
ultimately
,
that
is
the
satisfaction
of
what
we
do
.
I
mean
,
you
know
it's
nice
to
make
a
living
and
support
your
family
and
everything
,
but
that's
not
.
What
is
really
,
really
satisfying
and
gratifying
is
having
somebody
who
really
is
miserable
and
then
they
say
I'm
better
because
of
what
you
did
.
I
mean
that
really
makes
you
feel
like
you're
on
the
planet
for
a
reason
you
know
,
I
mean
I'm
not
a
very
religious
person
,
but
it's
not
like
.
Speaker 2
23:52
It's
sort
of
like
wow
,
I
mean
you're
glad
you
spent
so
much
time
trying
to
do
this
,
because
you
really
helped
that
person
.
Speaker 3
23:58
Yeah
,
and
the
impact
that
you
and
other
doctors
in
this
world
is
immeasurable
.
I
think
yeah
,
and
there
are
so
many
good
doctors
.
Speaker 2
24:07
I
can
only
speak
to
like
how
I
feel
about
it
and
I
never
.
Nobody
wants
to
be
the
person
on
the
mountain
.
It
says
,
come
see
me
on
the
mountain
.
It's
like
,
no
,
I'm
just
the
guy
that
just
try
.
I'm
interested
in
this
and
I
just
try
to
try
to
do
the
best
I
can
.
We
succeed
fairly
frequently
but
you
know
,
in
the
end
it's
an
interesting
thing
and
if
you
spend
it
and
we've
gotten
these
good
at
dealing
with
it
in
a
lot
of
cases
,
you
know
,
but
it's
not
that
crazy
.
It's
like
.
Speaker 1
24:27
I
don't
know
how
to
be
built
in
.
Speaker 2
24:28
You
know
,
you
go
to
a
mechanic
and
they're
like
,
oh
my
god
,
how
do
you
do
that
?
And
they're
like
,
wow
,
it's
easy
.
You
just
go
to
this
school
and
you
learn
how
to
do
it
.
Speaker 1
24:35
Yeah
,
we
all
use
our
gifts
and
skills
and
talents
differently
to
impact
the
people
around
us
and
create
change
,
and
I
think
that's
the
best
way
to
do
it
.
What
makes
us
unique
as
humans
and
one
of
the
things
that
I
guess
I
have
a
question
on
as
well
is
when
you
see
these
patients
come
in
you've
done
everything
you
can
.
Are
there
points
that
they
need
to
see
another
surgeon
At
what
point
?
Say
it's
vascular
for
stents
and
things
like
that
?
Are
there
next
steps
?
How
often
does
that
happen
when
you
do
get
vascular
compression
issues
?
Speaker 2
25:15
Or
is
it
easier
to
surgically
on
your
end
.
So
,
specifically
for
vascular
issues
,
that's
a
really
good
point
.
So
if
you
have
an
area
that
,
if
you
believe
that
there's
a
vein
compressing
a
nerve
,
there's
two
different
ways
to
think
about
it
.
One
is
that
you
can
just
remove
the
vein
,
which
is
what
I'm
gonna
do
.
Or
you
could
try
to
address
why
is
the
vein
overly
distended
,
therefore
causing
compression
?
So
the
Mayt-Thurner
idea
,
so
Mayt-Thurner
syndrome
for
your
audience
that
doesn't
know
that
there's
plenty
of
people
don't
know
what
this
is
.
Even
plenty
of
physicians
don't
know
what
this
is
.
Speaker 2
25:46
Mayt-thurner
syndrome
is
a
condition
where
the
left
common
iliac
vein
,
so
the
vena
cava
a
lot
of
people
have
some
idea
what
the
vena
cava
is
.
It's
the
largest
vein
in
the
body
that's
going
up
and
down
your
body
.
If
you
look
at
a
Da
Vinci
anatomic
thing
,
you'll
see
the
vena
cava
,
the
big
blue
vein
in
the
middle
.
Well
,
it
splits
into
two
veins
going
down
into
each
leg
,
called
the
common
iliac
veins
.
There
is
an
anatomic
situation
where
the
left
common
iliac
vein
has
to
travel
underneath
one
of
the
common
iliac
arteries
and
the
common
iliac
or
the
arteries
are
kind
of
hard
that
they
have
thick
walls
,
whereas
veins
are
really
floppy
bags
and
sometimes
there
is
an
anatomic
situation
where
the
left
common
iliac
vein
gets
pinched
between
the
left
common
iliac
artery
and
the
spine
or
the
sacrum
and
it
leads
to
the
venous
return
on
that
left
side
of
the
pelvis
being
blocked
.
It's
like
someone's
holding
onto
the
hose
,
like
if
you
can
imagine
that
someone's
pinching
the
hose
and
the
water
won't
get
through
.
So
that
big
vein
on
that
left
side
is
partially
closed
by
the
fact
that
there's
this
unusual
anatomic
compression
,
and
so
the
veins
that
then
are
tributaries
to
that
big
vein
are
inherently
going
to
be
engorged
because
the
blood
isn't
getting
through
easily
.
So
there's
more
pressure
in
those
veins
.
So
because
the
veins
are
very
floppy
,
they
are
inherently
going
to
be
bigger
and
stretched
.
And
so
if
you
were
to
combine
that
with
some
kind
of
anatomical
situation
where
the
vein
happens
to
be
kind
of
wrapped
over
the
top
of
the
nerve
and
then
it's
kind
of
overly
engorged
because
it's
not
draining
very
well
,
you
might
get
a
situation
where
there
are
somatic
nerves
that
are
getting
compressed
by
veins
,
and
so
one
option
is
to
surgically
go
in
and
just
identify
the
veins
that
are
offending
and
just
seal
them
and
cut
them
,
which
is
actually
fine
to
do
.
The
veins
are
a
huge
network
of
it's
like
a
street
map
.
There's
just
so
many
different
ways
to
get
from
here
to
there
.
So
if
you
seal
a
couple
of
veins
,
the
blood
will
find
other
ways
to
get
home
.
So
it's
not
like
the
blood
won't
get
back
to
the
heart
.
So
that's
one
thing
to
do
.
Speaker 2
27:56
The
other
thing
to
do
is
to
try
to
address
the
fundamental
issue
of
the
fact
that
the
common
iliac
vein
is
compressed
,
and
that
is
by
putting
a
stent
in
the
common
iliac
vein
,
which
it
sounds
like
that's
what
you
had
done
,
and
so
that's
like
putting
a
scaffolding
in
the
vein
that
props
it
open
so
that
it
drains
.
Well
,
I
don't
do
that
.
That
would
be
something
that's
done
by
an
interventional
radiologist
,
possibly
by
a
vascular
surgeon
,
but
usually
they're
done
by
interventional
radiologists
now
that
have
kind
of
an
interest
in
that
area
.
I
know
somebody
that
does
that
kind
of
stuff
in
here
in
Portland
,
so
that's
kind
of
another
pathway
.
You
know
,
when
it
comes
to
the
other
things
I
do
,
like
there
aren't
a
lot
of
other
surgeons
that
do
it
.
Like
vascular
surgeons
don't
do
this
stuff
.
I
don't
know
how
much
they
know
about
it
.
They
probably
do
to
some
extent
,
but
that's
not
something
that
they
commonly
do
.
Speaker 2
28:42
There
are
other
areas
of
compression
too
.
Like
you
can
get
a
compression
in
your
wrist
carpal
tunnel
syndrome
because
of
a
compression
of
your
median
nerve
.
That's
usually
not
venous
,
it's
usually
from
a
physical
compression
with
the
tendons
and
so
forth
.
But
there's
always
other
people
to
involve
when
people
have
recurrent
pain
.
I
think
it's
important
to
try
to
engage
other
surgeons
in
a
thoughtful
way
,
like
if
there's
something
that
really
you
have
a
rational
reason
to
believe
that
they
have
something
to
offer
that
might
be
useful
,
then
it's
very
good
to
rope
them
in
.
I
don't
really
like
it
when
it's
like
well
,
I
don't
know
what's
wrong
with
you
,
just
go
to
the
doctor
,
maybe
they'll
figure
it
out
.
It's
like
,
well
,
I
mean
,
maybe
that'll
work
.
But
I
would
like
to
have
a
good
reason
to
believe
that
the
interventional
radiologist
has
something
to
offer
.
I'd
like
to
have
a
good
reason
to
believe
that
the
orthopedist
is
that
the
person
is
a
prompt
with
their
hip
or
whatever
.
Speaker 2
29:32
But
,
yes
,
but
in
a
thoughtful
way
,
hopefully
.
Speaker 1
29:35
Yeah
,
how
frequent
do
you
see
EDS
issues
vascular-wise
?
Because
we've
talked
about
this
before
.
I
myself
have
EDS
and
I
feel
like
a
lot
of
people
who
have
EDS
have
nerve
vascular
issues
along
the
way
.
Speaker 3
29:58
Are
you
seeing
a
lot
of
?
Speaker 2
29:59
that
I
have
a
question
that
I
don't
necessarily
have
a
definitive
answer
for
.
I
mean
I
can
kind
of
speculate
.
I
mean
I
do
have
a
fair
number
of
patients
who
have
EDS
.
There
are
a
fair
number
of
patients
that
have
self-diagnosed
with
EDS
but
haven't
necessarily
gotten
an
actual
genetic
confirmation
of
that
.
So
EDS
is
Ehlers-Danlos
Syndrome
.
It's
a
condition
where
you
have
the
most
common
variation
of
Ehlers-Danlos
Syndrome
is
a
hypermobility
where
your
tendons
and
ligaments
are
very
stretchy
and
so
you
have
kind
of
an
unusual
amount
of
mobility
in
your
joints
.
There
are
some
more
advanced
versions
of
it
where
they
can
have
major
vascular
issues
,
where
they
get
like
aortic
aneurysms
and
heart
aneurysms
and
stuff
.
That's
actually
pretty
uncommon
and
quite
dangerous
when
it's
present
.
Speaker 2
30:42
But
the
veins
are
made
up
of
have
connective
tissue
walls
,
and
so
if
you
have
a
collagen
defect
,
part
of
what
makes
up
the
integrity
of
the
vessels
is
collagen
,
and
so
the
vessels
may
inherently
be
more
stretchy
because
the
integrity
of
the
venous
walls
is
just
not
as
good
as
to
how
often
like
?
I
don't
routinely
get
EDS
diagnoses
like
studies
or
anything
you
know
.
There
are
geneticists
that
do
that
,
so
it's
hard
for
me
to
say
.
I
would
say
that
I
have
a
fair
number
of
patients
that
say
they
have
EDS
and
some
of
them
who
have
clear
hypermobility
that
makes
me
convinced
that
they
do
.
There
is
a
somewhat
of
a
selection
bias
in
there
.
That
EDS
is
popular
in
the
.
There's
a
lot
of
discussion
of
it
in
online
communities
and
a
lot
of
patients
come
to
me
through
various
online
referrals
,
and
so
maybe
you
have
over
representation
of
people
that
have
become
aware
of
EDS
.
Speaker 2
31:31
Because
a
lot
of
people
don't
know
idea
what
it
is
.
One
thing
I
know
for
sure
is
that
,
like
when
I
was
a
medical
student
or
when
I
was
a
resident
,
eds
was
like
a
bizarre
diagnosis
which
like
,
oh
yeah
,
I
read
that
in
a
book
somewhere
but
nobody
has
that
and
I
think
we're
finding
out
or
it's
so
rare
.
It's
like
this
is
not
really
very
common
.
Speaker 2
31:46
I
think
what
we're
finding
out
is
that
EDS
is
actually
more
common
than
we
previously
understood
,
and
that
there
are
just
a
variety
of
people
that
have
some
defects
in
their
college
and
synthesizing
system
,
that
have
hypermobility
,
and
as
for
I
think
it
may
cause
pain
because
of
vascular
issues
,
but
I
think
it
may
also
cause
pain
because
the
joints
are
chronically
being
stretched
beyond
the
limits
of
what
they
were
evolved
to
stretch
out
to
,
and
so
you're
getting
arthritic
changes
within
the
joints
or
you
may
be
getting
chronic
pain
within
the
ligaments
themselves
.
That's
all
fairly
speculative
ideas
,
but
so
I
don't
have
a
hard
answer
to
your
question
,
but
just
a
little
discussion
,
I
guess
.
Speaker 1
32:25
Yeah
,
yeah
,
it's
just
interesting
because
we've
gone
down
a
lot
of
rabbit
holes
of
did
the
chicken
or
the
egg
first
?
And
I
think
that
that
is
true
within
the
endometriosis
community
at
large
,
of
knowing
what
came
first
and
what
to
address
first
.
And
I
think
,
when
it
comes
to
vascular
and
understanding
all
the
caveats
to
it
,
it
can
be
really
overwhelming
to
a
lot
of
us
who
are
kind
of
chasing
whether
it's
pain
from
X
,
y
or
Z
.
And
so
I
just
have
,
I
think
,
having
a
better
understanding
of
things
to
consider
is
what
will
,
I
think
,
allow
us
to
advocate
better
for
ourselves
and
know
a
better
roadmap
of
where
to
go
.
Speaker 1
33:08
And
the
thing
that
I
think
we
miss
out
a
lot
on
is
talking
about
those
vascular
and
nerve
issues
which
I
think
can
affect
us
,
sometimes
even
more
than
the
actual
endometriosis
.
And
so
I
think
it's
a
powerful
statement
to
say
most
of
us
have
at
least
some
maybe
vascular
,
but
mostly
nerve
involvement
as
well
.
If
it's
not
on
it
,
it's
usually
around
it
.
Hence
what
you
were
saying
earlier
about
it
Everyone
has
nerve
involvement
,
whether
it's
just
close
or
not
.
By
definition
,
pain
is
nerve
involved
,
exactly
,
thank
you
.
Speaker 2
33:43
But
the
question
is
is
it
something
that's
surgically
addressable
?
Speaker 1
33:46
or
not
Exactly
.
Speaker 2
33:48
You
could
say
all
pain
is
nerve
pain
,
but
then
you
kind
of
lose
the
meaning
of
what
do
you
mean
when
you
say
nerve
pain
.
Everyone
does
it
all
comes
down
to
we
can
speculate
and
we
can
talk
about
intellectually
,
about
why
people
are
having
pain
,
and
then
we
can
talk
about
what
are
the
parts
of
that
that
we
can
actually
intervene
with
,
right
,
and
just
like
you
can
learn
a
lot
about
EDS
and
saying
,
well
,
this
is
why
I'm
having
pain
or
not
,
but
can
I
intervene
?
Like
,
are
we
really
just
kind
of
navelgazing
here
by
trying
to
think
about
all
this
in
this
really
kind
of
intellectual
way
?
But
does
it
actually
lead
us
to
having
interventions
that
are
gonna
help
people
or
not
,
or
are
we
just
sitting
around
talking
about
it
?
Yeah
,
it's
kind
of
smart
you
know
Right
.
Speaker 2
34:26
And
so
there
are
elements
of
vascular
and
nerve
issues
that
can
be
intervened
with
,
but
not
all
of
them
,
not
every
single
person
that
has
persistent
or
recurrent
pain
.
That
that's
the
answer
.
It
is
an
answer
in
some
and
it's
a
miraculous
answer
in
some
.
To
be
honest
,
like
I've
had
some
people
that
I'm
shocked
by
how
much
doing
some
vascular
interventions
worked
,
but
not
all
of
them
,
but
some
of
them
.
When
I
started
out
doing
some
of
the
vascular
decompression
stuff
I
do
,
I
was
skeptical
of
it
because
I
really
only
had
Mark
Posover
to
believe
,
like
he
wrote
some
papers
and
he
got
some
education
.
But
there
are
plenty
of
people
that
felt
like
that's
crazy
,
that's
just
normal
anatomy
.
Like
what
are
you
doing
?
You're
just
going
in
there
and
cutting
some
normal
stuff
.
Like
that's
not
even
,
that's
not
a
disease
state
.
Speaker 2
35:11
And
I
was
skeptical
of
it
myself
.
I'm
like
I
don't
know
,
am
I
actually
doing
something
useful
here
?
But
I've
had
some
patients
that
are
just
so
much
better
from
what
I
did
.
I'm
like
wow
,
I
mean
I'm
surprised
almost
.
Considerations in Pain Management and Surgery
Speaker 2
35:23
But
it
sort
of
led
me
to
be
more
believing
in
what
I
was
doing
and
that's
part
of
why
I
do
more
neuro-paleveology
stuff
than
I
used
to
,
because
I
was
kind
of
a
dabbler
in
it
in
the
beginning
,
not
necessarily
because
I
didn't
not
how
to
do
it
technically
,
but
I
wasn't
sure
how
well
it
worked
and
like
I
didn't
,
I
didn't
really
want
to
go
evangelize
something
that
I
don't
want
to
be
a
snake
oil
salesman
,
you
know
it's
like
does
this
actually
work
,
you
know
?
Speaker 2
35:44
I
mean
,
you
know
you
start
attracting
patients
who
are
desperate
.
They're
going
to
pay
you
to
do
some
surgery
and
it
doesn't
even
work
.
And
then
you
just
feel
like
you're
.
I
don't
feel
good
about
that
.
Speaker 2
35:53
And
so
it
took
a
certain
amount
of
experimentation
before
you
kind
of
become
convinced
.
Oh
,
wow
,
yeah
,
this
is
really
a
thing
you
know
.
This
really
does
work
in
a
subset
of
patients
,
and
then
can
we
accurately
identify
which
those
patients
are
ahead
of
time
.
You
hate
to
just
say
,
well
,
it
works
half
the
time
,
Like
anytime
you
have
a
surgery
that
works
half
the
time
and
someone
says
,
oh
,
the
surgery
is
50%
effective
.
I
said
no
,
no
,
it's
100%
effective
and
50%
of
the
people
Right
yeah
.
Speaker 2
36:17
You
know
.
And
so
don't
just
be
satisfied
and
saying
like
,
oh
,
it
works
half
the
time
,
no
,
it's
because
you
suck
at
figuring
out
who
to
operate
on
.
You
know
,
it
works
100%
of
the
time
in
half
the
people
,
which
means
like
there
is
a
refinement
there
to
make
.
Well
,
let
me
say
this
when
you
have
a
surgery
that
works
half
the
time
,
you
could
say
well
,
it's
because
I'm
not
doing
the
surgery
well
enough
,
and
if
I
did
the
surgery
better
,
it
would
work
80%
of
the
time
.
Sometimes
,
that's
true
,
it's
more
likely
that
you
are
not
good
at
identifying
which
person
actually
would
benefit
from
the
surgery
.
So
that's
an
intellectual
process
,
that's
an
educational
process
,
that's
an
experimental
,
that's
a
cognitive
issue
,
that's
not
a
technical
issue
.
And
so
we
really
have
to
think
about
refining
who
we
should
do
some
of
these
unusual
things
on
,
not
just
how
to
do
those
techniques
better
,
because
if
you
do
it
on
the
wrong
patient
,
it's
gonna
fail
100%
of
the
time
,
it
doesn't
matter
how
beautiful
a
surgery
you
did
.
Speaker 3
37:11
Yeah
,
I
think
it's
important
that
just
because
you
understand
why
someone
is
in
pain
,
you
know
you
might
be
able
to
be
like
,
yeah
,
it's
this
nerve
right
here
,
this
is
where
it's
coming
from
.
But
that
doesn't
necessarily
mean
that
it's
something
you
can
address
.
It
might
be
too
dangerous
,
it
might
cause
other
issues
.
It
could
cause
,
you
know
,
long-term
issues
for
people
.
Speaker 2
37:28
Sometimes
the
answer
is
just
to
address
the
pain
.
When
the
problem
is
pain
,
the
problem
is
pain
and
people
say
I
don't
want
to
just
cover
it
up
,
I
want
to
get
to
the
root
of
it
.
I
want
to
get
to
the
root
cause
of
it
.
It's
a
very
popular
thing
to
say
I'm
like
wait
,
the
root
cause
of
it
is
that
you're
in
pain
.
That's
the
problem
.
That's
the
thing
that
is
affecting
your
quality
of
life
.
That
is
the
thing
that's
keeping
you
from
doing
what
you
want
to
do
in
your
life
.
If
we
can
make
the
pain
go
away
,
your
quality
of
life
is
better
.
It
doesn't
really
matter
why
we
,
how
we
did
it
.
And
so
,
being
open
to
the
idea
of
neuromodulation
,
of
nerve
stimulation
,
of
acupuncture
,
of
different
things
that
may
affect
pain
,
don't
worry
about
the
fact
that
I'm
not
addressing
the
root
cause
.
The
root
cause
is
pain
.
The
root
cause
of
your
life's
dysfunction
is
the
fact
that
you're
in
pain
.
So
if
there
is
stuff
that's
making
it
better
,
then
it's
making
it
better
.
Speaker 2
38:17
So
sometimes
when
someone
has
some
nerve
compression
,
that
I
think
is
they
do
have
a
specific
nerve
lesion
,
but
it's
just
not
addressable
surgically
.
Sometimes
the
answer
is
to
have
an
interventional
pain
management
doctor
put
an
electrical
lead
on
that
nerve
and
create
a
stimulation
signal
that
just
blocks
the
pain
signal
and
those
things
.
Again
you
hear
all
these
stories
of
those
things
failing
.
Again
,
it's
a
selection
Like
the
right
patient
can
be
very
,
very
benefited
from
that
.
But
you
can't
just
like
globally
say
,
oh
yeah
,
just
put
a
nerve
stimulator
in
the
person
because
they
have
pain
.
Speaker 2
38:48
It's
like
,
do
does
that
patient
have
a
very
specific
somatic
distribution
of
pain
that
says
I'm
having
pain
going
down
a
particular
couple
of
nerve
roots
and
we
can't
seem
to
address
it
surgically
.
But
we
could
put
an
electrode
on
there
and
we
can
send
a
signal
that
blocks
that
pain
signal
from
getting
to
their
brain
and
replaces
it
with
a
little
buzzing
feeling
that
goes
on
to
they
.
Eventually
the
patient
doesn't
even
notice
anymore
.
That's
fixing
the
problem
.
Or
maybe
it's
going
to
create
a
70%
reduction
in
the
problem
and
it's
okay
to
be
open
to
that
.
You
don't
have
to
look
at
that
as
like
giving
up
.
Speaker 2
39:18
I
think
that
sometimes
people
look
at
that
oh
,
I'm
just
giving
up
and
going
to
pain
management
,
like
no
,
no
,
you're
not
giving
up
,
you're
looking
at
a
different
modality
of
how
we
can
address
the
problem
you're
having
,
and
so
I
hate
it
when
people
think
of
different
pathways
as
being
failures
.
Speaker 2
39:36
Taking
hormonal
manipulation
for
endometriosis
,
that's
a
failure
.
I
want
to
just
cut
it
out
.
That
may
be
right
,
like
maybe
cutting
it
out
is
the
right
thing
to
do
,
but
that's
not
a
failure
.
If
that
pathway
is
improving
your
quality
of
life
,
then
great
.
Don't
reject
it
because
of
some
like
religious
devotion
to
surgery
.
Speaker 2
39:50
You
know
,
some
patients
will
benefit
from
hormonal
treatment
of
endometriosis
very
much
,
and
part
of
why
people
think
that
hormonal
manipulation
for
endometriosis
doesn't
work
is
because
the
people
that
got
better
from
taking
birth
control
pills
went
on
with
their
life
and
they
didn't
get
on
the
Nancy
snook
.
So
there
are
a
large
subset
of
people
that
do
benefit
from
hormonal
manipulation
for
endometriosis
and
if
they're
having
a
good
quality
of
life
on
it
,
great
.
There's
,
you
know
,
and
some
of
them
will
have
progression
of
disease
.
I
don't
want
to
get
too
much
into
that
rabbit
hole
,
but
the
point
is
,
is
that
,
look
at
quality
of
life
.
What
can
we
do
to
improve
quality
of
life
and
be
open
to
everything
,
whether
it
be
surgery
,
whether
it
be
medications
,
whether
it
be
pay
management
options
,
steroid
injections
,
whether
it
be
implantable
neuro
stimulators
.
There's
just
a
lot
of
different
pathways
and
they're
all
have
benefits
in
some
patients
.
Speaker 3
40:37
Right
,
yeah
.
Yeah
,
it's
not
just
surgery
and
physical
therapy
and
that's
it
.
So
yeah
,
sometimes
it
works
.
Speaker 2
40:43
Yeah
it
.
I
mean
I
do
a
lot
of
surgery
and
a
lot
of
patients
benefit
from
it
.
But
let's
give
it
an
example
.
I
had
a
patient
that
had
a
very
,
very
deep
lesion
going
into
her
sacrum
nerve
roots
and
we
ended
up
doing
a
valer
section
,
did
a
hysterectomy
,
did
a
lot
of
stuff
and
she
got
way
better
from
it
.
But
if
she
were
to
have
persistent
pain
in
the
distribution
of
those
nerve
roots
I
would
not
go
re-operate
on
her
.
I
already
did
the
best
surgery
I
can
do
.
I
have
no
reason
to
believe
that
me
going
and
mucking
around
in
there
it's
going
to
make
her
better
.
If
no
,
I'm
thinking
of
one
particular
patient
.
She's
not
having
that
problem
.
But
if
she
were
to
have
that
problem
again
,
I
would
say
you
know
what
?
Let's
try
to
put
an
electrical
leads
on
those
nerve
roots
and
see
if
we
can
block
whatever
residual
signals
going
there
.
Let's
see
if
we
can
just
block
it
electrically
,
because
you
know
the
answer
isn't
always
just
go
operate
again
.
Speaker 2
41:30
Right
yeah
,
and
so
from
the
surgeon's
point
of
view
.
I
think
it's
not
optimal
for
the
surgeon
to
think
that
the
surgery
is
always
the
answer
,
but
it's
also
not
optimal
for
patients
to
think
the
answer
is
always
to
have
another
surgery
because
it's
not
.
Speaker 1
41:41
Yeah
,
oh
,
I
mean
,
I
think
that's
refreshing
to
hear
for
a
lot
of
people
.
I
think
that
we
don't
hear
enough
of
that
within
that
space
.
I
at
some
point
we'd
love
to
talk
more
about
what
happens
vascularly
after
hysterectomies
and
things
like
that
.
Those
are
all
important
topics
to
cover
as
well
,
because
a
lot
of
us
and
a
lot
of
us
experience
this
.
So
at
some
point
we
can
do
that
,
but
you're
going
to
be
at
the
summit
this
year
in
person
.
Speaker 3
42:09
Yes
.
Speaker 2
42:09
I'm
going
to
be
there
.
I
think
I'm
going
to
talk
about
some
side-against
me
trio
.
So
,
since
some
of
this
stuff
and
I'm
sure
a
zillion
people
can
curbside
me
and
we
can
talk
about
all
kinds
of
things
,
yeah
,
well
,
we'll
be
there
,
so
maybe
we
can
catch
up
then
and
chat
about
some
stuff
,
yeah
.
Fabulous
.
Yeah
,
I
think
I'm
just
talking
for
like
20
minutes
or
something
,
but
I'll
be
there
for
a
couple
days
and
I'll
chat
with
as
many
people
,
as
I
want
to
talk
.
Speaker 1
42:32
Yeah
,
it's
always
a
good
time
and
it's
always
a
good
experience
.
Yeah
,
we
can't
wait
to
go
back
.
Speaker 3
42:36
We
had
so
much
fun
last
year
.
Oh
good
,
I've
never
been
.
Speaker 2
42:40
I've
spoken
remotely
on
adit
,
but
this
is
the
first
time
I'm
going
to
be
there
in
person
.
Speaker 3
42:44
Yeah
,
no
,
you'll
like
it
.
It's
a
lot
of
fun
.
It
is
a
lot
of
fun
,
yeah
,
cool
.
Speaker 1
42:49
It's
a
great
time
and
thanks
for
explaining
those
things
to
us
,
and
I
am
just
fascinated
every
time
that
you
bring
something
else
up
,
because
it's
something
else
that
I
hadn't
thought
of
before
,
because
it's
not
often
talked
about
.
So
thank
you
for
being
the
voice
to
that
and
helping
us
understand
that
.
Yeah
,
absolutely
,
of
course
,
not
a
bit
.
Speaker 2
43:08
Great
,
really
nice
to
talk
to
both
of
you
.
I
appreciate
you
having
me
on
and
I
look
forward
to
seeing
you
in
Orlando
.
Speaker 1
43:12
Yeah
,
we
will
see
you
then
.
Speaker 2
43:13
The
last
thing
that's
going
to
come
in
to
Endo
Summit
in
Orlando
.
Feel
free
to
come
up
If
you
see
me
come
up
and
say
hello
and
ask
me
.
Whatever
you
want
,
I'm
happy
to
talk
while
I'm
there
,
we
will
.
Speaker 3
43:22
We're
not
shy
,
we're
not
shy
at
all
Okay
.
Speaker 1
43:25
Until
next
time
,
Endo
Battery
,
continue
advocating
for
you
and
for
those
that
you
love
.