Bio

Bio


Dr. Levin completed a residency in physical medicine and rehabilitation at the University of Michigan in 2007, and a pain medicine fellowship at the Virginia Commonwealth University in 2008. Currently, he is a member of both the departments of orthopedic surgery and neurosurgery at Stanford University, where he also is the director of the PM&R interventional spine fellowship and the interim director of the PM&R residency program.

Clinical Focus


  • Physical Medicine and Rehab
  • Spine care
  • Spine Injections
  • EMG (nerve tests)

Academic Appointments


Administrative Appointments


  • Interim Director, Physical Medicine and Rehabilitation Residency, Stanford (2018 - Present)
  • Director, Physical Medicine and Rehabilitation Spine Fellowship, Stanford (2015 - Present)

Boards, Advisory Committees, Professional Organizations


  • Health Policy Committee Member, Spine Intervention Society (SIS) (2014 - Present)

Professional Education


  • Board Certification: Electrodiagnostic Medicine, American Board of Electrodiagnostic Medicine (2010)
  • Board Certification: Physical Medicine and Rehab, American Board of Physical Medicine and Rehab (2008)
  • Board Certification: Pain Medicine, American Board of Physical Medicine and Rehab (2008)
  • Fellowship:Virginia Commonwealth University-Graduate Medical EducationVA
  • Medical Education:Virginia Commonwealth University (2003) VA
  • Residency:University of MichiganMI
  • Internship:St. Joseph Mercy HospitalMI

Publications

All Publications


  • Intra-articular Steroids vs Saline for Lumbar Z-Joint Pain: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial. Pain medicine (Malden, Mass.) Kennedy, D. J., Fraiser, R., Zheng, P., Huynh, L., Levin, J., Smuck, M., Schneider, B. J. 2018

    Abstract

    Objective: To determine if intra-articular (IA) injection of corticosteroids is effective in reducing the need for radiofrequency ablation (RFA) in those with dual comparative medial branch block (MBB)-confirmed lumbar z-joint pain.Design: This was a randomized, double blind, placebo-controlled study.Setting: Two academic medical centers.Subjects: Fifty-six consecutive subjects who had ≥80% pain relief during an initial screening MBB were recruited.Methods: Patients received a second confirmatory MBB and concurrent IA injection of either corticosteroid or saline per randomization. Twenty-nine of 56 received intra-articular corticosteroid (triamcinolone 20mg), of whom 24 also had a positive confirmatory MBB per Spine Interventional Society guidelines, with ≥80% pain relief from both MBBs. Twenty-seven of 56 received IA saline into the z-joint during the confirmatory MBB, of whom 22 also had a positive confirmatory MBB. The primary outcome measure was the categorical need for RFA due to insufficient pain relief with intra-articular injection, and the secondary outcome was time to RFA.Results: There was no statistically significant difference in the need for an RFA between the groups (16/24 steroid, 67%, 95% confidence interval [CI]=47-82%) vs 15/22 saline (68%, 95% CI=47-84%, P=1.00). The average time to RFA was also not different, at 6.00weeks for steroids vs 6.55weeks for saline (P=0.82).Conclusions: Intra-articular corticosteroids were not effective in reducing the need for or the time to a radiofrequency ablation of the medial branches in those with dual MBB-confirmed lumbar z-joint pain.

    View details for DOI 10.1093/pm/pny225

    View details for PubMedID 30541041

  • Corticosteroid Injections Into Lumbar Facet Joints: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION Kennedy, D. J., Huynh, L., Wong, J., Mattie, R., Levin, J., Smuck, M., Schneider, B. J. 2018; 97 (10): 741–46

    Abstract

    Corticosteroid injections into the intra-articular zygapophysial (z-joints) are frequently used to treat this cause of low back pain. No studies have been done on the efficacy of intra-articular corticosteroids in those with z-joint pain confirmed by dual comparative medial branch blocks.The aim of the study was to determine whether an injection of a corticosteroid into lumbar z-joints is effective in reducing pain and the need for radiofrequency neurotomy.This is a double-blind, prospective, randomized, placebo-controlled trial. The study was conducted in Academic Medical Center. Twenty-eight subjects with z-joint pain confirmed by medial branch blocks were included in the study. Subjects with confirmed z-joint pain via dual comparative medial branch block were randomized to receive either intra-articular corticosteroid (triamcinolone 20 mg) or saline via fluoroscopic guided injection.No statistically significant difference in the need for radiofrequency neurotomy (radiofrequency neurotomy) between the groups, with 75% (95% confidence interval = 50.5%-99.5%) of the saline group vs. 91% (95% confidence interval = 62.3%-100%) of the corticosteroid group receiving radiofrequency neurotomy. There is no difference in mean time to radiofrequency neurotomy between saline (6.1 wks) and corticosteroid (6.5 wks) groups. There is a need for radiofrequency neurotomy.Corticosteroid injections into the lumbar z-joints were not effective in reducing the need for radiofrequency neurotomy of the medial branches in those with z-joint pain confirmed by dual comparative medial branch blocks.

    View details for DOI 10.1097/PHM.0000000000000960

    View details for Web of Science ID 000444968800014

    View details for PubMedID 29734232

  • Is a History of Severe Episodic Low Back Pain an Indicator of a Discogenic Etiology? PAIN MEDICINE Levi, D., Carnahan, D., Horn, S., Levin, J. 2018; 19 (7): 1334–39

    Abstract

    To determine if a history of severe episodic low back pain (LBP) correlates with positive discography.A retrospective chart review identified patients undergoing discography from January 2012 through February 2016. The review determined if the patient's LBP began or continued with severe disabling episodes (lasting a minimum of two days). A gradual onset or initiating event with continuous symptoms was considered a nonepisodic history. Patients were excluded for unclear record, workers' compensation, litigation, prior lumbar surgery, radiologic instability, or indeterminate discography.Seventy-eight patients underwent discography. Thirty-nine patients were included, 31 of which had positive discograms. Eight had negative discograms. Nineteen patients had a history of episodic LBP, and 20 had no history of episodic LBP. Of those 19 with a history of episodic LBP, 18 had positive discography and one had negative discography. Of those with no history of episodic LBP, 13 had positive discography and seven had negative discography. Using the historical finding of severe episodic LBP as a test for discogenic source of LBP, the sensitivity is 58% (95% confidence interval [CI] = 41-75%) and the specificity is 88% (95% CI = 65-100%). The likelihood ratio is 4.7 (95% CI = 0.72-30). The positive predictive value (PPV) is 95% (95% CI = 72-100%). The PPV is based upon a prevalence of 79% (discogram positive) in our sample of patients considering fusion surgery. The diagnostic confidence odds are 18.2, with a diagnostic confidence of 95%.A positive history of severe episodic LBP may be a strong indicator for a discogenic etiology.

    View details for DOI 10.1093/pm/pnx147

    View details for Web of Science ID 000444271900005

    View details for PubMedID 29016955

  • The Value of Electrodiagnostic Studies in Predicting Treatment Outcomes for Patients with Spine Pathologies. Physical Medicine and Rehabilitation Clinics of North America Barrette, K., Levin, J., Miles, D., Kennedy, D. 2018
  • Does Immediate Pain Relief After an Injection into the Sacroiliac Joint with Anesthetic and Corticosteroid Predict Subsequent Pain Relief? Pain medicine (Malden, Mass.) Schneider, B. J., Huynh, L., Levin, J., Rinkaekan, P., Kordi, R., Kennedy, D. J. 2017

    Abstract

    To determine if immediate pain response following an injection with local anesthetic and corticosteroid predicts subsequent relief. Prospective observational cohort. An institutional review board-approved prospective study from a single academic medical center. Patients with clinical diagnosis of sacroiliac (SIJ) pain and referred for SIJ injection were enrolled; 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg/mL were injected into the SIJ. Pain score on 0-10 numeric rating scale (NRS) during provocation maneuvers was recorded immediately before injection, immediately after injection, and at two and four weeks of follow-up. Oswestry Disability Index (ODI) was also recorded. Various cutoffs were identified to establish positive anesthetic response and successful outcomes at follow-up. These were used to calculated likelihood ratios. Of those with 100% anesthetic response, six of 11 (54.5%, 95% confidence interval [CI]+/-29.4%, +LR 2.6, 95% CI = 1.1-5.9) demonstrated 50% or greater pain relief at follow-up, and four of 11 (36.5%, 95% CI+/-28.4%, +LR 3.00, 95% CI = 1.4-5.1) had 100% relief at two to four weeks. Fourteen of 14 (100%, 95% CI+/-21.5%, -LR 0.0, 95% CI = 0.0-2.1) with an initial negative block failed to achieve 100% relief at follow-up. Patients who fail to achieve initial relief after SIJ injection with anesthetic and steroid are very unlikely to achieve significant pain relief at follow-up; negative likelihood ratios (LR) in this study, based on how success is defined, range between 0 and 0.9. Clinically significant positive likelihood ratios of anesthetic response to SIJ injection are more limited and less robust, but are valuable in predicting 50% relief or 100% relief at two to four weeks.

    View details for DOI 10.1093/pm/pnx104

    View details for PubMedID 28521006

  • A Paradigm Shift? Pain medicine (Malden, Mass.) Schneider, B. J., Levin, J., Kennedy, D. J. 2017

    View details for DOI 10.1093/pm/pnx093

    View details for PubMedID 28431156

  • TO THE EDITOR. Spine Levi, D., Levin, J. 2016; 41 (6): E379-?

    View details for DOI 10.1097/BRS.0000000000001413

    View details for PubMedID 26720175

  • A Narrative Review of Intraarticular Zygapophysial Steroid Injections for Lumbar Zygapophysial Mediated Pain. Current Physical Medicine and Rehabilitation Reports Schneider, B., Levin, J. 2016; 4 (2): 108-116
  • A Systematic Review of Available Treatments for Discogenic Low Back Pain. Current Physical Medicine and Rehabilitation Reports Lucas, M., Stewart, C., Mattie, R., McCormick, Z., Saltychev, M., Levin, J. 2016; 4 (2): 117-131
  • Spinal Cord Stimulation for CRPS. Current Physical Medicine and Rehabilitation Reports Drakeley, M., Ho, S., Helm, E., Levin, J., Rosenquist, R. 2016; 4 (2)
  • Intradiscal Platelet-Rich Plasma Injection for Chronic Discogenic Low Back Pain: Preliminary Results from a Prospective Trial. Pain medicine (Malden, Mass.) Levi, D., Horn, S., Tyszko, S., Levin, J., Hecht-Leavitt, C., Walko, E. 2016; 17 (6): 1010–22

    Abstract

    Platelet-rich plasma (PRP) has been found to be effective for a variety of musculoskeletal conditions. The treatment of discogenic pain with PRP is under investigation.To assess changes in pain and function in patients with discogenic low back pain after an intradiscal injection of PRP.Prospective trial.Patients were diagnosed with discogenic low back pain by clinical means, imaging, and exclusion of other structures. Provocation discography was used in a minority of the patients. Patients underwent a single treatment of intradiscal injection of PRP at one or multiple levels.Patients were considered a categorical success if they achieved at least 50% improvement in the visual analog score and 30% decrease in the Oswestry Disability Index at 1, 2, and 6 months post-treatment.22 patients underwent intradiscal PRP. Nine patients underwent a single level injection, ten at 2 levels, two at 3 levels, and one at 5 levels. Categorical success rates were as follows: 1 month: 3/22 = 14% (95% CI 0% to 28%), 2 months: 7/22 = 32% (95% CI 12% to 51%), 6 months: 9/19 = 47% (95% CI 25% to 70%).This trial demonstrates encouraging preliminary 6 month findings, using strict categorical success criteria, for intradiscal PRP as a treatment for presumed discogenic low back pain. Randomized placebo controlled trials are needed to further evaluate the efficacy of this treatment.

    View details for DOI 10.1093/pm/pnv053

    View details for PubMedID 26814283

  • Epidural Steroid Injections are Safe and Effective: Multisociety Letter in Support of the Safety and Effectiveness of Epidural Steroid Injections PAIN MEDICINE Kennedy, D. J., Levin, J., Rosenquist, R., Singh, V., Smith, C., Stojanovic, M. P., Vorobeychik, Y. 2015; 16 (5): 833-838

    Abstract

    In April 2014, the Food and Drug Administration (FDA) issued a Drug Safety Communication requesting that corticosteroid labeling include warnings that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.The International Spine Intervention Society spearheaded a collaboration of more than a dozen other medical societies in submitting the letter below to the FDA on November 7, 2014. We are publishing the letter to ensure that the readership of Pain Medicine is aware of the multisociety support for the safety and effectiveness of these procedures. A special note of thanks to all of the societies who signed on in support of the message.

    View details for DOI 10.1111/pme.12667

    View details for Web of Science ID 000354742300001

    View details for PubMedID 25586082

  • A Systematic Review of the Literature on Caudal, Interlaminar, and Transforaminal Injections From the Last 5 Years. Curr Phys Med Rehabil Rep Mattie, R., McCormick, Z., Yu, S., Kennedy, D., Levin, J. 2015: 159-172
  • A Quantitative Study of Intervertebral Disc Morphologic Changes Following Plasma-Mediated Percutaneous Discectomy PAIN MEDICINE Smuck, M., Levin, J., Zemper, E., Ali, A., Kennedy, D. J. 2014; 15 (10): 1695-1703

    Abstract

    To quantitatively evaluate interval magnetic resonance imaging (MRI) changes in disc morphology following plasma-mediated percutaneous discectomy.A retrospective comparison of pretreatment and posttreatment MRIs at a single university spine clinic.From a group of 60 consecutively treated patients, 15 met the study inclusion and exclusion criteria. All had either failed treatment or had other clinical reasons for a posttreatment MRI.Two independent physicians electronically measured disc protrusion size and disc height at the treatment discs and adjacent discs on pre- and posttreatment MRI scans. Additionally, images were compared for gross anatomic changes including disc degeneration by Pfirrman classification, new disc herniations, high intensity zone (HIZ), vertebral endplate changes, post-contrast enhancement, and changes in segmental alignment. Pearson r correlation was used to determine interobserver reliability between the two physicians' MRI measurements. Paired t-tests were calculated for comparisons of pre- and posttreatment MRI measurements, and an ANOVA was performed for comparison of pre- to posttreatment changes in disc height measurements at treatment levels relative to adjacent levels.Correlation was high for measurement of disc height change (r = 0.89; P < 0.0001) and good for anteroposterior protrusion size change (r = 0.51; P = 0.0512). Disc height at treated discs demonstrated a small but statistically significant mean interval reduction of 0.48 mm (P = 0.0018). This remained significant when compared with the adjacent control discs (P < 0.0001). Pretreatment mean disc protrusion size (4.74 mm; range 3.75-6.55 mm) did not differ significantly (P = 0.1145) from posttreatment protrusion size (4.42 mm; range 2.55-7.95 mm). Gross anatomic changes at treatment levels included reduced disc protrusion size (N = 6), enlarged protrusion (N = 3), resolution of HIZ (N = 3), and improvement in endplate signal changes (N = 1). Also, 11/15 posttreatment MRIs included post-contrast images that showed epidural fibrosis (N = 1), rim enhancement (N = 2), and enhancement of the posterior annulus (N = 4).Based on MRI examinations, subtle anatomic changes may occur following plasma-mediated percutaneous discectomy. Further study is required to determine the clinical relevance of these changes.

    View details for DOI 10.1111/pme.12525

    View details for Web of Science ID 000344244800005

  • The importance of image guidance during epidural injections: Rates of incorrect needle placement during non-image guided epidural injections J Spine Levin, J., Wetzel, R., Smuck, M. 2012; 1 (2)
  • Evidence-Based Conviction PM&R Levin, J. H., Smuck, M. 2009; 1 (9): 891-892
  • Prospective, double-blind, randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us SPINE JOURNAL Levin, J. H. 2009; 9 (8): 690-703

    Abstract

    The prospective, double-blind, randomized, placebo-controlled study design is essential in the interventional spine literature to truly evaluate whether or not a procedure is effective.This article will critically evaluate the highest quality interventional spine literature with strict interpretation of the results of these trials.Review article.Extensive Medline/Pubmed searches and searches of the large review articles on the major interventional spine topics were performed to find all prospective, double-blind, randomized placebo-controlled trials in the English language interventional spine literature.Fluoroscopically-guided lumbosacral transforaminal epidural corticosteroid injections are effective in the treatment of acute/subacute lumbosacral radicular pain, and in preventing future surgeries. Injection of corticosteroid or Sarapin on the cervical or lumbar medical branch nerves is not effective. When done with proper technique, percutaneous radiofrequency lumbar and cervical medial branch neurotomy are both effective. Intraarticular sacroiliac joint corticosteroid injections are effective in patients with spondyloarthropathy. IDET is modestly effective in the treatment of lumbosacral discogenic pain in carefully selected patients. Percutaneous radio frequency neurotomy of the ramus communicans is effective in the treatment of lumbosacral discogenic pain. No firm conclusions can be drawn about cervical epidural corticosteroid injections, lumbosacral epidural corticosteroid injections for the treatment of chronic radicular pain, cervical or lumbosacral intraarticular zygapophysial joint corticosteroid injections for the treatment of degenerative zygapophysial joint pain, or intradiscal corticosteroid injections.The prospective, double-blind, randomized placebo-controlled trials in the interventional spine literature demonstrate efficacy from several different procedures when properly performed on appropriate patients. Other procedures have been shown to lack efficacy, while inconclusive evidence exists from multiple other interventional spine procedures. Further details are discussed in the text.

    View details for DOI 10.1016/j.spinee.2008.06.447

    View details for Web of Science ID 000268786300013

    View details for PubMedID 18789773

  • Rethinking convention. PM & R : the journal of injury, function, and rehabilitation Levin, J. H. 2009; 1 (7): 694-?

    View details for DOI 10.1016/j.pmrj.2009.04.004

    View details for PubMedID 19627966

  • Re: Manchikanti L, Singh V, Falco FJ, et al. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine 2008;33:1813-20. SPINE Smuck, M., Levin, J. H. 2009; 34 (10): 1116-1116

    View details for DOI 10.1097/BRS.0b013e3181a0a262

    View details for Web of Science ID 000265677900017

    View details for PubMedID 19404184

  • Re: Scanlon GC, Moeller-Bertram T, Romanowsky SM, et al. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine 2007;32:1249-56. Spine Smuck, M. W., Levin, J. H. 2007; 32 (23): 2638-?

    View details for PubMedID 17978668

  • Epidural fibrosis following percutaneous disc decompression with coblation technology. Pain physician Smuck, M., Benny, B., Han, A., Levin, J. 2007; 10 (5): 691-696

    Abstract

    Complications reported from percutaneous disc decompression (PDD) include discitis, anaphylaxis (with chemonucleolysis), instability, increased back pain, and reherniation. To the best of our knowledge, there is no report of epidural fibrosis occurring with any of the many types of PDD.To document a case of epidural fibrosis following PDD with coblation technology (Nucleoplasty), a previously unreported complication of this procedure.Case report.Details are presented on a 46-year-old man's history, diagnostic test results, treatments, and progression of his symptoms.Following PDD with coblation technology at L5-S1, the patient noticed improvement in his left lower extremity radicular symptoms and low back pain. He continued to improve over the following week to near complete relief. He resumed his normal activities. Three months post treatment, he experienced a recurrence of his radicular pain with a diminished left Achilles reflex. A subsequent MRI showed improvement of the previous left paracentral protrusion at L5-S1 along with a new contrast enhancing soft tissue mass. This mass, consistent with epidural fibrosis, was located in the left antero-lateral spinal canal and encased the left S1 nerve root. On the patient's next follow-up visit, he reported spontaneous resolution in his symptoms. He had stopped all pain medications and returned to his usual activities.This case is the first reported occurrence of epidural fibrosis following percutaneous lumbar disc decompression.

    View details for PubMedID 17876367

  • Radiculopathy from herniation of the nucleus pulposus: 1. Epidemiology, pathophysiology, and natural history J. Back Musculoskeletal Rehabil Levin J, Smuck M 2007; 20 (2,3): 97-101
  • Radiculopathy from herniation of the nucleus pulposus: 2. The role of corticosteroids J. Back Musculoskeletal Rehabil Levin J, Smuck M 2007; 20 (2,3): 103-13